Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to administer the physician ordered vitamin Certavite senior for 1 of 33 residents, Resident #44. The findings included: For Resident #44, the facility staff failed to administer the physician ordered vitamin Certavite senior per the physicians order. Resident #44's clinical record included the diagnosis Alzheimer's disease, dysphagia, benign prostatic hyperplasia, and cognitive communication deficit. Resident #44's annual MDS (minimum data set) assessment with an ARD (assessment reference date) of 11/17/21 included a BIMS (brief interview for mental status) summary score of 3 of 15. 01/26/22 7:43 a.m., the surveyor observed LPN (licensed practical nurse) #1 prepare and administer Resident #44's morning medications. After this observation, the surveyor reconciled Resident #44's medications using the clinical record. Resident #44's clinical record included an order for Certavite senior/antioxidant tablet (multiple vitamin with minerals) give 1 tablet by mouth one time a day for supplement with an order date of 12/11/2020. Per the medication administration record, this medication was to be administered at 9:00 a.m. daily. The surveyor did not observe this medication being prepared or administered. 01/26/22 8:04 a.m., LPN #1 stated the Certavite was house stock and they had forgotten to administer it. LPN #1 pulled the bottle of Certavite from the medication drawer, placed it into a clear medication cup, and stated they would administer it to Resident #44. 01/26/22 4:00 p.m., the administrator, DON (director of nursing), assistant administrator, and ADON (assistant director of nursing) were made aware of the issue regarding Resident #44's Certavite. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation the facility staff failed to provide a private uninterrupted space for council meeting. The findings included On 5/22/19 at 10:47 am, the surveyor was conducting a group meeting with the Resident council. The surveyor observed a facility staff member come into the room where the group meeting was being conducted. The surveyor observed the staff member place a tray on a tray cart and then removed the entire tray cart from the room. On 5/22/19 at 3:45 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/22/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, and clinical record review, the facility staff failed to ensure that 1 of 37 Residents in the survey sample was free of restraints, Resident # 55. The findings included The facility staff had fall mats and bed and chair alarms in place for Resident # 55, which restricted Resident # 55 from moving and transferring. Resident # 55 was a [AGE] year-old-male who was admitted to the facility on [DATE]. Diagnoses included but were not limited to; obstructive and reflux uropathy, hypertension, type 2 diabetes mellitus, and benign prostatic hyperplasia. The clinical record for Resident # 55 was reviewed on 5/21/19 at 4:05 pm. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 3/15/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 55 had a BIMS (brief interview for mental status) score of 12 out of 15, which indicated that Resident # 55 was cognitively intact. On 5/21/19 at 3:07 pm, the surveyor was in the hallway outside of Resident # 55's room and heard an alarm sounding. The surveyor knocked and was invited into the room by Resident # 55. The surveyor entered the room to observe Resident #55 sitting in his wheelchair with a bed alarm in his hand attempting to stick his finger in a hole on the bottom of the bed alarm. Resident # 55 stated, I'm trying to get my finger in here to turn this thing off. I hate this thing; it makes you scared to move because this thing goes beep, beep, beep every time you move. Resident # 55 then stated, They keep putting those mats down and they get in the way of embarking and disembarking. They restrict me every chance they get when they put those pads down. Resident # 55 pointed at fall mats that were down on the floor next to his roommate's bed and fall mats that were observed against the wall on Resident # 55's side of the room. The surveyor observed that the fall mat that was down next to Resident # 55's roommate's bed extended to Resident # 55's side of the room and was positioned against the wheels on Resident # 55's wheelchair. On 5/22/19 at 8:16 am, the surveyor reviewed the clinical record for Resident # 55. The surveyor observed a telephone order that was written on 5/3/19. The telephone order was documented as, D/C (discontinue) bed/chair alarms & low beds with mats d/t (due to) not attempting to get up unassisted. On 5/22/19 at 3:45 am, the administrative team was made aware of the findings as stated above. No further information regarding this issue was provided to the survey team prior to the exit conference on 5/23/19.

Based on staff interview, clinical record review, facility document review, and during a medication pass and pour observation, the facility staff failed to follow standards of professional practice for 1 of 37 Residents, Resident #16. The findings included: The facility staff failed to obtain the resident's apical pulse prior to administering the medication digoxin. The clinical record review revealed that Resident #16 had been admitted to the facility 10/21/10. Diagnoses included but were not limited to, dementia, delusional disorders, heart failure, atrial fibrillation, and hypertension. Section C (cognitive patterns) of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/13/19 included a BIMS (brief interview for mental status) summary score of 4 out of a possible 15 points. The resident's comprehensive care plan included the following focus areas-has altered cardiovascular status related to congestive heart failure and atrial fibrillation and is on digoxin therapy. Interventions included, but were not limited to, vital signs as ordered and report to physician if pulse falls below 60 or rises above 110 or if you detect skipped beats or other changes in rhythm. On 05/22/19 at 8:24 a.m., the surveyor observed LPN (licensed practical nurse) #3 prepare and administer Resident #16's morning medications to include the medication digoxin 125 mg. Prior to administering the resident's medications LPN #3 obtained the resident's blood pressure (124/58) and pulse (77) using an electronic blood pressure machine. After this medication observation, the surveyor used the resident's clinical record to reconcile the resident's medications. The resident's clinical record included the order digoxin 125 mcg one time a day related to atrial fibrillation hold for apical pulse less than 60 beats per minute. After this reconciliation, the surveyor interviewed LPN #3. LPN #3 was asked how she had obtained the resident's pulse. LPN #3 replied, I should have used my stethoscope. The unit included a Mosby's Nursing Drug Reference book that included the following information regarding the medication digoxin .NURSING CONSIDERATIONS Assess: Apical pulse for 1 min (minute) before giving product, if pulse < (less than) 60 in adult take again in 1 hr (hour) .Cardiac Status: apical pulse, character, rate, rhythm . The facility was notified of the above issue during a meeting with the survey team on 05/22/19 at 3:00 p.m. No further information was provided to the survey team prior to the exit conference.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure 1 of 37 Residents were free of accident hazards (Resident #96). The findings included: Resident #96 had a physician order for padded side rails and geri-sleeves. These were not observed to be in place. The clinical record review revealed that Resident #96 had been admitted to the facility 07/31/18. Diagnoses included, but were not limited to, dementia, altered mental status, Parkinson's disease, abnormal posture, hypertension, osteoarthritis, and benign prostatic hyperplasia. Section C (cognitive patterns) of the Residents quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 04/02/19 included a BIMS (brief interview for mental status) summary score of 4 out of a possible 15 points. Section G (functional status) had been coded to indicate the Resident required extensive assistance of one person for bed mobility. The Residents clinical record included a physicians order dated 07/18/18 for padded side rails and gerisleeves to bilateral arms at all times for protection. The Residents comprehensive care plan included the focus areas of has Parkinson's, activities of daily living/self-care deficit, limited physical mobility, high risk for falls, potential for pressure ulcer related to immobility/incontinence. Interventions included, but were not limited to, adaptive devices as recommended by therapy, geri-sleeves as ordered and padded siderails. The facility staff provided the surveyor with a copy of the tasks for this Resident these included Safety .padded siderails .Resident Care .Geri-sleeves per order . The Resident was observed on 05/22/19 at 9:40 a.m. and again at 10:39 a.m. with no geri sleeves in place and no padding to the Residents side rails. On 05/22/19 at 10:45 a.m., LPN (licensed practical nurse) #4 (agency nurse) was asked how she knew what care to provide to this Resident. LPN #4 stated she asked one of the regular CNA's (certified nursing assistants). LPN #4 and the surveyor then proceeded to the Residents room and checked the Resident and again this Resident was observed without their physician ordered geri sleeves and padding on the side rails. The facility was notified of the above issue during a meeting with the survey team on 05/22/19 at 3:00 p.m. No further information was provided to the survey team prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, Resident interview, and staff interview, the facility staff failed to ensure 1 of 37 residents in the survey sample had orders for Foley catheter, Resident # 55. The findings included: The facility staff failed to ensure that Resident # 55 had orders for Foley catheter that included catheter and bulb size. Resident # 55 was a [AGE] year-old-male who was admitted to the facility on [DATE]. Diagnoses included but were not limited to; obstructive and reflux uropathy, hypertension, type 2 diabetes mellitus, and benign prostatic hyperplasia. The clinical record for Resident # 55 was reviewed on 5/21/19 at 4:05 pm. The most recent MDS (minimum data set) assessment was a significant change assessment with an ARD (assessment reference date) of 3/15/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 55 had a BIMS (brief interview for mental status) score of 12 out of 15, which indicated that Resident # 55 was cognitively intact. Section H of the MDS assesses bladder and bowel. In Section H0100, the facility staff documented that Resident # 55 had an indwelling catheter. The plan of care for Resident # 55 was reviewed and revised on 3/28/19. The facility staff documented a focus area for Resident # 55 as, Resident # 55 has indwelling catheter: He is unable to void after removal. Interventions included but were not limited to; Change catheter per order/facility protocol. The surveyor reviewed the current orders for Resident # 55 and did not locate any orders for a Foley catheter that included a catheter and bulb size. On 5/21/19 at 3:21 pm, the surveyor was in Resident # 55's room conducting a Resident interview. The surveyor asked Resident # 55 if he had a catheter. Resident # 55 stated, I have a leg catheter. On 5/22/19 at 9:15 am, the surveyor interviewed unit manager RN # 1 (registered nurse). The surveyor asked RV # 1 if Resident # 55 had a Foley catheter. RN # 1 stated, Yes he does. The surveyor asked RN # 1 if she could show the surveyor an order for Foley catheter for Resident # 55. The surveyor and RN # 1 reviewed the current physician's orders for Resident # 55. RN # 1 stated, I see an order for catheter care, but not for the catheter. RN # 1 agreed that Resident # 55 did not have an order for a Foley catheter that included a catheter and bulb size. On 5/22/19 at 3:45 pm, the administrative team was made aware of the findings as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 5/22/19.

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to ensure 1 of 37 residents (Resident #16) was free of a significant medication error. The findings included: The facility staff failed to obtain the resident's apical pulse prior to administering the medication digoxin. The clinical record review revealed that Resident #16 had been admitted to the facility 10/21/10. Diagnoses included but were not limited to, dementia, delusional disorders, heart failure, atrial fibrillation, and hypertension. Section C (cognitive patterns) of the resident's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 02/13/19 included a BIMS (brief interview for mental status) summary score of 4 out of a possible 15 points. The resident's comprehensive care plan included the focus areas altered cardiovascular status related to congestive heart failure and atrial fibrillation and is on digoxin therapy. Interventions included, but were not limited to, vital signs as ordered and report to physician if pulse falls below 60 or rises above 110 or if you detect skipped beats or other changes in rhythm. On 05/22/19 at 8:24 a.m., the surveyor observed LPN (licensed practical nurse) #3 prepare and administer Resident #16's morning medications to include the medication digoxin 125 mg. Prior to administering the resident's medications LPN #3 obtained the resident's blood pressure (124/58) and pulse (77) using an electronic blood pressure machine. After this medication observation, the surveyor used the resident's clinical record to reconcile the resident's medications. The resident's clinical record included the order digoxin 125 mcg one time a day related to atrial fibrillation hold for apical pulse less than 60 beats per minute. After this reconciliation, the surveyor interviewed LPN #3. LPN #3 was asked how she had obtained the resident's pulse. LPN #3 replied, I should have used my stethoscope. The facility was notified of the above issue during a meeting with the survey team on 05/22/19 at 3:00 p.m. No further information was provided to 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 provide the Residents and their representative with a summary of the baseline care plan for two of 35 residents in the survey sample (Resident #363 and #44). The findings included: 1. The facility staff failed to provide the residents and their representatives with a summary of the baseline care plan for Resident #363. Resident #363 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to encounter for palliative care, Alzheimer's disease, high blood pressure and diabetes. The admission MDS was not completed at this time due to the resident being admitted on [DATE]. The surveyor performed a clinical record review of Resident #363's chart on 3/21 and 3/22/18. During this review, the surveyor noted there was no documentation in the clinical record stating that a summary of the baseline care plan had been provided to the resident or representative. On 3/22/18 at 9:53 am, the surveyor asked the director of nursing (DON) how the facility documents the implementation of the baseline care plan within 48 hours of the resident's admission to the facility and was the resident and representative given a summary of this care plan. The DON stated that she would get back to me regarding this request. At 10:20 am, Registered Nurse (RN) #1 provided the surveyor with a copy of the resident's care plan. RN #1 stated, I did the care plan within 48 hours of admission but did not review it with the resident or provide a copy to the resident or representative. At 1:45 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/22/18. 2. For Resident #44, facility staff failed to provide a written baseline care plan on admission. Resident # 44 was admitted to the facility on [DATE] with diagnoses including history of myocardial infarction, peripheral neuropathy, hypertension, end stage renal disease with hemodialysis, cardiopulmonary disease, and major depression. On the admission minimum data set assessment (MDS) with assessment reference date 1/5/18, the resident scored 14/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting others. On 03/22/18 at 11:05 AM, Resident # 44 reported he had not been given a written plan of care upon admission to the facility. The surveyor interviewed the MDS nurse, who stated she had not been there when the resident was admitted . She reported checking with the other MDS staff who said they had not offered the resident a copy of the baseline care plan. The administrator and director of nursing were notified of the concern during a summary meeting on 3/22/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to review and revise the person centered comprehensive care plan for one of 35 residents in the survey sample (Resident #63). The findings included. The facility staff failed to review and revise the person centered comprehensive care plan for Resident #63. Resident #63 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, diabetes and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/17/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #63 was also coded as requiring limited assistance of 1 staff member for dressing and only supervision with personal care. The surveyor conducted a clinical record review of Resident #63 on 3/22/18. In the nursing documentation dated 3/7/18 read in part, .he was fitted for a Tactile Medical Flexitouch Compression pump . while the resident was at a doctor's appointment on this date. On 3/16/18 in the nursing documentation, it read in part, May start Tactile medical flexitouch compression pump on 3/19/18 . The surveyor also reviewed the care plan of Resident #62 on 3/22/18. The surveyor noted that the person centered comprehensive care plan for this resident was not updated to include the use of the Tactile Flexitouch compression machine. On 3/22/18 at 1:45 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/22/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record the facility staff failed to ensure a hazard free environment for two of 35 Residents in the survey sample (Resident's #45 and #107). The findings included: 1. The bed alarm for Resident #45 was observed by the surveyor to be in the off position and not in the proper operating mode. Resident #45 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to stroke, carcinoma of the liver, hemiplegia of the right side and hemiparesis also of the right side, dementia, major depressive disorder and diabetes. The entry MDS (Minimum Data Set) dated for 3/5/18 was the only MDS available at the time of the clinical record review performed by the surveyor. On 3/21/18 10:10 am, the surveyor went into Resident #45's room and observed the bed alarm was in the off position and not in the proper operating mode. Licensed Practical Nurse (LPN) #1 went back into the resident's room with the surveyor. LPN #1 stated to the surveyor the alarm is not on. She then proceeded to turn the alarm on. The surveyor performed a clinical record review on 3/21/18 at 1030 am. The person centered comprehensive care plan had the following documentation noted by the surveyor: Under Section titled Focus it read in part, .high risk for falls/injury r/t (related to) Gait/balance problems, hemiplegia .Unawareness of safety needs. Under Interventions, it read in part, The resident uses a sensor pad to his bed . The surveyor notified the administrative team of the above documented findings on 3/21/18 at 4:37 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 3/22/18. 2. Facility staff failed to follow physician orders for a bed alarm for Resident # 107. The resident's clinical record was reviewed on 3/21/18 at 11:00 AM. Resident #107 was admitted to the facility on [DATE]. His diagnoses included hypertension, depression, gout, and kidney disease. The latest MDS (minimum data set) assessment dated [DATE], coded the resident as unimpaired cognitively. He needed staff help with hygiene, but could eat unassisted with a tray set-up. The latest CCP (comprehensive care plan) reviewed an revised on 11/17/17 documented the resident at risk for falls/injury due to deconditioning. The staff interventions included: The resident uses a sensor pad to his bed The resident uses a sensor pad to his chair . Resident #107's physician's orders, signed and dated on 2/7/18, included orders for a sensor pad alarm to his bed and his wheelchair at all times. 03/21/18 at 09:06 AM the surveyor was interviewing the resident. A personal alarm was observed on both the bed & chair. The resident got up off bed, transferred himself to the chair without difficulty and alarm never went off. The resident stated That's why I'm here--I fell and busted my shoulder & hip. My shoulder is still hurting. That alarm on bed never works. The surveyor observed the wire was not plugged into the alarm hanging from the bed. LPN I was asked to come to the room and determine why the alarm was not plugged up. She plugged it in and left the room. On 3/21/18 at 4:55 PM, the DON told the survey team that the MDS nurse had observed the resident cut off his chair alarm. She also said she had talked to a CNA that said , H cuts it off all the time--but I never told anyone about it. The DON said she was having inservices to ensure the staff communicated issues with the chair and bed alarms and particularly when they were found to be cutting them off. The DON said they would revisit his care plan and find another way to monitor his movements. No additional information was available prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to offer non-pharmacological interventions for pain management for 2 of 35 residents in the survey sample (Resident's #63 and #76). The findings included: 1. The facility staff failed to offer non-pharmacological interventions for pain management for Resident #63. Resident #63 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, diabetes and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/17/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #63 was also coded as requiring limited assistance of 1 staff member for dressing and only supervision with personal care. The surveyor conducted a clinical record and Medication Administration Record (MAR) review of Resident #63 on 3/22/18. The surveyor noted that the resident had physician orders to receive the following medication: Acetaminophen (Tylenol) Tablet 325 MG (milligram) Give 2 tablet by mouth every 6 hours as needed for pain Tramadol HCl Tablet 50 MG Tablet Give 1 tablet by mouth every 6 hours as needed for pain. According to the MAR for the month of March 2018, the resident received Tylenol for pain on 3/19/19 at 5:05 am. It was also documented that the resident received Tramadol for pain on 3/3/18 at 7:54 am, 3/10/18 at 9:41 pm, 3/19/18 at 8:51 am, 3/20/18 at 8:50 am and 3/21/18 at 9:15 pm. The surveyor reviewed the nurses' notes. It was noted that there were no non-pharmacological interventions documented as being offered prior to the administration of the above documented pain medications to the resident. On 3/22/18 at 11:10 am, the surveyor notified Registered Nurse (RN) #1 of the above documented findings. RN #1 reviewed the clinical record of Resident #63 and stated, I don't either. At 1:45 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/22/18. 2. The facility staff failed to offer non-pharmacological interventions for pain management for Resident #76. Resident #76 was readmitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, diabetes, aphasia, stroke, hemiplegia, Anxiety Disorder, depression, Post Traumatic Stress Disorder (PTSD) and Chronic Obstructive Pulmonary Disease. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/24/18, the resident was coded as requiring supervision of 1 staff member for dressing, personal hygiene and bathing. Resident #76 was also coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. The surveyor conducted a review of the resident's clinical record and MAR (Medication Administration Record) on 3/21/18 through 3/22/18. For the month of March 2018, the resident received Hydrocodone-Acetaminophen 325 mg (milligram) 1 tablet by mouth every 6 hours as needed for pain on the following dates and times as documented on the MAR: 3/1 at 8:30 pm, 3/2 at 12:50 pm and 8:21 pm, 3/3 at 4:48 pm, 3/5 at 8:30 pm, 3/6 at 8:32 pm, 3/7 at 8:41 pm, 3/9 at 8:01 pm, 3/10 at 11:02 am, 3/12 at 9:03 pm, 3/13 at 8:06 am, 3/14 at 9:07 pm, 3/17 at 4:25 pm, 3/18 at 11:11 am, 3/19 at 8:35 pm, and 3/20 at 8:36 pm. The surveyor reviewed the nurses' notes. It was noted that there were no non-pharmacological interventions documented as being offered prior to the administration of the above documented pain medication, Hydrocodone-Acetaminophen, to the resident. On 3/22/18 at 11:10 am, the surveyor notified Registered Nurse (RN) #1 of the above documented findings. RN #1 reviewed the clinical record of Resident #63 and stated, I don't either. At 1:45 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/22/18.

Based on observation and staff interview it was determined that the facility staff failed to discard expired medications on 1 of 3 Units, Unit 2 West. The facility staff failed to discard expired medications. The Unit 2 [NAME] refrigerator contained a multi-dose vial of Tuberculin Purified Protein Derivative that expired on 3/6/18. The medication was available for use. The Findings Included: On March 21, 2017 at 10:31 a.m., the surveyor observed the 2 [NAME] med room/carts. LPN (#1) accompanied the surveyor into the medication room. The surveyor observed a small medication refrigerator in the medication room. The surveyor opened the refrigerator and observed a multi-dose vial of Tuberculin Purified Protein Derivative. The multi-dose vial had a sticker attached. The sticker read: DO NOT USE AFTER 3/6/18. The surveyor pulled the multi-dose vial out of the refrigerator and notified LPN (#1) that the medication was expired and was available for use. On March 21, 2018 at 4:43 p.m. the survey team met with the Administrator (Adm), Director of Nursing (DON) and Quality Assurance and Performance Improvement (QAPI) Nurse. The surveyor notified the Administrative Team (AT) of multi-dose vial of Tuberculin Purified Protein Derivative that was expired and still available for use on the 2 [NAME] Unit. The surveyor notified the AT that the expiration on the multi-dose vial was 3/6/18. The DON stated that she was surprised when the facility staff notified her that the surveyor had found the expired medication in the 2 [NAME] refrigerator. No additional information was provided prior to leaving the facility as to why the facility staff failed to discard expired medications. The Tuberculin Purified Protein Derivative was still available for use in the 2 [NAME] refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility staff failed to ensure infection control was followed for 1 of 35 residents in the survey sample (Resident #14). The findings included: Resident #14 was readmitted to the facility on [DATE]. According to the significant change MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 12/13/17, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #14 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene care and being totally dependent on 1 staff member for bathing. The resident had the following diagnoses of, but not limited to anemia, coronary heart disease, chronic obstructive pulmonary disease, diabetes, high blood pressure, heart failure, renal failure, diabetes and depression. On 3/21/18 3:39 pm, the surveyor observed the oxygen tubing that connects to the O2 condenser for the resident's CPAP machine, lying in the floor. The surveyor notified LPN (Licensed Practical Nurse) #1 of this. LPN #1 went back into the resident's room with the surveyor. LPN #1 stated, I will replace this because he has a breathing problem and we don't want him to get an infection. The surveyor notified the administrative team of the above documented findings on 3/21/18 at 4:37 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 3/22/18.

4. For Resident #41, the facility failed to ensure a monthly drug regimen review with recommendations to decrease seroquel was reported to the medical director. The record review revealed that Resident #41 had been admitted to the facility 09/17/14. Diagnoses included, but were not limited to, osteoarthritis, chronic rhinitis, Barrett's esophagus, Alzheimer's disease, hypertension, and vascular dementia. Section C (cognitive patterns) of the Residents annual MDS (minimum data set) assessment with an ARD of 01/04/18 included a BIMS (brief interview for mental status) summary score of four out of a possible 15. The clinical record included a monthly drug regimen review dated 01/30/18. The pharmacist had recommended a trial dose reduction of the antipsychotic medication seroquel. This drug regimen review had been signed by the attending but had not be signed by the medical director to indicate they had reviewed the recommendation. On 03/22/18 at approximately 10:25 a.m. the unit manager was asked about the medical director reviewing the drug regimen recommendation. The unit manager verbalized to the surveyor that the drug regimen review/recommendation had not been signed or reviewed by the medical director. The unit manager did add that new interventions were to be implemented. The administrative staff were notified of the above during a meeting with the survey team on 03/22/18 at approximately 1:45 p.m. No further information regarding this issue was provided to the survey team prior to the exit conference. Based on staff interview and clinical record review, the facility staff failed to report irregularities to the facility's medical director for 4 of 35 residents (Resident #41, Resident #74, Resident #86 and Resident #117). The findings included: 1. The facility staff failed to report irregularities identified on Resident #86's February 28, 2018 monthly drug regimen review to the medical director. The clinical record of Resident #86 was reviewed 3/20/18 through 3/22/18. Resident #86 was admitted to the facility 3/28/17 with diagnoses that included but not limited to legal blindness, actinic keratosis, benign prostatic hypertrophy, hypothyroidism, Alzheimer's disease, atherosclerotic heart disease, chronic obstructive pulmonary disease, chronic diastolic heart failure, vascular dementia with behavioral disturbances, hypertension, and Vitamin D deficiency. Resident #86's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/1/18 was assessed with long term memory problems, short term memory problems, and significantly impaired cognitive skills for daily decision making. Resident #86 was assessed to have inattention, disorganized thinking, physical behaviors directed at others, and rejection of care. No psychosis present. During the clinical record review, Resident #86 had a monthly drug regimen review dated 2/28/18 with the following written: Psychotropic Drug Use Review Antipsychotic Please note that this resident has taken their current dose of antipsychotic medication Seroquel 25 mg (milligrams) qhs (at bedtime) since 9/17. Federal guidelines recommend periodic dose reduction for psychotropic medications unless several previous attempts have failed or it is clinically contraindicated as documented by the physician in the resident's medical record. Consider a trial dose reduction or please document the need to continue current dose. Signed by consultant pharmacist. Physician Response (select one): Comment noted; no action desired. No change resident cont (continues) with paranoia & resistance to care. Signed by physician assistant (PA). There was no evidence the medical director had been informed of the irregularities identified in the February 2018 MRR (monthly regimen review). The surveyor informed the unit manager licensed practical nurse #1 of the concern on 3/20/18 at 1:44 p.m. L.P.N. #1 stated the physician assistant reviews the monthly drug reviews and stated she puts them in her box. The surveyor informed the director of nursing on 3/21/18 about the lack of medical director review of the irregularities in the February 28, 2018 monthly drug regimen review for Resident #86. The director of nursing informed the surveyor that the PA reviews them for Resident #86's attending physician and that there was no indication the medical director had been informed. The DON identified the PA's signature only on the monthly review. The surveyor informed the administrator, the director of nursing, and the QAPI (quality assurance/performance improvement) nurse of the above identified concern in the end of the day meeting on 3/21/18 at 4:36 p.m. No further information was provided prior to the exit conference on 3/22/18. 2. The facility staff failed to ensure the medical director was informed of irregularities from Resident #74's January 30, 2018 monthly drug regimen review. The clinical record of Resident #74 was reviewed 3/20/18 through 3/22/18. Resident #74 was admitted to the facility 7/28/17 with diagnoses that included but not limited to bacterial pneumonia, hypothyroidism, depressive disorder, Alzheimer's disease, unspecified psychosis, and dementia without behavioral disturbances. Resident #74's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 1/25/18 assessed the resident with long term memory problems, short term memory problems, and severely impaired cognitive skills for daily decision making. Resident #74 was assessed with inattention, disorganized thinking, and wandering but no psychosis or behaviors affecting others. During the clinical record review, Resident #74 had a monthly drug regimen review dated 1/30/18 with the following written: Psychotropic Drug Use Review Antipsychotic Please note that this resident has taken their current dose of antipsychotic medication Seroquel 25 mg (milligrams) q8 hours psychosis (every 8 hours) since 7/17. Federal guidelines recommend periodic dose reduction for psychotropic medications unless several previous attempts have failed or it is clinically contraindicated as documented by the physician in the resident's medical record. Consider a trial dose reduction or please document the need to continue current dose. Signed by consultant pharmacist. Physician Response (select one): Accept above recommendation. Signed by physician assistant (PA). A telephone order dated 2/6/18 read in part Decrease am (morning) Seroquel to 12.5 mg qam (every morning). There was no evidence the medical director had been informed of the irregularities identified in the January 30 2018 MRR (monthly regimen review). The surveyor informed the director of nursing on 3/21/18 at 10:22 a.m. about the lack of medical director review of the irregularities in the January 30, 2018 monthly drug regimen review for Resident #74. The director of nursing informed the surveyor that the PA reviews them for Resident #74's attending physician and that there was no indication the medical director had been informed. The DON identified the PA's signature only on the monthly review. The surveyor informed the administrator, the director of nursing, and the QAPI (quality assurance/performance improvement) nurse of the above identified concern in the end of the day meeting on 3/21/18 at 4:36 p.m. No further information was provided prior to the exit conference on 3/22/18. 3. The facility staff failed to ensure the medical director was informed of irregularities from Resident #117's December 31, 2017 monthly drug regimen review. The clinical record of Resident #117 was reviewed 3/20/18 through 3/22/18. Resident #117 was admitted to the facility 2/20/15 with diagnoses that included but not limited to unspecified psychosis, atrial fibrillation, idiopathic neuropathy, atherosclerotic heart disease, osteoarthritis, prostate cancer, and dementia without behavioral disturbances. On the quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 2/15/18, the resident scored 14/15 on the brief interview for mental status and was without signs of delirium, psychosis or behaviors affecting others. During the clinical record review, Resident #117 had a monthly drug regimen review dated 12/31/17 with the following written: Psychotropic Drug Use Review Antipsychotic Please note that this resident has taken their current dose of antipsychotic medication Quetiapine 12.5 mg (milligrams) bid (twice a day) since 6/17. Federal guidelines recommend periodic dose reduction for psychotropic medications unless several previous attempts have failed or it is clinically contraindicated as documented by the physician in the resident's medical record. Consider a trial dose reduction or please document the need to continue current dose. Signed by consultant pharmacist. Physician Response (select one): Accept above recommendation. Signed by physician assistant (PA). A telephone order dated 1/5/18 read Per pharm (pharmacy) rec (recommendations) attempt dose reduction Seroquel-DC (discontinue) am (morning) dose Seroquel 12.5 mg & cont (continue) evening dose. Document s/sx (signs/symptoms) psychosis. There was no evidence the medical director had been informed of the irregularities identified in the December 30, 2017 MRR (monthly regimen review). The only signature on the page was that of the PA. The surveyor informed the administrator, the director of nursing, and the QAPI (quality assurance/performance improvement) nurse of the above identified concern in the end of the day meeting on 3/22/18 at 1:45 p.m. No further information was provided prior to the exit conference on 3/22/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to identify and monitor target behaviors associated with the use of Seroquel for Resident # 156. Resident # 156 is a [AGE] year-old male that was admitted to the facility on [DATE]. Diagnoses included but were not limited to: dementia with behavioral disturbances, anxiety, Alzheimer's disease, and hypertension. The clinical record for Resident # 156 was reviewed on 3/22/18 at 9:38 am. The most recent MDS (minimum data set) assessment was an annual assessment with an ARD (assessment reference date) of 3/1/18. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 156 had a BIMS (brief interview for mental status) score of 3/15, which indicated severe cognitive impairment. The current plan of care for Resident # 156 was reviewed and revised on 3/8/18. The current plan of care has documentation that states, Resident # 156 uses psychotropic medications related to behavior management. Interventions included but were not limited to: Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor /record occurrence of target behavior symptoms. The physician signed the most recent physician's orders for Resident # 156 on 2/6/18. Resident # 156 has current orders for Quetiapine Fumarate (Seroquel) Tablet 25 mg (milligrams) Give 1 tablet by mouth one time a day related to unspecified dementia with behavioral disturbance. This dose was ordered to be given at 9:00 am. Resident # 156 has another order for Quetiapine Fumarate Tablet 50 mg, Give 1 tablet by mouth one time a day related to unspecified dementia with behavioral disturbance. This dose was ordered to be given at 5:00pm. The surveyor reviewed the clinical record and could not locate and person centered target behaviors or monitoring of behaviors associated with the use of Seroquel for Resident # 156. On 3/22/18 at 9:50 am, the surveyor spoke with LPN (licensed practical nurse) #1 and asked about the targeted behaviors and how the nurses were monitoring the behaviors associated with the use of Seroquel for Resident # 156. LPN # 1 showed the surveyor a place on the MAR (medication administration record) where the staff was monitoring the side effects of the medication. The surveyor then asked LPN #1 what resident specific target behaviors did Resident # 156 exhibit. LPN # 1 stated that Resident # 156 resisted care at times. The surveyor explained to LPN # 1 that resisting care is not a reason to administer Seroquel. The nurse was unable to provide any documentation on the target behaviors for Resident #156 or any information on how the nurses were monitoring the effectiveness of the Seroquel. On 3/22/18 at 1:15 pm, the surveyor spoke with the director of nursing about the identification of target behaviors and lack of monitoring for effectiveness associated with the use of Seroquel for Resident #156. The director of nursing stated that she was aware of the problem in this area and stated the facility would be working to make improvements. On 3/22/18 at 2:26 pm, the administrative team was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 3/22/18. Based on staff interview and clinical record review, it was determined that the facility staff failed to ensure that 2 of 35 Residents in the sample survey were free from unnecessary medications, Resident #46 and Resident #156. The facility staff failed to monitor for the use of psychotropic drug (Seroquel) use to include specific behaviors, nursing interventions, side effects and effectiveness for both Resident #46 and Resident #156. The Findings Included: 1. For Resident #46 the facility staff failed to monitor for Seroquel, a Psychotropic, drug use to include specific behaviors, nursing interventions and effectiveness Resident #46 was a [AGE] year old male who was admitted to the facility on [DATE]. Admitting diagnoses included, but were not limited to: Benign Prostatic Hyperplasia with lower urinary tract infection, anxiety, quadriplegia, major depression, spinal stenosis of the cervical region, Diabetes Mellitus, hypertension, dementia with behavioral disturbance and acute kidney failure. The most current Minimum Data Set (MDS) assessment located in the clinical record was a Quarterly MDS assessment with an Assessment Reference Date (ARD) of 1/9/18. The facility staff coded that Resident #46 had a Cognitive Summary Score of 7. The facility staff also coded that Resident #46 required extensive (3/3) to total nursing assistance (4/3) with Activities of Daily Living (ADL's). In Section N.0410 Medications, the facility staff documented that Resident #46 had received 7 days of a psychotropic medication. On March 22, 2018 at 10:49 a.m., the surveyor reviewed the clinical record. Review of the clinical record produced physician orders. Physician orders included, but were not limited to: QUEtiapine (Seroquel) Fumarate Tablet 25 mg Give 1 tablet by mouth one time a day for behaviors Side effect codes: 0= no side effects; 2=sedation; 3= headache; 5= dizziness; 8= dry mouth. (sic) The order for the Seroquel initiated on 9/22/17. Continued review of the clinical record produced the March 2018 Medication Administration Records (MAR's). The March 2018 MAR's documented that the staff were administering the Seroquel every day at 2 p.m. The facility staff were also documenting on the March 2018 MAR's 0 indicating that Resident #46 did not have any side effects from the use of the Seroquel. Further review of the clinical record failed to document Resident #46's specific behaviors, nursing interventions or effectiveness of the use of the psychotropic medication (Seroquel). Additional review of the clinical record produced the Comprehensive Care Plan (CCP). The CCP identified the following Focus and Interventions. Focus (name of Resident withheld) presents with potential for fluctuations in mood state and behavior pattern r/t (related to) hx (history) and Dx (diagnosis) dementia with behavioral disturbances, GAD (general anxiety disorder), and MDD (major depressive disorder), Mood state and behavioral pattern have been stable over the long term. Interventions Practice active listening and offer a supportive presence during times of interaction and prn (as needed) in effort to develop rapport with (name of resident withheld). Recognize and report possible triggers of possible triggers of behavioral disturbances or fluctuation in mood state, work to meet any unmet needs and/or address triggers if possible. If unable to reduce or eliminate triggers, work with resident towards developing coping mechanisms (appropriate for cognitive function). (sic) CCP initiated on 10/31/16. The surveyor observed two Licensed Practical Nurses (LPN's) sitting at the nurses' station. The surveyor asked the LPN's why Resident #46 was receiving the Seroquel. The LPN's were unable to tell the surveyor why Resident #46 was receiving the Seroquel. The surveyor asked the LPN's what Resident #46's specific behavior was. The LPN's could not tell the surveyor what Resident #46's behavior (s) were. The surveyor reviewed Resident #46's clinical record with the two LPN's. The surveyor reviewed the physician orders and the March 2018 MAR's with the two LPN's. The two LPN's reviewed the clinical record and were unable to locate a diagnosis and/or specific behaviors as to why Resident #46 was receiving the Seroquel. One of the LPN's stated she would contact the Director of Nursing (DON) to help the surveyor. Within a few moments, the DON approached the surveyor. The surveyor notified the DON that Resident #46 was receiving Seroquel. The surveyor notified the DON that the surveyor could not locate a diagnosis for the use of Seroquel. The surveyor also notified the DON that specific behaviors regarding the use of the psychotropic medication (Seroquel) could not be located in the clinical record. The surveyor additionally notified the DON that review of the clinical record failed to document effectiveness and nursing interventions that had been provided other than administering the psychotropic drug to Resident #46. The DON stated that this surveyor had sited her for the same issue last year and that she, the DON, thought she had fixed the problem. The surveyor and DON reviewed Resident #46's clinical record. The DON was unable to locate any documentation regarding Resident #46's specific behavior/diagnoses, nursing interventions and/or effectiveness in the use of the Seroquel. The DON stated she was going to call the Quality Assurance and Performance Improvement (QAPI) nurse. Within a few minutes, the QAPI nurse approached the surveyor and DON. The surveyor and DON explained to the QAPI nurse that Resident #46 was receiving Seroquel. The surveyor notified the QAPI nurse that specific behaviors, nursing interventions and effectiveness of the use of the Seroquel could not be located in the clinical record. The QAPI nurse and DON reviewed the clinical record. The DON stated that she had seen a document in the clinical record that stated prior to Resident #46's admission into the facility that Resident #46 yelled. The surveyor notified the DON and QAPI Nurse that Resident #46 had been on the Seroquel since 9/23/17 and that no specific behaviors that were being monitored, nursing interventions other than administering the Seroquel had been documented nor had the effectiveness of the Seroquel been documented. On March 22, 2018 at 2:45 p.m., the surveyor notified the Administrator (Adm), DON and QAPI Nurse that Resident #46 was receiving Seroquel, a Psychotropic drug. The surveyor notified the Administrative Team (AT) that the facility staff were not monitoring Resident #46 for the use of the psychotropic drug to include specific behaviors, nursing interventions and effectiveness. No further information was provided to the team prior to exiting the facility as to why the staff failed to ensure that Resident #46 was free from unnecessary medications. The facility staff failed to monitor for the use of a Psychotropic Drug (Seroquel) to include specific behaviors, nursing interventions and effectiveness.