Every finding on record at Diversicare of Bessemer

Based on interview; document review; the Rules of the Alabama State Board of Health, Alabama Department of Public Health (ADPH), Chapter [DATE], Nursing Facilities; and the facility's job description for Dining Services Director/Account Manager; the facility failed to ensure the full time Dietary Manager, Employee Identifier (EI) #11, met the definition of a Dietary Manager per the rules of the State of Alabama. This had the potential to affect 130 of 130 residents receiving meals from the facility kitchen. Findings Include: The Rules of the Alabama State Board of Health, ADPH, Chapter [DATE], Nursing Facilities, original rules effective [DATE] and last amendments effective [DATE] included the following: . [DATE]-.01 Definitions. (1) Definitions - (a list of selected terms often used in connection with these rules): . (b) These Rules - Rules [DATE]-.01 through [DATE]-.11, Chapter [DATE], Nursing Facilities, Alabama Administrative Code. (l) Director of Food Services/Dietary Manager - . who is a full-time employee, and if not a qualified dietitian, is one who: (1) is a graduate of a dietary manager's training program, approved by the Dietary Manager's Association (name changed to Association of Nutrition & Foodservice Professionals in 2012), or (2) is a graduate of a dietetic technician program approved by the American Dietetic Association (name changed to Academy of Nutrition and Dietetics in 2012), or (3) is a graduate from a college or university who has received a B.S. (Bachelor of Science) degree in the field of dietetics, food and nutrition or food service management which included course work in diet therapy and quantity food production. The facility's job description for Dining Services Director/Account Manager, undated, included the following: . Must hold state . required credential . On [DATE] at 5:10 PM, Employee Identifier (EI) #10, the Registered Dietitian (RD), provided requested documents for Food and Nutrition Services (FNS). EI #10 said the facility's FNS management was recently contracted out to a healthcare foodservice management company. EI #10 said she normally worked about three days per week. EI #10's credentials included the Alabama Board of Dietetics & Nutritionists License, expiring [DATE], and the Commission on Dietetic Registration credential verification, expiring [DATE]. EI #11 was identified by the RD (EI #10) as the full-time Dietary Manager (DM). EI #11's credentials included a ServSafe Certification, expiring [DATE], and a Food Safety Education certification from the [NAME] County Department of Health, expiring [DATE]. EI #10 was asked if EI #11 had Dietary Manager's training as approved by the Association of Nutrition & Foodservice Professionals (ANFP), formerly named the Dietary Manager's Association. EI #10 said no. When asked if EI #11 was a Dietetic Technician as approved by the Academy of Nutrition and Dietetics, formerly named the American Dietetic Association; EI #10 said no. Upon being asked if EI #11 had a B.S. degree in Dietetics, Food and Nutrition, or Food Service Management; EI #10 said no. EI #10 was asked if EI #11 was currently enrolled in a dietary manager's training program. EI #10 said she did not think so. Also, EI #10 was asked about EI #12's position and credentials. EI #12 was identified by the RD (EI #10) as the Regional Dietary Manager who periodically visits the facility. EI #12's credentials included certification of completing an AFNP approved dietary manager's training program by the University of Florida, dated [DATE]; Certified Dietary Manager and Certified Food Protection Professional examination documentation from the Certifying Board for Dietary Managers (CBDM), dated [DATE], and verification of current certification from the CBDM, dated [DATE]. When asked if EI #12 was at the facility full time, EI #10 said no. On [DATE] at 8:35 AM, the RD (EI #10) and DM (EI #11) were interviewed in the kitchen. EI #11 was performing AM Cook duties today. EI #11 was asked how long she had worked at the facility. EI #11 said she had worked here as a DM for [AGE] years with another DM; she said there were two since the place was so large. EI #11 said she then left for a year and came back on [DATE] as an Assistant DM and Relief Cook. At 8:45 AM, EI #10 said the previous DM had been gone about two months and that EI #11 was then promoted to DM. EI #10 further said the healthcare foodservice management company started at the facility about February or March of 2022. The RD (EI #10) has been working at the facility for about a year since Oct. 2021; primarily as clinical and, when needed, as an operational consultant. An interview on [DATE] at 3:38 PM, EI #11 said, she had started a dietary manager's training course with the University of North Dakota about a year ago. EI #11 said this was started while she was working at a different nursing home. In addition, EI #11 said her RD [NAME] was unavailable for health reasons and did not want to come into the building because of COVID so this threw her behind. EI #11 said she was halfway through the training, but her expiration date for her course expired. EI #11 stated she still had the books and contact information for the University of North Dakota. EI #11 confirmed she was not a dietetic technician and she did not have a Bachelor of Science degree.

Based on observation, interview, the Resident Council Meeting on 11/30/2022, and a test tray on 12/01/2022; the facility failed to ensure scrambled eggs were served warm, palatable, and appetizing in appearance. This had the potential to affect 130 of 130 residents receiving meals from the kitchen. Findings Include: A Resident Council Meeting was conducted on 11/30/2022 at 11:00 AM with fourteen residents attending. During this meeting, the residents attending complained that hot foods were being served cold and the food did not taste good. On 12/01/2022 at 6:40 AM, the steamtable was observed to be setup with breakfast food items. The plate warmer not turned on. Employee Identifier (EI) #13, a Dietary Aide, turned on the plate warmer twenty minutes before the start of trayline. At 6:50 AM, the food thermometer was calibrated to 32 degrees Fahrenheit in an ice water slush by Dietary staff. At 6:55 AM, the Scrambled Eggs were 174 degrees Fahrenheit on the steamtable. At 7:00 AM, the Breakfast trayline started. EI #13, a Dietary Aide, was at the starter position, EI #15, a Dietary Aide, was serving from the steamtable, EI #14, a Dietary Aide, was loading trays onto the carts, and EI #11, the DM, was acting AM Cook/Runner/Cart Deliverer. The Regular Diet breakfast had two pancakes, two strips bacon, scrambled eggs, grits, juice, 2% Milk, and a syrup cup. The plates were covered with an insulated lid; but no insulated plate underliners were used, although 74 insulated plate underliners were observed on carts in the kitchen. When a low-profile 4-ounce (oz.) bowl was used directly on the meal plate, the insulated lid covered the plate fully. When a fluted, high-profile 4-oz. bowl was used, as seen for Oatmeal, the insulated lid was tilted askew; causing a gap that allowed heat to escape. At 8:03 AM, the next to last cart was being loaded with breakfast trays, dietary staff started to use insulated plate underliners as plate covers. At 8:10 AM, the surveyor asked for a Regular Diet test tray as the last trays was about to be placed on the last cart. At 8:13 AM, the loading of the last cart began. At 8:25 AM, the plate for the test tray was prepared. At 8:28 AM, the last cart was placed in the elevator for delivery to the 2nd floor. There were 22 trays on the cart, including the test tray. At 8:29 AM, the last cart was removed from the elevator on the 2nd floor by two staff waiting for the cart at the elevator. At 8:29 AM, the first tray was served. Three staff were serving trays from the cart to residents in their rooms. At 8:40 AM, the last resident tray had been served and the test tray was sampled. The Scrambled Eggs had a slight green tinge and air holes on surface. The appearance of the eggs was not attractive. The eggs tasted overcooked and had a slightly rubbery texture. The eggs were not hot. 12/01/2022 09:00 AM Results of the test tray findings were shared with the Dietary Manager, EI #11. EI #11 said there was an issue obtaining insulated plate lids, insulated plate underliners, and 4-oz. low profile bowls. This deficiency was written as a result of the investigate on of AL00042272.

Based on observation, interview, the facility's policy for Food Storage: Cold Foods, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure: 1.) the dishmachine drain did not extend down into the floor drain, thereby creating the potential for backflow; 2.) food in the Walk-in Cooler was not stored on shelves that were less than six inches from the floor and with accumulated debris on the floor beneath the shelves; and 3.) the surfaces of the dishmachine wall, the shelf beneath the dishtable, and the interior of two food delivery carts were clean. This had the potential to affect 130 of 130 residents receiving meals from the kitchen. Findings Include: 1.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 5-402.11 BackflowPrevention. (A) . a direct conection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 11/30/2022 at 9:10 AM, Employee Identifier (EI) #10, the Registered Dietitian (RD), and EI #11, the Dietary Manager (DM), were present during the observation of the Dishwashing Machine area. The drain pipe from the dishwashing machine was observed to be extending into the floor drain. EI #10 agreed there should be an air-gap to prevent potential back-flow from the sewer into the dishmachine. On 11/30/2022 at 9:21 AM, EI #3, the Maintenance Director, measured the distance that the dishwashing machine drainpipe extended into floor drain. It was three inches from the floor level to the end of the drainpipe. On the same day 2:55 PM, EI #3 said he had checked his book and found that to avoid backflow, there needed to be at least a one inch gap between the drain and floor. 2.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm [centimeters] (6 inches) above the floor. The facility's policy for Food Storage: Cold Foods, dated April 20, 2018, included the following: . Policy Statement All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures 1. All food items will be stored 6 inches above the floor . On 11/30/2022 at 12:48 PM, five shelving units in the Walk-in Cooler had bottom shelves at a level that was less than 6 inches from floor. In addition, built-up debris was on the floor underneath the shelving units. At 4:38 PM, EI #12, the Regional Dietary Manager, measured the distance from the Walk-in Cooler floor to the bottom shelving as 2 1/2 inches. 3.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. . (C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an acculmulation of dust, dirt, FOOD residue, and other debris. On 11/30/2022 at 9:10 AM, EI #10, the RD, and EI #11, the DM, were present in the Dishwashing Machine area during an observation. There was a dark build-up on the wall and sink behind spray/scrap sink. When EI #11 was asked what the dark build-up was, EI #11 said mildew and further said it needed to be cleaned. The shelf beneath the dishtable on the dirty side of the dishwashing machine had a build-up of grime. EI #11 said this area also needed to be cleaned as the grime could attract roaches. On 11/30/2022 at 12:34 PM, during the lunch trayline, the interior of a food delivery cart was observed to have food particles on the bottom of the far left tray holding section and midway up on the door. On 12/01/2022 at 7:50 AM, during the breakfast trayline, four food delivery carts were checked. Some of the carts had stains, but only one had food particles. There were three particles/flakes of an apparent bread product on the inside floor of the cart.

Based on observation, interview, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure the dumpster area was not littered with unneeded or discarded equipment, which could provide harborage for vermin. This had the potential to affect 138 of 138 residents in the facility. Findings Include: The 2017 Food Code of the U.S. Public Health Service and FDA included the following: . 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; . On 11/30/2022 at 8:50 AM, the dumpster area was observed with Employee Identifier (EI) #10, the Registered Dietitian (RD). There were nine wooden pallets stacked up by the facility building across from dumpster area. A hospital-style bed frame and mattress were observed beside the garbage dumpsters. A wooden door was observed leaning against the retaining wall behind the dumpsters. EI #10 was asked if the pallets, bed frame, mattress, and door should be there. EI #10 said, No. When asked why those items should not be there, EI #10 said there would be the potential for unwanted critters. On 11/30/2022 at 9:31 AM, EI #3, the Maintenance Supervisor was interviewed. EI #3 said the bed frame, pallets, door, and mattress should not be out by the dumpsters. EI #3 said they were a hazard. EI #3 also agreed pests could harbor in those items.

Based on observations, interviews, a copy of Your Resident Rights and Protections Under State and Federal Law, and the facility's Position Description for Maintenance Supervisor, the facility failed to ensure the building was in good repair as evidenced by stained ceiling tiles, loose hand rails, a loose door knob, holes in walls under residents' sinks exposing pipes and adjoining rooms, hole in wall in hallway, broken window with a cut edge open to outside elements/torn window screen, missing sheetrock behind a resident's toilet, toilets leaking/not flushing properly, missing/scraped paint on walls, doors and base boards, detached pieces on residents' doors, black residue under air conditioning (AC) units, sinks and smoke detector, loose baseboards, holes in resident walls, and torn sheetrock under sinks. This affected 3 out of 4 floors of the facility. Findings Include: A review of an undated document titled, Your Resident Rights and Protections Under State and Federal Law, revealed, . A nursing home must care for you in a manner and environment that promotes the maintenance and enhancement of your quality of life. A review of an undated facility's position description for Maintenance Supervisor revealed, . KEY RESPONSIBILITIES: Administrative Functions Supervise, repair, plan, organize, and conduct the day-to-day activities of the physical plan and operations department. Complete routine plant and grounds inspections . Maintenance Functions Maintain/repair/replace-toilets, sinks, faucets, drains . Repair/replace window screens . Repair/replace doors, hinges, handles, and locks . Repair/replace major and minor plumbing systems . Paint walls, ceilings, doors, window and door frames . Replace ceiling and floor tile . The following observations were made regarding Room Locators (RL). RL 1: On 11/29/2022 at 5:14 PM, observed stained area on three ceiling tiles. On 11/30/2022 at 8:27 AM, stained areas remained on three ceiling tiles. On 12/01/2022 at 7:45 AM, stained areas remained on three ceiling tiles. RL 2: On 11/29/2022 at 11:55 AM, observed pipe access panel not replaced behind the toilet and pipe leaked when flushed. RL 3: On 11/29/2022 at 10:27 AM, observed window pane broken on left window and outside window screen torn on right hand side. On 11/30/2022 at 11:26 AM, observed window pane still broken. RL 4: On 11/30/2022 at 11:39 AM, observed base floor boards covering up a hole located under the fire extinguisher. Tiles above the fire extinguisher and above the AC unit appeared to have water damage around AC pipes. RL 5: On 11/29/2022 at 11:05 AM, Observed sign on bathroom door that read Out of Order and dated 08/23. Toilet did not flush properly. RL 6: On 11/29/2022 at 8:12 AM, observed loose door knob on bathroom door. On 11/30/2022 at 8:42 AM, door knob to bathroom remained loose. On 12/01/2022 at 7:55 AM, door knob on bathroom door remained loose. RL 7: On 11/29/2022 at 4:58 PM, observed the bottom of resident's door with missing pieces of paint. Observed area beneath sink in room with loose sheetrock and pipes exposed. On 11/30/2022 at 8:45 AM, observed same missing pieces of paint on resident's door. Area beneath sink observed with same loose sheetrock and pipes exposed. On 12/01/2022 at 7:57 AM, observed same missing pieces of paint on resident's door. Area beneath sink observed with same loose sheetrock and pipes exposed. RL 8: On 11/29/2022 at 4:23 PM, observed missing pieces of paint beneath the door handle to the resident's room. On 11/30/2022 at 8:49 AM, observed same missing pieces of paint beneath the door handle. On 12/01/2022 at 8:08 AM, observed same missing pieces of paint beneath the door handle. RL 9: On 11/29/2022 at 4:22 PM, observed detached piece on left side of resident's door. Observed a small circular stain on one ceiling tile. On 11/30/2022 at 8:48 AM, observed detached area on left side of door. Stain remained on ceiling tile in room. On 12/01/2022 at 8:11 AM, observed detached area on left side of door. Stain remained on ceiling tile in room. RL10: On 11/30/2022 at 11:47 AM, observed loose hand rail. RL 11: On 11/29/2022 at 8:35 AM, observed pieces of paint missing on bottom of resident's door. On 11/30/2022 at 8:52 AM, pieces of paint remained missing from left side on bottom of door. On 12/01/2022 at 8:21 AM, pieces of paint remained missing from bottom of door. RL 12: On 11/29/2022 at 8:45 AM, observed stain on one ceiling tile above the fire extinguisher. On 11/30/2022 at 8:54 AM, stain remained on ceiling tile. On 12/01/2022 at 8:20 AM, stain remained on ceiling tile. RL 13: On 11/29/2022 at 8:32 AM, observed black residue under both AC units, six discolored/stained ceiling tiles, baseboard on floor from plug to end loose and held in place with tv table and blue tape, black residue under AC unit over fire extinguisher, black substance on the rim of the AC unit, plaster on wall bubbled, and black and gray discolored area on ceiling tile at smoke detector. On 11/30/2022 at 4:58 PM, observed black residue on units, same loose baseboard from the wall with blue tape holding it in place, same discolored ceiling tiles. RL 14: On 11/29/2022 at 9:14 AM, observed hole under sink exposing RL 15. Observed scrapes on lower edges of wall. On 11/30/2022 at 5:16 PM, observed same hole under sink. RL 15: On 11/29/2022 at 9:14 AM, observed hole under sink exposing RL 14 and hanging sink plaster/sheetrock. On 11/30/2022 at 5:16 PM, observed same hole under sink. RL 16: On 11/29/2022 at 9:05 AM, observed plaster torn and hanging under sink. On 11/30/2022 at 5:13 PM, observed same plaster torn and hanging under sink. The following observations were made regarding RL 17: On 11/29/2022 at 8:59 AM, observed scrapes and scratches behind bed. On 11/30/2022 at 5:12 PM, observed same scraped and scratched wall. RL 18: On 11/29/2022 at 8:55 AM, observed scratches and holes in wall behind television. On 11/30/2022 at 5:09 PM, observed same scratches and holes on wall behind television. RL 19: On 11/29/2022 at 8:53 AM, observed black residue under the sink. On 11/30/2022 at 5:07 PM, observed same black residue on plaster under sink. RL 20: On 11/29/2022 at 8:50 AM, observed scratches on wall under bed A light. RL 21: On 11/29/2022 at 8:46 AM, observed water dripping on the floor. On 11/30/2022 at 5:03 PM, water continued dripping on floor where toilet was leaking. RL 22: On 11/29/2022 at 8:44 AM, observed large cut out area under sink exposing plumbing. On 11/30/2022 at 5:01 PM, observed same large cut out area under sink exposing plumbing. On 12/01/2022 at 4:58 PM, observation of the following areas was made with Employee Identifier (EI) # 3, Maintenance Director: RL #1-EI #3 stated he observed water spots on three ceiling tiles. RL #2-EI #3 agreed with the observation of pipe access panel not replaced behind the toilet and pipe leaked when flushed. RL#3-EI #3 stated he observed a broken window pane and torn window screen. RL #4-EI #3 stated he observed the wall caved in behind the base board in the wall under the fire extinguisher and stained ceiling tiles above the fire extinguisher and above the AC unit. RL #5-EI #3 stated he observed the out of order sign. EI #3 stated a diaphragm was needed to address the leaking. RL #6-EI #3 acknowledged the door knob to the bathroom was loose. RL #7-EI #3 stated he saw missing paint at the bottom of the door and loose sheetrock beneath the sink, exposing pipes. RL #8-EI #3 stated he observed missing pieces of paint beneath the door handle. RL #9-EI #3 stated he observed a detached piece of the door and a small circular stain on one ceiling tile RL #10-EI #3 stated he observed the loose hand rail. RL #11-EI #3 stated he observed missing pieces of paint on bottom of door. RL #12-EI #3 stated he observed a stain on one ceiling tile. RL #13-EI #3 stated he saw mildew from the unit, tape holding up the baseboard, mildew under one unit on one side, where the wall needed to be sanded down and painted and mildew by the smoke detector. RL #14-EI #3 stated he observed scrapes on the lower edges of wall on baseboards. RL #15-EI #3 stated he observed a hole under the sink and hanging plaster. RL #16-EI #3 stated he observed torn, hanging plaster under the sink. RL #17-EI #3 stated he observed scrapes on the wall from the bed rail. RL #18-EI #3 stated he observed nail holes on the wall that appeared to be from a previous television rack on the wall. RL #19-EI #3 stated he observed a black resident under the sink that appeared to be from when the plumber made a repair and did not clean it. RL #20-EI #3 stated he observed scratches on the wall under the light. RL #21-EI #3 stated he observed the toilet cut off leaking. RL #22-EI #3 stated he observed a cut out area under the sink exposing plumbing. EI #3 stated it was an old building and the cast iron was cracking so the plumbing was being replaced. EI #3 stated replacing plumbing stated before he took that position. EI #3 stated he repaired part of the hole on 12/01/2022. He stated he would fill the rest of the hole with foam and cut to shape. In an interview on 12/01/2022 at 4:58 PM, EI #3 stated he had worked at the facility for three months. He stated his responsibilities included general upkeep of the building and repairs. EI #3 stated the building was older and he tried to keep it clean and in good repair but he had only been in his position a short time. In an interview on 12/02/2022 at 11:50 AM EI #1, Administrator, stated she and Maintenance were responsible to ensure the building was clean and in good repair. EI #1 stated housekeeping and team members were expected to report anything they saw that needed repairs. EI #1 stated that utilized the TELS system for reporting issues and Maintenance was expected to check TELS and make the repairs. EI #1 stated she made rounds throughout the facility weekly. EI #1 stated the items identified by the surveyors and Maintenance were things EI #3 was addressing. EI #1 stated the building that had issues and they were getting things repaired one by one or in groups if they are connected. EI #1 stated they had major plumbing repairs because of the galvanized pipes. This deficiency was written as a result of the investigate on of AL00042272.

Based on interview, record review, observations, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, the facility failed to ensure Resident Identifier (RI) 120's Minimum Data Set (MDS), with an Annual Assessment Reference Date (ARD) of 09/07/2022 was accurately coded to reflect RI #120 did not have an indwelling catheter. This deficient practice affected RI #120, one of twenty-six sampled resident's whose MDS's were reviewed. Findings Include: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, dated October 2019, revealed: . SECTION H: BLADDER AND BOWEL Intent: The intent of the items in this section is to gather information on the use of bowel and bladder appliances, the use of and response to urinary toileting programs, urinary and bowel continence, bowel training programs, and bowel patterns. Each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible . RI #120 was admitted on [DATE] with no diagnosis that would require RI #120 to have an indwelling catheter. RI #120 Physician's Orders dated 08/31/2021 - 11/30/2022 did not identify an order for an indwelling catheter. RI #120 annual MDS with an Assessment Reference Date of 09/07/2022, Section H .H0100. Appliances. A. Indwelling catheter (including suprapubic catheter and nephrostomy tube) . is coded for an indwelling catheter. On 11/29/2022 at 11:16 AM and 11/30/22 at 02:59 PM, RI #120 lying in bed in a supine position. RI #120 was observed not to have an indwelling catheter. On 12/01/2022 at 8:48 AM, an interview was conducted with Employee Identifier (EI) #6, Licensed Practical Nurse (LPN), who stated RI #120 has never had an indwelling catheter. On 12/01/2022 at 8:55 AM, an interview was conducted with Employee Identifier (EI) #7, MDS Coordinator. He stated that RI #120 being coded for an indwelling catheter was an error. EI #7 stated RI #120 should not have been coded for an indwelling catheter.

Based on interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual Chapter 4, the facility failed to ensure: 1) a nutritional care plan was implemented for Resident Identifier (RI) #76; and 2) an at risk and actual pressure ulcer care plan was implemented for RI #74. RI #74 developed a pressure ulcer to the sacrum 07/20/2022, which has since healed, however; the facility did not implement an at risk or the actual pressure ulcer care plan. This deficient practice affected RI #74 and 76, two of twenty-six sampled resident's whose plans of care were reviewed. Findings include: A review of the RAI Manual Chapter 4 October 2019 revealed . Chapter 4 Care Area Assessment Process and Care Planning . 4.7 . The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths and needs. Develops and implements a intradisciplinary care lan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow up .Provides information regarding how the causes and risks associated with issues and or conditions can be addressed to provide for a resident's highest practicable level of well-being (care planning). 1) RI #76 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of Obesity. A review of RI #76's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/22/2022, Section V: Care Assessment (CAA) Summary, revealed under Nutritional Status RI #76 triggered for a Care Planning Decision. Further review of the CAA worksheet revealed: Care Plan Considerations Will Nutritional Status - Functional Status be addressed in the care plan? Yes If care planning for this problem, what is the overall objective . Avoid complications . Minimize risk (were checked) . On 12/01/2022 at 11:54 AM, the surveyor conducted an interview with Employee Identifier (EI) # 7, the MDS Coordinator. When asked to locate a nutritional care plan for RI #76, EI #7 said he did not see one. The surveyor asked EI #7 how would it be determined if RI #76 needed a nutritional care plan. EI #7 said RI #76's CAAs would indicate that. EI #7 said according to RI #76's CAAs, RI #76 should have a nutritional care plan. When asked what was the rationale for implementing a nutritional care plan for RI #76, EI #7 said you would not want any adverse outcomes and you would want to make sure all of RI #76's nutritional needs were met. The surveyor asked EI #7 who would be responsible for ensuring RI #76's nutritional care plan was implemented. EI #7 said he and the care plan coordinator work together in creating care plans. 33739 2) RI #74 was admitted to the facility on [DATE]. A review of a Quarterly Minimum Data Set with an Assessment Reference Date of 10/28/2022 indicated RI #74 was at risk for pressure ulcers and also coded RI #74 had a Stage 3 Pressure Ulcer. A review of RI #74's care plans did not reveal any pressure ulcer care plans. On 11/29/2022 at 3:55 PM, a body audit was conducted on RI #74 which revealed no open areas. On 11/30/2022 at 5:28 PM, an interview was conducted with EI #16, a Registered Nurse (RN). EI #16 was asked if there was a care plan for RI #74 for pressure ulcer; she said there was not. EI #16 was asked, what type care plan should RI #74 have. EI #16 said RI #74 should have an at risk and actual pressure ulcer care plan. EI #16 was asked when should a care plan for pressure have been done. EI #16 said typically when the problem was identified. EI #16 was asked, what was the policy for developing care plans. EI #16 said to follow the RAI manual. EI #16 was asked, why was a care plan not done for pressure ulcers for RI #74. EI #16 said, human error. EI #16 was asked, what was the harm in not having a care plan for a pressure ulcer. EI #16 said, not knowing the resident has a pressure ulcer and not knowing how to care for it.

Based on observations, interviews, record review and review of the Unit Managers Duties and Responsibilities, the facility failed to ensure Resident Identifier (RI) #65's nebulizer mask was dated and labeled; and the nebulizer mask was stored in a bag on three of five days of the survey. This deficient practice affected RI #65, one of one resident observed with nebulizer equipment at the bedside. Findings include: Review of an undated UNIT MANAGER DUTIES AND RESPONSIBILITIES, revealed the following: . MONDAY check rooms for correct dates and storage of 02 and nebulizer tubing. These are changed out, bagged, and dated weekly on Sunday night by night shift . RI #65 was was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure and Dyspnea. A review of RI #65's November 2022 Order Summary Report (Physician Orders) revealed RI #65 had an order to receive Ipratropium-Albuterol Solution 0.5 -2.5 (3) MG (milligrams)/3 ML (millimeters) 3 ml inhale orally via (by way of) nebulizer every 6 hours related to Acute and Chronic Respiratory Failure with Hypercapnia. On 11/29/2022 at 12:58 PM, RI #65's nebulizer mask was observed on top of the nebulizer machine not in a bag. There was also no date on the nebulizer tubing. On 11/30/2022 at 8:54 AM, RI #65's nebulizer mask remained on top of the nebulizer machine not in a bag. A review of RI #65's November 2022 eMAR revealed RI #65 had received his/her nebulizer treatments as ordered. On 12/01/2022 at 8:25 AM, the nebulizer mask remained on top of the nebulizer machine not in a covering. RI #65 stated he/she had a breathing treatment that morning. A review of RI #65's December 2022 eMAR revealed RI #65 had received his/her nebulizer treatment as ordered that morning. On 12/01/2022 at 10:53 AM, an interview with Employee Identifier (EI) #18, a LPN (Licensed Practical Nurse). EI #18 said RI #65 received breathing treatments ever six hours. When asked where should RI #65's nebulizer mask be stored, EI #18 said at the bedside in a plastic bag. When asked when not stored in this manner what was that considered, EI #18 said an infection control issue because anything could get on the mask. On 12/01/2022 at 10:59 AM, the surveyor entered RI #65's room with EI #18. RI #65's nebulizer mask remained on top of the nebulizer machine not in a covering. On 12/02/2022 at 11:35 AM, the surveyor conducted an interview with EI #2, the Director of Nursing (DON). EI #2 said the resident's nebulizer mask should be stored in a plastic bag at the bedside when not in use. EI #2 said this would prevent contamination. When asked who was responsive for ensuring the mask was stored properly, EI #2 said the nurse. On 12/02/2022 at 12:57 PM, in a follow-up interview with EI #2, the surveyor asked what did the U-SA on RI #65's eMAR for the breathing treatments mean. EI #2 said that meant RI #65 self administers his/her breathing treatments. EI #2 said the nurse is still responsible for putting the nebulize mask in a plastic bag when a resident self administers a breathing treatment. On 12/02/2022 at 2:05 PM, the surveyor conducted an interview with EI #19, the RN (Registered Nurse) Unit manager. EI #19 said the resident's nebulizer should be stored in a plastic Ziploc bag when not is use. EI #19 said when not stored in this manner there was a potential for infection control. EI #19 said the nurse that is giving the treatment is responsible for ensuring this is done. When asked how she as the Unit Manager ensured this was being done by the nurses, EI #19 said the nebulizer mask are changed out on Sunday night; and she as the Unit manger do walking rounds on Monday to make sure this was done. EI #19 said when she made her walking rounds on Monday she did not recall if RI #65's nebulizer mask was stored in a bag or dated.

Based on observation, interviews, record reviews and review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals, the facility to store controlled refrigerated Ativan/Lorazapam in a secured non removable box in the medication room. Findings Include: A review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals with a revision date of 7/21/2022, revealed . Procedure .3.1.1 Store all drugs and biolgicals in locked compartments including Schedule II-V medications in a separately, permanently affixed compartments . On 12/01/2022 at 9:05 AM, an observation was made of the medication room with Employee Identifier (EI) #17, Licensed Practical Nurse (LPN). The refrigerator had a clear secured box on bottom shelf with nothing in the box, two vials of injectable Ativan belonging to a resident was not in any box only in plastic bag on the shelf and in the locked refrigerator. A green box was on the top shelf with a combination lock. EI #17 was asked what was in the green box; she said an oral Ativan and an injectable Ativan. EI #17 was asked how should Ativan be stored in the medication room refrigerator. EI #17 said in a locked box with the refrigerator locked and the medication room locked. EI #17 was asked if the ativan box was secured properly to the refrigerator; she said if the green box was to be secured it was not. On 12/01/2022 at 9:17 AM, an interview was conducted with EI #2, Registered Nurse, Director of Nursing. EI # 2 was asked what did she see; she said the green box on the shelf with a combination lock and a green pharmacy tag with according to packing slip concentrate ativan and ativan injection. EI #2 was asked what were the two vials on the shelf, she said two vials of Ativan two milligrams each, EI #2 opened the green box and was asked what was in the box. EI #2 said one liquid Ativan and one two milliliter vial of injectable Ativan. EI #2 was asked if they were stored properly; she said no they were on the shelf. EI #2 was asked, where should they have been stored. EI #2 said, in the secured non removable box. EI #2 was asked, how should controlled ativan be secured. EI #2 said in a box that cannot be removed, it should be attached to the refrigerator. When asked if the Ativan was secured properly she said no it was not secured to the refrigerator. EI #2 was asked what was the harm in the Ativan not stored properly. EI #2 said the possibility of diversion, the box was double locked, however, not secured to the refrigerator. EI #2 was asked, what was policy for storing the Ativan. EI #2 said in the refrigerator in a secured box attached or non removable box.

Based on interview, medical record review, the facility's Customer Concern / Grievance Communication Form, the facility's Resident Council Meeting minutes, the facility's Food Preference policy, and the facility's former Daily Alternate List; the facility failed to provide Resident Identifier (RI) #65's long-standing request for Chef Salad at supper on Monday nights and Cottage Cheese with Fruit at supper on Wednesday nights, which she had received for years. This affected RI #65, one of 130 residents receiving meals from the kitchen. Findings Include: The facility's Food Preferences policy, dated May 2014, included the following: Policy Statement It is the center policy that individual food preferences are identified for all residents . food and fluid preferences will be entered into the resident profile in menu management software system. Resident Identifier (RI) #65 was originally admitted to the facility on [DATE] and was last readmitted on [DATE]. RI #65's diagnoses included Anxiety Disorder, Type 2 Diabetes Mellitus Without Complications, and Difficulty in Walking. RI #65's Quarterly Minimum Data Set (MDS) Assessment with an ARD (Assessment Reference Date) of 9/13/2022 included a BIMS (Brief Interview for Mental Status) score of 15; indicating the resident was cognitively intact. This MDS also revealed the resident had adequate hearing, clear speech, adequate vision, the ability to make oneself understood, and the ability to understand others. The MDS also revealed RI #65 was independent for eating and only required setup assistance. RI #65's Physician Orders for November 2022 and December 2022 each included the following: . No Salt Packet (NSP) diet Regular Texture . 04/05/2022 . RI #65's RD (Registered Dietitian) Nutritional Assessment's Annual Summary, dated 3/3/2022, included the following: . h/o (history of) moderate protein calorie malnutrition . often requests specific foods and has a limited range of foods . stating . unable to chew due to poor dental status. Continue to provide preferences and requests as able. RI #65's RD Nutritional Assessment's Summary, dated 4/13/2022, included the following: . Resident recently hospitalized . had a significant loss of 6.5% . Wt. (Weight) loss likely r/t (related to) hospitalization . Due to resident's poor dentition, . doesn't eat certain foods. prefers soft foods and soup, but does not want a mechanically altered diet. Continue with plan of care and honor preferences/dislikes. RI #65's RD Nutritional Assessment's Summary, dated 5/16/2022, included the following: . Diabetes mellitus Type 2 diet controlled. h/o chewing problems r/t poor dentition. recently saw a dentist. has multiple food preferences . enjoys soups, hot tea . Continue to honor preferences as facility is able. Customer Concern / Grievance Communication Form, dated 11/28/2022, included the following summary statement for RI #65's expressed concern: Food Preferences not provided - (RI #65) contacted Admin. (Administrator) . regarding the unavailability of salads for several days a week. Resident reports (she/he) has special dental issues and can only tolerate certain foods. During an interview with RI #65 on 11/29/2022 at 12:40 PM, RI #65 said he /she spoke with the Administrator (EI #1) on Tuesday morning (11/29/2022) about not being able to get a Chef Salad like she had been getting. The Administrator was supposed to be following up to see why RI #65 was not getting the Chef Salad. On 11/30/2022 at 3:38 PM, Employee Identifier (EI) #11, the Dietary Manager, was interviewed. EI #11 was asked why were residents no longer able to receive Chef Salads. EI #11 said the facility told us that we were not to do that anymore. My boss, (name of EI #12), told me that about a month ago. When asked why, EI #11 said I am just going on what I was told to do. On 11/30/2022 at 4:06 PM, EI #12, the Regional Dietary Manager for the healthcare foodservice management company contracted by the facilty, was interviewed. When asked why were residents told they would no longer be able to receive Chef Salad, EI #12 said because that is not on the always available menu; it is not on the menu that the facility gave us to follow. EI #12 further said it was not on their order guide. On 12/01/2022 at 4:45 PM, RI #65 was interviewed. When asked about the follow up to the concern voiced to the Administrator (EI #1) on 11/29/2022, RI #65 said he/she received a Chef Salad for lunch and it was wonderful. The resident said he/she was used to receiving Cottage Cheese with Fruit every Wednesday evening and Chef Salad every Monday evening. RI #65 said I don't understand the high-handedness of just stopping it and not allowing something simple like this. The resident further said he/she was fearful that he/she would not be able to get Chef Salad and Cottage Cheese with Fruit after the survey. When asked who told you they were going to stop the Chef Salad and Cottage Cheese with Fruit, RI #65 said no one; they just stopped sending it. RI #65 said when the Aides (CNAs) went down to find out, they were told it was being stopped by Dietary. RI #65 futher said that when the people who now own Dietary, not (the name of the facility), first came; they tried to stop my Chef Salads and Cottage Cheese with Fruit, but the Administrator was able to fix it for a few months. RI #65 said she/he had been at the facility for eight years and had received Chef Salad on Monday nights and Cottage Cheese with Fruit on Wednesday nights for years. On 12/01/2022 at 6:00 PM, EI #11, the Dietary Manager, was interviewed. EI #11 was asked when was the last time she visited RI #65 about food preferences. EI #11 said about three weeks ago. When asked how long RI #65 had been receiving Chef Salad on Monday nights and Cottage Cheese and Fruit on Wednesday Nights; EI #11 said for quite a while, probably years. Upon being asked how and when RI #65 was informed that he/she would no longer be receiving Chef Salad on Monday nights and Cottage Cheese and Fruit on Wednesday Nights; EI #11 said she did not remember telling the resident. When asked if it was unreasonable for a resident to request a Chef Salad or a dish of Cottage Cheese and fruit as a food preference, EI #11 said no. EI #11 was asked if it was possible for the kitchen to provide those items. EI #11 said we can, but it is not my call; (name of EI #12) is my boss. On 12/01/2022, immediately following the 6:00 PM interview with the Dietary Manager; the Registered Dietitian (RD), EI #10, was interviewed. Upon being asked how and when RI #65 was informed that she/he would no longer be receiving Chef Salad on Monday nights and Cottage Cheese and Fruit on Wednesday nights, EI #10 said I do not know. When asked if it was it unreasonable for a resident to request a Chef Salad or a dish of Cottage Cheese and fruit as a food preference; EI #10 said I don't think it is unreasonable to request that. EI #10 was asked if it was possible for the kitchen to provide those items. EI #10 said Cottage Cheese would have to be a special purchase because it is no longer on our menu or order guide anymore. On 12/01/2022 at 7:03 PM, EI #12, the Regional Dietary Manager was interviewed. When asked if it was unreasonable for a resident to request a Chef Salad or a dish of Cottage Cheese and fruit as a food preference; EI #12 said no, it is not unreasonable, but we do not always have it on hand. EI #12 was asked if it was possible for the kitchen to provide those items. EI #12 said if we could get it approved by (name of the facility's company) as one one of their always available menu options, we could do that. EI #12 further said I not sure who wrote the menu or who would be able to change the menu options, but I would take it to my Director of Operations and she would coordinate it. On 12/02/2022 at 9:00 AM, EI #11, the Dietary Manager, was asked when were the residents told about the new menu and what were they told. EI #11 said the residents were told at Resident Council. EI #11 further said Activity had record of the meeting date. EI #11 said she told the residents that the menu was to be changed. There would no longer be a Everyday Meal option (Daily Alternate List), which included items to be offered on designated days; such as Chef Salad on Mondays, Cottage Cheese and Fruit on Wednesdays, Hot Dogs on Fridays, and Hamburgers on Sundays. There would be the Regular menu, an alternate menu choice, and a health care alternate choice; but the Everyday Meal/Daily Alternate List was being discontinued. On 12/02/2022 at 12:10 PM, EI #4, the Activity Supervisor, provided a copy of the Resident Council minutes when the Dietary Manager (EI #11) announced new menus on 10/17/2022. The minutes documented that 20 residents attended the meeting. RI #65 was not listed as attending the meeting. EI #4 said she posts the date and time for the Resident Council Meeting on the facility's hall calendars and goes around to invite the residents to attend the meeting. When asked if information or minutes from the meeting are given to the residents who did not or could not attend; EI #4 said no. On 12/02/2022 at 12:47 PM, the Administrator, EI #1, was interviewed. EI #1 said (name of RI #65) did talk with her on Tuesday, 11/29/22, about not getting Chef Salad and said the resident also talked about Cottage Cheese and Fruit. EI #1 said the resident (RI #65) wanted to file a grievance. EI #1 also said the resident (RI #65) had explained that the Chef Salad with Boiled Eggs and the Cottage Cheese with Fruit was easier to chew and that the resident liked those things. EI #1 said she told RI #65 that she would go to the kitchen and take a list of what the resident desired: two cartons of milk to mix with Slimfast for lunch and for dinner the Cottage Cheese and Fruit. EI #1 said I went to the kitchen to turn in the request and I talked with the (name of healthcare foodservice contract management company's) Regional Dietary Manager, (name of EI #12). There was some discussion and then there was agreement that they would be getting it. EI #1 was asked if she could speak to RI #65's comment that you, the Administrator, were previously able to hold them (the healthcare foodservice contract management company) off from stopping the Chef Salad and Cottage Cheese with Fruit for a few months. EI #1 said their system is that they have a set menu and an alternate that they serve at lunch and at dinner. EI #1 was told that the Regional Dietary Manager, EI #12, had said they were bound to serving the menu, which (the name of the facility's company) had given them to follow. EI #1 said I am not aware of (name of the facility's company) presenting (name of the healthcare foodservice management company) with a menu for them to use. That is their work.

Based on interviews, record reviews and facility policies titled Resident Screening Guidelines and Evaluations, the facility failed to initiate an evaluation for Physical Therapy as indicated by a screening for Resident Identifier (RI) #139. This affected one of one resident sampled for Physical Therapy. Findings Include: A Policy titled, Resident Screening Guidelines with a revision date of 03/14/2018, documented, Policy . that screenings be completed . on all new admission, readmissions, or upon referral by the medical and/or nursing department of a facility .This is done to: .2. Help identify indications of functional loss or aptitude that may require the need for a rehabilitation referral to evaluate for additional skilled services .6. The screening process concludes with one of these possible recommendations: referral for evaluation . A policy titled Evaluations with a revision date of 09/05/2017, documented, Policy . all patients identified as needing an assessment of functional status and potential to benefit from rehabilitation services be evaluated in order to determine an appropriate plan of care. Procedure Evaluations will be initiated within a reasonable amount of time of receipt of physician's order or authorization . RI #139 was admitted to the facility on [DATE] with a diagnosis to include Fibromyalgia. RI #139 was ordered PT eval and treat as indicated on 10/25/2022 RI #139's Interdisciplinary Rehabilitation Screening Form dated 11/01/2022, documented, Screening . 3. Recommendations: Request Evaluations (select all that apply) . PT . An interview was conducted with RI #139 on 11/29/2022. RI #139 stated he/she has been at the facility for a month and still had not received therapy. An interview was conducted with Employee Identifier (EI) # 8, Physical Therapist on 12/01/2022. EI #8 stated she conducted a screening for RI #139 on 11/01/2022. EI #8 stated she recommended Physical Therapy indicated to get a baseline. EI #8 stated therapy department must wait on authorization for evaluation to determine frequency of therapy. An interview was conducted with EI #9, Director of Physical Therapy on 12/01/2022. EI #9 stated once screening was completed, and it was determined that Physical Therapy was a need. She completed a Payer Verification Form and sent to administrator for approval. EI #9 stated administrator approves Medicaid residents off her determination. EI #9 stated she is not sure where RI #139's evaluation fell through. EI #9 stated the concern of not receiving therapy when needed is decrease mobility, decrease independence and decrease range of motion. An interview was conducted with EI #2, Director of Nursing (DON) on 12/02/2022. EI #2 stated she was not involved in the evaluation decision that was between the therapist and the administrator. EI #2 stated the concern of a resident not receiving therapy when needed is them not getting better and resident not reaching their maximum potential. An interview was conducted with EI #1, Administrator on 12/02/2022. EI #1 stated the process of Payer Verification Form is resident comes in and are screened and its determined what is needed. EI #1 stated that RI #139's Payer Verification Form was submitted, and she didn't respond to it. EI #1 stated that was her oversight. EI #1 stated the concern of a resident not receiving therapy when needed is a service the facility did not complete.

Based on an observation, interviews and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a wound bandage was disposed of in a manner to prevent cross contamination. On 12/12/2022, a wound bandage was observed in one of the shower rooms at the facility. This deficient practice has the potential to affect all residents using one of two shower rooms on one of three floors at the facility. Findings include: A review of Potter and Perry's FUNDAMENTALS OF NURSING with a copyright date of 2017, Chapter 48 Skin Intergrity and Wound Care, page 1221, revealed the following: SAFETY GUIDELINES FOR NURSING SKILLS . Keep a plastic bag within reach to discard dressings and prevent cross contamination . On 11/30/2022 at 12:27 PM, a blood tinged dressing was observed laying on the shower grab bar in a shower room at the facility. At this time an interview was conducted with Employee Identifier (EI) #19, the RN (Registered Nurse) Unit Manager. When asked what was on the shower bar, EI #19 said it looked like a bandage that might have come off in the shower. EI #19 said when dressing are removed from a resident they are usually put in a bag in the soiled utility room in the red barrel. When asked what type concern it would be when dressing are not place in the appropriate receptacle, EI #19 said infection. On 12/02/2022 at 11:28 AM, an interview with the Director of Nursing, EI #2 who said, when a dressing comes off of a resident it should be disposed of in the trash. EI #2 said when not disposed of in that manner, it would be an infection control issue.

Based on observations, interviews and review of the facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, the facility failed to ensure the DAILY NURSE STAFFING FORM reflected the census on one of five days of the survey; and reflected the number of staff working on two of five days of the survey. This deficient practice had the potential to affect all 138 residents residing in the facility. Findings Include: A review of the facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form dated 11/29/2022 revealed there were 138 residents residing in the facility during the survey. On 11/28/2022 at 6:10 PM, the surveyor observed the DAILY NURSE STAFFING FORM posted. The census was missing from the form. On 11/30/2022 at 8:29 AM, the surveyor observed the same DAILY NURSE STAFFING FORM from the following day (11/29/2022) posted. There was no number of staff and hours worked for the 3 PM - 11 PM and 11 PM - 7 AM shifts. On 11/30/2022 at 8:33 AM, Employee Identifier (EI) #20, the Work Force Manager removed the DAILY NURSE STAFFING FORM from the holder and stated she was getting ready to put up a new form for that day. On 12/01/2022 at 5:11 PM, the surveyor conducted an interview with EI #20. EI #20 said one of her job responsibilities was to post nurse staffing. When asked what was some of the information that should be listed on the DAILY NURSE STAFFING FORM, EI #20 said the date, the census, how many resident were in the facility, the name of the facility and how many RNs (Registered Nurses), CNAs (Certified Nursing Assistants) and LPNs (Licensed Practical Nurses) were working. The surveyor asked EI #20 what information was missing from the 11/28/2022 DAILY NURSE STAFFING FORM. EI #20 said the census, and the 11-7 staff information. When asked what information was missing from the 11/29/2022 DAILY NURSE STAFFING FORM, EI #20 said the staff for the 3 PM - 11 PM and 11 PM - 7 AM shifts. The surveyor asked EI #20 why was it important to ensure all information was on the DAILY NURSE STAFFING FORM. EI #20 said it helped facility staff to know how many residents and staff were in the building. EI #20 said it would also let the State know if there was enough staff. On 12/02/2022 at 11:32 AM, the surveyor conducted an interview with EI #2, the Director of Nursing (DON). When asked what type information should be listed on the DAILY NURSE STAFFING FORM, EI #2 said the census and the staffing per shift. EI #2 said it was EI #20's responsible for ensuing the information was on the form. EI #2 said it was important to ensure the correct information was on the form to ensure the facility had appropriate staffing.

Based on interviews, record review, review of facility policies titled Abuse, Neglect, Misappropriation, Exploitation Policy and Medication Administration Guide, review of the facility's Controlled Substances Accountability Guideline, review of the facility's investigative file and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure Employee Identifier (EI) #4, a LPN (Licensed Practical Nurse), upon receipt of medications from the pharmacy properly received, accounted for and stored the Controlled Substance medications per the facility's policy and procedure. As a result, Resident Identifier (RI) #7's narcotic medications ([MEDICATION(S)] 7.5-325 mg [milligram] 60 pills) were unable to be located. This deficient practice affected RI #7, one of three residents sampled for Misappropriation of Resident Property. Findings include: Review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of 01/2019, revealed the following: . Definitions: . Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident consent. Review of an undated facility policy titled Medication Administration Guide, revealed the following: . All medications received from pharmacy should be verified by two licensed nurses and signatures witnessing the medications received with the correct count . Review of the facility's undated Controlled Substances Accountability Guideline, revealed the following: . Chapter 3 Receiving Controlled Substances . Procedures for receiving controlled substances include: . Receiving person transfers controlled substances and accompanying inventory sheets to an authorized nurse on the unit (if different than the nurse who received the CS (Controlled Substance) medication. Nurse and witness . shall login received controlled substance medications onto the change of shift reconciliation log with CS medications being immediately placed into secure storage. Controlled substances are placed into a secured locked controlled substance storage area of medication cart or in secured locked controlled substance cabinet in the medication room. RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #7's Active September 2021 Order Summary Report (Physicians Orders) revealed the following: . [MEDICATION(S)] Tablet 7.5-325 MG ([MEDICATION(S)]-Acetaminophen) Give 1 tablet by mouth at bedtime related to Pain . [MEDICATION(S)] Tablet 7.5-325 MG ([MEDICATION(S)]-Acetaminophen) Give 1 tablet by mouth every 12 hours as needed for pain . [MEDICATION(S)] Tablet 7.5-325 MG ([MEDICATION(S)]-Acetaminophen) Give 1 tablet two times a day related to Pain . Review of a Delivery Receipt from Omnicare, the Pharmacy delivering medications to the facility, revealed on 09/04/2021 two medication cards of [MEDICATION(S)] ([MEDICATION(S)]) 7.5-325 mg with 30 tablets on each medication card was delivered to the facility. EI #4, the licensed nurse receiving the medication, signed he received the medication but failed to record the quantity of controlled substances received, and the date and the time he received the controlled substances. Further review of the Delivery Receipt revealed there was no signature of a second licensed staff member verifying the controlled substances had been received into the facility nor was there evidence the controlled substance medications was logged in onto the change of shift reconciliation log and immediately placed into a secured storage area. A review of an ADPH Online Facility Reported Incident dated 09/07/2021, revealed the following: . Incident Type . Misappropriation of Resident Property . Incident Detail . Narrative summary of incident: This evening at approximately 5:00pm (5:00 p.m.), resident was noted to not have any [MEDICATION(S)] 7.5 mg in medication cart. Medication was obtained through pharmacy after resident requested medication for pain. Initial investigation - pharmacy reported that 2 cards of [MEDICATION(S)] (containing 60 pills) were delivered to Center on 9/5/2021 at approximately 12:26am (12:26 a.m.). and signed by Interim Charge Nurse (EI #4, LPN). Center has not identified any records of medication being placed in medication cart. A review of a facility form titled INVESTIGATION TEMPLATE from the facility's investigative file revealed the following: . Date of Report: September 7, 2021 . Alleged Incident Category: . Exploitation/Missing Items (was checked) . Incident Date: September 7, 2021 Time: 5:00 PM . Resident Involved: (name of RI #7) . Description of the Allegation: On evening of 9/7/2021 at approximately 5:00pm (5:00 p.m.), resident's [MEDICATION(S)] was not observed in medication cart. Charge Nurse did not observe [MEDICATION(S)] 7.5 mg. tablet and alerted ADNS (Assistant Director of Nursing Services) and pharmacy. Medication - 7.5 mg [MEDICATION(S)] - had been ordered and delivery manifest from pharmacy indicated delivery had been made. Medication was not available in resident's narcotic drawer. Nursing management requested one time dose of [MEDICATION(S)] 7.5 mg from pharmacy to administer medication. Pain assessment conducted when discovery was made that medication was not available. Pain assessment score was zero. Pain medication administered as per order and pain level monitored as per protocol. An initial investigation, Pharmacy reported - [MEDICATION(S)] 7.5 mg was presented to Center on 9/5/2021 at approximately 12:26am (12:26 a.m.). Delivery was confirmed by signature of Interim Charge Nurse (name of EI #4) . Although [MEDICATION(S)] medication was signed as received, no [MEDICATION(S)] for (name of RI #7) was available for resident. On 09/30/2021 at 9:40 a.m., the surveyor conducted an interview with EI #3, the Charge Nurse caring for RI #7 on 09/07/2021, when it was discovered RI #7 did not have any available [MEDICATION(S)] 7.5 mg medication in the facility. EI #3 confirmed RI #7 was to receive the controlled substance, [MEDICATION(S)] 7.5 mg. EI #3 said she did not remember the exact date the [MEDICATION(S)] was not available, but when this occurred she contacted the pharmacy and was told RI #7 should have the medication in the facility. When asked what she did at that time, EI #3 said she brought it to the attention of the ADNS. A review of the facility form titled INVESTIGATION TEMPLATE from the facility's investigative file revealed the following interview conducted with EI #2, the ADNS: . ADNS (name of EI #2) reported to DNS (Director of Nursing Services) that resident (name of RI #7) did not have medication needed for 5:00PM medication pass. (name of EI #2) reported that medication was not in resident' narcotic drawer. On 09/30/2021 at 10:40 a.m., the surveyor conducted an interview with EI #2. EI #2 said EI #3 reported to her the pharmacy informed her it was too soon to refill RI #7's narcotic prescription when she (EI #3) called them. EI #2 said EI #3 was about to administer RI #7's last [MEDICATION(S)] 7.5 mg pill and the [MEDICATION(S)] medication was scheduled. EI #2 said RI #7 did not have any more [MEDICATION(S)] medication in the narcotic box at that time. EI #2 said she called the pharmacy to clarify what was meant by it was too soon to refill the [MEDICATION(S)] prescription and was told that the [MEDICATION(S)] prescription had recently been refilled. EI #2 said she asked the pharmacy to send the manifest to the facility and was informed EI #4 signed for the [MEDICATION(S)] (on 09/05/2021). EI #2 said when she informed the Interim DNS she (EI #2) was asked to go and look for the narcotics again. EI #2 said all six medication carts, the locked narcotic boxes as well as areas where the non-narcotic medications were kept were searched. EI #2 said an immediate med count was done with the controlled medications on all of the med carts and RI #7's [MEDICATION(S)] medications were not found. EI #2 said at that point the Administrator, EI #1, was notified. When asked what it would be considered when a resident has a medication that should be available and it is not available when the pharmacy had delivered the medication, EI #2 said Misappropriation of Resident Property. The surveyor asked EI #2, from the facility's investigation what occurred when EI #4 received the controlled substance medications that should not have occurred. EI #2 said once EI #4 received the medications from the courier the delivery manifest should have been signed by both of them, once the medication was taken back to the 2nd floor it was laid on the counter, and each floor should have received their medications, or EI #4 should have locked the medications up. EI #2 said looking at the delivery manifest EI #4 did not initial he received the two cards of [MEDICATION(S)], nor did he date and sign the time he received the controlled substances. EI #2 said since the incident, education had been done with the licensed staff, observations were done on the delivery process to see where there was an opportunity for improvement; and conversation had been done with the pharmacy about their process as well. A review of the facility form titled INVESTIGATION TEMPLATE from the facility's investigative file revealed the following interview conducted with EI #4: . DNS interviewed (EI #4) on 9/9/2021 regarding the medication delivery. (EI #4) reported to DNS that he received a call from the pharmacy driver on 9/4/2021 regarding the evening delivery and he went downstairs to receive the medications . (EI #4) said he opened the purple bag, counted the medication and signed the paperwork for narcotics delivery with driver. DNS reported that (EI #4) stated he brought medications back upstairs, laid medications on counter and went to complete his medication pass. DNS asked (EI #4) if this was his normal process to handle medications delivery and narcotics - and (EI #4) responded - the night was hectic, and he was trying to get caught up. DNS questioned (EI #4) regarding location of manifest and (EI #4) stated that it was in the bag. DNS also reported that (EI #4) told her - he had no excuse for his negligence . On 09/30/2021 at 12:57 p.m., the surveyor conducted a telephone interview with EI #4. EI #4 said when he got to work that night (09/04/2021) he was scheduled to work from 7 P - 7 A. EI #4 said someone called the floor (2nd floor) and said a man was at the front door with medications. EI #4 said he went down, and the meds were in a purple bag. EI #4 said there were two manifest and he and the courier both signed them after they made sure the medications were there and the count was right. EI#4 said he did not remember if he signed the date and time, he received the medications on the manifest. EI #4 said he took the bag upstairs and laid the medications on the counter. When asked were the medications narcotic medications, EI #4 said yes. The surveyor asked EI #4, as a nurse, what should be done with narcotic medications when received from the pharmacy. EI #4 said they should be locked up. EI #4 said that was negligence on his part for leaving the narcotic medication out. EI #4 said he thought he put the medications on the counter out of sight. On 09/30/2021 at 5:59 p.m., the surveyor conducted an interview with EI #1, the Administrator. EI #1 said she was made aware RI #7 had missing narcotics on the evening of 09/07/2021. EI #1 said she was told it was time for RI #7's next med pass and the narcotics were not available. EI #1 said RI #7 was assessed for pain and the pharmacy was called and a code was received to remove the [MEDICATION(S)] from the Omnicell. EI #1 said an investigation was started and the initial findings were that the medication had been delivered but facility staff could not locate it. EI#1 said the incident was reported to the ADPH as a Misappropriation of Personal Property, the police were called and the pharmacy was notified the facility was not able to find RI #7's controlled substance and would need to replace it. EI #1 said EI #4 informed the DNS he brought the medication back upstairs and laid all the mediations on the desk and then went down the hall to complete his medication pass. When asked what should EI #4 have done after receiving the medications, EI #1 said EI #4 should have gone to each nurse's station to deliver the medications and narcotics and followed the protocol for delivering medications and narcotics. ******************************************************************* .The surveyors determined current facility compliance by: 1) Review and verification of the facility's Action Plan as outlined in general terms below: STEP 1 What immediate interventions were initiated for resident identified? 09/07/2021, RI #7 assessed for pain which was recorded as 0 09/07/2021, Obtained [MEDICATION(S)] dose from Omnicell 09/07/2021, Investigation begun. Pharmacy verified shipment with signed signature of manifest 09/07/2021, M.D., family, Police, ADPH notified Ad Hoc QAPI (Quality Assurance and Process Improvement) meeting was held on 09/07/2021 to discuss the root cause analysis for the incident. The root cause was found to be EI #4 did not follow the facility's policy and procedures for delivery, accountability and storage of narcotic medications . STEP 2 What immediate actions were taken to identify all residents potentially affected? What continued and immediate interventions were implemented for identified residents? 09/07/2021, Card of 30 pills obtained from pharmacy and placed in narcotic box on medication cart at no cost to resident; billed to facility 09/09/2021, Review of all narcotics from Ominicare sent were received and in place in medication carts for 09/01 - 09/07/2021 for all residents STEP 3 What system changes were made or modified? What systemic education was completed to enhance knowledge development of team members? 09/07/2021, In-service to Licensed Nurses of correct way to verify and place narcotics upon receipt from pharmacy into narcotic box and log into book immediately upon receipt STEP 4 Continued Quality Assurance audits implemented to ensure enhanced system compliance? Monitoring plan? DNS/ADNS will review narcotics delivery 3 x/week for 4 weeks to ensure narcotics delivered are logged in and placed in narcotic box. Any discrepancies will be immediately addressed with report to QAPI monthly for further interventions . 1) Observations were made during the survey of how the facility receives, accounts for and stores controlled substance mediations. 2) Various interviews with current staff verified they have received education and were aware of policies in place regarding receiving, accounting for and storing narcotic medications 3) Reviews were made of the facility's monitoring of narcotic deliveries **************************************************************** This deficiency was cited as a result of the investigation of complaint/report number AL 559.

Based on observation, interview, record review, and document review, the facility failed to ensure two of 34 sampled residents (Resident Identifier (RI) #74 and RI #69) received nursing care and services in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin assessments did not accurately record the resident's skin condition and a medicated cream prescribed by the physician was not implemented. RI #69 had a recent history of a fecal impaction. The resident complained of severe constipation during the survey. Staff failed to monitor and document his/her bowel movements to ensure he/she was not constipated. Findings include: 1. Review of the undated Admission Record, in the electronic medical record (EMR) under the Profile tab revealed RI#74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the paper copy of the hospital History and Physical in the resident's chart, dated 06/27/19, revealed RI#74 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the nursing home following this hospitalization . Review of the Clinical physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/26/20, located in the EMR under the MDS tab, revealed the resident did not speak, rarely/never made him/herself understood, rarely/never understood others, and was unable to complete the Brief Interview for Mental Status (BIMS) test. The resident was severely impaired in cognitive skills for decision making. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan dated 09/22/20, in the EMR under Care Plan tab, documented the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record Report for the month of June 2021 in the EMR under the Orders tab revealed no order or administration of [MEDICATION(S)]. Review of the weekly Total Body Skin Assessments dated 04/01/21, 04/08/21, 04/22/21, 04/29/21, 05/06/21, 05/13/21, 05/20/21, 05/27/21, 06/03/21, 06/10/21, 06/17/21, in the EMR under the Assessment tab, all revealed RI #74's skin had good elasticity, was normal in color, was warm in temperature, with normal moisture, and normal in condition (degree of dryness -oiliness). During an interview on 06/22/21 at 2:25 PM, RI #74's family member stated he/she went to see RI #74 on 06/03/21 and the resident was crying. RI #74's family member stated that he/she asked for medicine (for pain), adding, I did not know the psoriasis came back so bad. He/she stated the resident's skin itched, got scratched, which made sores. RI #74's family member stated the resident could not move his/her arms; they were crossed (contracted), but he/she tried to scratch the psoriasis. He/she stated the resident's physician had ordered some cream to treat the resident's psoriasis. Observation on 06/21/21 at 3:16 PM resident was in bed and the top part of the resident's back was visible and was observed with scaly, white, dry, flaky skin; the resident's scalp near the hairline also had significant white, crusty, matter attached to the hair follicles. Observation on 06/22/21 at 11:21 AM, the resident was positioned in bed. Small pieces of what looked like grey lint (which was dead skin) covered the bottom sheet/bedding. Observation on 06/23/21 at 11:25 AM, the resident was lying in bed. The resident's scalp had a scaly, crusty, white substance visible along the hairline. On 06/23/21 at 1:15 PM, the resident's skin was observed with RI #74's family member and Employee Identifier (EI) #20 Registered Nurse (RN). The resident was turned on his/her side and the resident's back had numerous areas of dry, flaky skin and scabbed areas. The resident's scalp at the hairline had thick, white, flaky, scabby matter. RI #74's family member said when he/she tried to remove it (white flaky matter), the resident's hair pulled out with the flaky, scabby, white matter. There was flaky skin on the front of the resident's legs and his/her feet had scabbed flaky areas. There was a significant amount of grey dead skin covering the resident's bedding. On 6/24/21 at 9:25 AM the resident's skin was observed by EI #12, Licensed Practical Nurse (LPN). Both of the resident's lower extremities were noted to have profoundly dry flaky skin from the resident's feet to the knees with dead skin observed throughout the sheets and on the resident's clothing. The skin was open with a shallow scratch and probably due to the resident scratching his/her leg with his/her right foot. The resident's hands were contracted and he/she couldn't reach his/her shin to scratch with his/her hands. There were also areas of psoriatic/extremely dry skin on his/her scalp and on his/her back just below the hairline about 2-3 cm area at hairline and scattered areas on the lower back and under the arms/shoulders. During an interview on 06/23/21 at 11:38 AM, EI #23, Certified Nursing Assistant stated RI #74 required total care. EI #23 stated the resident had a skin condition, scabbing sores, and he/she, greased her down good using barrier cream (skin cream intended to maintain the skin's physical barrier, providing protection from irritants and drying out). During an interview on 06/23/21 at 12:38 PM, EI #20 stated the resident was treated with adalimumab ([MEDICATION(S)]) prior to the initiation of hospice on 05/19/20. She stated the medication could not be continued due to financial reasons, stating Medicaid did not cover it. EI #20 stated the resident received nothing (medication) to treat the psoriasis currently, but staff tried to keep it moisturized and ensure the resident got baths. During an interview on 06/23/21 at 3:30 PM, EI #20 stated he/she was not aware of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 06/24/21 at 11:43 AM, EI #20 stated the order for [MEDICATION(S)] was signed off by a nurse. He/she verified the order had not been implemented. During an interview on 06/24/21 at 3:20 PM, the Medical Director (also the resident's physician) stated he/she ordered the [MEDICATION(S)] cream in May for psoriasis. He/she stated, I would expect the nursing staff to implement the order. I am not sure on the oversight. I talked to the skin nurse and [EI #20] and with the resident's [family member]. During an interview on 06/24/21 at 4:35 PM, EI #2, Director of Nursing (DON) stated he/she had talked with RI #74's family member about the resident's skin and not much had helped (medications). He/she stated the nursing staff should have taken off the order for [MEDICATION(S)] cream and implemented it, verifying this was not done. EI #2 stated the weekly skin assessments should not document the resident's skin was normal and rather should document the resident's psoriasis. Review of the paper copy of the Skin Care Guideline policy dated July 2018 revealed the purpose was to provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption in skin integrity. The policy indicated weekly review of the resident's skin would be completed by the nurse and documented in the electronic medical record. The resident would be observed by the nurse aide team members daily for changes in skin condition. These changes would be reported to the licensed nurse and documented in the electronic medical record. 2. Review of the Admission Record dated 05/23/21, in the EMR under the Profile tab, revealed RI #69 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Quarterly MDS with an ARD of 05/28/21, in the EMR under the MDS tab, revealed RI #69 re-entered the facility on 05/23/21 following an acute hospital stay. The resident had clear speech and was usually understood by others, and usually understands others. The BIMS test was not conducted. RI #69 required extensive assistance of one staff for toilet use. The resident was always incontinent of bowel and bladder. Review of the paper Order Summary Report dated 05/31/21, in medical record under Orders, revealed the resident was prescribed oxycodone-acetaminophen (narcotic pain medication) tablet 5-325 mg, give one tablet every four hours as needed ordered on 05/23/21, and Polyethylene [MEDICATION(S)] (medication for constipation) 3350 Kit 17 mg daily, ordered on 05/23/21 for other symbolic dysfunction. Review of the Care Plan initiated on 02/19/20, in the EMR under the Care Plan tab, revealed a focus area of, Alteration in elimination of bowel and bladder AEB (as evidenced by) Bowel and Bladder incontinence, Acute Kidney Failure, assistance needed with transfers, Risk for Constipation and UTI (urinary tract infection). Interventions to address the problem included: [RI #69] will have a soft formed bowel movement [BM] at least every three days . Monitor bowel status frequency. Observe and report changes in ability to toilet or continence status. Provide extensive assistance x1 (from one person) to toilet. Review of a paper Hospital's Progress Note dated 04/16/21, in the medical record under the Physician tab, revealed the resident was admitted to the hospital on 04/14/21 with altered mental status and agitation. The resident had chronic CVAs (strokes); however, there were no acute findings. The CT (computerized tomography) a radiologic imaging indicated the resident had a possible fecal impaction along with concerns of gall bladder changes, possible kidney stones, and chronic [CONDITION(S)]. Under the Assessment/Plan heading, RI #69 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the POC [Point of Care] Response History Report, for bowel elimination, dated 05/23/21 - 06/23/21, in the EMR under the POC tab, revealed the resident had three BMs in the prior 30-day timeframe, occurring on 06/01/21, 06/04/21, and on 06/11/21. There were 10 days when no bowel movement was documented, one day when not applicable was documented. Nothing (no entries for the specified date) was recorded for the remaining 14 days. According to the report, the resident's last BM occurred on 06/11/21. Review of the paper Lookback Report for 06/01/21 - 06/23/21, printed for the surveyor, also revealed RI #69 had his/her last BM on 06/11/21. The report documented BMs on 06/01/021, 06/04/21 and on 06/11/21. On 06/21/21 at 3:27 PM, the door was open, and the sound of crying and moaning was heard. RI #69, who was writhing in bed, stated he/she was constipated and asked the surveyor to notify the nurse he/she was very uncomfortable and wanted the nurse to come. The surveyor notified EI#18, licensed practical nurse (LPN) who was at the nurses' desk EI#18 stated the resident's health had declined due to having had open heart surgery a couple months ago. EI#18 stated the resident used to get up and use the commode and could not do that now. EI#18 stated the resident was getting therapy to regain her strength. He/she stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress Notes for 06/21/21 in the EMR under the Progress Notes tab showed no documentation of this incident. During an interview on 06/23/21 at 11:34 AM, EI#23, certified nursing assistant (CNA) stated since the resident had gotten sick, staff had to change her (incontinence brief), dress her and provide total assistance with some ADLs. EI#23 stated RI #69 was walking and self-toileting, he/she got sick, went to the hospital and now he/she wore a brief and could not stand up like she used to. EI#23 stated sometimes the resident knew when he/she needed to go to the bathroom. CNA #3 stated the resident had not complained of constipation the last couple times (he/she assisted her). EI#23 stated the resident had bowel movements every few days. The bowel policy and/or standing orders for lack of bowel movement/constipation were requested. During an interview on 06/24/21 at 09:40 AM, EI#2 stated there was no bowel protocol or standing orders in place (if a resident did not have a BM) and there was no policy. During an interview on 06/24/21 at 10:29 AM, EI#20 (charge nurse) stated R#69 had a bowel movement on Monday (06/21/21) according to the CNAs. EI#20 stated, the resident was weak and had difficulty pushing out bowel movements. He/she stated he/she would check with the CNAs to see if the resident had a bowel movement (BM) since 06/21/21. When asked how he/she knew if the resident had bowel movements when the bowel records indicated no bowel movements occurred, he/she stated, The CNAs let us know. I am aware of lack of documentation and that it needs improvement. EI#20 stated he/she was not aware of the hospital documentation showing the recent bowel impaction in April 2021. EI#20 stated he/she thought RI #69 had BMs every few days and had not needed additional medications for constipation (in addition to the Polyethylene [MEDICATION(S)]). He/she stated he/she would check with the CNAs to see if RI#69 has had one since Monday (06/21/21). During a follow up interview on 06/24/21 at 11:51 AM, EI#20 stated the CNAs told him/her RI #69 had BMs on [CONDITION(S)] days following the resident's return from [CONDITION(S)]. The resident had [CONDITION(S)] on Mondays, Wednesdays and Fridays. During an interview on 06/24/21 at 4:32 PM, EI#2 stated he/she understood a lack of documentation was an issue. EI#2 stated patient care was the routine; however, documentation was not as much the routine. He/she stated, We have seen some improvements. It is nowhere close to where it needs to be. During an interview on 06/24/21 at 3:18 PM, the Medical Director (also the resident's physician) stated the facility should have complete bowel records. He/she stated, in light of the resident's hospitalization record showing a fecal impaction, the facility should be documenting bowel movements. Review of a written statement by EI#2 dated 06/24/21 documented in full, Diversicare does not have a specific policy for bowel and bladder.

Based on observation, interview, and record review, the facility failed to provide interventions for one of eight residents reviewed for range of motion impairment (Resident Identifier (RI) #74). RI #74) had contractures, including to his/her hands with callused areas observed from where his/her fingernails dug into his/her palms in the sample of 34. The contractures developed and/or worsened over the past year. No interventions had been or were currently in place to address the limitations in range of motion. Findings include: Review of the undated Admission Record, in the electronic medical record (EMR) under the Profile tab revealed RI #74 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the hospital History and Physical in the resident's chart, dated 06/27/19, revealed RI #74 was admitted to the hospital and was dependent in activities of daily living (ADLs). The resident was admitted to the nursing home following this hospitalization . There was no documentation in the History and Physical of the presence of contractures prior to nursing home admission. Review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/26/20, located in the EMR under the MDS tab, revealed the resident did not speak, rarely/never made him/herself understood, rarely/never understood others, and was unable to complete the Brief Interview for Mental Status (BIMS) test. The resident had impaired ROM to both of his/her upper extremities (shoulder, elbow, wrist, hand). The resident was not receiving any physical therapy (PT), or occupational therapy (OT) and he/she was not on a restorative nursing program such as the provision of ROM exercises or splint/brace assistance. Review of the Quarterly MDS with an ARD of 03/11/21, located in the EMR under the MDS tab, revealed RI #74 now had impairment in ROM on both sides to the upper and lower extremities. The resident received no therapy (PT or OT) and was not on a restorative nursing program such as the provision of ROM exercises or splint/brace assistance. Review of the Clinical physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revised on 08/26/19, in the EMR under the Care Plan tab, revealed a focus of, Physical functioning deficit related to: Mobility impairment, Self-care impairment, Dementia, Contractures present, [CONDITION(S)]. There were no interventions on the care plan to address the contractures or to prevent further decline. During an interview on 06/22/21 at 2:25 PM, RI #74's family member stated the resident did not previously have contractures. He/she stated No one told me about her legs .She can't move her arms, they are crossed . RI #74's family member stated he/she found a sore in RI #74's hand when she opened it and the resident's hand was dirty. He/she stated he/she cleaned the resident's hand and he/she put a wash cloth in the resident's hand but when he/she came to visit the next time it was gone. He/she stated the other hand also had a sore in it. RI #74's family member stated she talked to floor nurse and the RN supervisor about his/her concerns. Observation on 06/21/21 at 12:22 PM, RI #74 was lying in bed. RI #74's right hand was visible and contracted into a fist. No splint/device was in place in the resident's hand. Observation on 06/22/21 at 10:08 AM, RI #74 was lying in bed. Both hands were visible and were contracted into fists. No splint or other device was observed in either hand. Observation on 06/23/21 at 12:57 PM, RI #74 was lying in bed. Both of the resident's arms and hands were observed crossed with his/her contracted hands up near her opposite shoulders. No splint/devices were present in the resident's hands. On 06/23/21 at 1:25 PM, with Employee Identifier (EI)#20, Registered Nurse (RN) (charge nurse) and RI #74's family member observed RI #74 who was lying in bed. The resident's arms continued to be crossed/contracted with his/her contracted hands near his/her opposite shoulders. No splints/devices were observed in the resident's hands. The resident's legs/knees were also contracted. They were bent in fixed positions. RI #74's hands were partially opened by RI #74's family member. The fingers opened but the resident's hands continued to be in a semi-fist position. There was darkened skin in the palms of the resident's hands. RI #74's family member stated the area in the resident's right hand was raw and the resident's fingernails had been digging in. RI #74's family member stated he/she usually put a towel in the resident's hands. On 6/24/21 at 9:25AM, EI#12, License Practical Nurse (LPN) observed that RI#74's hands were contracted and rolled wash cloths were located in both of the resident's palms. EI#12 opened the resident's palms to observe the skin. The palms had areas in the fleshy part of palm just below thumbs where the resident had rubbed a callused area, dry but more callused than psoriatic, but not opened. During an interview on 06/23/21 at 11:38 AM, EI#23, Certified Nursing Assistant (CNA) stated that RI #74 required total care. He/she stated sometimes RI #74 had something in his/her hands and that staff had put wash cloths in his/her hands. During an interview on 06/23/21 at 1:43 PM, EI#19 stated RI #74 was very contracted. He/she stated there was moisture and the skin was macerated in the resident's hands and he/she had tried to get the wound doctor to see the resident. He/she stated the wound doctor wound not add the resident to his/her rounds because they weren't wounds (area in the hands). He/she stated he/she tried to keep the resident's fingernails trimmed. During an interview on 06/23/21 at 12:53 PM, EI#20 stated, at one point, something was placed under RI #74's legs to stretch them out, causing him/her to bend more at the hips. EI #20 stated, RI #74 pulls upward. EI #20 stated RI #74 had limitations in hie/her legs before but it had gotten worse. EI #20stated, staff had put things in the resident's hands for the contractures but the resident had not done well and would pull at them and pull them out. EI #20 indicated there was nothing in place currently for the contractures. During an interview on 06/24/21 at 4:41 PM, EI#2, Director of Nursing (DON) stated he/she thought RI #74's contractures had gotten worse. He/she stated the resident should have a wash cloth in place in his/her hands; however, it was painful for the resident to have something placed in his/her hands and possibly that was the reason staff had not been putting wash cloths in his/her hands. During an interview on 06/24/21 at 3:20 PM, the Medical Director (also the resident's physician) stated he/she did not know if RI #74's contractures had been addressed. He/she stated the resident's hands were contracted but probably had gotten worse. He/she stated the resident was very demented and indicated the resident's hands would need to be assessed.

Based on observation, interview, record review and facility policy review, the facility failed to ensure the kitchen staff adhered to safe practices to prevent the potential spread of food-borne illness to all residents who received their meals from the kitchen. Concerns were noted with dish-washing procedures, sanitizing solution concentrations, cleaning contact surfaces after exposure to raw meat, failure to remove significantly dented cans from the general canned food supply, and cleanliness in the dry food store room. Findings include: 1. On 06/21/21 from 10:40 AM - 11:05 AM, the three-sink pot washing sinks were in use, each filled with a separate solution (wash, rinse, sanitize). There were multiple pots on counter drying next to the third sink. Employee Identifier (EI)#9, Diet Tech (kitchen manager) used a quaternary [MEDICATION(S)] test strip to check the level of the sanitizing solution in the third sink. The test strip did not register any parts per million (PPM) of the sanitizer. EI#9, asked EI#11,Cook, who was in the vicinity to drain the sink and refill it. EI#9 asked EI#11 why there was no sanitizer present in the third sink. EI#11 stated he did not know. 2. On 06/23/21 at 10:05 AM, EI#10, Cook, prepared the pureed pork chops for the noon meal. EI #10 first took a steam table pan full of boneless pork chops and watery fluid and drained the fluid off the meat, pouring it down the left side of the food preparation sink. There were two food prep sinks right next to each other. EI#10 then placed the pork chops into the Robot Coupe commercial food processor and took the steam table pan to the three-sink pot washing area. After blenderizing the pork chops, he/she washed the pan that held the pork chops in the food preparation sink, dunked it in the rinse solution in the second sink, and then dunked it in the sanitizer solution in the third sink. He/she then brought the pan back to where he/she prepared the pureed pork chops. He/she did not immerse the pan in the third sink for more than a second when he/she dunked it. EI#10 then poured the pureed pork chops into this steamtable pan and reheated the mixture to bring it up to temperature for serving. EI#9 was notified of the observation at this time and stated that the pots should be immersed in the third sink sanitizer solution but would have to check on how much time the pots should be immersed. 3. On 06/23/21 at approximately 10:12 AM, EI#11 took a batch of raw pork chops and placed them in the food preparation sink and kneaded the pork chops with a spice mixture. After the pork chops were removed, he/she wiped out the sink with a wiping rag from the sanitizer bucket without washing the sink first with soap/detergent. EI#11 was interviewed at the time and stated he/she used the rag that was in the sanitizing solution to wipe out the sink and had not washed the sink first with soap or detergent. Review of the facility's policy titled, Dietary Food Handling with an effective date of 01/01/17, from the DMS Policy & Procedure Food Service Manual, revealed, It is the policy of this center to provide guidelines for the safe preparation, handling and storage of perishable foods and proper environmental cleaning .Each time there is a change in processing from raw to ready to-eat foods, each new operation should begin with clean and sanitized food contact surfaces and utensils . Review of the facility's policy titled, Pots and Pans with an effective date of 08/01/12, from the DMS Policy & Procedure Food Service Manual, revealed it was the policy of the facility to, clean and sanitize pots and pans to maintain sanitary food preparation, service and delivery environment .The three-sink system is preferred if the dishwashing machine is not used. For three-sink system: In Sink No [number] 1 [wash sink] prepare a hot solution of facility approved cleaner. Sink No. 11 [Rinse Sink] should be a clear, hot water rinse. In Sink No. III [Sanitizing Sink], prepare a solution of the facility approved sanitizer and hot water. After pre-soak/wash, excess soil was to be scraped, all surfaces were to e scrubbed, the item was to be immersed in the rinse sink and then immersed in the sanitizing sink following manufacturer instructions for sanitizer. Review of the Manufacturer's Instructions titled, Auto Chlor System, Dishwashing Three Sink Method instructions, revealed the system included wash [clean water and detergent], rinse [clean water], and sanitizing [clean water and sanitizer] solutions be used in that order. Food contact surfaces sanitizing called for a solution between 200 - 400 PPM of the sanitizer [quaternary [MEDICATION(S)]]. The product label was to be consulted for the required contact time [of the sanitizer]. Review of the product label revealed thorough washing was to occur prior to sanitizing. The treated surfaces must remain wet for 60 seconds [with the sanitizer solution]. 4. During the initial kitchen inspection with EI#9 on 06/21/21, from 10:40 AM - 11:05 AM, the dry store room was observed. There was a #10 can in the general can rack with a dent of approximately one - two inches along the bottom seal of the can. In addition, there was a window sill that had dirt, debris and contained approximately five dead bugs. There were also multiple spider webs in the window sill area. There was canned food on a shelf in the window near the window sill. 5. During a second observation with EI#9 on 06/23/21 at 9:24 AM, in the dry store room there was a dented #10 can noted on 06/21/21 (apple pie filling) and there were three significantly dented #10 cans of peaches with large dents along the bottom seal. The cans were disfigured from the large dents. EI#9 stated the staff member who put away the last order should not have put the peaches on shelf with canned goods that were to be used. He/she stated the dented cans were supposed to be placed on a separate shelf and it was supposed to be labeled (although it was not) with a sign for dented cans. The window sill was in the same condition noted on 06/21/21 with approximately five dead bugs, multiple spider webs, and cans of soup and olives stored on shelf near the window sill. EI#9 stated the area needed to be cleaned. Review of the facility's policy titled, Dry Storage with an effective date of 01/01/17, from the DMS Policy & Procedure Food Service Manual, revealed, It is the policy of this center to store, prepare and serve food that is stored in accordance with federal, state, and local sanitary codes . The floors, walls, shelves, and equipment in the storeroom will be kept clean and in good repair . The storeroom will be kept free from insects and rodents . Leaking cans and spoiled food will be removed promptly. Damaged cans will be identified for removal . Damaged canned food containers will be stored together in the storeroom in a separate and distinct area away from other food items. This area should be labeled. The damaged food containers will be returned to the vendor .Damaged containers are defined as: a. all dented containers (other than those with a slight to moderate dent that does not involve the seam and does not rock on a flat surface) . Review of the facility's policy titled, Equipment Cleaning Schedules with an effective date of 08/01/12, from the DMS Policy & Procedure Food Service Manual, revealed, It is the policy of this facility to assign cleaning schedules on a daily, weekly and monthly basis. The policy indicated the dry store room was scheduled for weekly cleaning. 6. On 06/23/21 at approximately 10:24 AM, a dietary aide was observed removing clean dishes from the commercial dish machine. He/she wiped out a small, clean bowl with a dry rag and stacked it with the clean dishes. Review of the Food Code U.S. Public Health Service, Food and Drug Administration, College Park MD, 2017 indicates, Drying 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. During an interview on 06/24/21 at 4:47 PM, EI#8, Registered Dietitian (RD), stated dented cans should be placed in a separate area (distinct from the general can storage area). EI#8 stated the sanitizer level for quaternary [MEDICATION(S)] sanitizer should be between 200-400 PPM. Regarding immersion of pots/pans in the sanitizer solution in the third sink for pot washing, he/she stated items should be immersed, but the manufacturer's information did not document an exact time and instead it indicated the items should be immersed or remain wet for 60 seconds. EI#8 stated he/she had gone by 30 - 60 seconds timeframe for how long pots should be immersed in the third sink sanitizer solution. When notified of the food preparation sink with raw meat and wiping it with a wiping rag that was in the sanitizing solution prior to washing the sink first, she/he stated the sink should be washed first and then staff should sanitize it. EI#8 stated dishes should be air dried when they were removed from the dish machine and should not be dried with towels.

Based on interview and document review, the facility failed to support the residents' right to participate in a resident group by not restarting the resident council meetings post Coronavirus Disease 2019 (COVID-19). This deficient practice affected four residents in the sample of 34 (Resident Identifier (RI) #'s 85, 2, 39 and 53). Findings include: During an interview on 06/21/21 at 10:30 AM, Resident Identifier (RI) #85 stated he/she did attend Resident Council (RC) meetings prior to the COVID-19 pandemic, but there have not been any meetings held since they were discontinued due to the pandemic restrictions. During an interview on 06/21/21 at 10:40 AM, RI #2 stated he/she did attend RC meetings prior to the COVID-19 pandemic, but there have not been any meetings held since they were discontinued due to the pandemic. During an interview on 06/21/21 at 11:00 AM, RI #39 stated he/she did attend RC meetings prior to the COVID-19 pandemic, but the RC meetings have not been restarted post pandemic. During an interview on 06/21/21 at 2:30 PM, RI #53 stated he/she did attend RC meetings prior to the COVID-19 pandemic, but there have not been any meetings held since they were discontinued during the pandemic. RI #53 revealed he/she was the RC President. During an interview on 06/23/21 at 9:25 AM, Employee Identifier (EI) #4, the Activities Director stated that RC meetings have not been occurring to my knowledge. During an interview on 06/23/21 at 10:00 AM, EI #2, Director of Nursing (DON), E stated RC meetings were being held prior to COVID-19. Review of the RC Binder revealed the last recorded RC meeting was held March of 2020 with 10 residents in attendance.

Based on interview, record review, document review, facility assessment, policy review and review of Centers for Medicare and Medicaid memo, the facility failed to ensure pharmacy services thoroughly reviewed the resident medication regimens to identify irregularities related to the use of [CONDITION(S)] medications, and residents who were prescribed [CONDITION(S)] medications received gradual dose reductions (GDR) or had a physician documented clinical rationale for the continued use of the [CONDITION(S)] medication for four (Resident Identifier (RI) #32, RI#76, RI#75 and RI#18) of five residents reviewed for unnecessary [CONDITION(S)] medication. Findings include: 1. Review of RI #32's electronic medical record (EMR) undated Face Sheet under the face sheet tab revealed RI #32 was admitted to the facility on [DATE]. Review of RI #32's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/20/20 under the MDS tab revealed RI #32's Brief Interview for Mental Status (BIMS) score was a 14 which indicated he/she was cognitively intact. RI #32 received an antipsychotic, antidepressant, and antianxiety medication routinely for seven-days during the assessment period and was indicated to have depression listed under psychiatric/mood disorder. It was documented RI #32 had no behaviors or [CONDITION(S)]. Review of RI #32's EMR quarterly MDS with an ARD of 03/19/21 under the MDS tab revealed RI #32's BIMS score was 15 which indicated that he/she was cognitively intact with a psychiatric/mood diagnosis of depression. It was documented RI #32 received an antidepressant and antianxiety medication routinely for seven-days during the assessment period and was indicated to have depression under psychiatric/mood disorder. There were no behaviors or [CONDITION(S)] documented. There was no documentation RI #32 received an antipsychotic medication. Review of RI #32's EMR Medication Administration Record (MAR) dated for the month of March 2021 under the orders tab verified RI #32 had received the antipsychotic medication [MEDICATION(S)] daily during the MDS ARD of 03/19/21 and for the entire month of March 2021. Review of RI #32's EMR Clinical Physician Orders dated from 04/20/12 through June 2021 under the orders tab revealed RI #32 was prescribed [MEDICATION(S)] (an antipsychotic medication) routine daily starting 10/01/19 and continued to the current active medication orders (June 2021). Review of RI #32's EMR Care Plan under the care plan tab with various dates revealed RI #32 had a care plan for the use of an antidepressant, antianxiety, and antipsychotic medication. The care plan problem and goal were as follows; .02/03/20 Potential for drug related complications associated with the use of [CONDITION(S)] medications .the goal RI #32 will be free of [CONDITION(S)] drug related complications and the target date was for 01/15/21. The care plan interventions were as follows: .08/02/19 Monthly pharmacy review of medication regimen, 09/13/19 [CONDITION(S)] medication risk/benefit and reduction plan as recommended by physician and pharmacist . Review of RI #32's handwritten Physician's Orders located in the hard copy chart dated 06/03/21 revealed there was a physician order to discontinue [MEDICATION(S)] 2 milligrams (mg) and start [MEDICATION(S)] 5 mg every day (QD). There was no specification to which 2 mg [MEDICATION(S)] order was to be discontinued. RI #32 had been prescribed [MEDICATION(S)] 2 mg by mouth (PO) every night at hour of sleep (QHS) on 02/17/21 in addition to a prior order of [MEDICATION(S)] 2 mg PO QD ordered on 12/04/20. Only one of the [MEDICATION(S)] 2 mg orders was discontinued on 06/03/21 leaving one [MEDICATION(S)] 2 mg order and the new [MEDICATION(S)] 5 mg order for a total of 7 mgs of [MEDICATION(S)] prescribed daily. This irregularity was not identified through pharmacy review or by the facility. Review of the facility's monthly Gradual Dose Reduction Tracking Report provided by the facility and completed by the pharmacy dated from January 2021 through May 2021 revealed there was no tracking report provided for the month of March 2021. The report detailed the following information: In January 2021 RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/01/21. There was no pharmacy GDR consultation report provided for this medication review. In February 2021 RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/01/21. There was no pharmacy GDR consultation report provided for this medication review. In April 2021 RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/23/21. There was no pharmacy GDR consultation report provided for this medication review. In May 2021 RI #32 was prescribed a routine antidepressant medication for depression on 10/01/19, antipsychotic medication for mood disorder on 10/01/19, and an anxiolytic medication for anxiety on 12/04/20. The antidepressant next review for GDR was on 03/31/22, the antipsychotic next review for GDR was on 10/29/21, and the antianxiety next review for GDR was on 01/28/22. There were no pharmacy consultation reports provided for these medication reviews. Review of RI #32's pharmacy Consultation Report for GDR recommendations dated October 22, 2020, through October 25, 2020, revealed documentation that the pharmacy reviewed the following [CONDITION(S)] medications: [MEDICATION(S)] 1 mg QD, [MEDICATION(S)] 25 mg QHS, [MEDICATION(S)] 30 mg twice daily (BID), and [MEDICATION(S)] 5 mg QHS. It was documented the physician declined the GDR without an appropriate clinical rationale to continue the prescribed medications. There were no GDR pharmacy consultation report recommendations for the dates of January 2021 through May 2021 to correlate with the dates of the monthly Gradual Dose Reduction Tracking Report. Review of RI #32's physician visit progress note with no title dated 01/13/21, located in the MISC section of the EMR revealed RI #32 was seen by the physician for a readmission from the hospital and annual review. The physician documented reviewing the antianxiety, antidepressant and antipsychotic medications and the plan stated the medication to be continued, consider taper or adjustment if patient tolerates and psych consult as needed. The goal documented was the .member's depression will improve by goal target date 01/13/22 . There was no documentation of an attempted gradual dose reduction, no clinical rationale for continuing the [CONDITION(S)] medications and no assessment of the resident's identified target behaviors related to the prescribed medications. Review of RI #32's physician visit progress notes with no title dated 02/15/21, 03/12/21, 03/23/21, 04/26/21, 05/20/21, 05/24/21, and 06/07/21, revealed there was no documentation of attempted gradual dose reduction for the prescribed [CONDITION(S)] medications, no clinical rationale for continuing the [CONDITION(S)] medications and no assessment of the resident's identified target behaviors related to the prescribed medications. During an interview on 06/24/21 at 2:47 PM, the Medical Director (MD) confirmed RI #32's [MEDICATION(S)] medication was generally used for specific type of diagnoses such as [CONDITION(S)] and [CONDITION(S)] disorder and stated RI #32 did not have those diagnoses. The MD stated due to the COVID pandemic the main concern was making sure the residents were doing well emotionally and he/she had not wanted to make any unnecessary medication changes and the goal was to not be too aggressive. In regard to RI #32's prescribed medication [MEDICATION(S)] and the discrepancy with the written [MEDICATION(S)] order in June 2021, the MD stated the 4 mg dose had to be ordered for once a day and did not come in a 4 mg tablet, so he/she had to order the 5 mg tablet daily. The MD stated he/she was not aware the facility had not discontinued both of the prior 2 mg daily orders. The MD confirmed the intention was not for the resident to be prescribed a total of 7 mg daily and stated that was facility and pharmacy error and confirmed the order should have been clarified. The MD stated RI #32 was originally placed on [CONDITION(S)] medications by another physician and that physician was a psychiatrist from the community prior to RI #32's admission to the facility. The MD stated the community physician knew RI #32 well and had treated him/her for psychiatric depression. The MD stated it was his/her opinion that was why RI #32 was placed on the [MEDICATION(S)] antipsychotic medication in the first place. 2. Review of RI #76's undated Face Sheet in the EMR revealed the resident was admitted on [DATE] with diagnoses including: [CONDITION(S)] of right below the knee amputation/stump, muscle weakness, unsteady gait and falls. Review of a scanned physicians progress note found in the MISC tab of the EMR and dated 04/05/21 revealed the MD was RI#76's attending physician. Review of RI#76's gero-psychiatric evaluation dated 02/20/21 indicated RI#76 reported no history of mental health treatment prior to this assessment. The psychiatrist added Trazadone (an antidepressant/sedative medication) to aid in sleep and recommended supportive treatment .follow up 1-2 months . There were no other psychiatric notes located in the medical record review. Review of RI#76's Physician Orders under the Orders tab, in the EMR for the months of January 2021 through June 2021 revealed the resident was prescribed the following [CONDITION(S)] medications: [MEDICATION(S)] (anti-anxiety medication) 20mg daily for depression (not included in diagnoses list); [MEDICATION(S)] (anti-psychotic medication) 150mg daily for behavioral disturbances and acute agitation. There was no appropriate psychiatric diagnosis for RI#76's use of an antipsychotic medications: Trazadone (antidepressant medication) 150mg at bedtime for depression/sleep; -[MEDICATION(S)] (anti-[CONDITION(S)] medication) 600mg twice daily for mood. There was no indication in the medical record review that RI #76 had seizures; and [MEDICATION(S)] (antipsychotic medication) 10mg twice daily for agitation. There was no psychiatric diagnosis for RI#76's use of an antipsychotic medication. Review of the consultant pharmacy monthly reviews for RI#76 titled, Gradual Dose Reduction Tracking Report from the resident's admission in January 2021 through the current survey in June 2021 revealed the following: February 26, 21 - revealed the pharmacy requested a diagnosis (required for antipsychotics) to support the use of the [MEDICATION(S)]. March 30, 21 - again, the pharmacy requested a supporting psychiatric diagnosis. April 26, 21 - the request for a supporting diagnosis had not been answered. May 27, 21 - the physician added an additional antipsychotic ([MEDICATION(S)]). There continued to be no supporting psychiatric diagnosis to support the use of antipsychotics. Additionally, on this report the pharmacist noted the MD had also added [MEDICATION(S)] on 05/20/21. [MEDICATION(S)] is a Selective Serotonin Reuptake Inhibitor/SSRI a psychoactive medication used to treat depression, obsessive-compulsive disorder, bulimia, and panic disorder. RI#76 did not have a diagnosis to support the use of [MEDICATION(S)]. The MD also added [MEDICATION(S)] on 05/20/21 for mood. [MEDICATION(S)] is an anticonvulsant medication but has been used off label to modify mood/behaviors. RI#76 had no diagnoses of mood disorders or of seizures/convulsions. A phone interview on 06/24/21 at 12:00 PM, with the Consultant Pharmacist revealed she did not believe there were specific pharmacy policies for performing GDRs. The Consultant Pharmacist stated, .we try to go slow and stay low with respect to psychoactive medications. When asked if she followed up with the physician when the pharmacy recommendations went unanswered, the Consultant Pharmacist stated, No. 3. Review of RI# 75's Admission Record located in the EMR indicated the resident was admitted to facility on 01/10/14 with a diagnosis that included but not limited to Alzheimer, dementia without behavioral disturbance, and anxiety disorder. Review of RI#75's Physician Orders located under the Orders Tab of the EMR for May 2021 and June 2021 revealed the resident was prescribed [MEDICATION(S)]. Further review of the Physician Order, found under the Orders Tab of the EMR, dated 11/18/20, documented, [MEDICATION(S)] tablet 100 mg. Give one tablet at bedtime related to unspecified dementia without behavioral disturbance. On 04/13/21, RI#75 was ordered [MEDICATION(S)] tablet 100mg. Give one 50 mg every morning and at bedtime related to unspecified Dementia without behavioral disturbance. During an interview with the Consultant Pharmacist on 06/24/21 at 12:09 PM, the Pharmacist stated that on April 26, 2021, she completed a recommendation to clarify the diagnosis of dementia without behavioral disturbance and to change the diagnosis to dementia with behavioral disturbances if he/she was having behaviors. When asked if he/she thought the diagnosis was appropriate indication for use [for the antipsychotic], EI#24 stated, I think so if the resident is on an antipsychotic for dementia with behavioral disturbance. Review of the Gradual Dose Reduction Tracking Report, provided by the facility revealed RI#75 was reviewed for use of antipsychotic medication on 12/17/21, 01/26/21 and 02/26/21. Further review of the Consultation Report completed by the Consultant Pharmacist and provided by the facility, indicated there was a recommendation to discontinue the as needed order for the medication [MEDICATION(S)] due to antipsychotic medications can only be limited to 14 days. This was the only Consultation Report the facility was able to provide. 4. Review of RI #18's undated Face Sheet in the EMR revealed RI #18 was admitted on [DATE] with diagnoses of adjustment disorder with depressed mood, unspecified dementia with behavioral disturbance, anxiety disorder due to known physiological condition, [CONDITION(S)]. Review of RI #18's admission MDS with an ARD dated 03/09/21 revealed RI #18 was moderately cognitively impaired with no behaviors. RI #18 was independent with activities of daily living. RI #18 received an anti-psychotic medication during the assessment period. Review of RI #18's EMR annual MDS with an ARD of 03/09/21 under the MDS tab revealed RI #18's BIMS score was a 11 which indicated he/she was moderately cognitively impaired. RI #18 received an antipsychotic, antidepressant, and antianxiety medication routinely for seven-days during the assessment period. It was documented RI #18 had no behaviors or [CONDITION(S)]. Review of RI #18's EMR Order Summary Report dated 06/24/21 under the orders tab revealed RI #18 was prescribed [MEDICATION(S)] routine daily starting 03/19/20 and continued to the current active medication orders (June 2021). Review of RI #18's EMR Care Plan under the care plan tab with the target date of 06/22/21 revealed RI #18 had a care plan for the use of an antidepressant, antianxiety, and antipsychotic medication. The care plan problem and goal were as follows; .revision date 04/26/21 Potential for drug related complications associated with the use of [CONDITION(S)] medications .the goal RI #18 will be free of [CONDITION(S)] drug related complications and the target date was for 09/20/21. The care plan interventions were as follows: .05/07/17 Monthly pharmacy review of medication regimen, 05/07/17 Medication risk/benefit and reduction plan as recommended by physician and pharmacist . During an interview on 06/24/21 at 12:05 PM, the Consultant Pharmacist stated that EI#2, Director of Nursing (DON) should have the paper copies of the gradual dose reduction request she made for RI #18 for the dates of 08/11/20, 12/16/20 and 04/26/21. During an interview on 06/24/21 at 3:55 PM, EI #2 stated she could not locate the GDR requests made by the Consultant Pharmacist for RI #18 for the dates of 08/11/20, 12/16/20 and 04/26/21. Review of RI #18's physician's visit progress notes with no title dated 02/22/21 and 03/22/21 revealed there was no documentation of attempted gradual dose reduction for the prescribed [CONDITION(S)] medications, no clinical rationale for continuing the [CONDITION(S)] medications and no assessment of the resident's identified target behaviors related to the prescribed medications. Review of the Facility Assessment Tool dated/reviewed on 06/04/21 revealed under the Mental Health and Behavior section, Manage the medical condition and medication-related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with these issues . Under the Medications section of the assessment indicated, .Assessment/management of polypharmacy is important. Gradual dose reduction is done on antipsychotic medications, antianxiety medications, antidepressant medications, anxiolytics/antianxiety and hypnotics. Review of Centers for Medicare and Medicaid S&Q Memo Ref 13-35-NH dated May 24, 2013 revealed: . When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective. In addition, they commonly cause complications such as movement disorders, falls, hip fractures, [CONDITION(S)] adverse events ([CONDITION(S)] accidents and transient ischemic events) and increased risk of death . Review of the undated facility's policy titled, Antipsychotic Reduction Guide indicated that the facility would establish a quality committee to monitor all antipsychotic medications at least monthly and consider tapering or discontinuing the use of antipsychotic medication in the residents that do not exhibit behaviors. The facility provided a letter dated 06/23/21 which indicated the facility did not have a [CONDITION(S)] medication policy.

Based on record review, staff interviews, review of the facility's assessment, review of the manufacturer's guidelines for medication use, review of Centers for Medicare and Medicaid Services memo and review of the facility's policies and procedures, the facility failed to ensure that four of five residents (Resident Identifier (RI) #18, RI#32, RI#75, and RI#76) were free from unnecessary [CONDITION(S)] medications. Specifically, an antipsychotic and psychoactive medications were used by the facility without an attempted gradual dose reduction (GDR), proper medical rationale, proper indication for use, and the lack of /or behavior and side effect monitoring. Additionally, residents received PRN (as needed) anti-anxiety medication for more than 14 days without proper medical rationale and/or indication for use. Findings include: Review of Centers for Medicare and Medicaid S&Q Memo Ref 13-35-NH dated May 24, 2013 revealed: . The problematic use of medications, such as antipsychotics, is part of a larger, growing concern. This concern is that nursing homes and other settings (i.e., hospitals, ambulatory care) may use medications as a quick fix for behavioral symptoms or as a substitute for a holistic approach that involves a thorough assessment of underlying causes of behaviors and individualized, person-centered interventions . When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective. In addition, they commonly cause complications such as movement disorders, falls, hip fractures, [CONDITION(S)] adverse events ([CONDITION(S)] accidents and transient ischemic events) and increased risk of death . Review of the facility's Facility Assessment Tool dated/reviewed on 06/04/21 revealed under the Mental Health and Behavior section, Manage the medical condition and medication-related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with these issues .Under the Medications section of the assessment indicated, .Assessment/management of polypharmacy is important. Gradual dose reduction is done on antipsychotic medications, antianxiety medications, antidepressant medications, anxiolytics/antianxiety and hypnotics . 1. Review of RI #32's electronic medical record (EMR) undated Face Sheet under the face sheet tab revealed RI #32 was admitted to the facility on [DATE]. Review of RI #32's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/20/20 under the MDS tab revealed RI #32's Brief Interview for Mental Status (BIMS) score was a 14 which indicated he/she was cognitively intact. RI #32 received an antipsychotic, antidepressant, and antianxiety medication routinely for seven-days during the assessment period and was indicated to have depression listed under psychiatric/mood disorder. It was documented RI #32 had no behaviors or [CONDITION(S)]. Review of RI #32's EMR quarterly MDS with an ARD of 03/19/21 under the MDS tab revealed RI #32's BIMS score was 15 which indicated he/she was cognitively intact with a psychiatric/mood diagnosis of depression. It was documented RI #32 received an antidepressant and antianxiety medication routinely for seven-days during the assessment period and was indicated to have depression under psychiatric/mood disorder. There were no behaviors or [CONDITION(S)] documented. There was no documentation RI #32 received an antipsychotic medication. Review of RI #32's EMR Medication Administration Record (MAR) dated for the month of March 2021 under the orders tab verified RI #32 had received the antipsychotic medication [MEDICATION(S)] daily during the MDS ARD of 03/19/21 and for the entire month of March 2021. Review of RI #32's EMR Clinical Physician Orders dated from 04/20/12 through June 2021 under the orders tab revealed RI #32 was prescribed [MEDICATION(S)] (an antipsychotic medication) routine daily starting 10/01/19 and continued to the current active medication orders (June 2021). Review of RI #32's handwritten Physician's Orders located in the hard copy chart dated 06/03/21 revealed there was a physician order to discontinue [MEDICATION(S)] 2 milligrams (mg) and start [MEDICATION(S)] 5 mg every day (QD). There was no specification to which 2 mg [MEDICATION(S)] order was to be discontinued. RI #32 had been prescribed [MEDICATION(S)] 2 mg by mouth (PO) every night at hour of sleep (QHS) on 02/17/21 in addition to a prior order of [MEDICATION(S)] 2 mg PO QD ordered on 12/04/20. Only one of the [MEDICATION(S)] 2 mg orders was discontinued on 06/03/21 leaving one [MEDICATION(S)] 2 mg order and the new [MEDICATION(S)] 5 mg order for a total of 7 mgs of [MEDICATION(S)] prescribed daily. This irregularity was not identified through pharmacy review or by the facility until the re-certification survey from 06/21/21 through 06/24/21. Review of the facility's monthly Gradual Dose Reduction Tracking Report provided by the facility and completed by the pharmacy dated from January 2021 through May 2021 revealed there was no tracking report provided for the month of March 2021. The report detailed the following information: In January 2021, RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/01/21. There was no pharmacy GDR consultation report provided for this medication review. In February 2021, RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/01/21. There was no pharmacy GDR consultation report provided for this medication review. In April 2021, RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/23/21. There was no pharmacy GDR consultation report provided for this medication review. In May 2021, RI #32 was prescribed a routine antidepressant medication for depression on 10/01/19, antipsychotic medication for mood disorder on 10/01/19, and an anxiolytic medication for anxiety on 12/04/20. The antidepressant next review for GDR was on 03/31/22, the antipsychotic next review for GDR was on 10/29/21, and the antianxiety next review for GDR was on 01/28/22. There were no pharmacy consultation reports provided for these medication reviews. Review of RI #32's pharmacy Consultation Report for GDR recommendations dated October 22, 2020, through October 25, 2020, revealed documentation that the pharmacy reviewed the following [CONDITION(S)] medications: [MEDICATION(S)] 1 mg QD, [MEDICATION(S)] 25 mg QHS, [MEDICATION(S)] 30 mg twice daily (BID), and [MEDICATION(S)] 5 mg QHS. It was documented the physician declined the GDR without an appropriate clinical rationale to continue the prescribed medications. There were no GDR pharmacy consultation report recommendations for the dates of January 2021 through May 2021 to correlate with the dates of the monthly Gradual Dose Reduction Tracking Report. Review of RI #32's EMR General and Weekly Nurses Notes located under the Progress Notes tab dated from 01/04/21 through 06/04/21 revealed there was no documentation of RI #32's behaviors related to the routine use of multiple [CONDITION(S)] medications. Review of RI #32's physician visit progress note with no title dated 01/13/21, located in the MISC (miscellaneous) tab of the EMR revealed RI #32 was seen by the physician for a readmission from the hospital and annual review. The physician documented he was reviewing the antianxiety, antidepressant and antipsychotic medications and the plan stated the medication to be continued, consider taper or adjustment if patient tolerates and psych consult as needed. The goal documented was the .member's depression will improve by goal target date 01/13/22 . There was no documentation of an attempted gradual dose reduction, no clinical rationale for continuing the [CONDITION(S)] medications and no assessment of the resident's identified target behaviors related to the prescribed medications. Review of RI #32's physician visit progress notes with no title dated 02/15/21, 03/12/21, 03/23/21, 04/26/21, 05/20/21, 05/24/21, and 06/07/21, revealed there was no documentation of attempted gradual dose reduction for the prescribed [CONDITION(S)] medications, no clinical rationale for continuing the [CONDITION(S)] medications and no assessment of the resident's identified target behaviors related to the prescribed medications. During an interview on 06/23/21 at 12:10 PM, EI #20, Registered Nurse (RN) revealed RI #32 was alert and oriented times three and was up daily to the wheelchair out of his/her room socializing with other residents and staff. EI #20 stated in regard to behaviors, RI #32 had no behaviors such as yelling out, or anything negative towards others or harm to self. EI #20 stated when RI #32 had gone out to the hospital a while back he/she was having hallucinations and was more depressed, but not recently. EI #20 stated the reason the resident was prescribed an antipsychotic was for psychotic behaviors which RI #32 did not have any longer. EI #20 stated RI #32's depression goes up and down and RI #32 would cry a lot at times. EI #20 stated resident behaviors should be monitored daily and documented on the behavioral monitoring sheets kept in the narcotic binder on the medication cart. EI #20 stated sometimes the nurses would chart a behavior in the progress notes under the general note. EI #20 stated she wasn't aware of any recent GDRs related to RI #32's [CONDITION(S)] medications. During an interview on 06/23/21 at 1:24 PM, RI #32 revealed he/she was alert and oriented and answered questions accurately and when asked how he/she was doing, RI #32 stated, I'm fine and feel pretty good. RI #32 stated he/she had no concerns related to medications. RI #32 stated the MD had explained the medications that were prescribed, and he/she had understanding of the potential side effects. RI #32 stated he/she had received visits from psych services and had a visit last week with no new recommendations. During an interview on 06/24/21 at 3:30 PM, EI#2, Director of Nursing (DON) stated in regard to the RI #32's incorrect antipsychotic medication order, EI #2 stated the expectation would be for any physician order that was in conflict with another order should be clarified for accuracy. EI #2 stated it would be the responsibility of the nurses to check physician orders for accuracy. 2. Review of RI#76's undated Face Sheet in the EMR revealed resident was admitted on [DATE] with diagnoses including [CONDITION(S)] of right below the knee amputation/stump site, muscle weakness, unsteady gait and falls. Review of R76's quarterly MDS with an ARD of 04/28/21 revealed the BIMS score of 13 which indicated RI#76 had mild cognitive impairments but was capable of making decisions regarding in his/her care. The MDS further documented that RI#76 had no behaviors, no hallucinations, or delusions, and had no active neurological or psychiatric diagnoses. The MDS indicated that RI#76 received antipsychotic medications on five of seven days, an antianxiety medication on six of seven days and an antidepressant medication on seven or seven days., In an interview on 06/22/21 at 4:25 PM, EI#12, Licensed Practical Nurse (LPN) stated, [name of resident] settled down since he/she got here .can still be manipulative but used to be out right mean. EI#12 stated RI #76 was aggressive and frequently attempted to hit staff during cares when he/she was admitted . Review of a physicians progress note found in the MISC. tab of the EMR and dated 02/20/21 revealed that since RI#76's admission to the facility he/she had a gero-psychiatric evaluation on 02/20/21. The psychiatric note revealed RI#76 reported no history of mental health treatment prior to this assessment. Per the 02/20/21 psychiatric progress note the psychiatrist added Trazadone 100mg at bedtime (an antidepressant/sedative medication) to aid in sleep and recommended supportive treatment .follow up 1-2 months . There were no added psychiatric diagnoses; nor were there any follow up psychiatric notes located in RI#76's medical record review . On 06/23/21 at 4:15 PM. EI#2 was asked if there were additional psychiatric notes. She stated, only this one, but I will check again. EI#2 concurred that RI#76 did not have psychiatric diagnosis from either the Medical Director/attending physician or by the psychiatrist. Review of RI#76's Physician Orders under the Orders tab in the EMR for the months of January 2021 through June 2021 revealed the resident was prescribed the following [CONDITION(S)] medications by the attending physician/Medical Director (MD): [MEDICATION(S)] (anti-anxiety medication) 20mg daily for depression (not included in diagnoses list) [MEDICATION(S)] (anti-psychotic medication) 150mg daily for behavioral disturbances and acute agitation. There was no appropriate psychiatric diagnosis for the use of antipsychotics. Trazadone (antidepressant medication) 150mg at bedtime for depression/sleep [MEDICATION(S)] (anti-[CONDITION(S)] medication) 600mg twice daily for mood. There was no indication in the medical record review that RI#76 had seizures. [MEDICATION(S)] (antipsychotic medication) 10mg twice daily for agitation. There was no psychiatric diagnosis for the use of antipsychotic medication. There were no orders to monitor medication specific adverse effects or to monitor for resident specific target behaviors related to the use of these [CONDITION(S)] medications. On 06/23/21 at 4:20 PM, EI#2 was asked about behavior monitoring and stated the was no flow sheet, some of the nurse's notes should include behaviors if exhibited, and there was an area on the back of the MAR the nurses could use to document behaviors. Review of RI#76's nursing progress notes under the Progress Notes tab in the EMR revealed the following: Describe Behavior/Mood, what the resident is doing, interventions attempted and effectiveness. 01/23/21 at 10:51 PM - very hostile behavior .verbally abusive staff .curses frequently . no interventions were included. 02/05/21 at 5:55 PM - resident very hostile .continuous outbursts .much profanity and derogatory and racial remarks to staff. Interventions included a call to the physician and a psychiatric consult was ordered. [Psychiatrist name] contacted and orders received: [MEDICATION(S)] 50mg TID [three times a day]) and Buspar15 mg with meals . -02/12/21 at 7:00 PM, RI#76 threatened to throw a urinal full of urine at another resident as he/she passed RI#76's room in wheelchair because RI#76 asked for a cigarette from the other resident. No interventions were included. -03/21/21 - called to lobby by staff - resident was in lobby cussing at staff about food .cussed another resident about cigarettes. Resident redirected was the intervention. -04/18/21 - the resident was yelling and cussing .CNA [Certified Nurse Aid] found cigarettes and a lighter in resident room and turned into the nurses station. Resident threatening to throw things .and cussing .resident doubled up fist .stated I am going to have your job and say you stole my money and my watch .you should have given those cigarettes to me not the nurse . Intervention was MD notified of behaviors. -05/09/21 at 4:30 PM .resident came to 4th floor using profanity and yelling at staff .became loud using racial slurs to both black and wite [sic] staff .making sexually inappropriate comments .swung and attempted to hit a female resident confined to a wheelchair. Stated he was going to punch her in the face. MD [name] Administrator and DON notified of behaviors. Review of the consultant pharmacist's monthly reviews titled, Gradual Dose Reduction Tracking Report from RI#76's admission in January 2021 through the current survey in June 2021 revealed the following: February 26, 2021 - revealed the pharmacy requested a diagnosis (required for antipsychotics) to support the use of the [MEDICATION(S)]. March 30, 2021 - again, the pharmacy requested a supporting psychiatric diagnosis. April 26, 2021 - the request for a supporting diagnosis had still been unanswered. May 27, 2021 - the physician added an additional antipsychotic ([MEDICATION(S)]). There continued to be no supporting psychiatric diagnosis to support the use of antipsychotics. Additionally, on this report the pharmacist noted that the MD had also added [MEDICATION(S)] on 05/20/21. [MEDICATION(S)] is a Selective Serotonin Reuptake Inhibitor/SSRI a psychoactive medication used to treat depression, obsessive-compulsive disorder, bulimia, and panic disorder. There was no documentation in RI#76' medical record of these diagnoses. The MD also added [MEDICATION(S)] on 05/20/21 for mood. [MEDICATION(S)] is an anticonvulsant medication but has been used off label to modify mood/behaviors. Review of RI#76 medical record revealed no diagnoses of mood disorders or of seizures/convulsions. No GDR attempts had been made for R76's psychoactive medications. During an interview on 06/24/21 at 2:30 PM, RI#76's MD stated he/she reviews the nurse's notes and talks to staff and the residents to make resident care decisions. The MD stated, I manage those medications [psychotropics] unless [psychiatrist name] has decided to make recommendations. The MD further stated that he/she was not sure if he/she had included a written indication for use of each specific [CONDITION(S)] medication and that he/she was unaware the pharmacy had made multiple requests for an appropriate diagnosis for the use of the antipsychotic medications [MEDICATION(S)] and [MEDICATION(S)]. The MD stated that he/she was unaware that the facility had no specific behavioral monitoring program and/or policy to assure that residents on [CONDITION(S)] medications were monitored for specific behaviors (delusions and hallucinations) and/or side effects of [CONDITION(S)] medications. 3. Review of RI# 75's Admission Record located in the EMR indicated the resident was admitted to facility on 01/10/14 with a diagnosis that included but not limited to Alzheimers, dementia without behavioral disturbance, and anxiety disorder. Review of RI#75's significant change MDS with an ARD of 03/04/21 indicated the resident was moderately impaired with no hallucinations, delusions or any type of behaviors. The resident was not coded as having any psychotic disorders including [CONDITION(S)]. Review of RI#75's Physician Orders located under the Orders Tab of the EMR for May 2021 and June 2021 revealed the resident was prescribed [MEDICATION(S)], an antipsychotic medication. Further review of the Physician Order, found under the Orders Tab of the EMR, dated 11/18/20, documented, [MEDICATION(S)] tablet 100 mg. Give one tablet at bedtime related to unspecified Dementia without behavioral disturbance. On 04/13/21 RI#75 was ordered [MEDICATION(S)] tablet 100 mg. Give one 50 mg every morning and at bedtime related to unspecified Dementia without behavioral disturbance. Review of RI#75's care plan for Potential drug related complication associated with use of psychotic medication, revised on 11/13/20, did not list any non-pharmacological interventions for the resident as well as list any specific behaviors to monitor. During an interview with EI #15, an LPN, on 06/23/21 at 10:55 AM regarding RI#75's behaviors stated she had not observed any behaviors with RI#75. No hallucination/disorganized speech. Stated the resident had been on [MEDICATION(S)] for a while. EI#15 reviewed the Physician Order stated the resident was just ordered the [MEDICATION(S)] on 05/12/21. EI#15 stated she has been up and down with his/her meds. When asked about what behaviors RI#75 exhibits she stated RI#75 talks to himself/herself but knows he/she is talking to himself/herself so that is the behavior we monitor. Interview with EI #15 on 06/23/21 at 2:04 PM, stated Social Services has not put the Behavioral Monitoring Flowsheets out for this month. She stated the old flowsheet can be found in the paper chart. EI#15 also stated behaviors are documented on the MAR. When asked how you know which behaviors to observe, she indicated the Behavior Monthly Flowsheet. Review of the paper chart revealed the only Behavior Monthly Flowsheet was last dated February 2021. The behavior code for monitoring indicated, 12. Depression/Withdrawn and 17. Hallucinations paranoia/ delusions There was no Behavior Monthly Flowsheet for the months March, April, May and June 2021. Review of RI#75's, Progress Notes, found under the Notes Tab of the EMR, from January 2021 until June 2021 revealed the following: Weekly note, dated 03/25/21- . Have conversation with self at intervals. Frequently yelling out ghost busters . 04/13/21- Behavior Charting revealed - Resident has noted change in behaviors all throughout the day, increased agitation with attempting to redirect him/her, becomes more aggressive with the staff and other residents, excessive eating throughout the day, yelling out, medications not effective and attempted to get on the elevator to leave the facility, looking for his/her sister, MD has been notified of increased behaviors. Further review of RI#75's Progress Notes located in the EMR, indicated from 04/15/21 to 06/23/21, the question Was a behavior observed? Answered Yes. There was no additional documentation indicating what behavior was observed. Review of the most recent Psych Note found in the paper medical record, dated 02/19/21, indicated no symptoms of suicidal idealities, auditory/visual hallucinations, or delusions. During an interview with the Consultant Pharmacist, on 06/24/21 at 12:09 PM, she stated on April 26, 2021, she completed a recommendation to clarify the diagnosis of dementia without behavioral disturbance and to change the diagnosis to dementia with behavioral disturbances if RI #75 was having behaviors. When asked if she thought the diagnosis was appropriate indication for use [for the antipsychotic], the Consultant Pharmacist said she thought so if the resident is on an antipsychotic for dementia with behavioral disturbance. During an interview with EI#2 on 06/24/21 at 2:18 PM, in regard to the resident being on an antipsychotic without appropriate indication. EI#2 stated, in our population we have residents with dementia on antipsychotic medication that if they were not, they could potentially be a threat to themselves and others. RI#75 falls into that category when he/she is off his/her medication. Our Behavior Monitoring is in our nursing notes or our point of care document. We do have Behavior Monitoring Flowsheets for residents on psych meds and they are put in the chart by our Social Worker and nursing document on them. The form should be put out for nursing at the beginning of the month, and it is collected at the end of the month and returned to the Social Worker for review. The form should never go back into the medical chart. EI#2 was informed there was no Behavior Monitoring Flowsheet for the Month of June currently for nursing to document on. EI#2 confirmed there were no additional flowsheets for RI#75. Interview with the MD on 06/24/21 at 3:03 PM, in regard to the indication for use for the [MEDICATION(S)], the MD stated, no dementia is not an indication for use. 4. Review of RI #18's undated Face Sheet in the EMR revealed RI #18 was admitted on [DATE] with diagnoses of adjustment disorder with depressed mood, unspecified dementia with behavioral disturbance, anxiety disorder due to known physiological condition, [CONDITION(S)]. Review of RI #18's admission MDS with an ARD dated 03/09/21 revealed RI #18 has a BIMS score of 11 which indicates resident was moderately cognitively impaired with no behaviors. RI #18 received anti-psychotic medication during the assessment period. Review of RI #18's Physician Orders included the following: 03/19/20- [MEDICATION(S)] 100 mg tablet give 1 tablet by mouth three time a day related to anxiety disorder due to known physiological condition. There was no indication for use listed for this antipsychotic medication. 03/19/20 - [MEDICATION(S)] 150 mg tablet take one tablet by mouth at bedtime related to unspecified dementia with behavioral disturbance. There was no indication for use listed. Review of the manufacturer's guidelines for the [MEDICATION(S)] revealed that they were to treat specific conditions, which did not include dementia, anxiety, and agitation. In addition, use of these medications for residents with dementia placed the resident at increased risk of death. These guidelines included: Review of the manufacturer's guidelines for the use of the medication [MEDICATION(S)] last updated 10/20 revealed, .Approved Uses [MEDICATION(S)] is a once-daily tablet approved in adults for major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; [CONDITION(S)] disorder; acute manic or mixed episodes in [CONDITION(S)] disorder alone or with [MEDICATION(S)] or divalproex; long-term treatment of [CONDITION(S)] disorder with [MEDICATION(S)] or divalproex; and [CONDITION(S)] .Elderly patients with dementia-related [CONDITION(S)] (having lost touch with reality due to confusion and memory loss) treated with this type of medicine are at an increased risk of death, compared to placebo (sugar pill). [MEDICATION(S)] is not approved for treating these patients . During an interview on 06/24/21 at 3:55 PM, EI #2, stated he/she could not locate the GDR request documentation made by the pharmacist (dated 08/11/20, 12/16/20 and 04/26/21) for RI #18. Review of the manufacturer's guidelines for the use of the medication [MEDICATION(S)] last updated 10/20 revealed, .Approved Uses [MEDICATION(S)] is a once-daily tablet approved in adults for major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; [CONDITION(S)] disorder; acute manic or mixed episodes in [CONDITION(S)] disorder alone or with [MEDICATION(S)] or divalproex; long-term treatment of [CONDITION(S)] disorder with [MEDICATION(S)] or divalproex; and [CONDITION(S)] .Elderly patients with dementia-related [CONDITION(S)] (having lost touch with reality due to confusion and memory loss) treated with this type of medicine are at an increased risk of death, compared to placebo (sugar pill). [MEDICATION(S)] is not approved for treating these patients . Review of the undated facility's policy titled, Antipsychotic Reduction Guide revealed the facility would establish a quality committee to monitor all antipsychotic medications at least monthly and consider tapering or discontinuing the use of antipsychotic medication in the residents that do not exhibit behaviors. The facility provided a letter dated 06/23/21 stating they have no [CONDITION(S)] medication policy.

Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #1, a resident with left-sided weakness was not left unattended by Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA) on 6/3/2016 during a transfer from the bed to the wheelchair. Employee Identifier (EI) #5 did not maintain her hands on RI #1 while providing care; EI #5 turned her back to reach for RI #1's wheelchair. RI #1 fell off the bed onto the floor and sustained a scalp laceration, that required six staples to close. This affected RI #1, one of three sample residents reviewed for falls. Finding include: RI #1 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. RI #1's CLINICAL HEALTH STATUS admission note dated 4/23/2016 7:00 PM, indicated RI #1 had left-sided weakness. RI #1's Admission History and Physical ADMISSION NOTE dated 4/25/2016 3:24 PM, indicated RI #1 was a high fall risk. RI #1's care plan initiated on 4/26/2016 revealed, the resident was at risk for falls related to left sided weakness. RI #1's Minimum Data Set, with an assessment reference date of 6/21/2016, revealed RI #1 was assessed as requiring extensive assistance with bed mobility, dressing and personal hygiene. The GOLDEN LIVING- MEADOWOOD physician progress notes [REDACTED].#1 was a high fall risk. RI #1's VERIFICATION OF INVESTIGATION indicated on 6/3/2016 at 6:00 AM, a Certified Nursing Assistant (CNA) was giving RI #1 morning care prior to getting RI #1 up. RI #1 was sitting on the side of the bed, the CNA turned to get RI #1's wheelchair and RI #1 fell off the left side of the bed onto the floor. RI #1 was assessed and noted to have a three inch laceration to the left scalp and a large knot over the left eye. The report indicated RI #1 has left sided weakness from a previous stroke. The physician was called and the nursing home received orders to send RI #1 to a local hospital for further evaluation. According to the report, the causal/contributing factor included: the CNA turned her back to get the resident's wheelchair. To prevent reoccurrence, the facility educated the staff to maintain hands on RI #1 while providing care due to the resident being at risk for falls. The local hospital report revealed, RI #1 arrived in the emergency roiagnom on [DATE] at 7:34 AM with a chief complaint of fall. The primary [DIAGNOSES REDACTED]. RI #1's scalp laceration was cleaned and numbed with Lidocaine and six staples were placed to close the area. RI #1 was then discharged back to GLC-Meadowood on 6/3/2016. In an interview on 7/12/2016 at 2:35 PM, Employee Identifier (EI) #5, acknowledged she was the CNA who was providing care to RI #1 on 6/3/2016 when the resident fell off the bed onto the floor. When asked if she should have turned her back to get RI #1's wheelchair, which left RI #1, a resident with left-sided weakness, sitting unassisted, EI #5 replied no, that she probably should not have done that. EI #5 was then asked, what she should have done. EI #5 stated, she should have had RI #1's wheelchair closer to the bed. EI #5 explained that she had received re-education about transferring residents from EI #4, a Registered Nurse (RN) Unit Manager (UM), to use better precaution and to not turn her back on the resident. According to the SUMMARY REPORT OF MEETING dated 6/3/2016, EI #5 received a lecture from EI #4 (RN UM). The subject covered was listed as Leaving residents unattended who have impaired safety awareness and judgement and/or who is a fall risk . SUMMARY AND CONCLUSION: Employee will not leave a resident who has impaired safety awareness and judgment and/or who is a fall risk unattended. Staff will maintain hands on contact while providing care to the residents to ensure resident is safe and to prevent injury from occurring. During an interview on 7/12/2016 at 3:20 PM, EI #6, an RN acknowledged she was the nurse who responded to RI #1's fall on 6/3/2016. When asked, if the CNA (EI #5) should have turned her back on RI #1, a resident with left-sided weakness, EI #6 said no. When asked, what should have been done when transferring a resident from the bed to the wheelchair, EI #6 stated, the CNA should have had everything within reach and sight before getting the resident up to transfer. EI #6 was asked, could RI #1's fall on 6/3/2016 could have been avoided. EI #6 replied, yes, if the CNA would have had everything within reach and sight. If the wheelchair was placed by the bed, she would have seen the resident going forward. This deficiency was cited as a result of the investigation of complaint/report number AL 520.