Every finding on record at Heartway at Henryetta Health and Rehab

Based on observation and interview, the facility failed to maintain sanitary conditions in the laundry area for one of one observation. The administrator identified 36 residents resided in the facility. Findings: On 05/07/25 at 1:02 p.m., a large 55 gallon laundry barrel full of soiled laundry was observed uncovered, sitting outside of the laundry room door on the sidewalk. There were flies observed swarming the barrel. On 05/07/25 at 1:10 p.m., the laundry supervisor stated they did not know why the laundry barrel was uncovered, but it should not be. On 05/07/25 at 1:20 p.m., the infection preventionist stated they had been to the laundry and did not like the way the dirty laundry had to sit out on the sidewalk. They stated laundry was washed in an outside building then brought into the facility to be sorted and dispersed. They stated the laundry barrels should be covered.

Based on record review, observation, and interview, the facility failed to develop and implement comprehensive care plans to address resident care needs for two (#12 and #13) of 22 residents whose care plans were reviewed. The facility failed to develop a care plan: a. to help prevent the recurrence of falls for Res #12. b. related to Res #13's psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident Census and Conditions of Residents form documented 27 residents resided in the facility. Findings: 1. Res #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 08/22/22, documented Res #13 was moderately impaired in cognition, was independent or required supervision with ADLs, had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, with a review completion date of 08/29/22, was reviewed and did not reveal a plan of care related to Res #13's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 09/02/22, documented the facility was to administer [MEDICATION(S)] (an antipsychotic medication) 1.5 mg one time daily for prophylaxis related to [CONDITION(S)]. On 10/28/22 at 7:48 a.m., Res #13 was observed moving to the smoking area in his wheelchair. On 10/28/22 at 12:33 p.m., the DON reviewed Res #13's plan of care and confirmed a plan related to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Res #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 06/01/22, documented Res #12 was moderately impaired in cognition, required limited assistance with transfer and bed mobility, did not ambulate, and had bilateral lower extremity ROM impairment. An incident report, dated 06/29/22, documented Res #12 was in the north hallway in a wheelchair having [CONDITION(S)] like symptoms and fell resulting in a skin tear to the left hand and swelling to the right side of their face. Res #12 was sent to the ER for evaluation and treatment. A nurse note, dated 06/29/22, documented Res #12 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A care plan for Res #12 was reviewed and did not document a plan of care for falls. On 10/25/22 at 1:00 p.m., Res #12 was observed lying in bed with their legs supported by pillows. The resident was able to move their upper arms upon request but denied being able to move lower legs. The resident reported having been bed bound and relied on staff for transfers into and out of their bed. On 10/27/22 at 9:03 a.m., the DON was asked for documentation of falls on Res #12's care plan. She reported the care plan used to have an actual fall care plan but it had been resolved and removed on 10/13/22. The DON stated she did not know falls had to remain in a resident's plan of care and be revised with new interventions after each fall.

Based on record review, observation, and interview, the facility failed to assess and monitor a resident while providing a respiratory treatment for one (#12) of one resident who was observed to have received a respiratory treatment during medication administration. The Resident and Census and Conditions of Residents documented eight residents received respiratory treatments. Findings: Res #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A policy titled Specific Medication Administration Procedure, effective date July 2015, in reference to administration of medications through a handheld nebulizer read in parts, .obtain baseline pulse, respiratory rate and lung sounds .remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer .approximately five minutes after the treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse .monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment .obtain post-treatment pulse, respiratory rate and lung sounds and document findings on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, dated 02/04/21, documented to give aerosol or bronchodilators as ordered and monitor/document any side effects and effectiveness. A physician order, dated 09/23/22, documented to administer budesonide suspension 0.5 MG/2 ML inhaled orally two times a day related to [CONDITION(S)] with acute exacerbation. A significant change assessment, dated 10/17/22, documented the resident was moderately impaired in cognition and totally dependent with most ADLs. On 10/27/22 at 8:30 a.m., LPN #1 was observed to administer a budesonide respiratory treatment to Res #12. LPN #1 was observed to not assess the resident's pulse, respiratory rate, or lungs sound prior to, during, or after the treatment. LPN #1 did not remain with the resident during the respiratory treatment. On 10/27/22 at 1:48 p.m., LPN #1 was asked if she obtained and documented pulse, respiratory rate, and lung sounds prior to, during, or after respiratory treatments and remained in the room with residents during administration. She stated she had never remained in the room to monitor residents during respiratory treatments and was not aware of the policy which required obtaining vital signs prior to, during, and after treatments. On 10/27/22 at 2:00 p.m., the administrator stated Res #12 was not capable of self administration of respiratory treatments and the LPN should have remained in the room and performed all steps according to the policy.

Based on record review and interview the facility failed to submit accurate data regarding direct care staffing information to CMS. The Resident Census and Conditions of Residents form documented 27 residents resided in the facility. Findings: A PBJ report for the third quarter of 2022 documented the facility failed to have adequate licensed nursing staff 24 hours a day for the following days: 04/03/22, 04/16/22, 04/17/22, 04/24/22, 04/28/22, 04/30/22, 05/08/22, 05/19/22, 05/22/22, 05/28/22, 05/29/22, 06/12/22, 06/24/22, 06/25/22, and 06/29/22. On 10/31/22 at 1:15 p.m., the assistant administrator provided documentation of coverage by licensed nurses on the dates in question. On 10/31/22 at 1:16 p.m., the administrator and assistant administrator stated they have a real problem with correctly coding the PBJ which they were unaware of until this survey.

Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of disease. The facility failed to: a. use universal source control (masking) when the county transmission level was high and failed to provide signage on the entry door instructing visitors on when and how infection control measures were to be utilized while in the facility. b. ensure infection control measures were maintained during medication pass and with respiratory treatments. The Resident Census and Conditions of Residents form documented 27 residents resided in the facility. Findings: 1. A facility policy titled COVID-19 Source Control Policy, dated 07/19/21, read in part, .A minimum of a surgical mask worn appropriately at all times within the building and while in a vehicle with residents and/or employees is the requirement of the facility and is mandated to all staff . On 10/25/22 at 10:15 a.m., the facility was entered for a recertification survey. The external entry was observed and revealed no documentation describing what type of infection control measures were required in the facility by visitors or staff. On entry to the facility multiple staff members were observed throughout the facility unmasked, carrying out their duties, and interacting with unmasked residents. At that time, the assistant administrator, who was also unmasked, stated the facility stopped requiring staff, visitors, and residents, to wear masks the previous week. On 10/25/22 at 1:13 p.m., the IP was asked about the facility decision to forgo wearing masks. The IP stated it was because the County Positivity Rate was low. She was asked if the decision was based on the COVID-19 Community Level or the Transmission Level. She consulted the CDC website and stated the community level was low but the transmission level was high. She stated she unaware she was using the wrong data. 2. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/28/22 at 8:30 a.m., during an observation of a medication pass, CMA #1 was observed to press a tablet of calcium from a blister pack and the tablet was observed to fall on the paper which was used for documentation of vital signs. The CMA was observed to use the paper to funnel the tablet back into a medication cup and administer it to the resident along with other routine medications. On completion of the med pass she stated she should have disposed of it but in her mind at the time she felt if it fell on the paper it was still sanitary. She stated when she thought about it she should have disposed of it. On 10/28/22 at 8:54 a.m., the DON stated if a medication had been dropped it should have been disposed of and the CMA should have started the pass over. 3. A policy titled Specific Medication Administration Procedure, effective date July 2015, in reference to administration of medications through a handheld nebulizer read in parts, .rinse and disinfect the nebulizer equipment according to manufacturer's recommendations, or 1. wash pieces (except tubing) with warm, soapy water daily. Rinse with hot water. Allow to air dry completely on paper towel. 2. Once a week disinfect equipment by using a Microsteam bag in the microwave for time recommended on bag, or soaking for five minutes in 70% isopropyl alcohol and then rinse with sterile water .when equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Res #12 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order, dated 09/23/22, documented to administer budesonide suspension 0.5 MG/2 ML inhaled orally two times a day related to [CONDITION(S)] with acute exacerbation. A significant change assessment, dated 10/17/22, documented the resident was moderately impaired in cognition and totally dependent with most ADLs. On 10/27/22 at 8:30 a.m., LPN #1 was observed to administer a budesonide respiratory treatment to Res #12. The nebulizer mask was observed not to have been stored in a plastic bag and was sitting face side down on Res #12's bedside table. LPN #1 did not cleanse the mask prior to adding medication to the nebulizer container or placement on the resident's face. On 10/27/22 at 8:35 a.m., LPN #1 was asked if nebulizer equipment was kept in a bag in between respiratory treatments for infection control prevention. She stated the equipment was not routinely placed in a bag with the resident's name and date but draped over the nebulizer compressor between use. LPN #1 stated she had not realized this practice was an infection control risk and was not aware of the facility's nebulizer policy. On 10/27/22 at 2:00 p.m., the administrator stated LPN #1 did not follow the policy but should have.

Based on record review and interview, the facility failed to ensure nursing home staff members with a COVID-19 vaccine religious exemption and/or staff who were not up to date with the COVID-19 vaccinations were tested for COVID-19 based on the county transmission level and guidance from OSDH and CMS. The IP identified one unvaccinated staff member with a religious exemption and 21 staff members who were not up to date on their COVID-19 vaccination who worked in the facility during April, May, and June of 2022. Findings: A Covid-19 Vaccine Mandate Policy for Religious Exemption Consideration policy, revised 01/13/21, documented unvaccinated staff will be subject to COVID-19 testing as required by the OSDH and CMS. A CMS memorandum titled QSO-20-38-NH, revised 03/10/22, read in parts, .Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community .The facility should test all staff, who are not up-to-date, at the frequency prescribed in the routine testing table based on the level of community transmission reported in the past week .routine testing table intervals documented the following: moderate (yellow) once a week, substantial (orange) twice a week, and high (red) twice a week . On 10/31/22 at 12:00 p.m., the IP was asked if the unvaccinated staff member had been tested for COVID-19 as required by OSDH and CMS guidelines during the months of April, May, and June 2022. She stated the facility was not in outbreak during this time and no residents or staff were routinely tested including the unvaccinated staff member or the staff members who were not up to date on their vaccinations. The IP stated the unvaccinated staff member as well as those not up to date on their COVID-19 vaccinations should have been tested regularly based on the Community Transmission Level from CDC according to the facility policy but they had not been.

Based on record review, observation, and interview, the facility failed to have and/or maintain documentation that an alleged abuse allegation was thoroughly investigated for one (#21) of one resident reviewed for abuse. The facility identified two allegations of abuse in the previous six months. Findings: An undated facility policy titled Abuse Policy read in parts, .INVESTIGATION: Any allegation of abuse will be investigation by the Administrator or the Director of Nursing. The Administrator and the Director of Nursing will at a minimum: .iii. Witness reports will be reduced to writing with the witness signing and dating the report on the Witness Report form. The witness will write his/her own report . Res #21 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse note, dated 07/10/22, documented the resident had reported an unidentified CNA had stood over her head while the resident was in bed and did not speak but shook the bed three times. The note documented Res #21 stated she would rather be awakened by touching her arm. A state reportable incident, dated 07/10/22, documented Res #21 had spoken with a charge nurse and complained CNA #3 had startled her when awakening her. The incident report documented when the assistant administrator spoke with the resident, she stated at first she thought the CNA was trying to be mean, then changed the story, and stated it was due to the CNA's size and whenever she moved it bumped the bed. The incident report documented the resident stated as the CNA was leaving the room the resident attempted to ask questions and the CNA did not answer. The incident report documented the assistant administrator spoke with residents and staff and unsubstantiated the allegation. The incident report did not include written witness statements from the resident, the accused staff member, other residents, or other staff members, who might have had knowledge pertinent to the allegation. A quarterly MDS assessment, dated 09/22/22, documented Res #21 was intact in cognition and independent to requiring limited assistance with ADLs. On 10/25/22 at 4:10 p.m., Res #21 was observed sitting in a wheelchair in her room. The resident stated she liked living at the facility and the staff treated her well. When asked about verbal or physical abuse Res #21 report one staff member had acted in an abuse manner to her a few months ago. She stated she informed the assistant administrator and the staff member was no longer at the facility. On 10/31/22 at 9:28 a.m., during an interview with the assistant administrator, she stated she had found out about this incident a day after it had allegedly occurred. She stated she did not have to suspend the staff member as she was not scheduled to work for the next five days. She stated she conducted the investigation and found it to be unfounded. The assistant administrator stated the abuse investigation did not contain written statements from the interviewed residents or staff or a list of residents or staff who were interviewed. She stated she did not have each person she spoke with do their own statement. She stated CNA #3 still works at the facility but works on a different hall.

Based on record review, interview, and observation, the facility failed to conduct an assessment which accurately reflect a resident status for one (#5) of two residents reviewed for falls. The Resident Census and Conditions of Residents form documented 27 residents resided in the facility. Findings: Res #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An end of PPS MDS assessment, dated 09/14/22, documented Res #5 had one fall with minor injury. A fall incident note, dated 09/18/22, documented Res #5 was found on the floor bleeding from his right arm. The note documented the skin tear was treated per the facility standing orders and the resident was sent to the local emergency room for evaluation. A quarterly assessment, dated 10/24/22, documented Res #5 had not had any falls since admission/entry or reentry or the prior assessment. On 10/28/22 at 3:30 p.m., Res #5 was observed in his room on his bed and appeared to sleep. An unidentified CNA was present in the resident's room. On 10/28/22 at 3:45 p.m., the DON reviewed the MDS assessment, dated 10/24/22, and reported it was not correct in the area of falls.

Based on record review, observation, and interview, the facility failed to notify OHCA when a resident with documented mental illness for a possible PASRR II evaluation for one (#13) of one resident reviewed for PASRR evaluations. The administrator reported six residents residing at the facility had a PASRR II evaluation in their clinical records. Findings: Res #13 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR level I screening, dated 02/05/15, documented Res #13 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASRR I screening form did not document if OHCA had made this determination. An annual assessment, dated 02/19/22, documented Res #13 was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. On 10/28/22 at 07:48 a.m., Res #13 was observed in a wheelchair going out to the smoking area. On 10/28/22 at 10:51 a.m., the administrator reported the individual who was the DON at the time and who completed the PASRR I screening was no longer at the facility. The administrator reviewed the PASRR I screening and confirmed OHCA should have been informed for a possible PASRR II evaluation. She stated she could not confirm the facility had notified OHCA.

Based on record review, observation, and interview, the facility failed to ensure a resident with limited ROM received services to increase, maintain, or prevent further decline in ROM, for one (#10) of one resident reviewed for limited ROM. The Resident Census and Conditions of Residents documented 27 residents resided in the facility. Findings: Res #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission assessment, dated 08/18/22, documented the resident was severely impaired in cognition, required limited assistance with bed mobility and transfer, required supervision with ambulation and locomotion, and had limited ROM in the upper extremity and bilateral lower extremities. The Care Area Assessment indicated yes for ADL functional/rehabilitation potential. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The care plan for Res #10 was reviewed and did not document restorative services. On 10/25/22 at 12:23 p.m., the resident was observed sitting in a wheelchair in their room. The resident stated he had a stroke a few months ago which resulted in right sided weakness. The resident stated he wanted the facility to provide some type of therapy to help him increase strength and mobility but the facility had not provided any yet. On 10/28/22 at 11:38 a.m., the DON stated the facility provided restorative services but Res #10 had not received restorative care. The DON was asked if Res #10 would have benefited from restorative care. She stated she was unaware residents on Medicaid qualified for restorative care services and this resident should have received restorative services. On 10/28/22 at 11:47 a.m., the restorative aide (RA) #1 stated she had not provided restorative services to Res #10 because restorative care had not been ordered. She stated Res #10 required stand by assistance for transfer and one person assistance for dressing and showering. She stated that Res #10 would have benefited from restorative care but had not had any since admission.

Based on record review, observation, and interview, the facility failed to attempt alternatives, assess residents for risk of entrapment, review the risks and benefits of use of a grab bar/U rail with the resident or resident representative, and obtain an informed consent prior to installing a grab bar/U rail on a resident bed for one (#5) of one resident reviewed for use of grab bars/U rails. The administrator identified 20 residents who resided in the facility and had any type of grab bar, U rail, or rail attached to their beds. Findings: Res #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medicare 5 day MDS assessment, dated 08/14/22, documented the resident was severely impaired in cognition and did not walk. The assessment documented the resident had fallen and sustained a minor injury. A care plan, dated 09/13/22, documented Res #5 had an actual fall related to poor balance, poor communication/comprehension, and unsteady gait. The care plan documented an intervention of a U-Rail placed on the resident's bed. On 10/28/22 at 3:30 p.m., the resident was observed lying on his bed sleeping. A grab bar was observed to have been in the up position on the left side of the resident's bed. At that time an unidentified CNA was observed in the room and stated Res #5 used the grab bar to assist himself to set up. On 10/28/22 at 3:45 p.m., the DON reported the grab bar had been placed on the care plan by the MDS coordinator who worked off-site. She reviewed the resident's clinical records and reported there was not documentation of performing an assessment for the use of side rails or grab bars and it was not an option in this resident's EHR. At that time, the assistant administrator stated she was unaware grab bars were considered a type of side rail. She stated she was aware of the regulation related to the use of side rails.

Based on interview and record review, it was determined the facility failed to provide written information to residents and/or their representatives on the formulation of advance directives for three (#4, #17, and #19) of three sampled residents who were reviewed for advanced directives. The facility identified 21 residents as residing at the facility. Findings: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual assessment, dated 06/27/21, documented the resident was moderately impaired with cognition and required limited to extensive assistance with most activities of daily living. Review of the resident's clinical record revealed no advance directive or any documentation the resident or representative received information regarding the formulation of an advance directive. On 07/01/21 at 1:30 p.m., the director of nursing (DON) stated the only information related to advance directives in the resident's chart was a form containing definitions related to advance directives. This form was signed by the resident. On 07/01/21 at 1:52 p.m., the DON stated the facility did not have a policy regarding advance directives. She stated the admission packet contained the advance directives. On 07/01/21 at 2:42 p.m., the assistant administrator was asked who was responsible for filling out the advance directives for the residents on admission. She stated certified nurse aide #1 and the social service/activities staff member were responsible. The assistant administrator stated they re-educated the staff members yesterday on the advance directives and informed them they needed to get the residents' signature and mark if the resident wanted or did not want an advance directive. On 07/01/21 at 2:47 p.m., CNA #1 stated they had new admission packets, and she now knew to have the resident sign and not just put NA. She stated the resident needed to sign and mark if they wanted one or not. She stated if the resident wanted an advance directive, she would take it to the charge nurse to be filled out. 2. Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 05/21/21, documented the resident was severely impaired with cognition and required extensive assistance with activities of daily living. Review of the resident's clinical record revealed an advance directive acknowledgement form that was signed by the resident on 05/11/11; however, the form did not indicate whether the resident wanted or did not want to execute an advance directive. On 07/01/21 at 1:32 p.m., the resident's chart was reviewed by the DON. She stated the form was signed on 05/11/11 by the resident. She stated the form was not complete as the form was not marked if the resident wanted an advance directive or not. The DON stated the resident was not capable of telling staff if she wanted an advance directive or not at this time. 3. Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change assessment, dated 06/19/21, documented the resident was moderately impaired with cognition and required extensive assistance with most activities of daily living. Review of the resident's clinical record revealed an advance directive acceptance or declaration form with only the resident's name on the form. The form was not signed by the resident or the representative, and it was not documented whether the resident wanted to execute an advance directive or not. The resident's information sheet, located in the clinical record, documented the resident requested for cardiopulmonary resuscitation to not be performed; however, the Do Not Resuscitate form was blank. On 07/01/21 at 1:37 p.m., the DON stated the advance directives were completed by either the activities director or CNA #1. She stated the resident's paper work was not filled out. She stated the resident had a neighbor drop her off, and she had no family. She stated the resident was capable of letting the facility know if she wanted an advance directive or not at this time. On 07/01/21 at 2:47 p.m., CNA #1 stated she was the one who wrote the resident's name on the paper work in the chart, but she did not go to the resident's room to finish the paper work.

Based on interview and record review, it was determined the facility failed to ensure rationales were provided for declining pharmacist recommendations for three (#7, #15, and #16) of five sampled residents who were reviewed for unnecessary medications. The facility identified 21 residents as receiving medications. Findings: The facility's policy and procedure related to consultant pharmacist reports, dated 07/2015, documented, . Prescriber accepts and acts upon suggestions or rejects and provides an explanation for disagreeing . If there is a potential for serious harm and the attending physician or prescriber does not concur, or refuses to document an explanation for disagreeing, the director of nursing and the consultant pharmacist will contact the medical director . 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and Alzheimer's disease. Review of physician's orders documented the resident had received: ~ [MEDICATION(S)], an antianxiety medication, 15 milligrams (mg) three times daily since 05/15/18; ~ [MEDICATION(S)], an antipsychotic medication given intramuscularly, 12.5 mg every 14 days since 11/22/18; and ~ [MEDICATION(S)], by mouth, 0.25 mg every day from 09/04/19 through 08/19/20 and twice daily since 08/19/20. Review of behavior monitoring documentation and progress notes, dated 09/2020 through 12/2020, revealed no documentation the resident exhibited any behaviors. A medication regimen review, dated 01/11/21, documented, . Please review the following agents for their continued appropriateness and a possible dose reduction: . [MEDICATION(S)] 0.25 mg twice daily; [MEDICATION(S)] 12.5 mg q [every] 2 weeks; [MEDICATION(S)] [[MEDICATION(S)]] 15 mg tid [three times daily] . It was documented the physician disagreed with the recommendation on 01/27/21; however, no rationale was provided for declining the recommendation. On 07/06/21 at 11:58 a.m., the director of nursing (DON) stated the physician had disagreed with the pharmacist's recommendation on 01/11/21. She stated the physician had not provided a rationale for the declination. The DON stated it was difficult at times to get the physician to provide a rationale for declining a pharmacist recommendation. She stated she always encouraged the physician to do so, and she would notify the administrator if she had difficulties. 2. Resident #16 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, cerebral infarction, delusional disorders, and [CONDITION(S)] not due to a substance or known physiological condition. The resident's care plan, dated 02/17/17, documented the resident used [CONDITION(S)] medications related to behavior management with an intervention to . Consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly . A physician's order, dated 01/15/19, documented to give [MEDICATION(S)] 3 mg, one-half tab, by mouth at bedtime. A pharmacy medication regimen review, dated 01/10/20, documented a request to consider a reduction of the resident's bedtime dose of [MEDICATION(S)]. A response of No Change, dated 01/21/20, was documented by the physician on the form. A pharmacy medication regimen review, dated 01/11/21, documented a request to consider a reduction of the resident's bedtime dose of [MEDICATION(S)]. The physician marked an option that read, . Disagree, a reduction is clinically inappropriate/contraindicated at the present time for the following reason (please check most appropriate response and document clinical rationale below): . No rationale was provided. The document was signed by the physician and dated 01/27/21. On 07/06/21 at 3:40 p.m., the DON was asked if a rationale should have been provided for the physician's declination of the pharmacist's recommendation to reduce the resident's dose of [MEDICATION(S)]. She stated, Yes. The DON stated it was difficult at times to get the physician to provide a rationale for declining a pharmacist recommendation. She stated she always encouraged the physician to do so, and she would notify the administrator if she had difficulties. 3. Resident #7 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and depression. A behavior note, dated 09/08/20 at 12:41 p.m., documented, . over the last 2 weeks resident is constantly stalking the staff over food and smoking. She is been caught coughing in her hand and slinging snot and [MEDICATION(S)] in the floor and wiping it on the walls. She cont [continue] to steal food at of the others rooms and eats it. She has been spoken to by the DON several times in the last 2 weeks without success . A physician's order, dated 09/30/20, documented the resident was to receive [MEDICATION(S)], an antipsychotic medication, 5 mg at bedtime for [CONDITION(S)]. A physician's order, dated 11/12/20, documented the resident was to receive [MEDICATION(S)], an antianxiety medication, 0.5 mg one tab three times a day for anxiety/agitation; [MEDICATION(S)], a dementia medication, 20 mg at bedtime for dementia; and [MEDICATION(S)], an antidepressant, 50 mg at bedtime for depression. A medication regimen review, dated 02/10/21, documented, . please review the following for a possible dose reduction: [MEDICATION(S)] 5mg at bedtime, [MEDICATION(S)] 0.5mg three times a day, [MEDICATION(S)] 50mg daily, and [MEDICATION(S)] 50mg at bedtime . It was documented the physician disagreed with the recommendation; however, no rationale was provided. On 07/06/21 at 3:40 p.m., the DON stated if the physician disagreed with the consulting pharmacist recommendation, the physician should document a rationale. The DON stated she had spoken to the physician regarding providing rationales for declining pharmacy recommendations. She stated she had informed the administrator and the medical director was aware as well.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (#15) of five sampled residents who were reviewed for unnecessary medications received gradual dose reductions of [CONDITION(S)] medications and did not receive a [CONDITION(S)] medication without adequate indication for its' use. The facility identified 15 residents as receiving a [CONDITION(S)] medication. Findings: 1. Resident #15 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and Alzheimer's disease. Review of physician's orders documented the resident had received: ~ [MEDICATION(S)], an antianxiety medication, 15 milligrams (mg) three times daily since 05/15/18 for unspecified [CONDITION(S)]; ~ [MEDICATION(S)], an antipsychotic medication given intramuscularly, 12.5 mg every 14 days for unspecified [CONDITION(S)] since 11/22/18; and ~ [MEDICATION(S)], 0.25 mg by mouth twice daily for unspecified [CONDITION(S)] since 12/18/18. A progress note, dated 04/08/19 at 6:39 p.m., documented, . Resident is wandering up and down the halls, easy to redirect . A progress note, dated 05/02/19 at 5:26 a.m., documented, . resident is restless and has been pilfering, wondering [sic] aimlessly. redirection successful with one on one and toileting . A progress note, dated 06/17/19 at 4:25 p.m., documented, . Resident is wondering [sic] anxiously when redirected she becomes very aggressive, resident is slapping at staff as well as picking up floor signs to hit staff. She is not easily redirected, takes two staff members to redirect . A progress note, dated 06/18/19 at 9:43 a.m., documented, . has been busy all morning and has been trying to move furniture and carry chairs . is getting harder to redirect . The clinical record contained no documentation related to what nonpharmalogical interventions were attempted, other than redirection. A progress note, dated 06/18/19 at 10:21 a.m., documented, . Resident seen by the Dr [doctor] this am with the following new orders received [MEDICATION(S)] 0.25 mg po [by mouth] q [every] hs [night] and [MEDICATION(S)] 0.5 mg po q am . A progress note, dated 07/14/19 at 9:55 p.m., documented, . Observed resident ambulate from her room into hallway after CNAs [certified nurse aides] had placed her in bed. Appeared to lean to the right, then fell on to right side/shoulder, striking head on floor . Approx [approximate] 5 cm [centimeter] hematoma noted to right side of head/forehead . Right shoulder with mild redness . A care plan update, dated 07/14/19, documented, . GDR [gradual dose reduction] done on PO [MEDICATION(S)] d/t [due to] fall . A physician's order, dated 07/16/19, documented the resident's dose of oral [MEDICATION(S)] was to be decreased to 0.25 mg every day. A progress note, dated 08/22/19 at 1:40 p.m., documented, . resd. [resident] with increased agitation, such as; [sic] hitting and pinching staff, Pacing throughout facility very restless, PCP [primary care physician] aware. Received orders to change [MEDICATION(S)] 0.25 [mg] po to BID [twice daily] . Review of the clinical record revealed no documentation any nonpharmalogical interventions were attempted. A progress note, dated 12/04/19 at 1:58 p.m., documented, . resident is having increased restlessness and pacing. After several attempts to redirect her to have a seat and rest without success, spouse here and ask that the Dr. be called and a med given to help her with pacing today and allow her to rest. the Dr was called and a one time order for [MEDICATION(S)] 0.25 mg given at this time. Will monitor for effectiveness . Review of the clinical record revealed no documentation any other interventions were attempted before administering the one-time dose of [MEDICATION(S)]. A progress note, dated 04/20/20 at 6:14 p.m., documented, . Resident with aggression noted towards staff, she was trying to push another resident in her w/c [wheelchair], a resident of which we have constantly taken back to her room numerous times due to trying to comply with the social distancing in the facility, but she yet continues to come out, the staff member was trying to get [resident #15] to let go of residents w/c by speaking calmly with resident and guiding her hands away from the w/c, resident [resident #15] then began hitting at staff member, another staff member came to assist and got [resident #15] to leave that area and began to walk her around the facility to help her calm down, which did help . A progress note, dated 08/22/20 at 6:17 p.m., documented, . Resd. attempted to hit a staff member during an attempt to be redirected. Resd. miss [sic] staff and the hallway wall [sic] causing a s/t [skin tear] to the top of her left hand . A progress note, dated 08/25/20 at 5:33 p.m., documented, . Resident was spitting her food at the staff 1/1 [one on one] inefecctive [sic] and she was redirected to another area of the building without any further eposide [sic] noted . Review of clinical documentation, including progress notes and behavior monitoring, dated 09/2020 through 01/11/21, revealed no documentation of behaviors. A medication regimen review, dated 01/11/21, documented, . Please review the following agents for their continued appropriateness and a possible dose reduction: . [MEDICATION(S)] 0.25 mg twice daily; [MEDICATION(S)] 12.5 mg q [every] 2 weeks; [MEDICATION(S)] [[MEDICATION(S)]] 15 mg tid [three times daily] . It was documented the physician disagreed with the recommendation; however, no rationale was provided for declining the recommendation. Review of clinical documentation, including progress notes and behavior monitoring, dated 01/12/21 through 05/14/21, revealed the resident had behaviors on 04/15/21 and 04/16/21. There was no documentation recording what the behaviors were or what interventions were attempted. The resident's care plan, revised 05/14/21, documented a problem of aggression towards others related to Alzheimer's disease. The goal was the resident would have fewer episodes of aggressive behaviors towards others. Interventions included to administer medications as ordered, intervene as necessary, and minimize the potential for disruptive behaviors. Another problem was related to the resident's use of [CONDITION(S)] medications. The goal was the resident would remain free of [CONDITION(S)] medication complications. Interventions included to consult with the physician and pharmacist at least quarterly to consider dose reductions when clinically appropriate. A quarterly assessment, dated 05/15/21, documented the resident had long and short term memory problems; disorganized thinking; physical symptoms towards others; and other behavior symptoms. It was also documented the resident received antipsychotic, antianxiety, and hypnotic medications on seven of the preceding seven days. Review of clinical documentation, including progress notes and behavior monitoring, dated 05/15/21 through 06/16/21, revealed no documentation of behaviors. Behavior monitoring documentation, dated 06/17/21 and 06/18/21, documented the resident had behaviors. There was no documentation recording what the behaviors were or what interventions were attempted. On 06/30/21 at 11:00 a.m., the resident was observed propelling her wheelchair by the south hall nurses' station. No staff were present. The resident picked up a wet floor warning sign, propelled her chair to room 27, and placed the sign in the room. A staff member walked by, observed the resident, and escorted the resident from the room. No aggressive behaviors were noted. On 07/06/21 at 9:18 a.m., the resident was observed sitting in her wheelchair by the south hall nurses' station. She appeared calm, and no behaviors were noted. On 07/06/21 at 10:51 a.m., certified nurse aide (CNA) #2 stated the resident would sometimes hit or slap at the staff. She stated it was mainly when the resident was being changed. CNA #2 stated the resident did not have behaviors all the time, it just depends on the day. She stated when the resident was agitated, she would try to calm her down by talking with her, rubbing her hand, and trying to soothe her. She stated she had not observed the resident having behaviors towards other residents. On 07/06/21 at 10:55 a.m., certified medication aide (CMA) #1 stated the resident sometimes had behaviors. She stated, I think it is more just agitation. She stated when the resident had behaviors, she would redirect her, give her time to calm down, or give her a snack or drink. CMA #1 stated the resident did not have behaviors daily. She stated she had not observed the resident's behaviors affecting other residents. CMA #1 stated, Some of them kind of baby her. On 07/06/21 at 11:08 a.m., licensed practical nurse (LPN) #1 stated the resident could get a little aggressive at times. She stated the resident was better since she was taking [MEDICATION(S)]. LPN #1 stated if staff allowed the resident time to calm down, she was ok. She stated the resident did not have behaviors daily. LPN #1 stated she did not know how long the resident had been taking [MEDICATION(S)], but she knew it had been over a year. She stated she believed the diagnosis for the use of the [MEDICATION(S)] was dementia with behaviors. LPN #1 stated when the resident had behaviors, the staff was to try to redirect her or distract her. She stated the resident's behaviors never affected any other resident. LPN #1 was asked what behaviors prompted the use of the [MEDICATION(S)]. She stated it was aggression towards the staff. On 7/06/21 at 11:58 a.m., the director of nursing (DON) stated the resident had a wide range of behaviors, from resisting care to physical abuse directed to staff. She stated at one point the facility had assigned a walker to the resident. She stated that was one staff member assigned to the resident while she was out and about in the facility. The DON stated staff was supposed to let the resident calm down or redirect her when she was having behaviors. The DON was asked where the resident's behaviors were documented. She stated it should be on the behavior monitoring, but it was the resident's normal. She stated the resident received a [MEDICATION(S)] injection every 14 days, and when it was within a couple of days of the next injection, her behaviors would escalate. The DON reviewed the resident's progress notes and behavior monitoring and stated she could not find any documentation on the resident's behaviors. She stated staff had probably quit charting the behaviors. The DON was asked what types of behaviors the resident exhibited towards the staff. She stated the resident hit and punched at the staff. She stated it did not hurt the staff. She stated she may have bit someone last year. The DON stated the resident's behaviors did not affect the other residents. The DON was asked how the behaviors affected the resident herself. She stated she caused herself to have skin tears. The DON was asked how long the resident had been receiving the antipsychotic medications. She stated the resident had been receiving [MEDICATION(S)] since 04/17/18, oral [MEDICATION(S)] since 10/21/17, and injectable [MEDICATION(S)] since 07/23/18. She stated the resident had last been sent to a geriatric psychiatric hospital on 09/12/18. The DON was asked how psychiatric services were involved in the resident's care. She stated they were not because of the resident's cognition. She stated she was not a physician, but as far as the resident's behaviors were concerned, she was not as aggressive since she had been on the medications. The DON was asked when a gradual dose reduction had been attempted last with the resident's antipsychotic medications. She stated the pharmacist had made a recommendation on 01/11/21. She stated the physician had disagreed but had not provided any rationale for the declination.

Based on observation, interview, and record review, it was determined the facility failed to maintain sanitary conditions in the dietary department. The facility failed to ensure the ice machine was clean and sanitary for 19 of 19 residents who received meals from the dietary department. Findings: On 06/30/21 at 10:03 a.m., an initial tour of the kitchen was conducted. At 10:10 a.m., the ice machine located in the kitchen was checked. The ice drop was wiped with a clean white cloth. After wiping the ice drop, the cloth had a black substance on it. The dietary manager (DM) also used the cloth and wiped the ice drop. She also obtained a black substance from the ice machine. The DM stated the ice would be disposed of and the ice machine would be cleaned. She stated the ice machine should be cleaned monthly. On 06/30/21 at 10:15 a.m., the log sheet for cleaning the ice machine was reviewed. The month of 06/2021 was marked, but there was no date documented for when the ice machine was cleaned.

Based on observation, interview, and record review, it was determined the facility failed to ensure hot running water was available for six (#5, #12, #13, #14, #15, and #16) of 16 sampled residents who were reviewed for a home like environment. The facility identified eight residents as residing in rooms with private baths. Findings: 1. Resident #13 was readmitted to the facility on [DATE]. A quarterly assessment, dated 05/13/21, documented the resident was cognitively intact, required limited assistance with toileting, and required extensive assistance for personal hygiene. Resident #13 resided in room 27. Resident #16 was admitted to the facility on [DATE]. A quarterly assessment, dated 05/21/21 documented the resident was moderately impaired in cognitive skills and was independent in transfers, toileting, and personal hygiene. Resident #16 resided in room 26. On 06/30/21 at 10:20 a.m., water temperatures were checked in the bathroom for rooms 26 and 27. No water was observed when the hot water spigot was turned on. 2. Resident #14 was admitted to the facility on [DATE]. A quarterly assessment, dated 05/14/21, documented the resident was severely cognitively impaired, transferred independently, and required limited assistance with toileting and personal hygiene. Resident #14 resided in room 30. On 06/30/21 at 3:04 p.m., water temperatures were checked in the bathroom for room 30. No water was observed when the hot water spigot was turned on. 3. Resident #12 was admitted to the facility on [DATE]. An admission assessment, dated 05/10/21, documented the resident was moderately cognitively impaired, required limited assistance with toileting, and required assistance of one for personal hygiene. Resident #12 resided in room 31. Resident #5 was admitted to the family on 03/26/20. An annual assessment, dated 04/03/21, documented the resident was severely impaired in cognitive skills, was independent with transfers and toileting, and required assistance of one for personal hygiene. Resident #5 resided in room 32. Resident #15 was readmitted to the facility on [DATE]. A quarterly assessment, dated 05/15/21, documented the resident was severely impaired in cognitive skills, required extensive assistance with toileting, and required limited assistance with personal hygiene. Resident #15 also resided in room 32. On 06/30/21 at 3:41 p.m., water temperatures were checked in the bathroom for rooms 31 and 32. No water was observed when the hot water spigot was turned on. On 07/06/21 at 4:01 p.m., the administrator was asked why there was no running water when the hot water spigots were turned on. She observed each of the bathrooms and stated they were supposed to have hot water. The administrator stated the plumber had been out to fix the bathroom for rooms 31 and 32. She stated he had tried to access the sink through the closet and had to jack hammer concrete from the floor, but the problem had not been fixed. She stated the plumber had stated he was coming back, but he had never returned. She stated he had been at the facility a few months back. The administrator stated there was a hand sink in the area beside the south nurses' station the residents and staff could use to wash their hands in. The administrator was asked who staff should report concerns, such as no hot water, to. She stated they were to report to her or the assistant administrator, but no one had reported anything.

Based on observation, interview, and record review, it was determined the facility failed to ensure assessments were accurate for bed rails for one (#4) of 16 residents whose assessments were reviewed. The facility identified three residents as having bed rails. Findings: Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/29/21, documented the resident was moderately impaired with cognition and required limited to extensive assistance with most activities of daily living. The assessment documented the resident did not have bed rails in use. An annual assessment, dated 06/27/21, documented the resident was moderately impaired with cognition and required limited to extensive assistance with most activities of daily living. The assessment documented the resident did not have bed rails in use. On 06/30/21 at 11:46 a.m., the resident was observed in her bed with half rails in the up position on her bed. On 07/06/21 at 4:30 p.m., the DON stated she completed the assessments and care plans for the residents. She stated she did not have the bed rails documented on the assessment or care planned for the resident. She stated the bed was a hospice bed and was brought to the facility in June, 2020.

Based on observation, interview, and record review, it was determined the facility failed to develop a care plan related to the use of bed rails for one (#4) of 16 sampled residents whose care plans were reviewed. The facility identified three residents who had half rails on their beds. Findings: Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/29/21, documented the resident was moderately impaired with cognition and required limited to extensive assistance with most activities of daily living. The assessment documented the resident did not have bed rails in use. A care plan, dated 06/17/21, did not document the use of bed rails for the resident. There was no problem, goals, or interventions listed. An annual assessment, dated 06/27/21, documented the resident was moderately impaired with cognition and required limited to extensive assistance with most activities of daily living. The assessment documented the resident did not have bed rails in use. On 06/30/21 at 11:46 a.m., the resident was observed in her bed with half rails in the up position on her bed. On 07/06/21 at 4:30 p.m., the DON stated she completed the assessments and care plans for the residents. She stated she did not have the bed rails documented on the assessment or care planned for the resident. She stated the bed was a hospice bed and was brought to the facility in June, 2020.

Based on observation, interview, and record review, it was determined the facility failed to ensure an environment free of accident hazards when it did not assess bed rail use for one (#4) of one sampled resident who was reviewed for the use of bed rails. The facility identified three residents as having bed rails. Findings: Resident #4 was admitted to the facility on [DATE] with diagnoses that included scoliosis, dyspnea, and endstage heart failure. A quarterly assessment, dated 03/29/21, documented the resident was moderately impaired with cognition and required limited to extensive assistance with most activities of daily living. The assessment documented the resident did not have bed rails in use. An annual assessment, dated 06/27/21, documented the resident was moderately impaired with cognition and required limited to extensive assistance with most activities of daily living. The assessment documented the resident did not have bed rails in use. On 06/30/21 at 11:46 a.m., the resident was observed in her bed with half rails in the up position on her bed. On 06/30/21 at 2:22 p.m., the resident stated she wanted the bed rails to hold on to when turning. The resident stated she tried to do some things for herself. During the interview, the resident stuck her hand through the rail and stated she wished the openings were wider so she could reach the items on her night stand. On 07/06/21 at 4:20 p.m., the director of nursing (DON) was asked to provide the bed rail assessment for the resident. The DON stated she was not aware there was an assessment for use of the bed rails. She stated the resident was oriented, and she believed the resident requested the bed rails. On 07/06/21 at 4:30 p.m., the DON stated she completed the assessments and care plans for the residents. She stated she did not have the bed rails documented on the assessment or care planned for the resident. She stated the bed was a hospice bed and was brought to the facility in June, 2020. The DON stated she thought the rails were quarter rails, not half rails. She stated the facility was restraint free and should not have bed rails on the resident's bed. On 07/06/21 at 4:43 p.m., the resident was observed on her back in the bed with both half rails in the up position. The resident stated she used the rails to hold on to when staff repositioned her in bed. She said she could not stay on her side, and she was on her back most of the time. She was asked if she could roll herself or get out of bed. She stated she could not turn on her own and required assistance from staff. She was asked if she could get herself out of the bed rails if she happened to get stuck in the rail. She stated she did not know, and she did not want to try. On 07/06/21 at 4:48 p.m., certified nurse aide (CNA) #3 stated the resident did not move herself in the bed but held on to the rail when being assisted with her care. She stated she had never seen the resident move herself in the bed. On 07/06/21 at 4:51 p.m., licensed practical nurse (LPN) #1 stated she knew the resident had bed rails but was not aware they were half rails. She stated the resident did not move in the bed by herself. She stated she needed assistance to roll over. She stated the resident would hold on to the rails when she received care.

Based on observation, interview, and record review, it was determined the facility failed to ensure alternatives were attempted prior to the use of bed rails for one (#4) of one sampled resident reviewed for bed rails. The facility failed to assess and review the risks of entrapment, review the risks and benefits of bed rails with the resident, and obtain informed consent. The facility identified three residents as having bed rails. Findings: Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly assessment, dated 03/29/21, documented the resident was moderately impaired with cognition and required limited to extensive assistance with most activities of daily living. The assessment documented the resident did not have bed rails in use. An annual assessment, dated 06/27/21, documented the resident was moderately impaired with cognition and required limited to extensive assistance with most activities of daily living. The assessment documented the resident did not have bed rails in use. On 06/30/21 at 11:46 a.m., the resident was observed in her bed with half rails in the up position on her bed. On 06/30/21 at 2:22 p.m., the resident stated she wanted the bed rails to hold onto when turning. The resident stated she tried to do some things for herself. During the interview the resident stuck her hand through the rail and stated she wished the openings were wider so she could reach the items from her night stand. On 07/06/21 at 4:20 p.m., the director of nursing (DON) was asked to provide the bed rail assessment for the resident. The DON stated she was not aware there was an assessment for use of bed rails. She stated the resident was oriented, and she believed the resident requested the bed rails. On 07/06/21 at 4:30 p.m., the DON stated she completed the assessments and care plans for the residents. She stated she did not have the bed rails documented on the assessment or care planned for the resident. She stated the bed was a hospice bed and was brought to the facility in June, 2020. The DON stated she thought the rails were quarter rails, not half rails. She stated the facility was restraint free and should not have bed rails on the resident's bed. On 07/06/21 at 4:43 p.m., the resident was observed on her back in the bed with both half rails in the up position. The resident stated she used the rails to hold on to when staff repositioned her in bed. She said she could not stay on her side, and she was on her back most of the time. She was asked if she could roll herself or get out of bed. She stated she could not turn on her own and required assistance from staff. She was asked if she could get herself out of the bed rails if she happened to get stuck in the rail. She stated she did not know, and she did not want to try. On 07/06/21 at 4:48 p.m., certified nurse aide (CNA) #3 stated the resident did not move herself in the bed but held on to the rail when being assisted with her care. She stated she had never seen the resident move herself in the bed. On 07/06/21 at 4:51 p.m., licensed practical nurse (LPN) #1 stated she knew the resident had bed rails but was not aware they were half rails. She stated the resident did not move in the bed by herself. She stated she needed assistance to roll over. She stated the resident would hold on to the rails when she received care.