**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observations, interviews, and record review, the facility failed to provide respiratory care in accordance with professional standards. The facility failed to ensure 2 of 2 residents (R) 34 and R195's, continuous positive airway pressure (CPAP), were properly cleaned and stored after each use. This failure has the potential to cause respiratory and other communicable infections/complications. Findings Include: Review of the facility policy titled, CPAP/BiPAP Support, with a revised date of March 2015, states, 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. Review of R34's face sheet revealed he was admitted to the facility on [DATE], with diagnoses including, but not limited to hypertension and obstructive sleep apnea. Review of R34's treatment orders revealed an order dated 01/11/24, which indicated, continuous positive airway pressure (CPAP), hour of sleep starting, resident should have on at bedtime, the settings are set on the machine and the patient is able to apply head mask. Review of R34's care plan revealed, R34 has periods of breathing difficulty at night related to a diagnosis of sleep apnea. The goal is for R34 to have no difficulties with breathing at night through the next review, with an intervention of using a CPAP machine and O2 at night per medical doctor orders. During an observation on 01/29/24 at approximately 3:00 PM, R34's face mask was observed uncovered, lying on his bedside table. During an observation on 01/31/24 at approximately 12:30 PM, R34's face mask was observed uncovered, lying on his bedside table. Review of R195's face sheet revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, nonrheumatic aortic stenosis, hypertension, and obstructive sleep apnea. Review of R195's treatment orders revealed an order dated 01/24/24, indicating, continuous positive airway pressure (CPAP), hour of sleep starting, resident may use own CPAP. Review of R195's care plan revealed that, R195 has periods of breathing difficulty at night related to a diagnosis of sleep apnea. The goal is for R195 to have no difficulties with breathing at night through the next review, with an intervention of using a CPAP machine at night per medical doctor orders. During an observation on 01/29/24 at approximately 2:00 PM R195's face mask was observed uncovered, lying on his bedside table. During an interview on 01/31/24 at 4:00 PM with the Director of Nursing (DON), she stated that she has not had any notification of the resident refusing to wear a CPAP machine, and the resident is self-compliant with donning/doffing the apparatus. She also stated that the device should be air dried and if it is put in a bag, bacteria would grow if it was enclosed in a bag. She said she was unaware of their policy that indicated that they should be storing the face mask a specific way. During an interview on 01/31/24 at 4:10 PM with the facility Administrator, revealed that the policy that was provided, is the only policy that they have in reference to storing and caring for respiratory devices. During an interview on 01/31/24 at 4:13 PM, Certified Nursing Assistant (CNA)1, revealed they use bags with oxygen tubing or a mask that is not in use, so they are not sitting out in the open. She stated the bags are located at the nurse's station and we (CNAs) carry them in our pockets. CNA1 stated they use clear trash bags and put the date on the outside of the bag. CNA1 stated if she witnessed oxygen tubing or a mask on the floor, she will pick it up and discard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observations, interviews, and manufacturer package inserts, the facility failed to maintain clean medication carts for 2 of 7 med carts and failed to prevent expired and/or improper storage of medications in 2 of 4 med rooms. Findings include: Review of the facility's policy titled, Storage of Medications, revised [DATE], stated that the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of the facility's policy titled, Medication Labeling and Storage, dated February 2023, stated that if the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. On [DATE] at approximately 1:08 PM inspection of the 100-hall south medication cart revealed sticky substances on bottles of Pro-stat and bottom of third (3rd) drawer on left side of cart. On [DATE] at approximately 1:13 PM, during an interview, Licensed Practical Nurse (LPN)1 acknowledged that the medication storage drawer and bottles of Pro-Stats were dirty and needed to be cleaned. On [DATE] at approximately 9:28 AM inspection of the 200-hall north medication room revealed an open approximately half (½) full tube of MediHoney labeled Sterile and Single-use by the manufacturer stored in an upper cabinet. The MediHoney instructions state that it should only be used once; instead, it was used continuously. The inspection also revealed one (1) Povidone-Iodine Prep Pad with an 04/2020 expiration date and 1 Povidone-Iodine Prep Pad with an 08/2020 expiration date. On [DATE] at approximately 9:35 AM, LPN2 acknowledged, during an interview, that the Medi-Honey was being used for Resident(R)18 and she was unaware that the medication was designated for single sterile use. LPN2 also acknowledged that she was unaware of the expiration dates on the Povidone Iodine Prep-Pads. On [DATE] at approximately 2:07 PM inspection of the 200-hall north medication cart revealed sticky substances on the bottom of the 3rd drawer on the left side of medication cart. This finding was acknowledged during an interview with LPN2 in the presence of the Assistant Director of Nursing. On [DATE] at approximately 10:35 AM inspection of 100-hall north medication room revealed a container of True Metrix 50 count test strips expired on [DATE] stored in top cabinet. On [DATE] at approximately 10:40 AM, LPN3 stated, during an interview, that the test strips were used on night shift to check residents blood sugar levels and she advised she was unaware of the expiration date.

Based on review of the facility policy, observation, and interview, the facility failed to establish and maintain an infection prevention and control program to prevent the development and transmission of communicable disease and infections related to influenza for one of one, Resident (R)1. Findings include: Review of the facility policy titled Influenza, Prevention and Control of Seasonal, revised March 2022 states, This facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. Influenza Control, 6. Visits to residents on precautions for influenza are scheduled and controlled to allow for: a. screening visitors for symptoms of acute respiratory illness before entering the facility; and b. providing instruction before visitors enter residents' rooms, on hand hygiene, limiting surfaces touched, and use of personal protective equipment (PPE) while in resident's room. Infection Precautions: 1. Contact and droplet precautions are implemented for residents with suspected or confirmed influenza for seven (7) days after illness onset or until 24 hours after resolution of fever and respiratory symptoms, whichever is longer. Precautions may be applied for longer periods based on clinical judgement. 2. Information about residents with suspected, probable, or confirmed influenza is communicated to appropriate personnel before transferring them to other departments in the facility or to other facilities. During an interview on 01/30/24 at 3:15 PM with the Certified Occupational Therapist, (COTA)1 revealed he was waiting for a few more residents to have a group therapy session. He has two group sessions a week, Tues/Thursday. He said, Right now, we have 2-3 residents that have the flu. He pointed to R1's room, and said she has the flu. When asked if there should be precautions?, he said, I don't know why she doesn't, she should have them. I walked into her room a few days ago and didn't even know it. During an interview on 01/30/24 at 3:37 PM with the Infection Control Preventionist (ICP), revealed precautionary measures were used for R1, with the flu. She revealed the facility uses present Centers for Disease Control (CDC) guidelines, and log residents' temperature that lasts for over 24 hours. In order to confirm a resident has the flu, the facility uses the swab method. The ICP revealed R1 never had a temperature and there are no precautions used for newly flu diagnosed residents. She stated, Resident just self-isolate and staff do not wear full PPE, just masks. The ICP revealed staff are made aware of a resident who has the flu via a report and per CDC guidelines, residents with no signs and symptoms do not have to isolate. During an interview on 1/31/24 at 10:06 AM with Licensed Practical Nurse (LPN)1 revealed the signage on the door of R1's room is because she has the flu. She stated, R1 tested for Influenza on Friday, 01/26/24, and we got the results back on Saturday. She's been having a runny nose and cough for a while. During an interview on 01/31/24 at 10:10 AM with the ICP, she stated, I wanted to tell you I was incorrect on the flu precautions. I checked the CDC and learned that a resident who has tested positive for influenza should be on contact precautions for seven days. We put isolation precautions in place yesterday for R1 because she has tested positive and today is the seventh day. The ICP also stated, The staff who pass trays to the residents should sanitize before they begin delivering trays. She said, If they require meal setup, you make sure you do not touch the straw in a way that your hands actually touch the straw itself, only the paper. When unwrapping the silverware, they should not actually touch the silverware with their bare hands. An observation on 01/31/24 at 10:05 AM of R1's room revealed droplet signage and a cart outside the door containing face masks, N95s, face shields, gloves, etc.

Based on observations, interviews, and review of the facility policy, the facility failed to ensure foods that are stored in the refrigerator and dry storage were labeled and discarded after the manufacturer's expiration date. Findings Include: Review of the facility's policy titled, Food Receiving and Storage, with a revised date of November 2022, reveals, Food shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage: 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated. Such foods are rotated using a first in-first out system. Refrigerated/Frozen Storage: 7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. During an initial tour observation on 01/29/24 at 12:24PM, in the walk-in refrigerator and dry storage area revealed: 1. One unopened five-pound bag of Mozzarella cheese labeled with a received date of 12/29/23, had a manufactured expiration date of 11/29/23, which also contained mold. 2. A blue bucket that did not contain any label of the contents, an opened or expiration date. The Dining Service Manager (DSM) confirmed that the contents were mushrooms. 3. A box containing approximately twelve squash that were molded, had a received date of 01/07/24. 4. A box containing single packs of Mayonnaise had a manufactured expiration date of 01/26/24. 5. A five-pound container of baking powder, that was half full, had a manufactured expiration date of 05/09/21. 6. An unopened eight-ounce jar of Pad Thai Sauce had a manufactured expiration date of 07/28/23. An interview on 01/29/24 at 12:35 PM with the DSM, revealed that they check the food contents on a weekly basis, and they use a first in and first out method. He included that the stock they have usually does not last beyond two weeks as they are constantly using the items that they have ordered, and they replenish about every week. An interview on 01/31/24 at 2:02 PM with the Certified Dietary Manager (CDM), revealed that he is primarily responsible for ensuring that all items that are stored are labeled and dated and are within the manufactured expiration date. He stated that he is responsible for all the kitchen areas to include the main and satellite. He also is responsible for providing in- services to staff when there is an area that needs to be revisited or just general information/guidelines, as well as performing bi-weekly audits. The CDM stated he was unaware of any expired items, and they use the first in- first out method to ensure expired items are discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Advance Directives, the facility failed to ensure Resident (R)19 and R42 were afforded the right to formulate an advance directive for 2 of 4 residents reviewed for Advance Directives. Findings Include: The facility admitted R19 with diagnoses including, but not limited to, bipolar disorder, schizoaffective disorder, anxiety and legal blindness. Review on [DATE] at 1:22 PM of the medical record for R19 revealed no documentation to ensure R19 was afforded the right to formulate an Advance Directive. Further review on [DATE] at 1:25 PM of the medical record for R19 revealed no assessments and signatures of 2 physician's indicating that R19 was not able to make her own healthcare decisions. During an interview on [DATE] at 3:35 PM with the Director of Nursing (DON), she confirmed that R19 was not afforded the right to formulate her choices for an Advance Directive. Review on [DATE] at 9:14 AM of the facility policy titled, Advance Directives, states, Advance directives will be respected in accordance with state law and facility policy. The Policy Interpretation and Implementation states under #1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medial or surgical treatment and to formulate an advance directive if he or she chooses to do so. Number 6 states, Prior to or upon admission of a resident, the social services director or designee will inquire of the resident, or his/her family members and/or his or her legal representative, about the existence of any written advance directives. Number 7 states, Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Number 8 states, If the resident indicates that he or she has no established advance directives, the facility staff will offer assistance in establishing advance directives: a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Number 9 states, The attending physician will provide information to the resident and legal representative regarding the resident's health status, treatment options and expected outcomes during the development of the initial comprehensive assessment and care plan. Review of the electronic medical record (EMR) Face Sheet revealed R42 was admitted on [DATE] with diagnoses including but not limited to; vascular dementia with behavioral disturbance, schizoaffective disorder, anxiety disorder, and unspecified protein-calorie malnutrition. Review of R42's clinical EMR revealed there was no documentation of an Advanced Directive. Review of R42's comprehensive Care Plan revealed the resident was a Full Code (Direction to perform Cardiopulmonary Resuscitation (CPR) in the event the heart stops) . In an interview with the DON on [DATE] at 12:00 PM, it was confirmed that there was no documentation to show Advanced Directives information provided to R42. She further stated that there were some family dynamic issues surrounding R42, and the facility was working to get them resolved.

Based on observation and interview, the facility failed to maintain a homelike environment for one of two residents (Resident (R) R42) reviewed for environment. Specifically, R42 had food crumbs, paper trash, and other particles on the floor. This had the potential to affect all 47 residents residing in the facility. Findings Include: During initial tour of the facility on 01/31/22 at 12:43 PM, observation of food crumbs and paper trash were noted lying on the floor in R42's room. Observation on 02/01/22 at 8:54 AM , food crumbs and paper trash were observed on the floor in R42's room located in the same place as observed on the previous day. Observation on 02/02/22 at 8:59 AM, food crumbs and paper trash were observed on the floor in R42's room located in the same place as observed on the previous dates of 01/31/22 and 02/01/22. Observation on 02/02/22 at 8:59 AM, during a wound care observation with R42, it was noted the floor had a large amount of food crumbs and other non-identified dirt particles, a smashed brown food substance, a dried red liquid substance, gauze, and paper debris (under the bed), and pink plastic caps from nebulizer medication solution containers. The food and unidentified dirt particles were scattered throughout the room floor and on of the overbed tables. There was no liner in the trash can in the room. In an interview with the Housekeeper on 02/02/22 at 3:45 PM, she stated the skilled unit was normally her assigned unit, however, since she was the only housekeeper, she covered the entire facility at this time. She stated the routine procedure was to clean every resident room daily. She stated because of her being the only housekeeper, she was unable to get to every resident's room every day. She stated she would start on one day at one end of the hallway and then the next day the other end of the hallway. She stated she had not cleaned R42's room today (02/02/22). She confirmed the R42's floor was dirty, and she would get to it the next day. She confirmed the smashed in substance on the floor was food and the red substance was some type of liquid. She stated when asked if R42 had kept her room messy with food and paper products, Not too much, she doesn't get out of bed most days. The Housekeeper stated she thought she had cleaned R42's room, at least swept it the day before, but wasn't sure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of two sampled residents (Residents (R) R30 and R42), who were given mental health diagnoses and were not provided a Pre-admission Screening and Resident Review (PASARR) level 2 evaluation to determine the need for individualized mental health treatment and support services. Specifically, R30 was admitted with diagnoses of depression and psychotic disorder and received antipsychotic medication with no PASARR level 2 referred. R42 was admitted with a diagnosis of dementia and was later given a diagnosis of schizophrenia disorder and was prescribed an antipsychotic medication with no PASARR level 2 referred. This failure placed the residents at risk for unmet care needs, unnecessary medication/s, and at risk for not receiving appropriate mental health treatment and support/services needed. This had the potential to affect all residents with a mental health diagnosis. Findings Include: Review of the Review of the Diagnostic Criteria for delirium in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) provided the following information regarding psychotic disorder due to general medical condition: .A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by a mental disorder. D. The disturbance does not occur exclusively during the occurrence of delirium .The hallmark features of psychotic disorders such as schizophrenia are hallucinations, delusions, and disordered thinking . Review of the National Institute of Mental Health booklet titled, Schizophrenia, (NIH Publication No. 15-3517), indicated, Symptoms [of schizophrenia] such as hallucinations and delusions usually start between ages 16 and 30 .Most commonly, schizophrenia occurs in late adolescence and early adulthood. It is uncommon to be diagnosed with schizophrenia after age [AGE]. Review of the Behavioral Assessment, Intervention and Monitoring Policy dated March 2019 stated: .1. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder. a. All residents will receive a Level I PASARR screen prior to admission, b. If the Level I screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability, or related condition he or she will be referred to the state PASARR representative for the Level II (evaluation and determination) screening process. c. The Level II evaluation report will be used when conducting the resident assessment and developing the care plan . 1 . Review of R30's electronic medical record (EMR), Face Sheet stated, R30 was admitted on [DATE] with diagnoses of but not limited to Parkinson's disease, history of anxiety disorder, a single episode of major depression and psychotic disorder. R30 received a diagnosis of schizophrenia on 08/30/21. Review of R30's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/19/21 revealed R30 scored a 14 out of 15 on the Brief Instrument for Mental Status (BIMS) assessment, indicating R30 was cognitively intact. It was documented R30 had a progressive neurological condition. It was documented R30 had an active diagnosis of psychoactive disorder (other than schizophrenia) with no behaviors, hallucinations, or delusions present. Review of R30's significant change in status MDS with an ARD of 01/04/22, documented in the PASARR section of the assessment that R30 was not evaluated for a level two PASARR. It was documented R30 declined in cognition and scored a 02 out of 15 on the BIMS assessment. R30 was documented with changes in mood and exhibited no change in behavior. It was documented R30 had an active diagnosis of anxiety, depression, psychoactive disorder (other than schizophrenia), and schizophrenia with no behaviors, hallucinations, or delusions present. R30's functional status indicated no change and documented R30 required supervision to extensive assistance from staff with activities of daily living (ADL). Review of the PASARR level one screening for R30 dated 10/24/19, documented diagnoses of HTN (hypertension), depression, and gastro esophageal. There was no mention of the psychiatric disorder diagnosis as mentioned on the admission diagnoses. There was no PASARR level two referred for the mental health diagnosis of a psychiatric disorder or for the schizophrenia disorder diagnosis given on 08/30/21. 2 . Review of R42's EMR face sheet stated, R42 was admitted on [DATE] with diagnoses of but not limited to, repeated falls; pain in right hip; muscle weakness (generalized); cognitive communication deficit; other reduced mobility . Review of the PASARR level one dated 01/13/21 for R42 revealed a diagnosis of closed fracture of neck of right femur. There was no documentation indicating R42 had a mental diagnosis. Review of the admission MDS with an ARD of 01/20/21 for R42 revealed in the PASARR and condition assessment, it was documented R42 had not had a PASARR level two referral completed. It was documented R42 had no behaviors. Review of the quarterly MDS with an ARD of 10/16/21 for R42 revealed active diagnoses of dementia, anxiety disorder, and schizophrenia disorder with no PASARR level two referral completed. There was no documented mood or behaviors. It was documented R42 received seven days of antipsychotic and antidepressant medications. There were no psychological therapy minutes documented. Review of the annual MDS with an ARD of 01/16/22 for R42 revealed active diagnoses of dementia, anxiety disorder, and schizophrenia disorder with no PASARR level two referral completed. It was documented R42 was assessed to be severely cognitively impaired and unable to make decisions. R42 was assessed to have disorganized thinking, difficulty focusing, and altered level of consciousness. It was documented R42 received six days of antipsychotic medications and seven days of antidepressants. There were no psychological therapy minutes documented. An interview on 02/03/22 at 9:30 AM, with the Social Worker (SW), confirmed the PASARR process was not done correctly, and the facility should have referred a PASARR level two for R30 and R42 for the newly diagnosed mental illness. She confirmed she was aware of the regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement the comprehensive care plan interventions for two residents (Resident (R) 30 and 41) of five reviewed for psychotropic medication care plan/s. These failures had the potential to affect all residents prescribed psychotropic medications with target behaviors by increasing the potential for harm due to the facility failing to implement nonpharmacological methods that were identified on the care plan with the usage of unnecessary medications. Findings include: Review of the admission Record, located on the Face Sheet in the electronic medical record (EMR), indicated R41 was admitted to the facility on [DATE] with diagnoses including but not limited to; acute pulmonary edema, major depressive disorder, unspecified dementia, repeated falls, and anxiety disorder. Review of the EMR admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/14/22, revealed R41 was moderately cognitively impaired and was documented to have a diagnosis of dementia requiring staff assistance with activities of daily living (ADL). Review of the Physician Order Report located under the tab Physicians Orders in the EMR revealed starting 01/07/22 an order for R41 to receive Xanax 0.5 mg (milligram) tablet As needed every six hours. The notes stated Indication: anxiety, agitation, Instructions: Therapeutic Range. There were no orders to monitor adverse side effects or identified target behavior/s for the use of the medication. Review of the Physician Order Report located under the tab Physicians Orders in the EMR revealed starting 01/13/22, an order for R41 to receive Xanax 0.5 mg tablet Every evening starting 01/13/22. Review of R41's comprehensive care plan titled Care Plan Report with the problem .R41 has behavior symptoms AEB (As evidenced by) yelling, agitation, episodes of hitting/slapping her arm, prefers to not use utensils at times . dated 01/07/22 revealed the goal was to decrease the resident ' s behavior symptoms over the next review AEB the nursing documentation of the episodes. The interventions listed were .Encourage caregivers to participate in activities with resident to promote positive interactions. Document behaviors in clinical record. Monitor pattern of behavior (time of day, precipitating factors, specific staff, or situations). Respond in a calm voice; maintain eye contact. Remove from area if resident is agitated. Resident has a purple hat she wears at times to help calm her. Tv on with soft music channel on may also calm her. Resident has a favorite quilt that she likes to be put over her legs . Review of R41's behavioral monitoring documentation located on the Medication Administration Record (MAR) located in the EMR dated 02/02/22 through 02/03/22 revealed .Action: antianxiety side effects and behaviors however, there were no specific target behaviors listed. The daily documentation for the month of January 2022 had not been documented. Further review revealed the two days where there were behavioral symptoms noted the documentation had not specified what type of target behavior was exhibited. However, there was documentation to show the resident was re-directed successfully with non-pharmacological interventions with no specific documentation to show which intervention was implemented. The documentation revealed that the facility had not consistently monitored and implemented the plan of care related to the use of psychotropic medication and the correlated identified target behavior/s. Progress note dated 02/01/22 stated PRN Xanax continues for anxiety with good effect when used. Purple hat also helpful with calming pt. In an interview with the Physical Therapist on 02/02/22 at 11:54 AM, she stated The resident ' s agitation fluctuates throughout the day. When she verbally gets frustrated and gets loud, staff redirects and speaks with her calmly. She follows commands with extra time and reminders. Her frustration is due to dementia and when she gets tired. When this happens, staff repositions her in the bed and she calms down. In an interview with Licensed Practical Nurse (LPN) 3 on 02/02/22 at 11:58 AM, she stated When staff tries to get the resident out of the bed, her agitation stems from confusion, she doesn't know where she is and why she's here. Staff redirects her and speaks with her calmly and answers her questions (e.g., Where she is? Where are her kids?). Other than redirection, she is taken out of stimulating areas, staff will dim the lights in her room, etc. In an interview with the Social Services Director on 02/02/22 at 2:44 PM, she stated The resident's agitation depends, she has her moments. You cannot put chocolate in front of her and she likes staff to write down what they are doing today. She naturally speaks loudly and will repeat herself at least 3 or 4 times. She wants everything explained to her. She likes the engagement stations (e.g., folding clothes) she does not like big social groups, she likes listening to music, but [NAME] sets her off because that is her and her husband ' s song and she will get upset when she hears it. She likes the concerts, one-to-one activities, and she likes crafts, but it has to be one or two steps. If agitated staff would ask her what she wants, sometimes she gets frustrated because she cannot communicate what she wants. Staff would redirect or relocate the resident and try to find the solution and determine if she is upset because of the location or if it is too much stimulation. The facility's certified dementia training tells you how to approach the situation to determine why the residents are upset and how to resolve the issue. The resident was in memory care, but now that she's in rehab and sometimes she doesn't want to participate. During a phone interview with LPN 4 on 02/03/22 at 9:58 AM, she stated At night the resident gets agitated, and she tries to get out of bed, but she isn't aggressive. If she gets agitated, I do one to one, hold the resident ' s hand, and then she calms down. If a PRN is given for 14 days, the resident should be reevaluated because she may need to have it routinely if that is going to be used to get her anxiety under control. When they receive training, they are introduced to residents that have a diagnosis of dementia, informed of the care plan which tells them how to proceed with providing care for the resident. Staff indicated in interviews that R41 was easily redirected by utilizing non-pharmacological interventions however, according to review of R41's MAR, the PRN Xanax was administered on the following dates: 01/07/22, 01/08/22, 01/09/22, 01/10/22, 01/11/22, 01/15/22, 01/16/22, 01/18/22, 01/20/22, 01/21/22, 01/22/22, 01/23/22, 01/24/22, 01/25/22, 01/28/22, and 01/29/222 without complete documentation of what behavior was targeted, what non-pharmacological intervention was implemented prior to administering the medication, and how successful was that intervention. Review of R30's EMR, Face Sheet indicated, R30 was admitted on [DATE] with diagnoses including but not limited to; Parkinson's disease, history of anxiety disorder, a single episode of major depression and psychotic disorder. R30 received a diagnosis of schizophrenia on 08/30/21. Review of R30's admission MDS with an ARD date of 02/19/21 revealed R30 scored 14 out of 15 on the Brief Instrument for Mental Status (BIMS) assessment which meant R30 was cognitively intact. It was documented R30 had a progressive neurological condition. It was documented R30 had an active diagnosis of psychoactive disorder (other than schizophrenia) with no behaviors, hallucinations, or delusions. Review of R30's Quarterly MDS dated [DATE] revealed BIMS score of 08 out of 15; showed no evidence of an acute change in mental status from the resident's baseline; Section D-Mood, showed no change from resident's baseline, with a severity score of 00; Section E-Behavior showed no change from resident's baseline; I- Active Diagnosis: anxiety disorder, depression (other than bipolar), psychotic disorder (other than schizophrenia), Schizophrenia (e.g., schizoaffective and schizophreniform disorders). Section N-Medications - Medications revealed antipsychotics were received on a routine basis only, GDR has not been documented by a physician as clinically contraindicated. Section Q-Participation in Assessment and Goal Setting- resident participated along with family member. Review of R30's Quarterly MDS dated [DATE] revealed BIMS score of 08 out of 15, Section D- Mood - no change since last quarter; Section E-Behavior -no change since last quarter Section N- revealed antipsychotics were received on a routine basis only, GDR has not been documented by a physician as clinically contraindicated. Review of R30's MDS - Significant Change in Status Assessment, dated 01/04/22, documented re-entry from an acute hospital on [DATE]. Section C- Cognitive Patterns R30 declined to a BIMS score of 02. Section D - Mood R30 showed some change with mood scored 04 on the Resident Mood Interview. Section E - Behaviors it was documented R30 exhibited no change in behavior. Review of Psychoactive Utilization records for 07/20/21 and 08/13/21, 08/20/21 and 09/09/21, and 11/20/21 and 12/12/21, document Risperidone (for Schizophrenia) Tab 1 MG q 12 hrs., Nuplazid (for hallucinations) 34 mg qd, and Cymbalta (for depression anxiety) bid - depr, are being prescribed by orders dated 02/12/21, with the next evaluation date shown as 06/21. Review of Progress notes dated 02/12/21 through 01/31/22. There were no documented notes from the physician or the Interdisciplinary Team indicating that R30's medications had been reviewed. Review of Non-PRN Treatment Notes, (which monitor the behaviors and side effects of the medications), from 11/21 - 02/22 documented one incident of hitting and kicking, on the evening of 01/24/22. Clinical Notes documented by the Pharmacist show on 12/12/21: Note to MD regarding psych meds; 01/15/21: Resident is now Hospice status. NP c/I GDRs 12/15/21. No irregularities found. Review of the Recommendation to MD from Pharmacist letter, dated 12/12/21, and the Summary of Recommendations to MD and Nursing letter, dated 12/21/21, document the Pharmacist sent letters to the physician and the facility, regarding R30's psychotropic medications: Nuplazid 34 mg qd+ Risperdal 1 mg bid +Klonopin .25 mg qd+ Cymbalta 60 mg bid. There were no signed documents of these two forms. During an interview with the Pharmacist on 2/3/22 at 11:59 AM, she stated she has worked for the facility for four years, and visits once a month, or more if needed. She conducts monthly pharmacy reviews, and the inhouse pharmacist conducts the initial Medication Regimen Review (MRR). If the doctor does not respond to the MRR, she will follow up within two months. The facility doesn't consistently respond to the MRR. Sometimes the medical staff will document on the progress notes. She reviews the nurses' notes for behaviors, medications given and the reason, PRN medication usage and will check the Medication Administration Record (MAR) to review how often PRN was given. The Pharmacist reviews the care plan of hospice residents to evaluate the continuation of medications. She attends the Quality Assurance meetings and follows a template that ask general questions about the number of residents on psychotropic medications. When she brings up her concerns in the QA meetings, the MD states they are aware of the issue. The Pharmacist confirmed that she knows that the regulation states antipsychotics must be written every 14 days and it has been discussed with medical staff. Ideally, she would like to see on admission, the MD write the order for 14 days which will discontinue the use of the antipsychotic, if not reevaluated. Box warnings are placed on antipsychotics. She confirmed that schizophrenia is unlikely to be diagnosed after the age of 30.

Based on observations, record review, interview and review of the facility's policy titled, Wound Care, and Handwashing/Hand Hygiene, the facility failed to ensure proper wound care for Resident (R)1 for 1 of 3 residents reviewed for Pressure Ulcers. Findings Include: The facility admitted R1 with diagnoses including but not limited to; pressure ulcer of left and right hip, repeated falls, difficulty walking and lack of coordination. Review on 2/2/22 at 12:05 PM of the medical record for R1 revealed a physician's order for wound care. The order reads: Clean the left and right buttocks and perineum with wound cleanser and pat dry. Apply collagen powder and calcium alginate to the wound bed and cover with a dry dressing and secure with tape. An observation on 2/2/22 at 12:10 PM of wound care for R1 went as follows: Registered Nurse (RN)1 and Licensed Practical Nurse (LPN)1 began preparing R1 for the wound care. RN1 applied gloves to her hands and removed the top cover from the resident and raised the bed for better access to R1's wounds. Using the same gloved hands, RN1 mixed the collagen powder with normal saline making a paste like consistency. The LPN assisting applied gloves and aided R1 in removing his pants, and removing the brief. Using the same gloved hands, RN1 then sprayed wound cleanser on 4x4s and the open area and began wiping back and forth across the wounds. Then taking clean 4x4s in hand, she patted the area dry. Never changing her gloves and never washing or sanitizing her hands. RN1 then applied the collagen powder paste using a wooden applicator and then applied a full sheet of calcium alginate over R1's entire bottom, not applying it to only the wound beds. RN1 then, using the same gloved hands, peeled the back off a large piece of clear tape and applied this over the entire dressing. Using the same gloved hands, RN1 cleaned the paper off the bed and placed it in a trash bag and removed her gloves that she had used during the entire procedure, washed her hands and charted the treatment. During an interview on 2/2/22 at 4:30 PM with RN1, she confirmed that she had not washed her hands, changed her gloves nor had she used hand sanitizer during the entire dressing change. RN1 also confirmed that she had used the entire sheet of calcium alginate and placed it over R1's entire bottom and not just the wound beds as ordered. Review on 2/3/22 at 7:45 AM of the facility policy titled, Wound Care, states under, Purpose, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Under, Steps in the Procedure, number 2 states, Wash and dry your hands thoroughly. The wound are policy also states after removing a soiled dressing, Wash and dry your hands thoroughly. Review on 2/3/22 at 7:50 AM of the facility policy titled, Handwashing/Hand Hygiene, states under the policy statement, The facility considers hand hygiene the primary means to prevent the spread of infections. Under the Policy Interpretation and Implementation states under number 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Number 9 states, The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation and interviews, the facility failed to ensure there was sufficient nursing staff available to respond to call lights and assist residents as needed for five of the 12 residents (Residents (R) R32, R10, R22, R29, R39) attending the Resident group and one of two residents reviewed for environment (R32). This failure has the potential to affect all residents who resided in the facility. The census was 43. Findings include: On 01/31/22 at 12:47 PM, R32 was observed eating while in bed. R32 was leaning to her right side while eating her food with her left hand. When asked if she was ok, R32 stated she was concerned about her position because she couldn't see her food. When asked if R32 had activated the call light to request for assistance in positioning, R32 stated she didn't know where the call light was. Further observation revealed after activating the call light it was approximately 15 minutes later, staff had not come to assist the R32. Observation of the nurse ' s station revealed no one was at the nurse's station at the time R32's call light was activated. During an interview on 01/31/22 at 3:20 PM with R10, it was revealed R10 stated that they (meaning the facility) don't have enough staff. R10 stated when he rings his call light; staff do not come in a timely manner. During an observation and interview with R32 on 02/02/22 at 8:59 AM, R32 was observed leaning in bed and stated that she wished she could have a straw to drink her juice with so it wouldn't spill. Further observation revealed R32 activated her call light for assistance and at 9:08 AM, there was still no response to the call light. During an interview with Licensed Practical Nurse (LPN) 4 on 02/02/22 at 9:08 AM revealed LPN4 stated he would assist R32 after surveyor intervention. Further interview at 9:15 AM with LPN4 stated that the call light system was a pager system and when activated, the pager gives an alert to the Certified Nursing Assistant (CNA) and also showed on the facility's computer system at the nurse's station. During the Resident group meeting on 02/02/22 at 11:03 AM, R10, R22, R29, R32, R39 stated that they had to wait extended times when they activated their call light system. During an interview on 2/03/22 with the Director of Nursing (DON), it was stated that they are working on call light response times and making sure the call light pagers are actually working. Audits were completed in January for this process. .

Based on observation and interview, the facility failed to respond to Resident (R)41 during a hallucination episode. Findings Include: An observation on 2/2/22 at 11:09 AM revealed R41 in the dining area having a hallucination episode for 20 minutes with little to no staff intervention or redirection attempts. Certified Nursing Assistant (CNA)1 was observed during this time period on their phone in close proximity to the resident. Further observation revealed Physical Therapist (PT) 2 redirect the resident and assist them to the therapy gym. An interview on 2/2/22 at 11:37 AM with CNA1 revealed that he heard the resident yelling, but didn't think to help with an intervention because he thought the therapy staff had it covered. Further interview confirmed that CNA1 was on the phone looking through messages during the time of R41's hallucination episode. A phone interview with the Resident Representative for R41 revealed ongoing concerns related to staffing and the quality of care R41 is currently receiving at the facility. An interview with the Director of Nursing (DON) on 2/3/22 at 3:20 PM revealed CNA1 was terminated from the facility due to lack of providing care to multiple residents.

Based on observations, interviews and review of the facility policy titled, Administering Medications, the facility failed to ensure medications were not touched for Resident (R)145 with bare hands during administration of medications on the 200 Hall for 4 medications out of 25 opportunities for error. The medication error rate was 16 percent. Findings Include: An observation on 2/1/22 at approximately 8:00 AM of medication administration for R145 revealed Licensed Practical Nurse (LPN)1 administering medications to R145. The LPN had 4 pills in a medicine cup and went to R145's room. She sat the cup of medications on a 3 drawer compartment outside R145's room door used for personal protective equipment. The LPN accidentally knocked over the cup of medications and picked them up one by one using her bare hands. The Director of Nursing was observing and asked the LPN if she had made sure that the cup now contained the total of 4 and the LPN stated it did. LPN1 then carried the pills into the resident's room and administered them to R145. During an interview on 2/1/22 at approximately 8:15 AM with LPN1 and the Director of Nursing, they both confirmed that LPN1 had touched the medications with her bare hands. Review on 2/1/22 at approximately 9:00 AM of the facility policy titled, Administering Medications, states under the Policy Statement, Medications are administered in a safe and timely manner and as prescribed. The Policy Interpretation ad Implementation states under #2, The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Number 25 states, Staff follows, established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc) for the administration of medications, as applicable.

Based on observations, interviews and review of the facility policy titled, Storage of Medications, the facility failed to ensure expired medications were removed from the 200 North Hall medication cart and not stored with medications for resident use on 1 of 4 medication carts observed . The facility further failed to ensure medication carts were locked on on the 100 North Hall and on the 200 South Hall for 2 of 4 medication carts observed. The facility additionally failed to ensure expired mediations were removed from the refrigerator in the 200 South Hall medication room for 1 of 4 medication rooms reviewed. Findings Include: An observation on 2/1/22 at 3:00 PM of the 200 North Hall medication cart revealed the medication, Oxycodone 1 tablet of 5 milligrams expired on 1/20/22. The medication Oxycodone 1 tablet of 10 milligrams expired on 1/20/22 and Oxycodone Hydrocel 1 tablet of Lot 21021 16616A KvK-Tech expired on 1/20/22. During an interview on 2/1/22 at 3:00 PM the Director of Nursing confirmed the expired medications and removed them from medications for resident use. An observation on 2/2/22 at 8:00 AM revealed the medication cart on 100 North Hall unlocked and unattended. An observation on 2/2/22 at 11:55 AM revealed mediation cart on the 200 South Hall unlocked and unattended. An interview on 2/2/22 at 8:00 AM with Registered Nurse (RN)2 confirmed the findings and locked the cart and using the key pad on the cart. Review on 2/2/22 at 9:50 AM of the facility policy titled, Storage of Medications, states, under policy statement, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Under, Policy Interpretation an Implementation, number 4 states,Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Number 6 states, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. An observation on 2/3/22 at 3:05 PM of the 200 South medication room refrigerator revealed 8 droppers of Serum 50% Ophthalmic Drops Lot# 01392021@9 with a use by date of 5/3/21. The findings were confirmed and removed by the consulting Pharmacist.

Based on observations, interviews and review of the facility policy titled, Administering Medications, the facility failed to ensure medications were not touched for Resident (R)145 with bare hands during administration of medications on the 200 Hall for 4 medications out of 25 opportunities for error. Findings Include: An observation on 2/1/22 at approximately 8:00 AM of medication administration for R145 revealed Licensed Practical Nurse (LPN)1 administering medications to R145. The LPN had 4 pills in a medicine cup and went to R145's room. She sat the cup of medications on a 3 drawer compartment outside R145's room door used for personal protective equipment. The LPN accidentally knocked over the cup of medications and picked them up one by one using her bare hands. The Director of Nursing was observing and asked the LPN if she had made sure that the cup now contained the total of 4 and the LPN stated it did. LPN1 then carried the pills into the resident's room and administered them to R145. During an interview on 2/1/22 at approximately 8:15 AM with LPN1 and the Director of Nursing, they both confirmed that LPN1 had touched the medications with her bare hands. Review on 2/1/22 at approximately 9:00 AM of the facility policy titled, Administering Medications, states under the Policy Statement, Medications are administered in a safe and timely manner and as prescribed. The Policy Interpretation ad Implementation states under #2, The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Number 25 states, Staff follows, established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc) for the administration of medications, as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, review of the manufacturer's guidelines for medication use, and review of the facility's policy and procedures, the facility failed to ensure that three of five residents (Resident (R) R30, R41, and R42) reviewed for unnecessary medication use did not receive psychoactive medications without an appropriate assessment and indication for use, monitoring of adverse effects, attempting gradual dose reductions when appropriate, reducing or discontinuing as needed psychotropics past the 14 day criteria, identifying and routinely monitoring specific target behaviors, and developing and implementing resident specific non-pharmacological interventions. This deficient practice had the potential for serious harm and/or death for all residents who reside in the facility. Findings include: Review of the facility's policy dated April 2018 titled, Medication Utilization and Prescribing- Clinical Protocol stated Assessment and Recognition:2. As part of the overall review, the physician and staff will evaluate the rationale for existing medications that lack a clear indication or are being used intermittently on a PRN (as needed basis). Monitoring: 1. The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to determine if the medication and doses are still relevant and are not causing undesired complications . Review of the facility's policy dated January 2018 tilted, Medication Monitoring and Management stated .6. As needed (PRN) orders include an indication for use. A. If the PRN medication is used to modify behavior, the indication(s) for use is clearly defined in objective terms, e.g., what specific symptom(s) is being addressed. B. The resident is monitored for the effectiveness of the medication or possible adverse consequence. Results are documented in the resident's active record 8. The medication regimen is re-evaluated periodically to determine whether prolonged or indefinite use of a medication is indicated. A. Prescribers, facility staff, and consultants document progress towards, maintenance of, or regression from therapeutic goals . According to the manufacturer's box warning dated 02/2021, revealed .WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA RELATED PSYCHOSIS Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. RISPERDAL is not approved for use in patients with dementia-related psychosis. INDICATION AND USAGE for prescribing RISPERDAL is an atypical antipsychotic indicated for: Treatment of schizophrenia, as monotherapy or adjunctive therapy with lithium or valproate, for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder, and treatment of irritability associated with autistic disorder . Review of the Review of the Diagnostic Criteria for delirium in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) provided the following information regarding psychotic disorder due to general medical condition: .A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition. C. The disturbance is not better accounted for by a mental disorder. D. The disturbance does not occur exclusively during the occurrence of delirium .The hallmark features of psychotic disorders such as schizophrenia are hallucinations, delusions, and disordered thinking . Review of the National Institute of Mental Health booklet titled, Schizophrenia, (NIH Publication No. 15-3517), indicated, Symptoms [of schizophrenia] such as hallucinations and delusions usually start between ages 16 and 30 .Most commonly, schizophrenia occurs in late adolescence and early adulthood. It is uncommon to be diagnosed with schizophrenia after age [AGE]. Review of the facility's policy titled Antipsychotic Medication Use, dated December 2016, stated .Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. 3. The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic episodes, and will differentiate them from enduring psychiatric conditions. 4. The attending physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions. 5. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will: a. Complete PASARR screening (preadmission screening for mentally ill and intellectually disable individuals), if appropriate; or b. Re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether or not the medication can be reduces, tapered, or discontinued. c. Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication. 6. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident . 1. Review of R30's electronic medical record (EMR), Face Sheet stated, R30 was admitted on [DATE] with diagnoses of but not limited to Parkinson's disease, history of anxiety disorder, a single episode of major depression and psychotic disorder. R30 received a diagnosis of schizophrenia on 08/30/21. Review of R30's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/19/21 revealed R30 scored a 14 out of 15 on the Brief Instrument for Mental Status (BIMS) assessment which meant R30 was cognitively intact. It was documented R30 had a progressive neurological condition. It was documented R30 had an active diagnosis of psychoactive disorder (other than schizophrenia) with no behaviors, hallucinations, or delusions present. Review of R30's significant change in status MDS with an ARD of 01/04/22, documented in the PASARR section of the assessment that R30 was not evaluated for a level two PASARR. It was documented R30 declined in cognition and scored a 02 out of 15 on the BIMS assessment. R30 was documented with changes in mood and exhibited no change in behavior. It was documented R30 had an active diagnosis of anxiety, depression, psychoactive disorder (other than schizophrenia), and schizophrenia with no behaviors, hallucinations, or delusions present. R30's functional status indicated no change and documented R30 required supervision to extensive assistance from staff with activities of daily living (ADL). Review of R30's Care Area Assessment (CAA) Summary, dated 01/13/22, for care area Cognitive Loss/Dementia, Psychosocial Well-Being and Psychotropic Drug Use, revealed R30 had Parkinson's induced hallucinations, and schizoaffective disorder with confusion. R30 was at risk for cognitive impairment related to the progression of R30's disease process. Will proceed to care plan. Review of R30's Non-PRN Treatment Notes, where the facility documented target behaviors dated from November 2021 through February 2022, had documented one incident of hitting and kicking, on the evening of 01/24/22. All other documentation was documented that R30 had no behaviors. Review of R30's Recommendation to MD from Pharmacist dated 12/12/21, and the Summary of Recommendations to MD and Nursing dated 12/21/21, revealed R30 was prescribed Risperdal (antipsychotic medication) 1 mg (milligram) bid (twice daily) routinely with no indication for use. 2. Review of the admission Record, located on the Face Sheet in the EMR, indicated R41 was admitted to the facility on [DATE] with diagnoses of acute pulmonary edema, major depressive disorder, unspecified dementia, repeated falls, and anxiety disorder. Review of the EMR admission MDS with an ARD of 01/14/22, revealed R41 was moderately cognitively impaired and was documented to have a diagnosis of dementia. The MDS documented R41 as exhibiting disorganized thinking, but indicated R41 did not exhibit behaviors of hallucination or delusions. Section N: Medications of the MDS documented R41 as receiving the following types of medications: Antipsychotic 0 days; Antianxiety 6 days; Antidepressant 7 days; Hypnotic 0 days; Anticoagulant 0 days; Antibiotic 0 days; Diuretic 0 days; Opioid 6 days. Section V: Care Area Assessment (CAA) Summary of the MDS documented R41 triggered the following care areas: Cognitive Loss/Dementia, Communication, Urinary Incontinence, and Indwelling Catheter, Falls, Nutritional Status, Pressure Ulcer, and Psychotropic Drug Use. Review of the Physician Order Sheet for the month of January 2022 located under the tab Physicians Orders in the EMR dated for 01/07/22 revealed an order for R41 to receive Xanax (an antianxiety medication) 0.5 mg (milligram) tablet as needed every six hours. The notes stated Indication: anxiety, agitation, Instructions: Therapeutic Range There were no orders to monitor for medication adverse side effects or resident specific target behaviors for the use of the medication Xanax. Review of the Physician Order Sheet for the month of January 2022 located under the tab Physicians Orders in the EMR dated for 01/13/22, revealed an order for R41 to receive Xanax 0.5 mg tablet every evening starting 01/13/22 Review of the pharmacy recommendations titled, Recommendation to MD From Pharmacist dated 01/15/22 stated .Updated F758 regulation states: Residents do not receive PRN psychotropic drugs unless med is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic drugs are limited to 14 days. If order needs to be extended, physician should document their rationale in the medical record and indicate the duration. PRN orders for antipsychotic drugs are limited to 14 days. Orders cannot be renewed unless physician evaluates the resident for continued appropriateness of med. In order to comply with updated psychoactive PRN medication regulation, please evaluate the following PRN medications: Xanax .5 mg q (every) 6 hr [sic] (hours) PRN (as needed) initiated in hospital. Please continue x (times) 14 days from admission [DATE]) and then reevaluate for d/c (discontinue). She also receives .5 mg q hs [sic] (hours of sleep) . Review of the pharmacy recommendations titled, Summary of Recommendations to MD and Nursing dated 01/15/22 stated .This resident receives psych meds which should have physical monitors attached to med orders so behaviors and side effects can be monitored. Non-pharmacological methods should be attempted before giving the PRN Xanax. Please add an entry so side effects can (be) monitored daily and behaviors can be monitored every shift. Please add non-pharmacological entry so nurses can document before giving PRN Xanax . Further review of the resident's EMR revealed there was no clinical rationale for the continued use of the PRN Xanax beyond the standard 14 days. Review of R41's behavioral monitoring documentation located on the Medication Administration Record (MAR) dated 02/02/22 through 02/03/22 revealed .Action: antianxiety side effects and behaviors . with no resident specific target behaviors listed. There was no consistent daily behavior documentation showing what target behavior was exhibited and what non-pharmacological intervention was attempted with the outcome prior to administering the PRN psychotropic medication for the month of January 2022, however, there was documentation to show the resident was re-directed successfully with non-pharmacological interventions. Review of the nursing progress notes titled, Progress Notes in the EMR located under the tab Progress Notes dated from 01/30/22 to 02/02/22 revealed there was documentation of R41 becoming agitated at times however, staff interviews indicated that R41 was easily re-directed without pharmacological intervention. Progress note dated 01/30/22 stated .Tramadol PRN given at 8:30 am. Patient yells and grimaces and grabs left hip during repositioning and incontinent care .PRN Xanax given at 8:30 am for agitation not resolved by redirection or other attempts. Patient will attempt to hit staff during dressing changes, incontinent care, and transfers. Patient has a purple hat that can be very calming for her to wear . Review of the Progress Note dated 02/01/22 stated .PRN Xanax continues for anxiety with good effect when used. Purple hat also helpful with calming pt [sic] (patient) An observation on 02/03/22 at 9:13 AM R41 was in in her room smiling, lying in bed, and listening to music. R41 stated, She was feeling fine, and she was happy. In an interview with the Physical Therapist (PT) on 02/02/22 at 11:54 AM, she stated R41's agitation fluctuates throughout the day. When she verbally gets frustrated and gets loud, staff redirects and speaks with her calmly. She follows commands with extra time and reminders. Her frustration is due to dementia and when she gets tired. When this happens, staff repositions her in the bed and she calms down. In an interview with LPN 3 on 02/02/22 at 11:58 AM, she stated When staff tries to get R41 out of the bed, her agitation stems from confusion, she doesn't know where she is and why she's here. Staff redirects her and speaks with her calmly and answers her questions (e.g., Where she is? Where are her kids?). Other than redirection, she is taken out of stimulating areas, staff will dim the lights in her room, etc. In an interview with the Social Worker (SW) on 02/02/22 at 2:44 PM, she stated R41's agitation depends, she has her moments. You cannot put chocolate in front of her and she likes staff to write down what they are doing today. She naturally speaks loudly and will repeat herself at least 3 or 4 times. She wants everything explained to her. She likes the engagement stations (e.g., folding clothes) she does not like big social groups, she likes listening to music, but [NAME] sets her off because that is her and her husband's song and she will get upset when she hears it. She likes the concerts, one-to-one activities, and she likes crafts, but it has to be one or two steps. If agitated staff would ask her what she wants, sometimes she gets frustrated because she cannot communicate what she wants. Staff would redirect or relocate the resident and try to find the solution and determine if she is upset because of the location or if it is too much stimulation. The facility's certified dementia training tells you how to approach the situation to determine why the residents are upset and how to resolve the issue. The resident was in memory care but now that she's in rehab and sometimes she doesn't want to participate. During a phone interview with LPN 4 on 02/03/22 at 9:58 AM, she stated At night R41 gets agitated, and she tries to get out of bed, but she isn't aggressive. If she gets agitated, I do one to one, hold the resident's hand, and then she calms down. If a PRN is given for 14 days, the resident should be reevaluated because she may need to have it routinely if that is going to be used to get her anxiety under control. When they receive training, they are introduced to residents that have a diagnosis of dementia, informed of the care plan which tells them how to proceed with providing care for the resident. 3. Review of the EMR Face Sheet for R42, revealed that R42 was admitted on [DATE] with diagnoses of but not limited to vascular dementia with behavioral disturbance, schizoaffective disorder (unspecified), anxiety disorder (unspecified), and cognitive communication deficit. Review of the MDS with an ARD of 01/16/22 revealed R42 was assessed to have short- and long-term memory deficit. Further review of the MDS assessment revealed R42 was rarely or never understood. R42 exhibited behaviors and received seven days of antipsychotics routinely. Review of R42's Physician Orders, dated from 01/13/21 through 02/01/22 located in the EMR revealed R42 had been prescribed Seroquel (an antipsychotic medication) 25 mg (milligrams) daily for the of vascular dementia with hallucinations, starting on 02/23/21. Review of R42's EMR Progress Notes dated 02/23/21 documented that the chief complaint and reason for the visit was hallucinations and medication review. The description of health present illness related to the visit stated that the patient .has dementia and is alert and only oriented to self and does follow some commands at times. She has been having hallucinations. She is a bit more anxious then normal . R42's active medical problems were listed as dementia, muscle wasting, at risk for malnutrition, closed fracture of right femur, sick sinus syndrome, and anxiety. The documented assessment and plan were: .dementia: chronic-worsening anxiety and hallucinations. Seroquel 25 mg daily started, and she was to continue Aricept and Trazadone . The diagnosis was vascular dementia without behavioral disturbance, anxiety disorder (unspecified), and hallucinations (unspecified). Review of R42's EMR Progress Notes dated 03/18/21 documented that the chief complaint and reason for the physician visit was a follow up on the hallucinations and anxiety. The description of health present illness related to the visit stated that the patient .has dementia and is alert and oriented to self and does follow some commands at times. She was started on Seroquel at her last visit for hallucinations and anxiety, which is improved. She is calm on exam. No acute concerns voiced by staff . The assessment and plan were .dementia: chronic-anxiety and hallucinations improved. Continue Seroquel 25 mg daily. She will continue on this likely indefinitely . The diagnosis was vascular dementia without behavioral disturbance, anxiety disorder (unspecified), and hallucinations (unspecified). Review of R42's EMR Progress Notes dated 05/12/21 documented that the chief complaint and reason for the physician visit was a follow up on schizoaffective disorder and dementia. The description of health present illness related to the visit stated that the patient .is alert but not oriented. She has dementia. She is on Seroquel for schizoaffective disorder. Unable to GDR current medication given this was tried in the past and she did not tolerate .The assessment and plan was schizoaffective disorder with dementia. Continue Seroquel for schizoaffective disorder without dose change today. Unable to Gradual Dose Reduce (GDR) current medication given this was tried in the past and she did not tolerate. Continue to monitor for behavior changes. Psychiatric consult placed. The diagnosis was schizoaffective disorder (unspecified). Review of R42's EMR Progress Notes dated 07/14/21 documented that the chief complaint and reason for the physician visit was the follow up on the multiple medical concerns. The description of health present illness related to the visit stated that the patient .is alert but not oriented due to dementia .The assessment and plan is .dementia: chronic baseline .insomnia: chronic trazadone, agitation: stable on Seroquel . Review of R42's EMR Progress Notes dated 07/30/21 documented that the chief complaint and reason for the physician visit was the follow up on dementia. The description of health present illness related to the visit stated that the patient .she is alert but confused secondary to dementia which appears to be at baseline without behavior disturbance noted today on exam. She is on Seroquel for behaviors secondary to dementia. GDR (Gradual Dose Reduction) attempted in the past but unsuccessful given she became agitated and anxious. She remains stable on current dose .The assessment and plan is dementia with behavioral disturbance: chronic, remains stable. Continue Aricept and Seroquel as ordered for now. She is on Seroquel for behaviors secondary to dementia. GDR attempted in the past but unsuccessful given she became agitated and anxious. Will get psychiatric consult. Continue to monitor . Review of the Medication Administration Record (MAR) for December 2021 revealed that R42 had behavioral symptoms 18 days (1, 5, 6, 7, 10, 12, 13, 14, 17, 18, 21, 22, 24, 26, 27, 28, 30, 31) of 31. Notes stated R42 was crying out/yelling/screaming for all days except for the 6th which documented R42 had delusions, on the 7th R42 was striking out, on the 12th it was documented R42 had hallucinations, and on the 24th it was documented R42 was refusing care. Review of the MAR for January 2022 revealed that R42 had behavioral symptoms 17 days (1, 2, 3, 4, 5, 7, 8, 10, 11, 12, 16, 20, 21, 24, 28, 29, 31) of 31. The notes stated that R42 was crying out/yelling/screaming on those days. Review of the EMR current comprehensive Care Plan for R42 revealed interventions as: .monitor and record mood or behavior problems; monitor for adverse effects associated with antidepressants (insomnia, restlessness, weakness, fatigue, headache, nausea/vomiting, anorexia, diarrhea, delusions, disorientation, etc.; monitor for adverse effects of medications and report to charge nurse/MD; encourage appropriate behavior and praise efforts; monitor for opportunity to decrease psychotropic medications quarterly; monitor for appetite and weight changes; remove from stressful situations as needed; encourage and assist to attend group activities or to do independent activities of choice, provide soothing type pm [sic] activities . In an interview with the Director of Nursing (DON) on 02/03/22 at 11:48 AM, she stated The facility has a functional wellness program for skilled and assistant living. Activities does weekly exercise and mobility program. Nurses and Certified Nursing Assistants (CNAs) monitor daily range of motion (ROM) for upper and lower extremities. There is not an order to document this information. The Nurses and Nurse managers, monitor psychotropics, behavioral health and psychiatric services. The Care Manager, the Nurses, and the Nurse managers monitor effectiveness of care plan. This is ongoing if something needs to be added or changed. IDT have meetings Monday-Friday (stand -up meetings), Medicare meetings are Thursdays for rehab, and they discuss LTC if anyone needs to be added to therapy, psychotropics are discussed, newly and existing psychotropics. The Nurse practitioner attends these meetings daily when things are added or discontinued. The Nurse Practitioner works under the Medical Director. The Medical Director or Nurse Practitioner can send a referral for psychiatric services for evaluation. The facility utilizes Life Source. The facility asks agency staff to come an hour before their assigned shift to have orientation to the floor. The facility utilizes shift key for online modules and testing. The staff receive yearly training on Dementia and behavior training. The facility provides a list of requirements with the agency, and they only assign staff to a shift if they meet those requirements. The facility emails these requirements to the agency. In an interview with the Pharmacist on 02/03/22 at 11:58 AM, she stated I visit the facility once a month or when needed. Monthly pharmacy review, inhouse pharmacist does initial Monthly Review Reports (MRR). I attend the Quality Assurance (QA) meetings and follow a template that asks general questions like number of prescriptions, and how many residents are on psychotropics. If the doctor does not respond to the MRR recommendation, then I will follow up the next month or two months. The facility does not consistently respond to MRR recommendations and sometimes the medical staff will document on the progress notes if they do not document on the recommendation. I review nurses' notes as far as behaviors, if meds were given and the reason, PRN medication usage, pulling up the MAR to see how often PRN medications are given. For hospice residents I use the care plan as the rationale when no evaluation or rationale to continue medication are provided. When brought up in the QA meetings the MD states that they are aware. Ideally, I would like to see on admission the MD write the order for 14 days which will discontinue the use of it if it is not reevaluated. Box warnings are placed on antipsychotic medications related to contraindications in the elderly. If a resident is on antipsychotic medication on admission, I try to find out if there are notes of a psychiatric evaluation. I haven't completed my review to see if I received any responses from the MD for the pharmacy recommendations from last month (January 2022) yet. In an interview with the Medical Director on 02/03/22 at 3:04 PM, she stated I have been with Wellmore since June/ July 2021. Primary care for over 60 residents, 20 of them are in Assisted Living (AL), and some residents are in Long Term Care (LTC) and rehab. I visit the facility once a week and am reachable by phone every day. I am involved with the Quality Assurance/Process Improvement (QAPI) meetings, every Thursday . She stated she overseen the behavioral health treatment and services for the residents in collaboration with psych services. She further stated that the management of mental health for psychotropics use was a collaborative effort with psych services. She stated the facility had overused antianxiety medications. She stated PRN medication were evaluated after 14 days to determine if they should be continued. She stated when pharmacy made their review, they usually had something in their notes and there was a form that was signed and scanned into the facility and EMR. She further stated a target behavior would be considered as yelling. If the resident were yelling once in a while that would be fine however, if it were multiple times the underlying issue should be assessed. She stated they would collaborate with the psych group to determine if a medication was appropriate for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to ensure foods stored in the kitchen were labeled, dated, and not expired. These failures had the potential to increase the prevalence and spread of foodborne illness and infection to all facility residents. Findings include: Review of the Pye [NAME] Quality Control Checklist for Cleaning of Exhaust System dated 11/18/20, 3/3/21, 8/24/21, and a 01/31/22 email and on 1/17/22, cleaning was canceled and rescheduled for 3/28/22. During a review of the facility's policy and procedures the following was revealed: The Refrigerators and Freezers policy stated .#7 All food shall be appropriately dated to ensure proper rotation by expiration dates . Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage . Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened . #8 Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes . Review of the Food Receiving and Storage policy stated .#1 Food Services, or other designated staff, will maintain clean food storage areas at all times.#7 Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first-in first out system. #8 All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date).#14. b. Food items and snacks kept on the nursing units must be maintained as indicated below: All foods belonging to residents must be labeled with the resident's name, the item and the use by date. #14. d. Beverages must be dated when opened and discarded after twenty-four (24) hours. #14. e. Other opened containers must be dated and sealed or covered during storage . On 01/31/22 at 11:01 AM, during the initial kitchen tour, the following was observed: In the main kitchen, a bag of opened carrots was observed in the refrigerator not dated, a bag of opened cooked Italian sausage was observed in the freezer not dated, and four Ziploc bags of ham hocks was observed in the freezer not labeled or dated. On the shelf in the main kitchen, the following was observed: eight bottles of expired Nepro (a nutritional supplement) with an expiration date of [DATE], 23 bottles of expired Vital HP (a nutritional supplement) with an expiration date of October 2021, and one can of dented apple pears was on the shelf in the dry storage area. Debris on the side of the kitchen hood in the main was observed. In the Rehab North Nourishment Room, three bottles of expired Osmolite (a nutritional liquid meal) were observed in the refrigerator with an expiration date of December 1,2021. In the South Rehab Nourishment Room, two white containers were observed in the refrigerator without a label and open date. One container said, No name no date. In the South Skilled Nourishment Room, one bottle of Med Pass Fortified Nutritional Shake Vanilla was observed opened without an opened date. The directions on the shake stated, Discard four days after opening. During an interview with the Dining Room Manger (DRM), Assistant Administrator (AA), and the Certified Dietary Manager (CDM) about the facility's expectation on sanitation practices and date marking and labeling revealed: on 01/31/22 at 11:26 AM, the DRM stated Staff checks dates daily. There's a new system they are piloting about food safety training where the chef and sous-chef checks labels daily. If an item is found unlabeled and the opened date is unknown they throw it out. The kitchen is audited monthly. During an interview on 01/31/22 at 12:09 PM, the AA stated All food in the refrigerator should be marked with the date it was opened, expiration date, and resident's name when applicable. Kitchen equipment is cleaned a few times a week if not every day when cleaning the kitchen. During an inteview on 01/31/22 at 12:12 PM, the CDM stated Food items in the kitchen should have the date its used, item name, use by date, and initials. Staff are trained to discard items when they are not labeled. Appliances are cleaned every day at the end of every shift.