Every finding on record at Grand Avenue Rest Home

Based on interview and document review, the facility failed to ensure timely physician notification of resident leave of absence from the facility and notification of multiple missed scheduled insulin doses that may have required additional evaluation and treatment 1 of 3 residents (R1) reviewed for elopement.Findings include:R1's order summary report dated 7/8/26, identified R1's diagnoses included schizoaffective disorder, bipolar, major depressive disorder and post-traumatic stress disorder.R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had no cognitive impairment and was independent for activities of daily living (ADL).R1's care plan dated 6/22/26 indicated R1 will receive prescribed medications while on leave of absence (LOA) and day pass.R1's provider's orders dated 7/8/26 included the following:Insulin 100 unit/ml (Insulin Aspart), inject as per sliding scale: if 70-150 =0 units; 151-200=2 units; 201- 250 =4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units; 401-999=12 units, subcutaneously three times a day related to type 2 diabetes mellitus. If blood sugar is 0-69 initiate hypoglycemia order.Insulin Aspart subcutaneous solution pen-injector 100 unit/ml. Inject 6 unit subcutaneously three times a day.Lantus subcutaneous solution (insulin glargine). Inject 34 units subcutaneously in the morning for type 2 diabetes mellitus.Blood Glucose Test in Vitro four times a day related to type 2 diabetes mellitus. Review of R1's June 2026 Medication Administration Record (MAR) indicated R1 did not receive prescribed insulin doses on the following dates and times. Each MAR entry documented the reason as resident not at home.On 6/8/26 at 7:30 a.m., insulin aspart 6 units was not administered. On 6/8/26 at 8:00 a.m., Lantus 10 units was not administered. On 6/16/26 at 5:00 p.m., insulin aspart 6 units was not administered. On 6/17/26 at 7:30 a.m., insulin aspart 6 units was not administered. On 6/17/26 at 8:00 a.m., Lantus 10 units was not administered. On 6/17/26 at 5:00 p.m., insulin aspart 6 units was not administered.On 6/17/26 at 8:00 p.m., Lantus 24 units was not administered. On 6/18/26 at 7:30 a.m., insulin aspart 6 units was not administered. On 6/18/26 at 8:00 p.m., Lantus 24 units was not administered. In review of R1 medical record, it was not evident whether the provider was notified about R1 not receiving the prescribed insulins on the above dates.On 6/9/26 at 11:54 p.m., a progress note indicated R1 had signed a leave of absence (LOA) from 9:00 p.m. to 4:00 a.m. and felt safe returning at night.On 6/10/26 at 5:07 a.m., a progress note indicated staff called R1's phone multiple times with no answer and then R1 called after saying she will be back at 8:00 a.m.On 6/17/26 at 9:18 p.m. a progress note indicated R1 was absent from the facility at 12:00 p.m. and planned to return at midnight. The note further indicated R1 did not take her evening medications.On 6/18/26 at 11:55 a.m., a progress note indicated R1 returned back to the facility from her 6/17/26 LOA. The note indicated R1 missed her morning short acting insulin while on LOA.Review of R1's medical record including assessments and progress notes lacked documentation of a provider's order authorizing R1's LOA. The medical record also lacked documentation the provider had been notified regarding R1's repeated missed medications while on LOA.On 7/8/26 at 12:02 p.m., a licensed practical nurse (LPN)-A stated R1 was required to sign LOA form when leaving the facility and document her expected return time. LPN-A stated if R1 did not return as scheduled, did not answer telephone calls, and it became late, nursing staff were required to call the law enforcement to report her as a missing person. LPN-A explained R1 missed her prescribed medications on multiple occasions while absent from the facility on LOA. LPN-A did not recall notifying the provider regarding R1's missed medications.On 7/9/26 at 1:43 p.m., a social service designee (SSD)-A stated she could not find leave of absence assessment completed at the time of R1's admission. SSD-A stated R1 had been leaving the facility on LOA to go into the community but had not been following the facility's return policy. SSD-A stated she completed R1's wandering risk assessment on 6/12/26 and presented it to the interdisciplinary team (IDT) for review. SSD-A further stated she did not know whether nursing staff had notified the provider or obtained a provider's order for R1's LOA.On 7/9/26 at 3:33 p.m., the director of nursing (DON) stated R1 had been missing her evening medications and nursing staff notified the provider; however, the provider did not issue any new orders. The DON stated R1's boyfriend had received medication administration education and was authorized by the facility to administer medication to R1 while she was on LOA. The DON confirmed the facility did not notify the provider regarding R1's LOA.On 7/9/26 at 12:34 p.m., a nurse practitioner (NP)-A stated she did not receive a request for an order related to R1's LOA. NP-A stated she did not receive any telephone call regarding R1's missed medications including insulin. NP-A stated the facility had her cell phone number and staff could have left a voicemail regarding R1's medication-related issues. NP-A further stated that when a resident consistently misses prescribed medications, nursing staff are required to notify the provider.The Facility Leave of Absence (Therapeutic Leave) Policy dated January 2026 directed the facility to have an order authorized by a physician for all residents who go on LOA stating they can leave the facility unsupervised. If they cannot leave unsupervised, a responsible party must accompany them.

Based on interview and record review, the facility failed to ensure resident's right to be treated with respect and dignity for 1 of 3 residents (R1) when the facility conducted searches of R1's personal belongings/room without R1's or her representative 's consent.Findings include:R1's admission Record dated 5/29/23 indicated R1's diagnoses included Major depressive disorder, suicidal ideation, anxiety disorder, psychosis, and schizoaffective disorder.R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 is completely independent with activities of daily living (ADLs) and had intact cognition.R1's care plan, dated 4/28/25, indicated R1 drinks alcohol when under stress and got into a fight with peer. Staff interventions included random room/personal effect searches when indicated and as needed.R1's treatment administration record (TAR) dated 6/25/25, included and order to checks/searches R1's room for for alcohol (ETOH). The TAR indicated for nursing staff conducted R1's room searches on 10/1/2025 through 10/15/25. In review of R1's record did not include R1 or R1's representative agreed to a voluntary search and understood the reason for the search. R1's medical record did not identify that any search resulted in finding alcohol or any illegal substances. On 10/9/25 at 9:47 p.m., a progress note indicated nursing staff conducted a search in R1's room to make sure no ETOH (the type of alcohol found in alcoholic beverages) was stored. The note also indicated R1 had signs and symptoms of being intoxicated this evening.On 10/10/25 at 5:22p.m., a progress note indicated R1 was found intoxicated upon arrival at the hospital.On 10/14/25 at 9:45 a.m., a progress note indicated nursing staff followed up with R1 regarding drinking and R1 refused to sign a contract agreement.On 10/16/25 at 9:20 a.m., R1 stated she was independent for ADLs and did not want to talk to the facility provider. R1 denied giving a consent/agreement to search her room to make sure alcohol was not stored. R1 stated she was not aware of her room being search for illegal substances and/or alcohol.On 10/16/25 at 12:39 p.m., a registered nurse (RN)-A stated R1's room search was discussed during an interdisciplinary meeting, and it was entered into the medical record as nursing order. RN-A did not notify the physician about R1's room search nursing order. RN-A stated staff searched R1's room daily and had to document completion. RN-A could not find R1's consent to a voluntary search in her medical record.On 10/16/25 at 2:40 p.m., RN-B stated she searched R1's room at the beginning of her shift to make sure R1 was not hiding any alcohol. Nursing staff were expected to document room search completion in the TAR. RN-B stated she never found any illegal substances during R1's room search. RN-B was not aware if R1 had signed an agreement to a voluntary search.On 10/16/25 at 1:27 p.m., a licensed social worker (LSW)-A stated the interdisciplinary team discussed adding room searches for alcohol to R1's care plan. LSW-A stated the illegal substance policy said to notify the local law enforcement unless there was an immediate danger which was not R1's case. LSW-A stated R1 did not sign an agreement to a voluntary room search and added she did not know if nursing was doing room searches daily.On 10/16/25 at 10:53 a.m., a medical director (MD)-A stated she was not aware of a room search order request from the facility. MD-A stated when the facility requested a verbal order, she will send one of her medical team members to the facility to verify if the request was reasonable. MD-A could not find anything in her system which suggested R1's room search was needed.On 10/16/25 at 2:14 p.m., MD-B stated searching resident's room was not part of the facility's standing orders. MD-B stated attending physician give an order for searching resident's room in regard to the substance abuse policy.On 10/16/25 at 4:09p.m., the director of nursing (DON) stated she expected nursing staff to follow the facility substance abuse policy. The DON stated with R1's alcohol intoxication signs and symptoms, nurses updated the care team to include the intervention to make sure no alcohol was stored. The DON was not aware if staff have had ever found an illegal substance and/or alcohol in R1's room. The DON stated R1 was aware of her room search, however could not find any documentations about when R1 agreed to a voluntary search and the reason for the search.According to the State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities, revision 229, issued 4/25/25, If the facility determines through observation that a resident may have access to illegal substances that they have brought into the facility or secured from an outside source, the facility should not act as an arm of law enforcement. Rather, in accordance with state laws, these cases may warrant a referral to local law enforcement. The facility staff should not conduct searches of a resident or their personal belongings unless the resident, or resident representative agrees to a voluntary search and understands the reason for the search.The facility policy for Alcohol and Chemical dated 2/13/25 directed nursing to notify the resident primary physician, guardian, and/or responsible party if substance used is suspected. The policy indicated resident room, and personal searches will only be conducted with resident consent, unless there is an immediate safety concern and law enforcement may be contacted as required by law.

Based on observation, interview and record review the facility failed to ensure facility was kept sanitary and maintained in good repair which had the potential to affect all 19 residents, staff, and visitors of the facility.Findings include:Walls:During observation on 9/8/25 at 12:18 p.m., wallboard under the hand railing leading to second floor had several areas of missing wallboard and peeling paint showing underlayment. The dining room had curling vinyl tile on the floor along wall the with the window and old-style radiator. A window air conditioner unit was attached to the upper sash of window that had curled up blue masking tape surrounding it while it was wedged into the window on a board. Air space was observed on the bottom of the unit. On second floor, the shower room had broken vinyl wall board at the top of wall above the toilet. The second-floor lounge room had an alcove with exposed mechanical venting material, and the three walls were peeling and missing paint and part of baseboard. In addition, dark red carpet on the floor of second floor lounge area had area of 24 inches by 24 inches of bright white stains.During observation and interview on 9/8/25 at 1:46 p.m., R7 was lying in bed of their shared room with two other residents. The window ledge along the wall where R7's bed was aligned had peeling and flaking paint, the window was unable to close completely showing a small area of opening, and there was crumpled up clear plastic wrap hanging from the top half of the window attached by two-sided tape. R7 pointed to the window and said the condition of the window ledge and hanging plastic wrap has been on there since I have been here and did not like the look of the window and stated [I] just have to take what they give me.During observation and interview with infection control preventionist (ICP) on 9/10/25 at 10:38 a.m., ICP stated expectation of maintenance to visit facility daily and do their rounds to look at building including walls, floors [sic] and talk to staff about any concerns. ICP stated there was no formal process to request and perform repairs. ICP observed the holes in the wall below the hand railing leading up to the second floor and said, I do not know how long that has been there. It should be fixed because it is peeling and not attractive. Is should be repaired and painted to match the wall.During interview with R16 on 9/10/25 at 12:40 p.m., R16 pointed to wall below the hand railing leading to the second floor and stated she did not like the holes in the wall, looks awful like no one cares. R16 also stated the window air conditioner unit in the dining room should look better. It is barely in there and Looks like it is gonna fall out. The floor [pointing to the dining room floor] has old peeling tiles and it looks awful.During interview with R7 on 9/10/25 at 12:46 p.m., R7 pointed to the wall below the hand railing leading to the second floor and said, 'I don't like the hole in that wall there. Should be fixed.During interview with nursing assistant (NA)-A on 9/10/25 at 1:58 p.m., NA-A stated staff do not have to fill out any form or anything [for work orders]. NA-A stated the maintenance director (M-D) arrived every day and fixes what needs to be fixed.During observation on 9/11/25 at 8:01 a.m., first floor lounge with door to unit bathroom had white plumbing tubing extending out from the wall in an area taking up 18 inches long by 10 inches wide and extended beyond the wall by 6 inches. The patched area was never finished to match the wall.During observation on 9/11/25 at 8:18 a.m., an outside post railing at the bottom of the stairs had metal bracket that was attached to the front of the stairs and then formed around a loose and rotting post with no attachments noted. The area where the metal bracket could attach to outside of railing had no concrete to attach to due to cracked and missing concrete corner. The post was loose and was not secured causing anyone who held onto the railing to sway.During interview with R2 on 9/11/25 at 8:21 a.m., R2 stated, the stains [on second floor carpet] are nasty!! I don't like the looks of it. Should be replaced. Been there a long time. The wall there [second floor alcove] needs to get fixed. Should be covered.During interview with R1 on 9/11/25 at 8:26 a.m., R1 was walking up the stairs from first floor past the holes in the wall and stated, I hate the holes in the wall there. The carpet [on second floor lounge] should be fixed and replaced. Too many stains. It looks awful.During interview with M-D on 9/11/25 at 8:37 a.m., M-D stated the facility did not have a formal request system for work orders. M-D stated he had no evidence of what he worked on and what was repaired. M-D stated the staining on the second-floor lounge carpet, broken wallboard, cracked and peeling vinyl wall in the upstairs bathroom and the downstairs dining room, exposed plumbing into the first floor lounge, the air conditioner unit that was taped to a wallboard with blue masking tape with visible areas outside, and the unsecured post at the bottom of the stairs all posted a sanitary issue. M-D stated they were all in need of repair and finishing. M-D stated R7's bedroom window ledge which was covered with large bits of peeling paint and the crumpled-up plastic wrap hanging on her window needed attention. That [crumpled up plastic wrap] is winter window covering for insulation. It should be removed after winter. Looks bad. Should be thrown away. M-D agreed the outside stair post was used by all the residents and staff and that it should be repaired and, That is wobbly.Facility policy titled Maintenance, updated 5/5/25 identified objective is to maintain a safe and sanitary environment for residents and staff. The scope of the policy applies to the physical plan of the nursing home, including :Resident rooms and bathroomsCommon areas (lounges, dining rooms, hallways, therapy rooms)Mechanical and utility systemsExterior grounds and structures.

Based on observation and interview, the facility failed to ensure soiled linen was covered when transporting it through facility. This had the potential to impact all 19 residents of the facility. Findings include: During observation on 9/8/25 at 11:50 a.m., a staff member was observed walking through first floor living room and dining room with uncovered linen basket that also had no liner or bag. There were 4 residents sitting in the living room and 3 residents sitting in the dining room as he walked past. Staff transported uncovered linen outside of the building and around the corner to the back of the facility and then entered the facility to walk down the stairs to the laundry room.During interview with on 9/8/25 at 2:06 p.m., with trained medication aide (TMA)-A admitted he was the one that transported the uncovered soiled linen from upstairs of the facility (second floor) and walked it down the stairs, through the living room and dining room to outside the facility and around the back to the basement laundry area. TMA-A verified the dirty linen basket he transported had no liner and was not closed or cinched. TMA-A stated, I should have it all covered for infection control.During interview with infection control preventionist (ICP) on 9/10/25 at 10:38 a.m., ICP stated expectation of staff to ensure all linen is covered, in a plastic bag to prevent infection. ICP stated expectation of staff to should wrap the clothes in the liner or plastic bag and then cover it with the lid [of the laundry basket]. It should always be covered when transporting linen, whether it is clean or dirty.During interview with nursing assistant (NA)-A on 9/10/25 at 1:58 p.m., NA-A stated expectation of staff to cover all linen when transporting it through the facility. NA-A stated each laundry basket should have a plastic bag as a liner which will have to be cinched prior to transporting it. NA-A stated importance of covering dirty laundry during transport is important for infection control contamination.Facility policy titled Linen and Laundry, updated 5/2025 identified soiled linen is transported in covered containers only.

Based on interview and document review, the facility failed to ensure recommended influenza, pneumococcal, and Covid-19 vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (R3) reviewed for immunizations.Findings include: R3's immunization tab and progress notes in electronic medical record (EMR) lacked evidence R3 was educated about, offered, and received or declined the influenza, pneumococcal and Covid-19 vaccine.During interview with infection control preventionist (ICP) on 9/10/25 at 11:36 a.m., ICP stated expectation of facility to offer and document vaccine status for all residents. ICP stated expectation of staff to document in a progress note of any vaccine education, what was offered, what was received or declined. ICP reviewed R3's EMR and stated R3 EMR lacked documentation of refusals and follow up for influenza, pneumococcal, and Covid vaccine status.Facility policy titled Influenza and Pneumococcal Immunizations and Covid, updated 05/14/2025 identified, all residents and their legal representative will be offered the opportunity to receive the Influenza [and Covid-19] Vaccine on a yearly basis and that the Pneumovax and Prevnar Vaccine will also be made available to each resident. In addition, the EMR will be documented with the following:Education provided, whether they received it and did not receive it including refusals.

Based on interview and document review, the facility failed to ensure a comprehensive care plan was maintained to ensure appropriate care was provided for 1 of 2 residents (R1) reviewed for discharge planning. Findings include: R1's quarterly Minimum Data Set (MDS) assessment, dated 6/13/25, indicated R1 had intact cognition with hallucination, delusions with fluctuating disorganized thinking and was independent with all activities of daily living (ADLs). Section Q indicated there was no active discharge plan for resident to return to the community. During an interview on 9/8/25 at 2:44 p.m., R1 stated she was looking forward to moving to an assisted living. R1 stated she had an assessment and was told it might take 6 months to find a place which R1 was frustrated by. R1 stated again that she wants to move out of the facility.R1's care plan, printed 9/8/25, indicated the following: -Discharge plan: discharge plans reviewed with resident on 3/10/25 and R1 wants to remain in the facility and does not have any plans to discharge. Resident only want to be asked about discharge plans yearly which was last revised on 3/21/25. R1's progress notes, dated 5/6/25 to 9/8/25, were reviewed and identified the following:-5/6/25: R1 expressed her intention to give notice to move out of the facility. -5/12/25: R1 canceled meeting with care coordinator for assessment on 5/22/25.-5/27/25: R1 expressed a desire to move out of facility, obtain a part-time job and rent a hotel room. Social worker told her it was not an appropriate discharge and her worker would only assist her if she decided to move into an Assisted Living.-7/23/25: R1 had an assessment to assess what resident would qualify for housing services for an assisted living. R1 ended the assessment as R1 was told staff would enter her room to clean.-6/24/25: care conference note: DISCHARGE PLAN: Resident is appropriate for this facility; no discharge is planned. Resident has stated she would like to discharge to the community without services, but this goal may be unrealistic. Declined to be assessed for CADI Waiver.-6/9/25: Discharge Plans: Resident believes she can discharge to independent living. Resident declined to work with her Health Plan Coordinator to discharge to an ALF or Group Home. Resident only wants to be asked about her discharge plans yearly.re not.-9/3/25: R1 completed assessment with care coordinator and will be referred for further assistance for discharge planning for an Assisted Living Facility. -9/4/25: reviewed issues with resident regarding delusions related to wanting to discharge and doing a MN-Choice Assessment. This was completed with staff assistance yesterday. No further follow up needed. R1's care plan lacked evidence of being updated after R1 expressed desire to move out of the facility. During an interview on 9/10/25 at 10:57 a.m., nursing assistant (NA)-A stated they were not aware of any discharge plans for R1. NA-A stated R1 talked about a lot of things but were not sure if they could recall if R1 had talked about wanting to move out. During an interview on 9/10/25 at 11:15 a.m., assistant director of nursing (ADON) stated she was aware of R1 wanting to discharge as R1 mentioned it this week. R1 stated the social worker was assisting her with this. ADON stated a comprehensive care plan should be up to date and include residents' goals and preferences. ADON reviewed R1's care plan and verified it did not reflect R1's desire to move out of the facility. ADON verified discharge plans should be updated and on the care plan. During an interview on 9/11/25 at 10:35 a.m., social worker (SW)-A verified that R1 had expressed desire to move out of the facility. SW-A stated social services had assisted with setting up assessments for relocation services for R1. SW-A stated when a resident's discharge plans changed then the care plan needed to be updated. SW-A verified R1's care plan had not been updated to reflect her desire to move and should have been updated. A facility policy titled Comprehensive Care Plan Policy, updated 5/2025, indicated residents shall have a comprehensive care plan which include the following: reflects their assessed care needs, preferences, goals and values; identify risks to their safety, well-being, and quality of life; details planned interventions and strategies to meet their care needs; promote coordination across multidisciplinary teams; it will be regularly reviewed and updated to reflect changes in condition or preferences.

Based on interview and document review, the facility failed to collaborate with a resident's external mental health provider to ensure adequate behavioral services were provided if needed for 1 of 2 residents (R4) reviewed for behavioral Health Services. Findings include: R4's quarterly minimum data set (MDS), dated [DATE], indicated R4 was admitted to the facility on [DATE] and was cognitively intact. R4's diagnoses list, printed 9/18/25, indicated R4 had several medical diagnoses including major depressive disorder, attention deficit hyperactivity disorder, generalized anxiety disorder, panic disorder, and post-traumatic stress disorder (PTSD). R4's care plan, revised 12/19/24, indicated R4 had a history of trauma and was classified high risk and in need for psychotherapy for PTSD. Interventions included ACP [Associated Clinic of Psychology] therapy with her provider. R4's electronic medical record (EMR) lacked evidence the facility was in collaboration with R4's outside therapy provider. During an interview on 9/9/25 at 11:46 a.m., the director of social services (DSS) confirmed the facility did not have a process for ensuring therapy notes for R4 were obtained and did not have a process for collaboration between the facility and outside provider. The DSS stated the facility rarely received notes from outside therapists, although if there was an issue she would try to collaborate. During an interview on 9/10/25 at 8:12 a.m., the director of nursing and the administrator stated it would be expected that the facility collaborate with outside therapy providers, stating social services would be expected to review the notes for any new information and upload them into the resident's EMR. During an interview on 9/10/25 at 12:58 p.m., R4 stated the facility had assessed if she had PTSD but did not assess specific triggers for her. R4 confirmed she went to therapy outside the facility. A facility policy on behavioral health was requested but not received.

Based on interview and document review, the facility failed provide and document appropriate nonpharmacological interventions prior to administering as needed (PRN) psychotropic medication consumption for 3 of 5 residents (R16, R17, R1) reviewed for unnecessary medication use. Findings include: R16’s annual Minimum Data Set (MDS) dated [DATE], identified R16 with experiencing hallucinations (false perceptions that seem real but are not) and delusions (misconceptions or beliefs that are opposite of reality), and had psychiatric diagnoses of anxiety, depression, psychotic disorder, schizophrenia and post-traumatic stress disorder (PTSD). R16’s Pharmacist Consultant Report dated July 11, 2025-July 13, 2025, identified “[R16] receives frequent doses of diazepam prn (as needed psychotropic medication). Ensure staff document dangerous or distressful behavior, nonpharmacological interventions attempted before psychotropic administration, and effectiveness of the psychotropic and any adverse effects.” R16’s physician order dated 7/16/25, “diazePAM Oral Tablet 5 MG (Diazepam, also known as Valium) Give 1 tablet by mouth as needed for give 1 tab BID PRN related to ANXIETY DISORDER, UNSPECIFIED (F41.9) Document non pharmaceutical intervention before administering med. -Start Date07/16/2025 1700”. R16’s Medication Administration Report dated July, August, and September identified R16 was administered prn diazepam the following dates: July 17-31, 2025: Received one dose on 5 of the 15 days. Received two doses on 10 of the 15 days. August 1-31, 2025: Received one dose on 15 days. Received two doses on 16 days. September 1-10, 2025: Received one dose on 5 days. Received two doses on 4 days. R16's medical record lacked identification or documentation of non-pharmacological approaches prior to administration of diazepam. During interview with licensed practical nurse (LPN)-A on 9/10/25 at 9:57 a.m., LPN-A stated expectation of nursing staff to document behaviors in a progress note including, “what worked and what happened” with psychotropic medication administration. LPN-A stated purpose of nonpharmacological interventions was “to reduce the need of taking [prn] psychotropics”. LPN-A reviewed R16’s electronic medical record (EMR) and stated she had documented administering the prn Valium but there was nothing in the EMR that identified what nonpharmacological interventions were used prior to administering the medication. During interview with assistant director of nursing (RN)-A on 9/10/25 at 10:14 a.m., RN-A identified purpose of assessing nonpharmacological medications prior to administering it was, to reduce anxiety meds”. RN-A reviewed R16’s EMR and verified the Pharmacist Consultant Report dated July 11, 2025-July 13, 2025, had instructed nursing staff to document nonpharmacological interventions attempted before administering prn Valium and that it was not done. R1 R1’s quarterly Minimum Data Set (MDS) assessment, dated 6/13/25, indicated R1 had intact cognition with hallucination, delusions with fluctuating disorganized thinking and was independent with all activities of daily living (ADLs). MDS-Section N indicated R1 was taking antipsychotic, antianxiety, antianxiety and antidepressant medications. R1’s diagnosis report, printed 9/11/25, included the following diagnosis: bipolar disorder with psychotic features (a severe form of bipolar disorder characterized by psychotic symptoms such as hallucinations and delusions during manic and depressive episodes), anxiety disorder, and schizoaffective disorder (a mental health disorder that combines symptoms of schizophrenia and a mood disorder). R1’s September 2025 Medication Administration Record (MAR), printed 9/11/25, included the following: -hydroxyzine (an antihistamine that helps with anxiety) 50 milligrams (mg) tablet – give one tablet by mouth as needed for anxiety/sleep for 30 days with a start date of 8/15/25 and end date of 9/9/25 which was administered eight (8) times from 9/1/25 to 9/9/25. Administrations were documented with an “e” indicating effective. There was no documentation on the MAR of nonpharmacological interventions prior to administration. -hydroxyzine 50 mg tablet – give one tablet by mouth as needed for anxiety/sleep starting 9/9/25 until 9/14/25 – nonpharmacological intervention attempted before psychotropic administration effectiveness / any adverse effects with a start date of 9/9/25 which was administered once on 9/10/25. Administrations were documented with an “e” indicating effective. There was no documentation on the MAR of nonpharmacological interventions prior to administration. The MAR lacked evidence of offering any nonpharmacological interventions prior to administration of administering PRN psychotropic medication. R1’s care plan, printed 9/8/25, indicated R1 received psychotropic medications. Care plan listed the following nonpharmacological interventions: -encourage (R1) to decrease TV watching late at night -encourage R1 to be up more during the day -attempt to re-direct and cue -offer psychotherapy bi-weekly -give her alone space/time to process emotions R1’s progress notes, dated 9/1/25 to 9/11/25, reviewed and lacked evidence of documentation of any nonpharmacological interventions offered prior to administration of psychotropic medication. During an interview on 9/10/25 at 11:23 a.m., assistant director of nursing (ADON) stated any nonpharmacological interventions offered prior to administration of PRN medications would be documented in the progress notes. ADON reviewed R1’s progress notes and electronic medical record (EMR) and verified there was no documentation of nonpharmacological interventions offered to R1 prior to administration of PRN psychotropic for the month of September. ADON stated nonpharmacological interventions should be offered and documented prior to administration of PRN medications. Surveyor attempted to reach consulting pharmacist. A voicemail was left for pharmacist on 9/11/25 at 8:08 a.m. without a return call. A facility titled Policy and Procedure for Administering PRN Psychotropic Medication, updated 5/5/25, indicated that the nurse attempts an intervention prior to administering a PRN psychotropic medication.

Based on observation, interview and document review, the facility failed to ensure pharmacist recommendations were acted upon timely for 2 of 5 residents (R3, R1) reviewed for unnecessary medication use.Findings include: Findings include: R3’s quarterly Minimum Data Set (MDS) dated [DATE] identified R3 with diagnoses of hallucinations (false perceptions that seem real but are not) and delusions (misconceptions or beliefs that are opposite of reality), anxiety, schizophrenia, and was taking antipsychotics and antidepressants. R3’s physician orders dated 2/22/25 identified the following: Quetiapine Fumarate Oral Tablet 400mg, give 400mg by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE (F25.0) with Medication Class: ANTIPSYCHOTICS/ANTIMANIC AGENTS, Quetiapine Fumarate Oral Tablet 100mg, give 100mg by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE (F25.0) with Medication Class: ANTIPSYCHOTICS/ANTIMANIC AGENTS, and ARIPiprazole ER Intramuscular Prefilled Syringe 400MG, inject 1 syringe intramuscularly one time a day every 4 weeks on Friday for Schizophrenia related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE (F25.0). Review of R3’s electronic medical record (EMR) for medication review recommendations (MRR’s) from April to September of 2025, identified missing MRR for June 2025. During an interview on 9/11/25 at 10:40 a.m., administrator stated the facility did not have any more pharmacy reviews than what had been provided and verified the facility did not have the June pharmacy review for R3. R1’s quarterly Minimum Data Set (MDS) assessment, dated 6/13/25, indicated R1 had intact cognition with hallucination, delusions with fluctuating disorganized thinking and was independent with all activities of daily living (ADLs). R1’s Order Summary Report, printed 9/11/25, identified R1 had current physician orders for several psychotropic medications including: -hydroxyzine 50 milligram (mg) tablet - give one tablet by mouth as needed for anxiety twice a day as needed for anxiety/sleep for 30 days - nonpharmacological intervention attempt before psychotropic administration effectiveness/any adverse effects with a start date of 9/9/25 and end date of 9/14/25 -lurasidone 60 mg tablet – give one tablet by mouth in the evening for bipolar – give with dinner with a start date of 2/15/25. -melatonin 3 mg tablet – give one tablet by mouth at bedtime for insomnia with a start date of 12/26/23. -trazodone 100 mg tablet – give 150 mg by mouth at bedtime for insomnia with a start date of 11/21/24. R1’s progress notes, dated 5/8/25 to 9/10/25, were reviewed for pharmacy recommendations and identified the following: -5/8/25: Medication regimen review: Based upon information available at time of review and assuming accuracy and completeness of such information, it is my professional judgment that the medication regimen contained no new irregularities. -6/10/25: Medication regimen review: see comments for recommendations. -7/13/25: Medication review: Based upon information available at time of review and assuming accuracy and completeness of such information, it is my professional judgment that the medication regimen contained no new irregularities. -8/8/25: Medication review: see recommendation -9/4/25: Medication review: see recommendation R1’s Consultant Pharmacist’s Medication Review, dated 6/10/25, identified the consulting pharmacist (CP) a recommendation: “Please attempt a gradual dose reduction (GDR) of Trazodone to 100mg QD. If contraindicated, please provide a detailed rationale.,” along with a section titled Rationale for Recommendation which outlined requirements for GDR. A Physician’s response section directed the physician to check if they accepted or rejected the recommendation. Furthermore, if the recommendation for a GDR was clinically contraindicated to mark either box 1 or 2 along with providing a patient-specific rationale. However, neither of the boxes were marked nor did the report have any signature from the physician to demonstrate it had been reviewed and/or addressed. A cover letter, dated 7/16/25, was provided. The cover letter was a “Fax Transmittal Sheet” with a note “please see attached pharmacy recommendation and address” with R1’s name and date of birth . However, the cover letter lacked confirmation of fax transmission. Surveyor attempted to reach consulting pharmacist. A voicemail was left for pharmacist on 9/11/25 at 8:08 a.m. without a return call. During an interview on 9/11/25 at 10:43 a.m., assistant director of nursing (ADON) stated the June pharmacy recommendation review was not signed by the provider. ADON stated the provider was sent the recommendation and the facility did not receive a response. ADON stated she was unsure if the facility attempted to follow up with provider and was going to investigate this as it should have been. No additional information was provided. A facility policy on pharmacy recommendations was requested; however, none was received.

Based on observation and interview, the facility failed to provide at least 80 square feet per resident in three resident bedrooms (room numbers 101,102,103) affecting 9 of 19 residents (R15, R8, R13, R4, R9, R17, R2, R3, R7) whose bedrooms had less than the required square footage.Findings include:During observation on room [ROOM NUMBER] had three residents residing in the room and measured approximately 197.83 square feet of useable space or 65.9 square feet for each resident.During observation on room [ROOM NUMBER] had three residents residing in the room and measured approximately 239 square feet of useable floor space or 79.6 square feet for each resident.During observation room [ROOM NUMBER] had three residents residing in the room and measured approximately 220.71 square feet of useable floor space or 73.6 square feet for each resident.The rooms were observed to pose no safety hazards and were furnished adequately. There was no observable evidence R15, R8, R13, R4, R9, R17, R2, R3, R7 were negatively impacted by their room size. During interview with R7 on 9/8/25 at 1:46 p.m., R7 stated she shared a bedroom with two other residents, and [there was] Not enough room in my room to get around. During an interview on 9/10/25 at 12:58 p.m., R4 stated she did not feel like she had enough space in her bedroom shared with two other residents. R4 stated she enjoyed doing a lot of crafting and did not have the space in her room for it. R4 stated she could use the tables in the dining room, but they were often taken up by group activities, mealtimes, or staff and residents lounging in the area. During interview on 9/11/25 at 12:33 p.m., the administrator indicated there had been no changes or updates to the rooms since the prior survey.

Based on interview and record review, the facility failed to prepare resident care plans with an interdisciplinary team (IDT) to include a nursing aide (NA), the attending physician, or a resident/resident representative. This deficiency had the ability to affect all 19 residents. Findings include: During an interview on 1/21/25 at 9:11 a.m., the director of nursing (DON) stated the IDT consists of an RN, the administrator, herself, the social worker, a member from medical records, the infection preventionist (IP) nurse, the minimum data set (MDS) nurse, and a compliance nurse. During an interview on 1/21/25 at 9:39 a.m., the administrator stated the facility's IDT consists of a RN, the DON, a member of the activities department, herself, the social services director, the social services assistant, and a member of the kitchen. During an interview on 1/21/25 at 11:35 a.m., the DON stated they do not take IDT notes. The DON stated during the IDT meetings they will look at the risk management and then they will update the care plan. The DON stated they do not take notes as to what they talk about or who attends the meetings. The facility's IDT policy revised on 12/24 stated the IDT will consist of the DON, one other nurse designated by the DON, social services director and/or the social services assistant, the activity director and/or designee, and other staff members as established by the Administrator.

Based on interview and record review the facility failed to ensure their director of nursing (DON) was a registered nurse (RN) when the facility had a licensed practical nurse (LPN) in the DON role since 7/30/24. This deficiency had the ability the affect all 19 residents. Findings include: During an interview on 1/16/25 at 11:39 a.m., the administrator stated the DON is a LPN. The administrator she knew the facility has to hire an RN to be in the DON role. There is not a signed DON job description for the current DON. During an email correspondence on 1/16/25 at 2:21 p.m., the administrator stated the DON has been in her role since 7/30/24. During an interview on 1/21/25 at 9:11 a.m., the DON stated she is a LPN who worked a the facility full time. On 1/16/25, the facility provided the DON's LPN license which is valid. The facility provided the DON's education which did not contain any training for the DON role. The facility provided an undated Director of Nursing job description. The description stated an RN must be hired in the DON role.

Based on interview and document review, the facility failed to have a functioning antibiotic stewardship program. This had the potential to affect any resident who had infections requiring antibiotic use. Findings include: During an interview on 8/28/24 at 10:04 a.m., the infection preventionist (IP) stated they started this role two weeks ago and identified there was no functioning antibiotic stewardship program in place. IP stated it was their intention to rebuild the program. The one-page Grand Avenue Rest Home Antibiotic Stewardship Program policy undated, indicated the IP will track and assess all antibiotic use to review patterns of use and assure appropriate antibiotic use . The IP will review any antibiotic order and reassess the ongoing need for and choice of an antibiotic as more information becomes available. The policy lacked protocols and criteria for determining what was appropriate use.

Based off interview, observation, and document review the facility failed to utilize proper handling of linen to prevent contamination, failed to have a functioning infection surveillance program, and failed to have a functioning water management program. This had the potential to affect all residents who resided in the facility. Linen During an observation on 8/26/24 at 2:53 p.m., nursing assistance (NA)-A walked through the kitchen carrying a mesh-designed hamper and within it, dirty resident clothing. During an interview on 8/26/24 at 2:55 p.m., cook aide (CA)-B stated other staff will walk through the kitchen with laundry or go out and around the back. During an observation and interview on 8/27/24 at 2:04 p.m., NA-A carried an uncovered basket of clean linen through the kitchen. NA-[NAME] stated this was their process to bring clothing through the kitchen, clean and dirty. During an interview on 8/28/24 at 9:33 a.m., the interim director of nursing (DON) stated staff should be using the back door to the basement not going through the kitchen when dealing with laundry. DON stated it was an infection control concern regarding the clean linen and for sanitary conditions for the kitchen. During an interview on 8/28/24 at 8/28/24 at 10:09 a.m., infection preventionist (IP) stated that linen should be not carried through the kitchen and that it posed an infection control concern. Policy requested regarding linen and/or transportation of linen requested, none provided. Infection Surveillance During an interview on 8/28/24 at 10:04 a.m., the infection preventionist (IP) stated they started this role two weeks ago and identified there was no functioning infection surveillance program in place. IP stated it was their intention to rebuild the program. Water Management During an interview on 8/28/24 at 10:04 a.m., the infection preventionist (IP) stated they started this role two weeks ago and identified there was no functioning water management program in place. IP stated it was their intention to rebuild the program.

Based on observation, interview and record review, the facility failed to identify quality deficiencies and to develop and implement appropriate actions to correct these deficiencies. Furthermore, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during Quality Assurance and Performance Improvement (QAPI). This had the potential to affect all 18 residents. Findings include: A review of the Certification and Survey Provider Enhanced Reporting (CASPER) system report (a quality measure report for nursing facilities) last updated 8/18/24, indicated the facility had the following deficiencies with a survey exit date of 9/01/23: - F727 RN Coverage for 8 hours per day for 7 days per week. - F758 Free from Unnecessary psychotropic medications. - F880 Infection prevention and control. - F881 Antibiotic Stewardship program - Emergency Preparedness (EP)0009 Local, State, Tribal Collaboration Process - EP0029 Development of Communication Plan - EP0039 EP Testing Requirements The CASPER report also revealed the facility had the following repeat deficiencies with a survey exit date of 9/2022: - F880 Infection prevention and control. - EP0009 See F727 See F757 See F880 See F881 See EP009 See EP0039 A review of the facility's QAPI meeting minutes for quarter 2 dated 6/19/24, lacked documentation of improvement activities. The minutes lacked documentation of tracking adverse events and/or medical errors and any analysis of causes. Furthermore, the meeting minutes lacked documentation of preventive actions and mechanisms implemented to improve performance. A review of the facility's QAPI reports for quarter 2 included infection control tracking, skin and wounds, and medication errors. The report lacked documentation on analysis of their causes or preventive actions implemented. A review of the facility's Quality Assurance/Assessment and Performance Improvement Plan last updated 8/24/23, indicated its purpose was to utilize an on-going, proactive approach to advance the quality of life and quality of care for all residents. The plan indicated the principles would drive the facility's decision making to promote excellence in all resident and staff related areas. Furthermore, the plan indicated the facility would review data and identify areas where gaps in performance could negatively affect resident or staff outcomes and prioritize focus areas for PIP development. The plan guided staff to consider activities that were high-risk to resident and/or staff, high-volume or problem-prone areas, health outcomes, resident safety, resident autonomy, resident choice, cost, feasibility, relevance, responsiveness, and areas not outside of benchmarks but still important to the resident population served. The plan advised staff within the PIP to develop an action plan with an identified problem statement, causes, goals, and interventions, staff responsible, and due dates. During interview on 8/28/24 at 1:43 p.m. social services (SS) stated the facility's QAPI team met every three months and reviewed corrections from survey results, trends for falls and medications, and changes in staffing. The SS stated the medical director also provided educational information to review during QAPI meetings. Additionally, the SS stated if a grievance was brought forward, the QAPI team would address the grievance. The SS stated the QAPI team utilized root cause analysis to remedy grievances and identify and overcome trends. The SS stated after last year's survey results, the QAPI team focused extensively on infection prevention and control and sanitary environment issues. The SS stated the QAPI team ensured corrective actions were implemented and effective by performing general monitoring and spot checking. The SS was unaware of any ongoing PIPs in the facility.

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 18 residents at the facility. Findings include: Review of the facility staff schedules and staffing hours from 1/1/24 to 3/31/24 revealed there was no RN scheduled for 1/14/24, 1/20/24, 1/21/24, 1/27/24, 1/28/24, 2/3/24, 2/4/24, 2/16/24, 2/17/24, 2/18/24, 2/24/24, 3/2/24, 3/3/24, 3/9/24, 3/10/24, 3/16/24, 3/17/24, 3/23/24, 3/30/24, and 3/31/24. During interview on 8/26/24 at 9:17 a.m., the interim director on nursing (DON) confirmed the dates identified that there was no RN coverage. During a follow up interview on 8/28/24 at 9:39 a.m., the interim DON stated they were to have an RN in the building at least 8 hours a day. Requested a policy regarding staffing, none provided.

Based on interview and document review, the facility failed to ensure orthostatic blood pressure monitoring was in place for 4 of 5 residents (R1, R8, R5, R13) reviewed for psychotropic medications. Findings include: R1 R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of high blood pressure, high cholesterol, anxiety, depression and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). R1's MDS further indicated she took antidepressant, antianxiety, and antipsychotic medications on a routine basis. R1's Care Area Assessment (CAA) for psychotropic drug use dated 2/28/24, indicated she mental illnesses and was being treated long-term with psychotropic medications for her personal best in mental health stability. The CAA indicated all disciplines were working with R1 to minimize the risks related to psychotropic medication use. R1's order summary report, printed 8/27/24, included the following orders: - Orthostatic blood pressure monthly, three times a day every 28 day(s) for psychotropic medication monitoring, dated 5/8/22. - sertraline hydrochloride (HCl) (for depression) oral tablet 50 milligrams (mg), Give 1 tablet by mouth in the morning every day, dated 8/27/24. - cariprazine HCl (for schizoaffective disorder, depression) oral capsule 4.5mg, Give 4.5mg by mouth in the morning, dated 8/8/24. - diazepam (for anxiety) oral tablet 2mg, Give 2mg by mouth three times per day as needed, dated 5/2/24. R1's treatment administration record (TAR) dated May 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R1's TAR dated June 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R1's TAR dated July 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R1's TAR dated August 2024, indicated R1 refused to have orthostatic blood pressures taken. R1's care plan dated 5/10/22, indicated R1 had daily psychotropic drug use that could have altering effects on the mind with risks characterized by possible problems with cardiac, neuromuscular, and gastrointestinal symptoms. The care plan identified a goal to show minimal or no side effects of mediations taken. The care plan indicated the interdisciplinary team (IDT) would evaluate the effectiveness and side effects of medications for possible need of increase, decrease or elimination of psychotropic drugs and discuss with provider for instruction quarterly and as needed. R1's electronic health record (EHR) lacked further documentation of orthostatic blood pressure readings. R8 R8's quarterly MDS, dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited verbal and other behavioral symptoms 1 -3 days of the lookback period, and had diagnoses of high blood pressure, high cholesterol, bipolar disorder (a mental disorder that causes extreme mood swings), anxiety, schizophrenia, and a traumatic brain injury or TBI (an injury to the brain that occurs when the head is suddenly struck, or when an object pierces the skull and enters the brain). R8's MDS further indicated she took antidepressant, antianxiety, and antipsychotic medications on a routine basis. R8's CAA for psychotropic drug use dated 3/15/24, indicated staff would continue to follow the plan of care to maintain her current level of functioning to minimize risks. R8's order summary report, printed 8/27/24, included the following active orders: - Orthostatic blood pressure monitoring monthly, three times a day every 28 day(s) for psychotropic medication monitoring, dated 8/23/24. - lurasidone HCl (for bipolar disorder) oral tablet 80mg, Give 80mg by mouth in the evening, dated 12/12/23. - trazodone HCl (for insomnia) oral tablet 50mg, Give 50mg by mouth after bedtime dose after one hour if not asleep as needed, dated 8/23/24. - trazodone HCl (for insomnia) oral tablet 50mg, Give 50mg by mouth at bedtime, dated 8/23/24. R8's TAR dated May 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R8's TAR dated June 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R8's TAR dated July 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R8's TAR dated August 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. A progress note dated 11/9/23, indicated R8's blood pressure while laying down was 125/74 millimeters of mercury (mmHg), while sitting was 122/76 mmHg, and standing was 109/75 mmHg. A progress note dated 12/21/23, indicated R8's blood pressure while laying down was 113/69 mmHg, while sitting was 105/77 mmHg, and standing was 107/81 mm Hg. A progress note dated 1/18/24, indicated R8's blood pressure while laying down was 119/62 mmHg while sitting was 118/77 mmHg, and standing was 98/76 mmHg. R8's care plan dated 3/21/24, indicated R1 had daily psychotropic drug use that could have altering effects on the mind with risks characterized by possible problems with cardiac, neuromuscular, and gastrointestinal symptoms. The care plan identified a goal to show minimal or no side effects of mediations taken. The care plan indicated the interdisciplinary team (IDT) would evaluate the effectiveness and side effects of medications for possible need of increase, decrease or elimination of psychotropic drugs and discuss with provider for instruction quarterly and as needed. R8's electronic health record (EHR) lacked further documentation of orthostatic blood pressure readings. R13 R13's annual MDS dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of anxiety, depression, psychotic disorder (disorder characterized by a disconnection from reality), schizophrenia, and post-traumatic stress disorder or PTSD (mental health condition that can develop after a person experiences or witnesses a traumatic event). R13's MDS further indicated she took antidepressant, antianxiety, and antipsychotic medications on a routine basis. R13's CAA for psychotropic drug use dated 7/12/24, indicated she was at risk for adverse reactions to the medications and staff would proceed to the care plan related to risks. R13's order summary report, printed 8/26/24, included the following orders: - Orthostatic blood pressure monitoring monthly, three times a day every 28 day(s) for psychotropic medication monitoring, dated 8/27/24. - prazosin HCl (for schizoaffective disorder, bipolar type) oral capsule 2mg, Give 2mg by mouth at bedtime, dated 8/22/24. - Rozerem (for PTSD) oral tablet 8mg, Give 8mg by mouth in the evening, dated 2/19/24. - trazodone HCl (for insomnia) oral tablet 150mg, Give 150mg by mouth at bedtime, dated 12/26/23. - venlafaxine HCl extended release (ER) (for anxiety) oral capsule 24-hour 150mg, Give 1 capsule by mouth one time per day, take with food, dated 2/7/24. - venlafaxine HCl extended release (ER) (for anxiety) oral capsule 24-hour 75mg, Give 1 capsule by mouth one time per day, take with food, dated 2/7/24. - ziprasidone HCl (for schizoaffective disorder, bipolar type) oral capsule 20mg, Give 2 capsules by mouth in the evening, take with food, dated 2/6/24. - ziprasidone HCl (for schizoaffective disorder, bipolar type) oral capsule 80mg, Give 2 capsules by mouth in the evening, take with food, dated 2/6/24. R13's TAR dated May 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R13's TAR dated June 2024, lacked documentation of ordered orthostatic blood pressure monitoring for 6/27/24. R13's TAR dated July 2024, lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. PointClickCare (PCC)'s weights and vitals summary, printed 8/29/24, indicated R13's sitting blood pressure on 8/27/24 was 123/94 mmHg, and standing blood pressure was 124/89 mmHg. No laying blood pressure was documented for 8/27/24. Furthermore, on 2/2/24, the weights and vitals summary indicated R13's lying blood pressure was 143/96 mmHG, sitting was 143/101 mmHg, and standing was 134/92 mmHg. R13's electronic health record (EHR) lacked further documentation of orthostatic blood pressure readings. R13's care plan dated 11/15/22, indicated R13 had daily psychotropic drug use that could have altering effects on the mind with risks characterized by possible problems with cardiac, neuromuscular, and gastrointestinal symptoms. The care plan identified a goal to shave no injury related to medication usage or side effects. The care plan indicated the interdisciplinary team (IDT) would evaluate the effectiveness and side effects of medications for possible need of increase, decrease or elimination of psychotropic drugs and discuss with provider for instruction quarterly and as needed. During interview on 8/27/24 at 1:22 p.m., the interim director of nursing (DON) stated they realized there were no active orders for orthostatic blood pressure monitoring for residents on psychotropic medications. The DON stated orders to assess orthostatic blood pressures for psychotropic medication monitoring were entered a month prior. The DON was unable to locate documentation of orthostatic blood pressures for R1, R8, and R13. The DON stated it was important to monitor residents on psychotropic medications to know if the medication is effective and to monitor for side effects. 49654 R5's quarterly minimum data set (MDS) dated [DATE] indicated R5 had diagnoses of seizure disorder, anxiety disorder, depression, and schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors). The MDS also indicated R5 was prescribed antipsychotic, antianxiety, and antidepressant medications. R5's treatment administration records dated May 2024, and June 2024 lacked order for orthostatic blood pressure monitoring and lacked documentation of orthostatic blood pressures. R5's care plan dated 12/30/23, indicated R5 had daily psychotropic drug use that could have altering effects on the mind with risks characterized by possible problems with cardiac, neuromuscular, and gastrointestinal symptoms. The care plan identified a goal to demonstrate steady gait/balance and to have minimal/no side effects related to medication usage. The care plan indicated the interdisciplinary team (IDT) would evaluate effectiveness and side effects of medications for possible need of increase, decrease or elimination of psychotropic drugs and confer with M.D. quarterly and as needed. During interview on 8/28/24 at 10:00a.m., director of nursing (DON) stated the facility hadn't been completing any orthostatic blood pressures for any residents An undated facility policy titled Psychotropic Medication Side Effect Monitoring, indicated it was the policy of the facility to assess residents taking psychotropic medications for side effects on an ongoing basis and document the results of these assessments monthly. Additionally, the policy indicated its purpose was to assure the prompt recognition of psychotropic medications side effects.

Based on record review and interview the facility failed to ensure a potential incident of neglect was recognized and reported to the State Agency (SA) after the administration had knowledge of the incident. This deficient practice had the potential to affect all residents residing in the facility. Findings include: During interview on 8/27/24 at 11:17 a.m. interim Director of Nursing (DON) stated she was aware of a fire that had taken place a few weeks before she started working at the facility. DON stated she did not see any investigation report regarding the fire. DON stated she did not know if the fire had been reported to the SA. During interview on 08/27/24 at 11:28 a.m. Administrator acknowledged there had been a fire in the smoking room on the second floor of the facility sometime in May 2024 and the incident should have been investigated by the social worker (SW). Administrator went on to say she expected staff to file an incident report, update the management staff and complete all appropriate reporting to SA. Administrator stated the SW was enroute to the facility and would be available to interview later that day. During interview on 8/27/24 at 2:32 p.m. R-13 stated another resident had altered her of a fire in a plastic garbage can in the smoking room. R-13 stated she went to the smoking room and attempted to put out the fire with a fire extinguisher but was unable to pull the pin on the extinguisher. R-13 stated the cook came to the smoking room and took the fire extinguisher from her and was able to extinguish the fire. During interview on 8/27/24 at 2:41 p.m. cook-A stated he was working on the day of the fire. Cook-A stated he had been in the kitchen when a resident came into the kitchen yelling there was a fire in the smoking room. Cook-A told the resident to call 911 and he went up the stairs to the smoking room. Cook-A stated R-13 was present in the smoking room and was attempting to pull the pin on the fire extinguisher. Cook-A took the fire extinguisher from R-13, pulled the pin out and was able to extinguish the fire. Cook-A stated the nurse who had been working at the time of the fire had removed all the residents from the facility and the fire was completely out by the time the fire department showed up approximately five minutes later. Cook-A stated the fire department brought fans into the facility to clear out the smoke. On 8/27/24 at 2:54 p.m. an attempt was made to contact the nursing staff who had been working the day of the fire but was unable to reach or leave a message requesting return call. During a second interview on 8/28/24 at 9:09 a.m. Administrator stated she had discussed the incident with the SW and was informed there was no investigation completed, and the incident had not been reported to the SA. During interview on 8/28/24 at 1:03 p.m. infection preventionist (IP) who was overseeing the DON acknowledged he was aware of the incident and his expectation of all staff was to complete an incident report and report any like incidents to the SA. IP went on to say if staff were unaware of how to report to SA the expectation of staff was to at minimum report all incident to management for further investigation and instructions. IP stated this was important so all incidents could be investigated thoroughly and promote resident safety. The facility's document titled, Abuse, Neglect, and Exploitation Prevention Policy, dated 4/26/22, recognizes the right of residents to be free from abuse and neglect. The policy provides the following definitions: a) Abuse - non-therapeutic conduct which produces or could reasonably be expected to produce physical pain or injury or emotional distress and is not accidental; b) Neglect - failure of the facility to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress; c) Financial exploitation - engaging in unauthorized expenditure of vulnerable adult's funds which is likely to result in detriment, failure to use financial resources for vulnerable adult's needs which results or is likely to result in detriment, and in the absence of legal authority, using or withholding vulnerable adult's funds or property; d) Immediately - immediately after an incident occurs for alleged violations of maltreatment, abuse, neglect, and financial exploitation. The policy identifies procedures for abuse prevention including employee training about reportable incidents to assist them in identifying these incidents; providing instructions and encouragement to staff, families, residents to immediately report incidents of suspected maltreatment including how and to whom incidents should be reported; reporting by staff of suspected maltreatment are mandatory, the administrator is to be notified immediately of any events of suspected or reported vulnerable adult abuse events. The policy directs staff to report any situation where there is reason to believe that a vulnerable adult is being or has been abused and/or neglected. The policy also directs the administrator, director of nursing, and the social service director, or designee to conduct all vulnerable adult investigations, review results, and respond appropriately to the results of the internal investigation.

Based on observation, interview and document review, the facility failed to ensure personal privacy could be maintained in resident room for 1 of 3 residents (R8) reviewed for privacy. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and was independent with her activities of daily living (ADLs). R8's MDS also indicated she had diagnoses of anxiety, bipolar disorder, and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). Furthermore, the MDS indicated R8 experienced hallucinations and delusions and exhibited verbal and other behavioral symptoms for 1-3 days during the lookback period. R8's annual MDS dated [DATE], indicated she felt it was very important to take care of her personal belongings and things. A progress note dated 3/25/24 indicated staff knocked on R8's door and when they did not hear a response, opened the door, and invited her to an activity. The progress note indicated later, R8 came downstairs and reported discomfort when staff walked into her room while she was changing and requested that staff wait on a response before entering her room. The progress note indicated staff did not challenge R8's assertion so that the situation would not be escalate., The note indicated when staff approached R8 earlier to invite her to the activity, she was sitting on her bed fully clothed. R8's care plan lacked documentation of privacy preferences or assessment. During observation on 8/25/24 at 6:16 p.m., there were no privacy curtains or privacy screen in R8's bedroom that she shared with two other residents. During interview on 8/26/24 at 12:48 p.m., R8 stated she would like to have privacy curtains, especially when you're changing clothes. It would be nice to have privacy. During interview on 8/28/24 at 8:42 a.m., licensed practical nurse (LPN)-A stated there was not really any privacy in resident rooms. LPN-A stated if a resident needed privacy, they would have to come to the nursing office or go to the bathroom. During interview on 8/28/24 at 9:13 a.m., the director of nursing (DON), verified there were no privacy curtains in the resident rooms and stated the facility was in the process of looking into privacy curtains. A facility policy titled Resident Privacy updated 9/14/23, indicated the facility wanted to provide privacy to residents and endorsed some challenges they faced. The policy indicated if a resident wanted more privacy in a shared bedroom, they could request a privacy screen. The policy recognized there are some beds where privacy screens would not be able to be used as they would create an accident hazard. The policy provided alternative options to meet the privacy needs of each resident, including moving the resident to a different bed or room, or discharge may be an appropriate option for some residents.

Based on observation, interview and document review, the facility failed to notify and consult with the resident's physician after a resident (R1) was tested for Coronavirus disease 2019 (COVID-19). Findings include: R1's quarterly Minimum Data Set (MDS), dated [DATE], indicated she had intact cognition, had hallucinations and delusions, exhibited no physical, verbal or wandering behaviors, and had diagnoses of high blood pressure, high cholesterol, anxiety, depression and schizophrenia (a mental disorder characterized by thoughts or experiences, seemingly out of touch with reality, that affects a person's ability to think, feel, and behave clearly). R1's Care Area Assessment (CAA) for nutritional status dated 2/28/24, identified she had a respiratory disease that could affect her appetite or nutritional status. An initial nursing assessment, careplan, and progress notes document dated 2/21/24, indicated R1's lung sounds were clear with no labored breathing noted. The assessment further indicated R1 did not have a cough. R1's care plan lacked documentation on R1's respiratory status. An after-visit summary (AVS) dated 4/15/24, indicated R1 was seen at an urgent care center for cough, bronchitis (swelling or inflammation of the airways leading to your lungs), and a history of emphysema (lung condition that causes shortness of breath). The AVS instructed R1 to call a doctor or seek immediate attention if she experienced the following symptoms: - new or worse trouble breathing. - coughing up dark brown or bloody mucus (sputum). - new or higher fever. - new rash. R1's electronic health record (EHR) was reviewed daily during the survey week (8/24/24 - 8/28/24) and lacked documentation of reported symptoms by R1. Furthermore, R1's EHR lacked documentation of a COVID test or result. During observation and interview on 8/25/24 at 2:00 p.m., R1 sat in the 2nd floor TV lounge and coughed harshly. She stated the cough was not productive and she had it for approximately one week. R1 denied telling staff about her symptoms but stated she planned to tell them and request a coronavirus (COVID) test. During observation and interview 8/26/24 at 8:52 a.m., R1 sat in the 2nd floor TV lounge and stated I don't feel good this morning. My head feels bizarre, my stomach hurts and I'm shaky. R1 stated she asked for a COVID test and staff reported they would give her one, but they weren't sure when. R1 reported staff had not taken her temperature or assessed her vital signs. During interview on 8/27/24 at 8:15 a.m., R1 reported increased difficulty breathing and said, I can't breathe. She stated staff administered a COVID test the day before but had not given her the results. During observation on 8/27/24 between 2:05 p.m. and 3:17 p.m., R1 reported to social services (SS) she wanted help filing a report. SS questioned R1 for further information and R1 told her she was not feeling and wanted to go to urgent care. SS discussed the options for filing the report and it was agreed they would file the report first. SS and R1 walked to the nursing office to file the report. At 3:17 p.m., R1 walked into the 2nd floor TV lounge with her coat on. She appeared short of breath and stated staff refused to call 911 for her. R1 stated the director of nursing (DON) told me I needed to take a nebulizer treatment. She stated no one had listened to her lungs but checked her oxygen saturation levels (a measure of how much oxygen is in your blood) which was 100%. R1 stated she was going to call 911 herself. She walked away and into the telephone room and closed the door. During interview on 8/28/24 at 8:42 a.m., licensed practical nurse (LPN)-A stated R1 first reported difficulty breathing around the end of my shift at approximately 3:00 p.m. on 8/27/24. LPN-A stated the DON requested an oxygen saturation level check, but LPN-A did not listen to R1's lung sounds. During interview on 8/28/24 at 8:53 a.m., the DON reported being first notified of R1's respiratory symptoms of cough and difficulty breathing on 8/27/24 when R1 came into the nursing office and wanted staff to call 911. The DON stated R1 would not allow staff to fully assess her and said she wanted to go to the hospital. The DON reported R1 walked out of the nursing office and called an ambulance for herself. The DON stated she offered R1 a nebulizer treatment but R1 declined. The DON verified being aware that R1 requested a COVID test. The DON stated, I don't know why she wanted the COVID test. It was negative, I saw the results. The DON expected staff to document the results and notify the provider. The DON verified R1's EHR lacked such documentation. The DON expected staff to follow up if they were made aware of a resident not feeling. A request for a notification of change policy was requested but not received.