Every finding on record at Good Samaritan Care Center

Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections, when staff failed to review the program, policies and procedures annually and update as needed. The facility census was 52. Review of the facility's infection prevention and control program policy, dated 2001, showed staff are directed to review the program annually and updated the policy as necessary. The policy did not contain documentation the policy was reviewed annually. During an interview on 05/22/26 at 10:18 A.M., the Assistant Director of Nursing (ADON) said he/she was not aware the infection prevention and control program process needed reviewed annually or updated as needed. During an interview on 05/22/26 at 10:27 A.M., the Director of Nursing (DON) said they do not sign off anywhere the infection prevention and control programs been updated or reviewed annually or as needed. He/She is unsure why they don't document or update the IPCP. During an interview on 05/22/26 at 10:11 A.M., the administrator said the ADON is responsible for reviewing and updating the infection prevention and control program policy and procedure. He/She said they don't document the dates. The administrator said they do not sign off and review it annually in the infection prevention and control program book. The administrator said he/she is responsible for ensuring it's completed.

Based on observation, interview and record review, facility staff failed to maintain kitchen equipment, lighting devices and air movement systems in a clean sanitary manner to prevent the potential for cross-contamination. The facility census was 50. 1. Review of the facility's policy titled, Cleaning and Sanitation, revised 10/18/23, showed staff were directed to wipe down the oven range after every meal. Wipe down all surfaces of the oven after every meal and deep clean as needed (PRN). Sprinkler pipes should be cleaned with degreaser and wiped down once a month. Make sure no food is out when wiping down the pipes. Review of the facility's kitchen cleaning schedule, undated, showed staff were directed to clean every night before closing up the kitchen. The schedule did not direct staff to clean the oven, hood, fans, or vents. Review of the facility's policy titled, Dishwasher Instruction, revised 10/19/23, showed staff were directed to watch the temperature of the dishwasher, and check it if it gets above 120 degrees Fahrenheit. Log the dishwasher temperature and sanitizer level on the daily log sheet. 2. Observation of the kitchen on 10/16/23 at 10:34 A.M., showed: -A [NAME] ceiling fan on in the kitchen, the fan hung above the food preparation area and had one of four blades missing. The other three blades bowed down and had white dirt and debris covering the surface; -Front and bottom of stainless steel oven doors had a black grease like substances running down them; -Exhaust hood had a build up of black and brown, grease like substances; -Broken light cover for florescent light fixture above stored foods in dry storage; -Sprinkler system line ran above stove and food preparation areas, had debris and grease like substance built up on it; -Window Air Conditioner (AC) blew air across food preparation areas and had black, circular spots and debris on the vents. 3. Observation of kitchen on 10/18/23 at 8:45 A.M., showed the centralized AC ceiling vents had a build up of dirt and debris on them, and blew air directly down on the fryer and stove during food preparation. During an interview on 10/18/23 at 2:04 P.M., Dietary Aide (DA) T said he/she was not sure who was responsible for cleaning the vents, but thought it was the maintenance staff. The DA said he/she hasn't seen a cleaning schedule, and the Dietary Manager (DM) just tells him/her when something needs cleaned. The DA said the staff doesn't have scheduled times to clean the stove hood. The DA said the cook is supposed to clean the oven and stove. The DA said he/she is supposed to tell the DM is he/she sees something that needs fixed, or cleaned by maintenance. The DA said he/she goes into the dry storage every day and has not seen a broken light cover. The DA said he/she usually checks the temperature of the dishwasher and it has not been reaching the required temperature, he/she told the DM when the facility first got it, about a couple months ago. During and interview on 10/18/23 at 2:12 P.M., Cook V said staff have a cleaning schedule on the fridge and they use it every night. The cook said maintenance cleans sprinklers, fans and vents. The cook said the hood company comes and cleans the hood, and they were at the facility about a month ago. The cook said he/she notifies the DM and he/she lets maintenance know when something needs to be done. The cook said he/she had not noticed the broken light cover. The cook said the ceiling fan needs to be cleaned, but he/he has not notified the DM. The cook said the hood, vents and AC unit are dirty and need cleaned. The cook said he/she had not notified the DM. During an interview on 10/18/23 at 2:21 P.M., the DM said maintenance cleans the AC units, but he/she is not sure if it's scheduled. Maintenance cleans sprinklers, and the stuff that is up high should be reported to him/her and he/she reports it to maintenance, or in the maintenance log. The DM said he/she asked maintenance to take down the ceiling fan, because it does not work right, and just collects dust. The DM said the facility has a company that comes in and cleans the hood quarterly and the kitchen staff will wipe down the outside. He/She said the company just cleaned the hood. If staff find something that needs repaired they are supposed to fill out a repair sheet on the clip board kept by the housekeeping department. The DM said he/she did not know a light cover in dry storage was broken. The DM said the evening kitchen staff are supposed to clean the stove, but anyone who sees it dirty, can clean it. The DM said he/she had a staff member who completed the deep cleans, but lost him/her two weeks ago, but honestly if staff in the kitchen sees something is dirty, staff should be cleaning it. During an interview on 10/19/23 at 9:59 A.M., the Maintenance Director (MD) said maintenance staff should clean the AC unit in the kitchen. The MD said he/she expects staff to fill out maintenance request forms if something needs cleaned. The MD said maintenance staff should have seen how dirty the AC is, when washing and cleaning the AC filters. The MD said ceiling vents are cleaned on a quarterly basis, the staff use dusters, but the ones in the kitchen should had been taken down and washed. The MD said he/she didn't know that there was anyone designated to clean ceiling fan, he/she would hope anyone who found it dirty would clean it. The MD said he/she did not double check on their accuracy of work, by the contracted company who cleaned the hood, he/she just checked to see the hood had a clean sticker, he/she should have looked deeper at the hood to make sure they cleaned it. The MD said dietary cleans the stove and equipment. The DM said maintenance cleans the sprinkler heads to make sure they are grease free. The MD said no staff from maintenance had been assigned to clean sprinkler lines in the past. 4. Review of Dishwasher directions label, showed wash and rinse cycle should reach a minimum of 120 degrees. Observation on 10/18/23 at 9:11 A.M., showed DA U complete a wash cycle of breakfast dishes. The wash cycle heated to 85 degrees Fahrenheit and the rinse cycle heated to 95 degrees Fahrenheit. Further observation showed the DA continued to wash and rinse four loads of resident dishes and place the dishes on a drying rack. Observation on 10/18/23 at 9:21 A.M., showed the DA U washed a load of resident water pitchers. The wash cycle heated to 82 degrees Fahrenheit and the rinse cycle heated to 87 degrees Fahrenheit. Further observation showed the DA took dishes off the drying rack and stacked on other dishes ready for use. During an interview on 10/18/23 at 9:18 A.M., DA U said he/she normally runs the dishwasher. The DA said the dishwasher is a low temperature dishwasher. The DA said he/she doesn't know the temperatures the wash cycle and rinse cycle is supposed to get to. The DA said staff are supposed to check dishwasher temperatures daily. The DA said he/she checks the temperatures daily, but later in the day, because the dishwasher starts to heat up. During an interview on 10/18/23 at 10:42 A.M., maintenance worker (MW) S said the company the facility got the dishwasher from, said 90 degrees Fahrenheit to 130 degrees Fahrenheit is the effective range for the chlorine to work. During an interview on 10/18/23 at 9:25 A.M., the DM said he/she does not know the temperatures the dishwasher has to reach for the wash and rinse cycle. The DM said the dishwasher doesn't have a thermometer. The DM said maintenance checks the dishwasher temperatures once a month. The DM said kitchen staff does not check dishwasher temperatures daily. The temperature of the water in the dishwasher is whatever the temperature of the water in the building is. The DM said maintenance is who talks to the dishwasher company. During an interview on 10/19/23 at 9:59 A.M., the MD said he/she didn't know the low temperature dishwasher temperatures needed to be checked. The MD said no one has checked the dishwasher and that was his/her fault.

Based on observation, interview and record review, the facility staff failed to ensure the residents' environment remained free of accident hazards when the facility staff failed to ensure sharps, chemicals and medications were stored in a manner not accessible to residents. The facility census was 50. 1. Review of the facility's Hazardous Areas, Devices and Equipment policy, dated July 2017, showed: -All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety mitigate accident hazards to the extent possible; -As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee; -A hazard is defined as anything in the environment that has the potential to cause injury or illness; -Examples of environmental hazards included, but are not limited to the following: a. Equipment and devices that are left unattended or are malfunctioning; b. Devices and equipment that are improperly used or poorly maintained; c. Sharp objects that are accessible to vulnerable residents; d. Open areas or items that should be locked when not in use; g. Access to toxic chemicals; -The safety committee will recommend measures to ensure that the vulnerable residents ca not access hazardous areas in the facility (locks, alarms, supervision, etc.); -The safety committee will periodically check for the implementation and integrity of measures intended to prevent residents from accessing hazardous areas; -Interim safety measures for temporary hazards such as painting or construction work, may be necessary. These may included posting warning signs, redirecting foot traffic, increasing supervision and if necessary, limiting access to anyone but authorized personnel. 2. Observation on 10/18/23 at 1:45 P.M., showed the doors to the closet located between resident occupied rooms [ROOM NUMBERS] unlocked and the area unattended by staff. Observation showed two mechanical saws with blades and other maintenance tools stored unsecured in the closet. During an interview on 10/18/23 at 1:45 P.M., the maintenance director said the maintenance tools were placed in the closet for storage. The maintenance director said there were confused residents on the unit that would be able to access the closet and maintenance tools and sharp objects like saw blades should not be stored accessible to residents. Observation on 10/18/23 at 1:50 P.M., showed a 32 ounce spray bottle of disinfectant spray and one gallon of bleach stored unsecured in the shared bathroom to resident rooms [ROOM NUMBERS] and the area unattended by staff. During an interview on 10/18/23 at 1:50 P.M., the maintenance director said he/she believed the chemicals were left in the bathroom because the resident in room [ROOM NUMBER] was on transmission based precautions, but chemicals should be locked up when not in use and not be left accessible to residents no matter what. Observation on 10/18/23 at 2:25 P.M., showed the doors to the closet at the end of the 200 hall unlocked and the area unattended by staff. Observation showed nine five gallon buckets of vinyl floor adhesive stored unsecured in the closet. Further observation showed human health and hazard warnings printed on the product labels. During an interview on 10/18/23 at 2:25 P.M., the maintenance director said toxic materials should not be stored accessible to residents and he/she did not know why the buckets of floor adhesive were stored in the closet. The maintenance director said the facility had residents that would be able to access the closet. During an interview on 10/19/23 at 9:45 A.M., the Director of Nursing (DON) said, while it is a global effort among all staff, environmental staff are responsible to maintain the environment free of hazards. The DON said sharp objects like saw blades and chemicals should not be stored in a manner accessible residents and if anyone sees them improperly stored, they should remove them and secure them elsewhere. The DON said storing toxic materials and sharp objects in a manner accessible to residents had the potential for injury and illness. During an interview on 10/19/23 at 10:10 A.M., the administrator said maintenance staff is responsible for the storage of maintenance tools and supplies and environmental services staff are responsible for the storage of chemicals and other toxic materials. The administrator said neither should be stored accessible to residents and should be locked up when not in use. The administrator said whomever last the item should ensure that it is stored properly and the storage of such materials accessible to residents had the potential of injury and illness. 3. Review of Resident #48's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/18/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Wanders daily; -Independent with going from sitting position to standing position, transferring from bed to chair and chair to bed, toilet transfers and walking up to 150 feet; -Received Antipsychotics on a routine basis; -Diagnoses of Non-Traumatic Brain Dysfunction (injuries to the brain that are not caused by an external physical force to the head), Alzheimer's Disease (progressive mental deterioration, due to generalized degeneration of the brain and causes premature senility), Dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, resulting from organic disease of the brain) and Parkinson's Disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). Review of the resident's care plan, dated 10/02/2023, showed staff documented the resident has Dementia with behavioral disturbances and Parkinson's disease, is very confused and wanders about most of the day, is severely impaired with decision making, wanders about the facility and is not aware of own safety, could potentially be found in a dangerous place, will wander into other residents rooms, and receives antipsychotics medications due to hallucinations. Observation on 10/17/23 at 9:21 A.M., showed the resident sat in his/her recliner. The resident then got up, wandered out to the hall, and walked own the hall independently with a walker. Observation on 10/17/23 at 10:16 A.M., showed the resident appeared confused and unable to communicate. A sharps container with used sharps in it, sat on the resident's window sill along with an insulin pen and unused needles. Observation on 10/17/23 at 3:56 P.M., showed the sharps container with used sharps and a Glargine Insulin pen with 40 units of insulin still in the pen, sat on the resident's window sill. Further observation showed four needle caps four millimeters (mm) in size for the Glargine insulin pen, still in the package, on the window sill. A blue twin blade razor sat on a table beside the toilet in the resident's room. Observation on 10/17/23 at 4:05 P.M., showed the resident got up from the table and walked with his walker to his/her bathroom independently. Certified Nurse Aide (CNA) A encouraged the resident to use the bathroom and then left the resident in the bathroom. Observation on 10/18/23 at 12:01 P.M., showed the sharps container, four mm needles and insulin pen still on window sill of the resident's room. Further observation showed the razor blade still sat on the table by the resident's toilet. During an interview on 10/18/23 at 3:21 P.M., CNA A said he/she thinks the nurse is supposed to have the sharps and insulin pen. The CNA said the resident can stand and ambulate independent, but is very confused, so there is potential for an accident with the insulin being left out. The CNA said the razor should be secured in the shower room. The CNA said he/she did not know why it was still in there. During an interview on 10/18/23 at 3:34 P.M., Licensed Practical Nurse (LPN) G said the resident had sharps in his/her room because his/her roommate is a diabetic. The LPN said the sharps and insulin started getting left in the room when the resident's roommate had COVID and the resident had been moved to another room, but the resident had been moved back into the room. The LPN said it was something staff should probably take out of there. The LPN said the razor should be out of reach of the resident and kept in a sharps container in the shower room. The LPN said the insulin, needles and razor were overlooked. During an interview on 10/19/23 at 9:38 A.M., the DON said the resident's cognition is probably poor. The resident wanders some. The DON said the resident can transfer and ambulate independently. The DON said insulin should not be in the resident's room, and staff should have placed the insulin in the medication room. The DON said impaired residents should not have access to razors. The DON said staff are instructed to keep razors in a locked cabinet in the shower room, so impaired residents do not have access. During an interview on 10/19/23 at 10:54 A.M., the Administrator said staff should store insulin and sharps in the medication room. The administrator said impaired residents could get into the medication and have an adverse reaction to it. The administrator said staff should store razors in locked shower rooms when not in use. The administrator said there is a risk of injury for cognitively impaired residents. 37131

Based on observation, interview, and record review, facility staff failed to prevent the spread of bacteria and other infection causing contaminants during the provision of care for two residents (Residents #37 and #36) when staff failed to remove soiled gloves and/or properly wash hands. The facility census was 50. 1. Review of the facility's policy titled, Perineal Care, dated February 2018, showed staff were directed to do the following: -Place the equipment on the beside stand; -Wash and dry hands; -Provide perineal care; -Remove gloves and discard into designated container; -Wash and dry hands thoroughly; -Reposition bed covers. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated August 2019, showed staff were directed to do the following: -This facility considers hand hygiene the primary means to prevent the spread of infections; -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of health-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin, after contact with blood or bodily fluids, and after removing gloves; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 2. Observation on 10/16/23 at 3:02 P.M., showed Nurse Aide (NA) K and Restorative Nurse Aide (RNA) Therapist entered Resident #37's room to provide perineal care. The NA and RN A provided perineal care, did not wash hands or change gloves, and pulled the resident's brief up. The NA touched the resident, the wheelchair, and the remote with the same soiled gloves. The RNA placed a nasal cannula on the resident and repositioned the resident with the same soiled gloves on. The NA removed his/her gloves and without performing hand hygiene, touched the gait belt and the wheelchair. 3. Observation on 10/17/23 at 9:36 A.M., showed NA H, NA I, Certified Nurse Aide (CNA) J and Licensed Practical Nurse (LPN) L entered Resident #26's room to provide perineal care. CNA J closed the drapes and put on gloves without performing hand hygiene. CNA J pulled down the brief and assisted the resident onto the commode, removed the gait belt and adjusted the resident's clothing without performing hand hygiene or changing gloves. LPN L wiped the resident's buttocks and with the same soiled gloves on, placed his/her hand in a container of A and D ointment (barrier cream), and applied cream to resident. CNA J removed the resident's soiled brief, removed gloves, did not perform hand hygiene, and put a clean brief on resident. During an interview on 10/19/23 at 8:27 A.M., CNA N said staff should perform hand hygiene when entering a resident room and before putting gloves on. The CNA said staff should perform hand hygiene and change gloves after providing care and before putting a clean brief on the resident. If staff does not perform hand hygiene or change gloves after providing care and before moving on to a clean task, it could spread germs. During an interview on 10/19/23 at 8:41 A.M., LPN M said staff should gather supplies, wash hands and apply gloves prior to providing care. The LPN said staff have been educated to change gloves and perform hand hygiene when moving from dirty to clean tasks. The LPN said staff should always perform hand hygiene after removing gloves, since gloves are porous and do not replace hand washing and could potentially contaminate surfaces. If staff provided care, then placed the same soiled gloves into the container of A and D ointment, it would contaminate the entire container of ointment. During an interview on 10/19/23 at 9:54 A.M., the Administrator said staff were educated to change gloves and perform hand hygiene when going from a dirty to a clean task. He/She said there is a risk of contamination and infection if staff did not perform hand hygiene and change gloves between task. During an interview on 10/19/23 at 10:22 A.M., the Director of Nursing (DON) said staff should assume everything they touch is dirty and hands should be washed before, during and after cares. The DON said staff should perform hand hygiene in between glove changes, especially if visibly soiled, and work from dirty to clean. The DON said gloves do not replace the need for hand hygiene and he/she expects staff to use soap and water or an Alcohol Based Hand Rub (ABHR), especially between glove changes. He/she said the facility does pericare audits that has a check list for hand hygiene and they are due by the end of the month.

Based on interview and record review the facility failed to notify one resident's (Resident #1) family in a timely manner to report a change in condition after a fall that required a transfer to an acute care hospital. The facility census was 42. 1. Review of the Facility's Change in Condition Policy, dated December 2016, showed staff are directed to promptly notify the resident's representative of changes in the resident's medical/mental condition and/or status and document it in the resident's medical record. 2. Review of the Resident #1's quarterly minimum data set (MDS), a federally mandated assessment, dated 09/02/20, showed staff assessed the resident as follows: -Brief Interview for Mental Status (BIMs) score of 14 (intact cognitive response) ; -Required extensive assistance of two staff member with toileting; -Required extensive assistance of one staff member with transfers, locomotion, dressing, and bathing; -Required limited assistance of one staff member with bed mobility and personal hygiene; -diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's plan of care, dated 8/26/20, showed staff assessed the resident as follows: -Alert and oriented; -At risk for falls; -Therapy for strenghening; -Use a walker for mobility; -Dependent on oxygen. Review of the resident's progress notes, dated 09/03/20 at 05:33 A.M., showed staff documented the resident requested to be transferred to the hospital after a fall for evaluation. Staff did not document they notified the family of the transfer. During an interview on 04/20/21 at 10:52 A.M., Licensed Practical Nurse (LPN) A said anytime a resident is discharged from the facility staff are expected to notify the resident's family and/or responsible party. During an interview on 04/20/21 at 1:01 P.M., the Director of Nursing (DON) said he/she would expect staff to notify the resident's family anytime they are transferring from the facility. He/She said the policy states they are to contact the resident's family, he/she would expect staff to follow the policy. The DON said he/she believes the nurse just got caught up in the emergent situation and just didn't do it. During an interview on 04/20/21 at 11:57 A.M., the administrator said he/she couldn't provide any documentation to show the nurse notified the resident's family of the discharge because he/she simply didn't do it and it simply was not done. He/She said the nurse wrote on the report sheet that he/she passed on to the oncoming nurse the family was notified but he/she later reported he/she did not notify the family when asked about it. The Administrator said he/she found out the family hadn't been notified when the nurse called to check on the resident and family asked why they weren't notified about the fall or the discharge. MO 980

Based on observation, interview, and record review, facility staff failed to remove soiled gloves and/or properly wash hands to prevent the spread of bacteria and other infection causing contaminants during the provision of care for four sampled residents (Residents #1, #2, #3 and #4). The facility census was 47. 1. Review of the facility's Handwashing/Hand Hygiene Policy, dated August 2019, showed the staff are directed as follows: -All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be accessible and convenient for staff use to encourage compliance with hand hygiene policies. -Wash hands with soap (antimicrobial or non-antimicrobial) and water for when hands are visibly soiled; -Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before and after direct contact with residents, before and after handling an invasive device (e.g., urinary catheters, IV access sites); and before moving from a contaminated body site to a clean body site during resident care, such as contact with a resident's intact skin, contact with blood or bodily fluids, contact with objects (e.g., medical equipment) in the immediate vicinity of the resident after removing gloves; -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 2. Review of the facility's Perineal Care policy, dated February 2018, showed the staff are directed as follows: -Wash and dry your hands thoroughly; -Put on gloves; -Wet washcloth and apply soap or skin cleansing agent; -Wash perineal area, wiping from front to back; -Continue washing the perineum moving from inside outward to the thighs; -If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter; -Wash the rectal area thoroughly, wiping from front to back; -Remove gloves and discard into designated container; -Wash and dry your hands thoroughly. 3. Review of the facility Catheter Care, Urinary Policy, dated September 2014, showed the staff are directed as follows: -Use standard precautions when handling or manipulating the drainage system; -Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag; -Routine hygiene is appropriate. 4. Review of Resident #1's Significant Change Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as follows: -Had an indwelling catheter (plastic tube inserted into the bladder that remains there to provide continuous urinary drainage); -Had an active [DIAGNOSES REDACTED]. -Required extensive one person assistance with personal hygiene. Review of the resident's progress notes, dated 1/29/2020, showed staff documented the foley catheter drained a small amounts of dark urine and a complete blood count (CBC) (gives information about the cells in a person's blood and can assist with detecting infection) ordered. Staff documented the resident admitted to the hospital with [REDACTED]. Observation on 2/11/2020 at 10:35 A.M., showed certified nursing assistant (CNA) B and CNA C entered the resident's room, applied gloves and explained the procedure to the resident. Observation showed CNA B cleaned the catheter tube, and removed his/her gloves. Observation showed CNA B applied clean gloves without performing hand hygiene. Observations showed CNA B applied barrier cream to the resident's bottom. CNA B removed his/her soiled gloves and applied clean gloves. The CNA B did not wash his/her hands after he/she removed his/her dirty gloves and applied clean gloves in order to prevent the spread of bacteria. 5. Observation on 2/11/2020 at 10:22 A.M., showed CNA D and Nursing Assistant (NA) E entered Resident #3's room. CNA D and Nursing Assistant (NA) E, applied gloves. Observation showed CNA D and NA E removed the resident's brief. Observation showed NA E provided perineal care and wiped from the back to the front. Observation showed NA E did not fold the wipe over to a clean area of the wipe before he/she wiped a second time. Observation showed the NA E removed his/her gloves and appled clean gloves. The CNAs did not wash their hands after they removed their dirty gloves and applied clean gloves in order to prevent the spread of bacteria. During an interview on 2/11/2020 at 1:50 P.M., NA E said he/she should wash his/her hands when entering a resident's room and change his/her gloves after providing perineal care to the front of the resident before moving to the back. NA E said he/she is not aware of anything he/she is expected to do between glove changes. Additionally, the NA said when he/she is performing perineal care, he/she wipes from the back to the front. NA E said he/she is not aware why the catheter bag needs to below the bladder. 6. Observation on 2/11/2020 at 10:48 A.M., showed CNA C entered Resident #4's room, applied clean gloves. Observation showed CNA C provided perineal care and removed his/her gloves. Observation showed CNA C left the resident's room and re-entered the resident's room with a clean pad and placed the pad on the resident's bed. The CNA did not wash his/her hands after he removed his/her gloves and left the room in order to prevent the spread of bacteria. During an interview on 2/11/2020 at 1:36 P.M., CNA C said hand washing is important to prevent cross-contamination. CNA C said he/she did not wash his/her hands because he/she forgot. 7. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident with an indwelling catheter. Observation on 02/11/20 at 1:25 P.M., showed CNA B and CNA A entered the resident room. Observation showed the CNAs applied gloves and explained to the resident the procedure to the resident. Observation showed CNA B cleansed the perineal area and removed his/her gloves. Observation showed CNA B applied cleans gloves. Observation showed the CNAs assisted the resident into the Hoyer lift (a mechanical lift) to transfer the resident. Observation showed the CNAs placed the cather bag on the lift above the resident's bladder. The CNAs did not wash their hands after they removed their dirty gloves and applied clean gloves in order to prevent the spread of bacteria. 8. During an interview on 2/11/2020 at 1:36 P.M., CNA B said staff wash their hands when they walk in the room, when they switch gloves, and when they are finished providing care. CNA B said gloves should be changed when going from front to back during perineal care and after cleaning the resident's bottom. He/She said there is a catheter care policy and the catheter bag should be lower than the resident's bladder. CNA B said he/she did not wash his/her hands because he/she forgot. Additionally, he/she said he/she did not realize the catheter bag was placed above the resident's hips. During an interview on 2/11/2020 at 1:42 P.M., Licensed Practical Nurse (LPN) A said hands should be washed before gloves are put on, in between glove changes, and when gloves are removed. LPN A said when performing perineal care, staff should start from the front of the resident and wipe back toward the resident's bottom. He/She said staff can continue to use the same wipe as long as they fold the wipe to find a clean area. LPN A said staff should never wipe from back to front because there is a chance of getting germs into the urethra and could introduce E. coli (bacteria that could cause illness including diarrhea or illness outside of the intestinal tract) or a UTI. The LPN said the catheter bag should be kept below the resident's abdomen and it should never be resting on the resident's bed. MO 291

Based on interview and record review the facility staff failed to document the resident's code status consistently, Do Not Resuscitate (DNR) or Full Code (Resuscitate refers to cardiopulmonary resuscitation-CPR) and ensure staff knew how to access the information in an emergency for four residents (Resident #14, #24, #34, and #193). The facility census was 46. 1. Review of the facility's policy Advance Directives, revised (MONTH) (YEAR), showed it directs the staff: -Advance Directives will be respected in accordance with state law and facility policy; -Prior to or upon admission of a resident the Social Services Director or designee will inquire of the resident, his/her family members and/or his/her legal representative, about the existence of any written advance directive; -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; -The plan of care for each resident will be consistent with his/her documented treatment preferences and/or advance directive. 2. Review of Resident #14's medical record, showed: -Code status on the POS is DNR; -The record did not contain a red sticker on the spine of the hard chart; -Resuscitation Plan showed DNR; -Out of hospital DNR form completed; -Face sheet showed Full Code status. 3. Review of Resident #24's medical record, showed: -Code status is not listed on the POS; -The record did not contain a red sticker on the spine of the hard chart; -The record did not contain a Resuscitation Plan; -Out of hospital DNR form completed; -Face sheet did not contain a code status. 4. Review of Resident #34's medical record, showed: -Code status on the POS is DNR; -Red sticker on the spine of the hard chart; -The record did not contain a Resuscitation Plan; -Out of hospital DNR form completed; -The face sheet did not contain a code status. 5. Review of Resident #193's medical record, showed: -Code status on the POS is Full Code; -Does not have a red sticker on the spine of the hard chart; -Resuscitation Plan is Full Code; -Does not contain Out of hospital form; -The face sheet is DNR. 6. During an interview on [DATE], at 10:57 A.M., the director of nursing (DON) said if a resident is DNR status, the spine of the hard chart should have a red sticker. He/She said the resident's code status should be on their POS, face sheet, and the resident's Resuscitation Plan. He/She does not know why Resident #24 did not have indication of code status except for the out of hospital form. He/She said residents with a full code status do not have a sticker on their chart, their name plate with the resident's name outside of their room is highlighted yellow. During an interview on [DATE], at 11:09 A.M., licensed practical nurse (LPN) A said residents' code status is listed on the resident face sheet. He/She said if the resident is a DNR, the resident's hard chart has a red dot on the bind, and the full codes are highlighted at the door of the resident's room. He/She said the social services director (SSD) fills out the Resuscitation Plan, the charge nurse or SSD puts the status on the face sheet or POS. He/She said the SSD clarifies the resident's wishes with the resident and/or the resident's representative. He/She said the charge nurse clarifies/notifies the code status with the physician. He/She said if the code status is not clarified, the resident is considered a full code until it is determined. He/She said it could be confusing and someone could do the wrong thing, if they looked at the wrong code status. During an interview on [DATE], at 11:34 A.M., certified nurse assistant (CNA) D said the resident's code status should be on the face sheet in the resident's chart. He/She said if the resident is a DNR, there should be a red dot on the outside of the resident's hard chart. During an interview on [DATE], at 11:35 A.M., CNA [NAME] said the residents name on their door is highlighted if the resident is a full code; but he/she isn't sure. He/She said he/she checks the chart if someone needs to know in an emergency, but does not know what to check. He/she said he/she does not know what the red dot on the chart means. During an interview on [DATE], at 11:39 A.M., CNA F said he/she looks on the care plan if someone needs to know a resident's code status. During an interview on [DATE], at 11:40 A.M. CNA G said if a resident is a full code, it is highlighted on their name by the door, and top of the face sheet in the chart. He/She does not know what the red dots on the chart means. During an interview on [DATE], at 3:40 P.M., the DON said the resident's code status is expected to be on the face sheet, and the POS. He/She said if a resident is a DNR, a red sticker should be on the outside of the chart, and their name should be highlighted in yellow on their name plate for their room. During an interview on [DATE], at 12:41 P.M., the SSD said when residents are admitted to the facility, he/she meets with the resident and/or representative, and goes over the Resuscitation Plan which clarifies the resident's decision if he/she wants CPR or wants to be a DNR status, and related choices. If the resident wants to be a full code, the Resuscitation plan documents it and their name is highlighted on the outside of the resident's door. He/she said if the resident wants to be a DNR status it is documented on the Resuscitation plan and a red dot is placed on the outside of the resident's chart.

Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when they failed to keep the medication room door and shower room cabinet containing cleaning chemicals and razors closed/locked and also failed to keep medication locked in one resident's room (Resident #2). Facility staff also failed to ensure a safe/appropriate technique to lift and move one resident (Resident #24). The facility census was 46. 1. Review of the facility's policy Storage of Medications, Revised (MONTH) 2007, directs staff to: -Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transports such items shall not be left unattended if open or otherwise potentially available to others. -Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. 2. Observation on 5/22/19 at 10:46 A.M., showed the shower room door on the 300 hall propped open. Further observation showed a cabinet with a padlock on it, unlocked with the following inside: razors, power clean, pre-disinfectant, multi-quat, and turbo clean with a label that read, Keep out of the reach of children. Additional observation showed the cabinet was unsupervised and not within eyesight of staff. Observation on 5/22/19, at 3:52 P.M., showed the shower room on the 100 hall unlocked. Additional observation showed a cabinet unlocked with a sign that says, keep razors and chemicals locked at all times. The cabinet contained razors and Triple one step disinfectant in the unlocked cabinet. Further observation showed a drawer by the sink with bandage scissors, alcohol swabs with keep out of reach of children on the label, and unisolve-adhesive remover with keep out of reach of children on the label. Observation On 5/23/19 at 10:21 A.M., showed Resident #2 had two bottles of [MEDICATION NAME] (medication used for congestion) in his/her unlocked bathroom cabinet. Observation on 5/24/19 at 8:42 A.M., showed the medication room on the 300 hall was propped open with a bedside table. Further observation showed staff were not present in the medication room. 3. During an interview on 5/28/19 at 3:23 P.M., Certified Nursing Assistant (CNA) [NAME] said the only medications that should be left in the residents' rooms are the ones inside the lock boxes on the walls. He/She said the shower room should be locked when unsupervised due to the contents in the cabinet that can be harmful to the residents. During an interview on 05/28/19 03:37 P.M., CNA C said the chemicals and sharps in the shower rooms should be in a locked cabinet. During an interview on 5/28/19 at 3:31 P.M., Licensed Practical Nurse (LPN) J said he/she expects staff to keep the shower room cabinet locked when unsupervised. He/She said the medication room should not be propped open when the nurse is not in there. Both situations cause a safety risk to the residents. He/She said all medications should have an order by the physician and if residents keep them in their rooms, they are kept in the locked cabinet unless there is an order to keep at bedside. He/She said there should not be any medications in resident's rooms that do not have a physician's orders [REDACTED].>During an interview on 05/28/19 03:39 P.M., the director of nursing (DON) said chemicals and razors in shower room should be in a locked cabinet. He/she also said the medication room door should not be left propped open. He/she does not expect medication to be in an unlocked cabinet in residents' bathrooms without an order. 4. Review of the facility's policy Safe Lifting and Movement of Residents, dated (MONTH) (YEAR), showed it directed staff: -Use appropriate techniques and devices to lift and move residents; -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Assess individual residents needs for transfer assistance on an ongoing basis; -Staff will document resident transferring and lifting needs in the care plan, assessment will include mobility, resident's size, weight-bearing ability, cognitive status, if the resident is usually cooperative with staff; -Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. 5. Review of Resident #24's admission Minimum Data Set (MDS), a federally mandated assessment, dated 4/5/19, showed staff assessed the resident as follows: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Rejection of care one to three days out of seven days; -Fall with fracture prior to admission. Review of the resident's care plan, dated 4/11/19, showed staff documented the resident requires the assistance of two staff members for transfers. Observation on 5/24/19, at 10:46 A.M., showed the resident in a recliner in the TV room. Additional observation showed CNA G, and LPN I place a gait belt around the resident. The staff raised the resident with the gait belt to an upright position. Further observation showed the resident's feet with socks on, did not make contact with the floor. The staff carried the resident by his/her gait belt and under his/her arms three to four steps to the resident's wheelchair. The staff each took one arm and scooped the resident under the thigh while holding the gait belt and lifted the resident into the air. The resident's yelled out, Ouch that hurts, and the staff lowered the resident into his/her wheelchair. Observation on 5/28/19, at 10:56 A.M., showed the resident in a recliner in the TV room. Additional observation showed CNA G and CNA H place a gait belt around the resident. The staff raised the resident with the gait belt to an upright position. Further observation showed the resident held his/her legs straight out, and his/her feet did not make contact with the floor. The CNAs, with pressure to the resident's gait belt and underarms carried the resident four to five steps to the resident's wheelchair. The staff each took one arm and scooped the resident under the thigh while holding the gait belt and lifted the resident into the air, and the staff lowered the resident into his/her wheelchair. During an interview on 5/28/19, at 2:27 P.M., CNA H said staff are expected to use a gait belt when transferring residents. He/She said the weight should be through the gait belt and never on a resident's armpit/shoulder area. H/eShe said the resident sometimes can bear weight, but it depends on his/her mood, and sometimes he/she will put his/her legs straight out and not help at all. He/She said the resident stands half the time and half the time he/she doesn't. The CNA said the resident has to be lifted in the air because his/her chair is too tall, the resident cannot just sit in it, he/she has to be lifted to get over the edge of the seat. During an interview on 5/28/19, at 3:29 P.M., CNA B said staff do a dead man or fireman lift if a resident will not stand. He/She said the preferred technique would be a mechanical lift, but if the resident has not been evaluated, then staff do a deadman lift. During an interview on 5/28/19, at 3:34 P.M., CNA C said the resident does not always put his/her feet on the ground. He/She said staff try to do a two person transfer with a gait belt with residents if they can bear some weight, but if they do not bear weight at all then staff use a hoyer (mechanical lift). He/She said staff do not routinely lift residents by the thigh area into the chair. During an interview on 5/28/19, at 3:40 P.M., the DON said if a resident does not always bear weight then staff are expected to use a hoyer lift. He/She said there are not any residents staff should routinely use a dead man or fireman lift on. He/She said the resident should not be lifted into the air manually.

Based on observation, interview, and record review, facility staff failed to ensure staff obtained a 14 day stop date or a clinical rationale to justify continued use of as needed (PRN) [MEDICAL CONDITION] medication for one resident (Resident #9) out of 6 sampled residents, and also failed to attempt a dose reduction for 2 residents (Resident #23 and #31) out of 6 sampled residents. The facility also failed to ensure residents were free from unnecessary medications when they failed to document a proper [DIAGNOSES REDACTED].#38) out of 6 sampled residents out of 6 sampled residents. The facility census was 46. 1. Review of the facility's [MEDICAL CONDITION] Medication Policy, dated 8/17, showed the following: -The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications within the facility. This is to include the regular review for continued need, appropriate dosage, side effect, risk and/or benefits. -The facility supports the appropriate use of psychopharmacological medications that are therapeutic and enabling for residents suffering from mental illness. -The facility supports the goal of determining the underlying cause of behavioral symptoms for the appropriate treatment of [REDACTED]. -The facility supports the goal of determining the underlying cause of residents having difficulty sleeping so the appropriate treatment of [REDACTED]. -Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation. -Psychopharmacological medications will never be used for the purpose of discipline or convenience. -[MEDICAL CONDITION] medications include: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. -Orders for [MEDICAL CONDITION] medication only for the treatment of [REDACTED]. -Documents rationale and [DIAGNOSES REDACTED]. -Documents discussion with the resident and or responsible party regarding the risk versus benefit of the use of these medications included in the he discussion and documentation must be the presence of any black box warning or off label use of the medication affecting the prescribing of the medication to the resident. -Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within one month of initiating, increasing, or decreasing dose and during routine visits thereafter. -Monitors the resident for lack of drug efficacy clinically and in discussions with the interdisciplinary team, within one month of initiating and during routine visits. -Attempt a gradual dose reduction (GDR) decrease or discontinuation of [MEDICAL CONDITION] medications after no more than 3 months unless clinically contraindicated. Gradual dose reduction must be attempted for 2 separate quarters (with at least one month between attempts). Gradual dose reduction must be attempted annually thereafter or as the resident's clinical condition warrants. -Sedative/Hypnotics will be reviewed quarterly for gradual dose reduction. GDR must be attempted quarterly unless clinically contraindicated. -Orders for PRN [MEDICAL CONDITION] medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances. -Obtains psychiatric consultation as resident's clinical condition requires. 2. Review of the facility's Antipsychotic Medication Use policy, revised (MONTH) (YEAR), showed the following: -Antipsychotic medications shall generally be used only for the following conditions/[DIAGNOSES REDACTED]. a. [MEDICAL CONDITION]; B. Schizo-affective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. [MEDICAL CONDITION] disorder, depression with psychotic features, and treatment refractory [MEDICAL CONDITION]); f. [MEDICAL CONDITION] in the absence of dementia; g. Medical illnesses with psychotic symptoms and/or treatment-related [MEDICAL CONDITIONS](e.g., high-dose steroids); h. [MEDICAL CONDITION]'s Disorder; i. [MEDICAL CONDITION]; j. Hiccups (not induced by other medications); or k. Nausea and vomiting associated [MEDICAL CONDITION] or [MEDICAL CONDITION]. -The need to continue PRN orders for [MEDICAL CONDITION] medications beyond 14 days requires that the practitioner document the rational for the extended order. The duration of the PRN order will be indicated in the order. -PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. 3. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 2/25/19, showed staff assessed the resident as: -Severe cognitive impairment; -[DIAGNOSES REDACTED].>-The resident did not have behaviors; -The resident did not receive hypnotic medications. Review of the resident's physician's orders [REDACTED]. Additional review showed the order for the medication did not contain a stop date. During an interview on 5/28/19, at 3:40 P.M., the director of nursing (DON) said PRN [MEDICAL CONDITION] should have a stop date of 14 days or less. 4. Review of Resident #23's significant change MDS, dated [DATE], showed staff assessed the resident as: -Mild cognitive impairment; -[DIAGNOSES REDACTED]. -Staff assessed resident with a total mood severity score of 14; and -No Physical behaviors during the look back period. Review of the resident's care plan, dated 4/4/19, showed staff are directed as follows: -Give medications as ordered; -Monitor for side effects to prescribed medication. Review of the resident's POS, dated 5/1/19-5/31/19, showed staff obtained a physician's orders [REDACTED]. Further review showed staff also obtained an order on 8/2/18 for [MEDICATION NAME] 20 mg one tablet po twice per day (BID). Review of the resident's progress notes, dated 8/2/18-5/28/19, showed the pharmacist did not document a recommendation to attempt a GDR for the [MEDICATION NAME] or the [MEDICATION NAME] to the physician. Further review showed the physician did not document the need for continued use or contraindication for a GDR. 5. Review of Resident #31's quarterly review MDS, dated [DATE], showed the resident's [DIAGNOSES REDACTED]. -Hypertension -Anxiety Disorder -Depression -Asthma, [MEDICAL CONDITIONS] or [MEDICAL CONDITION] (e.g., chronic [MEDICAL CONDITION] and restrictive lunch disease such as [MEDICAL CONDITION]). Review of the resident's POS, dated 05/01/19-05/31/19, showed staff obtained a physician's orders [REDACTED]. Further review showed staff obtained a physician's orders [REDACTED]. Review of resident's progress notes, dated 07/02/18-05/28/19, showed the pharmacist did not document a recommendation to attempt a GDR for the [MEDICATION NAME] or the [MEDICATION NAME] to the physician. Further review showed the pharmacist did not document the need for continued use or contraindication for a GDR. 6. Review of Resident #38's quarterly MDS, dated [DATE], showed the resident's [DIAGNOSES REDACTED]. -Hypertension -[MEDICAL CONDITION] Disorder of [MEDICAL CONDITION] -Depression Review of the resident's POS, dated 03/12/19, showed an order for [REDACTED]. During an interview on, 05/24/19 at 10:30 A.M., the DON said the resident's family does not want the resident's medication changed. The DON said [MEDICATION NAME] is not used for treatment of [REDACTED]. During an interview on 5/28/19 at 9:53 AM, LPN J said he/she would not expect [MEDICATION NAME] to be used to treat [MEDICAL CONDITION]. 7. During an interview on 5/24/19 at 10:30 A.M., The DON said he/she and the Assistant Director of Nursing (ADON) are responsible for tracking the GDR's. They review the medications as part of their QAPI meeting and the pharmacist also reviews them. He/She said often times the reductions are not done because the family refuses to let them change the medications. During an interview on 5/28/19 at 9:53 A.M., LPN J said the DON and ADON are responsible for the GDRs. He/She said if they obtain an order for [REDACTED]. He/She said all medications should have an appropriate [DIAGNOSES REDACTED].

Based on observation, interview, and record review, facility staff failed to discard expired medication in one medication room out of one sampled and one medication cart out of two sampled. The facility census was 46. 1. Review of the facility's policy on discarding and destroying medication, revised (MONTH) 2007, showed staff are directed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 2. Observation on [DATE] at 10:20 A.M., showed the following expired medication in the medication room refrigerator: - One and one half packets of therapeutic [MEDICATION NAME] 900 billion bacteria per packet (used to keep gut healthy), expiration date [DATE]; - One opened bottle of [MEDICATION NAME] chewable tablets (used to replace gut flora), expiration date [DATE]. Medication Cart: - One bottle of [MEDICATION NAME] 400 microgram (mcg) sublingual tablets (a medication used to treat chest pain), expiration date [DATE]; - One box of epi-twin 0.3 milligrams (mg) auto injectors (two injections of [MEDICATION NAME], a medication used to treat severe allergic reactions), expiration date [DATE]; - [MEDICATION NAME] 10mg tablets (a medication used to treat short-term [MEDICAL CONDITION]), expiration date [DATE]; - One card containing two tablets of [MEDICATION NAME] bactrim DS ,[DATE]mg (an antibiotic), expiration date [DATE]; - Two cards containing two tablets each of [MEDICATION NAME] 250mg (an antibiotic), expiration date [DATE]; - One vial of [MEDICATION NAME] 500g powder for intramuscular (IM) use (an antibiotic), expiration date [DATE]. 3. During an interview on [DATE] at 10:45 A.M., licensed practical nurse (LPN) A said everyone who administers medication are supposed to check medication expiration dates at least once a week. 4. During an interview on [DATE] at 2:51 P.M., certified nursing assistant/certified medical technician (CNA/CMT) B said everyone who administers medication are supposed to check medication expiration dates about once a week. He/she said only nurses check the emergency medicine located in the (emergency kits) ekits in the medication rooms. 5. During an interview on [DATE] at 3:45 P.M., the director of nursing (DON), and the minimum data set (MDS) coordinator, said they expect charge nurses to check expiration dates on narcotics, refrigerated medication, and medication in emergency kits (e-kits). They said the person in charge of a medication cart for the day should check the medication in the regular medication carts. They said they do not have a sign off sheet or a system in place to routinely check medication expiration dates.

Based on observation, interview and record review the facility staff failed to offer resident's the complete ordered diet for five resident's (Resident #18, #20, #24, #27, and #34). The facility also failed to obtain and transcribe physician's orders [REDACTED].#34). The facility census was 46. 1. Review of the facility's Therapeutic Diets policy, dated (MONTH) (YEAR), showed the following: -Therapeutic diets are prescribed by the Attending Physician; -A therapeutic diet must be prescribed by the resident's attending physician, the physician may delegate this task to a registered or licensed dietitian; -A therapeutic diet is a diet that modifies specific nutrients or to alter the texture of a diet. 2. Review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 12/17/18, showed the staff assessed the resident with severe cognitive impairment, required extensive assistance of one staff member for eating, and a weight of 196 lbs. Review of the resident's significant change MDS, dated [DATE], showed the staff assessed and documented the resident weighed 188 lbs. Review of the resident's physician's orders [REDACTED]. Review of the resident's Care Plan, dated 3/14/19, showed it directed the staff: -Requires assist of one staff member with verbal cues, and sometimes needs to be fed; -Please send diet as ordered; -The resident has mental disabilities, difficulties with memory, and communication. Review of the facility menus dated 05/28/19 (Week 4, Day 24), showed staff were directed to provide the residents on pureed diets with the following: -four ounces (oz.) of pureed fried chicken; -four oz. of mashed potatoes with two oz. of gravy; -a #12 (2.6 oz.) scoop of pureed buttered peas; -four oz. of pureed apple pie; -4 oz. ice cream cup; -a #16 (two oz.) scoop of pureed bread. Observation on 05/28/19 at 11:39 A.M., showed the staff served Resident #18 a #6 (5.3 oz.) scoop of pureed chicken with gravy (1.3 oz. more than directed by the menus). Observation also showed the staff did not offer the resident the pureed apple pie and ice cream as directed by the menus. 3. Review of Resident #20's admission MDS, dated [DATE], showed the staff assessed the resident with severe cognitive impairment and required extensive assistance of one staff member for eating. Review of the resident's physician's orders [REDACTED]. Review of the facility menus dated 5/22/19 (Week 3, Day 18), showed the staff were directed to provide the residents on regular diets with the following: -eight ounces (oz.) of chicken gumbo soup; -four crackers; -a turkey club sandwich made of two oz. of turkey and two slices of bread; -a dill pickle spear; -four oz. of fresh grapes; -a 3 x 2.5 inch chocolate chip brownie. Observation on 5/22/19 from 11:50 A.M. to 12:35 P.M., showed the staff served the resident the chicken gumbo soup, crackers, half of a turkey club sandwich, and peaches. Observation showed the staff fed the resident 100% of all food items offered. Further observation showed the staff removed the resident from the table and did not offer the resident the dill pickle spear and chocolate chip brownie as directed by the menus. Review of the facility menus dated 5/23/19 (Week 3, Day 19), showed the staff were directed to provide the resident on regular diets with the following: -six oz. of beef stroganoff over four oz. of noodles; -four oz. of seasoned broccoli; -eight oz. of side salad with two tablespoons of dressing; -one serving of cream puff dessert; -one slice of wheat bread with one teaspoon (tsp.) of margarine. Observation on 5/23/19 from 11:56 A.M. to 12:26 P.M., showed the staff served the resident half of a lunch meat sandwich and beef stroganoff over noodles. Observation showed the resident consumed his/her sandwich and the meat off the beef stroganoff. Observation at 12:17 P.M., showed the resident's family member requested a dessert for the resident. Further observation showed the staff did not offer the resident the side salad with dressing, seasoned broccoli and the bread with margarine as directed by the menus. Review of the facility menus dated 05/28/19, showed staff were directed to provide the residents on regular diets with the following: -a three oz. edible portion of fried chicken; -four oz. of mashed potatoes; -four oz. of buttered peas; -1/8th slice of apple pie; -4 oz. ice cream cup; -one slice of wheat bread with one teaspoon tsp. of margarine. Observation on 5/28/19 from 11:45 A.M. to 12:15 P.M., showed the staff served the resident the fried chicken, mashed potatoes, peas, and pie. Further observation showed the staff removed the resident from the table and did not offer the resident the ice cream or the bread and margarine as directed by the menus. During an interview on 05/28/19 at 12:43 P.M., Restorative Nurses Aide (RNA) K said he/she did not give the resident ice cream because the resident does not like cold foods. The RNA said he/she did not ask the kitchen staff for an alternative for the ice cream since the resident did not like cold foods. 4. Review of Resident #24's admission MDS, dated [DATE], showed the staff assessed and documented the resident with severe cognitive impairment, required extensive assistance of one staff to eat, and a weight of 96 lbs. Review of the resident's 14 day MDS, dated [DATE], showed the staff assessed and documented the resident with a weight of 87 lbs. and significant weight loss. Review of the resident's physician's orders [REDACTED]. Review of the resident's Care Plan, dated 4/11/19, showed it directed the staff: -Requires assist of one staff member to be eat; -Healthshakes three times a day; -Likes sweets and snacky items; -Send diet as ordered. Review of the facility menus dated 5/22/19 (Week 3, Day 18), showed the staff were directed to provide the residents on regular diets with the following: -eight ounces (oz.) of chicken gumbo soup; -four crackers; -a turkey club sandwich made of two oz. of turkey and two slices of bread; -a dill pickle spear; -four oz. of fresh grapes; -a 3 x 2.5 inch chocolate chip brownie. Observation on 5/22/19 from 11:55 A.M. to 12:25 P.M., showed the staff served the resident the chicken gumbo soup, crackers, and half of a turkey club sandwich. Observation showed the staff fed the resident 75% of his/her meal. Further observation showed the staff removed the resident from the table and did not offer the resident the dill pickle spear, grapes, and chocolate chip brownie as directed by the menu. Review of the facility menus dated 5/23/19 (Week 3, Day 19), showed the staff were directed to provide the resident on regular diets with the following: -six oz. of beef stroganoff over four oz. of noodles; -four oz. of seasoned broccoli; -eight oz. of side salad with two tablespoons of dressing; -one serving of cream puff dessert; -one slice of wheat bread with one tsp. of margarine. Observation on 5/23/19 from 11:52 A.M. to 12:27 P.M., showed the staff served the resident chicken gumbo soup, a half of a turkey club, a pickle and grapes. Additional observation showed the staff fed the resident 25% of his/her meal. Further observation showed the staff removed the resident from the table and did not offer the resident the dessert as directed by the menu. The meal served was the alternate for the listed menu item. The resident requested the alternate. During an interview on 5/23/19 at 12:40 P.M., the resident said he/she likes desserts. The resident said, Did they have one (dessert)? Do I have to ask for it? Review of the facility menus dated 05/28/19 (Week 4, Day 24), showed staff were directed to provide the residents on regular diets with the following: -a three oz. edible portion of fried chicken; -four oz. of mashed potatoes; -four oz. of buttered peas; -1/8th slice of apple pie; -4 oz. ice cream cup; -one slice of wheat bread with one tsp of margarine. Observation on 5/28/19 from 11:45 A.M. to 12:15 P.M., showed staff served the resident a barbecued beef sandwich, mashed potatoes, peas, and cake, the alternate menu. Further observation showed the staff did not offer the resident the ice cream as directed by the menu. During an interview on 05/28/19 at 12:43 P.M., RNA K said he/she forgot to ask the resident if he/she wanted the ice cream. 5. Review of Resident #27's significant change MDS, dated [DATE], showed the staff assessed and documented the resident with severe cognitive impairment, required supervision of staff with eating, and a weight of 188 lbs. Review of the resident's 30 day MDS, dated [DATE], showed the staff assessed and documented the resident with a weight of 167 lbs. Review of the resident's physician's orders [REDACTED]. Review of the resident's Care Plan, dated 4/4/19, showed it directed the staff to: -Send diet as ordered; -Offer different options if the resident does not like the meal; -Carnation instant breakfast with lunch and supper. Review of the facility menus dated 5/23/19 (Week 3, Day 19), showed staff were directed to provide the residents on mechanical soft diets with the following: -six oz. of ground beef stroganoff over four oz. of noodles; -four oz. of cooked broccoli; -four oz. of soft cooked vegetable; -one serving of cream puff dessert; -one slice of wheat bread with one tsp. of margarine. Observation on 5/23/19 from 11:45 A.M. to 12:15 P.M., showed the staff served the resident beef stroganoff with noodles. Observation showed the staff did not serve the resident a full meal and the resident consumed 25% of of the beef stroganoff with noodles. Further observation showed the staff removed the resident from the table and did not offer or serve the resident the vegetables, dessert and bread as directed by the menus. Review of the facility menus dated 5/24/19 (Week 3, Day 20), showed the staff were directed to provide the residents on mechanical soft diets with the following: -a #12 scoop of ground hot turkey on one slice of bread; -four ounces of mashed potatoes with two ounces of gravy; -four ounces of cauliflower with cheese sauce; -a 3 x 2.5 inch serving of boston cream cake; -one slice of wheat bread with one tsp. of margarine. Observation on 5/24/19 from 11:55 A.M. to 12:20 P.M., showed the staff served the resident a half portion of the open faced turkey sandwich. Observation showed the staff did not offer the resident any additional food as directed by the menus. Review of the facility menus dated 05/28/19, showed staff were directed to provide the residents on mechanical soft diets with the following: -a #12 scoop of ground fried chicken; -four oz. of mashed potatoes with two oz. of gravy; -four oz. of buttered peas; -1/8th slice of apple pie; -4 oz. ice cream cup; -one slice of wheat bread with one teaspoon (tsp) of margarine. Observation on 5/28/19 from 11:45 A.M. to 12:15 P.M., showed the staff served the resident a barbecued beef sandwich (alternate) and lima beans. Observation showed the staff did not offer the resident the mashed potatoes, apple pie and ice cream as directed by the menus. 6. Review of Resident #34's annual MDS, dated [DATE], showed the staff assessed and documented the resident with severe cognitive impairment, required extensive assistance of one staff with eating, and a weight of 122 lbs. Review of a progress note dated 4/02/19, showed the Dietary Manager (DM) documented the resident on a pureed diet with nectar thickened liquids. Review also showed the DM documented the resident had trouble with swallowing and pocketing food. Review of the resident's significant change MDS, dated [DATE], showed the staff assessed and documented the resident with a weight of 117 lbs. Review of the resident's Care Plan, dated 4/11/19, showed it directed the staff: -Pureed diet and nectar thick liquids; -Resident has a poor appetite; -Health shake with each meal; -Encourage resident to eat and drink; -Send diet as ordered Review of the resident's 14 day MDS, dated [DATE], showed the staff assessed and documented the resident with a weight of 114 lbs. Review of the resident's Care Plan, dated 4/29/19, showed it directed the staff to serve the resident a mechanical soft diet. Observation on 5/22/19 from 11:50 A.M. to 12:35 P.M., showed the staff served the resident pureed meat with gravy, mashed potatoes with gravy, soup with a red chunk like tomato, and regular chocolate pie with crust. Observation showed the resident consumed 25% of his/her meal. Observation on 5/23/19 from 11:59 A.M. to 12:42 P.M., showed the staff served the resident beef stroganoff, broccoli, and creamed corn. Observation showed the resident consumed 25% of his/her meal. Further observation showed staff removed the resident from the table and did not offer the resident the dessert as directed by the menu. Review of the facility menus dated 5/28/19 (Week 4, Day 24), showed staff were directed to provide the residents with the following: -fried chicken; -mashed potatoes; -buttered peas; -apple pie; -ice cream cup; -wheat bread and margarine. Observation on 5/28/19 from 11:40 A.M. to 12:40 P.M., showed staff served Resident #34 a grilled cheese sandwich and bowl of tomato soup and walked away. Observation showed staff were not present at the table to provide feeding assistance to the resident until 11:48 A.M. Further observation showed staff did not offer the resident the apple pie and ice cream as directed by the menus. During an interview on 05/28/19 at 12:40 P.M., the resident said he/she liked pie and would take a piece if it came his/her way. The resident also said he/she like ice cream. During an interview on 05/28/19 at 12:43 P.M., RNA K said he/she forgot to ask the resident if he/she wanted the pie and ice cream. 7. During an interview on 5/28/19 at 2:23 P.M., the DM said staff should serve residents in accordance with the menus. The DM said he/she would expect staff to provide cognitively impaired residents all the food items on the menu and the residents should have received the ice cream. 8. During an interview on 5/28/19 at 3:40 P.M., the director of nursing (DON) said he/she expects the staff to serve resident's with dementia the full meal. 9. During an interview on 05/28/19 at 3:45 P.M., the administrator said staff are expected to serve foods in accordance with menus. The administrator said all foods should be offered to residents and he/she would expect staff to serve all food items on the menus to residents with cognitive impairments.

Based on observation, interview, and record review, facility staff failed to properly propel three residents (Resident #31, Resident #199 and an unidentified resident) in wheelchairs in a manner to prevent accidents. Additionally, facility staff failed to ensure one resident (Resident #19) remained free from accident hazards after staff documented the resident had repeated falls. Facility staff also failed to ensure the residents' environment remained free of accident hazards when they failed to ensure razors and chemicals were not accessible to residents. The facility census was 48. 1. Review of the facility policies showed the facility did not provide a policy to direct staff how to propel residents in wheelchairs in a manner to prevent accidents. 2. Review of Resident #26's Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/26/18, showed facility staff assessed the resident as follows: -Moderately impaired cognitive status; -Required extensive assistance of two or more staff for bed mobility, transfer, dressing, and toilet; -Required extensive assistance of one staff member for locomotion on unit and personal hygiene; -Required use of wheelchair. Observation on 4/10/18 at 11:09 A.M., showed Certified Nurse Assistant (CNA) B propelled the resident into dining room in his/her wheelchair without foot pedals. Observation showed the resident's feet dragged the floor. 3. Review of Resident #31's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Supervision for bed mobility, transfer, locomotion, dressing, eating, toileting, and personal hygiene. Review of the resident's care plan dated 03/08/18, showed staff are directed the resident has red and swollen feet which is painful and the resident uses a four wheeled walker to get around the facility because he/she can walk by himself/herself. Observation on 4/10/18 at 10: 59 A.M., showed Restorative Nurse Aid (RNA) O propelled the resident down the 100 hall to the dining room in his/her wheelchair without foot pedals. Observation showed the resident's feet dragged the floor. Observation on 04/12/18 at 12:55 P.M., showed CNA B propelled the resident in his/her wheelchair without foot rests. The CNA told the resident to hold his/her feet up. 4. Review of Resident #199's admission care plan, dated 04/12/18, showed staff are directed the resident uses a wheelchair and he/she is able to propel himself/herself for short distances. Observation on 04/10/18 at 11:38 A.M., showed CNA I propelled the resident in his/her wheelchair without foot rests. Observation showed the resident's feet dragged the floor. 5. During an interview on 04/12/18 at 3:31 P.M., CMT J said you should put a resident's foot pedals on before transporting them in a wheelchair. He/She said you should never propel a resident without foot pedals. During an interview on 04/12/18 at 3:48 P.M., CNA K said you should put foot pedals on before pushing a resident in a wheelchair. He/She said you should never push a resident without foot pedals unless they are care planned not to have them. During an interview on 04/12/18 at 3:34 P.M., LPN D said staff should always make sure a resident's foot pedals are on before propelling them. He/She said if a resident can propel themselves you can walk beside them and assist but never push them long distances. During an interview on 04/12/18 at 4:28 P.M., the DON said if staff push a resident in a wheelchair from behind they should have foot pedals but if they are walking beside them and the resident is able to self-propel they do not have to have foot pedals. He/She said if staff see other staff propelling a resident without foot pedals they should say something. 6. Review of Resident #19's MDS, dated [DATE], showed staff assessed the resident as follows: -Moderately impaired cognition; -Required extensive assistance of two or more staff with bed mobility, dressing, and toilet use; -Totally dependent on two or more staff with transfers; -Required extensive assistance of one person with locomotion on and off unit via wheelchair; -Feeling tired or having little energy (2-6 days) over the seven day review period. Review of the resident's nurse's notes, dated 11/16/17, showed staff documented the resident was found on the floor beside the bed, next to the window on his/her right side. The resident said he/she was trying to get candy out of his/her drawer when he/she fell . The family and physician were notified, and the resident was sent to the emergency room for medical treatment. Review of the resident's nurse's notes, dated 1/13/18, showed staff documented the resident had an unwitnessed fall and was found on the floor in his/her room on his/her right side. The resident said he/she slid out of the wheelchair. Staff documented they applied an ice pack to swelling above his/her right eye, and applied a dressing to a skin tear on the resident's right arm. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -Moderately impaired cognition; -Required extensive assistance of two or more staff with bed mobility, transfers, dressing, and toilet use; -Required extensive assistance of one person with locomotion on and off unit via wheelchair; -Trouble falling or staying asleep, or sleeping too much (2-6 days) over the seven day review period; -Feeling tired or having little energy (2-6 days) over the seven day review period. Review of the resident's care plan, last updated 2/15/18, showed staff are directed: -The resident takes a [MEDICAL CONDITION] and has had a recent fall; -In a low bed; -Need to have a mat on both sides of the bed when the resident lies down; -Make sure call light is within reach; -Remind the resident to call for help when needed; -Allow the resident to do as much as possible with his/her ADL's; -Supervision and set up help with eating; -Extensive assist of one person with locomotion on and off unit; -No impairments to upper extremities (shoulder, elbow, wrist, hand); -Watch for side effects of medications: [REDACTED]. Staff did not document interventions for the use of side rails on the care plan. Observation and interview on 4/09/18 at 7:36 P.M., showed the resident in bed on his/her left side. The resident said is there any water in here, I need a drink. Observation showed a bedside table parked against the wall next to the sink (behind the resident), approximately three to four feet from the bed, contained a water pitcher with the paper still attached to the straw. Staff did not ensure the resident's water pitcher was within reach to prevent accident hazards. Observation on 4/10/18 at 9:49 A.M., showed the resident in bed on his/her left side. Further observation showed the bedside table parked against the wall next to the sink (behind the resident), approximately three to four feet from the bed, contained a water pitcher with the paper still attached to the straw. Staff did not ensure the resident's water pitcher was within reach to prevent accident hazards. Observation on 4/11/18 at 10:35 A.M., showed the resident sat in his/her wheelchair in his/her room, with eyes closed and head tilted downwards. Observation showed the lights off, and the call light outside the resident's reach, by approximately four to five feet. Further observation showed the paper still attached to the straw inside the water pitcher that sat on the bedside table parked behind the resident, next to the sink. Staff did not ensure the resident's call light and water pitcher were within reach, to prevent accident hazards. Observation on 4/11/18 at 11:00 A.M., showed the resident sat in his/her wheelchair in his/her room, with eyes closed and head tilted downwards. Observation showed the lights off, the call light outside the resident's reach, by approximately four to five feet. Further observation showed the paper still attached to the straw inside the water pitcher, that sat on the bedside table, parked behind the resident, next to the sink. Staff did not ensure the resident's call light and water pitcher were within reach, to prevent accident hazards. Observation on 4/11/18 at 3:05 P.M., showed the resident in bed on his/her left side. Further observation showed the right side rail (toward window) in the raised position, between the bed and the drawers of the nightstand. Staff did not ensure the resident was able to freely access the drawers on the nightstand to prevent accident hazards. Observation on 4/11/18 at 4:03 P.M., showed the resident in bed on his/her left side, with the right side rail in the raised position, between the bed and the drawers of the nightstand. Staff did not ensure the resident was able to freely access the drawers on the nightstand to prevent accident hazards. Observation on 4/12/18 at 9:36 A.M., showed the resident laid in bed on his/her left side. Further observation showed a bedside table parked against the wall next to the sink (behind the resident), approximately three to four feet from the bed, contained a water pitcher with the paper still attached to the straw. Staff did not ensure the resident's water pitcher was within reach. During an interview on 4/11/18 at 3:01 P.M., Certified Nurse's Assistant (CNA) G said the resident fell from his/her wheelchair and hit his/her head a couple months prior. The CNA said the resident falls about every three to four months. The CNA said staff sometimes lock the wheelchair and have the resident face the bed, so if he/she happens to fall from the chair, he/she does not hit the ground directly. During an interview on 4/11/18 at 4:14 P.M., CNA G said the resident tries to get into his/her drawers on the nightstand for candy or other items, and with the rail raised, it would prevent him/her from opening the drawer and possibly hurt his/her hand. During an interview on 4/12/18 at 8:51 A.M., CNA A said the resident does not use side rails. He/She said residents that use side rails will have interventions listed on their care plan, and will also have a pink circular tab attached to the rail. The CNA said he/she was not sure why staff placed the water pitcher on the bedside table next to the sink, outside the resident's reach. During an interview on 4/12/18 at 4:29 P.M., the DON said the side rails should not be raised when the resident is left in bed. Staff may raise the side rails during care, but lowered when they exit the room. The DON said staff are expected to place the resident's call light, and water pitcher within reach. 7. Observation on 04/09/18 at 9:47 P.M., showed the shower room on the 300 Hall unlocked and unattended. Further observation showed the shower room contained barbicide, spray cleaner, disinfectant cleanser, razors, lime away, mild acid restroom cleaner, an unlabeled chemical bottle, two bottles of pre-disinfectant chelating detergent, three bottles of disinfectant/cleaner/detergent/fungicide/virucide/deodorizer which read danger: keep out of reach of children stored in unlocked areas. Observation on 04/09/18 at 9:53 P.M., showed the storage room next to the 300 Hall shower room unlocked and unattended. Further observation showed the storage room contained five bottles of pre-disinfectant chelating detergent, two bottles of disinfectant/cleaner/detergent/fungicide/virucide/deodorizer which read danger: keep out of reach of children, and sani-wipes stored in unlocked areas. Observation on 04/09/18 at 9:58 P.M., showed the 100 Hall shower room unlocked and unattended. Further observation showed the shower room contained barbicide, two boxes of razors, lime away, one bottle of pre-disinfectant chelating detergent, and seven bottles of disinfectant/cleaner/detergent/fungicide/virucide/deodorizer which read danger: keep out of reach of children stored in unlocked areas. Observation on 04/09/18 at 10:06 P.M., showed the sprinkler room at the end of the 200 Hall unlocked and unattended. Further observation showed the room contained four five gallon drums of floor adhesive which read, danger: keep out of reach of children. Observation on 04/10/18 at 10:01 A.M., showed the storage room next to the 300 Hall shower room unlocked and unattended. Further observation showed the storage room contained sani-wipes stored in an unlocked area. Observation on 04/10/18 at 10:15 A.M., showed the shower room on the 300 Hall unlocked and unattended. Further observation showed the shower room contained barbicide, spray cleaner, disinfectant cleanser, razors, lime away, mild acid restroom cleaner, an unlabeled chemical bottle, two bottles of pre-disinfectant chelating detergent, three bottles of disinfectant/cleaner/detergent/fungicide/virucide/deodorizer which read danger: keep out of reach of children stored in unlocked areas. Observation on 04/11/18 at 11:09 A.M., showed the 100 Hall shower room unlocked and unattended. Further observation showed the shower room contained barbicide, two boxes of razors, lime away, one bottle of pre-disinfectant chelating detergent, and seven bottles of disinfectant/cleaner/detergent/fungicide/virucide/deodorizer which read danger: keep out of reach of children stored in unlocked areas. An unidentified resident propelled himself/herself in his/her wheelchair down the hall outside the shower room. Observation on 04/12/18 at 08:57 A.M., showed the shower room on the 300 Hall unlocked and unattended. Further observation showed the shower room contained barbicide, spray cleaner, disinfectant cleanser, razors, lime away, mild acid restroom cleaner, an unlabeled chemical bottle, two bottles of pre-disinfectant chelating detergent, three bottles of disinfectant/cleaner/detergent/fungicide/virucide/deodorizer which read danger: keep out of reach of children stored in unlocked areas. Additional observation showed two unidentified residents unaccompanied by staff in the hall outside the shower room. 8. During an interview on 04/12/18 at 12:40 P.M., CNA A said chemicals and sharps are supposed to be stored behind lock and key. He/She they should be locked up because the residents could get ahold of them and harm themselves. He/She said there are no chemicals or sharps in the shower rooms that are not locked up. He/She said they are to be stored in locked cabinets. During an interview on 04/12/18 at 12:58 P.M., CNA B said sharps should be stored in sharps containers. He/She said the razors are kept in the locked nurse's room. He/She said chemicals like cleaning supplies should be kept in the housekeeping closet behind a locked door. He/She said they should be locked up to prevent resident access. He/She said the sharps and chemicals are kept in a cabinet in the shower room but it is supposed to be locked. He/She said the shower room is kept unlocked. During an interview on 04/12/18 at 1:02 P.M., LPN C said sharps and chemicals should be kept behind locked doors. He/She said they should never be left in a room that is not locked or attended by staff. He/She said there are sharps and chemicals in the shower room but he/she thinks they keep them locked up. He/She said there is a cabinet in the shower room that locks. During an interview on 04/12/18 at 4:28 P.M., the DON said razors are kept behind the nurse's station and locked up if not in use. He/She said they should be locked up in the medication room or in a locked cabinet in the shower room. He/She said chemicals should be stored in the locked medication room or in a locked cabinet in the shower room. He/She said sani-wipes should be locked up. He/She said staff should notify the charge nurse or housekeeper if they see chemicals or sharps accessible to residents and immediately put them up in a safe place.

Based on observation, interview, and record review, facility staff failed to obtain informed consent, or a physician's order with medical diagnoses, and failed to document entrapment assessments for use of bed rails for seven residents (Resident #5, #8, #19, #30, #33, #48, and #199). The facility census was 48. 1. Review of the facility's policy on Bed Rail Entrapment Risk Notification, undated, showed staff documented the facility does not use side rails without first reading, understanding, and explaining the Bed Rail Entrapment Risk Notification to residents and resident representatives. Staff are directed to: -Consider alternatives to restraints include the following: -lower the bed; -keep the bed wheels locked; -place fall mats next to the bed; -use transfer or mobility aides; -monitor residents frequently; -routinely attend to patient needs; -Understand the risks and benefits of bed rails; -Have the physician and family review the resident's medical condition for need; -Properly assess the equipment; -Frequently monitor the equipment; -Comply with instructions and warnings about the use of side rails; -Understand conditions such as restlessness, mental deterioration and dementia or [MEDICAL CONDITION] disorders, sleeping problems, and incontinence can increase a resident risk of entrapment; -Use with both rails in the up position; -Never use bed rails for restraint purposes (preventing or hindering the resident within the bed from exiting the bed as they wish); -Reassess the need for using bed rails on a frequent, regular basis. 2. Review of Resident #5's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/22/18, showed staff assessed the resident as follows: -[DIAGNOSES REDACTED]. -Moderately impaired cognition; -No behaviors or rejection of care; -Extensive assist of two or more staff with bed mobility, transfers, dressing, and toilet use. Review of the resident's care plan, updated 1/26/18, showed staff are directed: -Resident has [MEDICAL CONDITION]'s Disease which causes him/her to have jerky movements which significantly increases risk for falls; -Low bed due to several falls, please put bed in the lowest position when resident is in it; -Resident does not have jerky movements when asleep; -Requires assist of one to two staff with bathing, transfers, bed mobility, and toileting; -Use top side rails, bed is against the wall with a pad to prevent resident from hitting his/her head, and also have padding on the other top rail. Review of the resident's Physician's Order Sheet (POS), dated (MONTH) (YEAR), showed an order directed staff may use one top side rail for controlling bed, begin 8/25/16. Further review showed no medical [DIAGNOSES REDACTED]. Review of the resident's medical records showed staff did not obtain informed consent. Further review showed staff did not document any alternatives prior to the installation of the side rails, and did not complete an entrapment assessment. Observation on 4/10/18 at 10:19 A.M., showed the resident's bed with raised side rails to both sides at the head of the bed. Observation on 4/11/18 at 9:58 A.M., showed Certified Nurses Assistant (CNA) E and CNA F transferred the resident from his/her wheelchair to the bed, covered the resident, and left the room. Further observation showed the bed against the wall, with raised side rails to both sides at the head of the bed. Observation on 4/12/18 at 10:31 A.M., showed the resident in bed. Further observation showed raised side rails to both sides at the head of the bed. 3. Review of Resident #8's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Intact cognition; -Did not display behaviors; -Extensive assistance of one staff for bed mobility, dressing, and transfers; -Independent with eating and personal hygiene; -Occasionally incontinent of bladder; -Has a condition that causes tremors, involuntary muscle movements, and mental deterioration; -Regular diet; -No restraints (bedrails or alarms). Review of the resident's care plan, dated 02/01/18, showed staff are directed to allow the resident to use top side rails for turning and positioning in bed. Further review showed no instruction to assess for continued need or to monitor for safety. Review of the resident's POS, dated (MONTH) (YEAR), showed an order, dated 08/25/16, directed staff the resident may have upper side rails to help with positioning when in bed. Further review showed no medical [DIAGNOSES REDACTED]. Review of the resident's electronic medical records showed staff did not complete an entrapment assessment or obtain informed consent for the use of side rails. Observation on 04/11/18 at 2:41 P.M., showed the resident in his/her recliner next to his/her bed. Additional observation showed half rails on both sides of the bed with only the left side in the up position. Observation on 04/12/18 at 8:54 A.M., showed the resident sat in his/her recliner next to his/her bed. Additional observation showed half rails on both sides of the bed with only the left side in the up position. During an interview on 04/11/18 at 2:41 P.M., the resident said he/she uses the side rail to pull himself/herself up. He/She said he/she only use the left side rail and leaves the right side rail down. He/She said he/she does not remember signing a consent for the rails. 4. Review of Resident #19's significant change MDS, dated [DATE], and the quarterly MDS dated [DATE], showed staff assessed the resident with moderate cognitive impairment, and requires extensive of two or more staff with bed mobility, dressing, transfer, and toilet use. Review of the resident's care plan, last updated 2/15/18, showed staff are directed: -The resident takes [MEDICAL CONDITION] medications and has had a recent fall; -Low bed; -Mat on both sides of the bed when the resident lies down; -Make sure call light is within reach; -Remind him/her to call for help when needed. Review of the resident's medical records showed staff did not obtain informed consent or obtain a physician's order with appropriate medical [DIAGNOSES REDACTED]. Further review of the records showed staff did not document any alternatives prior to installation of the side rails, and did not complete an entrapment assessment. Additional review showed staff documented the resident did not express desire to have bed rails in place. Observation on 4/09/18 at 7:37 P.M., showed the resident in bed on his/her left side, fall mats to both sides of bed, and bed rails attached to both sides at the head of the bed. Observation on 4/11/18 at 3:05 P.M., showed the resident in bed on his/her left side. Further observation showed the right side rail (towards window) in the raised position, and fall mats at the bedside. Observation and interview on 4/11/18 at 4:03 P.M., showed the resident in bed on his/her left side, with the right side rail in the raised position. CNA G and CNA H entered the room and provided care to the resident in bed. The resident did not hold on to the side rail during care. The CNA's said the resident does not have an order for [REDACTED]. During an interview on 4/12/18 at 8:51 A.M., CNA A said the resident should not have side rails in use. The CNA said if the side rail is raised (with resident in bed) and did not have a pink tag, that is a no-no and could possibly be a restraint to the resident. 5. Review of Resident #30's quarterly MDS dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Total dependence of two or more staff with bed mobility, dressing, and transfer; -Impairment on both sides upper (shoulder, elbow, wrist, hand) extremities. Review of the resident's care plan, last updated 3/8/18, showed staff are directed: -Total assist required with ADL's. The resident is unable to stop himself/herself if he/she would start to fall; -Hoyer lift with 2 staff for transfers; -Does not use side rails and has mats on the floor next to his/her bed. Review of the resident's medical records showed staff did not obtain informed consent, or obtain a physician's order with appropriate medical [DIAGNOSES REDACTED]. Further review of the records showed staff did not document any alternatives prior to installation of the side rails, and did not complete an entrapment assessment. Additional review showed staff documented the resident did not express desire to have bed rails in place. Observation on 4/09/18 at 8:36 P.M., showed the resident in a low bed on his/her right side, fall mats at bedside, and a raised grab bar to the left side of the bed (next to window). Observation and interview on 4/12/18 at 8:59 A.M., showed CNA A and CNA F provided care to the resident. Observation showed grab bars to both sides of the bed. CNA A said the resident does not use the grab bars attached to the bed, and they should never be raised while the resident is in bed. 6. Review of Resident #33's MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance of two or more staff for bed mobility, transfers, dressing, toilet use, and bathing; -Required extensive assistance of one staff member for locomotion, and personal hygiene. Review of the resident's side rail assessment, dated 3/5/18, showed staff documented the resident continues to use upper half side rails to help with turning and positioning. The resident used side rail to pull up and for positioning. Review of the resident's care plan, dated 3/8/18, showed staff documented the resident used top side rails for turning and positioning in bed at times Review of the resident's electronic medical records showed staff did not complete an entrapment assessment or obtain informed consent for the use of side rails. Review of the resident's POS, dated (MONTH) (YEAR), showed an order directed staff the resident may have upper side rails to help with turning and positioning while in bed, ordered on [DATE]. Further review showed the POS did not contain a [DIAGNOSES REDACTED]. Observation on 4/09/18 at 8:30 P.M., showed the resident in his/her room in bed with two half upper grab bars in the raised position on the resident's bed. Observation on 4/10/18 at 10:08 A.M., showed the resident in bed with right half upper side rail raised in the raised position on the resident's bed. 7. Review of Resident #48's MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and required supervision with bed mobility and transfers. Review of the resident's care plan, last updated 2/15/18, showed staff are directed to provide assistance with transfers, dressing, and transfers to the bathroom. Review of the resident's POS, dated (MONTH) (YEAR), showed an order directed staff the resident may have upper side rails to help with turning and repositioning while in bed, begin 3/2/18. Further review showed no medical [DIAGNOSES REDACTED]. Review of the resident's medical records showed staff did not obtain informed consent, and did not complete an entrapment assessment. Observation and interview on 4/09/18 at 8:03 P.M. showed raised side rails to both sides at the head of the bed. The resident said he/she uses the rails to help him/her get out of bed. Observation on 4/10/18 at 2:23 P.M. showed the resident sat on his/her bed, and held on to the rail to assist with repositioning in bed. During an interview on 4/12/18 at 9:15 A.M., the resident said he/she was unsure if he/she signed a consent for the side rails. 8. Review of Resident #199's POS dated 04/05/18, showed the resident may use half side rails to aide with turning and positioning in bed. Further review showed the POS did not contain a [DIAGNOSES REDACTED]. Review of the resident's care plan dated 04/12/18, showed staff are directed the resident requires: -Assist of one staff for bathing, dressing, and toileting; -Short term memory loss. Further review showed staff are directed to put up the resident's top side rails while in bed to help him/her change position. Review of the resident's electronic medical records showed staff did not complete an entrapment assessment or obtain informed consent for the use of side rails. Observation on 04/11/18 at 2:54 P.M., showed the resident lay in bed with the half rails on both sides placed in the down position. Observation on 04/12/18 at 8:52 A.M., showed the resident's bed with the half rails on both sides placed in the up position. During an interview on 04/11/18 at 2:54 P.M., the resident said he/she did not know if he/she had side rails or not. 9. During an interview on 04/12/18 at 12:40 P.M., CNA A said they put a pink tag on side rails to let staff know which residents are supposed to have them. He/She said there are rails attached to all of the beds but they are left in the down position unless the resident is care planned for them. He/She said the last he/she knew Resident #33 was supposed to have rails on both sides because his/hers has a pink tag. During an interview on 04/12/18 at 12:58 P.M., CNA B said the side rails have pink tags on them if the resident are supposed to use them. He/She said all of the beds come with rails but they keep them down if a resident does not have an order for [REDACTED]. During an interview on 04/12/18 at 1:02 P.M., LPN C said the bed rails are manufactured with the beds. He/She said the MDS Coordinator is in charge of side rails and does the entrapment assessments. He/She said if a resident is supposed to use the side rails they will have a pink band around them. The grab bars do not have the pink band and the residents can use those if they want. During an interview on 04/12/18 at 3:34 P.M., LPN D said they obtain consents before a resident uses bed rails and the MDS Coordinator makes sure it is done before they are put on the bed or used. He/She said the MDS Coordinator obtains the orders for side rails. He/She said staff review whether or not the resident needs side rails, what type of rails they should use, and if the rails are per the resident's request it should be listed on the order. He/She said the orders for side rails do not include [DIAGNOSES REDACTED]. During an interview on 04/12/18 at 4:28 P.M., the DON said staff educate residents and families on the dangers of side rails during the admission process, but do not obtain consent for use at that time. He/She said the Social Services Director is responsible to obtain the side rail consents. He/She said they do not obtain new consents when they approve or install side rails for use. He/She said staff should document a resident's need and ability to use side rails. He/She said staff should also obtain a physician's order with a diagnosis, an explanation of what type of rails the resident needs, and what the use would be.

Based on interview and record review, facility staff failed to ensure residents' monthly pharmacy drug regimen recommendations were accurately reviewed to identify irregularities and prevent or minimize adverse consequences related to medication therapy to the extent possible for four residents (Resident #2, #8, #33, and #43) of five sampled residents reviewed for unnecessary medications. The consultant pharmacist also failed to address the use of a cognition-enhancing medication for an inappropriate [DIAGNOSES REDACTED].#43). The facility census was 48. 1. Review of the facility's policy on [MEDICAL CONDITION] Medication, undated, showed staff are directed: -Make every effort to comply with state and federal regulations related to the use of psychopharmacological medications including regular review for continued need, appropriate dosage, side effects, and risks and/or benefits; -Support the appropriate use of psychopharmacological medications that are therapeutic and enabling for residents suffering from mental illness; -Support the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment environmental, medical, and/or behavioral intervention can be utilized to meet the needs of the individual resident; -Support the goal of determining the underlying cause of behavioral symptoms of residents having difficulty sleeping so the appropriate treatment environmental, medical, and/or behavioral intervention can be utilized; -Make efforts to reduce dosage or discontinue psychopharmacological medications on an ongoing basis appropriate for the clinical situation; -Do not use psychopharmacological medications for the purpose of discipline or convenience; -Understand [MEDICAL CONDITION] medications include: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. The Primary Care Physician, Physician's Assistant (PA) or Advanced Practice Nurse (APN) is responsible for: -Making sure orders for [MEDICAL CONDITION] medication are only used to treat a special medical and/or psychiatric condition or when the medication meet the needs of the resident to alleviate significant distress not met by non-pharmacological approaches; -Documenting rationale and [DIAGNOSES REDACTED]. -Documenting discussions with the resident or responsible party regarding risks and benefits including black box warnings or off label use of the medication; -Evaluating the effects and side effects of psychoactive medication use with the interdisciplinary team within one month of initiating, increasing, or decreasing a medication; -Monitoring the resident for drug efficacy clinically and in discussions with the interdisciplinary team within one month of initiating and during routine visits; -Attempting gradual dose reductions (GDRs) or discontinuing [MEDICAL CONDITION] medications after no more than three months unless clinically contradicted and do so in two separate quarters with at least one month in between attempts and annually thereafter or as the resident's condition warrants; -Reviewing sedative/hypnotic medications quarterly for GDRs unless clinically contradictive; -Ordering PRN (as needed) medications on a time-limited basis (two weeks) and only for specific clearly documented circumstances; -Obtaining psychiatric consultations as the resident's clinical condition requires. Facility Nursing Staff is responsible for: -Monitoring [MEDICAL CONDITION] drug use daily noting any adverse effects such as increased somnolence or functional decline; -Monitoring for the presence of target behaviors on a daily basis and charting by exception (only when behaviors are present); -Reviewing the use of the medication with the physician and interdisciplinary team on a quarterly basis to determine the continued presence of target behaviors and/or the presence of any adverse effects of the use of the medication; -Performing AIMS on any resident on any antipsychotic on a quarterly basis and reporting changes to the physician; -Developing behavioral care plans. Pharmacy staff are responsible for: -Monitoring [MEDICAL CONDITION] drug use in the facility to ensure medications are not used in excessive doses or for excessive durations; -Participating in the interdisciplinary quarterly review of residents on psychoactive medications. 2. Review of Resident #2's quarterly Minimum Data Set, (MDS), a federally mandated resident assessment tool, dated 01/08/18, showed staff assessed the resident as: -Moderate cognitive impairment; -No behaviors; -Antipsychotic, antianxiety, and antidepressant use. Review of the resident's care plan, dated 01/11/18, showed staff are directed to watch the resident for side effects of [MEDICAL CONDITION] medication such as increased sleepiness, low blood pressure, tremors, lip smacking, and jerky movements. Review of the resident's Pharmacy Communication Form for pharmacy consultation dated 01/08/18, showed it did not contain any documentation under the pharmacy observation, nursing suggestion, or physician response. Further review showed the resident's physician did not sign the form. Review of the resident's Pharmacy Communication Form for pharmacy consultation dated 02/07/18, showed it did not contain any documentation under the pharmacy observation, nursing suggestion, or physician response. Further review showed the resident's physician did not sign the form. Review of the resident's Pharmacy Communication Form for pharmacy consultation dated 03/05/18, showed it did not contain any documentation under the pharmacy observation, nursing suggestion, or physician response. Further review showed the resident's physician did not sign the form. Review of the resident's physician's orders [REDACTED]. Review of the resident's physician's orders [REDACTED]. Observation on 04/09/18 at 8:30 P.M., showed the resident in his/her recliner with his/her eyes closed and appeared to sleep. Observation on 04/12/18 at 8:58 A.M., showed the resident sat in his/her wheelchair and looked out the window. He/She was clean, dressed, groomed. 3. Review of Resident #8's annual MDS, dated [DATE], showed staff assessed the resident as: -Intact cognition; -Did not display behaviors; -Has a condition that causes tremors, involuntary muscle movements, and mental deterioration; -Antianxiety, antidepressant, and opiod medication use. Review of the resident's Pharmacy Communication Form for pharmacy consultation, dated 01/08/18, showed it did not contain any documentation under the pharmacy observation, nursing suggestion, or physician response. Further review showed the resident's physician did not sign the form. Review of the resident's care plan dated 02/01/18, showed staff are directed to watch the resident for side effects of medication (increased sleepiness, low blood pressure, tremors, lip smacking, and jerky movements). Review of the resident's Pharmacy Communication Form for pharmacy consultation, dated 02/07/18, showed it did not contain any documentation under the pharmacy observation, nursing suggestion, or physician response. Further review showed the resident's physician did not sign the form. Review of the resident's Pharmacy Communication Form for pharmacy consultation, dated 03/05/18, showed it did not contain any documentation under the pharmacy observation, nursing suggestion, or physician response. Further review showed the resident's physician did not sign the form. Review of the resident's POS, dated 04/01/18, showed staff are ordered to administer one 25 mg [MEDICATION NAME] (antidepressant) tablet to the resident once a day in the morning for [MEDICAL CONDITION] and [MEDICAL CONDITION] with increased symptoms with a start date of 08/19/16. Review of the resident's POS, dated 04/01/18, showed staff are ordered to administer one 1 mg [MEDICATION NAME] (antianxiety/sedative) tablet to the resident once a day at bedtime for anxiety disorder with a start date of 09/01/16. Observation on 04/10/18 at 11:53 A.M., showed the resident closed his/her eyes, jerked his/her head up and down several times, and appeared to nod off to sleep at the dining room table at lunch. Observation on 04/12/18 at 8:54 A.M., showed the resident sat in his/her recliner next to his/her bed with a needle and thread in hand. During an interview on 04/10/18 at 10:05 A.M., the resident said he/she is tired today and is tired most days and has to nap. During an interview on 04/10/18 at 11:54 A.M., LPN L said the resident gets up at 4:00 A.M. and is tired most of the day. During an interview on 04/12/18 at 8:54 A.M., the resident said he/she was very tired and may not be able to sew. 4. Review of Resident #33's MDS, dated [DATE], showed facility staff assessed the resident as follows: -Moderate cognitive impairment; -Had delusions; -Physical behavior occurred one to three days; -Rejection of care occurred four to six days; -Wanders occurred one to three days; -[DIAGNOSES REDACTED]. -Seven days of antipathetic medications; -Seven days of antidepressant medications. Review of the resident's Pharmacy Communication Form for pharmacy consultation, dated 12/5/17, showed it did not contain any documentation under the diagnosis, labs done, pharmacy observation, nursing suggestion, or physician response. Further review showed the resident's physician did not sign the form. Review of the resident's Pharmacy Communication Form for pharmacy consultation, dated 1/8/18, showed it did not contain any documentation under the diagnosis, labs done, pharmacy observation, nursing suggestion, or physician response. Further review showed the resident's physician did not sign the form. Further review showed staff documented the resident's medication included [MEDICATION NAME] (anxiety medication) 0.5 milligram (mg) by mouth every six hours as needed and [MEDICATION NAME] 0.5 mg intramuscularly (IM) every six hours as needed. Review of the resident's Physician order [REDACTED]. Review of the resident's Pharmacy Communication Form for pharmacy consultation, dated 2/8/18, showed it did not contain any documentation under the diagnosis, labs done, pharmacy observation, nursing suggestion, or physician response. Further review showed the resident's physician did not sign the form. Further review showed staff documented the resident's medication included [MEDICATION NAME] 0.5 milligram (mg) by mouth every six hours as needed and [MEDICATION NAME] 0.5 mg intramuscularly (IM) every six hours as needed. Review of the resident's Physician order [REDACTED]. Review of the resident's Pharmacy Communication Form for pharmacy consultation, dated 3/5/18, showed it did not contain any documentation under the diagnosis, labs done, pharmacy observation, nursing suggestion, or physician response. Further review showed the resident's physician did not sign the form. Further review showed staff documented the resident medication included [MEDICATION NAME] 0.5 milligram (mg) by mouth every six hours as needed, [MEDICATION NAME] 0.5 mg intramuscularly (IM) every six hours as needed and [MEDICATION NAME] (medication used to control blood sugar) 20 units at bedtime. Review of the resident's Physician order [REDACTED]. Review of the resident's care plan, dated 3/8/18, showed staff are directed to do the following: -Give medications as ordered; -Seen by psychiatry group when they visit; -Watch for side effects of medication (increased sleepiness, low blood pressure, changes in my ability to perform activities of daily living (ADL), tremors, lip smacking, and abnormal movements). Review of the resident's Pharmacy Communication Form for pharmacy consultation, dated 4/6/18, showed it did not contain any documentation under the diagnosis, labs done, nursing suggestion, or physician response. Further review showed the resident's physician did not sign the form. Review showed a check mark behind pharmacy observation. Further review showed staff documented the resident medication included [MEDICATION NAME] 0.5 milligram (mg) every six hours as needed, [MEDICATION NAME] 0.5 mg intramuscularly (IM) every six hours as needed, [MEDICATION NAME] 20 units at bedtime, and [MEDICATION NAME] (an antipsychotic medication) 25 mg twice a day. Review of the resident's Physician order [REDACTED]. 5. Review of Resident #43's medical records showed the resident was admitted on [DATE] with an order for [REDACTED]. Review of the resident's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Received antipsychotic medications on a routine basis, for seven days during the seven-day review period, with no attempted GDR; -Received antianxiety medications for seven days during the seven-day review period. Review of the resident's physician's orders [REDACTED]. -[MEDICATION NAME] 5mg PO daily, for Major [MEDICAL CONDITION], begin 8/23/17; -[MEDICATION NAME] 5mg PO at bedtime (HS), for anxiety, begin 8/23/17; -[MEDICATION NAME] (used to treat anxiety) 0.25mg PO twice daily (BID), for anxiety, begin 6/15/17; -[MEDICATION NAME] (used to treat anxiety) 0.5mg PO BID, for anxiety, begin 6/13/17. Review of the Pharmacy Communication Form/Drug Regimen Review dated 10/5/17, signed by the Pharmacist and a facilty nurse, showed staff documented [MEDICATION NAME] 2 mg daily. Staff did not document the correct dose of Abilfy 5mg, and did not document the [MEDICATION NAME] 5mg (as directed on the POS). Review showed it did not contain any documentation under the labs done, nursing suggestion, or physician response, and the physician did not sign the communication form. Review of the Pharmacy Communication Form/Drug Regimen Review dated 11/7/17, signed by the Pharmacist and a facilty nurse, showed staff documented [MEDICATION NAME] 2mg daily. Staff did not document the correct dose of Abilfy 5mg, and did not document the [MEDICATION NAME] 5mg (as directed on the POS). Review showed it did not contain any documentation under the labs done, nursing suggestion, or physician response, and the physician did not sign the communication form. Review of the Pharmacy Communication Form/Drug Regimen Review dated 12/5/17, signed by the Pharmacist and a facilty nurse, showed staff documented [MEDICATION NAME] 2mg daily. Staff did not document the correct dose of Abilfy 5 mg, and did not document the [MEDICATION NAME] 5 mg (as directed on the POS). Review showed it did not contain any documentation under the labs done, nursing suggestion, or physician response, and the physician did not sign the communication form. Review of the Pharmacy Communication Form/Drug Regimen Review dated 1/8/18, signed by the Pharmacist and a facilty nurse, showed staff documented [MEDICATION NAME] 2 mg daily. Staff did not document the correct dose of Abilfy 5 mg, and did not document the [MEDICATION NAME] 5mg (as ordered directed on the POS). Review showed it did not contain any documentation under the labs done, nursing suggestion, or physician response, and the physician did not sign the communication form. Review of the Pharmacy Communication Form/Drug Regimen Review dated 2/8/18, signed by the Pharmacist and a facilty nurse, showed staff documented [MEDICATION NAME] 2 mg daily. Staff did not document the correct dose of Abilfy 5 mg, and did not document the [MEDICATION NAME] 5 mg (as directed on the POS). Review showed it did not contain any documentation under the labs done, nursing suggestion, or physician response, and the physician did not sign the communication form. Review of the Pharmacy Communication Form/Drug Regimen Review dated 3/5/18, signed by the Pharmacist and a facilty nurse, showed staff documented [MEDICATION NAME] 2 mg daily. Staff did not document the correct dose of Abilfy 5mg, and did not document the [MEDICATION NAME] 5mg (as directed on the POS). Review showed it did not contain any documentation under the labs done, nursing suggestion, or physician response, and the physician did not sign the communication form. Review of the resident's care plan for [MEDICAL CONDITION] drug use, last updated 3/23/18, showed staff are directed: -Give medications as ordered; -Seen by Psychiatry group when they visit; -Watch for side effects of medication (increased sleepiness, low blood pressure, changes in my ability to perform activities of daily living (ADL), tremors, lip smacking, and abnormal movements). Review of the nurse's notes on 3/31/18, showed staff documented a new order received from the physician to discontinue the scheduled [MEDICATION NAME], and change to [MEDICATION NAME] 0.25 mg as needed (PRN) at bedtime. Review of the resident's POS dated (MONTH) (YEAR), showed on 3/31/18, staff documented [MEDICATION NAME] 0.25 mg PO BID for anxiety, was discontinued, and a new order started for [MEDICATION NAME] 0.25 mg PO PRN at HS for anxiety. Review of the nurse's notes dated 4/1/18 showed staff documented the resident was more alert since his/her [MEDICATION NAME] was held, and [MEDICATION NAME] was not given and made PRN. Review of the resident's POS, dated (MONTH) (YEAR), showed the following orders: -[MEDICATION NAME] 5 mg PO daily, for Major [MEDICAL CONDITION], begin 8/23/17; -[MEDICATION NAME] 5 mg PO HS, for anxiety, begin 8/23/17; -[MEDICATION NAME] 0.25 mg PO PRN at HS, for anxiety, begin 3/31/18 (did not include a stop date). Review of the Pharmacy Communication Form/Drug Regimen Review dated 4/6/18, signed by the Pharmacist and a facilty nurse, showed staff documented [MEDICATION NAME] 2 mg daily and [MEDICATION NAME] 0.25 mg BID. Staff did not document the correct dose of Abilfy 5 mg, did not document the correct dose of [MEDICATION NAME] 0.25 mg PRN at HS, and did not document the [MEDICATION NAME] 5 mg (as directed on the POS). Review showed it did not contain documentation under the labs done, nursing suggestion, or physician response. Review showed a check mark behind pharmacy observation, and the physician did not sign the communication form. Further review showed the consultant pharmacist did not address the use of [MEDICATION NAME] (a cognition-enhancing medication) for an inappropriate [DIAGNOSES REDACTED]. 6. During an interview on 4/11/18 at 12:18 P.M., the DON said Certified Medication Technician (CMT) P assists with medical records and is responsible to complete the Pharmacy Communication Form/Drug Regimen Review forms to accurately match the POS. The DON said he/she expects the pharmacist to review the orders on the POS as well. During an interview on 04/12/18 at 1:02 P.M., LPN C said the pharmacist reviews the residents' medications once a month and he/she signs the POS once it is reviewed. He/She said the pharmacist makes recommendations and passes them on to the MDS team. He/She said he/she learns of the recommendations verbally. He/She said he/she uses redirection as an alternative to [MEDICAL CONDITION] medications and he/she documents it in the nursing notes. He/She said the residents have a 14 days stop date on their PRN [MEDICAL CONDITION] meds. He/She said staff concerns about psychtropic medications and any changes after a discussion with physician are documented in the nurse's notes. During an interview on 04/12/18 at 3:34 P.M., LPN L said when they get an order for [REDACTED]. During an interview on 4/12/18 at 4:09 P.M., CMT P said he/she uses information from the new order book as well as the POS to update the Pharmacy Communication Form/Drug Regimen Review a couple times per month. The CMT said the communication forms should include all the resident's medications, along with the associated diagnosis. He/She was unsure if any other staff double checks that the information on the forms match the POS's. The CMT said he/she updated some of the forms this month (April), but did not know which specific residents, and did not have a system to determine which ones were updated. He/She said some of the forms may not have been updated due to him/her away on vacation, or a resident being hospitalized . During an interview on 04/12/18 at 4:10 P.M., the DON said the pharmacist comes in monthly to review medications. He/She said the Pharmacy Communication Form for pharmacy consultation should be updated with the correct medications monthly. He/She said the pharmacist should be able to see the [DIAGNOSES REDACTED]. He/She said the Pharmacist reviews the form and the POS but not at the same time. The DON said the Pharmacist may not document recommendations when he/she reviews the medications and signs the form and POS but he/she does sometimes call the physician or has nursing call the physician to discuss changes. He/She was not aware the pharmacist had to document if he/she does not have recommendations. The DON said he/she was not aware the physician has to document whether or not he/she agrees with the pharmacist's recommendations and why. He/she said the Psychiatrist comes in quarterly and reviews medications and he/she thought he/she was doing the gradual dose reductions (GDRs). He/She said [MEDICAL CONDITION] medication changes are documented in the psychiatric section of the residents' paper charts. He/She said the pharmacist should be assisting to make sure GDR attempts are done.

Based on interview and record review, facility staff failed to develop, maintain, and follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice, and/or fail to assess and vaccinate four residents (Resident #17, #19, #26, and #33) of five sampled eligible residents (over [AGE] years old), with doses of the pneumococcal vaccine, as recommended by the Centers for Disease Control and Prevention (CDC). The facility census was 48. 1. Review of the facility's Pneumococcal Vaccine Policy, dated 9/2011, showed: -The vaccine will be given once in a lifetime if the resident is over [AGE] years of age; -If the resident is under [AGE] years of age, they will have a booster [AGE] years from the original vaccine, unless order is changed by the physician; -If a resident is admitted to the facility with uncertain or unknown vaccination status, the person will be vaccinated, unless contraindicated or resident/legal representative refusal; -An education fact sheet regarding the benefits and potential side effects of the pneumococcal vaccine will be sent to the resident's legal representative; -Documentation will be provided in the chart of the immunization. 2. Review of the US Department of Health and Human Services CDC Pneumococcal Vaccine Timing for Adults dated 11/30/15 showed the following: -Two pneumococcal vaccines were recommended for adults: 13-valent pneumococcal conjugate vaccine (PCV13, PREVNAR13) and 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23, [MEDICATION NAME] 23); -One dose of PCV13 was recommended for adults [AGE] years or older who had not previously received PCV13; -One dose of PPSV23 was recommended for adults [AGE] years or older, regardless of previous history of vaccination with pneumococcal vaccines. Once a dose of PPSV23 was given at age [AGE] years or older, no additional doses of PPSV23 should be administered; -For those age [AGE] years or older who had not received any pneumococcal vaccines, or those with unknown vaccination history administer one dose of PCV13. Administer one dose of PPSV23 at least one year later for most adults or at least eight weeks later for adults with immunocompromising conditions; -For those age [AGE] years or older who previously received one dose of PPSV23 and no doses of PCV13 administer one dose of PCV13 at least one year after the dose of PPSV23 for all adults regardless of medical conditions. 3. Review of the CDC's website, last updated 12/6/17, showed healthcare providers are directed: -There are two types of pneumococcal vaccines available in the United States: Pneumococcal conjugate vaccine (PCV13 or Prevnar13®) Pneumococcal [MEDICATION NAME] vaccine (PPSV23 or [MEDICATION NAME]®) *Adults [AGE] years or Older CDC recommends pneumococcal vaccination for all adults [AGE] years or older: -Give 1 dose of PCV13 to all adults [AGE] years or older who have not previously received a dose. -Give 1 dose of PPSV23 to all adults [AGE] years or older at least 1 year after any prior PCV13 dose and at least 5 years after any prior PPSV23 dose. -Adults who received one or two doses of PPSV23 before age 65 should receive one final dose of the vaccine at age 65 or older. 4. Review of Resident #17's significant change Minimum Data Set (MDS), a federally mandated assessment, dated 1/26/18, showed the resident was admitted at age [AGE] years old, on 2/25/16, and his/her pneumococcal vaccination was up to date. Further review of the record showed staff documented PCV13 was administered to the resident on 2/17/09. Additional review showed staff did not document that the resident was offered, as recommended by the CDC, or that his/her representative consented/refused the PPSV23 vaccine since admission (seven years after the PCV13 was administered). 5. Review of Resident #19's quarterly MDS, dated [DATE] showed the resident was admitted at age [AGE] years old, on 10/11/16, and his/her pneumococcal vaccination was up to date. Review of the medical records showed staff did not document a history of pneumococcal vaccination prior to admission, and the resident representative signed a consent on 1/18/17 for the resident to have the pneumococcal vaccination. Staff documented they administered PPSV23 to the resident on 1/27/17. Staff did not initially administer PCV13 as recommended by the CDC in (YEAR). 6. Review of Resident #26's quarterly MDS, dated [DATE], showed the resident was admitted at [AGE] years old, on 1/20/10, and his/her pneumococcal vaccination was up to date. Review of the medical records showed staff did not document a history of pneumococcal vaccination prior to admission, and the resident representative signed a consent on 1/27/10 for the resident to have the pneumococcal vaccination. Staff documented they administered PPSV23 on 1/28/10. Further review of the records (eight years later), showed staff did not document they offered/administered a second dose of the PPSV23 at least five years after the first dose was administered, as recommended by the CDC in (YEAR). 7. Review of Resident #33's quarterly MDS, dated [DATE], showed the resident was admitted at [AGE] years old, on 6/2/14, he/she was offered the pneumococcal vaccine and declined. Review of the medical records showed staff did not document history of the pneumococcal vaccination prior to admission, and did not document that the resident was offered, or that his/her representative refused the pneumococcal vaccine. 8. During an interview on 4/10/18 at 5:24 P.M., with the Director of Nursing (DON) and the Administrator, the DON said Pneumonia vaccines are offered yearly to residents, consents are sent out, and should be in the charts. The Administrator said he/she personally helped another staff to prepare the forms/consents to be mailed to the resident representatives. During an interview on 4/11/18 at 11:18 A.M., the DON said the consultant pharmacist tried to assist facility staff to figure out which residents had what vaccines and which ones were still needed. He/She said the facility did not have any Pneumococcal vaccines on order for administration at this time. During an interview on 4/12/18 at 3:25 P.M., the MDS Coordinator said vaccine consent forms are mailed out yearly with one of the resident's billing statements. He/She said consents for the pneumococcal vaccine is sent as soon as facility staff figure out if the resident requires the vaccine. During an interview on 4/12/18 at 9:00 A.M., the DON said if the consent form was not in the chart, the resident probably wasn't offered the vaccine. The DON said the information sheets are mailed/provided with consents, and filed separately.

Based on observation, interview, and record review, facility staff failed to complete inspection of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for seven of seven sampled residents (Residents #5, #8, #19, #30, #33, #48, and #199), with side rails/grab bars to reduce the risk of accidents. The facility census was 48. 1. Review of the FDA (Federal Drug Administration) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated (MONTH) 10, 2006 showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. 2. Review of the FDA document entitled, Practice Hospital Bed Safety dated (MONTH) 2013, showed seven different potential, zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment. 3. Review of the FDA document entitled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, showed the potential risks of bed rails may include: -Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; -More serious injuries from falls when patients climb over rails; -Skin bruising, cuts, and scrapes; -Inducing agitated behavior when bed rails are used as a restraint; -Feeling isolated or unnecessarily restricted; -Preventing patients, who are able to get out of bed, from performing routine activities such are going to the bathroom or retrieving something from a closet. 4. Review of the facility's policy on Bed Rail Entrapment Risk Notification, undated, showed staff documented the facility does not use side rails without first reading, understanding, and explaining the Bed Rail Entrapment Risk Notification to residents and resident representatives. Staff are directed to: -Consider alternatives to restraints include the following: -lower the bed; -keep the bed wheels locked; -place fall mats next to the bed; -use transfer or mobility aides; -monitor residents frequently; -routinely attend to patient needs; -Understand the risks and benefits of bed rails; -Have the physician and family review the resident's medical condition for need; -Properly assess the equipment; -Frequently monitor the equipment; -Comply with instructions and warnings about the use of side rails; -Understand conditions such as restlessness, mental deterioration and dementia or [MEDICAL CONDITION] disorders, sleeping problems, and incontinence can increase a resident risk of entrapment; -Use with both rails in the up position; -Never use bed rails for restraint purposes (preventing or hindering the resident within the bed from exiting the bed as they wish); -Reassess the need for using bed rails on a frequent, regular basis. 5. Review of Resident #5's Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as follows: -[DIAGNOSES REDACTED]. -Moderately impaired cognition; -No behaviors or rejection of care; -Extensive assist of two or more staff with bed mobility, transfers, dressing, and toilet use. Review of the resident's medical records showed staff did not complete a maintenance inspection to include an entrapment assessment for use of the side rails. Observation on [DATE] at 10:19 A.M., showed the resident's bed with raised side rails to both sides at the head of the bed. Observation on [DATE] at 9:58 A.M., showed Certified Nurses Assistant (CNA) E and CNA F transferred the resident from his/her wheelchair to the bed, covered the resident, and left the room. Further observation showed the bed against the wall, with raised side rails to both sides at the head of the bed. Observation on [DATE] at 10:31 A.M., showed the resident in bed. Further observation showed raised side rails to both sides at the head of the bed. 6. Review of Resident #8's annual MDS, dated [DATE], showed staff assessed the resident as: -Intact cognition; -Did not display behaviors; -Extensive assistance of one staff for bed mobility, dressing, and transfers; -Independent with eating and personal hygiene; -Has a condition that causes tremors, involuntary muscle movements, and mental deterioration; -No restraints (bedrails or alarms). Review of the resident's care plan, dated [DATE], showed staff are directed to allow the resident to use top side rails for turning and positioning in bed. Review of the resident's physician's orders [REDACTED]. Review of the resident's electronic medical records showed staff did not complete a maintenance inspection, to include an entrapment assessment, for the use of side rails. Observation on [DATE] at 2:41 P.M., showed the resident in his/her recliner next to his/her bed. Additional observation showed the resident's bed with half rails on both sides of the bed and the left side in the up position. Observation on [DATE] at 8:54 A.M., showed the resident in his/her recliner next to his/her bed. Additional observation showed the resident's bed with half rails on both sides of the bed and the left side in the up position. During an interview on [DATE] at 2:41 P.M., the resident said he/she uses the side rail to pull himself/herself up. He/She said he/she only uses the left side rail and leaves the right side rail down. He/She said he/she does not remember signing a consent for the rails. 7. Review of Resident #19's MDS, dated [DATE], showed staff assessed the resident as follows: -Moderately impaired cognition; -Extensive assist of two or more staff with bed mobility, transfers, dressing, and toilet use. Review of the resident's medical records showed staff did not complete a maintenance inspection to include an entrapment assessment, for the use of the side rails. Observation on [DATE] at 3:05 P.M., showed the resident in bed on his/her left side. Further observation showed the right side rail (towards window) in the raised position, and fall mats at the bedside. Observation and interview on [DATE] at 4:03 P.M., showed the resident in bed on his/her left side, with the right side rail in the raised position. CNA G and CNA H entered the room and provided care to the resident in bed. The resident did not hold on to the side rail during care. The CNA's said the resident does not have an order for [REDACTED]. 8. Review of Resident #30's MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Total dependence on two or more staff with bed mobility, dressing, and transfer; -Impairment on both sides upper (shoulder, elbow, wrist, hand) extremities. Review of the resident's medical records showed staff did not complete a maintenance inspection to include an entrapment assessment, for the use of the side rails. Observation on [DATE] at 8:36 P.M., showed the resident in a low bed on his/her right side, fall mats at bedside, and a raised grab bar to the left side of the bed (next to window). Observation on [DATE] at 8:38 PM showed the resident in a low bed on his/her right side, fall mats at bedside, and a raised grab bar to the left side of the bed (next to window). Observation and interview on [DATE] at 8:59 A.M., showed CNA A and CNA F provided care to the resident. Observation showed grab bars to both sides of the bed. CNA A said the resident does not use the grab bars attached to the bed, and they should never be raised while the resident is in bed. 9. Review of Resident # 33's MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required extensive assistance of two or more staff for bed mobility, transfers, dressing, toilet use, and bathing; -Required extensive assistance of one staff member for locomotion, and personal hygiene. Review of the resident's side rail assessment, dated [DATE], showed staff documented the resident continues to use upper half side rails to help with turning and positioning. The resident used side rails to pull up and for positioning. Review of the resident's care plan, dated [DATE], showed staff documented the resident used top side rails for turning and positioning in bed at times Review of the resident's medical record showed staff did not complete a maintenance inspection to ensure the side rails were properly secured and did not document an entrapment assessment with measurements for the use of side rails. Review of the resident's POS, dated (MONTH) (YEAR), showed an order directed staff the resident may have upper side rails to help with turning and positioning while in bed, ordered on [DATE]. Further review showed staff did not document a [DIAGNOSES REDACTED]. Observation on [DATE] at 8:30 P.M., showed the resident in bed with two half upper grab bars in the raised position on the resident's bed. Observation on [DATE] at 10:08 A.M., showed the resident in bed with the right half upper side rail in the raised position on the resident's bed. 10. Review of Resident #48's MDS, dated [DATE], showed staff assessed the resident as cognitively intact, and required supervision with bed mobility and transfers. Review of the resident's medical records showed staff did not complete a maintenance inspection to include an entrapment assessment, for the use of the side rails. Observation and interview on [DATE] at 8:03 P.M. showed raised side rails to both sides at the head of the bed. The resident said he/she uses the rails to help him/her get out of bed. Observation on [DATE] at 2:23 P.M. showed the resident sat on his/her bed, and held on to the side rail to assist with repositioning in bed. 11. Review of Resident #199's POS, dated [DATE], showed staff are directed the resident may use half side rails to aide with turning and positioning in bed. Review of the resident's admission care plan, dated [DATE], showed staff are directed: -Assist of one staff for bathing, dressing, and toileting; -Short term memory loss. Further review showed staff are directed to put up the resident's top side rails while in bed to help him/her change position. Review of the resident's electronic medical records showed staff did not complete a maintenance inspection to include an entrapment assessment, for the use of the side rails. Observation on [DATE] at 2:54 P.M., showed the resident in bed with the half rails on both sides placed in the down position. Observation on [DATE] at 8:52 A.M., showed the resident's bed with the half rails on both sides placed in the up position. During an interview on [DATE] at 2:54 P.M., the resident said he/she did not know if he/she had side rails or not. 9. During an interview on [DATE] at 2:30 P.M., the Maintenance Director said he/she does not document entrapment assessments for resident beds with side rails. During an interview on [DATE] at 3:34 P.M., LPN D said someone should be measuring the bedrails for an entrapment risk. He/She said nurses do look at them to make sure they look safe. He/She said Maintenance is responsible for the measuring. He/She said they should measure in between the mattress and the rails but he/she is unsure about zones. During an interview on [DATE] at 4:28 P.M., the DON said the Maintenance Director is supposed to do entrapment assessments and he/she does not know why he/she is not doing them. He/She said all the zones should be measured. He/She said they do not routinely inspect the rails for safety but staff documents in the maintenance log if they see anything wrong with the rails.

Based on interviews and record reviews, facility staff failed to immediately report an allegation of resident to resident physical abuse towards one resident (Resident #26), of 14 sampled residents, to other officials in accordance with State law (including the State survey and certification agency). The facility census was 48. 1. Review of the facility's Abuse and Neglect Policy, updated 5/3/17, showed staff are directed: -The resident has the right to be free from abuse, corporal punishment and involuntary seclusion; -Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the individual, family members, or legal guardians, friends, or other individuals; -Physical abuse includes hitting, slapping, pinching and kicking; -It is the responsibility of every employee of the facility to report the following types of alleged violations: -In the event an employee witnesses or has knowledge of any abuse situation occurring in the facility, the employee is to immediately notify the supervisor, who will notify the Administrator and/or Director of Nursing Services; -An injury of unknown source must be reported to the Administrator and/or Director of Nursing Services (DON); -Any allegation of abuse (whether it is substantiated or not), reported by the resident, staff or responsible party/resident; -Misappropriation of resident property. -Alleged incidents include occurrences between staff/resident, resident/resident, family, visitor, volunteer, responsible party/resident; -Once the facility employee becomes aware of any of these alleged violations, the home must report (within 2 hours) to the designated state agency. It is irrelevant whether the facility investigated the incident and determined the allegations were unfounded; all allegations must be reported immediately. 2. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 11/27/17, showed staff assessed the resident with: -Severe cognitive impairment, unclear speech, and sometimes understood; -Physical behaviors directed towards others, rejection of care; -Wandering that did not impact others; -Requires extensive assist with locomotion on and off unit via wheelchair. Review of the nurse's notes, dated 1/09/18, showed staff documented the oncoming nurse reported he/she witnessed Resident #33 hit the resident in the face, and the resident yelled ow my nose. The resident had some dry skin around nose, but no noted injuries. Physician and Resident Representative (RR) were notified. Review of the resident's quarterly MDS, dated [DATE], showed staff assessed the resident with: -Moderate cognitive impairment, unclear speech, and sometimes understood; -Physical behaviors directed towards others, rejection of care; -Wandering that did not impact others; -Requires extensive assist with locomotion on and off unit via wheelchair. 3. Review of Resident #33's quarterly MDS, dated [DATE], showed staff assessed the resident with: -Disorganized thinking and delusional thoughts; -Physical behaviors (example, hitting, kicking, pushing, scratching, grabbing) towards others. Review of the resident's nurses notes, dated 1/9/18, showed staff documented an oncoming nurse reported the resident hit Resident #26 in the face. The resident was separated from Resident #26 by staff and re-directed to the Social Services Director's office. The resident said I will do it again, he/she knows what he/she is doing and I will bust his/her head open. The DON, Administrator, Physician, and RR were notified. The RR was concerned about the resident becoming meaner. 4. Review of the facility's records showed facility staff conducted an investigation of the allegation on 1/9/18. 5. Review of the State Survey Agency database, showed facility staff did not report the allegation of resident-to-resident physical abuse. 6. During an interview on 4/10/18 at 2:20 P.M., the Administrator said he/she remembered the situation and thought the DON had the paperwork regarding it. The Administrator said facility staff did not report the incident to the state survey agency because they did not determine that the resident was actually hit by the other resident, based on the facility's investigation. During an interview on 4/11/18 at 9:39 A.M., CNA B said staff are trained to report observations or suspicions of abuse and neglect to their immediate supervisor, and the allegation should be reported to the state survey agency within a couple of hours. During an interview on 4/11/18 at 4:23 P.M., Licensed Practical Nurse (LPN) D said allegations of abuse and neglect should be reported to the state survey agency within two hours. The LPN said he/she did not know if the allegation was reported to the state survey agency, but based on training he/she received on reporting allegations of abuse and neglect, staff should have reported the incident.

Based on record review and interview, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment) when they did not accurately code contractures for one resident (Resident #16), and a fall with injury for one resident (Resident #19), of 14 sampled residents. The facility census was 48. 1. Review of Resident #16's MDS, dated [DATE], showed staff assessed the resident as follows: -No impairment in range of motion of the upper extermities; -Impairment on both sides of the lower extermities. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -No impairment in range of motion of the upper extremities; -Impairment of both sides of the lower extremities. Observation on 4/10/18 at 11:16 A.M., showed the resident with contractures of both his/her hands. Observation on 4/10/18 at 4:36 P.M., showed the resident in the dining room. Observation showed the resident with contractures of both his/her hands. Observation on 4/11/18 at 8:56 A.M., showed the resident in activity room with contractures of both his/her hands. Observation on 4/11/18 at 2:08 P.M., showed the resident in his/her room in bed. Observation showed the resident with contractures of both his/her hands. During an interview on 4/11/18 at 3:06 P.M., Licensed Practical Nurse (LPN) D said the resident has contractures in both of his/her hands and both of his/her lower extremities. During an interview on 4/11/18 at 3:10 P.M., Certified Nurse Assistant (CNA) M said the resident had contractures in both of his/her hands and both of his/her lower extremities. Staff did not accurately code the resident's contractures on his/her MDS assessments. 2. Review of Resident #19's quarterly MDS, dated [DATE], showed staff assessed the resident with no falls since admission or prior assessment (prior assessment date 11/17/17). Review of the resident's Care Plan, updated 2/15/18, showed staff are directed the resident takes a [MEDICAL CONDITION] medication and had a recent fall. Review of the nurse's notes, dated 1/13/18, showed staff documented the resident had an unwitnessed fall and was found on the floor in his/her room on his/her right side. Staff documented they applied an ice pack to swelling above his/her right eye, and applied a dressing to a skin tear on the resident's right arm. During an interview on 4/11/18 at 3:01 P.M., CNA G said the resident fell from his/her chair and hit his/her head a couple months prior. Staff did not document the resident's fall with injury on 1/13/18 as required on section J1800 of the MDS. 4. During an interview on 4/12/18 at 3:25 P.M., the MDS Coordinator said he/she completes the MDS assessments per the RAI guidelines, and the MDS should accurately reflect the residents. He/She updates MDS assessments quarterly, annually, and with significant changes. The MDS Coordinator said Resident #16's contractures should be documented on his/her MDS, and Resident #19's falls should also be documented on his/her MDS. During an interview on 4/12/18 at 4:29 P.M., the Director of Nursing (DON) said he/she expects the MDS's to accurately reflect the residents. The DON said he/she expects staff to document Resident #16's contractures, and Resident #19's falls on their MDS assessments.

Based on observation, interview and record review, facility staff failed to update the care plan with changes in care needs for four residents (Resident #5, #16, #31, and #33) of fourteen sampled residents. The facility census was 48. 1. Review of the facility's Care Planning Policy, updated 2/2017, showed staff are directed: -All residents will have a comprehensive plan of care that is reviewed and revised based on the assessments performed; -The care plan will include and identify measurable objectives with timetables to meet a resident's medical, nursing, mental, and psychosocial needs; -Care plans will also include updates to falls with interventions, pressure ulcers/skin issues, treatment changes to wounds, medications will also be included with the side effects if needed; -Fall risk assessment will be care planned if resident has had a change in score or has indicated that the risk is high; -The Braden scale (assessment to determine risk of skin breakdown) will be included if the resident's score has changed or score has indicated there is an increased risk for breakdown; -All items in the care plan will have a date for initiation, changes, and discontinuations; -Goals and approaches will be reviewed with changes in condition, desired objection has not been achieved, when resident is readmitted from hospital, rehabilitation stay, and at least quarterly. 2. Review of Resident #5's Minimum Data Set (MDS), a federally mandated assessment, dated 1/22/18, showed staff assessed the resident as: -[DIAGNOSES REDACTED]. -Moderately impaired cognition; -Extensive assist of two or more staff with bed mobility, transfers, dressing, and toilet use; -One non-injury fall since admission or the prior assessment (prior assessment date 10/23/17). Review of the nurse's notes, dated 2/17/18, showed staff documented the resident was heard crying in his/her room, and found on the floor beside the couch in the room. The resident's body was on the mat, and his/her head on the floor. Staff assessed the resident with no injuries, and documented they notified the family and the physician. Review of the nurse's notes, dated 2/26/18, showed staff documented the resident was found on the floor between the bed and the wall, with his/her head against the mat on the wall and his/her feet on the bed. The resident was unable to explain what happened, staff notified the family and physician. Review of the resident's care plan, last updated 1/26/18, showed staff are directed: -Resident has [MEDICAL CONDITION]'s Disease which causes him/her to have jerky movements and significantly increases risk for falls; -Resident also takes a [MEDICAL CONDITION] medication which puts him/her at risk for falls; -Encourage the resident to use the call light and wait for help when needed. -Low bed due to several falls, please put bed in the lowest position when resident is in it. -Resident does not have jerky movements when asleep; -Requires assist of 1 to 2 staff with bathing, transfers, bed mobility, and toileting; -Use top side rails, bed is against the wall with a pad to prevent resident from hitting his/her head, and also padding on the other top rail. Staff did not review or update the resident's care plan with interventions for falls after the resident fell on [DATE] and 2/26/18 (twice), from different locations in his/her room. Observation on 4/10/18 at 10:18 A.M., showed the resident lay on the couch in his/her room with eyes closed. Observation showed a padded mat on the floor next to the couch. Observation on 4/11/18 at 9:58 A.M., showed Certified Nurses Assistant (CNA) E and CNA F transferred the resident from his/her wheelchair to the bed, covered the resident, and left the room. Observation showed the bed against the wall, with raised unpadded side rails to both sides at the head of the bed. Further observation did not show any padded material to prevent the resident from hitting is/her head, as directed by the care plan. Observation on 4/12/18 at 10:31 A.M., showed the resident in bed. Further observation showed raised unpadded side rails to both sides at the head of the bed. Staff did not pad the side rails to prevent the resident from hitting his/her head, as directed by the care plan. During an interview on 4/10/18 at 10:12 A.M., Registered Nurse (RN) Q said the resident had a non-injury fall on 2/17/18 and another on 2/26/18. During an interview on 4/12/18 at 3:25 P.M., the MDS Coordinator said residents' falls should be updated on their care plans, but he/she was not sure what additional interventions staff could have documented for Resident #5, because he/she already had fall interventions in place. 3. Review of Resident #16's MDS, dated [DATE], showed staff assessed the resident as follows: -No impairment in range of motion of the upper extremities; -Impairment on both sides of the lower extremities. Review of the resident's MDS, dated [DATE], showed staff assessed the resident as follows: -No impairment in range of motion of the upper extremities; -Impairment of both sides of the lower extremities. Review of the resident's care plan, dated 2/8/18, showed staff did not update the care plan to direct staff on care for the resident's contractures. Review of the resident's radiograph (x-ray), dated 3/16/18, showed the resident had contractures of the left foot. Observation on 4/10/18 at 11:16 A.M., showed the resident with contractures in both of his/her hands. Observation on 4/10/18 at 4:36 P.M., showed the resident in the dining room. Observation showed the resident with contractures in both his/her hands. Observation on 4/11/18 at 8:56 A.M., showed the resident in activity room with contracture in both of his/her hands. Observation on 4/11/18 at 2:08 P.M., showed the resident in his/her room in bed. Observation showed the resident with contractures in both his/her hands. During an interview on 4/11/18 at 3:06 P.M., Licensed Practical Nurse (LPN) D said the resident has contractures in both of his/her hands and both of his/her lower extremities. During an interview on 4/11/18 at 3:10 P.M., Certified Nurse Assistant (CNA) M said the resident has contractures in both of his/her hands and both of his/her lower extremities. 4. Review of Resident #31's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Not at risk for pressure ulcers; -Pressure ulcers not present. Review of the resident's care plan, dated 12/07/17, showed staff did not assess the resident as at-risk for pressure ulcers on his/her feet. Review of the resident's physician's orders [REDACTED]. Review of the resident's nurse's notes, dated 01/02/18, showed staff documented the resident had a pressure ulcer on the fourth toe of his/her right foot. Review of the resident's POS dated 02/24/18, showed staff are directed to apply triple antibiotic ointment to the resident's fourth toe on his/her right foot twice a day. Review of the resident's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Supervision for bed mobility, transfer, locomotion, dressing, eating, toileting, and personal hygiene; -Two unstageable pressure ulcers (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar). Review of the resident's care plan dated 03/08/17, showed staff did not provide information related to care of the pressure sores on the resident's feet. Observation on 04/11/18 at 10:03 A.M., showed the resident in bed. He/She had his/her feet uncovered at the foot of the bed. He/She had two scabbed sores on the top of the second toe on his/her right foot, a healing sore on the top of the fourth toe of his/her right foot, and a sore on the top of the first toe of his/her left foot. During an interview on 04/11/18 at 10:03 A.M., the resident said he/she is not sure if the sores on his/her toes are healed or not. 5. Review of Resident #33's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Disorganized thinking and delusional thoughts; -Physical behaviors (example, hitting, kicking, pushing, scratching, grabbing) towards others; Review of the resident's care plan, last updated 12/7/17, showed staff documented the resident has hallucinations and or delusional thoughts at times and can be combative when attempts are made to redirect, and directed staff: -Continue to invite me to activities; -Encourage to participate with therapy; -Resident has been known to refuse insulin; -Resident likes to have babies with him/her; -May be seen by psychiatry group when they visit. Staff did not update the resident's care plan with interventions to address physical behavioral symptoms toward others after a staff member reported he/she witnessed the resident physically hit another resident on 1/9/18, and staff investigated the allegation. During an interview on 4/11/18 at 9:39 A.M., CNA B said he/she did not think staff made any changes to the resident's care plan after the incident. During an interview on 4/11/18 at 10:00 A.M., CNA F said he/she did not think staff made any changes to the resident's care plan after the incident occurred. During an interview on 4/12/18 at 12:29 P.M., with the MDS Coordinator and the Director of Nursing (DON), the MDS Coordinator said he/she is responsible as part of a team, to update resident care plans. The MDS Coordinator said the resident has displayed behaviors towards staff before, but never toward another resident. The MDS Coordinator said he/she should have updated the resident's care plan after the incident occurred, but he/she did not. The DON said some kind of intervention should have been documented on the care plan. 6. During an interview on 04/12/18 at 12:40 P.M., CNA A said the MDS Coordinator creates and updates the care plans. He/She said staff use the care plan to know how to care for the residents and if there have been any changes. He/She is unsure if Resident #31's pressure sores are listed on the care plan. During an interview on 04/12/18 at 12:58 P.M., CNA B said staff look at the care plan to know what kind and level of care a resident needs. He/She said the MDS Coordinator is responsible for updating the care plans. He/She said resident conditions like contractures and pressure sores should be listed on care plans. He/She said Resident #16 has contractures on his/her arms and legs and they should be listed on his/her care plan. He/She said Resident #31 has sores on his/her toes and said the sores should be listed on the care plan. During an interview on 04/12/18 at 1:02 P.M., LPN C said the MDS Coordinator, Social Services Director, Dietary Manager, Activities Director, and the DON all create the care plan. He/She said they can all update the care plan and nursing staff can also. He/She said a resident's contractures should be on the care plan. He/She said Resident #16 has contractures and they should be on the care plan but he/she does not know if they are. He/She said the pressure ulcers on Resident #31's toes should be addressed on the care plan but he/she does not know if they are. During an interview on 04/12/18 at 4:28 P.M., the DON said updating care plans is a group effort. He/She said they should be updated with any change like a new medication, condition, or treatment. He/She said staff do not update the care plans with new falls if they feel care plan interventions are working. He/She said staff update care plans with new phone orders weekly and with the MDS assessments regularly. He/She said the care plan in the book at the nurse's station is the most up to date care plan. He/She said the hand written updates are added to the typed care plan in the electronic medical record (EMR) at the time of the quarterly update. He/She does not know why staff did not include Resident #16's contractures on his/her care plan. He/She said the contractures are listed in the treatment book but the CNA's do not have access to the treatment book. He/She said he/she expects staff to update the care plan with pressure ulcer information soon after the resident was diagnosed with [REDACTED].

Based on interview and record review, facility staff failed to obtain stop dates of 14 days or less on as needed (PRN) [MEDICAL CONDITION] medications (chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior), for two residents (Resident #2 and #43) of five sampled residents reviewed for unnecessary medications. The facility census was 48. 1. Review of the facility's policy on [MEDICAL CONDITION] Medication, undated, showed the facility will: -Make every effort to comply with state and federal regulations related to the use of psychopharmacological medications including regular review for continued need, appropriate dosage, side effects, and risks and/or benefits; -Support the appropriate use of psychopharmacological medications that are therapeutic and enabling for residents suffering from mental illness; -Support the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment environmental, medical, and/or behavioral intervention can be utilized to meet the needs of the individual resident; -Support the goal of determining the underlying cause of behavioral symptoms of residents having difficulty sleeping so the appropriate treatment environmental, medical, and/or behavioral intervention can be utilized; -Make efforts to reduce dosage or discontinue psychopharmacological medications on an ongoing basis appropriate for the clinical situation; -Not use psychopharmacological medications for the purpose of discipline or convenience; -Understand [MEDICAL CONDITION] medications include: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs. The Primary Care Physician, Physician's Assistant (PA) or Advanced Practice Nurse (APN) is responsible for: -Making sure orders for [MEDICAL CONDITION] medication are only used to treat a special medical and/or psychiatric condition or when the medication meet the needs of the resident to alleviate significant distress not met by non-pharmacological approaches; -Documenting rationale and [DIAGNOSES REDACTED]. -Documenting discussions with the resident or responsible party regarding risks and benefits including black box warnings or off label use of the medication; -Evaluating the effects and side effects of psychoactive medication use with the interdisciplinary team within one month of initiating, increasing, or decreasing a medication; -Monitoring the resident for drug efficacy clinically and in discussions with the interdisciplinary team within one month of initiating and during routine visits; -Attempting gradual dose reductions (GDRs) or discontinuing [MEDICAL CONDITION] medications after no more than three months unless clinically contradictive and do so in two separate quarters with at least one month in between attempts and annually thereafter or as the resident's condition warrants; -Reviewing sedative/hypnotic medications quarterly for GDRs unless clinically contradictive; -Ordering PRN (as needed) medications on a time-limited basis (two weeks) and only for specific clearly documented circumstances; -Obtaining psychiatric consultations as the resident's clinical condition requires. The Psychiatrist/Mental Health Provider is responsible for: -Assisting the facility in establishing appropriate guidelines for use, dosage, and monitoring of [MEDICAL CONDITION] medications; -Following the same standards listed above in recommendations to physicians; -Providing in service training to nursing, medical, and other facility staff as appropriate; -Being available for consultation; -Helping develop behavior management plans when needed. Facility Nursing Staff is responsible for: -Monitoring [MEDICAL CONDITION] drug use daily noting any adverse effects such as increased somnolence or functional decline; -Monitoring for the presence of target behaviors on a daily basis and charting by exception (only when behaviors are present); -Reviewing the use of the medication with the physician and interdisciplinary team on a quarterly basis to determine the continued presence of target behaviors and/or the presence of any adverse effects of the use of the medication; -Performing AIMS on any resident on any antipsychotic on a quarterly basis and reporting changes to the physician; -Developing behavioral care plans. Pharmacy staff are responsible for: -Monitoring [MEDICAL CONDITION] drug use in the facility to ensure medications are not used in excessive doses or for excessive durations; -Participating in the interdisciplinary quarterly review of residents on psychoactive medications. The Medical Director is responsible for: -Reviewing the [MEDICAL CONDITION] medication policy with the interdisciplinary team at least annually; -Monitoring the overall use of these medications in the facility; -Identifying any resident care or potential regulatory issues due to the use of [MEDICAL CONDITION] medications and discuss them with medical staff as appropriate; -Participating in the interdisciplinary quarterly review of residents on psychoactive medications and facilitating communication with attending physicians on any recommendations from the interdisciplinary team. 2. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 01/08/18, showed staff assessed the resident as: -Moderate cognitive impairment; -No behaviors; -Antipsychotic, antianxiety, and antidepressant use. Review of the resident's care plan dated 01/11/18, showed staff are directed to watch the resident for side effects of [MEDICAL CONDITION] medication (increased sleepiness, low blood pressure, tremors, lip smacking, and jerky movements). Review of the resident's physician's orders [REDACTED]. Staff did not obtain or document a stop date of 14 days or less for the PRN [MEDICAL CONDITION] medication. 3. Review of Resident #43's MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Received antianxiety medications for seven days over the seven day look back period. Review of the nurse's notes, dated 3/31/18, showed staff documented a new order received from the physician to discontinue the scheduled [MEDICATION NAME] (medication to treat anxiety), and change to [MEDICATION NAME] 0.25 milligram (mg) PRN at bedtime. Review of the resident's physician's orders [REDACTED]. -[MEDICATION NAME] 0.25 mg by mouth (PO) twice daily for anxiety, discontinued 3/31/18; -[MEDICATION NAME] 0.25 mg PO PRN at bedtime for anxiety, begin 3/31/18. Staff did not obtain or document a stop date of 14 days or less for the PRN [MEDICAL CONDITION] medication. Review of the resident's POS dated (MONTH) (YEAR), showed an order for [REDACTED]. During an interview on 4/11/18 at 12:00 P.M., the Director of Nursing (DON) said the Pharmacist visited the facility on 4/7/18, and reviewed and signed the most recent POS in the resident's records. The consultant pharmacist did not document recommendation for a stop date of 14 days or less, for the PRN [MEDICAL CONDITION] medication. 4. During an interview on 04/12/18 at 1:02 P.M., LPN C said the Pharmacists reviews the residents' medications once a month and he/she signs the POS once it is reviewed. He/She said the Pharmacists makes recommendations and passes them on to the MDS team. He/She said he/she learns of the recommendations verbally. He/She said he/she uses redirection as an alternative to [MEDICAL CONDITION] medications and he/she documents it in the nursing notes. He/She said the residents have a 14 days stop date on their PRN [MEDICAL CONDITION] meds. He/She said staff concerns about psychtropic medications and any changes after a discussion with physician are documented in the nurse's notes. During an interview on 04/12/18 at 3:34 P.M., LPN L said when they get an order for [REDACTED]. During an interview on 04/12/18 at 4:10 P.M., the DON said the Pharmacist comes in monthly to review medications. He/She said the Pharmacy Communication Form for pharmacy consultation should be updated with the correct medications monthly. He/She said the Pharmacist should be able to see the [DIAGNOSES REDACTED]. He/She said the Pharmacist reviews the form and the POS but not at the same time. He/She said the Pharmacist may not document recommendations when he/she reviews the medications and signs the form and POS but he/she does sometimes call the physician or has nursing call the physician to discuss changes. He/She was not aware the Pharmacist had to document if he/she does not have recommendations. He/She was not aware the physician has to document whether or not he/she agrees with the Pharmacist's recommendations and why. He/She expects the pharmacist to follow CMS guidelines regarding MRR and PRN orders for psych meds not to exceed 14 days. He/She said he/she tries to review resident orders for PRN medications regularly. He/She said new orders are put on the POS and in the new order book but staff will start checking for PRN stop dates. He/She said if staff notice a PRN does not have a stop date they will notify the physician. He/She expects staff to recognize the PRN [MEDICAL CONDITION] order requires a stop date because facility staff were recently inserviced on that. He/She expects staff to clarify a stop date with the physician for Resident #43's PRN order.