Every finding on record at Brighton Place North

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to have sufficient licensed nursing staff 24 hours a day.Finding included:- On 10/14/25 at 03:00 PM, a review of Licensed Nurse (LN) H had an employment date of 09/25/23, and license verification revealed LN H's license had lapsed on 06/30/25. LN H, the only LN scheduled, worked the following dates:July 2025: 1, 2, 3, 7, 8, 9, 10, 14, 15, 16, 17, 21, 22, 23, 24, 25, 28, 29, 30, and 31.August 2025: 4, 5, 6, 7, 11, 12, 13, 14, 18, 19, 20, 21, 25, 26, 27, and 28.September 2025: 1, 2, 3, 4, 8, 9, 10,11,15, 16, 17, 18, 22, 23, 24, 25, 29, and 30.October 2025: 1, 2, 6, 7, 8, 9, 10, and 13.On 10/14/25 at 03:30 PM, Administrative Staff A and Administrative Nurse D stated they became aware of LN H's lapsed license on this day when they had checked the verification on the Kansas Board of Nursing verification. Administrative Staff A stated LN H had been removed from the schedule until the renewal process had been completed. Administrative Nurse D stated that LN H must not have been responsible enough to have gotten the renewal process completed.Upon request, the facility failed to provide a Licensed Nurse Coverage policy.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety in one kitchen. Findings included:- On 10/13/25 at 08:00 AM, observation in the kitchen revealed the following.A kitchen refrigerator labeled #1 had a 1/2 full, five-gallon container of cottage cheese with an expiration date of 09/20/25.On 10/13/25 at 08:05 AM, Certified Dietary Aide (CNA) M verified the finding and stated she was not a dietary staff member; she was helping today. CNA M discarded the cottage cheese container.On 10/13/25 at 08:10 AM, Social Services X walked into the kitchen by the prep area without a hair net, took a plate of food from CNA M, and delivered it to a resident at the dining room table.On 10/13/25 at 08:12 AM, Social Services X verified she had entered the kitchen prep area without a hair net and stated she probably forgot to put a hair net on, and she should have. On 10/13/25 at 11:08 AM, an observation revealed in a freezer, located in the dry storage room, was an unlabeled and undated plastic bag of fish patties. The freezer had 1/2 to 1 inch ice buildup on the inside top and each shelf. Dietary Staff (DS) BB verified the above finding and stated they should be labeled and dated.The Kitchen Cleaning Schedule documented tasks for dietary staff to complete before leaving their scheduled shift.The facility's Food Safety Storage Policy, revised 09/24/25, instructed staff to wrap, cover, or seal all refrigerated food and label and date per food code guidelines (provide a framework for food safety, which includes standards for cooking, storing, and handling food to prevent foodborne illnesses).

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to implement Enhanced Barrier Precautions (EBP- an infection control practice that uses personal protective equipment (PPE) to reduce the spread of multi-drug-resistant organisms (MDRO- common bacteria that have developed resistance to multiple types of antibiotics) for Resident (R) 4, who had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag). The facility also failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems and chronic lung disease). Findings included:- R4's Electronic Medical Record (EMR) included diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), epilepsy (brain disorder characterized by repeated seizures), and hypothyroidism (a condition characterized by decreased activity of the thyroid gland).R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented R4's staff cognition assessment as modified independence, experienced inattentiveness and disorganized thinking which fluctuated, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), verbal behaviors directed toward others daily, other behaviors not directed toward others daily and rejected care for four to six days during a seven-day look-back period. R4 required setup and clean up assistance with eating and dressing, and partial to moderate assistance with oral care, toileting, and personal hygiene, and independent with mobility. R4 had an indwelling urinary catheter and was frequently incontinent of bowel.R4's Care Plan dated 08/25/25 documented R4 had potential for complications related to an indwelling suprapubic catheter. The Care Plan directed staff to assess, record, and report to the physician signs and symptoms of urinary tract infection (UTI- an infection in any part of the urinary system). Encourage fluid intake, cleanse drainage bags with vinegar solution, maintain a closed drainage system, and secure the bag to the leg. The Care Plan further directed staff to keep appointments every six weeks with urology and nursing may change the catheter as needed if dislodged or clogged. The Care Plan lacked information related to EBP.R4's Care Plan dated 08/25/25 documented R4 had potential for complications related to the indwelling catheter for chronic bladder obstruction and cryoablation (a medical procedure that uses extreme cold to destroy abnormal or diseased tissue) of prostate cancer. The Care Plan directed staff to assess, record, and report to the physician as needed, signs or symptoms of urinary tract infection.The Physician Order dated 01/27/23 directed staff to stop obtaining urine specimens unless the patient complained of symptoms, and no prophylactic (preventative in nature) antibiotic (medications used to treat infectious processes) was needed.The Progress Note dated 02/23/25 at 05:58 AM documented that staff found R4 unresponsive at 04:30 AM. After receiving physician orders to send R4 to the emergency room to evaluate and treat R4. Staff called 911, and the ambulance left with the resident at 04:50 AM.The Progress Note dated 02/25/25 at 11:22 AM documented that R4 had returned to the facility at 10:45 AM.The Progress Note dated 03/25/25 at 12:22 PM documented that R4's practitioner had been notified that R4 had a fever and a change in his level of consciousness. The practitioner ordered R4 to be sent to the emergency room. The ambulance left with R4 at 12:21 PM.The Progress Note dated 04/03/25 at 11:09 AM documented that R4 had returned to the facility.On 10/14/25 at 08:09 AM, R4 ambulated independently to the commons area toward the facility entry. He was dressed in sweatpants with a urine collection bag attached to his right lower leg. He had frequent jumping and hand gestures to point a gun and verbalized Bam.On 10/14/25 at 11:59 AM, Certified Nurse Aide (CNA) N assisted R4 to a bathroom across the hall from the residents' room. R4's room lacked EBP signage or had gown or gloves stored in the room. CNA N explained to R4 that she was going to empty the catheter drainage bag. CNA N put on a pair of disposable gloves, emptied the drainage bag into a measuring container, wiped the drainage spout with an alcohol pad, emptied the container into the toilet, rinsed the measuring container, and returned the measuring container to a clear plastic bag. CNA N then removed the gloves and washed her hands. CNA N stated staff used gloves when handling the catheter tasks for R4 and did not wear a gown during the process. CNA N reported that gowns were available for use if the staff wanted to use them.On 10/15/25 at 09:11 AM, Administrative Nurse D stated she was not aware of EBP requirements, and staff utilized standard precautions when caring for R4's catheter.On 10/14/25 at 10:43 AM, upon requesting information for the facility's waterborne pathogen/Legionella program, Administrative Staff A stated he was not aware of the requirement and did not have a system in place for it.On 10/15/25 at 10:00 AM, Administrative Staff A reported the facility lacked a policy regarding a Legionella prevention policy but was researching the information to implement one.The facility's undated Enhanced Barrier Precaution policy documented to adhere to the Centers for Disease Control (CDC) guidelines and CMS regulatory requirements as related to Enhanced Barrier Precautions to prevent the transmission of CDC targeted multi-resistant organisms (MDRO) while promoting resident quality of life by addressing the need for psychosocial well-being of residents who are infected or colonized with an MDRO and for those residents with chronic wound or indwelling medical device.

The facility had a census of 33 residents. The sample included 12 residents, with five reviewed for unnecessary medications. The facility failed to ensure as-needed (PRN) psychotropic medication had a stop date for Resident (R) 2, R5, and R26. The facility also failed to complete gradual dose reductions (GDR), with the physician's rationale of risk versus benefits, and if the GDR was clinically contraindicated for continued use of psychotropic medications for R2, R5, and R26.Findings included:- R2's Electronic Medical Record (EMR) documented that R2 had a diagnosis of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R2 was independent with most activities of daily living (ADL). The MDS documented R2 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the look-back period. R2's Care Plan, revised 06/30/25, instructed staff to administer psychotropic medications as the physician ordered, monitor for side effects and effectiveness of medications, and discuss with the physician the ongoing need for use of medication. The MDS instructed staff to review behaviors/interventions and alternative therapies attempted and the effectiveness per facility, and monitor, document, and report PRN any adverse reactions of psychotropic medications. The Physician Order, dated 12/13/23, instructed staff to administer to R2, Asenapine (an antipsychotic, a class of medications used to treat major mental conditions that cause a break from reality), 10 milligrams (mg), every day, and Aripiprazole (an antipsychotic medication), 10 mg tablet by mouth at bedtime for schizophrenia. R2's EMR from 10/09/24 -10/06/25 lacked documentation regarding a recommendation from the Consulting Pharmacist (CP) for a gradual dose reduction (GDR) for R2's Aripiprazole and Asenapine. On 10/14/25 at 12:05 PM, observation revealed R2 ambulated with red tennis shoes and eyeglasses on from the dining room to the commons area with a side-to-side gait. On 10/15/25 at 09:45 AM, Administrative Nurse D verified the facility lacked documentation regarding GDRs attempted for R2. Administrative Nurse D stated the facility did not try GDRs with residents, which could make a difference in their quality of life, but the facility had started a form yesterday, for GDR recommendations for the physician to sign and give his/her rationale for keeping residents on psychotropic medications. The facility's Psychotropic Drug Use Policy, undated, documented that GDRs would be conducted per Centers for Medicare and Medicaid (CMS) guidelines. - R5's Electronic Medical Record (EMR) included diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar type (a major mental illness that causes people to have episodes of severe high and low moods), severe intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). R5's Annual Minimum Data Set (MDS), dated [DATE], documented that R5 had moderately impaired cognition, hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and other behavioral symptoms not directed toward others behaviors which occurred one to three days of the seven day look back period. R5 required setup and clean-up assistance with personal hygiene and eating; otherwise, R5 was independent with all other functional abilities and mobility. The MDS further documented that R5 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antianxiety (a class of medications that calm and relax people), and an antidepressant (a class of medications used to treat mood disorders). The antipsychotics were received on a routine basis only and had no gradual dose reduction (GDR) or physician documented GDR as clinically contraindicated. The Psychotropic Drug Use Care Area Assessment (CAA), dated 09/05/25, documented R5 had been prescribed Trazodone (an antidepressant) every bedtime and slept at long intervals most nights. R5's Care Plan dated 09/06/25, documented R5 needed psychotropic (alters mood or thought) medications related to schizoaffective, bipolar type, and an increased risk for falls related to psychotropic medications. R5 needed haloperidol (an antipsychotic) PRN and readily available to manage episodes of acute agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition) and aggression, and R5's behaviors may result in harm to self or others. The Care Plan directed staff to administer medication per the doctor's orders, to always closely supervise R5 taking medications due to a history of pocketing (holding in the mouth and not swallowing) them. The Physician Orders dated 02/11/21 directed staff to administer: Clozaril (an antipsychotic) 200 milligrams (mg) by mouth every day, related to schizoaffective disorder, bipolar type. Clozaril 200 mg, two tablets by mouth at bedtime, related to schizoaffective disorder, bipolar type. Invega Sustenna Suspension (an antipsychotic) prefilled syringe 234 mg/1.5 milliliter (ml) intramuscularly (injected into a muscle) every 28 days related to schizoaffective disorder, bipolar type. Lamotrigine (mood stabilizer) 200 mg by mouth one time a day related to schizoaffective disorder, bipolar type. Mirtazapine (an antidepressant) 15 mg by mouth at bedtime for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Trazodone 100 mg, give two tablets by mouth at bedtime for insomnia (inability to sleep). Trazodone 50 mg by mouth at bedtime for insomnia. Haloperidol (an antipsychotic) 5 mg by mouth two times a day, related to schizoaffective disorder, bipolar type. Haloperidol 5 mg/5 ml intramuscularly every 24 hours as needed for psychosis (any major mental disorder characterized by a gross impairment in reality perception) related to schizoaffective disorder, bipolar type. This order lacked a duration or a stop date. Trazodone 50 mg by mouth every 24 hours as needed for insomnia. This order lacked duration or a stop date. R5's Consultant Pharmacist Monthly Review from 10/09/24 to 10/06/25 lacked a recommendation related to a GDR of psychotropic drug use or required duration for PRN antipsychotic and antianxiety medication. On 10/14/25 at 10:31 AM, R5 was walking around the facility, dressed and groomed appropriately for the day. R5 had been to the dining room for breakfast earlier. On 10/15/25 at 09:11 AM, Administrative Nurse D reported due to the clients the facility cared for, the facility did not do GDR's and the Consultant Pharmacist had not recommended them either. Administrative Nurse D stated the facility had been working on getting stop dates for psychotropic medications. The facility's undated Psychotropic Drug Use policy documented that residents would only receive antipsychotic and psychotropic medications when necessary to treat specific conditions for which they are indicated and effective, and would not be used for discipline or the convenience of the staff. Limit PRN orders for anti-depressant, hypnotics, and antianxiety drugs to 14 days. This may be extended beyond the 14 days through documentation in the medical record by the practitioner as to why this should occur. Limit PRN orders for anti-psychotics to 14 days. They may not be renewed unless the practitioner evaluates the resident for appropriateness of the drug. Gradual dose reductions would be conducted per CMS (Centers for Medicare and Medicaid Services) guidelines. The community shall elicit the Physician's response and request documentation on whether the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. - R26's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) bipolar type (a major mental illness that causes people to have episodes of severe high and low moods), constipation (difficulty passing stools), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R26 had intact cognition and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). R26 required setup/clean up assistance with eating and showering, and was independent with all other functional abilities and mobility. R26 was always continent of urine and bowel. The MDS further documented that R26 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antianxiety (a class of medications that calm and relax people). The antipsychotic was received on a routine basis, and a gradual dose reduction (GDR) was attempted on 08/07/20; the physician had documented the GDR as clinically contraindicated on 08/07/20. The Psychotropic Drug Use Care Area Assessment, dated 05/1/25, documented R26 had a medical history of hypotension (low blood pressure), COPD, constipation, and schizoaffective disorder. No analysis findings were completed. R26's Care Plan dated 09/05/25, documented R26 used psychotropic medications related to schizoaffective disorder, bipolar type, had hoarding (practice of accumulating and hiding away goods and resources), self-care deficit, and a history of aggressive behavior. The Care Plan directed staff that R26 needed hydroxyzine (used to treat anxiety- mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) 50 mg PRN to manage acute episodes of agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition) and aggression, and his behavior may result in harm to self or others. The Care Plan further documented that R26 would be followed by psychiatry, to monitor for extrapyramidal symptoms (EPS- movement disorder that can occur as side effect of certain medications) and tardive dyskinesia (an abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk (TD) symptoms, would take all prescribed medications as ordered and would be monitored for effectiveness and/or side effects. The staff are to monitor/document/ report PRN any adverse reactions to psychotropic medications. On 02/03/21, the Physician Order directed staff to administer: Haloperidol (an antipsychotic) 5 milligrams by mouth two times a day for schizoaffective disorder, bipolar type. Quetiapine (an antipsychotic) 100 mg by mouth two times a day, related to schizoaffective disorder, bipolar type. Haloperidol 5 mg by mouth every four hours as needed for psychosis related to schizoaffective disorder, bipolar type (the order lacked a stop or duration date). Hydroxyzine (lacked specific dose) by mouth every six hours for itching and up to two tablets at bedtime. Lorazepam (an antianxiety) 2 mg by mouth every four hours as needed for psychosis related to schizoaffective disorder, bipolar type (the order lacked a stop or duration date). Review of R26's Consultant Pharmacist Monthly Reviews dated 10/09/24 to 10/06/25 lacked a recommendation related to a GDR of psychotropic drug use or required duration for PRN antianxiety or antipsychotic medication. On 10/14/25 at 08:30 AM, R26 was up and dressed for the day. He has finished breakfast in the dining room and is called over to the medication cart for his medications. He took them without problems. On 10/15/25 at 09:11 AM, Administrative Nurse D reported due to the clients the facility cared for, the facility did not do GDR's and the Consultant Pharmacist had not recommended them either. Administrative Nurse D stated the facility had been working on getting stop dates for psychotropic medications. The facility's undated Psychotropic Drug Use policy documented that residents will only receive antipsychotic and psychotropic medications when necessary to treat specific conditions for which they are indicated and effective, and will not be used for discipline or the convenience of the staff. Limit PRN orders for anti-depressant, hypnotics, and antianxiety drugs to 14 days. This may be extended beyond the 14 days through documentation in the medical record by the practitioner as to why this should occur. Limit PRN orders for anti-psychotics to 14 days. They may not be renewed unless the practitioner evaluates the resident for appropriateness of the drug. Gradual dose reductions will be conducted per CMS (Centers for Medicare and Medicaid Services) guidelines. The community shall elicit the Physician's response and request documentation on whether the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences.

The facility had a census of 33 residents. The sample included 12 residents, with five reviewed for unnecessary medications. The facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities to the attending physician, the facility medical director, and the director of nursing for Resident (R) 2, R6, R5, and R26. Findings included:- R2's Electronic Medical Record (EMR) documented that R2 had a diagnosis of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R2's Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R2 independent of most activities of daily living (ADL). The MDS documented R2 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the look-back period. R2's Care Plan, revised 06/30/25, instructed staff to administer psychotropic medications as the physician ordered, monitor for side effects and effectiveness of medications, and discuss with the physician the ongoing need for use of medication. The MDS instructed staff to review behaviors/interventions and alternative therapies attempted and the effectiveness per facility, and monitor, document, and report as needed (PRN) any adverse reactions of psychotropic medications. The Physician Order dated 12/13/23 instructed staff to administer Asenapine (an antipsychotic, a class of medications used to treat major mental conditions that cause a break from reality), 10 milligrams (mg) every day, and Aripiprazole (an antipsychotic medication), 10 mg tablet by mouth at bedtime for schizophrenia. R2's EMR from 10/09/24 -10/06/25 lacked documentation. The CP identified and reported to administration the need for a gradual dose reduction (GDR) for R2's Aripiprazole and Asenapine. On 10/14/25 at 12:05 PM, observation revealed R2 ambulated with red tennis shoes and eyeglasses on from the dining room to the commons area with a side-to-side gait. On 10/15/25 at 09:45 AM, Administrative Nurse D verified the CP had not identified R2's need for a GDR for R2's psychotropic medications. Administrative Nurse D stated the facility did not try GDRs with residents, which could make a difference in their quality of life, but the facility had started a form yesterday, for GDR recommendations for the physician to sign and give their rationale for keeping residents on psychotropic medications. The facility's Pharmacy Services Policy, undated, documented that the CP would help establish procedures for conducting the monthly medication regimen review (MRR) for each resident in the facility. The facility's Psychotropic Drug Use Policy, undated, documented GDRs would be conducted per Centers for Medicare and Medicaid (CMS) guidelines. - R6 's Electronic Medical Record (EMR) documented that R6 had a diagnosis of psychotic disturbance (any major mental disorder characterized by a gross impairment in reality perception). R6's Quarterly Minimum Data Set (MDS) dated [DATE] documented R6 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS documented R6 independent of most activities of daily living (ADL). The MDS documented R6 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the look-back period. R6's Care Plan, revised 09/06/25, instructed staff to administer R6 's psychotropic medications as the physician ordered and monitor R6 for side effects and effectiveness of her medications. The plan instructed staff to consult with the CP and, physician to consider dosage reduction when clinically appropriate at least quarterly. The plan instructed staff to monitor R6 for adverse reactions to her psychotropic medications. The Physician Order dated 02/28/24 instructed staff to administer Aripiprazole (an antipsychotic medication). R6's EMR from 10/09/24 -10/06/25 lacked documentation regarding the CP identified and reported to administration the need for a gradual dose reduction (GDR) for R6's Aripiprazole. On 10/14/25 at 12:00 PM, R6 sat quietly at the dining room table with other residents, independently eating her meal. On 10/15/25 at 09:45 AM, Administrative Nurse D verified the CP had not identified R6's need for a GDR for R6's psychotropic medication. Administrative Nurse D stated the facility did not try GDRs with residents, which could make a difference in their quality of life, but the facility had started a form yesterday, for GDR recommendations for the physician to sign and give their rationale for keeping residents on psychotropic medications. The facility's Pharmacy Services Policy, undated, documented that the CP would help establish procedures for conducting the monthly medication regimen review (MRR) for each resident in the facility. The facility's Psychotropic Drug Use Policy, undated, documented GDRs would be conducted per Centers for Medicare and Medicaid (CMS) guidelines. - Resident (R) 5's Electronic Medical Record (EMR) included diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar type (a major mental illness that causes people to have episodes of severe high and low moods), severe intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life), and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). R5's Annual Minimum Data Set (MDS), dated [DATE], documented that R5 had moderately impaired cognition, hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and other behavioral symptoms not directed toward others behaviors which occurred one to three days of the seven day look back period. R5 required setup and clean-up assistance with personal hygiene and eating; otherwise, R5 was independent with all other functional abilities and mobility. The MDS further documented that R5 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antianxiety (a class of medications that calm and relax people), and an antidepressant (a class of medications used to treat mood disorders). The antipsychotics were received on a routine basis only and had no gradual dose reduction (GDR) or physician documented GDR as clinically contraindicated. The Psychotropic Drug Use Care Area Assessment (CAA), dated 09/05/25, documented R5 had been prescribed Trazodone (an antidepressant) every bedtime and slept at long intervals most nights. R5's Care Plan dated 09/06/25, documented that R5 needed psychotropic (alters mood or thought) medications related to schizoaffective, bipolar type, and an increased risk for falls related to psychotropic medications. R5 needed haloperidol (antipsychotic) as needed (PRN) and readily available to manage episodes of acute agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition) and aggression, and R5's behaviors may result in harm to self or others. The Care Plan directed staff to administer medication per the doctor's orders, to always closely supervise R5 taking medications due to a history of pocketing (holding in the mouth and not swallowing) them. The Physician Orders dated 02/11/21 directed staff to administer: Clozaril (an antipsychotic) 200 milligrams (mg) by mouth every day, related to schizoaffective disorder, bipolar type. Clozaril 200 mg, two tablets by mouth at bedtime, related to schizoaffective disorder, bipolar type. Invega Sustenna Suspension (an antipsychotic) prefilled syringe 234 mg/1.5 milliliter (ml) intramuscularly (injected into a muscle) every 28 days related to schizoaffective disorder, bipolar type. Lamotrigine (mood stabilizer) 200 mg by mouth one time a day related to schizoaffective disorder, bipolar type. Mirtazapine (an antidepressant)15 mg by mouth at bedtime for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Trazodone 100 mg, give two tablets by mouth at bedtime for insomnia (inability to sleep). Trazodone 50 mg by mouth at bedtime for insomnia. Haloperidol (an antipsychotic) 5 mg by mouth two times a day, related to schizoaffective disorder, bipolar type. Haloperidol 5 mg/5 ml intramuscularly every 24 hours as needed for psychosis (any major mental disorder characterized by a gross impairment in reality perception) related to schizoaffective disorder, bipolar type. This order lacked a duration or a stop date. Trazodone 50 mg by mouth every 24 hours as needed for insomnia. This order lacked duration or a stop date. R5's Consultant Pharmacist Monthly Review from 10/09/24 to 10/06/25 lacked a recommendation related to a GDR of psychotropic drug use or required duration for PRN antipsychotic and antianxiety medication. On 10/14/25 at 10:31 AM, R5 was walking around the facility, dressed and groomed appropriately for the day. R5 had been to the dining room for breakfast earlier. On 10/15/25 at 09:11 AM, Administrative Nurse D reported due to the clients the facility cared for did not do GDR's and the consultant pharmacist had not recommended them either. Administrative Nurse D stated the facility had been working on getting stop dates for psychotropic medications. The facility's undated Pharmacy Services policy documented that the Licensed Pharmacist shall collaborate with staff and practitioners to address and resolve medication-related needs or problems and help the facility establish procedures for conducting the monthly medication regimen review for each resident in the facility. The facility's undated Psychotropic Drug Use policy documented that GDR dose reductions will be conducted per the Centers for Medicare and Medicaid Services (CMS) guidelines. The community shall elicit the Physician's response and request documentation on whether the benefits of the medication outweigh the risk or suspected or confirmed adverse consequences. - R26's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), bipolar type (a major mental illness that causes people to have episodes of severe high and low moods), constipation (difficulty passing stools), and chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). R26's Quarterly Minimum Data Set (MDS), dated [DATE], documented that R26 had intact cognition and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). R26 required setup/clean up assistance with eating and showering, and was independent with all other functional abilities and mobility. R26 was always continent of urine and bowel. The MDS further documented that R26 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antianxiety (a class of medications that calm and relax people). The antipsychotic was received on a routine basis, and a gradual dose reduction (GDR) was attempted on 08/07/20; the physician had documented the GDR as clinically contraindicated on 08/07/20. The Psychotropic Drug Use Care Area Assessment, dated 05/18/25, documented R26 had a medical history of hypotension (low blood pressure), COPD, constipation, and schizoaffective disorder. No analysis findings completed. R26's Care Plan dated 09/05/25, documented R26 used psychotropic medications related to schizoaffective disorder, bipolar type, had hoarding (practice of accumulating and hiding away goods and resources), self-care deficit, and a history of aggressive behavior. The Care Plan directed staff that R26 needed hydroxyzine (used to treat anxiety) 50 mg as needed (PRN) to manage acute episodes of agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition) and aggression, and his behavior may result in harm to self or others. The Care Plan further documented that R26 would be followed by psychiatry, to monitor for extrapyramidal symptoms (EPS- movement disorder that can occur as side effect of certain medications) and tardive dyskinesia (an abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk (TD) symptoms, would take all prescribed medications as ordered, and would be monitored for effectiveness and/or side effects. The staff are to monitor/document/ report PRN any adverse reactions of psychotropic medications. On 02/03/21, the Physician Order directed staff to administer: Haloperidol (an antipsychotic) 5 milligrams by mouth two times a day for schizoaffective disorder, bipolar type. Quetiapine (an antipsychotic) 100 mg by mouth two times a day, related to schizoaffective disorder, bipolar type. Haloperidol 5 mg by mouth every four hours as needed for psychosis related to schizoaffective disorder, bipolar type (the order lacked a stop or duration date). Hydroxyzine (lacked specific dose) by mouth every six hours for itching and up to two tablets at bedtime. Lorazepam (an antianxiety) 2 mg by mouth every four hours as needed for psychosis related to schizoaffective disorder, bipolar type (the order lacked a stop or duration date). Review of R26's Consultant Pharmacist Monthly Reviews dated 10/09/24 to 10/06/25 lacked a recommendation related to a GDR of psychotropic drug use or required duration for PRN antianxiety or antipsychotic medication. On 10/14/25 at 8:30 AM, R26 was up and dressed for the day. He had finished breakfast in the dining room and was called over to the medication cart for his medications. He took them without problems. On 10/15/25 at 09:11 AM, Administrative Nurse D reported due to the clients the facility cared for did not do GDR's and the consultant pharmacist had not recommended them either. Administrative Nurse D stated the facility had been working on getting stop dates for psychotropic medications. The facility's undated Pharmacy Services policy documented that the Licensed Pharmacist shall collaborate with staff and practitioners to address and resolve medication-related needs or problems and help the facility establish procedures for conducting the monthly medication regimen review for each resident in the facility. The facility's undated Psychotropic Drug Use policy documented that GDR dose reductions would be conducted per the Centers for Medicare and Medicaid Services (CMS) guidelines. The community shall elicit the Physician's response and request documentation on whether the benefits of the medication outweigh the risk or suspected or confirmed adverse consequences.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide a Bed Hold Notification for Resident (R) 4, who was hospitalized on [DATE] and 03/25/25, and R6 hospitalization on 06/26/25. Findings included:- R4's Electronic Medical Record (EMR) included diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), epilepsy (brain disorder characterized by repeated seizures), and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented R4's staff cognition assessment as modified independence, experienced inattentiveness and disorganized thinking which fluctuated, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), verbal behaviors directed toward others daily, other behaviors not directed toward others daily, and rejected care for four to six days during a seven-day look-back period. R4 required setup and clean up assistance with eating and dressing, and partial to moderate assistance with oral care, toileting, and personal hygiene, and independent with mobility. R4 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was frequently incontinent of bowel. R4's Care Plan dated 08/25/25, documented R4 had potential for complications related to the indwelling catheter for chronic bladder obstruction and cryoablation of prostate cancer (a treatment method that uses cryotherapy to freeze and destroy cells in the prostate gland). The Care plan directed staff to assess, record, and report to the physician as needed, signs or symptoms of urinary tract infection. The Progress Note dated 02/23/25 at 05:58 AM documented that staff found R4 unresponsive at 04:30 AM. After receiving physician orders to send R4 to the emergency room to evaluate and treat R4, staff called 911. The ambulance left with the resident at 04:50 AM. The Progress Note dated 02/25/25 at 11:22 AM documented that R4 had returned to the facility at 10:45 AM. The Progress Note dated 03/25/25 at 12:22 PM documented that R4's practitioner had been notified that R4 had a fever and a change in his level of consciousness. The practitioner gave orders to send R4 to the emergency room. The ambulance left with R4 at 12:21 PM. The Progress Note dated 03/25/25 at 12:26 PM documented that the bed hold policy was sent to R4's guardian family member. The Progress Note dated 04/03/25 at 11:09 AM documented that R4 had returned to the facility. On 10/14/25 at 08:09 AM, R4 ambulated independently to the commons area toward the facility entry. He was dressed in sweatpants with a urine collection bag attached to his right lower leg. He had frequent jumping and hand gestures to point a gun and verbalized Bam. On 10/15/25 at 09:11 AM, Administrative Nurse D reported that the bed holds were to be sent when a resident went to the hospital, but at times the resident was not able to sign for themselves, or the facility would call or email the resident's representative. Administrative Nurse D stated that verbal confirmation had not been documented, or the notices were not followed up on to obtain signatures. On 10/16/25 at 10:00 AM, Social Services X stated the bed hold had not been sent for R4's hospital admission of 02/23/25, and a bed hold for the 03/25/25 hospitalization had not been returned signed from R4's guardian family member. The facility's Discharge/Transfer/Bed Hold policy, dated 12/10/24, documents that a bed hold policy would be signed by the resident or legal representative upon transfer. - R6's Electronic Medical Record (EMR) documented the resident had diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and dementia (a progressive mental disorder characterized by failing memory and confusion). R6's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented R6 independent with most activities of daily living (ADL). The MDS documented R6 had no urinary tract infection (UTI- infection in any part of the urinary system). R6's Care Plan, revised 09/06/25, instructed staff to monitor/document/report as needed (PRN) any changes, any potential for improvement, reasons for self-care deficit, expected course, or declines in function. R6's Progress Notes, dated 06/26/25, documented R6 was transferred to the hospital. The Bed Hold Policy, dated 06/26/25, lacked R6's or her representative's signature. The clinical record lacked documentation of R6, or her representative was provided written notice of her transfer to the hospital. On 10/14/25 at 02:20 PM, Social Services X verified R6, or her representative, had not signed the bed hold policy when R6 was transferred to the hospital. Social Services X stated R6 was unable to sign, and she had provided R6's representative the bed hold policy by telephone and had documented the notification in the progress notes. On 10/15/25 at 09:45 AM, Administrative Nurse D stated Social Services X was responsible for providing R6 or her representative with the bed hold policy when a resident is transferred to the hospital if the resident is unable to sign, Social Services X would notify the representative over the phone. Administrative Nurse D verified the facility had not followed up and received a signed bed hold policy from R6 or her representative. Administrative Nurse D was unaware the facility was to provide written notice to R6 or her representative, explaining the reason for R6's transfer to the hospital. The facility's Discharge/Transfer/Bed Hold policy, revised 12/10/24, documented a bed hold policy would be signed by the resident or legal representative upon transfer to the hospital.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to submit a required discharge and re-entry Minimum Data Set for Resident (R) 4, who was hospitalized on [DATE] and returned to the facility on [DATE].Findings include:- R4's Electronic Medical Record (EMR) included diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), epilepsy (brain disorder characterized by repeated seizures), and hypothyroidism (a condition characterized by decreased activity of the thyroid gland).R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented R4's staff cognition assessment as modified independence, experienced inattentiveness and disorganized thinking which fluctuated, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), verbal behaviors directed toward others daily, other behaviors not directed toward others daily and rejected care for four to six days during a seven-day look-back period. R4 required setup and clean up assistance with eating and dressing, and partial/moderate assistance with oral care, toileting, and personal hygiene, and independent with mobility. R4 had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and was frequently incontinent of bowel.R4's EMR lacked a discharge MDS for R4's admission to the hospital on [DATE] and an entry MDS on 04/03/25, when R4 was readmitted to the facility.R4's Care Plan dated 08/25/25, documented R4 had potential for complications related to the indwelling catheter for chronic bladder obstruction and cryoablation (a medical procedure that uses extreme cold to destroy abnormal or diseased tissue) of prostate cancer. The Care plan directed staff to assess, record, and report to the physician as needed, signs or symptoms of urinary tract infection (UTI- an infection in any part of the urinary system).The Progress Note dated 03/25/25 at 12:22 PM documented that R4's practitioner had been notified that R4 had a fever and a change in his level of consciousness. The practitioner gave orders to send R4 to the emergency room. The ambulance left with R4 at 12:21 PM.The Progress Note dated 04/03/25 at 11:09 AM documented that R4 had returned to the facility.On 10/14/25 at 08:09 AM, R4 ambulated independently to the commons area toward the facility entry. He was dressed in sweatpants with a urine collection bag attached to his right lower leg. He had frequent jumping and hand gestures to point a gun and verbalized Bam.On 10/15/25 at 09:11 AM, Administrative Nurse D reported that she was responsible for the MDS process, and a discharge and entry should have been done for R4's admission to the hospital on [DATE] and an entry MDS on 04/03/25.The facility's undated MDS Assessment policy documented that a Registered Nurse shall be designated the responsibility of conducting and coordinating each resident's assessment (MDS).

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the medication and biologicals for the residents were not outdated.Finding included:- On [DATE] at 09:07 AM, the facility had one medication and treatment cart. Upon initial tour of the facility treatment cart revealed Resident (R) 29 Nystatin Cream (an antifungal which treats fungal or yeast infections) had an expiration date of [DATE]. Licensed Nurse (LN) G verified the expiration date and removed it from the cart.On [DATE] at 09:11 AM, Administrative Nurse D stated it was the charge nurse's responsibility to check the expiration dates of the treatments. Administrative Nurse D reported that R29's expired medication had been removed from the treatment cart.The facility's Storage of Medication policy, dated [DATE], documented that the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, interventions, and record review, the facility failed to implement protocols to avoid unnecessary and/or inappropriate antibiotic (medications used to treat infectious processes) use, adverse events, and multidrug-resistant organisms (MDRO- common bacteria that have developed resistance to multiple types of antibiotics), and to assess for infection using standardized tools and criteria before antibiotic use.Findings included:- On 10/15/25 at 09:11 AM, a review of the facility's Antibiotic Stewardship Program revealed that Administrative Nurse D provided the monthly tracking logs of infections and treatments. The tracking logs documented the type of infections to include respiratory, urinary tract, ophthalmic (pertaining to the eye), optic (pertaining to the ear), skin, wounds, gastrointestinal (pertaining to the stomach or intestinal tract), and other. The monthly tracking log also recorded the treatment course for the infections, including the start and end of antibiotic use. Administrative Nurse D stated the facility had not utilized a standardized criteria tool before antibiotics were ordered, nor a stop and watch system, and was unsure what McGeer's criteria were. Administrative Nurse D stated the staff reported signs and symptoms to the physicians, and occasionally, the physician would obtain a culture for urinary tract infections and would change the antibiotic if needed. Administrative Nurse D stated the physician would generally order a broad-spectrum antibiotic to ensure the infectious process was covered by the causing microorganism. The facility's undated Infection Control Program-Antibiotic Stewardship policy documented that the community had established an infection prevention and control program that included protocols to establish a system for the use and monitoring of adverse effects of antibiotics. Antibiotic Stewardship is a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse effects associated with antibiotic use. Loeb Criteria (minimum criteria for the initiation of antibiotics) and McGeer Criteria (surveillance criteria) were used as a guideline.

The facility had a census of 33 residents. The facility had one kitchen. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 32 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 02/20/24 at 10:30 AM, a review of the noon meal consisted of spaghetti and noodles, lettuce salad, and peach cobbler. On 02/20/24 at 11:00 AM, observation revealed Dietary Staff (DS) BB in the kitchen overseeing the preparation of the noon meal. On 02/20/24 at 10:30 AM, DS BB stated he was not certified and was not enrolled in certified dietary manager classes. On 2/21/24 at 1:05 PM, Administrative Nurse D verified DS BB was not certified and had not started dietary certification classes. Upon request, the facility did not provide a policy regarding a certified dietary manager. The facility failed to employ a full-time certified dietary manager, for 33 residents who resided in the facility who received meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.

The facility had a census of 33 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 1 and FY 2023 Quarter 2 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple (10) dates. A review of the facility licensed nurse timeclock data for the dates listed on the PBJ revealed a licensed nurse was on duty for 24 hours a day seven days a week. On 02/19/24 at 08:30 AM, observation revealed a registered nurse on duty in the facility. On 02/21/24 at 10:00 AM, Administrative Staff verified the facility did not send in the correct data to CMS for payroll-based data. The facility's undated Reporting Payroll Based Data Journal policy, states that complete, and accurate direct care staffing information is to be reported electronically and, in the uniform, specified by CMS. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure staff possessed the knowledge necessary to provide medications within acceptable standards of practice when staff pre-set nine residents' medications before administration time. This placed the residents at risk of receiving the wrong medications. Findings included: - On 02/19/24 at 09:40 AM, observation in the top drawer of the medication cart revealed medication cups, each containing various unidentified and unlabeled pills. The cups were labeled with a resident name. Licensed Nurse (LN) G verified the cups contained noon medications for nine residents and stated she always set them up a little early. On 02/19/24 at 09:43 AM, Administrative Nurse D verified the above resident medications were pre-set and stated it was all right for LN G to pre-set medications if the medication cups were well marked. Administrative Nurse D stated if the nurse had an emergency and had to leave after pre-setting the medications, staff would destroy the medications and administer new ones from the residents' pill cards. The facility's Medication Management Policy, undated, documented medications would be administered at the time they are prepared. Medications are not pre-poured. Medications would be administered without unnecessary interruptions. The person who prepares the dose for administration is the person who administers the dose. The facility failed to ensure staff possessed the knowledge necessary to provide medications within acceptable standards of practice when staff pre-set nine residents' medications before administration time. This placed the residents at risk of receiving the wrong medications.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to discard an outdated insulin (a hormone that lowers the level of glucose in the blood) pen and failed to place an open date on two insulin pens (a disposable or reusable instrument, the size of a marker, used to deliver insulin) in the medication room. The facility failed to store medications properly, in their original packaging which included the medication name, dosage, and instructions for administration. This placed the residents at risk for medication errors and receiving ineffective medications. Findings included: - On 02/19/24 at 09:32 AM, observation of the medication room revealed a resident's Lantus (long-acting insulin) insulin pen with an open date of 12/25/23, a Humalog (a fast-acting insulin) pen without an open date, and an unreadable open date on a resident's Levemir (a long-acting insulin) insulin pen. On 02/19/24 at 09:32 AM, Licensed Nurse (LN) G verified the above findings and discarded the insulin pens in the medication room. On 02/19/24 at 09:40 AM, observation in the top drawer of the medication cart revealed medication cups, each containing various unidentified and unlabeled pills. The cups were labeled with a resident name. Licensed Nurse (LN) G verified the cups contained noon medications for nine residents and stated she always set them up a little early. On 02/19/24 at 09:43 AM, Administrative Nurse D verified the above resident medications were pre-set and stated it was all right for LN G to pre-set medications if the medication cups were well marked. Administrative Nurse D stated if the nurse had an emergency and had to leave after pre-setting the medications, staff would destroy the medications and administer new ones from the residents' pill cards. On 02/21/24 at 01:05 PM, Administrative Nurse D stated she expected staff to immediately date insulin pens when they opened the pens. The facility's Storage of Medications Policy, undated, documented the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The facility failed to appropriately store medications and failed to ensure insulin pens were dated when opened and discarded when outdated. This placed the affected residents at risk for medication errors and ineffective medications.

The facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise Resident (R)7's Care Plan to include a section with instructions to staff regarding R7's safety with smoking. This placed the resident at risk for impaired care due to uncommunicated care needs. Findings included: - R7's Electronic Medical Record (EMR) documented R7 had diagnoses of schizoaffective disorder (mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). R7's Annual Minimum Data Set (MDS), dated [DATE], documented R7 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R7 was independent with activities of daily living (ADLs) and had delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue). The Care Area Assessment (CAA) did not trigger for smoking. R7's Care Plan, revised 02/02/24, documented R7 had an ADL self-care performance deficit related to her schizoaffective disorder. The care plan lacked a section with instructions to staff on R7's smoking safety. The Smoking Safety Screen, dated 11/01/23, documented R7 smoked five to ten times daily and she required supervision while smoking. The screen recorded the facility would store R7's lighter and cigarettes and instructed staff to light R7's cigarettes. On 02/20/24 at 08:27 AM, observation revealed R7 lined up by the exit door located off the dining room. Staff retrieved cigarettes from a locked locker on a tray with each resident's name on a separate cup. Staff gave R7 a cigarette, unlocked the exit door, and lit the cigarette outside the door. R7 went to the patio with staff supervision and smoked her cigarette. On 02/21/24 at 01:05 PM, Administrative Nurse D verified R7's Care Plan lacked a smoking section and stated she never developed a care plan for smokers unless they had health-related concerns. Administrative Nurse D said she did complete quarterly smoking assessments on R7. The facility's Care Plans-Comprehensive Policy, undated, documented the care planning/interdisciplinary team was responsible for periodic review and updating of care plans. The facility failed to update R7's Care Plan with a smoking section with instructions to staff for keeping R7 safe while smoking. This placed the resident at risk for impaired care due to uncommunicated care needs.

The facility had a census of 33. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the consultant pharmacist (CP) identified and reported the lack of a stop date for Resident (R) 24's as-needed (PRN) psychotropic (altering mood or thoughts) medication. This placed the resident at risk for unnecessary medication side effects. Findings included: - R24's Electronic Medical Record (EMR) documented R24 had a diagnosis of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R24's Admission Minimum Data Set (MDS), dated [DATE], documented R24 had a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS documented R24 was independent with most activities of daily living (ADLs) and received PRN antianxiety (class of medications that calm and relax people) medication daily during the observation period. R24's Care Plan, revised 01/27/24, documented the resident used psychotropic medications and instructed staff to administer those medications as the physician ordered. The plan directed staff to monitor, document, and report as needed any adverse reaction to the medications. The Physician Order, dated 12/23/23, instructed staff to administer lorazepam (antianxiety medication), 1 milligram (mg), twice a day PRN. The order lacked a stop date. The facility's CP Regimen Review, for 01/08/24 and 02/05/24 lacked documentation the CP identified R24's PRN lorazepam did not have a stop date. On 02/19/24 at 03:07 PM, observation revealed R24 sat quietly in a chair in the living room area, looking at a book. On 02/20/24 at 01:00 PM, Administrative Nurse D verified R24's PRN lorazepam had no stop date and the pharmacist had failed to identify it needed one. Administrative Nurse D stated the facility had to keep the lorazepam PRN for the resident because she had anxiety. Administrative Nurse D stated as far as she knew, mental health facilities were exempt from having a stop date on psychotropic medications. The Pharmacy Services Policy, undated, documented the licensed pharmacist would help establish procedures for conducting the monthly medication regimen review (MRR) for each resident in the facility. The facility failed to ensure the CP identified and reported the lack of a stop date for R24's PRN psychotropic medication. This placed the resident at risk for unnecessary medication side effects.

The facility had a census of 33 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure a 14-day stop date for Resident (R) 18's as-needed (PRN) antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment testing) and further failed to ensure R24's PRN lorazepam had a 14-day stop date, or a specified duration with a physician documented rationale for extended use. This placed the residents at risk for unnecessary psychotropic (alters mood or thought) medications. Findings Included: - R18's Electronic Medical Record (EMR) documented R18 had diagnoses of schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) and psychosis (any major mental disorder characterized by a gross impairment in perception). R18's Annual Minimum Data Set (MDS), dated [DATE], documented R18's Brief Interview of Mental Status (BIMS) score was 15, which indicated intact cognition. The MDS documented R18 was independent with activities of daily living (ADLs). The MDS documented R18 received an antipsychotic, an antianxiety (class of medications that calm and relax people) medication, and an antidepressant (class of medications used to treat mood disorders) medication every day during the observation period. The Psychotropic Care Area Assessment (CAA), dated 02/02/24, documented R18 yelled out at unseen others and had mental illness which affected her memory and thought process at times. R18 received a psychotropic medication daily during the observation period. R18's Care Plan, revised 11/07/23, documented R18 had an increased risk for ADL self-care performance deficit related to schizoaffective disorder and instructed staff to praise her for all efforts she made towards independent decisions about ADLs. The plan directed staff to provide reassurance that the water and soap would not make R18 sick and to wash and give R18 her clothes back to her as soon as possible. Staff should supervise R18 when she shaved. The care plan instructed staff to administer R18 all medication on time per physician order, observe for any adverse or positive effects, and report and document refusal of medication to the psychiatric physician. The care plan instructed staff to make sure R18's Haldol (antipsychotic medication) and lorazepam (antianxiety) medications were readily available to manage R18's acute episodes of agitation and aggression. The Physician Order, dated 02/02/23, instructed staff to administer Haldol, 10 milligrams (mg), one-half tablet PRN. The order lacked a stop date. On 02/19/24 at 04:20 PM, observation revealed R18 sat quietly in a chair in the living area by the front entrance door. On 02/20/24 at 01:00 PM, Administrative Nurse verified R18's physician order for PRN Haldol had no stop date. Administrative Nurse D stated the facility had to keep the PRN Haldol for the resident. Administrative Nurse D said as far as she knew, mental health facilities were exempt from having a stop date on PRN psychotropic medications. The facility's Psychotropic Drug Use Policy, undated, documented PRN antipsychotics would be limited to 14 days. They may not be renewed unless the practitioner evaluates the resident for the appropriateness of the drug. The facility failed to place a stop date on R18's PRN Haldol. This placed the resident at risk of receiving unnecessary medication and complications. - R24's Electronic Medical Record (EMR) documented R24 had a diagnosis of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). R24's Admission Minimum Data Set (MDS), dated [DATE], documented R24 had a Brief Interview of Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. The MDS documented R24 was independent with most activities of daily living (ADLs) and received PRN antianxiety (class of medications that calm and relax people) medication daily during the observation period. R24's Care Plan, revised 01/27/24, documented the resident used psychotropic medications and instructed staff to administer those medications as the physician ordered. The plan directed staff to monitor, document, and report as needed any adverse reaction to the medications. The Physician Order, dated 12/23/23, instructed staff to administer lorazepam (antianxiety medication), 1 milligram (mg), twice a day PRN. The order lacked a stop date. On 02/19/24 at 03:07 PM, observation revealed R24 sat quietly in a chair in the living room area, looking at a book. On 02/20/24 at 01:00 PM, Administrative Nurse D verified R24's PRN lorazepam had no stop date and stated the facility had to keep the lorazepam PRN for the resident because she had anxiety. Administrative Nurse D stated as far as she knew, mental health facilities were exempt from having a stop date on psychotropic medications. The facility's Psychotropic Drug Use Policy, undated documented PRN antipsychotics would be limited to 14 days. They may not be renewed unless the practitioner evaluates the resident for the appropriateness of the drug. The facility failed to place a stop date on R24's PRN lorazepam. This placed the resident at risk of receiving unnecessary medication and complications.

The facility identified a census of 34 residents. The sample included 12 residents with two reviewed for bowel and bladder management. Based on observation, record review, and interviews, the facility failed to assess, identify and implement an individualized bowel and bladder interventions for Resident (R)18 who had increased incontinence. This deficient practice placed the resident at risk for complications related to increased incontinence. Findings Included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of eight indicating moderate cognitive impairment. The MDS recorded he was always continent of bladder but occasionally incontinent of bowel. The MDS noted he had no toileting program for bowel or bladder and was independent with all his activities of daily living (ADL's). A review of R18's Cognitive Loss Care Area Assessment (CAA) dated 06/10/22 noted that he was diagnosed with limited intelligence ability. The CAA noted that he had infrequent periods of time with bowel and bladder incontinence. R18's Urinary Incontinence CAA was not triggered. A review of R18's Baseline Care Plan dated 05/13/21 noted that he was continent of bowel and bladder. R18's Care Plan initiated 09/7/21 noted that he had increased bowel and bladder incontinence. The plan indicated to establish a voiding pattern, provide incontinence products and peri-care, and wash clothing and bedding immediately after incontinence episode to avoid odor. A review of R18's Bladder Incontinence Evaluation dated 02/10/22 noted that he had complete control of his bladder and a bladder program was not indicated. The evaluation noted that R18 had occasional bowel incontinence but did not list interventions or if a bowel toileting program would be appropriate. R18's EMR lacked documentation of other evaluations. A review of R18's coloscopy (examination of the colon for abnormalities) results on 03/22/22 revealed no abnormalities or complications. A review of R18's Care Plan Note dated 07/08/22 noted that he required assistance with his ADL's. The note indicated that he wore incontinent briefs at all times due to him being incontinent of both bowel and bladder. The note indicated that R18 had no [CONDITION(S)] activity since his admission. R18 could not tolerate community living due to not initiating any of his self-care activities himself; R18 had daily delusions. R18's clinical record lacked evidence the facility reassessed R18's voiding and elimination patterns or type of incontinence and lacked evidence interventions were attempted to address the increased bowel and bladder incontinence. On 10/18/22 at 12:38PM R18 returned from his lunch. He stated that he was heading back to his room to rest. He stated that he does have episodes of incontinence of both bowel and bladder and wore briefs under his clothing in case he had an accident. R18 did not know if he had an individualized toileting program to help incontinent episodes. On 10/20/22 at 11:40AM an interview with Certified Medication Aid (CMA) R, she stated that all residents were toileted every two hours. She stated that R18 was incontinent of bowel and bladder with occasional accidents. She stated that R18 was not on a toileting program for his incontinence. On 10/20/22 at 11:50AM an interview with Licensed Nurse (LN) G, she stated that R18 went to the bathroom on his own and she not sure if R18e was on an individualized toileting program. She stated that the residents were taken to the bathroom every two hours and ensured they were clean. On 10/20/22 at 12:30PM an interview with Administrative Nurse D, she stated that R18 could toilet himself and a trial toileting program was not completed because he would become easily agitated. She stated that he was sent out for a colonoscopy which revealed he had a sensitivity to spicy food. A review of the facility's Incontinence policy (undated) indicated that the bowel continence will be evaluated upon admission and quarterly. The policy states that staff will appropriately manage and screen individuals with fecal incontinence. The facility failed implement an individualized bowel and bladder toileting program to address increased incontinence for R18. This deficient practice placed the resident at risk for complications related to incontinence.

The facility identified a census of 43 residents. The sample included 12 residents, which included five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for Resident (R) 5 and R15 related to the lack of a 14 day stop date for as needed (PRN) antipsychotic medication (class of medications used to treat [CONDITION(S)] (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions). This deficient practice placed R5 and R15 at risk for unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R5's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and [CONDITION(S)] disorder [CONDITION(S)] type (a mental disorder in which a person experiences a combination of symptoms of [CONDITION(S)] and mood disorder). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated severely impaired cognition. The MDS documented that R5 required limited assistance of one staff member for activities of daily living (ADL's). The MDS documented R5 had received antipsychotic medication, antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) for seven days during the look back period. R5's [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 07/14/22 documented she received antipsychotic medication daily. R5's Care Plan last revised 05/06/22 directed staff was to administer medication as ordered. Review of the EMR under Orders tab revealed physician orders: [MEDICATION(S)] [MEDICATION(S)] (antipsychotic) five milligrams (mg) tablet by mouth every 24 hours as needed for [CONDITION(S)] dated 05/27/22. Review of the Medication Administration Record from 07/01/22 through 10/19/22 revealed [MEDICATION(S)] was last administrated on 08/02/22. Review of the Monthly Medication Review (MMR), performed by the CP, reviewed October 2022 through October 2022 did not address the lack of 14 day stop date for the as needed antipsychotic medication. On 10/19/22 at 07:11 AM R5 laid on the bed full dressed, eyes closed, no behaviors noted. On 10/20/22 at 11:50 AM Licensed Nurse (LN) G stated she did not know of a 14 day stop date for as needed antipsychotic medication. LN G stated the CP reviewed the resident's charts monthly and the Director of Nursing received the MRR's. LN G stated she would change any new orders received from the physician. On 10/20/22 at 12:10 PM Administrative Nurse D stated the MRR's are sent to her, she prints them are had the physician review, make changes and return. Administrative Nurse D stated since the facility was a mental health facility and the medication were reviewed by a nurse practitioner from the psychiatrist office, the as needed antipsychotic medications did not need a duration or stop date. On 10/24/22 at 09:36 AM CP GG stated he reviewed the resident's clinical record monthly. CP GG stated he had noted and made recommendations for a duration for as needed antipsychotic medications and the facility had requested the CP not make those recommendations related to the facility being a mental health facility and the medications were reviewed by a nurse practitioner from the psychiatrist office The facility's Pharmacy Services policy undated documented the CP would conduct monthly medication regimen reviews of each resident's chart. The CP would collaborate with the staff and practitioners to address and resolve medication-related needs or problems. The facility [CONDITION(S)] Drugs undated policy documented as needed orders for [CONDITION(S)] drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that is appropriate for the as needed order to be extended beyond the 14 days. The facility failed to ensure the CP identified and reported the lack of a 14 day stop date for PRN antipsychotic medication for R5, which had the potential of unnecessary [CONDITION(S)] medication administration thus leading to possible harmful side effects. - R15's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of [CONDITION(S)] disorder, depressive type (a mental disorder in which a person experiences a combination of symptoms of [CONDITION(S)] and mood disorder). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R15 required supervision of one staff member after setting up assistance for activities of daily living (ADL's). The MDS documented R15 had received antipsychotic medication (class of medications used to treat [CONDITION(S)] (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) and antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) for seven days during the look back period. The MDS documented R15 had verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others, four to six days, but less than daily during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 11 which indicated moderately impaired cognition. The MDS documented that R15 required supervision of one staff member after setting up assistance for ADL's. The MDS documented R15 had received antipsychotic medication, antidepressant medication, antianxiety medication (class of medications that calm and relax people with excessive anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), nervousness, or tension), and hypnotic medication (a class of medications used to induce sleep and treat [CONDITION(S)]) for seven days during the look back period. The MDS documented R15 had verbal behavioral symptoms directed toward others had occurred one to [NAME] days during the look back period. R15's [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 03/30/22 documented she received antipsychotic medication daily. R15's Care Plan last dated 04/25/22 directed staff to administer antipsychotic medication as ordered by the physician. Monitor for side effects and effectiveness every shift. Review of the EMR and clinical record under Orders tab revealed physician orders: [MEDICATION(S)] (antipsychotic) 50 milligrams (mg) give one tablet by mouth every six hours as needed for agitation/anxiety dated 03/17/22. The order lacked a stop date. [MEDICATION(S)] 50mg/milliliter (ml) inject 100mg intermuscular (IM) every six hours as needed for agitation/anxiety dated 03/17/22. The order lacked a stop date. Review of clinical record of the Medication Administration Record from 07/01/22 through 10/19/22 revealed [MEDICATION(S)] was last administrated on 09/21/22 for R15. Review of the Monthly Medication Review (MMR), performed by the CP, reviewed October 2022 through October 2022 failed to address the lack of 14 day stop date for the PRN antipsychotic medication for R15. On 10/19/22 at 09:10 AM R15 sat in a chair in common area, with no behaviors noted. On 10/20/22 at 11:50 AM Licensed Nurse (LN) G stated she did not know of a 14 day stop date for as needed antipsychotic medication. LN G stated the CP reviewed the resident's charts monthly and the Director of Nursing received the MRR's. LN G stated she would change any new orders received from the physician. On 10/20/22 at 12:10 PM Administrative Nurse D stated the MRR's are sent to her, she prints them are had the physician review, make changes and return. Administrative Nurse D stated since the facility was a mental health facility and the medication were reviewed by a nurse practitioner from the psychiatrist office, the as needed antipsychotic medications did not need a duration to be given. On 10/24/22 at 09:36 AM CP GG stated he reviewed the resident's clinical record monthly. CP GG stated he had noted and made recommendations for a duration for as needed antipsychotic medications and the facility had requested the CP not make those recommendations related to the facility being a mental health facility and the medications were reviewed by a nurse practitioner from the psychiatrist office The facility's Pharmacy Services policy undated documented the CP would conduct monthly medication regimen reviews of each resident's chart. The CP would collaborate with the staff and practitioners to address and resolve medication-related needs or problems. The facility [CONDITION(S)] Drugs undated policy documented as needed orders for [CONDITION(S)] drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that is appropriate for the as needed order to be extended beyond the 14 days. The facility failed to ensure the CP identified and reported the lack of a stop date for PRN antipsychotic medication for R15, which had the potential of unnecessary [CONDITION(S)] medication administration thus leading to possible harmful side effects.

The facility identified a census of 43 residents. The sample included 12 residents, which included five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician documented a duration not to exceed 14 days for use of as needed (PRN) antipsychotic medication (class of medications used to treat [CONDITION(S)] (any major mental disorder characterized by a gross impairment testing) and other mental emotional conditions). This deficient practice placed Resident (R)5 and R15 at risk for unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R5's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and [CONDITION(S)] disorder [CONDITION(S)] type (a mental disorder in which a person experiences a combination of symptoms of [CONDITION(S)] and mood disorder). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight which indicated severely impaired cognition. The MDS documented that R5 required limited assistance of one staff member for activities of daily living (ADL's). The MDS documented R5 had received antipsychotic medication, antianxiety medication (class of medications that calm and relax people with excessive anxiety, nervousness, or tension), and antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) for seven days during the look back period. R5's [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 07/14/22 documented she received antipsychotic medication daily. R5's Care Plan last revised 05/06/22 directed staff was to administer medication as ordered. Review of the EMR under Orders tab revealed physician orders: [MEDICATION(S)] [MEDICATION(S)] (antianxiety) five milligrams (mg) tablet by mouth every 24 hours as needed for [CONDITION(S)] dated 05/27/22. The order lacked a stop date. Review of the Medication Administration Record from 07/01/22 through 10/19/22 revealed [MEDICATION(S)] was last administrated on 08/02/22. On 10/19/22 at 07:11 AM R5 laid on the bed full dressed, eyes closed, and no behaviors noted. On 10/20/22 at 11:50 AM Licensed Nurse (LN) G stated she did not know of a 14 day stop date for as needed antipsychotic medication. LN G stated the CP reviewed the resident's charts monthly and the Director of Nursing received the MRR's. LN G stated she would change any new orders received from the physician. On 10/20/22 at 12:10 PM Administrative Nurse D stated the MRR's are sent to her, she prints them are had the physician review, make changes and return. Administrative Nurse D stated the medication were reviewed by a nurse practitioner from the psychiatrist office. The facility [CONDITION(S)] Drugs undated policy documented as needed orders for [CONDITION(S)] drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that is appropriate for the as needed order to be extended beyond the 14 days. The facility failed to ensure a 14 day stop date for PRN antipsychotic medication for R5, which had the potential of unnecessary [CONDITION(S)] medication administration thus leading to possible harmful side effects. - R15's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of [CONDITION(S)] disorder, depressive type (a mental disorder in which a person experiences a combination of symptoms of [CONDITION(S)] and mood disorder). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. The MDS documented that R15 required supervision of one staff member after setting up assistance for activities of daily living (ADL's). The MDS documented R15 had received antipsychotic medication (class of medications used to treat [CONDITION(S)] (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) and antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness) for seven days during the look back period. The MDS documented R15 had verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others, four to six days, but less than daily during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 11 which indicated moderately impaired cognition. The MDS documented that R15 required supervision of one staff member after setting up assistance for ADL's. The MDS documented R15 had received antipsychotic medication, antidepressant medication, antianxiety medication (class of medications that calm and relax people with excessive anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), nervousness, or tension), and hypnotic medication (a class of medications used to induce sleep and treat [CONDITION(S)]) for seven days during the look back period. The MDS documented R15 had verbal behavioral symptoms directed toward others had occurred one to [NAME] days during the look back period. R15's [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 03/30/22 documented she received antipsychotic medication daily. R15's Care Plan last dated 04/25/22 directed staff to administer antipsychotic medication as ordered by the physician. Monitor for side effects and effectiveness every shift. Review of the EMR and clinical record under Orders tab revealed physician orders: [MEDICATION(S)] (antipsychotic) 50 milligrams (mg) give one tablet by mouth every six hours as needed for agitation/anxiety dated 03/17/22. The order lacked a stop date. [MEDICATION(S)] 50mg/milliliter (ml) inject 100mg intermuscular (IM) every six hours as needed for agitation/anxiety dated 03/17/22. The order lacked a stop date. Review of clinical record of the Medication Administration Record from 07/01/22 through 10/19/22 revealed [MEDICATION(S)] was last administrated on 09/21/22 for R15. On 10/19/22 at 09:10 AM R15 sat in a chair in common area, with no behaviors noted. On 10/20/22 at 11:50 AM Licensed Nurse (LN) G stated she did not know of a 14 day stop date for as needed antipsychotic medication. LN G stated the CP reviewed the resident's charts monthly and the Director of Nursing received the MRR's. LN G stated she would change any new orders received from the physician. On 10/20/22 at 12:10 PM Administrative Nurse D stated the MRR's are sent to her, she prints them are had the physician review, make changes and return. Administrative Nurse D stated since the facility was a mental health facility and the medication were reviewed by a nurse practitioner from the psychiatrist office, the as needed antipsychotic medications did not need a duration to be given. On 10/24/22 at 09:36 AM CP GG stated he reviewed the resident's clinical record monthly. CP GG stated The facility [CONDITION(S)] Drugs undated policy documented as needed orders for [CONDITION(S)] drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that is appropriate for the as needed order to be extended beyond the 14 days. The facility failed to ensure a 14 day stop date for PRN antipsychotic medication for R15, which had the potential of unnecessary [CONDITION(S)] medication administration thus leading to possible harmful side effects.

The facility had a census of 34 residents. Based on observations, record review, and interview, the facility failed to provide a certified dietary manager to carry out the functions of food and nutritional services for the 34 residents who resided in the facility and received meals from the facility kitchen. Findings included: - On 07/01/21 at 11:36 AM, observations revealed Dietary Staff (DS) BB participated and provided oversight of the lunch meal preparation and service. On 07/06/21 at 08:02 AM, observations revealed DS BB participated and provided oversight of the breakfast meal preparation and service. In an interview on 07/06/21 at 10:41 AM, Administrative Staff A stated the facility did not have a dietician or a certified dietary manager on staff. He also stated they have a dietician consultant who came to the facility on ce a month and as needed. The facility's undated Food Service Staffing policy, documented the facility must have a qualified dietitian, certified dietary manager, certified food service manager or staff member with similar certification in food service management and safety from a national certifying body on staff. The facility failed to provide a certified dietary manager to carry out the function of food and nutritional services, placing the 34 residents who received meals from the facility kitchen at risk for nutritional problems and weight loss