Per interview and record review that facility failed to provide abuse training prior to a substantiated sexual assault for one out of six employees sampled. Findings include: Per interview on 11/12/24 at 1:25 PM, the Director of Nursing confirmed that the facility substantiated that LNA #1 sexually assaulted Resident #1 on 11/6/24. A review of all educational materials used to train staff on abuse, neglect, exploitation, misappropriation of resident property was reviewed while investigating the allegations of sexual abuse. The education provided included a PowerPoint titled The Manor C.A.R.E.S. and Incident reporting Requirements (CMS F-609) of Crimes of Abuse, Neglect, Injuries of Unknown Origin, Mistreatment, and Misappropriation of Property [last revised 11/23]. The facility also has an Annual Employee Education packet that contains quizzes based on training for subjects including Incident Reporting Requirements (F-609) and Resident Rights. The facility also supplied a Harassment and Sexual Harassment policy [last revised 10/22] as well as a handout discussing Suspected Physical Abuse/ Assault, Suspected Sexual Assault, and Suspected Theft. Per record review of the facility's Incident Reporting Requirements (CMS F-609) of Crimes, Abuse, Neglect, Injuries of Unknown Origin, Mistreatment, and Misappropriation of resident property policy last revised on 11/2023 states, staff and volunteers will be trained on abuse policy and procedures when beginning work, and annually thereafter. This facility will educate staff and volunteers on the Incident Reporting Requirements policy and procedures of the facility including Crimes Abuse, Neglect, Injuries of Unknown Origin, Mistreatment, and Misappropriation of resident property. Per record review of LNA #1's human resources file, there was no education in his/her file, and specifically no training on abuse. The Human Resources Director confirmed on 11/12/24 at 4:26 PM that the facility did not have any abuse education or training for LNA #1 to provide to the surveyors because LNA #1 did not complete the abuse training. Per record review, LNA #1 worked at the facility for 73 days with no abuse training or education in his/her file at the facility.

Based upon observation, interview, and record review, the facility failed to implement procedures that assure the accurate acquiring, dispensing and administering drugs to meet the needs of one resident [Res.#45] of 23 sampled residents. Finding include: Review of Res.#45's medical record reveals the resident has diagnoses that include Hypertension [high blood pressure], Hypokalemia [low potassium levels in the blood], Dementia with Behavioral Disturbance, restlessness and agitation, osteoarthritis of the right knee, and an Overactive bladder, Review of Physician Orders for Res.#45 include: Amlodipine tab - related to Essential Hypertension. Potassium Chloride tab- related to Hypokalemia Quetiapine tab- related to Restlessness and Agitation Diclofenac Topical Gel- for Right Knee pain Acetaminophen- for pain Myrbetriq Oral Tablet- for overactive bladder Review of the facility's 'Administering Medications' policy [Version 2.0 Revised Dec. 2021] includes Medications must be administered in accordance with the orders, including any required time frames. Additionally, the policy states The individual administering the medication must sign on the resident's electronic Medication Administration Record [MAR] on the appropriate space after giving the medication, the individual administering the medication will record in the resident's medical record the date and time the medication was administered, and if a drug is withheld, refused, or given at time other than the scheduled time, the individual administering the medication shall indicate such on the electronic MAR. Per interview on 2/6/24 at 4:34 PM with a Staff Nurse regarding unavailable medications; if a medication is unavailable, the resident's Nurse should check the backup medications stored in the medication room to see if the missing medication is available. If not, then call the Pharmacy to expedite delivery of the medication. The Nurse should also notify the resident's Physician if it is an 'important' medication such as to treat high blood pressure. The nurse then documents in the resident's medical record if and when the medication was given, if not why not, and contact made with the physician and if any orders were given. Review of Res.#45's Medication Administration Record [MAR] for October 2023 reveals blank spaces on the resident's MAR on 10/4/23 for the medications; Amlodipine for hypertension, Potassium Chloride for hypokalemia, Quetiapine for Restlessness and Agitation, Diclofenac Topical Gel for Right Knee pain, and Acetaminophen for pain. Review of Res.#45's medical record reveals no documentation as to why the medications were not given as ordered, if the medications were unavailable, and if the physician was notified that multiple medications were not administered as ordered to meet the needs of the resident. Review of Res.#45's MAR for November 2023 reveals blank spaces on the resident's MAR on 3 dates [11/2, 11/7, & 11/18] for Amlodipine, Potassium Chloride, Quetiapine, Diclofenac Topical Gel, and Acetaminophen. An additional medication, Myrbetriq for overactive bladder, is also blank on the MAR on 11/18. Again, Review of Res.#45's medical record reveals no documentation as to why the medications were not given as ordered, if the medications were unavailable, and if the physician was notified that multiple medications were not administered as ordered to meet the needs of the resident. Review of Res.#45's MAR for December 2023 reveals blank spaces on the resident's MAR on 12/19 for the same 6 medications: Amlodipine, Potassium Chloride, Quetiapine, Diclofenac Topical Gel, Acetaminophen, and Myrbetriq. Again, Review of Res.#45's medical record reveals no documentation as to why the medications were not given as ordered, if the medications were unavailable, and if the physician was notified that multiple medications were not administered as ordered. An interview was conducted with a second Staff Nurse on 2/7/24 at 12:56 PM. The Staff Nurse reported that the facility keeps a supply of Stock medications available in medication room. Review of the list of medications available includes 3 of Res. #45's medications not given as ordered: Amlodipine, Potassium Chloride, and Quetiapine. An interview was conducted with the facility's Quality Assurance Director on 2/7/24 at 10:00 AM. The Quality Assurance Director [QAD] confirmed that Res.#45's Medication Administration Record [MAR] contained multiple dates where multiple medications were not documented as given as ordered. The QAD also confirmed Res.#45's medical record contained no documentation as to why the medications were not given as ordered, if the medications were unavailable, and if the physician was notified that multiple medications were not administered as ordered. The QAD also confirmed that 3 of the medications not administered were available in the facility's stock medication supply. The QAD stated they would investigate why the medications were not dispensed and administered to meet the needs of Res. #45 and would report back to the surveyor. The QAD did not return with any results of an investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Per record review Resident #10 had an order for Lorazepam oral tablet 0.5 mg (an anti-anxiety medication) to be given every 8 hours as needed (PRN) for anxiety without a specified duration of days. This order was noted to have become active on 7/21/23. Per interview with the consultant Pharmacist on 2/6/24 at 11:30 AM requests for duration for PRN use of Lorazepam were made on November 23, 2023 and repeated on [DATE] without physician response. Based on interview and record review the facility failed to ensure the physician documented a duration of use or rational for extending the use for an as needed (prn) psychotropic medication for 2 of 5 sampled residents (Residents #51 and #10 ). Findings include: 1. Per record review Resident #51 has a Physicians order for Mirtazapine (antidepressant) 7.5mg every 24 hours as needed (PRN) related to dementia with psychotic disturbance. The order exceeds the required limit of 14 days with no specified duration or documented rational to exceed 14 days. During interview on 2/7/2024 at 2:30 PM the Director of Nursing (DON) confirmed that there was no documented duration or rational for exceeding the 14 day limitation for the PRN Mirtazapine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and maintain contact precautions for 1 resident [Res.# 108] of 23 sampled residents. Findings include: Per record review, Physician Orders for Res.#108 dated 1/26/24 call for Maintain contact precautions due to C-Diff unless otherwise instructed. Every shift. [Clostridioides difficile (C-Diff) is a bacterium that causes an infection of the colon. Symptoms can range from diarrhea to life-threatening damage to the colon. Because C. difficile can live outside the body, the bacteria spread easily. Not washing hands or cleaning well make it easy to spread the bacteria.] (https://www.mayoclinic.org/diseases-conditions/c-difficile/symptoms-causes/syc-20351691) Per observation, posted on the outside of Res.#108's room is a Centers for Disease Control and Prevention [CDC] sign reading STOP. CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Per observation on 2/5/24 at 9:41 AM, the resident's spouse was sitting in a chair next to the resident in bed. The spouse was holding the resident's left hand. After a few minutes' observation, the spouse exited the room with a water pitcher without washing hands, walked to the nurse's station to have the pitcher filled and returned with the water pitcher to the room. No hand hygiene was observed by the spouse prior to exiting or entering the resident's room. An interview was conducted on 2/6/24 at 9:53 AM with the spouse and the resident in the resident's room. The spouse was holding hands with the resident throughout the interview. Regarding Res.#108's contact precautions the spouse stated, I don't know what it is and I have no idea. Some kind of precautions. It might have something to do with [h/her] feet or wounds. The spouse was then observed exiting the room with no hand hygiene and walking through the Spruce and [NAME] resident units to the Care and Services Director's office. An interview was conducted with a Staff Nurse on 2/5/24 at 9:45 AM. The Staff Nurse confirmed that Res.#108 was on contact precautions and stated that anyone entering and exiting the room was required to wash their hands. An interview was conducted with a second Nurse on 2/6/24 at 9:49 AM. The nurse confirmed Res.#108's spouse was sitting with the resident in the resident's room, holding the resident's hand. The nurse confirmed the spouse had failed to wash their hands before entering the room and again after exiting the room. The nurse stated that Contact Precautions were not being properly implemented and reported they will mention it to the Charge Nurse. Per observation, there was no education provided to the spouse or the resident regarding hand washing and contact precautions during the two days of observation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to treat one of twenty nine sampled residents with respect and dignity related to the use of physical restraints, as evidenced by: Per the record review Resident # 15 is a [AGE] year-old person with diagnoses including dementia without behavior disturbance, hypertension, atrial fibrillation, and heart failure. Resident #15 has a BIMS score of 2 per the assessment of 12/19/22 (a BIMS score is determined following a brief interview of mental status. A score of 0-7 indicates severe cognitive impairment). On 2/13/23 at approximately 12:00 PM Resident #15 was observed in the assistive dining room (which also functions as a day room) seated in a Geri-chair with an approximately 6-inch wide yellow lap restraint secured with velcro in the lap area, the belt encircled the resident's trunk and back of the chair, it was also noted that the resident was seated on a chair alarm (a pressure sensitive alarm which sounds when the resident lifts from the seat). During this observation Resident #15 was noted picking up a dish containing a slice of cake and attempting to consume it. On 2/14/23 at 11:35 am observed Resident #15 in the assistive dining room sitting in a Geri chair with a yellow lap restraint wrapped only around the resident's torso. Interviewed an LNA who was present at the time to inquire what the belt was and how it worked. The LNA stated it was used to keep the resident from getting up from the chair and falling adding that the resident is kept in the dayroom so staff can keep an eye on him. On 2/14/23 at 11:50 am met with Clinical Coordinator to view the resident with a lap belt to see if the resident could release it on request. When the resident was asked what the belt was, he/she was unable to focus on the belt, when asked to release the lap belt the resident pulled at the blanket on the side of the chair and pulled at his/her pants while verbalizing in a non-coherent manner. The clinical coordinator confirmed the resident was not able to release the belt. Resident #15's electronic medical record was reviewed, and a fall risk assessment dated [DATE] was noted to contain 19 risk factors including decreased safety awareness, decreased muscle coordination, and balance problems when standing. A review of the resident care plan revealed the following intervention for the nursing diagnosis potential for injuries/trauma/falls Lap belt to be on when seated in a wheelchair, the patient is able to remove and fasten voluntarily and at will, use of posey vest when in a wheelchair to help decrease the risk of falls (nursing staff made aware). Nursing staff to make daily checks to confirm the voluntary release of belt and posey. Also noted in the care plan written in all capital letters was DO NOT LEAVE IN ROOM PLEASE ENCOURAGE RESIDENT TO REMAIN IN COMMON AREA FOR OBSERVATION DUE TO IMPULSIVITY WITH SELF RELEASING SAFETY REMINDER BELT. The record indicates the lap belt was initiated on 12/21/21, and it is noted that the resident has had 12 falls documented since the initiation of this intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to initiate and complete a thorough investigation of a possible abuse allegation in accordance with state law for 1 of 29 sampled residents (Resident #5). Findings include: Per record review Resident # 5 was admitted on [DATE] with diagnoses to include Alzheimer's disease and Major Depressive Disorder. Physician notes written between 6/9/22 - 12/26/22 reflect that the Resident has intermittent episodes of irritability and agitation. Review of the resident's care plan revealed a behavior care plan focus of alteration in thought process due to dementia. Interventions include report pain indicators, acknowledge resident's perspective and maintain safety of resident and others. Nurse's progress notes going back to July of 2022 show this resident has mood fluctuations which have resulted in episodes of anger directed at staff as noted on 07/31/22, 12/16/22, and 02/08/23. A progress note dated 10/05/22 reads that, Resident is in a bad mood, tried to take another resident's glasses and sweater . I separated the two and s/he has now settled down. Will continue to make sure they don't get close to each other as it really upset the other resident. Another progress note dated 10/26/22 reads, The LNA's told me that resident threw a cup of coffee at another resident, so we will keep them separated. During interview on 2/15/23 at 9:15 AM the Director of Nursing confirmed that throwing coffee at another resident could be considered abuse, or in the least, an incident the facility would investigate to determine abuse. The DNS also confirmed that there was no further documentation regarding the incident in the medical records and no assessments were completed specific to the other resident involved. An investigation was not initiated or completed because administration, had not been made aware of the incident by the facility staff member who documented the incident. Review of the facility policy titled Abuse Prevention Policy and Procedure and Reporting Requirements last reviewed and revised on 10/22, Page 6 reads, All episodes of witnessed or suspected abuse .must be reported to the Supervisor or Administrator/designee immediately. During off hours and weekends, the nursing supervisor is to contact the Director of Nursing Services or designee as soon as the incident has been reported. The policy also reads that, The Administrator/designee will investigate the incident in the following ways: a. By interviewing all persons who may have knowledge of the incident. b. By reviewing medical records or other written reports. c. Or by taking any other action(s) believed to be helpful in establishing the facts of the incident . On page 9 of the policy specific to Follow-Up it reads, All employees must orally report any incidents of witnessed or suspected altercations between residents/vulnerable adults to the supervisor immediately. This oral report must be followed by a written report within six hours of the altercation. During the interview on 2/15/23 at 9:15 AM the DNS confirmed the above policy was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to review and/or revise care plans regarding fall prevention for 2 residents (#17 0) of 29 sampled residents. Findings include: 1. Per record Review, Resident #17 was admitted to the facility on [DATE] and has diagnoses that include acute respiratory failure, mild acute heart failure, and history of falls. Since his/her admission, S/he has sustained falls on 8/13/22, 8/15/22, 8/18/22, 8/23/22, 8/25/22, 8/30/22, 9/5/22, 9/17/22, 11/16/22, 1/26/23, and 2/7/23. Review of Resident #17's care plan does not reveal any interventions to prevent falls on after S/he suffered from falls on 8/18/22, 9/5/22, 9/17/22, 11/16/22, and 1/26/22. Per interview on 2/15/23 at 1:13 PM, the DON stated that it is hard for staff to know what are new care interventions and where to enter interventions the way it is set up in the electronic medical system. S/He confirmed that Resident #17 did not have new interventions added to his/her care plan for each fall since his/her admission. 2. Per record Review, Resident #48 was admitted to the facility on [DATE] and has diagnoses that include dementia with behavioral disturbances, neurogenic bladder [loss of bladder control], and anemia. Since his/her admission, S/he has sustained falls on 7/25/22, 8/31/22, 9/18/22, 11/23/22, 1/3/23, 1/8/23, and 1/11/23. Review of Resident #48's care plan does not reveal any interventions to prevent falls on after S/he suffered from falls on 7/27/22, 9/18/22, 1/3/23, 1/8/23, and 1/11/23. Per interview on 2/15/23 at 1:13 PM, the DON confirmed that Resident #48 did not have new interventions added to his/her care plan for each fall since his/her admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to ensure 5 residents [#15, #21, #51, #17, & #48] of 29 sampled residents remained free of accident hazards as possible regarding adequate supervision, implementing interventions to reduce hazards and risks, and assessing interventions for effectiveness: Findings include: Review of the facility's Resident Falls and Incident Reporting policy includes It is The Manor Policy to promote an environment that minimizes the occurrence of falls and other incidents that place residents at increased risk for injury . minimizing injury through the use of . post incident monitoring and post incident analysis are an integral part of The Manor's approach to resident safety. Under the policy's Prevention section is All staff are responsible for identifying and addressing conditions that may place residents at increased risk of falling . care plans will be updated based on identified needs. 1.) Per record review Resident #15 is a 90-old person with diagnosis including dementia without behavior disturbance, hypertension, atrial fibrillation, and heart failure. Record review reveals Resident #15 has sustained numerous falls including, 2 falls on both 2/14/22 and 2/15/22, 1 fall on 4/13/22, 4/19/22, 6/1/22, 8/1/22 and 11/26/22. A review of Resident #15's care plan revealed that the most recent care plan update was completed on 11/26/22. Following the update to the care plan Resident #15 suffered 3 more falls (12/26/22, 12/29/22, and 2/8/23). The fall on 2/8/23 resulted in documented injuries including a skin tear, avulsion (a traumatic injury in which one or more pieces of tissue are torn and detached from the body), and a hematoma (collection of blood beneath the skin) to the right forearm. On 2/14/23 the DON confirmed the care plan had not been revised since 11/26/22. 2.) Per record review, Res. #21 was admitted to the facility with diagnoses that include depression, functional quadriplegia, psychoactive substance use, and wandering. The resident's Care Plan identified the resident as having Potential for Trauma- falls, due to Impaired balance, decreased mobility, unsteady gait, and use of devices for walking. Shortly after Res. #21's admission, several interventions are added to the Care Plan to decrease the risk of falls, dated 3/2/22. Review of the facility's Resident Falls and Incident Reporting policy includes It is The Manor Policy to promote an environment that minimizes the occurrence of falls and other incidents that place residents at increased risk for injury . minimizing injury through the use of . post incident monitoring and post incident analysis are an integral part of The Manor's approach to resident safety. Under the policy's Prevention section is All staff are responsible for identifying and addressing conditions that may place residents at increased risk of falling . care plans will be updated based on identified needs. A review of Nurses Notes for Res. #21 reveal: On 11/8/22 at 8:46 PM resident fell onto [his/her] left side in hallway while ambulating with walker in hallway. On 11/13/22 at 12:30 AM Licensed Nurses Aid [LNA] was walking in hallway and when passed by resident's room, found resident lying on floor by bed. On 11/14/22 at 8:40 AM resident found on floor with walker in front of [him/her] . per previous staff notes resident has been exhibiting similar behavior past few days. On 11/17/22 at 3:16 AM LNA hears resident hollering help. Resident noted kneeling on the floor next to her bed with vomit on self and bed. Review of Res. #21's Care Plan after the fall on 11/8/22 reveals interventions repeated from the Care Plan dated 3/2/22, with no new interventions added to prevent future falls. When Res. #21 falls again 5 days later on 11/13/22, there is no mention of the fall in the resident's Care Plan and no changes or new interventions added. Per Nurses Notes, Res. #21 falls again the next day, 11/14/22, and the Care Plan again repeats interventions from 3/22/22 that have not prevented the resident from falling on 11/8/22, 11/13/22, and 11/14/22. No new interventions were added to the Care Plan. On 11/17/22, 3 days after the last fall, Res. #21 falls again. The resident's Care Plan on 11/21/22 notes the fall and lists continue with plan of care: no new interventions are added. An interview was conducted with the facility's Director of Nursing [DON] on 02/15/23 at 8:36 AM. The DON confirmed that despite the 4 documented falls listed above, the facility did not add any new interventions to Res. #21's Care Plan to prevent future falls. 3.) Per record review, Res. #51 was admitted to the facility with diagnoses that include a displaced fracture of the right lower leg, stroke, and dementia. The resident's Care Plan identified the resident as having Potential for Trauma- falls, due to gait/balance, history of falls, dementia/cognitive impairment, and age related physical decline. A review of Nurses Notes for Res. #51 reveal: On 1/6/23 at 4:02 PM Activity assistant updated nurse that resident was on the floor. Staff went to room and observed recliner in upright position, resident on floor in front of recliner, on back with blanket and pillow on ground with resident. On 1/15/23 at 12:30 PM LNA found resident on floor and notified nursing. Review of Res. #51's Care Plan reveals no mention of either fall. Further review reveals no new interventions added to Res. #51's Care Plan after the fall on 1/6/23. When the resident falls again on 1/15/23, again no new interventions are added to the Care Plan. An interview was conducted with the facility's Director of Nursing [DON] on 02/15/23 at 8:36 AM. The DON confirmed that the facility did not add any new interventions to Res. #51's Care Plan to prevent future falls after either fall on 1/6/23 or 1/15/23. 4.) Per record Review, Resident #17 was admitted to the facility on [DATE] and has diagnoses that include acute respiratory failure, mild acute heart failure, and history of falls. Since his/her admission, S/he has sustained falls on 8/13/22, 8/15/22, 8/18/22, 8/23/22, 8/25/22, 8/30/22, 9/5/22, 9/17/22, 11/16/22, 1/26/23, and 2/7/23. Review of Resident #17's care plan does not reveal any interventions to prevent falls on after S/he suffered from falls on 8/18/22, 9/5/22, 9/17/22, 11/16/22, and 1/26/22. Per interview on 2/15/23 at 1:13 PM, the DON stated that Resident #17 did not have new interventions added to his/her care plan for each fall since his/her admission. 5.) Per record Review, Resident #48 was admitted to the facility on [DATE] and has diagnoses that include dementia with behavioral disturbances, neurogenic bladder [loss of bladder control], and anemia. Since his/her admission, S/he has sustained falls on 7/25/22, 8/31/22, 9/18/22, 11/23/22, 1/3/23, 1/8/23, and 1/11/23. Review of Resident #48's care plan does not reveal any interventions to prevent falls on after S/he suffered from falls on 7/27/22, 9/18/22, 1/3/23, 1/8/23, and 1/11/23. Per interview on 2/15/23 at 1:13 PM, the DON confirmed that Resident #48 did not have new interventions added to his/her care plan for each fall since his/her admission.

Based on staff interview and record review, the facility failed to ensure PRN (as needed) orders for psychotropic drugs are limited to 14 days for 3 of 29 sampled residents (Residents #11, #33, and #34) and that a GDR (gradual dose reduction) was attempted for 2 of 29 sampled residents (Resident #20 and #50). Findings include: 1. Review of Resident #11's medical record reveals a physician order dated 1/13/23 for Clonazepam (anti-anxiety; psychotropic) 0.25 milligrams (mg) every 8 hours as needed for anxiety/air hunger with no end date. Review of Resident #11's medication administration record (MAR) reveals they are currently receiving approximately one as needed dose per day. A Pharmacist recommendation from 2/3/23 states Per the November 2017 Medicare MEGA Rule regulations, if PRN psychotropic medications are to be continued, they need a specific duration & rationale for continuing use. Resident has the following order: Clonazepam 0.25 mg po q8hrs prn [by mouth every 8 hours as needed] anxiety/air hunger. Resident has requests ~one dose per day . Please document rationale for continuing this order. 2. Review of Resident #33's medical record reveals a physician order dated 1/9/23 for Lorazepam (anti-anxiety; psychotropic) 0.5 mg every 8 hours as needed for anxiety with no end date. Review of Resident #33's MAR reveals they received the as needed dose once in January 2023. A Pharmacist recommendation from 2/3/23 states Per the November 2017 Medicare MEGA Rule regulations, if PRN psychotropic medications are to be continued, they need a specific duration & rationale for continuing use. Resident has the following order: Lorazepam 0.5 mg po q8hrs prn [by mouth every 8 hours as needed] anxiety. Resident has used one dose since this order was started 1/9/23 . Please document rationale for continuing this order. 3. Review of Resident #34's medical record reveals physician orders for Lorazepam 0.5 mg every 2 hours as needed for anxiety with no end date starting 11/16/22, and Prochlorperazine 10 mg every 6 hours as needed for nausea with no end date starting 1/13/23. Review of Resident #34's MAR reveals they are currently receiving approximately 1-5 as needed doses of Lorazepam per day. A Pharmacist recommendation from 2/3/23 states This portion of my consult is repeated from December, as it has not yet been addressed. Per the November 2017 Medicare MEGA Rule regulations, if PRN psychotropic medications are to be continued, they need a specific duration & rationale for continuing use. It appears that the following order had a change in directions 11/19/11, but no duration given: Lorazepam 0.5 mg po q2hrs prn [by mouth every 2 hours as needed] anxiety. Resident does use anywhere from 2-5 doses per day . Please document rationale for continuing this order, and Resident has the following order: Prochlorperazine 10 mg po q6hrs prn [by mouth every 6 hours as needed] nausea. Though this med is used for nausea, it is classified as an antipsychotic & is therefore subjected to the MEGA rule & PRN orders can only be used for 14 days. 4.Review of Resident #20's clinical record reveals a physician order dated 7/27/22 for Fluoxetine (an antidepressant and psychotropic) 40 mg daily. Review of Resident #20's MAR reveals they are currently receiving this medication as ordered. A Pharmacist recommendation from 1/5/2023 states Per survey guidelines, it is time for me to ask for a Gradual Dose Reduction (GDR) of Resident's antidepressant. They currently receive: Fluoxetine 40 [by mouth daily]. Consider a dose reduction to Fluoxetine 30 mg [by mouth daily]. During their most recent MDS mood interview, they did not have any complaints. In your October note, you mentioned reassessing in the winter if dose could be decreased or discontinued. If a GDR is not indicated, please document a RISK/BENEFIT note or an official 'no GDR' note, so we can be complaint for Survey. 5. Review of Resident #50's medical record reveals physician orders dated 5/25/22 for Aripiprazole [Abilify; antipsychotic] 30 mg daily in the morning, Citalopram [antidepressant; psychotropic] 10 mg daily in the morning, Quetiapine [Seroquel; antipsychotic] 100mg daily in the morning and 600 mg daily in the evening. Review of Resident #50's MAR reveals they are currently receiving these medications as ordered. A Pharmacist recommendation from 11/4/2022 states Per Survey Guidelines, each psychotropic Medication requires periodic attempts at GDRs (Gradual Dose Reductions). Resident currently receives: Abilify 30 mg po qd [by mouth once daily], Citalopram 10 mg po qd [by mouth once daily], Seroquel 100 mg po qam [by mouth every morning] + 600 mg po hs [by mouth every evening]. I am aware that Resident has long standing schizophrenia. If you wish to continue their current regimen, please document a RISK/BENEFIT note or why a GDR would be contraindicated at this time. Per interview on 2/15/23 at 1:13 PM, the Director of Nursing (DON) stated that the facility had lost a provider and there are new providers. S/He confirmed that PRN psychotropic medications need an end date and there were no end dates for the PRN psychotropic medications prescribed to Residents #11, #33, and #34, and a GDR had not been attempted or documented for Residents #20 and #50. On 2/15/23 at 2:35 PM, the DON confirmed that a physician did not include the required rational for not attempting a GDR in Resident #20's and #50's medical record.

Based on interview and review of documentation, the facility failed to designate a physician to serve as medical director and who coordinates medical care and implements facility policies. Findings include: On 02/15/23 review of the facility's documentation of Quality Assurance Performance and Improvement (QAPI) meeting agenda and staff attendee signature sheets, reveal the presence of a medical director's participation at meetings for the following dates: April 2022, July 2022, and October 2022 on a quarterly bases, however there is no proof of attendance at a meeting held on January 17, 2022. The next quarterly meeting is due to be held in April 2023. Interview on 02/15/23 at 1:30pm with the Administrator, Director of Quality, and the Director of Nursing reveals that the facility does not currently have a Medical Director. (cross tag F 868)

Based on interview and review of documentation, the facility failed to maintain the position of a Medical Director as part of the Quality Assurance Performance and Improvement (QAPI) committee. Findings include: On 02/15/23 review of the facility's documentation of Quality Assurance Performance and Improvement (QAPI) meeting agenda and staff attendee signature sheets, reveal the presence of a medical director's participation at meetings for the following dates: April 2022, July 2022, and October 2022 on a quarterly bases, however there is no proof of attendance at a meeting held on January 17, 2022. The next quarterly meeting is due to be held in April 2023. Interview on 02/15/23 at 1:30pm with the Administrator, Director of Quality, and the Director of Nursing reveals that the the facility does not currently have a medical director. (cross tag F841)

Based on interview it was determined that the facility failed to ensure a system to prevent and identify causes of infection by failing to develop and implement measures to prevent the growth of Legionella in the facility's water system. Findings include: Per the Mayo Clinic: 'Legionnaires' disease is a serious type of pneumonia you get when Legionella bacteria infect your lungs. Symptoms include high fever, cough, diarrhea, and confusion. You can get Legionnaires' disease from water or cooling systems in large buildings, like hospitals or hotels. Legionnaires' disease can be life-threatening. (https://www.mayoclinic.org/diseases-conditions/legionnaires-disease/symptoms-causes) On 2/15/23 at 10:09 AM an interview was conducted with the Director of Nurses (DON), who is also one of the two Certified Infection Preventionist (CIP) in the facility, revealed that S/he is unaware of Centers for Disease Control (CDC) and Center for Medicare and Medicaid Services (CMS) required that the facility have Legionella prevention measures in place and referred to the Maintenance Director and/or the Administrator. On 02/15/23 at 1:30 PM an interview with the Facility Administrator revealed that S/he was unaware of the CDC and CMS requirements related to prevention of Legionella in the facilities water system. The Administrator confirmed that the facility does not have measures in place to prevent the growth of Legionella in the facility water system.