Based on interview and record review, it was determined that the facility failed to develop a care plan for psychotropic medications in 1 out of 5 residents reviewed for unnecessary medications in a final sample of 12 residents (Resident Identifier #2). Findings include: Review on 3/27/24 of Resident #2's current electronic Medication Administration Record (eMAR) revealed 3 psychotropic medications (Prozac start date 7/5/23, Wellbutrin start date 7/5/23, Buspar start date 1/23/24) administered between 3/1/24 and 3/27/24. Review on 3/27/24 of Resident #2's Psychotropic Medication Use Monthly Review dated 3/10/24 revealed the reason for medication use was depression. Symptoms observed in the past month were the resident staying in his/her room, occasionally attending meals, and sleeping late. Individual non-pharmacological approaches included: life enrichment, room visits, reading, and movies. Review on 3/27/24 of Resident #2's comprehensive care plan revealed no care plan for psychotropic (antidepressant, antianxiety) medications or symptom management. Interview on 3/27/24 at approximately 10:30 a.m. with Staff A (Directors of Nursing) confirmed the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to follow physician orders for 1 of 1 resident reviewed for constipation/diarrhea and 1 of 5 residents reviewed for unnecessary medications in a final sample of 12 residents (Resident Identifiers #7 and #24). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #7 Review on 3/27/24 of Resident #7' Medication Administration Record (MAR) revealed the following physician orders: Milk of Magnesia Suspension 1200 mg/ml [milligram per milliliter] (Magnesium Hydroxide), give 30 ml by mouth every 24 hours as needed for constipation, may offer after second day without a bowel movement (30 ml), start date 7/5/23; stop date 2/29/24. Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)), Give 17 grams by mouth every 24 hours as needed for constipation, mix with 4-6 ounce (oz) liquid of choice, start date 7/5/23. Senna S Oral Tablet, 8.6 - 50 mg (Sennosides-Docusate Sodium), give 2 tablets by mouth as needed for constipation PRN [as needed] for constipation PRN 1x [time] /day, Start Date 7/5/23. Review on 3/27/24 of Resident #7's Bowel Elimination Record from 2/1/24 through 3/26/24 revealed that Resident #7 did not have a bowel movement for two or more days during the following days: on 2/4/24, 2/5/24, and 2/6/24; on 2/25/24, 2/26/24, and 2/27/24; and on 3/5/24, 3/6/24, and 3/7/24 Interview on 3/27/24 at approximately 8:45 a.m. with Staff A (Director of Nursing) confirmed the above findings. Staff A revealed that the facility did not have a bowel policy/protocol. Resident #24 Review on 3/27/24 of Resident #24's March 2024 MAR revealed the following physician order: Blood glucose monitoring, two times a day, start date 7/5/23. Further review revealed no documentation of morning glucose monitoring on 3/2/24, 3/7/24, 3/8/24, 3/14/24, 3/15/24, and 3/22/24. Interview on 3/27/24 at approximately 11:15 a.m. with Staff A confirmed the above findings.

Based on observation, record review, and interview it was determined that the facility failed to follow the comprehensive care plan for 1 of 1 residents reviewed for skin conditions in a final sample of 15 residents (Resident identifier is #19). Findings include: Observation on 2/8/23 of Resident #19 at 10:00 a.m. revealed Resident #19 in bed. Further observation revealed Resident #19's soft ankle position booties on his/her side table. Observation on 2/8/23 of Resident #19 at 2:25 p.m. revealed Resident #19 in bed. Further observation revealed Resident #19's soft ankle position booties on his/her side table. Observation on 2/8/23 of Resident #19 at 9:45 a.m. revealed Resident #19 in bed. Further observation revealed Resident #19's soft ankle position booties on his/her side table. Review on 2/9/23 of Resident #19's current care plan (Creating Home as a Team (CHAT) biography) for skin revealed the following: .At risk for pressure ulcers or other skin abnormalities . [name omitted] has a history of vascular ulcers on [pronoun omitted] LE's [lower extremities] . care team can do the following to keep skin intact . soft blue booties when in bed to protect heels . Interview on 2/9/23 at 1:15 p.m. with Staff H (Licensed Practical Nurse (LPN)) confirmed Resident #19's soft ankle position booties on his/her side table. Interview also revealed Licensed Nursing Assistants (LNAs) are responsible for applying Resident #19's soft ankle position booties. Observation on 2/9/23 at 1:20 p.m. with Staff H revealed Resident #19 awake in bed with slipper socks and a pillow under his/her legs. Further observation revealed Resident #19's heels were pink and intact. Interview on 2/9/23 at 1:30 p.m. with Staff I (LNA) revealed he/she did not apply Resident #19's soft ankle position booties while in bed because it was not in his/her care plan. Interview on 2/9/23 at 2:36 p.m. with Staff G (Charge Nurse, LPN) revealed Resident #19 should have soft ankle position booties on while in bed and LNAs would have access to the care plan. Interview on 2/9/23 at 2:45 p.m. with Staff F (Director of Nursing) confirmed Resident #19 should have soft ankle position booties on while in bed. Review of the facility policy titled, Skin Care, Guidelines; Wounds; Treatment Modalities revealed the following: .Skin Care and Treatments . #9 . Utilize pressure-reducing overlays, mattresses, chair cushions, individualized positioning schedules and devices . Procedure: 5. Chat/Care Plan interventions will be reviewed .

Based on interview and record review, it was determined that the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committe met quarterly and consisted of the required members in 2022. Findings include: Review on 2/10/23 of the facility's QAPI meetings for 2022 revealed that meetings were conducted on 3/10/22, 9/13/22, and 12/13/22. Interview on 2/10/23 at 3:11 p.m. with Staff D (Administrator) confirmed that there were no documented QAPI meeting between 3/10/22 and 9/13/22. Review on 2/10/23 of the facility's form titled QAPI Meeting-Attendance dated 3/10/22 revealed that the Medical Director was not listed or documented as being in attendance. Interview on 2/10/23 at 3:11 p.m. with Staff D confirmed that there was no documentation that the Medical Director attended the 3/10/22 QAPI meeting. Review on 2/10/23 of the facility's Quality Assurance/Performance Improvement Plan revealed, .The QAPI Steering Committee will be comprised of the Medical Director . each team will report their activities and progress to the QAPI Committee at least quarterly .