**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide toileting assistance for dependent residents for 1 of 1 supplemental resident (R39) reviewed for Activities of Daily Living (ADLs) assistance. Staff did not assist R39 with toileting assistance after an incontinent episode. Evidenced by: Facility policy, entitled Activities of Daily Living (ADL), dated 3/15/21, with revision date of 2/25/25 states in part: Policy: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services . Procedure: .2. The facility will provide care and services for the following activities of daily living: . Toileting: Assisting with using the bathroom and maintaining cleanliness . R39 was admitted to the facility on [DATE] with diagnoses that include, in part, Type 2 Diabetes Mellitus, Weakness, Generalized Anxiety Disorder, Hypertension, Unspecified Dementia, moderate with mood disturbance, Major Depressive Disorder, Altered Mental Status, Disorientation unspecified, Repeated Falls, Muscle Wasting and Atrophy, Unsteadiness on Feet, and Unspecified Abnormalities of Gait and Mobility. R39's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/17/25 documented that R39 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R39 has moderate cognitive impairment. R39's Care Plan, includes, in part: Focus: The resident has an ADL self-care performance deficit r/t (related to) weakness, moderate dementia with mood disturbances. Date Initiated: 3/8/24. Revision Date: 2/20/25 Goal: The resident will maintain current level of function in toileting through next review date. Date initiated: 3/8/24. Revision Date: 9/29/24. Intervention: Toilet Use Assist - One. Date Initiated 3/8/24. Focus: Actual for alteration in elimination (bladder incontinence) r/t dementia, altered mental status, weakness. Date Initiated: 3/8/24. Revision Date: 12/17/24. Goal: Resident will be clean, dry and odor free daily through staff assistance and interventions through next review. Date Initiated: 3/8/24. Intervention: Position body with pillows/support devices. Date initiated 7/20/22 .Offer to toilet resident q2 (every two) hours, remind resident to use call light for assistance, check frequently. Date Initiated: 3/8/24. Revision Date: 12/17/24. Focus: I am at risk for alteration in skin integrity related to weakness, reduced mobility . Date Initiated: 3/8/24. Revision Date: 4/15/25. Intervention: Keep my skin clean and dry. Date initiated 3/8/24. R39's CNA (Certified Nursing Assistant) [NAME] includes, in part: -3/16/24 Offer to toilet resident q2 hours, remind resident to use call light for assistance, check frequently -Assist [Resident Name] with toileting approximately every 2 hours 3/16/24 -Incontinence care after each incontinent episode -Incontinent brief due to incontinence -Scheduled Toileting Program Q2 hours -Toilet Use Assist - One On 4/14/25 at 1:55 PM, Surveyor observed R39 in the post-acute rehab living room sitting in her wheelchair a few feet from the nurse's station. Surveyor observed that R39 was wearing a short sleeve top and light peach colored capri pants. Surveyor observed that R39's pants were wet on the backside from the knees down. Surveyor walked to the nurse's station and smelled a strong urine odor coming from R39. On 4/14/25 at 2:00 PM, Surveyor observed CNA H (Certified Nursing Assistant) and two other CNAs sitting at the nurse's station a few feet away from R39. On 4/14/25 at 2:02 PM, Surveyor observed CNA K walk by R39 while assisting another resident with ambulation. On 4/14/25 at 2:10 PM, Surveyor observed ADON D (Assistant Director of Nursing) sitting at the nurse's station a few feet away from R39. On 4/14/25 at 2:19 PM, Surveyor observed CNA K walk by R39 again. On 4/14/25 at 2:21 PM, Surveyor observed CNA K and PT L (Physical Therapist) walk by R39 sitting in her wheelchair. On 4/14/25 at 2:22 PM, Surveyor observed CNA M walk by R39 while pushing the Hoyer lift. On 4/14/25 at 2:27 PM, Surveyor observed ADON D walk by R39 pushing the EZ Stand lift. On 4/14/25 at 2:28 PM, Surveyor observed RN E (Registered Nurse), LPN N (Licensed Practical Nurse), and CNA O walk by R39 sitting in her wheelchair. On 4/14/25 at 2:29 PM, Surveyor observed CNA G stop and talk to R39 sitting in her wheelchair, and then continue on. On 4/14/25 at 2:30 PM, Surveyor observed LPN N walk by R39 twice, carrying two pitchers of water. On 4/14/25 at 2:40 PM, Surveyor observed AD J (Activities Director) stop and talk with R39, invite her to the afternoon activity, and then continue on. On 4/14/25 at 2:45 PM, Surveyor observed R39 wheel herself into her room and look for something in her bedside table. On 4/14/25 at 3:07 PM, Surveyor observed R39 wheel herself back out into the living room. On 4/14/25 at 3:10 PM, Surveyor observed CNA O walk by R39 again. On 4/14/25 at 3:34 PM, Surveyor observed CNA G and CNA M take R39 into her room and shut the door. On 4/14/25 at 3:44 PM, Surveyor observed R39 be wheeled out of her room and back to the living room wearing navy blue pants and a different shirt. On 4/14/25 at 3:45 PM, Surveyor interviewed CNA M and asked her how soaked R39's incontinence brief was when she changed her. CNA M stated that it was moderately soaked. Surveyor asked CNA M if there was a strong urine odor from R39. CNA M replied no that the urine odor was not too bad. Surveyor asked CNA M when was the last time R39 had been assisted to the bathroom. CNA M stated that she started at 2:00 PM and didn't know when R39 was last assisted to the bathroom. Surveyor asked CNA M how often R39 was to receive toileting assistance. CNA M stated R39 was to be toileted every 2-3 hours. Surveyor asked CNA M that if R39's clothes were soaked through, could that be a dignity concern? CNA M nodded yes. On 4/14/25 at 3:48 PM, Surveyor interviewed CNA G and asked her how soaked R39's incontinence brief was when she changed her. CNA G stated that the brief was very soaked and that R39 had to have a complete clothing change and be washed up head to toe because she was soaked in urine. Surveyor asked CNA G if there was a strong urine odor from R39. CNA G replied yes there had been a strong urine odor. Surveyor asked CNA G when the last time R39 had been assisted to the bathroom. CNA G stated that she came in at 2:00 PM so she wasn't sure. CNA G looked in the charting history to find out when R39 was last assisted to the bathroom, and said the last time R39 was toileted was 12:16 PM. Surveyor asked CNA G how often R39 was to receive toileting assistance per her care plan. CNA G stated R39 was to be toileted every 2 hours. Surveyor asked CNA G if waiting that long and being soaked in urine could be a dignity concern. CNA G replied yes, that was definitely a dignity issue, since R39 was soaking wet when she changed her. On 4/14/25 at 3:54 PM, Surveyor interviewed AD J and asked her if she could see R39's clothing were soiled with urine or a smell of urine odor when she stopped and invited her to activities. AD J stated yes, she smelled the urine odor today and had smelled it before on other days as well but had not seen R39's wet pants. AD J indicated that R39 could be very irritable at times and refuses help. Surveyor asked AD J if being soaked with urine and wearing wet pants would be considered a dignity concern. AD J replied yes, that was definitely a dignity concern. On 4/14/25 at 3:57 PM, Surveyor approached R39 sitting in the dining room in her wheelchair watching TV. Surveyor told R39 she looked nice in her new clothes and asked how she felt. R39 stated that she felt much better now that she was wearing dry clothes. On 4/14/25 at 3:59 PM, Surveyor interviewed DON B (Director of Nursing) and asked her about R39's two-hour toileting schedule. DON B stated that R39 often refuses, so she gives them a 2-3 hour toileting window. Surveyor shared with DON B the observation of R39 sitting for two hours in soiled, wet pants and smelling strongly of urine. Surveyor asked DON B what her expectation was for the staff regarding assisting R39 with toileting needs. DON B stated she would expect them to follow the toileting schedule and intervene if they saw or smelled urine. Surveyor asked DON B if this situation would be a dignity concern for R39. DON B replied yes, 100% that would be a dignity issue. The facility failed to provide toileting assistance to a dependent resident, resulting in R39's loss of dignity due to sitting in visibly soiled clothes for two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice (SOP), to prevent pressure injuries (PI) for 1 of 3 residents (R253) reviewed for pressure injuries. R253 is at risk for PI (pressure injury) development. R253 was admitted with two stage 3 PIs. Staff did not confirm accurate measurements were taken of R253's PI upon admission and weekly to ensure that R253's PIs did not deteriorate. Evidenced by: The AMDA (American Medical Directors Association) clinical practice guideline titled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. The ulcer may present as intact skin or as an open ulcer and may be painful. The ulcer occurs as a result of intense or prolonged pressure or pressure in combination with shear .Recognition: Early recognition of pressure ulcers and of any risk associated with the development of pressure ulcers and other wounds is critical to their successful prevention and management .Assessment: The purpose of the assessment is to collect enough information to evaluate the patient's general condition, characterize a pressure ulcer, and identify related causes and complications. The National Pressure Injury Advisory Panel (NPIAP) at www.NPIAP.com defines PIs in the following categories: Category/Stage II: Partial thickness loss - Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister. Category/Stage III: Full thickness skin loss - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown. Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. The facility's policy titled Pressure Injury Prevention and Wound Care Management, dated 8/26/18, with last revision date of 3/4/24, states in part, Purpose . To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown . Policy . A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers. Procedure: Risk Identification and Assessment: A complete assessment is essential to an effective pressure injury prevention and treatment program. A comprehensive assessment helps the facility to identify residents at risk of developing pressure ulcers, as well as the level and nature of their risks . 8. Documentation of the wound characteristics will be completed in PCC (Point Click Care) using the PCC Skin and Wound Assessment. This assessment is started in the mobile application. If a device is not available or in need of service, the documentation will be completed in the resident's electronic medical record. Consent for photography will be obtained in the admission packet . R253 was admitted to the facility on [DATE] with diagnoses that include Cellulitis of Buttock, Acute Kidney Failure, Venous Insufficiency, Morbid Obesity, and Depression. R253's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/28/25 indicates R253 has a BIMS (Brief Interview for Mental Status) score of 8 out of 15, indicating that R253 has moderate cognitive impairment. Section GG0130 of the MDS indicates that R253 requires partial/moderate assistance from staff for toileting and dressing needs, and is dependent on staff bathing, transfers, and bed mobility. Section H0300 of the MDS indicates R253 is frequently incontinent of bladder and bowel. Section M0300 of the MDS indicates R253 had two Stage 3 pressure ulcers upon admission. R253's Comprehensive Care Plan, states in part: Focus: I have an alteration in skin integrity - pressure wounds #5 sacrum, #6 coccyx. Date Initiated: 3/24/25. Revision on: 4/2/25. Goal: My alteration in skin integrity will show signs of improvement in healing by the review date. Date Initiated: 3/25/25. Intervention: Assess/monitor the alteration in my skin integrity and document status weekly. Date Initiated: 3/24/25. R253's Wound Evaluation for #5 Pressure Ulcer - Stage 3. Location Sacrum, indicates the following measurements: 3/24/25: 2.09 cm (centimeter) square area; 2.15 cm length; 1.26 cm width 3/30/25: 1.61 cm square area; 1.93 cm length; 1.17 cm width Week of 4/6/25: no measurements 4/13/25: 0 cm square area; 0 cm length, 0 cm width R253's Wound Evaluation for #6 Pressure Ulcer - Stage 3. Location Coccyx, indicates the following measurements: 3/24/25: 0 cm square area; 0 cm length, 0 cm width 3/30/25: 0 cm square area; 0 cm length, 0 cm width 4/6/25: 0.74 cm square area; 2.38 cm length; 1.16 cm width Week of 4/13/25: no measurements (It is important to note that there were pictures taken upon admission and weekly, but not all of the pictures had corresponding measurements taken). On 4/15/25 at 1:01 PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked her who was responsible for ensuring wound measurements were completed upon admission. NHA A stated that it varies depending on who is the schedule that day, but that the ADONs (Assistant Director of Nursing) typically do them. On 4/15/25 at 1:14 PM, Surveyor interviewed ADON F (Assistant Director of Nursing) and asked her who was responsible for ensuring that resident admission assessments were complete. ADON F stated that she does the bulk of the admission. Surveyor asked ADON F who was responsible for ensuring wound measurements were completed. ADON F indicated that typically the floor nurses complete the skin checks and take the wound pictures and then the ADONs will go through and review them along with the care plans and ensure there are treatment orders in place. Surveyor reviewed R253's missing wound measurements with ADON F, who stated that there must have been a miscommunication between the phone camera that they use and the charting system because it doesn't translate to PCC (Point Click Care electronic health record). ADON F indicated that they have helix stickers, and the camera phone takes the measurements of the wounds, and with the stickers on there the camera can gauge the size of the wound based on the sticker. Surveyor asked ADON F if the measurements could be taken and entered into PCC manually. ADON F replied yes, the measurements could be taken and entered into the resident's medical record manually. Surveyor asked ADON F if R253's medical record should have been reviewed to ensure there were measurements in PCC upon admission and weekly. ADON F stated yes, that R253's medical record should have been reviewed to ensure all measurements were taken and recorded in PCC. Surveyor asked ADON F if it was important to have admission and weekly measurements to determine the wound history and to gauge if the wound was improving or deteriorating. ADON F agreed that yes, that was important. On 4/15/25 at 1:30 PM, Surveyor interviewed ADON D and asked her who is responsible for making sure that resident admissions were complete. ADON D stated that depending on which unit, either herself or ADON F would do the full head to toe assessment with the resident and enter all the admission assessments in PCC. Surveyor asked ADON D who was responsible to take wound measurements and ensure their accuracy. ADON D stated that the floor nurses or the float nurse would take the wound measurements. Surveyor asked ADON D who verifies the wound measurements are accurate and complete. ADON D indicated that DON B (Director of Nursing) would look at the wound pictures and determine if it is labeled correctly and staged correctly then DON B closes that assessment. On 4/15/25 at 2:18 PM, Surveyor interviewed DON B about the admission process and who was responsible for taking wound measurements on admission. DON B stated that the nurses would be taking the wound measurements. Surveyor asked DON B who was responsible for verifying the measurements were completed and accurate. DON B stated that the nurses should be verifying the measurements. Surveyor reviewed R253's missing measurements in PCC. DON B indicated that those measurements weren't taken because the floor nurses use a wound camera and that the wound measurements get transferred to PCC but that the measurements did not translate in this case. DON B indicated that the day after an admission the ADON does an audit, but they were looking at the pictures and not the measurements, not realizing that the measurements didn't transfer into PCC. DON B stated that was an error on their part and she would be educating all the nurses on how to use the wound phone so that it works correctly Surveyor asked DON B if it was her expectation that wound measurements be taken on admission and weekly. DON B stated yes that was her expectation. R253 was admitted to the facility with two Stage 3 pressure ulcers. The facility failed to ensure complete and accurate documentation of these wounds' progressions, including admission and weekly measurements of the wounds it should be noted based on facility pictures there was no evidence of decline in the PI's.

Based on observation, interview, and record review the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 sampled resident's (R19) reviewed for dialysis and 2 of 2 supplemental residents reviewed for dialysis (R28, R49). R19, R28, and R49's care plans did not include emergency actions for any staff; no Nurses, CNA's (Certified Nursing Assistants) or any Ancillary staff (i.e. housekeeping, dietary, therapy, etc.). Staff were not able to voice the appropriate procedure if they encountered bleeding from a dialysis site. R19 and R49 did not have a soft clamp present in room to aid in a bleeding emergency. This is evidenced by: The Facilities Policy and Procedure entitled Care of Hemodialysis Resident dated 1/28/25, documents in part: .Post Dialysis .If bleeding occurs from fistula (surgical connection between an artery and a vein typically in the arm) site, apply pressure with clean gauze for 5-10 minutes. Repeat until bleeding stops. If unable to stop the bleeding, call the dialysis center or the physician for further instructions .External Catheters .A smooth clamp should be kept at the bedside for emergency situations . Example 1 R19 is a long-term resident of the facility. R19 has the following diagnoses: end stage renal disease, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease, and dependence on renal dialysis. R19 has an external catheter for his dialysis treatments. R19 did not have a soft clamp in room for an emergency situation. R19's care plan for end stage renal disease does not include any emergency actions for staff to conduct if a bleeding emergency occurs or document that he could have bleeding from his dialysis site. It is important to note that R19 is also on an anticoagulant medication (medication that delays or prevents blood clots from forming or growing) which could cause R19 to bleed more easily and take longer to stop bleeding. Example 2 R28 is a long-term resident of the facility. R28 has the following diagnoses: end stage renal disease, hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease, and dependence on renal dialysis. R28 has a fistula for his dialysis treatments. R28's care plan for chronic renal failure documents the following intervention- .Monitor fistula for bleeding . R28's care plan does not include any emergency actions for staff to conduct if a bleeding emergency occurs or document that he could have bleeding from his dialysis site. Example 3 R49 is a short-term resident of the facility. R49 has the following diagnoses: end stage renal disease and dependence on renal dialysis. R49 has an external catheter for his dialysis treatments. R49 did not have a soft clamp in room for an emergency situation. R49's care plan for chronic renal failure r/t (related to) End stage disease does not include any emergency actions for staff to conduct if a bleeding emergency occurs or document that he could have bleeding from his dialysis site. On 4/15/25 at 12:50 PM, Surveyor interviewed LPN P (Licensed Practical Nurse). Surveyor asked LPN P what action she would take if she found a resident bleeding from their dialysis site, LPN P stated apply pressure and get EMS (Emergency Medical Services) here. Surveyor asked LPN P if the dialysis residents had any type of emergency supplies or kit for if they had bleeding from their dialysis site, LPN P said no emergency kit that I know of. On 4/15/25 at 12:56 PM, Surveyor interviewed CNA Q (Certified Nursing Assistant). Surveyor asked CNA Q what action she would take if she found a resident bleeding from their dialysis site, CNA Q stated get nurse right away. Surveyor asked CNA Q how she would get the nurse right away, CNA Q said yell out down the hallway and turn on the call light. Surveyor asked CNA Q what she would do for the resident in that situation, CNA Q replied comfort them. Surveyor asked CNA Q if she would apply pressure to the area that is bleeding, CNA Q stated no the nurse does that. On 4/15/25 at 12:56 PM, Surveyor interviewed CNA T. Surveyor asked CNA T what action she would take if she found a resident bleeding from their dialysis site, CNA T stated get nurse right away. Surveyor asked CNA T how she would get the nurse right away, CNA T said yell out down the hallway or use radio to page the nurse. Surveyor asked CNA T what she would do for the resident in that situation, CNA T replied comfort them. Surveyor asked CNA T if she would apply pressure to the area that is bleeding, CNA T stated, I don't know much about this. On 4/15/25 at 01:01 PM, Surveyor interviewed LPN R. Surveyor asked LPN R what action she would take if she found a resident bleeding from their dialysis site, LPN R replied she would alert the RN (Registered Nurse), make sure there is pressure on it, and call EMS. Surveyor asked LPN R if the dialysis residents had any type of emergency supplies or kit for if they had bleeding from their dialysis site, LPN R stated no kit with clamp, use gloves and clean towel if around. On 4/15/25 at 01:03 PM, Surveyor interviewed RN E. Surveyor asked RN E if the dialysis residents had any type of emergency supplies or kit for if they had bleeding from their dialysis site, RN E stated no kit with clamp or tourniquet in it, we do not have that here. On 4/15/25 at 1:05 PM, Surveyor interviewed CNA S. Surveyor asked CNA S what action he would take if he found a resident bleeding from their dialysis site, CNA S stated get the nurse. Surveyor asked CNA S how he would get the nurse, CNA S said by putting the call light on. Surveyor asked CNA S what he would do for the resident in that situation, CNA S replied comfort the resident. Surveyor asked CNA S if there was anything else he would for the resident, CNA S could not voice anything else. Surveyor asked CNA S if the dialysis residents had any type of emergency supplies or kit for if they had bleeding from their dialysis site, CNA S stated no emergency kit that he knows of. On 4/15/25 at 1:07 PM, Surveyor interviewed ADON D (Assistant Director of Nursing). Surveyor asked ADON D if the dialysis residents had any type of emergency supplies or kit for if they had bleeding from their dialysis site, ADON D stated no kit with clamp or tourniquet. On 4/15/25 at 2:14 PM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). Surveyor asked DON/IP B would you expect your CNA's and Nurses to know how to handle bleeding from a dialysis site, DON/IP B stated yes. Surveyor asked DON/IP B if a dialysis resident is bleeding from their dialysis port (catheter, fistula) what would you expect your staff to do, DON/IP B said respond with first aid, dressing or gauze, use a tourniquet or just apply pressure, and call 911. Surveyor asked DON/IP B do each of your dialysis residents have an emergency kit (clamp, clean gauze) easily accessible in the event of a bleeding emergency, DON/IP B replied not in their room. Surveyor asked DON/IP B are you aware of what your Policy and Procedure for dialysis residents says for emergency actions, DON/IP B said have to look at. It is important to note that the Policy and Procedure speaks to applying pressure with clean gauze to a fistula site and using a soft clamp to a catheter site.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not have sufficient staff with appropriate competencies and skill sets to provide direct nursing and related services to assure resident safety and for each resident to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident's (R) reviewed (R253) who have a mental health diagnosis as well as a history of self-harm statements. R253 verbalized suicidal ideation which was not recognized by the facility and was not taken seriously. R253's statement was not documented in his medical record, interventions were not put in place, R253's POA (Power of Attorney) and PCP (Primary Care Physician) were not notified, increased monitoring was not initiated, and R253's care plan was not updated. Findings include: Facility policy, titled Responding to Intent of Self-Harm or Suicide Threat, dated 8/1/15 with last revision date of 9/6/24, states in part: Purpose: To establish a process to meet the psychosocial and emotional needs of each resident and to identify risk of suicidal and/or parasuicidal thoughts, behaviors, and action. The process will ensure resident suicide threats are taken seriously and interventions for prevention are put in place immediately. Definitions: Suicidal Ideation: Verbal expressions of thoughts of harming oneself that may or may not lack specific intent or associated actions and which are generally vague, passing thoughts related to poorly defined, circumstantial issues . Procedure: 1. Any staff member who becomes aware of a resident's intent to inflict self-harm, including but not limited to suicidal ideation . is required to report the behavior to the nurse and/or social worker immediately or as soon as possible given the situation. 2. The nurse is to contact the resident's physician . to seek appropriate treatment. 3. The DPOA/Responsible party will be notified of the resident's intent to inflict self-harm . 12. In the event that the risk does not warrant hospitalization or transfer to more acute care . staff may be requested to provide routine checks as directed . these checks are to be documented in the medical record. These routine checks are to continue until . deemed no longer necessary . 14. Continued documentation must be kept ongoing. Said documentation to include all plans, goals, interventions and care plan updates when applicable. Always document efforts, situation, observations, date and times, location, witnesses, staff members present, outcomes, who was contacted and who made the contact as well as future plans for safety. R253 was admitted to the facility on [DATE] with diagnoses that include Cellulitis of Buttock, Acute Kidney Failure, Venous Insufficiency, Morbid Obesity, and Depression, unspecified. R253's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/28/25 indicates R253 has a BIMS (Brief Interview for Mental Status) score of 8 out of 15, indicating that R253 has moderate cognitive impairment. Section D0150 of the MDS indicates that R253 feels down, depressed, or hopeless half or more of the days, has trouble falling or staying asleep, or sleeping too much several days of the week, and sometimes feels social isolation. R253's Comprehensive Care Plan, states in part: Focus: The resident has a potential psychosocial well-being problem r/t (related to) admission, diagnosis of Depression, getting angry easily/swearing at family/staff and has a hard time calming down. Date Initiated: 3/24/25. Revision on: 4/9/25. Goal: Resident will demonstrate adjustment to nursing home placement by next review date. Date Initiated: 3/24/25. Revision on: 4/2/25. Intervention: Allow the resident time to answer questions and to verbalize feelings, perceptions, and fears. Date Initiated: 3/24/25 . Increase communication between resident/family/caregivers about care and living environment. Explain all procedures and treatments, medications, results of lab tests, condition changes, rules, options. Date Initiated: 3/24/25 . Monitor/document resident's feelings relative to unhappiness, anger, loss. Date Initiated: 3/24/25. On 4/9/25 at 10:40 AM, Surveyor interviewed R253, who was upset about not being able to go home. On 4/9/25 at 10:50 AM, Surveyor interviewed NHA A (Nursing Home Administrator) about R253's desire to go home. NHA A indicated that R253 thought he was being discharged today, but it was really next Wednesday, and that he was upset about that. On 4/10/25 at 9:50 AM, Surveyor observed R253's provided by LPN C (Licensed Practical Nurse). When removing the old dressings, a small laceration from the white border foam dressing caused R253 to begin bleeding, dripping blood all over the floor. LPN C applied pressure with paper toweling and pushed R253's call light for assistance. ADON D (Assistant Director of Nursing) entered the room and LPN C requested the blood spill kit. ADON D left the room and returned a few minutes later with the blood spill kit. R253 became upset and verbalized concern that this new open area would prevent him from going home next week. R253 stated, I wish someone would take me out to the street and just run me over. What the hell do I have to for; I'm serious. LPN C reassured R253 that the plan was still for him to return home with home health services to help with the wound care. R253 continued to be upset and asked that the Surveyor leave the room. On 4/10/25 at 1:57 PM, Surveyor interviewed ADON D about their facility's suicide policy. ADON D stated that she didn't know but she would look it up and get back to Surveyor with that information. Surveyor asked ADON D what the process would be if a resident made a self-harm statement. ADON D stated they would remove from the room anything they can harm themselves with and ensure their environment is safe. Surveyor repeated back to ADON D the statement that R253 had made that morning during wound care and asked what should be done in this situation. ADON D stated she would check with him to see if he has any plans or any means to accomplish what he said, and she would do follow-up with him. ADON D stated she would also let the social worker know that he made the statement. Surveyor asked if any of this follow-up had been done or if she had let the social worker know. ADON D replied that she did not have the chance to see SW I (Social Worker) yet, but she could send her an email. Surveyor asked ADON D if there should be some urgency to this situation. ADON D stated that if she felt that he was serious yes, but that R253 is rather disgruntled currently because of miscommunication over his discharge plans. ADON D stated that she took it as an offhand remark because he's not happy to be here and he really wants to go home, but that if he had said it with a different demeanor, she would have thought red flags. On 4/10/25 at 2:03 PM, Surveyor interviewed LPN C about the facility's suicide policy. LPN C stated that first she would make sure they are free from harm and then she would report to the administrator. LPN C stated that depending on what type of suicide threat, if there is a weapon or anything involved, she would notify the local police department that there could be someone in danger, and from there she would contact the on-call doctor to see about sending them out for further evaluation. Surveyor repeated back to LPN C the statement that R253 had made that morning during wound care and asked what should be done in that situation. LPN C stated she had just reassured him that they were working toward his ultimate goal of getting him home like he wants to. Surveyor asked LPN C if statements like R253 made should be taken seriously. LPN C stated that she did take it seriously because he was upset, however she did not feel like he could realistically get out in the street and do harm to himself in that way. Surveyor asked LPN C if she had reported to anyone what R253 had said. LPN C indicated that the only person she told was ADON D who was in the room when the statements were made. LPN C indicated that she and ADON D had talked about some of the statements that he had made and decided that it was important to reassure him that they would work to get him healed and, on the path, to home. LPN C stated that in the moment she was more focused on trying to control his bleeding and holding pressure and that his safety right in the moment was more important than the statement he had made. On 4/10/25 at 2:21 PM, Surveyor interviewed SW I (Social Worker) and asked what the process was if a resident made a suicidal statement. SW I stated that if someone expresses that they are suicidal, she usually will do an assessment that asks if they are a harm to themselves, if they have a plan in place, and do they feel safe. SWI indicated that staff would notify her of the statement and then she would go talk to the resident, but if she wasn't in the building she would hope people would know the policy to keep people safe, see if they have a plan, and to keep watch on them like 1:1 monitoring. Surveyor asked SW I if she was aware of the self-harm statement made that morning by R253. SW I said, I just heard about if five minutes ago. Surveyor asked SW I what the process would be now that she was made aware of R253's statement. SW I said she would sit down with him and ask him if he feels suicidal, and if he expressed that he was serious she would ask if that was his plan or if he had another plan in place and if he felt safe. SW I indicated that if R253 was indeed suicidal and had a plan, she would put him on 1:1 monitoring and update the doctor right away as well as notifying the POA (Power of Attorney) if he had one. SW I indicated that currently R253 was playing cards, and he was in a safe environment, but that she did plan on interviewing him and making sure that he was not suicidal and didn't have a plan in place. Surveyor asked SW I if it was her expectation that staff would have notified her right away of R253's suicidal statement. SW I said, yes, she would definitely want to be notified right away so she could make sure he was not serious. Surveyor asked SW I what her next steps in this situation would be. SW I stated she would follow-up with R253 and enter a progress note in his medical record. On 4/10/25 at 2:33 PM, Surveyor interviewed DON B (Director of Nursing) and asked about the statement that R253 had made that morning during wound care. DON B stated she had spoken with LPN C, who explained the new wound triggered him into feeling anxious about not being able to go home, so LPN C stayed with him to calm him down and to determine if it was serious or if he was just saying that. DON B stated that R253 was much better now, and that LPN C had talked him through it and reassured him that he would be able to still go home. DON B stated that she felt that LPN C and ADON D had handled the situation appropriately, that if he was serious and had a plan then they should have updated the doctor and his family and the social worker. Surveyor asked if LPN C or ADON should have documented his statement somewhere in his medical record. DON B indicated that if there is no further threat then she didn't think it was necessary. DON B stated that LPN C did enter a progress note indicating that R253 had become upset about a new area opening up during wound care, and that she had stayed with him and talked with him until he had calmed down. DON B stated that it would have been different if R253 had a plan, then they would have notified the social worker, updated the care plan, and notified the doctor if necessary. DON B indicated that LPN C had assessed R253 and determined that he didn't mean it. On 4/10/25 at 2:48 PM, Surveyor interviewed NHA A (Nursing Home Administrator) about the situation that happened during R253's wound care and the suicidal statement he had made. Surveyor asked NHA A what her expectation was when a resident made a self-harm statement. NHA A stated she would expect that they would assess the resident immediately to determine if there is an imminent threat or danger. NHA A stated that with R253 it was hard to say because since admission he was upset over his situation and didn't want to be there. Surveyor asked NHA A if R253 had ever made suicidal comments before today. NHA A stated that R253 had made statements before like I want to die and Dr [Name] put me here to rot and die. Surveyor asked NHA A what should have been done when R253 made his suicidal statement this morning. NHA A stated they would need to look at the seriousness of it and determine if there was potential threat to himself and other residents, reaching out the doctor, having the social worker come do a depression screening and possibly contacting a psychiatrist if someone was very depressed with suicidal thoughts. NHA A stated that she felt the statement R253 made today should potentially be looked at as his desire to cause harm to himself, and that when people make those statements they need to determine if that is serious. Surveyor asked NHA A if more follow-up and monitoring should have been done. NHA A stated that they needed to go talk to R253 and see if there was an immediate threat or he was just saying that. Surveyor asked NHA A if there should be some urgency to following up when residents made suicidal statements. NHA A stated yes, that she would have expected that there would have been quicker follow-up including reaching out to the doctor and letting the social worker know so that she could go and talk to him. The facility failed to recognize and take seriously a verbalized suicidal threat by a resident with a history of Depression who had expressed suicidal ideation in the past. Prompt follow-up with the resident was not completed, nor was a monitoring plan put in place to ensure his safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure the provision of pharmaceutical services (including procedures that assure that accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 out of 3 supplemental residents (R24, R30, R303). R24 received a full tab of Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligrams) instead of a half tab as ordered on 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/17/25, 3/18/25, 3/20/25, and 3/21/25. R30 received 1 mg of lorazepam instead of the 0.5 mg ordered on 2/1/25. R303 received Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg instead of the Hydrocodone-Acetaminophen Oral Tablet 5-325 mg as ordered on 4/6/25. Evidenced by: The facility policy, entitled Medication Error and Drug Interactions, dated 8/1/15 with last revision date 2/12/24, states in part: . Definition: Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: 1. The prescriber's order . Example 1: R24 was admitted to the facility on [DATE] and has diagnoses that include Major Depressive Disorder, Type 2 Diabetes Mellitus, and Primary Osteoarthritis (a painful, chronic condition that occurs when the flexible, protective tissue at the ends of bones, called cartilage, wears down). R24's Minimum Data Set (MDS) Assessment, dated 2/5/25 indicates R24 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating R24 is cognitively intact. R24's Physician Orders include, in part: -Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligram). Give 1 tablet by mouth every 6 hours as needed for pain. Start Date: 11/7/24. Discontinue date: 3/22/25. -Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give 0.5 tablet by mouth every 6 hours as needed for pain. Start Date: 3/22/25. R24's MAR (Medication Administration Record) for March 2025 indicates in part: -Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. One full tablet given on: 3/8/25 at 1:23 AM 3/9/25 at 12:22 AM 3/10/25 at 1:12 AM 3/12/25 at 1:14 AM 3/17/25 at 12:08 AM 3/18/25 at 12:12 AM 3/20/25 at 2:04 PM 3/21/25 at 11:34 PM R24's Progress Note on 3/27/25 states in part: . on 3/5/25 ADON F (Assistant Director of Nursing) requested that [Resident Name] Norco (Hydrocodone-Acetaminophen) be decreased to a half tab per [Resident Name]'s request On the overnight pharmacy delivery on 3/6/25 there was a card of Norco 5/235 mg ½ tabs sent and received. The new card was signed in to the narcotic book according to policy. However, there was no new script sent to [Facility Name] indicating there was a change in dosage for Norco. The nurse signing in the medication did not realize that there was a change in dosage. All of the nurses were continuing to administer the PRN (as needed) dose of Norco 5/325 mg full tab because that was the order that was in PCC (Point Click Care electronic health record), and we had a card for that strength . Please note: Despite the physician decreasing the dosage to ½ tabs on 3/5/25, R24 continued to receive the full tab strength until 3/21/25. On 4/19/25, Surveyor interviewed R24 and asked her if her pain was well managed. R24 stated that it was, but that for a while she was getting too much of her pain medication, which she didn't like because it made her too drowsy all day. Example 2: R30 was admitted to the facility on [DATE] and has diagnoses that include Anxiety Disorder, Dementia severe, with psychotic disturbance, Alzheimer's Disease, late onset, Major Depressive Disorder, Repeated falls, Weakness. R30's MDS Assessment, dated 2/24/25, indicates R30 has a BIMS score of 00 out of 15, indicating R30 is severely cognitively impaired. R30's Physician Orders include, in part: -Lorazepam 0.5 mg (milligram) tablet. Give 0.5 mg by mouth two times a day for anxiety disorder, unspecified at 1200 (12:00 PM) and 2000 (8:00 PM). -Lorazepam 1 mg tablet. Give 1 tablet by mouth two times a day for anxiety disorder, unspecified at 0800 (8:00 AM) and 1600 (4:00 PM). R30's Progress Note on 2/2/25 states, in part: . the resident was given 1 mg lorazepam at HS (bedtime) instead of the ordered dose of 0.5 mg . Example 3: R303 was admitted to the facility on [DATE] and has diagnoses that include Type 2 Diabetes Mellitus and Major Depressive Disorder, unspecified. R303's MDS Assessment, dated 4/8/25, indicates R303 has a BIMS score of 15 out of 15, indicating R303 is cognitively intact. R303's Physician Orders include, in part: -Hydrocodone-Acetaminophen Oral Tablet 5-325 mg. Give 1 tablet by mouth every 8 hours as needed for pain. R303's Progress Note on 4/6/25 states, in part: . resident had received a hydrocodone-acetaminophen 7.5-325 mg when they were prescribed hydrocodone-acetaminophen 5-325 mg . On 4/15/25 at 1:30 PM, Surveyor interviewed ADON D (Assistant Director of Nursing) and asked her about the process for when medications are received from the pharmacy. ADON D stated that she didn't really know for sure because she had never been a part of that process, as the medications are usually delivered on the PM and night shifts. Surveyor asked ADON D who was responsible for entering the physician orders onto PCC (Point Click Care electronic health record). ADON D stated that sometimes the float nurse would put them in, sometimes the medication nurse would put them in, and sometimes she would put them in. Surveyor asked ADON D if the doctors ever used e-script (electronic prescribing) and would send them directly to the pharmacy. ADON D indicated that they try to encourage the doctors to give them the prescription but if it was a narcotic the physician would have to escribe, but if it was a regular medication like Tylenol, they would just give them the order. Surveyor asked ADON D what the process was for e-scripted medications like narcotics. ADON D indicated that usually the doctor would give them the order so that they could enter it into PCC and then the doctor would send the e-script to Omnicare Pharmacy. Surveyor asked ADON D who was responsible for verifying that the physician orders were entered correctly into PCC. ADON D stated that the floor nurses would enter the orders but that they need to be confirmed by another nurse, herself or the DON (Director of Nursing). On 4/15/25 at 2:18 PM, Surveyor interviewed DON B and asked her if the doctors use e-script to send medication orders directly to the pharmacy. DON B stated that sometimes they do. Surveyors asked DON B what the process was when the doctor uses e-script. DON B indicated that the doctor would send their prescription to the pharmacy, and they would receive a fax so that they could enter it into PCC. Surveyor asked DON B who was responsible for verifying that the physician orders were entered correctly. DON B stated any of the nurses could do that. Surveyor asked DON B about R24 receiving multiple doses of the wrong medication dose. DON B stated that the pharmacy received the order but did not send it to the facility. DON B indicated that when they get an order from the doctor, they enter it right away, but that they don't know when a doctor faxes the pharmacy and doesn't call or send them a copy so that it can be transcribed. DON B stated that when the card with ½ tabs was received for R24, the nurse should have caught it. DON B indicated that they did an investigation into this situation and that the nurse's weren't doing their checks. DON B stated that it is still their responsibility as the nurse, and that education was given to the nurses involved with the medication error. DON B stated that she did a bigger education in the winter going over the narcotic policy, but that she does education with the nurses directly whenever it is needed. Surveyor asked DON B if it was her expectation that the physician orders be correctly entered and followed. DON B stated yes, that was her expectation. Despite having online education completed in November 2024 on Avoiding Medication Errors and a Monthly Nurse's Meeting on Controlled Medication Management in January 2025, medication errors continued in February 2025, March 2025 and April 2025 without further house-wide education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 15 residents (R253) reviewed for infection control. The facility failed to recognize CDC (Centers for Disease Control) guidance that all residents with wounds would meet the criteria for Enhanced Barrier Precautions. This is evidenced by: The facility policy titled Enhanced Barrier Precautions, dated 3/6/24, indicates in part: . Overview: Enhanced Barrier Precautions (EBP) will not only focus on residents with infection or colonization with MDRO's (Multi Drug Resistant Organism) but will also address residents at risk for developing or becoming colonized. Enhanced Barrier Precautions are precautions that are between Standard Precautions and Contact Precautions. Enhanced Barrier Precautions require gown and glove use for residents with a novel or targeted MDRO or any resident with a wound . during specific high-contact resident care activities . Purpose: . High contact resident care activities include Wound care: any skin opening requiring a dressing . Procedure: 1. Standard Precautions should be applied to all residents at all times. 2. Transmission-based precautions should be applied to all residents when standard precautions alone do not prevent pathogen transmission. 3. EBP are used in conjunction with standard precautions and expand the use of PPE (Personal Protective Equipment) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. a. EBP are indicated for residents with any of the following: . Wounds and/or medical devices even if the resident is not known to be infected or colonized with a MDRO. b. Wounds generally include chronic wounds, not short-lasting wounds . Examples of chronic wounds include, but are not limited to, pressure ulcers . d. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility . CDC (Centers of Disease) guidance for the Implementation of Personal Protective Equipment in Nursing Homes to Prevent the Spread of Multi Drug Resistant Organisms (MDROs) states the following: 1. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 2. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: a. Wounds or indwelling medical devices, regardless of MDRO (Multiple Drug-Resistant Organism) colonization status b. Infection or colonization with an MDRO. 3. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. Residents in nursing homes are at increased risk of becoming colonized and developing infection with MDROs, more than 50% of nursing home residents may be colonized with an MDRO, nursing homes have been the setting for MDRO outbreaks, and when these MDROs result in resident infections, limited treatment options are available . Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, who by definition have no symptoms of illness. MDRO colonization may persist for long periods of time (e.g., months) which contributes to the silent spread of MDROs. Findings include: R253 was admitted to the facility on [DATE] with diagnoses that include Cellulitis of Buttock, Acute Kidney Failure, Venous Insufficiency, Morbid Obesity, and Depression, unspecified. R253's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/28/25 indicates R253 has a BIMS (Brief Interview for Mental Status) score of 8 out of 15, indicating that R253 has moderate cognitive impairment. Section M0300 of the MDS indicates R253 has two Stage 3 pressure ulcers present upon admission. According to the Centers for Medicare and Medicaid Services (CMS) a Stage 3 pressure ulcer is defined as Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. R253's physician orders include: -Location: stage 3 pressure injury to right and left buttocks. Cleanse with normal saline or wound cleanser, and pat dry. Apply calcium alginate to wound beds and cover with large silicone border 9X9 or sacral dressing only. Do not use white border gauze on skin. Change once daily and PRN (as needed) for soiled or saturated dressing. One time a day for skin integrity. Start Date: 3/24/25. No end date. On 4/10/25 at 9:50 AM, Surveyor observed wound care on R253's wounds with LPN C (Licensed Practical Nurse). Surveyor observed LPN C wash hands and don gloves but no gown. Surveyor asked LPN C about the PPE (Personal Protective Equipment) cart and EBP (Enhanced Barrier Precautions) sign located between R253's room and the next room. Surveyor asked LPN C if R253 was on enhanced barrier precautions. LPN C stated no, that the cart and sign were placed there for the next room but not for R253. LPN C then entered R253's room and proceeded to complete wound care. When removing the old dressings, a small laceration from the white border foam dressing caused R253 to begin bleeding, dripping blood all over the floor. LPN C applied pressure with paper toweling and pushed R253's call light for assistance. ADON D (Assistant Director of Nursing) entered the room and LPN C requested the blood spill kit. ADON D left the room and returned a few minutes later with the blood spill kit. Note: At no time did LPN C or ADON D don a gown, despite R253's wound continuing to drip blood all over the floor. On 4/15/25 at 1:30 PM, Surveyor interviewed ADON D and asked if R253 was on EBP. ADON B replied no, R253 was not on EBP. Surveyor asked ADON D what her expectation would be for PPE when the staff do wound care dressing changes. ADON D stated that it was her expectation that staff wear gloves only when doing wound care dressing changes. On 4/15/25 at 2:15 PM, Surveyor interviewed DON B (Director of Nursing) and asked if R253 was on EBP. DON B stated no, he was not on EBP because he did not have a history of an MDRO. Surveyor asked DON B if it was her expectation that nurses where gowns when doing wound care. DON B stated yes, that was her expectation. The facility was not following CDC recommendations to recognize that all chronic wounds warrant EBP to prevent the development and transmission of communicable diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 sampled residents (R2). R2 is at risk for falls and was left unsupervised in a bathroom, still connected to a mechanical lift, and experienced a fall while unsupervised. R2 was also observed to not have an anti-rollback device installed on his wheelchair as stated in his care plan. This is evidenced by: The facility policy entitled, Sit-to-Stand Mechanical Lift-SNF, dated 8/22/23, states, in part: . Purpose: To assist residents with transfers who are able to bear weight with some assistance. Employees will use the sit to stand mechanical lift per policy to ensure safety for the resident and the employee. Procedure: 1. Sit to stand mechanical lift will be used with two caregivers .8. Transfer according to manufacture direction guidelines . The mechanical lift used in the transfer has manufacturer recommendations that state, in part: Intended use . [Product Name] shall always be handled by a trained caregiver, continuously attending to the resident . R2 admitted to the facility on [DATE] with diagnoses that include Parkinson's disease (brain disorder that causes problems with movement, balance, and coordination), type 2 diabetes mellitus, Crohn's disease (inflammatory bowel disorder), irritable bowel syndrome, dementia, polyneuropathy (peripheral nerve damage causing pain, decreased sensation, and weakness), unsteadiness on feet, and muscle wasting and atrophy. R2 has an activated Healthcare Power of Attorney. R2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/21/24, indicates R2 has a Brief Interview of Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Section GG indicates R2 is dependent on staff for toileting hygiene, toilet transfers, chair/bed-to-chair transfers, and to move from sitting to standing. Section GG also indicates that the facility could not attempt to assess R2 walking 10 feet due to a concern for resident safety. R2's Comprehensive Care Plan, states, in part: . Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) Parkinson's, DM2 (Diabetes mellitus type 2), Crohn's disease, GERD (gastroesophageal reflux disease), MDD (Major Depressive Disorder), IBS (irritable bowel syndrome), rhabdomyolysis. Date Initiated: 5/20/24. Interventions: . Dressing assist - two person assist . toilet use assist- [Mechanical Lift Product Name] . Focus: The resident has limited physical mobility r/t Parkinson's. Date initiated: 5/20/24. Interventions/Tasks: AMBULATION/LOCOMOTION- WHEELCHAIR-MANUAL. AMBULATION/LOCOMTION- [Mechanical Lift Product Name]. AMBULATION/LOCOMTION ASSIST- FRONT WHEELED WALKER . TRANSFER ASSIST- Two person assist with transfers. Focus: The resident has impaired cognitive function or impaired through processes r/t Parkinson's diagnosis. Date Initiated: 5/20/24. Interventions/Tasks: Ask yes/no questions in order to determine resident's needs. COMMUNICATION: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distraction-turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Cue, reorient and supervise as needed . Present just one thought, idea, question or command at a time. Focus: The resident is HIGH risk for falls r/t Parkinson's disease, poor safety awareness. 4/6/24, 5/22/24, 5/24/24, 6/10/24, 6/20/24, 6/23/24, 7/8/2024, 7/13/24, 8/23/24, 8/25/24, 8/31/24, 9/2/24. Date initiated: 5/20/2024. Revision on: 9/4/2024 Interventions/Tasks: 4/8/24 anti-rollbacks added to w/c (wheelchair). 5/24/24 have up in w/c when anxious and place in dining area for more observation of patient. 6/10/24- Intervention is to put resident into recliner following meals and after toileting. 8/23/24- Do not leave unattended on the toilet. 8/31/24- scheduled toileting for 2100 (9:00 PM). 9/2/24- Room changed to room [ROOM NUMBER]. Assist R2 up in wheelchair before breakfast and provide a snack as needed 6/23/24. Day shift to check on R2 at the beginning of the 6 am shift 7/15/24. Get resident up to the bathroom x1 on NOC (night shift) at 0200 (2:00 AM) to try to have a BM (bowel movement) (7/8/2024). Intervention is to put in bed between 7-7:30 pm to assure no attempts to put self in bed. Q 1-hour checks. Scheduled toileting program (Q 2 hours). Provide/offer snacks in between meals and/or with signs of restlessness. PT/OT (Physical therapy/Occupational Therapy) to evaluate and treat. Low bed. Gripper socks on when up (4/7/24). Skid Resistant shoes. Focus: Vulnerability: Resident being dependent on staff for cares and transfers. Initiated on 05/20/2024. Interventions/Tasks: . Provide safe environment . R2's Fall Report, dated 8/23/24 at 14:20 (2:20 PM), states, in part: . Nursing Description: CNA (Certified Nursing Assistant) alerted this nurse that Pt (Patient) had a change of plane while sitting on [Mechanical Lift] in bathroom. Arrived at patients room. Pt was sitting on left side of toilet, his bottom was not on the floor, as it was on the sling of the EZ stand. PT also had his left arm on his sink bracing himself along with right arm holding onto handle bar. Resident Description: Resident Unable to give Description. Was this incident witnessed: N Immediate Action Taken: Description: New intervention will be to not leave patient unattended in [Mechanical Lift] while in bathroom. Mental Status: Baseline for individual, Oriented to Time, Oriented to Person . Predisposing Physiological Factors: Gait imbalance, Weakness/Fainted, Impaired Memory. On 9/18/24 at 12:15 PM, Surveyor observed R2 seated in a mechanical wheelchair in the dining room. The mechanical wheelchair was not equipped with an anti-rollback device as stated in the comprehensive care plan. On 9/17/24 at 2:15 PM, Surveyor interviewed CNA C. CNA C was the CNA who reported R2's fall on 8/23/24. CNA C described the incident. As CNA C started her shift and got report, she was told that R2 was in the bathroom on the mechanical lift. CNA C went in to check on R2 who told CNA C he needed more time. CNA C left the room to assist a different resident who needed help. When CNA C returned to R2 to see how he was doing, R2 was half-off the toilet and holding on to the sink and one of the lift handles to try to hold himself up. CNA C got the nurses attention without leaving the resident and he was assisted off the toilet. CNA C stated that when she found R2 after the fall, he was still connected to the mechanical lift. Surveyor asked CNA C what she believed to be the root cause for R2's fall. CNA C stated that R2 tried to stand while he was still connected to the sling and the sling slipped so that it was no longer supporting R2. Surveyor asked CNA C if she normally leaves R2 alone in the bathroom. CNA C stated she normally stays within his line of sight so that she can ensure his safety, but at this time she was called away to assist another resident. Surveyor asked CNA C if R2 is supposed to have an anti-rollback device installed on his wheelchair. CNA C stated, Absolutely. On 9/17/24 at 2:19 PM, Surveyor asked CNA C to identify which lift was being utilized the day of the fall. CNA C identified the EZ stand lift. On 9/17/24 at 2:25 PM, Surveyor interviewed CNA D. CNA D described the appropriate transfer procedure utilizing a mechanical lift and states that staff always needed 2 people to transfer a resident. Surveyor asked CNA D if residents could be left alone in the bathroom while connected to a lift. CNA D stated that it depends on the resident; some residents who are cognitively impaired or have poor safety awareness should be supervised more closely while in the bathroom. On 9/17/24 at 2:48 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectation is for staff while transferring residents with a mechanical lift. DON B stated that there needs to be two (2) staff present while the mechanical lift is in motion. Surveyor asked DON B what her expectation is for staff supervising residents while connected to a mechanical lift. DON B stated that it depends on the resident, and that this information should be included in the care plan if they are safe to be left alone in the bathroom or not. Surveyor asked DON B if R2 was able to be left unsupervised while connected to a lift. DON B stated he is not anymore. After the fall on 8/23/24, it was decided that he was not able to be left in the bathroom unsupervised. Surveyor asked DON B if she had completed any staff education regarding mechanical lift procedure, fall prevention, or supervision after R2's fall. DON B stated she did not because prior to the fall, R2 had not had any incidents while being unsupervised in the bathroom, so an intervention was just added to the care plan after the fall. Surveyor asked DON B if R2 is supposed to have an anti-rollback device on his wheelchair. DON B stated if it is on the care plan, it should be on his wheelchair. On 9/17/24 at 3:04 PM, DON B returned after consulting with staff to inform Surveyor that R2 is supposed to have an anti-rollback device on his wheelchair; however, when R2 had his shower day yesterday (9/16/24) he was accidentally returned to the wrong wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 1 resident (R1) reviewed for pain. R1 complained of pain during pericare. R1 was observed to wince and cry due to the pain. At no point during this interaction did staff stop care and let R1 take a break, or immediately notify the nurse of R1's pain. Evidenced by: The facility policy, Pain Management and Assessment, revised 4/27/22, indicates in part the following: The purpose of this policy is to develop a standardized method for assessing, monitoring, evaluating, managing, and documenting pain in both cognitively intact and impaired residents. Residents will receive necessary comfort, exercise greater independence, and enhance dignity through optimizing their ability to perform activities of daily living. Evaluate for behavioral responses to pain: a. facial wrinkling/grimacing; c. crying or moaning; g. decreased interaction. Non-pharmacological interventions (i.e. repositioning resident, turning lights off, warm cloth, etc.) will be attempted prior to the use of PRN (as needed) analgesics whenever appropriate. Use of interventions and effectiveness will be documented. R1 was admitted to the facility 4/9/24 with diagnoses including, but not limited to, spondylosis, osteoporosis, dementia, major depressive disorder single episode, total retinal detachment, occlusion and stenosis of bilateral carotid arteries, muscle wasting and atrophy. R1's admission Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) of 13, indicating she is cognitively intact. R1's PHQ-9 indicates Minimal Depression. R1 is her own person. R1's Certified Nursing Assistant (CNA) [NAME] documents, in part, the following: Transfer, Toileting, Bathing, Bed Mobility, Dressing assist of one (1). In addition, Toileting indicates the following interventions: Apply barrier cream to peri area after each incontinent episode; Check and change resident as needed due to incontinence; Incontinence care after each incontinent episode; Record bowel movement pattern each day. Describe amount, color, and consistency; Scheduled Toileting Program for incont (incontinent) episode at 3 hours. The section Skin indicates other pain intervention: May use lotion and water on wash clothes to remove bm more gently; offer whirlpool baths more frequently as she allows, apply barrier cream/ointment with peri care interaction, other medication cream or pads as ordered. On 7/30/24 at approximately 12:30 PM, Surveyor spoke with CNA/Scheduler C (Certified Nursing Assistant/Scheduler). Surveyor asked CNA/Scheduler C to described what occurred during her shift on 7/7/24. CNA/Scheduler C stated, she was working as 1/2 Bath Aide and 1/2 CNA. CNA/Scheduler C stated, at approximately 1:30 PM, she answered R1's call light. CNA/Scheduler C stated, When washing her up I could feel her wince and My hands are huge, and I was trying to be gentle. CNA/Scheduler C stated, she observed a tear on R1's nose. CNA/Scheduler C stated, when she could see R1 was in pain she pushed R1's call light for assistance and nobody answered my call light. CNA/Scheduler C stated, she finished cleaning R1 up and transferred her to the recliner. CNA/Scheduler C asked RN E to follow up regarding R1's pain. On 7/24/24 the Administrator spoke with CNA/Scheduler C (Certified Nursing Assistant) regarding an allegation made by R1. The Nursing Home Administrator (NHA) asked CNA/Scheduler C to explain what occurred on 7/7/24 with R1. CNA/Scheduler C summarized she went to assist R1 due to a call light being on. She had stool stuck in her butt crack, so it was hard to get off. It wasn't soft stool but wasn't hard. It was sticky. As I was wiping her, I could see her body wince and she started to cry. She said it was very painful. At that point, I pulled her call light in the bathroom to see if I could have the nurse come in to assist since she was in a lot of pain. I tried to just pat her back and forth with a wash cloth instead of rubbing. It took about 10-15 minutes to get her all cleaned up. I told her, I'm sorry and that I was doing my best to not hurt her, but also had to get the stool off her. After I was completed, I applied a barrier cream to her and assisted with clean clothes. I went straight to the nurse on duty RN E (Registered Nurse) and asked her if she had anything more she could give or do for R1's butt pain as she was crying because of the pain. Administrator asked if R1 had said anything to her to stop. CNA C said she did not verbally say stop. She just said it was painful and I told her I was sorry. It is important to note, during this incident of incontinence and pericare, CNA/Scheduler C indicates the following: As I was wiping her, I could see her body wince and she started to cry and she was crying because of the pain. At no point during this interaction did CNA/Scheduler C stop cares and let R1 take a break, nor did CNA/Scheduler C physically go notify the RN E. RN E (Registered Nurse) statement indicates as follows: CNA C approached me on 7/7/24 and asked if R1 is always in a lot of pain during toileting/pericare. CNA C told me that R1 was crying and verbalized she was in a lot of pain. CNA C asked if I could give her something for her butt pain specifically. I explained to her that I did not have anything for butt pain besides the calmoseptine cream. I worked a 16-hour shift and interacted with R1 off and on that day and she did not express being in distress or any pain to me. On 7/30/24 at 2:50 PM, Surveyor spoke with RN E (Registered Nurse). RN E works PRN (as needed) at the facility. Surveyor asked RN E to described what occurred during her shift on 7/7/24. RN E stated on 7/7/24 she worked from 6:00 AM-10:00 PM. RN E stated CNA/Scheduler C reported to her that she had just assisted R1 with incontinence care and it was quite painful for her. RN E stated, CNA/Scheduler C wanted her to check in with R1 after that. RN E stated when she went in the room R1 was resting in her chair. RN E stated, she did not want to disturb R1 and did not wake her up. RN E stated, during her 16-hour shift R1 did not mention the allegation. RN E stated the only order she has for R1's bottom was Calmoseptine. Collateral Statements from 7/7/24 Self Reportable: LPN D (Licensed Practical Nurse) - R1 stated to LPN D that she needed help in the bathroom and CNA/Scheduler C came in to wash her up. Resident stated, it hurt so bad and said she yelled out because it was so painful it got worse. She (R1) doesn't want her bathing her or washing her up anymore. She did it hard and it hurt. Nurse wrote up a concern form to Administrator. On 7/30/24 at 2:30 PM, Surveyor spoke with LPN D (Licensed Practical Nurse). Surveyor asked LPN D to described what occurred during her shift on 7/7/24. LPN D stated, R1 reported to her that CNA/Scheduler C was Very rough and Rough washing up my bottom and Look at her (CNA/Scheduler C), look at me she is much bigger than me and She was right there washing and didn't stop. LPN D stated she reported this to NHA A (Nursing Home Administrator). On 7/30/24 at 9:10 AM, Surveyor spoke with R1. R1 stated she has a concern with CNA/Scheduler C, R1 stated, CNA/Scheduler C treated me very roughly, more than roughly, cruelly. R1 added, I call it a brutal beating. Surveyor asked R1 did CNA/Scheduler C say anything to you. R1 stated, she didn't answer just kept on going. On 7/20/24 at 3:20 PM, Surveyors spoke with NHA A (Nursing Home Administrator). Surveyor asked NHA A, what did R1 report regarding the 7/7/24 allegation. NHA A stated, R1 reported, She (CNA/Scheduler C) wiped me really hard, and it hurt. and was really painful. NHA A stated, R1 shared she has hemorrhoids and has some pain to her private area after having 6 babies. NHA stated, R1 stated she asked CNA/Scheduler C to stop but she kept on doing it and didn't say anything. NHA A stated, CNA/Scheduler C stated R1 did not tell her to stop; however, she observed and stated that R1 was crying and in visible pain. Surveyor asked NHA A, did you educate CNA/Scheduler C and other staff regarding pain and stopping cares when a resident is in pain. NHA A stated that she, DON B (Director of Nursing) and HR (Human Resources) provided education to CNA/Scheduler C over the phone; however, there is no documentation that CNA/Scheduler C was educated regarding pain. NHA A stated that other staff were not educated regarding pain. Surveyor asked NHA A, should you have educated CNA/Scheduler C and all other staff regarding pain following this allegation. NHA A stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure oxygen therapy equipment was maintained per physician's order for 1 of 1 (R1) residents reviewed for respiratory care. R1 was to have the filter of his oxygen concetrator cleaned weekly. Observations found the filter to be covered with lint and dust. Findings include: Review of the facility policy titled, Oxygen Administration and Storage, last reviewed 04/26/22, read, Filters should be removed and cleaned by rinsing with clear, cool water weekly to maximize flow rate of clean air. Review of the undated user manual for the oxygen concentrator read, To reduce the risk of infections it is very important to keep your equipment clean .Cleaning Your Oxygen Equipment: Clean any filters with warm water and let dry before putting them back in the machine . R1 was admitted on [DATE] with diagnoses of obstructive sleep apnea and a history of COVID-19. Review of R1's Care Plan, revised on 12/27/22 had a focus area of altered respiratory status/difficulty breathing r/t (related to) heart failure, obesity, chronic sinusitis, and low oxygen levels with activity. The care plan indicated R1 was to receive oxygen at two liters per minute. The care plan did not address cleaning the oxygen concentrator filter. R1's undated Order Summary report, revealed R1 was to receive oxygen at 2 liters a minute as needed. The orders also indicated, since 07/24/22, the oxygen filter was to be cleaned once a week. R1's Medication Administration Record (MAR), dated 01/2022 revealed the filter on R1's oxygen concentrator was to be cleaned weekly on Sundays. The MAR was signed as completed 01/01/22. Surveyor made observations on 1/3/23 at 10:17 AM, 1/4/23 at 8:15 AM. Both observations revealed the oxygen concentrator filter had an accumulation of dirt and lint covering the entire surface of the filter. During an observation and interview on 01/04/23 at 1:16 PM, RN C (Registered Nurse) stated oxygen concentrator filters were cleaned on the night shift. RN C verified the filter on R1's oxygen concentrator was dirty. During an interview on 01/04/23 at 1:26 PM, DON B (Director of Nursing) stated she expected the oxygen concentrator filters to be cleaned weekly when the tubing was changed. DON B stated there was not a system for monitoring to ensure filters were cleaned weekly. The DON identified the initials on the MAR as RN D's. During an interview on 01/05/23 at 10:34 AM, DON B stated she had talked with RN D and RN D had stated she was called away from R1's room prior to cleaning the oxygen concentrator filter and forgot to go back and clean it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and policy review, the facility failed to identify and report PRN (as needed) psychotropic drug use beyond 14 days without a documented rationale for 1 of 3 residents (R35) reviewed for psychotropic medications out of a total sample of 13 residents. R35 had an order for as needed lorazepam, an antianxiety medication. There was no stop date after 14 days, and no assessment for the continued use of the medication. Findings include: Review of a facility policy titled, Psychotropic Medication, revised on 05/25/21 and provided by the facility, revealed, .PRN (as needed) orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of the PRN order . R35 was admitted to the facility on [DATE] with diagnoses that included dementia. Review of R35's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) with a score of zero out of 15 indicating R35 had severe cognitive impairment. Review of R35's Care Plan, dated 08/10/22, included use of antianxiety medication related to anxiety disorder and required assistance with self-care tasks related to dementia. Review of R35's Physician Orders, dated 08/10/22 included lorazepam (anti-anxiety) PRN for anxiety with a stop date of 02/10/23 beyond 14 days after the order date. Review of R35's Psychiatry Consult Note, dated 12/19/22 and provided by the facility, did not include use of lorazepam PRN for anxiety. Review of R35's Medication Administration Record (MAR), revealed R35 did not receive any PRN doses of lorazepam in August 2022, resident refused one dose on 09/16/22, none administered in October or December 2022, and received one dose of lorazepam 0.5mg on 11/23/22 and 11/24/22. Review of R35's Consultation Reports revealed the pharmacist did not address psychotropic drug use beyond 14 days related to PRN use during monthly reviews from August 2022 through December 2022. During an interview on 01/05/23 at 11:43 AM, the RPh E (Registered Pharmacist) stated that psychotropic medications not used as an antipsychotic medication should be limited to 14 days. If the physician feels the order needs to be extended beyond the 14 days there should be a rationale documented by the physician. RPh E was not aware of R35 having a prn lorazepam order that exceeded 14 days without physician rationale/documentation. During an interview on 01/05/23 at 4:10 PM, DON B (Director of Nursing) confirmed the pharmacist's Consultation Reports from August 2022 through December 2022 did not identify that R35 had an order for psychotropic prn administration of lorazepam beyond 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and policy reviews, the facility failed to ensure antibiotics were not used for an excessive duration and without adequate monitoring for 1 of 5 residents (R35) reviewed for unnecessary medications in a total sample of 13 residents. R35 was receiving a prophylactic antibiotic for a history of UTIs (Urinary Tract Infections). There was no rationale for R35 to receive this medication. Findings include: Review of the facility policy titled, Antibiotic Stewardship, provided by the facility and revised on 12/20/19, stated the purpose was to promote appropriate use of antibiotics for quality of care, successful resident outcomes and reduction of potential adverse consequences related to antibiotic use .The nurse will utilize the McGeers Minimum Criteria protocol .to determine if it is necessary to treat with antibiotics or if adjustments in therapy need to be made .The nurse will notify the physician/practitioner of resident change of condition and evaluation information will communicate to the provider the infection criteria protocol to treat the respective infection. If antibiotics are ordered prior to any diagnostic testing or outside of the parameters of the McGeer Minimum Criteria the nurse will request a written note from the physician/practitioner as to the rationale and will document such request . R35 was admitted to the facility on [DATE] with diagnoses that included dementia and urinary incontinence (uncontrolled leakage of urine). There was no mention of chronic urinary tract infections. Review of R35's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 indicating R35 had severe cognitive impairment. Additionally, the MDS indicated that R35 had not had any infections within the past 30 days. Review of R35's Physician Orders, dated 08/10/22 included nitrofurantoin (antibiotic) for prophylactic (preventive) related to a history of chronic UTI (urinary tract infection). Review of R35's McGeer's Infection Criteria assessment dated [DATE], revealed Section B Urinary Tract Infections (UTIs) was not filled out which indicated the resident must have at least one of the following signs or symptoms: acute dysuria (painful urination), fever, or elevated white blood cells and at least one of the following: acute costovertebral angle pain and tenderness, suprapubic pain, gross hematuria (blood in urine), new or marked increase in incontinence, new or marked increase in urgency, or new or marked increase in frequency .Section E Communication with Physician stated If orders do not meet criteria, has the physician been informed and has the physician given a rationale for continued antibiotic use? R35 just completed cefdinir 300mg BID (twice daily) for 7 days for a UTI (urinary tract infection). She admitted on nitrofurantoin 100mg daily ongoing, prophylactically due to chronic UTIs. UA culture grew klebsiella pneumoniae on 08/02/22 [sic]. Review of R35's most recent urine culture was dated 08/02/21, over a year prior to her admission to the facility. Review of R35's Care Plan dated 08/10/22, included prophylactic antibiotic usage with interventions including monitoring/documenting/reporting signs and symptoms of UTI to include fever, abdominal pain, mental status change, weakness, functional decline, nausea, vomiting, dark cloudy urine, foul smelling urine, blood in urine, pus in urine. Review of R35's Progress Notes, revealed from 8/9/22 through 1/4/23, R35 had no signs or symptoms of urinary tract infections. Review of R35's physician progress note, dated 08/22/22, revealed the physician stated that R35 had a history of .chronic UTI's and was on prophylactic treatment, but I think that has been stopped . Visit notes from September 2022 through 01/04/23 did not address long term, prophylactic use of antibiotics or monitoring of laboratory values. Review of R35's pharmacist Consultation Report, dated 11/30/22, recommended, Please discontinue nitrofurantoin while monitoring for signs and symptoms of recurrent UTI. Rationale for Recommendation: The potential for developing pulmonary fibrosis, hepatotoxicity, C.difficile infection, and peripheral neuropathy increases with duration of use . As of 01/04/23, the physician had not responded to the pharmacy recommendation. Review of R35's Medication Review Report, dated 11/07/22 indicated the physician reviewed the nitrofurantoin order and approved continued use with no documented rationale. During an interview on 01/05/23 at 11:43 AM, RPh E (Registered Pharmacist) stated that when residents are on prophylactic antibiotics, recommendations are made to the physician that include providing a statement indicating why there is a need for prophylactic antibiotic use and they also suggest periodic monitoring for renal function, etc. The goal was to ensure there was no organ damage related to long term use of antibiotics. Review of a letter sent to physicians in August 2022, provided by DON B (Director of Nurses), stated in part, .The facility understands that as the primary care doctor or nurse practitioner, you know your patients' history and may still choose to place your patient on an antibiotic despite not meeting the McGeer Criteria. The facility asks that you provide us with a statement to support this for facility records . During an interview on 01/05/23 at 12:30 PM, DON B confirmed that R35 was admitted to the facility on [DATE] with orders for nitrofurantoin for chronic UTI. DON B stated that an annual notification goes out to all physicians, with the most recent notification dated August 2022 and referenced above. Additionally, all residents must have a physician order for antibiotics, and McGeer's Criteria assessment must be performed by the nurse prior to the start of antibiotics. During an interview on 01/05/23 at 4:10 PM, DON B stated that she spoke with R35's physician regarding laboratory monitoring and confirmed that the most recent laboratory monitoring was in July 2022, there were no current orders on file for monitoring laboratory values, and that the physician had provided verbal orders for the discontinuation of nitrofurantoin as of 01/05/23 without rationale. DON B's expectation related to pharmacist recommendations was for the physician to respond to any recommendations within 30 days; DON B confirmed that the physician had not responded to the pharmacists recommendation regarding discontinuation of nitrofurantoin prior to this surveyor bringing it to her attention or prior to her call to the physician's office. The physician was not available for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure that 3 of 3 resident (R47, R23, and R35) residents reviewed for unnecessary medications had an order for an as-needed (PRN) psychotropic medication which did not extend beyond 14 days, without a physician assessment and documented rationale. Findings include: Review of a facility policy titled, Psychotropic Medication, revised on 05/25/21 and provided by the facility, stated, .PRN (as needed) orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration of the PRN order . Review of a facility policy titled, Medication Regimen Review (MRR), revised on 03/03/20 and provided by the facility, stated, .The pharmacist will address copies of residents' MRRs to the Director of Nursing and/or the attending physician and to the Medical Director. Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of MRRs .The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record . Example 1: R47 was admitted on [DATE] with diagnosis of dementia with agitation and bipolar disorder (serious mental illness of bouts of depression and increased activity/excitability). Review of R47's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating R47 had moderate cognitive impairment. Review of the September 2022 MRR revealed a physician's order, which originated on 09/08/22, for Ativan (lorazepam, an anti-anxiety medication), 0.5 milligrams every 12 hours as needed for agitation. R47's Care Plan, revised 09/08/22 stated, Administer medications as ordered. Monitor/document for side effects and effectiveness. My medications for behavior are: Ativan (lorazepam) for anxiety, and Lexapro for bipolar depression. Review of a Pharmacy Consultant Note dated 09/28/22 indicated, Note Text: Please see consultant report. Further documentation found under the Miscellaneous tab revealed the pharmacist's recommendation: R47 has a PRN (as needed) order for an anxiolytic, which has been in place for greater than 14 days without a stop date: lorazepam 0.5 mg every 12 hours as needed for agitation. Recommendation: Please discontinue PRN lorazepam, tapering, as necessary. If the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of the medication, and the rationale for the extended time period. Review of R47's Medication Administration Records (MAR) for September, October, and November 2022, revealed R47 continued to receive the medication eight times after the 14 day stop date. Review of R47's EMR revealed no documentation by the resident's physician of the clinical rationale for continued use of the Ativan without any attempts at a gradual dose reduction until 11/04/22. During an interview on 01/04/23 at 3:39 PM, the DON B (Director of Nursing) stated that on 11/01/22, R47's doctor had notified the facility via telephone that the lorazepam was discontinued as of that date. The DON did not provide any documentation by the physician related to the clinical rationale for continued use of the medication, or documentation of the risks versus benefits of continued use being discussed. Example 2 R23 was admitted on [DATE] with diagnoses including macular degeneration, hallucinations, and muscle wasting. Review of R23's Care Plan revised 09/07/22, indicated he was prescribed antipsychotic medication related to delusions, striking out, hitting, biting, and hallucinations. Review of R23's annual MDS dated [DATE] included a BIMS score of 11 out of 15 indicating R23 had moderate cognitive impairment. Review of R23's Orders included lorazepam (antianxiety medication) 1mg tablet to be given every 24 hours as needed for anxiety and dated 05/09/22 with a stop date of 10/13/22. Review of R23's document titled Consultation Report, dated 08/25/22 and provided by the facility, revealed the pharmacist's comment that R23 .has a PRN order for an anxiolytic, which as been in place for greater than 14 days without a stop date: lorazepam 1mg every 24 hours as needed for anxiety; note has a routine order for lorazepam 1mg every morning. Recommendation: Please discontinue PRN lorazepam, tapering as necessary . The order was not discontinued by the physician until 09/25/22. Review of R23's MAR revealed R23 did not receive any PRN doses of lorazepam from May 2022-August 2022 and one dose of PRN lorazepam on 09/07/22. Example 3 R35 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and anxiety. Review of R35's Care Plan, dated 08/10/22, included use of antianxiety medication related to anxiety disorder and required assistance with self-care tasks related to dementia. Review of R35's quarterly MDS dated [DATE] revealed a BIMS score of zero out of 15 indicating R35 had severe cognitive impairment. Review of R35's Order Summary Report, included lorazepam 0.5mg tablet every 24 hours as needed for increased anxiety, dated 08/10/22 with a stop date of 02/10/23. Review of R35's Consultation Reports revealed the pharmacist did not address psychotropic drug use beyond 14 days related to PRN use. Review of R35's MAR, revealed R35 did not receive any PRN doses of lorazepam in August 2022, refused one dose on 09/16/22, none administered in October or December 2022, and received one dose of lorazepam 0.5mg on 11/23/22 and 11/24/22. During an interview on 01/05/23 at 11:43 AM, RPh E stated that psychotropic medications not used as an antipsychotic medication should be limited to 14 days; if the physician feels the order needs to be extended beyond the 14 days there should be a rationale documented by the physician. Interview on 01/04/23 at 11:21 AM with DON B confirmed R23, R35, and R47 had a PRN order for an anxiolytic (lorazepam) that was in place for greater than 14 days without a stop date but should have been. Additionally, the DON confirmed that the physician did not respond to pharmacy recommendations in a timely manner.