**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and Nurse Practitioner (NP), Medical Director, family member, and staff interviews, the facility failed to prevent medication errors when Nurse #1 administered medications to Resident #23 prescribed for Resident #240 which included fish oil (used to promote health by reducing triglycerides) and famotidine (decreases stomach acid and used to treat heart burn and gastroesophageal reflux disease). The facility also failed to prevent medication errors when medications were not administered as ordered by the physician (Resident #55). This deficient practice affected 2 of 8 residents whose medications were reviewed (Residents #23 and #55). The findings included: 1. Resident #23 was admitted to the facility on [DATE]. Resident #240 was admitted to the facility on [DATE]. A review of the physician orders dated July 2024, scheduled for 9:00 AM, revealed Resident #240 had orders for: - Famotidine 20 milligrams (mg) by mouth one time a day related to gastroesophageal reflux disease. -Fish Oil (reduces triglycerides) 1000 mg by mouth one time a day for nutritional support/supplementation for heart health. A progress note written by Nurse #1 dated 07/30/24 indicated that Resident #23 had received the wrong morning medications. Resident #23 had not shown any affects from the medications that were given. A phone interview occurred with Nurse #1 on 12/18/24 at 5:40 PM. She explained that she no longer was employed at the facility but recalled the details of the medication error that occurred with Resident #23 on 07/30/24. She stated that on the morning of 07/30/24 she was preparing medications for Resident #23 but inadvertently used Resident 240's medications. Nurse #1 explained when she administered the crushed medications to Resident #23 that the resident stated, yuk! and that's when she suspected she made the error. Nurse #1 indicated she did not know how it happened, but she realized it immediately and notified the unit manager and the Director of Nursing. Nurse #1 went on to say she also notified the NP of the error, and she received new orders to monitor Resident #23. Review of the Nurse Practitioner (NP) # 1's acute visit note dated 07/31/24 revealed Resident #23 was seen due to reports of receiving the wrong medication on 07/30/24. Nurse #1 informed the NP that Resident #23 received the following medications in error: fish oil and famotidine. Essentially, Resident #23 ended up receiving Resident #240's morning medications instead of her prescribed medications. There were no reports of adverse effects from medications received on 07/30/24. Will continue to monitor of any adverse effects, today she was hemodynamically stable and in no acute distress. A phone interview occurred with the NP #1 on 12/18/24 at 5:08 PM and she stated she was notified of the medication error that occurred on 07/30/24 with Resident #23. NP #1 further stated she evaluated Resident #23 the following day and Resident #23 had no adverse outcomes from the medication error. The Administrator was interviewed on 12/19/24 at 9:34 AM and explained that during a medication pass, Resident #23 was given the incorrect medications. Nurse #1 prepared the wrong medications and administered them to Resident #23. The Administrator stated that Nurse #1 no longer was employed at the facility. The Administrator also stated the staff did everything they should have done after the incident occurred. The Administrator further stated that nursing staff should have provided the correct medication to the correct resident. 2a. Resident #55 was admitted on [DATE] with a diagnosis of anxiety. The quarterly Minimum Data Set, dated [DATE] indicated she was cognitively intact, and she did not exhibit any behaviors. Resident #55 was coded for the use of antianxiety medication. Review of Resident #55's revised care plan dated 03/22/24 included a care area for problematic behaviors in which she exhibited ineffective coping related to anxiety in which she got upset easily yelling, cursing, and screaming at others. Review of a physician order dated 07/12/24 read Resident #55 was prescribed Ativan (antianxiety medication) 0.5 milligrams (mg) three times a day for anxiety and anxiousness. Review of an incident report (medication error) dated 08/30/24 timed 3:12 PM read while giving Resident #55 her 8:00 AM medications, Nurse #2 popped her morning dose of Ativan out of the medication card, but she did not notice that the medication was still stuck in the backside of the card pack and did not fall into the medication cup. This was not noticed until the shift change during the medication count. The report was completed my Nurse #2. During an interview with Nurse #2 on 12/18/24 at 10:30 AM, she stated she was precepting Nurse #1 so she pulled the medications for Resident #55 for Nurse #1 to administer, she did not notice that when she popped the Ativan out of her narcotic medication card, that the Ativan had not fallen into the pill cup but was still stuck inside the plastic bubble on the back of the medication card and later during medication count, it was discovered. An interview was completed on 12/18/24 at 1:15 PM with NP #2. She confirmed she was working in the facility on 08/30/24 and was made aware of the omission of Resident #55's morning Ativan dose on 08/30/24. She stated there was no concern for harm to Resident #55. An interview was completed on 12/18/24 at 1:00 PM with the Medical Director. He stated there was no harm to Resident #55. An interview was completed with the Administrator on 12/19/24 at 9:34 AM. She stated she would expect nurses to provide all prescribed medications to Resident #55 and not omit any doses. 2b. Review of a physician order dated 07/12/24 read Resident #55 was prescribed Ativan (antianxiety medication) 0.5 milligrams (mg) three times a day for anxiety and anxiousness. Review of an incident report (medication error) dated 08/30/24 timed 2:47 PM for Resident #55 read she was given the wrong dose of Ativan at 2:00 PM. Instead of receiving 0.5 mgs, she received 1 mg. The report indicated NP #2 and Resident #55's RP. This report was completed by Nurse #1. A telephone interview was completed on 12/18/24 at 5:40 PM with Nurse #1. She recalled the medication error with Resident #55. She stated she did not pull the Ativan for Resident #55 but rather Nurse #2 did and handed it to her to administer to Resident #55. Nurse #1 stated Resident #55 did not have any 1 mg Ativan tablets in the narcotic box and that Nurse #2 must have pulled the 1 mg of Ativan from another resident's narcotic pill card. Nurse #1 stated she resigned that day. During an interview with Nurse #2 on 12/18/24 at 10:30 AM, she stated she was precepting Nurse #1 at the time of this medication error on Resident #55 at 2:00 PM on 8/30/24. Nurse #2 stated she was not standing over Nurse #1 at the time of this medication error, but she felt Nurse #1 was not checking the computer when she pulled the incorrect Ativan dose and administered it to Resident #55. When asked why she was not with Nurse #1 since she was precepting her, Nurse #2 stated she should have been right beside her, but she did not want to hover over her and make her more nervous. An interview was completed on 12/18/24 at 1:15 PM with NP #2. She confirmed she was working in the facility on 08/30/24 and was made aware of the double dose of Resident #55's Ativan on 08/30/24 was administered at 2:00 PM. She stated there was no concern for harm, but Nurse #1 and Nurse #2 were instructed to observed for increased sedation. An interview was completed on 12/18/24 at 1:00 PM with the Medical Director. He stated there was no harm to Resident #55. Another interview was completed with the Administrator on 12/19/24 at 9:34 AM. She stated she would expect nurses to provide the medications to the right person, the right route and right dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews with residents and staff, the facility failed to provide routine hair trimming. This was for 4 of 6 residents reviewed for activities of daily living (ADL) (Residents #36, # 50, #53, and #77). The findings included: 1. Resident #36 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact. During an interview and observation with Resident #36 on 12/18/24 at 10:00 AM, he expressed that he would like to have his hair cut as it was longer than he liked to wear it. He explained he had not been able to get his hair cut in four months since the facility no longer had anyone available to provide this service. Resident #36 was unable to recall the staff that he talked to about getting his hair cut. Resident #36's hair was long on the sides and was long around the ears. On 12/18/24 at 10:41 AM, the Social Services Director was interviewed and stated that she was not aware that Resident #36 wanted his hair cut. She added she was unsure whose role it was to cut residents' hair. The Activities Director was interviewed on 12/18/24 at 10:47 AM and stated that nursing staff did not trim residents' hair, but that some family members came in and cut their loved ones' hair. She stated she didn't know how other residents got their hair cut. She indicated that the Nursing Assistants (NAs) could not cut hair. The Activities Director further stated that the facility did not have transportation available to take residents out for hair trimming, but she clarified the facility does have transportation to take residents to medical appointments. An interview occurred with the Director of Nursing (DON) on 12/18/24 at 11:04 AM. She stated that she had only been in the DON position since October 2024. She stated she had not been informed that she was responsible for finding someone to cut the residents' hair. She stated that the NAs could brush the residents' hair as part of routine activities of daily living (ADL) care, but they were not allowed to trim it. She relayed there had been candidates interviewed for the position of hairstylist, but that no one had been hired to her knowledge. An interview was completed with the Administrator on 12/18/24 at 11:10 AM. She stated she was unaware Resident #36 wanted a haircut. She stated she had been recruiting for a hairstylist for the facility. The Administrator further stated that the facility had not been making appointments to take residents out for hair trimming due to being unaware this service was wanted. 2. Resident #50 was admitted to the facility on [DATE]. A quarterly Minimum Data Set assessment dated [DATE] indicated that Resident #50 was cognitively intact. During an interview and observation with Resident #50 on 12/18/14 at 10:00 AM, she expressed that she would like to have her hair cut as it was longer than she liked to wear it and stated she had to rely on family members to trim her hair since the facility did not have anyone able to perform this service for the last four months. She explained she had asked staff several times about getting her hair cut but was unable to recall which staff. Resident #50's hair touched her collar in the back and was long around the sides. On 12/18/24 at 10:41 AM, the Social Services Director was interviewed and stated that she was not aware that Resident #50 wanted her hair cut. She added she was unsure whose role it was to cut residents' hair. The Activities Director was interviewed on 12/18/24 at 10:47 AM and stated that nursing staff did not trim residents' hair, but that some family members came in and cut their loved ones' hair. She stated she didn't know how other residents got their hair cut. She indicated that the NAs could not cut hair. The Activities Director further stated that the facility did not have transportation available to take residents out for hair trimming, but she clarified the facility does have transportation to take residents to medical appointments. An interview occurred with the Director of Nursing (DON) on 12/18/24 at 11:04 AM. She stated that she had only been in the DON position since October 2024. She stated she had not been informed that she was responsible for finding someone to cut the residents' hair. She stated that the NAs can brush the residents' hair as part of routine ADL care, but they were not allowed to trim it. She relayed there had been candidates interviewed for the position of hairstylist, but that no one had been hired to her knowledge. An interview was completed with the Administrator on 12/18/24 at 11:10 AM. She stated she was unaware Resident #50 wanted a haircut. She stated she had been recruiting for a hairstylist for the facility. The Administrator further stated that the facility had not been making appointments to take residents out for hair trimming due to being unaware this service was wanted. 3. Resident #53 was admitted to the facility on [DATE]. An annual Minimum Data Set assessment dated [DATE] indicated that Resident #53 was cognitively intact. During an interview and observation with Resident #53 on 12/18/14 at 10:00 AM, she stated that she would like to have her hair cut as it was longer than she liked to wear it and stated the facility did not have anyone able to perform this service for the last four months. She explained she had asked staff several times about getting her hair cut but was unable to recall which staff. She stated that she had not been offered an appointment with anyone outside of the facility to get her hair cut. Resident #53's hair was past her shoulders and was sticking out around her head. On 12/18/24 at 10:41 AM, the Social Services Director was interviewed and stated that she was not aware that Resident #53 wanted her hair cut. She added she was unsure whose role it was to cut residents' hair. The Activities Director was interviewed on 12/18/24 at 10:47 AM and stated that nursing staff did not trim residents' hair, but that some family members came in and cut their loved ones' hair. She stated she didn't know how other residents got their hair cut. She indicated that the NAs could not cut hair. The Activities Director further stated that the facility did not have transportation available to take residents out for hair trimming, but she clarified the facility does have transportation to take residents to medical appointments. An interview occurred with the Director of Nursing on 12/18/24 at 11:04 AM. She stated that she has only been in the DON position since October 2024. She stated she had not been informed that she was responsible for finding someone to cut the residents' hair. She stated that the NAs could brush the residents' hair as part of routine ADL care, but they were not allowed to trim it. She relayed there had been candidates interviewed for the position of hairstylist, but that no one had been hired to her knowledge. An interview was completed with the Administrator on 12/18/24 at 11:10 AM. She stated she was unaware Resident #53 wanted a haircut. She stated she had been recruiting for a hairstylist for the facility. The Administrator further stated that the facility had not been making appointments to take residents out for hair trimming due to being unaware this service was wanted. 4. Resident #77 was admitted to the facility on [DATE]. An annual Minimum Data Set assessment dated [DATE] indicated that Resident #77 was cognitively intact. During an interview and observation with Resident #77 on 12/18/14 at 10:00 AM, he expressed that he would like to have his hair cut as it was longer than he liked to wear it and stated he had to rely on family members to trim his hair since the facility did not have anyone able to perform this service for the last four months. He explained he had asked his son to let the staff know he wanted a haircut, but he was not sure which staff his son spoke with. Resident #77's hair was long on the sides. On 12/18/24 at 10:41 AM, the Social Services Director was interviewed and stated that she was not aware that Resident #77 wanted his hair cut. She added she was unsure whose role it was to cut resident's hair. The Activities Director was interviewed on 12/18/24 at 10:47 AM and stated that nursing staff did not trim residents' hair, but that some family members came in and cut their loved ones' hair. She stated she didn't know how other residents got their hair cut. She indicated that the NAs could not cut hair. The Activities Director further stated that the facility did not have transportation available to take residents out for hair trimming, but she clarified the facility does have transportation to take residents to medical appointments. An interview occurred with the Director of Nursing (DON) on 12/18/24 at 11:04 AM. She stated that she had only been in the DON position since October 2024. She stated she had not been informed that she was responsible for finding someone to cut the residents' hair. She stated that the NAs can brush the residents' hair as part of routine ADL care, but they were not allowed to trim it. She relayed there had been candidates interviewed for the position of hairstylist, but that no one had been hired to her knowledge. An interview was completed with the Administrator on 12/18/24 at 11:10 AM. She stated she was unaware Resident #77 wanted a haircut. She stated she had been recruiting for a hairstylist for the facility. The Administrator further stated that the facility had not been making appointments to take residents out for hair trimming due to being unaware this service was wanted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and Nurse Practitioner, Medical Director, family member, and staff interviews, the facility failed to prevent significant medication errors when Nurse #1 administered medications to Resident #23 prescribed for Resident #240 which included Eliquis (used to prevent blood from clotting), buspirone (used to treat anxiety disorders), gabapentin (used to treat epilepsy), isosorbide (used to treat high blood pressure), metoprolol (used to treat high blood pressure), spironolactone (used to treat high blood pressure), citalopram (used to treat depression). In addtion Resident #4 was administered medications prescribed to Resident #191 which included Aricept (used to treat dementia), Lexapro (used to treat depression) and Tramadol (used to treat pain). This deficient practice affected 2 of 8 residents whose medications were reviewed (Residents #23 and #4). The findings included: 1. Resident #23 was admitted to the facility on [DATE]. A review of the physician orders dated July 2024, scheduled for 9:00 AM, revealed Resident #23 had orders for: - Ingrezza 40 milligrams (mg) by mouth one time a day for tardive dyskinesia. - Sertraline (an antidepressant medication) 50 mg, give1.5 tablets, by mouth one time a day related to generalized anxiety disorder and major depressive disorder. - alprazolam (a benzodiazepine-central nervous system depressant medication) 0.25 mg tablet by mouth two times a day for anxiety. - Benztropine Mesylate (an anticholinergic medication) 0.5 mg by mouth every 12 hours for EPS (extrapyramidal signs or muscle stiffness/rigidity). - Depakote Delayed Release Sprinkle (an anticonvulsant and mood stabilizer medication) 125 mg, give 2 capsules by mouth three times a day for schizophrenia. -Risperdal (an antipsychotic medication) 0.5 mg tablet, give 1.5 tablets, by mouth two times a day related to paranoid schizophrenia. The annual Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #23 had severely impaired cognition. Resident #240 was admitted to the facility on [DATE]. A review of the physician orders dated July 2024, scheduled for 9:00 AM, revealed Resident #240 had orders for: - Apixaban (an anticoagulant medication) 2.5 mg by mouth two times a day related to atrial fibrillation. -Buspirone (an anxiolytic medication) 10 mg HCl by mouth three times a day related to generalized anxiety disorder. -Gabapentin (an anticonvulsant medication) 300 mg by mouth two times a day related to polyneuropathy. Do not crush or chew. - Isosorbide Mononitrate Extended Release (a nitrate with vasodilating properties medication) 30 mg by mouth one time a day for hypertension. Do no crush or chew. - Metoprolol Tartrate (a beta blocker medication) 0.5 tablet to = 12.5 mg by mouth two times a day related to primary hypertension. -Spironolactone (used to treat hypertension) 25 mg by mouth one time a day for Hypertension. -Citalopram Hydrobromide (an antidepressant medication) 10 mg by mouth one time a day related to generalized anxiety disorder and major depressive disorder. A progress note written by Nurse #1 dated 07/30/24 , indicated that Resident #23 had received the wrong morning medications. Nurse Practitioner #1 was notified and stated to monitor Resident #23 for 48 hours. Resident #23 had not shown any affects from the medications that were given. A phone interview occurred with Nurse #1 on 12/18/24 at 5:40 PM. Nurse #1 stated she no longer was employed at the facility but recalled the details of the medication error that occurred with Resident #23 on 07/30/24. She indicated that she was a new nurse, did not have very much training and did not know the residents well. She stated that on the morning of 07/30/24 she was preparing medications for Resident #23 but inadvertently used Resident 240's medications. Nurse #1 explained when she administered the crushed medications to Resident #23 that the resident stated, yuk! and that's when she suspected she made the error. Nurse #1 indicated she did not know how it happened, but she realized it immediately and notified the unit manager and the Director of Nursing. Nurse #1 went on to say she notified the Nurse Practitioner of the error, and she received new orders to monitor Resident #23. She also explained Resident #23's family member was in the room at the time, but she did not inform her of the medication error. Nurse #1 stated she was new and was unsure what the steps were after notifying the NP on 7/30/24. She further explained that she did not have a preceptor with her on 07/30/24 and she was alone on the medication cart. Review of the Nurse Practitioner (NP) #1's acute visit note dated 07/31/24 revealed Resident #23 was seen due to reports of receiving the wrong medication on 07/30/24. Nurse #1 informed the NP that Resident #23 received the following significant medications in error: Eliquis 10mg, buspirone 10mg, gabapentin 300mg, isosorbide 30mg, metoprolol 25mg, spironolactone 25mg, and citalopram 10mg. The NP noted essentially, Resident #23 ended up receiving Resident #240's morning medications instead of her prescribed meds. During the phone call on 07/30/24 orders included for vital signs to be checked every six hours x 48 hours, hold Resident #23's morning and afternoon routine medications and resume her regular scheduled medications at bedtime. The nurse was also instructed to monitor for signs and symptoms of increased bleeding, bruising, hypo/hypertension, altered mental status and increased drowsiness x 48 hours. There were no reports of adverse effects from medications received on 07/30/24. Will continue to monitor of any adverse effects, today she was hemodynamically stable and in no acute distress. A phone interview occurred with the family member on 12/18/24 at 5:15 PM and she stated she was at the facility on 07/30/24 when the medication error had occurred, however no one told her it had occurred at that time. She explained that Nurse #1 administered Resident #23's morning medications in her presence. She further explained Nurse #1 came back to the room a few minutes later and got Resident #23's vital signs (VS) and the family member stated, oh you're getting her VS? The nurse only said yeah, they want me to get them, but never said why she was getting them. An interview occurred with the Medical Director on 12/18/24 at 1:10 PM and he stated he did not recall being notified of the medication error for Resident #23. He explained he felt the medication error was significant due to the medications that Resident #23 had received. He also stated he had not heard that the medications had caused any harm to Resident #23. A phone interview occurred with Nurse Practitioner (NP) #1 on 12/18/24 at 5:08 PM and she stated she would consider the medication error that occurred on 07/30/24 with Resident #23 a significant medication error. She explained she gave orders to monitor Resident #23's vital signs and monitor for signs and symptoms of bleeding. NP #1 further stated she evaluated Resident #23 the following day and she had no adverse outcomes from the medication error. The Administrator was interviewed on 12/19/24 at 9:34 AM and explained that during a medication pass, Resident #23 was given the incorrect medications. Nurse #1 prepared the wrong medications and administered them to Resident #23. The Administrator stated that Nurse #1 no longer was employed at the facility. The Administrator stated the staff did everything they should have done after the incident occurred. The Administrator stated that nursing staff should have provided the correct medication to the correct resident. 2. Resident #4 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, congestive heart failure and diabetes type 2. Review of Resident #4's August 2024 physician orders included the following morning medications: - Clozaril (an antipsychotic medication) 50 milligrams (mg) give 1.5 tablet by mouth twice a day for paranoid schizophrenia. - Haldol (an antipsychotic medication) injection 5 mg per milliliters (ml). Inject 2 ml intramuscularly every shift for agitation. - Fentanyl patch (an opioid) 12 micrograms per hour. Apply one patch transdermally every 72 hours. The quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #4 had moderately impaired cognition. Resident #191 was admitted to the facility on [DATE]. A review of the August 2024 physician orders for Resident #191 included the following morning medications: - Aricept 5 mg one tablet by mouth every morning. - Lexapro (an antidepressant) 10 mg one tablet by mouth every morning. - Tramadol (used to treat pain) 25 mg one tablet by mouth twice a day. An incident report dated 8/24/24 written by Nurse #2 revealed Resident #4 had received the wrong morning medications by Nurse #1. The incident was reported to the Medical Director at 10:31 AM and the responsible party (RP) at 7:31 PM. A nursing progress note dated 8/24/24 indicated that Resident #4 had received the wrong morning medications. The physician was notified to and stated to monitor Resident #4 for 24 hours. Resident #4 had not shown any affects from the medications that were given. A phone interview occurred with Nurse #1 on 12/18/24 at 5:40 PM. Nuse #1 explained that she no longer was employed at the facility but recalled the details of the medication error that occurred with Resident #4 on 8/24/24. She stated that on the morning of 8/24/24 she was preparing medications for Resident #4 but inadvertently used Resident 191's medications. She stated that Nurse #2 was her preceptor as she was a new nurse and had asked her if Resident #4 had received her Haldol injection. That was when it was identified that Resident #4 had received Resident #191's medications in error. Nurse #1 went on to say that Nurse #2 notified the physician and RP of the error. On 12/18/24 at 10:31 AM, an interview occurred with Nurse #2. She explained that Nurse #1 was a new nurse and that she was precepting her on 8/24/24. She stated that she asked Nurse #1 if Resident #4 had received her Haldol injection that morning and Nurse #1 responded that Resident #4 wasn't ordered an injection. That prompted her to begin asking more questions and found out that Nurse #1 had given Resident #191's medications to Resident #4. She went to assess Resident #4 who was at her baseline and stable, then notified the physician and RP. Nurse #2 stated she should have been standing right next to Nurse #1 when she was preparing the medications. An interview occurred with the Medical Director on 12/18/24 at 1:00 PM and stated he was notified of the medication error, but didn't feel that any of the medications that were received by Resident #4 would have caused any harm. The Administrator was interviewed on 12/19/24 at 9:34 AM and explained that during a medication pass, Resident #4 was given the incorrect medications. Nurse #1 was being precepted by Nurse #2 but was standing away from the medication cart when Nurse #1 prepared the medications for Resident #4. Nurse #1 prepared the wrong medications and administered them to Resident #4. The Administrator stated that Nurse #1 no longer was employed at the facility. The Administrator further stated that Nurse #2 immediately notified the physician, assessed the resident and notified the RP following the incident. The Administrator stated the staff did everything they should have done after the incident occurred. She added that Nurse #2 should have been monitoring the medications that were being prepared by Nurse #1 closer. The Administrator stated that nursing staff should have provided the correct medication to the correct resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews, the facility failed to avoid the use of the term feeder when referring to a resident who required assistance with meals for 1 of 1 dining observations (Resident # 87). The reasonable person concept was applied as individuals have the expectation of being treated with dignity and not be referred to as feeder. The findings included: Resident #87 was admitted [DATE]. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired and required supervision and set up only during the assessment period. Resident # 87's comprehensive care plan was last revised 8/3/2023 and included a focus for nutritional status due to inadequate intake. On 8/28/2023 at 12:37 PM Resident #87 was observed in the dining area. The Occupational Therapy Assistant (OTA) provided Resident #87 with assistance eating and drinking. On 8/29/2023 at 12:45 PM Resident #87 was observed in the dining area. OTA provided Resident #87 with assistance eating and drinking. On 8/30/2023 at 12:30 PM Resident #87 was observed sitting in the dining area with his lunch tray in front of him. He made several attempts to put a straw in the lid of a cup and was unsuccessful. He was observed making three attempts to grasp a piece of steamed broccoli and place it in his mouth with his fingers but dropped it in his lap before it reached his mouth. The resident was then observed attempting to place the straw into the lid of a cup again. After several attempts, Resident #87 lost his grip on the straw, and it fell to the floor. During the above observation, Nurse Assistant (NA) #3 was standing in the door of the dining room, directly behind Resident #87. NA #3 was not observed assisting Resident #87 with his meal. At 12:40 PM this writer asked NA#3 if Resident #87 needed assistance with meals. NA#3 stated, I don't know. I don't usually work back here, I am the scheduler. NA#3 then walked to another dining area, stood in the door of the dining room and asked NA #4 if Resident #87 was a feeder. NA#4 replied, yes. NA#3 then walked back to dining area #1, pulled up a chair and began to assist Resident #87 with his meal. On 8/31/2023 at 10:08AM and interview was conducted with NA#3. She stated she should not have referred to Resident #87 as a feeder. She should have asked NA#4 if Resident #87 required assistance with his meal. 08/31/2023 1:17 PM and interview with Unit Manager #1 was conducted. She stated staff have been provided education on not referring to residents as feeders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interviews, the facility failed to assess Residebt #22 for self administration of medication for 1 of 1 resident observed to self-administer medication. Findings included: Resident #22 was admitted to the facility on [DATE]. A review of Resident #22's current physician orders did not include an order for the resident to self-administer medications. The annual Minimum Data Set, dated [DATE] documented Resident #22 had a moderately impaired cognition. The resident's active diagnoses were hypertension, arthritis, and osteoporosis. Resident #22's care plan dated 7/1/23 revealed the resident was not care planned to self-administer medications. On 08/28/23 at 9:55 am entry to Resident #22's room (room [ROOM NUMBER]), it was observed that the resident was holding a medication cup with 3 pills. The resident was taking a pill independently during entry into the room. Nurse #1 was not present. The remaining pills were red and orange in color. The resident continued to take her medication one at a time with water. The resident was slow and careful. During concurrent interview with Resident #22, she stated that sometimes the Nurse had not waited until I take all my medication and left the room. I take long to swallow; it was difficult for me, and the staff left before I was finished. The resident stated she would prefer the staff stay in the room, I think that was what they were supposed to do. An interview was conducted on 8/28/23 at 10:15 am of Nurse #1. Nurse #1 stated that she provided Resident #22 with her morning medication, handed her the cup with medication, and left the room. Nurse #1 stated she knew she was not supposed to leave the room while a resident took their medication independently, and I should not have left the room before the resident had taken her medication. Nurse #1 further stated Resident #22 was not independent with taking her medication. Nurse #1 had no further comments. On 8/31/22 at 1:55 pm an interview was conducted with the Administrator. She stated that the Director of Nursing (DON) was aware Nurse #1 had administered medication to Resident #22 unsupervised and staff would receive education. Nurse #1 had informed the DON. All medication administration was required to be supervised unless there was an order for self-administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, the facility failed to request a level II Preadmission Screening and Resident Review (PASRR) for a resident (Resident #81) newly diagnosed mental illness for 1of 1 residents reviewed for PASRR. The findings included: Resident #81 was admitted from another facility on 6/7/22 with diagnoses of Diabetes, Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. He was admitted with a level 1 PASRR as of 6/1/20 and no further screening was required unless a significant change occurred to suggest a diagnosis of mental illness. Resident #81 was seen by Psychiatry on 12/14/22 due to anger, aggression and mood instability. Resident #81 was newly diagnosed with Borderline Personality Disorder, Bipolar Disorder and Narcissistic Personality Disorder. Resident #81's annual Minimum Data Set, dated [DATE] indicated he was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. An interview was completed with Social Worker #1 on 8/29/23 at 1:50 PM. She stated she completed the requested for Resident #81 to be screened for a PASRR level 2 earlier on 8/29/23. Social Worker #1 stated she was not aware that a PASRR level 2 screen was required when a resident was newly diagnosed with a serious mental illness and/or intellectual disability or related condition. An interview was completed on 8/31/23 at 1:35 PM with the Administrator. She stated a PASRR level 2 screening request should have been sent at the time Resident #81 was newly diagnosed with Borderline Personality Disorder, Bipolar Disorder and Narcissistic Personality Disorder on 12/14/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to develop a comprehensive care plan in the areas of personal and incontinence care refusal (Resident #32) and nutrition and weight loss (Resident #50) for 2 of 22 residents reviewed for care plan. Findings included: 1. Resident #32 was admitted to the facility on [DATE] with the diagnosis of schizophrenia. A review of Resident #32's electronic medical records from 6/1/23 to 8/31/23 documented the resident refused care, including incontinence care when needed at least once a week. Resident #32's care plan dated 7/26/23 documented she was totally dependent of 2 staff for bathing and was incontinent of bowel and bladder. There was no mention of care refusal. Resident #32's quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had an intact cognition. The resident had feelings of being down and refused care 3 to 5 times a week. No other behaviors were coded. The resident was dependent for bathing and required assistance of 1 staff for dressing and incontinence care. On 8/30/21 at 2:40 pm an interview was conducted with Resident #32. The resident stated she did not like to get out of bed and staff provided care and she had no concerns (the resident had not recalled refusing care). On 8/31/23 at 11:50 am an interview was conducted with MDS Coordinator #1. She stated Resident #32 had a care plan for manipulative behaviors but not for refusal of care. A care plan for refusal of care would be added. On 8/31/23 at 2:40 pm an interview was conducted with the Administrator. The Administrator stated she was not aware Resident #32 had no care plan for refusal of care and she would follow up with the MDS Coordinator. 2. Resident #50 was admitted to the facility on [DATE] with dementia. Resident #50's quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had cognition that was severely impaired. The diagnoses were dementia and gastric reflux disease. The resident had weight loss, an undetermined amount. A review of Resident #50's electronic medical record for the month of August 2023 documented she ate between 25 to 50% of her meals. The resident had weight loss of 11.2% in 3 months. The dietician notes documented she was following and requested weekly weights. The resident was receiving a protein supplement and multivitamin for weight gain. The Registered Dietician (RD) note dated 8/8/23 documented Resident #50 had continued weight loss for the past 30 days. The RD evaluated and prescribed nutritional supplement to prevent weight loss. The resident would be weighed weekly for 4 weeks or until weight was stable (no further weight loss). Resident #50 had a physician order dated 8/13/23 for Mirtazapine each day (appetite stimulant). On 8/31/23 at 11:50 am interview was conducted with MDS Coordinator #1. She stated Resident #50 had no care plan for nutrition and weight loss. A nutrition and weight loss care plan area would be added. On 8/31/23 at 2:40 pm an interview was conducted with the Administrator. The Administrator was not aware Resident #50 had no care plan for weight loss. The resident's weight loss was discussed in morning meetings and the Dietary Manager was addressing the issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and record review, the facility failed to provide assistance with eating to maintain a resident's ability to feed himself for 1 of 1 residents (Resident #87) reviewed for activities of daily living (ADL). The findings included: Resident #87 was admitted [DATE] with diagnoses that included dementia. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident required supervision and set up only during the assessment period. Resident # 87's care plan was last revised 8/3/2023 and included a focus for activities of daily living and personal care deficit. Interventions included provide supervision with minimal set up or assistance with cutting food, verbal cues and/or assist to complete meals as needed. Resident #87's medical record also contained an Occupational Therapy (OT) Plan of Care dated 8/4/2023. The OT care plan indicated the resident's current level of function required total assist for completion of meals. On 8/28/2023 at 12:37 PM Resident #87 was observed in the dining area. The Occupational Therapy Assistant (OTA) provided Resident #87 with assistance putting straw in cup lid and getting cup to his mouth. Additionally, the OTA was observed putting food on the utensils and assisting Resident #87 with getting the food up to his mouth. On 8/29/2023 at 12:45 PM Resident #87 was observed in the dining area. The OTA provided Resident #87 with assistance eating and drinking. On 8/30/2023 at 12:30 PM Resident #87 was observed sitting in the dining area with his lunch tray in front of him. The OTA was not present. Resident #87 made several attempts to put a straw in the lid of a cup and was unsuccessful. He was observed making three attempts to grasp a piece of steamed broccoli with his fingers and place it in his mouth but dropped it in his lap before it reached his mouth. The resident was then observed attempting to place the straw into the lid of a cup again. After several attempts, Resident #87 lost his grip on the straw, and it fell to the floor. During the above observation, Nurse Assistant (NA) #3 was standing in the door of the dining room, directly behind Resident #87. NA #3 was not observed assisting Resident #87 with his meal. When Resident #87 moved his wheelchair back to look for the straw he dropped, the wheelchair contacted NA#3. NA#3 picked up the straw, placed it in the trash, and placed a clean straw in the resident's cup. She then went back to standing in the door of the dining area. At 12:40 PM on 8/30/2023 this writer asked NA#3 if Resident #87 needed assistance with meals. NA#3 stated, I don't know. I don't usually work back here; I am the scheduler. NA#3 then walked to another dining area, stood in the door of the dining area and asked NA #4 (who was seated assisting another resident) if Resident #87 was a feeder. NA#4 replied, yes. NA#3 then walked back to dining area where Resident #87 was sitting, pulled up a chair, and assisted Resident #87 with his meal. On 8/31/2023 at 10:08AM and interview was conducted with NA#3. She stated she did not work in the unit very often. She was not aware Resident #87 received assistance with his meals. On 8/31/2023 at 10:18 AM an interview was conducted with the Occupational Therapist (OT). He stated Resident #87 was on OT case load and receiving therapy services. The OT stated Resident #87 had a global functional decline over the previous 4 weeks. He further stated the staff had noticed Resident #87 needed assistance with meals. The OT stated he communicated with the unit staff frequently since 8/4/2023 and the staff were aware of the resident's decline. He stated the resident may have fallen through the cracks on 8/30/2023 because the staff working in the unit that day were not familiar with the residents. 08/31/2023 1:17 PM and interview with Unit Manager #1 was conducted. She stated NA#3 did not work in the unit routinely and was not aware Resident #87 required assistance with his meal.

Based on observation and staff interview, the facility failed to maintain a clean floor and walls in the dry food storage room for 1 of 2 dry food storage rooms observed (the emergency dry food storage area). Findings included: On 08/28/23 at 9:34 am an initial observation of the kitchen, including the emergency dry food storage room was conducted. The dry food storage room floor and walls had black soiling all over them (entire floor and wall without shelves) as well as the front of the ice machine. The inside of the ice machine was clean and had ice. Concurrent interview with the Dietary Manager was conducted. He stated the floor had not been cleaned in a couple of days and the black was soil not aging of the floor tile and the front of the ice machine had splatter. The Dietary Manager stated that a couple of weeks ago the Maintenance staff had serviced the ice machine and caused the splatter which had not been cleaned. On 8/31/23 at 1:40 pm the Administrator was interviewed. The Administrator stated she was not aware the emergency dry food storage room floor and walls were dirty and would follow up with the Dietary Manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint survey conducted on 2/3/2022. This was for 5 deficiencies in the areas of resident rights, safe/clean/comfortable homelike environment, accuracy of assessments, care plans, and services to meet professional standards, previously cited on 2/3/2022 and recited on the current recertification and complaint survey of 8/31/23. The duplicate citations during two federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1. F550- Based on observations, record reviews, and staff interviews, the facility failed to avoid the use of the term feeder when referring to a resident who required assistance with meals for 1 of 1 dining observations (Resident # 87). The reasonable person concept was applied as individuals have the expectation of being treated with dignity and not be referred to as feeder. During the facility's recertification survey of 2/3/2022 the facility failed to promote a dignified dining experience by serving meals on disposable plates and utensils. The facility also failed to provide dignity by allowing a resident to eat in a room with a strong urine odor. 2. F584- Based on observations and staff interviews, the facility failed to have a Packaged Terminal Air Conditioner (PTAC) unit in good repair (room [ROOM NUMBER]). This was for 1 of 6 rooms reviewed for comfortable, clean, and homelike environment. During the facility's recertification survey of 2/3/2023 the facility failed to maintain a clean environment as evidenced by dirty toilets and strong urine smells in bathrooms and failed to provide clean bed linens for 2 of 2 residents. 3. F641-Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications (Resident #13 and Resident #42) for 2 of 22 residents reviewed. During the facility's recertification survey of 2/3/2022 the facility failed to accurately code the MDS assessment in the areas of nutrition, falls, pressure ulcers, dental status, and urinary catheters. 4.F656-Based on record review and staff and resident interviews, the facility failed to develop a comprehensive care plan in the areas of personal and incontinence care refusal (Resident #32) and nutrition and weight loss (Resident #50) for 2 of 22 residents reviewed for care plan. During the facility's recertification survey 2/3/2022 the facility failed to develop a comprehensive care plan for Activities of Daily Living (ADL) assistance, for the use of a prophylactic antibiotic, and for a right-hand contracture. 5. F658- Based on record reviews, observation, and staff interviews, the facility failed to clarify a consultation note and discontinue an order to flush an abscess drain (Resident #25). This was for 1 of 1 resident reviewed for well-being. During the facility's recertification survey of 2/3/2022 the facility failed to follow physician's order by not holding the Lantus and Lispro insulin (used to treat diabetes mellitus) for blood sugar of 150 or less.

Based on record review, and staff interviews, the facility failed to document reported grievances and resolutions for two Resident Council meetings (9/16/21 and 11/18/21). This was for 2 of 4 resident council meetings reviewed. The findings included: A review of the Resident Council minutes from 9/16/21 listed grievances as: second shift taking breaks together leaving no one on the hall to answer call lights and nurse aides (NAs) rough with care. The minutes further revealed the Administrator was present at the meeting and would address the grievances. A review of the Resident Council minutes from 11/18/21 listed grievances as: 800 hall call lights not being answered in a timely manner, residents don't know who the first or second shift aides are and lift batteries not being charged daily so residents can get in and out of bed. The minutes further revealed the Administrator was present at the meeting. A review of the facility grievance logs from September 2021 to January 2022 did not reveal any grievance forms that had been completed on behalf of the Resident Council meetings for the dates of 9/16/21 or 11/18/21. On 1/26/22 at 2:00 PM, an interview was conducted with the Activities Director (AD) who stated if a grievance was expressed during a Resident Council meeting, she would have completed the Resident Council Grievance Form and provided to the Administrator for proper investigation to occur. She recalled the 9/16/21 meeting, stated the prior Administrator was present who told her she would complete the grievance form and have the concerns investigated. The AD further stated for the 11/18/21 concern she completed the Resident Council Grievance Form and handed to the Administrator for further investigation. She was unaware where the form was but recalled providing a verbal response to the Resident Council that the Administrator had taken care of their concerns. The Administrator was interviewed on 1/27/22 at 9:15 AM. She stated she was unable to locate a Resident Council Grievance Form for 9/16/21 and couldn't comment on the reason as the incident occurred with the previous Administrator. She went onto say she recalled being present at the Resident Council meeting on 11/18/21 as she had just started in the position within that week. The Administrator stated she followed up with staff regarding expectations to prevent the grievance issues from reoccurring but failed to initiate a Resident Council Grievance form as she thought the AD had done one. She added it was an oversight and expected all Resident Council grievances to be documented, logged, investigated, with resolutions documented and communicated back to the Resident Council.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to provide a written grievance response summary for 3 of 3 residents reviewed for grievances (Residents #32, #36 and #81). The findings included: 1) Resident #32 was admitted to the facility 10/23/21. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 had severe cognitive impairment. Review of the facility grievance logs indicated a grievance form was initiated on 12/14/21 by a family member for Resident #32, regarding a missing TV, glasses, and dentures. The grievance form indicated the Social Worker (SW) spoke with the family member on 12/23/21 at 1:00 PM in person related to the resolution of the grievance. The form indicated a written response was not requested nor provided to the family member, was signed by the Administrator and dated 12/29/21. On 1/25/22 at 2:55 PM, an interview occurred with the Social Worker (SW) who stated she had been employed at the facility for 4 months. She explained normally verbal responses were made to the person filing the grievance and she would document on the form the date, time, who she talked to and what was discussed. The SW stated she was not aware a written response was required for grievances, nor had she been told to provide written responses for grievance resolutions. Several attempts were made to contact family member of Resident #32 on 1/25/22 and 1/26/22. The Administrator was interviewed on 1/27/22 at 9:15 AM and stated she was unaware a written grievance response was required in addition to the verbal responses when a grievance had been resolved. The Administrator stated it was her expectation that the facility adhered to the regulatory guidelines regarding written grievance response summaries. 2) Resident #36 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] indicated Resident #36 was cognitively intact. Review of the facility grievance logs indicated the following grievance forms had been initiated by Resident #36: - A grievance form was initiated on 1/10/22, regarding a housekeeping employee entering his room without knocking. The grievance form indicated the Housekeeping Director spoke with Resident #36 on 1/10/22 in person related to the resolution of the grievance. The form indicated a written response was not requested nor provided, was signed by the Administrator and dated 1/10/22. - A grievance form was initiated on 1/24/22, regarding not being assisted with the breakfast meal. The grievance form indicated the Director of Nursing (DON) spoke with Resident #36 on 1/24/22 in person related to the resolution of the grievance. The form indicated a written response was not requested nor provided, signed by the Administrator, and dated 1/24/22. On 1/25/22 at 2:55 PM, an interview occurred with the SW who stated she had been employed at the facility for 4 months. She explained normally verbal responses were made to the person filing the grievance and she would document on the form the date, time, who she talked to and what was discussed. The SW stated she was not aware a written response was required for grievances, nor had she been told to provide written responses for grievance resolutions. An interview was completed with the Housekeeping Director on 1/26/22 at 11:09 AM who explained on 1/10/22 Resident #36 expressed a grievance regarding one of her employees. She reported it to the Administrator, completed a Grievance form and investigated the concern. The Housekeeping Director added after her investigation was completed, she verbally reported to Resident #36 what the resolution was and returned the form to the Administrator. On 1/26/22 at 12:16 PM, an interview occurred with Resident #36 and verified he had not received any written responses regarding his recent grievances that had been filed. The Administrator was interviewed on 1/27/22 at 9:15 AM and stated she was unaware a written grievance response was required in addition to the verbal responses when a grievance had been resolved. The Administrator stated it was her expectation that the facility adhered to the regulatory guidelines regarding written grievance response summaries. 3. Resident #81 was admitted to the facility on [DATE]. Review of the grievance log was conducted. Resident #81's responsible party (RP) had filed a grievance dated 8/19/21. The grievance concern was for missing personal items. The grievance concern was investigated, and action was taken. Missing items were searched and were accounted for. The grievance resolution including investigation findings reported to person voicing concern were left blank. The form was completed and signed by the previous Administrator with the date of 9/7/21. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident # 81 had moderate cognitive impairment. Resident #81's RP was unable to be reached for an interview. The Social Worker (SW) was interviewed on 1/25/22 at 2:55 PM. The SW stated that she thought she was the grievance officer. She reported that the department heads investigated the concerns and then turned into her to be logged in. The SW reported that did not know why the grievance resolution and the response notification for the grievance dated 8/19/21 were left blank. She indicated that normally, a verbal response was made to the person filing the complaint. The SW stated that she was not aware that a written response was required for grievances. The Administrator was interviewed on 1/27/22 at 9:15 AM. The Administrator stated that the facility did not provide written response to the grievance unless requested by the person filing the grievance. She further reported that a verbal response was provided but she was not aware that a written response was required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to report to the Administrator an incident of resident (Resident #54 towards Resident #41) to resident abuse immediately or as soon as practicable. Resident #54 shoved Resident #41 in the chest with no negative outcome. This was for 1 of 1 incident reviewed for resident-to-resident abuse. The findings included: a) Resident #54 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbance. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54 had severe cognitive impairment and was coded for physical and verbal behavioral symptoms directed towards others. b) Resident #41 was admitted to the facility on [DATE] with multiple diagnoses that included dementia with Lewy Bodies and anxiety disorder. An annual MDS dated [DATE] indicated Resident #41 had severe cognitive impairment and was not coded with any behaviors. Review of a nursing note dated 12/15/21 at 3:20 PM, read Resident #54 had gotten in front of Resident #41, and punched her in the chest without any word exchange. Resident #54 gave no explanation for his actions. Resident #41 reported pain just after the incident which later subsided. Both residents were separated and assessed with no injuries noted and vital signs stable. The responsible parties for both residents were notified as well as the physician. Both residents were assessed by the facility practitioner on 12/16/21 and the psychological service provider on 12/17/21 where Resident #54's medications were adjusted. A review of the Initial Allegation Report dated 12/16/21 revealed the incident occurred on 12/15/21 but the facility became aware of the incident on 12/16/21 at 1:30 PM. The allegation details read During the 24-hour nursing note review, it was noted a resident-to-resident altercation was identified. Resident #54 is currently on one on one. Physician and Resident Representatives were notified. The form stated both residents were on the dementia unit and had severe cognitive impairment. Upon assessment of Resident #41 there was no bruising or redness. No concerns were identified with the 5-day Investigation Report. Review of an In-Service Training Report dated 12/16/21 indicated all facility staff received education on the importance of reporting abuse, resident to resident, staff to resident and read as follows: Protect resident first Put other resident on 1 on 1 Report immediately to Director of Nursing (DON) and Administrator, family, and physician. Administrator is the abuse coordinator. State must be notified within 2 hours. On 1/26/22 at 8:00 PM, an interview occurred with Nurse #1 who was on duty at the time of the resident-to-resident incident between Residents #54 and #41. Nurse #1 explained when she arrived for her shift at 3:00 PM on 12/15/21, both residents were walking in the hallway with no agitation. She went behind the nursing station to get ready for the evening and heard the Nurse Aide (NA) calling out that Resident #54 had punched Resident #41 in the chest. The residents were separated, and Nurse #1 assessed Resident #41 who was free from any redness or bruising. Neither resident was able to state what occurred. The physician and resident representatives were notified. Nurse #1 stated the DON was still in the building and she notified her that there had been an incident but couldn't recall if she told her any further details. She further stated with the prior administrative staff she had always just notified the DON who then let the Administrator know when there was a resident-to-resident altercation. Nurse #1 stated on 12/16/21 she was counseled by the Administrator and DON who made it clear that both should be notified immediately when any type of abuse occurred. The Administrator and DON were interviewed on 1/27/22 at 9:00 AM and stated they felt the delay in notification to them of the incident was lack of communication. The DON stated on 12/15/21 when the incident occurred, she was leaving the facility when Nurse #1 approached her and said, we had an incident back there but it's ok now. She stated Nurse #1 didn't elaborate and she didn't ask further questions. The DON stated the next day she was reviewing the 24-hour nursing report and saw where a resident punched another resident in the dementia unit and immediately reported it to the Administrator. The investigation began, Resident #54 was observed 1:1 for 24 hours, the facility practitioner assessed and examined both residents and the psychological service provider saw both residents. The Administrator explained a conversation took place with Nurse #1 regarding the incident and the importance of reporting abuse to her immediately. The Administrator added that 100% staff education began on 12/16/21 and was completed by 12/21/21 regarding reporting allegations of or witnessed abuse. On 1/27/22 at 10:31 AM, an interview took place with NA #1 who had worked at the facility for 3 months and was present during the incident between Residents #54 and #41. She recalled Resident #41 was bent over pretending to wipe the floor as she normally did and was outside of a room in the hallway. Resident #54 walked up to this room thinking it was his. She stated she was assisting another resident at the nursing station and overheard Resident #54 say something like move or get out of the way. When she heard him say that she began walking down towards him as she recognized Resident #54 was becoming agitated. As she got closer to them, she saw Resident #54 shove Resident #41 with an open hand in the middle of her chest. Resident #41 didn't fall but began crying. NA #1 stated she put herself in the middle of them with her back to Resident #54 and began walking Resident #41 to the nursing station. Both residents were separated and assessed by the nurse. NA #1 stated she reported the incident to the nurse immediately. On 1/27/22 at 1:34 PM, both the Administrator and DON stated it was their expectation for facility staff to report any witnessed or allegations of abuse immediately to them. The Administrator stated abuse allegations should be reported to the state survey agency within 2 hours of becoming aware of the incident and a full investigation report sent within 5 working days of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and staff interviews, the facility failed to develop a comprehensive care plan for Activities of Daily Living (ADL) assistance (Resident #31), for the use of a prophylactic antibiotic (Resident #64) and for a right-hand contracture (Resident #27). This was for 3 of 26 residents care plans reviewed. The findings included: 1) Resident #31 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and chronic pain. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 had severe cognitive impairment and required extensive assistance from staff for eating and bed mobility and was dependent on staff for personal hygiene, transfers, dressing, toileting, and bathing. Review of the active care plan dated 11/5/21 revealed Resident #31 was not care planned for the ADL assistance that she required. Review of the nursing progress notes from 10/23/21 to 1/26/22 indicated Resident #31 required extensive to total assistance from staff to complete ADL's. On 1/27/22 at 12:51 PM, an interview occurred with MDS Nurse #1 who reviewed Resident #31's active care plan. She confirmed an ADL assistance care plan had not been developed but should have been and stated it was an oversight. The Administrator and Director of Nursing were interviewed on 1/27/22 at 1:34 PM and stated it was their expectation for the care plan to be person centered and should have included assistance required with ADL's. 2) Resident #64 was admitted to the facility on [DATE] with diagnoses that included dementia, osteoarthritis, and diabetes type 2. A review of Resident #64's medical record revealed an order dated 11/10/21 for Macrodantin (an antibiotic) 100 milligrams (mg) 1 tab every night. Review of the active care plan, dated 11/16/21, revealed Resident #64 was not care planned for the use of an indefinite antibiotic. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 had severe cognitive impairment, was frequently incontinent of bladder and occasionally incontinent of bowel. No infections were coded but she did receive 7 days of an antibiotic during the 7 day look back period. Review of the Medication Administration Records (MARs) from 11/10/21 until 1/24/22, showed Resident #64 received Macrodantin 100mg every night as ordered. On 1/27/22 at 12:51 PM, an interview occurred with MDS Nurse #1 who reviewed Resident #64's active care plan, verified a care plan was not present for the indefinite or prophylactic use of an antibiotic and felt it was an oversight. The Administrator and Director of Nursing were interviewed on 1/27/22 at 1:34 PM and stated it was their expectation for the care plan to be person centered and should have included the use of the indefinite antibiotic. 3. Resident #27 was admitted on [DATE] and readmitted on [DATE] with cumulative diagnoses of a Cerebral Vascular Accident, hemiplegia and a right-hand contracture. His quarterly Minimum Data Set (MDS) dated [DATE] indicated severe cognitive impairment, no behaviors and supervision eating. All of his other activities of daily living required extensive to total staff assistance. He was not coded for any impairment to his upper extremities. Review of Resident #27's comprehensive care plan last revised on 10/14/21 did not include a care plan addressing his right hand contracture and limited range of motion. An observation was conducted on 1/25/22 at 12:15 PM of Resident #27. He was lying in bed with an obvious right-hand contracture. He was holding his right hand with his left raising his right arm up and manipulating his fingers on his right hand. An interview was conducted on 1/26/22 at 3:00 PM with Nursing Assistant (NA) #12. She stated Resident #27 had his right-hand contracture on admission and he performed his own range of motion with his left hand throughout the day. An interview was conducted with MDS Nurse #1 on 1/27/22 at 1:00 PM. She stated she had been doing MDS assessments and care plans for 3 MDS Nurse #1 stated she should have care planned Resident #27 for his right-hand contracture, but it was an oversight likely due staffing problems and staff being out sick with COVID. An interview was conducted on 1/27/22 at 1:34 PM with the Administrator and the Director of Nursing (DON). Both stated MDS Nurse #1 should have included Resident #27's right-hand contracture in Resident #27's comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #16 was admitted to the facility on [DATE] with diagnoses that included dementia, fracture to the right leg and chronic pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 had severe cognitive impairment, had 1 fall with no injury and 1 fall with major injury since the last MDS assessment was completed. Review of Resident #16's medical record revealed a Rehabilitation Screen dated 10/15/21 indicating the resident was screened following a recent fall. The comments noted the therapist provided a positioning wedge for the left side of the bed to decrease rolling out and to decrease fall risk. Nursing was notified about the findings and recommendations. An Investigational Summary form dated 10/18/21 indicated the Unit Manager fully investigated a fall that occurred 10/14/21 and noted the resident had tendency to move self to the edge of the bed. The form indicated the care plan was to be updated to ensure positioning device was in place. Resident #16's active care plan revealed a focus area for risk for falls characterized by actual falls with injury, multiple risk factors related to: impaired mobility, tibia fracture. This was initiated on 10/4/21 and the latest revision date of 10/26/21. The interventions included the following : Bed in lowest position. Other: knee immobilizer and ortho consult as ordered. Position of bed with use of pillow/wedge with proper turning. Provide frequent staff observation of resident. On 1/24/22 at 1:00 PM, an observation was made of Resident #16 in her bed. The positioning wedge was noted to the right side of the bed leaving the left side unprotected. An interview occurred with the Unit Manager on 1/26/22 at 2:40 PM, who indicated she completed the falls investigation and updated resident care plans with new interventions. She verified after the therapy department completed a screen they would provide her with the Rehabilitation Screen form regarding any interventions they may have put into place as well. The Unit Manager reviewed Resident #16's care plan, confirmed the intervention to place a positioning wedge to the left side of the bed was not present and stated it was an oversight not to have updated the care plan when she completed the falls investigation on 10/18/21. The Director of Nursing was interviewed on 1/27/22 at 1:34 PM and stated it was her expectation for the interventions to be updated and accurate following the completion of a fall's investigation. Based on record review and staff interview, the facility failed to revise the care plan in the areas of tube feeding (Resident #90) and falls (Resident #16) for 2 of 26 sampled residents reviewed. Findings included: 1. Resident #90 was admitted to the facility on [DATE] with multiple diagnoses including severe protein calorie malnutrition. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #90 had severe cognitive impairment and was on mechanically altered diet. Resident #90's care plan that was initiated on 8/5/20 revealed that the resident was receiving tube feeding. On 10/28/21, the attending physician had ordered to discontinue the tube feeding due to resident's refusal. Resident #90's care plan (revision date of 12/21/21) was reviewed. The care plan was not revised to address the discontinuation of the tube feeding. The care plan problem was 16 French Gastrostomy (G) tube to assist resident in maintaining or improving nutritional status. The care plan goal was will be free from complications of G tube feeding. The care plan approaches included tube feeding formula and water flushes as ordered by the physician, observe for signs/symptoms of tube feeding complications, observe respiratory rate following feeding, observe for dyspnea, respiratory distress during and following feeding and check for residual prior to feeding as ordered by the physician. MDS Nurses #1 & #2 were interviewed on 1/27/22 at 12:58 PM. They both verified that Resident #90's tube feeding was discontinued on 10/28/21. They stated that Resident #90's care plan was reviewed on 12/21/21 and the care plan problem, goals and approaches should have been revised to reflect the discontinuation of the tube feeding. The Director of Nursing and the Administrator were interviewed on 1/27/22 at 1:36 PM. The Administrator stated that facility had 3 MDS Nurses and she would expect the care plan to be reviewed and revised when there were changes and when a new MDS was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Medical Director interviews, the facility failed to schedule a follow-up appointment with Orthopedic for 1 of 3 residents reviewed for well-being (Resident #16). The findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses that included dementia, idiopathic aseptic necrosis of the left femur (a bone condition that results from poor blood supply to the hip bone) and disorder to the bone density and structure. A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 had severe cognitive impairment and was dependent on staff for all activities of daily living. Review of Resident #16's medical records indicated a fall occurred on 10/2/21 from her bed resulting in a laceration to her head. She was transported and assessed in the emergency room (ER). Review of the emergency room Physician Documentation report dated 10/2/21 indicated Resident #16 had a right knee x-ray revealing a right tibial (lower leg) fracture. A knee immobilizer was placed, a follow-up appointment was made with an Orthopedic provider for 10/6/21 and Resident #16 returned to the facility. Review of a Report of Consultation from an Orthopedic provider dated 10/6/21 revealed Resident #16 was seen for a fracture of the right tibia. The provider documented Resident #16 was to continue to wear the knee immobilizer and non-weight bearing status for 1 month. The recommendations were to follow-up in 1 month. The nurse assigned to Resident #16 on 10/6/21 was not available for interview. On 1/25/22 at 12:06 PM, Resident #16 was observed lying in bed. Able to respond when her name was called and shook her head no when asked if she had any discomfort. Immobilizer was present to her right leg. On 1/26/22 at 12:00 PM, an interview occurred with the Resident Transporter and Scheduler who stated there were no other appointments for Resident #31 to follow-up with the orthopedic provider. She stated Resident #16 required ambulance transfers to outside appointments. She explained when a resident went to an appointment, she would get a copy of the consultation form from the Unit Manager to schedule any follow-up appointments, arrange for transportation if needed and log on the calendar. She was unable to state if she had received the consultation form dated 10/6/21 for Resident #16. An interview was held with the Unit Manager on 1/27/22 at 10:47 AM, who explained when a resident returned from a provider appointment the nurse on duty would provide her with a copy of the consultation form so she could verify any new orders. In addition, she would provide a copy to the Resident Transporter and Scheduler so any follow-up appointments could be made, transportation scheduled and logged on the calendar. The Unit Manager was unable to recall if the Orthopedic consultation form dated 10/6/21 had been provided to the Resident Transporter and Scheduler. The Director of Nursing (DON) was interviewed on 1/26/22 at 1:00 PM and stated the Resident Transporter and Scheduler had made a call to the Orthopedic provider and verified a follow-up appointment had not been made for Resident #16 after the 10/6/21 visit but had scheduled one for this week. The DON explained she had been in this role since 12/8/21 and felt it was an oversight for the Resident Transporter and Scheduler to not have received a copy of the consultation form in order to schedule a follow-up appointment. On 1/26/22 at 1:50 PM, the Medical Director was interviewed and stated he was unaware Resident #16 did not have follow-up with the orthopedic provider after the 10/6/21 appointment, however it would not have caused any serious outcome as she was already non-weight bearing prior to fracture. The Medical Director further stated he would expect residents to have follow-up appointments scheduled as recommended for any specialist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #16 was admitted to the facility on [DATE] with diagnoses that included dementia, fracture to the right tibia (lower leg), idiopathic aseptic necrosis of the left femur (a bone condition that results from poor blood supply to the hip bone) and disorder to the bone density and structure. Review of Resident #16's medical record revealed she experienced a fall on 10/1/21 at 10:10 PM when she was found on the floor beside her bed. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 had severe cognitive impairment, had 2 falls since the last MDS assessment was completed. A nursing progress note dated 10/14/21 indicated Resident #16 was found on the floor beside her bed at 9:20 PM. The note indicated Resident #16 had been repositioned multiple times throughout the day due to being found close to the edge of the bed. Review a Rehabilitation Screen dated 10/15/21 indicated Resident #16 was screened by therapy, following a recent fall. The comments noted the therapist provided a positioning wedge for the left side of the bed to decrease rolling out and to decrease fall risk. Nursing was notified about the findings and recommendations. An Investigational Summary form dated 10/18/21 indicated the Unit Manager investigated a fall that occurred on 10/14/21 and noted the resident had a tendency to move herself to the edge of the bed. The form indicated the care plan was to be updated to ensure the positioning device was in place. Resident #16's active care plan revealed a focus area for risk for falls characterized by actual falls with injury, multiple risk factors related to: impaired mobility, tibia fracture. This was initiated on 10/4/21 with the latest revision date on 10/25/21. The interventions included the following: Bed in lowest position. Other: knee immobilizer and ortho consult as ordered. Position of bed with use of pillow/wedge with proper turning. Provide frequent staff observation of resident. The Resident Care Guide was initiated on 1/28/21 and last revised on 10/25/21. This guide was reviewed and did not contain an intervention to use the positioning wedge to the left side of the bed for falls safety. On 1/24/22 at 1:00 PM, an observation was made of Resident #16 in her bed. The positioning wedge was noted to the right side of the bed leaving the left side unprotected. Resident #16 was observed lying in bed on 1/25/22 at 11:15 AM and the positioning wedge was present to the right side of the bed. There was no positioning device nor pillows to the left side of the bed. An interview was conducted with Nurse Aide (NA) #10 on 1/26/22 at 11:18 AM, who indicated she worked through an agency and had been assisting the facility since October 2021. NA #10 was familiar with Resident #16; was aware a positioning wedge was present for her bed and stated it was placed to the right side of the bed so Resident #16 didn't lean against the wall. She added when she provided care to Resident #16, she ensured the bed was in the lowest position and she centered in the bed for safety. On 1/26/22 at 2:40 PM, an observation of Resident #16 occurred with the Unit Manager (UM). Resident #16 was lying in her bed with the positioning wedge to the right side of the bed and no positioning wedge or pillow to the left side of the bed. The UM was unable to state why the positioning wedge was not located on the left side of the bed as intended to prevent further falls. She indicated she completed the falls investigation reports and reviewed them in the interdisciplinary team meeting every weekday morning. She further explained, if the therapy department completed a screen due to a fall, they would provide her with the Rehabilitation Screen form regarding any interventions they may have put into place as well. The Unit Manager added she updated the care plan and care guide with any new interventions but confirmed this had not occurred for Resident #16 after a fall on 10/14/21. NA #11 was interviewed on 1/26/22 at 3:30 PM and confirmed she was familiar with Resident #16 and provided her care on the 3:00 PM to 11:00 PM shift. NA #11 explained she was aware a positioning wedge was to be used on the left side of the bed as Resident #16 had a history of wiggling to the edge of the bed causing her to fall. She reviewed the Resident Care Guide and stated the information was not present on there but should be, so other NAs would know how to use the device as it was intended to be used for safety. The Director of Nursing was interviewed on 1/27/22 at 1:34 PM and stated it was her expectation for the safety interventions to be utilized as they were intended to be. Based on record review and staff interview, the facility failed to provide direct supervision and smoking apron while smoking to a resident assessed as unsafe smoker (Resident #81) and failed to implement a fall intervention as intended (Resident #16) for 2 of 8 sampled residents reviewed for accidents. Findings included: The facility's smoking policy (last revised on 3/27/19) revealed that smoking aprons, smoking blankets and fire extinguishers are provided as safety measures. The policy continued to indicate a licensed nurse, upon admission, readmission or significant change, will assess each resident who desires to smoke, utilizing the smoking evaluation. Thereafter, residents determined to be unsafe smokers will be assessed at least quarterly and safe smokers at least monthly, utilizing the smoking evaluation by a licensed nurse. When the smoking evaluation identifies a resident with any potential hazard risk, including but not limited to a cognitive deficit, the resident will be allowed to smoke only during the facility ' s designated smoking times with direct staff supervision. 1. Resident #81 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting unspecified side. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #81 had moderate cognitive impairment and was currently using tobacco. Resident's #81's care plan initiated on 6/20/19 was reviewed. The care plan problem was problematic manner in which resident acts characterized by inappropriate smoking or use of tobacco/tobacco substitute products (cigarettes) related to decreased safety awareness. The goal was resident will smoke safely in designated areas with supervision. The approaches included do not leave resident unattended while smoking. The approaches did not address the use of the smoking apron. Resident #81 had smoking assessments completed on 1/18/21 and he was deemed to be an unsafe smoker and required direct supervision while smoking. The incident report dated 2/13/21 at 7:30 AM was reviewed. The report indicated that the nurse was administering Resident #81's scheduled insulin in his abdomen when she noticed cigarette burn marks, 2 on his abdomen and 1 on his right thigh. Intervention put in place called the Administrator and Director of Nursing - set plan of no smoking was put in place. The nurse who completed this report was no longer an employee of the facility. A nurse's note (written by Nurse # 3) dated 2/13/21 at 11:11 AM indicated that per the administrator, Resident #81 was no longer able to go out even with supervision to smoke. The family was made aware. Resident #81's nurse's note dated 2/13/21 at 12:22 PM revealed that while the nurse was giving Resident #81 his scheduled insulin in the morning, the nurse noticed two burn marks on the right side of his abdomen and another burn mark on the right thigh. The burn marks looked like they came from a cigarette. The resident was a frequent smoker. The resident did not complaint of any pain. The nurse informed the Director of Nursing, Nurse Practitioner, and the family. The writer of this note was no longer an employee of the facility. A witness statement dated 2/16/21 was reviewed. The statement read while I had (name of Resident #81) out smoking, he dropped his cigarette. I checked him and chair and grounds, didn't see it. ((name of resident) said he dropped it on the ground and not on himself. The writer of this statement was a NA who no longer works at the facility. A Quality Assurance and Performance Plan (QAPI) was provided and was reviewed. The Plan was initiated on 3/13/21. The Summary of the event was Resident #81 dropped a lit cigarette on himself causing several small burn areas. The resident was not wearing a smoking apron while smoking. The plan was to educate the staff that all smoking residents must be assisted outside to smoke and must wear smoking apron while smoking. The monitoring was weekly smoking assessments on current smokers x (for) 4 weeks to monitor compliance. The QAPI meeting minutes and the QAPI coordinator signature were blank. The staff in-service for smoking was completed by Nurse #3 and was reviewed. The subject covered on the in-service included all residents must wear a smoking apron at all times, staff were not to smoke at the same time - watch residents carefully. On 1/26/22 at 9:50 AM, Nurse # 3 was interviewed. Nurse #3 was the weekend Unit Manager assigned to Resident #81. She stated that she was informed that Resident #81 was noted to have 3 cigarette burn marks on 2/13/21. The Administration was notified, and the Administrator had made the decision not to allow the resident to smoke. Nurse #3 further reported that the responsible party (RP) was called and informed of the plan to stop Resident #81 from smoking and the RP had agreed. Nurse #3 reviewed the QAPI plan was unable to remember who completed the form. She also reported that the staff involved during the smoking incident with Resident #81 were no longer employees of the facility. She added that the NA who assisted Resident #81 to smoke did not use a smoking apron and did not monitor the resident carefully while smoking. She reported that the burn marks were small, and they healed up without treatment. The resident did not complain of any pain. On 1/27/22 at 1:40 PM, the Administrator was interviewed. She stated that the incident had happened before she was the administrator of the facility. She reviewed the QAPI plan and stated that somebody had started the plan but did not finish it. She reported that there was no monitoring completed and there was no staff signature who completed the QAPI plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Medical Director and staff interviews, the facility failed to have an adequate clinical indication for the use of an antibiotic (Resident #64). This was for 1 of 8 residents whose medications were reviewed. The findings included: Resident #64 was admitted to the facility on [DATE] with diagnoses that included dementia, osteoarthritis, and diabetes type 2. There was no diagnosis of recurrent urinary tract infections (UTIs) or history of UTI. A physician's order for Resident #64 dated 11/10/21 indicated Macrodantin (used to treat or prevent urinary tract infections) 100 milligrams (mg) 1 tab every night with no indication of use or a stop date. A review of the Medication Administration Records (MARs) revealed Resident #64 was administered Macrodantin 100mg every night from admission [DATE]) through 1/25/22. The January 2022 MAR physician's orders revealed the Macrodantin order continued to be active, had no clinical indication for use or stop date. A review of Resident #64's medical record from 11/10/21 until 1/25/22 did not reveal any urinalysis completed or urology appointments since her admission. A physician progress note for 11/12/21 did not reveal any comments regarding the use of Macrodantin or its clinical indication. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 had severe cognitive impairment, was frequently incontinent of bladder and occasionally incontinent of bowel. No infections were coded but she did receive 7 days of an antibiotic during the 7 day look back period. A physician's progress note indicated on 12/8/21 Resident #64 was assessed due to routine follow-up. There was no mention of urinary tract concerns in her past medical history, or the clinical indication for the continued use of an antibiotic. A Nurse Practitioner progress note dated 12/30/21 did not indicate a clinical indication for the continued use of an antibiotic. A physician progress note for 1/1/22 made no mention of any urinary tract concerns in Resident #64's past medical history or current issues. The progress note did not indicate a clinical indication for the continued use of an antibiotic nor was the antibiotic mentioned in the Plan section of the note. Review of a Nurse Practitioner progress note dated 1/18/22 did not indicate a clinical indication for the continued use of an antibiotic. A physician progress note dated 1/23/22 did not include any urinary concerns in Resident #64's past medical history and did not note a clinical indication for the continued use of an antibiotic. An interview was conducted with Nurse #7 on 1/25/22 at 3:33 PM, who was familiar with Resident #64. She stated she was unaware of the reason why Resident #64 continued to receive an antibiotic. Nurse #7 reviewed Resident #64's record and verified there was no clinical rationale for the use the antibiotic and that Resident #64 had no active infections since her admission. On 1/26/22 at 1:00 PM, an interview occurred with the Assistant Director of Nursing (ADON) who also served as the Infection Control (IC) Nurse. She reported it was not normal practice to utilize an antibiotic without an adequate clinical indication. Resident #64's physician orders and MARs were reviewed with the IC Nurse, who indicated Resident #64 was on the antibiotic at the time of admission to the facility. She was unable to state why the antibiotic did not have adequate clinical indication for its use. An interview occurred with the Medical Director on 1/26/22 at 1:50 PM. He stated there should be better documentation to support the use of an antibiotic for Resident #64 since she had not been seen by a urologist nor had been symptomatic of a urinary tract infection since her admission. The Medical Director was unable to state why this had not been addressed when Resident #64 was admitted to the facility or during any of the follow-up exams. The Director of Nursing was interviewed on 1/27/22 at 1:34 PM and stated she expected use of antibiotics to have an adequate clinical indication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and record review, the facility failed to promote a dignified dining experience by serving 9 of 9 observed meals on disposable plates and utensils on 7 of 7 halls that included Resident #36 and Resident #24. The facility also failed to provide dignity by allowing a resident to eat in a room with a strong urine odor for 1 (Resident #25) of 1 resident reviewed for dignity. The findings included: 1. During the initial kitchen tour on 1/24/22 at 12:10 PM, the kitchen staff were serving meals on disposable plates and using disposable utensils. The Dietary Manager (DM) stated the rationale for using disposable plates and utensils was because of COVID. Observations conducted on all 7 halls revealed all the residents except for the tube feeding residents were served meals on disposable plates and utensils for lunch and dinner on 1/24/22, breakfast, lunch and dinner on 1/25/22, breakfast, lunch and dinner on 1/26/22, breakfast and lunch on 1/27/22. Review of the facility grievance logs from October 2020 to present did not include any grievances related to dining on disposable plates and utensils. An interview was conducted with the DM on 1/26/22 at 9:20 AM. He stated he had worked at the facility less than a year. He stated he was told it was a standard practice to serve meals on disposable plates and utensils. He stated it was a corporate directive for COVID. An interview was conducted with [NAME] #1 on 1/26/22 at 11:30 AM. He stated he had worked at the facility for 24 years. He stated on occasion a staff member called out but there was enough staff to wash the dishes but rather serving meals on disposable plates and utensils due to COVID. Dietary Aide #1 stated she thought the reason all meals were served on disposable plates and utensils for only due to COVID. a. Resident #36 was admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #36 was cognitively intact. On 1/26/22 at 12:16 PM, an interview occurred with Resident #36 who stated all meals had been served on Styrofoam plates with plastic utensils since he had returned to the facility on 1/19/21. He went onto say, he could understand someone with COVID-19 being served on disposable dinnerware but not everyone. Resident #36 added, he would prefer to have normal plates and utensils for his meals. b. Resident #24 was originally admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #24 had moderate cognitive impairment and she was independent with eating. Resident #24 was observed on 1/24/22 at 12:30 PM and on 1/25/22 at 12:32 PM during a lunch meal observation. Her food was served on a styro foam plate with plastic utensils. When interviewed, she stated that she would prefer to use regular plate and regular utensils. She also indicated that she was told by the staff that disposable plates and plastic utensils were used due to the pandemic. She also reported that she had been served disposable plate and plastic utensils since she was admitted to the facility. An interview was conducted on 1/27/22 at 1:34 PM with the Administrator. She stated she had only been at the facility a few months and she was not aware that the residents were eating off of disposable plates and using disposable utensils. The Administrator stated there was no reason for the residents to being eating from disposable items due to the COVID pandemic at this point unless they were COVID positive. 2. Resident #25 was admitted to the facility on [DATE] with multiple diagnoses including dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #25 had moderate cognitive impairment and was occasionally incontinent of bowel and bladder. The resident needed extensive assistance with toilet use. Resident #25 was observed on 1/24/22 at 12:10 PM. He was up in wheelchair on the hallway. His room was noted to have a strong urine odor. His bed sheet and draw sheet were noted to be wet with urine. On 1/24/22 at 12:15 PM, NA #4 was observed to bring Resident #25 to his room and to serve his lunch tray in front of him. At 12:17 PM, Resident #25 was observed to transfer self from his wheelchair into the side of his bed and started eating his lunch. The resident sat on the call light that was on his bed and the call light had turned on. On 1/24/22 at 12:17 PM, NA #5 was observed to answer the call light on Resident #25's room. She noticed that Resident #25 was sitting on his call light and asked him to stand up and she removed the call light from the bed. When interviewed after she left the room, NA #5 stated that she noticed the wet bed sheet and draw sheet from the resident's bed and the urine odor in the room. She indicated that she thought she would remove the wet sheets and would change the bed after the resident had finished eating his lunch. When asked if it was okay to let resident eat in a room with urine odor, she responded that she would go ahead and remove the wet sheets from his bed. On 1/24/22 a 12:30 PM, NA #4 was interviewed. She verified that she served the lunch tray to Resident #25. She stated that she did not notice the urine odor and the wet bed sheet and draw sheet in resident's bed. On 1/27/22 at 1:35 PM, The Director of Nursing (DON) was interviewed. She stated that residents should not be eating in a room with urine odor. She expected the NA to remove the wet sheets from the room before the tray was served to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #100 was admitted to the facility 10/6/2020 with diagnoses that included age related osteoporosis. Her quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident had moderate cognitive impairment, understands others, and could be understood by others. During the assessment period the resident required extensive assistance with all activities of daily living and personal hygiene. The resident was coded as total dependent in bathing with one person assistance. The MDS did not indicate the resident rejected care during the assessment period. Resident #100's comprehensive care plan last updated 1/7/2022 had a focus for care. Interventions included baths and showers and indicated resident preferred showers. On 1/24/2022 at 12:14 PM an interview was conducted with Resident 100. She stated she had made staff aware she would like to have showers and have her hair washed more often. She stated she did not get her hair washed unless she got a shower and she had not had one in a long time. She further stated her shower days were Wednesdays and Saturdays, but she rarely got a shower. Resident #100's hair was observed to be greasy and in need of cleaning. Bath logs for Resident #100 from 10/26/2021 through 1/11/2022 revealed the resident received 3 showers (11/3/2021, 11/20/2021, and 1/8/2022). All other days were document as bed baths. There was one refusal by resident documented on 12/14/2021. On 1/26/2022 at 2:31 PM an interview was conducted with Nurse Assistant (NA) #3. She stated she worked with Resident #100 and had never known her to refuse a bath or shower. When asked if she had ever given the resident a shower, she stated she had not. When asked how long she had worked in the facility she stated she was contract staff and had been in the facility for 4 months. She further stated staffing was the reason residents did not get scheduled showers. If there was one NA assigned to a hall, residents who require two-person assistance could not get a shower. Residents who required one person assistance did not always get their showers either. If she is assisting a resident with a shower, and she is the only NA on the hall, there is no one to cover her area while she is assisting in the shower. She further stated all residents got a bed bath daily unless they refused. 3. Resident #6 was admitted on [DATE] with a compression fracture to Thoracic vertebra 9 and 10. Review of her admission Minimum Data Set (MDS) dated [DATE] indicated Resident #6 was moderately cognitively impairment and she exhibited no behaviors. Resident #6 was coded for total assistance for bathing and that choosing between and bath or shower was very important to her. Review of Resident #6's activities of daily living (ADLs) care plan revised on 10/19/21 indicated she required assistance with bathing due to her fracture and weakness. Interventions included staff assisting with bathing. There was no care plan for any ADL refusals. Review of Resident #6's aide documentation regarding bathing and bath type from 10/31/21 to 1/25/22 included one refusal and no documented evidence of any showers. An interview and observation was conducted on 1/26/22 at 1:30 PM with Resident #6. She appeared clean, groomed and absent of odors. Resident #6 stated she received a shower yesterday but prior to that, she wasn't sure when the last time was that she had a shower. She stated about 2 weeks ago, the Activity Director came in on the weekend and took her and some of the other residents to the beauty shop and washed everyone's hair. Resident #6 stated it was very important to her to have regular showers and have her hair washed. She stated her scheduled shower days were Monday and Thursdays on first shift. An interview was conducted on 1/27/22 at 11:35 AM with Nursing Assistant (NA) #12. She stated there was not enough time to give her assigned residents which included Resident #6 their scheduled showers due to staffing. NA #12 stated she was not aware of any ADL refusals by Resident #6 and she was aware that it was every important to Resident #6 to have her showers and her hair washed. An interview was conducted on 1/27/22 at 1:34 with the Director of Nursing (DON). The DON stated the facility was having problems with staffing and utilizing mostly agency staff. She stated honoring Resident #6's preference to receive her scheduled showers was likely due to staffing. She stated it was important for the facility to provide Resident #6's scheduled showers and wash her hair. Based on record review, observation and staff and resident interviews, the facility failed to accommodate resident's request to be assisted out of bed (Resident #24), failed to honor resident's choice to smoke (Resident #81) and failed to provide showers/shampoo as preferred and scheduled (Residents #100 & #6). This was evident for 4 of 5 sampled residents reviewed for choices. Findings included: 1. Resident #24 was originally admitted to the facility on [DATE] with multiple diagnosis including right above the knee amputation (AKA). On 10/7/21, the resident was readmitted to the facility with diagnosis of left below the knee amputation (BKA). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #24 had moderate cognitive impairment. Resident #24's care plan dated 10/14/21 was reviewed. The approaches included transfers with one- person mechanical device/total dependence. On 1/27/22 at 9:55 AM, Resident #24 (residing on 200 hall) was observed in bed. She stated that she had been waiting for NA (Nurse Aide) #1 to get her out of bed. She told the NA right after breakfast and the NA told her that she was coming back at 9:00 AM to get her up and it is almost 1 hour, and she has not come back. On 1/27/22 at 10:30 AM, Resident #24 was observed in bed with a frowning face. She stated that NA #1 has not come back to get her up and she had been waiting since after breakfast. On 1/27/22 at 10:35 AM, NA #1 was observed heading to 200 hall from 100 hall. When interviewed, she stated that Resident #24 had requested to be out of bed his morning (not sure of time) and she told the resident that she would be back. She explained that she had 9 residents on the quarantine hall (100 hall) and 3 residents on 200 hall. She started working on the 100 hall and would go to 200 hall when finished. NA #1 added that it would be before 11 AM that she would be able to get Resident #24 up. On 1/27/22 at 1:40 PM, the Director of Nursing (DON) was interviewed. The DON verified that there were 2 NAs assigned to 100 and 200 halls. One of the two NAs had a split hall (100 and 200 hall). The DON stated that she expected residents to be up as requested. The DON reported that she was aware that the facility was short of staff, but the administration was trying to hire more staff. The facility also was utilizing the agency for staffing needs. 2. Resident #81 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting unspecified side. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #81 had moderate cognitive impairment. Resident #81 had smoking assessments completed on 1/18/21 and 2/14/21 and he was deemed to be an unsafe smoker and required direct supervision while smoking. Resident #81's nurse's note dated 2/13/21 at 12:22 PM revealed that he was observed to have 2 cigarette burn marks on his right abdomen and 1 burn mark on his right thigh. The Director of Nursing (DON), Nurse Practitioner and the family were notified. The writer of this note no longer works at the facility. The incident report dated 2/13/21 was reviewed. The report indicated that the nurse was administering Resident #81's scheduled insulin in his abdomen when she noticed cigarette burn marks, 2 on his abdomen and 1 on his right thigh. Intervention put in place called the Administrator and Director of Nursing - set plan of no smoking was put in place. The nurse who completed the report no longer works at the facility. On 1/26/22 at 9:50 AM, Nurse # 3 was interviewed. Nurse #3 was the weekend Unit Manager assigned to Resident #81. She stated that she was informed that Resident #81 was noted to have 3 cigarette burn marks on 2/13/21. The Administration was notified, and the Administrator had made the decision not to allow the resident to smoke. Nurse #3 further reported that the responsible party (RP) was called and informed of the plan to stop Resident #81 from smoking and the RP had agreed. Nurse #3 reported that the resident was never asked if he was willing to stop smoking. On 1/27/22 at 1:40 PM, the Administrator was interviewed. She stated that the incident had happened before she was the administrator of the facility. She stated that the staff could assist the resident in holding the cigarette if the resident was unable to hold the cigarette but not to stop him from smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, the facility failed to maintain a clean environment as evidenced by dirty toilets and strong urine smells in 3 of 7 bathrooms observed on the 500 hall. In addition, the facility failed to provide clean bed linens for 2 of 2 residents (Residents #6 and #59). The findings included: 1) On 1/25/22 at 12:15 PM, observations of the 500 hall revealed the following: - Bathroom in room [ROOM NUMBER] had a strong urine smell and dark yellow stains on the floor around the toilet. - Bathroom between rooms [ROOM NUMBERS] had a strong urine smell. There were yellowish orange stains on the toilet seat and dark yellow stains noted on the floor around the toilet. - Bathroom between rooms [ROOM NUMBERS] had a strong urine smell. There were yellowish orange stains on the toilet seat. On 1/26/22 at 11:09 AM, an interview occurred with the Housekeeping Director and stated that if she or her staff observed areas in the bathroom that needed repair or replacing such as the yellowish orange stains to the toilet lids, a work order would be sent to the Maintenance department. She was unable to state if work orders had been completed for the stains to the toilet lids on the 500 hall. Another observation was made on 1/26/22 at 3:07 PM of the 500-hall revealing the following: - Bathroom in room [ROOM NUMBER] had strong urine smell with dark yellow stains on the floor around the toilet. - Bathroom between rooms [ROOM NUMBERS] had strong urine smell and dark yellow stains around the base of the toilet. The toilet lid was free of yellowish orange stains. - Bathroom between rooms [ROOM NUMBERS] had a strong urine smell and dark yellow stains on the floor around the toilet. The toilet lid was free of yellowish orange stains. An interview occurred with the Maintenance Director on 1/27/22 at 8:37 AM. He stated if there was a need for an item to be replaced due to stains in the bathrooms, he would receive a work order. He verified that on 1/26/22 the housekeeping director mentioned several toilet lids needed replacing on the 500 hall which he completed. The Maintenance Director further stated several years ago it was decided to add extra caulk around the base of the toilet to prevent urine from seeping into the floor. If a bathroom was observed to have buildup of stains around the toilet he would receive a work order and would replace the toilet seal and caulk. He denied receiving any such work orders recently. On 1/27/22 at 9:38 AM, Housekeeper #1 was observed mopping in a resident's room and bathroom on the 500 hall. She stated she was the normal housekeeping aide assigned to that area and cleaned the residents' rooms, bathrooms, and common areas daily. When cleaning in the bathrooms she wiped down the fixtures, toilet seat, scrubbed the toilet bowl and mopped the floor making sure to get around the base of the toilet. She stated it was difficult to get the strong odor of urine out of the bathrooms. The Administrator was interviewed on 1/27/22 at 1:34 PM and stated she was unaware of the condition of the bathrooms on the 500 hall, but expected the facility to be clean, sanitary, and homelike. If stains were present in the bathrooms that could not be removed by cleaning, she would expect a work order to be sent to the Maintenance Department so it could be addressed. 2. Resident #6 was admitted on [DATE]. Review of her admission Minimum Data Set (MDS) dated [DATE] moderate cognitive impairment and she exhibited no behaviors. Resident #6 was coded for frequent incontinence of bladder and bowel. An interview and observation was conducted on 1/26/22 at 3:20 PM with Resident #6. She stated her bed linens were not changed unless they were wet with urine or stool. She stated her bed linen had not been changed since sometime last week. The bed linens were observed and there was noted to have orange colored stains on them. Resident #6 stated the stains were food stains. Observations of linen closet on 1/26/22 at 4:10 PM for the hall Resident #6 resided were well stocked with clean bed linens. An interview was conducted on 1/27/22 at 11:35 AM with Nursing Assistant (NA) #13. She stated the aides did not have time to change the bed linens more frequently due to the staffing issues. She stated there was no problem with the supplies of clean linens but the only problem was not enough time. An interview was conducted on 1/27/22 at 1:34 PM with the Administrator and Director of Nursing (DON). The DON stated she was not aware that the bed linens were not being changed and stated she expected the bed linens to be changed on shower days and as needed but staffing was an issue and they were operating with mostly agency staff. 3. Resident #59 was admitted on [DATE]. Her admission Minimum Data Set (MDS) dated [DATE] indicated Resident #59 was cognitively intact and she exhibited no behaviors. Resident #59 was coded for frequent incontinence of bladder and bowel. An interview and observation was conducted on 1/26/22 at 3:35 PM with Resident #59. She stated her bed linens were not changed consistently. She was able to recall that her bed linens were changed sometime last weekend because the linens were soiled. She stated she thought the bed linens were only changed when they were visibly soiled. The bed linens were observed and noted to have a tan stain on her top bed linen. She stated it was a peanut butter stain. Observations of linen closet on 1/26/22 at 4:10 PM for the hall Resident #59 resided were well stocked with clean bed linens. An interview was conducted on 1/27/22 at 11:35 AM with Nursing Assistant (NA) #13. She stated the aides did not have time to change the bed linens more frequently due to the staffing issues. She stated there was no problem with the supplies of clean linens but the only problem was not enough time. An interview was conducted on 1/27/22 at 1:34 with the Administrator and Director of Nursing (DON). The DON stated she was not aware that the bed linens were not being changed and stated she expected the bed linens to be changed on shower days and as needed but staffing was an issue and they were operating with mostly agency staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident #88 was admitted to the facility on [DATE] with diagnoses that included obstructive and reflux uropathy (urine can not drain from bladder and backs up into kidneys). The resident's baseline care plan dated 6/17/2021 had a focus for altered pattern of urinary elimination with indwelling catheter(suprapubic). The resident's most recent comprehensive care plan, last updated on 12/23/2021 also indicated the resident had a suprapubic catheter. Resident #88's significant change Minimum Data Set (MDS) dated [DATE] indicated the resident did not have any cognitive impairment and he was not coded for indwelling urinary catheter or suprapubic catheter. Resident #88's medical record contained a urology consult dated 7/22/2021. The urologist recommended the suprapubic catheter be changed out monthly and as needed for obstruction. On 1/24/2022 the resident was observed to have a urinary catheter drainage bag. During an interview he stated he had a suprapubic catheter when he was admitted to the facility. On 1/26/2022 at 8:52 AM an interview was conducted with nurse #2 who was assigned to Resident #88 that day. She confirmed the resident had a suprapubic catheter. An interview was conducted with MDS Nurse #1 on 1/26/2022 at 9:08 AM. She stated the change in condition MDS dated [DATE] should have indicated the resident had a suprapubic catheter. She further stated it was an oversight. 3) Resident #16 was admitted to the facility on [DATE] with diagnoses that included dementia, adult failure to thrive and anorexia. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #16 had severe cognitive impairment. She was coded for weight gain of 5% or more in the last month or gain of 10% or more in the last 6 months. Resident #16's weight data revealed the following weights during the MDS assessment look back period of May 2021 to October 2021, which showed a 3.36% weight loss in a month and 12.11% weight loss in 6 months: 10/7/21- 98.3 pounds (lbs.) 9/1/21- 101.6 lbs. 5/2/21- 110.2 lbs. On 1/27/22 at 12:51 PM, an interview was conducted with MDS Nurse #1, who reviewed the MDS assessment dated [DATE] as well as the weight data for Resident #16. The MDS Nurse #1 indicated the assessment had been coded in error and should have reflected a weight loss and not a weight gain. During an interview with the Administrator and Director of Nursing on 1/27/22 at 1:34 PM, they both indicated it was their expectation for the MDS assessment to be coded accurately. 4. Resident #3 was admitted [DATE] with cumulative diagnoses of Cerebral Vascular Accident (CVA) and Dysphagia (difficulty swallowing). Review of his annual Minimum Data Set (MDS) dated [DATE] indicated moderate cognitive impairment, no behaviors, nutrition via a feeding tube and no broken natural teeth or pain. Review of Resident #3's quarterly MDS dated [DATE] indicated moderate cognitive impairment, no behaviors, nutrition via a feeding tube and no broken natural teeth or pain. An observation and interview with Resident #3 was completed on 1/24/22 at 2:19 PM. He was observed with missing and broken teeth to both upper and lower gums. He stated he was not experiencing any dental pain and stated his teeth just fell out. The facility was unable to find any documentation prior to 1/5/22 of a dental exam. The 1/5/22 dental exam indicated Resident #3 was missing 13 teeth. An interview was conducted on 1/26/22 at 8:35 AM with Nursing Assistant (NA) #2. She stated she had worked several times with Resident #3 and noted his missing and broken teeth. NA #2 stated he did not complain of any oral pain during his oral care. An interview was conducted with MDS Nurse #1 on 1/27/22 at 1:00 PM. She stated Resident #3 did have missing and broken teeth when the annual MDS was completed, and it should have been coded as such. She stated part of the MDS assessment included observation, but the error was an oversite. An interview was conducted on 1/27/22 at 1:34 PM with the Administrator and the Director of Nursing (DON). Both stated they expected the MDS to reflect Resident #3's accurate dental status. 5. Resident #6 was admitted on [DATE] with a compression fracture to Thoracic vertebra 9 and 10, and an open unstageable pressure ulcer to her sacrum. Review of Resident #6's hospital discharge orders dated 10/6/21 read she had an unstageable pressure ulcer to her sacrum with orders to clean her sacrum with an antibiotic and collagenase ointment to the necrotic tissue and a foam sacral border. Review of Resident #6's admission orders dated 10/6/21 included orders for wound care to her unstageable pressure ulcer using collagenase ointment. Review of her admission Minimum Data Set (MDS) dated [DATE] moderate cognitive impairment and she exhibited no behaviors. She was coded as having no pressure ulcers except a deep tissue injury on admission. An interview was conducted with MDS Nurse #1 on 1/27/22 at 1:00 PM. She stated she thought Resident #6 only had a suspected deep tissue injury to her sacrum on admission. She stated her admission MDS dated [DATE] was inaccurate and she was unsure what happened. An interview was conducted on 1/27/22 at 1:34 PM with the Administrator and the Director of Nursing (DON). Both stated they expected the MDS to reflect that Resident #6 was admitted with an open unstageable pressure ulcer. Based on record review and staff interview, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of nutrition (Residents #24 & #16), falls (Resident #1), pressure ulcers (Resident #6), dental status (Resident #3) and urinary catheter (Resident #88) for 6 of 26 sampled residents reviewed. Findings included: 1. Resident # 24 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with multiple diagnoses including left above the knee amputation (AKA). The quarterly MDS assessment dated [DATE] indicated that Resident #24 had moderate cognitive impairment and had no weight loss. Review of the Resident #24's weight revealed that she was admitted on [DATE] with the weight of 256 pounds (lbs.) and on 10/13/21, she weighed 185 lbs., a 71 lbs. weight loss. MDS Nurses #1 & #2 were interviewed on 1/27/22 at 12:58 PM. They both verified that Resident #24 had a significant weight loss due to amputation and the MDS dated [DATE] should have been coded for weight loss but it was not. The Director of Nursing and the Administrator were interviewed on 1/27/22 at 1:36 PM. The Administrator stated she would expect the MDS assessments to be coded accurately. 2. Resident # 1 was admitted to the facility on [DATE] with multiple diagnoses including dementia. The annual MDS assessment dated [DATE] indicated that Resident #1 had severe cognitive impairment and had 1 fall with no injury since admission, readmission, or prior assessment. Review of the nurse's note dated 1/2/22 at 10:06 AM revealed that the roommate alerted the staff that Resident #1 was on the floor. The resident was noted sitting on the floor and there was blood on her fingers from the skin tear on her elbow. MDS Nurses #1 & #2 were interviewed on 1/27/22 at 12:58 PM. MDS Nurse #1 reviewed the annual MDS dated [DATE] and the nurse's note dated 1/2/22 and verified that the MDS should have been coded for 1 fall with injury due to the skin tear. The Director of Nursing and the Administrator were interviewed on 1/27/22 at 1:36 PM. The Administrator stated she would expect the MDS assessments to be coded accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician's order by not holding the Lantus and Lispro insulin (used to treat diabetes mellitus) for blood sugar of 150 or less for 1 of 8 sampled residents reviewed for medications (Resident #81). Findings included: Resident #81 was admitted to the facility on [DATE] with multiple diagnoses including diabetes mellitus (DM). The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident # 81 had moderate cognitive impairment and he had received an insulin for 7 days during the assessment period. Resident #81 had physician's orders dated 5/23/20 for Lispo insulin 12 units subcutaneous (SQ) before meals for DM (8 AM, 12 PM & 5 PM) - hold for blood sugar less than 150 and on 7/7/21 for Lantus insulin 40 units SQ twice a day (9 AM & 9 PM) - hold for blood sugar equal or less than 150. The monthly drug regimen review (DRR) revealed that the Pharmacy Consultant had addressed drug irregularity to the Director of Nursing (DON) on 5/11/21 and 9/6/21. The consult sent to the DON was that Resident #81 had an order to hold all insulins for blood sugar equal or less than 150. Review of the Medication Administration Records (MARs) revealed that insulins were administered with the blood sugar of less than 150 on several occasions in April 2021 (4/1/21, 4/5/21 & 4/6/21 and in August 2021 (8/4/21, 8/11/21, 8/13/21, 8/14/21, 8/16/21, 8/23/21 & 8/27/21). The facility responded to the consult had made order in bold on the MAR. Review of the nurse's notes and MARs from 11/2021 through 1/2022 revealed Resident #81 did not have any episodes of hypoglycemia documented. Review of the MARs for November 2021, December 2021 and January 2022 revealed that Lispro and Lantus insulins were administered for blood sugars (BS) less than 150 on the following dates: 11/7/21(BS 77) & 11/15/21 (BS 112) - 7:30 AM - Lispro was given 11/16/21 (BS 128), 12/10/21 (BS 148),12/19/21 (BS 118), 1/3/22 (BS 111), 1/14/22 (BS 133), 1/6/22 (BS 141), 1/21/22 (BS 121) - 4:30 PM - Lispro was given 12/8/21 (BS 120), 1/6/22 (BS 113), & 1/21/22 (BS 98) - 11:30 AM - Lispro was given 12/11/21(121), 1/20/22 (BS 122), 1/21/22 (BS 86) & 1/22/22 (BS 92) - 7:30 AM - Lispro and Lantus were given 12/12/21 (BS 134), 12/13/21 (BS 130), 12/15/21 (BS 130), 12/30/21 (BS 120) - 8:00 PM - Lantus was given 12/19/21(BS 140), 1/2/22 (BS 77), 1/3/22 (BS 117) - 7:30 AM - Lispro was given 1/15/22 (149) & 1/20/22 (BS 149) - 8:00 PM - Lantus was given Nurse #5, assigned to Resident #81 on 1/3/22,1/20/22, 1/21/22 and 1/22/22, was interviewed on 1/27/22 at 11:05 AM. She stated that she started working at the facility in December 2021 as an agency nurse. She verified her initials on the MARs and stated that she was aware of the order to hold the insulins for Resident #81 for BS less than 150. She reviewed the MARs and indicated that she missed holding the insulins on the days she was assigned to the resident. The Director of Nursing (DON) was interviewed on 1/27/22 at 1:40 PM. The DON stated she started working at the facility as DON in December 2021. She stated that nobody had been monitoring the MARs to ensure that orders were followed. She indicated that she expected the nurses to follow physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, resident, family and staff interviews, the facility failed to trim and clean dependent residents' nails (Residents #36, and #52), failed to ensure resident's hair and nails were clean (Resident #91) and failed to provide showers as scheduled (Residents #31& #32). This was for 5 of 5 residents reviewed for dependency on staff for Activities of Daily Living (ADLs). The findings included: 1) Resident #36 was admitted to the facility on [DATE] with diagnoses that included a spinal cord injury and diabetes type 2. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact and was dependent on staff for personal hygiene. A review of Resident #36's active care plan, last reviewed on 11/9/21, revealed a focus area for ADL/personal care dependent on staff due to quadriplegia. The interventions included personal hygiene/grooming: provide total care for wash and dry face, skin, nails, hands, and perineum. A review of the nursing progress notes from 5/1/21 to 1/25/22 revealed no refusals of nail care documented. An observation was made of Resident #36 on 1/24/22 at 1:05 PM while he was lying in bed. He was noted to have long, clean, jagged fingernails to the left hand and long, clean nails to the right hand. Resident #36 stated his nails had not been cut in a while and he tried to bite the nails on the left hand which had resulted in jagged nails and could not get anyone to cut them. On 1/25/22 at 4:00 PM, Resident #36 was observed lying in his bed. His fingernails remained long and jagged. An interview occurred with Nurse Aide (NA) #10 on 1/26/22 at 11:18 AM. She stated she worked with an agency and had been assisting the facility since October 2021. NA #10 was familiar with Resident #36 and normally cared for him. She stated nail care would be completed if needed during personal care and was unaware he had long and jagged fingernails but would take care of them. Resident #36 was observed lying in his bed on 1/26/22 at 12:16 PM waiting for the lunch meal. His fingernails remained long and jagged and he stated that no one had come in to offer to cut them for him. The Unit Manager was interviewed on 1/26/22 at 2:40 PM and stated nail care should be completed during the residents scheduled shower and/or with daily personal care. She explained the NAs should ensure resident's nails were short, to the residents' preference, not jagged and clean. The Unit Manager stated she was unaware Resident #36 needed nail care. NA #11 was interviewed on 1/26/22 at 3:30 PM. She indicated she worked the 3:00 PM to 11:00 PM shift and was familiar with Resident #36. NA #11 explained nail care should be completed when showers or personal care was rendered but at times it was difficult due to staffing. She went onto say that since the COVID-19 pandemic began, she had normally worked as the only aide to one and a half hallways and found it difficult to get nail care completed as well as scheduled showers. On 1/27/22 at 1:34 PM, an interview was completed with the Director of Nursing (DON). She stated it was her expectation for nail care to be provided during personal care tasks and if a NA was not able to complete the task she would expect the nurse to be notified of the need. The DON was unable to explain why nail care had not occurred for Resident #36 as there was no documentation to show this had or had not been completed or attempted. 2) Resident #52 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 had severe cognitive impairment and was dependent on staff for personal hygiene. A review of Resident #52's active care plan revealed a focus area for ADL/personal care dependent on staff due to hemiplegia and cognitive deficit, that was initiated on 11/15/21. The interventions included personal hygiene/grooming: provide total care for wash and dry face, skin, nails, hands, and perineum. A review of the nursing progress notes from 11/2/21 to 1/25/22 revealed no refusals of nail care documented. An observation was made of Resident #52 on 1/22/22 at 12:04 PM while she was sitting in a recliner chair in the hallway. She was noted to have a dark substance under fingernails to both hands. An interview occurred with Nurse Aide (NA) #10 on 1/26/22 at 11:18 AM. She stated she worked with an agency and had been assisting the facility since October 2021. NA #10 was familiar with Resident #52 and normally cared for her. She stated nail care would be completed if needed during personal care and was unaware the resident had a dark substance under nails but would take care of them. Resident #52 was observed lying in bed with her hands on top of the bed covers on 1/26/22 at 11:25 AM. Her fingernails remained with a dark substance under them. The Unit Manager was interviewed on 1/26/22 at 2:40 PM and stated nail care should be completed during the residents scheduled shower and/or with personal care daily. She explained the NAs should ensure resident's nails were short, to the residents' preference, not jagged and clean. The Unit Manager stated she was unaware Resident #52 needed nail care. NA #11 was interviewed on 1/26/22 at 3:30 PM. She indicated she worked the 3:00 PM to 11:00 PM shift and was familiar with Resident #52. NA #11 explained nail care should be completed when showers or personal care was rendered but at times it was difficult due to staffing. She went onto say that since the COVID-19 pandemic started, she had normally worked as the only aide to one and a half hallways and found it difficult to get nail care completed as well as scheduled showers. On 1/27/22 at 1:34 PM, an interview was completed with the Director of Nursing (DON). She stated it was her expectation for nail care to be provided during personal care tasks and if a NA was not able to complete the task she would expect the nurse to be notified of the need. The DON was unable to explain why nail care had not occurred for Resident #52 as there was no documentation to show this had or had not been completed or attempted. 3) Resident #31 was admitted to the facility on [DATE] with diagnoses that included vascular dementia and diabetes type 2. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31 had severe cognitive impairment and was dependent on staff for bathing. A review of the medical records indicated Resident #31 was to receive a shower every Wednesday and Saturday on the 7:00 AM to 3:00 PM shift. A review of Resident #31's personal care records indicated she received 3 showers from 11/1/21 to 1/25/22. She was showered on 11/12/21, 12/8/21 and 12/30/21. The personal care records indicated a refusal of bathing assistance on 1/8/22. The nursing progress notes were reviewed from 11/1/21 to 1/25/22 and did not reveal any refusals of showers. On 1/24/22 at 12:10 PM, a family member of Resident #31 was interviewed and stated she was concerned that Resident #31 was not receiving showers as scheduled but had not inquired about them. On 1/25/22 at 11:52AM, NA #9 was observed coming out of Resident #31's room and stated that she had just provided her with a full bed bath and added she had never known Resident #31 to refuse showers or bed baths. NA #7 was interviewed on 1/26/22 at 3:15 PM and stated she was frequently the only NA scheduled for the unit finding it difficult to get the showers completed as scheduled. She was unaware of Resident #31 refusing showers or bed baths. An interview was completed with NA #14 who worked the 3:00 PM to 11:00 PM shift, on 1/26/22 at 3:20 PM. She was familiar with Resident #31 and stated it was not uncommon for her to be the only NA for the area that Resident #31 resided on. She stated when this occurred it was impossible to get showers completed as scheduled. On 1/27/22 at 9:54 AM, NA #15 was interviewed. She worked the 7:00 AM to 3:00 PM shift in the area that Resident #31 resided. She was unaware of Resident #31 refusing showers or bed baths but stated at times it was difficult to get showers completed as scheduled due to staffing needs. The Director of Nursing (DON) was interviewed on 1/27/22 at 1:34 PM and stated she expected all residents to receive showers as requested and scheduled. If a resident refused, the NA should alert the nurse so a progress note could be written, and alternate means of a bath provided. 4) Resident #32 was admitted to the facility on [DATE] with diagnoses that included dementia, osteoarthritis, and insomnia. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #32 had severe cognitive impairment and was dependent on staff for bathing. Resident #32's active care plan, dated 11/5/21, revealed a focus area for assistance with ADLs/Personal Care. The interventions included one-person total dependence for bathing. A review of the medical records indicated Resident #32 was to receive a shower every Tuesday and Friday on the 3:00 PM to 11:00 PM shift. A review of Resident #32's personal care records indicated she received 5 showers from 10/30/21 to 1/25/22. She was showered on 11/22/21, 11/23/21, 12/8/21, 12/15/21, and 12/21/21. The personal care records indicated a refusal of bathing assistance 3 times. The nursing progress notes were reviewed from 10/30/21 to 1/25/22 and did not reveal any refusals of showers. On 1/25/22 at 11:52AM, NA #9 was interviewed and stated she had never known Resident #32 to refuse showers or bed baths. NA #7 was interviewed on 1/26/22 at 3:15 PM and stated she was frequently the only NA scheduled for the unit finding it difficult to get the showers completed as scheduled. She was unaware of Resident #32 refusing showers or bed baths. An interview was completed with NA #14 who worked the 3:00 PM to 11:00 PM shift, on 1/26/22 at 3:20 PM. She was familiar with Resident #32 and stated it was not uncommon for her to be the only NA for the area that Resident #32 resided on. She stated when this occurred it was impossible to get showers completed as scheduled. On 1/27/22 at 9:54 AM, NA #15 was interviewed. She worked the 7:00 AM to 3:00 PM shift in the area that Resident #32 resided. She was unaware of Resident #32 refusing showers or bed baths but stated at times it was difficult to get showers completed as scheduled due to staffing needs. The Director of Nursing (DON) was interviewed on 1/27/22 at 1:34 PM and stated she expected all residents to receive showers as requested and scheduled. If a resident refused, the NA should alert the nurse so a progress note could be written, and alternate means of a bath provided. 5. Resident #91 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #91 had severe cognitive impairment and was dependent on the staff for bathing. The assessment further indicated that the resident needed extensive assistance with personal hygiene, and he had no behavior nor rejection of care. Resident #91's current care plan for activities of daily living (ADL) was reviewed. The care plan indicated that the resident refused to bathe at times and prefers bed bath (initiated 7/10/19) and provide extensive assistance to total care with personal hygiene/grooming (combing hair, shave, wash, and dry face). Resident #91 was observed in bed on 1/24/22 at 2:22 PM and on 1/25/22 at 12:50 PM. He was in bed and his fingernails on his left hand were dirty with brown colored matter underneath his nails. His right hand and arm were covered with compression stocking. His hair (chin length) was greasy and uncombed. Nurse Aide (NA) #3, assigned to Resident #91, was interviewed on 1/26/22 at 10:56 AM. She stated that Resident #91 did not refuse care, he cussed though, but it depended on how you approached him. NA #3 added that night shift was responsible for providing bed baths to Resident #91, and she did not know if his hair was washed. She added that she was not assigned to the resident on 1/24/22 and 1/25/22. She added that when she checked him this morning, she did not notice his fingernails being dirty nor his hair greasy and uncombed. NA #6 was interviewed on 1/26/22 at 4:10 PM. NA #6 added that when she worked 11-7 shift, she provided Resident #91 a partial bed bath, she did not have the time to wash his hair. When she observed resident's hair on 1/26/22 at 4:11PM, she stated that his hair needed to be washed and combed and his fingernails cleaned. On 1/27/22 at 1:40 PM, the Director of Nursing (DON) was interviewed. The DON reported that the facility was short of staff, but the administration was trying to hire more staff. The facility also was utilizing the agency for staffing needs. She reported that currently, the facility was using the agency staff on 7-3 shift only. She indicated that she would talk to the scheduler to start using the agency staff for 3-11 and 11-7 shift if needed. The DON added that she expected the staff to wash resident's hair and to clean fingernails when a bed bath was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #50 was admitted to the facility 1/20/2021 with diagnoses that included venous insufficiency and chronic ulcer of the right foot. Resident #50's annual Minimum Data Set (MDS) dated [DATE] indicated the resident had moderately impaired cognition, could understand others, and be understood by others. He required extensive assistance with bed mobility, activities of daily living, toileting, and personal hygiene. The resident was coded at risk for pressure injuries but had no pressure injuries at the time of the assessment. He had an indwelling catheter and was coded as occasionally incontinent of bowel. The resident's comprehensive care plan last updated 11/16/2021 included a focus for risk of skin breakdown or development of further pressure ulcers related to diabetes. Interventions included inspecting skin and notifying nurse of abnormal changes per facility protocol. On 1/25/2022 at 11:28 AM an interview was conducted with Resident #50. He stated he had a wound on his ankle that had been present for a long time. He then stated he thought he had a wound on his buttocks because he was experiencing pain when he sat in his chair or when the staff provided cleaned the area after toileting. Resident #50 stated he had frequent diarrhea, but he had no concerns with staff being available to assist him with toileting (bed pan) or cleaning him in a timely manner. Resident #50's most recent skin assessment completed 1/23/2022 included a chronic venous stasis ulcer and suprapubic catheter site. There was no documentation the resident had skin breakdown on his buttocks. Resident #50's medical record revealed he had been treated by wound care providers outside the facility and had been evaluated by a vascular surgeon for the chronic non-healing venous stasis ulcer of the right foot and ankle. There was no documentation indicating the resident had a pressure injury to the buttocks. On 1/26/2022 at 9:43 AM during observation of catheter care by NA #2 the resident requested the bed pan. When the resident was turned to place bed pan, two dime sized stage 2 pressure injuries were observed on the right and left buttocks. Observed barrier cream covering the sacral and both buttocks. When the resident was turned and cleaned, the skin breakdown was observed again. The resident voiced pain when NA #2 was cleaning the area. The NA made no comment regarding the skin breakdown. When asked if the resident was receiving care for the skin breakdown on his buttocks, she stated she was agency and she was not familiar with the resident. She knew he was receiving care for his leg wound but was not certain about his buttocks. An interview was conducted with the wound nurse on 1/26/2022 at 10:13 AM. She stated the resident got protective cream for his skin due to diarrhea. She was not made aware of skin breakdown on his buttocks. She stated the resident had a history of skin breakdown in the area. She contributed the breakdown to chronic and frequent diarrhea. On 1/26/2022 at 2:30 PM an interview was conducted with NA# 3. NA#3 stated she was assigned to Resident #50 on 1/25/2022. She stated she aided with toileting multiple times on 1/25/2022. When asked if he had any skin breakdown, she stated he did have two very small spots on his buttocks. When asked if she reported the breakdown, she stated she thought she reported it to her nurse, Nurse #2. When asked if she reported to the wound nurse, she stated she did not but assumed her nurse would report it to the wound care nurse. An interview was conducted with Nurse #2 on 1/26/2022 at 2:45PM. She stated she was not made aware Resident #50 had skin breakdown on his buttocks. Based on observations, record reviews, interviews with the Nurse Practitioner (NP), residents and staff, the facility failed to obtain treatment orders for the right outer ankle pressure ulcer (Resident #81) and failed to identify and treat a pressure ulcer (Resident #50) for 2 of 3 sampled residents reviewed for pressure ulcers. The findings included: 1. Resident #81 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting unspecified side. Resident #81's pressure ulcer assessments were reviewed. The assessment dated [DATE] revealed a stage 2 pressure ulcer was identified to right outer ankle measuring 1.1-centimeter (cm.) x (by) 1 cm. x 0.1 cm (depth). On 9/8/21, the pressure ulcer was assessed as stage 3 due to the presence of eschar. On 1/20/22, the pressure ulcer remained as a stage 3 measuring 1.2 x 1 x 0.1 cm. Resident #81 had a doctor's order dated 9/10/21 to treat the right outer ankle pressure ulcer with Santyl (used to remove dead skin tissue and aid in wound healing) and alginate (highly absorbent and enhances wound healing) and to cover with dry dressing daily Monday through Friday for 2 weeks (9/10/21 - 9/24/21). There was no treatment ordered from 9/25/21 through 1/19/22. On 1/20/22, there was an order to clean the right outer ankle pressure ulcer with wound cleanser and to apply alginate and cover with dry dressing 3 times a week. The Treatment Administration Records (TARs) for Resident #81 were reviewed. The September 2021 and October 2021 TARs revealed that the right outer ankle pressure ulcer was treated with Santyl and alginate from 9/13/21 through 10/30/21. The November 2021, December 2021, and January 2022 (1/1//22 - 1/19/22) revealed that the right outer ankle pressure ulcer was treated with iodoflex (an antimicrobial and highly absorbent used to treat pressure ulcer). The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #81 had moderate cognitive impairment and he had a stage 3 pressure ulcer that was not present on admission. Resident #81's care plan dated 12/4/21 was reviewed. The care plan problem was pressure ulcer to the right outer ankle, stage 3. The approaches included treatment as ordered by the physician. Resident #81 was observed during the dressing change on 1/26/22 at 11:20 AM. The pressure ulcer on the right outer ankle was observed to have no signs/symptoms of infection. The wound bed was red and there was no eschar/necrosis noted. The measurement was 1.2 x 1.5 x 0.2 cm. The Treatment Nurse was observed to clean the ulcer with wound cleanser, alginate was applied to the wound bed and covered with dry dressing. The Treatment Nurse was interviewed on 1/26/22 at 11:35 AM. The Treatment Nurse reviewed Resident #81's records and stated that she could not find any treatment ordered after 9/10/21 for the right outer ankle pressure ulcer. She explained that she was out on leave, and nobody had followed up after the order on 9/10/21 for 2 weeks was completed. She also reported that there was no order for the iodoflex in the resident's medical records. The Treatment Nurse stated that the Nurse on the floor was responsible for the treatment when she was out on leave. She was unable to remember the exact date when she was out on leave. She stated that she did not know who transcribed the order for the iodoflex. The Director of Nursing (DON) was interviewed on 1/27/22 at 1:40 PM. The DON stated that she started working as DON in December 2021. She indicated that she expected nursing to obtain treatment orders for residents with pressure ulcers. The DON reported that the facility was short of staff and was utilizing the agency for staffing needs. The Nurse Practitioner (NP) was interviewed on 2/3/22 at 8:55 AM. The NP stated that she was familiar and had been following up Resident #81's pressure ulcers. The NP stated that the resident was high risk for the development of pressure ulcer due to his condition, including immobility of the lower extremities and his non- compliant to his care. He was referred and was seen by the wound clinic but had refused to go starting in September 2021. The NP reported that she had called and involved his family regarding his care. She added when she visited Resident #81, his feet were elevated, however his right leg/foot was rotated outward, and it was hard to reposition due to pain. Resident #81 was on scheduled pain medication. She indicated that when she examined his right ankle, it was hard to see the pressure ulcer due to his right foot positioning. She commented that she thought the development and the decline of the pressure ulcer were unavoidable. The NP did not comment on the missing treatment orders and the use of the iodoflex to the pressure ulcer.

Based on record review, observation, and interview with resident, family and staff, the facility failed to provide sufficient nursing staff to provide nail and hair care (Residents #36, #52 & #91) and showers as scheduled (Residents #31 & #32). This was for 5 of 5 sampled residents reviewed for Activities of daily living (ADL). Findings included: This tag is cross referenced to: F 677 - Based on record reviews, observations, resident, family and staff interviews, the facility failed to trim and clean dependent residents' nails (Residents #36, and #52), failed to ensure resident's hair and nails were clean (Resident #91) and failed to provide showers as scheduled (Residents #31& #32). This was for 5 of 5 residents reviewed for dependency on staff for Activities of Daily Living (ADLs). Nurse Aide (NA) #3 was interviewed on 1/26/22 at 10:56 AM. The NA reported that the staffing at the facility was bad and most of the time there was only 1 NA on the hall. Most of the residents needed 2-person assist for care. If a resident needed 2- person assist for shower/bath, it was impossible to provide the shower/bath if you're alone on the hall. NA #6 was interviewed on 1/26/22 at 4:10 PM. NA #6 stated that she was assigned on 100 (quarantine hall) and 200 halls with 23 total residents. She stated that the facility had been short of staff. She had been complaining to the administration, but she was told it will get better. She works 3-11 shift but was asked to work double due to short staff. She reported that when 1 NA was assigned with 20+ residents, care was not provided such as showers, assisting residents to eat, call light not answered timely, incontinent rounds not done timely, and residents were not assisted in getting in and out of bed as requested. NA #6 further stated that most of the residents were 2-person assist due to their weight or behaviors. She added that she rushed all the time to be able to provide care to residents. The Director of Nursing (DON) was interviewed on 1/27/22 at 10:40 AM. The DON stated that she just started as the DON of the facility in December 2021. She reported that she was aware that the facility was short of staff and the administration had been trying to hire more staff. She added that the facility had been utilizing the agency to help with the staffing needs. The Administrator was interviewed on 1/27/22 at 1:35 PM, The Administrator stated that she just started as administrator of the facility in December 2021. She was aware of the staffing shortage at the facility and had been working to hire and to retain more staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews with staff, Pharmacy Consultant, Psychiatric Nurse Practitioner and Medical Director, the Pharmacy Consultant failed to identify the facility's need to monitor target behaviors and side effects of psychotropic medications (Residents #29, #86, #50, #54, #64, and #81) and failed to identify the use of an indefinite antibiotic (Resident #64). This deficient practice affected 6 of 8 residents whose medication were reviewed. Findings included: 1.Resident #50 was admitted to the facility 1/20/2021 with diagnoses that included major depressive disorder and anxiety disorder. The resident's annual Minimum Data Set (MDS) dated [DATE] indicated Resident #50 was moderately cognitively impaired, could understand other, be understood by others, and had no moods or behaviors during the assessment period. Resident #50 had a physician's order for citalopram 20 milligrams (mg) orally daily for depression. Resident #54's Medication Administration Record (MARs) from 11/1/2021 to 1/25/2022 indicated he received citalopram as ordered. The MAR did not list any side effect monitoring for Resident #50. A review of Resident #50's medical record to include nursing progress notes from 11/01/2021 until 1/25/22 revealed no monitoring of side effects to the psychotropic medication. On 1/24/2022 at 3:13 PM Resident #50 was observed lying in bed with his eyes closed making a repetitive rolling movement with his mouth. 1/26/2022 at 10:21 AM an interview was conducted with Nurse #2. She stated she had not noticed any behaviors related to depression with Resident #50. She stated there was not an area in the medical record that specified what behaviors to monitor or what side effects to look for. When asked about the rolling motion the resident made with his mouth, she stated she had noticed it but was not sure if it was a side effect of his medication or just a behavior he had. When asked if she had documented the observation, she stated she had mentioned it to the nurse practitioner a while back, but she had not documented the observation. The Director of Nursing (DON) was interviewed on 1/26/22 at 10:40 AM and stated behavior and side effect monitoring for psychotropic medications was documented in the nursing progress notes when observed. She further stated she would expect the Pharmacy Consultant to identify any irregularities and to monitor side effects that could occur due to psychotropic medications. On 1/27/2022 at 10:44 AM The psychiatric Nurse Practitioner was interviewed. She stated she expected target behaviors and side effects to be monitored daily to determine if a gradual dose reduction (GDR) would be beneficial. Review of monthly drug regimen reviews from 11/1/8/2021 and 12/8/2021 revealed the pharmacy consultant did not identify the need for side effects monitoring. The pharmacy consultant was interviewed on 1/27/2022 at 11:40 AM the Pharmacy Consultant stated that she expected target behaviors to be identified and monitored. She also stated she felt staff were aware of the resident's behaviors. She further stated she expected staff to monitor the side effects of the psychotropic medications. 2.Resident #29 was admitted to the facility on [DATE] with multiple diagnoses including depression, general anxiety and insomnia. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #29 was severely cognitively impaired and displayed no moods or behaviors during the assessment period. The resident received antianxiety medications 1 out of 7 days and antidepressant medications 7 out of 7 days during the assessment period. Resident #29's comprehensive care plan, updated 11/4/2021, had a focus for use of psychotropic medications with the potential for side effects. Interventions included monitoring for effectiveness and side effects and observe resident's mental status on an ongoing basis. The resident's active orders included a physician's order for paroxetine (antidepressant) 10mg orally daily, and duloxetine (antidepressant) 60mg orally daily. Resident #29's nursing progress notes from 6/1/2021 through 1/25/2022 revealed no monitoring of side effects of the psychotropic medication. Review of monthly drug regimen reviews completed on 8/9/2021, 9/6/2021, 10/13/2021, 11/11/2021, and 12/8/2021 revealed the pharmacy consultant did not identify the need for side effects monitoring. The Director of Nursing (DON) was interviewed on 1/26/2022 at 10:40 AM. The DON stated that nursing staff were not monitoring the resident's behaviors and side effects on an ongoing basis. The nursing staff was documenting behaviors by exception. The pharmacy consultant was interviewed on 1/27/2022 at 11:40 AM the Pharmacy Consultant stated that she expected target behaviors to be identified and monitored. She also stated she felt staff were aware of the resident's behaviors. She further stated she expected staff to monitor the side effects of the psychotropic medications. The pharmacy consultant added that staff are documenting resident's behaviors by exception. 2) Resident #54 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, major depressive disorder, anxiety disorder and mood disorder. A review of the physician's orders revealed an order dated 11/2/21 for Seroquel (an antipsychotic medication) 25 milligrams (mg) by mouth twice a day. The admission Minimum Data Set (MDS) assessment for 11/9/21 indicated Resident #54 had severe cognitive impairment and displayed physical and verbal behavioral symptoms towards others 1 to 3 days during the 7 day look back period. He was coded as receiving 6 days of an antipsychotic medication. A review of Resident #54's medical record to include nursing progress notes from 11/2/21 until 1/25/22 revealed no monitoring of side effects to the antipsychotic medication. The nursing notes included a few episodes of verbal and physical aggression towards staff and other residents and agitated behavior. A review of the Pharmacy Consultant medication review notes from 11/2/21 to 1/25/22 did not reflect the need for monitoring side effects of the antipsychotic medication. Resident #54's Medication Administration Record (MARs) from 11/2/21 to 1/25/22 indicated he received Seroquel as ordered. The MAR did not list any side effect monitoring that may be displayed from Resident #54 or the medication. On 1/25/22 at 11:50 AM, Resident #54 was observed ambulating in the hallway of the memory care unit without any behaviors noted. The Director of Nursing (DON) was interviewed on 1/26/22 at 10:40 AM and stated behavior and side effect monitoring for antipsychotic medications was documented in the nursing progress notes when observed. She further stated she would expect the Pharmacy Consultant to identify any irregularities regarding Resident #54, to include the need to monitor side effects that could occur due to the antipsychotic medication. A phone interview occurred with the Pharmacy Consultant on 1/27/22 at 11:40 AM, who stated she referred to the nursing and physician progress notes to monitor for behaviors related to psychotropic medications and felt the staff were aware of Resident #54's behavior. She added that she would expect the staff to monitor the side effects of the antipsychotic medication and document as well. 3a) Resident #64 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder, insomnia, and anxiety disorder. A review of the physician's orders revealed an order dated 11/10/21 for Ativan (an antianxiety medication) 0.5 milligrams (mg) by mouth twice a day. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 had severe cognitive impairment and displayed no behaviors. She was coded as receiving 7 days of an antianxiety medication. A review of the Pharmacy Consultant medication review notes from 12/9/21 and 1/12/22 did not reflect the need for monitoring side effects of the psychotropic medication. Review of Resident #64's medical records including the nursing notes from 11/10/21 to 1/25/22 revealed no monitoring of side effects to the antianxiety medication. Resident #64's Medication Administration Record (MARs) from 11/10/21 to 1/25/22 indicated she received Ativan as ordered. The MAR did not list side effect monitoring that may be displayed from Resident #64 or the medication. On 1/25/22 at 11:57 AM, Resident #64 was observed sitting in the dining room waiting for the lunch meal. She was easy to engage and smiled during conversation. The Director of Nursing (DON) was interviewed on 1/26/22 at 10:40 AM and stated side effect monitoring for psychotropic medications would be documented in the nursing progress notes if observed. She further stated she would expect the Pharmacy Consultant to identify any irregularities regarding Resident #64, to include the need to monitor side effects that could occur due to the psychotropic medication. A phone interview occurred with the Pharmacy Consultant on 1/27/22 at 11:40 AM, who stated she referred to the nursing and physician progress notes to monitor for behaviors related to psychotropic medications and felt the staff were aware of Resident #64's behavior. She added that she would expect the staff to monitor the side effects of the psychotropic medication and document as well. 3b) Resident #64 was admitted to the facility on [DATE] with diagnoses that included dementia, osteoarthritis, and diabetes type 2. A review of Resident #64's medical record revealed an order dated 11/10/21 for Macrodantin (an antibiotic) 100 milligrams (mg) 1 tab by mouth every night. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 had severe cognitive impairment, was frequently incontinent of bladder and occasionally incontinent of bowel. No infections were coded but she did receive 7 days of an antibiotic. A review of the Pharmacy Consultant medication review notes from 12/9/21 and 1/12/22 did not reflect the need for an adequate clinical indication for the antibiotic. Review of the Medication Administration Records (MARs) from 11/10/21 until 1/24/22, showed Resident #64 received Macrodantin 100mg every night as ordered. On 1/26/22 at 1:50 PM, the Medical Director was interviewed and stated he would have expected the Pharmacy Consultant to identify any irregularities regarding Resident #64's medication to include the need for an adequate clinical indication for the use of Macrodantin. A phone interview occurred with the Pharmacy Consultant on 1/27/22 at 12:35 PM who stated she wouldn't have made any recommendations to the physician regarding the indefinite use of an antibiotic as the medication was effective and Resident #64 had displayed no side effects. The Pharmacy Consultant stated it was an oversight not to have made a recommendation regarding a clinical indication for its use. The Director of Nursing (DON) was interviewed on 1/270/22 at 1:34 PM and stated would have expected the Pharmacy Consultant to identify any irregularities regarding Resident #64, to include the need of a clinical indication for the use of an antibiotic. 4. Resident #86 was originally admitted [DATE] and readmitted on [DATE] with cumulative diagnoses of anxiety, depression, an eating disorder and mood effective disorder. Review of Resident #86's admission physician orders dated 12/9/21 included the following medication orders: Lexapro 10 milligrams (mg) daily (antidepressant and antianxiety medication) Remeron 15 mg at night (antidepressant) Trazadone 50 mg at night (antidepressant and sedative) Buspar 15 mg three times daily (antianxiety) Ativan 1 mg every 8 hours as needed for anxiety for 90 days Resident #86 admission Minimum Data Set (MDS) dated [DATE] indicated moderate cognitive impairments and no behaviors. She was coded as taking antianxiety and antidepressant medications for 7 of 7 days of the look back assessment. Resident #86's psychotropic Care Area Assessment(CAA) dated 12/16/21 read she was on a routine antianxiety and antidepressant medications. Staff were to observe for changes, keep the Physician updated, administer medications as ordered and document any behavioral symptoms. The goal read she would tolerate her psychotropic medications without side effects. Review of Resident #86's January 2022 Physician orders were unchanged from her admission orders dated 12/9/21 with the exception of her Ativan increase to 1 mg every 6 hours as needed on 1/6/22. Review of a pharmacy note dated 1/12/22 at 11:07 AM read that medication review was completed and recommendations were sent to the Physician. Review of the pharmacy recommendations dated 1/12/22 included the following: Resident #86's new order for Ativan dated 1/6/22 needed a stop date. An interview was conducted on 1/26/22 at 10:40 AM with the Director of Nursing (DON). She stated had only been the DON for a little over a month. The DON stated the electronic medical records did not include the Physician orders or the medication administration records (MARs). She stated all the medication orders and documentation of administration of medications were documented on paper. The DON stated the consultant Pharmacist had electronic access to the Physician notes, the psychiatric NP notes, nursing notes and care plan but she would have to review the Physician orders and MAR's in the hard chart. She stated only the Physician's standing orders were in the electronic medical record An telephone interview was conducted on 1/27/22 at 11:40 AM with the consultant Pharmacist. She stated she was coming onsite to the facility to do her monthly and new admission medication reviews She stated she completed a medication review for Resident #86 on 1/12/22. She stated she reviewed the electronic medical record which included the nursing notes, care plan and provider notes and interviewed staff as part of her review. She stated she was not aware that the Physician orders and MAR's were not part of the electronic medical record but rather in a hard chart. An interview was conducted on 1/27/22 at 1:34 PM with the Administrator and the Director of Nursing (DON). Both stated the consultant Pharmacist should have included a review of the Physician orders and MAR's in the hard cart in order to complete a medication review. 5. Resident #81 was admitted to the facility on [DATE] with multiple diagnoses including paranoid schizophrenia. The annual Minimum Data Set (MDS)) assessment dated [DATE] indicated that Resident # 81 had moderate cognitive impairment and had no behaviors. The assessment further indicated that the resident had received an antipsychotic drug for 7 days during the assessment period. Resident #81's care plan dated 12/1/21 was reviewed. The problem was the use of psychotropic drug. The goal was for the resident not to show side effects of the medications. The approaches included to evaluate the effectiveness and side effects of medications for possible reduction/elimination of psychotropic drugs and to monitor resident's mood/behaviors with documentation per facility policy. Resident #81 had a doctor's order dated 6/18/19 for Seroquel (an antipsychotic drug) 500 milligrams (mgs.) at bedtime for paranoid schizophrenia. Review of Resident #81's medical records including the nurse's notes from 5/2021 through 12/2021 revealed no monitoring of resident's behaviors and side effects of the antipsychotic drug. Review of the monthly drug regimen reviews (DRR) from 5/2021 through 12/2021, the Pharmacy Consultant did not identify the need for the behavior and side effects monitoring for Resident #81. The Director of Nursing (DON) was interviewed on 1/26/22 at 10:40 AM. The DON stated that nursing staff were not monitoring the resident's behaviors and side effects of the drug on a regular basis, they only document behaviors and side effects by exception. The Pharmacy Consultant was interviewed on 1/27/22 at 11:40 AM. The Pharmacy Consultant stated that she expected target behavior identified and monitored but felt the staff were aware of the resident's behaviors. She also expected the staff to monitor the side effects of the antipsychotic drug. She added that staff were monitoring resident's behaviors and documented the behaviors by exception.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews with staff, psychiatric nurse practitioner, and medical director, the facility failed to identify target behaviors, failed to complete ongoing monitoring of identified behaviors, and failed to monitor for side effects of a psychotropic medication (Residents #29, #86, #50, #54, #64, and #81). The deficient practice affected 6 of 8 residents reviewed for medications. Findings included: 1. Resident #50 was admitted to the facility 1/20/2021 with diagnoses that included major depressive disorder and anxiety disorder. The resident's annual Minimum Data Set (MDS) dated [DATE] indicated Resident #50 was moderately cognitively impaired, could understand other, be understood by others, and had no moods or behaviors during the assessment period. Resident #50 had a physician's order for citalopram 20 milligrams (mg) orally daily for depression. Resident #54's Medication Administration Record (MARs) from 11/1/2021 to 1/25/2022 indicated he received citalopram as ordered. The MAR did not list any side effect monitoring for Resident #50. A review of Resident #50's medical record to include nursing progress notes from 11/01/2021 until 1/25/22 revealed no monitoring of side effects to the psychotropic medication. On 1/24/2022 at 3:13 PM Resident #50 was observed lying in bed with his eyes closed making a repetitive rolling movement with his mouth. 1/26/2022 at 10:21 AM an interview was conducted with Nurse #2. She stated she had not noticed any behaviors related to depression with Resident #50. She stated there was not an area in the medical record that specified what behaviors to monitor or what side effects to look for. When asked about the rolling motion the resident made with his mouth, she stated she had noticed it but was not sure if it was a side effect of his medication or just a behavior he had. When asked if she had documented the observation, she stated she had mentioned it to the nurse practitioner a while back, but she had not documented the observation. The Director of Nursing (DON) was interviewed on 1/26/22 at 10:40 AM and stated behavior and side effect monitoring for antipsychotic medications was documented in the nursing progress notes when observed. She further stated she would expect the Pharmacy Consultant to identify any irregularities and to monitor side effects that could occur due to psychotropic medications. The Medical Director was interviewed on 1/26/22 at 1:40 PM, stated he would expect side effect monitoring for psychotropic medications. On 1/27/2022 at 10:44 AM The psychiatric Nurse Practitioner was interviewed. She stated she expected target behaviors and side effects to be monitored daily to determine if a gradual dose reduction (GDR) would be beneficial. 2. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses including depression, general anxiety, and insomnia. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #29 was severely cognitively impaired and displayed no moods or behaviors during the assessment period. The resident received antianxiety medications 1 out of 7 days and antidepressant medications 7 out of 7 days during the assessment period. Resident #29's comprehensive care plan, updated 11/4/2021, had a focus for use of psychotropic medications with the potential for side effects. Interventions included monitoring for effectiveness and side effects and observe resident's mental status on an ongoing basis. The resident's active orders included a physician's order for paroxetine 10 milligrams (mg) orally daily for depression, and duloxetine 60mg orally daily for depression. Resident #29's nursing progress notes from 6/1/2021 through 1/25/2022 revealed no monitoring of target behaviors or side effects of the psychotropic medications. On 1/26/2022 at 2:31 PM an interview was conducted with nurse assistant (NA) #3. She stated she worked with Resident #29 and had never known her to have behaviors. She described the resident as pleasant but liked things done her way. She did not know what behaviors to monitor or side effects to watch for and she did not know where to look for information on behaviors and side effects for Resident #29. Interview was conducted with Nurse #2 who was assigned to Resident #29 on 1/26/2022 at 2:35 PM. She stated the resident had behaviors in the past but had been doing well for a while. She stated she was not certain what the resident's target behaviors were or where to find target behaviors, but she believed they included yelling out. 2) Resident #54 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, major depressive disorder, anxiety disorder and mood disorder. A review of the physician's orders revealed an order dated 11/2/21 for Seroquel (an antipsychotic medication) 25 milligrams (mg) by mouth twice a day. The admission Minimum Data Set (MDS) assessment for 11/9/21 indicated Resident #54 had severe cognitive impairment and displayed physical and verbal behavioral symptoms towards others 1 to 3 days during the 7 day look back period. He was coded as receiving 6 days of an antipsychotic medication. A review of Resident #54's active care plan, dated 11/15/21, included the following focus areas: - Problematic manner in which resident acts characterized by ineffective coping; verbal/physical aggression or agitated, combativeness, history of aggressive behavior toward others, also flirty at times. The interventions included to document summary of each episode and to monitor and document behavior per facility protocol. - Use of psychotropic drugs with the potential for or characterized by side effects of cardiac, neuromuscular, gastrointestinal systems: due to diagnoses of dementia, anxiety, major depressive disorder. The interventions included to administer medications per physician's order, monitor vital signs per facility protocol, observe interaction of resident with others for appropriateness and observe resident's gait for steadiness, balance, muscle coordination, ability to position and turn. A review of Resident #54's medical record including nursing notes from 11/2/21 until 1/25/22 revealed no monitoring of side effects to the antipsychotic medication. The nursing progress notes indicated Resident #54 had displayed a few episodes of verbal and physical aggression towards staff and other residents and agitated behavior. Resident #54's Medication Administration Record (MARs) from 11/2/21 to 1/25/22 indicated he received Seroquel as ordered. The MAR did not list any side effect monitoring that may be displayed from the medication. On 1/25/22 at 11:50 AM, Resident #54 was observed ambulating in the hallway of the memory care unit without any behaviors noted. Nurse #3, who was assigned to Resident #54, was interviewed on 1/26/22 at 8:50 AM. She explained there was no specific area to document side effect monitoring but nursing staff would document a progress note if any were observed and report to the physician. The Director of Nursing (DON) was interviewed on 1/26/22 at 10:40 AM, who stated there was no side effect monitoring for psychotropic medications but rather the nurses would document a progress note if any were observed. The DON added, a DISCUS test (Dyskinesia Identification System Condensed User Scale- used to identify drug-induced movement disorders) was completed every 6 months for residents on psychotropic medications and would capture any side effects to the medications. The Medical Director was interviewed on 1/26/22 at 1:40 PM, stated he would expect side effects to be monitored for psychotropic medications as it would be helpful when reviewing for effectiveness of the medication. A phone interview was completed with the Psychiatric Nurse Practitioner (NP) on 1/27/22 at 10:44 AM. She stated it would be an expectation for side effects to be monitored for psychotropic medications. The NP added monitoring would be beneficial when assessing for effectiveness and the possibility of gradual dose reduction (GDR). 3) Resident #64 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder, insomnia, and anxiety disorder. A review of the physician's orders revealed an order dated 11/10/21 for Ativan (an antianxiety medication) 0.5 milligrams (mg) by mouth twice a day. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #64 had severe cognitive impairment and displayed no behaviors. She was coded as receiving 7 days of an antianxiety medication. A review of Resident #64's active care plan dated 11/16/21, included a focus area for use of psychotropic drugs with the potential for side effects of cardiac, neuromuscular gastrointestinal due to diagnosis of anxiety and depression and routine use of antidepressant and antianxiety medications. The interventions included to administer medications per physician's order, monitor resident's mood/behaviors with documentation per facility policy and notify physician of any significant changes and observe resident's mental status functioning on an ongoing basis. A review of Resident #64's medical record including nursing notes from 11/10/21 until 1/25/22 revealed no monitoring of side effects to the antianxiety medication. Resident #64's Medication Administration Record (MARs) from 11/10/21 to 1/25/22 indicated she received Ativan as ordered. The MAR did not list any side effect monitoring that may be displayed from Resident #64. On 1/25/22 at 11:57 AM, Resident #64 was observed sitting in the dining room waiting for the lunch meal. She was easy to engage and smiled during conversation. Nurse #3, who was assigned to Resident #64, was interviewed on 1/26/22 at 8:50 AM. She explained there was no specific area to document side effect monitoring but nursing staff would document a progress note if any were observed and report to the physician. The Director of Nursing (DON) was interviewed on 1/26/22 at 10:40 AM, who stated there was no side effect monitoring for psychotropic medications but rather the nurses would document a progress note if any were observed. The DON added, a DISCUS test (Dyskinesia Identification System Condensed User Scale- used to identify drug-induced movement disorders) was completed every 6 months for residents on psychotropic medications and would capture any side effects to the medications. The Medical Director was interviewed on 1/26/22 at 1:40 PM, stated he would expect side effect monitoring for psychotropic medications as it would be helpful when reviewing for effectiveness of the medication. A phone interview was completed with the Psychiatric Nurse Practitioner (NP) on 1/27/22 at 10:44 AM. She stated it would be an expectation for side effects to be monitored for the use of psychotropic medications. The NP added this would be beneficial when assessing for effectiveness and the possibility of gradual dose reduction (GDR). 5. Resident #86 was originally admitted [DATE] and readmitted on [DATE] with cumulative diagnoses of anxiety, depression, an eating disorder and mood effective disorder. Review of Resident #86's admission physician orders dated 12/9/21 included the following medication orders: Lexapro 10 milligrams (mg) daily (antidepressant and antianxiety medication) Remeron 15 mg at night (antidepressant) Trazadone 50 mg at night (antidepressant and sedative) Buspar 15 mg three times daily (antianxiety) Ativan 1 mg every 8 hours as needed for anxiety for 90 Resident #86 admission Minimum Data Set (MDS) dated [DATE] indicated moderate cognitive impairments and no behaviors. She was coded as taking antianxiety and antidepressant medications for 7 of 7 days of the look back assessment. Resident #86's psychotropic Care Area Assessment(CAA) dated 12/16/21 read she was on a routine antianxiety and antidepressant medications. Staff were to observe for changes, keep the Physician updated, administer medications as ordered and document any behavioral symptoms. The goal read she would tolerate her psychotropic medications without side effects. Review of Resident #86's nursing notes from 12/9/21 to 1/26/22 included the following: 12/17/21 at 2:55 PM, Resident #6 was observed playing with her feeding tube and connectors caused the feeding to spill on to the bed. 12/26/21 at 12:39 AM, Resident #6 refused her tube feeding. 12/29/21 at 2:50 AM, Resident #6 refused her tube feeding. Review of Resident #86's January 2022 Physician orders were unchanged from her admission orders dated 12/9/21 with the exception of her Ativan increase to 1 mg every 6 hours as needed on 1/6/22. Review of a Physician progress note dated 1/6/22 read Resident #86 was being seen due to staff reporting her picking on her skin, arms and forehead. Staff report Resident #86 was more anxious. The note revealed Resident #86 stated she was feeling more anxious but was unsure as to why. New orders were given to increase her Ativan to 1 mg every 6 hours as needed for anxiety for 30 days and a psychiatric referral to assess her current issues and behaviors. An interview was conducted on 1/25/22 at 3:40 PM with Nurse #6. He stated he was an agency nurse and it was his first day working at the facility in a while. He stated he had little knowledge of Resident #86's behaviors. He stated he had worked in other facilities as an agency nurse and behavior and side effect monitoring were a part of the electronic MARs. Nurse #6 stated he did not know where he should document behaviors and side effects. He stated the only behavior he had noted was her repeatedly asking for her Ativan An interview was conducted on 1/26/22 at 10:40 AM with the Director of Nursing (DON). She stated the only side effect monitoring she was aware of was the DISCUS completed every 6 months and the nurses documented any behaviors in the nursing notes. An interview was conducted on 1/26/22 at 1:40 PM with the Medical Director (MD). He stated he was unaware that the facility was not doing ongoing monitoring for behaviors and side effects. The MD stated most of the facility staff knew Resident #86 behaviors but with all the agency staff and new staff, they would be unfamiliar with Resident #86. He stated he was very familiar with Resident #86's behaviors and often reviewed the psychiatric provider notes and staff interviews. The MD stated he expected the facility to have identified the need for monitoring of behaviors and side effect monitoring for Resident #86 psychotropic medications. He stated if there was ongoing target behaviors monitoring, it would provide evidence of a possible gradual dose reduction of some of her psychotropic medications An telephone interview was conducted on 1/27/22 at 10:44 AM with the Psychiatric NP. She stated she last saw Resident #86 on 11/24/21 for a re-evaluation. She documented that Resident #86 continued to refuse tube feedings by turning off the feeding tube pump and refused meals. She did not exhibit any signs of aggression, agitation or depression at the time of this visit. She stated it would benefit Resident #86 for monitoring of behaviors to show evidence of a possible GDR of some of her psychotropic medications. An interview was conducted on 1/27/22 at 1:34 PM with the Administrator and the Director of Nursing (DON). Both stated the facility should have identified the need for ongoing monitoring of behaviors and the need to monitor for side effects. 6. Resident #81 was admitted to the facility on [DATE] with multiple diagnoses including paranoid schizophrenia. The annual Minimum Data Set (MDS)) assessment dated [DATE] indicated that Resident # 81 had moderate cognitive impairment and had no behaviors. The assessment further indicate that the resident had received an antipsychotic drug for 7 days during the assessment period. Resident #81's care plan dated 12/1/21 was reviewed. The problem was the use of psychotropic drug. The goal was for the resident not to show side effects of the medications. The approaches included to evaluate the effectiveness and side effects of medications for possible reduction/elimination of psychotropic drugs and to monitor resident's mood/behaviors with documentation per facility policy. Resident #81 had a doctor's order dated 6/18/19 for Seroquel (an antipsychotic drug) 500 milligrams (mgs.) at bedtime for paranoid schizophrenia. Review of Resident #81's medical records including the nurse's notes from 5/2021 through 12/2021 revealed no monitoring of resident's behaviors and side effects of the antipsychotic drug. Nurse # 4, assigned to Resident #81, was interviewed on 1/25/22 at 12:45 PM. The nurse stated that resident's behaviors and side effects of the antipsychotic drugs were documented in the nurse's notes if any. When asked for the target behavior to be monitored for Resident #81, she replied I am not sure. The Director of Nursing (DON) was interviewed on 1/26/22 at 10:40 AM. The DON stated that nursing staff were not monitoring the resident's behaviors and side effects of the drug on a regular basis, they only document behaviors and side effects by exception. Interview with the Psychiatric Nurse Practitioner (NP) was conducted on 1/27/22 at 10:44 AM. The NP stated that she expected target behaviors identified and monitored including the side effects of the psychotropic drugs. She commented that the monitoring was beneficial for possible gradual dose reduction (GDR) of the psychotropic drugs.

Based on observations, resident and staff interviews and record review, the facility failed to provide effective oversight to ensure the facility provided a dignified dining experience by the use of disposable plates and utensils for all residents who received meals from the kitchen. The findings included: During the initial kitchen tour on 1/24/22 at 12:10 PM, the kitchen staff were serving meals on disposable plates and using disposable utensils. The Dietary Manager (DM) stated the rationale for using disposable plates and utensils was because of COVID. Observations conducted on all 7 halls revealed all the residents except for the tube feeding residents were served meals on disposable plates and utensils for lunch and dinner on1/24/22, breakfast, lunch and dinner on 1/25/22, breakfast, lunch and dinner on 1/26/22, breakfast and lunch on 1/27/22. An interview was conducted on 1/27/22 at 1:34 PM with the Administrator. She stated she had only been at the facility a few months and she was not aware that the residents were eating off of disposable plates and using disposable utensils. The Administrator stated there was no reason for the residents to being eating from disposable items.

Based on record review and staff interview, the facility failed to provide nurse's aides (NAs) with annual dementia training for 3 of 5 sampled NAs reviewed for required in-service training (NAs #7, #8 & #9). Findings included: NA #7 was hired on 11/7/18. Review of her in-service records revealed that she was not provided the annual dementia training. NA #8 was hired on 7/26/04. Review of her in-service records revealed that she was not provided the annual dementia training. NA #9 was hired on 2/12/96. Review of her in-service records revealed that she was not provided the annual dementia training. On 1/26/22 at 1:31 PM, the Staff Development Coordinator (SDC) was interviewed. The SDC stated that she had reviewed the in-service records for NAs #7, #8 & #9 and she could not find documentation that they were provided dementia and behavioral health training last year. She added that they had attended the exit seeking behavior training. On 1/26/22 at 3:01 PM, NA #7 was interviewed. She stated that she had been assigned to work in the dementia unit (SPARKS). NA #7 indicated that she could not remember if she had attended the annual dementia training. On 1/27/22 at 10:41 AM, NA # 9 was interviewed. She stated that she had been working at the facility's dementia unit and could not remember if she had attended the annual dementia training.