Every finding on record at Ark Healthcare & Rehabilitation at Governors House

Based on observations, review of facility policy and procedures and interviews, the facility failed to ensure the nourishment room refrigerator and room were cleaned and kept in a sanitary manner. The findings include:Based on observations, review of facility policy and procedures and interviews, the facility failed to ensure the nourishment room refrigerator and room were cleaned and kept in a sanitary manner. The findings include: An observation of the nourishment room on the second-floor unit with the DNS on 12/22/25 at 2:17 PM identified immediately upon entrance the nourishment room has a foul odor. The DNS indicated she smelled a foul odor and the longer she was in the room it did not smell, however immediately upon entering there was an odor. The DNS then opened the refrigerator and identified on lower section of the refrigerator a shelf which had two containers of facility poured applesauce, and underneath were two clear drawers. The bottom of the right drawer was noted to have a black stain along the side and on the bottom of the left drawer was noted to be covered with a tan colored coating. The refrigerator also contained 2 bottles of ginger ale, milk, thickener beverage, container with apple juice and small half-half. The nourishment floor had tan-colored spots. The DNS identified it was the responsibility of the housekeeping to clean the nourishment rooms, and she then contacted the housekeeping department via telephone. Interview on 12/22/25 at 2:23 PM with the Director of Food Services identified she had notified housekeeping regarding the cleaning of the nourishment room and refrigerator earlier in the morning, as it is their responsibility to ensure the room and fridge are cleaned. Interview on 12/22/25 at 2:52 PM with Housekeeper #1 identifies the nourishment room fridge and floor is cleaned by the staff member who starts at 7:00AM as he starts at 8:00 AM and was told to clean the nourishment room after the surveyor checked. Interview on 12/23/25 at 3:04 PM with Housekeeper #2 identified housekeeping is responsible for cleaning the floor three times per week and the kitchen staff was responsible for cleaning the refrigerator. Interview on 12/23/25 at 3:04 PM with the Assistant Director of Maintenance identified he had smelled the foul odor in the second-floor nourishment and was working on addressing the issue. He identified the smell probably was coming from the pipes. He further identified that the kitchen staff was responsible for cleaning the fridge.Interview on 12/23/25 at 3:07 PM with the Director of Food Services identified she had spoken to housekeeping and maintenance, and the foul odor was coming from the pipes. She further identified that the deep cleaning and defrosting of the fridge is done by maintenance and the cleaning is done at times by the kitchen staff but moving forward she will ensure it is completed. Review of the Sanitation Nourishment Rooms policy and procedure identifies it is the responsibility of the Food Service Director (FSD) and Maintenance Director to develop and enforce cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment. The policy and procedure further identified the Food and Nutrition Services Department is responsible for regular cleaning of the interior of the refrigerator and freezer. The housekeeping department is responsible for the regular cleaning of the remainder of the nourishment room surfaces.

Based on observations, review of facility policy and procedures, and interviews reviewed for one of two medication storage rooms, the facility failed to ensure that expired testing supplies were removed from medication room, facility failed to ensure items were not stored on the floor, facility failed to ensure staff personal food items were not being stored in the medication room and failed to ensure medication refrigerator temperatures were consistently completed. The findings include:1. Observation and tour of the first-floor medication storage room on 12/23/25 at 1:27 PM with the Assistant Director of Nursing (ADNS) identified the following items in the right upper cabinet on the second shelf: Two boxes of (Pilot) COVID-19 at home test with an expiration date of 4/14/25, which was 7 months past the expiration date. Two boxes of (Clear Detect) COVID-19 at home test with an expiration date of 5/31/25, which was 6 months past the expiration date. Two boxes of (iHealth) COVID-19 at home test with a used by date of 9/4/25, which was 3 months past the used by date. Interview on 12/23/25 at 1:30 PM with the DNS in the presence of the ADNS identified the medication storage room was considered a ready to use storage area as this is where the nurse on the unit would go to retrieved items for use, and the facility does have a central supply stockroom where items are taken from to stock the medication storage rooms. The DNS identified the central supply staff's responsibility is to stock the medication storage rooms, and to check and to remove expired items. She further identified the medication storage rooms are stocked based on the needs of the staff for patients on the unit. Review of the Medication Storage policy and procedure identifies expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy. 2. Observation and tour of the first-floor medication storage room on 12/23/25 at 1:27 PM with the Assistant Director of Nursing (ADNS) the following items were noted on the floor in front of the lower cabinet: One box containing a decoration item. One opened box containing individual boxes of extra-large size nitrile exam gloves which was approximately 3/4's filled with 3 books on the top of the box. One unopened box of medium powder free nitrile exam gloves containing 10 individual boxes. One box which seal was broken contained full-length face shield and on the top of the box noted a hair blow dryer labeled for first floor only, don't remove from floor. Interview on 12/23/25 at 1:30 PM with the DNS in the presence of the ADNS, the DNS identified she had checked the medication room earlier and they were not there. The DNS further identified it is the practice of the facility not to keep or store item on the floor. Although requested, a medication storage room policy was not provided. 3. Observation and tour of the first-floor medication room on 12/23/25 at 1:27 PM with the Assistant Director of Nursing (ADNS), identified on the top of the counter the following items were noted: One box of crackers One container of buffalo chicken dip One food storage container that was 3/4 filled A plastic bag containing a food storage container with food. One notebook Food storage container containing food labeled with the resident's room number date of 12/23 and used by 12/25. Interview on 12/23/25 at 1:30 PM with the DNS in the presence of the ADNS identified staff should not store personal items including food in the medication storage room. The DNS identified the facility has a staff break room and a closet on the unit for staff to store their personal items. The DNS indicated both nurses working on the unit were from the agency but picks-up shifts regularly at the facility and knows staff are not allowed to store their personal items and food in the medication storage room, as it is not a practice of the facility. Interview on 12/23/25 at 1:35 PM with the Charge Nurse (LPN #3) identified he was one of the nurses working on the unit and the items noted in the medication storage room on the counter did not belong to him but the other nurse. LPN #3 identifies he is aware that he cannot store personal food and his personal items in the medication room. Interview 12/23/25 at 1:38 PM with the Charge Nurse (LPN #8) identified the items noted on the counter belonged to her and she is aware that she cannot store her personal items in the medication room. LPN #8 then removed the items from the medication storage room. Review of the Medication Storage policy and procedure identifies employee, or resident food should not be stored in the medication refrigerator. Although requested, a medication storage room policy was not provided4. Observation and tour of the first-floor medication storage room refrigerator on 12/23/25 at 1:35 PM with the DNS and the ADNS identified unopened eye drops, intravenous medications, insulin pen and vials, medications and controlled medications in a locked boxed, no vaccine was noted in the fridge. Review of the medication storage refrigeration log for the month of December 2025 with the DNS and the ADNS identified missing temperature checks throughout the month. Review of the temperature logs for the month of December 2025 identified temperature checks were missing for the following dates: 12/4/25, 12/6/25, 12/9/25, 12/10/25, 12/13/25, 12/16/25, and 12/19/25. Review of the temperature logs for the month of November 2025 identified temperature checks were missing for the following dates:11/12/25,11/13/25, 11/16/25, 11/19/25, 11/20/25, 11/20/25,11/22/25, and 11/25/25. Review of the temperature logs for the month of October 2025 identified temperature checks were missing for the following date: 11/27/25. Review of the temperature logs for the month of September 2025 identified temperature checks were missing for the following dates: 9/1/25, 9/5/25, 9/9/25, 9/10/25, and 9/23/25. Interview on 12/23/25 at 1:40 PM with the DNS and ADNS identified the medication refrigerator temperatures are checked once daily if it does not contain any vaccine, but if it contains vaccine, the temperature should be checked twice daily. The DNS further identified it is the responsibility of the 11:00 PM to 7:00 AM shift nurse to check and document the fridge temperature daily on the log. Review of the Medication Storage policy and procedure identifies temperature will be checked daily to ensure it is within the specified range, if temperature is out of range the thermostat will be adjusted. Review of the Refrigeration Temperature Monitoring policy and procedure identifies temperature target for medications refrigerator is 36 degrees Fahrenheit (F) to 46F. Refrigerator temperatures will be checked two times daily and logged onto the temperature log. The policy further identifies medications rooms (refrigerator) checked by nursing.

Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews for the one sampled resident (Resident #42) reviewed for respiratory care, the facility failed to provide respiratory care and services as ordered by the physician (failed to deliver humidified oxygen as ordered), failed to notify the physician when there was a change in oxygen equipment, failed to ensure oxygen equipment was used according to the manufacturer specifications (application of the non-rebreather without the appropriate oxygen flow rate, or reservoir inflated), and failed to have trained, competent, qualified staff to provide oxygen therapy services. The findings include:Resident #42 was admitted to the facility October 2025 with diagnoses that included systemic Lupus Erythematosus, coronary artery disease, vitamin D deficiency and unstable angina. (No specific respiratory diagnosis)The admission Minimum Data Set (MDS) dated [DATE] identified Resident #42 had intact cognition, required supervision or touching assistance with chair/bed to chair transfer, and bed mobility.The care plan dated 10/22/25 identified Resident #42 required staff assistance with ADL's related to weakness with interventions to assist with mouth/dental care, toileting needs as needed, set-up for meals, keep commonly used/needed articles in reach. The care plan identified Resident #42 was at risk for cardiac issues related to cardiovascular disease and hypertension with interventions for oxygen therapy as ordered.Physician's order dated 10/28/25 directed administration of oxygen via nasal cannula with humidifier at 2 liters as needed to keep the blood oxygen level above 90%. A physician's order dated 11/3/25 directed addition of a humidifier bottle to O2 due to nasal dryness every evening shift. (there was not a physician's order that pre-dated 10/28/25).Observations of Resident #42 over the course of the survey 12/22, 12/23, 12/24, 12/29 and12/30 identified oxygen administration via nasal cannula without humidification.Review of the EMS report dated 10/27/25 identified upon EMS arrival Resident #42 was noted to have a non-rebreather in place without the reservoir bag inflated and flowing oxygen at 2 liters per minute.Interview with the responding EMT on 12/24/25 at 8:27 AM identified that when EMS responded to a 911 call made by Resident #42, Resident #42 was found in the resident room in bed with a non-rebreather in place without the reservoir bag inflated and flowing oxygen at 2 liters per minute. The EMT indicated that Resident #42 identified the call to 911 was for chest pain and indicated he/she felt suffocated.Observation of Resident #42 on 12/23/25 at 1:30 PM identified Resident #42 had an oxygen condenser unit in the resident room that was set to 2 liters per minute and attached was a nasal cannula that Resident #42 had in place. The oxygen did not have a humidifier attached.Observation on 12/24/25 at 10:35 AM identified Resident #42 was wearing a nasal cannula attached to the oxygen condenser with oxygen set at 2 liters per minute but did not have a humidifier attached.Interview with LPN#4 on 12/24/25 at 9:24 AM identified the first step for complaints of a dry nose with oxygen use is to make sure the oxygen was humidified. LPN#4 confirmed Resident #42's order and indicated that humidified oxygen should be in use according to the order. LPN#4 identified that a non-rebreather mask would not be appropriate for use with the room oxygen condensers and identified the respiratory supplies were kept in the storage area. LPN#4 went to the storage room and indicated that there were no other masks to use except the non-rebreather masks and breathing treatment masks.Interview with the Emergency Medical Technician (Person #2) on 12/24/25 at 9:27 AM identified he responded to Resident #42's 911 call on 10/27/25 and found Resident #42 with a non-rebreather mask in place with the reservoir bag not inflated and with a low oxygen flow.Interview with LPN#5 on 12/24/25 at 10:12 AM identified she was the LPN taking care of Resident #42 on 10/27/25 on the evening shift and indicated that LPN#5 replaced Resident#42's nasal cannula and administered a breathing treatment. LPN#5 identified that Resident #42 was placed on the bubbler, referring to the humidified oxygen and offered nasal saline. LPN#5 identified that she had notified the supervisor and was asked not to go back into Resident #42's room after that point. LPN#5 indicated Resident #42 asked for a mask, but she was not aware of who placed the non-rebreather on Resident #42 and did not see the resident with the non-rebreather in place. LPN#5 identified she was on a break when the EMTs responded to the facility.Interview with Resident #42 on 12/24/25 at 10:35 AM identified he/she had complained of a bloody nose and indicated that there were a lot of staff in his/her room. Resident #42 indicated that one of the staff members placed the mask on her face, although Resident #42 could not identify which staff member placed the mask. Resident #42 indicated he/she had the mask on for about an hour and did experience difficulty breathing and called 911 independently of the facility. Resident #42 identified that the mask had a bag attached that was not inflated and indicated that the responding EMTs explained that was not the way to use that mask.Interview with the Nurse Educator on 12/29/25 at 2:15 PM identified that although respiratory training was provided at the facility, the respiratory education dated August 2025 failed to include NA#5, LPN#5, nor the other NA working the unit on the date of the incidentObservation on 10/29/25 at 2:45 PM identified Resident #42 was wearing a nasal cannula with 2 liters of oxygen flowing but did not have humidification.Interview with the DNS on 12/29/25 at 9:35 AM identified she observed Resident #42 on 10/27/25 at around 4:30 PM and indicated Resident #42 had complained of a nosebleed and issues with the nasal cannula and was offered nasal saline but refused. The DNS identified that she was going to notify the practitioner of what Resident #42 was reporting but could not recall if that was done. The DNS could not recall if the oxygen contained a humidifier at the time. observed Resident #42 on 10/27/25 at around 4:30 PM and indicated Resident #42 had complained of a nosebleed and issues with the nasal cannula and was offered nasal saline but refused. The DNS identified that she was going to notify the practitioner of what Resident #42 was reporting but could not recall if that was done. The DNS could not recall if the oxygen contained a humidifier at the time.Interview with NA#5 on 12/29/25 at 3:14 PM identified she was working on 10/28/25 in the evening and recalled that Resident #42 had asked for a mask rather than the nasal cannula because of nasal bleeding but that NA#5 did not give the resident a mask, see Resident #42 with a mask, or know how Resident #42 received anything other than a nasal cannula at that time. NA#5 indicated that if she thought a resident needed a different oxygen device, she would notify the nurse.Interview with RN#3, RN Supervisor (RN#3) on 12/29/25 at 3:22 PM identified she was working on the evening of 10/26/25 as the nursing supervisor but was not aware that the non-rebreather masks were accessible for use. RN#3 indicated that she did not know who would have provided or placed the non-rebreather on Resident #42. RN#3 identified that if she had to go to get the non-rebreather and a different oxygen tank, she would just have called 911. RN#3 indicated that if Resident #42 needed an intervention other than the prescribed nasal cannula, a respiratory assessment should have been complete by the nurse, and the doctor would have to be notified of the need for the change.Interview with the medical supply representative on 12/30/25 at 10:42 AM identified that the facility ordered and received 5 simple masks on 11/3/25 but had not ordered or received any simple masks in the 12 months prior to this date.Interview with the Administrator on 12/29/25 at 2:06 PM identified he investigated the complaint from the EMTs and indicated he could not determine who put the non-rebreather mask on the resident but confirmed that Resident #42 was observed wearing the non-rebreather by staff although the Administrator could not identify which staff observed Resident #42 with the mask in place.Interview with LPN#3 on 12/30/25 at 11:05 AM identified Resident #42's active physician's order directed oxygen be administered at 2 liters per minute, humidified via nasal cannula and identified that Resident #42 was using oxygen that was not humidified.Interview with APRN#1 on 12/30/25 at 11:15 AM identified the expectation was for staff to follow orders as they were written and to notify the physician if there were concerns or changes needed. APRN#1 indicated that use of the non-rebreather would require a doctor's order and high flow oxygen which would not be available on the resident room oxygen concentrators.Interview with the Medical Director on 12/30/25 at 2:33 PM identified she expected oxygen to be administered to residents as ordered by the doctor and that Resident #42 should be receiving humidified oxygen if that was how it is ordered. The Medical Director indicated that a non-rebreather should not be used with low flow oxygen and would require an MD order to change the method of delivery from the ordered nasal cannula.Review of facility respiratory training for 2025 identified use of a non-rebreather should be ordered by the provider and used with high flow oxygen. Although the facility provided appropriate respiratory education, the LPN and both NAs responsible for Resident #42's care did not receive the training.Review of facility policy for oxygen administration identified the purpose for use of the non-rebreather mask was to deliver high flow oxygen through nose and mouth, per the physician's order (generally 10-15 LPM). Additionally, the policy indicated that oxygen flow rate should maintain reservoir bag at least one third to one-half full-on inspiration and are generally used for emergent situations and only for short periods of time.

Based on review of clinical records, review of facility documentation, review of facility policy/procedures and interviews one sampled record (Resident #70) review for significant change, the facility failed to ensure a registered nurse assessed the resident after a significant change of condition and for one sampled resident (Resident #58) reviewed for pain, the facility failed to ensure a medication was administered according to the physician's order. The findings include:Resident #70 had diagnoses that included protein malnutrition, chronic kidney disease, benign neoplasm of meninges, and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #70 had moderate cognitive impairment, and required extensive assistance with bed mobility, toileting, hygiene, transfers, and ambulation. The Resident Care Plan (RCP) dated 2/19/25 identified Resident #70 had a nutritional problem or potential nutritional problem related to kidney disease, neoplasm of meninges and dementia. Care plan interventions directed to monitor, record, and report to the physician signs and symptoms of malnutrition, evaluate and make diet changes as recommended, obtain and monitor laboratory or diagnostic tests as needed, and provide and serve diet as ordered. The nurse's note dated 3/22/25 at 12:01 AM identified Resident #70 was alert, verbal, had an episode of vomiting which consisted of good amount of a black substance. In addition, the note indicated that the supervisor was notified of the situation. Review of nurses' notes from 3/22/25 through 3/23/25 failed to identify that the physician and/or family were notified of Resident #70's episode of vomiting. The APRN's progress note dated 3/24/25 at 11:45 AM identified Resident #70 was seen related to reports of vomiting over the weekend with dark emesis. The resident denied any gastro-intestinal discomfort, pain and/or tenderness. Resident #70 experienced decreased appetite on the day of vomiting, but his/her appetite had resumed after the episode of vomiting and had not complained of any further gastro-intestinal symptoms. Interview with the DNS on 12/24/25 at 9:00 AM identified that the registered nurse is responsible for comprehensively assessing the resident after a significant change in condition. She identified that the assessment should be documented in the nursing progress notes and/or Situational, Background, Assessment, and Response (SBAR) would be created to identify that resident had a significant change in condition. She identified that Resident #70 had an episode of black emesis which required a comprehensive assessment from a registered nurse that should include an abdominal assessment, bowel sounds, vital sign, and reviewing the resident bowel regimen. She further identified that the resident was not assessed after a significant change in condition because she could not find the assessment in the nursing progress notes nor was a SBAR created after a significant change in condition. The facility Change in Resident Condition, Family, and/or Physician Notification policy identified that all significant changes in resident's condition will be reported to the physician and family. In addition, the policy also identified that a registered nurse assessment would be conducted, and the nurse would document that the assessment was completed, the physician, and the family have been notified of the change in condition. Resident #58's diagnoses included Parkinson's, malignant neoplasm of endometrium, and occipital neuralgia. The admission MDS assessment dated [DATE] identified Resident #58 was cognitively intact, had no behaviors, required partial/moderate assistance with bed mobility, transfers, substantial maximal assistance with dressing, and supervision with personal hygiene. The assessment further identified the resident utilized a walker and a wheelchair for mobility. The care plan dated 11/13/25 identified Resident #58 was at risk for pain/discomfort related to endometrial cancer with interventions that included medication as ordered, determine level of pain using pain scale, anticipate the needs for pain relief and respond promptly. Physician's orders dated 11/19/25 directed pregabalin oral capsule 25mg capsule give two capsules orally (50mg dose) at bedtime for peripheral neuropathy. Review of pharmacy control drugs dispensed identified twenty capsules of pregabalin 25mg were dispensed from the pharmacy on 12/5/25 for Resident #58. Review of the MAR (Medication Administration Record) for December 2025 identified the medication was administered on 12/20/25 (signed by the nurse as administered). Interview on 12/22/25 at 9:55AM with Resident #58 identified he/she did not receive the full ordered dose of pregabalin 50mg on 12/20/25 as the medication was unavailable in the full ordered dose of 50mg only 25mg was available. This helps to treat pain and help him/her sleep. Resident #58 identified the facility frequently runs out of medication especially the pregabalin and that on 12/20/25 was the most recent occurrence. Interview on 12/23/25 at 12:04 PM with Pharmacist #1 identified no refill request was entered on 12/20/25 when the resident was out of the medication until 12/22/25 when a 10-day supply was ordered. The pharmacy identified that it was not them who would only send a 10-day supply, it was the way in which the provider was ordering it from the facility. Pharmacist #1 further identified that the side effect from the resident not receiving the full dose could be the resident having pain. Interview on 12/23/25 at 12:49PM with LPN #7 identified she was the LPN working on 12/20/25 on the 3-11 shift when the ordered dose of pregabalin 50mg was due to be administered. LPN#7 indicated that there was one capsule of pregabalin 25mg available in Resident #58's blister pack to be administered. LPN#7 identified she went to look for the RN Supervisor to attempt to get another 25mg dose of pregabalin from the Pixus. LPN#7 could not locate him, and the resident really wanted their medication, so she gave Resident #58 the one available and continued to look for the RN Supervisor. LPN#7 found the RN Supervisor, and they went to attempt to retrieve the medication from the Pixus. LPN#7 identified there was only pregabalin 50mg available and due to the fact, the order was for 50mg and 25mg was already administered the medication was not administered. LPN#7 indicated the RN Supervisor asked her to go back to Resident #58 and see if he/she was ok with the 25mg dose. LPN#7 informed Resident #58 that the medication was not available, and Resident #58 indicated it helped a little bit but did not help completely as he/she used to get a 300mg dose a while back. LPN#7 indicated she did not contact any provider about a one-time order for the 25mg dose or a one-time order to administer a 75mg dose, she was agency and was told to just contact the supervisor with anything out of the ordinary. Review of the orders and progress notes for 12/20/25 failed to indicate any contact with the provider regarding the discrepancy and no new orders were obtained for this date. Interview with the RN Supervisor was attempted on 12/23/25 and 12/30/25, and the facility was requested to get in touch with the RN supervisor to contact the surveyor however no contact was made by the RN supervisor with the surveyor. Interview on 12/30/25 at 12:10 PM with the ADNS identified initially the APRN who ordered the medication only ordered one dose and it shouldn't have been ordered that way. Since then, it has been ordered for a10 day supply each time it has been ordered, however the ADNS was unsure if that was the way the prescriber ordered it or if that was the way in which the insurance covered it due to the fact, she was a short-term resident. The ADNS identified that she was aware that there had been an issue with the order running out as it was ordered as a 10-day supply however she believed that the provider who is a new APRN since the original one who ordered it, put in multiple refills. The expectation however was that the medication was re-ordered when there were four of six pills remaining which would be a two- or three-day supply. The provider could be contacted to reorder as the prescriber can do so electronically. If there are none remaining, then a nurse should get the 50mg dose from the Pixus to administer to the resident. Review of the Medication Shortages/Unavailable medications facility policy directed is a medication shortage is noted at the time of medication administration; the licensed nurse must immediately initiate action to obtain the medication and not wait until the medication pass is complete. If a medication shortage is noted after normal pharmacy hours a licensed nurse obtains the ordered medication from the emergency stock supply. Review of the Medication Ordering system policy directed reorder for on demand systems should occur when seventy hours of supply remain. Review of the Automated Dispensing Medication Dispensing system policy directed medications may be removed from the automated dispensing device following the devices instructions for medication needed on a PRN (as needed) basis.

Based on clinical record reviews, facility policy review, and interviews for one of two residents (Resident #64) reviewed for pain management, and for one sampled resident (Resident #70) reviewed for significant change in condition, the facility failed to ensure that the nurse administered the medication in accordance with the physician's order and failed to ensure a registered nurse assessed the resident after a significant change in condition. The findings include: Resident #64's diagnoses included type 2 diabetes mellitus, local infection of the skin and subcutaneous tissue, and Parkinson's disease.The Resident Care Plan (RCP) dated 10/22/25 identified Resident #64 had pain that may impact mobility, mood, sleep, and relationship to others. Care plan interventions directed to determine level of pain using pain scale, administer medication as ordered, report unrelieved pain to the physician, and watch for nonverbal signs and symptoms of increasing pain.The 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] identified Resident #64 had intact cognition, required extensive assistance with bed mobility, toileting, hygiene, transfers, and ambulation, utilized a rolling walker and wheelchair for mobility, and frequently complained of moderate to severe pain.The physician's order dated 12/2/25 directed to apply lidocaine external patch 4 percent (local anesthetic) to the left shoulder for pain daily.The physiatry progress notes dated 12/16/25 identified Resident #64's pain was re-evaluated and identified that he/she disliked the lidocaine patches because it easily fell off and the note further identified a recommendation to use diclofenac sodium gel 4 gram to the left shoulder and left hip three times per day.The physician's order dated 12/16/25 directed to apply diclofenac external gel 1 to 4.5 percent (analgesic anti-inflammatory), apply topically to the left shoulder three times a day for pain.The physiatry progress note dated 12/18/25 identified Resident #64 was not receiving the diclofenac gel to the left hip and left shoulder. In addition, the note identified that it was discussed with the facility nursing staff that the diclofenac medication had been ordered and was not available at the facility at that time.The physician's orders dated 12/22/25 directed to apply diclofenac sodium external gel 1 percent apply 4 grams topically to the left hip three times a day for pain daily.Review of the Medication Administration Record (MAR) from 12/16/25 to 12/22/25 identified that the diclofenac sodium external gel was being recorded as administered; however, the diclofenac sodium external gel was not available in the facility during that period. Interview with LPN #8 on 12/23/25 at 2:55PM identified that she administered muscle rub in replacement for diclofenac as written in the physician's order. She identified that she had called the pharmacy and the pharmacy identified they were not providing over the counter (OTC) medication. She identified that she spoke with APRN #1 regarding substituting the diclofenac with the muscle rub. She further identified that she should have obtained a new order from the APRN #1 for the muscle rub until the diclofenac was available, but she did not obtain a new order instead she had been administering the muscle rub without a physician's order.Interview with APRN #1 on 12/29/25 at 10:45 AM identified that the nursing staff should administer the medication written in the physician's orders. She identified that the muscle rub was not the same ingredients as the diclofenac. Although the muscle rub was not the same as the diclofenac, it was not harmful to the resident. She could not recall whether the nursing staff notified her that the diclofenac was not available, but she would have ordered the muscle rub until the diclofenac became available. Interview with the DNS on 12/30/25 at 10:30 AM identified that the nursing staff should administer medication exactly as written in the physician's order. She identified that the nursing staff should not substitute any OTC medication without obtaining a new order from the physician. The Medication Administration policy identified that all medications shall be administered safely and accurately in accordance with the physician's orders, facility protocol, and applicable state and federal guidelines. Resident #70 's with diagnoses that included protein malnutrition, chronic kidney disease, benign neoplasm of meninges, and dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that Resident #70 had moderate cognitive impairment and required extensive assistance with bed mobility, toileting, hygiene, transfer, and ambulation. The Resident Care Plan (RCP) dated 2/19/25 identified Resident #70 had a nutritional problem or potential nutritional problem related to kidney disease, neoplasm of meninges and dementia. Care plan interventions directed to monitor, record, and report to the physician sign and symptoms malnutrition, to evaluate and make diet changes as recommended, obtain and monitor laboratory or diagnostic test as needed, and provide and serve the diet as ordered.The nurse's note dated 3/22/25 at 12:01 AM identified Resident #70 was alert, verbal, had an episode of vomiting which consisted of good amount of a black substance. In addition, the note indicated that the supervisor was notified of the situation.Review of nurse's notes from 3/22/25 to 3/23/25 failed to identify that a registered nurse assessed Resident #70 after a significant change of condition.The APRN progress notes dated 3/24/25 at 11:45 AM identified that Resident #70 was seen related to the reports of vomiting over the weekend with dark emesis. He/she denied any gastro-intestinal discomfort, pain and/or tenderness. Resident #70 had experienced decrease appetite on the day of vomiting, but his/her appetite had resume after the episode of the vomiting. He/she had no further gastro-intestinal symptoms.Interview with the DNS on 12/24/25 at 9:00 AM identified that the registered nurse would be responsible for comprehensively assessing the resident after a significant change in condition. She identified that the assessment would be documented in the nursing progress notes and/or Situational, Background, Assessment, and Response (SBAR) would be created to identify that resident had a significant change in condition. She identified that Resident #70 had an episode of black emesis that would require a comprehensive assessment from a registered nurse that would include abdomen assessment, bowel sound, vital sign, and reviewing the resident bowel regimen. She further identified that the resident was not assessed after a significant change in condition because she could not find the assessment in the nursing progress notes nor was a SBAR created after a significant change in condition.The facility Change in Resident Condition, Family, and/or Physician Notification policy identified that all significant changes in resident's condition will be reported to the physician and family. In addition, the policy also identified that a registered nurse assessment would be conducted, and the nurse would document that the assessment was completed, the physician, and the family have been notified of the change in condition.

Based on clinical record review, facility policy review, and interviews for one sample resident (Resident #70) who experienced a significant change in condition, the facility failed to notify the physician and/or family of the significant change of condition. The findings include:Resident #70 had diagnoses that included protein malnutrition, chronic kidney disease, benign neoplasm of meninges, and dementia.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #70 had moderate cognitive impairment, and required extensive assistance with bed mobility, toileting, hygiene, transfers, and ambulation. The Resident Care Plan (RCP) dated 2/19/25 identified Resident #70 had a nutritional problem or potential nutritional problem related to kidney disease, neoplasm of meninges and dementia. Care plan interventions directed to monitor, record, and report to the physician signs and symptoms of malnutrition, evaluate and make diet changes as recommended, obtain and monitor laboratory or diagnostic tests as needed, and provide and serve diet as ordered.The nurse's note dated 3/22/25 at 12:01 AM identified Resident #70 was alert, verbal, had an episode of vomiting which consisted of good amount of a black substance. In addition, the note indicated that the supervisor was notified of the situation.Review of nurses' notes from 3/22/25 through 3/23/25 failed to identify that the physician and/or family were notified of Resident #70's episode of vomiting.The APRN's progress note dated 3/24/25 at 11:45 AM identified Resident #70 was seen related to reports of vomiting over the weekend with dark emesis. The resident denied any gastro-intestinal discomfort, pain and/or tenderness. Resident #70 experienced decreased appetite on the day of vomiting, but his/her appetite had resumed after the episode of vomiting and had not complained of any further gastro-intestinal symptoms.Interview with the DNS on 12/24/25 at 9:00 AM identified that the physician and family member should be notified immediately when a resident has a significant change in condition. In addition, the nurses' notes should indicate whether the physician and the family member were notified. She further identified that black emesis should be an immediate notification to the physician and responsible party. She further identified that she could not verify whether the physician and responsible party were notified because there is not a nurse's note indicating that they were notified.Interview with APRN #1 on 12/29/25 at 10:40 AM identified that the physician and/or APRN would be notified immediately when a resident has a significant change of condition. Although she was not the APRN at the time when Resident #70 had an episode of black emesis, she would expect the nursing staff to notify the physician immediately because black emesis could be a sign of bleeding in the intestinal organ. The Change in Resident Condition, Family, and/or Physician Notification policy identified that all significant changes in a resident's condition will be reported to the physician and family. In addition, the policy also indicated that a registered nurse assessment would be conducted, and the assessment documented, as well as documentation that the physician and the family had been notified.

Based on clinical record review, review of facility policies/procedures, review of facility documentation and interviews for one sampled resident (Resident #42) reviewed for dignity, the facility failed to ensure the resident was treated with dignity by facility staff. The findings include:Resident #42 was admitted to the facility in October 2025 with diagnoses that included systemic Lupus Erythematosus, coronary artery disease, vitamin D deficiency and unstable angina. The admission MDS assessment dated [DATE] identified Resident #42 had intact cognition, did not exhibit rejection of care behaviors, required supervision or touching assistance with chair/bed to chair transfers, and bed mobility. The care plan dated 10/22/25 identified Resident #42 required staff assistance with ADL's related to weakness with interventions that included: assist with mouth/dental care, toileting needs as needed, set-up for meals, keep commonly used/needed articles in reach. The care plan identified Resident #42 was at risk for cardiac issues related to cardiovascular disease and hypertension with interventions for oxygen therapy as ordered.Physician's order dated 10/28/25 directed the administration of oxygen via nasal cannula with humidifier at 2 liters as needed to keep the resident's oxygen level above 90%. A Physician's order dated 11/3/25 directed for the addition of a humidifier bottle to O2 (oxygen) due to nasal dryness every evening shift. Review of the accident and incident report and investigation dated 10/31/25 identified that LPN#5 had purchased an item for Resident #42 as a gift and subsequently, due to a disagreement, took the item back and threw it in the garbage. The facility replaced the item for Resident #42.Interview with LPN#5 on 12/24/25 at 10:12 AM identified that she had purchased a gift for Resident #42 and later had a strained interaction with the resident who told LPN#5 that she was not a compassionate nurse and didn't want anything from her. LPN#5 indicated she took the head wrap off the bed and discarded it in the trash, Resident #42 told LPN #5 that she was unprofessional. LPN #5 further noted that she walked out of the room without administering Resident #42's medications.Interview with Resident #42 on 12/24/25 at 10:35 AM identified Resident #42 was given a gift by LPN#5. Resident #42 indicated that another staff member informed Resident #42 that LPN#5 was speaking badly about the resident. Resident #42 identified that when LPN#5 came in to administer medications, Resident #42 asked LPN#5 why she was talking about him/her. Resident #42 indicated LPN#5 became angry and Resident #42 indicated he/she called LPN#5 unprofessional and uncompassionate and identified that LPN#5 grabbed the gift off the resident's bed and threw it away. Additionally, Resident #42 indicated LPN#5 did not administer his/her medications.Interview with the Administrator on 12/29/25 at 2:06 PM identified the incident with Resident #42 and LPN #5 was investigated by the facility. He indicated that because Resident #42 told LPN #5 that he/she didn't want anything from her, the facility felt Resident #42 would also not want the gift. The Administrator indicated that although Resident #42 could be challenging, LPN#5 could have reacted better but that there was not a finding for misappropriation of property although the item was replaced for the resident by the facility.Review of the facility policy for abuse identified that residents have the right to be treated with dignity and respect.

Based on observation, review of the clinical record, and interviews for one sampled resident (Resident #74) reviewed for resident assessment, the facility failed to ensure the MDS was coded accurately to reflect the current wheelchair mobility status of the resident. The findings include:Resident #74's diagnoses included severe protein calorie malnutrition, Marfan syndrome, osteoarthritis, and Alzheimer's.The physician's order dated 5/16/25 directed to have one person assist with bed mobility, two people assist with transfer, and non-ambulatory.The Occupational Therapy (OT) evaluation and plan of treatment dated from 5/21/25 to 8/11/25 identified Resident #74 required partial to moderate assistance with wheelchair mobility.The quarterly MDS assessment dated [DATE] identified Resident #74 had severe cognitive impairment and was dependent on staff for toileting, personal hygiene, dressing, transfers, and was non-ambulatory. Further review of the assessment identified Resident #74 was coded as independent for wheelchair mobility. The Physical Therapy (PT) evaluation and plan of treatment dated from 9/19/25 to 12/10/25 identified Resident #74 was dependent on staff for wheelchair mobility.The quarterly MDS assessment dated [DATE] identified Resident #74 had severe cognitive impairment and was dependent on staff for toileting, personal hygiene, dressing, transfers, and was non-ambulatory. Further review of the assessment identified Resident #74 was coded as independent for wheelchair mobility. The Resident Care Plan (RCP) dated 10/6/25 identified Resident #74 had limited physical mobility related to weakness and impaired balance. The care plan interventions directed the assistance of 1 person for bed mobility, toileting, assist of 2 people for transfers, and non-ambulatory. Observation on 12/24/25 at 10:10 AM identified Resident #74 sitting in a wheelchair with leg rests in place and the wheelchair was locked near the nurse station.Interview with NA #1 on 12/24/25 at 10:25 AM identified she was the regular nursing aide for Resident #74 on 7 AM -3 PM shift. She identified Resident #74 was dependent on staff for personal hygiene, toileting, dressing and required two people assist for transfer and he/she was not ambulatory. In addition, she identified that Resident #74 required staff assistance with wheelchair mobility and he/she could not self-propel while sitting on a wheelchair. She further identified that Resident #74 could not self-propel for over a year after he/she broke a hip.Interview with LPN #1 (MDS Coordinator) on 12/29/25 at 11:10 AM identified that she was responsible for coding section GG of the MDS assessment. She identified that she would make her own observation of the resident during the look back period and code the section GG based on her observations. She further identified that Resident #74 was independent with wheelchair mobility.Interview with OT #1 on 12/30/25 at 8:50 AM identified that she had treated Resident #74 for functional wheelchair mobility and identified Resident #74 required 2 people assist for transfer, and max assistance to total dependent with wheelchair mobility. She identified that Resident #74 was not independent with wheelchair mobility. Interview with OT #2 on 12/30/25 at 11:40 AM identified that Resident #74 was totally dependent for personal hygiene, toileting, transfer, non-ambulatory, and wheelchair mobility. She identified that Resident #74 was not independent with wheelchair mobility in the nursing unit and had a pending order for a customized wheelchair.The Resident Assessment Instrument (RAI) manual 3.0 in part of section GG functional abilities and goals indicated that a qualified clinician would code the data element based on the type and amount of assistance provided by a helper to reflect the resident's functional abilities.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #2 and 3) reviewed for pressure injuries (ulcers), the facility failed to ensure Braden scale assessments and weekly skin checks were documented and completed per facility policy. The findings include:1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease and dementia.The Braden scale assessment dated [DATE] identified Resident #2 was at moderate risk for developing pressure injuries.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had moderate impairment in cognition (Brief Interview for Mental Status (BIMS) score of 10), had one (1) unstageable pressure injury, and was at risk for developing pressure injuries.A physician's order dated 4/4/25 directed weekly skin checks.The Braden scale assessment dated [DATE] identified Resident #2 was at risk for developing pressure injuries.The care plan dated 4/9/25 identified Resident #2 had multiple pressure injuries. Interventions included to assess risk of skin breakdown using the Braden scale assessment per policy and check skin at least weekly on scheduled bath day.Review of the medical record failed to identify a Braden scale assessment was completed weekly during the first month of admission (for two out of four opportunities on 4/12/25 and 4/19/25).3. Resident #3 was admitted to the facility on [DATE] with diagnoses that included stroke, type II diabetes and gastrostomy.The care plan dated 1/7/25 identified Resident #3 had the potential for alteration in skin related to decreased mobility, diabetes and incontinence. Interventions included Braden scale assessment completed on admission and per facility skin protocol.The Braden scale assessment dated [DATE] identified Resident #3 was at risk of developing pressure ulcers/injuries.The re-entry skin check dated 1/31/25 identified Resident #3's skin was intact. The medical record failed to identify a skin check was completed for the week of 2/9/25 to 2/15/25.The Braden scale assessment dated [DATE] and 2/14/25 identified Resident #3 was at risk of developing pressure ulcers/injuries.Review of the medical record failed to identify a Braden scale assessment was completed weekly during the first month of admission (for one out of four opportunities on 2/21/25).The skin check dated 2/16/25 identified Resident #3 had no injuries after a fall.The medical record failed to identify a skin check was completed for the weeks of 2/23/25 to 3/1/25, 3/2/25 to 3/8/25, 3/9/25 to 3/15/25 and 3/16/25 to 3/22/25.The weekly wound evaluation dated 3/24/25 identified Resident #3 had a coccyx pressure injury measuring 1 centimeter (cm) by .5 cm by .1 cm. The weekly wound evaluation failed to identify a full body skin check was conducted.The weekly wound evaluation dated 3/31/25 identified Resident #3 had a coccyx pressure injury measuring 1 cm by .5 cm by .1 cm. The weekly wound evaluation failed to identify if a full body skin check was conducted.The skin check dated 4/4/25 identified Resident #3's skin was intact. The skin check failed to identify the status of Resident #3's coccyx pressure injury, and a weekly wound evaluation was not documented.The weekly wound evaluation dated 4/7/25 identified Resident #3 had a coccyx pressure injury measuring .5 cm by .2 cm by .1 cm.Interview with the DNS on 5/5/25 at 3:00 PM identified Braden scale assessments (risk evaluations) are to be completed per facility policy on admission/readmission, weekly for the first month, quarterly, and with a significant change. If there is a new skin concern identified, then a skin check form should be completed. She identified a weekly wound evaluation should be completed weekly for resident's with an existing wound and a separate skin check form should be completed for the weekly skin check (or documented in the TAR).Review of the skin integrity management policy directed to complete a risk evaluation on admission/readmission, weekly for the first month, quarterly, and with significant change in condition. Perform skin inspections (checks) on admission/readmission and weekly. Document on the TAR or in the electronic medical record. Perform wound observations and measurements and complete the skin observation tool upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound.Review of the nursing documentation policy directed that documentation should be completed as soon as possible after care is provided, assessments are conducted, or any significant event occurs, ideally within the same shift. All entries must be factual, complete, and reflect the resident's current condition and care provided.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for abuse, the facility failed to ensure staff reported an allegation of abuse timely. The findings include: Resident #1 was admitted to the facility with diagnoses that included intellectual disability, autism, and anxiety. An admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/12/2025 identified Resident # 1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition, and required set-up assistance for eating. The Resident Care Plan (RCP) dated 1/17/2025 identified Resident #1 required assistance for activities of daily living (ADLs) due to intellectual disability and had behaviors such as impulsiveness and screaming at staff. Interventions directed to encourage independence with ADLs and assist as needed. A facility reportable event (RE) form dated 3/11/2025 at 10:00 AM identified an allegation of staff-to-resident abuse without injury. NA #2 reported an incident that occurred on 3/3/2025 (8 days prior) at 12:30 PM in the dining room, where NA #1 had shouted and thrown a cup of juice at Resident #1. The facility RE report summary dated 3/14/2025 identified on 3/11/2025, NA # 2 reported that NA #1 shouted at Resident #1 and threw a cup of juice at the resident during lunch on 3/3/2025. An RN assessment identified no evidence of visible injuries. NA #1 denied yelling at the resident or throwing the glass of juice. NA #1 stated when she handed the resident a glass of juice in a plastic cup, Resident #1 squeezed the cup causing the juice to spill on table and on NA #1's clothing and shoes. NA #1 reported that she said oh my God loudly because she was soaked by the spilled orange juice. Staff interviews identified Resident #1's clothing was not wet, and the allegation of abuse was unsubstantiated. Interview and review of his facility statement with NA #2 on 3/26/2025 at 9:53 AM identified that during lunch on 3/3/2024 around 12:30 PM, he observed the interaction between Resident #1 and NA #1. He stated Resident #1 did not want to eat, despite continued verbal reinforcement from NA #1, and NA #1 was loudly telling the resident to eat, and began yelling at Resident #1. NA #1 then picked up Resident #1's cup of juice and threw the juice in Resident #1's face while making a comment that she could no longer take any more s***. NA #1 then left the dining room and NA #2 cleaned up the juice. NA #1 stated he continued working the remaining shift and did not report the observation to any other staff on 3/3/2024 because he was new to the unit and felt uncomfortable. NA #2 stated he called NA #4 a few days later and informed NA #4 of the observation, and NA #4 encouraged him to report the incident to the DON. NA #2 stated his next shift was on 3/11/2025 and her notified the DON then. NA #2 stated he should have reported the observation when he witnessed it. Interview and review of her facility statement with NA #4 on 3/26/2024 at 11:38 AM identified when NA #2 informed her of the incident that occurred on 3/3/2025, she encouraged him to report it. NA #4 thought NA #2 reported it, but realized on 3/11/2025 when she heard NA #4 asking to the scheduler to not schedule him on Resident #1's unit, she realized he had not reported the incident and she brought NA #2 to the DON to report the incident. NA #1 was unavailable for interview during survey. Interview with the DON on 3/27/20245 at 12:10 PM identified NA #2 should have reported the incident immediately when he observed it on 3/3/2025. Further, NA #4 should have also reported the incident when NA #2 had informed her. The facility Abuse, Resident Policy dated 7/23/2023 directed in part, anyone witnessing and/or having knowledge of abuse or mistreatment of any kind towards a resident will report the incident immediately to the supervisor, DON and Administrator.

Based on clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1 and 2) reviewed for abuse, the facility failed to ensure the resident was treated with respect and dignity. The findings include: a. Resident #1 was admitted to the facility with diagnoses that included intellectual disability, autism, and anxiety. An admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/12/2025 identified Resident # 1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition, and required set-up assistance for eating. The Resident Care Plan (RCP) dated 1/17/2025 identified Resident #1 required assistance for activities of daily living (ADLs) due to intellectual disability and had behaviors such as impulsiveness and screaming at staff. Interventions directed to encourage independence with ADLs and assist as needed. A facility reportable event (RE) form dated 3/11/2025 at 10:00 AM identified an allegation of staff-to-resident abuse without injury. NA #2 reported an incident that occurred on 3/3/2025 (8 days prior) at 12:30 PM in the dining room, where NA #1 had shouted and thrown a cup of juice at Resident #1. The facility RE report summary dated 3/14/2025 identified on 3/11/2025, NA # 2 reported that NA #1 shouted at Resident #1 and threw a cup of juice at the resident during lunch on 3/3/2025. An RN assessment identified no evidence of visible injuries. NA #1 denied yelling at the resident or throwing the glass of juice. NA #1 stated when she handed the resident a glass of juice in a plastic cup, Resident #1 squeezed the cup causing the juice to spill on table and on NA #1's clothing and shoes. NA #1 reported that she said oh my God loudly because she was soaked by the spilled orange juice. Staff interviews identified Resident #1's clothing was not wet, and the allegation of abuse was unsubstantiated. Interview and review of his facility statement with NA #2 on 3/26/2025 at 9:53 AM identified that during lunch on 3/3/2024 around 12:30 PM, he observed the interaction between Resident #1 and NA #1. He stated Resident #1 did not want to eat, despite continued verbal reinforcement from NA #1, and NA #1 was loudly telling the resident to eat, and began yelling at Resident #1. NA #1 then picked up Resident #1's cup of juice and threw the juice in Resident #1's face while making a comment that she could no longer take any more s***. NA #1 then left the dining room and NA #2 cleaned up the juice. NA #1 was unavailable for interview during survey. Interview with the DON on 3/27/2025 at 12:10 PM identified the facility did not substantiate the allegation as there were no other witnesses, and stated NA #2 may not have had a clear view of the interaction. b. Resident #2 was admitted with diagnoses that included pressure-induced tissue damage of the right and left heels, and depression. The Resident Care Plan (RCP) dated 1/3/2025 identified Resident #2 declined showers at times and had pressure injuries. Interventions directed to provide a full bed/sponge bath if shower was refused and treatments as ordered. A 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition, and required maximal assistance for personal hygiene. A facility reportable event (RE) form dated 3/14/2025 at 9:00 AM identified an allegation of staff-to-resident abuse without injury: Resident #2 reported that on 3/13/2024 at 6:00 PM, a NA told her that he/she stank. A facility RE summary dated 3/14/2025 identified Resident #2 reported to LPN #3 (11:00 PM -7:00 AM nurse) that a NA on the previous shift had offended her/him because the NA said that Resident #2 and his/her room stank. Resident #2 could not identify the staff member, and reported the NA was taking the dinner tray out of the room that contained a cup with a protein supplement left in it that Resident #3 wanted to finish. Resident #2 asked the NA to leave it on his/her overbed table. Resident #3 identified that the NA began to scream at him/her, verbalizing that Resident #2 was accusing her of stealing something and that she would never steal anything from Resident #2 because Resident #2 smelled and everything in the room smelled. The Facility identified the tray was removed by NA #5 and that NA #5 had told Resident #2 she did not take anything from the room. The summary indicated NA #5 did tell LPN #2 at the nurse's station that the room was smelly. Interview on 3/26/2025 at 1:50 PM with LPN #2 identified on 3/13/2025 she could see into Resident #2's room from the nurse's desk, and she observed NA #5 remove the dinner tray from Resident #2's room. LPN #2 stated as NA #5 was leaving the room with the tray, Resident #2 said NA #5 had taken something, and NA #5 replied she did not take anything and left the room. As NA #5 walked past LPN #2 she said that she wouldn't take anything from Resident #2's stinking room. LPN #2 stated she did not think Resident #2 could hear the comment, and Resident #2 called out a name at NA #5. LPN #2 stated there were no other issues during the shift and Resident #2 appeared to be at his/her baseline mood. Interview on 3/27/2025 at 9:47 AM with LPN #3 identified Resident #2 reported the allegation to him on 3/14/2025 about 5 AM, and Resident #2 expressed he/she knew the room smelled from his/her wounds. LPN #3 notified the supervisor of the allegation. Interview with NA #5 on 3/27/2025 at 10:56 AM identified on 3/13/2025 Resident #2 was sleeping when she went into the room for the dinner tray, and she asked LPN #2 if it was okay to take the tray. LPN #2 told her to take the tray and as she was leaving the room with the tray, Resident #2 asked her if she took something. NA #5 stated she did not respond but LPN #2 responded to Resident #2 that the dinner tray was being taken out of the room. NA #5 stated when she was in the hallway and thought Resident #2 could not hear, she said out loud, that of all the places, she'd never take anything from that smelly room. NA #5 indicated she knew she should not have said it. Interview with the DON on 3/27/2025 at 12:10 PM, identified NA #5 did not intend for Resident #2 to hear the comment, and the comment was disrespectful. The DON stated NA #5 should not have made the comment, even if she thought the resident could not hear; it was disrespectful and was poor customer service. The facility policy Residents Rights dated 2/2021, directed in part, that residents have the right to be treated with respect, kindness and dignity.

Based on clinical record reviews, facility documentation, facility policy review, and interviews for two of three sampled residents (Resident #1 and Resident #2) who were reviewed for an allegation of resident-to-resident physical abuse, Resident #1 had the right to be free from physical abuse by Resident #2. The findings include: Resident #1's diagnoses included stroke with resultant right sided hemiplegia (paralysis of one side of the body), epilepsy (seizure disorder), post-traumatic stress syndrome, developmental disability, anxiety, and depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living, needed substantial assistance with turning and repositioning while in bed, moderate assistance getting in and out of the bed and chair, and was independent for mobility with a wheelchair. The Resident Care Plan (RCP) dated 1/23/24 identified Resident #1 had impaired balance and was at risk for mood changes. Interventions directed to self-propel in the wheelchair for short distances, to anticipate needs as level of understanding may prevent knowing how to use the call bell, ask yes/no questions to determine needs, encourage to attend recreation activities and if sad or weepy, offer to talk. Resident #2's diagnoses included dementia, delusional disorder, stroke, and muscle weakness. The quarterly MDS assessment dated [DATE] identified Resident #1 had some short- and long-term memory recall problems, was independent with turning and repositioning while in bed, required moderate assistance with getting in and out of the bed and chair, was independent for mobility with a wheelchair and an assist of one (1) with ambulating with a walker. The RCP dated 3/5/24 identified Resident #2 had ineffective coping with paranoid, suspicious behavior. Interventions directed to cue, orient, supervise as needed, keep schedule routine and predictable, praise desirable behavior, anticipate needs and to provide an activities calendar, notify if any changes to the calendar. The care plan was updated on 3/19/24 due to physical aggression and identified Resident #2 had ineffective coping and was physically or verbally aggressive to other residents and staff with increased agitation at times due to dementia and paranoid thoughts. Interventions directed to remove resident from public area if behavior was disruptive or unacceptable, use a calm, low pitch voice to decrease behavior, be careful not to invade personal space, maintain a consistent routine, as predictable as possible, and to assist to identify problems that cannot be controlled. The Facility Reported Incident form dated 3/28/24 at 10:00 AM identified there was an incident of resident-to-resident abuse without injury. The report indicated staff witnessed Resident #2 strike Resident #1 multiple times, the residents were separated, Resident #2 was placed on one (1) to one (1) supervision for safety, a Registered Nurse assessment was completed on both residents, Resident #1 had no redness, bruising, or swelling on the face and denied pain or discomfort, the responsible parties and physicians were notified, Resident #2 remained on one (1) to one (1) supervision until transferred to the hospital Emergency Department (ED) for evaluation. The facility summary report dated 3/31/24 identified at approximately 10:00 AM staff had witnessed Resident #2 strike Resident #1 multiple times in the face with a closed fist, the incident occurred in the hallway near the recreation room. The report indicated the Assistant Maintenance Director was walking by the recreation room when he witnessed Resident #2 stand up over Resident #1, muttering unclear words while punching Resident #1 repeatedly in the face, the residents were immediately separated. The summary indicated Resident #2 returned from the ED later in the evening deemed not a risk for harm to self and others, was admitted to a room on another floor and placed on every fifteen (15) minute checks, social service and psych follow up for both residents were completed. Interview with the Assistant Maintenance Director on 4/23/24 at 10:00 AM identified on 3/28/24 he was painting a room on the second floor when he heard loud voices in the hallway. The Assistant Maintenance Director stated he observed Resident #2 standing over Resident #1 who was in a wheelchair, Resident #2 with a closed fist was punching Resident #1 in the face while yelling something at Resident #1. The Assistant Maintenance Director identified he immediately responded and stood between the two (2) residents while calling for assistance to the nursing staff. The Assistant Maintenance Director identified there were four (4) or five (5) residents in the hallway at the time, appearing to be waiting outside the recreation room for an activity as there was a delay in starting the activity. The Assistant Maintenance Director stated he had walked past the residents prior to the altercation and saw that Resident #1 and Resident #2 were both in wheelchairs, seated next to each other but were not interacting. Interview with the Social Worker (SW) #1 on 4/23/24 at 11:00 AM identified his office is on the second floor near the recreation room, and he responded when he heard the commotion. SW #1 stated when Resident #2 was asked why he/she had punched Resident #1, Resident #2 stated Resident #1 was a bad boy/girl and needed to be punished. Interview with the 7AM-3PM charge nurse, Registered Nurse (RN) #2, on 4/23/24 at 11:50 AM identified she was the charge nurse and assigned to Resident #1 on 3/28/24. RN #2 stated she heard the Assistant Maintenance Director call for assistance and responded to the hallway outside the recreation area. RN #2 identified when she arrived, the residents had been separated and that there were four (4) other residents in the hallway at the time and one (1) of the residents had tried to intervene and was visibly upset. RN #2 indicated she interviewed Resident #1 who at first just responded by saying he/she was ok and repeating that repeatedly, Resident #1 had no signs of injury and did not report any pain. RN #2 explained Resident #1 identified in a second interview, he/she was in Resident #2's way when Resident #2 wanted to move, and Resident #2 stood up and punched him/her. RN #2 identified although Resident #1 was independent in the wheelchair for mobility Resident #1 can only maneuver the wheelchair with his/her left hand due to his/her hemiparesis and moves slowly. Interview with the Director of Nursing (DON) on 4/23/24 at 1:00 PM identified Resident #2 punching Resident #1 was inappropriate and was due to Resident #2's history of delusions and lack of judgment. The facility's Recognizing Signs and Symptoms of Abuse/neglect policy, dated 2017, directed in part, that it is the policy of the facility is that any form of resident abuse will not be condoned. Abuse is defined as the willful infliction of injury.

Based on observations, review of the clinical record, staff interview, and review of facility documentation for 1 of 3 residents (Resident #39) reviewed for pressure ulcers, the facility failed to ensure off-loading of the heels was implemented to prevent a pressure ulcer. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnosis of cerebral vascular infarction (CVA), pleural effusion, and hemiplegia/hemiparesis. A Discharge Summary from the hospital dated 10/20/23 identified Resident #39's skin was without rashes, ulcerations, or petechiae. An Admission Braden scale dated 10/20/23 identified Resident #39 was at moderate risk for skin breakdown. A Health Status note dated 10/20/23 identified Resident #39's skin was clean, dry, and intact. The Admission Minimum Date Set (MDS) assessment dated [DATE] identified Resident #39 was moderately cognitively impaired and required maximum assistance for eating, was dependent for toileting, transfers, dressing and personal hygiene. Additionally, the MDS identified Resident #39 was physically impaired on one side, required moderate assistance to roll from one side to the other, was at risk for developing a pressure ulcer and did not have a pressure ulcer at the time of the MDS assessment. Review of the Resident Care Plan failed to identify a care plan regarding Resident #39 being at risk for skin breakdown or interventions that included off-loading of his/her heels. A facility Accident and Incident report dated 11/3/23 identified Resident #39 was observed with a hematoma (bruise) to the left heel that measured 5.0 centimeters (cm) round. A physician's note from the wound doctor dated 11/7/23 identified the wound to the left heel was a deep tissue injury (DTI) measuring 4.0 cm in length by 4.0 cm in width with an area of 16 square centimeters. Physician orders (subsequent to Resident #39 developing a DTI) dated 11/8/23 directed to provide a heel offloading cushion under Resident #39's bilateral lower extremities while in bed, always keep left heel off the bed, and apply skin prep to the left heel every shift. The Resident Care Plan was updated on 11/8/23 identifying a pressure injury related to the left heel with interventions that included to offload Resident #39's heels while in bed, turn and reposition per nursing standards of care/per policy, and check skin as least weekly on a scheduled bath day (which was Thursday). On 3/4/24 at 11:15 AM, observation of Resident #39 with LPN #1 identified Resident #39's heels were off loaded with a pillow. Additionally, a round DTI wound measuring 2.5 cm by 2.5 cm was observed to Resident #39's left heel. Additionally, no drainage or odor was noted, and the area was dry. Interview and review of the clinical record with RN #3 and RN #5 on 3/4/24 at 3:27 PM failed to identify Resident #39's heels were offloaded prior to a DTI developing on 11/3/23. Additionally, RN #3 and RN #5 identified a resident with a moderate risk for skin break down should have a care plan upon admission for potential for alterations in skin integrity which would include turning and repositioning, a pressure relieving mattress and skin checks weekly. Interview RN# 1 on 3/5/24 at 9:16 AM identified that a care plan for potential for alteration in skin integrity would include off-loading heel, repositioning, facility skin protocol, and a pressure reducing mattress. RN #1 stated it was her responsibility to initiate a care plan for pressure ulcer prevention. Interview with the Wound MD on 3/5/24 at 11:55 AM indicated that if Resident #39 had interventions to offload the heels implemented upon admission the resident would not have developed the DTI. Interview with NA #2 on 3/5/24 at 2:04 PM noted she routinely cared for Resident #39 who required assistance to offload his/her heels, reposition and turn her/himself. NA #2 further identified Resident #39 could not self-elevate his/her bilateral extremities. The facility policy for Care Plan states the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Care plans are maintained in the resident's clinical record and serve as a guide by which care is delivered and steered. The facility policy for Skin Assessment and Pressure Ulcer Prevention identifies A comprehensive skin assessment is done on every resident upon admission and the weekly. The Nursing Assistant caring for the resident monitors the skin daily and reports any changes to the licensed nurse. It is the policy of this facility that residents who are admitted without a pressure ulcer does not develop a pressure ulcer unless clinically unavoidable.

Based on the staff interviews, facility documentation, and review of the facility policies, the facility failed to ensure that Infection Prevention Control Program standards (IPCP) policies and procedures are reviewed annually by the Administrator, Medical Director, and the Director of Nursing and that the facility maintained an updated list of residents with Multidrug Resistant Organism. (MDRO) The findings included: On 3/1/24 at 11:07 AM, review of the Infection Prevention policies/procedure manual with RN #6 (the Infection Preventionist) and RN #7 (the previous Infection Preventionist) failed to identify the policies had been reviewed and signed by the Administrator, Medical Director, and Director of Nursing annually. Additionally, the signature page was blank, with no signatures present and both RNs stated that they were unaware that the policies needed to be signed on an annual bases. The MDRO (Multidrug Resistant Organisms) list was last updated on 4/14/23 with some of those residents having been discharged or no longer in the same rooms as identified on the MDRO list. RN #7 stated on 3/1/24 the Director of Admissions was aware of which residents were on the MDRO list and she was the one who had a current list. Interview on 3/1/24 at 2:17 PM with the Director of Admissions identified she had no knowledge of which residents were on the MDRO list and denied having a current or historical list of residents that had a MDRO. Subsequent to surveyor inquiry, the facility completed an updated MDRO log on 3/4/24.

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 5 residents (Resident # 7 and #43) reviewed for unnecessary medication, the facility failed to order as needed (PRN) psychotropic medications for only 14 days. The findings include: 1. Resident #7's diagnoses included Alzheimer's disease, anxiety disorder and Type 2 diabetes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 was moderately cognitively impaired and required practical assistance with shower transfer and toileting hygiene and maximal assistance with showering. The Resident Care Plan dated 11/10/23 identified Resident #7 had episodes of resistive to care- refused to shower, and refused to change clothes. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness. A physician's order dated 11/13/23 directed to provide Ativan (Lorazepam) 0.5 milligrams (mg), give 1 tablet by mouth every 24 hours as needed for anxiety/agitation prior to showers (administer 45 minutes prior to shower). However, but failed to indicate a stop date. Nursing notes dated 11/13/23, 11/24/23, 12/14/23 and 1/26/24 identified Resident #7 was administered Ativan (Lorazepam) prior to his/her shower for anxiety. Interview with the Pharmacy Consultant on 3/5/23 at 10:24 AM indicated that he had provided recommendations on 1/8/24 and 2/8/24 that indicated that PRN usage for psychotropic drugs were limited to 14 days, and further assessment by the prescribing physician was required if a PRN should be extended. Interview with the DNS on 3/5/24 at 12:10 PM indicated that she was unable to locate the signed acknowledged pharmacy recommendation for Resident #7 from the November 2023 to March 2024 time frame. Interview with the DNS on 3/5/24 at 1:00 PM indicated that once pharmacy consults/recommendations were sent to the facility, the recommendations were placed in the Medical Director's box and reviewed. The DNS indicated she and the Nursing Supervisors were responsible for putting the approved order in the medical records. The DNS was unable to explain the reason this was not done. Interview with the DNS on 3/5/24 at 2:17 PM indicated that she did not see the Psychiatrist note from 12/18/23, which directed Ativan PRN for 14 days. Subsequent to surveyor inquiry, Ativan 0.5 mg PRN was discontinued on 3/5/24. 2. Resident #43's diagnoses included dementia, depressive episodes, and history of fractures. a. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 was moderately cognitively impaired, was not identified to have behaviors, and required extensive one-person physical assistance with personal hygiene. Additionally, the MDS identified Resident #43 received an antidepressant medication. The Resident Care Plan (RCP) dated 2/17/22 identified Resident #43 had impaired cognitive function and thought processes related to dementia, and a mood problem related to admission. Interventions included to administer medications as ordered, monitor/document side effects and effectiveness, and behavioral health consults, including psychiatry, as needed. A physician's order dated 11/3/21 through 3/5/24 directed to administer Trazodone (medication used for depression) 25 milligrams (mg) every 8 hours PRN for agitation but failed to include a stop date of 14 days. Medication Administration Record dated 12/17/21, 12/26/21, 1/1/22, 1/2/22, 1/9/22, 1/15/22, 1/17/22, and 1/18/22 identified Resident #43 received Trazodone 25 mg for agitation. Although PRN Trazodone was renewed monthly by the physician, the resident had not received subsequent PRN doses. b. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 had a short/long term memory problem, was identified to have verbal behavioral symptoms occurring 1 to 3 days, and other behavioral symptoms occurring 4 to 6 days. Additionally, the MDS identified Resident #43 required partial/moderate assistance with toileting hygiene and upper/lower body dressing and that the resident received an antidepressant medication. The Resident Care Plan (RCP) dated 11/11/22 identified that Resident #43 used an antidepressant medication related to depression and psychotropic medications related to paranoia. Interventions included to administer medications as ordered, educate about the risks, monitor/document regarding adverse reactions, and to consult with the pharmacy/physician to consider a dosage reduction when clinically appropriate at least quarterly. A physician's order dated 10/14/22 through 2/14/24 directed to administer Ativan (medication used for anxiety) 0.5 mg every 4 hours PRN for anxiety but failed to include a stop date of 14 days. A physician's order dated 2/14/24 through 3/5/24 directed to administer Ativan 0.5 mg every 6 hours (decreased frequency from previous order of every 4 hours) PRN for anxiety or agitation. Do not give if resident is sleepy, lethargic, or sedated. Medication Administration Record dated 6/17/23, 6/21/23, 6/23/23, 6/26/23, 7/9/23, 7/29/23, and 7/30/23 identified Resident #43 received Ativan 0.5 mg for anxiety. Although PRN Ativan was renewed monthly, the resident had not received subsequent PRN doses. An interview with MD #1 on 3/4/24 at 3:16 PM identified that he was aware that psychotropic PRN medications should only be ordered for 14 days and could not identify the reason he did not include the 14 days stop date, but Resident #43 had been on psychotropic PRN medications for a long time. An interview with the Pharmacy Consultant on 3/5/24 at 10:10 AM identified that the duration of PRN psychotropic medications had been addressed in past reports. Subsequent to surveyor inquiry, both Trazodone and Ativan PRN medications were discontinued on 3/5/24. Review of the Psychotropic Medication PRN Usage policy directed, in part, that medication renewal is required every 14 days. To continue use, a new order for the PRN medication may be written if the prescribing practitioner directly examines and assesses the resident and documents the rationale for continuing use, which should include benefits of use for the resident. 50177

Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 5 residents (Resident #7 and Resident #43) reviewed for unnecessary medication, the facility failed respond to pharmacy recommendations related to an as needed (PRN) psychotropic medication. The findings include: 1. Resident #7's diagnoses included Alzheimer's disease, anxiety disorder and Type 2 diabetes. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #7 was moderately cognitively impaired, required practical assistance with shower transfer and toileting hygiene and maximal assistance with showering. The Resident Care Plan dated 11/10/23 identified Resident #7 had episodes being resistive to care- refused to shower and refused to change clothes. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness. A physician's order dated 11/13/23 directed to provide Ativan (Lorazepam) 0.5 milligrams (mg), give 1 tablet by mouth every 24 hours as needed for anxiety/agitation prior to showers (administer 45 minutes prior to shower). However, the physician order failed to indicate a stop date. Nursing Notes dated 11/13/23, 11/24/23, 12/14/23 and 1/26/24 identified Resident #7 was administered Ativan (Lorazepam)0.5 mg prior to a shower for anxiety. Interview with Pharmacy consultant on 3/5/23 at 10:24 AM indicated that he had provided recommendations for Resident #7 on 1/8/24 and 2/8/24 that indicated that PRN for psychotropic drugs are limited to 14 days, and further assessment by the prescribing physician was required if a PRN should be extended. Interview with the DNS on 3/5/24 at 12:10 PM indicated that she was unable to locate the signed acknowledged pharmacy recommendation for Resident # 7 from the November 2023 to March 2024 time frame. Interview with the DNS on 3/5/24 at 1:00 PM indicated that once pharmacy consults/recommendation were sent to the facility, consults are placed in the Medical Director's box and reviewed. The DNS indicated she and the Nursing Supervisors were responsible for putting the approved order in the medical records. The DNS was unable to explain the reason this was not done. Interview with the DNS on 3/5/24 at 2:17 PM indicated that she did not see a psychiatrist note from 12/18/23, which directed Ativan 0,5 mg PRN for 14 days. Subsequent to surveyor inquiry Ativan 0.5 mg PRN was discontinued on 3/5/24. 2. Resident #43's diagnoses included dementia, depressive episodes, and history of fractures. a. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 was moderately cognitively impaired, was not identified to have behaviors, and required extensive one-person physical assistance with personal hygiene. Additionally, the MDS identified Resident #43 received an antidepressant medication. The Resident Care Plan (RCP) dated 2/17/22 identified Resident #43 had impaired cognitive function and thought processes related to dementia, and a mood problem related to admission. Interventions included to administer medications as ordered, monitor/document side effects and effectiveness, and behavioral health consults, including psychiatry, as needed. A physician's order dated 11/3/21 through 3/5/24 directed to administer Trazodone (medication used for depression) 25 mg every 8 hours PRN for agitation but failed to include a stop date of 14 days. Medication Administration Record dated 12/17/21, 12/26/21, 1/1/22, 1/2/22, 1/9/22, 1/15/22, 1/17/22, and 1/18/22 identified Resident #43 received Trazodone 25 mg for agitation. Although PRN Trazodone was renewed monthly by the physician, the resident had not received subsequent PRN doses. b. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 had a short/long term memory problem, was identified to have verbal behavioral symptoms occurring 1 to 3 days, and other behavioral symptoms occurring 4 to 6 days. Additionally, the MDS identified Resident #43 required partial/moderate assistance with toileting hygiene and upper/lower body dressing and that the resident received an antidepressant medication. The Resident Care Plan (RCP) dated 11/11/22 identified that Resident #43 used an antidepressant medication related to depression and psychotropic medications related to paranoia. Interventions included to administer medications as ordered, educate about the risks, monitor/document regarding adverse reactions, and to consult with the pharmacy/physician to consider a dosage reduction when clinically appropriate at least quarterly. A physician's order dated 10/14/22 through 2/14/24 directed to administer Ativan (medication used for anxiety) 0.5 mg every 4 hours PRN for anxiety but failed to include a stop date of 14 days. A physician's order dated 2/14/24 through 3/5/24 directed to administer Ativan 0.5 mg every 6 hours (decreased frequency from previous order of every 4 hours) PRN for anxiety or agitation. Do not give if resident is sleepy, lethargic, or sedated. Medication Administration Record dated 6/17/23, 6/21/23, 6/23/23, 6/26/23, 7/9/23, 7/29/23, and 7/30/23 identified Resident #43 received Ativan 0.5 mg for anxiety. Although PRN Ativan was renewed monthly by the physician, the resident had not received subsequent PRN doses. Consultant Pharmacist Recommendations dated 2/8/22 identified that the Centers for Medicare and Medicaid Services guidelines will limit PRN psychotropic orders to 14 days maximum use without a reassessment. Recommendations included for the physician to assess continued need for PRN Trazodone or add a specific stop date to the order. The same recommendation was identified subsequently in the 5/6/22 and 8/12/22 reports. The 8/13/23 report included the same recommendation for PRN Ativan, as well as PRN Trazodone. All Pharmacy reports received failed to identify the physician responded to pharmacy recommendations. Additionally, pharmacy medication review failed to identify an open-ended PRN order for Trazodone and/or Ativan on 3/8/22, 4/7/22, 6/10/22, 7/14/22, 9/7/22, 11/7/22, 12/8/22, 1/4/23, 2/7/23, 3/6/23, 4/14/23, 5/9/23, 7/14/23, 9/20/23, 10/20/23, 11/10/23, 12/9/23, 1/8/24, and 2/9/24 despite the resident being prescribed PRN Tradozone and/or Ativan. An interview with MD #1 on 3/4/24 at 3:16 PM identified that he was aware that psychotropic PRN medications should only be ordered for 14 days and could not identify the reason he did not include the 14 days stop date, but Resident #43 had been on psychotropic PRN medications for a long time. An interview with the Pharmacy Consultant on 3/5/24 at 10:10 AM identified that the duration of PRN psychotropic medications had been addressed in past reports. An interview with the Director of Nursing Services (DNS) on 3/5/24 at 1:00 PM identified that she did not have a reason why the pharmacy reports and recommendations were not responded to by the physician. An additional interview with the Pharmacy Consultant on 3/6/24 at 12:05 PM identified that a pharmacy progress note stating no irregularities was generated when there is no physician recommendation report. 50177

Based on review of the clinical record, facility policy and interviews for 1 of 1 sampled residents (Resident #19) reviewed for dental, the facility failed to report missing dentures to afford the opportunity for Resident #19 to submit a grievance. Resident 19's diagnosis included unspecified sequelae of cerebral infarction, paroxysmal atrial fibrillation and Type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #19 was independent with eating, required supervision or touching assistance for oral hygiene, substantial/ maximal assistance for toileting hygiene, substantial/ maximal assistance for showering, partial/ moderate assistance for lower body dressing, supervision or touching assistance for upper body dressing. On 3/4/24 at 11:00 AM, interview with Resident #19 identified that his/her upper dentures were missing for about a week and could not recall if he/she told anyone. Interview with Licensed Practical Nurse (LPN) #1 on 3/4/24 at 12:07 PM identified that she was unaware that Resident #19's top dentures were missing. Interview with Social Worker (SW) #1 on 3/4/24 at 12:15 PM identified that he was unaware, and it was not reported to him that Resident #19's top dentures were missing. Interview with Nurse Aide (NA) #1 on 3/4/24 at 12:21 PM identified that although she noticed Resident #19's upper dentures were missing, she did not report the missing denture to licensed staff or the SW because she thought someone had already reported it. Although NA #1 was aware of Resident #19's missing upper dentures, she did not report to facility staff in order for a grievance to be initiated to resolve the missing denture.

Based on review of the clinical record, facility policy, and interviews for 2 of 5 sampled residents (Resident #2 and Resident #58) reviewed for unnecessary medications, the facility failed to initiate a Resident Care Plan related to a diagnosis with corresponding medication use. The findings include: 1. Resident #2's diagnoses included Atrial Fibrillation (A-fib), dementia, and hypothyroidism. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was moderately cognitively impaired and required assistance with ADL'S, meals, and medications. A physician's order dated 10/2/23 directed to administer Apixaban 2.5 milligram (mg) twice a day for atrial fibrillation (A-fib). Review of the Resident Care Plan (RCP) failed to identify a problem reflecting Resident #2's A-fib or the use of an anticoagulant medication (blood thinner). Interview and review of the clinical record with Registered Nurse (RN) #1 on 3/4/24 at 9:03 AM identified that there was not a RCP for the anticoagulant medication, and she must have missed adding the problem for Resident #2's anticoagulant medication use. Subsequent to surveyor inquiry, RN #1 indicated that the RCP would be revised to include the use of the anticoagulant medication. 2. Resident #58 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, morbid obesity, and Raynaud's syndrome. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was cognitively intact and required moderate assistance for transfers, maximum assistance for toileting, and setup assistance for personal hygiene. A physician's order dated 2/19/24 at 9:28 AM directed Resident #58 be administered Toujeo 50 units subcutaneously daily, and Mounjaro 5 milligrams subcutaneously every 7 days (both medications for diabetes). Review of the Resident Care Plan (RCP) failed to identify a care plan for Resident #58's diabetes or diabetic medication use. Interview and clinical record review with RN #1 on 3/4/24 at 12:22 PM, failed to identify Resident #58's had a RCP for his/her diabetes or for the use of diabetic medications. RN #1 identified that RN supervisors were responsible to initiate a RCP for pertinent diagnosis and medications upon admission but had not done so for Resident #58's diabetes. Additionally, a Resident Care Conference (RCC) had been held on 2/26/24 and although the interdisciplinary team was present, no one had initiated, updated, or identified the missing RCP for diabetes or diabetic medication use. RN #1 indicated that RCC's are used to review and revise the care plan so the missing RCP information should have been identified at that time, and that subsequent to surveyor inquiry a diabetic RCP would be generated. Review of the Care Planning policy directed, in part, that a comprehensive care plan for each resident is developed within 7 days of completion of the resident assessment. 50059

Based on observation, review of the clinical record, facility policy, facility documentation, and interviews for 1 of 4 sampled residents reviewed for accidents (Resident #15), the facility failed to revise the Resident Care Plan regarding discontinuation of anti-embolism stocking and initiation of interventions following a fall. The findings include: Resident #15's diagnoses included dementia, history of falling, and difficulty walking. a. A physician's order dated 4/7/22 through 3/1/23 directed Resident #15 was independent with bed mobility, wheelchair mobility, transfers, and ambulation with rollator within the facility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was moderately cognitively impaired, was independent with walking, and required partial/moderate assistance with sit to lying and sit to stand. The Resident Care Plan (RCP) dated 1/17/23 identified Resident #15 was at risk for falls and that Resident #15 had limited physical mobility. Interventions included a dycem to the wheelchair cushion, call bell within reach, encourage resident to wear nonskid socks over his/her stockings, and that the resident was independent with rollator or wheelchair for transfers and ambulation within the facility. A Reportable Event form dated 2/24/23 at 7:10 PM identified Resident #15 had a witnessed fall with severe pain and he/she was sent to the hospital for evaluation. Resident #15 was hospitalized [DATE] through 2/28/23 for a fall with left hip fracture and had surgery completed. Resident #15 was readmitted to the facility on [DATE]. A physician's order dated 3/3/23 through 4/15/23 directed Resident #15 was to wear Thrombo-Embolus Deterrent (Ted) stockings daily for 6 weeks. The RCP dated 3/3/23 identified that Resident #15 was to have [NAME] stockings on in the morning and removed in the evening. Observation on 2/29/24 at 9:17 AM identified that Resident #15 was not wearing [NAME] stockings. Interview and observation with LPN #1 on 3/1/24 at 12:25 PM identified that Resident #15 was wearing regular stockings and did not wear [NAME] stockings anymore. Interview with NA #3 on 3/1/24 at 12:50 PM also identified that Resident #15 wore regular stockings and did not wear [NAME] stockings. An interview and RCP review with the MDS Coordinator (RN #1) on 3/4/24 at 12:07 PM identified that [NAME] stockings remained on the RCP even though there was no current physician's order and Resident #15 no longer utilized them. Subsequent to surveyor's inquiry, the intervention for [NAME] stockings was removed from the RCP. b. The significant change Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was cognitively intact and required supervision or touch assistance with walking, sit to lying, and sit to standing. A physician's order dated 5/16/23 through 9/1/23 directed Resident #15 was independent with bed mobility, independent with a 4 wheeled walker for transfers, independent with a 4 wheeled walker for ambulation on level surfaces and supervision on uneven surfaces. The Resident Care Plan (RCP) dated 5/24/23 identified Resident #15 was at risk for falls and that Resident #15 had limited physical mobility. Interventions included a dycem to the wheelchair cushion, call bell within reach, encourage resident to wear nonskid socks over his/her stockings, and that the resident was an assist of 1 for bed mobility, and an assist of 1 with a 4 wheeled walker for both transfers and ambulation. A Reportable Event form dated 7/5/23 at 11:40 AM identified Resident #15 had an unwitnessed fall with severe pain after falling out of his/her wheelchair and he/she was sent to the hospital for evaluation. A nurse's note dated 7/7/23 at 10:00 PM identified that Resident #15 was readmitted to the facility. The Summary Report dated 7/7/23 and submitted to the State Agency from the Reportable Event dated 7/5/23 identified that to prevent reoccurrence, Resident #15 would be reminded to lock the wheelchair when stationary. Additionally, the summary from the Reportable Event identified Resident #15 had confirmed thoracic fractures. An interview and RCP review with the MDS Coordinator (RN #1) on 3/4/24 at 12:07 PM identified that the interventions (remind resident to lock the wheelchair when stationary) from the Corrective Action Plan was not added/included in the RCP. She further identified it was the responsibility of the Director of Nursing Services (DNS) to add interventions to the RCP resulting from the Corrective Action Plan, however the MDS Coordinator could also add interventions, as they work together. Subsequent to surveyor's inquiry, the intervention to remind the resident to lock the wheelchair when stationary was added to the RCP. c. A physician's order dated 10/11/23 through 3/5/24 directed that Resident #15 was an assist of 1 for bed mobility, independent with a 4 wheeled walker for transfers, and independent with a 4 wheeled walker for ambulation on the unit with supervision outdoors. The Resident Care Plan (RCP) dated 10/30/23 identified Resident #15 was at risk for falls and that Resident #15 had limited physical mobility. Interventions included a dycem to the wheelchair cushion, call bell within reach, encourage resident to wear nonskid socks over his/her stockings, and that the resident was an assist of 1 for bed mobility, independent with a 4 wheeled walker for transfers, and independent with a 4 wheeled walker for ambulation on the unit with supervision outdoors. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was moderately cognitively impaired, was independent with walking and sit to lying, and required supervision or touch assistance with sit to stand. A Reportable Event form dated 12/4/23 at 12:00 PM identified Resident #15 had an unwitnessed fall with reported spine pain after and he/she was sent to the hospital for evaluation. The root cause/conclusion from the Reportable Event investigation identified that the resident must wear rubber sole shoes. A nurse's note dated 12/5/23 at 2:21 AM identified Resident #15 had returned to the facility without any acute injuries or fractures to the thoracic/lumbar spine. An interview and RCP review with the MDS Coordinator (RN #1) on 3/4/24 at 12:07 PM identified that the interventions (the resident must wear rubber sole shoes) from the corrective action to prevent recurrence on the Reportable Event dated 12/4/23 were not added/included in the RCP. She further identified it was the responsibility of the Director of Nursing Services (DNS) to add interventions to the RCP resulting from the Corrective Action Plan, however the MDS Coordinator could also add interventions, as they work together. Subsequent to surveyor's inquiry, the intervention that the resident must wear rubber sole shoes was added to the RCP. Review of the Care Planning policy directed, in part, that a comprehensive RCP is developed within 7 days of completion of the resident assessment (MDS). The RCP is created by Interdisciplinary Team. The resident and family, or legal representative, are encouraged to participate in the development of and revisions to the RCP. RCP meetings will be scheduled at times best for the resident and family.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #650) reviewed for a change in condition, the facility failed to ensure the health care representative was notified of new orders for intravenous fluids timely. The findings include: Resident #1 had diagnoses that included congestive heart failure, chronic kidney disease, osteomyelitis of vertebra, dysphagia, diabetes mellitus, and dementia. Review of Resident #650's advance directives dated 11/19/2019 identified Person #3 was the designated health care representative authorized to make any and all health care decisions for Resident #650. The form directed Person #3 was authorized to make decisions including the decision to accept or refuse any treatment, service, or procedure used to diagnose or treat Resident #650's physical or mental conditions and the decision to provide, withhold, or withdraw life support systems. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #650 had severely impaired cognition and required extensive assistance of one (1) to two (2) persons with all ADL's (activities of daily living). The Resident Care Plan (RCP) dated 2/11/2023 identified Resident #650 required tube feeding related to dysphagia. Interventions directed to monitor/document/report as needed any signs/symptoms of aspiration (fever, shortness of breath) and abnormal lab values. Review of the physician progress notes dated 2/22/2023 at 1:58 PM by MD #1 identified MD #1 performed a face-face visit to assess hypernatremia in the setting of chronic congestive heart failure (CHF) and edema of the upper extremities. The note indicated a plan to hydrate gently with IV D5W at 50 cc/hour for two (2) liters. Review of the physician orders dated 2/22/2023 directed to administer Dextrose Intravenous Solution 5% at 50 ml/hr for hyperkalemia. Review of the nursing progress notes failed to identify documentation that Person #3 was notified regarding Resident #650's new order for IV hydration. Review of the Medication Administration Record (MAR) identified Resident #650 had received Dextrose Intravenous Solution 5% on 2/22 through 2/24/2023. Interview with LPN #8 on 3/13/2024 at 12:20 PM identified she did not make calls to notify families; if a call needs to be made, she notifies the supervisor to make the call. LPN #8 indicated she did not notify Person #3 of the orders for IV fluids. Interview with LPN #9 on 3/13/2024 at 2:15 PM identified she was unable to recall if she notified Person #3 and she would have written a nursing note if she had made the notification. LPN #9 identified the facility standard practice was to notify the POA at the time when an order is received. Review of the nursing schedule dated 2/22/2023 identified the DON was the RN Supervisor on 2/22/2023 during the 7:00 AM to 3:00 PM shift. Interview with DON on 3/13/2024 at 2:45 PM identified the facility staff should notify a resident's POA when there is a new medication order. The DON indicated the physician would not notify the POA, but upon placing the new order, the nursing staff or RN Supervisor should update the POA of the situation. The DON was unable to provide documentation that Person #3 was notified, indicated they should have been notified. Additional interview at 2:50 PM identified although the DON was the shift supervisor when the new order was obtained, the DON indicated she did not recall notifying Person #3. Review of the Change in a Resident's Condition or Status and Notification Policy identified the facility shall promptly notify the resident and representative (consistent with his or her authority) of changes in the resident's medical condition and/or status (e.g., changes in level of care). The Nurse Supervisor/Charge Nurse will notify the resident's family or representative.

Based on clinical record review, review of facility documentation and policies and procedures, and interviews, for two sampled residents, (Resident #125 and Resident #126) who required hydration monitoring, the facility failed to provide sufficient fluid intake based on individual needs and in accordance with facility policy. The findings include: a. Resident #125's [DIAGNOSES REDACTED]. A Nursing assessment dated [DATE] identified no cognitive impairment, independent decision-making, anxiety, tearfulness, two person assistance for ambulation, foley catheter, moderate to severe pain in the right hip, and report of constipation. Review of the clinical record including the Acute Care Hospital #1's discharge summary failed to identify Resident #125's weight. Review of the Dietary Notes failed to identify that a Nutritional assessment had been completed and/or that the baseline daily fluid requirements had been calculated. Review of an Intake and Output Record dated 12/07/10 through 12/11/10 identified twenty four hour totals on 12/08/10 of intake of 1260 cubic centimeters (cc's) and output of 950 cc's, on 12/09/10 intake of 1580 cc' s' and output of 1150 cc' s', and on 12/10/10 intake of 1120 cc' s' and output of 450 cc's. R #125 was admitted to the hospital on [DATE]. Review of the facility policy for Hydration identified, in part, that the registered dietician determined the daily fluid needs on admission and as needed, with the average daily intake for an adult of 1500 millimeters (ml's) and the output should be equivalent to the intake. The Registered Dietitian/Licensed Nurse assesses residents exhibiting signs associated with potential dehydration which might include dry mouth and lips, small concentrated urine output, thirst, dry skin with loss of turgor, confusion, sunken eyes, weakness and lethargy, [MEDICAL CONDITION] pallor and/or pulse greater then 100 beats per minute and/or systolic blood pressure (BP) less then 100 millimeters of mercury (mmHg). The Licensed Nurse notifies the Physician (MD) and resident's family upon identification of hydration concerns and documents the notification in the Interdisciplinary Progress Notes. Interview with the Dietician on 02/03/11 at 3:20 PM identified that he/she did not calculate the baseline fluid requirement and the complete Medical Nutrition Therapy Assessment for Resident #125, however the nursing staff knew how to calculate the range based on the resident's weight. Review of the clinical record and interview with the Director of Nursing on 02/03/11 at 4:00 PM identified that he/she expected that the weight would have been obtained and the baseline fluid requirement calculated by the Licensed Nurse on the unit as well as a more comprehensive Hydration Assessment performed if the resident exhibited signs of dehydration. The assessment should have been documented in the medical record. Notification of the the physician and/or responsible party of hydration concerns should have been documented in the medical record. b. Resident #126's [DIAGNOSES REDACTED]. A discharge summary from the acute care hospital dated 06/23/10 identified that the resident directed that his/her wishes were for medical therapy and no invasive and/or noninvasive procedures and if his/her condition worsened the resident wished for comfort measures only (CMO). An admission Minimum Data Set assessment ((MDS) dated [DATE] identified impaired cognition with moderately impaired decision-making, a sad, pained, worried look that was not easily altered, verbally abusive, resists care, extensive assistance of one to two staff for activities of daily living and mobility activities, usually continent of bowel and occasionally incontinent of bladder, leaves 25% or more of food uneaten at most meals, required antipsychotic medications daily, intake and output and monitoring of an acute medical condition. Review of a Medical Nutrition Therapy assessment dated [DATE] identified a baseline fluid requirement of 1900 mls per day to 2400 ml's per day and identified that Resident #126 was at nutritional risk. Review of Total Intake and Output Record identified the following twenty four hour totals for intake: 06/26/10-1380 cc's, 06/27/10-1120 cc's, 06/28/10-1400 cc's, 06/29/10-920 cc's, 06/30/10-840 cc's, 07/02/10-0 cc's, 07/03/10-120 cc's, 07/04/10-0 cc's, 07/05/10-840 cc's, and 07/06/10-120 cc's. Review of the facility policy for Hydration identified, in part, that the registered dietician determined the daily fluid needs on admission and as needed, with the average daily intake for an adult of 1500 millimeters (ml's) and the output should be equivalent to the intake. The Registered Dietitian/Licensed Nurse assesses residents exhibiting signs associated with potential dehydration which might include dry mouth and lips, small concentrated urine output, thirst, dry skin with loss of turgor, confusion, sunken eyes, weakness and lethargy, [MEDICAL CONDITION] pallor and/or pulse greater then 100 beats per minute and/or systolic blood pressure (BP) less then 100 millimeters of mercury (mmHg). The Licensed Nurse notifies the Physician (MD) and resident's family upon identification of hydration concerns and documents the notification in the Interdisciplinary Progress Notes. Review of the Interdisciplinary Progress Notes failed to identify that the Registered Dietitian and/or Nursing Staff assessed the resident further, according to the facility policy, when the resident did not meet his/her baseline fluid requirement. Review of the clinical record failed to identify that the physician and/or the responsible parties were notified prior to 7/7/10 that the resident continuously failed to meet his/her baseline fluid requirement. Review of a nursing note dated 07/07/10 at 1:00 PM and written by the former Director of Nursing, identified that the Power of Attorney (POA) was notified of Resident #126's deteriorating condition that included refusing food and fluids, drop in oxygen saturation, decline in swallowing and poor prognosis and that the POA agreed with comfort Measures Only (CMO), no artificial hydration, no intravenous therapy (IV's), and no life sustaining measures. Interview with the former Director of Nursing on 02/04/11 at 10:30 AM identified that he/she would have expected that intake and output would have been documented and reported to the physician and responsible party if the resident did not meet baseline requirements for three consecutive days. Notification and further assessment should have been documented in the clinical record. The facility failed to ensure that sufficient fluids were provided and/or hydration status was monitored, documented, and reported to the physician and or responsible party in accordance with facility policy.

Based on clinical record review, review of facility documentation, and interviews for one of two residents (Resident #126) reviewed for hydration and one of eleven residents (Resident #126) reviewed for unnecessary drugs, the facility failed to provide necessary care and services to ensure that the resident attained and/or maintained the highest practicable physical and/or psychosocial well-being in accordance with a comprehensive assessment. The findings include: a. Resident #126's [DIAGNOSES REDACTED]. A discharge summary from the acute care hospital dated 06/23/10 identified that the resident directed that his/her wishes were for medical therapy and no invasive and/or noninvasive procedures and if his/her condition worsened the resident wished for comfort measures only (CMO). An admission Minimum Data Set assessment ((MDS) dated [DATE] identified impaired cognition with moderately impaired decision-making, a sad, pained, worried look that was not easily altered, verbally abusive, resists care, extensive assistance of one to two staff for activities of daily living and mobility activities, usually continent of bowel and occasionally incontinent of bladder, leaves 25% or more of food uneaten at most meals, required antipsychotic medications daily, intake and output and monitoring of an acute medical condition. Review of a Medical Nutrition Therapy assessment dated [DATE] identified a baseline fluid requirement of 1900 mls per day to 2400 ml's per day and identified that Resident #126 was at nutritional risk. Review of Total Intake and Output Records identified the following twenty four hour totals for intake: 06/26/10-1380 cc's, 06/27/10-1120 cc's, 06/28/10-1400 cc's, 06/29/10-920 cc's, 06/30/10-840 cc's, 07/02/10-0 cc's, 07/03/10-120 cc's, 07/04/10-0 cc's, 07/05/10-840 cc's, and 07/06/10-120 cc's. Review of the facility policy for Hydration identified, in part, that the registered dietician determined the daily fluid needs on admission and as needed, with the average daily intake for an adult of 1500 millimeters (ml's) and the output should be equivalent to the intake. The Registered Dietitian/Licensed Nurse assesses residents exhibiting signs associated with potential dehydration which might include dry mouth and lips, small concentrated urine output, thirst, dry skin with loss of turgor, confusion, sunken eyes, weakness and lethargy, [MEDICAL CONDITION] pallor and/or pulse greater then 100 beats per minute and/or systolic blood pressure (BP) less then 100 millimeters of mercury (mmHg). The Licensed Nurse notifies the Physician (MD) and resident's family upon identification of hydration concerns and documents the notification in the Interdisciplinary Progress Notes. Review of the Interdisciplinary Progress Notes failed to identify that the Registered Dietitian and/or Nursing staff assessed the resident, according to the facility policy, when the resident did not meet his/her baseline fluid requirement. Review of the clinical record failed to identify that the physician and/or the responsible parties were notified prior to 07/07/10 that the resident continuously failed to meet his/her baseline fluid requirement. Review of a nursing note dated 07/07/10 at 1:00 PM and written by the former Director of Nursing, identified that the Power of Attorney (POA) was notified of R #126's deteriorating condition that included refusing food and fluids, drop in oxygen saturation, decline in swallowing and poor prognosis and that the POA agreed with comfort Measures Only (CMO), no artificial hydration, no intravenous therapy (IV's), and no life sustaining measures. Review of a Physician's Order dated 07/06/10 identified a change in advance directives status from Full Code to Do Not Resuscitate/Do Not Intubate/may be pronounced by nurse and, on 07/07/10, Comfort Measures Only (CMO). Interview with the former Director of Nursing on 02/04/11 at 10:30 AM identified that he/she would have expected that intake and output would have been documented and reported to the physician and responsible party if the resident did not meet baseline requirements for three consecutive days. Notification and further assessment should have been documented in the clinical record. The facility failed to ensure that sufficient fluids were provided and/or hydration status was monitored, documented, and reported to the physician and/or responsible party in accordance with facility policy. Interview with the former Director of Nursing on 02/04/11 at 10:30 AM further identified that on 07/07/10 Resident #126's POA accompanied Resident #126 to an orthopedic follow up appointment. While being transported to the appointment with the POA present, the resident's condition deteriorated and the ambulance was diverted to the closest Emergency Department. b. Acute Care Hospital #1 discharge summary for Resident #126 dated 06/23/10 identified discharge medications that included, in part, [MEDICATION NAME] one milligram by mouth every six hours for agitation, [MEDICATION NAME] one (1) milligram(mg) every morning and 1 mg every evening. Discharge Instructions dated 06/23/10 included, in part, [MEDICATION NAME] halftab, twenty five(25)mg by mouth at bedtime. Facility admission orders [REDACTED]. A physician's order dated 06/28/10 directed to discontinue [MEDICATION NAME] and start [MEDICATION NAME] M tab 1 mg by mouth twice a day and [MEDICATION NAME] 0.5 mg by mouth every four hours as needed for agitation and combativeness. A Psychiatry Consultation dated 06/28/10 recommended to discontinue [MEDICATION NAME]. A Behavioral Health Evaluation dated 06/29/10 recommended to discontinue [MEDICATION NAME]. A physician's order related to a psychiatrist's recommendation dated 07/01/10 directed to discontinue [MEDICATION NAME] M tab every morning and begin [MEDICATION NAME] 5 mg by mouth every PM. A physician's order dated 07/02/10 directed to discontinue all [MEDICATION NAME] and increase [MEDICATION NAME] Z to 5 mg every morning(AM) and 5 PM and add [MEDICATION NAME] solution 1 mg by mouth every eight hours as needed for punching and hitting. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. [MEDICATION NAME] 1 mg by mouth every six hours as needed was administered at 5 AM 06/27/10 and 1:30 PM 06/29/10. [MEDICATION NAME] 25 mg once a day was administered 06/25/10, 06/26/10, 06/27/10, 06/28/10, 06/29/10, and 06/30/10. [MEDICATION NAME] M tab 1 mg by mouth twice a day was administered 06/29/10 and 06/30/10. Resident #126 received [MEDICATION NAME] as a scheduled dose and an as needed dose, [MEDICATION NAME] and [MEDICATION NAME] on 06/29/10 and 06/30/10 despite the fact that the [MEDICATION NAME] had been discontinued and the psychiatrist had recommended discontinuation of the [MEDICATION NAME]. Resident #126 continued to receive [MEDICATION NAME] with additional antipsychotic and antianxiety medications until the [MEDICATION NAME] was discontinued on 07/04/10. The facility failed to ensure that Resident #126 was free of duplicate therapy and/or had adequate indications for use of multiple antipsychotic medications. Review of facility documentation dated 7/1/10 identified that Resident #126 was noted to have blue lips and fingertips, oxygen saturation of 83% on room air, was alert but lethargic and vital signs that included a blood pressure of 70/30, respiratory rate of 24-28, and heart rate of 96-130. A physician's order dated 07/01/10 directed to send to Emergency Department (ED) for evaluation. Interview with the Director of Nursing (DNS) on 02/04/10 at 2:00 PM following review of the clinical record, identified that there was a period of overlap of [MEDICATION NAME] and [MEDICATION NAME]. Review of the clinical record failed to identify that the facility was aware that Resident #126 was receiving multiple antipsychotic medications that should have been discontinued in accordance with physician's orders and/or psychiatric recommendations at the time the Resident #126 was transferred to the (ED) for evaluation.