Every finding on record at Attica Long Term Care Facility

The facility reported a census of 44 residents. The sample included five residents who were reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure residents remained free from resident-to-resident abuse. On 08/29/25 at approximately 01:10 PM, Resident (R)l, a cognitively impaired resident with a known history of aggression towards staff and other residents, approached her roommate, R2, in the common area, placed her hands around R2's neck, and began choking her. Staff heard the altercation, responded and intervened, though R1 continued to pull R2's hair while staff attempted to separate them. Staff separated the residents and assessed them. R1 had a small cut to her face and R2 had redness around her neck but no other visible injuries. The facility's failure to ensure residents remained free from abuse placed R2 in Immediate Jeopardy. Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included unspecified dementia (a progressive mental disorder characterized by failing memory and confusion) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R1's 07/28/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The assessment documented R1 had hallucinations (sensing things while awake that appear to be real, but the mind created) with physical and verbal behavioral symptoms directed towards others and wandering behaviors that occurred during the look-back period. The assessment documented the behaviors significantly intruded on the privacy or activities of others. The 07/28/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R1 previously lived at home with her spouse and had a diagnosis of Alzheimer's with difficulty remembering her room and saying things that were untrue. The 07/28/25 Behavioral Symptoms CAA documented R1 had wandering behavior that included going into other residents' rooms. R1 became easily upset and/or irritated with direction or redirection from staff. When R1 saw another resident sitting at a table, R1 displayed aggression and started to get in his face, and staff had to step between the residents to physically separate them. R1 also displayed behaviors of charging staff and ramming staff with her walker, throwing water on staff, and grabbing staff's clothing. The 07/28/25 Psychotropic Drug Use CAA documented R1 previously lived at home with her spouse, and he had administered Seroquel (quetiapine - a medication used to treat psychosis [any major mental disorder characterized by a gross impairment in reality perception]) to R1 three times at home since 06/25/25. The current medication regimen included Rexulti (a medication used to treat agitation associated with dementia due to Alzheimer's disease). R1's Care Plan dated 08/05/25 documented R1 had poor comprehension, which affected her understanding of her current impairments that caused increased restlessness and irritability. Interventions dated 07/30/25 directed staff to monitor R1's location and try to redirect any attempts to leave or enter other residents' rooms as best as possible to prevent a safety risk. The intervention provided suggestions such as sitting up front with peers and watching television, or on the patio as weather permitted. Staff would encourage activities and monitor for signs and symptoms of depression or anxiety and encourage R1 to express her feelings and provide support as needed. Staff were to attempt to provide a calm environment for her needs, redirect inappropriate behaviors, and offer food or fluids as needed for redirection. The intervention documented staff attempted the individualized activity of folding towels. Staff would monitor as needed use of Seroquel (quetiapine) for increased restlessness and irritability and monitor the use of Rexulti for dementia with anger and inappropriate behaviors, and unsettled restlessness. R1's Care Plan did not address interventions related to resident-to-resident abuse/aggression. Review of R1's EHR Census Records documented R1 admitted to the facilty on 07/17/25 at 10:21 AM. Review of the facility's investigation dated 07/17/25 revealed R1 was involved in an incident of resident-to-resident abuse on 07/17/25 at approximately 05:20 PM with R3 who received minor injuries. R1's EHR lacked information related to the resident-to-resident abuse incident that occurred on 07/17/25. Review of R1's EHR Census Records documented on 08/02/25 at 08:28 AM, R1's room assignment changed to the special care unit in a semi-private room with R2. R1's Progress Notes dated 08/29/25 at 02:03 PM, revealed Licensed Nurse (LN) G documented R1 pulled another resident's hair. LN G notified R1's son, who apologized for the incident, and LN G reassured R1's son the behavior was due to the dementia. Certified Nurse Aide (CNA) M's 08/29/25 Witness Statement recorded, on an undocumented date at approximately 12:30 PM, staff heard someone yelling. CNA M went into a resident's room where R1 had a hold of R2's arm and was pushing R2. CNA M was able to get between R1 and R2 and release R1's grip on R2; R1 slapped CNA M across the face. At approximately 01:00 PM, CNA M and the other [unnamed] staff were assisting another resident when they heard someone scream for help. CNA M noted they observed R1 grasping R2 by the throat and hair. Staff intervened and separated R1 and R2, and R1 attempted to bite the staff. Staff returned R1 to her room and called the nurse on duty. CNA M documented R1 was holding a clump of R2's hair in her hand when R1 returned to her room. CNA O's 09/29/25 Witness Statement recorded, on an undocumented date and illegible time, she was assisting another [unnamed] staff when R2 was heard yelling Help from the common area. CNA O went to investigate and observed R1 choking R2 and pulling R2's hair. CNA O alerted the other staff in the area. CNA O was unable to release R1's hand, so CNA O held R1 back while the other [unnamed] staff released R1's hand; R1 attempted to bite CNA O's chest. When R1's grip was released from R2, staff escorted R1 to her room, and she fought staff and attempted to bite them. CNA O stayed with R1 while the other staff member called the nurse to come as soon as possible. LN G's 08/29/25 Witness Statement documented on 08/29/25, staff called her on the unit and informed her that they heard R2 scream and then found R1 choking R2 with one hand and pulling her hair with the other. Staff attempted to pull R1's hands off R2's neck and hair and were successful after a short while. Staff escorted R1 back to her room. LN G assessed R2 and found red marks around her neck and many loose strands of hair on her clothes and on the recliner. LN G assessed R1 and found a small wound to her right upper lid. R1 had R2's hair woven through her fingers and on the front of her shirt. R1 denied doing anything to anyone and stated she would never hurt anyone. LN G documented staff moved R1 to a different room and performed one-on-one observation for others' safety. LN G documented the incident was reported to the on-call nurse and the residents' families. Review of the facility's investigation revealed CNA staff reported they came out of a resident's room to find R1 with her hands around the neck of R2. Both aides assisted in separating the residents, and R1 continued to pull on R2's hair. Once R1 and R2 were separated, staff contacted the charge nurse, who went to the [special care] unit to assess both residents. R2 had no visible injuries and was able to swallow and talk without discomfort; R1 had a small scratch to the upper right lip. The investigation noted that because the actual incident was unwitnessed, the administration reviewed camera footage, which revealed R2 sat in a recliner, running her fingers through her hair, and looking out the patio door. R1 exited her shared room with R2 and walked directly towards R2. R1 approached R2 and immediately grabbed the left side of R2's head and hair with both hands. Next, R1 took her left hand and encircled R2's throat. R2 attempted to pull away from R1 while staff exited a resident's room. Staff were behind R1 and attempted to remove R1 and got between both residents. While attempting to separate the residents, R1 clutched onto R2's hair. Once the two were separated, R1 attempted to bite the staff member's wrist. With staff on each side of R1, they assisted R1 back to her room, and staff stayed inside the room while the other staff went to the phone to call for help. Staff brought R1 out into the main commons area to keep R1 and R2 separated for a few minutes. After a while, R1 returned to the unit without further incident. The investigation revealed the facility performed one-on-one supervision until 09/03/25. Review of R1's EHR Census Records documented on 09/01/25 at 12:32 AM, R1's room assignment changed to a private room on the special care unit. During an observation on 10/14/25 at 12:25 PM, R1 rested in bed with her eyes closed. During an observation on 10/14/25 at 12:25 PM, R2 rested in bed with her eyes closed. During an interview on 10/14/25 at 12:30 PM, CNA N revealed in the event of a resident being aggressive or violent to another resident, staff would de-escalate the situation as best as possible while separating the residents and redirecting the aggressor. The nurse would be notified as soon as possible. Once the nurse arrived, the staff would follow the directions of the nurse. CNA N revealed she was aware of the incident that occurred between R1 and R2 on 08/29/25, but she was not working that shift. When CNA N returned to work after the incident on 08/29/25, R1 was having one-on-one observation, but CNA N could not recall for how long. CNA N denied knowledge of anywhere in the EHR or on paper where one-on-one observation was documented. CNA N denied any knowledge of any aggressive behaviors from R1 towards staff, or any additional aggressive behaviors towards other residents since 08/29/25. CNA N confirmed they received in-service training since the incident on 08/29/25. During an interview on 10/14/25 at 12:35 PM, CNA P revealed in the event of one resident being irritable or aggressive/violent to another resident, staff would separate the residents, de-escalate the situation, and redirect as needed, then alert the nurse. The nurse would then come, and the staff would follow the instructions of the nurse. CNA P stated she was aware of the incident that occurred between R1 and R2 on 08/29/25, although she was not working when it happened. When she came back to work, R1 was under one-on-one observation, and staff were instructed to stay within an arm's reach of R1. CNA P was unable to recall how long one-on-one observation was in place for. CNA P stated if a resident was in the common area, one staff member stayed with them, and if two staff were required to perform any care with any resident during that time, another staff member would come onto the special care unit so that no residents were left unsupervised in the common area. CNA P confirmed she has received in-service training since 08/29/25. During an interview on 10/14/25 at 01:00 PM, CNA Q revealed if one resident was being aggressive or irritable towards another resident, staff would attempt to de-escalate the situation by redirecting one or both residents with a variety of options such as food, drink, a distracting activity, or going for a walk. CNA Q revealed she was not aware of any resident-to-resident abuse incidents but reported she recently received an in-service training related to abuse. During an interview on 10/14/25 at 01:05 PM, LN H revealed if residents were being aggressive or irritable to one another, staff would separate and de-escalate the situation and notify the nurse as soon as possible. The nurse would assess the residents involved for any injury and render aid as needed. Once the situation was over, the nurse would notify the manager on duty and would collaboratively investigate. The nurse would also notify the residents' physician(s) as well as family or responsible parties and would hold a huddle with the staff members on duty to explain what new interventions would be implemented. LN H revealed she was aware of the incident that occurred on 08/29/25 between R1 and R2, but she was not working that shift. LN H stated the next time she worked after the incident, R1 was on one-on-one observation where staff remained within an arm's length of R1, perhaps two arm lengths. LN H said she was unsure of any documentation to show one-on-one observation was performed, other than the schedule that documented an extra person staffed in the special care unit. LN H revealed she was aware of reports of R1 being verbally aggressive towards staff and other residents and physically aggressive towards staff. During an interview on 10/14/25 at 01:30 PM, Administrative Nurse D revealed if a resident was aggressive with another resident, the expectation was that staff would separate and redirect the residents while also ensuring the safety of all the residents involved, then report the incident to the nurse as soon as possible. The nurse would collect written statements from everyone with any knowledge of the incident and then collaborate with the manager on duty to develop an intervention until the interdisciplinary team (IDT) could meet and develop an intervention to be placed on the care plan. After the incident on 08/29/25 between R1 and R2, R1 was placed on one-on-one observation until 09/03/25. Administrative Nurse D revealed the special care unit had dedicated staff, and all the dedicated staff received in-service training related to abuse prevention on 10/03/25. The facility's Preventing Resident-to-Resident Abuse policy, dated 05/2022, documented the facility would attempt to prevent resident-to-resident abuse through assessments and individualized interventions. The IDT would evaluate history obtained from the resident and their family, along with medical history related to the resident's history of physical and/or verbal abuse. The team would then develop a plan to create an environment supportive of the resident to decrease the opportunity for resident-to-resident abuse that focused on non-medication interventions. On 10/14/25 at 04:45 PM, Administrative Staff A, Administrative Nurse D, and Administrative Nurse E received a copy of the Immediate Jeopardy [IJ] Template and were informed of the IJ.The facility identified, implemented, and completed corrective measures on 10/03/25, which included the following: 1. On 08/29/25, R1 was placed on one-on-one supervision at all times.2. On 09/01/25, R1 was moved from a semi-private room on the special care unit with R2 to a private room on the special care unit.3. On 09/23/25, the facility held a quality assurance, process improvement (QAPI) meeting to discuss the incident.4. On 09/25/25, R1 was assessed by Physician Extender V, and the medication regimen was adjusted effective 09/26/25.5. On 10/03/25, staff education was provided to the dedicated staff for the special care unit related to aggressive behavior, resident-to-resident abuse, and dementia care.The onsite surveyor verified the above completed corrective action. Due to all corrections completed prior to the onsite survey, the deficient practice was cited as past noncompliance at a scope and severity of J (isolated, immediate jeopardy).

The facility identified a census of 36 residents. The sample included 13 residents with two residents sampled for nutrition. Based on observation, interview, and record review, the facility failed to provide care and services, which included supplemental nutrition and failed to follow the Registered Dietician (RD) recommendations to maintain acceptable parameters of nutritional status for Resident (R) 19. As a result of the facility failures, R19 had a significant unintended weight loss of 11.48 percent (%) over three months. This deficient practice also placed the resident at risk for malnutrition and further weight loss. Findings included: - R19's Electronic Medical Record (EMR) revealed the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation. R19's 03/17/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS recorded R19's weight was 136 pounds, and she had no known weight loss. She consumed a regular textured diet with no eating or swallowing concerns. The 03/17/25 Cognitive Loss / Dementia (CAA) documented R19 admitted to the facility after having a month-long stay at a behavioral health facility to address medications to limit her aggression and attain a better quality of life. She had increased forgetfulness and was unable to live with family helping at home. The CAA further noted R19 often asked where she was and why she was in the facility. R19's 06/09/25 Quarterly MDS documented a BIMS score of three. The MDS documented R19 had a significant weight loss and weighed 120 pounds. R19 was independent with eating. R19's Care Plan dated 03/25/25 documented R19 made her own food choices. She was on a liberalized geriatric diet with texture as tolerated. R19 had a goal that her nutritional needs would be met, and dietary risks would be avoided during her stay. Interventions for R19 on 03/25/25 documented she liked to have a cup of coffee first thing in the morning and asked for it throughout the day. She may prefer to have small portions. R19 came to the dining room to have meals, and staff may have to cue her when it was time for meals. She did not drink milk but tolerated it in food. She ordered her meals and fed herself after it was set up. The plan directed staff to show R19 how to get snacks, offer her snacks and fluids throughout the day, and encourage her to drink fluids. The plan noted staff weighed her and recorded her weight on Monday mornings. R19's EMR recorded an admission weight on 03/06/25 of 135 pounds. R19's Physician's Orders noted a liberalized geriatric diet with texture as tolerated, ordered on 03/06/25. R19's EMR lacked further orders related to nutrition. R19's Progress Note by the RD dated 03/07/25 at 12:14 PM documented R19 liked most foods. The RD noted that given the limited history she received, it was likely that R19 had lost weight over the past four to five years and was at risk for continued weight loss. R19's EMR recorded a weight on 03/31/25 of 127.5 lbs. but lacked evidence the physician was notified. R19's Progress Note from the RD dated 05/29/25 at 12:53 PM documented R19 had limited meal intake documented. With only 14 meals charted during the previous two weeks; intakes ranged from zero to less than 75%. The RD documented most meals documented indicated the resident consumed less than 26 % of meals. Staff reported R19 preferred to sleep late in the morning and even then, often preferred to remain in her room. She was more likely to come out of her room in the afternoon and she may sit in the lobby and have a snack or go to the dining room. Staff was able to encourage R19 to go to the dining room at around noon on that day. Staff assisted R19 with ordering a meal. Staff offered alternate meals, but R19 declined all suggestions, stating I'm just not hungry. I want to go back to my room and lie down. The RD documented she also attempted to encourage R19 to stay and offered the resident a milkshake and other dessert items, R19 continued to say she was not hungry. The RD noted R19's charting showed R19 had a bowel movement two days previous two weeks. The note recorded R19 had a significant weight loss and based on what staff reported and what R19 said, the resident may benefit from a trial of an appetite stimulant. At that time, it appeared R19 was at risk for continued weight loss. R19's RD Progress Note dated 06/09/25 at 06:14 PM documented R19 had a significant weight loss. The note documented nine meals were charted in the previous week and there was no chewing or swallowing difficulty noted. Staff noted R19 was sleeping a lot, and when staff woke her for meals, she only wanted a sandwich out of the snack refrigerator. Staff further noted when they gave R19 a sandwich, she would take one bite and go back to sleep. At night staff attempted to give R19 a snack (sandwich, chips, ice cream). The note documented R19 occasionally went to the dining room, but only wanted a dessert. R19's clinical record lacked evidence staff implemented non-pharmacological interventions to address weight loss. The record lacked documentation related to nutritional supplement intake. R19's EMR recorded a weight on 06/02/25 of 119.5 pounds but lacked evidence staff notified R19's physician of the weight loss. During an observation on 06/09/25 at 03:35 PM, R19 laid in bed with the door closed and her eyes closed. The blinds were closed, and it was dark in her room. During an observation on 06/11/25 at 12:15 PM, Certified Nurse Aide (CNA) O assisted R19 to the scale from her room. R19 stopped every couple of steps and turned to CNA O and asked where they were and where they were going then said, Okay. and proceeded to take a few more steps. CNA O directed R19 to stand on the scale. R19's weight was 120 pounds. On 06/11/25 at 08:17 AM, CNA O stated R19 was independent with her care. She usually got up for lunch and supper and went right back to bed. CNA O reportedR19 liked to sleep. On 06/11/25 at 08:31 AM, Licensed Nurse (LN) G stated R19 had weight loss. She said she tried to give R19 a protein shake but confirmed it was not documented. LN G said staff were able to document supplements with the meal's documentation. LN G said R19 sometimes went to the dining area to eat, then back to her room to the toilet, and she went back to bed while she was in her room. LN G said when a resident had weight loss, staff would usually get an order from the doctor for Ensure (liquid nutritional supplement), a protein shake, or a higher-calorie meal with fortified foods. LN G said the RD also made recommendations for medications like an appetite stimulant. LN G said she did not know why R19's RD recommendations were not followed or faxed to the provider. She said she would verify the provider was not notified and notify him now if needed. On 06/11/25 at 08:43 AM, Administrative Nurse D stated the RD came in once a week to address weight loss. Administrative Nurse D said the facility staff looked at the list and decided if the loss was planned, if the resident had edema, or what the problem was. Administrative Nurse D said the RD gave her a list of residents with weight loss weekly and let the nurses know the recommendations. The nurse would then talk to the doctor about the recommendations and get orders. Administrative Nurse D stated the facility staff was trying to figure out the problem with R19 and addressing medication concerns to lessen R19's sleeping all the time. During an interview on 06/11/25 at 10:04 AM, Consultant GG stated she charted the residents' weight loss, and talked to the staff for input. Consultant GG said she gave recommendations to the nurse for them to relay to the doctor and get orders. She said she was unsure if it always got done. Consultant GG said she met quarterly with the providers to discuss weight loss. She said she suggested nutrition shakes for R19 and was aware staff could document the supplements and shakes provided, and confirmed they should document them. Consultant GG was unsure if shakes were documented for R19. On 06/12/25 at 03:41 PM, Consultant HH stated she was not notified of R19's weight loss until 06/11/25 and she ordered health shakes to start with. Consultant HH stated she expected to be notified of weight loss by fax immediately or on the next rounding day. The facility policy Attica Long Term Care Weight Policy dated 05/2024 included: Care Plan Teams will meet on Tuesday to discuss weight. Documentation on weight changes will be documented. The nursing staff will notify the physician of needed medical intervention. Nursing staff documents decisions for supplements. The nursing director will notify the physician of significant weight loss.

The facility reported a census of 36 residents. The sample included 13 residents. Based on interviews, record reviews, and observation, the facility staff failed to implement adequate and acceptable infection control practices related to hand hygiene and laundry services. This deficient practice placed the residents at risk for infections. Findings included: - During an observation on 06/09/25 at 03:36 PM, Dietary CC delivered clean laundry to the resident rooms of the 300 hallway and did not sanitize hands before or after delivering clean laundry to each room. During an observation on 06/10/25 at 12:50 PM, Certified Nurse Aide (CNA) M wiped a resident's buttock with gloved hands. Upon completion, CNA M did not change gloves or complete hand hygiene before placing a clean brief on the resident. During an interview on 06/10/25 at 09:08 AM, Administrative Nurse D reported that hand sanitizing should be done whenever staff went in or out of rooms regardless of the situation. During an interview on 06/10/25 at 01:05 PM, CNA M stated that she had dirty gloves on when she placed the clean brief on the resident. During an interview on 06/10/25 at 01:43 PM, Dietary BB reported that whoever is delivering clean laundry should wash or hand sanitize their hands before entering or exiting a resident's room. During an interview on 06/10/25 at 02:49 PM, Housekeeping/Maintenance U reported that whoever delivered laundry should wash or hand-sanitize their hands prior to entering and delivering laundry to any resident and upon exiting the resident's room. During an interview on 06/11/25 at 08:48 AM, Administrative Nurse E reported that hands were to be sanitized before handling any clothes and before and after entering a room and/order delivering laundry. Facility policy Attica Long Term Care Hand Hygiene, dated 02/2025, indicated that all staff members would comply with the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. The policy further indicated that staff would perform hand hygiene practices before and after contact with inanimate objects including medical equipment in the immediate vicinity of the resident. The policy further indicated that staff would Change gloves when moving from a contaminated body site to a clean body site and they would decontaminate hands after removing gloves with appropriate hand hygiene. - During an observation on 6/10/25 at 01:50 PM observation revealed a working sink at the end of the clean linen folding counter with hand soap, hand sanitizer, and a funnel sitting around the sink. The clean linen folding counter had two containers that held numerous items including Kleenexes. Further observation revealed a dirty clothes cart with dirty linen sitting against the counter. During an observation on 06/10/25 at 01:55 PM a dusty bar of soap hung from the ceiling in the laundry washing and folding room and there was an air conditioning unit above the clean linen folding counter with dirty vents blowing towards the clean linen counter. During an interview on 06/11/25 at 08:39 AM, Administrative Staff A stated that each department staff was expected to clean their own area. During an interview on 06/11/25 at 08:41 AM, Administrative Nurse E reported that there should be nothing but clean linen on the clean linen processing area. The facility did not provide a policy related to laundry and/or processing clean linens.

R12's Electronic Medical Record (EMR) included the following diagnoses: post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R12's Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderately impaired cognition. He received antianxiety (a class of medications that calm and relax people) and an antidepressant (a class of medications used to treat mood disorders) during the assessment period. R12's Psychoactive Medications Care Area Assessment (CAA), dated 12/09/24, documented the resident received medications to treat the signs and symptoms of anxiety and depression. R12's Quarterly MDS, dated 03/10/25, documented the staff assessment for cognition revealed moderately impaired cognition. He received antianxiety and antidepressant medications during the assessment period. R12's Care Plan, revised 03/19/25, instructed staff the resident took medications for signs and symptoms of anxiety and depression. R12's EMR revealed the following physician's orders: Lorazepam (an antianxiety medication), 0.5 milligrams (mg), by mouth (PO), every day (QD), for a diagnosis of PTSD, ordered 06/03/25. Lorazepam, 0.5 mg, PO, at bedtime (HS), for a diagnosis of PTSD, ordered 06/03/25. Mirtazapine (an antidepressant medication), 15 mg, PO, atHS, for a diagnosis of abnormal weight loss, ordered 06/03/25. Sertraline (an antidepressant medication), 25 mg, PO, QD, for a diagnosis of depression, ordered 07/23/23. R12's EMR lacked evidence of informed consent for the use of lorazepam, mirtazapine, and sertraline. On 06/10/25 at 03:24 PM, Administrative Nurse D stated the facility had not completed informed consent for R12's psychotropic medications. The facility policy for Psychotropic Medication, approved 03/2025, included: The facility shall inform the resident, family and/or representative of the benefits, risks, and alternatives for each medication prior to adding, discontinuing, or changing any psychotropic medication. - R13's Electronic Medical Record (EMR) included the following diagnoses: panic disorder (frequent and unexpected panic attacks), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). R13's Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), and antidepressant (a class of medications used to treat mood disorders) medications during the assessment period. R13's Psychotropic Medication Care Area Assessment (CAA), dated 04/21/25, documented the resident had a history of mental health issues that affected her daily life. R13's Quarterly MDS, dated 01/27/25, documented the resident had a BIMS score of 12, indicating moderately impaired cognition. She received antipsychotic, antianxiety, and antidepressant medications during the assessment period. R13's Care Plan, revised 02/04/25, instructed staff the resident had a history of depression and anxiety. R13's EMR revealed the following physician's orders: Buspirone (an antidepressant medication), 10 milligrams (mg), by mouth (PO), twice daily (BID), for a diagnosis of panic disorder, ordered 01/28/24. Desvenlafaxine (an antidepressant medication), 100 mg, PO, every day (QD), for a diagnosis of major depressive disorder, ordered 05/17/23. Lorazepam (an antianxiety medication), 0.5 mg, PO, three times daily (TID), for a diagnosis of anxiety, ordered 09/16/24. Olanzapine (an antipsychotic), five mg, PO, at bedtime (HS), for a diagnosis of bipolar disorder, ordered 11/12/24. R13's EMR lacked evidence of informed consent for the use of buspirone, desvenlafaxine, lorazepam, and olanzapine. On 06/10/25 at 03:24 PM, Administrative Nurse D stated the facility had not completed informed consent for R13's psychotropic medications. The facility policy for Psychotropic Medication, approved 03/2025, included: The facility shall inform the resident, family and/or representative of the benefits, risks, and alternatives for each medication prior to adding, discontinuing, or changing any psychotropic medication. The facility reported a census of 36 residents. The sample included 13 residents. Based on interview, observation, and record review, the facility failed to inform Resident (R)32, R35, R12, R13 and/or their representative regarding the risks related to psychotropic (alters mood or thoughts) medications. These deficient practices had the potential to lead to negative and unwarranted physical side effects. Findings included: - R32's Electronic Health Record (EHR) included diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and adjustment disorder with mixed anxiety and depressed mood (a mental health condition that arises when someone struggles to cope with a significant life change or stressful event). R32's admission Minimum Data Set (MDS), dated 03/10/25, documented a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident's cognitive function was intact. The MDS section for mood indicated that R32 would sometimes isolate. The Psychotropic Medication Use Care Area Assessment (CAA), dated 03/10/25, documented the resident was taking an antidepressant (a class of medications used to treat mood disorders). R32 exhibited signs of depression, and disturbances of balance, gait, and positioning ability. R32's Quarterly MDS, dated 06/02/25, documented a BIMS score of 13, which indicated the resident's cognitive function was intact. The MDS section for mood indicated that R32 triggered for mild depression. R32's Care Plan dated 06/04/25 documented R32 had the potential to feel frustrated with life's challenges. An intervention dated 09/12/24 recorded staff monitored the use of bupropion (a medication used to treat depression) for depression with anxiety and restlessness and monitored R32's use of citalopram (a medication used to treat depression) for depression with tearfulness and frequent complaints. R32's EHR documented an order dated 03/03/25 for bupropion hydrochloride (HCL). R32's EHR documented an order dated 05/13/25 for citalopram. R32's EHR lacked evidence R32, or her representative, received education and/or informed consent with regards to the bupropion HCL or citalopram use including reason for use, expected therapeutic benefits and potential risks and side effects. During an interview on 06/10/25 at 03:24 PM, Administrative Nurse D reported that the facility did not have consent for psychotropic medications. Administrative Nurse D stated that she thought the consent was only needed if the facility started new psychotropic medications, not for residents that were currently taking psychotropic medications when they admitted to the facility. The facility policy for Psychotropic Medication, approved 03/2025, included: The facility will administer psychotropic medications, including anti-anxiety/hypnotic, antipsychotic, and antidepressant medication, appropriately to ensure the appropriate use, evaluation, and monitoring. The policy also indicated that the facility should inform the resident, family, and/or representative of the benefits, risks, and alternatives for each medication prior to adding, discontinuing, or changing any psychotropic medication. - R35's Electronic Health Record (EHR) included diagnoses of insomnia (inability to sleep), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and unspecified dementia (a progressive mental disorder characterized by failing memory and confusion). R35's Significant Change in Status Minimum Data Set, dated 04/28/25, documented a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident's cognitive function was intact. R35's Psychosocial Well-Being Care Area Assessment (CAA), dated 04/28/25, documented depression as a disease and condition that may impede her ability to interact with others. It also listed the health problems of falls, pain, and fatigue as health status factors that may inhibit her social involvement. The Psychotropic Medication Use Care Area Assessment (CAA), dated 04/28/25, documented the resident was taking an antidepressant (a class of medications used to treat mood disorders). R35 exhibited signs of falls, depression, disturbances of balance, gait, positioning ability, and sedation manifested by short-term memory loss, decline in cognitive abilities, slurred speech, drowsiness, and little/no activity involvement. R35's Care Plan dated 02/06/25 documented she was on a medication regime with potential reactions and adverse side effects. The intervention dated 02/06/25 listed duloxetine (a medication used to treat depression and anxiety) and listed the black box warning for monitoring. R35's EHR documented an order dated 01/27/25 for duloxetine. R35's EHR lacked evidence R35, or her representative, received education and/or informed consent with regards to the bupropion HCL or citalopram use including reason for use, expected therapeutic benefits, and potential risks and side effects. During an interview on 06/10/25 at 03:24 PM, Administrative Nurse D reported that the facility did not have consent for psychotropic medications. Administrative Nurse D stated that she thought the consent was only needed if the facility started new psychotropic medications, not for residents who were currently taking psychotropic medications when they admitted to the facility. The facility policy for Psychotropic Medication, approved 03/2025, included: The facility will administer psychotropic medications, including anti-anxiety/hypnotic, antipsychotic, and antidepressant medication, appropriately to ensure the appropriate use, evaluation, and monitoring. The policy also indicated that the facility should inform the resident, family, and/or representative of the benefits, risks, and alternatives for each medication prior to adding, discontinuing, or changing any psychotropic medication.

The facility identified a census of 36 residents. The sample included 13 residents with two residents sampled for nutrition. Based on observation, interview, and record review, the facility failed to notify the physician of significant weight changes in Resident (R) 19 who had a significant weight. This deficient practice also had the potential to negatively affect the resident's physical well-being and nutritional status. Findings: - R19's Electronic Medical Record (EMR) revealed the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation. R19's 03/17/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. The MDS recorded R19 ' s weight was 136 pounds, and she had no known weight loss. She consumed a regular textured diet with no eating or swallowing concerns. The 03/17/25 Cognitive Loss / Dementia (CAA) documented R19 admitted to the facility after having a month-long stay at a behavioral health facility to address medications to limit her aggression and attain a better quality of life. She had increased forgetfulness and was unable to live with family helping at home. The CAA further noted R19 often asked where she was and why she was in the facility. R19's 06/09/25 Quarterly MDS documented a BIMS score of three. The MDS documented R19 had a significant weight loss and weighed 120 pounds. R19 was independent with eating. R19's Care Plan dated 03/25/25 documented R19 made her own food choices. She was on a liberalized geriatric diet with texture as tolerated. R19 had a goal that her nutritional needs would be met, and dietary risks would be avoided during her stay. Interventions for R19 on 03/25/25 documented she liked to have a cup of coffee first thing in the morning and asked for it throughout the day. She may prefer to have small portions. R19 came to the dining room to have meals, and staff may have to cue her when it was time for meals. She did not drink milk but tolerated it in food. She ordered her meals and fed herself after it was set up. The plan directed staff to show R19 how to get snacks, offer her snacks and fluids throughout the day, and encourage her to drink fluids. The plan noted staff weighed her and recorded her weight on Monday mornings. R19's EMR recorded an admission weight on 03/06/25 of 135 pounds. R19's Physician's Orders noted a liberalized geriatric diet with texture as tolerated, ordered on 03/06/25. R19 ' s Progress Note by the registered dietician (RD) dated 03/07/25 at 12:14 PM documented R19 liked most foods. The RD noted that given the limited history she received, it was likely that R19 had lost weight over the past four to five years and was at risk for continued weight loss. R19's EMR recorded a weight on 03/31/25 of 127.5 pounds but lacked evidence the physician was notified. R19 ' s Progress Note from the RD dated 05/29/25 at 12:53 PM documented R19 had limited meal intake documented. With only 14 meals charted during the previous two weeks; intakes ranged from zero to less than 75%. The RD documented most meals documented indicated the resident consumed less than 26 % of meals. Staff reported R19 preferred to sleep late in the morning and even then, often preferred to remain in her room. She was more likely to come out of her room in the afternoon and she may sit in the lobby and have a snack or go to the dining room. Staff was able to encourage R19 to go to the dining room at around noon on that day. Staff assisted R19 with ordering a meal. Staff offered alternate meals, but R19 declined all suggestions, stating I'm just not hungry. I want to go back to my room and lie down. The RD documented she also attempted to encourage R19 to stay and offered the resident a milkshake and other dessert items, R19 continued to say she was not hungry. The RD noted R19's charting showed R19 had a bowel movement two days previous two weeks. The note recorded R19 had a significant weight loss and based on what staff reported and what R19 said, the resident may benefit from a trial of an appetite stimulant. At that time, it appeared R19 was at risk for continued weight loss. R19's EMR recorded a weight on 06/02/25 of 119.5 pounds but lacked evidence staff notified R19's physician notification of the loss. During an observation on 06/09/25 at 03:35 PM, R19 lay in bed with the door closed and her eyes closed. The blinds were closed, and it was dark in her room. During an observation on 06/11/25 at 12:15 PM, Certified Nurse Aide (CNA) O assisted R19 to the scale from her room. R19 stopped every couple of steps and turned to CNA O and asked where they were and where they were going then said, Okay. and proceeded to take a few more steps. CNA O directed R19 to stand on the scale. R19's weight was 120 pounds. During an interview on 06/11/25 at 08:17 AM, CNA O stated that R19 was independent with her care. She usually got up for lunch and supper and goes right back to bed; R19 liked to sleep. During an interview on 06/11/25 at 08:31 AM, Licensed Nurse (LN) G said when a resident had weight loss, staff would usually get an order from the doctor for Ensure (liquid nutritional supplement) or a protein shake, or a higher calorie meal. The registered dietician also makes recommendations for medications like an appetite stimulant. LN G said she did not know why R19's RD recommendations were not followed or faxed to the provider. She said she would verify the provider was not notified and notify him now if needed. During an interview on 06/11/25 at 08:43 AM, Administrative Nurse D stated the RD gave her a list of residents with weight loss weekly and let the nurses know the recommendations. The nurse would then talk to the doctor about the recommendations and get orders. During an interview on 06/12/25 at 03:41 PM, Consultant HH stated she was not notified of R19's weight loss until 06/11/25 and she ordered health shakes to start with. Consultant HH stated she expected to be notified of weight loss by fax immediately or on the next rounding day. The facility policy Attica Long Term Care Weight Policy, dated 05/2024, included: The nursing director will notify the physician of significant weight loss.

The facility reported a census of 36 residents with 13 residents sampled, including two residents reviewed for activities of daily living (ADL). Based on observation, interview, and record review, the facility failed to provide nail care for Resident (R)23 which placed the resident at risk for skin issues. Findings included: - R23's Electronic Medical Record (EMR) included the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion) and weakness (lacking strength). R23's Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderately impaired cognition. She was dependent on staff for personal hygiene. Review of the Functional Abilities Care Area Assessment (CAA), dated 08/19/24, documented the resident required staff assistance with all activities of daily living (ADL). R23's Quarterly MDS, dated 03/17/25, documented the staff assessment for cognition revealed moderately impaired cognition. She was dependent on staff for personal hygiene. She had no limitation in range of motion (ROM) and was dependent on staff for mobility in her wheelchair and personal hygiene. R23's Care Plan, revised 03/25/25, instructed staff the resident was dependent on staff for all ADLs. On 06/09/25 at 08:13 AM, R23 sat in her wheelchair. Her fingernails were long, jagged, and dirty. On 06/09/25 at 02:51 PM, R23's fingernails remained long, jagged, and dirty. On 06/10/25 at 09:49 AM, R23 participated in a group activity. Her fingernails remained long, jagged, and dirty. On 06/10/25 at 08:13 AM, Certified Nurse Aide (CNA) M stated staff cut and cleaned R23's fingernails on her shower days. On 06/10/25 at 10:10 AM, CNA MM stated R23 was dependent on staff for all ADLs, including fingernail care. On 06/10/25 at 08:37 AM, Administrative Nurse D stated she expected staff to ensure R23's fingernails were smooth and clean. The facility did not provide a policy for nail care.

The facility reported a census of 36 residents with 13 residents sampled, including two residents reviewed for activities. Based on observation, interview, and record review the facility failed to implement an ongoing, resident-centered activity program for Resident (R)12, to meet his interests and preferences. This placed the resident at risk of boredom and isolation. Findings included: - R12's Electronic Medical Record (EMR) revealed a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R12's Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderately impaired cognition. The MDS recorded it was somewhat important for him to have books, newspapers, and magazines to read, and he enjoyed listening to music he liked and to participate in religious practices. It was very important for him to keep up with the news and to do his favorite activities. He had no impairment in functional range of motion (ROM) and was able to ambulate independently. The Activity Care Area Assessment (CAA), dated 12/09/24, did not trigger. R12's Quarterly MDS, dated 03/10/25, documented the staff assessment for cognition revealed moderately impaired cognition. He had no impairment in functional ROM and was able to ambulate independently. R12's Care Plan for activities of daily living (ADL), revised 03/19/25, instructed staff to direct him to events, as needed. R12's EMR revealed an Activity Assessment, dated 03/05/25, which documented the resident enjoyed listening to music and finding places to sit and lie down. R12's EMR from 05/11/25 through 06/09/25 revealed the resident had an activity on 05/11/25 which lasted 15 minutes, and an activity on 05/14/25 which lasted 120 minutes. The EMR lacked evidence of further activity events. On 06/09/25 at 09:37 AM, R12 sat in a recliner in the front commons area. The TV was turned on to a sitcom however the resident was not watching TV. Observation revealed no other activities were taking place at that time. On 06/09/25 at 02:37 PM, R12 sat in a recliner in the front commons area. The TV was turned to a game show however the resident was not watching TV. Observation revealed no other activities were taking place at that time. On 06/10/25 at 08:23 AM, Certified Nurse Aide (CNA) P stated R12 enjoyed talking. CNA P was unsure of any other activities the resident enjoyed. On 06/10/25 at 08:23 AM, CNA Q stated R12 enjoyed one-to-one activity; staff documented all activities in his EMR. On 06/10/25 at 11:23 AM, Licensed Nurse (LN) G stated the activities in the dementia unit were different than the activities in the rest of the facility. LN G was unsure of activities R12 enjoyed. On 06/10/25 at 08:30 AM, Administrative Nurse D confirmed there were no other activities documented for R12. The facility policy for Life Enhancement and Activity Programming, approved 09/2022, included: Activities will be provided for all residents based on the comprehensive assessment and care plan and the preferences of each resident. An activity will be an endeavor intended to enhance the resident's sense of well-being and to promote physical, cognitive, and emotional health. Documentation will include participation in an activity rather than attendance.

- R23's Electronic Medical Record (EMR) included the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion) and weakness (lacking strength). R23's Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed moderately impaired cognition. She was dependent on staff for wheelchair mobility. Review of the Functional Abilities Care Area Assessment (CAA), dated 08/19/24, documented the resident required staff assistance with all activities of daily living (ADL). R23's Quarterly MDS, dated 03/17/25, documented the staff assessment for cognition revealed moderately impaired cognition. She was dependent on staff for wheelchair mobility. R23's Care Plan, revised 03/25/25, instructed staff the resident was dependent on staff for wheelchair mobility. On 06/09/25 at 08:13 AM, Certified Nurse Aide (CNA) M propelled the resident in her wheelchair. The resident's right shoed foot was off the foot pedal and skimmed the floor during transport. The resident's left foot remained on the foot pedal. On 06/10/25 at 12:11 PM, CNA MM propelled the resident from the front commons area to her room in her wheelchair. The resident's shoed feet were between the foot pedals of the wheelchair, skimming the floor. On 06/09/25 at 08:13 AM, CNA M stated that R23's feet did not always stay on the foot pedals of her wheelchair. On 06/10/25 at 12:11 PM, CNA MM confirmed that R23's feet did not always stay on the foot pedals of her wheelchair. On 06/10/25 at 08:37 AM, Administrative Nurse D stated she expected staff to ensure R23's feet stayed on the foot pedals of their wheelchairs during transport, to avoid injury. The facility did not provide a policy for wheelchair positioning including foot pedals. The facility reported a census of 36 residents with 13 residents selected for review. Based on observation, interview, and record review, the facility failed to identify and implement meaningful resident-centered fall prevention interventions to prevent falls for Resident (R) 36. The facility further failed to ensure R14 and R23 had wheelchair pedals when staff propelled them in the wheelchair. This placed the residents at risk for falls and avoidable accidents. Findings included: - R36's Electronic Medical Records (EMR) documented R36 had the following diagnoses that included a history of fractures and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R36's 05/12/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, indicating R36 was unable to answer the questions. The MDS documented per staff interview, R36 had memory impairment; she did not know the staff, where her room was, or that she was in a nursing home. R36 was on hospice services. R36 had fallen in the month prior to admission, falls within the last six months, and a fall resulting in a fracture. The 05/12/25 Falls Care Area Assessment (CAA) documented R36 had a fall with a hip fracture that required a surgical repair prior to admission. R36 was at risk for falls due to a history of falling, unsteadiness on her feet, and confusion. The CAA also documented R36 had behaviors of anxiety and trying to throw herself on the floor. The 05/12/25 Cognitive Loss/Dementia CAA documented R36 was confused and repeatedly asked the same question. Staff need to monitor her as she does not notify them of her needs. R36's Care Plan documented on 05/01/25 that R36 was at risk for falls with a history of falls. The plan noted R36 stood unassisted even with education and would stand again within minutes of the last redirection. It directed staff to monitor R36 for needs and help to meet them to prevent falls from occurring. Staff were directed to orient her to her call light for assistance and keep her walkways clean and clutter-free to prevent falls from occurring. R36's Care Plan documented the intervention dated 05/02/25 after R36's fall in the facility which directed staff to remind R36 to push the call light and wait for staff to come and help her. The plan lacked further interventions to address and prevent falls. R36's Progress Note dated 05/02/25 at 03:20 AM documented at 01:45 AM R36 was seated on the floor. R36 stated that she was sitting on the edge of her bed and decided to get up to get the Bible from her bedside table. She lost her balance and fell. R36 hit her head and received a skin tear below her chin on the right side. R36 reported some pain to the right chin and had a bump to the back of her head. Staff assisted R36 off the floor and walked to her recliner. R36's Event Report dated 05/02/25 documented the call light was on and within reach. The report noted the plan of care was to educate R36 to use the call light for help and wait for help to get something in her room. During an observation on 06/09/25 at 09:03 AM R36 sat in her recliner, in her room. R36 wore regular socks, but no shoes. During an observation on 06/09/25 at 03:38 PM, R36 was scooting forward in the recliner reaching for items on the shelf in front of her. During an interview on 06/11/25 at 08:17 AM, Certified Nurse Aide (CNA) O stated that R36 tried to get up without assistance. CNA O said R36 sometimes used her call light and said staff placed a soft pad call light under R36's hip so it would go off when she tried to get up. During an interview on 06/11/25 at 08:31 AM, Licensed Nurse (LN) G stated R36 gets up without waiting for staff. LN G said when a resident falls, the nurse looks for the root cause of the fall and places an appropriate intervention. LN G said the intervention to reeducate R36 was not an appropriate intervention for her. During an interview on 06/11/25 at 08:43 AM, Administrative Nurse D stated when a resident falls, staff discuss the falls in the monthly quality assurance meeting to ensure the interventions are appropriate. Administrative Nurse D said the nurse along with the restorative nurse and the CNAs came up with appropriate interventions based on the root cause of the fall. Administrative Nurse D said R36 was sometimes able to use her call light but often got up without assistance. The facility's policy Attica Long Term Care Fall Prevention Protocol dated 05-2021, documented on the day of admission, each resident will be assessed for fall risk by a licensed nurse. When a resident falls, a root cause analysis will be developed to identify trends and interventions. The fall is documented in the care plan with interventions to prevent further falls based on the determined causal factors at the time of the initial fall follow-up. The resident will be assessed and documented on every shift for the next 72 hours including the response to the current interventions. - R14's Electronic Medical Record (EMR) documented diagnoses that included dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). R14's 09/23/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R14 required substantial to maximal assistance with wheelchair mobility. R14's Cognitive Loss / Dementia (CAA) documented she had advancing dementia and varying cognitive levels. The CAA documented R14 had dementia, and her cognition continued to decline over time. R14's 03/17/25 Quarterly MDS documented a BIMS of two which indicated severely impaired cognition. R14 required substantial to maximal assistance with wheelchair mobility and was dependent on staff for transfers. R14's Care Plan included an intervention dated 12/29/22 which documented R14 used a wheelchair, and she propelled herself a bit, but staff propelled her to specific destinations. The plan directed staff to cue R14 to pick up her feet when staff pushed her in the wheelchair and to watch to be sure she did so. During an observation on 06/09/25 at 12:53 PM, R14 was at the back door, yelling for help to get outside. Certified Nurse Aide (CNA) JJ began pushing R14's wheelchair without foot pedals. When asked, CNA JJ stated staff were not supposed to push residents in their wheelchairs without foot pedals, but R14 usually self-propelled so she did not have foot pedals on her wheelchair. CNA JJ said staff were to take the foot pedals off the wheelchair when the resident self-propelled and put them back on when staff assisted the resident. CNA JJ looked for R14's foot pedals but did not find them. R14 then stated she would propel herself, and CNA JJ walked beside her wheelchair. During an interview on 06/11/25 at 08:17 AM, CNA O stated that stated staff should always use foot pedals when assisting residents in a wheelchair. During an interview on 06/11/25 at 08:31 AM, Licensed Nurse (LN) G stated residents were to have the foot pedals off when they were self-propelling, but staff should always place foot pedals on staff was propelling the chair. During an interview on 06/11/25 at 08:43 AM, Administrative Nurse D stated all residents should have foot pedals on their wheelchairs when being assisted in a wheelchair for safety. The facility did not provide a policy for wheelchair positioning including foot pedals.

The facility reported a census of 36 residents. The sample included 13 residents. Based on interviews, record reviews, and observation, the facility failed to ensure a safe environment in all areas of the facility including the laundry area. This deficient practice created the risk of an unsanitary environment. Findings included: - During an observation on 06/10/25 at 01:50 PM the clean clothes folding counter in the laundry washing and folding area had a patched hole three feet long and six inches wide that was patched with a piece of plain plywood. The observation also revealed several chipped areas in the folding counter. During an observation on 06/10/25 at 02:07 PM the clean linen storage closet had several ceiling tiles with broken areas that created large gaps and there was a large hole in one that had a plastic cover that did not entirely cover the hole, leaving gaps. During an interview on 06/11/25 at 08:23 AM, Housekeeping/Maintenance V reported that there was a repair request system that allowed staff to submit repair requests. Maintenance V also stated that he maintained a working list of maintenance items with resident related items as top priority. During an interview on 06/11/25 at 08:39 AM, Administrative Staff A reported that a work order should have been submitted to make or replace the broken counter for the clean linen processing area. Administrative Staff A also stated that ceiling tiles should be clean and fully intact. During an interview on 06/11/25 at 08:41 AM, Administrative Nurse E reported the linen processing area should have been clean and fully intact. The facility policy Attica Long Term Care Planned Preventative Maintenance Policy, dated 10/2019, indicated a preventative maintenance program has been implemented to promote the maintenance of fixtures and equipment in a state of good repair and condition. Routine inspections promote safety and aid in keeping fixtures and equipment in good working order and operating in accordance with the manufacturer's guidelines. The facility policy Attica Long Term Care Maintenance Checklist by Priority, dated 06/2019, indicated weekly checks of the kitchen and laundry to inspect for repairs as needed.

The facility census totaled 37 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to develop a comprehensive assessment Resident (R) 20 when they failed to include oxygen services (O2) and hospice services on the Quarterly Minimum Data Set (MDS) dated [DATE]. Findings included: - R20's Electronic Medical Record (EMR) revealed a diagnosis of metastatic lung cancer (cancer that has spread to other organs). The Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident received extensive assistance with transfers and toileting. The MDS lacked documentation the resident required O2 therapy and received hospice services. The Quarterly MDS dated [DATE] revealed a BIMS of 14, indicating intact cognition. The resident required extensive assistance of one to two staff for cares. The resident received pain medication on schedule. The MDS lacked evidence the resident required oxygen and hospice services. Review of the Care Plan dated 07/13/23 revealed R20's care plan lacked interventions regarding the use and care of oxygen. Review of the Physician Orders dated 08/23 lacked orders for the O2 the resident had at their bedside. On 08/21/23 11:11 AM R20 had O2 on at the bedside with the concentrator running but not on the resident. The cannula was laying down the inside of her recliner, not covered with a bag. The tubing and bubbler lacked a date indicating the last time it was changed. Observation on 08/22/23 at 01:00 PM revealed the resident asleep in her recliner. The O2 tubing laid on the floor with the cannula draped across the bedside table and hanging off the other side and touching the floor. The concentrator remained on, though not on the resident. The tubing and/or bubbler lacked a date indicating the last time it was changed. On 08/21/23 at 11:11 AM the resident reported she wore her O2 when she wanted to wear it. On 08/22/23 at 01:06 PM Certified Nursing Assistant (CNA) M reported she would estimate the resident wore her O2 three times a week. CNA M reported the O2 was ordered as needed (PRN) so the resident put it on and took it off. CNA M did not know when the tubing was changed. 08/22/23 at 04:19 PM Certified Medication Aide (CMA) R reported the resident required a two-person assistance with her cares. She used the O2 when she felt she needed it and was able to put it on and take it off. The resident was alert and able to voice her needs. On 08/22/23 04:22 PM CNA N reported the resident wore her O2 at night and whenever she felt she needed it. On 08/22/23 01:20 PM Licensed Nurse (LN) H reported the resident was on hospice and they had their own standing orders, but when an order was initiated it should have been added to the regular orders. Tubing changes were part of the facility standing orders. She did not know when the resident's tubing was changed and did not know why the tubing and cannula were not dated. She would get with medical records to see why there was no order for the O2. On 08/22/23 at 04:00 PM Administrative Nurse E reported she did not know why the hospice or the O2 were not on the MDS and stated it must have been a clerical error on her part. The O2 was not on the care plan because even though it was in the room and resident had access to use it anytime, she did not think the resident utilized it, so she did not include it on the assessment or care plan. On 08/23/23 1:25 PM Administrative Nurse D reported she expected the assessments to be accurate for each resident. A Policy was requested for MDS assessments on 08/23/23 at 01:00 PM. No policy was provided. The facility failed to develop a comprehensive assessment for the Quarterly Minimum Data Set (MDS) by the failure to include oxygen services (O2) and hospice services after the quarterly assessment.

The facility had a census of 37 residents, with 12 residents included in the sample. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for three Residents (R)13, R20, and R27, regarding the use of a nebulizer (a device that delivers medication as a mist to the lungs) and oxygen (a treatment that provides extra to breath in). Findings included: - R13's Physician Orders dated 06/15/23, revealed the following diagnoses included congestive heart failure (a condition with low heart output and the body becomes congested with fluid) and chronic obstructive pulmonary disease (COPD is a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. The resident had shortness of breath. The resident received oxygen therapy. The Care Plan dated 04/13/23 failed to include interventions related to the use of a nebulizer and/or interventions regarding the care of the nebulizer. Review of the Physician Orders dated 01/03/23, revealed an order for ipratropium-albuterol 0.5 mg (milligram) in three milliliters of normal saline inhalation, for COPD, four times a day, and every two hours PRN (as needed) Interview with R13 on 08/22/23 at 09:40 AM, indicated he received a breathing treatment four times a day. R13 indicated he left the nebulizer attached to the machine and staff changed the tubing approximately every 2 weeks. Interview with Administrative Nurse D revealed she expected the nursing staff to rinse the resident's nebulizer after each use and expected the nebulizer to be to be located on the resident care plans under medication use. The facility policy Attica Long Term Care Person- Centered, Comprehensive Care Plan revised on 09/22 the facility to provide and individualized, interdisciplinary plan of care for all elders that is appropriate to the elder's needs, strength, and goals based on initial, recurrent, and continual needs of the elder. The facility failed to develop a comprehensive care plan for R13 regarding the use and cleaning of the nebulizer. 31078 - R20's Electronic Medical Record (EMR) revealed the following diagnosis that included metastatic lung cancer (cancer that has spread to other organs). The Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident received extensive assistance with transfers and toileting. The resident received no oxygen (O2) therapy and R20 received hospice services. The Quarterly MDS dated [DATE]. revealed a BIMS of 14, indicating normal cognition. The resident required extensive assistance of one to two staff for cares. The resident received pain medication on schedule The assessment lacked the resident was receiving oxygen (O2) and hospice services. Review of the Care Plan dated 07/13/23 revealed the care plan lacked the use and care of the oxygen. No order on the physician orders for the O2 the resident had at bedside. On 08/21/23 at 11:11 AM, the resident had O2 at the bedside with the concentrator turned on, but the cannula was not on the resident. The cannula laid down the inside of her recliner, not covered with a bag. The nasal tubing and the humidifier bottle lacked a date when it was last changed. Observation on 08/22/23 at 1:00 PM revealed the resident asleep in her recliner. The O2 tubing was on the floor with the cannula laying across the bedside table and hanging off the side. The concentrator was turned on, however the resident did not have the nasal cannula on. The nasal tubing and humidifier bottle lacked a date when it was last changed. On 08/21/23 at 11:11 AM, the resident reported she wore her O2 when she wanted to wear it. On 08/22/23 at 01:06 PM, Certified Nursing Assistant (CNA) M reported she would estimate the resident wore her O2 was approximately three times a week. It is as needed (PRN), so she puts it on and take it off herself. On 08/22/23 at 04:19 PM, Certified Medication Aide (CMA) R reported the resident was a two-person assistance with her care. She used the O2 when she felt she needed it, and was able to put it on and take it off herself. The resident was alert and able to voice her needs. On 08/22/23 at 04:22 PM, CNA N reported the resident mostly wore her O2 at night and whenever she felt she needed it. On 08/22/23 at 04:00 PM, Administrative Nurse E reported the O2 was not on the care plan because even though it was in the room and resident had access to use it anytime, she did not think the resident utilized it, so she did not include it on the assessment or care plan. On 08/23/23 at 1:25 PM, Administrative Nurse D reported she expected the care plans to be accurate for each resident. The facility's policy for Person-Centered, Comprehensive Care Plans, dated 9/22, revealed It is the policy of this facility to provide an individualized, interdisciplinary care plan for all elders that is appropriate to the elders needs, strengths, limitations and goals based on initial, recurrent, and continual needs of the elder, Care, treatment and services are planned and provided to each elder. The facility failed to develop a comprehensive care plan to include the use of O2 and nebulizer treatments for R20. - R27's Electronic Medical Record (EMR) revealed the following diagnoses included chronic bronchitis (inflammation of the mucous membrane in the bronchial tubes), and COPD (Chronic Obstructive Pulmonary Disease is a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R27's Admission Minimum Data Set (MDS), dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating normal cognition. The resident was independent with her activities of daily living (ADL's). The resident had shortness of breath with a terminal diagnosis and received oxygen (O2) and hospice (end of life services). Medications included antianxiety (class of medications that calm and relax people with excessive anxiety), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression), and opioid (class of medications used to treat pain by interacting with opioid receptors in a person's cells) medications. Review of the Care Plan dated 08/01/23, revealed she tended to have low oxygen saturation when off her oxygen for even a few minutes. The care plan lacked guidance to the use and care of the nebulizer treatments. Review of the physician order dated 07/19/23 revealed O2 at 3 Liters (L)/minute per nasal cannula. Nebulizer treatments of Albuterol, four times a day, with Budesonide added to the Albuterol twice a day, per nebulizer. Observation on 08/22/23 at 4:00 PM, revealed the resident lying in bed with O2 on at 3 L/min. The resident was talkative and had her nebulizer mask propped up at the edge of her over bed table. There was a small amount of liquid that remained in the nebulizer chamber. Observation on 08/23/23 at 09:55 AM, revealed the resident sat up on the side of the bed. The O2 concentrator was on at 4 L/min per nasal cannula. The dated tape present on the tubing indicated the tubing had been changed on 08/22/23. The nebulizer mask had been propped up on the over bed table with fluid remaining in the nebulizer chamber. On 08/23/23 at 10:00 AM, the resident reported she would notify staff when she would completed her nebulizer treatment, however, staff does not always clean the nebulizer after the inhalation treatment completed. On 08/22/23 at 04:29 PM, Certified Nursing assistant (CNA) N reported the resident was short on air, and required to wear her O2 continuously. At times, she was so winded to use the toilet, that the resident required a bedside commode to use. Staff should clean the nebulizer mask after each treatment. On 08/23/23 at 10:00 AM, Licensed Nurse (LN) G reported the resident was a newer admit to the facility. She received hospice due to severe COPD. She required O2 on at 3 L/NC on a continuous basis. She preferred to do her own nebulizer treatments, as she needed more time to complete the treatment. She will take a rest break halfway through, then finish. LN G reported she was not aware if the resident's nebulizer was on the care plan, but stated it probably should be. 08/23/23 1:25 PM Interview with Administrative Nurse D would expect the nurses to rinse the nebulizer after each use place the nebulizer on a towel by the sink. Additionally, she expected staff to care plan the nebulizer. The facility's Person-Centered, Comprehensive Care plans dated 9/22, revealed it was the policy of this facility to provide an individualized, interdisciplinary care plan for all elders that is appropriate to the elders needs, strengths, limitations and goals based on initial, recurrent, and continual needs of the elder, Care, treatment and services are planned and provided to each elder. The facility failed to develop a comprehensive care plan to include the use of nebulizer treatments for R27.

The facility reported a census of 37 with 12 residents included in the sample. Based on observations, interview and record review the facility failed to provide activities of daily living (ADL) for resident (R)5 regarding nail care. Findings included: - The Physician Order dated 06/08/23, revealed the following diagnosis included cerebrovascular accident (sudden death of brain cells due to lack of oxygen cause by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severely impaired cognition. R5 required extensive assistance of one to two persons with activities of daily living (ADL) that included bed mobility, transfers, dressing and personal hygiene. The ADL Functional /Rehabilitation Potential Care Area Assessment (CAA) dated 08/07/23, revealed R5 had right sided weakness following a stroke. The CAA further revealed R5 fed himself and received Hospice services. The Care Plan, dated 08/02/23, revealed R5 required various levels of assistance for his daily care needs. The care plan instructed staff to clean and trim his nails after bathing. On 08/21/23 at 11:00 AM, revealed R5's fingernails on both hands had unexplained dark substance under his fingernails. On 08/22/23 at 10:05 AM, the resident's both hands remained to have dark colored substance underneath his fingernails. On 08/23/23 at 12:20 PM, R5 continued to have a dark substance under his fingernails on both hands. Interview with Certified Nurse Aide( CNA) M indicated that hospice staff provided R5 with ADL cares two times a week. CNA M further revealed R5 would allow staff to shave him and trim his nails. On 08/23/23 at 01:25 PM, Licensed Nurse (LN) G reported R5 could be aggressive when staff provide help with his ADL's. On 08/23/23 at 01:25 PM, Administrative Nurse D reported she expected staff to clean R5's nails between shower days. The facility policy for Restorative Activities of Daily Living Services, dated 07/14, revealed all elders of this facility would achieve and maintain the highest practicable level functionality with all activities of daily living. Elders would receive assistance with activities of daily living (ADL) every shift as appropriate. The facility failed to provide R5 with ADL's regarding nail care.

The facility had a census of 37 residents, with 12 residents included in the sample, that included three residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to provide necessary respiratory care consistent with professional standards of practice regarding the use of a nebulizer (a device that delivers medication as a mist to the lungs) and oxygen (a treatment that provides extra to breath in) for Resident (R)13, R20, and R27. Findings included: - R13's Physician Orders, dated 06/15/23 revealed the following diagnoses that included congestive heart failure (a condition with low heart output and the body becomes congested with fluid) and chronic obstructive pulmonary disease (COPD, a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set, dated dated dated [DATE], revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. The MDS further revealed R13 had shortness of breath and received oxygen therapy. The Care Plan dated 04/13/23 failed to include interventions related to the use of a nebulizer and/or interventions regarding the care of the nebulizer for R13. Review of the Physician Orders dated 01/03/23 revealed an order for ipratropium-albuterol 0.5 mg (milligram) in three milliliters of normal saline inhalation, for COPD, four times a day, and every two hours, as needed (PRN). Interview with R13 on 08/22/23 at 09:40 AM, indicated he received a breathing treatment four times a day. R13 indicated he left the nebulizer attached to the machine and staff changed the tubing approximately every two weeks. Observation on 08/21/23 at 01:34 PM, revealed R13's nebulizer chamber/ equipment was on the bedside table. The nebulizer chamber contained fluid/ moisture in the chamber. On 08/23/23 at 07:38 AM, observation revealed R13's nebulizer was in the bag, still attached to the machine, and the nebulizer had visible liquid in the nebulizer container. On 08/22/23 at 12:50 PM, Certified Nurse Aide (CNA) M explained the nurses were responsible for changing the tubing and care of the nebulizers. Interview on 08/23/23 at 09:10 AM with Licensed Nurse (LN) G regarding respiratory care for R13, revealed the resident received four nebulizer treatments daily, and the nursing staff changed the tubing every two weeks on the third and eighteenth of each month. LN G stated the nebulizer should be rinsed after each use and a date should be placed on the tubing when staff change the tubing. Interview with Administrative Nurse D on 08/23/23 at 01:25 PM, revealed she expected the nursing staff to rinse the resident's nebulizer after each use. The facility's policy for Attica Long Term Care Person- Centered, Comprehensive Care Plan revised September 2022, revealed the facility would provide an individualized, interdisciplinary plan of care for all elders that was appropriate to the elder's needs, strength, and goals based on initial, recurrent, and continual needs of the elder. The facility's policy for Nebulizer Therapy, revealed the facility would provide elders inhalation therapy as ordered by their physician utilizing quality standards of practice. The facility failed to provide respiratory care consistent with professional standards of care for R13 regarding the use and cleaning of the nebulizer. 31078 - R20's Electronic Medical Record (EMR) revealed the resident had a diagnosis of metastatic lung cancer (cancer that has spread to other organs). The Significant Change in Status Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident received extensive assistance with transfers and toileting. The MDS lacked documentation that the resident required oxygen (O2) therapy and received hospice services. The Quarterly MDS dated [DATE], revealed a BIMS of 14, indicating intact cognition. The resident required extensive assistance of one to two staff for cares. The resident received pain medication on schedule. The assessment lacked evidence the resident required O2 and hospice services. Review of the Care Plan dated 07/13/23, revealed R20's care plan lacked interventions regarding the use and care of oxygen. Review of the Physician Orders dated 08/2023, lacked orders for the O2 the resident had at their bedside. On 08/21/23 at 11:11 AM, revealed R20 had O2 on at the bedside with the concentrator running, but not on the resident. The resident's nasal cannula laid on the inside of her recliner, not covered with a bag. On 08/22/23 at 01:00 PM, revealed the resident asleep in her recliner. The O2 tubing laid on the floor with the cannula draped across the bedside table, that hung off the other side and touched the floor. The concentrator machine remained on, though the resident did not have the O2 applied. The resident's tubing and/or humidifier lacked a date indicating the last time staff changed them. On 08/21/23 at 11:11 AM, the resident reported she wore her O2 when she wanted to wear it. On 08/22/23 at 01:06 PM Certified Nursing Assistant (CNA) M reported she would estimate the resident wore her O2 three times a week. It is as needed (PRN) so she puts it on and take it off. On 08/22/23 at 04:19 PM, Certified Medication Aide (CMA) R reported the resident required two-person assistance with her cares. She used the O2 when she felt she needed it and was able to put it on and take it off. On 08/22/23 04:22 PM CNA N reported the resident wore her O2 at night and whenever she felt she needed it. On 08/22/23 at 04:00 PM Administrative Nurse E reported she did not know why the resident's O2 was not on the care plan because even though it was in the room and the resident had access to use it anytime, she did not think the resident utilized it, so she did not include it on the assessment or care plan. The facility policy Attica Long Term Care Person-Centered Comprehensive Care Plan dated 09/22 revealed the facility would provide an individualized, interdisciplinary plan of care for all elders that was appropriate to the elder's needs, strength, and goals based on initial, recurrent, and continual needs of the elder. The facility failed to provide respiratory care consistent with professional standards of care for R20 regarding the use and cleaning of the O2 cannula, O2 tubing, and nebulizer. - R27's Electronic Medical Record (EMR) revealed the diagnoses that included chronic bronchitis (inflammation of the mucous membrane in the bronchial tubes), chronic obstructive pulmonary disease (COPD-progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R27's Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was independent with her activities of daily living. The resident had shortness of breath with a terminal diagnosis and received oxygen (O2) and hospice (end of life services). Medications included antianxiety, antidepressant, and opioid pain medications. Review of the Care Plan dated 08/01/23 documented the resident had low oxygen saturation levels when off oxygen for even a few minutes. The resident's care plan lacked interventions related to the use and care of the nebulizer treatments. Review of the Physician Orders dated 07/19/23, revealed an order for O2 at three liters per minute, per nasal cannula. The orders further directed staff to give the resident nebulizer treatments of albuterol (inhaled medication to aide in breathing) four times a day with budesonide (inhaled medication to aide in breathing) added to the albuterol, twice a day, per nebulizer. Observation on 08/22/23 at 04:00 PM revealed the resident laid in bed with O2 on at three liters per minute. The resident's nebulizer mask was propped up at the edge of her overbed table with a small amount of liquid remaining in the bowl/chamber. Observation on 08/23/23 at 09:55 AM revealed the resident sat up on the side of the bed. O2 on at four liters per minute, per nasal cannula. The resident's nebulizer mask was propped up on the overbed table with fluid remaining in the bowl/chamber. On 08/23/23 at 10:00 AM the resident reported when she was done with her nebulizer treatments, she would let staff know so they could clean it. The resident reported her nebulizer did not always get cleaned. On 08/22/23 04:29 PM Certified Nursing assistant (CNA) N reported the resident was short on air and had to have her O2 on at all times. CNA N stated the resident's nebulizer mask should be cleaned after every treatment. On 08/23/23 at 10:00 AM Licensed Nurse (LN) G reported the resident was a newer admit to the facility. She received Hospice services due to severe COPD. She had O2 on three liters per nasal cannula, on a continuous basis. She preferred to do her own nebulizer treatments but needed more time to complete the task. She would take a rest break halfway through the treatment, then finish. She did not know if the nebulizer was on the resident's care plan, but stated it probably should be. On 08/23/23 at 01:25 PM an Interview with Administrative Nurse D revealed she would expect the nurses to rinse the resident's nebulizer after each use and place the nebulizer on a towel by the sink. Administrative Nurse D further expected the resident's nebulizer medication to be located on the resident's care plan under their medications. The facility policy Attica Long Term Care Person-Centered Comprehensive Care Plan dated 09/22 revealed the facility would provide an individualized interdisciplinary plan of care for all elders that was appropriate to the elder's needs, strength, and goals based on initial, recurrent, and continual needs of the elder. The facility failed to provide respiratory care consistent with professional standards of care for R27 regarding the use and cleaning of the nebulizer.

The facility reported a census of 37 residents with 12 residents included in the sample and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the consultant pharmacist identified the range or parameters for blood pressure for Resident (R) 8. Findings included: - The Physician Orders dated 07/01/23 revealed the resident had a diagnosis of hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severely impaired cognition. Review of the Medication Administration Record (MAR) from 12/01/22 to 08/20/23 revealed the resident had orders for Lisinopril-Hydrochlorothiazide (medication used to lower blood pressure) and Metoprolol (medication uses to lower blood pressure). Review of the resident's blood pressures on the Vitals Sheet from 12/01/22 to 08/20/23 lacked evidence the facility notified the physician when the resident's blood pressures measured outside of professional standards for normal range of blood pressure on: 02/26/23 at 2:52 PM with a 153/45 blood pressure. 03/12/23 at 5:54 PM with a 163/85 blood pressure. 03/22/23 at 05:52 AM with a 152/104 blood pressure. 03/24/23 at 03:44 AM with a 162/60 blood pressure. 08/06/23 at 07:19 PM with a 178/94 blood pressure. 08/06/23 at 07:41 PM with a 166/110 blood pressure. 08/09/23 at 08:11 AM with a 156/98 blood pressure. 08/09/23 at 7:56 PM with a 148/96 blood pressure. 08/12/23 at 06:25 AM with a 152/85 blood pressure. 08/17/23 at 07:38 AM with a 166/110 blood pressure. 08/18/23 at 09:21 AM with a 159/89 blood pressure. 08/20/23 at 09:03 AM with 155/98 blood pressure. Review of the Progress Notes from 12/01/ to 08/20/23 lacked notification to the physician when resident blood pressure measured outside of normal ranges. Interview with Licensed Nurse (LN) G on 08/23/23 at 09:00 AM revealed the licensed nurse would send a fax to the resident's physician regarding each resident's acceptable range for blood pressures as the facility did not have set parameters. Interview with Administrative Nurse D on 08/23/23 at 01:30 PM revealed she expected the licensed nurse to notify the resident's physician when blood pressures were out of parameters or out of normal range. Interview on 08/24/23 at 12:45 PM with Pharmacy Consultant GG revealed that during the monthly review Pharmacy Consultant GG would try to locate any abnormal blood pressures or pulse and monitor for notification to the physicians that is placed in the review for the facility. Pharmacy reviews from 08/01/22 to 07/31/23 lacked recommendations for blood pressures out of parameters or out of range. The facility failed to provide a policy regarding Pharmacy Reviews as requested on 08/23/23. The facility failed to ensure the consultant pharmacist identified lack of parameters or ranges regarding blood pressures for R8.

The facility reported a census of 37 residents with 12 residents included in the sample and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the efficacy of blood pressure medication for Resident (R) 8, when facility staff did not notify the physician of blood pressure readings out of the professional standards for normal blood pressure range. Findings included: - The Physician Orders dated 07/01/23 revealed the resident had a diagnosis of hypertension (elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severely impaired cognition. Review of the Medication Administration Record (MAR) from 12/01/22 to 08/20/23 revealed the resident had orders for Lisinopril-Hydrochlorothiazide (medication used to lower blood pressure) and Metoprolol (medication uses to lower blood pressure). Review of the Vitals Sheet from 12/01/22 to 08/20/23 lacked evidence the facility notified the physician when R8's blood pressures measured outside of professional standards for normal range of blood pressure on the following dates: 02/26/23 at 02:52 PM measured 153/45 millimeters of mercury (mmHg). 03/12/23 at 05:54 PM measured 163/85 mmHg. 03/22/23 at 05:52 AM measured 152/104 mmHg. 03/24/23 at 03:44 AM measured 162/60 mmHg. 08/06/23 at 07:19 PM measured 178/94 mmHg. 08/06/23 at 07:41 PM measured 166/110 mmHg. 08/09/23 at 08:11 AM measured 156/98 mmHg. 08/09/23 at 07:56 PM measured 148/96 mmHg. 08/12/23 at 06:25 AM measured 152/85 mmHg. 08/17/23 at 07:38 AM measured 166/110 mmHg. 08/18/23 at 09:21 AM measured 159/89 mmHg. 08/20/23 at 09:03 AM measured 155/98 mmHg. Review of the Progress Notes from 12/01/ to 08/20/23 lacked notification to the physician when resident blood pressure measured outside of normal ranges. Interview with Licensed Nurse (LN) G on 08/23/23 at 09:00 AM revealed the licensed nurse would send a fax to the resident's physician regarding each resident's acceptable range for blood pressure as the facility did not have set parameters. Interview with Administrative Nurse D on 08/23/23 at 01:30 PM revealed she expected the licensed nurse to notify the resident's physician when blood pressures were out of parameters or out of normal range. The facility failed to provide a policy regarding Physician Notification as requested on 08/23/23. The facility failed to ensure staff monitored for the efficacy of blood pressure medication received by R8, when staff did not notify the physician regarding blood pressure readings outside of normal professional standards.

The facility census totaled 37 residents with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to provide a sanitary environment by the failure to keep R20's oxygen cannula in a clean bag and off the floor and clean the nebulizer equipment between uses for R20, R27, and R13. Findings included: - R20's Electronic Medical Record (EMR) revealed the resident had a diagnosis of metastatic lung cancer (cancer that has spread to other organs). The Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident received extensive assistance with transfers and toileting. The MDS lacked documentation the resident required oxygen (O2) therapy and received hospice services. The Quarterly MDS dated [DATE] revealed a BIMS of 14, indicating intact cognition. The resident required extensive assistance of one to two staff for cares. The resident received pain medication on schedule The assessment lacked evidence the resident was required O2 and hospice services. Review of the Care Plan dated 07/13/23 revealed R20's care plan lacked interventions regarding the use and care of oxygen. Review of the Physician Orders 08/23 lacked orders for the O2 the resident had at their bedside. On 08/21/23 at 11:11 AM, R20 had O2 on at the bedside with the concentrator turned on, but the cannula was not on the resident. The cannula laid down the inside of her recliner, not covered with a bag. The tubing and humidifier bottle lacked a date indicating the last time staff changed the tubing and humidifier bottle. On 08/22/23 at 01:00 PM, observation revealed the resident asleep in her recliner. The O2 tubing laid on the floor with the cannula draped across the bedside table and hung off the other side and touched the floor. The concentrator remained on, though not on the resident. The tubing and/or humidifier bottle lacked a date indicating the last staff changed them. On 08/21/23 at 11:11 AM, the resident reported she wore her O2 when she wanted to wear it. On 08/22/23 at 01:06 PM, Certified Nursing Assistant (CNA) M reported she would estimate the resident wore her O2 three times a week. It is as needed (PRN) so she puts it on and take it off herself. On 08/22/23 at 04:19 PM, Certified Medication Aide (CMA) R reported the resident required a two-person assistance with her cares. She used the O2 when she felt she needed it, and was able to put it on and take it off herself. On 08/22/23 04:22 PM CNA N reported the resident wore her O2 at night and whenever she felt she needed it. The facility policy Nebulizer Therapy dated 11/21 revealed after each treatment, staff were to rinse the nebulizer cup with warm water, shake off excess water, place on towel, cover lightly with paper towel and let air dry. The facility failed to provide respiratory care consistent with professional standards of care and infection control practices for R20 regarding the use and cleaning of the O2 cannula, O2 tubing, and nebulizer. - R27's Electronic Medical Record (EMR) revealed the diagnoses included chronic bronchitis (inflammation of the mucous membrane in the bronchial tubes), and chronic obstructive pulmonary disease (COPD is a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R27's Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating normal cognition. The resident was independent with her activities of daily living (ADL's). The resident had shortness of breath with a terminal diagnosis and received oxygen (O2) and hospice (end of life services). Medications included antianxiety, antidepressant, and opioid pain medications. Review of the Care Plan dated 08/01/23 revealed she tended to have low oxygen saturation when off oxygen for even a few minutes. The resident's care plan lacked interventions related to the use and care of the nebulizer treatments. Review of the Physician Orders dated 07/19/23 revealed and order for O2 at three liters per minute, per nasal cannula. The orders further directed staff to give the resident nebulizer treatments of albuterol, four times a day, with budesonide added to the albuterol, twice a day, per nebulizer. Observation on 08/22/23 at 04:00 PM revealed the resident lying in bed with O2 on at three liters per minute. The resident's nebulizer mask was propped up at the edge of her over bed table with a small amount of liquid remaining in the bowl/ chamber. Observation on 08/23/23 at 09:55 AM revealed the resident sat up on the side of the bed. O2 on at four liters per minute, per nasal cannula. The resident's nebulizer mask was propped up on the over bed table with fluid remaining in the bowl/chamber. On 08/23/23 at 10:00 AM, the resident reported when she was done with her nebulizer treatments, she would let staff know so they could clean it. The resident reported her nebulizer did not always get cleaned. On 08/22/23 04:29 PM, Certified Nursing assistant (CNA) N reported the resident was short on air and had to always have her O2 on. CNA N stated the resident's nebulizer mask should be cleaned after every treatment. On 08/23/23 at 10:00 AM, Licensed Nurse (LN) G reported the resident was a newer admit to the facility. She received Hospice due to severe COPD. She had O2 on three liters per nasal cannula, on continuous basis. She preferred to do her own nebulizer treatments needed more time to complete. She would take a rest break halfway through then finish On 08/23/23 at 01:25 PM, an Interview with Administrative Nurse D revealed she would expect the nurses to rinse the resident's nebulizer after each use place the nebulizer on a towel by the sink. The facility policy for Nebulizer Therapy dated 11/21 revealed after each treatment, staff were to rinse the nebulizer cup with warm water, shake off excess water, place on towel, cover lightly with paper towel and let air dry. The facility failed to provide a sanitary environment by the failure to clean the resident's nebulizer consistent with professional standards of care for R27 regarding the use and cleaning of the nebulizer. - R13's Physician Orders dated 06/15/23 revealed the following diagnoses: congestive heart failure (a condition with low heart output and the body becomes congested with fluid) and chronic obstructive pulmonary disease (COPD, progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Annual Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. The MDS further revealed R13 had shortness of breath and received oxygen therapy. The Care Plan dated 04/13/23 failed to include interventions related to the use of a nebulizer and/or interventions regarding the care of the nebulizer for R13. Review of the Physician Orders dated 01/03/23 revealed an order for ipratropium-albuterol 0.5 mg (milligram) in three milliliters of normal saline inhalation for COPD, four times a day, and every two hours, as needed (PRN). Interview with R13 on 08/22/23 at 09:40 AM indicated he received a breathing treatment four times a day. R13 indicated he left the nebulizer attached to the machine and staff changed the tubing approximately every two weeks. Observation on 08/21/23 at 01:34 PM, the resident's nebulizer was attached to the nebulizer machine at the bedside table. Fluid remained inside the nebulizer chamber. On 08/23/23 at 07:38 AM, observation revealed R13's nebulizer was in the bag, still attached to the machine, and the nebulizer had visible liquid in the nebulizer container. On 08/22/23 at 12:50 PM, Certified Nurse Aide (CNA) M explained the nurses were responsible for changing the tubing and care of the nebulizers. Interview on 08/23/23 at 09:10 AM with Licensed Nurse (LN) G reported the resident received four nebulizer treatments daily, and the nursing staff changed the tubing every two weeks on the third and eighteenth of each month. LN G stated the nebulizer should be rinsed after each use and a date should be placed on the tubing when staff change the tubing. Interview with Administrative Nurse D on 08/23/23 at 01:25 PM, revealed she expected the nursing staff to rinse the resident's nebulizer after each use. The facility policy for Nebulizer Therapy dated 11/2,1 revealed after each treatment, staff were to rinse the nebulizer cup with warm water, shake off excess water, place on towel, cover lightly with paper towel and let air dry. The facility failed to provide a sanitary environment by the failure to clean the resident's nebulizer consistent with professional standards of care and infection control practices for this resident regarding the use and cleaning of the resident's nebulizer.

The facility census totaled 40 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the pharmacist identified and reported the use of as needed (PRN) Lorazepam ([CONDITION(S)] antianxiety medication) longer than 14 days without a renewed physician order or rationale by the physician for the continued administration of the [CONDITION(S)] medication on a PRN basis for Resident (R)38. Findings included: - The Electronic Health Record (EHR) under the Diagnosis and Problems tab documented diagnoses for R38 which included dementia (a progressive mental disorder characterized by failing memory, confusion), depressive disorder (an abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), pain, restlessness and agitation (a feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severely impaired cognition. The Quarterly MDS dated [DATE] documented a BIMS score of 00, which indicated severely impaired cognition. R38 received an antipsychotic and an antianxiety medication daily during the seven day look back period. The 08/12/21 [CONDITION(S)] Drug Use CAA documented R38 received lorazepam for anxiety. The Care Plan dated 08/04/21 documented R38 had some changes in his life situations. Staff were to make sure to give him his morning medications by 08:30 AM since he became agitated when his medications were late. A review of the Physicians Orders included the following: Order dated 08/17/21 for Lorazepam 1 mL (milliliter) topical cream every eight hours PRN for agitation. (This order did not include a stop date or a reason to continue the medication past 14 days.) The Electronic Medication Administration (EMAR) from August through November of 2021 documented R38 received lorazepam 1 mL topical on 09/21/21 and 1 mL given on 11/10/21. (These two PRN doses were administered beyond a 14-day time period of the 08/17/21 order.) A review of the pharmacy consultant Medication Regimen Review (MRR) reports from August to October 2021 lacked evidence the pharmacist identified the continued use of PRN Lorazepam longer than 14 days. Observation on 11/10/21 at 08:13 AM revealed R38 restlessly paced around the memory care unit (MCU). R38 did not appear anxious or agitated. On 11/10/21 at 09:36 AM Certified Medication Aid (CMA) B stated she kept an eye and R38 as he paced around the unit. When he began to enter other resident's rooms and looked restless she stepped in and redirected him. On 11/16/21 at 12:23 PM Licensed Nurse (LN) D stated it depended on the circumstances if a PRN Lorazepam order should have a 14-day stop date. If the order came from the Behavioral Health Unit,that's their call. LN D said it was better to be safe than sorry and have the medication available if needed, rather than wait for an order from the physician during emergent situations. On 11/16/21 at 11:44 AM Administrative Nurse A stated she expected the pharmacist to identify and recommend stop dates for PRN psychotropics. On 11/16/21 at 01:37 PM Pharmacist E stated he expected PRN Lorazepam orders to have a 14-day limitation, before needing a renewal, and stated he normally looked for this, during his medication review. The facility did not provide a policy for consultant pharmacist and MRR as requested on 11/16/21. The facility failed to ensure the pharmacist identified and reported the use of PRN lorazepam beyond the 14-day time period, without a renewed physician order or physician rationale for a continued administration on a PRN basis for R38.

The facility census totaled 40 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure one of five residents did not received unnecessary medications when the facility administered Resident (R)38's as needed (PRN) Lorazepam ([CONDITION(S)] antianxiety medication) longer than 14 days, without a renewed physician order or rationale by the physician for the continued administration of the [CONDITION(S)] medication on a PRN basis. Findings included: - The Electronic Health Record (EHR) under the Diagnosis and Problems tab documented diagnoses for R38 which included dementia (a progressive mental disorder characterized by failing memory, confusion), depressive disorder (an abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), pain, restlessness and agitation (a feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of one, which indicated severely impaired cognition. The Quarterly MDS dated [DATE] documented a BIMS score of 00, which indicated severely impaired cognition. R38 received an antipsychotic and an antianxiety medication daily during the seven day look back period. The 08/12/21 [CONDITION(S)] Drug Use CAA documented R38 received lorazepam for anxiety. The Care Plan dated 08/04/21 documented R38 had some changes in his life situations. Staff were to make sure to give him his morning medications by 08:30 AM since he became agitated when his medications were late. A review of the Physicians Orders included the following: Order dated 08/17/21 for Lorazepam 1 mL (milliliter) topical cream every eight hours PRN for agitation. (This order did not include a stop date or a reason to continue the medication past 14 days.) The Electronic Medication Administration (EMAR) from August through November of 2021 documented R38 received lorazepam 1 mL topical on 09/21/21 and 1 mL given on 11/10/21. These two PRN doses were administered beyond a 14-day time period of the 08/17/21 order. Observation on 11/10/21 at 08:13 AM revealed R38 restlessly paced around the memory care unit (MCU). R38 did not appear anxious or agitated. On 11/10/21 at 09:36 AM Certified Medication Aid (CMA) B stated she kept an eye and R38 as he paced around the unit. When he began to enter other resident's rooms and looked restless she stepped in and redirected him. On 11/16/21 at 12:23 PM Licensed Nurse (LN) D stated it depended on the circumstances if a PRN Lorazepam order should have a 14-day stop date. If the order came from the Behavioral Health Unit .that's their call. It was better to be safe than sorry and have the medication available if needed rather than wait for an order from the physician during emergent situations. On 11/16/21 at 11:44 AM Administrative Nurse A stated she expected PRN [CONDITION(S)] medications to have stop dates after 14 days. Review of the [CONDITION(S)] Medication Use policy dated 03/31/17 revealed, Both the Physician and the nursing staff will evaluate the effectiveness of PRN orders for [CONDITION(S)] drugs to manage behavior. The facility failed to ensure R38 did not received unnecessary medications when the facility administered PRN lorazepam beyond the 14-day time period, without a renewed physician order or physician rationale for a continued administration on a PRN basis.

The facility census totaled 49 residents with 13 residents included in the sample. Based on observation, interview, and record review the facility failed to provide pain assessment's before and after administration of pain medications for Residents (R) 44, R2, R5, and R42. Findings included: - Review of the signed Physician Order Sheet (POS) dated 01/20/20 revealed R42 the following Diagnoses: [REDACTED].) Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. R42 received an opioid (pain medication) daily. Review of the Annual MDS dated [DATE] revealed a BIMS score of 00, indicating severely impaired cognition. R42 received an opioid (pain medication) daily. Review of the undated Care Plan revealed R42 had arthritis in her right shoulder, knee, and hip. Staff to ask about pain daily. Notify nurse if having any signs/symptoms of pain. Staff to offer warm moist pack for pain relief. R42 was on routine pain regimen to help control her complaints of pain. If complaints of pain not controlled by routine pain regimen, alert PCP (Primary Care Physician) for further orders. Review of the resident's Physician Orders revealed R42 had orders dated 11/05/18 for: 1) [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) 7.5-325 mg (milligrams), oral, four times daily for pain. 2) [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg, oral every four hours as needed (PRN) for pain. R42 had an order dated 03/21/17 for [MEDICATION NAME] ([MEDICATION NAME] medication) 650 mg, oral, every six hours as needed for pain. Review of the (MONTH) 2019 Electronic Medication Administration Record [REDACTED]. Review of the (MONTH) 2020 EMAR revealed: 1) PRN [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg administered on 01/18/20 at 10:28 PM, no documentation of pain assessed or follow-up for effectiveness completed. 2) PRN [MEDICATION NAME] 650 mg administered on 01/18/19 at 09:53 PM, with no documentation of pain assessed, or follow-up completed. Review of (MONTH) 2020 EMAR revealed: PRN [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg administered on 02/06/20 at 12:09 AM, with no documentation of pain assessed or follow-up for effectiveness completed. An observation on 02/06/20 at 12:31 PM revealed R42 sat at a table in the dining room by herself eating lunch. R42 was calm, quiet, and did not show an signs of pain. During an interview on 02/10/20 at 10:27 AM, Licensed Nurse (LN) F stated R42 received scheduled and PRN [MEDICATION NAME]-[MEDICATION NAME] 7.5-325 mg. LN F verified the follow-up for pain on 02/06/20 was documented as YES but no numerical scale was used. During an interview on 02/10/20 at 02:01 PM Administrative Staff A stated she expected staff to assess resident pain levels using either a numeric pain scale or faces assessment prior to giving pain medications, and again afterwards, to assess for effectiveness in the pain assessment module of the computer software. Review of the facility policy Long Term Care Pain Management dated 08/2014 revealed it was the policy of the facility to respect and support the elder's right to optimal pain assessment and management. If the elder was identified with pain, the elder would undergo reassessment of pain at least one time per shift and before and after every pain control mechanism employed by the elder's care providers. Healthcare providers from any department, that had implemented a pain control mechanism, would reassess the elder within one-half (1/2) hour to determine the amount of pain control or relief achieved and document initial levels of pain, interventions, and final level of pain. The facility failed to monitor R42 for pain to ensure her pain issues were addressed before and after PRN pain medication administration. - Review of the signed Physician Order Sheet (POS) dated 01/09/20 revealed R44 with the following Diagnosis: [REDACTED].) Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. R44 was on a scheduled pain medication regimen and did not receive as needed (PRN) pain medications. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 00, indicating severely impaired cognition. R44 was on a scheduled pain medication regimen and did not receive as needed (PRN) pain medications. Review of the undated Care Plan revealed: R44 might be at risk for some discomfort. She had noted to complaints of pain in her knees and hips when staff walked with her. Interventions included: 1) Ask about pain daily and watch for signs and symptoms of pain. 2) Staff may utilize as needed (PRN) pain medications to help with breakthrough discomfort not helped by routine pain regimen. Review of the Physician Orders revealed R44 had an order dated 04/25/19 for: [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION] drug) 200 milligrams (mg), 1 capsule, by mouth, twice a day for [MEDICAL CONDITION]. Review of the physician orders revealed R44 had an order dated 07/01/19 for: [MEDICATION NAME] 200 mg, 1-2 tablets, by mouth, every four hours as needed for pain. Review of the (MONTH) 2019 Electronic Medication Administration Record [REDACTED]. Review of the (MONTH) 2020 EMAR revealed PRN [MEDICATION NAME] administered with missing documentation as follows. 1) [MEDICATION NAME] 400 mg on 01/04/20 at 12:37 PM. No follow-up assessment for effectiveness documented. 2) [MEDICATION NAME] 800 mg on 01/07/20 at 03:04 PM. No follow-up assessment for effectiveness documented. 3) [MEDICATION NAME] 400 mg on 01/13/20 at 03:42 PM. No follow-up assessment for effectiveness documented. 4) [MEDICATION NAME] 400 mg on 01/31/20 at 02:10 PM. No initial assessment for pain rating or follow-up assessment for effectiveness documented. Review of the (MONTH) 2020 EMAR revealed PRN [MEDICATION NAME] 400 mg administered on 02/04/20 at 03:40 PM. No initial assessment for pain rating or follow-up assessment for effectiveness documented. During an interview on 02/05/20 at 04:14 PM, Certified Medication Aide (CMA) H stated R44 could verbalize pain level on a pain scale of 0-10. CMA H stated R44 received [MEDICATION NAME] twice a day, and as needed. CMA H stated the nurse assessed and documented for initial pain and follow-up for effectiveness. During an interview on 02/10/20 at 09:51 AM, Licensed Nurse (LN) B stated R44 received [MEDICATION NAME] 200 mg, twice daily, and [MEDICATION NAME] 1-2 tablets, every four hours as needed. LN B stated nurses followed-up for pain medication effectiveness. LN B verified numerous follow-up assessments for effectiveness did not include numerical pain scales for effectiveness documented. During an interview on 02/10/20 at 02:01 PM, Administrative Nurse A stated she expected staff to assess resident pain levels using either a numeric pain scale or faces assessment prior to giving pain medications, and again afterwards to assess for effectiveness, and document this in the pain assessment module of the computer software. Review of the facility policy Long Term Care Pain Management dated 08/2014 revealed it was the policy of the facility to respect and support the elder's right to optimal pain assessment and management. If the elder was identified with pain, the elder would undergo reassessment of pain at least one time per shift and before and after every pain control mechanism employed by the elder's care providers. Healthcare providers from any department, that had implemented a pain control mechanism, would reassess the elder within one-half (1/2) hour to determine the amount of pain control or relief achieved and document initial levels of pain, interventions, and final level of pain. The facility failed to monitor R44 for pain to ensure her pain issues were addressed before and after PRN pain medication administration. - Review of the signed Physician Order Sheet (POS) dated 01/15/20 revealed R2 with the following Diagnosis: [REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Review of the undated Care Plan revealed R2 with the potential for discomfort, and reported he had pain everywhere. Staff were to inquire about pain daily. Review of the physician orders revealed R2 had orders dated 02/05/20 for: 1) [MEDICATION NAME] (narcotic pain medication) 5 mg (milligrams), by mouth, twice daily, and as needed for chronic pai[DIAGNOSES REDACTED]. 2) [MEDICATION NAME] 10 mg, by mouth, Daily (AM) for chronic pai[DIAGNOSES REDACTED] Review of the physician orders revealed R2 had an order dated 10/25/19 for [MEDICATION NAME] ([MEDICATION NAME] medication) 500 mg, by mouth, every four hours as needed for chronic pai[DIAGNOSES REDACTED]. Review of the (MONTH) Electronic Medication Administration Record [REDACTED] PRN [MEDICATION NAME] 500 mg was administered but no initial pain assessment or follow-up for effectiveness was documented for the following dates: 1) 01/05/20 at 07:53 PM 2) 01/04/20 at 07:38 PM 3) 01/05/20 at 08:27 PM 4) 01/06/20 at 08:46 PM 5) 01/07/20 at 08:25 PM 6) 01/08/20 at 08:09 PM 7) 01/09/20 at 02:10 PM (Numeric Pain Scale rating of 4.) 8) 01/11/20 at 09:02 PM 9) 01/14/20 at 08:16 PM 10) 01/15/20 at 08:45 PM 11) 01/16/20 at 08:51 PM 12) 01/19/20 at 08:58 PM 13) 01/20/20 at 08:59 PM 14) 01/21/20 at 08:07 PM 15) 01/22/20 at 08:26 PM 16) 01/28/20 at 08:38 PM (Numeric Pain Scale rating of 5.) 17) 01/29/20 at 08:36 PM 18) 01/30/20 at 08:29 PM Review of the (MONTH) EMAR revealed: PRN [MEDICATION NAME] 500 mg was administered but no initial pain assessment or follow-up for effectiveness was documented for the following dates: 1) 02/02/20 at 08:16 PM 2) 02/05/20 at 05:15 PM 3) 02/05/20 at 08:05 PM 4) 02/04/20 at 08:56 PM 5) 02/08/20 at 08:40 PM PRN [MEDICATION NAME] 5 mg was administered but no initial pain assessment or follow-up for effectiveness was documented on 02/08/20 at 08:13 AM. During an interview on 02/10/20 at 10:03 AM, Licensed Nurse (LN) B stated R2 received both scheduled and PRN [MEDICATION NAME]. LN B verified multiple follow-up assessments were completed as stating effective but did not use any pain scale. During an interview on 02/10/20 at 02:01 PM, Administrative Nurse A stated she expected staff to assess resident pain levels using either a numeric pain scale or a faces assessment tool prior to giving pain medications, and again afterwards to assess for effectiveness, and to document this in the pain assessment module of the computer software. Review of the facility policy Long Term Care Pain Management dated 08/2014 revealed it was the policy of the facility to respect and support the elder's right to optimal pain assessment and management. If the elder was identified with pain, the elder would undergo reassessment of pain at least one time per shift and before and after every pain control mechanism employed by the elder's care providers. Healthcare providers from any department, that had implemented a pain control mechanism, would reassess the elder within one-half (1/2) hour to determine the amount of pain control or relief achieved and document initial levels of pain, interventions, and final level of pain. The facility failed to monitor R2 for pain to ensure her pain issues were addressed before and after PRN pain medication administration. - Review of the signed Physician Order Sheet (POS) dated 01/14/20 revealed R5 had the following Diagnoses: [REDACTED].) Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. R5 was on a scheduled, and as needed (PRN) pain medication regimen. R5 received an opioid pain medication daily during the seven-day look back period. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognition. R5 was on a scheduled pain medication regimen and received an opioid pain medication daily during the seven-day look back period. Review of the Pain Care Area Assessment (CAA) dated 05/13/19 revealed: R5 reported she had pain frequently, and she reported the pain was all over and was due to [MEDICAL CONDITION] arthritis. R5 complained and asked for extra pain medications once in the review period. R5 will continue to be monitored and interventions provided as needed. Review of the undated Care Plan revealed R5 had [MEDICAL CONDITION] arthritis and reported this caused her to be in constant pain. Staff were to inquire about pain daily. Review of the Physician Orders revealed R5 had an order dated 11/23/19 for [MEDICATION NAME] ([MEDICATION NAME] medication) 500 mg (milligrams), by mouth, every four hours as needed (PRN) for pain or fever. Review of the Physician Orders revealed R5 had an order dated 05/25/18 for [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) 10-325 mg,1 tablet, by mouth, three times daily for arthritis. Review of the (MONTH) 2019 Electronic Medication Administration Record [REDACTED]. Review of the (MONTH) 2020 EMAR revealed: R5 received PRN Tylenol 500 mg on 01/21/20, no initial pain assessment or follow-up for effectiveness was documented. During an interview on 02/05/20 at 04:27 PM, Certified Medication Aide (CMA) I stated R5 received [MEDICATION NAME]-[MEDICATION NAME] 10-325mg and seemed to do well with this. CMA I stated the nurses followed-up for effectiveness and documented this. During an interview on 02/10/20 at 10:18 AM, Licensed Nurse (LN) G stated R5 received [MEDICATION NAME]-[MEDICATION NAME] 10-325 mg scheduled, and Tylenol 500 mg PRN. LN G verified that on 12/28/19 the follow-up for effectiveness was documented as YES for effectiveness but no numeric pain scale was used. During an interview on 02/10/20 at 02:01 PM, Administrative Nurse A stated she expected staff to assess resident pain levels using either a numeric pain scale or a faces assessment tool prior to giving pain medications, and again afterwards to assess for effectiveness, and to document this in the pain assessment module of the computer software. Review of the facility policy Long Term Care Pain Management dated 08/2014 revealed it was the policy of the facility to respect and support the elder's right to optimal pain assessment and management. If the elder was identified with pain, the elder would undergo reassessment of pain at least one time per shift and before and after every pain control mechanism employed by the elder's care providers. Healthcare providers from any department, that had implemented a pain control mechanism, would reassess the elder within one-half (1/2) hour to determine the amount of pain control or relief achieved and document initial levels of pain, interventions, and final level of pain. The facility failed to monitor R5 for pain to ensure her pain issues were addressed before and after PRN pain medication administration.

The facility census totaled 49 residents. Based on observation, interview, and record review the facility failed label opened injectable medications to meet professional standards when facility staff did not date an opened [MEDICATION NAME] multi dose vial, therefore facility staff did not know when the vial should be discarded. Findings included: - An observation of the facility medication room on 02/05/20 at 11:53 AM revealed an open multi dose vial of [MEDICATION NAME] purified protein derivative. The vial was approximately half full, with a visible needle puncture mark. Neither the vial nor the box the vial came in had an opened date. Since the vial was not dated when opened, the facility staff would be unable to determine when the vial should be discarded. During an interview on 02/05/20 at 12:02 PM Licensed Nurse (LN) D stated she expected staff to date an opened [MEDICATION NAME] vial. Review of the facility Long Term Care Medication Storage policy dated 10/2014 revealed: Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendation or those of the supplier. Review of the storage instructions for [MEDICATION NAME] purified protein derivative revealed Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. The facility failed to ensure opened injectable medications were dated when opened to meet professional standards.

The facility had a census of 47 residents. Seven residents lived on the special care unit (SCU). Based on observation, interview, and record review, the facility failed to ensure 2 residents on the SCU had the right to be free from abuse by a resident of the SCU. Resident #1, a resident of the SCU, repeatedly hit, punched, and grabbed, residents #2 and #4 over a period of 13 months. Residents sustained a cut and bruises as a result of the abuse inflicted by resident #1. The facility also failed to protect all the residents in the SCU from verbal abuse/threats of serious bodily harm from resident #1. The facility failure to take appropriate measures to prevent abuse placed all residents of the SCU in immediate jeopardy. Findings included: - Review of resident #1's signed physician orders [REDACTED]. condition). Review of the annual minimum data set ((MDS) dated [DATE] revealed short and long term memory problems. The resident could not recall the current season, location of his/her own room, staff names and faces, or that he/she lived in a nursing home. The resident had moderately impaired cognitive skills for daily decision making. The resident displayed fluctuating inattention. The resident displayed other behavioral symptoms not directed towards others 1-3 days of the observation period. The resident did not have any physical behaviors directed towards others. The resident wandered 1-3 days of the observation period. The resident required supervision of one staff for transfers, and supervision only for walking in the room and corridor, and locomotion on and off the unit. Review of the quarterly MDS dated [DATE] revealed a brief interview for mental status (BIMS) score of 0, indicating severe cognitive impairment. The resident did not exhibit any behaviors. Transfers, walking in the room and corridor, locomotion on and off the unit required supervision of one staff. Review of the care area assessments (CAAs) dated 11/10/16 revealed: Cognition - The resident had unspecific dementia with behavioral disturbances. Staff needed to anticipate his/her needs and help meet them. The resident required cuing and did not appear to know what his/her needs were. The resident wandered throughout facility and would go into any room and sit or lay on the bed even if was not his/her room. In this quarter, for no apparent reason, the resident would get upset and throw the direct care staff up against the wall in bathroom and hold him/her against it with his/her arm held above his/her head. The resident had behaviors at home of hitting his/her family member. Communication - The resident had trouble comprehending some conversation. The resident could talk and tell staff what he/she wanted at times but otherwise mumbled. Activities of Daily Living (ADL) - The resident needed help with daily cares because of cognition and not knowing his/her needs. Behavioral symptoms - The resident wandered throughout the facility unaware of his/her needs. The resident had behaviors at home prior to admission. The resident did not do much of anything without being told to do so. He/she attacked the direct care staff for no known reason when they were helping with daily needs for another resident. The resident took [MEDICATION NAME] (an antipsychotic medication) 50 milligrams (mg) and 100 mg at bedtime for dementia with behaviors and delusional disorder. Review of the resident's care plan dated 12/23/15 (most recently reviewed in a care plan meeting on 11/10/16) revealed the resident had a risk for mood and behavior issues. The resident had a history of [REDACTED]. Interventions directed staff to monitor for increased anger and try to redirect, walk away and send in another staff member if the resident resisted care. The resident walked without help or devices and transferred him/herself. The resident received [MEDICATION NAME] 25 mg twice daily for dementia with behaviors. The resident had a history of [REDACTED]. Staff revised the care plan with the following on these dates: 11/30/16- The resident could get very aggressive. He/she pushed staff up against the wall and held them there with their arm held over their heads. The resident also said to staff to Get the hell out of here. The care plan lacked direction for how staff should address aggressive physical behaviors. 1/22/16- [MEDICATION NAME] (an antianxiety medication) 1 mg topically every 2 hours as needed (PRN) for agitation. [MEDICATION NAME] (antipsychotic medication) 10 mg intramuscularly (IM) every 2 hours PRN. 3/18/16- have inquired for placement at behavioral health unit (BHU) multiple places. So far, there were no openings to have him/her evaluated. 3/18/16- redirect away from others' rooms. 3/19/16- [MEDICATION NAME] (antipsychotic medication) 2 mg tab every 4 hours PRN agitation. 5/31/16- [MEDICATION NAME] 200 mg at bedtime for delusional disorder. 2/2/17- If the resident got more agitated or resistive, see if he/she had pain. Monitor for increased anger and try to redirect. Assess/treat for pain. Staff also discontinued from the care plan [MEDICATION NAME] and [MEDICATION NAME]. Undated- [MEDICATION NAME] 2 mg IM PRN for agitation. Review of the nurse's note dated 3/10/16 at 8:30 PM revealed staff saw the resident assaulting resident #4 while he/she held the patio door open for resident #1. Staff and residents stated they witnessed resident #1 possibly hit and shake resident #4 by the shoulders. Staff intervened and separated the two. Staff called the nurse to the unit and upon arrival the nurse saw resident #4 crying and holding his/her chest. At that time, resident #4 stated resident #1 hit him/her in the chest. The nurse had staff take resident #1 to his/her room where the nurse assessed him/her. Resident #1 exhibited confusion, denying, and then admitting to assaulting resident #4. Staff gave [MEDICATION NAME] to resident #1. Review of the nurse's note dated 3/12/16 at 1 PM revealed resident #1 got upset with a direct care staff and followed him/her stating staff took his/her money. Resident #1did not believe staff did not have his/her money and continued to display agitation with the direct care staff. Staff applied topical [MEDICATION NAME] at 11:25 AM. The direct care staff then stepped out of sight to help the resident calm down. Resident #1 then proceeded to follow another direct care staff to the kitchen and he/she gave the resident food. The resident then took his/her hand and wanted the direct care to sit with him/her at the dining room table which he/she did. The direct staff began to address an issue with resident #2 sitting at the dining room table. Resident #1 got agitated at resident #2 because he/she would not do what the direct care staff asked him/her to do. Resident #1 then stood up behind the other resident and started shaking his/her chair. Resident #1 stated he/she thought resident #2 took his/her money and continued to shake the chair. The direct care staff asked resident #1 to stop and he/she did not comply. Resident #2 then stood up as resident #1 stopped shaking the chair and the residents were facing each other. Resident #1 then punched resident #2 once in the right eye. Resident #2 walked away and resident #1 continued to display agitation and raised his/her fist at resident #2 whenever he/she saw him/her. Review of a telephone physician order [REDACTED]. Review of the nurse's note dated 3/14/16 at 2:45 AM revealed the direct care staff on special care unit (SCU-a unit designed to provide specialized care for residents afflicted with Alzheimer's and related dementias) called for help. The staff stated resident #1 was ok, and then started yelling he/she had to get out of here. The resident swung his/her fists, picked up random belongings refused to put them down, and tried to get out the door. Other elders ambulated in the halls at that time. Staff attempted to re-direct the resident without success. Staff administered topical [MEDICATION NAME] to resident #1. Review of the nurse's note dated 3/14/16 at 11 AM revealed staff called the nurse to the unit to advise of the resident displaying aggressive behaviors. Staff administered 1 mg topical [MEDICATION NAME]. The resident kicked at the door and threatened staff. Staff discussed behavior with administrative nurse A and sent paperwork to a BHU. Review of the nurse's note dated 3/14/16 at 2:30 PM revealed the BHU denied admission for resident #1 due to his/her behaviors and the other residents they currently had. Review of the nurse's note dated 3/15/16 at 2:11 AM revealed at approximately 9:00 PM on 3/14/16 staff called the licensed nurse to the unit. A staff member reported resident #1 chased him/her to the kitchen and threatened bodily harm. Staff administered 1 milligram (mg) topical [MEDICATION NAME] (antianxiety mediation administered as an absorbed gel through the skin). The nurse reported to the room and resident #1 said to the nurse I should kill all of you and when asked why, resident #1 shrugged his/her shoulders and replied why not . Staff on the unit reported stepping between resident #1 and others due to the agitation of, and threats to inflict bodily harm to peers and staff, by resident #1. Unit staff advised if topical [MEDICATION NAME] did not appear to help, calm, and relax resident #1 after 2 hours, to notify the nurse and also if behaviors increased. Review of the nurse's note dated 3/15/16 at 1:00 PM. and 1:05 PM revealed staff contacted two BHUs for possible admission, and neither accepted the resident. Review of the nurse's note dated 3/19/16 at 7:00 PM revealed staff attempted to administer resident #1's HS (before bed) medications and he/she dumped them down the sink. At 9 PM, resident #1 attempted to get physical with another resident and direct care staff successfully redirected the resident. Review of a physician order [REDACTED]. Review of the nurse's note dated 3/24/16 at 2:05 PM revealed staff called the nurse to the unit with a report of resident #1 lunging at resident #4. The direct care staff jumped between them and resident #1 grabbed resident #4's left upper arm leaving a thumb print sized bruise. Staff notified the physician via fax and called another BHU to see if they would accept resident #1. The BHU reported they had no open beds. The facility contacted a psychiatrist associated with BHUs, who talked with the staff about the resident's behaviors and gave an order to increase [MEDICATION NAME] (an antipsychotic used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorders) to 200 mg by mouth at bed time and 100 mg by mouth every morning for major neuro-cognitive disorder due to Alzheimer's with behaviors. Progress notes dated 5-9-16 documented the psychiatrist saw the resident for the first time and recommended continuing the current meds, and that he/she would follow the resident as/when medically necessary or 90 days. The next progress note from the psychiatrist was dated 8-17-16. The plan was to continue the current psych meds and follow-up every 90 days or as/when medically necessary. The physician ordered a decrease in [MEDICATION NAME] on 8-4-16 to 50 mg in the morning and 100 mg at bedtime. A physician progress notes [REDACTED].#1 resided in the Alzheimer's unit due to his/her dementia and occasional tendency to become aggressive and the nursing staff reported no recent behavior problems. Review of a facility investigation dated 11/23/16 revealed resident #1 and resident #2 were in resident #1's room. Resident #2 started to move resident #1's bed and resident #1 wanted to help as well. Resident #2 did not want help and they both got between the bed and the wall and started swinging at each other. Direct care staff K split them up as soon as they started to swing, but resident #1 got a punch through to the side of resident #2's face. Review of the 11-23-16 at 8:40 p.m. nurses notes for resident #2 revealed an altercation between resident #1 and resident #2 occurred. Staff documented before staff could separate resident #1 and resident #2 that resident #1 struck resident #2 in the face just below the right eye causing a small cut and a hematoma. A physician progress notes [REDACTED].#1 for follow up and new [MEDICAL CONDITION] medications. Staff informed the physician the resident had been doing ok with no behaviors/agitation. The resident remained stable on current medications. Review of the nurse's note dated 2/11/17 at 11:00 PM revealed earlier on the shift resident #1 picked up a direct care staff members jacket and put it on. The resident refused to remove it, when asked. The resident sat at the dining room table and moved his/her foot which struck resident #3. Resident #3 said in a loud firm voice: Don't touch me. Staff observed no mark on resident #3's leg where resident #1's foot touched his/hers. Staff observed resident #1's leg movement was not an intentional attempt to hurt resident #3. Resident #1 became agitated when resident #3 raised his/her voice and resident #1 jumped up from the table, grabbed a blanket and began swinging it towards other residents. Resident #1 struck resident #2 with the blanket and resident #2 said: Don't start with me. Resident #1 jumped towards resident #2 and placed his/her right hand across resident #2's neck and pushed him/her backward-- making resident #2 bump into the wall. One direct care staff member placed his/her hands on resident #1's upper arms to hold him/her back from resident #2. Another direct care staff member directed resident #2 to step away from agitated resident #1. The direct care staff then called the nurse for immediate assistance on the unit. When the nurse arrived, resident #1 displayed agitation and attempted to pull away from the direct care staff that held his/her arms from behind him/her. The nurse medicated the resident with [MEDICATION NAME] 1 mg topical to the resident's back which was ordered for his/her agitation. As soon as staff administered the medication, staff removed the direct care staff jacket as the direct care staff let go of resident #1's arms. The resident sat down at the dining room table, away from other residents. The resident sat by him/herself for a while and began talking calmly with peers he/she had earlier exhibited agitation toward. Resident #1 remained calm for the remainder of the shift and went to bed at approximately 10:30 PM. Observation on 2/13/17 at 3:48 PM revealed direct care staff D sat in the living area of the SCU. The resident sat at the table with 2 other residents. The other 4 residents in the SCU were in the commons areas. Observation on 2/13/17 at 5:01 PM revealed the resident got up and wandered from resident room to resident room looking inside. At 5:03 PM, the resident went up behind resident #6 and rubbed his/her head, then stood behind resident #6's chair, ducking back where the resident could not see him/her when he/she tried to look back at him/her. Observation of the SCU on 2/13/17 at 9:28 PM revealed direct care staff J was the only staff in the SCU. Staff J reported he/she was the only staff on the SCU until 6 AM the next day. At 9:30 PM- 9:31 PM, staff J did not have view of the residents as he/she went to check on another resident in his/her room. At 9:32 PM resident #1 stood up from the table and stood rubbing the chair, rearranging the furniture, and pushing the chairs in. Staff J asked the resident if he/she needed to use the bathroom and he/she said yes. Residents #2, #5, and #4 were unsupervised from 9:33 PM- 9:36 PM while staff J took the resident to the bathroom. During the time staff was gone, resident #2 got up from the table and started to rearrange the chairs at the table. Staff J briefly came into view, and then left the residents unattended again from 9:37- 9:40 PM. Resident #2 walked around the dining room and pushed the chairs around. At 9:58 PM staff J went into a resident's room. Resident #2 went into his/her room and tinkered with the door knob then walked to sit down in the commons area. Staff J returned at 10 PM. At 10:28 PM, staff J took resident #3 to his/her room and residents #2, #5 and #1 remained in the commons area unsupervised. Resident #5 paced around and around the couch repetitively and residents #1 and #2 sat in living room chairs. Staff J came out to check on them for a moment at 10:30 PM, then left again at 10:30 PM and returned at 10:31 PM. Observation from 10:47 PM- 10:49 PM revealed staff could not view the residents. Interview with direct care staff D on 2/13/17 at 3:48 PM revealed the staff completed many tasks on the special care unit, which included: cooking, cleaning, personal cares, and activities. Staff D stated one staff member was not enough and sometimes two was not even enough. Staff D stated when there were multiple behaviors, staff needed to be able to deal with those behaviors one-on-one, and if the residents were all acting out, staff could not do that. Staff D said he/she could call for help from the other unit on the phone. Staff D reported staff worked 12 hour shifts and the facility had 2 staff in the special care unit, except at night when there was only one staff. Staff D stated he/she had not been working when the altercations occurred. Interview with direct care staff J on 2/13/17 at 9:42 PM revealed resident #1 usually had exit-seeking behavior and was in bed between that time and 11 or midnight. Staff J said he/she knew to back off and let the resident calm down if there were an aggressive resident. Staff J said he/she knew when a resident was aggressive; sometimes it meant the resident was in pain. Staff J said he/she would try to talk the resident down if a resident had his/her hands on another resident's neck, and then he/she would call the nurse. Staff J said if it continued to escalate, he/she did not know how he/she would diffuse that situation, and staff J would yell at the top of his/her lungs as he/she thought staff would hear it on the other side of the door. Interview with direct care staff J on 2/13/17 at 9:50 PM revealed he/she watched the residents' body language. Staff J stated resident #1 had a lot of different facial expressions. Staff J did not know how he/she learned about new behaviors, he/she just looked for them and if he/she saw new behaviors, he/she would let the next shift know. Staff J said he/she received online computer training about behaviors and monitoring and trying to figure out what caused them. Staff J stated he/she completed the hand to hand videos (dementia training) and classes. Interview with direct care staff E on 2/14/17 at 9:25 AM revealed they could not give one-on-one attention to the residents. Staff E stated when staff assisted resident #6 with daily cares, it required 20 minutes and during that time, no other staff supervised the residents in the special care unit. Interview with licensed nursing staff B on 2/14/17 at 3:18 PM revealed he/she was the charge nurse for the whole facility for the shift. Staff B did not know about the incident over the weekend (2/11/17) where the resident had his/her hands on resident #2's neck and said something should have been added to the care plan to try and prevent it from happening again and include some way to de-escalate any further incidents. Staff B said when something like a resident-to-resident incident happened, 1 staff on the SCU was not enough to provide adequate supervision for all 7 residents. Interview with administrative staff M and administrative nursing staff A on 2/14/17 at 1:00 PM revealed administrative staff M reported most of the problems the facility had with residents' aggressive behaviors, had to do with the way staff handled situations improperly. So, he/she provided staff education in those instances. Administrative staff M reported they had the Alzheimer's Association provide some different training and stated the facility had checked with a company about crisis prevention training but it was very expensive. Staff A acknowledged that the staff needed better education related to aggressive residents. Interview on 2/15/17 at 9:34 AM with administrative staff M revealed each time the resident had an incident, the investigation determined staff did something wrong that triggered the outburst, requiring staff education. Staff M also reported the facility changed the resident's medications and had a psychiatrist come in. Staff M said the facility tried to get resident #1 into a BHU, but the BHUs would not accept the resident. Interview on 2/15/17 at 9:34 AM with administrative nursing staff A revealed, when asked how staff protected the other residents on the SCU during and after resident #1's aggressive episodes, he/she stated they found in their investigations it was more of an issue requiring staff education, where staff had done something wrong to trigger the outburst. Interview on 2/15/17 at 9:40 AM with administrative staff M and administrative nursing staff A revealed staff A reported he/she knew the part of the admission criteria and the exclusion of residents with a history of harm of others. He/she stated the resident did not have any history of aggressive behavior prior to his/her [MEDICAL CONDITION]. We thought if we got him/her in a structured environment, he/she would be more managed. Staff M confirmed the resident did have a history of abusing a family member prior to admission to the SCU, but the facility felt it was more of an isolated incident. The facility used the information about the abuse to the family member to make a determination as to whether or not the resident was appropriate for admission to the SCU. Staff A said he/she felt like their SCU admission criteria meant something more aggressive, like shooting someone. Review of the Abuse, Neglect, Exploitation Prevention policy, dated 2014, revealed the facility developed and implemented the policy and procedure to prohibit mistreatment, neglect, and abuse of all elders and misappropriation of elder property. The policy stated all residents received protective oversight 24 hours a day and the staff had responsibility of the protection of the residents from abusive staff members, family members, and from other elders. The policy failed to direct staff in how to protect residents during resident-to-resident abuse. Review of the policy entitled Protecting an Elder during an Abuse and/or Neglect Investigation, revised on 9/2014, revealed residents would be protected from contact with anyone implicated in abuse or neglect until the investigation was completed. The policy failed to direct staff in how to protect residents during resident-to-resident abuse. Review of the undated policies specifically for the Memory Lane Special Care Unit revealed the policy instructed staff that residents may experience an emotional outburst (catastrophic reaction) usually related to the demented resident's perception of intrusion into his/her personal space. If an outburst occurred, the policy guided staff to immediately redirect the behavior and protect others in the immediate area. The policy lacked specific guidance on the protection of other residents during resident-to-resident abuse. The facility failed to ensure all residents on the SCU had the right to be free from physical and verbal abuse/threats of serious bodily harm by a resident of the SCU. Resident #1, a resident of the SCU, repeatedly hit, punched, threatened and grabbed other residents over a period of 13 months. Residents sustained a cut and bruises as a result of the abuse inflicted by resident #1. The facility failure to take appropriate measures to prevent abuse placed these residents of the SCU in immediate jeopardy of abuse. The facility abated the immediate jeopardy on 2/15/17 at 6 PM when the facility implemented one-on-one care for resident #1, added another staff member to the night shift in the SCU, initiating a pendant call light system for the staff on duty in the SCU, completed training on tips to deal with resident behaviors and preferences, and developed a new plan for orientation of new employees to include previously mentioned training. The deficiency remained at the scope and severity of a H.

The facility had a census of 47 residents. The sample included 3 residents. Seven residents lived on the special care unit (SCU). Based on observation, interview, and record review, the facility failed to protect all of the residents on the SCU from physical abuse by 1 sampled resident (#1) on the SCU who repeatedly exhibited aggressive behaviors of hitting, punching, and shoving other residents (#2, #3, #4, #6). This deficient practice placed the residents on the SCU in immediate jeopardy. Findings included: - Review of resident #1's signed physician orders [REDACTED]. condition). Review of the annual minimum data set ((MDS) dated [DATE] revealed short and long term memory problems. The resident could not recall the current season, location of his/her own room, staff names and faces, or that he/she lived in a nursing home. The resident had moderately impaired cognitive skills for daily decision making. The resident displayed fluctuating inattention. The resident displayed other behavioral symptoms not directed towards others 1-3 days of the observation period. The resident did not have any physical behaviors directed towards others. The resident wandered 1-3 days of the observation period. The resident required supervision of one staff for transfers, and supervision only for walking in the room and corridor, and locomotion on and off the unit. Review of the quarterly MDS dated [DATE] revealed a brief interview for mental status (BIMS) score of 0, indicating severe cognitive impairment. The resident did not exhibit any behaviors. Transfers, walking in the room and corridor, locomotion on and off the unit required supervision of one staff. Review of the care area assessments (CAAs) dated 11/10/16 revealed: Cognition - The resident had unspecific dementia with behavioral disturbances. Staff needed to anticipate his/her needs and help meet them. The resident required cuing and did not appear to know what his/her needs were. The resident wandered throughout facility and would go into any room and sit or lay on the bed even if was not his/her room. In this quarter, for no apparent reason, the resident would get upset and throw the direct care staff up against the wall in bathroom and hold him/her against it with his/her arm held above his/her head. The resident had behaviors at home of hitting his/her family member. Communication - The resident had trouble comprehending some conversation. The resident could talk and tell staff what he/she wanted at times but otherwise mumbled. Activities of Daily Living (ADL) - The resident needed help with daily cares because of cognition and not knowing his/her needs. Behavioral symptoms - The resident wandered throughout the facility unaware of his/her needs. The resident had behaviors at home prior to admission. The resident did not do much of anything without being told to do so. He/she attacked the direct care staff for no known reason when they were helping with daily needs for another resident. The resident received [MEDICATION NAME] (an antipsychotic medication) 50 milligrams (mg) and 100 mg bedtime for dementia with behaviors and delusional disorder. Review of the resident's care plan dated 12/23/15 (most recently reviewed in a care plan meeting on 11/10/16) revealed the resident had a risk for mood and behavior issues. The resident had a history of [REDACTED]. Interventions directed staff to monitor for increased anger and try to redirect, walk away and send in another staff member if the resident resisted care. The resident walked without help or devices and transferred him/herself. The resident received [MEDICATION NAME] 25 mg twice daily for dementia with behaviors. The resident had a history of [REDACTED]. Staff revised the care plan on the following dates: 1/22/16- [MEDICATION NAME] (an antianxiety medication) 1 mg topically every 2 hours as needed (PRN) for agitation. [MEDICATION NAME] (antipsychotic medication) 10 mg intramuscularly (IM) every 2 hours PRN. 3/18/16- have inquired for placement at behavioral health unit (BHU) multiple places. So far, there were no openings to have him/her evaluated. 3/18/16- redirect away from others' rooms. 3/19/16- [MEDICATION NAME] (antipsychotic medication) 2 mg tab every 4 hours PRN agitation. 5/31/16- [MEDICATION NAME] 200 mg at bedtime for delusional disorder. 11/30/16- The resident could get very aggressive. He/she pushed staff up against the wall and held them there with their arm held over their heads. The resident also told staff to Get the h*** out of here. The care plan lacked direction for how staff should address aggressive physical behaviors. 2/2/17- If the resident got more agitated or resistive, see if he/she had pain. Monitor for increased anger and try to redirect. Assess/treat for pain. Staff also discontinued from the care plan [MEDICATION NAME] and [MEDICATION NAME]. Undated- [MEDICATION NAME] 2 mg IM PRN for agitation. Review of the nurse's notes revealed: 3/10/16 at 8:30 PM- resident #1 assaulted resident #4 by shaking him/her and hitting him/her in the chest. 3/12/16 at 1 PM- resident #1 shook resident #2's chair, then punched him/her in the eye. 3/14/16 at 2:45 AM- the direct care staff on special care unit (SCU-a unit designed to provide specialized care for residents afflicted with Alzheimer's and related dementias) stated resident #1 swung his/her fists, picked up random belongings refused to put them down, and tried to get out the door. Other elders ambulated in the halls at that time. Staff attempted to re-direct the resident without success. Staff administered topical [MEDICATION NAME] to resident #1. 3/14/16 at 11 AM- staff called the nurse to the unit to advise of the resident displaying aggressive behaviors. Staff administered 1 mg topical [MEDICATION NAME]. The resident kicked at the door and threatened staff. Staff discussed behavior with administrative nurse A and sent paperwork to a BHU. The clinical record lacked evidence the resident transferred to a BHU. 3/15/16 at 2:11 AM- at approximately 9:00 PM on 3/14/16 staff reported resident #1 chased him/her to the kitchen and threatened bodily harm. Staff administered 1 milligram (mg) topical [MEDICATION NAME] (antianxiety mediation administered as an absorbed gel through the skin). Resident #1 said to the nurse I should kill all of you and when asked why, resident #1 shrugged his/her shoulders and replied why not. Staff on the unit reported stepping between resident #1 and others due to the agitation, and threats to inflict bodily harm to peers and staff, by resident #1. 3/19/16 at 7:00 PM- staff attempted to administer resident #1's HS (before bed) medications and he/she dumped them down the sink. At 9 PM, resident #1 attempted to get physical with another resident and direct care staff successfully redirected the resident. Review of the nurse's note dated 3/24/16 at 2:05 PM revealed staff called the nurse to the unit with a report of resident #1 lunging at resident #4. The direct care staff jumped between them and resident #1 grabbed resident #4's left upper arm leaving a thumb print sized bruise. Staff notified the physician via fax and called another BHU to see if they would accept resident #1. The BHU reported they had no open beds. The facility contacted a psychiatrist associated with BHUs, who talked with the staff about the resident's behaviors and gave an order to increase [MEDICATION NAME] (an antipsychotic used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorders) to 200 mg by mouth at bed time and 100 mg by mouth every morning for major neuro-cognitive disorder due to Alzheimer's with behaviors. Progress notes dated 5-9-16 documented the psychiatrist saw the resident for the first time and recommended continuing the current meds, and that he/she would follow the resident as/when medically necessary or 90 days. The next progress note from the psychiatrist was dated 8-17-16. The plan was to continue the current psych meds and follow-up every 90 days or as/when medically necessary. The physician ordered a decrease in [MEDICATION NAME] on 8-4-16 to 50 mg in the morning and 100 mg at bedtime. A physician progress notes [REDACTED].#1 resided in the Alzheimer's unit due to his/her dementia and occasional tendency to become aggressive and the nursing staff reported no recent behavior problems. Review of a facility investigation dated 11/23/16 revealed resident #1 and resident #2 were in resident #1's room. Resident #2 started to move resident #1's bed and resident #1 wanted to help as well. Resident #2 did not want help and they both got between the bed and the wall and started swinging at each other. Direct care staff K split them up as soon as they started to swing, but resident #1 got a punch through to the side of resident #2's face. Review of the 11-23-16 at 8:40 p.m. nurses notes for resident #2 revealed an altercation between resident #1 and resident #2 occurred. Staff documented before staff could separate resident #1 and resident #2 that resident #1 struck resident #2 in the face just below the right eye causing a small cut and a hematoma. A physician progress notes [REDACTED].#1 for follow up and new [MEDICAL CONDITION] medications. Staff informed the physician the resident had been doing ok with no behaviors/agitation. The resident remained stable on current medications. Review of the nurse's note dated 2/11/17 at 11:00 PM revealed earlier on the shift resident #1 picked up a direct care staff member's jacket and put it on. The resident refused to remove it. The resident sat at the dining room table and moved his/her foot which struck resident #3. Resident #3 said in a loud firm voice: Don't touch me. Resident #1 became agitated when resident #3 raised his/her voice and resident #1 jumped up from the table, grabbed a blanket and began swinging it towards other residents. Resident #1 struck resident #2 with the blanket and resident #2 said: Don't start with me. Resident #1 jumped towards resident #2 and placed his/her right hand across resident #2's neck and pushed him/her backward, making resident #2 bump into the wall. One direct care staff member placed his/her hands on resident #1's upper arms to hold him/her back from resident #2. Another direct care staff member directed resident #2 to step away from agitated resident #1. The direct care staff then called the nurse for immediate assistance on the unit. When the nurse arrived, resident #1 displayed agitation and attempted to pull away from the direct care staff that held his/her arms from behind him/her. The nurse medicated the resident with [MEDICATION NAME] 1 mg topical to the resident's back as ordered for agitation. Observation on 2/13/17 at 5:01 PM revealed the resident got up and wandered from resident room to resident room looking inside. At 5:03 PM, the resident went up behind resident #6 and rubbed his/her head, then stood behind resident #6's chair, ducking back where the resident could not see him/her when he/she tried to look back at him/her. Interview with direct care staff J on 2/13/17 at 9:42 PM revealed Staff J said he/she knew to back off and let the violet resident calm down. Staff J said he/she knew when a resident was aggressive; sometimes it meant the resident was in pain. Staff J said he/she would try to talk the resident down if a resident had his/her hands on another resident's neck, and then he/she would call the nurse. Staff J said if it continued to escalate, he/she did not know how he/she would diffuse that situation, and staff J would yell at the top of his/her lungs as he/she thought staff would hear it on the other side of the door. Interview with direct care staff E on 2/14/17 at 9:25 AM revealed they could not give one-on-one attention to the residents. Staff E stated when staff assisted resident #6 with daily cares, it required 20 minutes and during that time, no other staff supervised the residents in the special care unit. Interview with licensed nursing staff B on 2/14/17 at 3:18 PM revealed he/she was the charge nurse for the whole facility for the shift. Staff B did not know about the incident over the weekend (2/11/17) where the resident had his/her hands on resident #2's neck and said something should have been added to the care plan to try and prevent it from happening again, and included some way to de-escalate any further incidents. Interview with administrative staff M and administrative nursing staff A on 2/14/17 at 1:00 PM revealed administrative staff M reported most of the problems the facility had with residents' aggressive behaviors, had to do with the way staff handled situations improperly. So, he/she provided staff education in those instances. Administrative staff M reported they had the Alzheimer's Association provide some different training and stated the facility had checked with a company about crisis prevention training but it was very expensive. Staff A acknowledged that the staff needed better education related to aggressive residents. Interview on 2/15/17 at 9:34 AM with administrative staff M revealed each time the resident had an incident, the investigation determined staff did something wrong that triggered the outburst, requiring staff education. Staff M also reported the facility changed the resident's medications and had a psychiatrist come in. Staff M said the facility tried to get resident #1 into a BHU, but the BHUs would not accept the resident. Review of the policy entitled Protecting an Elder during an Abuse and/or Neglect Investigation, revised on 9/2014, revealed residents would be protected from contact with anyone implicated in abuse or neglect until the investigation was completed. The policy failed to direct staff in how to protect residents during resident-to-resident abuse. Review of the undated policies specifically for the Memory Lane Special Care Unit revealed the policy instructed staff that residents may experience an emotional outburst (catastrophic reaction) usually related to the demented resident's perception of intrusion into his/her personal space. If an outburst occurred, the policy guided staff to immediately redirect the behavior and protect others in the immediate area. The policy lacked specific guidance on the protection of other residents during resident-to-resident abuse. Review of the Abuse, Neglect, Exploitation Prevention policy, dated 2014, revealed the facility developed and implemented the policy and procedure to prohibit mistreatment, neglect, and abuse of all elders and misappropriation of elder property. The policy stated all residents received protective oversight 24 hours a day and the staff had responsibility of the protection of the residents from abusive staff members, family members, and from other elders. The policy failed to direct staff in how to protect residents during resident-to-resident abuse. The facility failed to protect the residents of the SCU from resident #1 during aggressive outbursts and physical abuse, which placed the residents on the SCU in immediate jeopardy. The facility abated the immediate jeopardy on 2/15/17 at 6 PM when the facility implemented one-on-one care for resident #1, added another staff member to the night shift in the SCU, initiating a pendant call light system for the staff on duty in the SCU, completed training on tips to deal with resident behaviors and preferences, and developing a new plan for orientation of new employees to include previously mentioned training. This deficient practice remained at the scope and severity of an E.

The facility had a total census of 50 residents with 21 sampled. Based on interview, record review and observations, the facility failed to provide services to ensure a resident who was initially assessed as not having psychosocial adjustment difficulty did not develop symptoms for 1 of 4 residents sampled for weight loss. (#16) Resident #16 developed weight loss after a fiend in the facility died . Findings included: - Review of resident #16's annual MDS (minimum data set) dated [DATE] revealed a BIMS (brief interview for mental status) score of 3 indicating the resident had severe cognitive impairment, had no behaviors, did not have signs of depression, had clear speech, and was able to understand others and be understood. The resident required extensive assist of one staff with personal hygiene, dressing, eating, had no weight loss, no swallowing problems, took an antipsychotic for 3 days and an antidepressant for all 7 days of the 7 day look back period. The MDS revealed the resident's weight was 140 pounds. Review of the cognitive loss CAA (care area assessment) dated [DATE] revealed the resident had dementia with behavioral disturbances/paranoia. The resident had depressed moods that were noted by the physician and were treated with [MEDICATION NAME] (an antidepressant) for refusal of care and decreased appetite. The CAA identified the resident's [MEDICATION NAME] was discontinued, but weight loss and increased depressed behaviors increased, so the [MEDICATION NAME] was restarted. The resident took [MEDICATION NAME] daily for depression, [MEDICATION NAME] (mood stabilizer) for dementia with behaviors, was withdrawn, ate slowly and very little most of the time even with cues. The resident needed staff assistance and encouragement, and showed resistance with meals, care, and medications. He/she had trouble with memory, was confused at times, did come out of room and sat next to a male/female resident in the facility but often sat with eyes closed, and required extensive assistance with ADL's (activities of daily living). Review of the [MEDICAL CONDITION] drug use CAA dated [DATE] revealed the resident had dementia with behavioral disturbances/paranoia, needed [MEDICATION NAME] daily for depression and was withdrawn the majority of the time. Review of the care plan for general information dated [DATE] and revised on [DATE], revealed the resident enjoyed attending events with a fell ow male/female resident and friend. The care plan directed staff to sit them together for events such as music and watching television in the lobby. The care plan identified the resident at times would hit, kick, scratch or spit at staff if they tried to care for the resident and he/she did not want them to. On [DATE], the resident's friend passed away. On [DATE], the physician discontinued the resident's [MEDICATION NAME]--given for the resident's depressive moods and withdrawn behavior. On [DATE], staff discontinued the intervention for staff to have the resident sit with the friend. Review of the care plan for meals/snacks dated [DATE] and last reviewed on [DATE] indicated the resident needed cues to eat and was fed by staff depending on mood, was given a shake (supplement) with all meals for increased intake. Review of the facility's weekly weight report revealed the resident's weight on [DATE] was 110 pounds. According to the facility's weight report, the resident lost a total of 30 pounds between [DATE] and [DATE], over a 63-day period. The weight loss percentage totaled 21.4%, a significant amount. Review of the meal intake logs for the month of [DATE] revealed a meal intake average of 37% with 6 meals refused. Review of the meal intake logs for the month of [DATE] revealed a meal intake average of 35% with 27 meals refused. The facility had not calculated a meal intake average for the month of May, but Dietary staff D confirmed on 5-,[DATE] at 12:07 p.m. that the resident had refused most of the meals for the month of May. Review of the behavior symptoms monitoring from February 2013 through [DATE] revealed the resident refused care for personal hygiene on [DATE], and [DATE] as well as refused care with personal hygiene, eating, medicine and dressing on [DATE]. Review of activities assessment completed on [DATE] in comparison to the assessment completed on [DATE], revealed the resident had declined in the participation in activities, rarely initiated conversation, did not enjoy small groups, and did not prefer to be out of his/her room. The assessment lacked identification of the resident's decline. Review of the social service notes dated [DATE] revealed a visit with the resident who smiled and gave 1 to 2 word answers with no concerns voiced at that time. Review of the social service notes dated [DATE] revealed the facility had a care plan meeting and would continue the same plan of care. The notes further indicated that social service provided 1 to 1 visits for social and mental stimulation, during the visits the resident had talked about daily seasonal events, family personal needs and social services would continue to visit and keep in touch with family. The social services failed to identify any further psychosocial changes for this resident. The clinical record lacked further evidence of social service involvement when the resident's mood declined. The social service notes lacked any monitoring of the resident's depressive moods after [DATE] when the physician discontinued the resident's antidepressant, [MEDICATION NAME], even though the resident had a history of [REDACTED]. Review of the nurse's notes dated [DATE] at 9:45 a.m. revealed staff reported the resident was not swallowing food and drink but was holding it in his/her mouth which had progressively worsened during the week. The note indicated the resident was no more confused than normal. Staff placed a call to the physician to discuss a swallowing evaluation. At 10:30 a.m. the staff had spoken with the physician who gave orders to taper [MEDICATION NAME] (mood stabilizer) and [MEDICATION NAME] (antidepressant), and did not order a swallow evaluation. Review of the nurse's note dated [DATE] at 4:15 p.m. revealed the resident ate very little lunch, spoke very little, and made little eye contact. The notes revealed a "special friend " had passed away approximately a week ago. Review of the dietician notes dated [DATE] revealed the resident's intake and weight had been decreased since mid March. The notes further indicated the resident had been reluctant to open his/her mouth and at some meals refused any intake at all. Review of the nurse's notes dated [DATE] at 2:30 p.m. revealed the resident had a significant weight loss over the last month along with tremendous decrease in appetite and refused to eat and drink most times. Review of the nurse's notes dated [DATE] revealed the resident ate very little, was becoming very antisocial, did not smile and stared aimlessly as well as averted eye contact. Review of the dietician notes dated [DATE] revealed the resident was put on "comfort care" by the physician. The notes revealed the medication changes made on [DATE] could have an effect on intake and a dentist appointment was set for [DATE] to check oral status.(8 weeks after identifying the resident was having difficulty chewing and swallowing food) The notes further indicated the resident was started on warm fluids and the foods were to be at either room temperature or lightly warmed (to prevent pain to teeth for extreme temperatures), and provided hot cereal at all meals with pudding and a pureed texture on all hot meals. Review of the dietician notes dated [DATE] revealed the resident continued on pureed food and continued to have very little intake. The notes indicated the resident shook his/her head "no" when offered food. The notes further indicated that most of the time and when he/she took a bite of food or drink it ran back out of his/her mouth. The notes indicated it appeared to the staff as if the resident just wanted to be left alone. Review of the nurse's notes on [DATE] revealed the resident was admitted to a local hospital for acute renal (kidney) failure. The resident re-admitted to the facility on [DATE] from the hospital. Review of the nurse's notes on [DATE] at 5:20 a.m. revealed the resident passed away. An observation on [DATE] at 11:52 a.m. revealed the resident sat at a table in the dining room, his/her head was hanging downward. The resident was served pureed chicken with gravy, mashed potatoes with cheese, and pureed spinach, a 6 ounce glass of orange juice and 8 ounce glass of water. At 11:56 after attempts from dietary staff to assist the resident with the meal, and the resident would shake his/her head "no" and refused the food and drink, the resident then was removed from the dining area and taken to his/her room and assisted to bed. On [DATE] at 12:16 p.m. in an interview direct care staff I reported the resident had not been eating for at least 2 weeks and he/she refused meals and liquids. Staff reported he/she had another resident friend who passed away recently and the resident had declined since then. Direct care staff I identified the resident's "friend" had passed away at the end of February 2013 or beginning of [DATE]. Staff I stated "The resident and the friend were very close and if asked they would say they were married to each other." "The resident's friend used to come looking for him/her all the time stating "where's my (resident's name)?" They sat together at the dining table for meals and during activities. The resident would smile when the friend was around. Staff stated "They even took their picture together." Staff pointed to a framed photo of the resident and the friend sitting close together, they both had smiles. Staff I reported the resident would feed himself/herself some of the time when the friend was present at the meal, however, after the friend passed away, there was a noticeable decline in the resident from that time. On [DATE] at 11:28 a.m. in an interview Social Service staff A reported the resident had declined over the last three months, slept for increasing periods of time, and was close to another resident who passed away recently, however, staff A then indicated that due to having dementia the resident would not have remembered the other resident who passed and felt the resident was no more depressed than previously. Staff A reported it was his/her opinion the resident was not depressed due to the other resident passing away. Staff A reported he/she does regularly attend the Quality Assurance meetings and did attend in [DATE] and was made aware of the change in the resident's status as far as refusing meals and the weight loss. Staff A reported not having attended the Quality Assurance meeting in [DATE] due to other appointments, however, did review the meeting notes and was aware the resident continued to have difficulty with refusing meals and weight loss. Staff A verified there were no further evaluations for depression performed on this resident and also verified that between the dates of [DATE] and [DATE] there were no documented 1 to 1 visits with this resident. On [DATE] at 12:07 p.m. in an interview dietary staff D reported the resident had another resident friend who encouraged him/her to eat and sat with him/her at meals and activities. The resident's friend passed away recently. The resident began refusing meals and supplements around that same time. Staff D further indicated this was brought up in the Quality Assurance meetings on [DATE], and each week thereafter. Staff D reported attempts were made in an effort to improve meal intake including a change of location of the dining to be away from other people, room temperature foods and drinks were offered, other staff encouragement, all with no better results. Staff D confirmed there were no swallow evaluations performed, no discussion for reviewed discontinued medications, discussions towards new medications to improve appetite with no follow through and no changes were made to the resident's care plan. On [DATE] at 2:33 p.m. in an interview Administrative nursing staff K reported the resident's weight loss and refusal of the meals had been brought up at the Quality Assurance meetings. Other staff had reported the resident had been close to another resident friend who resided at the facility evidenced by them sitting together at meals and for activities and the other resident had recently passed away. On [DATE] at 11:00 a.m., Administrative nursing staff K stated that the facility's process for identifying weight loss was done when Dietary staff D entered the weights into a computer program and received a weight report. This weight report was then utilized at a weekly care plan meeting where several Administrative staff, Consultant NN, and Social Service staff A gather to discuss what interventions had been attempted, which ones did not work, and what else needed to be tried. When asked which staff monitored for an increase in depression symptoms, Nurse K confirmed that it was Administrative Nursing staff R, when he/she completed the MDS. When Nurse R identified an increase in depression, Nurse R then shared that information with Social Service staff A and the resident's physician. Review of the facility's Mental and Psychosocial policy, dated ,[DATE], revealed the following: 1. Upon admission an assessment is completed on residents and the nursing staff addresses "mental status". The MDS Coordinator and Social Services during admission review mental/psychosocial needs. They also review resident's mental/psychosocial needs quarterly and upon any significant change. The interdisciplinary team also acknowledges any changes in resident's mental/psychosocial needs together as a team and the nursing home staff will implement care in collaboration with other members of the interdisciplinary team - ranging from the physician (who may need to consider medical issues that are complicit in care needs) to the nursing assistant (who provides the majority of care) - as well as the resident and his/her family members. 2. If it is determined that a resident is depressed, either by staff reporting to charge nurse or th interdisciplinary team, notification will be sent to the physician, one on one visits will be conducted to help identify other measures that might help depression prior to medication changes or additions, and if needed, will ask for psychiatric consult and treat. 3. Social Services will follow up to help address all on-going psychosocial needs. 4. For those residents who have an assessment that does not reveal a mental or psychosocial adjustment difficulty, display a pattern of decreased social adjustment difficulty, display a pattern of decreased social interaction and/or, display increased withdrawn, angry, or depressive behaviors staff will monitor in between assessments using the care tracker tool. The facility failed to assess the cause for recent changes in psychosocial adjustment and provide services and or treatments to prevent decline of the mental and physical health and well-being of resident #16 when he/she had weight loss, refused meals, activities and medications after his/her friend in the facility passed away.