**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure a gradual dose reduction was performed for 1 of 5 sample residents (#28) reviewed for unnecessary medications. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #28 had a brief interview for mental status score of 14 out 15, which indicated s/he was cognitively intact, and diagnoses which included end-stage renal disease and insomnia. Further review showed the resident used antidepressant medications during the look-back period. Review of the resident's physician orders showed s/he received trazodone (antidepressant) 50 mg by mouth at bedtime related to insomnia which was ordered on 7/21/23. The following concerns were identified: a. Review of the treatment administration records for January, February, and March 2025 showed the facility was monitoring the resident for restlessness at night and there were no documented episodes of restlessness indicated. b. Review of a Consultation Report dated January 1, 2025 through January 18, 2025 showed the pharmacist recommended to .Please attempt a gradual dose reduction (GDR) to 25 mg qhs (every day at hours of sleep). If you do not wish to decrease, please document risk vs. benefit of continuing Trazadone . The review showed the physician declined the recommendation because a GDR was Clinically Contraindicated for the resident and checked the box for the resident's target symptoms returned or worsened after the most recent GDR attempt within the facility and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder as documented below. Further review showed there was no additional or resident specific information documented below. c. Review of a Consultation Report dated May 20, 2024 through May 22, 2024 showed the pharmacist recommended If clinically appropriate, please consider a gradual dose reduction (GDR) to trazadone 25 mg daily, while concurrently monitoring for reemergence of target and withdrawal symptoms. The review showed the physician declined and checked the box that stated Continued use is in accordance with the current standard of practice and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating and underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW . Further review showed the physician wrote [S/he] is able to sleep with trazadone. d. Review of a Consultation Report dated January 29, 2024 through January 30, 2024 showed the pharmacist recommended If clinically appropriate, please consider a gradual dose reduction (GDR) to trazadone 25 mg daily, while concurrently monitoring for reemergence of target and withdrawal symptoms. The review showed the physician declined and checked the box that stated Continued use is in accordance with the current standard of practice and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating and underlying medical condition or psychiatric disorder AS DOCUMENTED BELOW . Further review showed there was no additional or resident specific information documented below. 2. Interview with the DON on 3/27/25 at 10:22 AM revealed the resident #28 previously had a successful gradual dose reduction attempted and she was unable to find any unsuccessful attempts. In addition, she was unable to locate where the physician provided additional resident specific information for the need of the medication. 3. Review of the facility policy titled Psychoactive Medication and Medication Regimen Review Management Standard dated 9.2024 showed .5. Gradual Dose Reduction/Tapering of Medications: The requirements underlying this guidance emphasize the importance of seeking an appropriate dose and duration for each medication and minimizing the risk of adverse consequences, The purpose of tapering a medication is to find an optimal dose or to determine whether continued use of the medication is benefiting the resident. Tapering may be indicated when the resident's clinical condition has improved or stabilized, the underlying cases of the original symptoms have resolved, and/or non-pharmacological interventions, including behavioral interventions, have been effective in reducing symptoms .

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented during meal delivery and assistance during 2 of 3 meal observations in the main dining room. The census was 56. The findings were: 1. Observation on 3/24/25 beginning at 5:43 PM showed CNA #1 was assisting a resident to eat dinner. The CNA was observed touching the resident's shoulder, arm, and wheelchair wheel while assisting the resident. Without performing hand hygiene, the CNA moved around the table and was observed placing her ungloved hand on top of another resident's hamburger and using her other hand to cut the hamburger in half. After it was cut, the CNA picked up half the hamburger, using both hands, and handed it to the resident, which the resident ate. The CNA then used her ungloved hand to pick up a French fry, dip it in ketchup, and hand it to the resident, which s/he ate. The CNA again picked up the resident's hamburger and handed it to the resident before standing from the table at washing her hands at the sink in the dining room. 2. Observation on 3/26/25 beginning at 12:04 PM showed CNA #1 assisted a resident by cutting his/her food and then touched the resident's shirt. The CNA left the table and obtained another plate at the kitchen window and took it to a 2nd resident, where she cut up the food using his/her silverware. The CNA placed her hand into her hair then obtained another plate from the kitchen window and delivered it to a 3rd resident. While delivering the meal tray, the CNA touched the resident's wheelchair before returning to the kitchen window to obtain another tray and delivering it to a 4th resident. No hand hygiene was performed during the observation. 3. Interview with the DON, infection preventionist, and dietary director on 3/27/25 at 9:48 AM revealed hand hygiene should occur during meal service between residents if resident contact occurred. They confirmed the CNA should perform hand hygiene before assisting a second resident and they would like staff to wear gloves if they are touching the resident's food items. Further interview revealed they expected hand hygiene to be performed after touching potentially contaminated items. 4. Review of a facility procedure titled . Hand Hygiene Competency dated 12.2019 showed .When to wash hands .Before each resident contact .After touching a resident or handling their belongings .After handling contaminated items (linens/garbage/briefs, etc.) .When can hand sanitizer be used .Before/after direct contact with resident .After contact with resident's intact skin .After contact with inanimate objects, such as medical equipment in resident's room or vicinity .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, facility incident review, and policy and procedure review, the facility failed protect the resident's right to be free from physical abuse by another resident for 1 of 3 sample residents (#2). Corrective measures were implemented prior to the survey and compliance was determined to be met on 8/9/24. The findings were: 1.Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a BIMS score of 5 out of 15, indicating severe cognitive impairment, had diagnoses which included non-Alzheimer's dementia, and did not exhibit behaviors. Review of the admission MDS assessment dated [DATE] showed resident #3 had a BIMS score of 9 out of 15, indicating moderate cognitive impairment, had diagnoses which included non-Alzheimer's dementia, and did not exhibit behaviors. The following concerns were identified: a. Review of an incident report dated 7/20/24 and timed 5 PM showed both resident #2 and #3 were in the dining room when resident #3 was seen rubbing resident #2's shoulder. Resident #3 then put his/her hand in resident #2's groin area. Resident #2 and #3 were separated at the time of the incident. b. Interview with CNA #1 on 12/27/24 at 12:05 PM revealed s/he witnessed resident #3 massaging resident #2' s groin area outside his/her pants. The CNA revealed resident #3 was immediately redirected and separated from resident #2. The CNA stated the residents didn't know what happened, they both have dementia. The CNA stated resident #2 showed no changes in demeanor following the incident. c. Interview with RN #2 on 12/27/24 at 2 PM with revealed s/he did not witness the incident but was made aware of it by CNA #1 immediately after it happened. The RN revealed s/he followed the facility policy and procedure for reporting abuse which included notifying the social services director. RN #1 confirmed resident #2 and #3 were separated and resident #3 was placed on increased supervision. RN #1 revealed no effects were noted after the incident but it's hard to tell with dementia. 2.Review of the Resident Rights provided on admission and last revised 05/19 showed .Restraint and Abuse, your right to be free from abuse and neglect . 3.Review of the facility's policy titled Abuse and Neglect Prevention Standard, last revised 1/23 showed .the resident has the right to be free from abuse . The definition of sexual abuse was .non-consensual sexual contact of any type with a resident . The definition of sexual abuse included .capacity and consent-residents have the right to engage in consensual sexual activity, however anytime the facility has a reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility must take steps to ensure that the resident is protected from abuse . 4.The following corrective action was implemented on 8/9/24 and verified during the survey: a. Resident #3 was monitored with increased supervision. b. Daily behavioral/intervention flow record was implemented for resident #3 until discharge from the facility on 8/9/24. c. New focus area with interventions was initiated in care plan on 7/25/24 for resident #3 to include out of character responses (sexual desires) due to dementia. Interventions included redirecting behaviors and providing male caregiver. d. Facility initiated assistance on 7/22/24 to family with helping find a memory care center for transfer. e. Abuse and neglect drill was performed 8/1/2024 and included summary of drill, improvement needed/actions taken and trends noted. f. Abuse and neglect education was provided at all staff meeting on 8/15/24. g. Safety fair on 11/14/24 for all staff included abuse and neglect training. h. Quality Assurance and Performance Improvement (QAPI) report included monthly abuse and neglect monitoring with trends and actions taken.

Based on medical record review, staff interview, and review of incident and facility documentation the facility failed to provide care in accordance with physician's orders and professional standards of practice for 1 of 3 residents (#1) with change in condition including resident #1. The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 11/19/24. The following concerns were identified: 1. Review of complaint/grievance report dated 11/13/24 showed resident #1 did not get transported to an appointment after it was ordered by the physician. 2. Medical record review showed resident #1 had a physician's order for an x-ray of his/her hip dated 10/26/24. On 11/8/24 the nurse attempted to have facility scheduler transport the resident for the x-ray; however, the scheduler was unable to take the resident until 11/11/24. Further review showed the resident received hip x-ray on 11/13/24, 5 days after it was ordered. 2. Interview with the social services staff member #4 on 12/30/24 at 11 AM revealed the delay in time of order and when x-ray done was due to facility miscommunication with scheduler and transportation. 3. Interview with the administrator on 12/27/24 at 12:40 PM confirmed the delay in completion of the treatment was due to facility miscommunication and transportation issues. 4.The facility implemented the following corrective action by 11/19/24 a. Inservice documentation on 11/18/24 revealed meeting with scheduling manager and DON regarding communication and transportation. b. Inservice documentation on 11/19/2024 revealed meeting with nursing staff regarding resident care management in regards to appointments and transportation process. c. QAPI report indicated issues with the timely appointment in trends and current actions taken as well as future intervention.

Based on observation, medical record review and staff and resident interviews, the facility failed to monitor the resident's access site upon return from dialysis treatment for 1 of 1 sample resident (#33) who received dialysis at an off-site dialysis center. The findings were: 1. Observation of resident #33 on 1/8/24 at 4:09 PM showed a bandage visible on his/her upper right chest. Interview with the resident at that time revealed s/he received dialysis three times a week at an off-site dialysis center. The following concerns were identified: a. Review of physician's orders showed the only order related to dialysis was for staff to record the resident's weight following dialysis. There lacked any orders related to the monitoring of the resident's dialysis access site. b. Review of the resident's care plan for hemodialysis initiated 8/23/23 showed Monitor/document/report PRN [as needed] signs/symptoms of infection to access site: redness, swelling, warmth or drainage and Monitor/document/report PRN for signs/symptoms of the following: bleeding, hemorrhage, bacteremia, septic shock. The care plan did not instruct staff to immediately monitor the status of the access port upon return from the dialysis center to observe for bleeding or other complications. c. Review of the December 2023 and January 2024 medication and treatment administration records and progress notes since December 1, 2023 showed no documentation that the resident's access site was monitored upon return from the dialysis center. d. During an interview on 1/10/24 at 3:23 PM the resident stated staff did not observe his/her access site when s/he returned from dialysis. e. On 1/10/24 at 3:24 PM RN #1 was asked what monitoring the resident received following a dialysis treatment. The RN stated they only needed to record the resident's weight, which the dialysis center usually recorded for them. f. On 1/11/24 at 8:23 AM the DON stated the facility did not have policies related to the monitoring of the access site. She confirmed the care plan only instructed for PRN monitoring and further confirmed there was no documentation to show staff were monitoring the access site.

Based on observation, staff interviews, review of manufacturer's instructions, and policy review, the facility failed to ensure infection prevention practices were followed by staff during 1 of 6 medication pass observations which affected residents (#5, #20). The findings were: 1. Continuous observation on 1/9/24 starting at 11:38 AM showed LPN #1 obtained a blood glucose level on resident #20. After the procedure was completed, the glucometer was returned to the medication cart without being disinfected by the LPN. At 12:23 PM LPN #1 obtained a blood glucose level on resident #5 using the same glucometer. After the procedure was completed, the glucometer was returned to the medication cart without being disinfected by the LPN. 2. Interview on 1/9/24 at 12:37 PM with LPN #1 confirmed she had not disinfected the glucometer between residents. 3. During an interview on 1/9/23 at 3:12 PM the infection control nurse and the MDS coordinator both confirmed the facility did not have any residents with known blood borne pathogens. 4. Interview on 1/10/24 at 2 PM with the DON and ADON revealed it was the facility's expectation to clean the glucometers between resident use. 5. Review of the manufacturer's instructions provided by the DON on 1/11/24 at 8:35 AM showed Cleaning & Disinfecting Guidelines .Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use using a commercially available EPA-registered disinfectant detergent or germicide wipe. 6. Review of the facility policy titled Blood Glucose Monitoring Equipment and Supplies provided by the DON on 1/11/23 at 9:54 AM showed .Clean and disinfect blood glucose meters between uses when equipment is shared .

Based on medical record review and staff interview, the facility failed to ensure PRN orders for anti-psychotic medications were limited to 14 days for 1 of 3 sample residents (#95). The findings were: 1. Review of physician's orders for resident #95 showed an order dated 10/18/22 for Zyprexa (anti-psychotic) 5 mg every 24 hours as needed for agitation. Review of the MAR for October and November 2022 verified the medication was a PRN order, with a start date of 10/18/22. The resident received one dose on 10/27/22. 2. During an interview on 11/2/22 at 5:39 PM the DON confirmed the PRN order for Zyprexa was not limited to 14 days. She stated the medication order should have had a 14 day end date, but did not. She further stated the facility was aware that regulations required PRN orders for anti-psychotics be limited to 14 days and required the physician to evaluate the resident before renewing the order.