Every finding on record at Greene County Health and Rehabilitation

Based on observation, interview, and facility policy review, the facility failed to maintain safe food handling and storage practices by not removing expired food items from the refrigerator and freezer and by not dating and labeling opened and repackaged food items for one (1) of three (3) days of survey.Findings include:A review of the facility's policy, Food Receiving and Storage, revised 11/2022, revealed, Foods shall be received and stored in a manner that complies with safe food practices.Refrigerated/Frozen Storge 1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.On 1/20/26 at 10:01 AM, during an observation and interview, the reach-in refrigerator #2 was observed to contain opened, repackaged sliced bologna sandwich meat labeled with an opened date of 10/8/25 and a best-by/use-by date of 11/8/25, which had expired. Reach-in refrigerator #2 was also observed to contain several packages of opened, repackaged sliced white cheese without an open date labeled and sliced American cheddar cheese that had been opened and repackaged without an open date labeled on the outside of the clear plastic bags. A container of French's mustard was observed opened, in use, and stored unrefrigerated on a shelf despite manufacturer instructions indicating the product should be refrigerated after opening. During the interview, the Dietary Supervisor acknowledged the expired and improperly labeled food items and reported it was the responsibility of all dietary staff to routinely check dates in refrigerators and freezers and to remove expired food items. On 1/22/26 at 2:50 PM, during an interview, the Administrator reported her expectation was for the dietary department to conduct routine weekly monitoring to ensure expired foods were identified and removed in a timely manner and foods were refrigerated as required. She stated both the Dietary Manager and Dietary Supervisor were responsible for oversight of food storage and safety practices. She further reported that while all staff were encouraged to check product dates when handling food items, the primary responsibility for monitoring expiration dates and proper labeling rested with the Dietary Manager and Dietary Supervisor to ensure compliance with food safety standards and to prevent the use of expired or improperly labeled food products.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to dignity by not covering a urinary catheter drainage bag for one (1) of (18) sampled residents, Resident #13.Findings include:A review of the facility's policy, Catheter Care (undated) revealed, .It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.Policy Explanations.2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use.A review of the facility's policy, Resident Rights, dated 02/2021, revealed, .Employees shall treat all residents with.dignity. Policy Interpretation and Implementation 1.These rights include the resident's right to: a. a dignified existence.A record review of the admission Record revealed the facility admitted Resident #13 on 3/3/25 with diagnoses including Dementia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/25, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated her cognition was moderately impaired.A record review of the Order Listing Report revealed Resident #13 had a Physician's Order, dated 12/29/25, for catheter care every shift and as needed.On 01/20/2026 at 11:59 AM, during an observation and interview, Resident #13 was lying in bed with an indwelling urinary catheter drainage bag hanging on the side of the bed, uncovered and visible to anyone when the resident's door was opened. Resident #13 stated she did not know why she had a urinary catheter.On 01/20/2026 at 12:05 PM, during an observation and interview Registered Nurse (RN) #2, she confirmed that Resident #13's urinary catheter drainage bag was exposed and not covered. RN #2 confirmed the catheter drainage bag should have been covered for resident dignity. On 01/21/2026 at 4:07 PM, during an interview, the Director of Nursing (DON), stated Resident #13 had an indwelling catheter since 12/28/2025. She explained wound care staff were responsible for catheter placement and changes. The DON confirmed staff were required to keep catheter drainage bags covered for dignity, and this expectation was reviewed during catheter care in-service training completed within the last year. She stated her expectation was for staff to ensure catheter drainage bags were covered at all times.On 01/22/2026 at 2:01 PM, during an interview, the Administrator stated she expected staff to place all catheter drainage bags in privacy covers to maintain resident dignity.

Based on interview, record review, and facility policy review, the facility failed to provide written notification of a resident transfer that included the specific reason for the transfer in a language and manner the resident's representative could understand for one (1) of two (2) residents sampled for hospitalization. Resident #49. Findings include:A review of the facility's policy, Transfer and Discharge (including AMA - Against Medical Advice (AMA), revised 2025, revealed, .Definitions: . 'Transfer and Discharge' includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical place or not. Policy Explanation and Compliance Guidelines: . 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all the following at the time it is provided: a. The specific reason and basis for transfer or discharge.A record review of the admission Record revealed the facility admitted Resident #49 on 9/15/24 and he had current diagnoses including Schizoaffective Disorder, Bipolar Type.A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/4/26 revealed Resident #49 had an unplanned discharge to an acute hospital with return anticipated on 1/4/26.A record review of the resident's Progress Notes revealed, .Effective Date 1/4/26 3:16 AM. Note Text: sent to (proper name of the local acute care hospital) ER (Emergency Room) for evaluation r/t r(elated to) low O2 (oxygen) sats (saturations) and elevated temp (temperature.A record review of the Notice of Resident Transfer or Discharge, dated 1/5/26, revealed Resident #49 was transferred to the local acute care hospital on 1/4/26 and listed the reason as Resident has transferred to the hospital/home with the anticipation of return. It did not indicate the clinical reason for the transfer. A record review of the resident's Progress Notes revealed, .Effective Date 1/4/26 8:15 PM. Note Text: resident disoriented, aroused with sternal rub. shows difficulty swallowing meds (medications).ordered for resident to sent to (proper name of a neighboring county acute care hospital - different facility from earlier transfer) for further treatment.A record review of the Notice of Resident Transfer or Discharge, dated 1/5/26, revealed Resident #49 was transferred to an acute care hospital in a neighboring county on 1/4/26 and listed the reason as Resident has transferred to the hospital/home with the anticipation of return. It did not specify the clinical reason for the transfer. On 1/22/26 at 2:30 PM, during an interview, the Business Office Manager reported Resident #49 was sent to the hospital twice on 1/4/26, which resulted in (2) transfer letters for that date. She reported she mailed the written notices to the resident's representative. She confirmed the notification did not list the specific reason for the transfer and stated she was not aware the specific reason was required to be included on the notices and checked only the general reason category on the letters. On 1/22/26 at 3:00 PM, during an interview, the Administrator reported she was not aware of the specific federal requirements for written notification of resident transfers. She stated her expectation was for staff to follow federal requirements for notice of transfers.

Based on observation, interview, record review, and facility policy review, the facility failed to provide respiratory care in accordance with physician orders and professional standards of practice by not administering oxygen at the ordered flow rate and by not documenting as-needed (PRN) oxygen administration for one (1) of (1) resident reviewed for respiratory care, Resident #2.Findings include:A review of the facility's policy, Oxygen Administration Policy, (undated) revealed, .Oxygen is administered to residents who need it in, consistent with professional standards of practice.Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician.3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy.On 1/20/26 at 12:09 PM, during an observation, Resident #2 was observed lying in bed with oxygen via nasal cannula (nc) running at two (2) liters per minute.On 1/20/26 at 12:22 PM, during an observation and interview, Licensed Practical Nurse (LPN) #1 who was the floor nurse for Resident #2, observed Resident #2's oxygen concentrator running at (2) liters per minute. She confirmed the setting and reported the setting did not align with the physician's order, which was three (3) liters per minute.On 1/21/26 at 12:13 PM, during an interview, Registered Nurse (RN) #1 explained it was the responsibility of the primary nurse, or floor nurse to monitor residents' oxygen flow rates and oxygen saturation levels.On 1/21/26 at 4:07 PM, during an interview, the Director of Nursing (DON) reported it was the responsibility of the floor nurse to ensure Resident #2's oxygen was administered at the physician-ordered rate. She reported medication nurses could also check oxygen settings during medication passes. She further reported the purpose of following physician orders was to maintain appropriate oxygen saturation levels and stated her expectation was for staff to verify oxygen flow rates during medication passes.On 1/22/26 at 2:45 PM, during an interview, the Administrator reported she had been advised that Resident #2's oxygen concentrator had been observed running at (2) liters per minute on 1/20/26 and that the physician order required (3) liters per minute. She stated the oxygen adjustment knob could be easily bumped but emphasized nursing staff were expected to routinely check oxygen flow rates to ensure consistency with physician orders and stated her expectation was for staff to always follow physician orders for prescribed oxygen levels.A record review of the admission Record revealed the facility admitted Resident #2 on 4/22/22 and she had current diagnoses including Hemiplegia and Hemiparesis.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/25 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated her cognition was moderately impaired.A record review of the Order Listing Report revealed Resident #2 had an active Physician's order, dated 7/18/24, for oxygen at (3) liters per minute as needed for shortness of breath or oxygen saturation less than 92%. A record review of the January 2026 Medication Administration Record (MAR) revealed no documentation indicating Resident #2 received PRN oxygen on 1/20/26, although the resident was observed wearing oxygen via nasal cannula.

Based on interviews, record review, and facility policy review, the facility failed to ensure that medications were administered in accordance with accepted standards of nursing practice and professional guidelines for one (1) of four (4) sampled residents (Resident #1) as evidenced by Licensed Practical Nurse (LPN) #1 failed to verify the resident's identity before administering medications and pre-pulled medications without immediate administration, resulting in Resident #1 receiving another resident's medications. This error caused the resident to experience an adverse drug reaction, decreased level of consciousness, and required transfer to an acute care hospital for intravenous (IV) fluids, potassium therapy, oxygen therapy, and observation.Findings include:A review of the facility's policy titled Administering Medications, revised April 2019, revealed, .Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation.9. The individual administering the medication verifies the resident's identity before giving the resident his/her medications.A record review of the facility's investigation revealed that on 5/15/25, at 10:09 AM, Licensed Practical Nurse (LPN) #1 administered medications to Resident #1. Resident #1 was assessed at 11:47 AM and received an order for evaluation at the emergency room (ER) at 12:10 PM. A Certified Nurse Aide (CNA) reported that she attempted to wake Resident #1 for lunch and saw a medication cup in the resident's trash can labeled with another resident's name. Resident #1 was treated with intravenous fluids and potassium replacement and remained in the ER overnight for observation.A review of the Medication Error Report, dated 5/16/25, revealed, .resident received wrong medication. Meds had been placed in cups with res (resident) names on cups. Wrong med cup given to resident. AEB (As evidenced by) a cup with another resident's name found in trash can.A record review of a handwritten statement by LPN #1, dated 5/18/25, revealed, On 5/15/25 during my med (medication) pass I accidentally administered the wrong medication to a resident.I take full responsibility for this error and deeply regret any distress or risk caused to the resident.A record review of the acute hospital documentation for Resident #1 revealed, .Brought from rehab with report of possible seizure less than 30 minutes ago.Upon assessment by staff she was noted to be drowsy but would clasp hands together and move extremities spontaneously. Upon arrival to ED (Emergency Department), CNA from the rehab disclosed she saw a cup of pills that may have not belonged to the patient. Nursing staff reported she may have received another patient's meds to include Vimpat, Keppra, Gabitril, hydrocodone, and clonazepam. Further review revealed the resident received Intravenous (IV) Normal Saline with potassium and was administered four (4) liters of oxygen at the hospital.A record review of the admission Record revealed the facility admitted Resident #1 on 5/10/25 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Type 2 Diabetes Mellitus.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/21/25, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.On 7/24/25 at 11:40 AM, during an interview, CNA #1 stated that when she entered Resident #1's room, she found the resident slumped in a chair, unresponsive to voice, and minimally responsive to physical stimulation. She noted this was not normal for the resident. While assisting the resident, CNA #1 observed a medication cup in the resident's trash can labeled with another resident's name. Recognizing a potential error, she immediately notified Registered Nurse (RN) #1.On 7/24/25 at 12:12 PM, during an interview, RN #1 stated that after being informed of a change in Resident #1's responsiveness, she immediately assessed the resident and noted the altered mental status. She notified the Nurse Practitioner (NP), who recommended transfer to the emergency department. RN #1 reported that CNA #1 informed her of the medication cup found in the room and that it was labeled with another resident's name. RN #1 stated that when she became aware that the medications given to the resident were not hers, she provided the NP with the full medication list that matched the other resident.On 7/24/25 at 1:00 PM, during an interview with Director of Nursing (DON), she confirmed that on 5/15/25, LPN #1, an agency nurse, pre-pulled Resident #2's medication and labeled the cup. The DON explained that the resident was in the shower, and the nurse intended to administer them once the resident returned. However, LPN #1 later administered the medication to Resident #1 without confirming the residents' identity. The DON acknowledged that this action violated the facility's medication administration policy and the professional nursing standard known as the five rights (right resident, right medication, right dose, right route, and right time). The DON confirmed that this failure did not reflect the standard of nursing care expected at the facility. She confirmed that LPN #1 did not pre-pull medications for any other residents and that this was an isolated occurrence. She further confirmed that Resident #2 later received the correct medications.On 7/24/25 at 1:30 PM, during an interview with the Administrator, she confirmed that LPN #1's actions did not meet the professional standards of nursing care. The Administrator stated that all licensed nurses are expected to follow the five rights of medication administration and verify resident identity prior to administration. She acknowledged that pre-pulling medications, even with the intent to administer them shortly after, is not permitted under facility policy and creates an increased risk of error.On 7/24/25 at 5:00 PM, during a phone interview with LPN #1, she confirmed that on 5/15/25 she placed Resident #2's medications in a cup and labeled it with the resident's name. She reported doing so because Resident #2 was in the shower, and she intended to administer the medications afterward. LPN #1 acknowledged that she mistakenly administered the pre-pulled medications to Resident #1, believing she had the correct resident. She stated that pre-pulling medications is not her routine practice, but she made the decision that morning due to a busy med pass and multiple residents being in the shower. She admitted that she failed to follow the five rights of medication administration and that her actions were a mistake.

Based on interview, record review, and facility policy review, the facility failed to ensure that a resident was free from a significant medication error for one (1) of four (4) sampled residents, as evidenced by Resident #1 received another resident's medications, which caused a change in mental status requiring hospital evaluation, overnight observation, and treatment, including intravenous (IV) fluids, potassium replacement, and oxygen therapy. Findings include:A review of the facility's policy titled, Administering Medications, revised April 2019, revealed, .Medications are administered in a safe and timely manner, and as prescribed .9. The individual administering the medication verifies the resident's identity before giving the resident his/her medications.Resident #1A record review of the admission Record revealed the facility admitted Resident #1 on 5/10/25 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Type 2 Diabetes Mellitus.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/21/25, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.Resident #2A record review of the admission Record revealed the facility admitted Resident #2 on September 29, 2021, with diagnoses of Epilepsy and Type 2 Diabetes Mellitus.A record review of Resident #2's Order Summary Report confirmed active orders for, Allopurinol 300 mg (milligram), Bacid oral capsule, Clonazepam 0.5 mg, Ergocalciferol 1.25 mg (5000 units), Hydrocodone-Acetaminophen 5-325 mg, Lacosamide 200 mg, Levetiracetam 750 mg (two tablets), Mag Ox 400 oral tablet, Metformin HCL 1000 mg, Sitagliptin Phosphate 100 mg, and Tiagabine HCL 4 mg.A record review of the facility's investigation revealed that on 5/15/25, at 10:09 AM, Licensed Practical Nurse (LPN) #1 administered medications to Resident #1. Resident #1 was assessed at 11:47 AM and received an order for evaluation at the emergency room (ER) at 12:10 PM. A Certified Nurse Aide (CNA) reported that she attempted to wake Resident #1 for lunch and saw a medication cup in the resident's trash can labeled with another resident's name. Resident #1 was treated with intravenous fluids and potassium replacement and remained in the ER overnight for observation.A review of the Medication Error Report, dated 5/16/25, revealed, .resident received wrong medication. Meds had been placed in cups with res (resident) names on cups. Wrong med cup given to resident. AEB (As evidenced by) a cup with another resident's name found in trash can.A record review of a handwritten statement by LPN #1, dated 5/18/25, revealed, On 5/15/25 during my med (medication) pass I accidentally administered the wrong medication to a resident.I take full responsibility for this error and deeply regret any distress or risk caused to the resident.A record review of the acute hospital documentation for Resident #1 revealed, .Brought from rehab with report of possible seizure less than 30 minutes ago.Upon assessment by staff she was noted to be drowsy but would clasp hands together and move extremities spontaneously. Upon arrival to ED (Emergency Department), CNA from the rehab disclosed she saw a cup of pills that may have not belonged to the patient. Nursing staff reported she may have received another patient's meds to include Vimpat, Keppra, Gabitril, hydrocodone, and clonazepam. Further review revealed the resident received Intravenous (IV) Normal Saline with potassium and was administered four (4) liters of oxygen at the hospital.During an interview conducted on 7/24/25 at 11:40 AM, CNA #1 stated that Resident #1 slumped in her chair and was unresponsive. This was unusual for the resident so she reported the change to the Registered Nurse (RN). She also found a medication cup in the resident's trash can that had another resident's name on it. During an interview on 7/24/25 at 12:12 PM, RN #1 confirmed that after being informed of the resident's condition, she assessed Resident #1, noted altered mental status, and contacted the Nurse Practitioner (NP) for evaluation. RN #1 confirmed that the medication cup in the room did not belong to Resident #1 and that the medications matched the profile of another resident (Resident #2).During an interview on 7/24/25 at 1:00 PM, the Director of Nursing (DON) confirmed that LPN #1, an agency nurse, administered another resident's medications to Resident #1 without verifying the resident's identity. She confirmed that this was a significant medication error resulting in the resident's transfer to the hospital for treatment.During an interview on 7/24/25 at 1:30 PM, the Administrator confirmed that LPN #1 failed to follow facility protocols and the five (5) rights of medication administration (right resident, medication, dose, time, and route).During a phone interview conducted on 7/24/25 at 5:00 PM, LPN #1 admitted she mistakenly administered another resident's medications to Resident #1 causing a significant medication error.

Based on observation, staff interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan to reflect the use of a restraint for one (1) of fourteen (14) sampled residents, Resident #38. Findings Include: A review of the facility's policy titled Use of Restraints, revised April 2017, revealed .17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s) but the underlying problems that may be causing the symptom(s) . 18. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use During an observation on 10/09/24 at 7:30 AM, Resident #38 was sitting in her wheelchair with a cloth cross-body strap support on her upper chest. A record review of the Comprehensive Care Plan revealed that there was no care plan developed related to the use of a physical restraint. During an interview on 10/09/24 at 11:05 AM, the Director of Nursing (DON) acknowledged Resident #38 was unable to remove the harness restraint while in her wheelchair. The DON confirmed Resident #38 had not previously been care planned for the restraint and explained the reason of care planning is to note the focus area with goals and interventions for the staff. The DON stated her expectation going forward is to care plan focus areas promptly so that staff can be aware of how to care for the residents. A record review of the Admission Record revealed that the facility admitted Resident #38 on 04/19/19 with diagnoses including Spastic Quadriplegic Cerebral Palsy. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/24 revealed that Resident #38's cognitive skills for daily decision-making were severely impaired. The resident required a staff interview for cognitive status.

Based on observation, staff interview, record review, and facility policy review, the facility failed to follow proper sanitation and food handling practices to prevent the possible outbreak of foodborne illnesses, as evidenced by a foreign object observed in the sugar bin for one (1) of four (4) kitchen observations. Findings Include: A review of the facility's policy titled Storage of Canned and Dry Food, revised 10/17, revealed, .The facility ensures the quality, nutritive value, and safety of canned and dry food through accepted storage practices. Procedure: 1. Dry storage is designated for the storage of dry goods such as single-service items, canned goods, and packaged or containerized bulk food .2. The dry storage room is a clean, dry area free from contaminants .10. Dry food products such as flour, cornmeal, sugar, etc., are removed from their original packaging and stored in bins. These bins are cleaned and sanitized according to the facility's cleaning schedule . On 10/07/24 at 10:36 AM, during an observation and interview of the dietary department, the State Agency (SA) observed what appeared to be a rock (foreign object) in the sugar bin. Dietary Staff #1 and Dietary Staff #2 confirmed during an interview that the foreign object was in the sugar bin. Dietary Staff #1 stated that she did not know how the object got into the sugar, but she explained that all staff members are responsible for checking the sugar. Dietary Staff #2 stated that she had used sugar from the second bin in the kitchen to make tea for the residents but was unsure how the object entered the sugar and emphasized that everyone who uses the dry goods should examine the products. During an interview on 10/08/24 at 2:00 PM, Dietary Staff #2 reported that she had dumped the contaminated sugar the previous day, cleaned the container, and refilled it halfway. Dietary Staff #2 also confirmed that residents could become ill from consuming food contaminated with foreign objects. During an interview on 10/08/24 at 2:55 PM, the Administrator expressed her expectations for staff to examine all food before serving it to residents. She further stated that it is the staff's responsibility to ensure that all food is sanitary and free from foreign objects for the residents, and she expects all staff members to examine dry goods. A record review revealed the facility conducted an in-service training on 03/25/24. The kitchen staff was trained to check containers of sugar, flour, and cornmeal, clean and sanitize containers, and refill them. Staff members signed to confirm their understanding and agreement.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical restraints by not identifying and documenting the use of a chest harness as a restraint for one (1) of fourteen (14) sampled residents. Resident #38 Findings Include: A review of the facility's policy titled Use of Restraints, revised April 2017, revealed: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully . When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and ongoing re-evaluation for the need for restraints will be documented. 1. Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached to the resident's body that the individual cannot remove . 2. If the resident cannot remove a device in the same manner in which the staff applied it, given the resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint A record review of Resident #38's medical record revealed there was no documentation regarding the use of a restraint. On 10/08/24 at 3:50 PM, during an interview with the Administrator, she explained that Resident #38 wore the support straps across her body while sitting in her wheelchair due to her medical condition. The Administrator stated that the facility did not consider the support device, which was a harness, as a restraint. She further explained that if a resident does not have the mental capacity to understand or remove the restraint, it was not considered a restraint by the facility. The Administrator confirmed that Resident #38 could not remove the harness without staff assistance. On 10/09/24 at 7:30 AM, in an observation, Resident #38 was observed sitting in her wheelchair with a cloth cross-body strap support on her upper chest. On 10/09/24 at 7:38 AM, during an interview, Licensed Practical Nurse (LPN) #1 stated that the resident wore the straps across her body when she was in her wheelchair to provide support. LPN #1 reported that Resident #38 was placed in her wheelchair for two (2) hours in the morning and then placed back in bed for two (2) hours, continuing this cycle throughout the day. LPN #1 added that the straps had been used since the resident was admitted to the facility. On 10/09/24 at 7:40 AM, during an interview, Certified Nursing Assistant (CNA) #2 confirmed that the straps were placed across the resident's chest to prevent her from falling out of the chair. CNA #2 also confirmed that Resident #38 could not remove the straps on her own. On 10/09/24 at 11:05 AM, in an interview, the Director of Nursing (DON) acknowledged that Resident #38 was unable to remove the harness from her wheelchair without staff assistance. The DON confirmed that the facility had not previously identified the strapping device as a restraint. The DON explained that, moving forward, the facility would conduct pre-restraint evaluations, obtain physician's orders, secure consents from the resident's representative, and ensure proper documentation. Additionally, the DON committed to providing in-service training to staff on identifying and documenting restraints. A record review of the Admission Record revealed that the facility admitted Resident #38 on 04/19/19 with diagnoses including Spastic Quadriplegic Cerebral Palsy. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/24 revealed that Resident #38's cognitive skills for daily decision-making were severely impaired. The resident required a staff interview for cognitive status.

Based on the facility policy, care plan review, and staff interviews the facility failed to develop and implement a comprehensive person-centered care plan for Resident (R)18. The resident's plan of care did not include person-specific, measurable objectives and a timeframe to evaluate the resident's progress to goals. Findings include: The following policies were reviewed: Care Planning- Interdisciplinary Team, Operational Policy and Procedure Manual, for Long Term Care, 2001 Med- Pass Inc., Revised (MONTH) (YEAR); and Care Plans, Comprehensive Person-Centered, (same manual), Revised (MONTH) (YEAR). According to the care plans comprehensive person centered policy, the care plan will include the following: measurable objectives and timeframe, a description of the services to be provided, include the resident's stated goals on admission, build on resident's strengths, have measurable outcomes, reflect current standards of practice, include interventions that address the underlying source of the problem, not just only symptoms or triggers, are ongoing in assessment, are interdisciplinary in approach, are reviewed and revised when the desired outcome is not achieved. Review of Resident #18's care plan reflected that many of the problems on the plan of care are dated from (MONTH) (YEAR), and have not been revised. Problems address the resident's medical [DIAGNOSES REDACTED]. Goals are not specific nor measurable. Interventions are not time limited. On 03/07/19 at 10:19 AM, an interview of the MDS/Care Plan Nurses, LPN #38 and LPN #39, who are responsible for completing the nursing portions of the MDS, making decisions on proceeding with the Care Assessment Areas (CAAs), and then developing the care plans was conducted. LPN #38 and LPN #39 stated during the care conferences, the entire plan of care including the interventions are reviewed then reprinted and placed on chart. Both the LPNs stated that it is not often that revisions are made to the goals, or interventions. Each discipline is responsible for developing their plan of care and for evaluating their interventions for effectiveness. It is the expectation that the discipline would come to the meeting with any changes they wanted made on the care plan. Discussion with the Minimum Data Set (MDS)/Care Plan Licensed Practical Nurses (LPN) regarding the activities goal that the resident would make eye contact with each interaction confirmed it was unrealistic since the resident is receiving end of life care and awareness varies over the day. Confirmed no identified measures included in the goal to determine progress or meeting a goal. Many of the interventions are assigned to one discipline; not promoting an interdisciplinary approach. Confirmed Hospice interventions for Resident #18 are not added to the plan of care except to say- contact Hospice if there are problems, but the problems were not identified. Continued interview of LPN #38 and LPN #39 on 03/07/19 at 10:19 AM, confirmed during care plan conference, the focus has not been on reviewing interventions for effectiveness and revising the plan of care, then revisiting the new interventions to see if they have had better results in achieving the goals. It was also discussed and confirmed that if the goal has not been achieved, then it may not have been realistic or was not stated in terms that were easily measurable. Further interview on 03/07/19 revealed LPN #38 and LPN #39 stated that they would expect the discipline to have documentation in the progress note as to whether the resident has made any progress, but they do not check to see if the documentation is present. Review of R #18's progress notes do not reflect documentation related to the resident progress toward goals.

Based on record review, staff interview, and facility policy review, the facility failed to ensure that one (1) resident, Resident #7, out of 11 sampled residents, had their care plans updated and revised to reflect their current status and care needs. Findings include: A facility policy entitled, Goals and Objectives, Care Plans dated as revised 09/13, indicated, . Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence with the resident's personal and cultural beliefs in the development of these goals .Goals and objectives are reviewed and/or revised .When there has been a significant change in the resident's condition .When the desired outcome has not been achieved . Resident #7: A care plan dated as initiated 10/10/17, identified Resident #7 had a [DIAGNOSES REDACTED]. The goal of the care plan was for the resident not to have a BIMS of less than 12 at the next review date. The date of this goal was 04/24/18. The approaches included medication as ordered, laboratory testing as related to the use of the antipsychotic [MEDICATION NAME], to observe for adverse side effects, and to education the resident on pros and cons of the use of a [MEDICAL CONDITION] medication. Review of the Face Sheet documented Resident #7 was re-admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Per review of the readmission Physician Orders, dated 10/10/17, noted Resident #7 was ordered [MEDICATION NAME] (an antipsychotic) 100 milligrams (mg) to be administered at bedtime. Per review of a physician order, dated 01/30/18, it directed clinical staff to change the [MEDICATION NAME] [DIAGNOSES REDACTED]. The care plan was updated on 01/30/18, and the [DIAGNOSES REDACTED]. The approaches were not updated at this time to reflect the new diagnosis, such as monitor for increase in behaviors related to [MEDICAL CONDITION]. In another care plan, the goal of Resident #7's BIMS score of less than 12 was reviewed with a new target date of 07/17/18. The care plan had an updated goal that Resident #7 would have a BIMS score of 8 or greater at the next review date of 04/02/19. A new goal was identified that Resident #7 would be able to recall the month by the next review date. The approaches remained the same. An interview was conducted with the former Director of Nursing (DON) on 03/07/19 at 7:21 AM. The former DON said her expectation for the revision of a care plan was to be done if there was a change in the resident's condition, quarterly, and annually.

Based on observation, clinical record review, staff and resident interviews, facility policy review, and review of the Food and Drug Administration (FDA) Medication Guide, the facility failed to ensure that one (1) resident, Resident #7, out of a survey sample of five (5) residents reviewed for unnecessary medications, was provided adequate indications for use of an antipsychotic medication [MEDICATION NAME]. Resident #7 had inadequate monitoring for the use of this antipsychotic medication; and the facility failed to ensure that one (1) resident, Resident #46, who was prescribed [MEDICATION NAME] (a medication for Pseudobulbar Affect (PBA) for symptoms of excessive crying and laughing), had adequate indications for use and monitoring. Findings include: Review of the facility's policy, undated, noted, . Antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition . Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms, and risks . Nursing staff will document in detail an individual's target symptoms(s) .The Attending Physician and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions . Resident #7: Per review of the readmission Physician order [REDACTED].#7 was ordered [MEDICATION NAME] (an antipsychotic) 100 milligrams (mg) to be administered at bedtime. Per review of the Food and Drug Administration (FDA) Medication Guide documented, . [MEDICATION NAME] may cause serious side effects, including: 1. risk of death in the elderly with dementia. Medicines like [MEDICATION NAME] can increase the risk of death in elderly people who have memory loss (dementia). [MEDICATION NAME] is not for treating [MEDICAL CONDITION] in the elderly with dementia. Review of the Face Sheet documented Resident #7 was re-admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A care plan for Resident #7 was dated as initiated on 10/10/17, and the identified problem was the resident had a [DIAGNOSES REDACTED]. A physician's note dated 10/18/18, documented Resident #7 was doing well. The physician noted the resident would continue on the current dose of [MEDICATION NAME]. There was no documentation that showed the resident was delusional, hallucinated, or was a risk to self or to others. The Medication Administration Record [REDACTED]. A Nursing Observation Record for the month of 10/18, identified Resident #7 yelled out on the 7:00 PM to 7:00 AM shifts, 23 times and was verbally inappropriate 22 times. It noted the resident was redirected, given food or a drink, or was provided a diversional activity. A document with no title dated for the month of 10/18, identified a column on the left side and was entitled Mood. There were multiple moods identified under this column. At the bottom of the document was ALL BEHAVIOR MUST BE EXPLAINED. Under the section, . Delusions (misconceptions or beliefs that are firmly held contrary to reality) . It was documented Resident #7 would yell out Peanut and believed her roommate was Peanut. It was noted the resident did this type of behavior 10 times during this month. Under the section . Physical behavioral symptoms directed toward others. it was documented Resident #7 would yell out Peanut. It was noted the resident did this type of behavior 10 times for the month of 10/18. Review of the Nurse's Notes for the month of 10/18. noted no behaviors exhibited by Resident #7. The MAR for 11/18, noted Resident #7 received [MEDICATION NAME] 50 mg at bedtime, daily for [MEDICAL CONDITION]. A Nursing Observation Record for 11/18, identified Resident #7 yelled out on the 7:00 PM to 7:00 AM shifts 25 times and was verbally inappropriate 24 times. It noted the resident was redirected or was given food or a drink. A document with no title dated for the month of 11/18, identified a column on the left side and was entitled Mood. There were multiple moods identified under this column. At the bottom of the document was ALL BEHAVIOR MUST BE EXPLAINED. Under the section, .Being short-tempered, easily annoyed . It was documented Resident #7 was upset at her roommate and was crying. It was noted the resident did this type of behavior 10 times during this month. Under the section Delusions . It was documented Resident #7 would yell out Peanut and believed her roommate was Peanut. It was noted the resident did this type of behavior 10 times. Under the section . Physical behavioral symptoms directed toward others. it was documented Resident #7 would yell out Peanut and would yell at her roommate to shut up. It was noted the resident did this type of behavior 10 times for the month of 11/18. Review of the Nurse's Notes for the month of 11/18, noted no behaviors exhibited by Resident #7. A physician's note dated 11/14/18, documented Resident #7 voiced no complaints on this date. The physician ordered to continue the use of the [MEDICATION NAME]. There was no mention if Resident #7 was delusional, hallucinated, or was a risk to self or to others. It was noted on a document entitled Encounter - Nursing Home Visit, Resident #7 was seen by the Mental Health Nurse Practitioner (MHNP) on 11/29/18. It was noted the resident was identified with depression, anxiety, and cognitive change. There was no evidence to show Resident #7 had any inappropriate behaviors, had delusions, hallucinated, or was identified as harmful to self or to others. There was no documented evidence to show the resident had past psychiatric history of [MEDICAL CONDITION] or Bi-polar disorder. On 12/06/18, the Nurse's Notes documented Resident #7 said . I'm coming to make you some biscuits . Resident #7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/11/18, identified Resident #7 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. Resident #7 did not exhibit any behavioral symptoms, such as hallucination or delusions or was a risk to self or to others. The MDS said the resident did have other behavioral symptoms that were not directed to others, and noted this type of behavior occurred four to six (6) days, but happened less than daily. The MDS assessment did not identify Resident #7 had a [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. The Social Service Progress Notes dated 12/11/18, showed Social Services met with Resident #7 for the quarterly assessment, and interviewed the resident for changes in her mood. It was at this time the resident voiced that she would be better off dead and . If I could get my hands on a gun I would blow my brains out and end my life. It was noted on a document entitled Encounter - Nursing Home Visit Resident #7 was seen by the MHNP on 12/11/18. It was noted the resident was identified with depression, anxiety, and cognitive change. The MHNP noted Resident #7 made a statement to harm herself and the MHNP was asked by staff to evaluate the resident. The MHNP noted the resident said she wanted to shoot herself, but did not have access to guns. The MHNP documented the resident voiced she was depressed about her condition and her roommate makes too much noise. The MHNP recommended an increase in the resident's antidepressant and recommended the antipsychotic [MEDICATION NAME] back to 100 mg at bedtime, daily. The MHNP documented the resident's depression needed to be addressed and monitored and said that her current suicidal plan was not viable since the resident did not have access to a gun. There was no evidence to show Resident #7 had any inappropriate behaviors, had delusions, hallucinated, or was identified as harmful to self or to others. There was no documented evidence to show the resident had a past psychiatric history of [MEDICAL CONDITION] or Bi-polar disorder. A physician's note dated 12/12/18, documented Resident #7 was seen by a psychiatric consult, and the MHNP had recommended to increase the [MEDICATION NAME] back to 100 mg at bedtime, daily. The physician wrote the resident experienced an increase in complaints of depression, suicidal thoughts and an increase in acting out and disruptive behavior. A physician's orders [REDACTED].#7 [MEDICATION NAME] 100 milligrams (mg) to increase the dose due to [DIAGNOSES REDACTED]. The date of the physician order [REDACTED]. The MAR for 12/18, noted Resident #7 received an increase of [MEDICATION NAME] 100 mg at bedtime, daily for [MEDICAL CONDITION]. A Nursing Observation Record for 12/18, identified Resident #7 yelled out on the 7:00 PM to 7:00 AM shifts 27 times and was verbally inappropriate 27 times. It noted the resident was redirected, given food or a drink, or was provided a diversional activity. A document with no title dated for the month of 12/18, identified a column on the left side and was entitled Mood. There were multiple moods identified under this column. At the bottom of the document was ALL BEHAVIOR MUST BE EXPLAINED. Under the section Delusions . It was documented Resident #7 would yell out Peanut and yelled out a family member's name. It was noted the resident did this type of behavior 12 times during the month of 12/18. Review of the Nurse's Notes for the month of 01/19, noted no behaviors exhibited by Resident #7. A Nursing Observation Record for 01/19, identified Resident #7 yelled out on the 7:00 PM to 7:00 AM shifts 30 times and was verbally inappropriate 30 times. It noted the resident was redirected, given food or a drink, or was provided a diversional activity. This was an increase in yelling and verbally inappropriate behavior from the previous month made by the resident. A document with no title dated for the month of 01/19, identified a column on the left side and was entitled Mood. There were multiple moods identified under this column. At the bottom of the document was ALL BEHAVIOR MUST BE EXPLAINED. The month was document as follows: little or no interest or pleasure in doing things, it was documented Resident #7 exhibited this behavior, on the day shifts, seven times; trouble falling or staying asleep, it was documented Resident #7 exhibited this behavior, on the day shifts, seven times; feeling tired or having little energy, it was documented Resident #7 exhibited this behavior, on the day shifts, seven times; trouble concentrating on things, it was documented Resident #7 exhibited this behavior, on the day shifts, seven times; being short tempered, easily annoyed, it was documented Resident #7 exhibited this behavior on the day shift three times and on the night shift two times. There were no details of Resident #7's behavior noted for this month. Review of the Nurse's Notes for the month of 01/19, noted no behaviors exhibited by Resident #7. The MAR for 01/19, noted Resident #7 received [MEDICATION NAME] 100 mg at bedtime, daily for [MEDICAL CONDITION]. The MHNP noted he saw Resident #7 on 01/11/19, and the chief complaint identified was Depression, Anxiety, and cognitive change. There was no evidence to show Resident #7 had any inappropriate behaviors, had delusions, hallucinated, or was identified as harmful to self or to others. There was no documented evidence to show the resident had a past psychiatric history of [MEDICAL CONDITION] or Bi-polar disorder. A physician's note dated 01/17/19, documented Resident #7 voiced no complaints on this date. There was no mention if Resident #7 was delusional, hallucinated, or was a risk to self or to others. The Consultant Pharmacist noted to the physician on 01/25/18, through a monthly medication review, . This resident is receiving the antipsychotic agent, [MEDICATION NAME], but lacks an allowable [DIAGNOSES REDACTED]. Because the atypical antipsychotic do not have an approved indication for Behavioral and Psychological Symptoms of Dementia, any use of these meds would be considered off-label and the potential benefits must outweigh the risks. (MONTH) wish to add/re-enforce [DIAGNOSES REDACTED]. On this review, the physician agreed with the Consultant Pharmacist and added the [DIAGNOSES REDACTED].#7's medical record. A document with no title dated for the month of 02/19, identified a column on the left side and was entitled Mood. There were multiple moods identified under this column. At the bottom of the document was ALL BEHAVIOR MUST BE EXPLAINED. There were no behaviors identified for this month. A physician's note dated 02/21/19, documented Resident #7 voiced no complaints on this date. There was no mention if Resident #7 was delusional, hallucinated, or was a risk to self or to others. An interview was conducted with Resident #7 on 03/06/19 at 9:06 AM. The resident said she did not have a history of mental health issues prior to her admission to the facility. She stated that she did not have [MEDICAL CONDITION]. On 03/06/19 at 10:05 AM, a Certified Nursing Assistant (CNA), CNA #40, was interviewed. CNA #40 said she has been employed at the facility for the past 2.5 years. The staff member said Resident #7 would see things occasionally, such as the resident's family member. She said the resident was very sweet. CNA #40 said she was not afraid of her and there were no other residents who were afraid of Resident #7. She said the resident will yell out occasionally and would state, Be quiet Peanut often referring this nickname to her family member. The staff member said the resident did not hit her or other staff or residents. She said if the resident had a behavior she would inform the nurse on duty. Another interview was conducted with CNA #80 at 10:31 AM. The staff member said she has not heard Resident #7 state that she wants to die or to take her own life. An interview was conducted with Licensed Practical Nurse (LPN) LPN #80 on 03/06/19 at 10:55 AM. LPN #80 said Resident #7 sees the resident at least one time per week to conduct a total body audit. LPN #80 said she was not afraid of the resident, the resident did not yell out constantly to be an annoyance, no other residents were afraid of her, and the resident has made no threats to harm herself to LPN #80. An interview was conducted on 03/06/19 at 1:09 PM, with Social Services (SS) SS #36. SS #36 said Resident #7 did make a comment one time about wanting to take her life and mental health was called in immediately after this comment was made. Per SS #36, the resident was determined not able to physically harm herself. A telephone interview was conducted with the Consultant Pharmacist (CP) on 03/06/19 at 2:48 PM. The CP said that she comes out to the facility on ce a month to review all residents' medications. The CP said she reviews the progress notes and will speak with nursing regarding behaviors of a resident. The CP said she did look for a [DIAGNOSES REDACTED]. The CP said indications for use of [MEDICATION NAME] was [MEDICAL CONDITION], Depression or [MEDICAL CONDITION]. She went onto say that if a resident was psychotic this could be a symptom of [MEDICAL CONDITION]. A telephone interview was conducted with the MHNP on 03/06/19 at 3:30 PM. The MHNP stated the indications for the use of [MEDICATION NAME] was for [MEDICAL CONDITION] or Bi-polar disorder. The MHNP said to use the term Psychotic or Dementia [MEDICAL CONDITION] was not specific enough. The Director of Nursing (DON) was interviewed on 03/07/19 at 6:55 AM. The DON said Resident #7 was Psychotic and said [MEDICATION NAME] was appropriate for the resident. The DON said the resident did yell but did not know the resident well enough to say if the resident yelled constantly. An interview was conducted with a night CNA #54 on 03/07/19 at 6:59 AM. CNA #54 said Resident #7 was not a threat to herself or to others and she had no behaviors and specifically stated she is a happy resident. The staff member said she was not afraid of the resident. The Medical Director (MD) was interviewed by telephone on 03/07/19 at 10:30 AM. The MD said he has known Resident #7 for [AGE] years. He said the resident was not at her normal baseline and the [MEDICAL CONDITION] was an associated psych feature and her hallucinations, were upsetting to her. He said that he was not using [MEDICATION NAME] off label. He confirmed the resident did not have a history of [MEDICAL CONDITION] or Bi-polar prior to her admission to the facility. Resident #46: Review of Physician Orders, dated (MONTH) 2019, revealed Resident #46 was ordered [MEDICATION NAME] 20 MG BID (twice a day) for PBA. The physician's orders [REDACTED]. Review of Resident #46's Face Sheet, revealed the facility admitted the resident on 08/01/17, with [DIAGNOSES REDACTED]. Review of Coastal Neurological Institute Progress Note, dated 03/21/18, revealed during a consultation visit, Resident #46 was diagnosed this date with PBA; however, there was no documented evidence to support the diagnosis. Observation, on 03/04/29 at 10:52 AM, revealed Resident #46 lying on the floor on a mat. Continued observation and attempted interview revealed no response from the resident. Further observation, on 03/04/19 at 1:56 PM, revealed resident sitting in his wheelchair watching television (TV.) Observation, on 03/05/19 at 8:51 AM, revealed Resident #46 in his room, sitting in his wheelchair, with the radio on. Observation, on 03/05/19 at 10:10 AM, revealed the resident in his room sitting in his wheelchair, with his eyes closed. Interview, on 03/06/19 at 1:52 PM, with the facility's Administrator in Training (AIT), revealed she took Resident #46 to his consultation appointment at (name of institution). Continued interview with the AIT revealed the resident was being seen by a Neurologist because of increased behaviors. Further interview revealed she presented the Neurologist that the resident would be calm one minute and then combative the next minute. The AIT stated the Neurologist reviewed the resident's medication regimen and made the recommendation for the medication of [MEDICATION NAME]. The AIT further stated she did not tell the Neurologist the resident had been laughing or crying uncontrollably and she assumed the resident was prescribed the [MEDICATION NAME] for his increased behaviors of verbal aggression, physical aggression, and other inappropriate behaviors. Interview, on 03/06/19 at 2:48 PM, with the facility's consulting pharmacist revealed the medication [MEDICATION NAME] was only used to treat PBA. Continued interview revealed she did not pick that medication up during the monthly medication regimen review (MRR) because the resident was seen by the Neurologist and the resident was diagnosed with [REDACTED]. Interview, on 03/07/19 at 9:07 AM, with Certified Nursing Assistant (CNA) #66, revealed she had been employed at the facility for one (1) year and being regularly assigned to Resident #46, she was familiar with him. Continued interview revealed she has witnessed Resident #46 acting out with physical aggression and verbal aggression; however, she has never witnessed him exhibit uncontrollable laughter or crying. Interview, on 03/07/19 at 9:21 AM, with CNA #55 revealed she had been employed at the facility for two (2) years and Resident #46 had calmed down a lot since he was admitted . The CNA stated since she had been employed by the facility, she has never seen or heard him laughing or crying uncontrollably. Interview, on 03/07/19 at 9:38 AM, with Licensed Practical Nurse (LPN) #82, revealed she had been employed at the facility for three (3)years. Continued interview revealed when Resident #46 was first admitted to the facility, his behaviors were really bad; however, the physicians have been able to regulate his medications and his behaviors are better and they are few and far in between now. When asked had she ever witnessed the resident laugh or cry uncontrollably, the LPN stated she had only seen the resident cry on occasion after his family had visited him. The LPN further stated, being a nurse and having experienced a patient with PBA, Resident #46 has not had the uncontrollable laughing and crying. Interview, on 03/07/19 at 10:18 AM, with the Director of Nursing (DON) revealed she believed Resident #46 was on the appropriate medication regimen because she has seen the resident go from one extreme to another. Continued interview revealed she did not think the resident could control the behaviors he did such as hitting and laughing inappropriately. Interview, on 03/07/19 at 10:27 AM, with the Administrator, revealed it was her expectation the facility would comply with regulations related to mediation and appropriate use of medications. The administrator stated it was important to ensure the proper needs of the resident were met.

Based on observation, interview, record and policy review, it was determined the facility failed to investigate an injury sustained by one (1) of 14 sampled residents, Resident #35. Failure to investigate and determine how the injury occurred puts the resident at risk for repeated and additional injuries. Findings include: Review of the facility policy titled Accidents and Incidents-Investigating and Reporting, revised (MONTH) (YEAR), revealed all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The policy also included a template for recording the incident, titled Report of Incident/Accident, and a template of a form titled, Accident, Incident, or Abuse Description by Witness, with a lined section for recording the name of the resident, date and time of the incident, the working shift, a description of the incident, and the name of the employee who would complete the form .incident/accident reports will be reviewed by the Safety Committee/interdisciplinary Team for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of Resident #35's clinical record on the Weekly Body Audit (flow sheet), dated 02/15/19 at 9:00 AM, revealed a licensed nurse discovered and assessed a skin tear on Resident #35's right upper arm and initiated the facility's standard protocol for treatment of [REDACTED]. Interviews with direct care staff revealed they thought the injury might have been the result of the resident's skin contact with a lift pad used when transferring the resident from his bed to a chair, but staff interviewed could not definitively identify the source of the injury. The facility's management staff did not review an incident report nor initiate an investigation of Resident #35's injury of unknown source, even though nurses documented treatment of [REDACTED]. Review of Resident #35's Face Sheet in the clinical record, revealed the facility admitted the resident on 08/10/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 9 on a scale of zero (0) to 15, on the Brief Interview for Mental Status (BIMS) assessment for cognition, indicating the resident could be interviewed. An attempt was made to ask Resident #35 about the bandaged area on his right arm, on 03/05/19 at 9:10 AM, the resident made eye contact with the surveyor, but did not provide an answer. Observation, on 03/05/19 at 9:19 AM, revealed Resident #35 was seated in a reclining chair near the nurses' station. The resident was wearing geriatric (Geri) sleeves on both arms which covered the resident's arms up to his elbows. The resident had a white bandage on his right arm above his elbow. Interview, on 03/05/19 at 9:30 AM, with Licensed Practical Nurse (LPN) #80, revealed she knew Resident #35 received a skin treatment to the site on his right upper arm, but she was not sure how he obtained the injury. She reviewed the nurses' progress notes within the resident's chart, but she did not find documentation that explained what happened. She said the Director of Nursing (DON) should have an incident report. Review of the Treatment Administration Record (TAR) for the month of (MONTH) 2019 and (MONTH) 2019, revealed a treatment to the resident's right upper arm was initiated on 02/15/19, and was to be administered on each shift at 7:00 AM and again at 7:00 PM. The treatment orders were changed on 02/21/19, and all treatment to the area at the right arm was discontinued on 03/05/19. Interview on 03/05/19 at 10:00 AM, with the DON, revealed she could not find any documentation that explained the reason for the injury in the nurses' progress notes, but that she should have an incident report on file that documented the injury on Resident #35's right upper arm. Continued interview, on 03/05/19 at 10:30 AM with the DON, revealed she could not locate an incident report for Resident #35's right upper arm injury. The DON said LPN #83 was on duty that day, and she would contact her to find out what happened to Resident #35's right upper arm. Review of a brief type written note, dated 03/05/19, provided to the surveyor, revealed the DON spoke with LPN #83. Further review of the note revealed LPN #83 was called to Resident #35's room on 02/15/19, by Certified Nursing Assistant (CNA) #60, because the resident had blood on his shirt sleeve. In the note the DON provided to the surveyor, the LPN described the injury on the resident's right upper arm as an abrasion. The note revealed that LPN #83 and CNA #60 agreed the lift's sling caused the injury when the resident was transferred from his bed to the Geri-chair. The note also indicated LPN #83 educated both CNAs by telling them to be sure the sling was not squeezing the resident's arm. Observation, on 03/05/19 at 2:15 PM, revealed Resident 35 was in bed in his room, but the bandage was no longer on the resident's right arm. The DON lifted the resident's right arm for the surveyor to view the site where the bandage had been earlier in the day. The area was light pink in color and there was not an open wound. She said the incident likely occurred early in the morning of 02/15/19, when the resident was transferred to the Geri-chair in preparation for a breakfast meal, because LPN #83 told her she observed dried blood on the resident's shirt when she first assessed the wound. Again, the DON confirmed LPN #83 did not complete an incident report. Continued interview, on 03/05/19 at 2:25 PM, with the DON, revealed the facility would normally complete an incident report for the type of injury Resident #35 had. She said if it had been an abrasion, the facility did not expect the staff to complete an incident report. She said LPN #83 described the area as only an abrasion. The DON said she thought that may have been why the nurse did not complete an incident report. However, she said on 02/15/19, LPN #83 initiated the treatment protocol the facility typically used to treat a skin tear. She said the treatment protocol was not in writing, so she could not provide it to the surveyor, but that the steps in the treatment were listed on Resident #35's Treatment Administration Record (TAR). Interview on 03/06/19 at 9:45 AM, with CNA #53, revealed she was not exactly sure of the date, but she observed a skin tear on Resident #35's right upper arm. She said she and CNA #60 reported it to LPN #83. She said she thought the lift pad may have caused the injury, but not when she assisted with the resident's transfer, because the blood on his shirt was not fresh but was older looking, dried blood. She said the injury could have occurred on the night shift (early morning) when staff transferred the resident from his bed to a chair for breakfast. Interview, on 03/06/19 at 10:00 AM, with CNA #60 revealed just after breakfast on 02/15/19, she and CNA #53 were transporting Resident #35 to his room to change his brief when she noticed dried blood on his right shirt sleeve. She said the injury looked like an area that could have been caused by the lift pad while staff transferred the resident from bed to chair. She said this was her best guess, but she did not know exactly how the resident's injury happened. She said she did not observe any blood on the lift pad used to transfer the resident from the chair to his bed. Interview on 03/06/19 at 10:15 AM, with LPN #83, revealed she was the treatment nurse on duty when CNA #53 and CNA #60 called her to Resident #35's room as they were putting the resident back to bed. The LPN said she observed the resident's right upper arm and saw blood on his sleeve. She further described the skin at the area as rolled back and hard, so not movable. The LPN said the resident had very fragile skin and the injury could have been caused by the lift pad used for transferring the resident, but she added this was only a guess on her part, and she didn't know for certain how the injury occurred. She said she did not complete an incident report because she thought the injury looked like an abrasion, but she also stated there was a moderate amount of blood on the resident's shirt sleeve. She said she was not sure if the resident was wearing his Geri-sleeves when she assessed him. The LPN said she did not notify the resident's physician, but if she had completed an incident report, she would have notified the doctor. She said she initiated treatment to the injury, per the facility's skin tear protocol. Interview, on 03/07/19 at 7:37 AM, with the DON, revealed if an incident report had been completed, it would have been reviewed at the next staff stand up meeting. Therefore, all staff who attended the meeting would have been aware of the injury. She said upon review of the incident report, the administrative staff would have determined if the facility needed to initiate an investigation of the incident/injury. The DON said, for Resident #35's case, LPN #83 should have completed an incident report for the Interdisciplinary Team (IDT) to review. She said in addition to that review, the facility's medical records personnel would have reviewed the incident report to ensure policies and procedures were followed, that the MD was notified, and that the episode was correctly documented. Interview, on 03/07/19 at 8:15 AM, with the Administrator, revealed it was not the facility's practice to complete an incident report for an abrasion, and it was her understanding the nurse identified Resident #35's injury as an abrasion. She said if the nurse assessed the skin as being rolled back and hard, she would consider that a skin tear, and an incident report should have been completed. The Administrator said it was important for the facility to determine the source of an injury so that care could be provided in a safe and proper manner. She said completion of an incident report was the first step in a process that would have provided the administrative staff the opportunity to investigate the situation and implement any necessary changes in the resident's care.

Based on observation, staff interviews, policy and record review, it was determined that the facility failed to ensure that pain management was provided to one (1) resident reviewed for pain management out of 14 sampled residents, Resident #18, who required pain management services. Findings include: Review of the Pain Assessment and Management Policy, 2001 Med-Pass, Inc. (Revised (MONTH) (YEAR)) the resident is to be assessed at least each shift for acute pain or significant changes in levels of pain. Pain management is defined in the policy as the process of alleviating the resident's pain to a level that is acceptable to the resident based on the resident's clinical condition and established treatment goals. The policy documented that a pain assessment tool, as indicated by facility protocol, will be necessary when performing pain assessment. The policy identifies behavioral signs of pain such as verbal expressions such as groaning, crying, and screaming as well as facial expressions that can indicate pain as well as physiological signs. Per policy, pain is to be assessed using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive status. The nurse is to document the resident's level of pain. The Wong-Baker scale is available for use on the Pain Flow Sheet. Per interview of the Registered Nurse (RN) Supervisor and the Quality Assurance and Performance Improvement QAPI) RN Nurse on 03/05/19 at 10:15 AM, the Pain Flow Sheet is only for documenting pain scores if the resident receives an as needed prn medication. A discussion of the facility policy with the RN Supervisor and the QAPI RN and the failure to follow the Pain Assessment and Management Policy, which instructs staff to use a standardized pain assessment tool to ensure a consistent approach in assessment of pain. Per the facility policy, the use of a standardized pain assessment instrument appropriate to the resident's cognitive status is to be used and the facility failed to follow the policy and do not use the standardized tool. Per policy, the resident is to be assessed at least each shift for acute pain or significant changes in levels of pain. Review of the Physician orders [REDACTED].#18 was placed on Hospice 05/26/17, for extensive pain management. The Resident's responsiveness to verbal and tactile stimuli varied making it difficult to assess pain levels. Resident #18's annual History and Physical dated 12/12/18, indicates that the resident has the following Diagnoses: [REDACTED]. The physician's annual History and Physical dated 12/12/18, states that the resident's acute problem was persistent pain and the [MEDICATION NAME] dosage was increased from 75 milligrams (mg) to 100 mg. On 01/17/19, the physician's progress note indicated that the resident has chronic intractable pain and does open eyes to verbal and tactile stimuli and mumbles incoherently. Aggressive palliative terminal comfort care is needed with narcotic [MEDICATION NAME]. On 02/21/19, physician notes documented resident has chronic intractable pain adequately controlled at this time. The resident has an order dated 06/15/17, for [MEDICATION NAME] 20 milligram/milliliter, give one (1) milliliter sublingual every one (1) hour as needed for pain or shortness of breath. There was no documentation that the as needed pain medication was given. According to the RN Supervisor and QAPI RN, interviewed on 03/05/19 at 10:15 AM, the Pain Flow Sheet is only for documenting pain scores if the resident receives an as needed prn medication. Pain is assessed each shift and placed in the nurse's notes. Review of the nurses notes from (MONTH) 2019 to (MONTH) 5, 2019, reflect notations that the resident has no signs or symptoms of pain, no shortness of breath, and the resident's level of alertness as appropriate but there is no pain score obtained from the use of a standardized pain scale documented. The DON verified the Wong-Baker scale is available for use on the Pain Flow Sheet but the nurses just document and do not use the standardized pain assessment tool. The Hospice document, Updated Plan of Care Comprehensive Assessment and Plan of Care dated 02/20/19, does not contain documentation related to pain scores. The resident's facility and Hospice plan of care related to pain relief does not identify an acceptable level of pain or any non-pharmacological or pharmacological interventions that should be used for various levels of pain.

Based on observation, policy, and staff interviews, the facility failed to ensure that multi-dose medication vials were labeled in accordance with currently accepted professional principles indicating when a multi- dose vial is first opened and needs to be discarded for four (4) medication vials on the medication cart for Hallway C and D; one (1) of two (2) medication carts. Findings include: The Administering Medications policy statement dated 2001, Med Pass, Inc. (Revised (MONTH) 2012) documented: The expiration/ beyond use date on the medication must be checked prior to administering. When opening a multi-dose vial, the date opened shall be recorded on the vial. On 03/5/19 at 02:29 PM, the medication cart for Hallway C and D was inspected with Licensed Practical Nurse (LPN) #78, the Director of Nursing (DON) and the Quality Assurance and Performance Improvement Registered Nurse (QAPI RN). A vial of [MEDICATION NAME] HCL was not sealed and the rubber top appeared to have been accessed by a needle. The notation 10/29 and unreadable initials appeared on the bottom of the vial which had an expiration date of 08/01/19. LPN #78 stated that she thinks the date on bottom of the vial is when it was open but is not sure. When asked how long an open vial of medication can be kept, LPN #78 stated that she is new and unsure. A vial [MEDICATION NAME] mg 2 ml/vial for Resident #9 was open and the date first accessed was not identified. Expiration date of 12/19, was indicated. The DON verified the vial was not dated when opened. Observation of an open multi-dose vial of [MEDICATION NAME] for Resident #33 was not dated as to when it was opened. The DON verified no date when the vial was accessed. A vial of insulin was found in the medication cart for Hallway C and D, open, with the date it was open not identified. The QAPI RN verified that the vial should have been dated as to when it was opened. The QAPI RN and the DON verified that multi-dose vials are to be discarded in 28 days after opening and if not dated they would be unable to determine when 28 days had passed.

Based on observation, policy review and staff interviews, the facility failed to ensure that resident care equipment shared among residents in Point- of-care testing (blood glucose monitoring) were properly cleaned/disinfected after each use according to manufacturer's instructions for multi-patient use for one (1) of 14 sampled residents, Resident #1. This deficient practice had the potential to affect any resident with diabetes (undetermined number present) who require point-of-care blood glucose monitoring. Findings include: The Blood Sampling-Capillary (Finger Sticks) policy provided by the DON from the Nursing Services Policy and Procedure Manual, 2001 Med-Pass Inc, revised (MONTH) 2012 indicates that an EPA registered disinfectant for cleaning of the sampling device should be used to clean and disinfect the device following manufacturer's directions. Survey tag referenced is F 441 and the CDC Clinical Reminder-Use of Fingerstick Devices on One or More Person Poses Risk for Transmitting Bloodborne Pathogens (undated reference). CDC guidelines recommend that whenever possible glucometers should not be shared among residents in Long Term Care settings but if necessary EPA approved disinfectants need to be used according to the manufacturer's directions. Observation on 03/06/19 at 12:15 PM, revealed Licensed Practical Nurse #(LPN) 84, who was the medication nurse for Hallway C and D, prepared to obtain a blood glucose level on Resident #1. She retrieved the glucometer from the medication cart drawer where it is stored along with other medication administration articles. She stated that the facility has two (2) glucometers (one for each hallway) that are stored in the medication carts and used for all residents requiring blood glucose monitoring. LPN #84 described the process while cleaning the glucometer as the following: PDI Super Sani-Cloth Disinfecting and Sanitizing Germicidal disposable wipes (purple top) are used to wipe all areas of the glucometer vigorously for 15-20 seconds. After cleansing, the glucometer was placed on a clean paper towel used as a barrier and taken into Resident #1's room. After she obtained the blood sugar reading and administered the correct dosage of Insulin, LPN #84 returned the glucometer to the medication cart and began to clean it with the PDI Super Sani-Cloth Disinfecting and Sanitizing Germicidal wipes wiping it thoroughly for 10-15 seconds then placed the glucometer in the drawer where it is stored. When asked if she knew the term wet contact time, she stated she had heard of it and explained that it was the time that the glucometer should dry. She was not able to state that the wet contact time for the Super Sani-Cloth Germicidal wipes to be effective nor was she aware that wet contact time referred to the amount of time that the surface one was cleaning, and disinfecting, needed to remain wet with the cleaning agent. LPN #84 was shown the large emblem on the front of the container that indicates that Super Sani-Cloth Germicidal wipe disinfects and is an effective bactericidal, tuberculocidal, and viricidal with a wet contact of two (2) minutes. Directions for use listed on the container states the following: To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two minutes. Let air dry. LPN #84 stated that she was not aware that the glucometer must remain thoroughly wet for two (2) full minutes then allowed to air dry before using it with another resident. At 12:45 PM on 03/06/19, interview of LPN #82, who is the medication nurse for Hallway A and B, was asked to describe the process she uses to clean the glucometer before and after resident use. She stated that she uses a Super Sani -Cloth Wipe to wipe the glucometer for 10-15 seconds. LPN #82 was unaware of the wet contact time of two (2) minutes and that the glucometer needed to remain thoroughly wet for two (2) full minutes and allowed to air dry. At 3:00 PM on 03/06/19, the Director of Nurses (DON) provided a copy as requested on the PDI Super Sani-Wipe directions which indicates a two (2) minute wet contact time. On 03/07/19 at 9:15 AM, the DON provided technical information on the PDI Disinfecting Cleaning Wipes (wrong product) pointing out that the cleansing wipes have a one (1) to two (2) minute wet contact time. The primary chemical in these wipes is alcohol and they are listed as having no efficacy as indicated on the technical specifications. These wipes are not the product used on the facility glucometers.

Based on record review, facility policy review, and staff interview, the facility failed to correctly code the Minimum Data Set (MDS) for a significant weight loss for one (1) of 14 resident records reviewed (Resident #2). Findings include: A review of the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, dated October 2016, noted that if a resident had experienced a weight loss of five (5) percent (%) or more in the last thirty (30) days of the Assessment Reference Date (ARD), and the weight loss was not planned or prescribed by the physician, the MDS should be coded as a loss under Section K of the MDS. Resident #2 Review of the MDS for Resident #2, with an ARD of 04/23/2017, revealed the MDS was coded with a zero (0), indicating that there was no weight loss of five (5) percent (%) or more in the last thirty (30) days. The DM completed and signed Section K of the MDS on 04/25/2017, indicating accuracy. Review of the Weight Flow Sheet for Resident #2, dated 2017, it was revealed that Resident #2's weight on 04/03/2017 was documented as 125 pounds. On 04/18/2017 and 04/26/2017, the Weight Flow Sheet revealed Resident #2 had a documented weight of 106 pounds. Review of the Nutrition Risk Evaluation Screening Progress Note, signed by the Dietary Manager (DM), on 04/05/2017, with observation dates of 03/30/2017 through 04/05/2017, revealed the documented weight for Resident #2 was 125 pounds. On a subsequent review of the Nutrition Risk Evaluation Screening Progress Note signed by the DM, on 04/23/2017, with observation dates of 04/17/2017 through 04/23/2017, Resident #2 had a documented weight of 106 pounds. During an interview on 05/10/2017 at 3:10 PM, Licensed Practical Nurse (LPN) #1 /MDS Coordinator, confirmed that the MDS with an ARD of 04/23/17, should have been coded with a weight loss of more than five (5)%. LPN #1 stated that according to the Resident's weight record for the seven-day look back period, for the MDS with the ARD of 04/23/2017, Resident #2 had lost 19 pounds in a period of 21 days. LPN #1 stated, I can do a Significant Correction MDS and resubmit it. LPN #1 also stated that the DM was responsible for completing the K section of every MDS and developing the area of the care plan related to weight, nutrition and diet concerns. During an interview on 05/10/2017 at 3:15 PM, the Dietary Manager (DM), confirmed that she was responsible for the coding of the K section of the MDS with an ARD of 04/23/17, where it indicated that Resident #2 had no weight loss. The DM stated that Resident #2 had a documented weight of 125 pounds on 04/03/2017. The DM also stated that Resident #2 had a documented weight of 106 pounds on 04/23/2017. The DM confirmed Resident #2 had a weight loss of 19 pounds in 21 days. The DM also confirmed that she documented Resident #2 had no weight loss in Section K of the MDS with the ARD of 04/23/2017. The DM stated that she signed the MDS on 04/25/2017, verifying she understood it to be correct. The DM revealed that she documented each resident's weight in their charts on their individual weight record. The DM confirmed that she was a member of the facility's weight team that weighs all the residents monthly and also the weekly and daily weights when ordered. During an interview on 05/10/2017 at 3:15 PM, the Director of Nursing (DON), confirmed Resident #2 had a 19 pound weight loss in 21 days on 04/23/2017. The DON confirmed that the MDS with the ARD of 04/23/2017, should have indicated a weight loss in section K. A review of the face sheet revealed the facility admitted Resident #2 on 02/01/2017, and readmitted Resident #2 on 02/06/2017, with [DIAGNOSES REDACTED]. A review of the MDS with an ARD of 04/23/2017, revealed the Resident's Brief Interview for Mental Status (BIMS) score was 6, which indicated severely impaired cognition.

Based on record review, facility policy review and staff interview, the facility failed to develop a comprehensive care plan for a significant weight loss for one (1) of 12 resident care plans reviewed, Resident #2. Findings include: Review of the facility's Care Plans - Comprehensive policy, not dated, revealed that the comprehensive care plan is based on a thorough assessment that includes the Minimum Data Set (MDS). The review also revealed that care plans are revised as information about the resident and the resident's condition changes. Review of the facility's Weight Assessment and Intervention policy, dated December 2008, revealed that care planning for weight loss will be individualized and shall address the causes of weight loss, goals, benchmarks for improvement, and time frames and parameters for monitoring and reassessment. Resident #2: Review of Resident #2's current comprehensive Care Plan, revealed there was no documentation of a significant weight loss of five (5) percent (%) or more in the last 30 days for the MDS with an ARD of 04/23/2017. During an interview on 05/10/2017 at 3:10 PM, Licensed Practical Nurse (LPN) #1/ MDS Coordinator, revealed that Resident #2's MDS with an ARD of 04/23/2017, should have been coded for a significant weight loss. LPN#1 stated that according to the Resident's weight record for the seven (7)-day look back period, Resident #2 had lost 19 pounds over a period of 21 days. LPN #1 also stated that the Dietary (DM) was responsible for completing the K section of the MDS and developing the care plan related to the weight and nutritional concerns. LPN #1 stated that the care plan team reviewed the Care Plan with each MDS assessment. During an interview on 05/10/2017 at 3:15 PM, the Dietary Manager (DM), confirmed that she was responsible for coding the K sections on every MDS. The DM confirmed she had coded the MDS with the ARD of 04/23/2017 for Resident #2, with no weight loss. The DM revealed that she documented on the Nutrition Risk Evaluation Screening Progress Note a weight of 125 pounds and a weight of 106 pounds for the look back period of 4/17/2017 through 04/23/2017. The DM confirmed that she was responsible for the portion of the care plan that addressed any weight concerns and that a care plan should have been developed to address the actual weight loss status for Resident #2. During an interview on 05/10/2017 at 3:10 PM, the Director of Nursing (DON), confirmed that Resident #2 had a 19 pound weight loss in 21 days from 04/03/2017 through 04/23/2017. The DON confirmed that a weight loss care plan should have been added to Resident #2's current care plan. A review of the face sheet revealed the facility admitted Resident #2 on 02/01/2017, and readmitted her on 02/06/2017, with [DIAGNOSES REDACTED]. A review of the MDS with an ARD of 04/23/2017, revealed the Resident's Brief Interview for Mental Status (BIMS) score was 6, which indicated severely impaired cognition.

Based on record review, facility policy review and staff interview, the facility failed to follow the Resident's Care Plan for one (1) of 12 resident care plans reviewed, Resident #2, as evidenced by not obtaining weekly weights as care planned. Findings Include: Review of the facility policy titled, Care Plan - Comprehensive, not dated, revealed that the care plan aids in preventing or reducing declines in the resident's functional status and/or functional levels, and to incorporate risk factors associated with identified problems. Resident #2 Review of the current Care Plan for Resident #2, with an onset date of 02/06/2017, revealed the need for a therapeutic, mechanical soft diet to meet the estimated nutritional requirements without Significant Weight Loss or a Significant Weight Gain with a goal date of 07/15/2017. The Approaches for the problem and goal included obtaining weekly weights. Review of the Weight Flow Record for Resident #2, dated 2017, revealed that the resident had only been weighed two (2) times in March 2017, and only three (3) times in April 2017. During an interview on 05/10/2017 at 3:10 PM, the Director of Nursing (DON) confirmed that one (1) of the care plan approaches was that Resident #2 would be weighed weekly related to Resident # 2's need for a therapeutic and mechanical soft diet. The DON confirmed that the Weight Flow Record for Resident #2 reflected that only two (2) weights were recorded in March 2017 and only three (3) weights were recorded in April 2017. The DON also confirmed that the weekly weights approach for the care plan had not been followed according to the documentation on the Weight Flow Record in Resident #2's medical record. A review of the face sheet revealed the facility admitted Resident #2 on 02/01/2017, and readmitted her on 02/06/2017, with [DIAGNOSES REDACTED]. A review of the Five (5) Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/2017, revealed the Resident's Brief Interview for Mental Status (BIMS) score was 6, which indicated severely impaired cognition.

Based on record review, staff interview, facility policy review, and review of the U.S. Food and Drug Administration Guidelines for prescribing Ambien, the facility failed to attempt a gradual dose reduction of Ambien, a Hypnotic medication for [MEDICAL CONDITION], for one (1) of 13 residents reviewed with the potential for resident harm, Resident #6. Findings Include: Review of the facility's policy entitled "Tapering Medications and Gradual Drug Dose Reduction" dated March 2015 revealed the staff and practitioner will seek an appropriate dose and duration for medications that also minimizes the risk of adverse consequences. This policy also stated after the first year the facility will attempt a gradual dose reduction at least annually unless contraindicated. Review of the guidelines for [MEDICATION NAME] the U.S. Food and Drug Administration [MEDICATION NAME] indicated for the short-term treatment of [REDACTED]. Review of Resident #6's physician's orders [REDACTED].) by mouth every bedtime as needed for [MEDICAL CONDITION]; resident must wear continuous positive airway pressure device ([MEDICAL CONDITION]) if taking Ambien. Review of Resident #6's Note to Attending Physician/Prescriber revealed on 08/18/14 the Consultant Pharmacist suggested [MEDICATION NAME] five (5)mg at bedtime as needed for sleep. Review of Resident #6's Consultant Pharmacist's Medication Regimen Review revealed the Consultant Pharmacist stated on 03/09/[MEDICATION NAME] was given every night but one (1) night in February. The Consultant Pharmacist recommended [MEDICATION NAME] if needed every night. On 04/01/15 at 4:30 PM, an interview with the Medical Director stated due to Resident #6's history of drug abuse, pain killers and narcotics,[MEDICATION NAME] the least problematic drug. The Medical Director stated we just knew Resident #6 would not tolerate or agree to any dose reduction. The Medical Director validated a dose reduction [MEDICATION NAME] not attempted. On 04/02/15 at 10:10 AM, an interview with the Director of Nursing (DON) stated Resident #6 was readmitted from the hospital on [DATE] with a physician's orders [REDACTED]. The DON stated Resident #6 had been taking this same dose since 04/18/14. On 04/02/15 at 11:15 AM, an interview with the Consultant Pharmacist stated he recommended [MEDICATION NAME] reduced to 5mg based on the fact that the [MEDICATION NAME] for geriatric females is 5mg. The Consultant Pharmacist stated all that is needed for a dose reduction is a trial, and if the resident doesn't tolerate the reduction, document the reason or results and place back on the prior dose. The Consultant Pharmacist stated effects of a dose reduction should be seen within two (2) weeks. Review of Resident #6's physician's orders [REDACTED]. Review of Resident #6's Face Sheet revealed the facility admitted her on 1/09/12, and readmitted her on 4/18/14. Resident #6's Face Sheet and physician's orders [REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date of 02/10/15 revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 15 indicating Resident #6 had no cognitive impairment. Further review of the MDS revealed an Active [DIAGNOSES REDACTED].