**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete a discharge assessments when residents were discharged to home. This affected one (Resident #12) of three discharged residents reviewed. The facility census was 19 residents. Findings include: Review of the medical record for Resident #12 revealed an admission date of 01/17/24 with diagnoses including respiratory failure, dysphagia, depression, anemia, depression, B-cell lymphocytic leukemia, adult failure to thrive, protein-calorie malnutrition, polyosteoarthritis, and malignant neoplasm. Review of the Minimum Data Set (MDS) assessment for Resident #12 dated on 02/02/24 revealed the resident had no cognitive impairments. Review of the nurse progress note for Resident #12 dated 03/29/24 revealed the resident was discharged to home on [DATE]. Review of the medical record for Resident #12 revealed there was discharge assessment was completed for the resident following the discharge on [DATE]. Interview on 06/18/24 at 08:23 A.M. with the Director of Nursing (DON) confirmed the facility should have completed a discharge MDS assessment for Resident #12 following the resident's discharge from the facility on 03/29/24, but the facility had not done so.

2. Review of the medical record for Resident #01 revealed an admission date of 04/03/24 with diagnoses including adult failure to thrive, major depressive disorder, and COPD. Review of the admission MDS assessment for Resident #01 dated 04/10/24, revealed the resident was cognitively intact and received antipsychotic medications. Review of the care plan for Resident #01 dated 04/23/24 revealed the resident used psychotropic medications, but the care plan did not include target behaviors or interventions related to the use of the medications. Review of the physician's order for Resident #01 revealed an order dated 05/01/24 for Risperdal 0.5 mg once daily and order dated 05/02/24 for Risperdal 1.0 mg once daily. Interview on 06/20/24 at 9:49 A.M. with the DON confirmed Resident #01 received antipsychotic medication but the care plan did not include target behaviors or interventions related to the use of the medication. 3. Review of the medical record for Resident #11 revealed an admission date of 12/07/22 with diagnoses including major depressive disorder, COPD, and dementia with other behavioral disturbances. Review of the care plan for Resident #11 initiated 12/07/22 revealed it did not include a care plan addressing the use of antipsychotic medications to include target behaviors and interventions. Review of the physician's orders for Resident #11 revealed an order dated 02/25/24 for Risperdal 0.5 twice daily. Review of the quarterly MDS assessment for Resident #11 dated 04/03/24 revealed the resident was cognitively impaired and received antipsychotic medication. Interview on 06/20/24 at 9:49 A.M. with the DON confirmed Resident #11 received antipsychotic medication but the care plan did not include use of the medication, target behaviors or interventions. Based on record review and staff interview the facility failed to develop comprehensive resident care plans. This affected four (Residents #01 #08, #11, and #118) of eight residents reviewed for care plans. The facility census was 19 residents. Findings include: 1.Review of the medical record for Resident #118 revealed an admission date of 04/25/24 with diagnosis including chronic obstructive pulmonary disorder (COPD), atherosclerotic heart disease, anxiety, vascular dementia with anxiety, diabetes mellitus type two, major depressive disorder, and panic disorder. Review of the admission Minimum Data Set (MDS) for Resident #118 for dated 05/02/24 the resident was cognitively impaired with verbal behaviors. Resident #118 was dependent on the staff with toileting hygiene, and showers or bathing, and required substantial to maximum assistance with bed mobility, transfers and mobility in her wheelchair. Resident #118 received antipsychotic and antidepressant medications. Review of the physician's orders for Resident #118 dated June 2024 revealed the resident had orders for Seroquel, an antipsychotic medication and Trazodone, an antidepressant medication. Review of the facility fall investigation for Resident #118 dated 05/10/24 revealed the resident had a fall without injuries while ambulating. Review of the physician's orders for Resident #118 dated June 2024 revealed the resident had orders for Seroquel, an antipsychotic medication and Trazodone, an antidepressant medication. Review of the nurse progress note for Resident #118 dated 06/17/24 timed at 5:11 A.M. revealed the resident began to yell out during morning care, was using profanity and was striking the staff and hitting, kicking and pulling the staff's hair. Staff were unable to redirect the resident. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident was at risk for falls, but the care plan did not include goals or interventions. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident had behaviors. but the care plan did not include target behaviors or interventions. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident had the potential to be verbally aggressive, but the care plan did not include goals or interventions. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident had impaired function/dementia and impaired thought processes, but the care plan did not include goals or interventions. Review of the care plan for Resident #118 dated 05/16/24 revealed the resident used psychotropic medications and antidepressant medications, but the plan of care had no goals or interventions. Interview on 06/20/24 at 9:11 A.M. with State Tested Nursing Assistant (STNA) #250 confirmed target behaviors, interventions for target behaviors, and fall precautions should be listed on the resident's plan of care. Interview on 06/20/24 at 9:17 A.M. with Registered Nurse (RN) #80 confirmed target behaviors with redirection interventions and fall precautions and interventions should be found on the plan of care. Interview on 06/18/24 at 2:58 P.M. with the Director of Nursing (DON) confirmed the care plans for Resident #118 were not complete in the areas of falls, dementia care, and psychotropic medications to include goals, interventions, and target behaviors. 4. Review of the medical record for Resident #08 revealed an admission date of 12/08/17 with diagnoses including COPD, osteoporosis, COVID-19, adult failure to thrive, dysphagia, encephalopathy, colitis, chronic kidney disease, depression, congestive heart failure, hypertension, and Alzheimer's disease. Review of the care plan for Resident #08 initiated 12/08/17 revealed there was no care plan for hospice services. Review of the MDS assessment for Resident #08 dated 02/09/24 revealed the resident had severe cognitive impairment. Review of physician's orders for Resident #08 revealed an order dated 03/26/24 for the resident to admit to hospice services. There was no terminal diagnosis included in the order. Interview on 06/18/24 at 11:17 A.M. with the DON confirmed Resident #08 received hospice services, but there was no care plan in place for the resident regarding hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and facility policy and procedure review the facility failed to ensure blood pressures and/or pulse were obtained for two residents (#2 and #15) prior to receiving antihypertensive medications as physician ordered. This affected one of four residents observed for medication administration and one of five residents reviewed for unnecessary medications. Findings include: 1. Review of Resident #15's medical record revealed an admission date of 06/07/19 with the admitting diagnoses of hypertension, non-rheumatic mitral valve insufficiency and anxiety. Review of the plan of care dated 06/23/19 revealed he was at risk for complications related to the diagnoses of hypertension and the use of antihypertensive medications. Interventions included to administer antihypertensive medications as ordered and obtain blood pressure (BP) readings before administration of the antihypertensive medications and daily. Review of the resident's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of 10. Review of the resident's monthly physician's orders for December 2019 revealed an order dated 06/07/19 for Lopressor (a medication used to lower BP) 25 milligrams by mouth twice a day with the special instructions to hold the medication if his pulse was less than 60 and/or systolic BP was less than 110 and/or diastolic BP was less than 60. Review of the November and December 2019 Medication Administration Record (MAR) revealed no documented pulse or BP prior to administering the medication Lopressor. On 12/28/19 at 9:06 A.M. observation of Licensed Practical Nurse (LPN) #150 administer Resident #15's morning medication revealed the LPN did not obtain a blood pressure or pulse for the resident prior to administering the medication Lopressor. On 12/28/19 at 10:48 A.M. interview with LPN #150 verified the resident's BP and pulse was not obtained prior to administering the residents medication Lopressor. 2. Review of Resident #2's medical record revealed an admission date of 10/26/16 with the admitting diagnoses of hypertension, Parkinson's disease and anxiety. Review of the resident's plan of care dated 02/24/17 revealed she had the potential for hyper/hypotension related to diagnoses of hypertension and receiving antihypertensive medications daily. Interventions included to administer antihypertensive medications as ordered. Review of the resident's quarterly MDS dated [DATE] revealed the resident had unclear speech, usually understands others, usually makes herself understood and no cognitive deficit as indicated by a BIMS score of 13. Review of the resident's monthly physician's orders for December 2019 revealed an order dated 06/07/19 for Propranolol 10 mg by mouth twice a day with the special instructions to hold the medication if his pulse was less than 60 and/or systolic BP was less than 110 and/or diastolic BP was less than 60. Review of the November and December 2019 MAR revealed no documented pulse or BP prior to administering the antihypertensive medication Lopressor. On 12/28/19 10:48 AM interview with LPN #150 verified the resident's BP and pulse were not obtained prior to administering the medication Propranolol. Review of the facility's policy titled, Medication Administration, dated 01/15/19 revealed medications are administered by licensed nurses who are legally authorized to, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Vital signs shall be obtained and recorded as per physician's order.

Based on observation, medical record review and staff interview, the facility failed to maintain acceptable standards of infection of control for one (Resident #73) during pressure ulcer dressing changes. This affected one of two residents reviewed for pressure ulcers. Findings include: Review of Resident #73's medical record revealed an admission date of 12/23/19 with the admitting diagnoses of hypertension, peripheral vascular disease and diabetes mellitus. Review of the admission skin observation tool dated 10/23/19 revealed the resident was admitted to the facility with a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) pressure ulcer to the right heel measuring 1.4 centimeters (cm) by 0.6 cm by 0.2 cm and a Stage I (An observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) pressure ulcer to her left heel measuring 1.5 cm by 2.0 cm. Review of the resident's nursing admission screening/history dated 12/23/19 revealed the resident was admitted from the local acute care hospital with the diagnoses of urinary tract infection (UTI) for long term care placement. She was alert and oriented to her name only. She was noted to have both long and short term memory problems, confusion and displayed both hallucinations and delusions. The assessment indicated the resident was dependent on staff for activities of daily living. Review of the baseline plan of care dated 12/23/19 revealed the resident had skin impairment upon admission to the facility. Interventions included specialized pressure reduction boots, float heels off the mattress while in bed and low air loss mattress to her bed. Review of the resident's admission physician's orders dated 12/23/19 indicated orders for a low air loss mattress to her bed, encourage her to wear her heel protectors boots as much as she can tolerate, float heels off the mattress while in bed as she can tolerate and cleanse the area to her right heel with normal saline, pat dry, apply maxasorb alginate to wound bed only then cover with a foam dressing twice a day and as needed. On 12/27/19 at 2:39 P.M. observation of Registered Nurse (RN) #160 provide the physician ordered treatment to the resident's right heel pressure ulcer revealed she entered the resident's room and positioned the resident. She removed the specialized pressure reduction boot pulled her sock off. She washed her hands and donned a clean pair of gloves. She then removed the soiled dressing and placed it in the trash can. She cleansed the wound with normal saline and a 4X4 gauze pad, and patted it dry. She then cut a piece of calcium alginate and placed on the wound. She then covered with the wound with a foam dressing. She then removed her gloves and dated the dressing. She replaced the sock and reapplied the specialized pressure reduction boot. RN #160 verified she did not wash her hands or change her gloves after removing the soiled dressing.