**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of twenty residents in the survey sample (Resident #56). The findings include: Section L. of Resident #56's annual MDS dated [DATE] assessed the resident with no dental impairments when the resident had multiple broken teeth with likely decay. Resident #56 was admitted to the facility with diagnoses that included hypertension, glaucoma, heart failure, anemia, obstructive sleep apnea, epilepsy, vitamin D deficiency and atrial flutter. The MDS dated [DATE] assessed Resident #56 with moderately impaired cognitive skills. On 2/6/23 at 3:15 p.m., Resident #56 was interviewed about quality of life and care in the facility. During this interview, Resident #56's lower bottom teeth were observed fragmented near the gum with dark, jagged areas on the tooth fragments. Resident #56 was interviewed at this time about the condition of his teeth. Resident #56 displayed his front teeth showing multiple broken teeth with dark gray/black areas of possible decay. Resident #56 stated he had several broken teeth and the lower front teeth were decayed almost to the gum. Resident #56 stated his teeth had been in poor condition prior to his admission to the facility. The resident's annual MDS with an assessment reference date of 1/12/23 documented in section L0200 that the resident had no dental issues. Item Z. in this section was checked indicating no tooth fragments, no obvious/likely cavities or broken natural teeth. On 2/7/23 at 4:00 p.m., the registered nurse MDS coordinator (RN #1) was interviewed about Resident #56's broken, fragmented teeth and the conflicting assessment indicating no dental issues. RN #1 stated the resident had broken, fragmented teeth. After reviewing the 1/12/23 MDS, RN #1 stated section L0200 was inaccurately coded indicating no dental issues. RN #1 stated item D. in section L0200 should have been marked indicating the resident had obvious or likely cavities and broken natural teeth. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual on pages L-1 and L-2 documented regarding section L. Oral/Dental status, .Assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions, such as aspiration, malnutrition, pneumonia, endocarditis, and poor control of diabetes . Conduct exam of the resident's lips and oral cavity . Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth .Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen . (1) This finding was reviewed with the administrator and director of nursing during a meeting on 2/7/23 at 5:10 p.m. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, Centers for Medicare & Medicaid Services, Revised October 2019

Based on medication pass and pour observation, staff interview, and clinical record review the facility staff failed to follow physician's orders for Resident # 58. Findings include: A medication pass and pour observation was conducted 2/7/23 beginning at 8:20 a.m. with LPN (licensed practical nurse) # 1. LPN # 1 prepared medications for Resident # 58, which included acetaminophen (Tylenol) 325 mg, two tablets. On 2/7/23 at approximately 9:05 a.m. the clinical record was reviewed to reconcile medications observed having been administered to the resident. An order with a start dated of 8/28/22 and included on the current POS (physician order summary) directed Tylenol Ex-Str 500 mg tablet- 2 tabs (1000 mg) po (by mouth) BID (twice a day) for general and/or mild pain . On 2/7/23 at approximately 9:35 a.m. LPN # 1 was asked about the discrepancy in what was observed administered, and the physician order. LPN # 1 stated Yes, she gets the 1000 mg tabs here on the medication card . LPN # 1 went to pull the card, stopped, and stated But that's not what I gave her, is it? I gave the 'house stock' Tylenol of 325 mg that's a med error On 2/7/23 the administrator and DON (director of nursing) were informed of the above findings. The DON stated LPN # 1 called me and told me what happened; we got a one time order from the medical director for additional Tylenol to equal the 1000 mg. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of employee personnel files and staff interview, the facility failed to ensure one of 25 employees reviewed was currently licensed. A Certified Nursing Assistant (CNA A), was working with an expired license, and did not renew the licensed until [DATE]. The findings were: On [DATE], during review of employee personnel files, a CNA A who was hired on [DATE] was found to have a Nurse Aide license that expired on [DATE]. The surveyor reported the finding to the Administrator and the Director of Nursing (DON) and asked if they could find a current license for the CNA A. At approximately 2:30 p.m. on [DATE], both the Administrator and the DON indicated there was not a current license on file for the CNA A. Asked if the CNA Awas still working, the DON said, Yes. The DON went on to say they were in phone contact with the CNA A and she (the CNA A) was in the process of sending them a copy of her license via text message. At approximately 3:00 p.m. on [DATE], the DON furnished the surveyor with a copy of the license sent by the CNA A. The license consisted of an Online Licensing Payment Receipt from the Board of Health Professions, which had a received date and time of [DATE] at 2:49 p.m. The matter of the expired license was discussed during a meeting with the administrative staff and the survey team prior to the Exit Conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for one of 20 residents in the survey sample. Resident #18's clinical record documented an inaccurate response to a pharmacy recommendation regarding use of an antipsychotic medication and documented psychotropic medication management by a consultant when psychiatric services had been discontinued. The findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included dementia with Lewy bodies, depression, psychosis, osteoarthritis and gout. The minimum data set (MDS) dated [DATE] assessed Resident #18 with short and long-term memory problems and severely impaired cognitive skills. Resident #18's clinical record documented a physician's order dated 6/22/18 for the medication Seroquel 50 milligrams (mg) to be given at each bedtime for management of dementia with aggressive behaviors. The clinical record documented a physician's order dated 2/22/21 to discontinue all psychiatric consultant services for Resident #18. A nursing note dated 2/22/21 listed all psychiatric services as discontinued because the resident was now on hospice. Resident #18's clinical record documented a pharmacy recommendation about a Seroquel dose reduction dated 2/2/21. The consultant psychiatrist documented a response on 2/9/21 to decline a reduction in the Seroquel dose. This response to the pharmacy recommendation was uploaded to the electronic health record on 3/19/21. Resident #18's clinical record documented a duplicate pharmacy recommendation about a Seroquel dose reduction dated 3/9/21. A physician's assistant (PA) documented a response to the recommendation on 3/15/21 stating the resident was followed by psychiatric consultant services even though the psychiatric services had been discontinued on 2/22/21. Resident #18's current physician order summary (printed 5/5/21) documented an order dated 3/2/17 stating a consultant psychiatrist managed the resident's psychotropic medications when psychiatric services were discontinued as of 2/22/21. On 5/5/21 at 2:05 p.m., the director of nursing (DON) was interviewed about the conflicting pharmacy recommendation responses and clinical record references to psychiatric services when the psychiatrist was discontinued on 2/22/21. The DON stated the original pharmacy recommendation about the Seroquel dose reduction was made on 2/2/21. The DON stated the psychiatrist response was not scanned into the electronic health record promptly. The DON stated when the pharmacist performed the next monthly medication review on 3/9/21 she found no response to the previous recommendation in the clinical record so re-issued another recommendation. The DON stated the response to the 2/2/21 recommendation was not uploaded into the electronic health record until 3/19/21, after the pharmacy review for March. The DON stated the information documented by the PA on the 3/9/21 recommendation that a consultant managed the psychiatric medications was not accurate as psychiatric services for Resident #18 were discontinued on 2/22/21. On 5/5/21 at 3:15 p.m., the DON stated documents were usually scanned and uploaded to the electronic health records daily. The DON stated Resident #18's pharmacy recommendation response dated 2/9/21 must have been missed. This finding was reviewed with the administrator and DON during a meeting on 5/5/21 at 3:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility staff failed to ensure a pharmacy GDR [gradual dose reduction] recommendation was completed for one of 20 residents [Resident #8]. Resident #8's physician signed a GDR pharmacy recommendation for Lunesta [a hypnotic medication for sleep] to be decreased from 2 mg [milligrams] to 1 mg nightly; however, Resident #8 continued to received 2 mg nightly for over 5 months. Findings include: Resident #8 was admitted to the facility on [DATE]. Diagnoses for Resident #8 included, but were not limited to: Parkinson's disease, Alzheimer's dementia, restless leg syndrome, anxiety disorder, and insomnia. The most current MDS (minimum data set) was a quarterly assessment dated [DATE]. This MDS assessed the resident as having short and long term memory impairment with severe impairment in daily decision making skills. Resident # 8's clinical records were reviewed on 05/05/21. A pharmacy recommendation dated 11/10/20 documented, .resident has been taking .hypnotic Lunesta 2 mg [milligram] .along with Melatonin 9 mg. Upon review, no episodes of insomnia were noted .please evaluate the current dose and consider a dose reduction .attempt dose reduction to Lunesta 1 mg .and continue current Melatonin . The physician marked agreed to the dose reduction from 2 mg to 1 mg and signed the recommendation on 11/16/20. Resident # 8's current physician's orders were reviewed and revealed the resident was still receiving Lunesta 2 mg every night, along with Melatonin 9 mg each night. The pharmacy recommendation dated 11/10/20 that the physician signed had not been completed. The resident's behavior tracking sheets for the medication Lunesta were reviewed from November 2020 through present [May 2021]. There were no behaviors listed. A pharmacy recommendation dated 03/09/21 was also reviewed. This recommendation documented, .resident has been taking .hypnotic Lunesta 2 mg [milligram] .along with Melatonin 9 mg. Upon review, no episodes of insomnia were noted .please evaluate the current dose and consider a dose reduction .attempt dose reduction to Lunesta 1 mg .and continue current Melatonin . The DON [director of nursing] signed that the recommendation was reviewed and signed on 03/13/21. There were three boxes to be checked by the provider, which were agree, disagree or other; none of the boxes were marked. A hand written entry by the DON documented, POA [power of attorney] does not want any changes. The PA [physician's assistant] signed this pharmacy recommendation. There was no clinical justification listed on the pharmacy recommendation or in the resident's clinical record. Resident #8's current care plan dated 04/26/21 was reviewed and documented, .receiving hypnotic medication .is necessary to treat insomnia .will receive gradual dose reduction, unless clinically contraindicated, in an effort to discontinue hypnotic medication .assure therapeutic dose .pharmacy recommendation to reduce dose of Lunesta declined per MD/PA [medical doctor/physician's assistant] review .will continue hypnotic . On 05/05/21 at 12:30 PM, the DON was made aware of the above information and was asked for clarification as to why the pharmacy recommendation dated 11/10/20 was not carried out and the resident continued to receive this medication for over 5 months. The DON was also asked to clarify why pharmacy recommendation dated 03/09/21 was not completed by the provider with a clinical justification if the medication was to be continued. On 05/05/21 at 2:00 PM, the administrator and DON were interviewed. The DON stated that a nursing note was written on 11/16/20 and stated that the nurse had called the resident's POA [power of attorney] and that the resident's POA did not want any changes to the resident's medications and that the physician agreed. The DON and administrator were made aware that there was no evidence in the resident's clinical record to evidence that the physician did not want to proceed with a GDR for Lunesta and that the family/POA not wanting medication changes for Resident #8 was not a clinical rationale for the continued use of this medication at a higher dose. No further information and/or documetnation was presented prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and clinical record review, facility staff failed to ensure an accurate Code Status for one (1) of 20 residents in the survey sample, Resident #31. Findings included: Resident #31 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Prostate CA (cancer) with metastasis to the vertebral column, Radiation Proctitis, Anemia, Hypertension, and Dementia. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 04/25/2019. Resident #31 was assessed as moderately impaired in his cognitive status with a total cognitive score of nine (9) out of 15. Resident #31's EMR (electronic medical record) was reviewed on 06/05/2019 at 10:00 a.m. While reviewing the Profile Page the Resuscitate status at the top of the page was noted as Yes-Full Code. On the same page, a chart flag included a DNR box (do not resuscitate). The physician order sheet dated June 2019 included an order originally dated 02/02/19, .Do Not Resuscitate . RN #1 (registered nurse) was interviewed on 06/05/2019 at 10:50 a.m. regarding where to locate a resident's code status. RN #1 stated, I look at the smart chart and then look at attachments to make sure a signed DNR is scanned into the system. LPN #1 (licensed practical nurse) was interviewed at 10:52 a.m. and she stated, I just look at the smart chart tab. I have never looked at the Resuscitate at the top of the screen. RN #1 called the SW (social worker) and asked who is responsible for filling in the Resuscitate portion on the profile page. The SW came to the sixth floor nurse's station and stated, That information is entered by [Name] (Medical Records) on admission. If the Code status changes, then the nurse should change on the profile screen. On 06/05/19 at 01:20 p.m. the DON (director of nursing) was interviewed regarding code statuses. The DON stated, We are working with AOD (answers on demand-computer system) right now. When the code status is Full Code or DNR this should automatically change the Resuscitate status in the computer. It is a glitch in the system and they are working on it. Hopefully it will be corrected in the next 24 hours. The Administrator was informed of the above information during a meeting with the survey team on 06/05/19. No further information was received prior to the exit conference.