**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview and review of the facility's policy, the facility failed to ensure residents oxygen tubing was changed according to the physicians orders and the facility policy. This affected one (#15) of one resident reviewed for oxygen use. The facility census was 24. Findings include: Review of the medical record for Resident #15 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, epilepsy, muscle weakness, hyperlipidemia, spondylosis without myelopathy, hypertension, personality disorder, fibromyalgia, and major depressive disorder. Review of the physician orders dated 06/28/21 revealed Resident #15 was to have oxygen tubing change weekly on concentrator. Review of Resident #15's medication administration record (MAR) revealed the residents oxygen tubing was to be changed weekly on Saturdays. The MAR documented Resident #15's oxygen was marked as changed on 11/05/22. Observation on 11/07/22 at 11:36 A.M., revealed Resident #15's oxygen tube was dated as being changed on 10/29/22. Observation on 11/09/22 at 10:15 A.M., revealed Resident #15's oxygen tube was dated as being changed on 10/29/22. Interview on 11/09/22 at 12:48 P.M., revealed Licensed Practical Nurse (LPN) #20 verified Resident #15's oxygen tubing was dated as being changed on 10/29/22. Interview on 11/09/22 at 1:00 P.M., with the Director of Nursing (DON) verified Resident #15's oxygen tubing is supposed to be changed according to physician orders which is weekly. The DON verified Resident #15's MAR indicated the oxygen tubing was changed on 11/05/22; however, the oxygen tubing was dated 10/29/22. Review of the facility's policy titled Oxygen Therapy, no date, revealed oxygen tubing must be dated/initialed and changed weekly per the oxygen company.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident was free from the unnecessary medications regarding the use of an antibiotic medication without an adequate indication for use. This affected one (#17) of six residents reviewed for unnecessary medications. The census was 24. Findings include: Review of Resident #17's medical record revealed an admission dated of 01/06/22. Diagnoses listed included epilepsy, dysphagia, aphasia, blindness, and multiple sclerosis. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired, required extensive staff assistance with activities of daily living (ADL's), and did not have a urinary tract infection (UTI) in the last 30 days. Review of MDS assessments dated 01/13/22, 04/11/22, 07/12/22, and 09/30/22 revealed Resident #17 had not had a UTI within the last 30 days of those assessments. Review of physician orders revealed an order dated 09/14/22 for Bactrim DS (antibiotic) 800-160 milligrams (mg), give one tablet by mouth (PO) one time a day every Monday, Wednesday, and Friday for monitoring. Further review of physician orders revealed an order dated 03/08/22 for Macrodantin Capsule (antibiotic) 50 mg via gastronomy tube (G-tube) one time a day for prophylactically. The order was discontinued on 09/14/22. Review of medication administration revealed Resident #17 received Macrodantin 50 mg daily starting on 03/09/22. Resident #17 continued to receive Macrodantin 50 mg daily through 09/14/22. Bactrim DS 800-160 mg was started on 09/16/22 and continued to be given through 11/07/22. Review of progress notes dated 03/08/22 revealed a new order was received for Macrodantin 50 mg daily indefinitely prophylactically for a history of an UTI. Review of a facsimile dated 09/12/22 revealed Macrodantin was suggested to be changed to Bactrim by Resident #17's neurologist. Review of physician progress notes dated 03/01/22, 04/05/22, 05/03/22, 06/07/22, 07/05/22, 08/02/22, and 09/06/22 revealed no documentation for the justification of continued use of an antibiotic for an UTI. Further review of Resident #17's medical record revealed no documentation of any UTI's or symptoms of UTI from admission [DATE] through 11/07/22. Interview with the Director of Nursing (DON) 11/09/22 08:35 A.M. confirmed there was no documented justification for the continued use antibiotic for Resident #17. The DON confirmed that Resident #17 has not had any signs of an UTI since admission to the facility. The DON confirmed the the continued use of Resident #17's antibiotic had not been addressed with Resident #17's primary care physician through the facility's antibiotic stewardship program. Review of the facility's undated policy titled Antibiotic Stewardship Program revealed residents without proof of review of infection symptoms prior to the initiation of an antibiotic will be reviewed for antibiotic holiday, culture and sensitivity results will be obtained/reviewed for sensitivity. The results of the testing ant eh recommendation for treatment will be discussed with the primary care physician (PCP) to ensure antibiotics are utilized in a responsible effective manner. Prescribers will be required to document dose, duration, and indication for all antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and policy review, the facility failed to protect a resident from verbal abuse and intimidation by a staff member. This affected one resident (Resident #17) of one resident reviewed for mood/behavior. The facility identified six residents (Resident #14, # 2, #17, #19, # 20, #7) with behavioral healthcare needs. The facility census was 24. Findings include: Medical record review of Resident #17 revealed an admission date of [DATE] with diagnoses including restlessness and agitation, major depressive disorder, dementia with behavioral disturbance. Review of the [DATE] admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of five. The score indicated the resident had a severe cognitive deficit. The resident was admitted to skilled nursing from the assisted living due to increased confusion and behaviors. Continued review of the medical record for Resident #17 revealed a current care plan was in place for behavior issues (agitation/motor restlessness), pacing, yelling out and repetitive questions, impaired cognition, impaired thoughts, as well as, psychosocial well-being problems related to inability to concentrate and recent admission. Interventions outlined to assist the resident included: Provide emotional support and reassurance as needed to help decease/resolve anxiety, talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior, allow (resident) time to answer questions and to verbalize feelings, perceptions and fears as needed, when conflict arises, remove (resident) to a calm , safe environment and allow to vent/share feelings. If strategies are not working, leave and reapproach later if safe to do so (list of interventions not all-inclusive). Further medical record review revealed a progress note entry of concern for Resident #17. On [DATE] at 7:04 P.M., Licensed Practical Nurse (LPN) #200 documented, Resident disruptive whole shift, causing commotion in dining room, creating poor atmosphere for others trying to eat. Continued after supper. Resident was told by nurse very sternly that she had to sit down at the nurses station and stop her yelling for help. Attempted interjection, but was motioned by nurse to be quiet every time. Was able to sit at front desk for about half hour, but nurse had to pass meds from cart at front desk. Resident still occasionally trying to interrupt and making it difficult to concentrate on med pass. Another progress note entered by LPN #200 on [DATE] at 7:17 P.M. stated, Resident becoming more and more loud in her calling out Help another resident across hall from her attempted to tell her to stop yelling. Resident won't get up or do anything for herself even though she has no problems doing so. Hour of sleep (HS) care given early and medications given to aid in quieting her down. Observation of Resident #17 was conducted on [DATE] at 3:52 P.M. The elderly resident was observed to be anxious and confused. Unsure where she was, spoke of wanting to go home, said her parents would be worried about her. Resident #17 stated, I'm worrying myself sick. A nursing assistant was seated beside the resident attempting to provide 1:1 distraction and comfort. Random observations were conducted throughout the survey dates of [DATE] - [DATE]. The resident was noted to have a behavior of calling out, help me, periodically. When staff responded the resident often did not remember yelling, or have a need for assistance. Staff interview with the Director of Nursing (DON) on [DATE] at 11:37 A.M. revealed they were not aware of the incidents documented by LPN #200 in Resident #17's chart. Upon reading and reviewing entries in the progress notes dated [DATE] at 7:04 P.M., the DON stated, This is not acceptable. During continued interview, the DON agreed LPN #200 mistreated Resident #17 and the incident on [DATE] would be viewed as abusive. The DON reported she had not been aware of the incident or the nurses behavior. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Resident Property, dated [DATE] revealed the Policy statement the facility corporation will not tolerate abuse. The definition of abuse in the policy included the actions of unreasonable confinement intimidation and verbal abuse. Additionally, the policy stated, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm pain or mental anguish.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview and policy review, the facility failed to follow its policy and protect a resident from verbal abuse and intimidation by a staff member. This affected one resident (Resident #17) of one residents reviewed for mood/behavior. The facility identified six residents (Resident #14, # 2, #17, #19, # 20, #7) with behavioral healthcare needs. The facility census was 24. Findings include: Medical record review of Resident #17 revealed an admission date of [DATE] with diagnoses including restlessness and agitation, major depressive disorder, dementia with behavioral disturbance. Review of the [DATE] admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of five. The score indicated the resident had a severe cognitive deficit. The resident was admitted to skilled nursing from the assisted living due to increased confusion and behaviors. Continued review of the medical record for Resident #17 revealed a current care plan was in place for behavior issues (agitation/motor restlessness), pacing, yelling out and repetitive questions, impaired cognition, impaired thoughts, as well as, psychosocial well-being problems related to inability to concentrate and recent admission. Interventions outlined to assist the resident included: Provide emotional support and reassurance as needed to help decease/resolve anxiety, talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior, allow (resident) time to answer questions and to verbalize feelings, perceptions and fears as needed, when conflict arises, remove (resident) to a calm , safe environment and allow to vent/share feelings. If strategies are not working, leave and reapproach later if safe to do so (list of interventions not all-inclusive). Further medical record review revealed a progress note entry of concern for Resident #17. On [DATE] at 7:04 P.M., Licensed Practical Nurse (LPN) #200 documented, Resident disruptive whole shift, causing commotion in dining room, creating poor atmosphere for others trying to eat. Continued after supper. Resident was told by nurse very sternly that she had to sit down at the nurses station and stop her yelling for help. Attempted interjection, but was motioned by nurse to be quiet every time. Was able to sit at front desk for about half hour, but nurse had to pass meds from cart at front desk. Resident still occasionally trying to interrupt and making it difficult to concentrate on med pass. Another progress note entered by LPN #200 on [DATE] at 7:17 P.M. stated, Resident becoming more and more loud in her calling out Help another resident across hall from her attempted to tell her to stop yelling. Resident won't get up or do anything for herself even though she has no problems doing so. Hour of sleep (HS) care given early and medications given to aid in quieting her down. Observation of Resident #17 was conducted on [DATE] at 3:52 P.M. The elderly resident was observed to be anxious and confused. Unsure where she was, spoke of wanting to go home, said her parents would be worried about her. Resident #17 stated, I'm worrying myself sick. A nursing assistant was seated beside the resident attempting to provide 1:1 distraction and comfort. Random observations were conducted throughout the survey dates of [DATE] - [DATE]. The resident was noted to have a behavior of calling out, help me, periodically. When staff responded the resident often did not remember yelling, or have a need for assistance. Staff interview with the Director of Nursing (DON) on [DATE] at 11:37 A.M. revealed they were not aware of the incidents documented by LPN #200 in Resident #17's chart. Upon reading and reviewing entries in the progress notes dated [DATE] at 7:04 P.M., the DON stated, This is not acceptable. During continued interview, the DON agreed LPN #200 mistreated Resident #17 and the incident on [DATE] would be viewed as abusive. The DON reported she had not been aware of the incident or the nurses behavior. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Resident Property, dated [DATE] revealed the Policy statement the facility corporation will not tolerate abuse. The definition of abuse in the policy included the actions of unreasonable confinement intimidation and verbal abuse. Additionally, the policy stated, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm pain or mental anguish.

Based on observation, staff interview and manufacturers recommendations, the facility failed to ensure all medications and biologicals were disposed of properly. This had the potential to affect 11 residents (#3, #8, #11, #16, #17, #19, #20, #21, #22, #23 and #25) who were admitted after the vial of tuberculin purified protein derivative should have been discarded. The facility census was 24. Findings include: Observation on 08/15/18 at 7:55 A.M. in the medication storae room revealed an opened vial of tuberculin purified protein derivative with an opened date of 02/19/18. Interview on 08/15/18 at 7:55 A.M. with Registered Nurse (RN) #50 provided verification of the opened date being well past the 30 day time frame recommended. Review of the manufacturers product insert revealed the vial should be discarded 30 days after opening. Review of the facility policy titled Preparation and General Guidelines: Vials and Ampules of Injectable Medications dated 08/2014 revealed vials of injectable medications are to be stored and disposed of in accordance with the manufacturer' recommendations.

Based on medical record review and staff interview, the facility failed to ensure current physician orders were available. This affected 12 residents (#2, #4, #11, #13, #14, #15, #16, #19, #20, #21, #23, and #26) of 20 resident records reviewed. The facility census was 24. Findings include: Review of the medical records for Residents #2, #4, #11, #13, #14, #15, #16, #19, #20, #21, #23, and #26 revealed no current physician orders for the month of August 2018. Additionally Residents #4, #13, #15, #16 and #21 had no orders listed for July 2018. Interview on 08/13/18 at 4:27 P.M. with the Director of Nursing (DON) provided verification of the lack of current physician orders in the medical records.