Every finding on record at Frederick Living - Cedarwood

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate treatment and services to maintain or improve the ability to carry out certain activities of daily living that included mobility and walking for one of five sampled residents who had limitations in carrying out activities of daily living. (Resident 8)Findings include: Clinical record review revealed that Resident 8 had diagnoses that included Parkinson's disease, dementia, restless leg syndrome, and an abnormal gait. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had some memory impairment and had limitations in range of motion in both upper and lower extremities. The MDS further indicated that the resident utilized a walker and a wheelchair and required assistance with walking. A review of the care plan revealed that the resident was on a restorative nursing program for ambulation (walking). There was an intervention for staff to walk her to lunch and dinner using a roller walker and the wheelchair to follow for 60 to 100 feet. Review of a physical therapy Discharge summary, dated [DATE], revealed that upon discharge from therapy services, the resident had been able to ambulate 100 feet with contact guard assistance (CGA) and the roller walker. Specifically, the therapy summary indicated that the long-term goal for the resident was for her to safely ambulate 100 feet using a two wheeled walker with CGA to prepare for walking to meals and to facilitate increased participation in functional activity. A review of nursing documentation, dated July 9, 2026, revealed that the resident had usually met the goal for her walk to dine program. A review of nurse aide (NA) documentation revealed that between July 15, 2026, and August 11, 2026, the task for her to walk to dine was marked as not applicable seven times, which indicated no evidence that staff assisted the resident to walk per the restorative nursing program. Observation on August 12, 2026, at 11:48 a.m., revealed that the resident was still in her room. At 11:50 a.m., the resident was observed being wheeled in her wheelchair by NA 1 from her room to the dining room for lunch. In an interview on August 13, 2026, at 10:53 a.m., the Director of Nursing confirmed that the resident was currently on a restorative nursing program for ambulation. The facility failed to ensure that the restorative program for ambulation was completed on a consistent basis as recommended by physical therapy in order to maintain the resident's ability to ambulate and be mobile. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician's order was implemented for three of 12 sampled residents. (Residents 22, 23, 30) Findings include: Clinical record review revealed that the physician directed staff to administer the following bowel protocol for Residents 22, 23, and 30: staff was to administer prune juice on day shift (7:00 a.m. to 3:00 p.m.) if the resident had no bowel movement (BM) in 72 hours. If prune juice was ineffective, staff was to administer milk of magnesia 24 hours later on evening shift (3:00 p.m. to 11:00 p.m.). If milk of magnesia was ineffective, a bisacodyl suppository was to be administered on night shift (11:00 p.m. to 7:00 a.m.). If the suppository was ineffective, an enema was to be administered on night shift, 24 hours later. Clinical record review revealed that Resident 22 was admitted to the facility on [DATE], with diagnoses that included dementia and constipation. On August 17, 2023, the physician directed staff to follow the bowel protocol as needed. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and was dependent on staff for toileting. Record review revealed that from October 7 through 11, 2023, the bowel protocol was not followed as ordered by the physician and the resident did not have a BM until October 11, 2023, at 10:39 p.m. Further review of the clinical record revealed that from October 11 through 15, 2023, the bowel protocol was not followed as ordered by the physician and the resident did not have a BM until October 15, 2023, at 1:29 p.m. Clinical record review revealed that Resident 23 was admitted to the facility on [DATE], with diagnoses that included dementia, stroke, and constipation. On November 24, 2020, the physician directed staff to follow the bowel protocol as needed. The MDS assessment dated [DATE], indicated that the resident had memory impairment and was dependent on staff for toileting. Review of nurse aide documentation revealed that the resident had a BM on October 18, 2023, at 9:15 p.m. Record review revealed that from October 18 through 24, 2023, the bowel protocol was not followed as ordered by the physician and the resident did not have a bowel movement until October 24, 2023, at 7:40 p.m. Clinical record review revealed that Resident 30 was admitted to the facility on [DATE], with diagnoses that included dementia and constipation. On April 27, 2022, the physician directed staff to follow the bowel protocol as needed. The MDS assessment dated [DATE], indicated that the resident had memory impairment and was dependent on staff for toileting. Review of Resident 30's medication administration record for September 2023, revealed that the resident had a BM after administration of prune juice on September 23, 2023, at 10:39 a.m. Further review revealed that from September 23, 2023, through October 1, 2023, the bowel protocol was not followed as ordered by the physician and the resident did not have a BM until October 1, 2023, at 3:43 p.m. Additionally, from October 1 through 8, 2023, the bowel protocol was not followed as ordered by the physician, and the resident did not have a BM until October 8, 2023, at 10:44 a.m. Record review revealed that from October 15 through 21, 2023, the bowel protocol was not followed as ordered by the physician and the resident did not have a BM until October 21, 2023. In an interview on October 26, 2023, at 9:31 a.m., the Director of Nursing stated that staff did not follow the bowel protocol per the physicians' orders. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on a confidential group interview, it was determined that the facility failed to administer vaccinations in a dignified manner to two of four residents at resident council. Findings include: During a confidential group interview on November 3, 2021, at 10:30 a.m., two residents stated that during the month of October 2021, the pharmacist entered the facility during lunch to administer the booster vaccine to all the residents. The residents stated, We felt like we were rounded up like cattle during our meal time to receive a booster vaccine. The residents stated that there was no privacy provided and that they were afraid to express their feelings about the situation. The residents felt the situation could have been handled in a more dignified manner. 28. Pa Code 201.29(i) Resident rights.

Based on clinical record review, observation and staff interview, it was determined that the facility failed to ensure that safety interventions were implemented and in place for one of 16 sampled residents. (Resident 42) Findings include: Clinical record review revealed that Resident 42 had diagnoses that included abnormalities of gait and mobility and history of falling. The current care plan identified that the resident was at risk to fall related to gait balance problems, poor safety awareness, history of falls, anxiety, and wandering. On September 6, 2021, Resident 42 fell in the dining room. Review of the incident report revealed the resident was to be placed in a stationary chair in the dining room as an intervention to prevent future falls, however there was no documented evidence that this intervention was implemented. On September 29, 2021, Resident 42 was lowered to the floor in the hallway when walking with a nurse aide. Review of the incident report revealed that to prevent recurrence, the resident was to walk with staff with a wheelchair readily available behind the resident. On November 2, 2021 at 11:34 a.m., Resident 42 was observed walking in the hallway with Nurse Aide 1 with no wheelchair available behind the resident. In an interview on November 4, 2021 at 12:25 p.m., the Director of Nursing confirmed that the stationary chair intervention was not implemented. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure pain management included the attempt to provide non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain mediation prescribed on an as needed basis for three of 16 sampled residents. (Residents 22, 28, 43) Findings include: Clinical record review revealed that Resident 22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain prior to the administration of the as needed narcotic pain medication Clinical record review revealed that Resident 28 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan instructed staff to provide non-pharmacological interventions such as: music, relaxation, and positioning for comfort. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain prior to the administration of the as needed narcotic pain medication. Clinical record review revealed that Resident 43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan instructed staff to provide non-pharmacological interventions such as: music, relaxation, positioning for comfort, and snacks. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was a lack of documentation to support that non-pharmacological interventions were offered to address the assessed pain prior to the administration of the as needed narcotic pain medication. In an interview on November 4, 2021, at 9:05 a.m., the Director of Nursing confirmed that there was a lack of documentation to support that non-pharmacological interventions were offered to Residents 22, 28, and 43 prior to or in conjunction with the administration of the as needed pain medication. 28 Pa. Code 211.12(d)(1)(5)Nursing services.

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to ensure call bells were answered in a timely manner for one of 15 sampled residents. (Resident 44) Findings Include: Clinical record review revealed that Resident 44 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], revealed that Resident 44 required assistance from one person for toilet use, hygiene, transferring, walking, and dressing. Review of Resident 44's care plan identified the resident had a self-performance deficit related to activity intolerance and joint pain and fall risk related to balance problems. There was an intervention to encourage the resident to use the call light for assistance from staff. In an interview on November 10, 2020, at 11:45 a.m., Resident 44 reported waiting up to 30 minutes for staff to respond to the call bell once it was engaged at least once daily. Subsequently, the resident stated that she occasionally used the bathroom without staff assistance. In an interview on November 12, 2020, at 2:07 p.m., the Director of Nursing and Administrator revealed that staff was expected to respond to call light within 10 minutes. Review of the facility call bell audit records for Resident 44's room from September 12, 2020, through November 12, 2020, revealed that the response time for Resident 44's call light alarm ranged between 11-58 minutes on 30 different occasions. 28 Pa. Code 201.29(j) Patient Rights

Based on clinical record review and staff interview, it was determined that the facility failed to provide written notification of transfer to the resident or the resident's representative(s) upon transfer from the facility for one of 15 residents. (Resident 22) Findings Include: Clinical record review revealed that Resident 22 was admitted to the hospital on October 19, 2020, due to a change in condition. There was no documented evidence that the resident or resident representative(s) were provided written information regarding the transfer to the hospital. In an interview on November 13, 2020, at 9:20 a.m., the Administrator confirmed there was no written transfer notice provided to the resident or the resident's representative(s) when transferred out of the facility.

Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain urinary continence and to restore continence to the extent possible for one of 19 sampled residents. (Resident 18) Findings include: Clinical record review revelaed that Resident 18 was admitted to the facility on (MONTH) 15, (YEAR), and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments, dated (MONTH) 22, (YEAR), and (MONTH) 7, 2019, indicated that the resident had memory problems and required the extensive assistance of staff to use the toilet. Review of the care plan that was initiated on (MONTH) 15, (YEAR), revealed that the resident was continent during the day and wore briefs at night for incontinence. In an interview on (MONTH) 18, 2019, at 12:03 p.m., the Director of Nursing confirmed that Resident 18 was continent during the day when admitted to the facility. A nurse note dated (MONTH) 27, 2019, at 2:54 p.m., reflected that the resident was mostly continent of urine with occasional accidents. Review of the clinical record revealed that the resident was incontinent of urine 27 of 29 day shifts from (MONTH) 19, 2019, through (MONTH) 17, 2019. There was a lack of documentation to support that the facility had provided services to maintain the resident's urinary continence or had assessed the resident for a change in urinary status. In an interview on (MONTH) 18, 2019, at 1:45 p.m., the Director of Nursing confirmed that Resident 18 was currently incontinent and was not assessed for the need for interventions to maintain and/or restore urinary continence. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 6/15/18

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician's order was implemented for one of 19 sampled residents. (Resident 252) Findings include: Clinical record review revealed that Resident 252 was admitted on (MONTH) 1, 2019 with [DIAGNOSES REDACTED]. The physician ordered a bowel protocol as follows: after 24 hours without a bowel movement, staff was to administer prune juice on day (7:00 a.m. to 3:00 p.m.) shift. If prune juice was ineffective, staff was to administer milk of magnesia on evening (3:00 p.m. to 11:00 p.m.) shift. If milk of magnesia was ineffective, a [MEDICATION NAME] suppository was to be administered on night (11:00 p.m. to 7:00 a.m.) shift. If the suppository was ineffective, an enema was to be administered. The Minimum Data Set (MDS) completed on (MONTH) 8, 2019, revealed that the resident's memory was impaired. The resident needed extensive assistance of one staff for most activities of daily living and required extensive assistance of one staff for toilet use. The MDS revealed that the resident was frequently incontinent of urine and was always continent of bowel. Nurse aide documentation revealed, the resident had a bowel movement on (MONTH) 7, 2019, at 6:50 a.m. Nurse aide documentation revealed the resident did not have a bowel movement the following day. The nurse administered prune juice (MONTH) 8, 2019, at 12:45 p.m., and documented the medication was ineffective. The nurse did not administer milk of magnesia (MONTH) 8, 2019, on evening shift. Between (MONTH) 10, 2019, and (MONTH) 15, 2019, the resident was administered laxatives four times and all were documented as ineffective. Review of the Medication Administration Record [REDACTED]. There was no documentation to support that the resident was offered an enema. Nurse aide documentation revealed that the resident did not have a bowel movement until (MONTH) 16, 2019, at 8:50 p.m. In an interview on (MONTH) 17, 2019, at 11:58 a.m., the Director of Nursing stated that the physician ordered bowel protocol was not followed. 28 Pa. Code 211.12 (d)(1)(5) Nursing services Previously cited 6/15/18

Based on clinical record review, observation and staff interview, it was determined that the facility failed to implement care planned interventions for two of 16 sampled residents. (Resident 18, 24) Findings include: Clinical record review revealed that Resident 18 had [DIAGNOSES REDACTED]. The current care plan revealed the resident was at risk for skin impairment. The care plan directed staff to apply bilateral heel boots while in bed to relieve pressure and to offload the resident's heels. Observation on (MONTH) 12, (YEAR) from 9:50 a.m. through 11:30 a.m., revealed that the resident was in bed without her heel boots applied. In an interview on (MONTH) 14, (YEAR), at 11:20 a.m., the Director of Nursing confirmed that the preventative pressure ulcer intervention was not implemented. Clinical record review revealed that Resident 24 had [DIAGNOSES REDACTED]. to prevent skin injuries and provide comfortable seating. The resident was observed seated in a wheelchair in the lounge on (MONTH) 12, (YEAR), at 11:22 a.m. and 12:27 p.m. and again on (MONTH) 13, (YEAR), at 9:29 a.m. without the calf/foot support in place. The resident's right leg was observed off the foot rest and rubbing against back of the foot rest on these three occasions. Staff did assist the resident to place her right leg back on the foot rest during two of the observations, however did not provide the calf/foot support as indicated in the plan of care. 28 Pa. code 211.12(d)(1)(5) Nursing services

Based on observation and staff interview, it was determined that the facility failed to maintain sanitary conditions in the food service areas. In addition, the facility failed to adequately monitor the dishmachine temperatures to effectively sanitize dinnerware, utensils and equipment. Findings include: Observation on August 25, 2015, at 9:25 a.m., in the main kitchen revealed rusted metal supports for the ceiling tiles in the dishmachine area and the pot washing machine area. There was a white residue on the exterior of the machine and on the mechanical ventilation area above the machine. In addition there was a green residue on the components above the pot washing machine. There were stained cracked spatulas in the food production area and the holder for the nozzle of the juice dispensing machine was soiled. The interior of the reach-in refrigerator in the Country Kitchen was soiled with dried-on residue and food particles and the exterior surrounding the handle was soiled with dried-on residue. The floor was soiled under the ice machine. The manufacturer's requirement for the final rinse cycle of the dishmachine in the Country Kitchen #2 was 180 degrees Fahrenheit. Observation on August 25, 2015, at 10:20 a.m., revealed the final rinse temperature had dropped suddenly during the operation of the dishmachine to 158 degrees Fahrenheit. An additional observation on August 27, 2015, at 9:44 a.m., had the temperature at 172 degrees Fahrenheit during the final rinse cycle. In an interview on August 27, 2015, at 9:44 a.m., the General Manager of Dining stated that staff were instructed to visualize the complete final rinse cycle temperatures in order to detect any irregularities. The General Manager confirmed the dishmachine was malfunctioning.

Based on observation, it was determined that the facility failed to maintain an effective pest control program. Findings include: Observations of the environment at various times on August 25, 2015, through August 28, 2015, identified flies in areas of the facility such as Country Kitchen #1, Country Kitchen #2, including the dining rooms in both areas, a resident room, and the nurses station/chart room. Observation during the environmental tour on August 25, 2015, at 9:35 a.m., identified a device to deter flies was installed in the vicinity of the trash compactor however, it was not functioning. 28 Pa. Code 207.2(a) Administrator's responsibility.

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to ensure that infection control and prevention had been implemented for one of two sampled residents on droplet precautions. (Resident R1348) Findings include: Review of the facility policy entitled "Infection Control-Droplet Precautions" dated March 2013 revealed that droplet precautions, including the use of Personal Protective Equipment (PPE), would be used for all contacts with residents known to be infected with organisms that can be transmitted by droplet or by contact with items in the environment. When the facility identified a resident with an infection, a Personal Protective Equipment (PPE) station supplied with gowns, gloves and masks, was to be set up outside that resident's room. Signage was also to be placed on that resident's door to direct visitors to the nurse's station for advisory. Resident R1348 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The pulmonologist confirmed the presence of a positive infection on July 18, 2013. Observation on July 31, 2013, at 9:15 a.m. revealed NA1 in the resident's room within three feet of the resident without a gown, gloves and mask, and then exited the room without handwashing. An additional observation on that same day at 1:55 p.m., revealed Dietary Aide 1 in Resident R1348's room, again without a gown, gloves and mask, and then exited the room without handwashing. On August 2, 2013, at 9:50 a.m., RN1 was observed to have left a stethoscope and blood pressure cuff, after resident use, outside the room on top of the PPE station. In an interview on August 1, 2013, at 11:00 a.m., the Director of Nursing confirmed that staff had not followed the facility's infection control policy. 28 Pa. Code 211.12 (d)(1)(5) Nursing services. Previously cited 7/18/12

Based on clinical record review and observation, it was determined that the facility failed to implement a care plan intervention for one of 14 sampled residents. (Resident R1310) Findings include: Clinical record review revealed that Resident R1310 had a history of [REDACTED]. On July 8, 2013, the resident had a fall from the chair. The care plan updated on July 9, 2013, directed staff to not leave the resident alone in his room when in his chair. Observations on July 30, 2013, from 2:50 p.m., to 4:10 p.m., revealed the resident in his room and there was no staff in attendance. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/3/12

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure that the physician was notified of a change in the resident's medical condition for one of 15 sampled residents. (Resident R40) Findings include: Review of the facility's policy entitled "Physician Notification", dated January 2012 revealed that physicians must be notified for any change in a resident's condition. Clinical record review revealed that Resident R40 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of nursing documentation on May 5, 2012, at 4:30 p.m., revealed that a nurse aide at 2:00 p.m., reported that the resident "had bleeding from the rectum". There was no documentation in the record that the physician had been notified. In an interview on July 3, 2012, at 9:30 a.m., RN1 confirmed that there was no documented evidence that the physician had been notified of this change in Resident R40's condition. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 8/5/11

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for two of 15 sampled residents. (Resident R7, R32 ) Findings include: Clinical record review revealed that Resident R7 had [DIAGNOSES REDACTED]. On October 24, 2011, a physician ordered for routine labs to be conducted every six months (May 2012), that included serum lipids (levels of fat in the blood) and liver function tests. There was no evidence that the labs were done in May 2012. In an interview on July 3, 2012, at 11:25 a.m., the Director of Nursing confirmed that the laboratory tests had not been completed as ordered by the physician. Clinical record review revealed that Resident R32 had [DIAGNOSES REDACTED]. On June 16, 2012, a wound doctor ordered Zinc Sulfate (medication that promotes wound healing) to be administered for 14 days. There was no documented evidence that the medication was administered. In an interview on July 3, 2012, at 8:57 a.m., RN1 confirmed that the resident had not received the medication as ordered by the physician. 483.25 Quality of Care. Previously cited 8/05/11 28 Pa. Code 211.12(d)(1)(5) Nursing services. Previously cited 08/05/11

Based on observation of the medication room, it was determined that the facility failed to ensure that all drugs were secured in a permanently affixed, locked compartment on one of one nursing units. Findings include: Observation of the medication room on July 1, 2012, at 10:40 a.m., revealed an unlocked refrigerator that contained two bottles of liquid Ativan (Schedule IV medication). Observation on July 2, 2012, at 8:16 a.m., revealed that the medication room door was unlocked which allowed accessibility to the refrigerator, that contained the Schedule IV medications. 28 Pa. Code 211.12(d)(1) Nursing services. Previously cited 8/5/11

Based on review of facility policy, personnel records and staff interview, it was determined that the facility failed to ensure that verification of licensure status was completed for two of three sampled employees. (Employees 1 and 2) Findings include: Review of the facility policy "Protection of Elders from Abuse", dated August 2010 revealed that for the purpose of screening potential hires, the Nurse Aid Registry or State Licensing Board was to be contacted to verify that an individual is in good standing with a current registry or license. Review of Employee 1's personnel record revealed that the employee had begun working at the facility on October 6, 2010. Employee 1's professional license verification was not completed until August 3, 2011. Review of Employee 2's personnel record revealed that the employee had begun working at the facility on July 15, 2011. Employee 2's registry verification was not completed until August 3, 2011. In an interview on August 4, 2011, at 11:15 a.m., the Human Resource Director verified that the online licensesure verification was not performed timely. 28 Pa. Code 201.19 Personnel policies and procedures.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders regarding care were implemented for four of 15 sampled residents. (Residents R17, R59, CR1, CR2) Findings include: Clinical record review revealed that Resident R17 had [DIAGNOSES REDACTED]. On May 16, 2011, the physician had ordered [MEDICATION NAME] injection (Vitamin B12). The injection was to be administered one time monthly on the sixteenth of each month. A review of the June 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the July 2011 MAR indicated [REDACTED]. There was no documented evidence to support that the Vitamin B12 had been administered at any other time or on any other day during the months of June and July 2011. In an interview on August 5, 2011, at 10:00 a.m., RN1 confirmed that the injection was not administered as ordered. Clinical record review revealed that Resident R59 had [DIAGNOSES REDACTED]. On April 28, 2011, the physician ordered [MEDICATION NAME] ear drops (an anti-infective/antibiotic for inflammation/infection) to be administered three times a day for seven days. A review of the April 2011 MAR indicated [REDACTED]. Further review of the May 2011 MAR indicated [REDACTED]. In an interview on August 5, 2011, at 12:15 p.m., RN1 confirmed that the medication was not administered as ordered. Clinical record review revealed that Resident CR1 had [DIAGNOSES REDACTED]. On April 14, 2011, the physician ordered staff to administer a medication to control blood pressure ([MEDICATION NAME]) once a day. Review of the MAR for April 2011 revealed that from April 14, through April 25, 2011, the resident received the medication twice a day. In an interview on August 5, 2011, at 11:15 a.m., RN 1 confirmed that the resident received six additional doses of the medication. Clinical record review revealed that Resident CR2 had [DIAGNOSES REDACTED]. Clinical record review revealed that on March 29, 2011, a physician ordered staff to administer a pain medication ([MEDICATION NAME]) once a day an hour prior to the resident's physical therapy session. Review of the MAR for March 2011 revealed that the medication was not administered as ordered on March 30, 2011. In an interview on August 5, 2011, at 11:15 a.m., RN1 confirmed that the medication was not administered as ordered by the physician. 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 7/8/10

Based on clinical record review, it was determined that the facility failed to ensure monitoring of behaviors to support medical justification for continued use of antipsychotic medication for one of seven sampled residents ordered an antipsychotic medication. (Resident R48) Findings include: Clinical record review revealed that Resident R48 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment of November 23, 2010, and May 23, 2011, indicated that the resident had impaired cognition and had not identified the resident as having [MEDICAL CONDITION] or hallucinations. On September 9, 2010, the physician ordered a change of the antipsychotic medication to [MEDICATION NAME] 0.5 milligrams to be administered daily. On March 7, 2011, the pharmacist recommended a gradual dose reduction of the [MEDICATION NAME] since there were no recent documented behaviors. It was not until June 14, 2011, that the physician identified the supportive [DIAGNOSES REDACTED]. The facility was unable to provide behavioral monitoring documentation from the time the medication was initially ordered through July 2011. The facility was unable to provide documentation that a gradual dose reduction for use of the medication [MEDICATION NAME] was attempted from March 2011 through August 3, 2011. In addition, the facility was unable to provide any physician documentation of the clinical rationale that justified why an attempted dose reduction would likely impair the resident's function or increase distressed behavior. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 7/8/10