Every finding on record at Goffstown Nursing and Rehab Center

Based on interview and record review, it was determined that the facility failed to inform residents or resident's representative of the risk and benefits of psychotropic medication use for 1 out of 6 residents reviewed for unnecessary medications in final sample of 12 residents. (Resident identifiers is #18.)Resident #18 Review on 12/2/25 of Resident #18's physicians orders revealed: Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (milligrams) (Divalproex Sodium), Give 500 mg by mouth one time a day for Bi-polar with Psychosis HOLD FOR SEDATION AND Give 750 mg by mouth in the evening for Bi-Polar with Psychosis, Order Date, 10/28/25. Review on 12/3/25 of Resident #18's medical record revealed that there was no documentation that Resident #18 and or the resident representative had been informed of the risks and benefits of the above medication. Interview on 12/3/25 at approximately 11:30 a.m. with Staff C (Director of Nursing) confirmed the above findings Review on 12/325 of the facility policy titled, Use of Psychotropic Medications, Dated 2025, revealed: . 9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use .

Based on interview and record review, it was determined that the facility failed to ensure that PRN orders for anti-psychotic drugs are limited to 14 days and are not renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication for 1 of 6 residents reviewed for unnecessary medications in a final sample of 12 residents. (Resident identifier is #2.) Findings include:Review on 12/2/25 of Resident #2's December 2025's MAR (Medication Administration Record) revealed the following physicians order: Quetiapine Fumarate oral tablet 25 mg (milligrams) Give 1 tablet by mouth every 12 hours as needed for psychosis, Start Date 10/23/25. Further review revealed no documentation from the physician of an evaluation for the appropriateness of the medication justifying continuation after 14 days. Interview on 12/3/25 at approximately 12:45 p.m. with Staff C (Director of Nursing) confirmed the above findings. Review on 12/3/25 of the facility policy titled, Use of Psychotropic Medications, Dated 2025 revealed: . 16 a. PRN (as needed) orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond 14 days. The medical record should include documentation from the physician.

Based on interview and record review, it was determined that the facility failed to ensure residents have a documented discharge summary for 1 of 3 closed records reviewed. (Resident identifier is #6.) Findings include:Review on 12/3/25 of Resident #6's medical record revealed that there was no documentation of discharge summary, medication reconciliation, or a post-discharge plan of care. Interview on 12/3/25 at approximately 11:30 a.m. with Staff C (Director of Nursing) revealed Resident #6 was discharged on 12/1/25 and confirmed the above findings. Interview on 12/3/25 at approximately 1:30 p.m. with Staff D (Director of Social Services) confirmed there was no documentation of discharge summary, medication reconciliation, or a post-discharge plan of care. Review on 12/3/25 of the facility policy titled, Documentation Requirements at Time of Resident Discharge Policy, undated revealed: . Documentation Requirements, 1. Discharge Summary, . 2. Medication Reconciliation, . 3. Follow-Up Care Instructions, . 4. Communication and Notification, . 5. Transfer/Transport Documentation, .

Based on observation, interview, record review, it was determined that the facility failed to dispose of a medication in a proper receptacle during observation of administration of 27 medications. Findings include: Observation on 12/3/25 at approximately 7:20 a.m. during medication administration with Staff A (Licensed Practical Nurse) revealed Staff A dispose of an Aspirin EC (enteric coated) 81 mg (milligrams) in the sharps container attached to the medication cart. Interview on 12/3/25 at approximately 7:20 a.m. with Staff A confirmed the above findings and revealed that he/she was unsure of the facility policy for medication disposal. Interview on 12/3/25 at approximately 10:00 a.m. with Staff C (Director of Nursing) revealed that the facility has a receptacle in the medication room for wasting of medication. Review on 12/3/25 of the facility policy titled, Medication Wasting Policy, undated revealed: . 4. Procedure for Wasting NON-Controlled Medications, . 3. Render medication non-retrievable by placing it in the facility's approved pharmaceutical waste container .

Based on observation, interview and record review, it was determined that the facility failed to provide services to maintain/prevent decrease in ROM/mobility for 1 out of 1 residents observed for mobility and positioning in a final sample of 12 residents. (Resident identifier is #20.)Observation on 12/2/25 at approximately 9:23 a.m. in Resident #20's room revealed a bedside table with four palm-wrist splints. Resident #20 was sitting in his/her wheelchair without a splint on his/her right hand. Observation further revealed that Resident #20's right hand was resting in a fisted position. Further observation revealed a sign, undated, on the wall near Resident #20's bed that stated Please put on [Resident #20's name omitted]'s palm splint in AM [morning] and remove before bed. rehab. Interview on 12/2/25 at approximately 9:30 a.m. with Resident #20 revealed that he/she wears a splint for his/her right hand but was unable to say when it should be worn. Observation on 12/2/25 at approximately 11:38 a.m. of Resident #20 revealed that he/she was self-propelling his/her wheelchair using his/her feet and left hand to the dining room. Resident #20 did not have his/her right palm-wrist splint on. Observation on 12/3/25 at approximately 7:38 a.m. of Resident #20 revealed that he/she was seated near the nurse's station and was not wearing his/her right palm-wrist splint. Review on 12/3/25 of Resident #20's care plan revealed a care plan for Resident #20's at risk for pain, decrease mobility, and skin breakdown related to contractures with a revision date of 9/26/25 with an intervention for splint/braces as per physician order. Review on 12/3/25 of Resident #20's physician orders revealed no current order for the application or removal of a right palm-wrist splint. Review on 12/3/25 of Resident #20's point of care task for the past 30 days revealed a task to apply a wrist splint to the left wrist (not the right wrist). Review also revealed that the splint was applied four times in the past 30 days. Observation on 12/03/25 at approximately 11:02 a.m. revealed Resident #20 not wearing his/her palm-wrist splint. Interview on 12/3/25 at approximately 12:15 p.m. with Staff C (Director of Nursing) confirmed that there was no order for Residents #20's right palm-wrist splint application. Interview on 12/4/25 at 11:38 a.m. with Staff G (Rehabilitation Director) revealed that Resident #20 was discharged for occupational therapy on 10/3/25 with intervention to apply a right palm-wrist splint daily for the entire day. Staff G confirmed that the point of care task for the application of a wrist splint was for the right hand and not the left.

Based on policy review and record review, it was determined that the facility failed to ensure that the provider reviewed irregularities identified by the pharmacist during the monthly Pharmacy Medication Regimen Review (MRR) timely for 1 of 5 residents reviewed for unnecessary medications (Resident Identifier is #1).Findings include:Review on 12/3/25 of the facility's policy Pharmacy Medication Review- Follow-up and Required Actions, undated, revealed: .II. Policy Statement .All pharmacist recommendations, identified irregularities, and follow-up items must be 1. Reviewed by the attending practitioner. 2. Addressed within the required regulatory timeframe .C. Practitioner Response Requirements 1. The attending practitioner must respond to each pharmacist recommendation within 5 business days, unless state law requires a shorter timeline. Review on 12/3/25 of Omnicare Consultation Report, monthly pharmacy review, recommendation date 6/20/25, for Resident #1 revealed the following recommendation: please consider gradual dose reduction of olanzapine to reduce fall risk . Physician response was entered on the consult form 8/12/25. Interview on 12/3/25 at approximately 3:38 p.m. with Staff B (Administrator) confirmed the above findings.

Based on observation, interview, and record review, it was determined that the facility failed to ensure a medication error rate less than 5 percent (%) for 3 of 27 medication administrations observed. (Resident Identifiers are #29 and #33.)Findings include:Resident #29 Observation on 12/3/25 at approximately 7:35 a.m. of medication administration with Staff A (Licensed Practical Nurse) revealed Staff A preparing Resident #19's medications at the medication cart outside of the nursing station. Staff A prepared Metoprolol Succinate ER (extended release) 50 mg (milligrams) and Vitamin E 200 units. Staff A proceeded to walk down the hall to Resident #19's room. Upon entering the room Staff A looked over at Resident #19 sleeping in his/her bed. Staff A then went over to Resident #29's (Resident #19's roommate) bedside. Staff A placed Resident #19's medication in a cup on Resident #29's bedside table. Staff A then began conversing with Resident #29 and obtained his/her oxygen saturation level. Staff A then stated to Resident #29, Here is your morning medication. Staff A was stopped at this time to ensure Resident #29 was not administered Resident #19's medications. As Staff A walked out of the room, Staff A turned to look at the names on the outside of the room and stated, I wish it had A or B next to their names. Interview on 12/3/25 at approximately 7:35 a.m. with Staff A confirmed the above findings. Review on 12/3/25 of the facility policy titled, Medication Administration Policy, undated, revealed: .4. Medication Administration Procedures, 4.1 Verification, Prior to administration, staff must verify the five rights: 1. Right Resident, 2. Right Medication .4.3 Administration, Identify the resident using two identifiers ., Explain the medication and purpose to the resident . Resident #33 Observation on 12/3/25 at approximately 7:30 a.m. of Staff A preparing Resident #33's Humalog Insulin Pen for administration revealed Staff A did not prime the insulin pen before dialing it to the ordered 4 units dose. Interview on 12/3/25 at approximately 7:30 a.m. with Staff A confirmed the above findings. Review on 12/3/25 of Resident #33's December 2025's MAR (Medication Administration Record) revealed the following physician's order: Humalog Kwikpen Subcutaneous Solution Pen-injector 100 Unit/ml (milliliter), . inject per sliding scale, . Start Date 11/14/25. 12/3/25 7:30 a.m. dose administered 4 units. Review on 12/3/25 of the manufacturer's instructions for Humalog KwikPen, Dated 2018 revealed: . Priming your Pen, Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. There were 3 medication errors out of a total of 27 medication administration opportunities resulting in a 11.11% error rate.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that an expired medication was removed from a medication cart for 1 of 2 carts observed and the facility failed to ensured that medications with a shortened shelf life were labeled with an opening date.North Medication Cart Observation on [DATE] at approximately 8:30 a.m. of the North Medication Cart revealed: One Facility Glucagon with an expiration date of 11/25One Degludec insulin pen (Resident #16) opened and not labeled with a date of opening or an open expiration date Interview on [DATE] at approximately 8:30 a.m. with Staff A (Licensed Practical Nurse) confirmed the above findings. Further interview revealed that Staff A administered Resident #16's morning dose of Degludec from the above insulin pen. Review on [DATE] of Resident #16's [DATE] MAR (Medication Administration Record) revealed:Insulin Degludec Subcutaneous Solution pen-injector 100 Uni/ml (milliliter) Inject 36 unit subcutaneously in the morning for DMII (Diabetes Type 2) . was checked as administered by Staff A. Observation on [DATE] at approximately 8:00 a.m. during medication administration observation in the South Medication Cart revealed: One Fluticasone Salmeterol Inhaler 250 mg (milligrams) (Resident #7) opened and not labeled with a date of opening or an open expiration date Interview on [DATE] at approximately 8:00 a.m. with Staff A confirmed the above findings. Review on [DATE] of the manufacturer's instructions for Glucagon, Dated 2025 revealed, . Do not use Glucagon if the expiration date has passed. Review on [DATE] of the manufacturer's instructions for Degludec Insulin, Dated [DATE] revealed: . Storage Conditions, Room Temperature for 56 days. Review on [DATE] of the manufacturer's instructions for Fluticasone Salmeterol Inhaler, Dated 8/2022 revealed: . Safely throw away Wixela Inhub in the trash 1 month after you open the foil pouch or when the counter reads 0, whichever comes first. Review on [DATE] of the facility policy titled, Labeling of Medications and Biologicals, Revision Date 2025, revealed: . 8. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed (needle-punctured); b. All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Review on [DATE] of the facility policy titled, Expired Medication Management Policy, undated, revealed: 4. Responsibilities, Nursing Staff/Medication Aides: . Immediately remove expired items from active medication supply.

Based on interview, observation, and record review, it was determined that the facility failed to maintain an equipment per manufacturer's instruction for 1 of 1 resident humidifier observed. (Resident identifier is #1.)Findings include: Observation on 12/2/25 at approximately 1:15 p.m. of Resident #1's room revealed that there was a humidifier at his/her bedside that was plugged into the wall. Interview on 12/3/25 at approximately 7:44 a.m. with Staff H (Licensed Practical Nurse), night nurse, confirmed the above observation. Staff H further revealed that the humidifier was brought in by family and had been present at the resident bedside since September 2025. Staff H stated that he/she did not clean and maintain the humidifier. Observation on 12/3/25 at approximately 7:45 a.m. with Staff H revealed that the humidifier had approximately 1/4-1/2 inch of water with a light tan film in the base of the unit. Further observation revealed that there was no indication that the humidifier had been inspected by maintenance. Interview on 12/3/25 at approximately 9:03 a.m. with Staff C (Director of Nursing) revealed the process for the resident to have a bedside humidifier would include a safety check by maintenance, cleaning schedule, and physician orders for use and maintenance. Review on 12/3/25 of Resident #1's medical record revealed no care plan and physician order for the use and maintenance of a bedside humidifier. Review on 12/3/25 of the facility's policy Resident Humidifier Use Policy, undated revealed . Use must be approved by nursing staff and documented in the resident's care plan Procedures 1. Physician/prescribers orders 1.1 Humidifier use must be indicated in the resident's plan of care or authorized by a physician .2. Equipment Safety .2.4Device s must be unplugged when not in use or during cleaning 3. Infection Control & Cleaning 3.1 Humidifiers must be cleaned and disinfected daily following manufacturer instructions 3.4 Reservoirs must be emptied, cleaned and dried before refilling 7. Documentation Physician order or plan of care authorization. Daily use cleaning and maintenance. Review on 12/3/25 of the facility's policy Electrical Equipment Inspection and Approval Policy, undated, revealed, Purpose To ensure the safety of residents, staff and visitors by requiring that all electrical equipment and devices are inspected and approved by the Maintenance Director before being placed in use within the facility 1.1 All electrical equipment must be submitted to the Maintenance Director prior to use 6. Resident and Family Education Residents and families must be informed that personal electrical items must be submitted for inspection before use. Review on 12/3/25 of Mistaire Ultrasonic cool Mist Humidifier user Manual Model: PEHUMIDIF revealed . General cleaning Inside the base of the unit. Pour excess water out of the unit. Wash out the unit with fresh water using the cleaning brush and soft cloth as needed Descaling Depending on usage and water type, cleaning to remove scale may be required weekly or every other week to optimize unit performance.

Based on interview and policy review it was determined that the facility failed to ensure that residents had access to their personal funds during off business hours. The facility manages personal accounts for 25 residents.Findings include:Review on 12/3/25 of the Facility's policy Resident Petty Cash Policy, undated, revealed Purpose To establish a clear procedure for .ensuring that residents have appropriate access during evenings and weekends 3. Weekend and Evening Availability .3.1 The facility will designate evening and weekend petty cash custodians, such as charge nurses, supervisors, or on-call administrative staff. 3.2 Access to funds during these periods will occur as follows: Evenings: Available until the end of the evening shift (typically 11:00 p.m.) through the charge nurse or supervisor. Weekends: Available during both day and evening shifts through designated nursing supervisors.Interview on 12/03/25 at approximately 1:06 p.m with Staff E (Business Office Manager) revealed that residents must request cash from him/her during regular business hours because residents are unable to access their personal funds in the evening or weekends because staff do not have the access to facility's petty cash during off hours.

Based on interview and record review, it was determined that the facility failed to submit to the Centers for Medicare & Medicaid Services (CMS) complete and accurate direct care staffing information based on payroll data for Fiscal Quarter 3 (April 1, 2024 - June 30, 2024). Review on 10/20/24 of the facility's Payroll Based Journal Staffing Data Report for Quarter 3 2024 (April 1, 2024 - June 30, 2024) revealed that the facility failed to submit data for the quarter. Interview on 10/22/24 at 1:00 p.m. with Staff F (Business Office Manager) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, for 3 of 30 days reviewed between September 15, 2024 - October 20, 2024. Findings include: Review on 10/21/24 of the facility's daily nursing time sheets for September 15, 2024 - October 19, 2024, revealed the following: On 9/15/24 there were no RN hours documented as worked; On 9/28/24 there were no RN hours documented as worked; On 10/13/24 there were no RN hours documented as worked. Interview on 10/21/24 at 9:00 a.m. with Staff E (Scheduler) confirmed that there was no RN on duty on 9/15/24, 9/28/24, and 10/13/24. Interview on 10/21/24 at 10:00 a.m. with Staff B (Director of Nursing) revealed that he/she was on call every other weekend when there was not an RN working but was not physically in the building for 8 consecutive hours.

Based on interview and record review, it was determined that the facility failed to follow antibiotic use protocols related to the appropriate use of antibiotic monitoring, tracking, and reviewing antibiotic use for 9 of 12 months reviewed for antibiotic use. Findings include: Review on 10/21/24 of the facility's line listing for antibiotic use from November 2023 through October 2024 revealed that the facility did not have documentation of a system to track antibiotic use within the facility from November 2023 through May 2024 and September 2024 to present. Interview on 10/21/24 at 12:00 p.m. with Staff C (Infection Prevention) confirmed the above findings. Interview further revealed that the facility did not have antibiotic monitoring and tracking from September 13, 2024, to present, including documentation that antibiotics met criteria for use. Staff A (Administrator) confirmed that the facility had residents with infections and who were on antibiotics from September 2024 to date. Review on 10/21/24 of the facility's policy titled, Infection Control - Antibiotic Stewardship, revised 2/11/22, revealed: .2. Accountability: a. An ASP Team will establish to be accountable for stewardship activities . i. Review infections and monitor antibiotic usage patterns on a regular basis. ii. Obtain and review antibiograms for institutional trends of resistance. iii. Monitor Antibiotics resistance patterns . iv. Report on number of antibiotics prescribed (e.g., days of therapy) and the number of residents treat each month. iv. Include a separate report for the number of residents on antibiotics that did not meet criteria for active infections .

Based on interview and record review, it was determined that the facility failed to maintain resident care equipment according to manufacturer's instructions for the hoyer lift. Findings include: Interview on 10/22/24 at approximately 9:57 a.m. with Staff J (Maintenance Director) revealed that the legs on the hoyer lift were difficult to open. Staff J stated that they had not performed routine inspections on the hoyer lift to determine any wear since he/she became employed at the facility approximately four months ago. Staff J revealed they had never performed routine maintenance on the hoyer lift, and did not have any documentation that the hoyer lift had been maintained, inspected or repaired at any time. Staff J confirmed that the hoyer lift was more than a year old and routine inspection and maintenance was required. Interview on 10/22/24 at approximately 10:29 a.m. with Staff K (Licensed Nursing Assistant(LNA)) revealed the hoyer lift is difficult to maneuver when a resident is in the lift. Interview on 10/22/24 at approximately 10:37 a.m. with Staff L (LNA) revealed the hoyer lift was hard to move and wobbly at times. Review on 10/22/24 of the hoyer lift manual, page 12 revealed: .Performing Maintenance, After the first year of use, the hooks of swivel bar and the mounting brackets of the boom should be inspected every three months to determine the extent of wear. If these parts become worn, replacements must be made .Casters and axle bolts require inspections every six months to check tightness and wear. After the first twelve months of operation, inspect the swivel bar and the eye of the boom (to which it attaches) for wear. If the metal is worn, the parts MUST be replaced. Make this inspection every six months thereafter. Regular maintenance of patient lifts and accessories is necessary to assure proper operation . Review on 10/22/24 of the Maintenance Safety Inspection Checklist in the hoyer lift manual, page 32, revealed: .for institution use of the hoyer lift, the lift and all components should be inspected or adjusted monthly .

Based on interview and record review, it was determined that the facility failed to report alleged violations of neglect to the State Survey Agency (SSA) for 1 of 3 residents reviewed for falls in a final sample of 15 residents (Resident Identifier #26). Findings include: Interview on 10/20/24 at approximately 10:48 a.m. with Resident #26 revealed that Resident #26 had fell from the hoyer lift about six weeks ago. Review on 10/22/24 of Resident #26's medical record revealed an Incident Note, entered 8/21/24, dated 8/20/24, that stated: .resident was being transferred from [pronoun omitted] wheelchair to [pronoun omitted] bed using a hoyer lift .More staff were called in for assistance and resident was lowered to the floor after moving the bed away and releasing the hoyer lift pad . Review on 10/22/24 of Resident #26's medical record revealed a provider note, dated 8/23/24, that stated .nursing reported that 2 days ago, [pronoun omitted] had an accidental fall during a mechanical lift transfer and got between [pronoun omitted] bed and [pronoun omitted] window sill slightly bumping [pronoun omitted] head . Interview on 10/22/24 at approximately 11:00 a.m. with Staff A (Administrator) revealed that Staff A was not aware of the above incident until 10/22/24 and was unable to provide any documentation of an investigation to determine if it should have been reported to the SSA. Review on 10/22/24 of facility policy titled, Accidents/Incidents Policy, dated 8/24/2024, revealed: .3. Reporting: D. The Administrator and/or DON (Director of Nursing) will verify that state reporting occurs within required time frames and via appropriate method of reporting .

Based on interview and record review, it was determined that the facility failed to ensure that alleged violations of neglect were thoroughly investigated for 1 of 3 residents reviewed for falls in a final sample of 15 residents (Resident Identifier #26). Findings include: Interview on 10/20/24 at approximately 10:48 a.m. with Resident #26 revealed that Resident #26 had fell from the hoyer lift about six weeks ago. Review on 10/22/24 of Resident #26's medical record revealed a provider note, dated 8/23/24, that stated .nursing reported that 2 days ago, [pronoun omitted] had an accidental fall during a mechanical lift transfer and got between [pronoun omitted] bed and [pronoun omitted] window sill slightly bumping [pronoun omitted] head . Interview on 10/22/24 at approximately 11:00 a.m. with Staff A (Administrator) revealed Staff A was not aware of the incident and Staff A was unable to provide documentation of an investigation of the incident. Interview on 10/22/24 at approximately 12:12 p.m. with Staff I (Licensed Nursing Assistant) revealed that he/she and another staff member were using the hoyer lift to transfer Resident #26 from Resident #26's wheelchair to their bed. The resident was flailing their arms and legs causing the hoyer lift to tip, and staff lowered Resident #26 to the floor. Staff I stated that the incident was reported to the Director of Nursing (DON), who was in the facility working on the unit at that time, but was not asked to provide a written statement of the incident. Review on 10/22/24 of facility policy titled Accidents/Incidents Policy dated 8/24/2024, revealed .4. Follow-up/Investigation: B. The Administrator, DON, or designee will review all accident/incidents to determine if: i) Accidents/Incidents or allegations have been appropriately and timely reported; ii) Required documentation has been completed; iii) Accident/Incident has been investigated . D. When conducting an investigation, the Administrator, DON, or designee will: i) Make every effort to ascertain the cause of the accident/incident; ii) Initiate a timeline chronology . iv) Conduct witness interviews from all staff and visitors who may have knowledge of the accident/incident; v) Document the root cause and initiate actions to prevent or reduce recurrence of further accident/incident . vii) Complete the investigation within five working days.

Based on interview and record review, it was determined that the facility failed to perform neurological assessments after a resident fell and hit their head for 1 out of 3 residents reviewed for falls in a final sample of 15 residents (Resident Identifier #26). Findings include: Journal of Nursing; AJN, November 2007 Vol. 107, No. 11. Retrieved from https://www.nursingcenter.com/pdfjournal?AID=751198&an=00000446-200711000-00030&Journal_ID=54030&Issue_ID=751137 on 10/30/20: When a Fall Occurs Step three: monitoring and reassessment. After the patient returns to bed, perform frequent neurologic and vital sign checks. Interview on 10/20/24 at approximately 10:50 a.m. with Resident #26 revealed that Resident #26 had a fall when being transferred with the hoyer lift, resulting in Resident #26 hitting their head. Review on 10/22/24 of Resident #26's medical record revealed an Incident note, dated 8/20/24, entered 8/21/24, that stated .Provider got notified and order was obtained to do neuro [neurological] checks for 72 hours . Further review revealed no electronic documentation indicating neurological assessments had been performed. Interview on 10/22/24 at approximately 11:00 a.m. with Staff A (Administrator) revealed Staff A was unable to provide any documentation indicating neurological assessments had been performed following the fall on 8/20/24. Review on 10/22/24 of the facility's policy, Accidents/Incidents Policy, dated 8/27/24, revealed: .Evaluation/Assessment, Medical Assistance, Documentation: .v) The physician/APP (Advanced Practice Provider) will be notified of any fall resulting in head injury, suspected head injury .These residents will be observed for neurological abnormalities by performing neuro checks according to the Neurological Evaluation policy and procedure after the accident/incident occurs .

Based on record review and interview, it was determined that the facility failed to identify trauma triggers to eliminate or mitigate triggers that may cause re-traumatization of the resident in 1 of 1 residents reviewed for Post Traumatic Stress Disorder (PTSD) in a final sample of 15 residents (Resident Identifier #10). Findings include: Record review on 10/22/24 of Resident #10's diagnosis list revealed a diagnosis of PTSD. Record review on 10/22/24 of Resident #10's last Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 8/8/24 revealed PTSD was a current diagnosis. Record review on 10/22/24 of Resident #10's care plans revealed a care plan for behaviors of crying, withdrawal, and lack of appetite associated with PTSD without identified triggers listed. Record review on 10/22/24 of Resident #10's Generations Psychiatry Progress Note dated 10/9/24, revealed no identified triggers for PTSD. Record review on 10/22/24 of Resident #10's behavior monitoring for [DATE] revealed Resident #10 had behaviors of grouchy, swearing and shrieking when moved. Record review on 10/22/24 of Resident #10's Social Services assessment dated [DATE] revealed no identified triggers for Resident #10's PTSD. Interview on 10/22/24 at approximately 10:45 a.m. with Staff A (Administrator) confirmed the facility had not been identified PTSD triggers for Resident #10.

Based on record review and interview, it was determined that the facility failed to ensure that resident's who take psychotropic medications received a Gradual Dose Reduction (GDR) or document if GDR was clinically contraindicated for 1 of 5 resident's reviewed for unnecessary medications in a final sample of 15 residents (Resident Identifier #13). Findings include: Review on 10/21/24 of Resident #13's physician orders revealed an order for Seroquel 50 milligrams (mg), 1 tablet by mouth 3 times a day. Review on 10/21/24 of Resident #13's Pharmacy Consultant Report, dated 8/8/2024, revealed a recommendation to attempt a gradual dose reduction for Resident #13's Seroquel medication. The report further revealed the provider checked decline and wrote please see visit note from 9/5/24. The report was signed 9/24/24. There was no documentation of continued clinical appropriateness for the Seroquel. Review on 10/22/24 of Resident #13's Generations Geriatric Psychiatry Progress Note in Facility, dated 9/5/24, revealed the last GDR attempt was May 2021, and further revealed .Goals for Next Visit: consider med decrease . Follow up interval: 2-3 months . There was no documentation of continued clinical appropriateness for the Seroquel. Interview on 10/22/24 at approximately 11:30 a.m. with Staff B (Director of Nursing) confirmed there was no documentation for an attempt or documentation of GDR being clinically contraindicated.

Based on observation, record review, and interview, it was determined that the facility failed to follow Center For Disease Control (CDC) guidance for wearing Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) for 1 of 1 residents reviewed for an indwelling catheter in a sample of 15 residents (Resident Identifier #32). Findings include: Observation on 10/20/24 of Resident #32's room revealed an indwelling catheter bag hanging from the bed. There was no sign posted indicating Resident #32 was on EBP, and there was no PPE provided for care. Further observation revealed an Licensed Nursing Assistant (LNA) performing care without PPE. Interview on 10/22/24 at 8:34 a.m. with Staff M (LNA) confirmed he/she provided care to Resident #32 on 10/20/24 without using PPE. Staff M stated they were not aware Resident #32 was on EBP. Review on 10/22/24 of Resident #32's active orders revealed an order for a urinary catheter, entered on 10/15/24 and an order for EBP, entered on 10/20/24. Further review revealed an order for Ciprofloxacin (Cipro) Oral Table 250 milligrams (mg) by mouth every 12 hours for Urinary Tract Infection (UTI), dated 10/22/24. Interview on 10/22/24 at 8:30 a.m. with Staff B (Director of Nursing) and Staff C (Infection Prevention) confirmed that Resident #32 was not on EBP. 51109