**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure a treatment was implemented when Resident #8 obtained a skin tear and the treatment was discontinued when the skin tear was resolved. This affected one resident (#8) of two residents reviewed for skin conditions. The facility census was 19. Findings include: Review of the medical record for Resident #8 revealed an admission date of 10/16/23. Diagnoses included but were not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, personal history of transient ischemic attack, anxiety disorder, muscle weakness and depression. Review of the progress notes dated 04/26/25 at 1:06 P.M. revealed resident obtained a two (2) centimeter(cm) by (x) 2 cm skin tear to the back of the right hand. Review of the physician orders for Resident #8 from 04/26/25 through 04/29/25 at 11:08 A.M. revealed no treatment was ordered for the skin tear to the back of the resident's right hand. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 04 which indicated severe cognitive impairment. The resident was assessed to require substantial/maximum assistance with toilet hygiene, shower/bathe self, bed mobility and transfers. Review of the weekly skin observation tool dated 04/29/25 for Resident #8 revealed a skin tear to the back of the right hand that measured 2.0 cm x 2.0 cm x 0.1 cm. Review of the plan of care revised 04/29/25 revealed the resident had a skin tear to the right hand with an intervention including but not limited to treat per facility protocol. Review of the physician order dated 04/29/25 at 11:08 A.M. for Resident #8 revealed a treatment for the right-hand skin tear, to cleanse skin tear with soap and water, pay dry and apply a clean, dry dressing every evening shift. Review of the weekly skin observation tool dated 05/06/25 for Resident #8 revealed the skin tear to the back of the right hand to be measured at 1.0 cm x 1.0 cm x 0.1 cm. Further review of the weekly skin observation tools dated 05/13/25, 05/20/25 and 05/27/25 for this resident revealed no skin tear to the back of the right hand was observed and no wound measurements were noted. Review of the Treatment Administration Record (TAR) for 05/13/25 through 05/27/25 revealed Resident #8 received ordered treatments for the right back of the hand skin tear even after the weekly skin assessments were completed with no skin tear present. Observation on 05/28/25 at 2:34 P.M. of Resident #8's back of the right hand revealed no skin tear and no dressing. Interview on 05/28/25 at 3:05 P.M. with the Director of Nursing and the Assistant Director of Nursing verified there was no order for the skin tear to the back of the hand from 04/26/25 until 04/29/25 at 11:08 A.M. for Resident #8. Also verified this resident still had an active order for the treatment of the back of the right-hand skin tear as of 05/28/25 with documentation of the nursing staff providing the ordered treatment on the TAR for the dates of 05/06/25 through 05/28/25. The area was healed after the 05/06/25 weekly skin observation tool, but the ADON was not sure when as it was not documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, the facility failed to ensure comprehensive pressure wound assessments were completed weekly. This affected one resident (#17) of two residents reviewed for pressure ulcers. The census was 19. Findings include: Review of the medical record for Resident # 17 revealed an admission date of 03/15/25. Diagnoses included but were not limited to pressure ulcer to the sacral region stage II (partial-thickness skin loss, presenting as an open sore or blister with a red or pink wound bed), depression, anxiety disorder, moderate protein-calorie malnutrition, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and acute chronic systolic heart failure. Review of the plan of care dated 03/15/25 for Resident #17 revealed her to have a stage II pressure ulcer area to the coccyx on admission and interventions including but not limited to assess/monitor the wound for healing. Assess and document the status of the wound perimeter, wound bed and healing process. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 which indicated the resident was cognitively intact. The resident was assessed to require supervision or touching assistance for showers/bathing self, partial/moderate assistance for toilet hygiene, roll left to right in bed transfers, substantial/maximum assistance with sit to lying and lying to sitting. This resident was also assessed to be at risk for developing pressure ulcers and to have a pressure ulcer on admission of a stage II. Review of the weekly skin observation tools dated 03/18/25, 03/25/25, 04/01/25 and 04/08/25 revealed no wound staging to the pressure ulcer on the resident's coccyx. Further review of the weekly skin observation tools for the pressure ulcer to the resident's coccyx, dated 03/25/25, 04/01/25, 04/22/25, 04/29/25, 05/06/25 and 05/20/25 revealed no assessment of the wound bed, wound edges or surrounding tissue was documented. Interview on 05/28/25 at 3:20 P.M. with the Assistant Director of Nursing verified no staging was documented for Resident #17's coccyx pressure ulcer on the weekly skin observation tools for the dates of 03/18/25, 03/25/25, 04/01/25, and 04/08/25. Interview on 05/29/25 at 9:27 A.M. with the Certified Nurse Practitioner #102 revealed it was the responsibility of the facility nurses to measure and document on the descriptions of pressure ulcers weekly as she does not always assess pressure ulcers at each visit and goes reviews their measurements for treatments. Interview on 05/29/25 at 9:40 A.M. with Regional Nurse (RN) #102 verified for the weekly skin observation tools dated for 03/25/25, 04/01/25, 04/22/25, 04/29/25, 05/06/25 and 05/20/25 did not include an assessment of the wound bed, wound edges or surrounding tissue. The RN verified this is part of the assessment and should have been included for Resident #17's coccyx pressure ulcer. Review of the facility policy titled Skin Care Management Procedure revised 12/09/22, revealed at least weekly at a minimum, documentation should include staging, wound bed which includes color and type of tissue/character including evidence of healing or necrosis and percent of tissue, and description of wound edges and surrounding tissue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a comprehensive care plan for pain for Resident #11, who received pain medication. This affected one resident (#11) of six residents reviewed for unnecessary medication use. Findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, anxiety disorder, dysphagia, cognitive communication deficit, pain in leg, major depressive disorder, type two diabetes mellitus and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/04/21 revealed Resident #11 had impaired cognition. The resident received opioid medications seven days during the look back period. Review of the physician's orders for October 2021 revealed an order for Tramadol 50 milligrams (mg) every day for pain and Tramadol 50 mg as needed for pain. Review of the Medication Administration Record (MAR) for October 2021 revealed Resident #11 received Tramadol 50 mg daily as ordered, she did not use the as needed Tramadol in October. Review of the resident's plan of care revealed no plan of care for pain had been developed for the resident. On 10/14/21 at 3:21 P.M. interview with Registered Nurse #204 confirmed the plan of care did not address the resident's pain or pain medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to follow up on pharmacy recommendations in a timely manner for Resident #11 and Resident #12. This affected two residents (#11 and #12) of five reviewed for unnecessary medication use. Findings include: 1. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including vascular dementia without behavioral disturbance, anxiety disorder, dysphagia, cognitive communication deficit, major depressive disorder, type two diabetes mellitus and depression. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/04/21 revealed the resident had impaired cognition. Review of the pharmacist recommendation, dated 08/03/21 revealed the pharmacist suggested adding a six month stop date to the as needed every eight hours Ativan 0.25 milligram (mg) medication. The physician responded on 09/01/21 and indicated he disagreed with the recommendation. On 10/14/21 at 9:13 A.M. interview with the Director of Nursing (DON) confirmed there was a delay in the physician following up with the pharmacist's recommendation. She was unsure of the cause in the delay and revealed pharmacy recommendations were put in a book for the physician to review weekly. 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, alcohol dependence with unspecified alcohol-induced disorder, dysphagia, personal history of malignant neoplasm of prostate and major depressive disorder. Review of the quarterly MDS 3.0 assessment, dated 08/16/21 revealed the resident had impaired cognition. Review of the pharmacy recommendation dated 09/01/21 revealed the pharmacist recommended trying a reduction of Depakote from 250 mg twice a day to 125 mg twice a day. The physician followed up on 09/29/21 and indicated he disagreed with the recommendation. On 10/14/21 at 3:21 P.M. interview with RN #204 confirmed the physician took 28 days to respond to the pharmacist's recommendation for Resident #12. RN #204 was unsure what caused the delay and reported the physician usually followed up on recommendations weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure non pharmacological interventions were attempted prior to administering pain medication. This affected one resident (#10) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including bladder cancer, anemia, atrial fibrillation, chronic kidney disease, asthma, protein calorie malnutrition, insomnia and chronic respiratory failure. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment revealed the resident's cognition was intact, he required limited assistance from one staff member for bed mobility, transfers, dressing and personal hygiene and required extensive assistance from one staff member for toilet use. Review of the physician's orders for 10/2021 revealed the resident had an order for the pain medication, Tramadol 50 milligrams (mg) every four hours as needed for pain. Review of the MAR for 08/2021 revealed the resident received Tramadol 50 mg every four hours as needed for pain on 08/25/21 and 08/30/21 with no attempts of non pharmacological interventions prior to the medication administration. Review of the MAR for 09/2021 revealed the resident received Tramadol 50 mg on 09/01/21, 09/02/21, 09/03/21, 09/06/21, 09/07/21, 09/08/21, 09/10/21, 09/13/21, 09/14/21, 09/16/21, 09/17/21, 09/21/21, 09/22/21, 09/23/21, 09/24/21, 09/25/21, 09/26/21, 09/27/21, 09/28/21, 09/29/21 and 09/30/21 with no attempts of non pharmacological interventions prior to the medication administration. Review of the MAR for 10/2021 revealed the resident received Tramadol 50 mg on 10/05/21, 10/07/21, and 10/10/21 with no attempts of non pharmacological interventions prior to the medication administration. On 10/14/21 at 11:50 A.M. interview with Minimum Data Set (MDS) Coordinator #204 confirmed there was no evidence of non-pharmacological interventions on the dates noted above prior to administering the medication. MDS Coordinator #204 revealed she was aware of concerns with nursing documentation and indicated they had been reminding and educating the nurses to document thoroughly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, alcohol dependence with unspecified alcohol-induced disorder, dysphagia, personal history of malignant neoplasm of prostate and major depressive disorder. Review of the quarterly MDS 3.0 assessment, dated 08/16/21 revealed the resident had impaired cognition. The only behavior documented during the look back period was rejection of care which occurred four to six days. Review of the plan of care dated 08/24/21 revealed Resident #12 was receiving an antipsychotic drug for dementia with behavioral symptoms with the potential for adverse side effects. Interventions included administering medications as ordered by physician and monitoring for side effects, monitor and document resident's behavior for desired effects, obtain psychiatric and social service consultation for assessment, and anticipating needs. Review of the current physician's orders revealed Resident #12 had an order for Depakote 250 milligram (mg) tablet to be administered twice a day for diagnoses of dementia with behavioral disturbance. The order was initiated on 05/04/21. Review of the Medication Administration Record (MAR) for 05/04/21 through 10/13/21 revealed the resident received the medication as ordered except when one dose was refused on 06/30/21, 07/31/21, 08/17/21, 09/13/21, 09/29/21, 10/01/21 and 10/04/21. Review of the Depakote delayed-release tablets prescribing information (dated June 2021) revealed the indications for use were treatment of manic episodes associated with bipolar disorder, some seizure types and prophylaxis of migraine headaches. On 10/14/21 at 11:55 A.M. interview with Registered Nurse (RN) #204 confirmed Resident #12 was on Depakote related to dementia with behavioral disturbance. She additionally confirmed the prescribing information for Depakote extended release did not include dementia as an indicated use. Based on record review and staff interview the facility failed to ensure non-pharmacological interventions were attempted prior to administering psychotropic medications and/or failed to ensure appropriate diagnosis for use of psychotropic medication. This affected three residents (#7, #10 and #12) of five residents reviewed for unnecessary medication use. Findings include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including right sided hemiplegia, ataxia, dysphagia, dementia, acute kidney failure, moderate protein calorie malnutrition and aphasia. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 09/15/21 revealed the resident was cognitively impaired, required extensive assistance from staff for bed mobility, transfers and toilet use and required extensive assistance from one person for dressing and personal hygiene. Review of the medication administration record (MAR) for 09/21 revealed the resident received Trazadone (antidepressant/sedative) 50 milligrams (mg) on 09/01/21, 09/02/21, 09/03/21, 09/06/21, 09/07/21, 09/08/21, 09/10/21, 09/13/21, 09/14/21, 09/15/21, 09/16/21, 09/17/21, 09/18/21, 09/19/21, 09/20/21, and 09/21/21 with no non-pharmacological interventions attempted prior to the medication administration. Review of the MAR for 09/2021 revealed the resident received Haloperidol (antipsychotic) 0.5 mg on 09/04/21 with no non-pharmacological interventions attempted prior to the medication administration. Review of the MAR for 10/21/21 revealed the resident received Seroquel (antipsychotic) 25 mg on 10/01/21 with no documented reasoning or non pharmacological interventions attempted prior to the medication administration. On 10/14/21 at 11:50 A.M. interview with Minimum Data Set (MDS) Coordinator #204 confirmed there was no evidence of non-pharmacological interventions on the above dates prior to administering the medications. She stated she was aware of concerns with nursing documentation and revealed they had been reminding and educating the nurses to document thoroughly. 2. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including bladder cancer, anemia, atrial fibrillation, chronic kidney disease, asthma, protein calorie malnutrition, insomnia and chronic respiratory failure. Review of the most recent MDS 3.0 assessment revealed the resident's cognition was intact, he required limited assistance from one staff member for bed mobility, transfers, dressing and personal hygiene and required extensive assistance from one staff member for toilet use. Review of the MAR for 08/2021 revealed the resident received Trazadone 50 milligrams (mg) on an as needed basis on 08/04/21, 08/05/21, 08/09/21, 08/10/21, 08/11/21, 08/12/21, 08/15/21, 08/16/21, 08/17/21, 08/19/21, 08/20/21, 08/23/21, 08/24/21, 08/25/21, 08/26/21, 08/27/21, 08/30/21, and 08/31/21 with no attempts of non pharmacological interventions attempted prior to the medication administration. On 10/14/21 at 11:50 A.M. interview with Minimum Data Set (MDS) Coordinator #204 confirmed there was no evidence of non-pharmacological interventions on the dates noted above prior to administering the medication. She stated she was aware of concerns with nursing documentation and revealed they had been reminding and educating the nurses to document thoroughly.