Every finding on record at Dooley Center

The facility had a census of 33 residents. Based on interview and record review the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hour data for all direct care personnel as required. This placed the residents at risk for impaired care due to unidentified staffing issues. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 4 indicated data triggered for no registered nurse hours for four or more days during the quarter and was triggered for one staff rating. On 02/19/24 at 07:28 AM Administrative Staff A stated the inaccurate PBJ reporting was due to a change of the staff responsible for the reporting. Administrative Staff A stated the facility had identified the error and started a performance improvement plan. The facility's Reporting Direct Care Staffing Information (Payroll-Based Journal) policy last revised 08/2022 documented that complete and accurate direct care staffing information would be reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. The facility failed to submit accurate information to the CMS PBJ. This placed the residents at risk for impaired care due to unidentified staffing issues.

The facility identified a census of 33 residents. Based on record review and interviews, the facility failed to designate a staff member with the required qualification and certification as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program. This deficient practice placed all residents at risk for lack of identification, tracking/trending, and treatment of infections. Findings included: - A review of the Department Heads form dated 02/13/24 revealed the Infection Control Preventionist position was vacant. On 02/20/24 at 03:44 PM Administrative Nurse D stated the facility did not have a certified Infection preventionist at this time. The facility's undated Infection Preventionist policy documented the infection preventionist was responsible for coordinating the implementation and updating of the infection prevention and control program. The infection preventionist was a nurse who had earned a certificate/diploma or degree in nursing. The facility failed to designate a staff member with the required qualification and certification as the Infection Preventionist, responsible for the facility's Infection Prevention and Control Program. This deficient practice placed all residents at risk for lack of identification, tracking/trending, and treatment of infections.

The facility had a census of 33 residents. The sample included 12 residents and two medication carts. Based on observation, record review, and interview the facility failed to provide a consistent reconciliation of controlled drugs at the end of each work shift. This placed the 14 residents with controlled substances on the cart at risk for misappropriation of medications. Findings included: - On 02/19/24 at 08:14 AM, observation on the 100-200 hall medication cart revealed staff counted and signed the Controlled Drug Record flow sheet for one work shift on 02/05/24, 02/06/24, 02/08/24, 02/09/24, 02/14/24, 02/15/24, 02/17/24, and 02/18/24 (eight times out of a possible 38 work shifts). On 02/19/24 at 08:15 AM, Licensed Nurse (LN) G stated nurses were expected to count the narcotics with another nurse each shift. LN G stated the nurse coming on duty and the nurse going off duty should ensure the narcotic count each shift. LN G stated she was unsure of the facility's policy for counting narcotics. On 02/20/24 at 11:04 AM, Administrative Nurse D stated she expected the nurse coming on duty and the nurse leaving duty to count each card, for a total number of cards. Administrative Nurse D stated nurses counted each card, and the total number was recorded. Administrative Nurse D said the two nurses together determined the count was correct. The Controlled Substance policy revised 04/2019 stated controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled medication should be reported to the Director of Nursing Services immediately. The facility failed to provide a consistent reconciliation of controlled drugs at the end of daily work shifts, placing the 14 residents with controlled substances on the cart at risk for misappropriation of medications by staff.

The facility identified a census of 33 residents. The sample included 12 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to revise the comprehensive care plan, to include oxygen therapy, for Resident (R) 20. This placed R20 at increased risk for respiratory infection and complications due to uncommunicated care needs. Findings included: - R20's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, respiratory disorders, dependence on supplemental oxygen (needs a constant supply of oxygen), and disorder of the nose and nasal sinuses. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R20 received oxygen during the observation period. R20's Functional Abilities Care Area Assessment (CAA) dated 11/16/23 documented R20 required assistance with her activities of daily living (ADLs). R20's Care Plan dated 08/18/23 documented staff should monitor the oxygen tubing over pressure points to prevent breakdown. R20's Care Plan lacked direction to address the care of oxygen tubing and equipment for R20. R20's EMR under the Orders tab revealed the following physician order dated 08/23/23: Change oxygen humidification bottles one time a day every seven days. On 02/19/24 at 11:03 AM, R20 reclined in her chair with her feet elevated. R20 received oxygen via a nasal cannula. Observation revealed the humidification bottle connected to the oxygen canister was dated 12/03/23. On 02/19/24 at 01:52 PM, R20 sat in her recliner and read a book. The humidification bottle connected to the oxygen canister was dated 12/03/23. On 02/19/24 at 12:15 PM Licensed Nurse (LN) G stated nurses were responsible for changing humidified oxygen bottles. LN G stated she expected the humidification bottle to be changed per the physician's order and to be signed for in the EMR. LN G stated she expected the bottle to be changed on the day the bottle was due, or staff should alert the next shift that the task was not completed. LN G stated the care plan should reflect oxygen therapy for R20. On 02/20/24 at 11:04 AM Certified Nurse's Aide (CNA) M stated she would be able to find direction for oxygen therapy on the Kardex for each resident. CNA M stated nurses' aides are not allowed to touch residents' oxygen, this is done by the nurse only. On 02/20/24 at 11:30 PM Administrative Nurse D stated if the humidified bottle on the concentrator was ordered to be changed every seven days, she expected the facility nurse to change the bottle. She said she also expected staff to document the task was completed in the resident's EMR. Administrative Nurse D stated oxygen therapy should be included in R20's care plan. The facility's Care Planning policy documented facility's care planning team is responsible for the development of an individualized comprehensive care plan for each resident. The facility failed to ensure R20's care plan reflected her oxygen therapy, which had the potential for alteration of continuous care among nursing staff. This placed R20 at increased risk for respiratory infection and complications due to uncommunicated care needs.

The facility reported a census of 33 residents. The sample included 12 residents. Based on interview and record review, the facility failed to establish and maintain a system to ensure nursing staff maintained current cardiopulmonary resuscitation (CPR- a life-saving medical procedure that consists of chest compressions to allow oxygenated blood to circulate to vital organs, such as the brain and heart and artificial ventilation) certification for healthcare providers. This deficient practice placed Resident (R) 21, who desired CPR if needed, at risk for inadequate resuscitative measures. Findings included: - On [DATE] Licensed Nurse (LN) I's CPR certification had an issue date of [DATE] and a renewal (expiration) date of ,d+[DATE]. On [DATE] at 08:43 AM, Administrative Staff A stated human resources tracked the CPR certification and LN I's CPR expired in September of 2023. Administrative Staff A stated LN I would renew her CPR certification before returning to work. On [DATE] at 12:30 PM, Administrative Nurse D stated she reviewed the nursing schedule to ensure there was always a CPR certified staff on duty. The facility's undated Emergency Procedure - Cardiopulmonary Resuscitation policy documented that staff would obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) for key clinical staff members who would direct resuscitative efforts, including non-licensed personnel. Maintain equipment and always supplies necessary for CPR/BLS in the facility. The facility failed to establish and maintain a system to ensure nursing staff maintained current CPR certification for healthcare providers. This deficient practice placed R21 who desired CPR at risk for inadequate resuscitative measures.

The facility identified a census of 33 residents. The sample included 12 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure physician's orders were followed for Resident (R)20's oxygen therapy when staff failed to change the oxygen bottle every seven days as ordered. This placed R20 at increased risk for respiratory infection and complications. Findings included: - R20's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of weakness, respiratory disorders, dependence on supplemental oxygen (needs a constant supply of oxygen), and disorder of the nose and nasal sinuses. The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R20 received oxygen during the observation period. R20's Functional Abilities Care Area Assessment (CAA) dated 11/16/23 documented R20 required assistance with her activities of daily living (ADLs). R20's Care Plan dated 08/18/23 documented staff should monitor the oxygen tubing over pressure points to prevent breakdown. R20's Care Plan lacked direction to address the care of oxygen tubing and equipment for R20. R20's EMR under the Orders tab revealed the following physician order dated 08/23/23: Change oxygen humidification bottles one time a day every seven days. On 02/19/24 at 11:03 AM, R20 reclined in her chair with her feet elevated. R20 received oxygen via a nasal cannula. Observation revealed the humidification bottle connected to the oxygen canister was dated 12/03/23. On 02/19/24 at 01:52 PM, R20 sat in her recliner and read a book. The humidification bottle connected to the oxygen canister was dated 12/03/23. On 02/19/24 at 12:15 PM Licensed Nurse (LN) G stated nurses were responsible for changing humidified oxygen bottles. LN G stated she expected the humidification bottle to be changed per the physician's order and to be signed for in the EMR. LN G stated she expected the bottle to be changed on the day the bottle was due, or staff should alert the next shift that the task was not completed. LN G stated the care plan should reflect oxygen therapy for R20. On 02/20/24 at 11:04 AM Certified Nurse's Aide (CNA) M stated she would be able to find direction for oxygen therapy on the Kardex for each resident. CNA M stated nurses' aides are not allowed to touch residents' oxygen, this is done by the nurse only. On 02/20/24 at 11:30 PM Administrative Nurse D stated if the humidified bottle on the concentrator was ordered to be changed every seven days, she expected the facility nurse to change the bottle. She said she also expected staff to document the task was completed in the resident's EMR. Administrative Nurse D stated oxygen therapy should be included in R20's care plan. The facility's Oxygen in Use Protocols policy documented that humidified bottles should be dated and initialed when used. The humidified bottle should be changed every seven days. The facility failed to ensure R20's humidified oxygen bottle was changed every seven days per physician's orders. This placed R20 at increased risk for respiratory infection and complications.

The facility identified a census of 33 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician was notified when Resident (R) 31's systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was outside the physician ordered parameters. This deficient practice placed R31 at risk for unnecessary medication use and delay in treatment or services related to hypertension (elevated blood pressure). Findings included: - R31's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension, and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. R31's Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 09/28/23 documented R31 had limited mobility and required assistance from the staff for ADL. R31's Care Plan dated 05/19/23 documented staff would administer antihypertensive medication as ordered. R31's EMR under the Orders tab revealed the following physician orders: Amlodipine besylate (antihypertensive) oral tablet 2.5 milligrams (mg) give one tablet by mouth one time a day related to hypertension. Contact physician for SBP greater than (>) 160 millimeters of mercury (mmHg) or diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) >100 mmHg. Hold medication if the heart rate was less than (<) 50 beats per minute dated 10/27/23. Review of R31's Medication Administration Record (MAR) in the EMR from 11/01/23 to 02/13/24 (105 days) revealed SBP was > 160mmHg (16 times) on the following dates 11/01/23, 11/28/23, 12/01/23, 12/02/23, 12/10/23, 12/28/23, 01/02/24, 01/05/24, 01/20/24, 01/22/24, 01/24/24, 01/25/24, 02/04/24, 02/09/24, and 02/11/24. A review of the EMR lacked evidence of the physician notification of SBP outside the physician-ordered parameters. On 02/19/24 at 10:23 AM, R31 ambulated with her walker in the hallway. On 02/20/24 at 11:15 AM, Licensed Nurse (LN) H stated the physician should be notified every time R31's SBP was outside the physician-ordered parameters. LN H stated an alert came up when the blood pressure was entered into the EMR. LN H stated the physician was notified by fax and that would be documented under the progress note. On 02/20/24 at 11:30 AM, Administrative Nurse D stated she expected the nurse to notify the physician when R31's SBP was outside the physician-ordered parameters. Administrative Nurse D stated the nurse would document the physician notification in R31's EMR under the progress notes. The facility's Guidelines for Notifying Physicians of Clinical Problems policy last revised 02/2014 documented the facility's guidelines to help ensure that medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and all significant changes in resident status are assessed and documented in the medical record. Depending on the situation, other physical findings may warrant physician notification such as a change in vital signs. Staff would follow these general guidelines: The facility failed to ensure the physician was notified when R31's SBP was outside the physician-ordered parameters. This deficient practice placed R31 at risk for unnecessary medication use and delay in treatment or services related to hypertension.

The facility identified a census of 31 residents. The sample included 12 residents with five reviewed for influenza and pneumococcal immunizations. Based on record review and interviews, the facility failed to provide pneumococcal vaccinations or informed refusals for Residents (R)2, R9, R15, and R23. This deficient practice placed the residents at risk for complication related to pneumonia. Findings included: - On 07/20/22 at 03:45 PM a review of Electronic Health Record (EHR) was completed for R2, R9, R15, and R23. The review revealed that R2, R9, R15, and R23 lacked documentation indicating that the four residents listed had been offered, consented, refused, or had received the pneumonia vaccination. On 07/21/2022 at 01:49 PM Administrator A stated that the facility was made aware that its pneumonia immunization program was behind on vaccination during a facility-wide audit completed in May 2022. She provided a Performance Improvement Plan (PIP) for the facility related to the missing documentation. The PIP indicated that the facility was in the process of updating all the resident's pneumonia vaccinations statuses but was not yet completed. A review of the facility's Pneumococcal Vaccine policy revised 10/2019 stated that residents were to be assessed for eligibility to receive the vaccination within 30 days of admission to the facility unless contraindicated or the resident has already had the vaccine. The policy noted that the education provided for pneumococcal vaccination, noted refusals, and the given vaccination's identifying information should be documented in the resident's chart upon completion. The facility failed to provide pneumococcal vaccinations or informed resfusals for R2, R9, R15, and R23. This deficient practice placed the residents at risk for complication related to pneumonia.

The facility identified a census of 31 residents. The sample included 12 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities for physician notification for Resident (R) 31's hypertensive medication (class of medication used to treat high blood pressure). This deficient practice placed R31 at risk for unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R31's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), hypertension (high blood pressure), and [CONDITION(S)] (any major mental disorder characterized by a gross impairment testing). The Significate Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Stubs (BIMS) score of two which indicated severely impaired cognition. The MDS documented that R31 required limited assistance of one staff member for activities of daily living (ADL's). The MDS documented R31 received antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) and antipsychotic medication (class of medications used to treat [CONDITION(S)] and other mental emotional conditions) for seven days during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 99, staff interview was completed documented a moderately impaired decision making. The MDS documented that R31 required extensive assistance of one staff member for ADL's. The MDS documented R31 received antidepressant medication and antipsychotic medication for seven days during the look back period. R31's [CONDITION(S)] Drug Care Area Assessment (CAA) dated 12/16/21 documented she had received [CONDITION(S)] (alters mood or thought) medication on a scheduled basis and had failed a gradual dose reduction. R31's Care Plan dated 03/22/21 documented staff was to administer medication as ordered by the physician. Review of the EMR under Orders tab revealed physician orders: [MEDICATION(S)] tablet (antihypertensive) five milligrams (mg) give one tablet by mouth daily for hypertension. Notify physician if systolic (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) greater than (>), 190 millimeters of mercury (mmHg) or diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) > 90mmHg or apical pulse > 120 or less than (<) 50 mmHg dated 01/05/22. Review of the EMR under the Reports tab for Medication Administration Record (MAR) reviewed from 04/01/22 to 07/19/22 (110 days) physician was not notified four days when DBP was outside physician ordered parameters on the following dates: 04/09/22, 05/16/22, 05/20/22, and 07/14/22. The Monthly Medication Review (MMR), performed by the CP, reviewed from July 2021 through June 2022 did not identify the lack of physician notification of DBP outside the physician ordered parameters for R31. On 07/21/22 at 08 :11 AM R31 walked with a steady gait assisted by front wheeled walker to the dining room area, nursing staff offered R31 verbal cues when R31 requested which direction she was to walk. On 07/21/22 at 01:25 PM Licensed Nurse (LN) G stated the MMR were faxed to the facility, then divided into the units. LN G stated the charge on the unit, reviewed the MMR's, then MMR's are faxed to the attending physician. LN G stated once the MMR's were returned by physician, the charge nurse on duty gets the new orders and notifies the family and pharmacy if need. LN G stated the MMR's were then sent to the director of nursing to be reviewed. On 07/21/22 at 02:15 PM Administrative Nurse D stated the charge nurse on the units complete the MMR's sent by the CP. Administrative Nurse D stated once the physician has reviewed them and made any changes she reviews them and then the MMR's are sent to medical records to be scanned tanto the residents EMR. On 07/25/22 at 010:458 AM CP GG stated she reviewed the resident clinical record monthly. CP GG stated she reviewed the vital signs during the monthly review. CP GG stated she would notify the facility of any BP outside the physician ordered parameters. CP GG stated if resident's vital signs continued to be outside the physician ordered parameters she would notify the physician. The facility's Medication Regimen Reviews policy revised May 2019 documented the goal of the MMR's was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medications. The facility failed to ensure the CP identified and reported irregularities when physician ordered parameters for antihypertensive medication for R31 were not followed. This had the potential for adverse of unnecessary medication administration or possible harmful side effects.

The facility identified a census of 31 residents. The sample included 12 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure the physician ordered parameters for Resident (R) 31's hypertensive medication (class of medication used to treat high blood pressure) were followed. This deficient practice placed R31 at risk for unnecessary medication administration thus leading to possible harmful side effects. Findings included: - R31's electronic medical record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significate Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Stubs (BIMS) score of two which indicated severely impaired cognition. The MDS documented that R31 required limited assistance of one staff member for activities of daily living (ADL's). The MDS documented R31 received antidepressant medication (class of medications used to treat mood disorders and relieve symptoms of depression) and antipsychotic medication (class of medications used to treat [CONDITION(S)] and other mental emotional conditions) for seven days during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 99, staff interview was completed documented a moderately impaired decision making. The MDS documented that R31 required extensive assistance of one staff member for ADL's. The MDS documented R31 received antidepressant medication and antipsychotic medication for seven days during the look back period. R31's [CONDITION(S)] Drug Care Area Assessment (CAA) dated 12/16/21 documented she had received [CONDITION(S)] (alters mood or thought) medication on a scheduled basis and had failed a gradual dose reduction. R31's Care Plan dated 03/22/21 documented staff was to administer medication as ordered by the physician. Review of the EMR under Orders tab revealed physician orders: [MEDICATION(S)] tablet (antihypertensive) five milligrams (mg) give one tablet by mouth daily for hypertension. Notify physician if systolic (SBP-relating to the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries) greater than (>), 190 millimeters of mercury (mmHg) or diastolic blood pressure (DBP-minimum level of blood pressure measured between contractions of the heart; the bottom number of a blood pressure reading) > 90mmHg or apical pulse > 120 or less than (<) 50 mmHg dated 01/05/22. Review of the EMR under the Reports tab for Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/21/22 at 08 :11 AM R31 walked with a steady gait assisted by front wheeled walker to the dining room area, nursing staff offered R31 verbal cues when R31 requested which direction she was to walk. On 07/21/22 at 01:25 PM Licensed Nurse (LN) G stated the physician would we notified by a fax communication if R31's DBP was outside the physician ordered parameters. LN G stated the charge would note any new orders from the physician and the signed communication would be sent to medical records to be scanned into the residents EMR. LN G stated a note would be documented under the Progress notes tab. On 07/21/22 at 02:15 PM Administrative Nurse D stated the charge nurse would notify the physician by phone or fax if not an emergency of any outside parameter vital signs obtained for the residents. Administrative Nurse D stated the returned faxed communication sheet would be reviewed for any new orders and then sent to medical records to be scanned into the residents EMR. The facility's Administering Medications policy revised April 2019 documented the following information was checked/verified for each resident prior to administration of medication: a. Allergies to medication; b. Vital signs, if necessary. The facility failed to ensure the physician ordered parameter was followed for antihypertensive medication for R31. This had the potential for adverse of unnecessary medication administration or possible harmful side effects.

The facility identified a census of 37 residents. The sample included 14 residents with 1 resident reviewed for respiratory. Based on record review, observation and interview, the facility failed to ensure sanitary replacement of oxygen tubing for resident #20. Findings included: - The electronic medical record (EMR) for resident #20 documented he/she admitted to the facility on [DATE]. Resident had a [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. He/she required extensive assistance of 1 staff for activities of daily living (ADL). He/she had shortness of breath on exertion, at rest, and when lying flat and lacked documentation of receiving oxygen therapy. Resident received diuretic and opioid medication 7 days. The quarterly MDS dated [DATE] documented a BIMS score of 15. He/she required extensive assistance of 1 staff for ADLs. He/she was short of breath on exertion, at rest, and when lying flat, and received oxygen therapy. Resident received diuretic and opioid medication 7 days. The care area assessment (CAA) dated 5/2/2019 assessed the resident as having [MEDICAL CONDITION]. Resident can perform most ADLs independently, but it takes him/her longer due to being short of air (SOA). The care plan effective 8/30/2012 advised staff that resident will report, and staff will monitor for, signs and symptoms of respiratory distress such as shortness of breath, wheezing, shallow respirations, increased anxiety, increased heartbeat, pallor in color, etc. Resident takes rest periods between activities to prevent fatigue and decrease SOA. The physician order [REDACTED]. The physician order [REDACTED]. On 6/25/19 at 12:38 PM and 6/27/19 at 9:53 AM the oxygen tubing on the concentrator in resident 20's room lacked documentation of a date of when the tubing was last changed. On 6/26/19 at 12:55 PM the resident was observed ambulating from the dining room with assistance of a walker with nasal cannula in place. On 6/26/19 at 3:55 PM licensed administrative nursing staff D stated that the day shift nurses are responsible to change the oxygen tubing weekly on Friday. The date of the change is indicated by placing a piece of tape with the date on it on the tubing, the change is also documented on the TAR. On 6/27/2019 at 9:18 AM direct care staff M stated the nurse is the one responsible to change to oxygen tubing weekly. On 6/27/19 at 10:54 AM licensed nursing staff G stated that the nurses change the oxygen tubing weekly, tubing should be dated and charted on the TAR. The facility undated Oxygen Use Protocol policy documented the nasal cannulas and nebulizer tubing should be changed every seven days, dated and initialed. The facility failed to provide respiratory care and services for resident #20 when they failed to ensure to sanitary replacement of oxygen tubing as ordered by the physician for resident #20 which placed him/her at risk for respiratory infection.

The facility had a census of 40 residents. The sample included 9 residents. Based upon observation, record review and observation the facility failed to provide adequate supervision and implement timely interventions for 2 (#11, #28) of 2 residents sampled for falls, failed to maintain safe water temperatures and failed to prevent accidents hazards in regards to an elevator and stairwell. Findings included: - Resident #11's annual Minimum Data Set ((MDS) dated [DATE] identified the resident scored 6 (severely impaired cognition) on the Brief Interview for Mental Status (BIMS), had no behaviors, required extensive staff assistance with bed mobility, transfers, walking in the room/corridor, locomotion on/off the unit, dressing, toilet use, and personal hygiene. The MDS recorded the resident was not steady, was only able to stabilize with human assistance when moving from a seated to a standing position, walking, turning around and facing the opposite direction while walking, moving on/off the toilet and surface to surface transfers. The MDS identified the resident utilized a walker and a wheelchair, was occasionally incontinent of urine and had 2 or more non- injury falls and 1 non-major injury fall since the prior assessment. The resident's Cognitive Care Area Assessment (CAA) dated 4/9/15 documented the resident had a [DIAGNOSES REDACTED]. The resident's ADL CAA dated 4/9/15 included the resident required increased staff assistance for ADL tasks. The resident required staff assistance with ambulation via a walker and with all transfers due to a history of falls. The resident had a balance problem and used a wheelchair for mobility when out of his/her room which the staff usually propelled. The resident transferred himself/herself without waiting for staff or calling for assistance. The resident's Fall CAA dated 4/9/15 documented the resident had multiple factors which increased his/her risk for falls and had a balance problem. The resident required staff assistance with transfers and ambulation with a roller walker. The resident had an unsteady gait with a wide stance and stooped posture and was getting weaker. The resident continued not waiting or calling for staff assistance at times but that was occurring less frequent. The resident attempted to get out of bed and would sleep in his/her wheelchair and refused to go to bed or rest in the recliner some days. The resident's Fall Risk Evaluation dated 4/28/14 identified the resident scored 15 (according to the legend a score of 10 or above represented the resident was high risk for falls). The resident's Fall Risk Evaluation dated 5/19/15 identified the resident scored 18. The resident care plan reviewed 5/24/15 addressed the resident was at risk for falls and required staff assistance when he/she ambulated short distances with a roller walker and staff propelled the resident's wheelchair. The resident ambulated in his/her room with a transfer belt and with a roller walker. The resident required 2 staff assistance when transferring and at times staff transferred him//her via a mechanical lift. The resident at times was dizzy when he/she stood and did not always call or wait for staff assistance which increased his/her risk for falling. The resident had intentionally slid out of bed and the recliner deliberately. Staff frequently checked on the resident throughout the night to monitor the resident's safety and attempts to self-transfer. Staff toileted the resident between 4:30 A.M. to 5:00 A.M. to prevent the resident from lowering himself/herself to the floor and staff responded to the resident ' s call light in a timely manner when the resident needed to use the toilet. The resident utilized a bedside commode during the night, a wheelchair with lateral supports, placed a grab bar in the resident's room. Staff placed a non-skid rubberized sheet of dycem (non-slip material) on top of the resident's low air loss mattress, under the fitted sheet to prevent the resident from sliding when he/she sat on the edge the bed. Staff ensured the resident was not left alone in his/her room when he/she sat in the wheelchair because the resident attempted to transfer himself/herself. Staff kept magazines and newspaper on top of the resident's Credenza within the resident's reach to prevent the resident from reaching too far and losing his/her balance when in the wheelchair. A nurse ' s note (NN) dated 8/30/14 and timed 5:45 P.M. documented the resident sat on the floor, leaned against the wall holding onto the grab bar with his/her right hand in the large bathroom. Intervention included staff assisted the resident to the bathroom immediately after the resident finished eating each meal. A NN dated 9/5/14 timed and 4:44 P.M. documented the resident fell on [DATE] at 2:29 A.M. when the resident attempted to transfer himself/herself onto the commode unassisted. The fall investigation included the resident's sensor was not functioning at the time of the resident's fall. A NN dated 1/3/15 and timed 6:47 A.M. documented the resident sat on the side of his/her bed on the floor. The resident had voided a large amount of urine. The resident had an abrasion to his/her mid thoracic spine and the superficial layer of skin was peeled back. A NN dated 1/25/15 and timed 1:45 P.M. documented the resident's chair alarm alerted staff, and staff found the resident face down on the floor in the living room. The resident sustained [REDACTED]. The resident had an abrasion on his/her scalp that measured 2 cm by 2 cm, small abrasions on his/her knees and a bruise on the top of his/her right hand and wrist that measured 5 cm by 3 cm. Interventions included staff would keep the resident's magazines within his/her reach. A NN dated 2/11/15 timed 6:34 P.M. documented the open area on the resident's upper forehead from the fall measured 3.2 cm by 2.6 cm with superficial depth and the current treatment was to cover the area with Vaseline and a non-adherent gauze. A NN dated 5/7/15 and timed 7:00 A.M. documented the resident sat on the floor on the mat next to his/her bed with his/her back against the side of the bed and his/her her legs out in front of him/her. There was a puddle of urine on the left side of the resident on the mat. The note included the root cause could be that the resident was usually up at least 15 minutes earlier than when he/she fell . Staff would anticipate the resident wanting to get out of bed unassisted around this time. A note dated 5/8/15 and timed 5:08 P.M. (follow up to the fall on 5/7/15) documented the resident attempted to exit his/her bed unassisted. The resident was incontinent of urine and staff determined the resident needed to use the toilet and that it was later than his/her usual time to be up. The resident had a rubberized anti-slip material that was used on his/her air mattress under the fitted sheet to prevent sliding. The anti-slip was not present which may be a contributing factor to the resident sliding off the edge of the bed. On 5/26/15 at 8:15 A.M. the resident sat in his/her wheelchair in the dining room. On 5/26/15 at 2:00 P.M. the resident laid in bed. Observation revealed a fall mat in place and grab bars in the resident's bathroom. On 5/27/15 9:08 A.M. direct care staff O and licensed nurse H transferred the resident from his/his wheelchair to the toilet via a mechanical lift. Licensed nurse H stated the resident had dycem under his/her wheelchair cushion. Observation revealed there was no dycem in place which licensed nurse H confirmed. On 5/27/15 at 3:06 P.M. direct care O stated the resident was at risk for falls, required 2 staff assistance with transfers, staff ensured the resident's bed was in a low position, utilized dycem in his/her wheelchair and on his/her bed and staff placed a fall mat on the resident's floor when he/she was in bed. On 5/27/15 at 3:28 P.M. licensed nurse H stated the resident was at risk for falls, utilized a floor mat when in bed because the resident slides from the bed to the floor. The resident had dycem in his/her wheelchair and in his/her bed. The facility discontinued the resident's bed alarms the first part of April and staff checked on the resident more frequently because most of the resident's falls occurred when the resident was in bed. Licensed nurse H stated the red raised area on the resident's right upper forehead was from a fall. On 5/27/15 at 5:23 P.M. administrative nursing staff D stated the resident was at risk for falls and the resident typically tried to exit out of his/her bed. The resident had an air mattress which slides, and staff placed dycem under the sheet to keep the resident from sliding off of the bed. The resident had a low bed, a floor mat, the resident had pressure alarms on his/her bed, and when the resident sat on the edge of the bed the alarms did not activate. He/she stated the facility discontinued the pressure alarms 6 weeks to a month ago and staff now checked on the resident every hour. The facility's Fall Prevention and Management Program policy and procedure revised 4/2013 included it was the policy of the facility to ensure a safe environment with least restrictive measures while promoting the highest possible level of independence and quality of life. The facility failed to ensure assistive devices properly functioned, and/or were in place as care planned and also failed to implement timely interventions to prevent falls for this severely cognitively impaired resident with a history of falls. - Resident #28's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 2 (severely impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required extensive staff assistance with bed mobility, transfers, dressing, personal hygiene, toilet use and walking in the room. The MDS recorded activity of walking in the corridor did not occur and the resident required limited staff assistance with locomotion on/off the unit. The resident was not steady but was able to stabilize without human assistance when moved from a seated to a standing position, was not steady and was only able to stabilize with human assistance when walking, turning around and facing the opposite direction while walking, moving on/off the toilet, and surface to surface transfers. The resident utilized a wheelchair and had not fallen since the prior assessment. The resident's Cognitive Loss Care Area Assessment (CAA) dated 1/31/15 documented the resident had short/long term memory problems and had poor vision. The resident's Fall CAA dated 1/31/15 included the resident was at high risk for falls and had a history of [REDACTED]. The resident continued to attempt to transfer or ambulate without waiting for staff assistance or calling for staff assistance. The resident had memory problems which could play a part in the resident attempting to transfer himself/herself. The resident's had pressure sensitive alarms in place on his/her bed and chairs. The resident's Fall Risk assessment dated [DATE] identified the resident scored 22 (a score of 10 or more represented the resident was at high risk for falls). The resident's Fall Risk assessment dated [DATE] identified the resident scored 16. The resident's care plan revised on 4/25/15 addressed the resident was at risk for falls and required 2 staff assistance with transfers and ambulation and utilized a wheel chair with a high back with a saddle. The resident was at risk for fall/injury due to poor vision, balance problems, a history of falls and agitation. The resident had a grab bar above the top of the wall unit and corner guard with cushions over the metal ends and staff placed a trash can close to the resident to prevent the resident from reaching. Staff toileted the resident every 2 to 3 hours after the resident went to bed to prevent unassisted transfers. Staff transferred the resident to a recliner when the resident leaned in his/her wheelchair due to fatigue or weakness. Staff checked on the resident frequently before he/she got up in the A. M. starting at 6 A.M. and when the resident stirred the staff got him/her up. The resident utilized floor pads while in bed for safety and the resident had a low bed. Staff kept the resident in view when the resident attempted to get up by himself/herself and did not want staff to assist him/her. The resident only wore cotton pajamas in bed to prevent the resident from sliding out of bed upon sitting on the edge of the bed. The resident had a non-skid mat on his/her mattress and checked on the resident every hour while in bed. The resident wore non-skid socks when his/her shoes were not on. Staff ensured the resident was properly seated in the wheelchair before moving the wheelchair. The resident routinely woke between 4 A.M. to 5 A.M. and believed it was time to get up; the light in the hallway may contribute to that or hearing his/her neighbor getting up next door. Staff anticipated the resident's unassisted transfers during that time frame and provided assistance. The resident's call bell wrist pendant was hooked around the back of the resident's wheelchair. Staff increased the frequency of the resident's checks throughout the night because the resident attempted to get up out of bed without staff assistance. Review of the resident's clinical record/fall investigations revealed the resident fell 14 times during the time frame of 3/11/14 to 5/10/15. A fall investigation dated 3/11/14 and timed 7:30 P.M. documented the resident laid on the floor on his/her right side. The resident sustained [REDACTED]. The resident's chair alarm did not activate and was not functioning. Interventions included staff changed the positron of the resident's recliner to another location and away from the phone that rung at the desk. A fall investigation dated 3/12/14 and timed 4:30 P.M. documented the resident laid on his/her left side, sustained an abrasion to his/her left shoulder, bruise to his/her knee and a hematoma to his/her left eyebrow. Intervention included staff initiated a voiding diary. A fall investigation dated 3/17/14 and timed 11:15 P.M. included the resident sat on the floor by the bed in his/her room. Staff changed the resident out of the silky material pajamas. A fall investigation dated 3/31/14 at 2:45 A.M. documented the resident was on the floor mat by his/her bed. Staff changed the resident out of the silky material pajamas and placed a non-skid material between the sheet and the mattress to prevent sliding. A fall investigation dated 6/25/14 and timed 3:45 P.M. documented the resident sat on the floor near the wheelchair near the nurse's station. The resident's chair alarm did not go off at the time of the fall. The pad was not fully in the center of the chair. Intervention included dycem was placed under the pad (cushion) to prevent slipping. A fall investigation dated 7/9/14 documented the resident sat on the floor. Intervention included the non-slip material was not on the resident's bed as care planned. A nurse's note dated 5/9/15 and timed 2:15 P.M. documented a resident alerted staff the resident was on the floor by his/her bed. The resident stated his/her left lateral calf felt stingy. The calf was slightly pink but was blancheable when staff moved the resident with the mechanical lift. A NN dated 5/10/15 and timed 1:48 A.M. documented the resident slid out of bed and laid on the floor mat on his/her left side. A note dated 5/11/15 and timed 6:43 P.M. documented the resident had two recent falls due to unassisted transfers from his/her bed. Intervention included staff provided frequent observations after toileting to ensure the resident was asleep and once asleep that he/she was not restless during sleep and was dreaming that he/she needed to get up out of bed. On 5/26/15 at 8:15 A.M. and 9:30 A.M. the resident laid in bed. Observation revealed the bed in a low position and a fall mat beside the resident's bed. On 5/27/15 at 7:00 A.M. the resident sat in his/her wheelchair. On 5/27/15 at 9:05 A.M. hospice staff MM and direct care staff P transferred the resident from the wheelchair to the recliner. On 5/27/15 at 2:54 P.M. direct care staff O stated the resident was at risk for falls, required 2 staff assistance with transfers. He/she stated the resident had dycem (non-slip) material in his/her wheelchair and on his/her bed. Direct care staff O sated the resident utilized a low bed and staff checked on the resident every 2 hours during the day and every hour during the night. On 5/27/15 at 3:35 P.M. licensed nurse H stated the resident was at extreme risk for falls, utilized a fall mat, slides out of the bed, sat on the side of the bed and slides to the floor. He/she stated the facility discontinued the resident's bed and chair alarms a month or so ago. Licensed nurse H stated the resident had dycem on top of his/her mattress and in his/her wheelchair. Licensed nurse H checked the resident's care plan and stated the care plan did not include the resident had dycem in his/her wheelchair. On 5/27/15 at 5:27 PM administrative nursing staff D stated the resident was at risk for falls, the facility discontinued the resident's alarms 6 weeks to a month ago. He/she stated after the facility discontinued the alarms staff performed more frequent checks on the resident. He/she stated the resident had a low bed and a floor mat. The facility's Fall Prevention and Management Program policy and procedure revised 4/2013 included it was the policy of the facility to ensure a safe environment with least restrictive measures while promoting the highest possible level of independence and quality of life. The facility failed to ensure assistive devices properly functioned, and/or were in place as care planned and also failed to implement timely interventions to prevent falls for this severely cognitively impaired resident with a history of falls. - During the initial tour on 5/20/15 at 9:15 A.M. observation of the stairwell next to the elevator revealed the door leading to the stairwell was not alarmed, only a wandergard device alerted staff when a resident wearing a bracelet tried to exit the door. Any resident not wearing a wandergard could exit the door and go down the stairwell without staff knowledge. This placed residents going down the stairs at risk for falling down the stairs. Observation of the elevator revealed the elevator was not alarmed, only a wandergard device alerted staff when a resident wearing a bracelet tried to get on the elevator. Any resident not wearing a wandergard could get on the elevator without staff knowledge. This placed residents using the elevator at risk for becoming trapped in the elevator without staff knowledge. Interview on 5/20/15 with administrative staff A revealed the facility has 2 cognitively impaired independently mobile residents that do not wear wandergard bracelets. Review of the facility policy not dated for accidents and hazards stated the facility prevents accidents by providing an environment that is free from hazards over which the facility has control. The facility failed to maintain an accident free environment.

The facility identified a census of 40 residents with a sample size of 9 residents with 2 residents reviewed for personal property. Based on observation, interview, and record review the facility failed to have a system in place to investigate missing items. Finding included: - Resident # 3 Minimum Data Set an annual assessment dated [DATE] listed the resident with a Brief Interview for Mental Status score of 15 indicating intact cognition. The resident was independent in activities of daily living. During stage 1 of the survey the resident indicated he/she had items missing, an intimate apparel item, a tan vest that had flowers on it, and a box of tissues. Review of the complaint grievance forms for this resident revealed there was no form filled out for the missing intimate item. Review of the complaint grievance form dated 3/5/15 for the tan vest and tissue revealed under the resolution section on the form dated 3/17/15a box of tissues reported missing was located, however the search for the tan vest was ongoing. The form continued to state the resident goes to the "R" store (a store where residents can exchange clothing) and she is aware that she left it somewhere. Staff placed a note on the monestary bulletin board. On 5/26/15 at 4:00 P.M. the resident was in his/her in room resting. On 5/27/15 at 7:30 AM the resident stated he/she was unsure of the timeframe but the intimate item was still missing but could not remember if he/she told any of the nursing staff about the missing item but did tell laundry staff. The resident stated he/she wrote his/her name on the tag but he/she probably did not write it big enough. I also had a vest with flowers on it that was missing, and it suddenly reappeared in my room I would like to know how it returned. On 5/27/15 at 7:30 AM licensed nursing staff H stated when an item was missing we look for it,and document in the nurses notes, a complaint grievance form was filled out, if the item was not found, the form was turned in to nursing administration. We keep looking. On 5/27/15 at 1:45 P.M. admininstrative staff C stated we use the grieviance form for missing items and the form goes to nursing administration where it is assigned to facility staff to follow up/seach for the item. If it is not found a replacement was offered to the resident. On 5/27/15 at 1:55 P.M. administrative staff C stated the staff in the laundry was aware of the missing intimate item and did not fill out the grievance form. He/she took it upon his/herself to reorder the item. On 5/27/15 at 2:00 P.M. administrative nursing staff C confirmed staff were not aware the vest was found, and stated the resolution statement on the form for the vest was vague, and that the resident stated the vest reappeared in her room, the facility did not follow up on the missing vest after 3/17/15. The facility provided a Grievance Policy and Procedure updated 3/15 that was used for missing items which did not address specifically how missing items were investigated or resolved. The facility failed to have a system in place to investigate and resolve missing items.

The facility identified a census of 40 residents. The sample included 9 residents. Based on observation, record review, and interview the facility failed to ensure individuals that provided direct care were employed by the facility for 1 (#3) of the sampled residents. Findings included: - Resident #35 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] listed long and short term memory problems. He/she required limited assistance of 1 staff member for dressing, toilet use, personal hygiene, and bathing. The 11/10/14 Care Area Assessment (CAA) regarding Cognitive Loss/Dementia: listed the resident had a cognitive deficit secondary to [MEDICAL CONDITION]. Mood/behavior problems had increased prompting admission to Behavioral Health Unit. Resident was cheerful and cooperative much of the time, can and does become physical with changing clothes and personal cares at times. He/she had an individual caretaker during the day and does become agitated and violent. The care plan with a reviewed date of 3/15 listed the durable power of attorney (DPOA) has hired companions to be with the resident from 8 A.M. to 6 P.M. Companions would provide supervision/assistance to the resident during scheduled hours. Companions to provide assistance as needed with activities of daily living (ADL) tasks. Bath aide and Companions will assist the resident with showering. On 5/26/15 at 10:15 A.M. the resident sat in the dining room with the companion he/she was ambulated to his/her room by the companion, the resident went into the bathroom supervised by the companion. On 5/26/15 at 5:45 P.M. the companion fed the resident food. On 5/27/15 at 2:30 P.M. the resident was in his/her room with the companion who helped the resident put on his/her shoes. On 5/26/15 at 10:15 A.M. companion staff LL stated the resident required 1:1 cares he/she confirmed he/she did not work for the facility. He/she works for an agency out of Leavenworth Kansas. On 5/27/15 at 2:30 P.M. companion staff LL stated agency staff provide care to the resident from 8 A.M. to 6 P.M Monday through Sunday. Sunday a person from the monastery provides 1:1 with the resident from 6:00 P.M. to 10:00 P.M. The resident is able to go to the bathroom by him/ herself but I provide peri care afterwards, he/she goes to the dining room to eat and if he/she did not eat I would feed him/ her as he/she allowed. In the mornings when I come sometimes he/she was dressed for the day, but if he/she were still in bed I would get the resident up and dressed. I assist the bath aide with bathing the resident. The staff here do not provide cares to the resident unless I need help. The resident can become physical and slap me in the face when he/she gets angry or upset. I have worked for the agency for 3 months and have worked with the resident at least 5 days a week. I was oriented on how to care for her by the previous agency staff. I was told about the door alarms and the wandergard bracelet the resident wears. I did not receive any orientation from the facility on how to care for the resident, or any orientation to the facility or any emergency procedures of the facility. My Supervisor is management staff at the agency. , I would do what the facility asked me to do unless I was not comfortable doing it then I would call the agency. I am not an employee of the facility On 5/27/15 at 2:45 P.M. direct care staff P stated the resident receives 1-2 baths a week as he/she would allow. The companions assist with bathing the resident. On 5/27/15 at 2:50 P.M. direct care staff Q stated when the companion is here we make the bed, pass towels and water pitcher and that was all. The companion gives direct care to the resident from 8-6 and from 6-10 a member of the convent was with the resident. We assist with cares when the resident gets aggressive, then you need to staff to help calm her down. On 5/27/15 at 3:00 P.M. licensed staff I stated the companion provides the majority of care to the resident with assistance as needed from the facility staff. She would be supervised by myself and I would assure tasks were completed. The facility did not have a policy for companions. The facility failed to ensure staff providing direct care to this resident were employed by the facility.

The facility had census of 40 residents. The sample included 9 residents. Based upon record review, observations and interviews the facility failed to provide adequate assistance during meals for 2 (#11, #28) of 3 residents sampled for activity of daily living task. Findings included: - Resident #28's quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident scored 2 (severely impaired cognition) on the Brief Interview for Mental Status, had no behaviors, required limited staff assistance with eating. The resident's Cognitive Loss Care Area Assessment (CAA) dated 1/31/15 documented the resident had short/long term memory problems and had poor vision. The resident's Activity of Living CAA did not trigger. The resident's care plan dated 4/25/15 included the resident received hospice care and weight loss was expected due to the resident's declining condition. The resident had impaired vision and needed staff assistance at meals and whenever food or fluids were offered. Staff sat with the resident, assisted and cued the resident at all meals due to poor vision. Staff used positions of the clock to orient the resident to the position of food on the divided plate and utensils. Staff provided assistance as needed for cutting up the resident's food and opening up containers. Staff may need to provide total assistance during meals, provided finger foods when possible, a cloth napkin, a brown pebble glass, a red divided plate and straw for all meals. Staff transferred the resident from his/her wheelchair to dining room chair at all meals to provide proper positioning and promote meal intake. A note date 2/7/15 and timed 2:03 P.M. documented the resident had experienced many changes in the last 30 days. The resident was usually total dependent upon staff during meals and would sometimes hold a drink and drink it with a straw independently. Review of the August 8, 2014 Community Life Meeting Minutes revealed several people felt uncomfortable and sad watching those who need assistance being the last ones served at every meal. Those in attendance came up with 2 potential options. Bring those people in a little earlier and let staff assist them or 2) do not bring them into the dining room until they can be served so they did not have to watch everyone else eating. Review of the March 26, 2015 Resident Life/Community Life Minutes included there was much discussion centered around meals, the length of time before being served, menus, and the concerns around those who need extra care. The minutes documented there was [MEDICATION NAME] concern raised regarding the residents who require assistance with "feeding". Those needing help need to be taken care of sooner for their dignity and sensitivity of all present. On 5/26/15 at 12:10 P.M. the resident sat in his/her high back wheelchair at the dining room table and the resident's lunch meal which consisted of a chicken breast with rice and zucchini and bread was in front of the resident in a red divided bowl. Further observation revealed the chicken breast not cut, the resident did not attempt to eat the meal and no staff cued or prompted to resident to eat. Observation revealed a direct care staff sat between this resident and another resident and assisted the other resident with the meal. At 12:20 P.M. a direct care staff came and sat next to the resident and cut up the resident's meat and offered the resident the meat and the resident ate. Observation revealed when staff offered the resident food the resident consumed the food but if staff did not offer the food the resident did not attempt to eat. On 5/27/15 at 7:35 A.M. the resident sat in his/her high back wheelchair at the dining table. Observation revealed a bowl of cereal, a cup of coffee, a dish of diced peaches and a dish of high fiber mix were in front of the resident. Observation revealed the resident did not attempt to eat the meal and no staff assisted or cued the resident to eat. Further observation revealed no spoon or utensil was in the bowl of cereal or the fruit. At 7:40 A.M. staff delivered the resident a piece of toast in a white divided bowl and a direct care staff then sat by the resident and assisted the resident with the meal. At 7:50 A.M. with staff assistance the resident consumed all of the food. On 5/20/15 during Stage 1 of the survey an interested party expressed concern that during meal resident(s) needing staff assistance do not receive staff assistance as needed. On 5/27/15 at 2:54 P.M. direct care staff O stated the resident required staff assistance with eating due to a vision impairment. He/she stated most of the times the resident was dependent upon staff for eating. On 5/27/15 at 3:35 P.M. licensed nurse H stated the resident needed staff assistance during meals. He/she stated sometimes if you give her food to hold he/she can eat it. On 5/27/15 at 5:27 P.M. administrative nursing staff D stated some days the resident required staff assistance during meals. He/she stated the resident was visually impaired and if staff informed the resident of the clock position of the food the resident would eat without staff assistance. Administrative nursing staff D stated due to the resident's vision impairment a red divided plate was provided. The facility's undated Assistance with Meals Policy and Procedure included residents would receive assistance with meals in a manner that met the individual needs of each resident. The facility failed to consistently assist this severely cognitive impaired resident with impaired vision with meals. - Resident #11's annual Minimum Data Set ((MDS) dated [DATE] identified the resident scored 6 (severely impaired cognition) on the Brief Interview for Mental Status (BIMS), had no behaviors and required staff supervision with eating. The resident's Cognitive Care Area Assessment (CAA) dated 4/9/15 documented the resident had a [DIAGNOSES REDACTED]. The resident's ADL CAA dated 4/9/15 included the resident required increased staff assistance for ADL tasks. Review of the August 8, 2014 Community Life Meeting Minutes revealed several people felt uncomfortable and sad watching those who need assistance being the last ones served at every meal. Those in attendance came up with 2 potential options. Bring those people in a little earlier and let staff assist them or 2) do not bring them into the dining room until they can be served so they did not have to watch everyone else eating. Review of the March 26, 2015 Resident Life/Community Life Minutes included there was much discussion centered around meals, the length of time before being served, menus, and the concerns around those who need extra care. The minutes documented there was [MEDICATION NAME] concern raised regarding the residents who require assistance with "feeding". Those needing help need to be taken care of sooner for their dignity and sensitivity of all present. On 5/20/15 during Stage 1 of the survey an interested party expressed concern that during meal resident(s) needing staff assistance do not receive staff assistance as needed. On 5/27/15 at 7:50 A.M. the resident sat in his/her wheelchair at a dining room table and the resident's head almost in direct contact with the table. Observation revealed the resident's breakfast meal which consisted of an egg, toast and peaches sat in front of the resident and the resident appeared asleep. Further observation revealed no staff cued or prompted the resident to eat. At 7:58 administrative nursing staff D assisted the resident with the meal. On 5/27/15 at 12:00 P.M. and 12:08 P.M. the resident sat in his/her wheelchair at a dining room table and the resident's head almost in direct contact with the table. Observation revealed a bowl of potato salad sat in front of the resident and no staff prompted or cued the resident to eat. At 12:18 P.M. direct care staff O assisted the resident to eat. On 5/27/15 at 3:06 P.M. direct care staff O stated the resident required staff assistance and not supervision with eating. On 5/27/15 at 3:28 P.M. licensed nurse H stated the resident required staff assistance with eating, not someone all the time but needed someone to cue him/her because he/she fell asleep, On 5/27/15 at 5:23 P.M. administrative nursing staff D stated the resident had not needed staff assistance with meals until the last couple of weeks, staff had to keep waking and prompting her. The facility's undated Assistance with Meals Policy and Procedure included residents would receive assistance with meals in a manner that met the individual needs of each resident. The facility failed to consistently assist this severely cognitive impaired resident with impaired vision with meals.

The facility had a census of 40 residents. Based upon observation, record review and interviews the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Findings included: - During Stage 1 of the survey interested party expressed concerns regarding sufficient nursing staff. One interested stated on the night shift there was only 1 licensed nurse on duty and he/she had to wait an extended amount of time for his/her pain pill. Another interested party stated there was not sufficient nursing staff and often times could not find staff to assist him/her. On 5/27/15 a call light on the 200 hall was on at 8:08 A.M., 8:09 A.M., 8:10 A.M. , 8:11 A.M. and was on at 8:25 A.M. During interview with the resident the resident stated his/her call light had been on for an extended amount of time and stated it takes a while for staff to respond. On 5/27/15 at 8:56 A.M. a call light on the 200 hall was on at 8:56 A.M. and staff responded to the call light at 9:04 A.M. On 5/27/15 a staff stated he/she did not feel night shift licensed staff was adequate. He/she stated some nights there is only 1 licensed nurse in the building and if a resident requested an as needed medication or required assistance from a licensed nurse depending on what the licensed nurse duties were at that time the resident would have to wait an extended amount of time to receive the medication or assistance from the licensed nurse. On 5/27/15 at 5:27 P.M. administrative nursing staff D stated due to the schedule rotation some nights there was 1 licensed nurse and 1 certified medication aide in addition to direct care staff. He/she stated if a resident requested an as needed medication there could be a delay in the resident receiving the medication depending upon the task of the licensed nurse at that time. The facility's undated Staffing Policy and Procedure included the facility provided adequate staffing to meet needed care and services for the resident population. The facility failed to ensure sufficient nursing staff.

The facility identified a census of 42 residents. The facility residents ate in either of two dining rooms. Based on observation, record review and interview the facility failed to provide adequate supervision in the Monestary dining room before and during meals for 3 of 4 days on site of the survey. Findings included: - Upon initial tour of the kitchen which was adjacent to the Monestary dining room on 1/27/14 from 9:52 A.M. until approximately 10:15 A.M. revealed the door to the dining room was unlocked and the doorway into the serving area did not have doors. The steam table was on with water in the reservoir wells of the steam table. The water temperature was 199.4 degrees Fahrenheit. Further observations on 1/28/14 at approximately 7:35 A.M. and on 1/29/14 at 11:48 A.M. revealed the steam table was on and there was not continuous supervision during the meal time. Interview with dietary staff DD on 1/27/14 at approximately 10:10 A.M. said the doors were not locked and anyone could come into the dining room. He/she said there were about 10 residents who came to this dining room daily to eat but that number varied from meal to meal. Review of facility provided information revealed up to 13 residents regularly eat one to three meals daily in the Monestary dining room. Observation on 1/27/14 at 11:50 A.M. revealed several residents as well as members of the Community came into the Monestary dining room, went into the serving area, served themselves and then went to the dining table and ate their meal. There was dietary staff available at the salad bar and to assist the residents or those members of the Community if they needed assistance. There were not nursing staff in the dining room during the meal. Further observations on 1/28/14 at approximately 7:35 A.M. and on 1/29/14 at 11:30 to 11:50 A.M. revealed there were no nursing staff in the Monestary dining room during these meals. Interview on 1/27/14 at 12:45 P.M. with dietary staff FF and activity staff LL said nursing staff were not in the Monestary dining room during meals. They both said that the number of residents who ate in the Monestary dining room varied with each meal but possibly between 5 to 10 residents at any meal. On 1/28/14 at 10:40 A.M. an interview with direct care staff Q said if a resident slumped over, became unresponsive or started choking, he/she would use the call light in the Dooley dining room and he/she said he/she did not think there was a call light in the Monestary dining room. Interview on 1/28/14 at 1:25 P.M. with direct care staff Q said some confused residents have a security bracelet that could prevent them from entering the Monestary dining room, but not all confused residents wore the security bracelet. An interview with dietary staff EE and who worked in the Monestary dining room on 1/28/14 at 11:10 A.M. said there was no call light in the Monestary dining room. It was pointed out to him/her there was one located by the piano and he/she said it was new and he/she was not made aware of it. Interview with licensed nursing staff J on 1/30/14 at 9:20 A.M. said several years ago he/she was going back to get his/her meal tray and they called for someone to come in because someone needed assistance because of choking. He/she said when he/she got to the dining room, several people surrounded the resident and were trying to help by hitting them on the back. Licensed nursing staff J told them to step back and he/she did the Heimlich maneuver with success. The resident dislodged a large piece of ice. Interview with administrative nursing staff D on 1/30/14 at 9:25 A.M. identified 5 cognitively impaired and independently mobile residents. He/she said all but one resident had a security bracelet and the Monestary dining room did have a unit to the door to alert if a resident got close and locked the door. He/she said there was a call system in the Monestary dining room for residents, family, or members of the Community to use if needed. The facility failed to provide interventions to effectively monitor the Monestary dining room and serving area during meals to ensure a safe environment free from accident hazards.

The facility identified a census of 42 residents. Based on observation and interview, the facility failed to prevent the spread of infection on 1 of 2 resident units. Findings included: Observation on 1/30/14 at 7:30 A.M. housekeeping staff Y sprayed Control disinfectant on a damp cloth, wiped the sink surface, and then promptly dried surface with dry clean cloth. Review of the Control disinfectant label revealed the solution must remain wet on a surface for 10 minutes in order to disinfect the surface. Interview on 1/30/14 at 10:55 A.M. housekeeping staff Y stated he/she was unaware the disinfectant needed to remain wet for 10 minutes. He/she said he/she was instructed to wipe a surface with the disinfectant and then dry it. Interview on 1/20/14 at 11:15 A.M. housekeeping staff X stated he/she was told by the manufacturer the disinfectant destroyed germs upon contact. The facility's policy "Cleaning of Resident Rooms" revised 02/2014 noted "directions on all product labels will be followed". The facility failed to follow manufacturer's instructions for cleaning solutions.

The facility reported a census of 42 residents. The sample included 9 residents. Based on observation, interview and record review the facilty failed to monitor the effectiveness of medications for 3 of 5 residents (#8, #15 and #34) reviewed for unnecessary medication. Findings included: - The physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 dated 11/7/13 revealed a Brief Interview for Mental Status (BIMS) of 3 which indicated severe cognitive impairment. The resident exhibited delusional behavior (an untrue persistent belief or perception held by a person although evidence shows it is untrue), physical and verbal behavior towards others and wandered. The staff determined compared to the previous assessment the resident behavior was worse. The resident received an antidepressant and an antianxiety medication on 7days of the 7 day look back period. The Care Area Assessment (CAA) dated 3/14/13 did not trigger for Mood or behavior symptoms. The CAA dated 3/14/13 revealed for [MEDICAL CONDITION] medication use the resident had a history of [REDACTED]. The resident exhibited agitation and/or irritation. The resident had a balance problem which was present prior to the start of the antidepressant. Review of the revised care plan dated 11/14/13 revealed the resident had a cognitive deficit and hearing loss which impaired his/her understanding, poor vision, and a [DIAGNOSES REDACTED]. The resident was known to hit/swat or become verbally abusive to staff. The staff would make sure they had his/her attention before beginning communication. The staff would address the resident by name and introduce themselves, speak slowly and clearing and distinctly. The staff would not shout or exaggerate mouthing of words and report any change in communication to the physician. The staff would monitor for signs of depression/mood changes such as statements of loss, hopelessness, decrease in appetite, sleep disturbances, or tearfulness. The staff would provide emotional support and validate the resident feelings. The director of pastoral care would assist the resident and family with spiritual issues as needed and requested. The staff would monitor for urinary tract infection, for increased confusion, restlessness, agitation, angry outbursts and obtain an order for [REDACTED]. The staff were to assess the resident's need for toileting or pain and assist as needed. The staff would call the resident's son or daughter for calming with the resident was anxious. The staff would reapproach the resident when he/she exhibited aggressive behavior. The staff would read to the resident for calming. The staff would include the resident with weekly pet therapy. The staff would have the resident fold linen or water plants for calming. The staff would offer the resident his/her favorite TV shows for an acitivity: Jeopardy, Wheel of Fortune, McNeil/Lehr report, Washington week in review. The staff would offer music to the resident. The resident's companion and daughter would come to visit. The consent for an antidepresant and antiaxiety medicaiton use was signed and on the chart. The pharmacist would do a monthly drug review. Review of the physician's orders [REDACTED].[REDACTED]. Review of the completed behavior monitoring forms for [MEDICATION NAME] (aggressive, angry outbursts and tearfulness) and [MEDICATION NAME] (tearfulness, angry outbursts, aggressive) were completed every 12 hours by the nurses. The documentation included the quantity of behaviors exhibited by the resident. Observation on 1/28/14 at 1:30 P.M. staff read to the resident who sat in the recliner in the common area. Observation on 1/28/14 at 5:15 P.M. the resident had a verbal outburst in the residents' dining room. The staff removed the resident from the dining room to a quiet area and reassured him/her. Observation on 1/28/14 at 5:30 P.M. the staff sat with the resident while the resident was at a table away from the dining room eating, and the resident displayed calm behavior. Observation on 1/29/14 at 11:10 A.M. the resident rested calmly in the recliner in the small common area. Interview at 1/29/14 at 3:29 P.M. direct care staff O stated the behaviors exhibited by the resident were hitting and directed at the staff. The behavior is usually after the family leaves or family absence and the resident occassionally swears or yelled. The staff would try to determine the cause of the behavior, reapproach the resident and keep the resident under constant observation. The nurses document any behaviors the resident exhibited. Interview on 1/30/14 at 10:13 A.M. direct care staff P stated behaviors exhibited by resident occurred more in the afternoon, The resident was not oriented to place or staff. All behaviors were report to the nurse and the nurse would assess the resident. The staff were to reapproach the resident but would keep the resident under observation. Interview on 1/29/14 at 4;39 P.M.licensed staff H stated the behaviors exhibited by the resident were to become verbally or physically abusive to the staff when the resident would attempt to stand by him/herself. The staff would reapproach and monitor from a safe distance. The behavior monitoring form was on the medication administration record (MAR). The resident usually exhibited the behaviors related to anxiety more than the depression but the behaviors are marked the same for both medications. Interview on 1/30/14 at 9:32 A.M. licensed staff I stated the behaviors were documented on the MAR and in the nurses' notes. The behaviors for the [MEDICATION NAME] and the [MEDICATION NAME] were the same and documented the same but had decreased since the scheduled [MEDICATION NAME] was started. Interview on 1/30/14 at 10:25 A.M.administrative nurse D stated the doctor determined the behavior to monitor for each medication. He/she acknowledged both medications had the same behaviors and if the behavior escilated the as needed [MEDICATION NAME] was used. The nursing staff reported the behaviors exhibited by the resident to the physician. Efficacy for each medication was not determined but as a combination of the two together. Interview on 1/29/14 at 1:50 PM administrative nursing staff E stated the resident's behavior was not an issue when the CAAs were completed in March as they were under control of the medication then. Review of the polcy provided by the facility for Psychoactive Drug Monitoring dated 2011 revealed the residents who recieved psychoative/psychopharmacological medication were monitored. These were defined as amy medicaiton used for managing behavior, stabilizing mood, or treating psychiatric disorders. Every effort was made to ensure that residents received these medications obtained the maximum benefit with the minimum of unwanted side effects. The continued need for psychoactive medication was reassessed regularly by the prescriber and the care planning team. If continuation was deemed necessary, it was indicated in the medical record. Effects and side effects of the medications were documented and monitored. The facility failed to effectively monitor for targeted behaviors for each [MEDICAL CONDITION] medication. - The Physician order [REDACTED].)), psychotic mood disorder (a mood disorder of any major mental disorder characterized by a gross impairment in reality testing), [MEDICAL CONDITION] (OCD) (an anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions sufficiently severe to cause marked distress, consume considerable time or significantly interfere with the patient ' s occupational, social or interpersonal functioning), dementia (progressive mental disorder characterized by failing memory, confusion), and anorexia (eating disorder characterized by immoderate food restriction and irrational fear of gaining weight). The quarterly Minimum Data Assessment (MDS) 3.0 dated 12/5/13 listed resident Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident's cognition was intact, had no behaviors, mood score was 17 (moderately severe depression), and he/she received antipsychotics, antidepressants, anticoagulants and diuretics each for 7 of 7 days during the look back period. The Care Area Assessment (CAA)s dated 7/15/13 for mood said the resident had long standing mood problems. He/she had [DIAGNOSES REDACTED]. She received antidepressant, antipsychotic and anticonvulsant medications to control these problems The CAAS dated 7/15/13 for [MEDICAL CONDITION] mood documented the resident had long standing mood problems. He/she had [DIAGNOSES REDACTED]. He/she received antidepressant, antipsychotic and anticonvulsant (help prevent [MEDICAL CONDITION]) medications to control these problems. The care plan dated 12/12/13 noted the resident suffered from [MEDICAL CONDITION] with psychotic features, OCD, and anxiety. The resident was educated on the adverse reactions of the [MEDICAL CONDITION] medications, received 2 antidepressants and an antipsychotic medication to help control mood, staff were to monitor for targeted behaviors as evidenced with concern over bowel and bladder control, repetitive anxious concerns sought attentions/reassurance regarding changing of schedules. The care plan dated 12/12/13 documented staff would monitor for mood or behaviors changes (withdrawal, elation, sudden resignation). The resident was aware of the need for the [MEDICAL CONDITION] medications and was educated on the adverse reactions. The resident signed a consent for antipsychotic, anti depressant medications, received 2 SSRI (selective serotonin re-uptake inhibitors were a class of compounds typically used as antidepressants in the treatment of [REDACTED]. The resident had specific people he/she was comfortable expressing his/her feelings to and would call on them if needed. The resident could ask for staff to arrange for individual counseling with a therapist if the resident desired. Staff to monitor, record, and report any changes in mood/behaviors and elations, withdrawal, sudden resignation, change in normal appearance, as evidenced by uncombed hair, and unchanged soiled clothing. Staff were to monitor for increased or excessiveness complaints of constipation, diarrhea, or urinary incontinence. The resident previously had long periods of anxiety when he/she waited a long time to go to the bathroom after meals, staff to attempt to use the mantra "all is well and God loves me", at times of confusion and anxiety and encourage the resident to repeat this. Review of the clinical record listed the resident was currently obsessed that the devil was possessing him/her. There was documentation of numerous staff, pastoral care, and priest visits with the resident regarding this. Review of the POS dated 1/14 listed orders for the resident to received the following psychoactive medications: [MEDICATION NAME] (anti-depressant used for treatment of [REDACTED]. [MEDICATION NAME] (anti-depressant used for treatment of [REDACTED]. [MEDICATION NAME] (anti-psychotic used for treatment of [REDACTED]. Review of the monthly behavior monitoring sheets from June 2013 to January 30, 2014 revealed staff monitored for agitation, sought attention, repetitive concerns for [MEDICATION NAME], and [MEDICATION NAME]. Observation on 1/28/14 at 1:28 P.M. revealed the resident sat in the living room in a recliner with the foot rest elevated. His/her eyes were closed and he/she rested quietly. Observation on 1/29/14 at 7:35 A.M. the resident was in the dining room eating breakfast. He/she responded when asked that breakfast was "pretty good" but had a flat affect and no expression change. Attempted to interview the resident on 1/29/14 at 1:50 P.M., he/she sat in the wheel chair in his/her room, looked into a mirror and barely offered one word answers, had flat affect and soft spoken voice. Interview on 1/29/14 at 4:30 P.M. with administrative nursing staff F who said the resident's behaviors cycled according to what the issue was, sometimes it was folding toilet paper forever or rolling it over and over again and now it was about the devil. He/she said we increased pastoral care and social service visits. Administrative nursing staff F said we monitored all the same targeted behaviors for the 2 anti-depressants and one anti-psychotic medication because all the medications worked together. He/she said he/she did not know which medications were started for which of the targeted behaviors listed because the resident received these medications for a long time. On 1/30/14 at 9:20 A.M. an interview with administrative nursing staff D said the resident had received these medications for so long they had no idea what behaviors the resident exhibited when the physician ordered the medications. The facility provided policy dated 3/11 documented residents who received psychoactive medications were monitored. These were defined as any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. Every effort was made to ensure the residents receiving these medications obtained the maximum benefit with the minimum of unwanted side effects. The continued need for the psychoactive medication was reassessed regularly by the prescriber and the care planning team. Effects and side effects of the medications were documented and monitored. Psychoactive drug monitoring guidelines include, but may not be limited to, anti-anxiety, anti-depressant, anti-psychotic, and sedative/hypnotic drugs. The facility failed to effectively identify and monitor the targeted behaviors for each psychoactive medication for this resident with psychiatric [DIAGNOSES REDACTED]. - The Physician order [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 dated 1/2/14 listed the resident's Brief Interview for Mental Status score as 15, indicated cognitively intact. The mood score of 3 which indicated minimal depression, received anti-anxiety (treatment for [REDACTED]. The Care Area Assessment (CAA)s dated 1/7/14 for [MEDICAL CONDITION] medication said the resident received anti-depressant medication for depression and anti-anxiety medication for [MEDICAL CONDITION]. The care plan dated 1/16/14 identified the resident did not accept change or loss well, did not have adequate coping skills and sometimes made negative and self-deprecating statements such as "no one likes me or I would be better off dead". The resident exhibited aggressive behaviors as evidence by bumping into another resident's walker instead of asking him/her to politely move. The resident had certain people he/she was comfortable expressing his/her feelings to and would talk to them when the resident wanted. The resident cries easily and needs staff to stay with him/her or ask if he/she wanted to be alone. Staff to inform the resident when they removed items from his/her room. Offer to contact social service, family or his/her companion when the resident was inconsolable or when he/she made negative statements. Notify the charge nurse when the resident made negative statements so the nurse could assess and document. Staff to monitor the targeted behaviors which were crying and making negative statements, and monitor mood or behavior changes such as an increase in agitation/anxiety. Change caregiver approach or activity as needed and observe for response, report any increase in behavior to the physician, determine underlying cause if possible, observe for early signs of distress/increasing anxiety, irritability, lack of cooperation, and body posture/expression. Staff to remain calm and redirect the resident when inappropriate behavior was exhibited, gently but firmly remind resident this was not acceptable behavior. The resident signed a consent to receive anti-anxiety and anti-depressant medication. The care plan for [MEDICAL CONDITION], generalized anxiety disorder and overactive bladder dated 1/16/14 documented staff to provide a regular bedtime routine such as the resident wanted to go to bed immediately following supper, toilet frequently during the night, encourage him/her to take decaffeinated beverages, check on noise and temp levels, leave the door slightly ajar during hours of sleep to facilities air flow in the room per the resident's preference, provide a scheduled medication as ordered for [MEDICAL CONDITION], place a cloth on my head, use a round pillow on/behind his/her neck and pillow under the left arm, and offer a snack such as crackers, toast, milk, cheese 1 to 2 times during the night when he/she was up to the bathroom. Review of the POS dated 1/14 revealed medication orders for the following psychoactive medications: Klonopin 0.5 milligram (mg) orally at bedtime for generalized anxiety disorder for [MEDICAL CONDITION], start date of 10/30/12 [MEDICATION NAME] 7.5 mg tablet at bedtime for depression, start date of 1/22/13 Review of the monthly behavior monitoring sheets dated from June 2013 to January 2014 revealed the staff monitored the resident for the following behaviors and associated medications: [MEDICATION NAME] for crying and/or negative statements and Klonopin for crying, negative statements and [MEDICAL CONDITION]. A sleep evaluation dated 1/2/14 noted the resident received Klonopin 0.5 mg at bedtime. The sleep assessment documented the resident had an overactive bladder and got up during the night to void. Pain, depression, Gastro [MEDICAL CONDITION] reflux (GERD) (backflow of stomach contents to the esophagus), and constipation would interfere with the resident's sleep. An observation on 1/28/14 at 5:00 P.M. and again at 5:30 P.M. revealed the resident laid in bed, with a cover partially covering his/her head, room was dark and the bed was in low position. An observation on 1/29/14 at 12:20 P.M. revealed the resident sat in the dining room in his/her wheel chair and visited with another resident. An observation on 1/30/14 at 7:35 A.M. revealed the resident sat in the wheel chair and fed self all of his her meal. An interview on 1/29/14 at 4:45 P.M. with Administrative nursing staff F said all the resident's targeted behaviors were the same for both psychoactive medications but staff also gave the Klonopin for [MEDICAL CONDITION]. He/she said the resident had behaviors of some type daily. Administrative licensed staff F said he/she did not know which medications were started for which of the targeted behaviors listed because the resident received these medications for a long time. On 1/30/14 at 9:20 A.M. an interview with administrative nursing staff D said the resident had received these medications for so long they had no idea what behaviors the resident exhibited when the physician ordered the medications. The facility provided policy dated 3/11 documented resident who received psychoactive medications were monitored. These were defined as any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. Every effort was made to ensure the residents receiving these medications obtained the maximum benefit with the minimum of unwanted side effects. The continued need for the psychoactive medication was reassessed regularly by the prescriber and the care planning team. Effects and side effects of the medications were documented and monitored. Psychoactive drug monitoring guidelines include, but may not be limited to, anti-anxiety, anti-depressant, anti-psychotic, and sedative/hypnotic drugs. The facility failed to effectively identify and monitor the targeted behaviors for each psychoactive medication for this resident with psychiatric [DIAGNOSES REDACTED].

The facility reported a census of 42 residents. The sample included 9 residents. Based on observation, interview and record review the facility failed to monitor the effectiveness of medications for 3 of 5 residents (#8, #15 and #34) reviewed for unnecessary medication. Findings included: - The physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 dated 11/7/13 revealed a Brief Interview for Mental Status (BIMS) of 3 which indicated severe cognitive impairment. The resident exhibited delusional behavior (an untrue persistent belief or perception held by a person although evidence shows it is untrue), physical and verbal behavior towards others and wandered. The staff determined compared to the previous assessment the resident behavior was worse. The resident received an antidepressant and an antianxiety medication 7days of the 7 day look back period. The Care Area Assessment (CAA) dated 3/14/13 did not trigger for Mood or behavior symptoms. The CAA dated 3/14/13 revealed for psychotropic medication use the resident had a history of [REDACTED]. The resident exhibited agitation and/or irritation. The resident had a balance problem which was present prior to the start of the antidepressant. Review of the revised care plan dated 11/14/13 revealed the resident had a cognitive deficit and hearing loss which impaired his/her understanding, poor vision, and a [DIAGNOSES REDACTED]. The resident was known to hit/swat or become verbally abusive to staff. The staff would make sure they had his/her attention before beginning communication. The staff would address the resident by name and introduce themselves, speak slowly and clearing and distinctly. The staff would not shout or exaggerate mouthing of words and report any change in communication to the physician. The staff would monitor for signs of depression/mood changes such as statements of loss, hopelessness, decrease in appetite, sleep disturbances, or tearfulness. The staff would provide emotional support and validate the resident feelings. The director of pastoral care would assist the resident and family with spiritual issues as needed and requested. The staff would monitor for urinary tract infection, for increased confusion, restlessness, agitation, angry outbursts and obtain an order for [REDACTED]. The staff were to assess the resident's need for toileting or pain and assist as needed. The staff would call the resident's son or daughter for calming with the resident was anxious. The staff would reapproach the resident when he/she exhibited aggressive behavior. The staff would read to the resident for calming. The staff would include the resident with weekly pet therapy. The staff would have the resident fold linen or water plants for calming. The staff would offer the resident his/her favorite TV shows for an activity: Jeopardy, Wheel of Fortune, McNeil/Lehr report, Washington week in review. The staff would offer music to the resident. The resident's companion and daughter would come to visit. The consent for an antidepressant and antianxiety medication use was signed and on the chart. The pharmacist would do a monthly drug review. Review of the physician's orders [REDACTED].[REDACTED]. Review of the completed behavior monitoring forms for Celexa (aggressive, angry outbursts and tearfulness) and Xanax (tearfulness, angry outbursts, aggressive) were completed every 12 hours by the nurses. The documentation included the quantity of behaviors exhibited by the resident. Review of the consultant pharmacist review the medical record review was done on: 2/27/13 the pharmacist reviewed the bowel monitor, [DIAGNOSES REDACTED]. On 4/18/13 the pharmacist reviewed the blood pressure, pulse, bowel monitor and antibiotic use and recommended a decrease of the Xanax. On 5/15/13 the pharmacist reviewed the vital signs, bowel monitor, pain and the nurses noted for medication changes. On 6/26/13 the pharmacist reviewed bowel monitor, diagnoses, sleep monitor and vision assessment. On 7/16/13 the pharmacist reviewed the bowel monitor and care plans. On 8/20/13 the pharmacist reviewed the bowel monitor, the as needed Xanax usage and diagnoses. On 9/20/13 the pharmacist reviewed the bowel monitor, diagnoses, sleep monitor and change of the Senna and to daily dosage and addition of Miralax. The pharmacist recommended a gradual dose reduction of the Celexa. The physician refused and signed 9/24/13 the benefits outweighed the risks. On 10/18/13 the pharmacist reviewed the vital signs, bowel monitor, black box warning and care plan. Acknowledged the physicians' order to maintain the Celexa and the antibiotic use. On 11/13/13 the pharmacist reviewed the bowel monitor and care plan and recommended to discontinue the Tylenol, increase the Senna. On 12/17/13 the pharmacist reviewed the bowel monitor, there were no new labs and recommended to change the Xanax from liquid to tablet form. On 1/15/14 the pharmacist recommended a decrease of the Lortab, no new labs, bowel monitor was checked, the as necessary Senna and Dulcolax were discontinued and the facility was to follow the bowel movement protocol. Observation on 1/28/14 at 1:30 P.M. staff read to the resident who sat in the recliner in the common area. Observation on 1/28/14 at 5:15 P.M. the resident had a verbal outburst in the residents' dining room. The staff removed the resident from the dining room to a quiet area and reassured him/her. Observation on 1/28/14 at 5:30 P.M. the staff sat with the resident while the resident was at a table away from the dining room eating, and the resident displayed calm behavior. Observation on 1/29/14 at 11:10 A.M. the resident rested calmly in the recliner in the small common area. Interview at 1/29/14 at 3:29 P.M. direct care staff O stated the behaviors exhibited by the resident were hitting and directed at the staff. The behavior is usually after the family leaves or family absence and the resident occasionally swears or yelled. The staff would try to determine the cause of the behavior, reapproach the resident and keep the resident under constant observation. The nurses document any behaviors the resident exhibited. Interview on 1/30/14 at 10:13 A.M. direct care staff P stated behaviors exhibited by resident occurred more in the afternoon, The resident was not oriented to place or staff. All behaviors were report to the nurse and the nurse would assess the resident. The staff were to reapproach the resident but would keep the resident under observation. Interview on 1/29/14 at 4;39 P.M. licensed staff H stated the behaviors exhibited by the resident were to become verbally or physically abusive to the staff when the resident would attempt to stand by him/herself. The staff would reapproach and monitor from a safe distance. The behavior monitoring form was on the medication administration record (MAR). The resident usually exhibited the behaviors related to anxiety more than the depression but the behaviors are marked the same for both medications. Interview on 1/30/14 at 9:32 A.M. licensed staff I stated the behaviors were documented on the MAR and in the nurses' notes. The behaviors for the Celexa and the Xanax were the same and documented the same but had decreased since the scheduled Xanax was started. Interview on 1/30/14 at 10:25 A.M. administrative nurse D stated the doctor determined the behavior to monitor for each medication. He/she acknowledged both medications had the same behaviors and if the behavior escalated the as needed Xanax was used. The nursing staff reported the behaviors exhibited by the resident to the physician. Efficacy for each medication was not determined but as a combination of the two together. Interview on 1/29/14 at 1:50 PM administrative nursing staff E stated the resident's behavior was not an issue when the CAAs were done in March as they were under control by medication then. Interview on 2/3/14 at 9:33 AM with pharmacy consultant KK (stated if there were medications from the same or different classification with the same behaviors he/she reviewed the start date of the medications. The mechanisms of actions were different for the medications and the resident was allowed to obtain the maximum dose before starting a new medication either in the same or a different class. The gradual dose reduction was recommended by the chronological start date of each medication. Review of the policy provided by the facility for Psychoactive Drug Monitoring dated 2011 revealed the residents who recieved psychoative/psychophrmacological medication were monitored. These were defined as amy medicaiton used for managing behavior, stabilizing mood, or treating psychiatric disorders. Every effort was made to ensure that residents received these medications obtained the maximum benefit with the minimum of unwanted side effects. The continued need for psychoactive medication was reassessed regularly by the prescriber and the care planning team. If continuation was deemed necessary, it was indicated in the medical record. Effects and side effects of the medications were documented and monitored. The consultant pharmacist failed to recognize the facility did not effectively monitor for targeted behaviors for each psychotropic medication. - The Physician order [REDACTED].)), psychotic mood disorder (a mood disorder of any major mental disorder characterized by a gross impairment in reality testing), obsessive compulsive disorder (OCD) (an anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions sufficiently severe to cause marked distress, consume considerable time or significantly interfere with the patient ' s occupational, social or interpersonal functioning), dementia (progressive mental disorder characterized by failing memory, confusion), and anorexia (eating disorder characterized by immoderate food restriction and irrational fear of gaining weight). The quarterly Minimum Data Assessment (MDS) 3.0 dated 12/5/13 listed resident Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident's cognition was intact, had no behaviors, mood score was 17 (moderately severe depression), and he/she received antipsychotics, antidepressants, anticoagulants and diuretics each for 7 of 7 days during the look back period. The Care Area Assessment (CAA)s dated 7/15/13 for mood said the resident had long standing mood problems. He/she had [DIAGNOSES REDACTED]. She received antidepressant, antipsychotic and anticonvulsant medications to control these problems The CAAS dated 7/15/13 for psychotropic mood documented the resident had long standing mood problems. He/she had [DIAGNOSES REDACTED]. He/she received antidepressant, antipsychotic and anticonvulsant (help prevent seizures) medications to control these problems. The care plan dated 12/12/13 noted the resident suffered from major depression with psychotic features, OCD, and anxiety. The resident was educated on the adverse reactions of the psychotropic medications, received 2 antidepressants and an antipsychotic medications to help control mood, staff were to monitor for targeted behaviors as evidenced with concern over bowel and bladder control, repetitive anxious concerns sought attentions/reassurance regarding changing of schedules. The care plan dated 12/12/13 documented staff would monitor for mood or behaviors changes (withdrawal, elation, sudden resignation). The resident was aware of the need for the psychotropic medications and was educated on the adverse reactions. The resident signed a consent for antipsychotic, anti depressant medications, received 2 SSRI (selective serotonin re-uptake inhibitors were a class of compounds typically used as antidepressants in the treatment of [REDACTED]. The resident had specific people he/she was comfortable expressing his/her feelings to and would call on them if needed. The resident could ask for staff to arrange for individual counseling with a therapist if the resident desired. Staff were to monitor, record, and report any changes in mood/behaviors and elations, withdrawal, sudden resignation, change in normal appearance, as evidenced by uncombed hair, and unchanged soiled clothing. Staff to monitor for increased or excessiveness complaints of constipation, diarrhea, or urinary incontinence. The resident previously had long periods of anxiety when he/she waited a long time to go to the bathroom after meals, staff to attempt to use the mantra "all is well and God loves me", at times of confusion and anxiety and encourage the resident to repeat this. Review of the clinical record listed the resident was currently obsessed that the devil was possessing him/her. There was documentation of numerous staff, pastoral care, and priest visits with the resident regarding this. Review of the POS dated 1/14 listed orders for the resident to received the following psychoactive medications: Effexor (anti-depressant used for treatment of [REDACTED]. Remeron (anti-depressant used for treatment of [REDACTED]. Zyprexa (anti-psychotic used for treatment of [REDACTED]. Review of the monthly behavior monitoring sheets from June 2013 to January 30, 2014 revealed staff monitored for agitation, sought attention, repetitive concerns for Effexor, Remeron, and Zyprexa. The monthly Drug Regimen Review (DRR) dated from 2/27/13 to 1/15/14 failed to address targeted behaviors or behavior monitoring. Observation on 1/28/14 at 1:28 P.M. revealed the resident sat in the living room in a recliner with the foot rest elevated. His/her eyes were closed and he/she rested quietly. Observation on 1/29/14 at 7:35 A.M. the resident was in the dining room eating breakfast. He/she responded when asked that breakfast was "pretty good" but had a flat affect and no expression change. Attempted to interview the resident on 1/29/14 at 1:50 P.M., he/she sat in the wheel chair in his/her room, looked into a mirror and barely offered one word answers, had flat affect and soft spoken voice. Interview on 1/29/14 at 4:30 P.M. with administrative nursing staff F who said the resident's behaviors cycled according to what the issue was, sometimes it was folding toilet paper forever or rolling it over and over again and now it was about the devil. He/she said the resident always had some type of behavior. He/she said we increased pastoral care and social service visits. Administrative nursing staff F said we monitored all the same targeted behaviors for the 2 anti-depressants and one anti-psychotic medication because all the medications worked together. He/she said he/she did not know which medications were started for which of the targeted behaviors listed because the resident received these medications for a long time. On 1/30/14 at 9:20 A.M. an interview with administrative nursing staff D said the resident had received these medications for so long they had no idea what behaviors the resident exhibited when the physician ordered the medications. An interview on 2/3/14 at 9:33 AM with pharmacy consultant KK stated if there were medications from the same or different classification with the same behaviors he/she reviewed the start date of the medications. He/she said the mechanisms of actions were different for the medications and the resident was allowed to obtain the maximum dose before starting a new medication either in the same or a different classification. The facility provided policy dated 3/11 documented resident who received psychoactive medications were monitored. These were defined as any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. Every effort was made to ensure the residents receiving these medications obtained the maximum benefit with the minimum of unwanted side effects. The continued need for the psychoactive medication was reassessed regularly by the prescriber and the care planning team. Effects and side effects of the medications were documented and monitored. Psychoactive drug monitoring guidelines include, but may not be limited to, anti-anxiety, anti-depressant, anti-psychotic, and sedative/hypnotic drugs. The consultant pharmacist reviewed and analyzed data related to psychoactive drug use in the facility as part of the Quality Assurance (QA) process. The pharmacy consultant KK failed to effectively identify the lack of the facility to identify and monitor the targeted behaviors for each psychoactive medication for this resident with psychiatric [DIAGNOSES REDACTED]. - The Physician order [REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 dated 1/2/14 listed the resident's Brief Interview for Mental Status score as 15, indicated cognitively intact. The mood score of 3 which indicated minimal depression, received anti-anxiety (treatment for [REDACTED]. The Care Area Assessment (CAA)s dated 1/7/14 for psychotropic medication said the resident received anti-depressant medication for depression and anti-anxiety medication for insomnia. The care plan dated 1/16/14 identified the resident did not accept change or loss well, did not have adequate coping skills and sometimes made negative and self-deprecating statements such as "no one likes me or I would be better off dead". The resident exhibited aggressive behaviors as evidence by bumping into another resident's walker instead of asking him/her to politely move. The resident had certain people he/she was comfortable expressing his/her feelings to and would talk to them when the resident wanted. The resident cries easily and needs staff to stay with him/her or ask if he/she wanted to be alone. Staff to inform the resident when they removed items from his/her room. Offer to contact social service, family or his/her companion when the resident was inconsolable or when he/she made negative statements. Notify the charge nurse when the resident made negative statements so the nurse could assess and document. Staff to monitor the targeted behaviors which were crying and making negative statements, and monitor mood or behavior changes such as an increase in agitation/anxiety. Change caregiver approach or activity as needed and observe for response, report any increase in behavior to the physician, determine underlying cause if possible, observe for early signs of distress/increasing anxiety, irritability, lack of cooperation, and body posture/expression. Staff to remain calm and redirect the resident when inappropriate behavior was exhibited, gently but firmly remind resident this was not acceptable behavior. The resident signed a consent to receive anti-anxiety and anti-depressant medication. The care plan for insomnia, generalized anxiety disorder and overactive bladder dated 1/16/14 documented staff to provide a regular bedtime routine such as the resident wanted to go to bed immediately following supper, toilet frequently during the night, encourage him/her to take decaffeinated beverages, check on noise and temp levels, leave the door slightly ajar during hours of sleep to facilities air flow in the room per the resident's preference, provide a scheduled medication as ordered for insomnia, place a cloth on my head, use a round pillow on/behind his/her neck and pillow under the left arm, and offer a snack such as crackers, toast, milk, cheese 1 to 2 times during the night when he/she was up to the bathroom. Review of the POS dated 1/14 revealed medication orders for the following psychoactive medications: Klonopin 0.5 milligram (mg) orally at bedtime for generalized anxiety disorder for insomnia, start date of 10/30/12 Remeron 7.5 mg tablet at bedtime for depression, start date of 1/22/13 Review of the monthly behavior monitoring sheets dated from June 2013 to January 2014 revealed the staff monitored the resident for the following behaviors and associated medications: Remeron for crying and/or negative statements and Klonopin for crying, negative statements and insomnia. A sleep evaluation dated 1/2/14 noted the resident received Klonopin 0.5 mg at bedtime. The sleep assessment documented the resident had an overactive bladder and got up during the night to void. Pain, depression, Gastro esophageal reflux (GERD) (backflow of stomach contents to the esophagus), and constipation would interfere with the resident's sleep. The Drug Regimen Review (DRR) dated monthly from 2/27/2013 to 1/15/14 failed to address behavior monitoring. An observation on 1/28/14 at 5:00 P.M. and again at 5:30 P.M. revealed the resident laid in bed, with a cover partially covering his/her head, room was dark and the bed was in the low position. An observation on 1/29/14 at 12:20 P.M. revealed the resident sat in the dining room in his/her wheel chair and visited with another resident. An observation on 1/30/14 at 7:35 A.M. revealed the resident sat in the wheel chair and fed him/her self all of his/her meal. An interview on 1/29/14 at 4:45 P.M. with Administrative nursing staff F said all the resident's targeted behaviors were the same for both psychoactive medications but staff also gave the Klonopin for insomnia. He/she said the resident had behaviors of some type daily. Administrative licensed staff F said he/she did not know which medications were started for which of the targeted behaviors listed because the resident received these medications for a long time. On 1/30/14 at 9:20 A.M. an interview with administrative nursing staff D said the resident had received these medications for so long they had no idea what behaviors the resident exhibited when the physician ordered the medications. An interview on 2/3/14 at 9:33 AM with pharmacy consultant KK stated if there were medications from the same or different classification with the same behaviors he/she reviewed the start date of the medications. He/she said the mechanisms of actions were different for the medications and the resident was allowed to obtain the maximum dose before starting a new medication either in the same or a different classification. The facility provided policy dated 3/11 documented resident who received psychoactive medications were monitored. These were defined as any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. Every effort was made to ensure the residents receiving these medications obtained the maximum benefit with the minimum of unwanted side effects. The continued need for the psychoactive medication was reassessed regularly by the prescriber and the care planning team. Effects and side effects of the medications were documented and monitored. Psychoactive drug monitoring guidelines include, but may not be limited to, anti-anxiety, anti-depressant, anti-psychotic, and sedative/hypnotic drugs. The consultant pharmacist reviewed and analyzed data related to psychoactive drug use in the facility as part of the Quality Assurance (QA) process. The pharmacy consultant KK failed to effectively identify the facility did not identify and monitor the targeted behaviors for each psychoactive medication for this resident with psychiatric [DIAGNOSES REDACTED].