Every finding on record at Cornerstone Care Center

Based on interview and record review, the facility failed to document the condition of one of two residents (Resident 2) upon discharge from the facility.This failure resulted in Resident 2's clinical record not containing details of his emergency discharge from the facility and events leading to why he was sent out by ambulance with police also being called to the facility.During a review of Resident 2's admission Record (AR), dated 1/21/26, the AR indicted Resident 2 was admitted to the facility on [DATE] and was discharged on 6/25/25.During a review of Resident 2's Progress Notes (PN), dated 6/25/26, the PN indicated, Resident was very aggressive to CNA [Certified Nursing Assistant] during care and hurt CNA wrist. DON [Director of Nursing] witness and called police. Resident was sent out approx. (approximately). 1030 am on gurney via emergency transportation. There were no further PN regarding this event. The PN was written by Licensed Vocational Nurse (LVN) 1.During a concurrent record review and interview on 1/29/26, at 2:35 p.m., with LVN 1, Resident 2's clinical record was reviewed. LVN 1 stated on 6/25/26, she was assigned to Resident 2's care. LVN 2 stated, That day, I don't really remember, my DON came in and dealt with the situation because I was passing medications. I was a brand new nurse. I didn't know I was supposed to make a 'SBAR' for that.(Note: SBAR is a standardized communication tool designed to facilitate the clear and efficient transfer of critical patient information between healthcare professionals.The acronym stands for:S - Situation: A concise statement of the current problem or the reason for the communication.B - Background: Relevant clinical context, such as the resident's admitting diagnosis, medical history, and recent medications.A - Assessment: An analysis of the situation based on clinical findings, vital signs, or the professional's interpretation of the issue.R - Recommendation: Specific requested actions, such as orders for tests, treatments, or an immediate evaluation.Purpose: It is primarily used during high-[NAME] moments like patient handoffs (shift changes), transfers between units, or when escalating a deteriorating patient's condition to a physician.)During a concurrent record review and interview on 1/29/26, at 2:40 p.m., with the Administrator, Resident 2's clinical record was reviewed. The Administrator stated the DON referenced in the 6/25/25 PN was no longer employed at the facility. The Administrator stated LVN 1 had started a 'SBAR', but it was incomplete. There should be notes about [Resident 2's] transfer. The Progress Note was incomplete, the 'SBAR' was incomplete, and [LVN 1] clearly did not complete this.During a review of the facility's Policy and Procedure (P&P) titled Transfer and Discharge, dated 12/19/22, the P&P indicated, Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting, such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). Document assessment findings and other relevant information regarding the transfer in the medical record.

Based on observation, interview, and record review, the facility failed to provide a specialized mattress to two of four sampled residents (Resident 1, Resident 4) who required them, due to both residents having significant pressure injuries (a severe wound, involving full-thickness tissue loss where skin, fat, muscle, tendon, or bone is exposed, also known as a pressure ulcer) to their sacrum (tailbone area), and failed to include the intervention of using a specialized mattress in the care plan for Resident 1. These failures had the potential for delayed healing to the pressure injuries, and an increase in the risk of the pressure injuries worsening, including further tissue loss, pain, and infection, to the two residents.During a concurrent interview and record review on 12/30/25, at 11:30 a.m., with the Assistant Director of Nursing (ADON), Resident 1's clinical record was reviewed. Resident 1's admission Record (AR), dated 12/30/25, indicated Resident 1 was admitted to the facility on [DATE], and was discharged on 12/30/25. Resident 1's Order Summary Report (OSR) indicated Resident 1 had a physician's order to care for a stage 4 pressure ulcer to Sacrum. Resident 1's Progress Notes (PG), dated 12/13/25, at 1:16 a.m., indicated she was admitted to the facility with the wound.Resident 1's PG dated 12/12/25, at 7:50 p.m., indicated Interventions for Skin/Wound Condition(s) were Pressure Redistributing Devices (e.g., .Mattress.) This PG entry was repeated eight (8) more times during Resident 1's stay at the facility: on12/23/25, at 12:16 p.m.12/22/25, at 10:55 a.m.12/20/25, at 9:39 a.m.12/19/25, at 10:41 a.m.12/18/25, at 3:54 p.m.12/17/25, at 3:54 p.m.12/16/25, at 1:24 p.m., and,12/15/25, at 9:11 a.m.The ADON stated, I remember [Resident 1]. She actually left the faciity on [DATE] to go to the hospital for low blood pressure but was not discharged from our census until today, on 12/30/25. She was on a regular mattress when she was here, I remember. She should have been on a specialized air mattress, like a low air loss mattress [LALM]. I don't know why she was not. [The need for] a LALM or other specialized mattress is not in her care plan. It should be there.During a concurrent observation and interview, on 12/30/25, at 12:15 p.m., with the ADON, Resident 4 was observed in his room, while he was in bed. The ADON stated Resident 4 had a pressure injury to his tailbone. While observing Resident 4's bed, the ADON stated he should have a pressure redistribution mattress. He does not have one, he has a regular mattress.During an interview with Resident 4, on 12/30/25, at 12:16 p.m., in his room while he was in bed, Resident 4 stated his mattress sucks, it's lumpy and unpleasant.During a concurrent interview and record review, on 12/30/25, at 12:35 p.m., with the ADON, Resident 4's clinical record was reviewed. The ADON stated, Resident 4's LALM was ordered on 12/24/25, I am not able to find where his physician was notified that the mattress he ordered for his patient is not in use. The ADON stated, We are out of them right now.During a review of Resident 4's AR, it indicated he was admitted to the facility on [DATE]. Resident 4's OSR, dated 12/24/25, indicated he had a physician's order for Pressure Redistribution Mattress - Low Air Loss. for wound to [tailbone]. Resident 4's PG dated 12/24/25, at 9:05 a.m., indicated a physician specializing in wound care into see resident [4] on 12/23/25 and wrote detailed orders for the care of Resident 4's pressure injury, including air mattress for wound to [tailbone] .During a review of the facility's Policy and Procedure (P&P) titled, Pressure Injury Prevention and Management, dated 9/12/23, the P&P indicated, This facility is committed to . provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Evidence-based interventions for prevention will be implemented for all residents who assessed at risk for who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: Provide appropriate, pressure-redistributing, support surfaces. Interventions will be documented in the care plan.During a review of the facility's Policy and Procedure (P&P) titled, Wound Treatment Management, dated 9/2/22, the P&P indicated, In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety when: 1.The food preparation sink's air gap (a vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water) was not appropriate for use in a nursing facility. This failure had the potential for contaminated water to flow back into the sink and result in pathogenic (viruses, bacteria and other types of germs that can cause disease) microorganism (an organism that is so small it can only be viewed under a microscope) growth that could inadvertently (accidentally) be transferred to food and served to 93 residents in the facility, causing foodborne illness. 2. Facility did not follow the thawing process for six packages of ground beef, stored in the refrigerator, with a prepared date of 4/16/25. 3. Two boxes of butter croissants stored in the walk-in pantry, instead of in the freezer These failures had the potential for residents to develop gastrointestinal illness (illness that affects the digestive system [GI tact] which runs from mouth to anus) which could result in serious health conditions. Findings: 1.During a concurrent observation and interview on 4/27/25 at 9:45 a.m. in the kitchen with Certified Dietary Manager (CDM), the CDM stated the air gap under the preparation sink had a back flow preventer built in to prevent back flow of dirty water from happening. The CDM stated she did not know how the air gap under the food prep sink works because it is different from the air gap behind the ice machine. The CDM stated the Regional Maintenance Director (RMD) will be able to explain better how the air gap under the food prep sink works. During an interview on 4/28/25 at 9:07 a.m. with the Maintenance Supervisor (MS), the MS stated the ice machine in the facility has an air gap. The MS stated air gap has to have a gap of 1.5-2 inches to allow water to drain and prevent backflow of dirty water. During an interview on 4/29/25 at 12:48 p.m. with the RMD, the RMD stated the air gap under the sink was a closed air gap and was installed last year. The RMD stated the air gap has a one-way valve to prevent the back flow of contaminated water back into the sink. The RMD stated he did not consult Department of Health Care Access and Information (HCAI-responsible for equitable access to health care for all Californians, ensuring safe and reliable healthcare facilities, and providing information to help improve care affordability and effectiveness) when he installed the air gap. The RMD stated he did not need to be certified to install air gap. During an interview on 4/30/25 at 9:05 a.m. with the Registered Dietitian (RD), the RD stated the air gap under a preparation sink was important to prevent back flow of dirty water and prevent contamination of food prepared in the sink. The RD stated the expectation was to ensure there was an air gap below the food prep sink to prevent residents from getting sick because of contaminated foods. During an interview on 5/1/25 at 1:45 p.m. with the Administrator (ADM), the ADM stated air gap was installed the previous year (2024). During a review of the professional reference titled, FDA Food Code 2022, Chapter 5. Water, Plumbing, and Waste, section 5-203.14 indicated, . A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT . backflow prevention is required by LAW, by: . providing an air gap as specified under § 5-202.13 . During a review of professional reference titled, FDA Food Code 2022 Annex 3. Public Health Reasons/Administrative Guidelines, section 5-202.13 indicated, . During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Standing water in sinks, dipper wells, steam kettles, and other equipment may become contaminated with cleaning chemicals or food residue . Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow . 2. During a concurrent observation and interview on 4/27/25 at 9:15 a.m. during an initial tour in the kitchen with the CDM, six packages of defrosted ground beef on the bottom shelf of the refrigerator. The CDM stated packages of ground beef were pulled out from the freezer on 4/16/25, use by date 4/29/25. The CDM stated the expectation was to pull out frozen foods to defrost up to three days before use. The DSM stated the packages of ground beef were pulled out from the freezer too soon. During a concurrent interview and record review on 4/29/25 at 11:10 a.m. with CDM, a photo of the ground beef taken on 4/27/25 was reviewed. The photo indicated prepared date 4/16/25, use by 4/29/25. The CDM stated she was not sure who pulled out the meat to thaw. The CDM stated the meat was sitting too long in the refrigerator to thaw and could grow bacteria. The CDM stated, We threw away the packages of meat, (they were) not safe to serve to residents. During an interview on 4/29/25 at 1:40 p.m. with Dietary [NAME] (DC) 1, DC 1 stated the practice was to pull out frozen meat to thaw three days before use. DC 1 stated ground beef should have been cooked and used on the third day. DC 1 stated packages of ground beef thawed were not safe to serve after three days, bacteria could have grown while it was sitting in the refrigerator. During an interview on 4/30/25 at 9:10 a.m. with the RD, the RD stated the practice was to pull out frozen meat to defrost in the refrigerator up to three days before the use date. The RD stated meat sitting out too long in the refrigerator can grow bacteria making it unsafe to serve to residents. The RD stated dietary staff did not want to serve unsafe foods to residents. The RD stated meat had to be used immediately or on the third day to prevent residents from getting sick. 3. During a concurrent observation and interview on 4/27/25 at 9:20 a.m. during an initial tour in the kitchen with CDM, observed two boxes of butter croissants in the pantry. The CDM stated the boxes of butter croissants indicated to keep frozen. The CDM stated the butter croissants were delivered Friday (4/25/25) and should have been left in the freezer. The CDM stated croissants, if not stored correctly, could cause foodborne illness (illness contracted from consuming contaminated food or beverage) if not thawed properly and served to residents. During an interview on 4/29/25 at 1:45 p.m. with DC 1, DC 1 stated butter croissants were delivered Friday and had to be stored in the freezer after delivery. DC 1 stated she was not sure if the croissants were pulled out to defrost and to be used but the menu spreadsheet does not call for use of croissants until Tuesday (4/29/25). DC 1 stated the box of butter croissants should have been left in the freezer to be safe to serve to residents. During an interview on 4/30/25 at 9:05 a.m. with RD, the RD stated she was not sure if staff were thawing butter croissants in the walk-in pantry. The RD stated butter croissants had to be stored properly to prevent bacteria from growing which could cause foodborne illness. The RD stated butter croissants could cause illness to residents if not thawed properly and served to residents. During a review of facility's policy and procedure (P&P) titled Food Storage (Dry, Refrigerated, and Frozen), dated 2020, the P&P indicated, .All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded . Follow and adhere to the guidelines regarding proper storage temperatures and maximum length of storage found in storage guidelines in the Sanitation section of the manual . Place frozen food deliveries in freezers immediately following their inspection. Never allow a frozen food to reach room temperature .During a review of the facility's policy and procedure titled Food Safety Requirements, dated 12/19/22, the P&P indicated, .Food safety practices shall be followed throughout the facility's entire food handling process . Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganism . Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer . Thawing - approved methods for thawing frozen foods including thawing in the refrigerator, submerging under cold water, thawing in a microwave oven, or as part of a continuous cooking process. Thawing at a room temperature is not acceptable . During a professional reference https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/big-thaw-safe-defrosting-methods. The reference indicated, . Raw or cooked meat, poultry or egg products, as any perishable foods, must be kept at a safe temperature during the big thaw. They are safe indefinitely while frozen. However, as soon as they begin to thaw and become warmer than 40 degrees Fahrenheit, bacteria that may have been present before freezing can begin to multiply. Perishable foods should never be thawed on the counter, or in hot water and must not be left at room temperature for more than two hours .

Based on observation, interview, and record review, the facility failed to follow their policy and procedure, Garbage and Rubbish Disposal for three of three outside trash bins when the garbage was filled over the top of the bin not allowing the lids of the bins to be closed. This failure had the potential to attract animals, insects and pests which could lead to infestation (large number of pests), and the spread of disease. Findings: During an observation on 4/27/25 at 7:45 a.m., behind the facility, in the trash bin storage area, three of three trash bins were observed with the lids sitting on top of cardboard boxes,. plastic and other debris filled above the top of the trash bins. During an interview on 4/27/25 at 2:30 p.m. with the Certified Dietary Manager (CDM), the CDM stated the trash should not go over the top of the bin, the exposed trash could attract mice or other animals to the area and bring disease to the facility. During an interview on 4/27/25 at 2:42 p.m. with the Maintenance Supervisor (MS), the MS stated that the lids of the trash should not have been open and there should never be trash piled in over the rim so that the trash can closes correctly. During an interview on 5/1/25 at 11:40 a.m. with the Administrator (ADM), the ADM stated the trash bins should not be filled above the top of the bin, becuase trash could fall on the ground and encourage insects and animals to get into the trash and cause the spread of disease or infection. During a review of the facility's policy and procedure (PNP), titled, Garbage and Rubbish Disposal dated 2000, indicated, the PNP indicated, .Food Related Garbage and Refuse Disposal indicated . All garbage or rubbish is to be put into waste containers which are emptied as often as necessary to prevent over filling . all containers will be provided with tight-fitting lids or covers, and will be leak proof and water proof . as to be inaccessible to vermin .

Based on observation, interview, and record review, the facility failed to ensure proper storage and disposal of medication and biologics in accordance with facility policy and procedures when: 1. A partially used Lantus insulin pen (medication used to control high blood sugar) for Resident 17 was discarded in a container labeled, Medications to be destroyed in the medication room. This failure had the potential for a medication error, and increased risk of injury and contamination, by not following facility policy. 2. The red container, Medication to be destroyed, was observed to be overflowing with medication. This failure had the potential for unauthorized access to medications. 3. In the IV (intravenous fluid- fluids given directly into the blood stream) medication cart shared between A and B Wing, two 100 ml (unit of measurement- milliliters) 0.9% Normal Saline (NS- solution of salt dissolved in water, used for hydration) IV bags were observed partially open with manufacturer's overwrap with no date. This failure had the potential of contamination and unsafe administration. Findings: 1. During a concurrent observation and interview on 4/27/25 at 10:31 a.m., in the medication storage room, with Licensed Vocational Nurse (LVN) 3, a partially used 3 ml Lantus pen (long-acting insulin to decrease blood sugar) for Resident 17 was observed stored in a red plastic bin with a removable lid labeled, Meds to be destroyed. LVN 3 stated insulin pens are put in sharps container because of the insulin inside, and acknowledged Resident 17's Lantus pen was not properly discarded. During a concurrent observation and interview on 4/27/25 at 10:31 a.m., with Director of Staff Development (DSD), the DSD stated insulin pens had to be wasted and put in the sharps container, the DSD stated, That cannot go in the red container labeled, 'Meds to be destroyed,' that bin is for pills only. During an interview on 4/28/25 at 1:52 p.m., with the Director of Nursing (DON), the DON stated the expectation of the nursing staff was to waste the remaining insulin and discard the pen in the sharps container, to prevent anyone from having access to the medication. During a review of the facility's Policy & Procedure (P&P) titled, Syringe and Needle Disposal, dated 1/18, the P&P indicated, .syringes and needles are placed into puncture resistant, one-way containers (sharps) specifically designed for that purpose .the disposal containers are fitted with a lid that prohibits reaching into the container . 2. During a concurrent observation and interview on 4/27/25 at 10:31 a.m., in the medication storage room, with LVN 3, the medication destruction bin labeled, Meds to be destroyed was observed to be overflowing with medication blister packs. Several blister packs (a form of packing where an individual pushed individually sealed tablets through the foil to take medication) were protruding above the rim of the container, preventing the lid from closing securely. Medications were visibly exposed and unsecured at the top of the bin. LVN 3 acknowledged the bin was overflowing and stated the bin should not be overflowing. During a concurrent observation and interview on 4/27/25 at 10:31 a.m., with the DSD in the medication storage room, the DSD stated the medication bin should not overflow. During an interview on 4/28/25 at 1:53 p.m., with the DON, the DON stated the facility should destroy the medication in the Meds to be destroyed bin before it overflowed. The DON stated it was important to keep it from overflowing because it gave easier access to the medications that needed to be destroyed. During an interview on 4/30/25 at 10:20 a.m., with the Consultant Pharmacist (CP), the CP stated the container containing discarded medication should be locked and should not be overflowing or preventing the lid from closing. The CP stated the overflowing medication container created easy accessibility to these medications. During a review of the facility's (P&P) titled, Storage of Medications, dated 1/18, the P&P indicated, .Medication storage areas are kept clean, well-lit, and free of clutter . 3. During a concurrent observation and interview on 4/28/25 at 9:17 a.m., with the Assistant Director of Nursing (ADON) at the A-wing IV medication cart, two 100 ml 0.9% NS bags were observed in a partially opened manufacturer overwrap and undated. The ADON stated once opened, item needs to be dated. During an interview on 4/28/25 at 1:55 p.m., with the DON, the DON stated the facility expectation whenever a multi pack is opened, is that it must be dated with the open date, and the expired date. The DON stated this was an important practice so that nursing staff did not administer expired medications to a resident. During a review of the facility's (P&P) titled, Storage of Medications, dated 1/18, the P&P indicated, .Certain medications or package types, such as IV solutions .require an expiration date shorter than the manufacturer's expectation date to insure medication purity and potency.

Based on observation, interview, and record review, the facility failed to ensure the planned menus were followed when: 1. Two of 10 sampled residents (Resident 50 and Resident 83) received portion sizes that were different from what was prescribed by their Medical Doctor on 4/27/25. This failure had the potential to result in Resident 50 and Resident 83 not meeting their physician's prescribed diet order and their nutritional needs not being met which can result in weight gain or weight loss. 2. Residents on a regular portion diet were served baked chicken portions during the lunch meal on 4/28/25 that were smaller than what was prescribed by their Medical Doctor. This failure had the potential for all residents on a regular portion diet to receive inadequate amounts of protein, potentially leading to weight loss and malnutrition. Findings: 1.During a review of Resident 50's admission Record, (AR-a document with personal identifiable and medical information), dated 4/30/25, the AR indicated Resident 50 was admitted to the facility on [DATE] with diagnoses which included obesity (overweight, too much body fat), convulsions (involuntary, sudden, and often violent muscle contractions that can cause shaking or jerking movements of the body) and hypertension (high blood pressure). During a review of Resident 50's Order Summary Report (OSR) dated 4/30/25, the OSR indicated, .Regular diet Regular texture, Regular (thin) consistency, small portions for breakfast and lunch .Order Date 3/5/25 . During a review of Resident 83's admission Record, dated 4/30/25, the AR indicated Resident 83 was admitted to the facility on [DATE] with diagnoses which included multiple fractures of pelvis (break in multiple bones of hip bones), and surgical aftercare following surgery on the digestive system. During a review of Resident 83's Order Summary Report, dated 4/30/25, the OSR indicated, .Regular diet Regular texture, Regular (thin) consistency, for Double portion of protein . Order Date 01/21/2025 . During a concurrent observation and interview on 4/27/25 at 11:55 a.m. in the dining room, Resident 50 was sitting up in his wheelchair and seated around a table with other residents. Resident 50 was eating lunch, his meal ticket indicated small portion. Resident 50's plate included a full portion of protein, bread, side dish and dessert. Resident 50 stated he did not have any problem with the food. During a concurrent observation and interview on 4/27/25 at 12:05 p.m. in the dining room, Resident 83 was seated in the dining room with other residents eating lunch. Resident 83 was observed with regular sized food portions on his plate. Resident 83's meal ticket indicated resident 83 was to receive a double portion of protein. Resident 83 stated he only received one slice of meat. During a concurrent observation and interview on 4/27/25 at 12:10 p.m. with Certified Nursing Assistant (CNA) 5, she stated Resident 83 has one slice of meat on his plate. CNA 5 stated Resident 83 received the same amount of food as the rest of residents eating in the dining room. CNA 5 stated Resident 83 did not receive double portion of protein. During a concurrent observation and interview on 4/27/25 at 12:15 p.m. with Registered Dietitian (RD), the RD stated Resident 50 and Resident 83 did not receive their correct diet orders. The RD stated Resident 50 has an order for a small portion diet but the food served to him was not a small portion. The RD stated Resident 83 has an order for double portion of protein, but the food served was not a double portion of protein. The RD stated Resident 83 should have received a double portion of meat. During an interview on 4/29/25 at 10:50 a.m. with the Certified Dietary Manager (CDM), the CDM stated it was the responsibility of dietary cook and dietary aide to ensure residents received the correct diet. The CDM stated she was not sure if food trays were double checked before food carts were pushed out of the kitchen to distribute to residents. The CDM stated it was the responsibility of the nursing staff to check the plates to ensure each resident received their correct food based on their ordered diet. The CDM stated residents not receiving their correct diet could result in weight gain or weight loss. During an interview on 5/1/25 with the Director of Nursing (DON), the DON stated her expectation was for licensed nurses to check food trays and ensure food on the tray matched the meal ticket. The DON stated CNAs are supposed to check food on the tray and compare it with the meal ticket when they place the food in front of residents. During a review of facility's policy and procedure (P&P) titled, The Dining Experience: Objectives dated 2020, the P&P indicated, .Meals will be planned to meet nutritional adequacy and according to the resident's plan of care, while not limiting the residents right to make personal choices . During a review of facility's policy and procedure titled, The Dining Experience: Staff Roles, dated 2020, the P&P indicated, .Staff will guide residents in selecting meals of nutritional adequacy, but not limit the right to make informed personal choices. A resident who is assessed to not be capable of making informed choices will receive the meal as planned according to the menu spreadsheet and meal card . 2. During a review of facility's Diet Spreadsheet for the lunch meal for April 28, 2025, showed the regular diet with regular portions to receive: 3 ounces (oz) Baked Chicken with Onion Gravy, #8 dip Herb Stuffing, 4 oz Vegetable Medley, 3X2-2 1/2 Apple Streusel Cake and 8 oz Beverage. During an observation of the lunch meal service on 4/28/25 starting at 11:40 a.m. in the kitchen, the steam table had the following foods: regular slices of chicken, regular herb stuffing, regular vegetable medley, mechanical chicken, mechanical vegetable medley, pureed chicken meat, pureed herb stuffing, pureed vegetables and gravy. During an observation of the lunch meal service on 4/28/25 starting at 11:41 a.m. in the kitchen, Dietary [NAME] (DC) 1 served one slice of baked chicken to residents on regular texture diet and dietary aide (DA) 1 used a yellow handled ladle to scoop gravy and pour on top of baked chicken meat. During a concurrent observation and interview on 4/28/25 at 12: 25 p.m. with DC 1, RD and DSM, DC 1 weighed several pieces of baked chicken, and the results ranged from 1.3 oz, 1.8 oz, 2 oz, 2 oz, 2.4 oz, 2.6 oz. DC 1 stated the chicken portion sizes served to residents on regular diet did not meet the ordered amount in the menu. DC 1 stated she felt bad because residents on regular diet did not receive the correct amount of chicken. During an interview on 4/29/25 at 10:59 a.m. with CDM, the CDM stated she ordered chicken from (name of company) and she made sure she picked the boneless four ounces. The CDM stated she was not sure why the portion sizes weights were less than 3 oz. The CDM stated residents on regular diet did not receive the correct portion sizes based on the diet spreadsheet and could result in weight loss. During an interview on 4/30/25 at 9:20 a.m. with the RD stated the menu on 4/28/25 was for 3 oz chicken pieces to be served to residents on regular diet. The RD stated residents on regular diet should have been served the correct portion size of chicken. The RD stated, It could result in weight loss if served under the recommended portion sizes. During a review of the facility's policy and procedure titled, Meal Identification, Resident Meal Card, dated 2020, the P&P indicated, . Resident meal cards will be used during meal service to ensure proper diets are served . During a review of the facility Job Description: Cook, dated 12/1/22, the job description indicated, . Adhere to all guidelines and approved menus and recipes when preparing meals, snacks, and all other food items . Be prepared and plan for all meals and snacks to ensure to ensure timely service for all meals . During a review of the facility Job Description: Culinary Director, dated 12/1/22, the job description indicated, . [NAME] and garnish meals with great taste and style . Create, plan and nurture culinary excellence . Ensure all foods being served and consistent with stated menu shared with residents and staff . During a review of the facility Job Description: Registered Dietitian, dated 12/1/22, the job description indicated, . Create a [NAME] culinary experience for our residents for every meal or snack every day . Ensure all local, state, and federal food handling, storage, and sanitation requirements are met or exceeded . Ensure all foods being served and consistent with stated menu .

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 15.38 percent. There were 27 opportunities for errors and four medication errors occurred for three of ten sampled residents (Resident 80, Resident 146, and Resident 294) when: 1. Resident 80's blood glucose (simple sugar - the body's primary source of energy from food) was assessed after Resident 80 began eating lunch and not before meals, according to the prescriber order. 2. Resident 146's blood glucose was assessed after Resident 146 began eating lunch and not before meals, and medication Calphron (medication used to control phosphate levels to keep them from getting too high) was not administered with meals, according to the prescriber orders. 3. Resident 294 was administered medication not in accordance with the prescriber orders. These failures in medication errors for Resident 80, Resident 146, and Resident 294, resulted in placing residents at risk for experiencing adverse side effects without adequate monitoring. Finding: 1. During a medication pass observation on 4/27/25 at 12:12 p.m., Resident 80 was observed eating lunch in his room. Resident 80 stated he was eating chicken soup that was brought in by his wife. In Resident 80's room, Licensed Vocational Nurse (LVN) 2 was observed performing blood glucose check on Resident 80, with a resulting blood glucose reading of 289. (normal blood glucose is 70-130) LVN 2 informed Resident 80 Insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) coverage was needed based on Resident 80's blood glucose reading of 289. During a review of Order Summary, dated 4/29/25, the Order Summary indicated, .May do Finger stick for Blood Glucose Levels before meals and at bedtime notify MD [Doctor of Medicine] if blood glucose is less than 70 or greater than 400. . Admelog Solo [NAME] Subcutaneous [under the skin] Solution (insulin Lispro) inject as per sliding scale: . 251-300 = 4 units; Order date: 4/25/25. During an interview on 4/27/25 at 2:25 p.m. with LVN 2, LVN 2 acknowledged Resident 80 had started eating his lunch before his blood glucose was assessed. LVN 2 stated the prescriber Insulin order instructed nursing staff to check blood glucose level before meals. LVN 2 stated blood glucose check done after eating would not be an accurate assessment of blood glucose per the order. LVN 2 stated it was important to check the blood glucose before meals, to know the resident's fasting blood levels and give the correct dose of insulin. During an interview on 4/28/25 at 1:59 p.m., with the Director of Nursing (DON), the DON stated it was important for nursing staff to follow orders with insulin checks before meals, so they don't give the wrong insulin dose. Durning an interview on 4/30/25 at 10:26 a.m., with Pharmacy Consultant (PC), the PC stated the nursing staff should check insulin before meals to see how much insulin is needed for that resident. PC stated if insulin was given after meals, it could lower the residents' blood sugar too much. 2. During a medication pass observation on 4/27/25 at 12:57 p.m., with LVN 2, LVN 2 was observed entering resident 146's room with the medication calcium acetate [brand name]. During this observation LVN 2 was observed assessing Resident146's blood glucose which resulted in reading of 353 mg/dL. LVN 2 stated she would administer insulin coverage based on the resident's blood glucose level. LVN 2 was observed administering resident 146's medication calcium acetate, including a subcutaneous injection of 10 units of insulin to Resident 146's upper abdomen. During an observation and interview on 4/27/25 at 1:03 p.m., with Resident 146, in Resident 146's room, Resident 146 was observed in bed with snacks at the bedside table, Resident 146 stated she had already had lunch at noon. Resident 146 stated she ate turkey steak with brown gravy, cauliflower, apple pie and a roll. During a record review of Resident 146's Order Summary, dated 4/29/25, the Order Summary indicated Monitor finger stick for Blood Glucose .before meals and at bedtime for diabetes. Order date: 3/22/25. . (Insulin Aspart) inject as per sliding scale: . 351-400= 10 units .subcutaneously before meals for Diabetes. During a concurrent interview and record review on 4/27/25 at 2:25 p.m., with LVN 2, LVN 2 acknowledged blood sugar check for Resident 146 was obtained after lunch. LVN 2 stated blood sugar check should be completed before meals, to know the residents fasting blood levels and give the correct dose of insulin. LVN 2 acknowledged medication calcium acetate [brand name] should have been given with meals, and was given after Resident 146 ate. During an interview on 4/28/25 at 1:59 p.m., with the DON), DON stated calcium acetate [brand name] will not work, the medication will not have the appropriate effect on the residents if given after meals. The DON stated it was also important for nursing staff to check the blood glucose level before meals to avoid administering the wrong insulin dose. During a review of the manufacturer's instruction for calcium acetate provided by the facility, revised 5/16, the manufacturer instructions indicated, [calcium acetate brand name] is a dietary supplement that binds dietary phosphate. By binding with dietary phosphate, oral supplementation with calcium can reduce the absorption of dietary phosphate. 3. During medication pass observation on 4/28/25 at 7:38 a.m., in A-Wing with LVN 3, LVN 3 was observed preparing and administering two tablets of sevelamer carbonate (medication used to control high levels of phosphorous) 800 mg (milligrams- unit of measurement) to Resident 294. During a record review of Resident 294's Order Summary, dated 4/29/25, Resident 294's Order Summary indicated, Sevelamer HCl tablet 800 MG give two tablets by mouth three times a day for hypocalcemia [low calcium in the blood] with meals. Order date: 4/19/25. During a concurrent interview and record review on 4/28/25 at 10:01 a.m., with LVN 3, Resident 294's Medication Administration Record (MAR), dated April 2025 was reviewed. Resident 294's MAR indicated, Sevelamar HCl 800 mg two tablets by mouth . LVN 3 acknowledged she administered Sevelemar Carbonate to Resident 294. LVN 3 stated the two medications were different. LVN 3 stated it was important for the right medication to be given to the residents because the medications are for specific diagnosis. During an interview on 4/28/25 at 1:59 p.m., with DON, the DON stated her expectation was for nursing staff to follow prescriber's orders as stated. DON stated it was considered a medication error During an interview with on 4/30/25 at 10:31 a.m., with the PC, the PC stated nursing staff should follow the prescribers order, if a medication was not administered as ordered, the resident's condition may not get treated appropriately. During a review of the facility's Policy and Procedure (P&P) titled Medication Administration-General Guidelines, dated 1/22, the P&P indicated, .A triple check .5 Rights .in the process of preparation of medication for administration . Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 rights. .Medications are administered in accordance with written order of the prescriber .

2. During a review of Resident 145's admission Record, dated 4/30/25, the AR indicated Resident 145 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, difficulty in walking, and fusion of spine (surgical procedure that permanently joints two or more vertebrae in the spine, preventing movement between them). During a review of Resident 145's Order Entry undated, the order indicated, . Order Date 4/21/2025 . Enhanced Barrier Precaution . During a concurrent observation and interview on 4/27/25 at 11:10 a.m. in Resident 145's room, Resident 145 was lying in bed covered with bed sheets from chest down to his feet. Resident 145 stated he had been in the facility for at least two weeks. Resident 145 stated he was in the facility for therapy and receiving antibiotics (medications that fight bacterial infections) through the peripherally inserted central catheter (PICC- long, thin, flexible tube inserted into a vein in the arm and threaded up to a large vein above the heart) on his right arm. During an observation on 4/27/25 at 11:47 a.m. in Resident 145's room, Certified Nursing Assistant (CNA) 1 was observed providing care to Resident 145 without donning (wearing) proper personal protective equipment (PPE). Resident 145's room had a sign near his door that read, Enhanced Barrier Precautions, and next to his name there was sticker that read EBP. The sign indicated, Providers and staff must also: Wear gloves and gowns for the following high-contact resident care activities. Dressing, Changing briefs, or assisting with toileting . CNA 1 was observed wearing gloves but not a gown as CNA 1 provided personal hygiene and changed incontinent briefs of Resident 145. During an interview on 4/27/25 at 2:17 p.m. with CNA 1, CNA 1 stated she did not work with Resident 145 often and was not aware he was on EBP. CNA 1 stated she had only worn gloves when she provided care to Resident 145. CNA 1 stated she should have worn gown also when she provided personal care to Resident 145. CNA 1 stated it was important to wear proper PPEs when providing personal care to residents on EBP to prevent the spread of infections to other residents. During a review of Resident 88's admission Record (AR-a document with personal identifiable and medical information), dated 4/30/25, the AR indicated Resident 88 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included hemiplegia hemiplegia (muscle weakness or partial paralysis[complete or partial loss of muscle function]) and hemiparesis (one-sided muscle weakness), obstructive and reflux uropathy (obstructed urinary flow) and benign prostatic hyperplasia (enlarged prostate gland). During a review of Resident 88's, Order Summary Report, dated 4/30/25, the order summary report indicated, .enhanced barrier precaution . Order Date 4/20/25 . During a concurrent observation and interview on 4/27/25 at 12:24 p.m. in Resident 88's room, Resident 88 was observed sitting up in bed eating. Observed on the side of the bed hanging on the bed rail was an uncovered urinary catheter bag filled with yellow urine. Resident 88 stated he had the urinary catheter but did not remember why. During an interview on 4/27/25 at 12:05 p.m. with the Treatment Nurse (TXN), the TXN stated the expectation was for staff to wear gowns and gloves when providing personal care to residents on EBP including changing incontinent briefs and handling of urinary catheter bags. TXN stated wearing proper PPE was important to prevent the spread of infection to other residents. During a concurrent observation and interview on 4/27/25 at 2:06 p.m. with CNA 2, CNA 2 entered Resident 88's room, removed Resident 88's urinary catheter bag from the rails and placed inside a privacy bag wearing gloves only. CNA 2 stated Resident 88 was on EBP because of the urinary catheter. CNA 2 stated she did not wear a gown when she touched Resident 88's urinary catheter bag and she should have. CNA 2 stated the facility practice was to wear proper PPE when providing personal care to residents on EBP to prevent spread of infections to other residents. During an interview on 4/29/25 at 9:40 a.m. with the Assistant Director of Nursing (ADON), the ADON stated she had been in the position for 10 days and assumed the position as the Infection Preventionist (IP) of the facility. The ADON stated currently the facility has a total of 32 residents on EBP. The ADON stated the Director of Staff Development (DSD) assisted in providing in-service training to nursing staff. The ADON stated the expectation was for all facility staff to wear the proper PPE when providing care to residents on EBP. The ADON stated licensed nurses and CNAs needed to wear gowns and gloves when providing personal care to residents on EBP to prevent the spread of infection and protect against the transmission of infections. During an interview on 5/1/25 at 1:21 p.m. with the DON, the DON stated her expectation was for staff to wear proper PPE when in contact with residents on EBP. The DON stated staff are expected to wear gowns and gloves when providing care to residents on EBP to protect residents from the spread of infections. During a review of facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 9/2/22, the P&P indicated, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organism . High-contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheter, feeding tubes . Staff receive training on enhanced barrier precautions and are expected to comply with all designated precautions . Enhanced barrier precautions should be followed outside the resident's room when performing transfers and assisting during bathing . or any high-contact area . Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent infections for three of eight sampled residents (Resident 2, Resident 88 and Resident 145) when: 1. Licensed Vocational Nurses (LVN) 4 did not properly disinfect a glucometer (device used to measure blood sugar) used for multiple residents after providing care for Resident 2. This failure had the potential for the development and the spread of infection to all residents who had their blood sugars checked with the glucometer. 2. Staff did not follow enhanced barrier precaution procedures prior to providing care to Resident 88 and Resident 145. This failures had the potential for the development and the spread of infection to all residents and/or staff in the facility. Findings: During a concurrent observation and interview on 4/27/25 at 11:50 a.m., with LVN 4 in the C wing, LVN 4 was observed cleaning and disinfecting a glucometer after using it to obtain Resident 2's blood sugar level. LVN 4 was observed wrapping the glucometer without cleaning all the surfaces of the glucometer with a germicidal bleach wipe. LVN 4 acknowledged she did not appropriately disinfect the glucometer by not cleaning each side of surfaces of the glucometer with a new wipe and then wrapping the glucometer with a new wipe. LVN 4 stated it was important to properly disinfect the glucometer in between use on residents, for infection control and to reduce transmission of germs. During an interview on 4/28/25 at 1:47 p.m., with Director of Nursing (DON), DON stated the expectation was for nursing staff to, Wipe it, throw it away, wipe it, throw it away, and wrap it with wipe covering the glucometer, keeping it wet according to manufacturer wet time. DON stated it was important to prevent the spread of infections. During a review of the manufacturer's instructions for the germicidal bleach wipe, the manufacturer indicated, .product is for the exterior surfaces of the blood glucose meter .cleaning is to include vigorous wiping .for all surfaces. During a review of facility's policy and procedure (P&P) titled, Glucometer Disinfection, dated 9/2/22, the P&P indicated, .Using first wipe, clean .the surface of the glucometer .After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions .

Based on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for two of 16 sampled residents (Residents 15 and 78), when: 1.The wall in Resident 78's bedroom had deep scratches, exposing white chalky building material, and missing paint. This failure resulted in Resident 78 feeling unimportant, and not listened to. 2.The wall in Resident 15's bathroom had an approximate one inch (unit of measure), by one inch hole in the wall. This failure had the potential to affect Resident 15's mental state as well as creating a portal for pests to enter the bathroom. Findings: 1.During a concurrent observation and interview on 4/27/25 at 10:26 a.m. with Resident 78 in her room, the wall in her room near her bed had several areas of deep scratches with missing paint and areas of exposed white chalky building material. Resident 78 stated, . if I had more money the nursing home would have fixed the wall . I cannot afford to get a better room . During a review of Resident 78's, Record of Admission (RA), dated 5/1/25, the RA indicated Resident 78 was admitted from the hospital to the facility on 9/26/24, with diagnoses which included, borderline personality disorder (BPD - a mental health condition where a person experiences intense, unstable emotions, relationships, and self-image, often struggling with impulsivity and a fear of abandonment), muscle weakness, paroxysmal atrial fibrillation (a type of irregular heartbeat where the electrical signals in the heart's upper chambers [atria] become chaotic, causing a fast, irregular rhythm that comes and goes, usually resolving on its own or with treatment within a week), and hypertension (a condition where the force of blood pushing against your artery walls is consistently too high). During a concurrent observation and interview on 4/27/25 at 11:40 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 78's room, the scratches and missing paint were observed. LVN 1 stated, the wall in Resident 78's room was not a homelike environment. LVN 1stated she would not like to be in a room with walls like the walls in Resident 78's room. 2.During an interview on 4/27/25 at 10:30 a.m. with Resident 15, Resident 15 stated there were holes and missing paint all over the building that have never been repaired. During a review of Resident 15's RA dated 4/30/25, the RA indicated Resident 15 had been admitted from the hospital to the facility on 2/25/25, with diagnoses which included, Diabetes Mellitus (DM - a condition where the body either doesn't produce enough insulin or can't effectively use the insulin it does produce, leading to high blood sugar levels), Depression (persistent sadness and a loss of interest or pleasure in activities), difficulty in walking, need for assistance with personal care, and muscle weakness. During a concurrent observation and interview on 4/27/25 at 10:48 a.m. with Certified Nurse Assistant (CNA) 4, in Resident 15's bathroom, CNA 4 stated, she had not noticed the hole in the bathroom wall. CNA 4 stated the hole should have been placed on the maintenance log for it to be repaired. CNA 4 stated the hole could allow pests to enter the bathroom. During an interview on 4/28/25 at 11:08 a.m. with the Maintenance Director (MD), the MD stated the holes and scratches in the wall should have been placed on the Maintenance Log so they could have been repaired. The walls with scratches, missing paint, and the hole in the bathroom do not provide a home-like environment for the residents and holes in the wall provide a passageway for insects to enter the building. During a review of the facility's policy and procedure (P&P), titled Maintenance Inspection dated 12/19/22, indicated, . it's the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents . During a review of the facility's P&P titled Preventative Maintenance Program dated 12/19/22, indicated, . the MD is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings . are maintained . During a review of the facility's P&P titled Safe and Homelike Environment dated 12/19/22, indicated, . A homelike environment is one that de-emphasizes the institutional character of the setting to the extent possible . that is neat and well kept .

Based on interview and record review, the facility failed to complete a Minimum Data Set (MDS-a computerized clinical assessment tool ) Significant Change in Status Assessment (SCSA-a comprehensive assessment that must be completed when the resident meets the significant change guidelines for either major improvement or decline) within 14 days, for one of five sampled residents (Resident 83) when a significant changed had occurred. This failure had the potential to delay identification and implementation of necessary interventions to address Resident 83's care and support needs. Findings: During a review of Resident 83's admission Record, (AR-a document with personal identifiable and medical information) dated 4/30/25, the AR indicated Resident 83 was admitted to the facility on [DATE] with diagnoses which included multiple fractures of pelvis (break in multiple bones of hip bones), and surgical aftercare following surgery on the digestive system. During a review of Resident 83's Order Summary Report, dated 4/30/25, the OSR indicated, .Regular diet Regular texture, Regular (thin) consistency, for Double portion of protein . Order Date 01/21/2025 . Weight Bearing as Tolerated . Order Date 03/07/2025 . During a concurrent interview and record review on 4/30/25 at 2:03 p.m. with the Minimum Data Set Nurse (MDSN), Resident 83's MDS assessments were reviewed. The MDSN stated Resident 83 had a follow-up appointment with the orthopedist (medical doctor specializes in bones ) and returned with a new order: Resident may have weight bearing as tolerated. The MDSN stated Resident 83's last MDS assessment was Medicare 5 (five) day assessment dated [DATE] and it was for the change of weight bearing status. The MDSN stated there was no significant change MDS assessment for Resident 83. The MDSN stated the significant change MDS assessment should have been completed within 14 days after the order was received for weight bearing. During an interview on 5/1/25 at 1:34 p.m. with the Administrator (ADM), the ADM stated his expectation was for MDSN to accurately complete MDS assessments timely. The ADM stated he expected the MDSN to review resident records and ensure assessments are opened and completed when due. During a review of the facility policy and procedure (P&P) titled, Conducting an Accurate Resident Assessment, dated 12/19/22, the P&P indicated, .The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment . The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status . Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment . During a review of facility's document Job Description: MDS dated 6/30/23, the job description indicated, . Conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment, including the implementation . Ensure that all assessments are completed and transmitted in a timely manner . Ensure that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions . During a review of professional guideline titled, Long Term Care Facility Resident Assessment Instrument version 1.19.1 Manual (RAI- core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) dated 10/24, indicated, . 5-Day Assessment and Significant Change in Status Assessment . Comprehensive item set . Must be completed (item Z0500B) within 14 days after the determination that the criteria are met for a Significant Change in Status assessment . The MDS records for a nursing home resident are expected to occur in a specific order. For example, the first record for a resident is expected to be an Entry record with entry type (item A1700) indicating admission, and the next record is expected to be an admission assessment . 5-Day assessment, a Discharge assessment, or Death in Facility tracking record. iQIES will issue a warning when an unexpected record is submitted . Entry Date (item A1600) for entry records, and the discharge date (item A2000) for discharge or Death in facility records .Discharge Assessment-Return Not Anticipated (A0310F = 10) . Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days .

Based on interview and record review, the facility failed to meet the required timelines for encoding and transmission of Minimum Data Set (MDS-evaluation of cognition, care needs and functional abilities) assessments for two of five sampled residents (Resident 44 and Resident 68) when the Minimum Data Set Nurse (MDSN) did not complete or transmit discharge MDS assessment for Resident 44 and Resident 68. This deficient practice resulted in the potential of resident's needs upon discharge going unmet. Findings: During a review of Resident 44's admission Record, (AR-a document with personal identifiable and medical information), dated 5/1/25, the AR indicated, Resident 44 was admitted to the facility on [DATE] with diagnoses which included asthma (difficulty breathing) hypertension (high blood pressure) and pain. During a review of Resident 68's admission Record, dated 5/1/25, the AR indicated Resident 68 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, chronic obstructive pulmonary disease (COPD-chronic lung disease causing difficulty in breathing) and anemia (a condition where the body does not have enough healthy red blood cells). During a concurrent interview and record review on 5/1/25 at 8:05 a.m. with MDSN, Resident 44's clinical record was reviewed. MDSN stated Resident 44 was admitted to the facility on [DATE]. MDSN stated Resident 44's last MDS assessment was a quarterly assessment dated [DATE]. MDSN stated Resident 44 was sent out to general acute hospital (GACH) on 1/23/25. The MDSN stated Resident 44 did not return to the facility. The MDSN did not find a completed and transmitted MDS discharge assessment tracking for Resident 44 when Resident 44 was discharged to GACH on 1/23/25. The MDSN stated she did not do the discharge MDS assessment for Resident 44's discharge which was required to be completed within 14 days from his discharge During a concurrent interview and record review on 5/1/25 at 8:20 a.m. with MDSN, Resident 68's clinical record was reviewed. MDSN stated Resident 68 was admitted to the facility on [DATE]. MDSN stated Resident 68 left the facility against medical advice (AMA-patient leaving a facility against the advice of their doctor) on 2/26/25. MDSN stated Resident 68's last MDS assessment was Medicare five (5) assessment dated [DATE]. The MDSN did not find a completed and transmitted MDS discharge assessment tracking for Resident 68 when Resident 68 left the facility AMA on 2/26/25. The MDSN stated she did not open and complete the MDS assessment for Resident 68's discharge which was required to be completed within 30 days from discharge. The MDSN stated it was her responsibility to ensure assessments were opened, completed and transmitted in a timely manner. During an interview on 5/1/25 at 1:34 p.m. with the Administrator (ADM), the ADM stated his expectation was for the MDSN to complete assessments, and be done in a timely matter. The ADM stated MDSN was responsible in reviewing resident records and ensure required assessments are opened and completed when due. During a review of the facility policy and procedure (P&P) titled, Conducting an Accurate Resident Assessment, dated 12/19/22, the P&P indicated, .The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment . The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status . Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment . During a review of facility's document Job Description: MDS dated 6/30/23, the job description indicated, . Conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment, including the implementation . Ensure that all assessments are completed and transmitted in a timely manner . Ensure that all members of the assessment team are aware of the importance of completeness and accuracy in their assessment functions . During a review of professional guideline titled, Long Term Care Facility Resident Assessment Instrument version 1.19.1 Manual (RAI- core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) dated 10/24, indicated, . The MDS records for a nursing home resident are expected to occur in a specific order. For example, the first record for a resident is expected to be an Entry record with entry type (item A1700) indicating admission, and the next record is expected to be an admission assessment . 5-Day assessment, a Discharge assessment, or Death in Facility tracking record. iQIES will issue a warning when an unexpected record is submitted . Entry Date (item A1600) for entry records, and the discharge date (item A2000) for discharge or Death in facility records .Discharge Assessment-Return Not Anticipated (A0310F = 10) . Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days . For a resident discharged to a hospital or other setting (such as a respite resident) who comes in and out of the facility on a relatively frequent basis and reentry can be expected, the resident is discharged return anticipated unless it is known on discharge that they will not return within 30 days. This status requires an Entry tracking record each time the resident returns to the facility and an OBRA Discharge assessment each time the resident is discharged . Must be completed (item Z0500B) within 14 days after the discharge date (item A2000) (i.e., discharge date (A2000) + 14 calendar days) .

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of five sampled residents (Resident 57) when Resident 57's pressure ulcer (localized injury to the skin and underlying tissue caused by prolonged pressure) was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 57's care needs not being met and the potential for pressure ulcer to worsen Findings: During a concurrent observation and interview on 4/27/25 at 12:26 p.m. with Resident 57 in his room, Resident 57 was sitting up in bed eating lunch. Resident 57 observed with low air loss mattress (mattress designed to prevent and treat pressure ulcers) and denied any complaints or pain. During a review of Resident 57's admission Record, (AR- a document with personal identifiable and medical information), dated 4/30/25, the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), hemiplegia (muscle weakness or partial paralysis[complete or partial loss of muscle function]) and hemiparesis (one-sided muscle weakness), and shortness of breath. During a concurrent interview and record review on 4/30/25 at 11:06 a.m. with the Treatment Nurse (TXN), the TXN stated Resident 57 was admitted to the facility on [DATE] and the pressure ulcer to his right buttock was reported on 6/25/23. The TXN stated the ulcer was diagnosed as unstageable pressure injury (UTD-pressure injury where the base of the ulcer was obscured by slough [yellowish, pale dead tissue] and or eschar [dried, leathery layer of dead tissue covering the true depth of the wound]). The TXN stated Resident 57's UTD diagnosis was changed to Kennedy ulcer (skin ulcer that appears in the sacrum [triangular bone in the lower back] often a sign of impending death) on 7/17/24. The TXN stated she did not know why diagnosis was changed. TXN stated she continues to do the treatment on Resident 57's ulcer because it is still open. During a review of Resident 57's Order Summary Report, (OSR) dated 4/30/25, the OSR indicated, . cleanse Sacrum [NAME] terminal with appearance of stage 3 [three] area with normal saline, pat dry, apply .every shift . Order Date 4/23/25 . During a concurrent interview and record review on 4/30/25 at 2:15 p.m. with the Minimum Data Set Nurse (MDSN), the MDSN reviewed Resident 57's MDS quarterly assessment dated [DATE] section M (Skin Conditions), Resident 57's ulcer was not coded in the MDS assessment. The MDSN stated the assessment was not accurately coded. The MDSN stated, I should have coded him [Resident 57] having a stage 3 [three] pressure ulcer [full-thickness skin loss] or any ulcer but I did not, it was an error in coding, the assessment was not accurate. The MDSN stated the wound doctor assessed Resident 57's wound on 10/8/24 and changed the diagnosis to Kennedy ulcer with appearance of a stage 3. During an interview on 5/1/25 at 1:25 p.m. with the Director of Nursing (DON), the DON stated she did not check MDS assessments for accuracy. The DON stated the expectation was that each person completing assessment is responsible in ensuring the assessments are accurate. The DON stated there was an MDS consultant but not sure if the consultant checked the assessments for accuracy. During an interview on 5/1/25 at 1:35 p.m. with the Administrator (ADM), the ADM stated the expectation was for the MDSN to ensure assessments are accurate, complete and done timely. During a review of facility's policy and procedure (P&P) titled, Conducting an Accurate Resident Assessment, dated 12/19/22, the P&P indicated, . Qualified staff who are knowledgeable about the resident will conduct an accurate assessment . The appropriate, qualified professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident's strengths to maintain or improve medical status . During a review of professional reference titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.19.1 10/24, indicated. . Definitions . Surgical Wounds Any healing and non-healing, open or closed surgical incisions, skin grafts or drainage sites . Steps for Assessment . Examine the resident and determine whether any ulcers, wounds, or skin problems are present .

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with accepted professional standards of quality of care for one of three sampled residents (Resident 147) when Licensed Vocational Nurse (LVN) 5 signed Resident 147's electronic Treatment Administration Record (eTAR-digital version of treatment administered to a resident) indicating Resident 147 was wearing compression stockings on 4/29/25. This failure had the potential for Resident 147 to not receive prescribed care which could result in more serious health conditions. Findings: During a concurrent observation and interview on 4/29/25 at 1:10p.m. in B wing hallway outside of Resident 147's room, Resident 147 was observed sitting up in wheelchair. Resident 147 was observed wearing non-skid socks and stated he did not remember wearing compression stockings since he was admitted in the facility. During a review of Resident 147's admission Record, (AR-a document with personal identifiable and medical information), dated 4/30/25, the AR indicated, Resident 147 was admitted to the facility on [DATE] with diagnoses which included encephalopathy (brain dysfunction- disruption in the way the brain functions), hypertension (high blood pressure) and muscle weakness. During a review of Resident 147's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 4/7/25, the MDS section C (Cognitive Patterns) indicated Resident 147 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 9 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview), which indicated Resident 147 was moderately impaired. During a review of Resident 147's Order Summary Report, dated 4/30/25, the OSR indicated, . Compression stockings-Apply in the morning and remove at bedtime . Order Date 04/25/2025, Start Date 04/25/2025 . During a review of Resident 147's Treatment Administration Record, (eTAR) dated 4/1/25-4/30/25, the eTAR indicated, Resident 147 wore his compression stockings on 4/26/25, 4/28/25, 4/29/25 and 4/30/25. During an interview on 4/29/25 at 1:11 p.m. with Certified Nursing Assistant (CNA)1, CNA 1 stated she was assigned to care for Resident 147. CNA 1 checked Resident 147 and stated Resident 147 was not wearing compression stocking, he was wearing non-skid socks. CNA 1 stated she did not put compression stockings on Resident 147 when she got him up in the morning. CNA 1 stated she did not know Resident 147 was supposed to wear compression stockings every day. During a concurrent interview and record review on 4/29/25 at 1:18 p.m. with LVN 5, LVN 5 reviewed Resident 147's clinical record and stated compression stocking order for Resident 147 was ordered on 4/25/25 for swelling to his lower legs. LVN 5 stated he marked Resident 147's eTAR without checking if Resident 147 was wearing compression stockings. LVN 5 stated Resident 147 did not have compression stockings on, and he should have. LVN 5 stated it was licensed nurses and CNAs responsibility to ensure Resident 147 wore compression stockings every day. LVN 5 stated it was his responsibility to check Resident 147 if he was wearing compression stockings before he signed the eTAR. LVN 5 stated Resident 147's swelling could get worse if not wearing compression stockings as ordered. During an interview on 5/1/25 at 1:28 p.m. with the Director of Nursing (DON), the DON stated her expectation was for licensed nurses to check or assess before signing eTAR and or eMAR. The DON stated LVN 5 could have checked Resident 147 first to ensure Resident 17 was wearing compression stockings then signed the eTAR. During a review of Job Description: Licensed Vocational Nurse, dated 12/1/22, the job description indicated, .Position Summary The LVN is responsible for assisting with resident care under the medical direction and supervision of the residents' attending physician . Examine the resident and his/her records and charts . Perform administrative duties such as completing medical forms, reports . Provide assessment and diagnostic services to residents . Provide therapeutic services . Give direct physical and psychological nursing care . During a review of Job Description: Certified Nursing Assistant, dated 12/1/22, the job description indicated, .Promptly assist residents with Activities of Daily Living (ADL) and daily nursing care needs as directed in service plan . Complete all service plan tasks as scheduled and sign-off on each by end of shift . Encourage teamwork among all departments .

Based on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for three of seven sampled residents (Resident 30, Resident 70 and Resident 294) when: 1. Residents 30 and 294 did not receive appropriate monitoring for Vitamin D (a nutrient that the body needs for absorption of calcium). This failure had the potential risk for Resident 30 and Resident 294 to result in toxicity or ineffective dosing from a continued and unmonitored Vitamin D administration. 2. Resident 294 was administered Torsemide (a medication used to help treat fluid retention and swelling) and did not have a diagnosis for fluid retention or swelling, and was administered Sevelamer Carbonate (a medication used to control high blood phosphate levels). Resident 294's record review indicated an active order for Sevelamer Hydrochloride (a medication used to control high blood phosphate levels) for hypocalcemia (low calcium blood levels) and did not have a diagnosis for hypocalcemia. These failures placed Resident 294 at risk for adverse effects from receiving medications without appropriate indications. 3. Resident 294 and Resident 70 were administered amiodarone (a medication used to treat irregular heartbeat) and did not have appropriate monitoring for TSH levels (Thyroid-stimulating hormone, a blood test is an indicator of thyroid function). These failures had the potential risk of Resident 294 and Resident 70 experiencing adverse effects from inadequate and inappropriate monitoring of thyroid levels including fatigue, irritability, and weight gain. 1a. During a record review of Resident 30's, admission Record, dated 4/29/25, the admission Record indicated, . Diagnosis information .Vitamin D deficiency (a condition where the body does not have enough vitamin D) . During a record review of Resident 30's Order Summary dated 4/29/25, the Order Summary indicated, Vitamin D3 capsule 1.25 MG [milligram- unit of measurement] (50000 units) one time a day every Monday, Wednesday, Friday for supplement. During an observation of medication cart for D Wing on 4/27/25 at 9:58 a.m. Resident 30 blister card containing 1 capsule vitamin D3 50,000 units capsule- take 1 capsule by mouth daily Monday, Wednesday, and Friday for supplement. During a concurrent interview and record review on 4/28/25 at 9:31 a.m., with Licensed Vocational Nurse (LVN) 1 for D wing, Resident 30's laboratory orders and results were reviewed. LVN 1 acknowledged Resident 30 was currently being administered Vitamin D three times a week. LVN 1 was unable to provide documentation for monitoring Resident 30's vitamin D levels. LVN 1 acknowledged Vitamin D levels were not obtained for Resident 30 and stated it was important to make sure vitamin D level was within a healthy normal range. Durning an interview on 4/28/25 at 2:08 p.m. with the Director of Nursing (DON), DON acknowledged Resident 30 did not have Vitamin D lab orders and was being administered Vitamin D without accurate monitoring of Resident 30's blood level. DON stated monitoring was important to determine how the resident was responding to treatment and to administer the appropriate medication. During a telephone interview on 4/30/25 at 10:03 a.m. with the Pharmacy Consultant (PC), the PC stated it was important to obtain baseline labs and continue to periodically monitor to determine if medication was to be given. 1b. During a record review of Resident 294's admission Record, dated 4/29/25, the admission Record indicated, .Diagnosis information .Atrial Fibrillation (an irregular, often rapid heartbeat), and End Stage Renal Disease (ESRD- a condition where the kidneys have permanently lost the ability to function). During a record review of Resident 294's Order Summary dated 4/29/25, the Order Summary indicated, Vitamin D capsule (Ergocalciferol) 50,000 units one time a day every Thursday for supplement. Order date: 4/19/25. During a concurrent interview and record review on 4/28/25 at 10:15 a.m., with LVN 3, Resident 294's Electronic Medical Records (EMR) was reviewed. LVN 3 was unable to provide documentation of Vitamin D monitoring for Resident 294. LVN 3 acknowledged Resident 294 was currently being administered Vitamin D 50,000 units every Thursday, and stated it was important to have labs to monitor the level of Vitamin D to determine its effect on Resident 294's health. During an interview on 4/28/25 at 2:08 p.m. with the DON, DON acknowledged Resident 249 did not have Vitamin D lab orders and was being administered Vitamin D without accurate monitoring of Resident 294's blood level. DON stated it was important to know the Resident's blood lab levels to administer appropriate medication and how the resident is responding to treatment. During a telephone interview on 4/230/25 at 10:03 a.m. with the PC, the PC stated there needed to be an order for baseline labs and continue to periodically monitor to determine if medication was to be given. 2. During a record review of Resident 294's admission Record, dated 4/29/25, the admission Record indicated, .Diagnosis information .Atrial Fibrillation (an irregular, often rapid heartbeat), Heart Failure (a condition when the heart can't pump enough blood to meet the body's needs.) and End Stage Renal Disease (ESRD- a condition where the kidneys have permanently lost the ability to function). During a record review of Resident 294's Order Summary dated 4/29/25, the Order Summary indicated, Sevelamer HCl 800 MG, two tablets three times a day for hypocalcemia with meals Torsemide 20 MG tablet one-time a day for edema. Order date: 4/19/25. During a review of Resident 294's Medication Administration Record (MAR- a standardized record that organizes essential information about a resident and their prescribed medication and treatment, dated April 2025, the MAR indicated, Sevelamer HCl tablet 800 MG, two tablets by mouth three times a day for hypocalcemia with meals. Torsemide tablet 20 MG give one tablet by mouth one time a day for edema. During a record review on 4/28/25 at 9:19 a.m. of Resident 294's Lab Results Report, dated 4/25/25, Lab Results Report indicated Resident 294's Calcium level results 9.6 mg/dL (grams per deciliter). Range 8.4-10.6 mg/dL. During a record review on 4/28/25 at 9:19 a.m. of Resident 294's Lab Results Report, dated 4/25/25, Lab Results Report indicated Resident 294's Phosphatase level results 152 U/L (units per Liter). Range (30-120) mg/dL Flagged as high levels. During a concurrent interview and record review on 4/28/25 at 9:53 a.m., with LVN 3, Resident 294's admission Record, Order Summary Report, and MAR, dated April 2025 were reviewed. LVN 3 stated Resident 294's medical diagnoses did not include edema. LVN 3 acknowledged Resident 294 was not receiving torsemide for edema. During a concurrent interview and record review on 4/28/25 at 10:01 a.m., with LVN 3, Resident 294's MAR, Order summary Report and Lab Results Report, dated April 2025, were reviewed. LVN 3 stated the physician order was written for Sevelamer HCl for hypocalcemia. LVN 3 acknowledged Resident 294 was administered Sevelamer Carbonate, and stated The order and the blister pack look different. LVN 3 acknowledged Resident 294's lab results dated 4/25/25 for Phosphatase lab levels are indicated as being high level, the calcium lab level was normal. LVN 3 stated it was important to give the right medication because it's for specific diagnosis. During an interview on 4/28/25 at 2:05 p.m., with the DON, the DON acknowledged Resident 294 was receiving torsemide for edema but did not have a history of edema. The DON stated the indication of use for torsemide was incorrect. The DON stated she confirmed with the physician the appropriate indication for administration was for heart failure and not edema. The DON stated Sevelamer HCl is used for high phosphate levels and not calcium. Durning an interview on 4/30/25 at 10:03 a.m. with the PC, the PC stated the indication for administration of the medication in question for Resident 294 was not accurate, if the indication is wrong the facility needs to talk to the doctor to clarify the indication and diagnosis, before administering the medication. PC stated the wrong medication given could change the resident's condition. During a review of the manufacturer's instructions for Sevelamer Carbonate, the manufacturer instructions indicated, .for the control of serum phosphorus. 3a. During a record review of Resident 70's admission Record, dated 4/29/25, the admission Record indicated, .Diagnosis information .Atrial Fibrillation (an irregular, often rapid heartbeat), hypertension (HTN-high blood pressure), and hypothyroidism (a condition where the thyroid gland doesn't produce enough thyroid hormone. During a record review of Resident 70's Order Summary dated 4/29/25, the Order Summary indicated, Amiodarone HCl oral tablet 100 MG . give one tablet by mouth one time a day for HTN hold if SBP< [less than] 100 and DBP < 60 pulse < 60 Amiodarone HCl oral tablet 200 MG give one tablet by mouth in the evening for hypertension hold if less than 100, DSP 60 and HR 60. . Levothyroxine Sodium [medication to treat low thyroid levels] Oral Tablet 75 MCG [micrograms] give one tablet by mouth in the morning for hypothyroidism. Order date: 11/11/24. Durning a record review of Resident 70's Lab Results Report, dated 11/12/24, the Lab Results Report for TSH indicated TSH levels 5.15 U/mL, normal range (0.45-5.33 U/ml). Durning a review of Lab Results Report, dated 1/27/25, the Lab Results Report for TSH indicated high TSH levels 8.73 U/mL, normal range (0.45-5.33 U/ml). During a review of Resident 70's Progress Notes (PN), dated 1/28/25, the PN indicated, .abnormal TSH level. Plan; increase [brand name for levothyroxine] to 88 mcg QD [one time a day] .recheck TSH in 6weeks. Author facility Nurse Practitioner (NP). Durning an interview on 4/28/25 at 2:52 p.m., with Registered Nurse (RN) 1, RN 1 stated Resident 70 was receiving Amiodarone 100 mg in the morning, 200 mg in the evening and Levothyroxine 75 mcg once daily since admission. RN 1 acknowledged Resident 70's TSH lab levels as critical being a high lab. RN 1 stated the expectation was to contact the physician as soon as possible, to get new orders to change the medication according to labs. RN 1 acknowledged the PN dated 1/28/25 from the NP, giving instructions to recheck labs in six weeks and increase levothyroxine to 88 mcg daily. RN 1 was unable to provide documentation the NP's orders were implemented, and stated it was important to follow up on the lab orders and medication change because the lab value was critical. During an interview on 4/28/25 at 2:55 p.m., with the DON, the DON stated the expectation for nursing staff was to carry out the prescriber's order. During an interview on 4/30/25 at 10:03 a.m., with the PC, the PC stated Resident 70's levothyroxine was not increased to 88 mcg daily as ordered, and the expectation was to carry out the providers' orders. The PC stated this medication change was important to have better control over Resident 70's condition. During a review of the manufacturer's drug information for amiodarone, the manufacturer indicated, .can cause either hypothyroidism or hyperthyroidism .Monitor thyroid function prior to treatment and periodically thereafter, particularly in elderly patients . 3b. During a record review of Resident 294's Order Summary dated 4/29/25, the Order Summary indicated, Amiodarone HCl oral tablet 200 MG give one tablet by mouth one time a day for abnormal heart rhythm. During a review of Resident 294's Lab Results Report for TSH, Resident 294's Lab Results Report, dated 4/25/25, indicated a TSH level of 0.00 ulU/ml (micro-International Units per milliliter- unit of measurement). During an interview on 4/28/25 at 10:16 a.m. with LVN 3, LVN 3 stated Resident 294 was admitted to the facility on [DATE] and the TSH lab was done on 4/19/25. LVN 3 stated the TSH levels was 0.00, indicating a critical lab value. LVN 3 stated the facility practice was to notify the provider right away and complete new orders. During an interview on 4/28/25 at 2:08 p.m., with the DON, the DON acknowledged Resident 294s TSH lab of 0.00 was a critical value. The DON stated there was no follow up and no TSH lab orders completed. The DON confirmed amiodarone was a medication known to have effects on thyroid levels. During a review of the facility's policy and procedure (P&P) titled, Laboratory Services and Reporting dated 9/2/22, the P&P indicated, .The facility is responsible for the timeliness of the services. Promptly notify the ordering physician, . nurse practitioner .of laboratory results that fall outside the clinical reference range.

Based on observation, interview, and record review the facility failed to provide food in accordance to resident preferences for one of six sampled resident (Resident 295) when Resident 295's preference to receive beverages other than milk was not followed. This failure caused resident 295 to be upset regarding the meal he had been provided and had the potential to cause Resident 295 to not receive the full nutritional benefit of his meal. Findings: During a review of Resident 295's, admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/1/25, the AR indicated Resident 295 was admitted to the facility on [DATE] with the following diagnoses: diabetes mellitus (A disease which results in too much sugar in the blood) and kidney failure (when the kidneys have been damaged over time resulting in decreased function). During a review of Resident 295's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 4/4/25, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 295 had no cognitive impairment. During an observation on 4/27/25 at 11:09 a.m. in Resident 295's room, Resident 295 was served milk with his lunch tray. Resident 295 stated he had told staff he did not want to receive milk with his meals because he was tired of receiving it for breakfast lunch and dinner. Resident 295 stated it made him upset to receive milk for all the scheduled meals of the day because it felt like staff did not listen to his request. During an interview on 5/1/25 at 9:27 a.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated nursing staff were responsible for ensuring meal trays were accurate and followed resident preferences when they came out of the kitchen. LVN 6 stated ensuring residents received food which they preferred was important because it helped residents eat the meal in order to not experience weight loss. During a concurrent interview and record review on 5/1/25 at 9:48 a.m. with the Certified Dietary Manager (CDM), Resident 295's Meal ticket, dated 4/27/25, was reviewed. The Meal Ticket indicated .No milk, offer other beverages . the CDM stated Resident 295's preference for no milk should have been honored. The CDM stated kitchen staff should have ensured the meal had everything Resident 295 wanted as it was served on the tray. The CDM stated Resident 295 may have felt frustrated as a result of receiving milk if he didn't want it. During a concurrent interview and record review on 5/1/25 at 10:37 a.m. with the Registered Dietician (RD), Resident 295's Progress Notes dated 4/7/25 was reviewed. The Progress Notes indicated . spoke to resident: allergy to fish and shellfish. Does not like hot cereal and cooked veggies. Would like to receive raw veggies only, and wants milk with his breakfast only . The RD stated Resident 295 made his preference clearly known and his preferences should have been honored. The RD stated if Resident 295's preference was not followed it put him at risk for malnutrition and following his meal preferences also provided a more homelike experience. During an interview on 5/1/25 at 11:52 a.m. with the Director of Nursing (DON), the DON stated all nursing and kitchen staff should have noticed Resident 295 was served milk. The DON stated Resident 295 should have received an alternative beverage as stated on the Meal Ticket and Progress Notes. The DON stated Resident 295 may have an uncomfortable reaction to drinking milk, so staff should have honored his preference. During a review of the facility's policy and procedure (P&P) titled, Food preferences, dated 2020, the P&P indicated . 1. Following admission The Dining Services Manager, Registered Dietitian, or other designee will interview the resident to determine food preferences . A form such as a Food Preference Form may be used to document this information. Information should be appropriately logged in the meal card . 5. Resident food preferences are kept on file in the dining Services Department as a part of the meal card system and used to ensure each resident's needs and desires are met .

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for one of nine sampled residents (Resident 88) when Resident 88's urinary catheter (flexible tube inserted into the bladder to drain urine) bag was not covered and was visible to residents and visitors This failure violated Resident 88's right to dignity and privacy and had the potential to lead to psychological harm. Findings: During a concurrent observation and interview on 4/27/25 at 12:24 p.m. in Resident 88's room, Resident 88 was sitting up in bed eating lunch. Resident 88's urinary catheter bag was hanging on the side of the bed uncovered. The urinary bag was visible when entering the room and the bag was filled with yellow urine. Resident 88 stated he had the foley catheter for a while but could not remember how long Resident 88 stated he did not know why staff had the catheter bag uncovered for everyone to see. During a review of Resident 88's, admission Record, (AR-a document with personal identification and medical information) dated 4/30/25, the AR indicated Resident 88 was re-admitted to the facility on [DATE] with diagnoses which included, hemiplegia (muscle weakness or partial paralysis[complete or partial loss of muscle function]) and hemiparesis (one-sided muscle weakness), obstructive and reflux uropathy (obstructed urinary flow) and benign prostatic hyperplasia (enlarged prostate gland). During a review of Resident 88's Order Summary Report, [OSR] dated 4/30/25, the OSR indicated, . Indwelling Urinary Catheter Size . Order Date 4/19/25 . During a concurrent observation and interview with Certified Nurse Assistant (CNA) 2 on 4/27/25 at 2:06 p.m. outside of Resident 88's room, CNA 2 stated she taking care of Resident 88 for the day. CNA 2 stated Resident 88 has a foley catheter and it should be covered with a privacy bag. CNA 2 entered Resident 88's room and stated Resident 88's catheter bag was uncovered and exposed. CNA 2 grabbed a pair of gloves and placed Resident 88's catheter bag inside a privacy bag. CNA 2 stated the practice was to ensure catheter bag was placed in a privacy bag. CNA 2 stated it was Resident 88's right to have his privacy and dignity respected. During a concurrent interview and record review on 4/29/25 at 9:40 a.m. with Infection Preventionist (IP- works to prevent germs from spreading within the facility), the IP reviewed list of residents on Enhanced Barrier Precaution (EBP-an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) and stated Resident 88 is on EBP. The IP stated foley catheter bag should have been in a privacy bag. The IP stated the expectation was for all licensed nurses and CNAs to ensure foley catheter bags are covered with privacy bags because it was a resident right to have their privacy and dignity respected. During an interview on 5/1/25 at 1:21 p.m. with the Director of Nursing (DON), the DON stated the practice was to ensure foley catheter bags are always placed in a privacy bag. The DON stated it was the responsibility of nursing staff to ensure foley catheter bags are covered. The DON stated it was a dignity issue for Resident 88 to have his foley catheter bag exposed. During a review of the facility's policy and procedure titled Dignity, dated 2/2021, the P&P indicated, . Residents are treated with dignity and respect at all times . Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity . for example . helping the resident to keep urinary catheter bags covered . During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated 9/22/22, the P&P indicated .The resident has a right to be treated with respect and dignity, including: 1. The right to be free from any physical or chemical restraints . The resident has a right to personal privacy and confidentiality .

Based on interview and record review, the facility failed to ensure their policy that only English is spoken in resident care areas when three out of six sampled residents (Resident 1, Resident 6, and Resident 7) stated they heard staff speak language(s) other than English to each other while in resident care areas. This failure had the potential to negatively impact the rights and dignity of the three affected residents by causing confusion and the residents being uninformed of their total health status, including their medical condition, in a language they can understand. Findings: During an interview on 1/22/25, at 1:55 p.m., with Resident 6, Resident 6 stated staff Will talk in their own native tongue [non-English] right in front of you to each other, when they are in my room. It's confusing to me. I don't know what's going on when I can't understand them. During an interview on 1/22/25, at 2:20 p.m., with Resident 7, Resident 7 stated staff speak non-English languages While in my room some of the time. During an interview on 1/22/25, at 2:55 p.m., with Resident 1, Resident 1 stated, Sometimes the staff talk to each other in another language, not English. When they are in my room, to each other. I'd say this happens frequently. It happens at least daily. I also hear it when I'm in the hallways. During a review of Resident 6's Minimum Data Sheet (MDS, a comprehensive, standardized assessment tool) , dated 1/16/25, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 6 was cognitively intact (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment). During a review of Resident 7's MDS , dated 1/13/25, the MDS indicated at Question C0500 a score of 12 out of a possible 15, which indicated Resident 1's cognition was moderately impaired. During a review of Resident 1's MDS , dated 10/22/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 1 was cognitively intact. During an interview on 1/22/25, at 3:15 p.m., with the Administrator, the Administrator stated, English should be spoken by all staff when in patient care areas, unless they are speaking to a resident who speaks another language, and the staff speak that language, then staff can speak that language to that resident. During a review of the facility's Policy and Procedure (P&P), titled Language , dated 7/1/08, the P&P indicated, The company believes that it is the best interest of quality care and residents' rights that all employees converse in the language of the majority of the residents while providing care or while in resident care areas. The Company recognizes and appreciates the variety of ethnic backgrounds of its employees and residents. While the Company values the cultural diversity of all employees, its employees must observe certain rules regarding speaking a language other than the residents' majority language while working, for the following reasons: - The residents' rights to dignity and respect; - The residents' right to be fully informed of their total health status including their medical condition in a language they can understand; - The facility's needs to promote quality care, operational efficiency and to avoid staff confusion and possible misunderstandings that interfere with teamwork care; and Therefore, for these residents' rights and business reasons, it is the Company's policy that all employees will speak the native tongue of the majority of the facility's residents when providing care to residents, when directing or communicating with residents, and in all resident care areas (for example in resident rooms, hallways, resident dining areas, nurses' stations, etc.) The language spoken by a majority of the residents is English unless otherwise determined by the Executive Director. These requirements will be observed even if an employee is not providing care for a resident or speaking directly to a resident.

Based on observation, record review, and interview, the facility failed to ensure the facility was free of accident hazards when: 1. One door at the end of C-Wing hallway (door number one) exiting directly to the exterior of the facility had a working alarm, 2. Sliding door number two that led to an outdoor patio courtyard contained an unlocked gate which opened to the exterior of the facility and did not have a working alarm, and there was no system in place to monitor nine more sliding doors (door number three through 11) that led to the same outdoor patio. These failures had the potential for residents to exit the building via multiple (11) exits without staff knowledge and/or supervision, causing potential harm and injury to those residents. Findings: 1. During a concurrent observation and interview on 1/3/25, at 11:26 a.m., with the Director of Maintenance (DM), the C-Wing exit door was observed. The doorframe had an electronic keypad attached to it. The C-Wing door did not alarm when pushed open, and opened immediately to the outdoors, a small concrete sidewalk, and then a public street. The DM stated the door should have sounded an alarm to alert staff when it is pushed open, and it has not been functional for over three weeks. The DM stated the keypad needs a new part to become operational again and the defective part was ordered, but a wrong part was sent and had to be reordered. The DM stated the part took forever to get here. The DM stated the facility does have some confused residents who wander and if they approach this door, staff re-directs them away. During an interview on 1/3/25, at 2:25 p.m., with the Director of Nursing (DON), the DON stated the facility does have some confused residents who wander. During a concurrent observation and interview on 1/7/25, at 3:50 p.m., with the DM, the C-Wing exit door was observed. The door's exit alarm was still not operational. The DM stated he was still working on it. 2. During a concurrent observation and interview on 1/22/25, at 2:10 p.m., with the DM, a sliding patio door leading from the dining room to an outdoor patio courtyard between B- and C- Wings was observed. There was an electronic keypad attached to the patio door frame. When the patio door was slid open, no alarm sounded. The DM stated, This is broken. It should alarm when opened. I just checked this; it was working recently. I'll order a replacement. The outdoor patio courtyard area was observed with the DM. The patio area led to an unlocked, but latched, gate at its far end. Once opened, the gate led to a sidewalk, then a public street. Around the perimeter of the patio were the exterior walls of the B-Wing and C-Wing resident rooms, which contained nine more sliding doors that also led directly into the outdoor patio courtyard (ten sliding doors total leading to the patio, only the door from the dining room was alarmed, but it was broken). The DM stated none of these nine doors from the resident rooms were locked and none had alarms. The DM stated a resident could open any of the ten sliding doors leading to the patio, walk through the courtyard, and exit the facility via the unlocked gate without staff being aware. The DM stated there was no system in place to monitor the nine doors leading to the patio from the nine resident rooms, only the door from the dining room, which had a broken alarm. During a review of the Facility Assessment Tool (FAT) , dated 11/10/24, the FAT indicated, The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Average daily census: 92-95. The FAT indicated the facility accepted residents for admission with the following common diseases, conditions, physical and cognitive disabilities (not having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident's environment), or combinations of conditions that require complex medical care and management: Psychiatric/mood disorders such as psychosis (mental disorder that can cause hallucinations and delusions, or seeing, hearing, and/or believing things that are not real), Impaired Cognition, Mental Disorders; Neurological system disorders (diseases of the brain) such as Alzheimer's Disease and Dementia (progressive diseases affecting one's mood, judgement, and memory) or exit seeking residents. The FAT indicated the type of care provided these residents include, Identify and prevent hazards and risks for residents. During a review of the facility's Policy and Procedure (P&P), titled Elopements and Wandering Residents , dated 12/19/22, the P&P indicated, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents. Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization. and/or any necessary supervision to do so. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including. evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks. 33126

Based on observation, record review, and interview, the facility failed to ensure two electrical outlets were not overloaded when outlet adapters were used to increase the number of items that could be plugged into them, and when an extension cord was noted plugged into a power strip adapter. These failures violated the facility's policy on Electrical Safety and had the potential to compromise the facility's safety by overloading outlets, potentially causing electrical circuit overload and/or fire. Findings: During a concurrent observation and interview on 1/3/25, at 11:37 a.m., with the Director of Maintenance (DM), the reception desk at the front lobby was observed. At the reception desk, a six-outlet adapter (electrical outlet extender) was plugged into a two-outlet receptacle. Three electrical cords were noted plugged into the adapter. The DM stated the six-outlet adapter should be in use. At the rear of the reception area, an orange extension cord was noted plugged into a power strip adapter, providing a nearby Christmas tree with electricity. The DM stated the extension cord should not be plugged into the power strip adapter, and therefore should not be in use. During a concurrent observation and interview on 1/3/25, at 11:40 a.m., with the DM, the facility's front door area was observed. On the upper right side of the interior doorway, a three-receptable adapter was noted plugged into a red, two-outlet receptacle. Three electrical cords were plugged into the three-receptacle adapter. The DM stated, I did not know that was there. It should not be there. During a review of the facility's Policy and Procedure (P&P), titled, Electrical Safety , dated 12/19/22, the P&P indicated, It is our policy to provide a safe and healthful environment. There is an increasing need for electrical equipment in our facility. The intent of this policy is to provide staff with information about our facility's method for ensuring safety as related to electrical wiring and equipment. Electrical outlets should never be overloaded. Extension cords shall be used for temporary use only by maintenance personnel. Extension cords shall be removed immediately upon completion of the purpose for which they were used. Adapters must screw attach to the wall receptacle. Adapters must contain circuit breakers or fuses to provide overcurrent protection. No extension cords, power strips. may be plugged into an adapter. The Maintenance Director or designee is responsible for the inspection and testing of electrical components. This includes receptacles, power strips, extension cords, and equipment. During a review of the facility's P&P titled, Physical Environment: Electrical Equipment , dated 12/19/22, the P&P indicated, The facility will maintain all mechanical, electrical, and patient care equipment in safe operating condition. The Maintenance Director shall maintain schedules for routine inspection and maintenance of all mechanical, electrical, and patient care equipment. Frequency of inspection and maintenance shall be in accordance with the facility's Electrical Safety policy, current Life Safety Code requirements, and manufacturer recommendations.

Based on observation, interview, and record review, the facility failed to ensure one of three shower rooms were clean when the D-Wing Shower room was noted to be unclean. This failure had the potential for residents needing a shower to do so in an area not clean and sanitary. Findings: During a concurrent observation and interview on 1/3/25, at 2:30 p.m., with Certified Nursing Assistant (CNA) 1, the D-Wing shower room was observed. CNA 1 stated she had used this room today to shower a resident. The D-Wing shower room was noted to have a trail of dark spots on the shower floor, leading out into the D-Wing hallway, in a dripping pattern two feet long. The D-Wing shower room door had several dark spots on the interior side of the door, dripping down the doorway. During a concurrent observation and interview on 1/3/25, at 2:32 p.m., with the Director of Nursing (DON), the D-Wing shower room was observed. The DON stated, This shower room should be clean. During a review of the facility's undated Policy and Procedure (P&P) titled, Policy and Procedure on Housekeeping and Facility Cleanliness , the P&P indicated, The facility is committed to providing a clean, safe, and sanitary environment for all residents, staff, and visitors. Housekeeping staff will follow a standardized cleaning protocol to minimize the risk of infection and maintain the overall cleanliness of the facility. Housekeeping staff are responsible for the daily cleaning and sanitization of resident rooms, common areas, and all facility spaces. Nursing staff may assist in maintaining cleanliness in resident care areas as needed.

Based on observation, interview and record review, the facility failed to ensure that one of nine sampled residents (Resident 75) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when: 1. The facility did not attempt or implement resident specific non pharmacological interventions (behavioral intervention not based on medicine) prior to prescribing and administration of alprazolam (an antianxiety medication), Resident 75 was administered alprazolam unnecessarily. 2. The facility did not provide documented clinical rationale for administrating and increasing the dosage of aripiprazole (an antipsychotic mild altering drug to treat mental illness) and quetiapine (antipsychotic medication), and Resident 75 was administered aripiprazole and quetiapine unnecessarily. 3. The facility did not attempt or implement resident specific non pharmacological interventions prior to prescribing and administration of escitalopram (antidepressant medication), and Resident 75 was administered inappropriate dosage of escitalopram. These failures resulted in Resident 75 experiencing falls, weight gain, dysphagia (difficulty swallowing) and increased the potential for Resident 75 to be isolated. Findings: 1. During a review of Resident 75's Hospital Medical Records (HMR) dated, 11/19/22, the HMR indicated, History of Present Illness . Per son, patient [Resident 75] has underlying memory issues but has not had formal evaluation . Assessment: Per [son], their father [Resident 75] lives alone though they tried to convince him to live with them but pt [patient] preferred to live by himself . Principal Diagnosis Cerebellar CVA [cerebral vascular accident happens when blood supply stops to the part of the brain that helps with body movement, eye movement, and balance] . Active Problem List . ataxia [loss of coordination] . During a review of Resident 75's Face Sheet (FS- a document containing resident's personal information), dated 6/7/24, Resident 75's FS indicated, Resident 75, was an [AGE] year old male who was admitted to the facility on [DATE] with diagnoses including ataxia following cerebral infarction, (CVA) and cerebellar stroke syndrome (CVA affecting a certain part of the brain). During an interview on 6/6/24 at 10:38 a.m., with Resident 75's Responsible Party (RP) 2, RP 2 stated he has had to help Resident 75 to keep his balance. RP 2 stated Resident 75 was pretty good, able to walk on his own and noticed Resident 75 couldn't keep his balance after the falls. During a concurrent interview and record review on 6/7/24 at 11:28 a.m., with (Licensed Vocational Nurse (LVN) 3, Resident 75's Physician Orders (PO), Medication Administration Record (MAR) for alprazolam and Nursing Progress Notes (NPN) were reviewed. Resident 75's PO and MAR indicated: Alprazolam 0.5 mg (milligrams unit of measure) by mouth every 12 hours for anxiety manifested by feeling panicky and getting in other residents and staffs' face while being around others 2/16/23 to 2/20/23 (order date to discontinue date) Alprazolam 1 mg by mouth every 12 hours for anxiety for feeling anxious manifested by feeling panicky and getting in other residents and staffs' faces while being around others 2/20/23 to 2/21/23 Alprazolam 0.5 mg by mouth every 12 hours for anxiety for feeling anxious manifested by feeling panicky and getting in other residents and staffs' faces while being around others 2/21/23 to 3/14/23 The review of Resident 75's NPN included: 2/20/23 12:43 a.m. At 1200 [a.m.] writer was called to resident's room by CNA [unknown], when writer entered the room resident was seen on the floor attempting to get himself back up. Resident was screaming at staff stating he wanted to go the restroom, but writer asked resident to be patient so that he may be assessed for any injuries. Writer then assessed resident for pain and resident reported a pain level of 0/10 [scale to measure pain, with 0 being least pain, 10 being most pain]. Head to toe assessment was performed, no superficial injuries noted. Resident refused to allow staff to use mechanical lift [device used to transfer a patient] to pick him up off the floor. Despite efforts of education and encouragement by staff resident stood up on his own and was then assisted to his wheelchair. Resident was then assisted to the restroom by CNA. [Phyician [PHY] 1] was notified via in person @ [at] 1225, gave new orders to monitor for delayed injury x [for] 3 days. Writer left a message for Emergency Contact [RP 2] via telephone to call back. LVN 3 acknowledged Resident 75 experienced a fall on 2/19/23, just prior to midnight. LVN 3 stated the facility consultant pharmacist (CRPH) reviewed Resident 75's medication regimen on 2/20/23 and recommended an assessment of Resident 75's alprazolam as the medication could cause dizziness, and confusion. LVN 3 stated Resident 75's alprazolam dose was increased from 0.5 mg every 12 hours to 1 mg every 12 hours from 2/20/23 to 2/21/23 and decreased back to 0.5 mg every 12 hours from 2/21/23 to 3/14/23. LVN 3 acknowledged Resident 75 had received alprazolam 0.5 mg dosing prior to fall and stated, I'm not seeing a decrease in dose. LVN 3 stated alprazolam can cause confusion, dizziness, fatigue, and falls, and acknowledged Resident 75 experienced unsteady coordination following his stroke. LVN 3 acknowledged Resident 75 did not have a fall prior to alprazolam being ordered. During a review of Resident 75's MAR dated 2/1/23 to 2/28/23, Resident 75's MAR indicated Resident 75 was administered alprazolam 1 mg on 2/20/23 at 8 a.m., 8 p.m., 2/21/23 at 8 a.m., alprazolam 0.5 mg on 2/16/23 at 8 p.m., twice daily at 8 a.m. and 8 p.m. on 2/17/23, 2/18/23, 2/19/23, 2/20/23 at 8 a.m., 2/21/23 at 8 p.m., and twice daily at 8 a.m. and 8 p.m. from 2/22/23 to 2/28/3. During a concurrent interview and record review on 6/7/24 at 11:44 a.m., with LVN 3, Resident 75's Care Plan (CP) and MAR dated 2/1/23 to 2/28/23 were reviewed. LVN 3 was unable to provide monitoring and implementation of resident specific non pharmacological interventions for Resident 75's behaviors for anxiety prior to initiation of alprazolam. LVN 3 stated, there were lots of side effects from pharmacological (medicine) interventions, and staff should have used the least invasive treatment that was beneficial for Resident 75. During a review of Resident 75's Interim Medication Regimen Review (IMRR), dated 2/21/23, Resident 75's IMRR recommendation for alprazolam indicated, Anxiolytic [alprazolam] medication can cause sedation, respiratory depression, confusion, disorientation, dizziness, skeletal/muscle weakness, visual disturbances, fatigue. Please assess the ongoing need at this time, is a GDR [gradual dose reduction - slowly reduce dose to see if patient condition can be managed on lowest dose possible or if medication can be discontinued] warranted at this time. During a telephone interview on 6/10/24 at 9:12 a.m., with CRPH, CRPH stated Resident 75's alprazolam dose was not appropriate. CRPH stated, for elderly patient, limited to 0.75 mg per day. CRPH stated she would ask why patient was administered medication, inquire if patient had taken it before and inform physician that dose is too high for resident. CRPH stated, benzodiazepines [alprazolam] increase risk of fall, that's what we are always worried about, can cause dizziness, confusion. CRPH stated if a fall occurred, it was important to reassess whether the medication was causing problem and whether it was possible to lower the dose. During a review of Resident 75's CVA Care Plan (CP), dated 12/29/22, Resident 75's CVA CP indicated, [Resident 75] is at risk for . generalized weakness, altered balance/gait . Interventions/tasks . PT [physical therapy- help one move better or help strengthen weakened muscles], OT [occupational therapy- to help one improve ability to participate in daily activities] evaluate and treat as indicated . During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for alprazolam indicated, Dosing: Older Adult Note: Avoid use; may be appropriate for severe generalized anxiety disorder. Immediate release: Oral: Use lower initial doses of 0.25 mg 2 to 3 times daily and titrate slowly . Debilitated [physically weak] patients: Use with caution in debilitated patients; use lower starting dose . Older adult patients: Older adults may be at an increased risk of death with use; risk has been found highest within the first 4 months of use in elderly dementia patients . Fall risk: Use with extreme caution in patients who are at risk of falls; benzodiazepines [anti anxiety drug] have been associated with falls and traumatic injury. 2. During an interview on 6/6/24 at 10:38 a.m., with Resident 75's RP 2, RP 2 stated he was previously told his father, Resident 75, had dementia. RP 2 stated that the facility however, told him that Resident 75 had Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and may seem like they have lost touch with reality), that is why Resident 75 was being administered medications for his behavior. RP 2 stated he thought it was dementia because people like Resident 75 didn't have short term memory but had long term memory. RP 2 stated, I guess they were having problems with him, he would get angry, and he wouldn't let them help him, they said it wouldn't harm him, it would help him be calm, it was last year or year before, I'm not sure. During an interview on 6/6/24 at 2:53 p.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated she had cared for Resident 75 for on and off for almost 2 years. CNA 8 stated when Resident 75 was first admitted on [DATE], he was more alert, would get into his wheelchair, go to the dining room; Resident 75 didn't have as many falls and ate a lot better. CNA 8 stated, she did not notice Resident 75 to have hallucination or delusions during her care. CNA 8 stated Resident 75 would look at staff confused and ask why everybody was in his house, say he wanted everybody out of his house, and ask for his family. During a review of Resident 75's PO and MAR for aripiprazole, Resident 75's PO and MAR indicated: Aripiprazole 2 mg daily for bipolar disorder manifested by slamming door shut, barricading door and jumping on bed 3/4/23 to 3/9/23 Aripiprazole 2 mg twice daily for bipolar disorder manifested by slamming door shut, barricading door, and jumping on bed 3/9/23 to 5/9/23 Aripiprazole 5 mg daily for schizoaffective (a mental health disorder marked by a major mood episode either manic or depressive that co occurs at the same time with symptoms of schizophrenia) disorder 6/29/23 to 7/13/23 Aripiprazole 5 mg twice daily for schizoaffective disorder 7/13/23 to 10/24/23 Aripiprazole 2 mg twice daily for schizoaffective disorder 10/24/3 to 5/6/24 Aripiprazole 2 mg daily for schizoaffective disorder 5/6/24 to 5/22/24 Aripiprazole 2 mg every other day for 5 days for schizoaffective disorder 5/22/24 to 5/27/24 During a review of Resident 75's PO and MAR for Quetiapine, Resident 75's PO and MAR indicated: Quetiapine 50 mg every 12 hours for schizoaffective disorder manifested by pacing down the hallways and yelling I own this building, I run this place and trying to hit everyone 5/4/23 to 7/11/23 Quetiapine 100 mg every 12 hours for schizoaffective disorder 7/11/23 to 10/24/23 Quetiapine 75 mg by mouth every 12 hours for schizoaffective disorder 10/23/23 to 2/6/24 Quetiapine 50 mg by mouth every 12 hours for schizoaffective disorder 2/6/24 to 5/6/24 Quetiapine 25 mg every 12 hours for schizoaffective disorder 5/6/24 to 5/30/24 Quetiapine 12.5 mg at bedtime for schizoaffective disorder 5/30/24 to present During a review of Resident 75's Nursing Progress Notes (NPN), Resident 75's NPN indicated on: 3/4/23 3:20 p.m. Resident [75] has a new order for [Brand name] Oral Tablet 2 MG (Aripiprazole) for Bipolar Disorder. Resident has been put on the medication due to behaviors. [PHY 1] was contacted and was described the resident's behaviors and manifestations. Resident has such Manifestations Slamming Door Shut, Barricading door and Jumping on bed and has visual Hallucinations of seeing a dog and other humans. [PHY 1] gave the orders for this medications along with a DX [diagnosis] of Bipolar Disorder to support the medication order. Resident is self RP and aware of this new order of the medication. 3/9/23 3:14 p.m. This order is outside of the recommended dose or frequency. [Brand name] Oral Tablet 2 MG (Aripiprazole) Give 1 tablet by mouth two times a day for Bipolar Disorder Manifested by Slamming Door Shut, Barricading door and Jumping on bed The frequency of 2 times per day exceeds the usual frequency of daily. 3/15/23 10:05 a.m. Resident medications have been changed from [Alprazolam brand name] to [Lorazepam brand name] due to medications being ineffective for the resident. Resident RP [2] was notified via phone of the changes and agreed. [PHY 1] gave the orders For [Lorazepam brand name] 0.5 mg every 12 hours. Will Continue to monitor for any side effects or any behaviors. 5/4/23 7:21 a.m. Writer contacted [PHY 1] by phone to notify him of the resident's recent behaviors of getting into other residents personal space, making threats and his non sleeping pattern. [PHY 1] gave new medication orders. [PHY 1] gave orders for [Quetiapine brand name] 50mg every 12 hours. [PHY 1]was asked what diagnosis [PHY 1] would like to give for this medication. [PHY 1] Stated Schizo effective Disorder. 7/10/23 7:49 a.m. Resident was seen by Psychologist [health professional that helps one address mental and behavioral issues] Face Face on 7/7/2023. No New Orders at this time. 7/11/23 1:36 a.m. Writer was informed of the resident going into other residents' room demanding that they leave and get the [expletive] out of his house now before his sister comes and kicks our asses. Writer contacted [RP 2] to speak to the resident to aid in calming him down. Writer spoke to son to provide information to the nights events. Resident is upset with the staff being in the facility. Resident keeps asking the staff when you leave are you gonna kill me. He is currently sitting at the nursing station in a chair. He is wearing his non skid footwear. Snacks have been offered. He reports no pain when asked. 7/11/23 6:23 a.m. Resident has had a substantial increase in behaviors. [PHY 1] was notified via phone. [PHY 1] Gave orders to increase [Quetiapine brand name] to 100 mg every 12 Hours. Resident was going to other resident's room telling them to get out of his house. Resident was trying to jump on beds and resident was screaming and everyone all night long. Resident was cussing at all the staff. Orders were carried out.Resident son [RP 2] was notified via phone of the changes in medications regimen. 7/12/23 2:22 a.m. Writer was informed by the CNA staff of the resident yelling get the [expletive] out of my house now. He is also going into other residents room demanding that they get the [expletive] out of his house now. Before his sister and brother come. Writer Resident is upset with the staff being in the facility. Resident keeps yelling and putting his fingers in the staff faces asking the staff when you leave. I will call the cops to arrest and shoot you guys. He is currently walking the halls of the facility. He is wearing his non skid footwear. Snacks have been offered. He reports no pain or any discomforts when asked. He just wants us out him house. 7/13/23 2:20 p.m. This order is outside of the recommended dose or frequency. [Brand name] Oral Tablet 5 MG (Aripiprazole) Give 1 tablet by mouth two times a day for Schizoaffective Disorder The frequency of 2 times per day exceeds the usual frequency of daily. During a concurrent interview and record review on 6/6/24 at 3:22 p.m., with MDS Nurse (MDSN) 1, Resident 75's Preadmission Screening and Resident Review (PASRR federal regulation that requires all individual being considered for admission to a Medicaid certified nursing facility be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual disability, or related condition) dated 11/29/22, Resident 75's PASRR was reviewed. Resident 75's PASRR indicated, . no serious mental illness . result of level I screening negative. MDSN 1 acknowledged Resident 75's PASRR was conducted upon admission to the facility. During a telephone interview on 6/6/24 at 3:34 p.m., with Psychologist (PSYCH), when asked about Resident 75's diagnosis of schizoaffective disorder, PSYCH stated he did not have a copy of the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 (handbook that contains criteria for diagnosing mental disorders and is used by healthcare professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders) to review the criteria for diagnosis, and his best guess was that he carried the diagnosis forward and did not diagnose Resident 75 with bipolar or schizoaffective disorder. During a review of Resident 75's Minimum Data Set (MDS) (assessment and care screening of a patient) dated 12/1/22, 2/28/23, and 5/30/23, Resident 75's MDS indicated Resident 75 did not have a diagnosis for psychiatric or mood disorder including bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows) or schizophrenia, and Resident 75 did not have a history of hallucinations (when one thinks something they see, hear, smell, touch or taste is real, but it's not or delusions (inability to distinguish what is real and what seems to be real). During a concurrent telephone interview on 6/6/24 at 4:15 p.m., with PHY 1, PHY 1 stated Resident 75 had diagnoses including dementia, hearing loss, post CVA and hypertension. When asked why Resident 75's diagnosis of dementia was not updated on Resident 75's electronic medical record or Minimum Data Set (MDS a standardized comprehensive assessment and care planning tool), PHY 1 stated, If you look at my notes, I mentioned it a few times, its what the clinicians see, it should be there some place. PHY 1 stated he did not diagnose Resident 75 with schizoaffective disorder, and that it came from a psychiatrist. During a review of Resident 75's Nursing Progress Note (NPN) dated 5/24/23, Resident 75's NPN indicated, Writer contacted [PHY 1] by phone to notify him of the resident recent behaviors of getting into other residents' personal space, making threats and his non sleeping pattern. [PHY 1] gave new medication orders. MD gave orders for [Quetiapine brand name] 50 mg every 12 hours. MD was asked what diagnosis MD would like to give for this medication. MD stated schizoaffective disorder. PHY 1 stated he gave the schizoaffective disorder diagnosis and that with schizophrenia, there was no chemical test. PHY 1 stated he had use the diagnosis to justify putting Resident 75 on those medications. PHY 1 acknowledged he did not perform an evaluation of Resident 75 for bipolar disorder of schizoaffective disorder prior to Resident 75's diagnoses of bipolar disorder and schizoaffective disorder. When asked why Resident 75 concurrently on aripiprazole 5 mg twice daily from 7/13/23 to 10/24/23 and quetiapine 100 mg twice daily from 7/11/23 to 10/24/23, PHY 1 stated that was bad practice and he didn't think he would put Resident 75 on two antipsychotics (drugs that affects brain activities associated with mental processes and behavior) at the same time. PHY 1 stated he doubted he authenticated (verified) the orders and would increase the dose of one, and not both. PHY 1 stated side effects would include falls, and requested the orders be sent to him. PHY 1 stated Resident 75 was on hospice, and he didn't ask for hospice (program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) and didn't know why Resident 75 was on hospice. During a review of Resident 75's PO dated 7/11/23 and 7/13/23, Resident 75's PO for aripiprazole and quetiapine indicated PHY 1 electronically authenticated the telephone orders for Resident 75's concurrent use of quetiapine and aripiprazole. During a review of Resident 75's Physician Progress Notes (PPN), dated 2/19/23 and 3/19/23, the PPN dated 2/19/23 indicated, Dementia suspected and the PPN dated 3/19/23 indicated, Dementia. During a review of Resident 75's IDT Post Fall Review and Recommendation (PFRR) records, Resident 75's PFRR indicated Resident 75 suffered from falls on 7/31/23, 8/4/23, 8/16/23, 12/5/23, 2/25/24, 2/27/24, 3/5/24, 3/17/24 (2 falls), 3/19/24, 4/4/24. During a concurrent interview and record review on 6/7/24 at 10:09 a.m., with LVN 3, Resident 75's FS dated 6/7/24 and HMR dated 11/19/22 were reviewed. LVN 3 was unable to provide documentation of Resident 75's diagnosis of dementia among Resident 75's list of diagnoses. LVN 3 stated that for symptoms like forgetfulness, the psychiatrist would come in and evaluate. LVN 3 acknowledged Resident 75 was forgetful. LVN 3 acknowledged Resident 75's HMR indicated Resident 75 had underlying memory issues. During a concurrent telephone interview and record review on 6/7/24 at 3 p.m., with Registered Dietician (RD) 2, Resident 75's Weights and Vitals Summary Log (WVSL) dated 11/1/22 to 6/30/24 and Dietician Progress Notes (DPN) dated 12/29/22, 4/4/23, 6/9/23, 7/7/23, and 10/2/23 were reviewed. Resident 75's weight log indicated, 12/7/22 111 lbs [pounds], 2/13/23 115 lbs, 3/2/23 122 lbs, 4/4/23 125 lbs, 5/1/23 126 lbs, 6/5/23 132 lbs, 7/4/23 135 lbs, 8/1/23 140 lbs, 9/4/23 139 lbs, 10/2/23 143 lbs, 11/6/23 145 lbs, 12/1/23 144 lbs, 1/2/24 143 lbs, 2/13/24 113 lbs, 3/1/24 114 lbs, 4/1/24 106 lbs, 5/4/24 104 lbs 6/2/24 108 lbs. RD 2 acknowledged Resident 75's weight gain and stated Resident 75's ideal body weight was 106 to 130, body max index (BMI- indicates high body fat and screens for weight categories that may lead to health problems). A review of Resident 75's DPN dated 12/29/22 indicated, 4 lb weight gain since admission weight 12/7 111 lbs BMI: 4 normal consuming 75-100% of meals. Good appetite noted attributing to weight gain. A review of Resident 75's DPN dated 4/4/23 indicated, 125 lb, non-significant weight gain x [in] 1 month (3/2: 122 lbs) and significant 8.7% 10 lb weight gain x 3 months (1/4: 115 lb) BMI: 22.9 normal. Weight gain was desired. On house supplement TID [three times daily] attributing to weight gain. Social Services/Activities: On [Brand name] (aripiprazole) for bipolar which may cause weight gain . Recommend to reduce to 120 ml [milliliters] at dinner . A review of Resident 75's DPN dated 6/9/23 indicated, CBW 132 lbs 6/5, 4.8% 6 lb weight gain x 1 month (5/1 126 lbs, significant 8.2% 10 lbs weight gain x 3 months (3/2 122 lbs), significant 18.9% 21 lb weight gain x 6 month (12/7 111 lbs). BMI 24.1 normal. Weight gain desirable. Nursing: On [Quetiapine brand name]- can contribute to weight gain. A review of Resident 75's DPN dated 7/7/23 indicated, CBW [current body weight] 135 lbs 7/4, 3 lb wt [weight] gain x 1 month (6/5 132 lbs), significant 8% 10 lb wt gain x 3 months (4/4 125 lbs), significant 17.4% 20 lb wt gain x 6 months (1/4 115 lbs). BMI 24.7 normal Previously discontinued house supplement last month in IDT [Interdisciplinary Team- group of healthcare professionals from different fields working together to determine a patient's treatment plan] wt variance d/t [due to] adequate oral intake. Nursing: On [Quetiapine brand name]; potentially contributing to wt gain. Lipid panel and A1c ordered by MD for this month. A!c 6.6% . MD [PHY 1] advised to just watch his diet. A review of Resident 75's DPN dated 10/3/23 indicated, Value 143. Resident previously reviewed by IDT for significant wt change. Stable wt trend x 4 months. IDT to remain available and monitor on monthly weights. A review of Resident 75's DPN dated 11/6/23 indicated, CBW 145 lbs 11/6, wt gain x1 month (10/2 143 lbss), 5 lb wt gain x 3 months (8/1 140 lbs), significant 15.1% 19 lb wt gain x 6 months (5/1 126 lbs). BMI 26.5 overweight status . No additional supplements provided. RD 2 stated Resident 75 had a weight alert due to a significant weight gain during a six-month period. RD 2 stated he was part of the IDT meetings and they looked at different medications such as antipsychotics that could cause weight gain. RD 2 stated, he did not see any indication in Resident 75's medical record that would indicate fluid retention due to medications or diagnosis. RD 2 stated he was aware antipsychotic medication could cause weight gain. RD 2 stated for patient on medications, he may have spoken to the physician to determine if there was a different medication the resident can try, and the physician can order a more beneficial medication for the resident without the weight gain. During a concurrent interview and record review on 6/10/24 at 8:31 a.m., with Minimum Data Set Nurse (MDSN), MDSN stated she was not aware Resident 75 had a diagnosis of dementia. MDSN stated if Resident 75's physician diagnosed Resident 75 with dementia, it should be added that same day into Resident 75's profile because that would be the day the diagnosis became active. MDSN stated MDS staff is expected to review Resident 75's chart and input any new diagnosis. MDSN stated this was important because it could affect Resident 75's care; if all of staff is not aware Resident 75 has dementia, they might not know how to approach him or that he needs a different kind of approach. During a concurrent interview and record review on 6/10/24 at 8:41 a.m., with Administrator in Training (AIT), Resident 75's PO for aripiprazole and quetiapine were reviewed. AIT acknowledged being the assistant director of nursing at that time and confirming Resident 75's initial quetiapine order for 50 mg every 12 hours for schizoaffective disorder on 5/4/23. AIT stated Resident 75 was having behaviors and told a nursing staff to call PHY 1 and asked PHY 1 what diagnosis to put for Resident 75's order for quetiapine. AIT also acknowledged obtaining telephone orders for all of Resident 75's quetiapine and aripiprazole orders including aripiprazole 2 mg by mouth once daily for bipolar disorder manifested by slamming door shut, barricading door, and jumping on bed, on 3/4/23 with PHY 1, aripiprazole 5 mg by mouth once daily for schizoaffective disorder on 6/28/23, and aripiprazole 5 mg by mouth twice daily. AIT stated he was aware that quetiapine and aripiprazole were both antipsychotic medications and acknowledged Resident 75 was concurrently administered both quetiapine and aripiprazole. AIT acknowledged aripiprazole was not a twice daily dosing medication, and stated he presented all the information to PHY 1 and told PHY 1 all the medications Resident 75 was being administered and that is what PHY 1 gave the nursing staff. AIT stated, [Resident 75] was so unmanageable on our end]. AIT was unable to provide documentation indicating clinical rationale for dose increases of aripiprazole and quetiapine. AIT stated he did not remember Resident 75 having dementia and was aware some medications had black box warnings (highest safety-related warning that medications can have assigned by the Food and Drug Administration, a federal government agency). During a telephone interview on 6/10/24 at 9:16 a.m., with CRPH, CRPH stated aripiprazole is long acting and given once daily. CRPH stated if aripiprazole is given twice daily, it has more side effects. CRPH stated she has not seen it used twice daily. CRPH acknowledged the concurrent use of quetiapine and aripiprazole was inappropriate and stated the physician should be notified of therapy duplication because the medications can cause side effects. CRPH stated a majority of antipsychotics can cause weight gain, and weight gain was a major side effect of quetiapine. CRPH stated the expectation was to ask the physician to do a gradual dose reduction, lower dose to treat patient condition and lower risk of side effect. CRPH stated she was not aware Resident 75 was diagnosed with dysphagia and acknowledged antipsychotics can induce dysphagia. CRPH sated dysphagia was difficulty swallowing and could contribute to Resident 75's weight loss because Resident 75 would not be able to eat. CRPH stated it was important to consider alternative medications that would not cause dysphagia and to see if another resident condition could be inducing dysphagia. CRPH stated she was not aware Resident 75 was diagnosed with dementia and had not seen any dementia medication. CRPH stated there was a boxed warning that antipsychotics increase risk of cardiovascular mortality rate in the elderly and because of that, the physician should evaluate risk versus benefit. During a review of Lexicomp, the manufacturer for aripiprazole indicated, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis . Avoid for behavioral problems associated with dementia or delirium unless alternative nonpharmacologic therapies have failed and patient may harm self or others. If used, consider deprescribing attempts to assess continued need and/or lowest effective dose . Aripiprazole may cause extrapyramidal symptoms (EPS), also known as drug-induced movement disorders . EPS presenting as dysphagia, esophageal motility disorder, or pulmonary aspiration [food, drink or other material enter lung] have also been reported with antipsychotics, which may not be recognized as EPS . All drugs may cause side effects. However, many people may not have side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away: . weight gain . During a review of Lexicomp, the manufacturer for quetiapine indicated, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis . Avoid for behavioral problems associated with dementia or delirium unless alternative nonpharmacologic therapies have failed and patient may harm self or others. If used, consider deprescribing attempts to assess continued need and/or lowest effective dose . Quetiapine may cause extrapyramidal symptoms (EPS), also known as drug-induced movement disorders . EPS presenting as dysphagia, esophageal motility disorder, or pulmonary aspiration [food, drink or other material enter lung] have also been reported with antipsychotics, which may not be recognized as EPS . All drugs may cause side effects. However, many people may not have side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away: . weight gain . During a review of the Publication titled The American Psychiatric Association [APA] Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia, dated 5/2016, the Publication indicated, Development of a Comprehensive Treatment Plan Statement 4. APA recommends that patients with dementia have a documented comprehensive treatment plan that includes appropriate person-centered nonpharmacological and pharmacological interventions, as indicated. Statement 8. APA recommends that if a risk/benefit assessment favors the use of an antipsychotic for behavioral/psychological symptoms in patients with dementia, treatment should be initiated at a low dose to be titrated up to the minimum effective dose as tolerated. APA recommends that in patients with dementia with agitation or psychosis, if there is no clinically significant response after a 4-week trial of an adequate dose of an antipsychotic drug [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents receive assistive devices to maintain hearing abilities for one of 28 sampled resident (Resident 75) when Resident 75 who was extremely hard of hearing, was assessed for the use of hearing aid, and was not provided with hearing aid. This failure resulted in Resident 75 not having hearing aid to maintain hearing for communication with staff regarding care needs and treatment, and compromise Resident 75's quality of life. Findings: During an observation on 6/5/24 at 4:36 p.m., in Resident 75's room, Resident 75 was observed lying on right side in his bed watching television. When asked how he was doing, Resident 75 responded, by pointing to his ears and stating he couldn't hear too good in a loud voice. During a review of Resident 75's Hospital Medical Records (HMR) dated, 11/19/22, the HMR indicated Resident 75 was an [AGE] year old male who was extremely hard of hearing. The HMR also indicated during a physical examination, Resident 75 was wearing a hearing aid in right ear. During a review of Resident 75's Face Sheet (FS - a document containing resident's personal information), dated 6/7/24 indicated, Resident 75's FS indicated Resident 75 was admitted to the facility on [DATE] with diagnoses including unspecified hearing loss, unspecified ear. During an interview on 6/6/24 at 2:36 p.m., with Certified Nursing Assistant (CNA) 8, CNA 8 stated Resident 75 was hard of hearing and if someone wanted to speak with him, they had to get close and speak in his ear. CNA 8 stated Resident 75 did not like staff getting close to him, so staff used their hands a lot. CNA 8 stated she did not know Resident 75 used hearing aids and had never seen him wear a hearing aid. During a review of Resident 75's Nursing Progress Notes (NPN), dated 11/29/22 at 12:14 p.m., the NPN indicated, Resident new admit. Resident alert and oriented x [for] 3 [measure for alertness and orientation]. Resident refused to get VS [vital signs medical signs that indicate the status of the body's vital functions] @ [at] 1100. Resident is non compliant and stated he is going to get up and walk home. Redirected resident to stay and get the help that he needs. Resident appears to not want to be here. Will cont. [continue] to monitor. During a review of Resident 75's Nursing Progress Notes (NPN), dated 12/1/22 at 4:23 p.m., the NPN indicated, .Writer tried to talk to resident but resident is hard of hearing and does not comprehending . During a concurrent record review and interview on 6/6/24 at 4:39 p.m., with the Social Services Director (SSD), the SSD was unable to provide facility documentation of Resident 75 using hearing aids. The SSD stated Resident 75 had never had hearing aid at the facility. SSD stated upon admission on 11/28/24, the facility should have done a social service evaluation to include an assessment for hearing aids. The SSD stated the social service evaluation was not completed and Resident 75's need for a hearing aid was not assessed upon admission to the facility. During an interview on 6/7/24 at 9:50 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated staff had to speak to Resident 75 loudly when communicating. LVN 3 stated Resident 75 got agitated when asked to do activities of daily living, however Resident 75 would not go out of his way to have an altercation. LVN 3 stated Resident 75 did not have a communication board in his room. LVN 3 stated if Resident 75 was admitted to the facility and documents from other facility stated Resident 75 had hearing aids, upon admission, staff should have ensured Resident 75 had hearing aids, check Resident 75's belongings, and monitor Resident 75 to ensure hearing aids were put in daily. LVN 3 stated if the hearing aids were not in Resident 75's belongings upon admission to the facility, staff should have called the previous facility or hospital and asked the Responsible Party (RP) 2 to get clarification to see if hearing aids were lost or the information had changed. During an interview on 6/10/24 at 10:20 a.m., with Medical Director (MD), MD stated social services and nursing staff should have identified Resident 75 was using a hearing aid and should have assessed Resident 75 and developed a care plan for it. MD stated not assessing or care planning for Resident 75 could have impacted social activities, meals, and interaction with people, and could have led to isolation, and depression. During a concurrent interview and record review on 6/10/24 at 1:22 p.m., with Director of Nursing (DON), DON was unable to provide documentation of Resident 75's care plan for hearing aid and stated she was unaware Resident 75 used hearing aid. DON stated, I didn't see any when he came. DON stated hearing aid was important for Resident 75's daily routine care and if Resident 75 was hard of hearing, he could have misunderstood words.

Based on observation, interview and record review, the facility failed to ensure accurate documentation of a mental health diagnosis for 1 of 28 sampled residents (Resident 75) based on standards of practice when Resident 75's medical record was marked with schizoaffective disorder (a mental health disorder marked by a major mood episode and a break down between thought, emotion, and behavior) as a diagnosis for use of quetiapine (brand name used- an antipsychotic [mind altering] medication used to treat mental disease) and aripiprazole (brand name used, antipsychotic) with no prior history of such diagnosis. This failure resulted in Resident 75 being inappropriately administered aripiprazole and quetiapine, which resulted in adverse events including weight gain. Findings: During an observation on 6/5/24 4:36 p.m., in Resident 75's room, Resident 75 was observed lying on right side in his bed watching television. When asked how he was doing, Resident 75 responded, by pointing to his ears and stating he couldn't hear too good in a loud voice. During a review of Resident 75's Hospital Medical Records (HMR) dated, 11/19/22, the HMR indicated, History of Present Illness . Per son, patient has underlying memory issues but has not had formal evaluation . Assessment: Per [son], their father lives alone though they tried to convince him to live with them but pt [patient] preferred to live by himself . Principal Diagnosis Cerebellar CVA [cerebral vascular accident happens when blood supply stops to the part of the brain that helps with body movement, eye movement, and balance] . Active Problem List . ataxia [loss of coordination] . During a review of Resident 75's Face Sheet (FS a document containing resident's personal information), dated 6/7/24, Resident 75's FS indicated, Resident 75 was admitted to the facility on [DATE] with diagnoses including ataxia following cerebral infarction, (CVA) and cerebellar stroke syndrome (CVA in certain area of the brain). During an interview on 6/6/24 at 10:38 a.m., with Resident 75's Responsible Party (RP) 2, RP 2 stated he was previously told his father, Resident 75, had dementia. RP 2 stated that the facility however, told him that Resident 75 had Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and may seem like they have lost touch with reality), that is why Resident 75 was being administered medication. RP 2 stated he thought it was dementia because people like Resident 75 didn't have short term memory but had long term memory. RP 2 stated, I guess they were having problems with him, he would get angry, and he wouldn't let them help him, they said it wouldn't harm him, it would help him be calm, it was last year or year before, I'm not sure. RP 2 stated, Resident 75 slept a lot more and didn't want to eat. RP 2 stated, He was always active then all of sudden he started getting tired, not wanting to get up and sleeping a lot and the food too, not wanting to eat I think started happening last year. RP 2 stated he has had to go to the facility to talk to Resident 75 and get him to understand the facility is there to help him and shared with the facility to tell Resident 75 that everything is all right, they're his friends and they're there to help him and he's safe. During a review of Resident 75's Minimum Data Set (MDS) (assessment and care screening of a patient) dated 12/1/22, 2/28/23, and 5/30/23, Resident 75's MDS indicated Resident 75 did not have a diagnosis for psychiatric or mood disorder including bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows) or schizophrenia, and Resident 75 did not have a history of hallucinations (when one thinks something they see, hear, smell, touch or taste is real, but it's not or delusions (inability to distinguish what is real and what seems to be real). During a review of Resident 75's Physician Orders (PO) and Medication Administration Record (MAR ) dated 2/23, 5/23, 6/23, 7/23, 8/23 2/24, 3/24, for aripiprazole, Resident 75's PO and MAR indicated for: Aripiprazole 2 mg (milligram unit of measure) daily for bipolar disorder manifested by slamming door shut, barricading door and jumping on bed 3/4/23 to 3/9/23 Aripiprazole 2 mg twice daily for bipolar disorder manifested by slamming door shut, barricading door, and jumping on bed 3/9/23 to 5/9/23 Aripiprazole 5 mg daily for schizoaffective disorder 6/29/23 to 7/13/23 Aripiprazole 5 mg twice daily for schizoaffective disorder 7/13/23 to 10/24/23 Aripiprazole 2 mg twice daily for schizoaffective disorder 10/24/3 to 5/6/24 Aripiprazole 2 mg daily for schizoaffective disorder 5/6/24 to 5/22/24 Aripiprazole 2 mg every other day for 5 days for schizoaffective disorder 5/22/24 to 5/27/24 During a review of Resident 75's PO and MAR for Quetiapine, Resident PO and MAR dated 2/23, 5/23, 6/23, 7/23, 8/23 2/24, 3/24, for quetiapine, Resident 75's PO and MAR indicated for: Quetiapine 50 mg every 12 hours for schizoaffective disorder manifested by pacing down the hallways and yelling I own this building, I run this place and trying to hit everyone 5/4/23 to 7/11/23 Quetiapine 100 mg every 12 hours for schizoaffective disorder 7/11/23 to 10/24/23 Quetiapine 75 mg by mouth every 12 hours for schizoaffective disorder 10/23/23 to 2/6/24 Quetiapine 50 mg by mouth every 12 hours for schizoaffective disorder 2/6/24 to 5/6/24 Quetiapine 25 mg every 12 hours for schizoaffective disorder 5/6/24 to 5/30/24 Quetiapine 12.5 mg at bedtime for schizoaffective disorder 5/30/24 to present During an interview on 6/6/24 at 2:53 p.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated she had cared for Resident 75 for on and off for almost 2 years. CNA 8 stated when Resident 75 was first admitted on [DATE], he was more alert, would get into his wheelchair, go to the dining room; Resident 75 didn't have as many falls and ate a lot better. CNA 8 stated she observed a big change in Resident 75 after he experienced COVID 19 (highly contagious respiratory disease cause by coronavirus) positive symptoms (December 2023); Resident 75 stopped eating for a little bit, and wanted to lay down, not wanting to get up or go to dining room. CNA 8 stated, she did not notice Resident 75 to have hallucination or delusions during her care. CNA 8 stated Resident 75 would look at staff confused and ask why everybody was in his house, say he wanted everybody out of his house, and ask for his family. During a review of Resident 75's Nursing Progress Notes (NPN), Resident 75's NPN indicated on: 11/29/22 12:14 p.m. Resident new admit. Resident alert and oriented x [for] 3 [measure for alertness and orientation]. Resident refused to get VS [vital signs medical signs that indicate the status of the body's vital functions] @ [at] 1100. Resident is non compliant and stated he is going to get up and walk home. Redirected resident to stay and get the help that he needs. Resident appears to not want to be here. Will cont. [continue] to monitor. 12/1/22 4:23 p.m. Writer was in room with resident and resident states they want to kill themselves, life is not living anymore and talks about past friend who killed themselves. CNA was also present and writer counted that resident repeated taking own life seven times approximately every other minute. Writer tried to talk to resident but resident is hard of hearing and does not comprehending. Resident kept going back to story of friend taking their own life and then resident states about taking own life. Writer inform DSD [Director of Staff Development], DON [Director of Nursing], Nurse and dinning services. Resident has one on one and on plastic utensils for 72 hours. 12/29/22 12:20 p.m. Resident is in bed watching the rain outside his window while having lunch. He is in a cheerful mood. Bed is in the lowest position along with call light/ bed control in his reach. He is telling the nursing team fond memories of his dog in the rain. His son did visit and will try to bring a photo the next time he visits him. 1/2/23 6:26 a.m. Resident is in a happy mood. A sign has been placed at his door to inform him that his son has his dog. He does enjoy talking to the noc [overnight] nursing team about life and his fond family memories. 1/20/23 10:50 a.m. Resident is S/P [status post after] room change to [room number]. He is adjusting well to his new room. He is in bed looking out the window and watching his tv. The bed is in the lowest position along with his bed controls being in his reach. He reports no pain or discomforts at this time. 1/21/23 10:56 a.m. Resident is S/P room change to [room number] He is adjusting well to his new room. He is in bed looking out the window and watching his tv. The bed is in the lowest position along with his bed controls being in his reach. He reports no pain or discomforts at this time. He keeps asking about his dog and is redirected by the staff. 1/24/23 3:22 p.m. Resident is S/P room change. He is adjusting well to room change. He has his call light and bed controls in his reach with his bed in the lowest position. He is in in his bed. 2/2/23 2:42 a.m. Writer observed resident resident getting into his roommates face telling him to get out of his room. Resident was educated on personal space and sharing the room. 2/2/23 4:57 a.m. Resident is upset to have another person in his room. He stated to the nursing team that he pays for this room and want to be alone in it. Writer educated the resident on the sharing of the room. He is upset and demanding that the other resident be moved out now. 2/13/23 9:59 p.m. Resident would mostly yell when he is hungry then shuts his door loudly which made another resident upset with the loud noise. He would also close the bathroom door so loud and his door closet. When resident is told about not shutting the doors, resident yells back at staff. 2/17/23 3:59 a.m. Resident continues to come out of room and ask about his dog and slam the room door. He reports his pain to be 0\10 with no discomforts. He has been offered several snacks and is now in his room watching the tv. 2/19/23 8:10 a.m. Writer along with the CNA staff have offered x3 to help the the resident change his clothing and to take a bed bath. He has refused x3 [three times] and yelled at the staff to get the hell out of his room now. Writer encouraged the resident to use a lower tone and to use his call light if he is in need of aid. 2/19/23 12:23 p.m. Resident is in bed having his lunch. He reports no pain or discomfort at this time. Bed is in the lowest position with call light and bed controls in his reach. Resident is able to make his needs known to the nursing team. He has been ambulating in the facility with ease with his non skid foot wear. He went outside with he writer to get some fresh air and look at he trees . He got excited when he saw all of the cars driving by. Call light and bed controls are in his reach. resident was offered aid to change his clothing he refused x3 again. 2/21/23 2:16 a.m. Resident is in his wheel chair looking for his dog at this time. He has been offered snack which he has eaten. He reports his pain to be none with no discomfort/ distress at this time. Writer did encourage him to wear non skid foot wear and to use the call light for aid. Writer did offer to help the resident change his clothing. Resident refused x 3. 2/25/23 11:59 a.m. Resident is on charting for s/p fall, no delayed injuries noted. Resident is alert. No new skin issues noted. Resident is in bed watching the tv and calling out for his dog. His call light/ bed control are within reach. He is s/p room change and is adjusting well to this new room. His son [RP 2] came to visit today. he was upset that he was not notified of his father being moved to another room. He informed the writer that the communication between the facility and family needs to greatly improve. Writer informed RP that this matter would be brought to the social service attention. 2/28/23 1:15 a.m. Resident is up opening his screen door yelling. Writer informed the resident that his dog was gone with his son. He was asked about pain he said no pain. Resident was given a snack. He is now in bed watching the tv. He was reminded to wear non skid footwear and to use his call light for aid. 3/2/23 6:11 a.m. Resident is up opening his screen door yelling out for his dog. Writer informed the resident that his dog was gone with his son. He was asked about pain he said no pain. Resident was given a snack. He is now in bed watching the tv. He was reminded to wear non skid footwear and to use his call light for aid. 3/3/23 2:02 a.m. Upon the NOC med pass. Writer was informed by the CNA on the wing of the resident slamming the restroom door in her face and striking her on the left shoulder. Writer asked the resident what was going on. He stated to the writer why is he in my bathroom? I pay rent here. Get him out of my house. Writer informed the reside that they all live here together. Along with sharing this space in the restroom. A snack was offered. Resident was helped back to his bed. Call light is in reach. Bed is in the lowest position. Writer asked resident if he was having any pain or discomfort. He replied no I'm fine just get him out of here. CNA did fill out an incident report. Writer did encourage he resident to keep his hands to himself. 3/3/23 2:13 p.m. Resident is being aggressive and getting into residents faces for being in common areas such as the hall way and restroom. He is not easily redirected until he feels as if he is getting his point across. He has been reminded of personal space and to keep his hands to himself and off others. resident was asked if he was in pain or having discomforts he responded with no I'm fine. Writer has placed his bed in the lowest position with the wheels being locked. A tv program of his choice is also playing. Resident is in a happy mood at this time. 3/4/23 3:14 a.m. Resident is being aggressive and getting into other residents/ staff faces for being in common areas such as the hallway and restroom. He is not easily redirected. He has been reminded of personal space and to keep his hands to himself and off others. Writer asked the resident was asked if he was in pain or having discomforts he responded with no. Writer is walking with the resident in the facility and looking outside with him to calm him talking about dogs and the war. Writer has placed his bed in the lowest position with the wheels being locked. A tv program of his choice is also playing. Resident is content and in bed. 3/4/23 3:20 p.m. Resident has a new order for [Brand name] Oral Tablet 2 MG (Aripiprazole) for Bipolar Disorder. Resident has been put on the medication due to behaviors. Resident MD [doctor] was contacted and was described the resident's behaviors and manifestations. Resident has such Manifestations Slamming Door Shut, Barricading door and Jumping on bed and has visual Hallucinations of seeing a dog and other humans. Resident MD gave the orders for this medications along with a DX [diagnosis] of Bipolar Disorder to support the medication order. Resident is self RP and aware of this new order of the medication. 3/5/23 00:11 a.m. Upon writers rounds the resident was in the hallway yelling for his dog. Writer informed the resident that his dog was with his son and that people are trying to sleep. Resident informed the writer that he don't care we are all nuts. Writer informed the resident that he was safe and being cared for. The resident was asked if he was in pain or having discomforts he responded with no. Writer has placed his bed in the lowest position with the wheels being locked. A tv program of his choice is on. Writer offered the resident a snack. He told writer thank you and sat on his bed. 6/23/23 2:06 a.m. Resident is up walking he halls of the wing. Going into other rooms demanding that the resident get the [expletive] out of his house or his sister will kick their ass. Writer informed the resident of personal space and using respectful language when talking to others. Resident has been redirected to the common areas of the facility. When asked about his pain he reports that he is fine and we need to get out of his house. Resident is in the common room watching the tv and having snacks. 6/26/23 2:06 a.m. Resident is up walking [the] halls of B wing. Going into the other rooms looking for his dog and questioning why all these people are here? He is demanding that we all leave his [expletive] trailer. Writer informed the resident of personal space and using respectful language when talking to others. Resident has been redirected to the common areas of the facility. When asked about his pain he reports that he is ok. Resident is in the common room watching the tv with other residents and having snacks. He has on his non skid footwear. His bed is in the lowest position with his call light in reach. 6/26/23 1:03 p.m. The resident is being aggressive and keeps wanting to leave the facility. Keeps asking bankruptcy and how it will effect his life. The writer redirected the resident he is in the facility at this time for rehab. Snacks and coffee was provided and offered him to join the other residents for coffee social. Resident is enjoying coffee in the dining room with other residents and is watching Tv. He is relaxed and calm. During a concurrent interview and record review on 6/6/24 at 3:22 p.m., with MDS Nurse (MDSN) 1, Resident 75's Preadmission Screening and Resident Review (PASRR federal regulation that requires all individual being considered for admission to a Medicaid certified nursing facility be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual disability, or related condition) dated 11/29/22, Resident 75's PASRR was reviewed. Resident 75's PASRR indicated, . no serious mental illness . result of level I screening . negative. MDSN 1 acknowledged Resident 75's PASRR was conducted upon admission to the facility. During a telephone interview on 6/6/24 at 3:34 p.m., with Psychologist (PSYCH), when asked about Resident 75's diagnosis of schizoaffective disorder, PSYCH stated he did not have a copy of the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 (handbook that contains criteria for diagnosing mental disorders and is used by healthcare professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders) to review the criteria for diagnosis, and his best guess was that he carried the diagnosis forward and did not make the diagnosis. During a concurrent telephone interview and record review on 6/6/24 at 4:15 p.m., with Physician (PHY) 1, PHY 1 stated Resident 75 had diagnoses including dementia, hearing loss, post CVA and hypertension. When asked why Resident 75's diagnosis of dementia was not updated on Resident 75's electronic medical record or Minimum Data Set (MDS -a standardized comprehensive assessment and care planning tool), PHY 1 stated, If you look at my notes, I mentioned it a few times, its what the clinicians see, it should be there some place. PHY 1 stated he did not diagnose Resident 75 with schizoaffective disorder, and that it came from a psychiatrist. During a review of Resident 75's Nursing Progress Note (NPN) dated 5/24/23, Resident 75's NPN indicated, Writer contacted [Physician] by phone to notify him of the resident recent behaviors of getting into other residents' personal space, making threats and his non sleeping pattern. MD [PHY 1] gave new medication orders. MD gave orders for [Quetiapine brand name] 50 mg every 12 hours. MD was asked what diagnosis MD would like to give for this medication. MD stated schizoaffective disorder. PHY 1 stated he gave the schizoaffective disorder diagnosis and that with schizophrenia, there was no chemical test. PHY 1 stated he had to use something else to justify putting Resident 75 on those medications. When asked why Resident 75 concurrently on aripiprazole and quetiapine, PHY 1 stated that was bad practice and he didn't think he would put Resident 75 on two antipsychotics at the same time. PHY 1 stated he doubted he authenticated the orders and would increase the dose of one, and not both. PHY 1 stated side effects would include falls, and requested the orders be sent to him. PHY 1 stated Resident 75 was on hospice (program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease), and he didn't ask for hospice and didn't know why Resident 75 was on hospice. During a review of DSM 5 criteria for schizoaffective disorder, the DSM 5 criteria indicated, Criterion A (an uninterrupted period of illness during which there is a major mood episode [depressive or manic] concurrent with Criterion A1 [at least 2 of the following, each present for a significant portion of time during a 1 month period [or less if successfully treated]. At least 1 of these must be 1, 2, or 3: 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior [lack of movement and communication] 5. Negative symptoms [diminished emotional expression]); Criterion B (delusions or hallucinations for at least 2 weeks in the absence of a major mood episode [depressive or manic] during the lifetime duration of the illness); Criterion C (symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness); Criterion D (the disturbance is not attributable to the effects of a substance or another medical condition). During an interview on 6/6/24 on 4:29 p.m., with MDSN 1, MDSN 1 was unable to provide a PASRR for Resident 75 upon initiation of aripiprazole for a mental illness. MDSN 1 stated a PASRR should have been completed when Resident 75 was given a new psychiatric diagnosis. MDSN 1 stated it was important to ensure that the facility was still the appropriate place for the resident to be. During an interview on 6/7/24 at 9:36 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 75 was moved to a private room to give him a change of scenery because it was difficult for him to have a roommate. Resident 75 would get agitated a lot and behaviors were escalating when he tried to jump over the fence and become physically aggressive. LVN 3 stated Resident 75 did better in the private room, and she (LVN 3) did not observe some of the behaviors that was said to have been happening in the other wing. LVN 3 stated Resident 75 often asked to go home. LVN 3 stated she was unaware why Resident 75 was moved to a room with another resident. During a review of Resident 75's Physician Progress Notes (PPN), dated 2/19/23 and 3/19/23, the PPN dated 2/19/23 indicated, Dementia suspected and the PPN dated 3/19/23 indicated, Dementia. During a concurrent interview and record review on 6/7/24 at 10:09 a.m., with LVN 3, Resident 75's FS dated 6/7/24 and HMR dated 11/19/22 were reviewed. LVN 3 was unable to provide documentation of Resident 75's diagnosis of dementia among Resident 75's list of diagnoses. LVN 3 stated that for symptoms like forgetfulness, the psychiatrist came in and evaluated resident. LVN 3 acknowledged Resident 75 was forgetful. LVN 3 acknowledged Resident 75's HMR indicated Resident 75 had underlying memory issues. LVN 3 acknowledged Resident 75's concurrent orders for antipsychotic medications quetiapine and aripiprazole. When asked about an evaluation or assessment from a physician or mental health provider for diagnosing Resident 75's with schizoaffective and bipolar disorders, LVN 3 was unable to provide documentation. LVN 3 stated she or the CNAs that worked during her shift had not observed Resident 75 experiencing hallucinations, however Resident 75 had been observed to be forgetful, confused and agitated. During a concurrent telephone interview and record review on 6/7/24 at 3 p.m., with Registered Dietician (RD) 2, Resident 75's Weights and Vitals Summary Log (WVSL) dated 11/1/22 to 6/30/24 and Dietician Progress Notes (DPN) dated 12/29/22, 4/4/23, 6/9/23, 7/7/23, and 10/2/23 were reviewed. Resident 75's weight log indicated, 12/7/22 111 lbs [pounds], 2/13/23 115 lbs, 3/2/23 122 lbs, 4/4/23 125 lbs, 5/1/23 126 lbs, 6/5/23 132 lbs, 7/4/23 135 lbs, 8/1/23 140 lbs, 9/4/23 139 lbs, 10/2/23 143 lbs, 11/6/23 145 lbs, 12/1/23 144 lbs, 1/2/24 143 lbs, 2/13/24 113 lbs, 3/1/24 114 lbs, 4/1/24 106 lbs, 5/4/24 104 lbs 6/2/24 108 lbs. RD 2 acknowledged Resident 75's weight gain and stated Resident 75's ideal body weight was 106 to 130, body max index (BMI indicates high body fat and screens for weight categories that may lead to health problems). A review of Resident 75's DPN dated 12/29/22 indicated, 4 lb weight gain since admission weight 12/7 [2022]111 lbs BMI: 4 normal . consuming 75 100% of meals. Good appetite noted attributing to weight gain. A review of Resident 75's DPN dated 4/4/23 indicated, 125 lb, non significant weight gain x [in] 1 month (3/2: 122 lbs) and significant 8.7% 10 lb weight gain x 3 months (1/4: 115 lb) BMI: 22.9 normal. Weight gain was desired. On house supplement TID [three times daily] attributing to weight gain. Social Services/Activities: On [Aripiprazole brand name] for bipolar which may cause weight gain . Recommend to reduce to 120 ml [milliliters] at dinner . A review of Resident 75's DPN dated 6/9/23 indicated, CBW [current body weight] 132 lbs 6/5, 4.8% 6 lb weight gain x 1 month (5/1 126 lbs, significant 8.2% 10 lbs weight gain x 3 months (3/2 122 lbs), significant 18.9% 21 lb weight gain x 6 month (12/7 111 lbs). BMI 24.1 normal. Weight gain desirable. Nursing: On [Quetiapine brand name] can contribute to weight gain. A review of Resident 75's DPN dated 7/7/23 indicated, CBW 135 lbs 7/4, 3 lb wt [weight] gain x 1 month (6/5 132 lbs), significant 8% 10 lb wt gain x 3 months (4/4 125 lbs), significant 17.4% 20 lb wt gain x 6 months (1/4 115 lbs). BMI 24.7 normal Previously discontinued house supplement last month in IDT [Interdisciplinary Team group of healthcare professionals from different fields working together to determine a patient's treatment plan] wt variance d/t [due to] adequate oral intake. Nursing: On [Quetiapine brand name]; potentially contributing to wt gain. Lipid panel and A1c [blood test about level of blood sugar over period of time] ordered by MD for this month. A1c 6.6% . MD advised to just watch his diet. A review of Resident 75's DPN dated 10/3/23 indicated, Value [weight] 143. Resident previously reviewed by IDT for significant wt change. Stable wt trend x 4 months. IDT to remain available and monitor on monthly weights. A review of Resident 75's DPN dated 11/6/23 indicated, CBW 145 lbs 11/6, wt gain x1 month (10/2 143 lbs), 5 lb wt gain x 3 months (8/1 140 lbs), significant 15.1% 19 lb wt gain x 6 months (5/1 126 lbs). BMI 26.5 overweight status . No additional supplements provided. RD 2 stated Resident 75 had a weight alert due to a significant weight gain during a six month period. RD 2 stated he was part of the IDT meetings and they looked at different medications such as antipsychotics that could cause weight gain. RD 2 stated, he did not see any indication in Resident 75's medical record that would indicate fluid retention due to medications or diagnosis. RD 2 stated he was aware antipsychotic medication could cause weight gain. RD 2 stated for patient on medications, he may speak to the physician to determine if there was a different medication the resident can try, and the physician could order a more beneficial medication for the resident without the weight gain. During a concurrent interview and record review on 6/10/24 at 8:31 a.m., with Minimum Data Set Nurse (MDSN), MDSN stated she was not aware Resident 75 had a diagnosis of dementia. MDSN stated if Resident 75's physician diagnosed Resident 75 with dementia, it should be added that same day into Resident 75's profile because that would be the day the diagnosis became active. MDSN stated MDS staff is expected to review Resident 75's chart and input any new diagnosis. MDSN stated this was important because it could affect Resident 75's care; if all of staff is not aware Resident 75 has dementia, they might not know how to approach him or that he needs a different kind of approach. During a concurrent interview and record review on 6/10/24 at 8:41 a.m., with Administrator in Training (AIT), Resident 75's PO for aripiprazole and quetiapine were reviewed. AIT acknowledged being the assistant director of nursing at that time and confirming an order for quetiapine 50 mg every 12 hours for schizoaffective disorder on 5/4/23. AIT stated Resident 75 was having behaviors and told a nursing staff to call PHY 1 and asked PHY 1 what diagnosis to put for Resident 75's order for quetiapine. AIT also acknowledged confirming all of Resident 75's quetiapine and aripiprazole orders including aripiprazole 2 mg by mouth once daily for bipolar disorder manifested by slamming door shut, barricading door, and jumping on bed, on 3/4/23 with PHY 1 and aripiprazole 5 mg by mouth once daily for schizoaffective disorder on 6/28/23. AIT stated he was aware that quetiapine and aripiprazole were both antipsychotic medications and acknowledged Resident 75 was concurrently administered both quetiapine and aripiprazole. AIT stated he presented all the information to PHY 1 and told PHY 1 all the medications Resident 75 was being administered and that was what PHY 1 gave the nursing staff. AIT stated, [Resident 75] was so unmanageable on our end]. AIT stated he did not remember Resident 75 having dementia and was aware some medications had black box warnings (highest safety related warning that medications can have assigned by the Food and Drug Administration, a federal government agency). During a telephone interview on 6/10/24 at 9:03 a.m., with Consultant Pharmacist (CRPH), CRPH acknowledged Resident 75 was administered aripiprazole twice daily. CRPH stated aripiprazole is usually given once daily because it is long acting. CRPH stated if aripiprazole was given twice daily, it would have more side effects and had not seen it used twice daily. CRPH stated if ordered twice daily, the expectation would be to ask the physician and confirm the order. CRPH stated concurrent administration of quetiapine and aripiprazole was not appropriate and the expectation would be to inform the physician because of increase side effects and therapy duplication. CRPH acknowledged antipsychotics can cause weight gain and stated weight gain was one of the major side effects of quetiapine. CRPH stated the expectation would be to ask the physician to gradually reduce the medication dosage to treat the resident's condition and lower the risk of side effect. CRPH stated the higher the dose, the higher the risk of side effect. CRPH stated doing a medication review to see if other medication that could cause weight gain and switching to other psychotropic medications that do not cause weight gain would also be an alternative. CRPH stated antipsychotics have a risk to increase blood sugars and fats. CRPH stated Resident 75 was not on any dementia medication and she was not aware Resident 75 had a diagnosis of dementia. During a telephone interview on 6/10/24 at 10:15 a.m., with Medical Director (MD), MD stated when there was a new diagnosis, facility is expected to update the resident's care plan. During an interview on 6/10/24 at 1:05 p.m., with DON, DON stated PHY 1 ordered antipsychotic medication and diagnosed Resident 75 with bipolar because Resident 75 was seeing his dog and other humans and had other behaviors. DON stated she was unaware aripiprazole was increase to twice daily and acknowledged aripiprazole was given once daily. DON acknowledged concurrent administration of quetiapine and aripiprazole was therapy duplication and stated the expectation was for nursing and pharmacy to clarify with the physician and monitor resi [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents right to be free from abuse (verbal and physical abuse) for one of three sampled residents (Resident 1) when Resident 2 hit Resident 1 on the right side of the face, in the same spot two times, threatened her and cursed at her. This failure resulted in Resident 1 experiencing fear, not wanting to leave her room to participate in activities or dine in the dining room from 2/7/23 to 2/9/23, an injury of pain and redness to the right side of her face with a pain rating (a way to measure pain so providers can help plan how best to manage the pain) of 8 out of 10 (zero means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) that required Oxycodone (an analgesic [acting to relieve pain] drug used to treat moderate to severe pain) which was avoidable. Findings: During a concurrent observation and interview on 2/9/23, at 1:55 p.m., with Resident 1, in Resident 1's room, Resident 1 was lying in bed. Resident 1's face was red, and her cheeks were patchy. Resident 1 had more red patchy area on the right side of her face than the left side. Resident 1 stated she had a history of her face turning red and developing a rash when she was stressed. Resident 1 stated Resident 2 used to be her roommate. Resident 1 stated on 2/6/23 Resident 2 was leaning over her while she was lying in bed and was screaming and cursing at her then hit her with a closed fist on the right side of her face two times. Resident 1 stated Resident 2 threatened her as she was leaving the room, stating Don't worry [Resident 1] I'm coming to get you and I will get you. Resident 1 stated she had a diagnosis of anxiety disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats leading to altered behavior and often to physical symptoms). Resident 1 stated she was hysterical (deriving from or affected by uncontrolled extreme emotion) and had a panic attack (a sudden feeling of acute and disabling anxiety) after being hit by Resident 2. Resident 1 stated she had severe pain to her face after being hit and was given medication. Resident 1 stated prior to the altercation with Resident 2 she used to eat meals in the dining room two times a week and attended activities in the dining room. Resident 1 stated she could not go to the dining room to eat or for activities after being hit by Resident 2 because she was too afraid and anxious she would see Resident 2 there. Resident 1 stated since being hit by Resident 2 on 2/6/23, she would become startled when the door to her room shuts too hard and when the lid to the clothing hamper in her room was closed. During a review of Resident 1's Admission Record (AR), dated 2/9/23, the AR indicated Resident 1 had a diagnosis of Anxiety Disorder, Unspecified. During an interview on 2/14/23, at 10:00 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated he was working on 2/6/23 when Resident 1 and Resident 2 had an altercation. CNA 1 stated, he was in another resident's room when he heard shouting followed by a smack through the wall. CNA 1 stated he went to Resident 1 and Resident 2's room where he saw Resident 2 shouting and cursing at Resident 1. CNA 1 stated Resident 1 was upset and irritated. During an interview on 2/9/23, at 2:55 p.m., with Resident 2, Resident 2 stated she hit and slapped Resident 1 once or twice in the face on 2/6/23. During a review of Resident 2's Admission Record (AR), dated 2/7/23, the AR indicated Resident 2 had the diagnoses of Unspecified Dementia (a mental disorder in which a person loses the ability to think, remember, learn make decisions, and solve problems) and Anxiety Disorder, Unspecified. During an interview on 2/7/23, at 10:51 a.m. with CNA 2, CNA 2 stated she was working on 2/2/23. CNA 2 stated around 7:00 a.m. she went into Resident 3's room because she heard gurgling noises. CNA 2 stated Resident 2 was lunged over Resident 3 with her hands on her neck. During a review of Resident 2's Progress Notes, dated 2/2/23, at [7:35 a.m.] the Progress Notes indicated, . [Resident 2] went to [Resident 3's] room because [Resident 3] was yelling. [Resident 2 stated that she put her hands on [Resident 3's] neck and told her to shut up . During a review of Resident 2's Progress Notes, dated 2/2/23, at [8:51 a.m.] the Progress Notes indicated, . [Resident 2] went to room [Resident 3's room] and was yelling at [Resident 3] and had put her hand on her neck to make her quiet . [Resident 2] was interviewed and [Resident 2] stated that [Resident 3] was yelling and she had to take care of it [Resident 2] stated that she put her hands around [Resident 3's] neck . During a review of Resident 2's Care Plan, dated 2/2/23, the Care Plan indicated, . [Resident 2] was alleged for putting her hands around a [Resident 3's] neck . Goal [Resident 2] will have no other episodes of this behavior . Interventions . Monitor [Resident 2] every 15 [minutes] for whereabouts . During an interview on 2/9/23, at 2:57 p.m., with the Activities Assistant (AA), the AA stated he kept track of what residents in the facility were participating in having meals in the dining room. The AA stated prior to the altercation on 2/6/23, Resident 1 normally ate in the dining room. The AA stated Resident 1 had not been to the dining room since 2/7/23 and had been not leaving her room since the altercation. During an interview on 2/9/23, at 3:16 p.m., with the Activities Director (AD) the AD stated she was familiar with Resident 1. The AD stated Resident 1, prior to the altercation on 2/6/23, participated in getting her nails done, movie socials, coffee socials and liked to be in the front lobby area of the facility. The AD stated Resident 1 liked to have lunch in the dining area. The AD stated Resident 1 was leaving her room prior to the altercation with Resident 2. The AD stated she had not seen Resident 1 leave her room since the altercation with Resident 2 on 2/6/23. During a concurrent observation and interview on 2/9/23, at 3:57 p.m., with the Resident 1 and the AD, in Resident 1's room, Resident 1 was lying in bed. Resident 1 stated she wanted to go to the dining room for meals but was fearful and did not want to see Resident 2. The AD stated Resident 1 was fearful and did not want to see Resident 2. During a concurrent observation and interview on 2/10/23, at 10:15 a.m., with Resident 2, in Resident 2's room, Resident 2 was sitting in her bed. Resident 2 stated she did not do what was right with Resident 1. Resident 2 stated what was right would be knocking her out. During an observation on 2/10/23, at 10:19 a.m., in the dining room, there were 12 residents having coffee. Resident 1 was not in attendance in the dining room. During an interview on 2/10/23, at 10:48 a.m., with Social Services Director (SSD) 1, SSD 1 stated Resident 1 was scared to be out of her room in the facility to do activities if Resident 2 was there. SSD 1 stated Resident 1 could hear Resident 2's voice while in her room and became scared Resident 2 would come in her room. SSD 1 stated Resident 1 ate meals in the dining room two to three times a week for lunch or dinner prior to the altercation with Resident 2. SSD 1 stated Resident 1 participated in activities two to three times a week prior to the altercation with Resident 2. SSD 1 stated Resident 1 had not been leaving her room since the altercation on 2/6/23 with Resident 2. During an interview on 3/15/23, at 10:34 a.m., with the Certified Dietary Manager (CDM), the CDM stated Resident 1 was not dining in the dining room for any meals. The CDM stated there was no way to look at previous dates to find where Resident 1 was eating her meals prior to the altercation on 2/6/23. The CDM stated she was only able to look at meal location for Resident 1 on the current date. During an interview on 3/15/23, at 11:07 a.m., with the Restorative Nursing Assistant (RNA), the RNA stated, she was familiar with Resident 1. The RNA stated Resident 1 was coming to the dining room twice a week prior to altercation with Resident 2. The RNA stated after the altercation with Resident 2, Resident 1 did not come to the dining room to eat. The RNA stated after the altercation, there were several days that week she didn't come out of her room at all. The RNA stated Resident 1 was afraid and teared up when talking about the altercation. During a review of Resident 1's Diet Order, dated 3/20/23, the Diet Order indicated . [Resident 1] . Breakfast . Dining Location: Eats in Room . Lunch . Dining Location: Eats in Room . Dinner . Dining Location: Eats in Room . During an interview on 3/15/23, at 2:59 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was working on 2/6/23 when Resident 1 and Resident 2 had an altercation. LVN 1 stated the altercation between Resident 1 and Resident 2 happened around 10:45 p.m. LVN 1 stated he heard screaming coming from their shared room. LVN 1 stated that Resident 2 was cursing at Resident 1. LVN 1 stated Resident 2 threatened to physically harm Resident 1. LVN 1 stated Resident 1 was scared and crying. LVN 1 stated Resident 1 was shaking, stuttering and unable to speak properly. LVN 1 stated Resident 1 had redness to the right side of her face. LVN 1 stated Resident 1 required medication for pain after the altercation. LVN 1 stated Resident 1 had a pain level of 8 out of 10 and he administered her Oxycodone. During a review of Resident 1's Progress Notes, dated 2/6/23, the Progress Notes indicated, . At [11:45 p.m.] there was a lot of shouting from the resident's room . [Resident 2] was cussing profusely and making threats to physically hurt the resident [Resident 1] . [Resident 1] seemed extremely scared . Upon skin assessment the [Resident 1] had redness to the right side of the face . [Resident 1] also stated that [Resident 2] slapped [Resident 1] multiple times in the face . During a review of Resident 1's Progress Notes, dated 2/7/23, at [2:13 p.m.] the Progress Notes indicated, . [Resident 1] reports right side of her face hurts . During a review of Resident 1's Progress Notes, dated 2/7/23, at [11:05 p.m.], the Progress Notes indicated, redness to right side face decreased almost to normal skin tone . During a review of Resident 1's Medication Admin Audit Report (MAAR), dated 3/15/23, the MAAR indicated, Resident 1 was administered Oxycodone HCl tablet 10 MG (milligram) on 2/7/23 at 12:39 a.m. During an interview on 3/15/23, at 1:05 p.m., with Social Services Designee (SSD) 2, SSD 2 stated, he met with Resident 1 on 2/8/23 Resident 1's room. SSD 2 stated Resident 1 had redness to the right side of her face. SSD 2 stated Resident 1 wanted the door to her room closed but remained scared with the door closed. SSD 2 stated he could tell Resident 2 was scared based on his interactions with her while working at the facility for two to three years. SSD 2 stated Resident 1 was fidgety. SSD 2 stated prior to the altercation with Resident 2, Resident 1 would eat in the dining area two times a week and would be out of her room four days a week. SSD 2 stated after the altercation with Resident 2, he did not see Resident 1 come out of her room for a week. During a review of Resident 1's Progress Notes, dated 2/8/23, the Progress Notes indicated, . [Resident 1] stated she does feel scared . During an interview on 3/16/23, at 12:42 p.m., with the AA, the AA stated he documented daily activities for residents at the facility. The AA stated Resident 1 attended a group activity outside of her room on 1/13/23, 1/17/23, 1/19/23, 1/20/23, 1/25/23, 1/26/23, 1/27/23, 1/28/23, 1/31/23 2/1/23, 2/2/23. The AA stated there was no record of Resident 1 participating in any activities on 2/7/23. The AA stated Resident 1 did not participate in out of the room activity on 2/8/23 and 2/9/23. The AA stated he met with Resident 1 on 2/9/23 in her room. The AA stated Resident 1 was afraid of Resident 2 and did not want to come out of the room. The AA stated Resident 1 appeared nervous, apprehensive, and depressed. During a review Resident 1's Follow Up Question Report (FUQR), dated 3/16/23, the FUQR indicated Resident 1 had participated in activities outside of her room as a group on 1/13/23, 1/17/23, 1/19/23, 1/20/23, 1/25/23, 1/26/23, 1/27/23, 1/28/23, 1/31/23, 2/1/23 and 2/2/23. The FUQR indicated no record of activity on 2/7/23. The FUQR indicated Resident 1 did not participate in a group activity outside of the room on 2/8/23 or 2/9/23. The FUQR indicated Resident 1 had a 1:1 (meeting in person between two people) with the AA on 2/9/23. During an interview on 3/15/23, at 2:06 p.m., with SSD 1, SSD 1 stated if a resident was abused and no longer wanted to leave their room out fear, the resident would be experiencing psychosocial distress (an unpleasant emotional experience). SSD 1 stated Resident 1 experienced psychosocial distress for four days following the altercation with Resident 2. During a review of Resident 1's Progress Notes, dated 2/8/23, the Progress Notes indicated, . [SSD 1] spoke with [Resident 1] about being scared. [Resident 1] stated she does want [Resident 2] to know where she is at. [SSD 1] reassured [Resident 1] that [Resident 2] does not know what room she is in . [SSD 1] asked [Resident 1] that arrangement were made in dining room if [Resident 1] wanted to attend. [Resident 1] declined at this time. [Resident 1] stated she can hear [Resident 2] close to her room. [SSD 1] assured [Resident 1] that her room is next to the dining room and [Resident 2] voice is echoing and that's why she can hear [duplicate word] her and sounds close by . During an interview on 3/17/23, at 1:55 p.m., with SSD 1. SSD 1 stated there had been a previous altercation between Resident 2 and another resident at the facility. SSD 1 stated Resident 2's prior altercation with Resident 3 was serious. SSD 1 stated the interventions put in place by the facility for Resident 2 were not effective. SSD 1 stated if Resident 2 had an intervention for one-on-one sitter monitoring (aimed to keep residents safe through direct observation by staff at all times) the altercation with Resident 1 could have been avoided. SSD 1 stated the residents at the facility had the right to be free from abuse. SSD 1 stated being hit was physical abuse. SSD 1 stated she made a progress note on 2/8/23, at 4:00 p.m. that had an error documented. SSD 1 stated the progress note should have said Resident 1 did not want Resident 2 to know where she was located at the facility. During an interview on 3/17/23, at 2:21 p.m. with the Director of Nursing (DON), the DON stated, Resident 2 had a previous altercation with another resident prior to the altercation with Resident 1. The DON stated Resident 2's previous altercation where she wrapped her hands around Resident 3's neck was serious. The DON stated the interventions put in place by the facility for Resident 2's previous altercation did not work and were not enough to keep her from another altercation with Resident 1. The DON stated if Resident 2 had an intervention in place for a one-on-one sitter monitoring the altercation with Resident 1 would not have happened. The DON stated the residents at the facility had the right to be free from abuse. The DON stated being hit, being threatened, and cursed at was abuse. During a review of the facility's policy and Procedure (P&P) titled, Preventing, Investigating, and Reporting Alleged Sexual and Abuse Violation, dated 2017, the P&P indicated, . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain or mental anguish . Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . Examples of verbal abuse include . threats of harm . saying things to frighten a resident . Physical Abuse includes hitting, slapping . Appropriate steps are taken to prevent recurrence of the incident .

Based on observation, interview and record review, the facility failed to meet the pain management needs of residents consistent with professional standards of practice for one of five sampled residents (Resident 1) when Resident 1's pain level of 10 out of 10 (a pain scale used to evaluate pain; 0 - no pain, 1 to 3 - mild pain, 4 to 7 - moderate, 8 to 10 - severe pain) was not managed effectively due to unavailability of Resident 1's Carbamazepine (medication used to treat certain types of nerve pain) and Licensed Nurses (LN) did not assess the pain, document, and notify the physician (MD - Medical Doctor) of Resident 1's severe pain in order to provide possible alternatives to address the pain. This failure resulted in Resident 1 experiencing avoidable severe uncontrolled pain (10 out of 10) and suffering for prolonged periods of time from 1/24/23 through 1/25/23 which led to her inability to sleep at night, crying, and unable to receive needed care due to severe pain to the areas of her body affected by pain. Findings: During a concurrent observation and interview on 2/6/23, at 10:30 a.m., in Resident 1's room, Resident 1 was in bed, awake. Resident 1 stated she did not receive her Carbamazepine for two days (1/24/23 and 1/25/23). Resident 1 stated she took her pain medications three times daily. Resident 1 stated, I can miss one to two doses, but I can't miss more than that and experienced 10 out of 10 on pain scale . Resident 1 stated, I live in fear that the facility will run out of my medication . I was crying in pain, but movement of my face while crying made my whole body feel like it was on fire. Resident 1 stated the facility missed four doses of pain medications because the facility ran out of supply of Carbamazepine. Resident 1 stated she informed staff of her pain level and the Licensed Nurses offered Ibuprofen (pain medication used to relieve mild pain). During a review of Resident 1's Face Sheet (FS) the FS indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of . Multiple Sclerosis (a condition wherein the body's immune system eats away at the protective covering of nerves) . Neuralgia (facial nerve pain caused by injury or infection or by damage of the nerve) . During a telephone interview on 2/6/23, at 12:35 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was assigned to Resident 1 on 1/24/23 (morning shift). CNA 1 stated she was cleaning Resident 1's face with a washcloth and Resident 1 told her she was in pain. CNA 1 stated she tried to brush Resident 1's teeth and Resident 1 told CNA 1 to stop because it hurt around her face and mouth. CNA 1 stated Resident 1 withdrew away while I was cleaning her face. CNA 1 stated, I was unable to apply lotion to her face or brush her teeth because Resident 1 did not want me to do it due to pain. CNA 1 stated Resident 1 told CNA 1 they (the facility) had run out of her pain medications. CNA 1 stated she went to the assigned LN to notify her of Resident 1's pain. CNA 1 stated LN told her Resident 1 was in pain because she was out of her medication. CNA 1 stated she worked the next day (1/25/23) and Resident 1 told her the pain was worse than the day before. During a concurrent interview and record review, on 2/6/23, at 1:15 p.m., with LN 1, Resident 1's Medication Administration Record (MAR) dated 1/2023 was reviewed. The MAR indicated, . Carbamazepine tablet 200 milligrams [mg, unit of measure] by mouth three times daily, related to muscle spasm pain . The administration date of 1/24/23 at 4:00 p.m. indicated a number 11 in the MAR box for Carbamazepine 200 mg. LN 1 stated the number 11 meant the medication was unavailable. LN1 stated the Carbamazepine for Resident 1 were also not given on 1/24/23 at 12:00a.m., 1/25/23 at 8:00 a.m., and 1/25/23 at 4:00 p.m. LN 1 stated Resident 1 missed 4 doses of her Carbamazepine. LN 1 stated she did not notify the MD and did not document the missed dosed of the pain medication. During a telephone interview on 2/6/23 at 2:00 p.m., with CNA 3, CNA 3 stated she was familiar with Resident 1 and cared for her in the past. CNA 3 stated Resident 1 made her needs known verbally. CNA 3 stated that it was the CNAs responsibility to alert the charge nurse when a resident was complaining of pain. CNA 3 stated, she was not assigned to resident 1 on 1/24/23 and 1/25/23. During a review of Resident 1's Care Plan (CP), dated 2/6/23, the CP indicated, . Administer pain medication as ordered . Evaluate and Establish level of pain on numeric scale/evaluation tool . Utilize pain monitoring tool to evaluate effectiveness of interventions . Patient will achieve acceptable pain level goal . During an interview on 2/7/23, at 9:15 a.m., with LN 2, LN 2 stated she did not give Resident 1 her pain medication (Carbamazepine) on 1/25/23 on the a.m. shift. LN 2 stated the medication was not available in the medication cart. LN 2 stated CNA 1 had come to her in the early afternoon of 1/25/23 to let her know Resident 1 was experiencing 10 out of 10 pain to her face, was feeling hot and that her whole body hurt. LN 2 stated she went to see Resident 1 in her room and Resident 1 told her it felt like her body was on fire and rated her pain level at a 10 out of 10 on the pain scale. LN 2 stated she offered Resident 1 ibuprofen. LN 2 stated she asked Resident 1 if she wanted to go to the hospital, and Resident 1 refused. LN 2 stated she did not document that encounter with Resident 1 being in pain in progress notes. LN 2 stated she should have called Resident 1's Medical Doctor when Resident 1 complained of feeling hot, her whole body hurting and 10 out of 10 pain level. LN 2 stated Resident 1's complaints were unusual. LN 2 stated she should have notified the Charge Nurse or the Director of Nursing (DON) to alert them about Resident 1's condition. During a concurrent interview on 2/7/23, at 10:00 a.m., with the DON, the DON stated Resident 1's complaint of feeling hot, full body aches, and pain level 10 out of 10 should have been addressed immediately. DON stated LN 2 should have completed a pain assessment of Resident 1, notified the MD and documented her findings. DON stated there were no documentation regarding Resident 1's pain in the progress notes. DON stated LN 2 did not follow the standard of practice. During an interview on 2/7/23, at 10:50 a.m., with LN 2, LN 2 stated, I was not aware I was supposed to call the MD when a medication is not available for a resident. LN 2 stated, Residents should not run out of any medications. LN 2 stated, Resident 1 experienced 10 out of 10 pain due to her pain medications not being available. LN 2 stated that it was important to have a complete and accurate pain assessment to include the level of pain, quality, region of the body, severity, and time to look back on and evaluate the underlying cause of the pain. LN 2 stated, If it's not documented, then it's not done. During an interview on 2/7/23, with DON, at 11:00 a.m., DON stated Resident 1 experienced pain due to the number of missed doses of pain medications. DON stated residents should not run out of needed medications. DON stated it unacceptable for resident to be in pain when there was an ordered pain medication. During a concurrent observation and interview on 2/7/23, at 12:15 p.m., in Resident 1's room, Resident was in bed, resting. Resident 1 stated, I asked CNA 1 not to touch around my face or brush my teeth due to pain of 10 out of 10 to my face. Resident 1 stated she had a pain level of 10 out of 10 and did not sleep during the night on 1/24/23. Resident 1 stated she experienced episodes of 10 out of 10 pain on 1/25/23 throughout the day. Resident 1 stated she did not receive her pain medications on 1/24/23 and 1/25/23. During a telephone interview on 2/7/23, at 12:52 p.m., with the facility's consultant Pharmacist, Pharmacist stated refill orders for medications were faxed by the facility which started the process to meet the facility's medications needs. Pharmacist stated that he received the fax from the facility for the Carbamazepine for Resident 1 on 1/23/23. Pharmacist stated the facility needed to reorder medications 3 to 5 days in advance (the facility's practice according to the policy) so they (Pharmacy) had enough time to process the order and get the medications delivered. During a review of the contracted pharmacy documentation titled, Pharmacy Refill Request, dated 1/2023, the document indicated, Carbamazepine for Resident 1 was reordered by the facility on 1/23/23 at 1:52 p.m. and the medication was delivered on 1/25/23 between 2:30 p.m. and 11 p.m. During an interview on 2/7/23, at 2:40 p.m., with LN 3, LN 3 stated, Resident 1 was alert and oriented and able to verbalize her needs and pain level. LN 3 stated residents' medications needed to be reordered 3-5 days on before they run out of their medication. LN 3 stated the Carbamazepine should have been reordered on 1/21/23. LN 3 stated, Resident 1's medication should have not been allowed to run out because Resident 1 can suffer moderate to severe pain. LN 3 stated, If a resident misses a dose of any medication, it is my responsibility to call the Pharmacy, Director of Nursing, and Medical Doctor and let them know Resident 1's medication was not available. LN 3 stated, she didn't think about calling the MD. LN 3 stated, the standard of practice was to call the MD and provide information so MD may order an alternative medication to keep resident from being in severe pain. During a telephone interview on 2/8/23, at 9:30 a.m., with the MD, the MD stated he did not recall receiving notification from the LNs regarding Resident 1's medication not being available. MD stated when Resident 1 missed 3-4 doses of the medication resident (Resident 1) would have increased pain. MD stated the resident could experience pain if they don't receive the medication as ordered. MD stated he was not notified by Licensed Nurses, when Resident 1 was having 10 out of 10 pain level. MD stated licensed Nurses should have notified him. MD stated he expected the Licensed Nurses to call him when Resident 1 was in pain. MD stated it was very important for Licensed Nurses to call if Resident 1 was out of Carbamazepine so he could provide a substitute medication. During an interview on 2/8/23, at 9:50 a.m., with LN 5, LN 5 stated Resident 1 was out of her medication for pain and she filled out the pharmacy form to reorder the medication. LN 5 stated she did not call the Assistant Director of Nursing (ADON) or DON. LN stated she did not notify the MD for the missed doses of Carbamazepine medication. LN 5 stated she didn't feel the need to call the MD because Resident 1 had gone for days (1/24/23 to 1/25/23) without the medication. LN 5 stated she told Resident 1 her medication was not available. LN 5 stated, Resident 1 gets upset when her medications run out and feels that it will be days before the medications come in. LN 5 stated, she did not document that conversation with Resident 1. During an interview on 2/8/23, at 11:15 a.m. with LN 6, LN 6 stated, she worked the p.m. shift on 1/25/23. LN 6 stated, the Carbamazepine tablet 200 mg (milligrams - unit of measure) was not available for the 4:00 p.m. administration time for Resident 1. LN 6 stated she completed her p.m. (afternoon/evening) medication pass and called the pharmacy to inquire about the medication. LN 6 stated she did not call the MD to let him know of the missed dose. LN 6 stated, she should have called the MD and alerted the DON or ADON of the unavailability of the medication. During a concurrent observation, interview and record review on 2/9/23, at 4:00p.m., in the DON's office, the ADON brought in staff In-service documents. DON stated, in-services were immediately provided to the staff. A review of the facility's Lesson Plan on Pain In-service, indicated, . Pain In-Service . Identify appropriate assessments of pain and different scales of pain and how to apply them to patient situations . A review of the Lesson Plan on Pharmacy Procedures and Communications, indicated, . Know what a satellite pharmacy and how to request STAT medications . Notification to MD, DON, and ADON of missing medications . Charting and Progress notes . Pharmacy medications and Delivery Procedures . During a review of the facility document titled, Job Description . Director of Nursing, dated 11/2016, the document indicated, . Manage and directs all aspects of the Nursing Services Department . ensure nursing personnel perform their work assignments in accordance with acceptable nursing standards . Review nursing personnel medical record documentation to ensure it is appropriately and accurately descriptive of the nursing care provided . During a review of the facility document titled, Job Description . Licensed Vocational Nurse, dated 11/2016, the document indicated, . The LVN [Licensed Nurse] is also responsible for the delivery of medications to residents in accordance with physician's orders . Organize central storage and delivery of medications for each shift. Assist with pharmacy delivery of medications . Order medications as needed . Ensure proper documentation of medication changes, new orders and refill order . During a review of the facility's policy and procedure (P&P) titled, Pain Management Guideline, undated, the P&P indicated, . To provide guidance for consistent assessment, management and documentation of pain in order to provide maximum comfort . Recognize that patients who have chronic pain will benefit most from an effective, scheduled pain medication regimen . Intervening to treat pain before pain becomes severe . Understanding the importance of effective pain management for quality of life . Documentation may appear on the following . Pain Evaluation . Pain Monitoring Tool . Nursing Progress Notes . Care Plan . During a review of pharmacy policy titled Medication Ordering and Receiving from Pharmacy, dated 1/2022, the policy indicated, . Ordering medications from the dispensing Pharmacy . Medication orders are written on a medication order form provided by the pharmacy The refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy . Reorder medication three to four days in advance of need, as directed by the pharmacy order and delivery schedule, to assure adequate supply is on hand . During a review of professional reference titled Pain Assessment and Management - Understanding the Requirements , dated 10/21/21, retrieved from https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/provision-of-care-treatment-and-services-pc/000002161/ indicated, . A 'screening' is a process for evaluating the possible presence of a problem. An 'assessment' gathers more detailed information through collection of data, observation, and physical examination. Assessments are completed individuals deemed qualified through education, training, licensure, etc., to conduct such evaluations. Pain assessment tools are generally evidence-based and often include, at a minimum, an evaluation of pain intensity, location, quality, and associated symptoms. An accurate pain screening and assessment is the foundation on which an individualized, effective pain management plan is developed. For example, a pain 'screening' may be used to determine if the patient has pain or not. If the patient answers yes, a comprehensive pain assessment would be indicated . Organizations are responsible for ensuring that appropriate screening and assessment tools are readily available and used appropriately . During a review of the professional reference titled, Lippincott Manual of Nursing Practice 11th edition (dated) 2020, page 15 indicated, . Standards of Practice . General Principles . 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable . b. These standards provide patients with a means of measuring the quality of care they receive . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: . follow physician orders . document appropriate information in the medical record . and follow physician's orders . Failure to implement a physician's . order properly . During a review of the professional reference titled Pain Management in the Geriatric Population, undated, retrieved from https://musculoskeletalkey.com/pain-management-in-the-geriatric-population/ .uncontrolled . Persistent pain may lead to functional loss, including impaired mobility and activities of daily life (ADL's) and generally reduced the Quality of life .pain can result in a significant physical and social consequences . Elderly with untreated pain may have exacerbation of cognitive impairment, mental health issues such as depression, and anxiety, and sleep disturbance .

Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents for two of three samples residents (Resident 1 and Resident 2) when: 1.Resident 1 did not receive her Carbamazepine (medication used to treat severe pain for facial neuralgia) for two days (four scheduled doses) due to the medication not being re-ordered timely (Within 3-5 days of medications running out). This failure resulted in Resident 1 to experience avoidable severe pain, measured as 10 of 10, which caused her suffering, bouts of crying and inability for staff to provide needed care to parts of her face. 2.Resident 2 did not receive his Lidocaine patch (an adhesive material used to relieve pain) for 12 days due to Licensed Nurses not being aware of the available stock supply of Lidocaine patches in the medication room. This failure placed Resident 2 at a potential risk to experience severe pain to his back. Findings: During a concurrent observation and interview on 2/6/23, at 10:30 a.m., in Resident 1's room, Resident 1 was in bed, awake. Resident 1 stated she did not receive her Carbamazepine for two days (1/24/23 and 1/25/23). Resident 1 stated she took her pain medications three times daily. Resident 1 stated, I can miss one to two doses, but I can't miss more than that and experienced 10 out of 10 on pain scale . Resident 1 stated, I live in fear that the facility will run out of my medication . I was crying in pain, but movement of my face while crying made my whole body feel like it was on fire. Resident 1 stated the facility missed four doses of pain medications because the facility ran out of supply of Carbamazepine. Resident 1 stated she informed staff of her pain level and the Licensed Nurses offered Ibuprofen (pain medication used to relieve mild pain). During a review of Resident 1's Face Sheet (FS) the FS indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of . Multiple Sclerosis (a condition wherein the body's immune system eats away at the protective covering of nerves) . Neuralgia (facial nerve pain caused by injury or infection or by damage of the nerve) . During a telephone interview on 2/6/23, at 12:35 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was assigned to Resident 1 on 1/24/23 (morning shift). CNA 1 stated she was cleaning Resident 1's face with a washcloth and Resident 1 told her she was in pain. CNA 1 stated she tried to brush Resident 1's teeth and Resident 1 told CNA 1 to stop because it hurt around her face and mouth. CNA 1 stated Resident 1 withdrew away while I was cleaning her face. CNA 1 stated, I was unable to apply lotion to her face or brush her teeth because Resident 1 did not want me to do it due to pain. CNA 1 stated Resident 1 told CNA 1 they (the facility) had run out of her pain medications. CNA 1 stated she went to the assigned Licensed Nurse (LN) to notify her of Resident 1's pain. CNA 1 stated LN told her Resident 1 was in pain because she was out of her medication. CNA 1 stated she worked the next day (1/25/23) and Resident 1 told her the pain was worse than the day before. During a concurrent interview and record review, on 2/6/23, at 1:15 p.m., with LN 1, Resident 1's Medication Administration Record (MAR) dated January 2023 was reviewed. The MAR indicated, . Carbamazepine tablet 200 milligrams [mg, unit of measure] by mouth three times daily, related to muscle spasm pain . The administration date of 1/24/23 at 4:00 p.m. indicated a number 11 in the MAR box for Carbamazepine 200 mg. LN 1 stated the number 11 meant the medication was unavailable. LN 1 stated the Carbamazepine for Resident 1 were also not given on 1/24/23 at 12:00a.m., 1/25/23 at 8:00 a.m., and 1/25/23 at 4:00 p.m. LN 1 stated Resident 1 missed 4 doses of her Carbamazepine. LN 1 stated she did not notify the MD and did not document the missed dosed of the pain medication. During a review of Resident 1's Care Plan (CP), dated 2/6/23, the CP indicated, . Administer pain medication as ordered . Evaluate and Establish level of pain on numeric scale/evaluation tool . Utilize pain monitoring tool to evaluate effectiveness of interventions . Patient will achieve acceptable pain level goal . During an interview on 2/7/23, at 9:15 a.m., with LN 2, LN 2 stated she did not give Resident 1 her pain medication (Carbamazepine) on 1/25/23 on the a.m. shift. LN 2 stated the medication was not available in the medication cart. LN 2 stated CNA 1 had come to her in the early afternoon of 1/25/23 to let her know Resident 1 was experiencing 10 out of 10 pain to her face, was feeling hot and that her whole body hurt. LN 2 stated she went to see Resident 1 in her room and Resident 1 told her it felt like her body was on fire and rated her pain level at a 10 out of 10 on the pain scale. LN 2 stated she offered Resident 1 ibuprofen. LN 2 stated she asked Resident 1 if she wanted to go to the hospital, and Resident 1 refused. LN 2 stated she did not document that encounter with Resident 1 being in pain in progress notes. LN 2 stated she should have called Resident 1's Medical Doctor when Resident 1 complained of feeling hot, her whole body hurting and 10 out of 10 pain level. LN 2 stated Resident 1's complaints were unusual. LN 2 stated she should have notified the Charge Nurse or the Director of Nursing (DON) to alert them about Resident 1's condition. During a concurrent interview on 2/7/23, at 10:00 a.m., with Director of Nursing (DON), the DON stated Resident 1's complaint of feeling hot, full body aches, and pain level 10 out of 10 should have been addressed immediately. The DON stated LN 2 should have completed a pain assessment of Resident 1, notified the MD and documented her findings. The DON stated there were no documentation in Resident 1's progress notes. The DON stated LN 2 did not follow the standard of practice. During an interview on 2/7/23, at 10:50 a.m., with LN 2, LN 2 stated, I was not aware I was supposed to call the MD when a medication is not available for a resident. LN 2 stated, residents should not run out of any medications. LN 2 stated, Resident 1 experienced 10 out of 10 pain scale due to her pain medications were not available. LN 2 stated that it was important to have a complete accurate pain assessment to include the level of pain, quality, region, severity, and time to have a trail to look back on and evaluate the underlying cause of the pain. LN 2 stated If it's not documented, then it's not done. During an interview on 2/7/23, at 11:00 a.m., with the DON, the DON stated the Licensed Nurses were to call the pharmacy right away to follow up on a refill order. The DON stated all resident medications documented on the MAR as unavailable should have been followed up with a call to the Medical Doctor (MD). The DON stated, she was unable to verify if the LNs' called the pharmacy because there was no documentation. The DON stated, Resident 1 should not have missed her medication because it was ordered specifically for her diagnosis Neuralgia (pain caused by damaged nerves). The DON stated, the LN's did not alert her of the unavailable medication for Resident 1. During a concurrent observation and interview on 2/7/23, at 12:15 p.m., in Resident 1's room, Resident was in bed, resting. Resident 1 stated, I asked CNA 1 not to touch around my face or brush my teeth due to pain of 10 out of 10 to my face. Resident 1 stated she had a pain level of 10 out of 10 and did not sleep during the night on 1/24/2023. Resident 1 stated she experienced episodes of 10 out of 10 pain on 1/25/23 throughout the day. Resident 1 stated she did not receive her pain medications on 1/24/23 and 1/25/23. During a telephone interview on 2/7/23, at 12:52 p.m., with the facility's consultant Pharmacist, Pharmacist stated refill orders for medications were faxed by the facility which started the process to meet the facility's medications needs. Pharmacist stated that he received the fax from the facility for the Carbamazepine for Resident 1 on 1/23/23. Pharmacist stated the facility needed to reorder medications 3 to 5 days in advance so they (Pharmacy) had enough time to process the order and get the medications delivered. The medication for Resident 1 should have been reordered on 1/21/23. During a review of the contracted pharmacy documentation titled, Pharmacy Refill Request, dated 1/2023, the document indicated, Carbamazepine for Resident 1 was reordered by the facility on 1/23/23 at 1:52 p.m. and the medication was delivered on 1/25/23 between 2:30 p.m. and 11 p.m. During an interview on 2/7/23, at 2:40 p.m., with LN 3, LN 3 stated, Resident 1 was alert and oriented and able to verbalize her needs and pain level. LN 3 stated residents' medications needed to be reordered 3-5 days on before they run out of their medication. LN 3 stated the Carbamazepine should have been reordered on 1/21/23. LN 3 stated, Resident 1's medication should have not been allowed to run out because Resident 1 can suffer moderate to severe pain. LN 3 stated, If a resident misses a dose of any medication, it is my responsibility to call the Pharmacy, Director of Nursing, and Medical Doctor and let them know Resident 1's medication was not available. LN 3 stated, she didn't think about calling the MD. LN 3 stated, the standard of practice was to call the MD and provide information so MD may order an alternative medication to keep resident from being in severe pain. During an interview on 2/7/23, at 4:00 p.m., with the Assistant Director of Nursing (ADON), the ADON stated, When a resident runs out of their medications, staff must call the pharmacy to follow up on the medication . residents should not run out of their medications. The ADON stated it was the LN's responsibility to call the MD when resident's medications were unavailable. The ADON stated, it was important to have a complete and accurate pain assessment to include the level of pain, quality, region, severity, and time to have a trail to look back on and evaluate the underlying cause of the pain. During a telephone interview on 2/8/23, at 9:30 a.m., with the MD, the MD stated he did not recall receiving notification from the LNs regarding Resident 1's medication not being available. The MD stated when Resident 1 missed 3-4 doses of the medication resident (Resident 1) would have increased pain. The MD stated the resident could experience pain if they don't receive the medication as ordered. The MD stated he was not notified by Licensed Nurses, when Resident 1 was having 10 out of 10 pain level. The MD stated licensed Nurses should have notified him. The MD stated he expected the Licensed Nurses to call him when Resident 1 was in pain. The MD stated it was very important for Licensed Nurses to call if Resident 1 was out of Carbamazepine so he could provide a substitute medication. During an interview on 2/8/23, at 9:50 a.m., with LN 5, LN 5 stated Resident 1 was out of her medication for pain and she filled out the pharmacy form to reorder the medication. LN 5 stated she did not call the Assistant Director of Nursing (ADON) or DON. LN stated she did not notify the MD for the missed doses of Carbamazepine medication. LN 5 stated she didn't feel the need to call the MD because Resident 1 had gone for days without the medication. LN 5 stated she told Resident 1 her medication was not available. LN 5 stated, Resident 1 gets upset when her medications run out and feels that it will be days before the medications come in. LN 5 stated, she did not document that conversation with Resident 1. During an interview on 2/8/23, at 11:15 a.m. with LN 6, LN 6 stated, she worked the p.m. shift on 1/25/23. LN 6 stated, the Carbamazepine tablet 200 MG was not available for the 4:00 p.m. administration time for Resident 1. LN 6 stated she completed her p.m. (afternoon/evening) medication pass and called the pharmacy to inquire about the medication. LN 6 stated she did not call the MD to let him know of the missed dose. LN 6 stated, she should have called the MD and alerted the DON or ADON of the unavailability of the medication. 2. During an interview on 2/6/23, at 11:30 a.m., with Resident 2, Resident 2 stated, he did not receive his Lidocaine Patch (a medication used to relieve pain) for several periods of time and experienced pain at a 8 out of 10 and had difficulty turning to his side during resident care. Resident 2 was unable to recall the dates of the missing medication. Resident 2 stated, During the time he did not have lidocaine patch there were a couple of times his pain increased to 8 out of 10 on the pain scale. Resident 2 stated, he was able to tolerate the pain because he received other pain medication. During a review of Resident 2's Face Sheet (FS), the FS indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2 had the following diagnosis related to pain: . fracture (break in the bone) of sixth cervical vertebra . fracture of left tibia (length of the bone below the knee and above the ankle) . During an interview on 2/7/23, at 11:00 a.m., with the DON, the DON stated the Licensed Nurses were to call the pharmacy right away to follow up on a refill order. The DON stated all resident medications documented on the MAR as unavailable should have been followed up with a call to the Medical Doctor (MD). The DON stated, she was unable to verify if the LN's called the pharmacy because there was no documentation. The DON stated, the LN ' s did not alert her of the unavailable medication for Resident 2. During a concurrent interview and record review, on 2/9/23, at 10:05 a.m., the ADON reviewed Resident 2's MAR dated 12/2022. The MAR indicated, . Lidocaine Patch 4% apply to lower back at 6:00 a.m. related to pain in thoracic spine (located in the upper and middle part of back). The ADON stated, he was responsible to reorder, stock and notify LNs of the availability of Over the Counter (OTC) medications for the residents such as Lidocaine patches. The ADON stated, he received 8 boxes of Lidocaine patches with 5 patches in each box for a total of a 40-day supply of patches on December 15, 2022. The ADON stated he placed one box of Lidocaine patches in the medication cart and put four boxes of Lidocaine patches in the medication room. The ADON stated, Resident 2 had a doctor's order to change patch daily. The ADON stated there were enough Lidocaine patches for Resident 2 until 1/24/23. The ADON stated, Resident 2 did not receive his Lidocaine patch for 12 days in the month of December 2022, even though Lidocaine patches were available. The ADON stated, the December 2022 MAR for Resident 2 showed a number 11 in the MAR box and LN initials. The ADON stated number 11 meant the medication was not available. The MAR indicated Lidocaine patches were marked unavailable and were not given to Resident 2 from December 15 to 20, 2022 and December 22 to 27, 2022. During a concurrent interview and record review on 2/9/2023, at 10:07 a.m., the ADON reviewed Resident 2's MAR dated 1/2023. The MAR indicated, . Lidocaine Patch 4% apply to lower back at 8:00 a.m.related to pain in thoracic spine. The ADON stated the January 2023 MAR for Resident 2 showed a number 11 in the MAR box with LN initials which indicates the medication was not available on those days. The ADON stated Resident 2 did not receive his Lidocaine Patch for 8 days in January 2023 even though the Lidocaine patches were available. The MAR indicated Lidocaine patches were marked unavailable and were not given on January 1, 5, 7, 8, 9, 11, 12, and January 21, 2023. The ADON stated, We should have monitored the ' Medication Not Available' documentation on MAR for no more than 3 missed doses and acted immediately. We failed to monitor and review the MAR for Resident 2. The ADON stated, the situation could have been much worse if the missed medications were a blood thinner or a blood pressure medication, that was not administered because LN did not know the medication was available and unaware of where to look for the medication. During a review of Resident 2's Care Plan (CP), dated 2/9/23, the CP indicated, . Administer pain medication as ordered . will not experience a decline in function related to pain . Will maintain adequate level of comfort as evidenced by no signs or symptoms of unrelieved pain or distress . During an interview on 2/9/23 at 11:00 a.m. with the ADON, the ADON stated, We should have asked LN 4 why she was not giving the Lidocaine Patch for Resident 2 when it was available. The ADON stated, the Lidocaine patches were available. The ADON stated, he communicated with the staff when he placed the boxes of Lidocaine patches in the medication room. The ADON stated, We are responsible to make sure residents get the ordered medications because we are management . We should have noticed the number of days Resident 2 was not receiving the medication . we are responsible for catching the medication errors. The ADON stated, there were no progress notes for all the missed doses. The ADON stated, there was a failure in communication by LN 4 and no available progress notes documented regarding the missed medications. The ADON stated the MD was not notified of the missed medication. During a telephone interview on 2/9/23 at 3:20 p.m., with LN 4, LN 4 stated she worked in December 2022 during the night shift. LN 4 stated, Resident 2 was scheduled for his Lidocaine Patches at 6:00 a.m. daily. LN 4 states Resident 2 also received Norco (medication used to treat moderate to severe pain). LN 4 stated, she documented in the MAR box as a 11 indicating Lidocaine Patch was not available. LN 4 stated, she was unable to find any Lidocaine patch in the medication room. LN 4 stated, I was under the assumption the medication was not here [in the facility]. LN 4 stated, she was busy and did not alert the DON or ADON about the unavailable medication. LN 4 stated, We should not let residents run out of their medications . I should have called the pharmacy, ADON or DON and MD, and I did not. LN 4 stated, she did not document in the progress notes about Resident 2 pain level or assess for pain. LVN 4 stated, it was important to have a complete and accurate pain assessment to include the level of pain, quality, region, severity, and time to have a trail to look back on and evaluate the underlying cause of the pain. During a concurrent observation, interview and record review on 2/9/23, at 4:00p.m., in the DON's office, the ADON brought in staff In-service documents. DON stated, in-services were immediately provided to the staff. A review of the facility's Lesson Plan on Pain In-service, indicated, . Pain In-Service . Identify appropriate assessments of pain and different scales of pain and how to apply them to patient situations . A review of the Lesson Plan on Pharmacy Procedures and Communications, indicated, . Know what a satellite pharmacy and how to request STAT medications . Notification to MD, DON, and ADON of missing medications . Charting and Progress notes . Pharmacy medications and Delivery Procedures . During a review of pharmacy policy titled Medication Ordering and Receiving from Pharmacy, dated 1/2022, the policy indicated, . Ordering medications from the dispensing Pharmacy . Medication orders are written on a medication order form provided by the pharmacy The refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy . Reorder medication three to four days in advance of need, as directed by the pharmacy order and delivery schedule, to assure adequate supply is on hand .

Based on observation, interview and record review, the facility failed to follow their policies and procedures regarding the safe and appropriate prescribing and administering of antipsychotic (used to treat [CONDITION(S)] - conditions that affect the mind, where there had been some loss of contact with reality) medication for four of five residents (Residents 4, 21, 20 and 52) when antipsychotic medications were prescribed and administered prior to determining the appropriate indications for use. The facility did not develop and implement non-pharmacologic (without the use of medications) interventions prior to physicians prescribing the use of anti-psychotic medications. Mental health professionals (psychologists and/or psychiatric providers) were not consistently consulted to accurately diagnose resident mental health illnesses and prior to the use of anti-psychotics. The anti-psychotics, once administered, were not appropriately monitored for negative effects. These failures resulted in the unnecessary use of [MEDICATION(S)] (used to treat mental disorders) for Resident 4 with the subsequent harm of experiencing difficulty swallowing, inability to take in adequate nutrition and a significant weight loss of 35 pounds in one month; and for Resident 21 the unnecessary use of [MEDICATION(S)] (used to treat [CONDITION(S)] [a condition that affects the persons ability to think, feel and behave clearly]), [CONDITION(S)] (a condition associated with episodes of mood swings), and depression (condition associated with persistent loss of interest in activities, causing impairment in daily life) and the decrease of quality of life. All four residents had the potential to experience the serious negative effects (medication interactions, adverse reactions, dizziness [increasing risk for falls], drowsiness, high cholesterol, high blood sugar [increasing risk for diabetes - high sugar in the blood]), liver dysfunction, weight gain, constipation, heartburn, dry mouth, akathisia (a state of agitation, distress, and restlessness), weakness, [CONDITION(S)] (NMS, a life threatening reaction from use of antipsychotic drug), uncontrolled body movements, decreased blood pressure, seizures and difficulty swallowing, pseudo parkinsonism (a medical condition causing slowed movements, muscle stiffness, and a shuffling walk), and indigestion of anti-psychotics. Findings: 1. During a review of Resident 4's Admission Record (AR), dated 2/9/22, the AR indicated Resident 4 is a [AGE] year old female who was admitted from an acute care hospital on 7/22/21 to the facility, whose diagnoses included [CONDITION(S)] (group of lung diseases that block airflow and make it difficult to breath), Anxiety Disorder, [CONDITION(S)], Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Dementia (a condition characterized by impairment of at least two brain fictions, such as memory loss and judgement Other Diseases Classified Elsewhere with Behavioral Disturbance. A review of Resident 4's Medical Record (MR), the MR indicated Resident 4 had an order for [MEDICATION(S)]. A review of the prescriber's (physician) order, dated 1/23/22, indicated the Resident had an order for [MEDICATION(S)] Tablet 20 MG (milligrams - a unit of measure) Give 1 tablet by mouth one time a day for Manifested by threatening behaviors to self and others related to [CONDITION(S)], UNSPECIFIED . During an observation, on 2/9/22 at 9:36 a.m., in Resident 4's room, Resident 4 was observed sleeping in her bed and did not awake when the door was knocked. During an observation, on 2/9/22 at 2:14 p.m., in Resident 4's room, Resident 4 was observed sleeping in her bed and did not awake when the door was knocked. During an observation, on 2/9/22 at 4:40 p.m., in Resident 4's room, Resident 4 was observed sleeping in her bed and did not awake when the door was knocked. During an interview on 2/9/22 at 2:19 p.m., with LVN 2, LVN 2 stated Resident 4 was not always sleeping when she first admitted to the facility. Now, she mostly sleeps, and this has been going on for about a month, since the start of the [MEDICATION(S)]. During a concurrent interview and record review, on 2/9/22 at 2:36 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 4's MR dated 2/9/22 was reviewed. LVN 2 stated there was no documentation on the MR that Resident 4 had a history or diagnosis of [CONDITION(S)]. LVN 2 stated having an inappropriate diagnosis or medications could affect Resident 4's health and mental status. During a concurrent interview and record review, on 2/9/22 at 2:49 p.m., with LVN 2, Resident 4's MR, dated 2/9/22 was reviewed. LVN 2 stated she never saw Resident 4 hurt others or herself. LVN 2 stated she did not observe Resident 4 exhibiting behaviors of delusion (a belief or altered reality that is persistently held despite evidence) or hallucinations ( a perception of having seen, heard, touched, tasted or smelled something that was not actually there). LVN 2 stated the MR indicated Resident 4's starting dose was [MEDICATION(S)] 20 mg. During a concurrent interview and record review on 2/9/22, at 3:20 p.m., with LVN 2, Resident 4's MR, dated 2/9/22 was reviewed. LVN 2 verified there was no documentation for non-pharmacological interventions or behavior monitoring prior to starting [MEDICATION(S)] for Resident 4. LVN 2 stated medication was not best because of side effects especially at their [resident's] older age and better to start with non-pharmacological interventions. During a concurrent interview and record review on 2/9/22, at 3:25 p.m., with the Infection Preventionist (IP), Resident 4's MR, dated 2/9/22 was reviewed. IP stated he previously worked as a charge nurse prior to his IP position and familiar with Resident 4's behaviors. IP stated the Medical Doctor (MD) was doing his rounds in the facility on 1/24/22 and he told the MD that there was no diagnosis for [MEDICATION(S)]. IP stated after reading the manifested behaviors [threatening behaviors to self and others] from the MR, MD wrote a diagnosis of [CONDITION(S)] for [MEDICATION(S)] 20 mg. During a concurrent interview and record review on 2/9/22, at 4:14 p.m., with LVN 2, Resident 4's MR, dated 2/9/22 was reviewed. LVN 2 stated Resident 4 had a weight loss of 35 lbs (pounds, unit of measurement). LVN 2 stated Resident 4's weight on 2/4/22 was 155 lbs, previous weight on 1/5/22 was 190 lbs. During a concurrent interview and record review on 2/9/22, at 4:16 p.m., with LVN 2, Resident 4's IDT[interdisciplinary Team] Weight Note (IWN), dated 2/3/22 was reviewed. The IWN indicated, . Resident has significant wt [weight] loss in 1 month . Resident's intake at 35-57% average last 17 meals, intake continues to be low . LVN 2 stated Resident 4's food intake on 2/9/22 for breakfast and lunch was 0-25%. During a concurrent interview and record review on 2/10/22, at 10:47 a.m., with Speech Therapist (ST), Resident 4's MR, dated 2/10/22 was reviewed. ST stated on 2/1/22, an ST order was placed by the charge nurse that Resident 4 was having difficulty swallowing. ST acknowledged Resident 4 did not have a prior history of dysphagia (difficulty swallowing) or pneumonia. ST stated Resident 4 had a recent onset with difficult masticating (chewing) and pocketing (holding food inside the mouth without swallowing) and nursing reported decline in oral intake. ST stated, when I assessed her tongue and lips, she had little resistance meaning she had weakness in tongue and lips that made it difficult for her oral phase of swallowing which is chewing and pushing food front to back and keeping food in mouth . oral sensation issues, could not feel food in mouth. ST stated Resident 4 had received five treatments for dysphagia rehabilitation. ST stated choking can be a negative outcome, as well as malnutrition and weight loss and Resident 4's enjoyment of food could be affected. During a concurrent interview and record review on 2/10/22, at 11:46 a.m., with (Registered Dietician) RD, Resident 4's MR, dated 2/10/22 was reviewed. RD stated Resident 4 had a weight loss of 35 lbs. RD stated Resident 4's weight on 2/4/22 was 155 lbs, previous weight on 1/5/22 was 190 lbs. RD acknowledged Resident 4 was placed on [MEDICATION(S)] on 1/23/22, with weight changes as well as dysphagia as a side effect. RD stated the IDT on 2/3/22 recommended 2.0 (type or kind) house supplement at 120 milliliters (ml - measurement of liquid volume) TID (three times a day) with med [medication] pass and weekly weight monitoring because Resident 4 had significant weight loss in 1 month, intake was low, and needed more help [verbal cueing and meal tray set-up] at mealtimes. During a concurrent interview and record review on 2/10/22, at 5:01 p.m., with LVN 9, Resident 4's Medication Administration Record (MAR), dated 2/10/22 was reviewed. The MAR indicated, . 1/1/22 - 1/31/22 . [MEDICATION(S)] Table 20 MG Give 1 tablet by mouth one time a day for Manifested by threatening behaviors to self and others related to [CONDITION(S)], UNSPECIFIED . Monitor Side Effects 1) [CONDITION(S)] [involuntary muscle contractions that cause repetitive twisting movements]: [CONDITION(S)] (stiffness of neck); 2) Anti-cholinergic symptoms [such as] A. dry mouth, blurred vision, B. Constipation, [CONDITION(S)]: 3) [CONDITION(S)] [low blood pressure]; 4) Sedation/drowsiness; 5) Increased falls/dizziness; 6) Cardiac Abnormalities; 7) Anxiety/agitation; 9) Sweating/rashes; 10) Headache; 11) [CONDITION(S)]/hesitancy; 14) Psuedoparkinsonism-Cogwheel rigidity [stiffening of muscles and tremors] Bradykinesia [slow moment], Tremors; 15) Appetite change/weight change; 16) Insomnia; 17) Confusion; 29) None . Monitor every shift . Day . # [number of times per shift] . Eve (evening) . # . Night . # . [29 was coded 28 times] LVN stated the MAR for 2/1/22 to 2/10/22 indicated no appetite change or weight change. LVN stated the MAR was not accurate because Resident 4 had a weight loss of 35 lbs last month. During a concurrent interview and record review on 2/10/22, at 5:07 p.m., with LVN 9, Resident 4's MR, dated 2/10/22 was reviewed. LVN 9 stated the IDT recommendation on 2/3/22 to weigh weekly was not ordered and implemented. LVN 9 stated, Nurse should have gotten the order from MD. Whenever there is a significant change in weight, we monitor the weight for 4 weeks. A review of the facility's consultant psychologist notes for Resident 4 titled, Psychology Treatment Memorandum, dated 1/25/22, indicated, . Initial evaluation . Depression . start [MEDICATION(S)] [used to treat depression and generalized anxiety disorder] 10 mg qd [daily] . Moderate Dementia w/ [with] behaviors . start [MEDICATION(S)] [used to treat confusion or dementia related to Alzheimer's, a progressive disease that destroys memory and other important mental functions] 5 mg qd after 1 month increased to 10 mg qd . Anxiety . During a telephone interview and record review on 2/14/22 at 10:29 a.m. with Consultant Psychologist (PSY), Resident 4's MR, dated 2/14/22 was reviewed. PSY stated he did not diagnose Resident 4 with [CONDITION(S)] and was not aware Resident 4 had been diagnosed with [CONDITION(S)]. PSY stated he was not aware Resident 4 had been initiated on [MEDICATION(S)]. PSY stated he saw Resident 4 on 1/25/22 for follow-up assessment related to diagnoses of anxiety, depression, and moderate dementia with behaviors. PSY stated [MEDICATION(S)] 20 mg was not an appropriate initial dose. PSY stated he would normally start at 2.5 mg twice a day then gradually increase as needed. PSY stated the facility should have a review process before starting an antipsychotic medication. PSY stated the facility should consult with the psychologist or a mental health profession prior to starting an antipsychotic medication regimen. PSY stated [MEDICATION(S)] could cause lethargy and lack of responsiveness, issues where the resident could become lethargic and not be able to eat. According to the manufacturer's package insert for [MEDICATION(S)] adult dosing for [CONDITION(S)] indicate, Initial: 5 mg once daily increasing to 10 mg once daily within several days or 10 mg once daily. Thereafter may increase dose based on response and tolerability in increments of 5 mg/day at intervals of 1 week up to 20 mg/day . During a telephone interview and record review on 2/14/22 at 12:38 p.m., with Consultant Pharmacist (CP), Resident 4's MR, dated 2/14/22 was reviewed. CP stated [MEDICATION(S)] 20 mg BID (two times a day) was not an appropriate initial dose. CP stated there was no documentation in Resident 4's medical records that indicated Resident 4 received non-pharmacological interventions prior to initiation of [MEDICATION(S)]. CP stated it was important to use non-pharmacological interventions because the interventions can reduce the need for antipsychotics and reduce associated side effects of the medications. CP stated [MEDICATION(S)] could cause lethargy, dry mouth, swallowing difficulty and weight loss. CP stated nursing should monitor Resident 4 for pseudo-parkinsonism and other adverse side effects of [MEDICATION(S)]. During a concurrent interview and record review on 2/14/22 at 3:48 p.m., with Director of Nursing (DON), Resident 4's MR, dated 2/14/22 was reviewed. DON stated she does not know how Resident 4 got the [CONDITION(S)] diagnosis and could be based on what the nurses reported to the doctor. DON stated the facility should have a psychological evaluation to properly diagnose and determine if the behavior was psychological or dementia related. The DON stated non-pharmacological interventions and behavioral monitoring should be initiated prior to and during use of [CONDITION(S)] medications. DON stated non-pharmacological interventions were necessary to make sure the facility tried other things [interventions] before initiating antipsychotics medication. During a concurrent interview and record review on 2/14/22 at 4:34 p.m., with DON, Resident 4's MR, dated 2/14/22 was reviewed. DON stated the facility did not follow the IDT recommendation for Resident 4 to conduct weekly weight for four weeks. DON stated it was not normal for a resident to lose 35 lbs in a short amount of time. DON stated if resident cannot swallow, behaviors could be more intense because the resident (Resident 4) was not getting the nutritional balance and had been continuously taking all her medications. During a concurrent interview and record review on 2/15/22 at 10:22 a.m., with the MD 2 and Administrator in Training (AIT), Resident 4's MR, dated 2/15/22 was reviewed. MD 2 stated Resident 4 diagnoses of [CONDITION(S)] came from the information he obtained from the nurses. MD 2 stated he prescribed a high dose of [MEDICATION(S)] [20 mg daily] for Resident 4. MD 2 stated the initial dose should be 2.5 mg or 5 mg daily. MD 2 stated he agreed with the manufacturer specification to start [MEDICATION(S)] at a lower dose. MD 2 stated that based on the DSM-5 (Diagnostic and Statical Manual of Mental Disorders, the standard used by mental health professionals in the United Stated to diagnose mental health disorder), the diagnosis of [CONDITION(S)] for Resident 4 was inappropriate, and should be changed or removed. MD stated there should be a clinical assessment for mental health diagnosis by a mental health professional, not just word of mouth from nurses. During a concurrent interview and record review on 2/15/22 at 10:22 a.m., with the AIT, Resident 4's MR, dated 2/15/22 was reviewed. AIT stated he was unable to find a documentation of Resident 4 having hallucinations and stated that non-pharmacological interventions were not attempted for Resident 4 before starting [MEDICATION(S)]. During a concurrent interview and record review on 2/15/22 at 10:46 a.m., with the MD 2 and AIT, Resident 4's MR, dated 2/15/22 was reviewed. MD 2 stated non-pharmacological interventions should be attempted first before giving medications. MD 2 stated antipsychotic medication should be the last choice. MD 2 stated he was aware of the black box warning (the highest safety-related warning that medications can have assigned by the Food and Drug Administration) for [MEDICATION(S)]. MD 2 stated patients with dementia-related [CONDITION(S)] treated with atypical anti-psychotic drugs are at an increased risk of death. MD 2 stated Resident 4's [MEDICATION(S)] could cause sedation, resulting to swallowing difficulty. MD stated he would follow-up with the DON and titrate (slowly increase) the dose. According to the manufacturer's package insert for [MEDICATION(S)], the Boxed Warning indicates, Elderly patients with dementia-related [CONDITION(S)] treated with antipsychotic drugs are at an increased risk of death . Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. According to the manufacturer's package insert, significant adverse reactions for [MEDICATION(S)] include, extrapyramidal symptoms (EPS), also known as drug-induced movement disorders. Antipsychotics can cause 4 main EPS: Acute [CONDITION(S)] (repetitive body movements, drug-induced parkinsonism (a medical condition causing slowed movements, muscle stiffness, and a shuffling walk), akathisia (a state of agitation, distress, and restlessness), and tardive dyskinesia (a medical condition characterized by involuntary movements of the face). EPS presenting as dysphagia (difficulty in swallowing), [CONDITION(S)] dysmotility (a sensation that food is stuck in the throat or chest), or aspiration (accidental breathing in of food or fluid into the lungs) have also been reported with antipsychotics, which may not be recognized as EPS. 2. During a review of Resident 21's Admission Record (AR), dated 2/8/22, the AR indicated Resident 21 was an [AGE] year old male who was admitted from an acute care hospital on 1/23/19 to the facility and readmitted to the facility on [DATE], whose diagnoses included unspecified dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) without behavioral disturbance, [CONDITION(S)] (high cholesterol), anxiety (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), muscle weakness, history of falling, and unspecified [CONDITION(S)] (a mental condition causing the person to experience false beliefs, seeing or hearing things that others do not see or hear) not due to a substance or known physiological (deals with the normal functions of the human body and parts) condition. A review of Resident 21's Medical Record (MR), indicated Resident 21 had an order for [MEDICATION(S)]. A review of the prescriber's order, dated 6/18/20, indicated the Resident had an order for [Brand Name for [MEDICATION(S)]] 50 mg (milligrams, unit of measurement) to be given twice a day for . UNSPECIFIED [CONDITION(S)] NOT DUE TO SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION m/b [manifested by] delusional statements where he believes others belongings are his and is causing his emotional distress which effects [affects] his quality of life. A review of the medication order, dated 7/3/20, indicated Resident 21's [MEDICATION(S)] order was increased to 100 mg twice a day for . UNSPECIFIED [CONDITION(S)] NOT DUE TO SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION m/b delusional statements where he believes others belongings are his and is causing his emotional distress which effects his quality of life. A review of the medication order, dated 9/23/20, indicated Resident 21's [MEDICATION(S)] order was increased to 200 mg twice a day for . UNSPECIFIED [CONDITION(S)] NOT DUE TO SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION m/b delusional statements where he is agitated and wanting to go home. A review of the medication order, dated 12/14/21, indicated Resident 21's [MEDICATION(S)] order was increased to 200 mg three times a day for . UNSPECIFIED [CONDITION(S)] NOT DUE TO SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. During a concurrent interview and observation, on 2/9/22 at 9:35 a.m., with Resident 21, Resident 21 was seating on his wheelchair and looking out through the patio door. Resident 21 stated, I cannot even think, I am lost, I feel dead here, I want to go home. During a concurrent interview and record review, on 2/9/22 at 10:54 a.m., with Licensed Vocational Nurse (LVN) 8 and Medical Record Director (MRD), Resident 21's Medical Record (MR), dated 2/9/22 was reviewed. LVN 8 stated there was no documentation on the MR that Resident 21 had a history of hallucinations, delusions, incoherent (unclear or confusing) thoughts related to [CONDITION(S)] prior to the diagnosis of [CONDITION(S)] on 2/21/19. LVN 8 stated having an incorrect diagnosis could result to wrong medication. During a concurrent interview and record review on 2/9/22, at 11:27 a.m., with LVN 8, Resident 21's MR, dated 2/9/22 was reviewed. LVN 8 stated there was no documentation for non-pharmacological interventions attempted for Resident 21 before starting [MEDICATION(S)]. LVN 8 stated relating to the care of Resident 21, Before we jump into medications we have to see if they calm down, sometimes we don't need medications. During a concurrent interview and record review on 2/9/22, at 12:21 p.m., with LVN 8, Resident 21's MR, dated 2/9/22 was reviewed. LVN 8 was unable to find documented evidence of monitoring for hemoglobin (red blood cell protein, hb [hemoglobin - a red protein responsible for transporting oxygen in the blood]) A1C (blood sugar measurement) for 2021 and no AIMS (Abnormal Involuntary Movement Scale) baseline when Resident 21 was started on [MEDICATION(S)]. LVN 8 stated the most recent A1C was on 9/17/20. LVN 8 stated without the appropriate monitoring of blood sugar, Resident 21 could have medical complications. LVN 8 stated an abnormal involuntary movement is a side effect of [MEDICATION(S)] and should be monitored and reported immediately to the doctor if symptoms of abnormal movement occur. LVN 8 also stated she could not locate in the MR documented evidence of monitoring for pseudoparkinsonism (a medical condition characterized by slowed movements, muscle stiffness, and a shuffling walk), akathisia (a set of symptoms that include agitation, distress, and restlessness), and tardive dyskinesia (a medical condition characterized by involuntary movements of the face). LVN 8 stated, If abnormal movement was observed, will have to stop the medication and notify the doctor immediately. Review of Resident 21's Medication Administration Record (MAR) dated 2/1/22-2/15/22, indicated . [[MEDICATION(S)] Brand Name] Tablet 200 MG ([MEDICATION(S)] [MEDICATION(S)]) Give 200 mg by mouth three times a day related to UNSPECIFIED [CONDITION(S)] NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION . Monitor Side Effects 1) [CONDITION(S)]: [CONDITION(S)] (stiffness of neck); 2) Anti-cholinergic (used to control involuntary muscle movements) symptoms? A. dry mouth, blurred vision, b. Constipation, [CONDITION(S)]: 3) [CONDITION(S)]; 4) Sedation/drowsiness; 7) Anxiety/agitation; 8) Blurred vision; 9) Sweating/rashes; 10) Headache; 11) [CONDITION(S)]/hesitancy; 12) Weakness; 13) Hangover effects; 28) Other [other side effects]; 29) None [no behavior] every shift . Hours . Day . # [number of times per shift] . Eve (evening) . # . Night . # . The order did not include monitoring for pseudoparkinsonism, akathisia, and tardive dyskinesia. According to the manufacturer's package insert, significant adverse reactions for [MEDICATION(S)] include, extrapyramidal symptoms (EPS), also known as drug-induced movement disorders. Antipsychotics can cause 4 main EPS: Acute [CONDITION(S)], drug-induced parkinsonism, akathisia, and tardive dyskinesia. During a concurrent interview and record review on 2/9/22, at 2:05 p.m., with LVN 8, Resident 21's MAR, dated 2/9/22 was reviewed. LVN 8 stated Resident 21 had 27 episodes of [CONDITION(S)] from 9/1/21 to 9/30/21, 23 episodes of [CONDITION(S)] from 10/1/21 to 10/31/21, and 15 episodes of [CONDITION(S)] from 11/1/2021 to 11/30/2021. LVN 8 stated Resident 21's [MEDICATION(S)] order was increased to 200 mg three times a day on 12/14/21. LVN 8 stated Resident 21's behavior decreased over the 3-month period [September 2021 to November 2021] and the [MEDICATION(S)] was increased on [DATE]. LVN 8 stated it does not make sense to increase the medication [[MEDICATION(S)]] when behavior had decreased. During a concurrent interview and record review on 2/9/22, at 2:05 p.m., with LVN 8, Resident 21's Progress Notes (PN), dated 12/13/21 was reviewed. The PN indicated, . 12/13/21 at 2:47 p.m., Resident was very calm and quiet up in his chair with good tolerance, sleep and ate when meals came but otherwise very quiet . No behaviors . 12/14/21 at 2:01 p.m., Resident was awake this am eating breakfast this am and did well no c/o [complain of] any pain or discomfort. He was up this am [meaning morning] was quiet and calm no behaviors at this time . 12/14/21 at 3:26 p.m., Resident has been lethargic [lack of energy] most of the time, at time he is awake and eats but lethargic most of the time. He has behaviors only in the evening. [ medical director (MD)] was here today and he was notified about resident being more lethargic and sleepier. See new orders. He was notified [Consultant Psychologist (PSY)], had placed him on this med see new changes. [name of wife] wife called via phone and notified and agree with orders . LVN 8 stated it does not make sense to increase the medication [[MEDICATION(S)]] when behavior had decreased from the previous months. LVN 8 stated increasing the medications could increase the side effects including the risk for fall, injury, and lethargy. During a concurrent interview and record review on 2/9/22, at 2:13 p.m., with LVN 2, Resident 21's MAR, dated 2/9/22 was reviewed. The MAR indicated, . 9/1/2021-9/30/2021 . Monitor for episodes of [CONDITION(S)] manifested by believing others are trying to hurt him and he has been kidnapped. Every shift related to UNSPECIFIED [CONDITION(S)] . Day . # [number of times per shift] . Eve (evening) . # . Night . # . [total 27] . 10/1/2021-10/31/2021 . Day . # [number of times per shift] . Eve (evening) . # . Night . # . [total 23] . 11/1/21-11/30/21 . Day . # [number of times per shift] . Eve (evening) . # . Night . # . [total 15] . LVN 2 stated Resident 21's behavior decreased over the 3-month period [September 2021 to November 2021] and the [MEDICATION(S)] was increased on [DATE]. LVN 2 stated it was not appropriate to increase the dose of [MEDICATION(S)] when behavior had decreased. During a telephone interview and concurrent record review on 2/14/22 at 10:03 a.m., with PSY, Resident 21's MR, dated 2/14/22 was reviewed. PSY stated he was not aware Resident 21's behavior decreased over the 3-month period [September 2021 to November 2021]. PSY stated he relied on the lead nurse for the summary of behaviors [monthly monitoring of behaviors]. PSY stated he increased the dosing of Resident 21's [MEDICATION(S)] based on the information he received from the nurse. PSY stated if the behavior was decreasing it does not warrant an increase in dose of [MEDICATION(S)]. PSY stated he was not aware of any attempted GDR [gradual dose reduction] with [MEDICATION(S)]. PSY stated he was not aware that [MEDICATION(S)] was for short-term use [for [CONDITION(S)]]. According to the manufacturer's package insert for [MEDICATION(S)], adult dosing for [CONDITION(S)] associated with dementia indicated, For short-term adjunctive [added second to another treatment] use while addressing underlying cause(s) if severe symptoms . Immediate release: Oral: Initial: 15 mg at bedtime; may increase dose gradually (e.g.[meaning for example], weekly) based on response and tolerability up to 75 mg twice daily . During a telephone interview and record review on 2/14/22 at 11:39 a.m., with Consultant Pharmacist (CP), Resident 21's MR, dated 2/14/22 was reviewed. CP stated [MEDICATION(S)] was primarily used for managing [CONDITION(S)] (chronic and severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others) or adjunct to depression. The CP stated the unspecified [CONDITION(S)] was a vague diagnosis and does not match the indications for use. CP stated the [MEDICATION(S)] order should have been clarified when it was first ordered by the attending physician. CP stated unspecified [CONDITION(S)] was not an FDA indication for [MEDICATION(S)]. CP stated there was no documentation in Resident 21's medical records that indicated Resident 21 received non-pharmacological (non-drug approach) interventions prior to initiation of [MEDICATION(S)]. CP stated it was important to reduce the necessity for use of antipsychotics because of their side effects. CP stated by using non-pharmacological interventions, this strategy could reduce the need for antipsychotic or eliminate its use even though that was rare. According to the manufacturer's package insert for [MEDICATION(S)], Elderly patients have an increased risk of adverse effects to antipsychotics. In light of this risk, and relative to their small beneficial effect in the treatment of dementia-related [CONDITION(S)] and behavioral disorders, patients should be evaluated for possible reversible causes before being started on an antipsychotic. Nonpharmacologic interventions should be tried before initiating an antipsychotic. During a telephone interview and record review on 2/14/22 at 12:20 p.m., with CP, Resident 21's MR, dated 2/14/22 was reviewed. CP stated no AIMS test (monitoring tool used to measure involuntary movement) was done at baseline for Resident 21. CP stated he requested the two previous DONs (Director of Nursing) to conduct AIMS test in 9/2021 and 11/2021, and both were not done. CP stated baseline AIMS was important, serving as a benchmark for monitoring adverse side effects of antipsychotics. CP stated he requested a GDR for [MEDICATION(S)] in October 2021 and November 2021 because of no behaviors noted. CP stated the provider declined the GDR recommendation since no clinical justification was given. CP stated the GDR was important because resident behavior can be controlled in a lower dose or no drug at all and could reduce side effects of drugs, drug-drug interactions, and drug-disease interactions. CP acknowledged nursing did not monitor for symptoms of pseudoparkinsonism, akathisia and tardive dyskinesia as side effects of [MEDICATION(S)] and stated nursing is expected to monitor those symptoms. According to the manufacturer's package insert (specific information about the drug) for [MEDICATION(S)], frequency of monitoring indicates, . monitoring parameter hbA1C . frequency of monitoring . annually . monitoring parameter tardive dyskinesia . at least annually or every 6 months if high risk. During a concurrent interview and record review on 2/14/22 at 3:06 p.m., with the DON, Resident 21's MR, dated 2/14/22 was reviewed. DON stated she did not find any indication or any behaviors in Resident 21's MR that would support the diagnosis of [CONDITION(S)]. DON stated the [MEDICATION(S)] [200 mg three times a day] dose was inappropriate and did not know why the attending physician wrote the [MEDICATION(S)] order. DON stated no AIMS test was completed, no Hb A1C for 2021, behavior and side effects monitoring were inadequate. The DON stated nonpharmacological interventions were not attempted prior to initiating [MEDICATION(S)]. DON stated baseline AIMS was important to monitor for pseudoparkinson, akathisia, and tardive dyskinesia. DON stated nursing staff should monitor for side effects and ensure resident was free from adverse reaction. The DON stated non-pharmacological interventions and behavioral monitoring should be initiated prior to and during use of [CONDITION(S)] medications. DON stated non-pharmacological interventions were necessary to make sure the facility tried other things [interventions] before initiating antipsychotics medication. DON stated she could not find GDR document and physician rationale for denying the GDR recommendation from the Consultant Pharmacist on 10/2021 and 11/2021. During a concurrent interview and record review on 2/14/22 at

Based on interview and record review, the facility failed to provide pain management services consistent with professional standards of practice for one of five sampled residents (Resident 56) when Licensed Vocational Nurse (LVN) 1 did not assess Resident 56's complaints of pain and report of redness, swelling and warmth to left hip area which started in the morning (8 a.m.) of 2/4/22. This failure resulted in Resident 56 experiencing pain and suffering and not being sent out to the hospital for evaluation until the night (11 p.m.) of 2/4/22. Findings: During a review of Resident 56's Change in Condition Evaluation (COCE), dated 2/4/22, the COCE indicated, . Date:2/4/2022 17:40 [5:40 p.m.] . Pain (uncontrolled) . Skin evaluation . Other 16a. Specify other: left leg swelling . Pain evaluation 17. Does the resident have pain? . Yes . Reported to primacy care clinician . 2/4/2022 . 1530 . Recommendation . X-ray . During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive [pertaining to reasoning, memory and judgement] and physical functioning level) assessment, dated 1/13/22, the MDS assessment indicated Resident 56's Brief Interview for Mental Status (BIMS - screening tool used in nursing home to assess cognition) assessment score was 13 out of 15, (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating no cognitive deficit. The MDS assessment Section G, dated 1/13/22, indicated, . A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture . 1. Self-Performance: . 3 [Extensive assistance (resident involved in activity staff provide weight-bearing support)] . 2. Support . 3 [Two+ persons physical assist] . B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . 3 [Extensive assistance] . 3 [Two+ persons physical assist] . Functional Limitation in Range of Motion . Coding: 1. Impairment on one side . A. Upper extremity (shoulder, elbow, wrist, hand) . Mobility Devices . C. Wheelchair . During a review of Resident 56's Core Analytics Lab [Laboratory] and Radiology, Patient Report, dated 2/4/2022, the report indicated, . Procedure . Hips, Bilat [Bilateral - both sides], W/ Pelvis . Findings: Pelvis and bilateral hips . active displaced fracture through the left femoral neck . IMPRESSION: Acute displaced fracture through the left femoral neck . During an interview on 2/10/22, at 9:38 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she was assigned to Resident 56 on 2/4/22 when Resident 56 complained of pain and discomfort on her left leg with movement. CNA 1 stated, Resident 56 was leaning on her side eating breakfast in bed. CNA 1 stated, Resident 56 complained of pain on her left leg when she (CNA 1) helped her (Resident 56) sit up straight in bed. CNA 1 stated, Resident 56 complained of pain and discomfort during her shift every time she (Resident 56) was moved and repositioned in bed. CNA 1 stated, she informed the LVN 1 when Resident 56 first complained of pain on the morning )7:30 a.m.) of 2/4/22. During a concurrent interview and record review on 2/10/22, at 9:56 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, she did not receive report about Resident 56's left leg pain from LVN 1 during change of shift (2:30 p.m. 2/4/22) report. LVN 2 stated, after the shift report, LVN 1 (am shift charge nurse) stated I forgot to tell you the Social Service Director (SSD) told me something about Resident 56's leg. LVN 2 stated, she went to check on Resident 56 after shift report. LVN 2 stated, . Her [Resident 56] legs were covered but I noticed the big bump over the left leg like a pillow. So, I uncovered her left leg and saw the left leg was twice the size, of the right leg . LVN 2 stated the left leg was swollen from the hip to the knee area. LVN 2 reviewed progress note dated 2/4/22, . Resident refused to work with physical therapy due to pain, writer [LVN 1] notified and went to assess resident, upon assessment resident left leg was swollen and resident complained of pain . During an interview on 2/10/22, at 10:30 a.m., with SSD, SSD stated, PTA (Physical Therapist Assistant) went to see her to report Resident 56 yelling out in her room. SSD stated, she went and talked to Resident 56 in her room. SSD stated, . She [Resident 56] asked me to move her leg and straighten her foot . SSD stated, she uncovered Resident 56's leg and saw her left leg was swollen, turned outward and was warm to the touch. SSD stated, she notified the charge nurse (LVN 1) right away (at around 1:15 p.m.) and reported what she observed on Resident 56. During a concurrent interview and record review on 2/10/22, at 11:10 a.m., with PTA, PTA reviewed Resident 56's Physical Therapy: Weekly TEN Details, dated 1/29/22 to 2/4/22, . Friday 2/4/2022 . Facilitated Pt [patient] in skilled interventions . Pt needed repositioning multiple times during Tx [treatment] activities secondary hip and knee pain at 6/10 with redness/warmth/swelling and RN [registered nurse] was notified. PTA stated, he went to see Resident 56 in her room before breakfast (7:45 a.m.) to set her up for therapy (on 2/4/22) and Resident 56 complained of discomfort. PTA stated, Resident 56's left leg was abducted (away from the right leg). PTA stated, when he started working on Resident 56 left leg, she complained of pain of 5 out of 10 (pain scale 0-10 and 10 is the highest) without him even touching the leg. PTA stated, Resident 56's pain increased to 6 out of 10 when her left leg was touched. PTA stated, he talked to the morning charge (LVN 1) nurse and asked if Resident 56 had a wound on her back side. PTA stated, . The charge nurse and I went to Resident 56 room and turned Resident 56 and when I grabbed her [Resident 56] left leg, it felt warm and with a little bit of redness . PTA stated, he compared the left leg with the right leg and the left leg was swollen, red and warm with complaints of discomfort with movement and touch. PTA stated, he told the charge nurse, . I think it is time to look into this because she had all the three indicators like pain, redness and swelling . PTA stated, the charge nurse said she was going to call the doctor. During a concurrent interview and record review on 2/10/22, at 1:58 p.m., with LVN 1, she stated she was the charge nurse for Resident 56 on 2/4/22, morning shift. LVN 1 stated, Resident 56 was her usual self. LVN 1 stated, Resident 56 only wanted cup of coffee during breakfast. LVN 1 stated, she remembered PTA kept going back to Resident 56's room but was not aware of the reason. LVN 1 stated, she did not recall any report of Resident 56 complaints of pain of the left leg during her shift from any staff (CNA, PTA, SSD or Night shift Nurse). LVN 1 stated, she went to Resident 56's room at 2:30 p.m. to do treatment on Resident 56 wound and observed her left leg bigger in size than usual compared to the right leg. LVN 1 stated, she tried calling the primary doctor towards the end of her shift but there was no answer. During an interview on 2/10/22, at 4:37 p.m., with CNA 2, CNA 2 stated, she worked on 2/4/22 (afternoon shift) and she took care of Resident 56. CNA 2 stated, she did not receive any report from the morning shift CNA or LVN 1 about Resident 56's complained of pain to her left leg. CNA 2 stated, between 9-9:30 p.m., the LVN 2 called her to assist in repositioning Resident 56 for the radiology technician to get an X-ray of resident's hip and leg. CNA 2 stated, as soon as Resident 56 was turned she noticed the left leg was swollen and was not straight. CNA 2 stated, Resident 56 complained of pain when turned and stated, ow, ow, ow repeatedly. CNA 2 stated, LVN 2 did not ask Resident 56 to rate the level of pain. During an interview on 2/11/22, at 8:39 a.m., with the Director of Nursing (DON), DON stated, there was no documentation indicating LVN 1 assessed the reported pain, redness and swelling of Resident 56's left leg. DON stated, she expected the nurses to address resident's pain and discomfort as soon as it was reported. During a review of the facility's policy and procedure (P&P) titled, Pain Management Guideline, undated, the P&P indicated, . To provide guidance for consistent assessment, management and documentation of pain in order to provide maximum comfort and enhanced quality of life . recognizing and reporting pain . assessing pain . Intervening to treat pain before the pain becomes severe .

Based on interview and record review, the facility failed to implement policies and procedures to prohibit misappropriation of resident property when one of two sampled residents (Resident 79's) wallet and cash was wrongfully accessed by facility staff and a total amount of $1,580.00 dollars were misappropriated. This practice failed to properly secure Resident 79's property from theft, misplacement and misuse. Findings: During an interview with the Business Office Manager (BOM) 1, on 5/21/19, at 3:35 p.m., BOM 1 stated she started her job on 4/15/19 and did not know Resident 79's money or wallet were kept inside the locked filing cabinet of the business office. BOM 1 stated she was informed Resident 79's wallet and money were kept inside the locked filing cabinet on 5/7/19. BOM 1 stated the payroll (PR) requested to see Resident 79's wallet on 5/7/19. BOM 1 stated she looked inside the filing cabinet and found Resident 79's wallet which contained his identification card and cash money. BOM 1 stated she and PR counted Resident 79's money and confirmed there was $401 dollars. BOM 1 stated PR told her there should have been more money inside Resident 79's wallet. BOM 1 stated she reported to the Administrator (ADM) there was money missing from Resident 79's wallet. BOM 1 stated she returned Resident 79's wallet with $401 dollars on 5/7/19 to Resident 79. BOM 1 stated prior to her being the facility's BOM, the facility employed BOM 2 who was responsible for the business office of the facility. BOM 1 stated BOM 2s last day of employment was on 4/12/19. During a review of Resident 79's Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) dated 4/20/19, indicated a Brief Interview for Mental Status (BIMS) (assessment of cognitive status-memory function) score of 10 of 15 points indicated Resident 79 had moderate cognitive impairment. During an interview with Resident 79, on 5/21/19, at 4:15 p.m., Resident 79 stated his wallet and money was given to BOM 2 when he was admitted to the facility on [DATE]. Resident 79 stated he had almost $2,000 in his wallet and someone took his money from his wallet. Resident 79 stated he did not remember if he was offered to open a trust account when he was admitted . During an interview with PR, on 5/21/19, at 4:30 p.m., she stated BOM 1 counted the money inside Resident 79's wallet with her on 5/7/19 and it was about $400 dollars. PR stated she remembered BOM 2 talked about Resident 79's money being kept inside the filing cabinet. PR stated there was no inventory or record keeping of the money that was being stored inside BOM 2's filing cabinet. During an interview and record review with the Director of Nursing (DON), on 5/21/19, at 4:40 p.m., the DON stated no record on file BOM 2 opened a trust account for the Resident 79. The DON stated the resident did not go to any facility outing or bought anything during his stay in the facility. The DON stated there were no cash withdrawals made during Resident 79's stay in the facility. The DON reviewed Resident 79's progress notes dated 10/9/18, which indicated Wallet containing $1,981.00 dollars in cash, chase debit card .given to business office. The DON stated BOM 2 did not mention anything to management. The DON stated the practice for new admission was to count the money and put in the narcotic box, count every shift until it was given to the business office. During an interview with the Administrator (ADM), on 5/21/19, at 5 p.m., the ADM stated she was made aware of the missing money on 5/7/19 when BOM 1 notified her Resident 79's wallet had $401 dollars instead of $1,981.00 dollars. The ADM stated the Social Service designee (SSD) called the Resident 79's family member (FM) 4 to verify the amount of money in Resident 79's wallet on admission to the facility and confirmed it was $1,981.00 dollars. The ADM stated, The facility practice was to open a Resident trust account and no funds should have been held by any staff for any resident except through the resident trust account. During a phone interview with FM 4, on 6/3/19, at 10 a.m., FM 4 stated the wallet and cash was given to him by BOM 2 after Resident 79's admission to the facility. FM 4 stated he brought the wallet and cash back because Resident 79 asked him to bring his wallet and cash back to the facility. FM 4 stated he was given a receipt on 10/17/18 by BOM 2 after he turned in Resident 79's wallet and cash. FM 4 stated he gave the wallet and cash to BOM 2 and a receipt was given to him. FM 4 stated he was told by BOM 2 a trust account would be opened for Resident 79. FM 4 stated he did not know if an interest bearing trust account was ever opened for Resident 79. During a concurrent interview and record review with the ADM, on 5/21/19 at 5:10 p.m., the ADM indicated a receipt was given the FM 4 on 10/17/18 by the BOM 2. The receipt indicated One thousand nine hundred eighty one dollars cash and wallet. The receipt was signed by BOM 2. During a phone interview with BOM 2, on 6/3/19, at 11:10 a.m., BOM 2 stated, The last day I worked in the facility was 4/12/19 and it was a few weeks after I left when they discovered the missing cash. BOM 2 stated, BOM 1 started right after I left so I don't know why they are blaming me. The BOM 2 stated he remembered calling FM 4 to bring the wallet and cash back per Resident 79's request and gave FM 4 a receipt. The BOM 2 stated he tried to open an account several times but Resident 79 refused to sign. BOM 2 stated he did not make any notes to demonstrate his attempts to have Resident 79 open an interest bearing account. BOM 2 stated he discussed Resident 79's refusal to open an interest bearing account with the ADM, and the ADM advised him to keep on trying. BOM 2 stated he put the money in the locked cabinet and Resident 79 did not complain of any missing money while BOM 2 was still employed in the facility. During a phone interview with the Social Service Designee (SSD), on 6/3/19 at 1:30 p.m., the SSD stated she notified the ADM of missing money when Resident 79 requested to see his wallet and there was only $401.00 dollars inside the wallet. The SSD stated she recognized Resident 79 had money in his wallet and told BOM 1 that Resident 79 should have had more money inside the wallet than $440.00. The SSD stated she remembered advising BOM 2 to open a trust account for the resident but did not follow up to see if an account was opened for Resident 79. Review of the Facility Policy and procedure titled, Safeguarding Resident Funds and Records dated 11/19/15, indicated, .ensure that all cash funds and checks held in the living center pending deposit .are properly secured from theft, misplacement or misuse . Cash funds, checks and records are considered properly secured when kept in a locked and contained environment . Review of Professional Reference titled, Nursing Home Resident Trust Fund dated 2/8/18, indicated, .Nursing homes are required to offer resident trust funds, but they cannot require residents to deposit money into them. Nursing homes don't have the legal right to manage their residents' finances, and they must receive express permission from a patient before using these funds for anything .

Based on interview and record review, the facility failed to develop and implement a resident centered comprehensive care plan for five of 44 sampled residents (Residents 495, 29, 13, 91, and 87) when: 1. The facility failed to document nursing care plan interventions on Resident 495's care plan for fever and the care plan interventions did not address the goal of reducing the signs and symptoms of infection and increased fever. (Cross reference F842). 2. Residents 29 and 13 were administered anticoagulant (blood thinners) medications and did not have a care plan for the use of anticoagulant medications. 3. Resident 91 used bed rails daily and did not have a care plan for the use of bed rails. 4. Resident's 87's care plan was not updated to reflect the bed mobility requirement of a two person assistance and Resident 87 fell to the ground when assisted by one staff member instead of two. For Resident 29, 13, and 91 these findings had the potential to result in residents not receiving the person centered care they required. (Cross reference F726). For Resident 87 this failure resulted in a fall from bed which required emergency room evaluation for a small frontal scalp hematoma (a bad bruise which occurs when an injury causes blood to collect and pool under the skin). Findings: 1. During an interview with Resident 495's family member (FM) 1, on 6/18/19, at 11:28 a.m., FM 1 stated she visited Resident 495 on 2/24/19, at approximately 2 p.m., and found Resident 495 unresponsive with a wet wash cloth on her forehead. She stated she alerted the nurse who then took Resident 495's temperature which indicated the resident had a fever of 103 degrees Fahrenheit (F). FM 1 stated Resident 495 was then sent by ambulance to an emergency room (ER) where she was later admitted and treated for [REDACTED]. FM 1 stated Resident 495 frequently had fevers while living at the facility and FM 1 frequently had to alert the staff to the presence of the fever. During a review of Resident 495's clinical record titled Situation/Background/Appearance/Review (SBAR) (an assessment used to communicate a change in condition for a resident) dated 2/8/19, at 10:28 a.m., indicated Resident 495 had a fever that started on 2/8/19 in the afternoon and indicated a current temperature of 99.4 degrees F after [MEDICATION NAME] (medication used for fever and pain) was given. During a review of Resident 495's care plan for fever, dated 2/8/19, indicated Goal .be free from signs and symptoms of infection elevated temp. The care plan indicated the interventions were Chest x-ray, elevated HOB (head of bed) to alleviate shortness of breath, and labs as ordered. During a concurrent interview and record review with the licensed vocational nurse (LVN) 5, on 6/20/19, at 10:05 a.m., she stated FM 1 notified her one time that Resident 495 felt warm. LVN 5 could not recall what date this was. LVN 5 could not remember if any cooling measures were implemented on Resident 495 by the Certified Nursing Assistants (CNA's) at that time and stated the CNAs did not document cooling measures were applied to Resident 495. During a joint interview with CNA 1 and CNA 2, on 6/20/19, at 3:00 p.m., both CNAs stated they were familiar with Resident 495 and often helped care for her. CNA 1 and CNA 2 stated they knew of her recurrent fevers. CNA 1 stated Resident 495 experienced fevers every other week. During a concurrent interview and record review with LVN 1, on 6/21/19, at 10:24 a.m., she stated she cared for Resident 495 on 2/8/19, and documented an SBAR. LVN 1 stated she created the care plan for Resident 495's fever. LVN 1 reviewed the care plan for fever and stated it was not adequate because two of the three interventions listed on the care plan were doctor's orders and not nursing interventions. LVN 1 stated she should have implemented interventions such as cooling measures, monitoring vital signs for fever, monitoring skin temperature and moisture, and monitoring for pain. LVN 1 stated she was unsure if cooling measures were carried out. LVN 1 stated the CNAs sometimes implemented cooling measures without being told by the nurse. LVN 1 stated cooling interventions were not documented in Resident 495's clinical record. During a concurrent interview and record review with the registered nurse assessment coordinator (RNAC), on 6/21/19, at 11:14 a.m., she stated Resident 495's care plan for fever should have nursing interventions to address Resident 495's fever. RNAC confirmed the care plan did not include interventions for cooling measures. During a concurrent interview and record review with the assistant director of nursing (ADON), on 06/21/19, at 1:57 p.m., she stated the interventions on Resident 495's care plan for fever were not reflective of the care plan goal. The ADON confirmed the care plan did not include interventions to assess the resident for fever or for cooling measures to be implemented. 2. During a review of Resident 29's clinical record titled ADMISSION RECORD undated, indicated Resident 29 was admitted to the facility with the [DIAGNOSES REDACTED]. During a review of Resident 29's clinical record titled Order Summary Report undated, indicated .([MEDICATION NAME] bisulfate) Tablet 75 MG (milligram-unit of measure-used to prevent blood clots) Give 1 tablet by mouth one time a day related to [MEDICAL CONDITIONS] ([MEDICAL CONDITION] caused by plaque build up in the arteries) .Order Status Active .Order Date 1/5/2018 . During a concurrent interview and record review with the ADON, on 6/20/19, at 10:28 a.m., the ADON stated Resident 29 was taking [MEDICATION NAME] blood thinner medication for [DIAGNOSES REDACTED]. The ADON stated [MEDICATION NAME] side effects included bleeding and increased risk of bruising. The ADON reviewed resident 29's care plans and stated there was no care plan developed for the use of [MEDICATION NAME]. The ADON stated a care plan should have been developed as soon as the medication was ordered. The ADON stated the care plan should have included interventions such as monitoring for signs of bleeding in the urine, stool, gums, and bruising. The ADON stated it was the responsibility of the nurse who obtained the order to initiate the care plan. During a review of Resident 13's clinical record titled ADMISSION RECORD undated, indicated Resident 13 was admitted to the facility with the [DIAGNOSES REDACTED]. During a review of Resident 13's clinical record titled Order Summary Report undated, indicated .apixaban Tablet 5 MG (blood thinning medication) Give 1 tablet by mouth two times a day related to UNSPECIFIED [MEDICAL CONDITION] FIBRILLATION .Order Status Active . Order Date 06/10/2018 . During an interview and record review with the ADON, on 6/20/19, at 4:29 p.m., the ADON stated Resident 13 was taking apixaban medication for [DIAGNOSES REDACTED]. The ADON stated a care plan should have been developed on admission or when the medication was ordered. The ADON stated care plan interventions should include monitoring for bruising, nose bleeds or blood in the stool and urine. The ADON stated care plans should be specific to the resident needs. 3. During a review of Resident 91's clinical record titled ADMISSION RECORD undated, indicated Resident 91 was admitted to the facility with the [DIAGNOSES REDACTED]. During an observation on 6/18/19, at 2:34 p.m., in resident 91's room, Resident 91 was lying in bed, on his back, with quarter length side rails up on both sides of the bed. During a concurrent interview and record review with the ADON, on 6/20/19, at 11:27 a.m., the ADON stated Resident 91 had a consent signed by family consenting to the use of side rails signed on 6/6/19. The ADON reviewed resident 91's care plans and stated there was no care plan developed for the use of side rails. The ADON stated the use of side rails should have been care planned to include interventions such as risk of entrapment and monitoring for continued use. The ADON stated the care plan for side rails should have been developed when the consent was signed by Resident 91's family. During an interview with the DON, on 6/21/19, at 7:59 a.m., the DON stated upon receiving an order related to a diagnosis, a care plan should be developed. The DON stated the care plan drove resident care to ensure residents care was being met. Review of the facility policy and procedure titled Side Rail Use dated 2/5/18, indicated .Care plan interventions are implemented when bed rails are utilized and reviewed at least quarterly . Review of the facility policy and procedure titled Care Planning Process dated 12/11/17, indicated .The interdisciplinary team shall prepare a comprehensive person centered care plan with the patient/resident and if applicable, the resident representative, to assist the patient/resident to reach his/her highest practicable level. The care planning process will begin upon admission to the center .The care plan will be person centered and incorporate the patient/resident's goal of care and treatment . 4. During a review of the clinical record for Resident 87 the Admission Record undated, indicated Resident 87 was admitted on [DATE] to the facility with [DIAGNOSES REDACTED]. During a review of Resident 87's clinical record titled, Minimum Data Set (MDS) (an evaluation of cognitive, physical status and care needs) assessment dated [DATE], indicated a BIMS (Brief Interview Mental Status-cognitive ability) score of 00 of 15 points indicated Resident 87 had severe cognitive impairment. The MDS assessment section under functional status, indicated Resident 87 required total dependence with two person physical assist for bed mobility and for personal hygiene during the MDS period of observation. The MDS assessment section H for bladder and bowel status indicated, Resident 87 was always incontinent of bowel and bladder during the period of observation. During a review of Resident 87's clinical record titled MDS KARDEX (paper system of resident needs) REPORT undated, indicated Bed Mobility, Dressing, Personal hygiene .Two (plus) persons physical assist. During a review of Resident 87's clinical record titled Progress Notes dated 6/3/19, at 12 p.m., indicated .during patient care, resident turned on left side and rolled over from bed and fell on floor . resident fell on left side had a small laceration to head . writer called (doctor), got order send resident to hospital . During an interview with CNA 8, on 6/21/19, at 10 a.m., CNA 8 stated Resident 87 was incontinent of bowel and bladder and required one person assist when providing care such as changing her briefs. CNA 8 stated during her rounds she noted Resident 87 needed her brief changed. CNA 8 stated, I was done cleaning up Resident 87 and turned Resident 87 to her left side to finish her brief change when Resident 87 started moving her arms and body in a jerking motion. CNA 8 stated she called out to CNA 10 who was assisting Resident 87's roommate for help with Resident 87 to prevent Resident 87 from falling. CNA 8 stated she and CNA 10 could not hold on to Resident 87 to prevent her from falling to the ground. CNA 8 stated, I did not know Resident 87 was a two person assist, I thought Resident 87 was a one person assist with ADL's (Activities of Daily Living). During an interview with CNA 10, on 6/21/19, at 10:45 a.m., CNA 10 stated she was assisting her resident in bed two (Resident 87's roommate) when CNA 8 called out to her for help with Resident 87. CNA 10 stated Resident 87 was on her left side moving her arms and body up and down and CNA 8 could not hang on to her. CNA 10 stated, I moved as fast as I could to help with Resident 87 but she fell to the ground before I could get there to help. During an interview with LVN 1, on 6/21/19, at 10:20 a.m., LVN 1 stated CNA's were able to check residents Kardex or care plan to verify if a resident was a one or two person assist. LVN 1 stated Resident 87 was a fall risk prior to her fall and Resident 87's Kardex indicated the resident required two staff to assist with care. LVN 1 stated Resident 87 was a two person assist. LVN 1 stated, The fall could have been prevented if two CNA's were assisting (Resident 87). During an interview and record review with the DON, on 6/21/19, at 11:30 a.m., the DON stated it was her expectation for the CNA's to review the Kardex and care plan before the start of every shift. The DON stated according to Resident 87's MDS dated [DATE], Resident 87 was an extensive two person physical assist. The DON stated the MDS was a comprehensive assessment and should have reflected the residents care plan. The DON reviewed Resident 87's care plan and stated the care plan was updated after Resident 87's fall on 6/4/19 and should have indicated a two person physical assistance with ADLs prior to Resident 87's fall. The DON stated the fall could have been prevented if two CNA's had assisted Resident 87 while providing care. During a review of Resident 87's acute care hospital records titled Imaging Results dated 6/4/19, inidcated Service Type: Emergency .CT (computed tomography-scan that provides more detailed information than a plain X-ray) Head .FINDINGS: Small frontal scalp hematoma. No fracture .