Every finding on record at Fowler Residential Care

The facility reported a census of 16 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food to prevent possible food-borne illness among the facility's residents. Findings included: On 02/24/25 at 10:58 AM, during an initial tour of the central kitchen and refrigerator storage areas with Dietary Staff BB, the following areas of concern were identified: One unsealed bag of broccoli, and a container of ranch dressing, in the refrigerator. One sealed bag of onion rings, three bags of hamburger buns, and a bag of hotdog buns without a date or label in the freezer. There was one cutting board with uncleanable surfaces that were discolored along with deep slices that were visible. On 02/24/25 at 11:15 AM, an interview with Dietary Manager BB revealed she expected staff to date opened food items. Dietary Manager BB stated that the above concerns identified with kitchen and freezer storage, which included undated and unsealed items, were unacceptable. The facility's policy on Dietary Purchase, Receipt, and Storage, dated 02/07/17, requires that all products be clearly labeled with the date of receipt. Staff must ensure that food items are rotated to use the oldest products first. The facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

The facility reported a census of 16 residents. The sample included eight residents. Based on interview and record review, the facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to two of three residents reviewed, Resident (R) 3 and R11. Findings included: - On 02/26/25 review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-10055 (SNF ABN- the waiver issued by providers when the services might not be covered) and the Notification of Medicare Non-Coverage Form 10123 (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) for three residents. R3 and R11 lacked the SNF ABN form, which is a requirement when discharging from skilled services, with days remaining, and remaining in the facility. The Beneficiary Notice documented R3's skilled discharge date as 05/22/24 and would remain in the facility. R11's skilled discharge date as 05/22/24 and would remain in the facility. R3's Skilled Nursing Beneficiary Protection Notification Review documented R3's start date of skilled services as 04/06/24 and end date of 05/22/24. R3 received only the NOMNC form signed on 05/17/24. R11's Skilled Nursing Beneficiary Protection Notification Review documented R11's start date of skilled services as 03/29/24 and end date of 05/22/24. R11 received only the NOMNC form signed on 05/17/24. On 02/26/25 at 09:03 AM, Administrative Staff A revealed she did not know they had to use both forms, confirmed that both forms should have been given as required. Administrative Staff A stated she did not know they were to use both forms. The NOMNC was easier for residents to understand. The facility's policy Right to be Informed of Professional and Financial Information dated 05/15/23, documented the facility would provide a notice of rights and services to each resident prior to or admission and during the resident's stay. The facility will provide the resident with the State-Developed notice of Medicaid rights and obligations. The facility will inform each Medicaid-eligible resident, in writing, at the time of admission to the facility and when the resident becomes eligible for Medicaid and of the changes in services or new charges. The facility failed to ensure the correct and complete Beneficiary Protection Notification forms (SNF ABN 10055) were issued to R3 and R11, as required.

The facility reported a census of 16 residents with two residents identified and reviewed for elopement. Based on interview, observation, and record review, the facility failed to provide adequate supervision to prevent one cognitively impaired Resident (R) 1, who was identified with an elopement risk and had a known history of elopement, from leaving the facility unsupervised and without staff knowledge. The facility staff last saw R1 on 04/21/24 sometime between 10:00 PM and 11:00 PM. On 04/22/24 at around 03:00 AM, facility staff were unable to locate R1. After searching and notifying Administrative Staff, Law Enforcement, and R1's family, the facility learned R1 was with his sibling in another state, over five hours away. R1 stated he used a hammer to remove the window braces, crawled out of the window, and walked over 100 feet to the back gate area, where a family member picked him up and drove him out of state. The lack of facility supervision for a resident who displayed verbal expressions of wanting to leave, placed R1 in immediate jeopardy. Finding included: - Residents (R) 1's Physician Orders dated 01/20/24, revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Annual Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 12, which indicated moderate cognitive impairment. The Quarterly MDS dated [DATE], documented a (BIMS) score of 00, indicating R1 refused to participate with the evaluator. R1 had behaviors of delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). R1 was independent with Activities of Daily Living (ADL). The Care Plan dated 09/26/23 lacked interventions regarding wandering/elopement, supervision, and visual checks for R1. The Care Plan dated 04/23/24, (after the resident left the facility without staff knowledge), identified R1 at risk for wandering/elopement when R1 eloped from the facility on 04/22/24. Staff were to supervise R1 when outside. Staff were to provide visuals check every 30 minutes to identify triggers for wandering/elopement. The Elopement assessment dated [DATE], documented a score of one, that indicated R1 was at risk for elopement. R1 verbally expressed the desire to go home, packed his belonging to go home or stayed near an exit door. The Elopement assessment dated [DATE], documented score of three, that indicated R1 was at risk. He had a BIMS score of seven, (severe cognitive impairment), and a history of elopement while at his home. R1 verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. The Elopement assessment dated [DATE], documented he had a history of elopement while at home and a history of attempting to leave the facility without informing staff. R1 continued to verbally express the desire to go home, packed his belonging to go home, or stayed near an exit door. The Nurses Notes dated 04/22/24, documented the nurse went to R1's room to check his blood sugar at 03:00 AM. The room was dark, and the television was off. Staff were unable to locate R1 in his room. The bottom window nearest R1's bed was partially opened and could be opened easily. Staff notified Administrative Staff A by telephone, and the staff conducted a full search. The staff notified R1's son at 03:20 AM. Law Enforcement arrived at the facility at 03:30 AM. R1 was last seen between 10 PM and 11 PM on 04/21/24 The Nurse Note dated 04/22/24 at 12:52 PM, documented law enforcement was able to confirm R1 was with his sibling at his home in another State. The note further revealed R1's son would return R1 to the facility. The Nurse Note dated 04/23/24 at 02:24 PM, documented R1 returned to the facility. According to Google Maps, the distance from the facility to the town where R1 located was approximately 325 miles away, and a non-stop trip would take approximately five and a half hours by vehicle each way (for a total of 11 hours round-trip). An outside observation on 04/22/24 at 01:30 PM revealed R1's room window braces had been removed. Further outside observation revealed train tracks approximately two blocks from the facility and a major highway approximately one quarter of a mile from the facility speed limits of 65 miles per hour. During an interview on 04/29/24 at 12:40 PM, R1 stated he removed the window braces and the screen from the window and crawled out of the window. He reported he did not want his sibling to be in trouble, and he reported he hitchhiked to a neighboring state. During an interview on 04/29/24 at 01:45 PM, Administrative Nurse D reported the facility expected the staff to know the whereabouts of the two elopement risk residents and provide those two residents hourly checks. Administrative Nurse D stated staff did not follow the elopement policy because the staff should have checked on R1 every hour. Administrative Nurse D reported the facility did not do any training regarding elopement after the incident. During an interview on 04/29/24 at 01:50 PM, Administrative Staff A revealed R1 had removed the braces on the window in his room and crawled out the window. Administrative Staff A said R1 walked approximately 100 feet to the back gate of the facility and used his cell phone to call his sibling to pick him up. The facility's Elopement Policy dated 02/02/17, revealed the facility wished to ensure the safety of those elders identified as being at risk for elopement. It was the policy of the facility to identify those elders at risk for elopement and take precautions to ensure their safety and well-being. The facility provided special secure living areas and additional security including a Wander Guard door locking system. This policy applied to all residents residing in any licensed area. The facility failed to provide adequate supervision to prevent the elopement of cognitively impaired Resident (R) 1, identified as an elopement risk and with a known history of elopement. On 04/22/24 R1 left the facility without staff knowledge and the staff did not know R1 was missing until they checked on him around 03:00 AM, which was 4 to 5 hours since staff last saw R1. The resident was located in another State, approximately five and a half hours from the facility. On 04/09/24 at 05:27 PM Administrative Staff A and Administrative Nurse D were provided the Immediate Jeopardy template and notified of the facility's failure to provide adequate supervision to prevent cognitively impaired Resident (R) 1, who was identified with an elopement risk and had a known history of elopement, from leaving the facility unsupervised and without staff knowledge. The immediate jeopardy was determined to first exist on 04/21/24 at 11:00 PM, approximately one hour since staff last saw R1 and around the one hourly check time, due to staff failure to supervise the resident's whereabouts. The facility identified and implemented the following corrective action on 04/30/24 which included: 1. Mandatory all staff review of elopement policy and online education prior to shift work confirmed by sign-in sheet and verification on online education program. Started 04/29/24 at 06:45 PM and will finish on 04/30/24 by 05:00 PM sign in and completion rosters included. 2. Counseling along with disciplinary action on staff involvement with the follow up with the Director of Nursing (DON) to assure compliance. Completed 04/30/24 at 07:50 AM. 3. Room was searched and R1's belonging searched R1 for any additional tools on 04/22/24 at approximately 05:00 AM and when the R1 returned to the facility on [DATE] at 09:20 PM. 4. The window cranks in areas where R1 spends time were replaced and window braces were repaired and secured by maintenance staff. Staff education regarding window repairs, cranks, and tool removal, completed on 04/30/24 at 04:09 PM. 5. Resident on visual checks every 15 minutes upon returning to the facility on [DATE] until reassessment on 04/29/24 by Director of Nursing. R1 will have visual checks every 30 minutes until the next mental health visit (May 14, 2024) which will result in an evaluation of frequency of visual checks. Visual checks will be monitored on the facility electronic charting, via tasks, program. 6. Licensed Nurse meeting held on 04/23/24 at 04:00 PM to discuss elopement assessment values. The surveyor verified the facility implemented the above corrective actions to remove the immediacy, while onsite on 04/30/24 at 04:32 PM. The deficient practice remained at a scope and severity of D.

The facility census totaled 14 residents with seven residents residing on hall 100, and one bath house used to bathe those seven residents on that hall. Based on observation, interview, and record review the facility failed to ensure call light accessibility to these seven residents when they received showers in this one bath house. The shower area lacked a cord on the call light located next to the shower making it inaccessible to residents receiving showers and staff providing showers, in case of emergency. Findings include: - Tour of the facility on 05/09/23 at 07:30 AM, revealed a shower room on the hall 100. While checking the room there was a call light box on the wall next to the shower with no pull cord attached for residents or staff to use in case of an emergency. Interview on 05/09/23 at 08:00 AM, Maintenance staff U reported he was aware of the cord being gone and was told about it several days ago, but just had not gotten around to replacing it yet. On 05/10/23 at 12:33 PM administrative staff A reported she was surprised about the cord. She thought she had taken care of that last week but would make sure it was corrected. Review of the facility policy named Nurse Alert System dated 01/17/23 revealed the facility was equipped with a call light system that included a wireless pager system. When the system is activated by an elder, an alert is sent to the pagers of the Direct Care Staff until it is answered and cleared. The nurse call system will be checked, and checks documented by the Environmental Services Staff on a routine basis. The facility failed to ensure call light accessibility to these seven residents when they received showers in this one bath house. The shower area lacked a cord on the call light located next to the shower making it inaccessible to residents receiving showers and staff providing showers, in case of emergency.

The facility reported a census of 14 residents and identified 1 with cognitive impairment and self-mobile. Based on interview, observation and record review the facility failed to ensure a safe environment for the one resident with the failure to secure hazardous chemicals in the facility's beauty shop. Findings include: - On 05/09/23 at 07:30 AM, observation of the facility beauty shop revealed two containers of hair spray unsecured. The hair spray bottles revealed warning labels to keep out of reach of children. On 05/09/23 at 08:00 AM, with notification to Maintenance Staff U of the unlocked chemicals, revealed the hair spray should be secured in a locked cabinet. On 05/10/23 at 12:57 PM, Licensed Nurse G reported that all chemicals in the building needed to be locked inside a cabinet. On 05/10/23 at 12:33 PM, Administrative Nurse D reported all chemicals should be locked inside a cabinet when not in use. The facility's Control of Hazardous Chemicals policy, dated 05/12/21 documented that all substances with warning labels, including but not limited to keep out of reach of children were to Always be locked at all times to avoid accessibility of any elder in the facility. The facility failed to ensure a safe environment for the one resident of the facility with cognitive impairment and self-mobile, related to accident hazards of unsecured chemicals in the facility's beauty shop.

The facility reported a census of 15 residents, with eight residents included in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to follow-up on the recommendations made by the pharmacist for Resident (R)1, R4, R7 and R14 medications. Findings included: - The August 2021 Physician Order Summary revealed R1 with the following diagnoses: anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), pain, irritability and anger, and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness.) The Annual Minimum Data Set (MDS) dated [DATE] revealed R1 was rarely or never understood, a Brief Interview for Mental Status (BIMS) score could not be completed, and noted R1 as moderately impaired for cognitive skills for daily decision-making. R1 received an antipsychotic, antianxiety, and an antidepressant medication daily in the seven-day review period. The Quarterly MDS dated [DATE] revealed R1 was rarely or never understood. A BIMS could not be completed and R1 was moderately impaired for cognitive skills for daily decision-making. R1 received daily antipsychotic, antianxiety, and an antidepressant medication. The Cognitive Loss/Dementia Care Area Assessment (CAA) revealed due to traumatic head injury R1 required assistance with all decision-making processes. Review of the [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 10/01/20 revealed R1 with a diagnosis of anxiety. He would at times refuse care by trying to hit staff and making an angry face. R1 received [CONDITION(S)] medications for depression, anxiety, irritability, and anger. Review of the Care Plan revealed R1 received [MEDICATION(S)] (an antidepressant medication also known as [MEDICATION(S)]) for depression. Review of the Physician Order dated 11/27/19 revealed R1 received [MEDICATION(S)] (an antidepressant medication) 100 milligrams (mg), one tablet through a G-Tube (a tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids) daily for major depressive disorder. Review of the monthly pharmacist Medication Regimen Review (MMR) revealed the pharmacist recommended a GDR be completed for [MEDICATION(S)] ([MEDICATION(S)]) during the months of 07/20, 01/21, 02/21 and 07/21. Review of the R1's Electronic Health Record (EHR) from 07/20 to present revealed no evidence of an attempted GDR or physician response. An observation on 08/25/21 at 10:42 AM revealed R1 sat in a wheeled recliner in the living room and the staff played a radio for him and then pushed R1 around to the various staff offices to say hello. R1 had a smile on his face and did not exhibit any negative behaviors. During an interview on 08/25/21 at 01:49 PM, Certified Nurse Aide (CNA) C stated R1 did not exhibit any negative behaviors towards staff. During an interview on 08/30/21 at 10:40 AM, Licensed Nurse (LN) E stated R1 exhibited negative behaviors like swatting at staff. During an interview on 08/30/21 at 11:40 AM, Administrative Nurse D confirmed the recommended GDRs were not completed for R1. Administrative Nurse D stated the pharmacist sent all GDR requests to the physicians. Administrative Nurse D stated she sent faxes to the physicians to follow-up on pharmacist recommendations and stated she expected the physicians to respond to the GDR request within 48-72 hours. Administrative Nurse D stated if she did not get a response from the physician, she would call them. Review of the Drug Regimen Review policy dated 02/17/20 revealed, The consultant pharmacist would perform a drug regimen on each elder .All medication orders would be reviewed for .Need for gradual dose reduction based on manufacturer's recommendations and regulatory requirements. The facility failed to ensure the physician responded to a GDR recommendation concerning [MEDICATION(S)] ([MEDICATION(S)]) for R1. - Review of the August 2021 Physician Order Summary revealed R7 had a diagnosis of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. R7 had a total mood severity score of three, which indicated minimal depression and received an antidepressant daily. The Quarterly MDS dated [DATE] revealed a BIMS score of nine, indicating moderate cognitive impairment. R7 had a total mood severity score of two, which indicated minimal depression and received an antidepressant daily. Review of the [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 03/18/21 revealed R7 was medicated with [CONDITION(S)] medications for multiple psychiatric diagnosis. The consultant pharmacist was to review medications and initiate gradual dose reductions to the Primary Care Physician (PCP). The Care Plan dated 10/21/18 revealed R7 used [CONDITION(S)] medications and [MEDICATION(S)] for depression. Review of the Physician Order dated 11/26/19 revealed R7 received, [MEDICATION(S)] (antidepressant medication also known as [MEDICATION(S)]) 20 milligrams (mg), one tablet, by mouth daily for major depressive disorder. Review of the pharmacist Medication Regimen Review (MMR) dated 10/18/20 revealed the pharmacist recommended a GDR be completed for [MEDICATION(S)] from 20 mg to 10 mg. Review of the R7's Electronic Health Record (EHR) revealed no evidence of an attempted GDR or physician response. An observation on 08/25/21 at 08:48 AM revealed R7 sat in her wheelchair in the dining room for breakfast. R7 was alert and did not appear sedated and did not exhibit any negative behaviors. During an interview on 08/25/21 at 01:47 PM, Certified Nurse Aide (CNA) C stated R7 has never exhibited any negative behaviors towards staff or other residents. During an interview on 08/30/21 at 10:34 AM, Licensed Nurse (LN) E stated R7 did not appear to be depressed. During an interview on 08/30/21 at 11:40 AM, Administrative Nurse D confirmed the recommended GDR for [MEDICATION(S)] was not completed for R7. Administrative Nurse D stated the pharmacist sent all GDR requests to the physicians. Administrative Nurse D stated she sent faxes to the physicians to follow-up on pharmacist recommendations and stated she expected the physicians to respond to the GDR request within 48-72 hours. Administrative Nurse D stated if she did not get a response from the physician, she would call them. Review of the Drug Regimen Review policy dated 02/17/20 revealed, The consultant pharmacist would perform a drug regimen on each elder .All medication orders would be reviewed for .Need for gradual dose reduction based on manufacturer's recommendations and regulatory requirements. The facility failed to ensure the physician responded to a GDR recommendation concerning [MEDICATION(S)] for R7. - R4's diagnoses from the Physician's Order dated 05/01/21 revealed the following : major depressive disorder recurrent severe with psychotic symptoms (major mood disorder), [CONDITION(S)] disorder [CONDITION(S)] type (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and traumatic brain injury (A head injury causing damage to the brain). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The resident had a mood severity score of two for mood at a two, not indicative of depression. R4 received antipsychotic, antidepressant, and hypnotic medications daily during the seven day look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/09/20 revealed R4 received antipsychotic medications for control of behaviors due to psychotic diagnosis. The Care Plan dated 06/25/21 revealed R 4 was at risk for a decline in psychosocial well being due to [CONDITION(S)] medications and history of traumatic brain injury. Current medications included [MEDICATION(S)] (antidepressant) and [MEDICATION(S)] (treat [CONDITION(S)], [CONDITION(S)]). The Pharmacy Medication Recommendation dated 12/22/20 revealed a recommendation that R4 was due for a dose reduction on the medication [MEDICATION(S)] 50 milligrams (mg) since November 2019. R4 would be a good candidate to decrease this medication to 25 mg at this time. The Electronic Medical Record from 12/20/20 to 08/26/21 revealed the medication [MEDICATION(S)] 50 mg continued without a dose reduction attempted. Observation of R4 on 08/25/21 at 11:46 AM in the dining room for lunch sits by himself if questions are asked by the staff R4 will give short answers no abnormal mouth movement or abnormal hand movements noted. Observed R4 08/25/21 at 03:16 PM going outside to smoke accompanied by a staff member returned inside facility at 3:22 PM went straight to his room and shut the door no behaviors noted. Observed R4 08/26/21 at 08:27 AM in dining room for breakfast sits by himself does not socialize with the staff or other residents no behaviors noted. Interview with Pharmacist F on 08/30/21 at 11:30 AM revealed she sends the recommendations to the physician and if no response will continue the dose, but would leave recommendations for the facility to fax if no changes in one month. She would make another recommendation in six months if still no response. Interview with Administrative Nurse D on 08/30/21 at 11:45 AM revealed the pharmacist sent the recommendations to the Director of Nursing and the physician to be followed up with in 48 to 72 hours and if still no response, would contact the physician office for completion. The facility policy Drug Regimen Review dated 02/20/17 revealed the consultant pharmacist will perform a drug regimen review on each elder living in this facility at the time of the elder's admission to the facility and at least monthly and when requested by team members of the facility, but no longer than every six months. The Director of Nursing will track physician response reports and if no response within five working days the or designee would place a phone call to the physician for a phone order response. If no response from the physician within 10 days working days, the facility's Medical Director would be contacted for requested response/recommendations. All responses would be documented in the elder's clinical record. The facility failed to follow-up on a pharmacist recommendation for a dose reduction for [MEDICATION(S)] for R4. - R14's Physician Orders dated 06/15/21 revealed a diagnosis of major depressive disorder (a mood disorder). The Annual Minimum Date Set dated 07/22/21 revealed a Brief Interview for Mental Status score of 15 indicating intact cognition. R14 received daily antidepressant medications during the seven-day look back period. The Physician Orders dated 08/26/21 included an order for [MEDICATION(S)] XR (extended release) 75 milligrams (mg) daily for major depressive disorder with a start date of 01/29/21. The Pharmacy Reviews dated 07/22/21 included a pharmacist recommendation R14 would be a good candidate for decreasing the dosage of [MEDICATION(S)] 75 mg, R14 received since 01/29/21, at this time. Observed R14 on 08/25/21 at 08:15 AM ambulating with walker in the hallway smiling and laughing with the staff. Interview with Pharmacist F on 08/30/21 at 11:30 AM revealed she sends the recommendations to the physician and if no response will continue the dose, but would leave recommendations for the facility to fax if no changes in one month. She would make another recommendation in six months if still no response. Interview with Administrative Nurse D on 08/30/21 at 11:45 AM revealed the pharmacist sent the recommendations to the Director of Nursing and the physician to be followed up with in 48 to 72 hours and if still no response would contact the physician office for completion. The facility policy dated 02/20/17 revealed the consultant pharmacist will perform a drug regimen review on each elder living in this facility at the time of the elder's admission to the facility and at least monthly and when physician for a phone order response. If no response from the physician within 10 days working days, the facility's Medical Director would be contacted for requested response/recommendations. All responses would be documented in the elder's clinical record. The facility failed to follow-up on a pharmacist recommendation for a dose reduction for [MEDICATION(S)] for R14.

The facility had a census of 15 residents with eight residents in the sample and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure four of five residents did not receive unnecessary medications when the facility failed to ensure the physician responded to a Gradual Dose Reduction (GDR) recommendation to be completed on [CONDITION(S)] medications (any medication capable of affecting the mind, emotions, and behavior) for Residents (R)1, R4, R7 and R14. Findings included: - Review of the August 2021 Physician Order Summary revealed R1 had the following diagnoses: anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), pain, irritability and anger, and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness.) The Annual Minimum Data Set (MDS) dated [DATE] revealed R1 was rarely or never understood. A Brief Interview for Mental Status (BIMS) score could not be completed and noted R1 as moderately impaired for cognitive skills for daily decision-making. R1 received an antipsychotic, antianxiety, and an antidepressant medication daily in the seven-day review period. The Quarterly MDS dated [DATE] revealed R1 was rarely or never understood. A BIMS could not be completed and R1 was moderately impaired for cognitive skills for daily decision-making. R1 received daily antipsychotic, antianxiety, and an antidepressant medication. The Cognitive Loss/Dementia Care Area Assessment (CAA) revealed due to traumatic head injury R1 required assistance with all decision-making processes. Review of the [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 10/01/20 revealed R1 had a diagnosis of anxiety. He would at times refuse care by trying to hit staff and making an angry face. R1 received [CONDITION(S)] medications for depression, anxiety, irritability, and anger. Review of the Care Plan revealed R1 received [MEDICATION(S)] (an antidepressant medication also known as [MEDICATION(S)]) for depression. Review of the Physician Order dated 11/27/19 revealed R1 received [MEDICATION(S)] (an antidepressant medication) 100 milligrams (mg), one tablet through a G-Tube (a tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids) daily for major depressive disorder. Review of the monthly pharmacist Medication Regimen Review (MMR) revealed the pharmacist recommended a GDR be completed for [MEDICATION(S)] ([MEDICATION(S)]) during the months of 07/20, 01/21, 02/21 and 07/21. Review of the R1's Electronic Health Record (EHR) from 07/20 to present revealed no evidence of an attempted GDR or physician response. An observation on 08/25/21 at 10:42 AM revealed R1 sat in a wheeled recliner in the living room and the staff played a radio for him and then pushed R1 around to the various staff offices to say hello. R1 had a smile on his face and did not exhibit any negative behaviors. During an interview on 08/25/21 at 01:49 PM, Certified Nurse Aide (CNA) C stated R1 did not exhibit any negative behaviors towards staff. During an interview on 08/30/21 at 10:40 AM, Licensed Nurse (LN) E stated R1 exhibited negative behaviors like swatting at staff. During an interview on 08/30/21 at 11:40 AM, Administrative Nurse D confirmed the recommended GDRs were not completed for R1. Administrative Nurse D stated the pharmacist sent all GDR requests to the physicians. Administrative Nurse D stated she sent faxes to the physicians to follow-up on pharmacist recommendations and stated she expected the physicians to respond to the GDR request within 48-72 hours. Administrative Nurse D stated if she did not get a response from the physician, she would call them. Review of the Drug Regimen Review policy dated 02/17/20 revealed, The consultant pharmacist would perform a drug regimen on each elder .All medication orders would be reviewed for .Need for gradual dose reduction based on manufacturer's recommendations and regulatory requirements. The facility failed to ensure the physician responded to a GDR recommendation concerning [MEDICATION(S)] ([MEDICATION(S)]) for R1. - Review of the August 2021 Physician Order Summary revealed R7 had a diagnosis of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. R7 had a total mood severity score of three, which indicated minimal depression and received an antidepressant daily. The Quarterly MDS dated [DATE] revealed a BIMS score of nine, indicating moderate cognitive impairment. R7 had a total mood severity score of two, which indicated minimal depression and received an antidepressant daily. Review of the [CONDITION(S)] Drug Use Care Area Assessment (CAA) dated 03/18/21 revealed R7 was medicated with [CONDITION(S)] medications for multiple psychiatric diagnosis. The consultant pharmacist was to review medications and initiate gradual dose reductions to the Primary Care Physician (PCP). The Care Plan dated 10/21/18 revealed R7 used [CONDITION(S)] medications and [MEDICATION(S)] for depression. Review of the Physician Order dated 11/26/19 revealed R7 received, [MEDICATION(S)] (antidepressant medication also known as [MEDICATION(S)]) 20 milligrams (mg), one tablet, by mouth daily for major depressive disorder. Review of the pharmacist Medication Regimen Review (MMR) dated 10/18/20 revealed the pharmacist recommended a GDR be completed for [MEDICATION(S)] from 20 mg to 10 mg. Review of the R7's Electronic Health Record (EHR) revealed no evidence of an attempted GDR or physician response. An observation on 08/25/21 at 08:48 AM revealed R7 sat in her wheelchair in the dining room for breakfast. R7 was alert and did not appear sedated and did not exhibit any negative behaviors. During an interview on 08/25/21 at 01:47 PM, Certified Nurse Aide (CNA) C stated R7 has never exhibited any negative behaviors towards staff or other residents. During an interview on 08/30/21 at 10:34 AM, Licensed Nurse (LN) E stated R7 did not appear to be depressed. During an interview on 08/30/21 at 11:40 AM, Administrative Nurse D confirmed the recommended GDR for [MEDICATION(S)] was not completed for R7. Administrative Nurse D stated the pharmacist sent all GDR requests to the physicians. Administrative Nurse D stated she sent faxes to the physicians to follow-up on pharmacist recommendations and stated she expected the physicians to respond to the GDR request within 48-72 hours. Administrative Nurse D stated if she did not get a response from the physician, she would call them. Review of the Drug Regimen Review policy dated 02/17/20 revealed, The consultant pharmacist would perform a drug regimen on each elder .All medication orders would be reviewed for .Need for gradual dose reduction based on manufacturer's recommendations and regulatory requirements. The facility failed to ensure the physician responded to a GDR recommendation concerning [MEDICATION(S)] for R7. - R4's diagnoses from the Physician's Order dated 05/01/21 revealed the following: major depressive disorder recurrent severe with psychotic symptoms (major mood disorder), [CONDITION(S)] disorder [CONDITION(S)] type (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and traumatic brain injury (A head injury causing damage to the brain). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The resident had a mood severity score of two for mood at a two, not indicative of depression. R4 received antipsychotic, antidepressant, and hypnotic medications daily during the seven day look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/09/20 revealed R4 received antipsychotic medications for control of behaviors due to psychotic diagnosis. The Care Plan dated 06/25/21 revealed R4 was at risk for a decline in psychosocial well being due to [CONDITION(S)] medications and history of traumatic brain injury. Current medications included [MEDICATION(S)] (antidepressant) and [MEDICATION(S)] (treat [CONDITION(S)], [CONDITION(S)]). The Pharmacy Medication Recommendation dated 12/22/20 revealed a recommendation that R4 was due for a dose reduction on the medication [MEDICATION(S)] 50 milligrams (mg) since November 2019. R4 would be a good candidate to decrease this medication to 25 mg at this time. The Electronic Medical Record from 12/20/20 to 08/26/21 revealed the medication [MEDICATION(S)] 50 mg continued without a dose reduction attempted. Observation of R4 on 08/25/21 at 11:46 AM in the dining room for lunch sits by himself if questions are asked by the staff R4 will give short answers no abnormal mouth movement or abnormal hand movements noted. Observed R4 08/25/21 at 03:16 PM going outside to smoke accompanied by a staff member and then R4 returned inside facility at 03:22 PM and went straight to his room, shut the door, with no behaviors noted. Observed R4 08/26/21 at 08:27 AM sat in dining room for breakfast by himself and did not socialize with the staff or other residents. Interview with Pharmacist F on 08/30/21 at 11:30 AM revealed she sends the recommendations to the physician and if no response will continue the dose, but would leave recommendations for the facility to fax if no changes in one month. She would make another recommendation in six months if still no response. Interview with Administrative Nurse D on 08/30/21 at 11:45 AM revealed the pharmacist sent the recommendations to the Director of Nursing and the physician to be followed up with in 48 to 72 hours and if still no response, would contact the physician office for completion. Review of the Drug Regimen Review policy dated 02/17/20 revealed, The consultant pharmacist would perform a drug regimen on each elder .All medication orders would be reviewed for .Need for gradual dose reduction based on manufacturer's recommendations and regulatory requirements. The facility failed to ensure R4 did not recieve unecessary medications when the facility follow-up on a pharmacist recommendation for a dose reduction of [MEDICATION(S)] for R4. - R14's diagnosis from the Physician Orders dated 06/15/21 revealed a diagnosis of major depressive disorder (a mood disorder). The Annual Minimum Date Set dated 07/22/21 revealed a Brief Interview for Mental Status score of 15 indicating intact cognition. Review of the medication section revealed R14 received 7 days of antidepressant during the look back period. The Physician Orders dated 08/26/21 included an order for [MEDICATION(S)] XR (extended release) 75 milligrams (mg) daily for major depressive disorder with a start date of 01/29/21. The Pharmacy Reviews dated 07/22/21 included a pharmacist recommendation R14 received [MEDICATION(S)] 75 mg since 01/29/21 and would be a good candidate to decrease the dose at this time. Review of the R14's Electronic Health Record (EHR) from 07/22/21-08/30/21 revealed no evidence of an attempted decrease in [MEDICATION(S)] dosage. Observed R14 on 08/25/21 at 08:15 AM ambulating with walker in the hallway smiling and laughing with the staff. Interview with Pharmacist F on 08/30/21 at 11:30 AM revealed she sends the recommendations to the physician and if no response will continue the dose, but would leave recommendations for the facility to fax if no changes in one month. She would make another recommendation in six months if still no response. Interview with Administrative Nurse D on 08/30/21 at 11:45 AM revealed the pharmacist sent the recommendations to the Director of Nursing and the physician to be followed up with in 48 to 72 hours and if still no response would contact the physician office for completion. The facility policy dated 02/20/17 revealed the consultant pharmacist will perform a drug regimen review on each elder living in this facility at the time of the elder's admission to the facility and at least monthly and when physician for a phone order response. If no response from the physician within 10 days working days, the facility's Medical Director would be contacted for requested response/recommendations. All responses would be documented in the elder's clinical record. The facility failed to ensure R14 did not receive unecessary medications when the facility did not follow-up on a pharmacist recommendation for a dose reduction for [MEDICATION(S)] for R14.

The facility census totaled 15 residents with eight included in the sample. Based on observation, interview, and record review the facility failed to remove expired medications from the refrigerator to include two single dose vaccination injections: one Influenza vaccine (flu vaccine) with an expiration date 06/30/21 and one single dose injection Pneumococcal-13 (pneumonia vaccine) with an expiration date 07/21. Findings included: - Observation of the Medication Room on 08/25/21 at 11:31 AM revealed the refrigerator contained two expired injectable vaccinations. A single dose of Influenza vaccine with the expiration date of 06/30/21 and a single dose of Pneumococcal-13 vaccine with the expiration date of 07/21 Interview with Licensed Nurse (LN) E on 08/30/21 at 09:28 AM revealed the medication room should be check weekly for expired medication by the night nurse. Interview with Administrative Nurse D on 08/30/21 at 10:52 AM revealed she expected the nursing staff to remove medications when expired. The facility policy Medication Labeling and Storage dated 09/18/19 lacked information regarding the disposal of expired medications. The facility failed to remove two expired injectable vaccinations from the medication room refrigerator.

The facility had a census of 15 residents with eight residents in the sample. Based on interview and record review the facility failed to ensure the infection preventionist completed specialized training in infection control and prevention. This had the potential of affecting all residents in the facility. Findings included: - An Entrance Conference interview completed on 08/24/21 at 08:50 AM identified Administrative Nurse B as the Infection Control Preventionist (ICP) for the facility. Review of information and documentation provided by the facility on 08/25/21 revealed the facility lacked evidence of specialized training in infection prevention and control completed by Administrative Nurse B. On 08/25/21 at 04:10 PM, Administrative Nurse B stated she had been the infection preventionist for about one and a half years but had not completed any specialized training for the position. Interview on 08/30/21 at 09:26 AM with Administrative Staff A revealed Administrative Nurse B had been in her position for about one and a half years and stated she hoped Administrative Nurse B would complete her training by the end of the year. Review of the undated Fowler Residential Care Infection Control Policy revealed, The Infection Control Preventionist .have completed specialized training in infection prevention and control . The facility failed to ensure the infection preventionist completed specialized training in infection prevention and control. This failure had the potential to affect all residents in the facility.

The facility census totaled 13. Based on observation, interview, and record review the facility failed to ensure the facilty utilized a chemical cleaner which eliminated [MEDICAL CONDITION] (C. difficile - contagious bacteria characterized by foul smelling frequent bowel movements) which placed all 13 residents at risk, if an outbreak occurred. Findings included: - Interview with Housekeeping Staff (HS) U on 11/21/19 at approximately 09:45 AM revealed staff used the chemical BNC-15 for all surface cleaning, no matter the condition of the room and/or knowledge of resident possible/actual infection. Interview with Licensed Nurse (LN) G on 11/21/19 at 10:07 AM revealed the facility no longer used bleach and only utilized the chemical BNC-15 for cleaning all surfaces because they understood it took care of all bacteria types. On 11/21/19 at approximately 10:15AM revealed a bottle of the chemical BNC-15 with a label at the nurse's station. LN G stated according to the label BNC-15 would not be effective against [DIAGNOSES REDACTED]icile. Interview with Administrative Staff A on 11/21/19 at approximately 11:20 AM revealed when the facility started cleaning with the chemical BNC-15 they were told it killed everything and the facility no longer needed to use bleach. The facility reported their policy directed them to use bleach for cleaning rooms with [DIAGNOSES REDACTED]icile. Review of the facility policy [MEDICAL CONDITION] dated 02/02/17 revealed the facility would ensure adequate cleaning and disinfection procedures of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently, would be cleaned with an Environmental Protection Agency (EPA)-registered sodium hypochlorite-based (household bleach) disinfectant with a 1:9 water ratio. The facility failed to ensure the utilization of a chemical which would eliminate the bacteria [MEDICAL CONDITION] (C.difficile) if an outbreak were to occur.

The facility reported a census of 13 residents with four sampled for activities. Based on interview, observation, and record review the facility failed to provide an ongoing activity program for the residents of the facility (which included weekends) and further failed to invite and include all residents in the activity programs available. Findings included: - Observation on 11/19/19 at 08:00 AM before exercise group time of 09:00 AM Activity Staff (AS) Z sat at a table in the commons area where she worked on the activity calendar. AS Z did not invite all residents to come to the group activity scheduled at 09:00 AM, to which only two residents attended. On 11/19/19 at 02:19 PM the Resident Council group reported there were no activities offered or available on the weekends. Observation on 11/19/19 at 03:00 PM revealed three residents attended BINGO. Observation prior to the start of BINGO lacked any observed invitation extended to the other residents of the facility. Observation on 11/19/19 at 04:25 PM revealed there were no one-on-one activities witnessed on this day. Review of the Activity Calendar posted and available for the residents had only Activity of Choice noted on each weekend through the month of (MONTH) 2019. An interview on 11/19/19 at 02:19 PM with AS Z revealed she did not invite all residents to the daily activities personally because she knew they could not attend. An interview on 11/21/19 at 08:11 AM with Certified Nurse Aide (CNA) P revealed he felt the facility lacked activities. CNA P stated the activity department could do more with the residents. CNA P confirmed the residents did tend to spend extra time in their rooms. An interview on 11/21/19 at 09:50 AM with CNA Q revealed the activities in the facility were lacking. CNA Q stated multiple staff tried to report the activity concerns and nothing changed. An interview on 11/20/19 at 10:57 AM with Licensed Nurse (LN) H revealed the facility lacked activities. LN H stated AS Z did not invite all of the residents to activities and the residents felt the activities were boring. An interview on 11/20/19 at 01:58 PM with Administrative Staff D revealed she felt there were plenty of activities for the residents to do and stated the resident chose to be in their rooms. An interview on 11/19/19 at approximately 04:00 PM with Administrative Staff A revealed she expected AS Z to ask or invite all residents to activities and givie the resident the option to come or not. Administrative Staff A stated she had no way of tracking refusals but stated she would come up with one. She reported the facility used to have a bigger turnout for activities, but the facility had a smaller group of residents. Administrative Staff A thought residents were bored and stated the staff were looking for more meaningful activities to regain resident interest. Review of the facilities Life Enhancement and Activity Programming policy dated 02/20/17 documented each resident would receive opportunities to experience pleasure of their choice each day. Everyone had something they enjoyed doing that brought them pleasure and it was the responsibility of the team members to offer options. The facility failed to provide an ongoing activity program for the residents of the facility (which included weekends), and further failed to invite and include all residents in the activity programs available.

The facility census totaled 13 with four residents reviewed for activities. Based on observation, interview, and record review the facility failed to maintain a dignified environment for residents who received Catholic Communion when staff announced the Catholic Communion in a derogatory tone. Findings included: - On 11/20/19 at approximately 10:30 AM Activity Staff (AS) Z sat in the commons area and read to approximately four residents. The front door alarm rang out and a representative from the Catholic Church entered the facility. The representative from the churched announced her presence and explained the purpose of her visit to AS Z and asked for the residents she would see. AS Z looked around for other staff and as two Certified Nurse Aides (CNA) entered the area, AS Z stated they needed to gather the Catholic residents because, The lady for the Catholic stuff is here. The two CNA's immediately left the area to gather the residents and escorted the Catholic Church representative to the resident's room. Interview with Administrative Staff A on 11/21/19 at approximately 11:00 AM revealed she expected staff to respect all residents no matter their religion or race. Administrative Staff A did not know about AS Z's body language or comment toward the resident's religion, but stated it would be addressed. Review of the facility policy Right to Dignity dated 02/20/17 revealed the facility would promote care for elders of the facility in a manner and in an environment that maintained and enhanced each elder's dignity and respect in full recognition of the elder's individuality. The facility failed to promote dignity and respect for residents' religious preferences.

The facility census totaled 13 with eight residents sampled. Based on observation, interview, and record review the facility failed to include treatment of [REDACTED]. Findings included: - Review of R6's signed Physician order [REDACTED]. Review of the 10/24/19 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the BIMS could not be completed R6 exhibited physical and verbal behaviors directed towards others and rejected cares one to three days of the seven day look back period. Review of the 07/25/19 Behavioral Symptoms Care Area Assessment (CAA) revealed the resident did have behavioral issues and would have management of behaviors including agitation, anger, and depression addressed in her care plan. Review of the resident's Care Plan initiated 02/22/18 revealed the following interventions: 10/23/19, R6 received an antipsychotic medication for her [DIAGNOSES REDACTED]. 10/31/18, if R6 becomes agitated, angry, hit or struck out, the staff were to help her not to hurt herself or others. She usually could not clearly say what made her so upset but staff were to ensure she was safe and to give her space. 03/21/19, R6 could demonstrate behaviors such has depression, anger, agitation and anxiety. Review of the 11/17/19 Nurse's Note revealed R6 became combative after staff attempted to clean a wound site located on the resident's nose. The staff sent a fax to the clinician to notify him of her skin tear obtained as well as her behaviors. Review of the treatment administration record (TAR) for (MONTH) 2019 revealed it lacked mention of a wound treatment for [REDACTED]. Interview with Licensed Nurse H on 11/20/19 at 10:57 AM revealed per the Director of Nursing instructions, treatments were not input on the TAR. LN H said the staff were to write an incident report when a situation occurred and were to write a progress note for assessments or treatments. The facility had standing orders for wound treatment but those were not placed in the resident's chart, making them patient specific. Interview with Administrative Nurse D on 11/20/19 at 01:58 PM revealed she did not expect skin tears or wounds to be placed on the MAR/TAR and she did not expect making standing orders patient specific for treatment. She reported treatments were taken care of via standing orders and were passed on through shift report. Administrative Nurse D expected her nurses to document assessments and treatments in a progress noted and stated she reviewed charts daily to ensure treatments were provided. Review of the undated facility policy Charting and Documentation revealed all observations, medications and services performed must be documented in the resident's clinical record but did not specifically address the treatment record. The facility failed to document treatments provided via standing orders in the resident's treatment administration record per standards of practice.

The facility census totaled 18 residents with 2 residents identified by the facility as at risk for elopement (occurs when a resident leaves the premises or a safe area without staff knowledge) and both were sampled. Based on observation, interview and record review the facility failed to review and revise the care plan for 2 of 2 residents in regards to exit seeking behavior (#1 and #2) Findings included: - The admission minimum data set (MDS) for resident #1 dated 8/21/16 revealed a brief interview for mental status (BIMS) score of 6 indicating severe cognitive impairment. He/she had no behaviors and was independent with activities of daily living (ADL). He/she required no assistive devices to ambulate and had no fall history. The quarterly MDS dated [DATE] included the same cognition with physical behavior towards others and other behaviors not towards others on 1-3 days of 7 day observation period and rejected care 1-3 days with no wandering behavior during the 7 day observation period. He/she ambulated independently but required limited assistance of one staff for bed mobility and transfers and extensive assist with dressing and toileting. The care area assessment (CAA) dated 8/22/16 revealed the following: The cognition CAA indicated the resident had an excellent long-term memory recall but the short-term memory fluctuated greatly. He/she could be reoriented easily then forgot again. He/she knew the location of his/her room, the dining room, and the east TV/lounge area where he/she enjoyed spending time with peers. The communication CAA indicated the resident had difficulty hearing and staff needed to speak his/her name first to gain attention. The activities of daily living CAA included the resident performed as much personal cares for him/herself as he/she could and at times would refuse help. The fall CAA identified the resident as unsteady when transitioning from one position to another and did not use assistive devices. The admission risk of elopement assessment dated [DATE] identified the resident as at risk for elopement related to cognitive impairment, independent ambulation, verbally expressed a desire to go home, wandered aimlessly and was a recent new admission and not accepting the situation. The assessment identified interventions of frequent monitoring of his/her whereabouts, recreational activities and staff awareness of resident's wander risk. The electronic care plan with a revision date of 2/22/17 included a problem of dementia (progressive mental disorder characterized by failing memory, confusion) and impaired cognition. He/she needed assistance with decision making. Staff should keep his/her routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. The care plan included a problem of elopement risk/wanderer with onset dated of 8/22/16. The plan included a goal of staff monitoring the resident's safety through the next review. The plan included interventions to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books. The care plan lacked a revision following the resident's elopement on 5/23/17. Review of the paper care plan in the nursing assistant care plan book revealed a sheet titled ADL Plan of Care with no date the sheet identified the resident as a fall risk, and independent with transfers, ambulation and toileting. It identified the resident with short-term memory problems and impaired decision making. Staff should check on the resident (did not specify how often, was handwritten without a date), he/she may need redirection to his/her room or reminded to use the bathroom. The resident thought he/she had 2 rooms sometimes (also hand written with no date). The care plan lacked information about his/her elopement risk, what interventions the resident needed related to elopement risk and failed to include an actual elopement on 5/23/17. Observation on 5/25/17 at 10:10 AM revealed the resident ambulated from his/her bathroom, walked into the hallway and into the adjacent east lounge area. At 10:12 AM he/she independently returned to his/her room and lay down in bed. Interview on 5/25/17 at 9:52 AM with direct care staff A revealed he/she worked all three shifts at the facility. He/she said the resident had confusion and would think he/she needed to go to church at 5:00 AM and it was not even Sunday. He/she did not know the resident was at risk for elopement or had tried the doors prior 5/23/17. Interview on 5/25/17 at 2:10 PM with direct care staff N revealed he/she reported previously seeing the resident go to the doors, push on them but not really trying to get out and could redirect him/her easily. Staff N said the resident frequently said he/she wanted to go home. He/she said the care plan book was how he/she knew what cares the resident needed. He/she looked at the nurse aide care plan book and confirmed it lacked information about elopement risk or actual elopement. Interview on 5/25/17 at 11:41 AM with licensed nurse P revealed he/she worked on the day and evening shifts. He/she reported seeing the resident on several occasion after supper walking around the back of the dining room and looking into the kitchen. The resident said he/she had a room over there. Then the nurse redirected the resident he/she said, I have 2 rooms here. The nurse indicated the resident's behavior of wandering and looking had increased since February/March 2017. He/she reported on occasion seeing the resident at the south door looking out, he/she would walk the halls looking at the pictures and would stop to look through the kitchen but had not entered it. He/she reported knowing the resident's elopement risk at what interventions to try by the care plan. Interview on 5/25/17 at 2:39 PM with administrative nurse C revealed an expectation for staff to complete the elopement risk assessment on admission with changes or an actual elopement. He/she said floor staff would receive a verbal notification if a resident was identified at risk. He/she expected the risk to be care planned and hoped it was also on the nurse aide care plan. He/she reported the nursing assistants refer to the paper care plan book for the basics they needed to know on how to care for the residents. At this time he/she reviewed the resident's nurse aide care plan and confirmed it lacked any information about elopement risk or interventions. He/she also confirmed the comprehensive care plan did not include the resident's recent exit-seeking behaviors or the actual elopement on 5/23/17. The facility's policy titled Quarterly Review of Care Plans dated 8/2006 included the care planning/interdisciplinary team is responsible for maintaining the resident's current status on the care plan. The team should update the care plan when there was a significant change in the resident's condition; a desired outcome was not met and at least quarterly. The facility failed to revise the comprehensive care plan to include the resident's recent exit seeking behavior and then actual elopement on 5/23/17. The facility also failed to ensure the care plan for the nursing assistants included the resident was assessed at risk for elopement and what behaviors to watch for and interventions to prevent elopement. - Review of the admission minimum data status (MDS) for resident #2 dated 6/6/16 revealed a brief interview for mental status (BIMS) score of 8 indicating moderate cognitive impairment. He/she displayed no behaviors and required extensive assistance of 2 staff with all activities of daily living (ADLs). The quarterly MDS dated [DATE] identified the resident with a BIMS score of 5 indicating severe cognitive impairment. He/she displayed verbal behaviors towards others on 4-6 days of the 7 day observation period, other behaviors on 1-3 days and rejected cares on 4-6 days of the observation period. He/she ambulated independently in his/her room and required supervision in the corridor and about the unit with limited assistance off the unit. The care area assessment (CAAs) with the 6/6/16 MDS included the cognitive loss CAA which indicated the resident had confusion and did not remember the time and place. He/she could be hard to redirect from what he/she wanted to do. His/her thoughts were jumbled at times and he/she had difficulty communicating his/her needs. The activities for daily living CAA indicated the resident had a history of [REDACTED]. He/she was unsteady, did not use the call light, and needed a front wheeled walker which he/she did not remember to use most of the time. The elopement risk assessment dated [DATE] indicated the resident was at risk related to cognitive loss, ambulatory and 2 elopements at home prior to admission. The assessment indicated the resident verbally expressed a desire to go home or would pack to go home or stay near the exit doors. He/she wandered aimlessly with a non-directed purpose. The assessment indicated the facility would provide frequent monitoring, recreational activities, and exercise and staff awareness of the resident's wander risk. The electronic care plan dated 2/27/17 included at risk for elopement with a goal of less episodes of wanting/trying to leave by staff redirection. The interventions included staff to make frequent visual checks of the resident, redirect the resident in times of confusion. Staff should try walking with the resident, have him/her listen or call family if necessary. The paper care plan used by the direct care staff was updated on 12/1/16 and identified the resident as a fall risk, he/she did not remember to use call light and required supervision for independent transfers and walked with a walker. The plan identified the resident had short term memory loss, impaired decision making and wore glasses. The care plan lacked any information about the resident's elopement risk. Review of the nursing notes between 3/23/17 and 5/25/17 revealed on 3/30/17 at 1:45 PM the resident had aggressive behavior towards staff and exit seeking behavior. He/she attempted to leave out the front door looking for family. Staff attempted to redirect the resident with food and fluids and was unsuccessfully. The nurse administered as needed medication for the behavior which was successful. On 4/19/17 at 12:39 PM the resident re-arranged his/her closet and dresser drawers while stating Think I need to stay today maybe I'll go home tomorrow. On 5/12/17 at 4:51 PM the resident started the shift agitated and wandering. After supper the resident brought his/her flowers to the nursing station and said he/she was going home. Observation on 5/25/17 at 10:12 AM revealed the resident was walking about his/her room independently. After lunch approximately 1:10 PM the resident returned to his/her room and got into bed. At 2:46 PM the resident remained in bed watching TV. Interview on 5/25/17 at 9:52 AM with direct care staff A revealed he/she worked all three shifts at the facility. He/she said the resident had confusion and would go to the doors at times, might pack up his/her stuff or say he/she want to go home. Staff A said he/she would refer to the paper care plan if he/she needed information on how to care for a resident. Interview on 5/25/17 at 2:10 PM with direct care staff N revealed he/she said the resident frequently said he/she wanted to go home. He/she said the care plan book was how he/she knew what cares the resident needed. He/she looked at the nurse aide care plan book and confirmed it lacked information about the resident's elopement risk. Interview on 5/25/17 at 11:41 AM with licensed nurse P revealed he/she worked on the day and evening shifts. He/she would check the resident's electronic care plan for information about the resident's elopement risk. If the resident displayed exit seeking behavior staff would communicate through shift to shift report. The direct care staff had a paper care plan to refer to (pointed to a notebook in a cabinet at the nursing station). Interview on 5/25/17 at 2:39 PM with administrative nurse C revealed an expectation for staff to complete the elopement risk assessment on admission with changes or an actual elopement. He/she said floor staff would receive a verbal notification if a resident was identified at risk. He/she expected the risk to be care planned and hoped it was also on the direct care staff care plan. He/she reported the nursing assistants refer to the paper care plan book for the basics they needed to know on how to care for the residents. At this time he/she reviewed the resident's nurse aide care plan and confirmed it lacked any information about elopement risk or interventions. The facility's policy titled Quarterly Review of Care Plans dated 8/2006 included the care planning/interdisciplinary team is responsible for maintaining the resident's current status on the care plan. The team should update the care plan when there was a significant change in the resident's condition; a desired outcome was not met and at least quarterly. The facility failed to review/revise the resident's care plan which included the paper care plan used by direct care staff about the resident's elopement risk, exit seeking behavior and expressed desires to go home.

The facility census totaled 18 residents with 2 residents identified by the facility as at risk for elopement (occurs when a resident leaves the premises or a safe area without staff knowledge and both were sampled. Based on observation, interview and record review the facility failed to keep the environment free of accident hazards and provide adequate supervision for 1 of 2 sampled residents (#1) when he/she went through an open kitchen door without staff's knowledge and exited the facility on 5/23/17. Findings included: - The admission minimum data set (MDS) for resident #1 dated 8/21/16 revealed a brief interview for mental status (BIMS) score of 6 indicating severe cognitive impairment. He/she had no behaviors and was independent with activities of daily living (ADL). He/she required no assistive devices to ambulate and had no fall history. The quarterly MDS dated [DATE] included the same cognition with physical behavior towards others and other behaviors not towards others on 1-3 days of 7 day observation period and rejected care 1-3 days with no wandering behavior during the 7 day observation period. He/she ambulated independently but required limited assistance of one staff for bed mobility and transfers and extensive assist with dressing and toileting. The care area assessment (CAA) dated 8/22/16 revealed the following: The cognition CAA indicated the resident had an excellent long-term memory recall but the short-term memory fluctuated greatly. He/she could be reoriented easily then forgot again. He/she knew the location of his/her room, the dining room, and the east TV/lounge area where he/she enjoyed spending time with peers. The communication CAA indicated the resident had difficulty hearing and staff needed to speak his/her name first to gain attention. The ADL CAA included the resident performed as much personal cares for him/herself as he/she could and at times would refuse help. The fall CAA identified the resident as unsteady when transitioning from one position to another and did not use assistive devices. The admission risk of elopement assessment dated [DATE] identified the resident as at risk for elopement related to cognitive impairment, independent ambulation, verbally expressed a desire to go home, wandered aimlessly and was a recent new admission and not accepting the situation. The assessment identified interventions of frequent monitoring of his/her whereabouts, recreational activities and staff awareness of resident's wander risk. The electronic care plan with a revision date of 2/22/17 included a problem of dementia (progressive mental disorder characterized by failing memory, confusion) and impaired cognition. He/she needed assistance with decision making. Staff should keep his/her routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. The care plan included a problem of elopement risk/wanderer with onset dated of 8/22/16. The plan included a goal of staff monitoring the resident's safety through the next review. The plan included interventions to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books. The care plan lacked a revision following the resident's elopement on 5/23/17. Review of the paper care plan in the nursing assistant care plan book revealed a sheet titled ADL Plan of Care with no date the sheet identified the resident as a fall risk, and independent with transfers, ambulation and toileting. It identified the resident with short-term memory problems and impaired decision making. Staff should check on the resident (did not specify how often, was handwritten without a date), he/she may need redirection to where his/her room or reminded to use the bathroom. The resident thought he/she had 2 rooms sometimes (also hand written with no date). The care plan lacked information about his/her elopement risk, what interventions the resident needed related to elopement risk and failed to include the actual elopement on 5/23/17. Review of the nursing notes 3/1/17 thru 5/25/17 revealed: 5/5/17 at 1:40 PM a nursing note indicated at 10:40 AM staff observed the resident coming from the east hall towards the nursing station. The nurse asked the resident if he/she was looking for a family member who had already left and the resident replied, I know. The resident kept walking past he nursing station towards the west employee exit. The nurse offered the resident something cold to drink and he/she said, No, I want to go home and then pushed on the west employee exit door which was locked and would not open. The nurse indicated he/she would monitor the resident and advise the oncoming shift. 5/12/17 at 4:46 AM staff noted the resident had been up and down all night. He/she had wandered the halls and did not receive redirection well. 5/13/17 at 11:32 AM the nurse wrote, at about 7:40 AM staff visualized the resident walking out of his/her room and starting down the hall. Staff approached the resident and asked, Would you like to go to the dining room and have a cup coffee? The resident said, No, shut up. The resident used his/her arm to push the staff member away and kept walking, then going into dining room with staff at his/her side. The nurse entered the dining room, walked behind the resident when the resident tried to get into the kitchen. The nurse closed the door and tried to redirect the resident away from the kitchen. The resident swung his/her arm at the nurse and yelled, Leave me alone! Staff then walked behind the resident and followed him/her while he/she wandered around the facility. The nurse visualized the resident again with exit-seeking behavior by trying to open the laundry door which was locked. An entry on 5/23/17 at 9:01 PM indicated at approximately. 6:48 PM staff found the resident wandering outside of building by the kitchen door when staff assisted 2 other residents outside. The nurse knocked on the kitchen door and dietary staff D answered the door and assisted the resident inside. The nurse assessed the resident for injury with none noted and notified the physician, family and administrative staff. The resident could not say how he/she got outside and stated he/she was headed home. During tour on 5/25/17 at 8:05 AM, observation revealed the exit door from the east and west hall, the employee entrance and the front door remained locked when the door handle was depressed. The facility identified the doors as magnetically locked and only opens with the keypad code entry or the fire alarm. At 8:13 AM observation revealed 2 doors which entered the kitchen. One door located beside the dishwashing area was open and another door which led to a hall and storage was locked. Administrative nurse C identified the hall door was open as per usual on 5/23/17 and led directly back to the exterior door leading into the parking lot where staff found the resident after his/her elopement and was the presumed point of exit. Observation at this time revealed the door opened freely from the inside but once closed, the door locked from the outside. Observation at this time also revealed when staff were washing dishes he/she could not supervise the open doorway because his/her back would be to the area. Observation on 5/25/17 at 10:10 AM revealed the resident ambulated from his/her bathroom, walked into the hallway and into the adjacent east lounge area. At 10:12 AM he/she independently returned to his/her room and lay down in bed. Interview on 5/25/17 at 8:14 AM with dietary staff E revealed the door from the dining room to the kitchen which led to the hall and storage was always kept open before the incident of 5/23/17 and since the incident staff were keeping it shut and locked. Interview on 5/25/17 at 8:15 AM with dietary staff F revealed the door used to be open during usual kitchen hours but now it was shut and locked. Interview on 5/25/17 at 9:52 AM with direct care staff A revealed he/she worked all three shifts at the facility. He/she worked the evening shift on 5/23/17. He/she reported assisting residents in the dining room and he/she observed the resident at the dining room table at approximately 6:20 PM. At about 7:00 PM he/she left the dining room to assist another resident. He/she said the resident had confusion and would think he/she needed to go to church at 5:00 AM and it was not even Sunday. He/she did not know the resident was at risk for elopement or had tried the doors prior to that day. Interview on 5/25/17 at 12:47 PM direct care staff B reported he/she returned to the facility on [DATE] around 6:00 PM and the resident was in the dining room with staff. At about 6:30 PM he/she saw the resident and another resident leave the dining room. Resident #1 sat in a red chair in the lobby area while staff B and the other resident headed to his/her office. At about 6:45 PM staff B returned to the lobby area and saw resident #1 was no longer there. A written statement from dietary staff G said he/she was wiping off the dining room tables after supper on 5/23/17. He/she reported the resident wandered around in the dining room, went to the kitchen entrance by the dishwashing area and stood. Staff G told him/her that was the kitchen and he/she went back to washing tables. He/she did not see the resident enter the kitchen and dietary staff H washed dishes at this time. A written statement from dietary staff H revealed at approximately 6:30 PM on 5/23/17 while putting dishes away the resident walked up to the door by the dishwashing room. He/she told the resident it was the kitchen and he/she walked back towards the dining hall. Staff H reported he/she did not see the resident enter the kitchen. Then approximately 10-15 minutes later licensed nurse J knocked on the delivery door and when he/she opened the door the resident was there. Interview on 5/25/17 at 11:24 AM with direct care staff K when asked how he/she knew residents who were at risk for wandering or getting into places they should not, he/she responded by the length of time knowing them and their usual habits. He/she said the resident did not wander aimlessly but was purposeful in leaving his/her room to the east lounge area or walk to the lobby and sit down or going to the dining room. He/she had not seen the resident try any exit doors but had heard him/her say he/she wanted to leave and thought he/she was going home. Staff K said staff should redirect the resident with a snack, drink or bathroom. He/she reported he/she seeing the resident stop at the kitchen door before but staff usually saw him/her and redirected him/her from the door. Interview on 5/25/17 at 12:22 PM with housekeeping staff L and housekeeping staff M revealed neither knew which residents were at risk for elopement and could not remember when they received training on the facility's elopement policy and procedures. Interview on 5/25/17 at 2:10 PM with direct care staff N revealed he/she was assisting other residents down the hall and did not have knowledge of the resident exiting the facility on 5/23/17. He/she reported previously seeing the resident go to the doors, push on them but not really trying to get out and could redirect him/her easily. Staff N said the resident frequently said he/she wanted to go home. He/she said the care plan book was how he/she knew what cares the resident needed. He/she looked at the nurse aide care plan book and confirmed it lacked information about elopement risk or actual elopement. Interview on 5/25/17 at 11:41 AM with licensed nurse P revealed he/she worked on the day and evening shifts. He/she reported seeing the resident on several occasion after supper walking around the back of the dining room and looking into the kitchen. The resident said he/she had a room over there. Then the nurse redirected the resident he/she said, I have 2 rooms here. The nurse indicated the resident's behavior of wandering and looking had increased since February/March 2017. He/she reported on occasion seeing the resident at the south door looking out, he/she would walk the halls looking at the pictures and would stop to look through the kitchen but had not entered it. He/she did not know of a facility system for identifying residents at risk as far as a written list. The risk assessments were done by licensed nurse O, who notified the floor nurses and updated the care plan. Nurse P indicated the training on the facility's elopement policy and procedure occurred when he/she started in December of 2016 and it was to call administrative personnel. Interview on 5/25/17 at 2:39 PM with administrative nurse C revealed an expectation for staff to complete the elopement risk assessment on admission with changes or an actual elopement. He/she said floor staff would receive a verbal notification if a resident was identified at risk. He/she expected the risk to be care planned and hoped it was also on the nurse aide care plan. He/she reported the nursing assistants refer to the paper care plan book for the basics they needed to know on how to care for the residents. At this time he/she reviewed the resident's nurse aide care plan and confirmed it lacked any information about elopement risk or interventions. He/she also confirmed the comprehensive care plan did not include the resident's recent exit-seeking behaviors or the actual elopement on 5/23/17. He/she did not know when staff last received training on the facility's policy and procedures for elopement risk. Interview on 5/25/17 at 11:51 AM with administrative staff Q revealed the exterior doors were magnetically locked and only open if the keypad code was entered or the fire alarm is activated then it would automatically open. He/she confirmed the exterior door from the kitchen did not have this type of lock and reported ordering one to be placed on 5/31/17. He/she confirmed prior to 5/23/17 the kitchen doors remained open during kitchen hours with dietary staff present. The facility's undated policy titled Elopement Policies included the nursing home strived to provide a safe environment for all the residents. The policy indicated staff would develop an individualized interdisciplinary plan of care. The policy directed staff would be trained to be vigilant in watching the facility exits and identifying residents. The facility's policy titled Missing Residents and dated March 2007 included personnel should make every effort to keep track of residents under their care. The facility failed to keep the environment free of accident hazards and provide adequate supervision for these residents when he/she went through an open kitchen door without staff's knowledge and exited the facility on 5/23/17.

The facility had a census of 17 residents with 9 reviewed for comprehensive assessments. Based on interview and record review the facility failed to develop care area assessments (CAAs) to include further assessment of conditions, symptoms and areas of concerns for 5 of 9 residents reviewed. (#3, #9, #13, #14, and #16) Findings included: - Review of the Physician order [REDACTED].#14 had [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident had behaviors present that fluctuated for inattention and disorganized thinking. The resident received an antipsychotic, antianxiety, and antidepressant medications daily. Review of the resident's Quarterly MDS dated [DATE] revealed a BIMS score of 5, indicating severe cognitive impairment. The resident had behaviors present that fluctuated for inattention and disorganized thinking. The resident exhibited verbal behavioral symptoms directed toward others, rejection of care and wandering behaviors 4-6 days of the observation period. The resident received antidepressant, and antipsychotic medications daily. Review of the [MEDICAL CONDITION] Drug Use Care Area Assessment (CAA) dated 6/6/16 revealed the CAA lacked any further assessment of the care area. During an interview on 5/2/17 at 2:03 PM administrative nursing staff D stated portions of the CAAs were not updated since the beginning of the year due to his/her unavailability. Review of the resident assessment instrument (RAI) manual revealed the CAA documentation explained the basis for the care plan by identifying causes and risk factors related to the specific care area. The CAAs included the exact nature of the resident's problem and why it is a problem. The facility failed to provide a policy on Care Area Assessments as requested on 5/4/17. The facility failed to develop further care area assessments to include conditions, symptoms and areas of concern for resident #14. - Review of resident #3's Physician order [REDACTED]. Review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident exhibited behaviors of rejection of care 1 to 3 days during the observation period. Review of the resident's Annual MDS dated [DATE] revealed a score of 8, indicating moderate cognitive impairment. The resident exhibited behaviors of rejection of care 1 to 3 days during the observation period. Review of the Psychosocial Well-Being Care Area Assessment (CAA) dated 4/25/17 lacked any further assessment of the care area. Review of the [MEDICAL CONDITION] Drug Use CAA dated 4/25/17 lacked any further assessment of the care area. During an interview on 5/2/17 at 2:03 PM administrative nursing staff D stated portions of the CAAs were not updated since the beginning of the year due to his/her unavailability. Review of the resident assessment instrument (RAI) manual revealed the CAA documentation explained the basis for the care plan by identifying causes and risk factors related to the specific care area. The CAAs included the exact nature of the resident's problem and why it is a problem. The facility failed to provide a policy on Care Area Assessments as requested on 5/4/17. The facility failed to develop further care area assessments to include conditions, symptoms and areas of concern for resident #3. - Review of resident #9's Physician order [REDACTED]. Review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 indicating the resident had intact cognition. The resident exhibited verbal behavioral symptoms directed toward others 1 to 3 days during the observation period. Review of the resident's Annual MDS dated [DATE] revealed a BIMS of 15 indicating the resident had intact cognition. The resident exhibited verbal behavioral symptoms directed toward others 1 to 3 days during the observation period. Review of the Mood State Care Area Assessment (CAA) dated 4/4/17 lacked any further assessment of the care area. Review of the Psychosocial Well-Being CAA dated 4/4/17 lacked any further assessment of the care area. During an interview on 5/2/17 at 2:03 PM administrative nursing staff D stated portions of the CAAs were not updated since the beginning of the year due to his/her unavailability. The facility failed to provide a policy on Care Area Assessments as requested on 5/4/17. Review of the resident assessment instrument (RAI) manual revealed the CAA documentation explained the basis for the care plan by identifying causes and risk factors related to the specific care area. The CAAs included the exact nature of the resident's problem and why it is a problem. The facility failed to develop further care area assessments to include conditions, symptoms and areas of concern for resident #9. - Review of resident #16's Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident received antipsychotic medications for 7 days of the 7 day observation period. The annual MDS also identified the resident needed assist of staff to stabilize his/her balance for getting on and off the toilet. Review of the [MEDICAL CONDITION] Drug Use Care Area Assessment (CAA) dated 7/29/16 revealed the care area triggered for additional investigation via the CAA assessment. Review of the clinical record revealed no evidence staff completed the [MEDICAL CONDITION] Drug Use CAA. Review of the Fall CAA dated 7/29/16 revealed the care area triggered for additional investigation via the CAA assessment. Review of the clinical record revealed no evidence staff completed the Fall CAA. Review of the care plan dated 9/6/16 revealed the resident had a risk for falls related to his/her traumatic head injury and sometimes having an unsteady gait. The care plan did not address [MEDICAL CONDITION] drug use. Observation on 5/3/17 at 12:30 PM the resident stood up from dining room table and walked over to talk to another resident. The resident exhibited no difficulty with balance and his/her gait was steady. During an interview on 5/4/17 at 11:19 AM administrative nursing staff D stated he/she did not complete all the CAAs due to having a difficult year. Review of the resident assessment instrument (RAI) manual revealed the CAA documentation explained the basis for the care plan by identifying causes and risk factors related to the specific care area. The CAAs included the exact nature of the resident's problem and why it is a problem. The facility failed to provide a policy on Care Area Assessments as requested on 5/4/17. The facility failed to complete a comprehensive assessment, including CAAs for resident #16. - Review of resident #13's admission minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 6, indicating severe cognitive impairment. The resident was independent with transfers and dressing. The resident did not have pain, shortness of breath, falls or history of falls. The resident did not receive physical therapy, occupational therapy or restorative services. Review of the quarterly MDS dated [DATE] revealed the resident required limited assistance of 1 staff for transfers and dressing. The resident denied pain. The resident did not receive physical therapy, occupational therapy or restorative services. Review of the quarterly MDS dated [DATE] revealed the resident required limited assistance of 1 staff for transfers and extensive assistance of 1 for dressing. The resident reported rare mild pain that did not affect sleeping or activity and took pain medication as needed during the observation period. The resident did not receive physical therapy, occupational therapy or restorative services. Review of the triggered care area assessments (CAA) dated 8/22/16 for cognitive loss/dementia (progressive mental disorder characterized by failing memory, confusion, communication, functional/rehabilitation, falls and nutritional status revealed all CAAs lacked further assessment/analysis of findings. Review of the ADL self-care performance care plan dated 8/22/16 revised on 2/22/17 revealed the resident needed help setting up the meal plate but could feed himself/herself. The resident required assist of 1 staff for help to get ready for bed at night and needed reminders to change his/her clothes. During an observation on 5/3/17 at 12:49 PM the resident straightened the bed covers on his/her bed and his/her standing and ambulation were steady. He/she sat on the bed, then lay down and his/her balance remained steady without staff assistance. During an interview on 5/2/17 at 2:03 PM administrative nursing staff D said portions of the CAAs were not updated since the beginning of the year since he/she unavailability due to health issues. During an interview on 5/4/17 at 10:26 AM administrative nursing staff D looked at the resident's CAAs and confirmed they were not complete for 8/22/16 triggered care areas. He/she did not know why the CAAs were not complete for that time frame. Review of the resident assessment instrument (RAI) manual revealed the CAA documentation explained the basis for the care plan by identifying causes and risk factors related to the specific care area. The CAAs included the exact nature of the resident's problem and why it is a problem. The facility failed to provide a policy on Care Area Assessments as requested on 5/4/17. The facility failed to develop further care area assessments to include a further assessment of symptoms and areas of concern for resident #13.

The facility had a census of 17 residents. Based on observation, interview and record review the facility failed to maintain the resident environment as free of accident hazards as possible by the failure to ensure side rails did not have unsafe gaps (greater than 4 ¾ inches) within them for 3 of 3 residents sampled for accidents (#1,#8, #16) and 10 of 15 residents observed during the initial part of the survey. (#3,#4,#6,#7,#9,#10,#13,#14,#15,#19) Findings included: - Review of resident #16's physician order sheet dated 4/28/17 revealed the following Diagnoses: [REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident was independent in all areas of activities of daily living (ADLs) and no staff supervision required. The resident received antipsychotic medications for 7 days of the 7 day observation period. Review of the Cognition Care Area Assessment (CAA) dated 7/29/16 revealed the resident's cognition fluctuated depending on his/her surroundings. His/her head injury caused the decline and had not appeared to worsen. Review of the Functional CAA dated 7/29/16 revealed the resident completed ADLs independently but the resident needed reminded to complete them sometimes. Review of the Fall CAA and Psychotropic Drug Use CAA dated 7/29/16 triggered for further assessment but were not completed. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 13, indicating intact cognition. The resident displayed continuous behavior of inattention. The remainder of the MDS remained same as the previous annual MDS dated [DATE]. Review of the care plan dated 9/6/16 revealed the resident had a risk for falls related to traumatic head injury and having an unsteady gait. The resident needed his/her call light within reach and encouraged to use it for assistance as needed. The care plan did not include anything about side rail use. Review of the care plan dated 9/7/16 revealed the staff monitored the resident to ensure he/she swallowed his/her pills and the resident pocketed them increasing his/her risk for seizures. If the resident seizured the staff ensured his/her safety by not restraining the resident or leaving him/her unattended. Observation on 5/1/17 at 2:32 PM revealed resident #16's bilateral grab bars measured 6 1/2 inch by 7 1/2 inch opening in the center Zone 1. Observation on 5/2/17 at 1:54 PM revealed the resident resting quietly on his/her left side. The resident's bed had the same grab bars affixed to both sides of the bed with the same grab bars as the previous observation. During an interview on 5/3/17 at 4:25 PM direct staff I stated he/she had not seen him/her have any accidents with the grab bar. Staff I stated that he/she had to observe resident due to his/her seizure disorder. During an interview on 5/3/17 at 9:23 AM, direct care staff J stated the resident had a seizure one time that the nurse reported to him/her. During an interview on 5/2/17 at 10:55 AM, administrative nursing staff E stated the resident, or family could request the use of grab bars. Staff E stated the facility may also receive a report from a hospital with a new admission and said the resident needed the use of grab bars. Staff E stated he/she did not complete any safe rail use assessments and did not know of any side rail policy and Food and Drug Administration (FDA) guidelines. During an interview on 5/2/17 at 10:55 AM maintenance supervisor staff F verified the space within the top portion of the grab bar measured approximately 6.5 inches. Staff F stated he/she mounted grab bars on beds only after the nursing staff requested them. Staff F stated he/she checked for loose bars with bed rails. Staff F verified 13 sets of grab bars of the same type in use with residents and another 5 sets of grab bars on beds in rooms not in use. Staff F stated he/she planned to remove the grab bars or add strapping to the existing rails that decreased the spaces. Review of the facility provided policy dated 10/12/16 and titled, Use of Side Rails, listed the gap measurements be performed to ensure safety from potential entrapment following the FDA guidelines for acceptable gaps as follows: Zone 1 (within the rail) any open space between the perimeters of the rail can present a risk of head entrapment with spaces of less than 4 3/4 inches. According to the FDA reference, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated 3/10/2006, Zone 1, the distance within the bed rail, should not contain gaps of greater than 4 ¾ inches on order to reduce the potential for entrapment within the rail. The facility failed to ensure resident #16 had grab bars on the resident's bed that had safe spaces inside the grab bars to prevent potential entrapment. - Review of resident #8's physician order sheet dated 4/28/17 revealed the following Diagnoses: [REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognition severely impaired and disorganized thinking that comes and goes. The resident required total assist of 2 staff for bed mobility and transfers. The resident had impaired Range of Motion (ROM) for his/her upper and lower extremities. Review of the Cognition Care Area Assessment (CAA) dated 7/19/16 revealed the resident continued having cognitive and physical decline, inability completing tasks and lacked understanding of spoken words a large percent of the time. Review of the Quarterly MDS dated [DATE] revealed the same as the Annual MDS dated [DATE] for cognition and bed mobility. Review of the care plan revised on 4/20/17 revealed the resident was a high risk for falls related to the resident's unawareness of safety needs. Observation on 5/2/17 at 12:22 PM the resident's grab bars had gaps within the rail that measured 6 1/2 inches wide and 7 1/2 inches tall. Observation on 5/2/17 at 2:08 PM the resident in bed resting on his/her left side with the same grab bars on both sides of bed. During an interview on 5/2/17 at 10:55 AM, administrative nursing staff E stated the resident, or family could request the use of grab bars. Staff E stated the facility may also receive a report from a hospital with a new admission and said the resident needed the use of grab bars. Staff E stated he/she did not complete any safe rail use assessments and did not know of any side rail policy and Food and Drug Administration (FDA) guidelines. During an interview on 5/2/17 at 10:55 AM maintenance supervisor staff F verified the space within the top portion of the grab bar measured approximately 6.5 inches. Staff F stated he/she mounted grab bars on beds only after the nursing staff requested them. Staff F stated he/she checked for loose bars with bed rails. Staff F verified 13 sets of grab bars of the same type in use with residents and another 5 sets of grab bars on beds in rooms not in use. Staff F stated he/she planned to remove the grab bars or add strapping to the existing rails that decreased the spaces. Review of the facility provided policy dated 10/12/16 and titled, Use of Side Rails, listed the gap measurements be performed to ensure safety from potential entrapment following the FDA guidelines for acceptable gaps as follows: Zone 1 (within the rail) any open space between the perimeters of the rail can present a risk of head entrapment with spaces of less than 4 3/4 inches. According to the FDA reference, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated 3/10/2006, Zone 1, the distance within the bed rail, should not contain gaps of greater than 4 ¾ inches on order to reduce the potential for entrapment within the rail. The facility failed to ensure the environment remained free of potential hazards (use of side rails with large gaps within the rails). - During the initial tour on 5/1/17 a total of 13 resident beds (#3,#4,#6,#7,#9,#10,#13,#14,#15,#19) were observed with bed rails with gaps within the rails that measured 6 1/2 inches wide and 7 1/2 inches tall. During an interview on 5/2/17 at 10:55 AM, administrative nursing staff E stated the resident, or family could request the use of grab bars. Staff E stated the facility may also receive a report from a hospital with a new admission and said the resident needed the use of grab bars. Staff E stated he/she did not complete any safe rail use assessments and did not know of any side rail policy and Food and Drug Administration (FDA) guidelines. During an interview on 5/2/17 at 10:55 AM maintenance supervisor staff F verified the space within the top portion of the grab bar measured approximately 6 1/2 inches. Staff F stated he/she mounted grab bars on beds only after the nursing staff requested them. Staff F stated he/she checked for loose bars with bed rails. Staff F verified 13 sets of grab bars of the same type in use with residents and another 5 sets of grab bars on beds in rooms not in use. Staff F stated he/she planned to remove the grab bars or add strapping to the existing rails that decreased the spaces. Review of the facility provided policy dated 10/12/16 and titled, Use of Side Rails, listed the gap measurements be performed to ensure safety from potential entrapment following the FDA guidelines for acceptable gaps as follows: Zone 1 (within the rail) any open space between the perimeters of the rail can present a risk of head entrapment with spaces of less than 4 3/4 inches. According to the FDA reference, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated 3/10/2006, Zone 1, the distance within the bed rail, should not contain gaps of greater than 4 ¾ inches on order to reduce the potential for entrapment within the rail. The facility failed to ensure the environment remained free of potential hazards (use of side rails with large gaps within the rails). - Review of resident #1's signed physician's orders dated 4/25/17 revealed the resident had the [DIAGNOSES REDACTED]. Review of the annual minimum data set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment, but knew that he/she resided in the nursing home. The resident depended totally on 2 staff for bed mobility, transfers, locomotion, dressing, personal hygiene and bathing. The resident depended totally on 1 staff for eating and toilet use. The resident had bilateral upper and lower body impairments, did not walk and used a wheelchair. The resident did not receive physical therapy, occupational therapy or restorative services. Review of the quarterly MDS dated [DATE] revealed there were no changes in cognition. The resident depended totally on 2 staff for bed mobility, transfers, and ambulation. The resident depended totally on 1 staff for toilet use and had a feeding tube (tube for introducing high calorie fluids into the stomach). The resident had bilateral upper and lower body impairments, did not walk and used a wheelchair. The resident did not receive physical therapy, occupational therapy or restorative services Review of the psychosocial well-being care area assessment (CAA) dated 10/14/16 revealed the resident had traumatic brain injury due to a car accident. Review of the traumatic brain injury care plan dated 10/12/16 revised on 4/20/17 revealed the resident had quadriplegia due to traumatic brain injury. The care plan lacked information about side rails. Review of the resident's side rail assessment dated [DATE] revealed the resident had very limited and involuntary movement. Bed rails were not indicated at that time. The resident used an adjustable height bed and a mattress with raised edges. No other side rail assessments were completed. Observation on 5/2/17 at 12:35 PM revealed the resident lay in bed with pillows supporting his/her position in the bed. There were grab bars on both sides of the bed that measured 6 1/2 inch by 7 1/2 inch opening in the center (Zone 1 - within the bed rail). During an interview on 5/3/17 at 1:22 PM direct care staff J said staff provided all cares for the resident. He/she said the staff propped the resident on his/her side with pillows and the resident could not grab the bed rail to assist with turning. During an interview on 5/1/17 at 3:17 PM licensed nursing staff H said the resident was totally dependent on staff for cares because of quadriplegia resulting from a car accident. Staff used a full sling lift for transfers and repositioned the resident in bed or chair every 2 hours. During an interview on 5/4/17 at 10:59 AM administrative nursing staff D said the resident had side rails on the bed since admission. He/she thought the bed rails were on the bed because the resident's family requested them for the resident's safety. During an interview at 5/2/17 at 10:55 AM administrative staff E stated either the resident, or family may request the use of grab bars. The facility may also receive a report from a hospital with a new admission and they may say the resident needs the use of grab bars. Staff stated he/she did not complete any safe rail use assessments and was not aware of any side rail guidelines. During an interview on 5/2/17 at 10:55 AM maintenance staff F verified the space within Zone 1 of the grab bar measured approximately 6.5 inches. Staff stated he/she got nursing staff requests for grab bars before he/she mounted the grab bars on a bed. Staff stated maintenance checked for loose bars and gaps with bed rails. Staff stated he/she could either remove the grab bars or add strapping to the existing rails that would decrease the space of Zone 1. Review of the facility policy dated 10/12/16 titled Use of Side Rails revealed staff followed the Food and Drug Administration (FDA) guidelines and measured side rails for acceptable gap sizes for zone #1, within the rail, to be less than 4 3/4 inches to ensure the residents' safety. Review of the FDA reference Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated 3/10/06, revealed 7 zones for potential entrapment of a person's body parts. Zone 1 gaps within the bed rail should be less than 4 3/4 inches. The facility failed to ensure the resident's environment remained as free from accident hazards as possible in regard to bed rail gaps large enough for potential entrapment of limbs, neck or head.

The facility census totaled 17 residents with 11 residents included in the sample. Three residents were reviewed for liability notices (a notice of Medicare non-coverage). Based on interview and record review, the facility failed to identify the type of service ending and failed to include the name and phone number of the Quality Improvement Organization (QIO- A federal program for improvement of health care that handles cases in which beneficiaries want to appeal a health care provider's decision to discharge them from the hospital or discontinue other types of services) for a resident to file an immediate appeal. This failure had the potential to affect all 3 residents reviewed. (#14, #20, #5) Findings included: - Review of the liability notice for resident #14 revealed the facility planned for the residents' current services to end on [DATE]. The form failed to list what Medicare services were ending. Under the section on How to ask for an immediate appeal, the form indicated the resident/family member should call the Quality Improvement Organization (QIO - A federal program for improvement of health care that handles cases in which beneficiaries want to appeal a health care provider's decision to discharge them from the hospital or discontinue other types of services) at {insert name and number of QIO} to appeal. Review of the liability notice for resident #20 revealed the facility planned for the residents' current services to end on [DATE]. The form failed to list what Medicare services were ending. Under the section on How to ask for an immediate appeal, the form indicated the resident/family member should call the QIO at {insert name and number of QIO} to appeal. Review of the liability notice for resident #5 revealed the facility planned for the residents' current services to end [DATE]. The form failed to list what Medicare services were ending. Under the section on How to ask for an immediate appeal, the form indicated the resident/family member should call the QIO at {insert name and number of QIO} to appeal. During an interview on [DATE] at 11:34 AM administrative staff G stated administrative nursing staff E completed the liability notices. Staff G stated he/she did not know the form the facility used had expired and that it did not include the type of service ending and did not list QIO name or phone number on all 3 residents. During an interview on [DATE] at 12:30 PM administrative staff G reported the facility did not have a policy on liability notices. The facility failed to include the services ending and the name and QIO number as required on the liability notices.

The facility had a census of 17 residents with 5 reviewed for unnecessary medications. Based on observation, interview and record review the facility failed to ensure 2 of 5 residents did not receive unnecessary medications related to the failure to monitor for the effectiveness of antipsychotic medications (#1, #14) and did not provide a justifiable use for [MEDICATION NAME] (#1). Findings included: - Review of the POS [REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident had behaviors present that fluctuated for inattention and disorganized thinking. The resident received an antipsychotic, antianxiety, and antidepressant medications daily. Review of the resident's Quarterly MDS dated [DATE] revealed a BIMS score of 5, indicating severe cognitive impairment. The resident had behaviors present that fluctuated for inattention and disorganized thinking. The resident exhibited verbal behavioral symptoms directed toward others, rejection of care and wandering behaviors 4-6 days of the observation period. The resident received antidepressant and antipsychotic medications daily. Review of the [MEDICAL CONDITION] Drug Use Care Area Assessment (CAA) dated 6/6/16 triggered for further assessment, but staff did not complete it. Review of the resident's care plan dated 2/28/17 revealed the resident had the potential to demonstrate physical behaviors, took [MEDICATION NAME] (an antipsychotic mediation) daily and staff were to monitor for effectiveness of this medication. No specific targeted behaviors were included in the care plan for staff to monitor for. Review of the physician orders [REDACTED]. Review of the nursing progress note dated 3/30/17 at 2:09 PM revealed the resident had aggressive behaviors toward staff as well as exit-seeking behavior, attempting to leave out the front door to find his/her family member. Staff attempted to redirect the resident but were unsuccessful. The resident refused food and fluids and had been recently been toileted. Review of the nursing progress notes February 2017-April 2017 contained documentation of resident behaviors but there was no documentation for specific targeted behaviors related to the use of [MEDICATION NAME]. An observation on 5/3/17 at 7:56 AM revealed the resident sat in the dining room eating breakfast with another resident. The resident conversed with staff and laughed. The resident did not exhibit any negative behaviors towards staff or other residents. During an interview on 5/3/17 at 8:04 AM direct care staff A stated he/she documented the resident's behaviors of anger and yelling. Staff stated these behaviors did not happen too often and mainly occurred during the evening or on weekends. Staff A stated when this happened staff tried to distract the resident or redirect him/her. Staff A stated he/she would let the nurse on duty know of the situation. During an interview on 5/4/17 at 8:37 AM licensed nursing staff C stated the resident took [MEDICATION NAME] for behaviors. Staff stated he/she knew the resident needed to be monitored for behaviors but did not know if there were any specific targeted behaviors included in the care plan to monitor for. Staff stated the resident had dementia and anxiety and so he/she received [MEDICATION NAME]. During an interview on 5/4/17 at 11:40 AM administrative nursing staff D stated the resident started on [MEDICATION NAME] before he/she arrived at the facility. Staff D stated the resident exhibited verbal behaviors of cursing, swearing and yelling and physical behaviors against staff. Staff D stated there was no monitoring for specific targeted behaviors but just for general behaviors and verified there were no specific targeted behaviors included in the care plan concerning the use of [MEDICATION NAME]. A policy concerning unnecessary medication use was requested on 5/4/17 but the facility failed to provide one. The facility failed to ensure resident #14 did not receive unnecessary medications by the failure to monitor for specific targeted behaviors related to the effectiveness of the resident's [MEDICATION NAME]. - Review of resident #1's signed physician orders [REDACTED]. Review of the annual minimum data set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment, but knew he/she resided in the nursing home. The resident's mood assessment indicated minimal depression. The resident did not have hallucinations, delusions, rejection of care, or wandering, but exhibited physical behavior symptoms directed toward others. The resident depended totally on 2 staff for bed mobility, transfers, locomotion, dressing, personal hygiene and bathing. The resident depended totally on 1 staff for eating and toilet use. The resident had bilateral upper and lower body impairments, did not walk and used a wheelchair. The resident received antipsychotic medications (medication used as a short-term treatment to control psychotic symptoms such as hallucinations, delusions, [MEDICAL CONDITION]) 7 days of the observation period. Review of the quarterly MDS dated [DATE] revealed no change in cognition from the annual MDS. The resident did not have hallucinations, delusions, or wandering, but exhibited rejection of care and physical behavior symptoms directed toward others. The resident depended totally on 2 staff for bed mobility, transfers, and ambulation. The resident depended totally on 1 staff for toilet use and had a feeding tube (tube for introducing high calorie fluids into the stomach). The resident had bilateral upper and lower body range of motion impairments, did not walk and used a wheelchair. The resident received antipsychotic, antianxiety, antidepressant and hypnotic medications 7 days of the observation period. Review of the cognitive loss care area assessment (CAA) dated 10/14/16 revealed the resident did not speak and made guttural (growling) sounds. He/she became angry at times and resisted care (oral care, feedings, and incontinence care) so staff left him/her alone and re-approached at a later time. The resident took antipsychotic medication for behavior (hitting and anger) and behavior improved. Staff talked to him/her calmly with cares. Sometimes he/she blinked once for yes and twice for no. The resident did not make his/her own decisions due to his/her lack of speech. The resident recognized all staff and knew the seasons. Review of the psychosocial well-being CAA dated 10/14/16 revealed the resident had [MEDICAL CONDITION] due to a car accident. He/she had a high risk for falls due to medications he/she took to keep his/her mood stable, including antipsychotic (medications used as a short-term treatment for [REDACTED]. Review of the [MEDICAL CONDITION] med use CAA dated 10/14/16 revealed the resident took antipsychotic medications to help him/her remain more calm. Review of the behavior care plan dated 10/14/16 revised on 4/20/17 revealed the resident had a behavior problem related to [MEDICAL CONDITION]. Staff administered medications as ordered. Staff monitored, documented, and reported behavior, side effects, and effectiveness to the physician. Staff attempted to determine the underlying cause of the resident's behaviors. If the resident became agitated, staff left the resident safely alone and re-approached at a later time. The care plan failed to address the resident's antipsychotic medication and the specific targeted behaviors to monitor for. Review of the signed physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The facility failed to identify specific targeted behaviors for the use of [MEDICATION NAME]. Review of the nurse's progress notes revealed the facility failed to identify and document specific targeted behaviors of [MEDICATION NAME]. Observation on 5/2/17 at 3:46 PM revealed the resident sat in the recliner and direct care staff K and direct care staff B transferred the resident to bed using the full sling lift. The resident had no obvious facial grimacing, tearfulness, swinging arms or legs to hit staff, or guttural sounds. The resident cooperated with staff for the transfer and blinked eyes once for yes and twice for no appropriately with staff questions. During an interview on 5/2/17 at 2:45 PM direct care staff K said the resident did not have behaviors, but had certain staff that he/she liked better than others and staff knew when he/she did not like them by his/her attitude because he/she could swing his/her left arm and kick his/her left leg at them and growl at staff. The resident blinked once for yes and twice for no. Staff said the resident made growling noises when he/she had a bad mood and did not want to be bothered by staff. Staff said sometimes the resident got teary when his/her family left after a visit. He/she said direct care staff did not chart behaviors in the electronic record, but they reported to the nurse to enter in the computer. During an interview on 5/4/17 at 10:32 AM administrative nursing staff D said the resident admitted to the facility on [MEDICATION NAME]. He/she thought the resident's behaviors were an appropriate indication to use [MEDICATION NAME]. He/she said staff documented behaviors by exception in the nurse's notes and identified behaviors as they occurred. During an interview on 5/4/17 at 1:52 PM administrative nursing staff D said the resident had intentional uncontrolled attempts to hit staff that interfered with his/her own care. He/she said the resident's actions were intentional and but the resident could not control the force. During an interview on 5/4/17 at 2:05 PM administrative staff G said the resident mostly had behaviors in his/her room with staff. He/she said he/she had not seen the resident have behaviors when the resident visited the common area. He/she said staff could anticipate a pending behavior because the resident's facial expression changed. He/she said the resident could get very angry, stiffened up and made intentional swings at staff with his/her arm or leg that interfered with staff process of care. The resident's behavior depended on which staff took care of him/her and the activity director could calm him/her down, but the activity director could not be in the facility 24 hours a day. During an interview on 5/4/17 at 11:45 AM physician M said the resident's indication for [MEDICATION NAME] use was not [MEDICAL CONDITION]. The physician said he/she would identify the resident with anger and hostility, but would not call the resident psychotic. He/she identified the resident's depression as an indication for the [MEDICATION NAME] use. The facility failed to provide a policy regarding antipsychotic medication use as requested on 5/4/17. The facility failed to ensure resident #1 remained free from unnecessary medication use by failing to identify an appropriate indication for use of [MEDICATION NAME] and failing to monitor specific targeted behavior for it's use.

The facility census totaled 17 with 5 residents reviewed for unnecessary medications. Based on observation, interview and record review the facility failed to ensure accurate pharmaceutical procedures by the failure to administer medications as ordered to 1 of 5 residents reviewed. (#1) Findings included: - Review of resident #1's signed physician orders [REDACTED]. Review of the annual minimum data set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment. The resident received antipsychotic, antianxiety, antidepressant and hypnotic medications 7 days of the observation period. Review of the quarterly MDS dated [DATE] revealed no change in cognition or medications from the annual MDS. Review of the psychotropic med use CAA dated 10/14/16 revealed the resident took antipsychotic medications to help him/her remain more calm. Review of the behavior care plan dated 10/14/16 revised on 4/20/17 staff administered medications as ordered. Staff monitored, documented, and reported behavior, side effects, and effectiveness of medications to the physician. Review of the Medication Administration Record [REDACTED] February 2017 at 11:30 PM: 2/1/17 Diazepam (medication given for anxiety), Urecholine (medication used to promote bowel and bladder motility), triple antibiotic ointment (TAO) to gastronomy (surgical creation of an artificial opening in to the stomach through the abdominal wall) tube site, Duoneb treatment (an inhalant medication that makes it easier to breathe) 2/2/17 TAO 2/4/17 Diazepam, Urecholine, Duoneb 2/15/17 TAO 2/17/17 Reglan (a medication given for heartburn), Diazepam, Urecholine, Duoneb 2/18/17 TAO 2/24/17 TAO March 2017 at 11:30 PM: 3/5/17 Diazepam, Urecholine, Reglan, TAO 3/6/17 Diazepam, Urecholine, Reglan, TAO 3/12/17 Diazepam, Urecholine, Reglan, TAO 3/31/17 Diazepam, Urecholine, Reglan, TAO April 2017 at 11:30 PM: 4/6/17 Diazepam, Urecholine, Reglan, TAO 4/10/17 Diazepam, Urecholine, Reglan 4/11/17 Diazepam, Urecholine, Reglan, TAO 4/15/17 Diazepam, Urecholine, Reglan, TAO 4/17/17 Diazepam, Urecholine, Reglan, TAO 4/18/17 Diazepam, Urecholine, Reglan, TAO 4/22/17 Diazepam, Urecholine, Reglan, TAO 4/27/17 Diazepam, Urecholine, Reglan, TAO 4/28/17 Diazepam, Urecholine, Reglan, TAO 4/29/17 Diazepam, Urecholine, Reglan, TAO 4/30/17 Diazepam, Urecholine, Reglan, TAO Review of the nurse's progress notes revealed the record lacked documentation giving a reason as to why the medications were not given. During an interview on 5/4/17 at 10:32 AM administrative nursing staff D confirmed the lack of documentation of medication administration from January 2017 through April 2017. He/she said he/she expected staff to administer medications according to physician's orders [REDACTED]. The facility failed to provide a policy regarding medication administration as requested on 5/4/17. The facility failed to administer medications to 1 resident.