Every finding on record at Lorien Mays Chapel

Based on observation, interview, and record review, the facility failed to ensure that oxygen tubing was changed and dated as per the physician orders and according to the oxygen therapy facility policy and procedures. This was evident in 4 (#56, #46, #38, #5) of 5 residents observed receiving oxygen during the annual survey.The findings include: 1. On 04/06/2026 at 12:54 PM, Resident #56 was observed receiving O2 at 2L/min. However, the O2 tubing was not labeled. The humidifier bottle was labeled with the date of 04/01/2026. On 04/07/2026 at 09:30 AM, the surveyor, during observation rounds on the clinical unit, observed that resident # 56 was receiving O2 therapy at 2 liters per minute via nasal cannula, and the oxygen tubing connected to the humidifier bottle was not labeled with a date indicating when the tubing was last changed. On 04/08/2026 at 08:30 AM, the surveyor reviewed the electronic medical record of Resident #56. The physician orders related to oxygen therapy revealed that the O2 nasal cannula tubing and humidifier were to be changed every week and that the resident was to receive O2 therapy via nasal cannula at the rate of 2 liters per minute for Resident #56. On 04/08/2026 at 08:46 AM, the surveyor, while performing observation rounds, the resident # 56 was receiving O2@2l/min via nasal cannula. The oxygen tubing for Resident #56 was not labeled with a date. On 04/08/2026 at approximately 10:30 AM, the surveyor requested the DON to provide a copy of the oxygen therapy policy and procedure. The DON stated that the staff is expected to change and date O2 tubing and humidifier bottles at least weekly. On 04/09/2026 at 08:45 AM, the surveyor reviewed the facility's oxygen therapy policy and determined that the dating and changing of the oxygen nasal cannula are part of the infection prevention process related to oxygen therapy for residents, per the facility's oxygen therapy policy and procedure. The facility was found to be non-compliant. 2. During observation rounds on 04/06/2026 at 8:06 am, Resident #46's oxygen nasal cannula and tubing were found tied and hanging from the cord of the resident's over the bed light fixture, not on the resident, and the other end of the oxygen tubing was connected to a concentrator that was running at 2 liters. The oxygen nasal cannula and tubing were also found not to be labeled with a date indicating when they were last changed. During interview and observation rounds on 04/06/2026 at 8:10 AM Staff # 3 verified that Resident #46's oxygen nasal cannula and tubing was tied and hanging from the cord of residents over the bed light fixture, not on resident, tubing was connected to a concentrator that was on running at 2 liters and there was no date indicating when the nasal cannula and tubing was last changed. Staff #3 immediately removed the oxygen nasal cannula and tubing for the cord and placed it on Resident #46. Staff #3 stated, The resident should have the oxygen on. Review of resident #46's medical record on 04/06/2026 at 9:54 AM revealed a physician's order dated 02/26/2026 stating the following: Oxygen: every shift O2 at 2 L/MIN CONTINUIOUS VIA N/C FOR >92 % every shift for MONITORING. Further review revealed a physician's order dated 02/10/2025 stating the following: OXYGEN EQUIPMENT: 11-7 Shift weekly WEEKLY 02/NEB Equipment CHANGE 02 TUBING NASAL CANNULA/MASK WEEKLY IF IN USE – LABEL TUBING WITH DATE CHANGED. During an interview on 04/06/2026 at 10:05 AM with the Director of Nursing (#2), was informed of the surveyor's observations as stated above. During an interview and review of resident #46's oxygen orders on 04/08/2026 at 1:18 PM, the Director of Nursing (#2) stated, Resident #46's oxygen PRN order dated 02/10/2025 should have been discontinued and was an oversight. I will call the doctor and get the order discontinued. The resident should be on oxygen 2 L/min by nasal cannula continuous. 3. On 4/06/2026 at 12:36 PM, the surveyor observed that Resident #38's oxygen tubing was not labeled with the date and time of administration. The oxygen tubing was also noted to be on the floor next to the resident's bed. On 4/06/2026 at 1:39 PM, the nurse (LPN #22) for Resident #38 was interviewed and asked why the resident did not have their oxygen on and why the oxygen tubing was not labeled with the date and time it was administered to the resident. LPN #22 responded that 'Resident #38 gets Nebulizer Treatment every 6 hours for his/her asthma and that he/she takes the mask off themself when if finished. He/she must have dropped it to the floor. The surveyor then asked LPN #22 if it was a standard practice not to date and time the tubing. LPN #22 responded, I will change it out and get a new one with the date and time on it. On 4/08/2026 at 1:42 PM, the surveyor asked the DON for a copy of the Oxygen Therapy Policy. After reviewing the Oxygen Therapy policy, the surveyor noted that it states within the policy that 'Tubing and bottles are labeled with date' and 'Clean and store equipment in a clean plastic bag with the date. 4. On 4/06/2026 at 1:27 PM, the surveyor observed that the Oxygen tubing for Resident #5 was on the floor and was not dated, and the Oxygen concentrator was still running. On 4/06/2026 at 1:39 PM, the nurse (LPN #22) for Resident #5 was interviewed and asked why the resident did not have their oxygen on and why the oxygen tubing was not labeled with the date and time it was administered to the resident. LPN #22 responded that 'Resident #5 receives Oxygen PRN and they take the nasal cannula off when they don't want it on. They must have dropped it to the floor.' The surveyor then asked LPN #22 if it was a standard practice not to date and time the tubing. LPN #22 responded, I will change it out and get a new one with the date and time on it. On 4/08/2026 at 1:42 PM, the surveyor asked the DON for a copy of the Oxygen Therapy Policy. After reviewing the Oxygen Therapy policy, the surveyor noted that it states within the policy that 'Tubing and bottles are labeled with date' and 'Clean and store equipment in a clean plastic bag with the date.

Based on record review and staff interview, the facility failed to ensure that required beneficiary protection notifications were provided to a resident. Specifically, the facility did not issue the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), Form CMS-10055, as applicable. This deficient practice was identified for 1 of 3 residents reviewed for Beneficiary Protection Notifications (Resident #38).Findings include:On 04/06/2026, the facility received Beneficiary Protection Notification Review forms for three residents, including Resident #38.On 04/08/2026 at 2:15 PM, the Director of Nursing (DON) returned the forms. Review indicated that Resident #38 did not receive the required NOMNC or SNF ABN.During an interview on 04/08/2026 at 3:34 PM, the DON confirmed that the notices were not provided and was unable to explain the omission.

Based on observations and interviews with facility staff it was determined the facility failed to ensure that residents' environment was clean and well maintained. This was found to be evident for 1 (Resident # 101) of 40 residents observed on the third floor during the facility's annual Medicare/Medicaid survey.Findings include,During an initial tour conducted on the third floor on 04/06/2026 at approximately 8:40 AM, an observation was made of Resident # 101's room. There were many dark marks noted on the floor in front of the resident's nightstand. The markings appeared to be marred onto the floor. The Administrator was made aware of the concerns at approximately 10:15 AM on the same date. He stated that maintenance would address the concerns.

Based on medical record review and staff interview, the facility failed to ensure that a gradual dose reduction (GDR) was attempted for an antianxiety medication and failed to provide adequate clinical documentation supporting the continued use of the medication. This deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #8).Findings include: Medical record review on April 7, 2026, revealed that Resident #8 has been receiving Ativan (lorazepam) three times daily since February 29, 2024, for dementia with agitation. A pharmacy consultant recommendation dated February 9, 2026, suggested a gradual dose reduction (GDR); however, the physician declined the recommendation, stating the resident was at high risk for decompensation. The medical record did not contain sufficient clinical documentation to support this determination, and there was no evidence that a GDR had ever been attempted.Further review indicated that the resident has also been receiving Cymbalta (duloxetine) 30 mg at bedtime since January 2024 for depression, which may also address anxiety symptoms. The dosage decreased to 20 mg on March 17, 2026. Behavioral monitoring sheets from November and December 2025 and January through March 2026 revealed no documented behaviors to substantiate the continued need for scheduled Ativan. Additionally, physician progress notes lacked documentation indicating that a GDR was attempted or provided a clear clinical rationale for the ongoing use of the medication.During an interview, the Director of Nursing (DON) stated that the behavioral monitoring sheets might be inaccurate and reported that the resident yells out. When asked whether the yelling could represent an unmet need, such as pain, particularly given the resident's cognitive impairment and inability to effectively communicate, the DON acknowledged that this was possible.

Based on medical record review and interviews with facility staff it was determined the facility failed to provide written information to the resident and/or the resident responsible party (RP) regarding a hospital transfer and provide them with a copy of the facility's bed hold policy. This was found to be evident for 1 (Resident # 90) of 3 residents reviewed for hospitalizations during the facility's annual Medicare/Medicaid survey.Findings include,A medical record review was conducted on 04/07/2026 1:15 PM and upon review, it revealed that Resident # 90 went to the hospital on 1/30/26 for expiratory rhonchi (low pitched rattling lung sounds heard primarily when breathing out, caused by air passing through narrow airways).The survey team requested documentation of written notification of the transfer documentation and the bed hold policy that was provided to the RP. The DON was unable to provide this documentation to the survey team.During a subsequent interview with the DON on 4/7/26 at 1:55 PM she was asked to explain why this resident RP was not notified of the hospital transfer and a hospital bed-hold policy was not provided and she stated that no bed hold policy was sent because it was missed. In addition, written documentation for RP notification should have been sent as well but was also not done. She went on to say that re-education will be provided for staff.All concerns were discussed with Administration at the exit conference conducted on 4/9/26.

Based on observations, staff interviews, and record review, it was determined that the facility failed to develop and implement a complete, comprehensive care plan. This was evident for 1 (Resident #38) out of 6 residents reviewed during this annual survey.A comprehensive person-centered care plan for each resident must include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.The findings include:On 4/06/2026 at 12:36 PM, the surveyor observed that Resident #38's oxygen tubing was not labeled with the date and time of administration. The oxygen tubing was also noted to be on the floor next to the resident's bed.On 4/06/2026 at 1:39 PM, the nurse (LPN #22) for Resident #38 was interviewed and asked why the resident did not have their oxygen on and why the oxygen tubing was not labeled with the date and time it was administered to the resident. LPN #22 responded that 'Resident #38 gets Nebulizer Treatment every 6 hours for her asthma and that she takes the mask off herself when if finished. She must have dropped it to the floor. The surveyor then asked LPN #22 if it was a standard practice not to date and time the tubing. LPN #22 responded, I will change it out and get a new one with the date and time on it.On 4/08/2026 at 1:42 PM, the surveyor asked the Director of Nursing (DON) for a copy of the Oxygen Therapy Policy and for a copy of the resident's care plan. On 4/08/2026 at 3:39 PM, after reviewing the care plan, the surveyor had an interview with the DON. The surveyor asked the DON to review the care plan for any respiratory care focus. The resident has a diagnosis of asthma/COPD and acute bronchitis. The DON looked over the care plan and then confirmed that she did not see any focus areas in the care plan for respiratory care.

Based on observations, staff interviews, and record review, it was determined that the facility failed to ensure that the comprehensive care plan was reviewed and revised after each assessment. It was evident for 1 (Resident #38) out of 6 residents reviewed during this annual survey. The findings include:On 4/08/2026 at 1:42 PM, the surveyor asked the Director of Nursing (DON) for a copy of Resident #38's care plan.On 4/08/2026 at 3:39 PM, after reviewing the care plan, the surveyor noted that the care plan was missing a respiratory focus area. The resident has a diagnosis of asthma/COPD and acute bronchitis. Resident #38 was admitted to the facility on [DATE] and had had 2 care plan meetings since admission on [DATE] and 4/09/2026. The surveyor asked the DON to come for an interview. The surveyor asked the DON to review the care plan for any respiratory care focus. The DON looked over the care plan and then confirmed that she did not see any focus areas in the care plan for respiratory care. The DON continued to state that she was unsure how this was missed in the care plan and that she would revise the care plan as soon as possible.

Based on observation, interview, and record review, the facility failed to follow the physician orders. This was evident 1 (Resident #46) out of 1 residents observed receiving oxygen during the annual survey. The findings include: During observation rounds on 04/06/2026 at 8:06 am Resident #46's oxygen nasal cannula and tubing was found tied and hanging from the cord of the residents over the bed light fixture, not on resident, and the other end of the oxygen tubing was connected to a concentrator that was on running at 2 liters.During interview and observation rounds on 04/06/2026 at 8:10 AM Staff #3 verified that resident #46 oxygen nasal cannula and tubing was tied and hanging from the cord of residents over the bed light fixture, not on resident, and tubing was connected to a concentrator that was on running at 2 liters. Staff #3 immediately removed the oxygen nasal cannula and tubing for the cord and placed it on resident #46. Staff #3 stated, resident should have the oxygen on.Review of resident #46 medical record on 04/06/2026 at 9:54 AM revealed a physician's order dated 02/26/2026 stating the following: Oxygen: every shift O2 at 2 L/MIN CONTINUIOUS VIA N/C FOR >92 % every shift for MONITORING. Further review revealed a physician's order dated 02/10/2025 stating the following: OXYGEN PRN FOR O2 BELOW 90% AS NEEDED FOR HYPOXIA every 15 minutes as needed for HYPOXIA TITRATE OXYGEN AS NEEDED TO MAINTAIN 02 SATURATION - 90%.During an interview on 04/06/2026 at 10:05 AM with the Director of Nursing staff #2 was informed of the surveyor observations as stated above. During an interview and review of resident #46 oxygen orders on 04/08/2026 at 1:18 PM with the Director of Nursing staff #2 stated, Resident #46 oxygen PRN order dated 02/10/2025 should have been discontinued and was an oversite. I will call the doctor and get the order discontinued. Resident should be on oxygen 2 L/min by nasal cannula.

Based on observations, administrative record review, and interviews, the facility failed to ensure the staffing ratios and assigned the registered nurse for the unit was posted on the white board utilized to display the staffing assignments on the clinical unit. This was evident to be true for 1 out of 2 clinical units observed during an annual survey.The findings include:On 04/06/2026 at 08:15 AM during an observation tour of second and third floor clinical units the surveyor observed that the white boards used to display clinical staffing assignments had not been filled out for the day shift. On 04/06/2026 at 08:28 AM during a second observation tour of the third floor clinical unit the surveyor observed that the white board used to display the clinical staffing assignment did not include the ratios of staffing/resident assignments for the GNA and LPN staff members nor did the census board reflect which RN was in charge of the unit. After the surveyor took a picture of the census board the surveyor interviewed the assigned charge nurse, a LPN # 20. During the interview with LPN #20 she stated that the census and staffing assignment are to be updated during the change of shift between 0700 AM and 07:30 AM. The surveyor also observed that there was no RN identified on the census board.On 04/06/2026 at approximately 10:15 AM during an interview with the administrator and the DON the surveyors shared their initial observations of the clinical units. The administrator and DON were informed that the census boards were not completed prior to 08:15 AM.On 04/07/2026 at 09:30 AM the surveyor performed an observation tour of the third-floor nursing unit and found that there were no nursing staffing ratios posted on the white board used for posting the staff assignments.On 04/08/2026 at 11:30 AM the surveyor performed an observation tour of the third-floor clinical unit and found that there were no nursing staffing ratios posted on the white board used for posting the staff assignments. The census board did display which RN was in charge of the clinical unit.The facility was non-compliant with posting the staffing ratios related to the number of residents assigned to each licensed practical nurse (LPN) and geriatric nursing assistant (GNA) working on the clinical unit.

Based on observation, interview, and record review, the facility failed to ensure the accuracy and timeliness of controlled substance documentation, resulting in unresolved discrepancies in narcotic counts. This was evident in 2 of 2 medication count reconciliations observed and reviewed for accuracy during the recertification survey.Findings include: On 4/8/26 at 8:00 AM, during an observation of the narcotic count on Unit 2, Staff #24 was observed signing the narcotic count sheet for Tramadol. The count sheet documented 12 tablets; however, an actual pill count revealed 11 tablets, indicating an unresolved discrepancy.Continued observation revealed that Lorazepam 0.5 mg had a documented count of 59 tablets as of 6:00 AM, while 67 tablets were physically present. This finding demonstrated inaccurate documentation and a failure to reconcile controlled substances.During an interview on 4/8/26, Staff #24 stated that he was signing off medications for 4/7/26 on 4/8/26 because the nurse who administered the medication had failed to document the administration. Staff #24 further stated that he miscounted the Lorazepam when it was administered and signed it off at 6:00 AM, acknowledging the inaccuracy of the documentation.When asked whether the narcotic count on 4/7/26 was conducted with the off-going nurse, Staff #24 confirmed that it was completed. However, when questioned why the discrepancy in the Tramadol count was not identified at that time, he stated, we both missed it.The Director of Nursing (DON), who was present on the unit and informed of the findings, instructed Staff #24 to let's do another narcotic count, confirming the facility's awareness of the discrepancy at the time of the survey.On 4/8/26 at 1:00 PM, during an interview, the DON stated that Staff #24 had been in-serviced on the facility policy regarding accurate and timely documentation of controlled substances and ensuring that discrepancies in narcotic counts are promptly identified and resolved.

Based on observation and staff interview, the facility failed to ensure medications were securely stored and controlled to prevent unauthorized access, and failed to ensure timely storage of medications upon delivery in accordance with accepted professional standards of practice. This deficient practice was identified in 1 (Resident #20) of 1 resident observed for medication storage during the annual recertification survey.Findings include:On 4/7/26 at 8:00 AM, during observation rounds, the surveyor observed a brown bag containing medications with a list of medications stapled to the outside. The bag was unattended on a bedside table next to the nurse's desk and was accessible to unauthorized individuals.On 4/7/26 at 8:15 AM, a Licensed Practical Nurse (LPN), Staff # 24, was interviewed regarding the medications. The LPN stated that the pharmacy had delivered the medications during the 11:00 PM-7:00 AM shift and that he did not have time to store them where they belong, indicating a failure to ensure timely and secure storage of medications upon delivery.Additionally, on 4/7/26 at 8:20 AM, Resident # 20 was observed with a plastic bottle located under the resident's bed. Further observation revealed the bottle contained Nystatin powder, demonstrating that resident medications were not maintained in a secure manner to prevent unauthorized access.The Director of Nursing (DON) was informed of these findings on 4/7/26 at 9:00 AM.

Based on observations and interviews with facility staff it was determined the facility failed to ensure that dishes were cleaned and stored properly, dishwashing machine temperatures were consistently entered on the dishwasher log, and, foods were dated upon opening and stored in a sanitary environment. This was found to be evident during the initial tour of the kitchen during the facility's annual Medicare/Medicaid survey.Findings include:An initial tour of the kitchen was conducted on 4/6/26 at approximately 7:50AM with the Kitchen Supervisor (KS #17), and the following concerns were identified:On the counter in the area where the dishwashing machine is located, there were 2 stacks of dirty food trays, 2 dirty pitchers and a dirty bowl present. At this time Staff #17 was asked to provide the surveyor with dishwashing machine temperature logs and he accompanied the surveyor to the location of the logs. Upon review, it revealed missing temperature entries of the dishwasher; the last temperature entry was on 4/2/26. Staff #17 stated that the dishwashing machine is to be checked each day and the temperatures are to be recorded.A continued tour of the walk-in refrigerator with the KS (#17), identified the following concerns:-an opened bottle of ranch dressing half full of no date when opened-a full bottle of Jelly that was opened with no date when opened-a large bag of broccoli florets that was opened and half full of no date when opened-slices of turkey luncheon meat that was sitting unwrapped in clear plastic wrap with no date.-a head of lettuce with no date.-large plastic bin that was filled with packs of chicken with water sitting at the bottom of the pan with no date.A continued tour of the dry storage area with the KS (#17) identified a large bag of sugar that was open and half full with no date when opened.The KS (#17) accompanied the surveyor to the area where refuse is taken for discard and upon entering the hallway, there were three separate bread holders that contained packs of bread that were stored. The first bread holder had 7 shelves filled with loaves of bread and/or rolls. The second bread holder had 6 shelves with an assortment of bread and rolls, and the 3rd bread holder had bread noted on a couple of the shelves. At the time of the observation, a staff member was observed pushing a mop and bucket past the bread, then another staff member came through the hallway pushing a large bin containing residents' laundry, past the bread containers. When the surveyor asked the KS about the bread containers being stored in the hallway, he stated that this is where the bread is usually stored. He was made aware that this was a concern.An interview was conducted with the Dietary Manager (DM #4), on 4/6/26 at approximately 10:45 AM in the presence of the survey team, and he was made aware of the identified concerns. He stated that the chicken was placed in the refrigerator on March 31, 2026, and that he has seven days to cook the chicken. At this time the survey team requested a copy of the facility's food storage policy. The DM returned to the survey team, moments later with a copy of the guidance that stated that food must be cooked after 3 days of being thawed, specifically for poultry. He stated that education will be done with the staff. He also stated that the bread will be moved from the laundry hallway and all identified concerns will be addressed.During a follow-up visit to the kitchen on 4/6/26, the chicken was removed and the bread containers were removed from the laundry hallway, and all other identified concerns were being addressed. The NHA and the DON were made aware of all the identified concerns at the exit conference on 4/9/26,

Based on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form. This was evident for 1 (#46) out of 6 residents' medical records reviewed during the annual survey. The findings include: Review of Resident #46's medical record on 04/06/2026 at 9:54 AM revealed a physician's order dated 02/26/2026 stating the following: Oxygen: every shift O2 at 2 L/MIN CONTINUIOUS VIA N/C FOR >92 % every shift for MONITORING. Further review revealed a physician's order dated 02/10/2025 stating the following: OXYGEN PRN FOR O2 BELOW 90% AS NEEDED FOR HYPOXIA every 15 minutes as needed for HYPOXIA TITRATE OXYGEN AS NEEDED TO MAINTAIN 02 SATURATION - 90%.During an interview and review of Resident #46's oxygen orders on 04/08/2026 at 1:18 PM with the Director of Nursing (#2) stated, Resident #46's oxygen PRN order dated 02/10/2025 should have been discontinued and was an oversite. I will call the doctor and get the order discontinued. Resident should be on oxygen 2 L/min by nasal cannula continuous.

Based on observation and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medication located in their designated treatment carts on nursing units. This practice was observed on both units of the facility involving 3 of 4 of the posted treatment carts. The findings include; During tour on the morning of 10/7/25 at approximately 8:00 AM on the 3rd floor, surveyor passed a treatment cart with a silver lock sticking out. This surveyor continued down the hall for the intended destination and noted that the resident was eating. This surveyor back tracked to the treatment cart and noted that it still had the silver lock protruding out. This surveyor attempted to open the top drawer, and it easily opened. Inside was hydrocortisone cream, bio freeze gel, nystatin powder all labeled with identifying resident names. While this surveyor was looking through the drawers, a staff member came out of the room adjacent to the treatment cart, looked at me and pushed the cart over so she could get out of the room with her linen carts, then proceeded on her way. During this time of perusing the treatment cart, the nurse at the medication cart could be heard having some issues with the computer. She waved to the unit manager (UM) to come over to assist her. This surveyor continued for another 12 minutes to stand at the cart and go through the drawers with no one questioning who I was or asking if I was in need of some assistance. This surveyor walked down the hall to where the UM was located. Upon approaching the UM at 8:14 AM, later identified as staff #0, another treatment cart was observed located behind where the UM was standing, this cart too was unlocked. This surveyor then proceeded to peruse through this cart as well and write down what was inside, including, Orajel (numbing oral pain reliever), Anasep gel (antimicrobial gel), nystatin powder (antifungal topical powder), Silvasorb gel (antimicrobial cream), all prescribed and labeled for individual resident use. The surveyor notified the staff UM #9 of the concerns at 8:18 AM and proceeded to the 2nd floor.On the second floor noted outside room # 211 with an employee water bottle on top. There were multiple staff members around, including nursing and GNA's. This surveyor proceeded to peruse this treatment cart as well and identified the same medications; Aspercreme, nystatin powder, hydrocortisone cream, some were noted as house stock while mist medications were individually ordered and prescribed to residents. It was not until I turned my back that a nurse in the area locked the cart and walked away down the hall. This surveyor proceeded down the 2nd floor hallway and identified another treatment cart, this one was locked, the only 1 of 4 treatment carts in the facility locked without surveyor interventions. This surveyor met with the facility DON at approximately 11:30 AM and updated her on the surveyors' observations. She was made aware of the 3 unlocked treatment carts found in the facility and the concern that when staff were around, they did not question this surveyor's presence and reasoning for going through the treatment cart.

Based on observation, record review and interviews, it was determined that the facility failed to maintain residents' medical records in a secure location. This was evident for the 4 (Resident #s 8, 25, 53, and 56) of 4 residents' charts observed during the recertification/complaint survey on the 2nd floor nursing unit. Findings include: On 01/09/25 10:35 AM, an observation on the second floor revealed that residents' charts were located on top of a wide filing cabinet in the hallway. The surveyors noted that 4 charts with residents' name and physician orders were found unattended on top of the file cabinet with the physician's order pages flagged (sticking out of the chart) and visible. Resident # 8, # 25, # 53 and # 56's physician orders were visible to the public eye and were not securely stored to ensure confidentiality of the resident's medical records. On 01/09/25 at 10:35 AM, in an interview with Staff #17, Staff #17 was notified of the surveyor's concerns, and she removed the charts. When asked who was responsible for leaving the chart on top of the filing cabinet, she stated the person who wrote the rehab orders. She explained that usually new orders were flagged and placed next to the computer station for the nurse to review.

Based on interview and record review it was determined the facility failed to ensure the abuse, neglect, exploitation and misappropriation policy was developed to include the required necessary reporting and response timeframes. This was evident during the surveyor's review of 1 out of 1 policy the facility had in place to prohibit and prevent abuse, neglect, expolitation and misappropriation during the facility's recertification/complaint survey. The findings include: On 1/8/25 at 7:59AM the surveyor conducted an entrance conference with the facility's Administrator at which time the surveyor requested a copy of the facility's abuse prohibition policy and procedures. On 1/10/25 at 12:15PM the surveyor conducted a review of the facility's abuse prohibition policy and procedures and noted the following information present in the reporting requirements section of the policy which contained numerous statements and included innaccurate reporting timeframes: The administrator will direct that a report of an allegation of abuse, exploitation, neglect, or unknown injury be faxed or emailed within 24 hours to the Office of Health Care Quality, In cases of reasonable suspicion of a crime the facility must notify OHCQ and one or more law enforcement agencies, Allegations of sexual abuse must be reported to the State Agency and law enforcement within 2 hours, The facility will report within two hours after forming the suspicion, if the events that caused the suspicion result in serious bodily injury, or not later than 24 hours if the events that caused the suspicion do not result in serious bodily injury, If the result that causes the suspension results in serious bodily injury, the individual shall report the suspension immediately, but not later than two hours after forming the suspicion, If the events that cause the suspension do not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion, Other agencies, if any, that Administrator may need to notify could include law enforcement agencies, licensing boards and the local ombudsman. Further review of the policy revealed the following information under the investigation section of the policy: See policy and procedure on Investigation of Abuse, Neglect, or Injury of Unknown Origin. Continued review of the policy revealed the following information under the identification section of the policy: Staff will document the allegations on an occurrence report. On 1/10/25 at 12:30PM the surveyor requested all policies, procedures, and protocols related to abuse, neglect, exploitation, and misappropriation and investigation thereof, to be provided to the surveyor, and in response, the facility's Administrator then referred to the previously provided policy and stated: This is the policy we use. On 1/10/25 at 1:03PM the surveyor conducted an interview with the facility Administrator who confirmed this policy was the only policy in place surrounding abuse, neglect, exploitation and misappropriation, and there were no other policies or procedures that existed to provide to the surveyor. When the surveyor inquired as to the policy referencing a policy and procedure surrounding investigation, the Administrator states the policy was referring to itself, that there was no other investigation policy or procedure. When the surveyor inquired as to occurrence reports that are utilized by staff to document allegations, the Administrator confirmed the facility does not use occurrence reports. At this time, the surveyor shared their concerns with the facility Administrator who stated to the surveyor: I understand your concerns. The concern was again shared with the facility Administrator and Director of Nursing at the time of the exit conference on 1/21/25 at 2:45PM.

Based on observation and staff interview, it was determined that the facility failed to ensure that stored food items were labeled and were not expired. This was evident during the initial tour of the food service department during the recertification/complaint survey. Findings include: On [DATE] at 08:10 AM, an observation during the kitchen tour revealed that there were: a 3 lbs can of strawberry topping with a used by date of [DATE]; a 6 lbs can of navy bean with unknown expiration date; 2 undated open bags cinnamon swirl bread with raisin and 2 undated open bags of hamburger buns. On [DATE] at 08:35 AM, an observation of the walk-in refrigerator revealed 2 open undated bags of mixed salad; an open undated bag of turkey breast deli meat, and a large open plastic container of cherry topping prepared on [DATE]; however, there were no expiration dates on the above-mentioned items. On [DATE] at 08:35 AM, in an interview with Staff #15, he stated that the open, undated bread were usually used within the day and they don't usually have left overs. He was also unable to clarify the expiration date on the above-mentioned canned goods. Also, he was unable to provide the expiration dates for the above-mentioned walk-in refrigerator items.

Based on a facility reported incident MD00204294, observation, record review, and staff interviews, it was determined that the facility failed to protect a resident's right to be free from any type of abuse. This was evident for 1(#28) of 15 residents reviewed for abuse during the facility's recertification/complaint survey. The findings include: On 1/8/25 at 10:26 AM during the initial pool selection, Resident #28 was observed in room sitting in a wheelchair watching TV. Resident #28 is a Korean speaking resident but able to understand and respond with limited English. When asked if everything was ok and if he/she has any concerns, he/she said OK and no problem. On 1/13/25 at 8:09 AM, review of the facilities investigative report MD00204294 had that on 4/2/24 a nurse aide, Geriatric Nursing Assistant (GNA) #23, was screaming and calling Resident #28 stupid and was pushing the resident back into the wheelchair. A review of the video footage confirmed this allegation. The nurse aide, GNA#23, was initially suspended pending investigation, he was later terminated and reported to the board of nursing. The Director of Nursing (DON) in an interview on 1/13/25 at 8:16 AM was asked the expectations for following up on allegations of abuse. She stated that when a resident makes an allegation, if it is an employee, the expectation is for them to go directly to a supervisor to report it or to the DON or Nursing Home Administrator (NHA) so an investigation can be started. She explained further that investigations are conducted following the facility's investigative policy and procedures. On 1/14/25 at 12:40 PM In another interview with the NHA, he stated that a thorough investigation for an allegation of this abuse was done. The investigation included talking to staff that were present including the alleged perpetrator, the resident, possibly anyone else that could be affected and anyone who would have some type of data on the alleged abuse. Camera footage review and key witness statements confirmed this allegation of abuse.

Based on interview and record review it was determined the facility failed to ensure a thorough review of background check results during the hiring process for a geriatric nursing assistant who had been employed with the facility for approximately one year. This was evident for 1 (GNA #16) out of 1 previously employed geriatric nursing assistant which was reviewed during investigation of an allegation of abuse for facility reported incident #MD00206160 during the facility's recertification/complaint survey. The findings include: On 1/10/25 at approximately 10:29AM the surveyor conducted a review of the employment file of Geriatric Nursing Assistant (GNA) #16 which revealed there was no background check present within the file, at which time the surveyor requested from the facility Administrator that a copy be provided. On 1/10/25 at approximately 12:00PM the surveyor reviewed the results of the background check documented as completed on 12/11/23 for GNA #16 which revealed the following documented information: second degree assault offense, guilty disposition, and sentencing details. On 1/15/25 at approximately 1:00PM the surveyor conducted an interview with the facility Administrator who reported GNA #16 was hired as a nurse aide in training by the facility and then during their employment with the facility, acquired their GNA certification through an approved program. When the surveyor inquired to the facility Administrator as to further details about the hiring of GNA #16 who had a resulted background check, they reported they did not have further information at this time and would need to get back to the surveyor. At this time, the surveyor offered opportunity for the Administrator to provide any and all supporting documentation as to the continued hiring of GNA #16 and the human resources recruiter contact information. On 1/21/25 at 11:50AM the surveyor conducted an interview with the facility Administrator who reported they were not made aware of the background check results regarding GNA #16 who was no longer employed with the facility. When the surveyor inquired as to the facility's process for screening for employment to the Administrator, they reported that when a background check results in a finding, they were expected to be notified and a discussion surrounding eligibility would take place prior to the applicant moving forward through the employment process. At this time the surveyor requested an interview with Human Resources department staff. At this time, the surveyor shared their concern with the facility Administrator who acknowledged and confirmed understanding of the concern. On 1/21/25 at 11:52AM the surveyor conducted an interview with Human Resources Director #18 who confirmed they were not made aware of the result of GNA #16's background check by Human Resources Recruiter #19 who is no longer in the recruiter role. After surveyor intervention, Human Resources Director #18 reported to the surveyor that since the situation had been brought to their attention, they were performing an audit to ensure no other employees background checks had a similar issue. At this time, the surveyor shared their concern with Human Resources Director #18 who acknowledged understanding of the concern. On 1/21/25 at 2:45PM the surveyor reviewed the concern during the exit conference with the facility's Administrator and Director of Nursing.

Based on interview and record review it was determined the facility failed to ensure: 1) timely reporting of a serious injury of unknown source (Residents #9, #82, #6 ), and 2) timely reporting of an allegation of abuse (Resident #81). This was evident for 4 (MD#00194057, MD#002044306, MD#00212835, #MD00181864) of 20 facility reported incidents reviewed during the facility's recertification/complaint survey. Findings Include: Situation, Background, Assessment, and Recommendation (SBAR) is a communication tool that helps healthcare professionals to share information about a patient's condition in a concise manner. 1) On 01/09/25 at 03:23 PM, a review of complaints MD#00193619 and #MD#00193826 submitted to the Office of Health Care Quality (OHCQ) alleged that on 5/31/23 Resident #9 was hit by a male aide, and the resident suffered blunt force head trauma to the entire left side of the forehead. A facility reported incident MD#00194057 alleged that the Resident #9 sustained an injury of unknown origin on 5/31/23. On 1/13/25 at 1:00 PM, a review of the facility's investigation file revealed that Resident #9 sustained an injury to the left side of the forehead/face on 5/31/23 at 8:00 PM; however, the facility reported the incident to OHCQ on 7/5/23 at 2:11 PM. On 1/13/25 at 1:52 PM, in an interview with Staff #27, the surveyor asked about the event of 5/31/23 and after reviewing the documents, she stated that they determined that Resident #9's injury was from the bedrail. On 1/14/25 at 12:50 PM, in an interview with the Nursing Home Administrator (NHA), he was asked about the delay in the reporting time for injury of unknown origin related to Resident #9 for the date of 05/31/23. The NHA stated that the patient representative expressed their concerns to the police and the ombudsman suggested that a facility self-report should be submitted to the OHCQ. He stated that the facility determined that the injury was from the bedrails as stated on the SBAR. The surveyor asked if there was a witness to Resident #9's injury, after further review of the documentation provided to the surveyor, he acknowledged that the injury was unwitnessed. He stated that they were interpreting the SBAR as a known origin injury from the bedrails and therefore they did not report the incident as required. 2) On 01/10/25 at 09:32 AM, a review of the facility reported incident form related to MD#002044306 revealed that on 4/2/24 a GNA noted a bruise on the Resident #82's arm; however, the GNA later stated that she thought it was an old bruise; therefore, the GNA failed to report the findings at that time. The facility's investigation report stated that on 4/3/24 near 09:00 AM, a second GNA notified the nurse about Resident #82's left arm bruise. On 4/3/24 near 09:45 AM the administrator was notified; however, OHCQ was notified 4/3/24 at 11:46 AM. On 01/10/25 at 11:25 AM, a review of Staff #28 (LPN) progress notes on 4/3/24 at 09:00 AM revealed that Staff#28 observed that Resident #82 had a mixture of black/Red/Brown discoloration to the left lateral forearm extended to the right mid arm(back). Staff #28 documented that she was unsure of the cause of injury. On 1/10/25 at 12:00 PM, in an interview with Staff #28, she was asked about the facility's process to report injuries of unknown origin, and she stated nurses are to report any issues to the administrator immediately, complete a skin assessment, review meds, complete the SBAR, and notify the supervisor, doctor and the resident's representatives. The surveyor asked her about the specific incident, and she stated that she does not remember the incident related to Resident #82. On 1/16/25 at approximately 2:53 PM, the NHA was notified that the facility failed to report the above-mentioned incident in a timely manner. 47200 3) On 1/17/25 at 2:39PM the surveyor conducted a review of the facility's complete investigation file for facility reported incident MD#00212835. Review of the initial report made by the facility documented the report was made for an injury of unknown source for Resident #6. Surveyor review of the final radiology results report for Resident #6 revealed their x-ray results detailing serious injury was reported to the facility on [DATE] at 11:15AM. Review by the surveyor on 1/21/25 at 8:28AM revealed the facility's initial self report for serious injury was documented as having been made on 12/16/24 at 11:00AM to the Office of Health Care Quality, however, review of MD#00212835 indicated the report was made to the Office of Health Care Quality on 12/18/24. On 1/21/25 at 8:56AM the surveyor conducted an interview with the facility's Administrator and inquired as to why the serious injury of unknown source was not reported timely, to which they replied they would have to review the file and get back to the surveyor. On 1/21/25 at 9:04AM the surveyor conducted an interview with the facility Administrator who confirmed with the surveyor that the report was made late. Review by the surveyor on 1/21/25 at 9:07AM of email documentation provided by the Administrator confirmed the initial report was submitted to the Office of Health Care Quality on 12/18/24 at 2:23PM, approximately more than 51 hours after the facility received notification of the x-ray result for Resident #6. At this time, the surveyor shared their concern with the Administrator who acknowledged and confirmed understanding of the concern. On 1/21/25 at 2:45PM the surveyor reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing. 4) On 1/14/25 at 12:38PM the surveyor conducted a review of the facility's complete investigation file for facility reported incident #MD00181864 in which a report was made by the facility to the Office of Health Care Quality for an allegation of abuse for Resident #81. Review of the initial self report form contained within the file revealed documentation that an allegation of abuse was made to the facility's social worker by Resident #81 on 8/8/22 at 2:15PM. Continued review of the contents of the facility's complete investigation file revealed a resident complaint form completed by Licensed Practical Nurse #21 on 8/7/22 which documented the allegation of abuse made to them by Resident #81 and their subsequent action taken to notify the facility's Director of Nursing. On 1/14/25 at 2:32PM the surveyor reviewed the email confirmation documentation provided by the facility Administrator which indicated the initial self report was not sent to the Office of Health Care Quality until 8/8/22 at 6:32PM. On 1/14/25 at 2:32PM the surveyor conducted an interview with the facility Administrator who acknowledged understanding of the concern, and no further documentation was provided prior to surveyor exit from the facility. On 1/21/25 at 2:45PM the surveyor again reviewed the concern during the facility's exit conference with the Administrator and Director of Nursing.

Based on medical record review and interviews with staff, it was determined the physician and/or nursing staff failed to keep residents' drug regimens free from unnecessary drugs in two of 27 sampled resident records reviewed in the Stage II investigation. The findings included: 1. The physician prescribed and the nursing staff administered an excessive dose of an antipsychotic medication, [MEDICATION NAME], without a medical indication for it's use resulting in the development of a serious side effect. The physician prescribed and the nursing staff administered [MEDICATION NAME] even though the resident's medical record documented an allergy to [MEDICATION NAME]. Resident #103 is [AGE] years old and has multiple [DIAGNOSES REDACTED]. Resident #103 has a history of [MEDICAL CONDITION] caused by underlying infections. [MEDICAL CONDITION] is a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking. The onset of [MEDICAL CONDITION] is usually sudden, often within hours or a few days. [MEDICAL CONDITION] can usually be traced to one or more contributing factors, such as a severe or chronic medical illness, infection, medication, surgery, or drug or [MEDICAL CONDITION]. [MEDICAL CONDITION] is treated by identifying and treating the underlying cause. Drug treatment is used to calm a person only when severe agitation or confusion prevents the performance of a necessary medical exam or treatment, endangers the person or threatens the safety of others and/or the severe agitation does not lessen with nondrug treatments. The usual drug of choice is an antipsychotic medication, such as [MEDICATION NAME], which may lessen the disorganized thinking that accompanies [MEDICAL CONDITION]. Again, drug treatment should be used only with severe agitation or confusion. Review of the nurses' notes from 04/03/10 to 06/17/10 revealed no documented behaviors of severe agitation or confusion. Review of the medical record revealed the following nurse's note dated 06/17/10: "(increased) agitation. Stools x 1, resident received incontinence care. (resident) wanted to return to bathroom and change herself due to stools x 2. For safety (resident has a history of falls) resident brought to front nurses station with extreme resistance. Believes she can stand and after writing many notes due to her [DIAGNOSES REDACTED] I (the nurse writing the note) attempted to have her sit with supervision for safety. She resisted and made attempts to leave nurses station. Dr. notified of resident status. When GNA(Geriatric Nursing Assistant) able we provided incontinence care and (resident's name) had dinner in dining room. After dinner with 3 alarms on (to alert staff to resident's attempts to stand alone) resident found on bathroom floor. Stools x 3 in diaper. Also confusion talking about going to wedding. Dr notified. New orders for stools x3 for [DIAGNOSES REDACTED] (infection causing multiple loose stools), [MEDICATION NAME] (antiinfective used to treat [DIAGNOSES REDACTED]), [MEDICATION NAME] (a [MEDICATION NAME] used to restore normal intestinal flora), [MEDICATION NAME]". [MEDICATION NAME] is an antipsychotic medication used to treat [MEDICAL CONDITION] such as [MEDICAL CONDITION] and can be used to treat severe agitation and/or confusion associated with [MEDICAL CONDITION]. Review of the medical record revealed that at 8:00PM on 06/17/10 the physician ordered 5mg of [MEDICATION NAME] to be given now and 5mg every 12 hours as needed. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' station to return to her bathroom following her being incontinent of stool and her confusion about going to a wedding. At 10:30PM on 06/17/10 the nurse documented that the resident was sleeping. Further review of the medical record revealed no behaviors documented in nurses' notes until 6/23/10 at 10PM when a nurse wrote, "... resident expressed that she has to go to Kmart to buy nylons and raincoat for roommate, etc redirected wrote notes calm but confused PRN [MEDICATION NAME] given. Effective, resident stopped preparing to go to Kmart and talking about. Placed in bed 8PM not sleeping talking to self". Review of the MAR indicated [REDACTED]. The nurse administered a potent antipsychotic medication for the resident's confusion about needing to go shopping at 10:00PM. Review of the medical record revealed no behaviors documented in nurses' notes until 7/19/10 when a nurse wrote that "prn [MEDICATION NAME] given for agitation and effective results noted". Review of the MAR indicated [REDACTED]. The medical record does not describe the agitation. Further review of the medical record revealed that the resident went out with her family at 11:10 AM on 07/24/10 without incident. Review of the medical record revealed no further confusion or behaviors documented until 08/02/10 when a nurse wrote at 4:45PM, "GNA escorting to dining room reported resident was packing up her room to go home. (resident's name) expressed to me that she needed a shopping bag to give the photos on her window sill to the person they belonged to...". According to the nurse's note the resident ate her dinner of soup and ginger ale. Review of the medical record revealed that the nurse administered 5mg of [MEDICATION NAME] at 5:00PM on 08/02/10 "for ideation of going home and packing up". Further review of the MAR indicated [REDACTED]. The medical record does not describe the agitation at 1:00AM. Review of the medical record revealed a nurse's note written at 6:30PM on 08/02/10 stating, "GNA and myself preparing resident for bed noticed, muscular spasm like movement of neck and clenching of teeth intermittently. (physician's name) ordered [MEDICATION NAME] x 1 for nausea and vomiting and possible dyskinesia and to DC (discontinue) [MEDICATION NAME]". 25mg of [MEDICATION NAME] was given at 7:30PM. Dyskinesia is the involuntary movements of the limbs and face and include tardive dyskinesia and [DIAGNOSES REDACTED]. [MEDICATION NAME] has the potential for severe side effects such as tardive dyskinesia (the involuntary repetitive movements of the facial muscles, tongue, arms and legs), and [DIAGNOSES REDACTED] (the prolonged abnormal contractions of muscle groups that include: spasm of the neck muscles, sometimes progressing to tightness of the throat, swallowing difficulty, difficulty breathing, and/or protrusion of the tongue). These symptoms may occur in susceptible individuals during the first few days of treatment. While these symptoms can occur at low doses, they occur more frequently and with greater severity at higher doses. Therefore, [MEDICATION NAME] in geriatric patients generally warrants the use of lower doses such as 0.5 to 2mg orally two to three times a day. Review of the medical record revealed a nurse's note dated 08/03/10 at 5:00AM stating, "noted muscular spasm of head, neck, and clenching of teeth". A nurse wrote on 08/03/10 at 11:00AM, "minimal spasms noted of head and neck...MD notified new order for ua c&s to r/o UTI (urine culture to rule out a urinary tract infection)...addition to allergies [REDACTED].@ 2:30PM pt attempting to get OOB (out of bed) patient re-directed several attempts unable to re-direct MD notified of patient's condition new order for [MEDICATION NAME] 1mg po x 1 dose now...". [MEDICATION NAME] is an antianxiety medication. The [MEDICATION NAME] was given at 2:50PM. Review of the medical record revealed a nurse's noted dated 08/03/10 stating that the physician had been in to see the resident and ordered a chest x-ray and blood tests to be done in the morning. The physician also ordered [MEDICATION NAME] 1mg BID for "cogwheeling and dyskinesia". 1mg of [MEDICATION NAME] was administered at @8PM. [MEDICATION NAME] is a medication used to treat the adverse effects of medications such as [MEDICATION NAME]. [MEDICATION NAME] also has the potential for serious side effects. After the [MEDICATION NAME] was administered the nurse noted "spasms of neck and chin decreasing during shift and absent during periods of sleep...". The chest x-ray done on 08/04/10 revealed a left lower lobe infiltrate(infection in left lung). The physician was notified and ordered [MEDICATION NAME] (an antibiotic) to treat the infection and discontinued the [MEDICATION NAME]. Further review of the medical record revealed a list of drug allergies [REDACTED]. Review of the medical record revealed that the [MEDICATION NAME] had been listed as an allergy since 09/20/09 when the resident had been readmitted to the facility following a hospitalization . Further review of the medical record revealed that on 09/19/09 [MEDICATION NAME] had been discontinued secondary to a dystonic reaction. [MEDICATION NAME] is an antipsychotic medication that has the same potential side effects of [MEDICATION NAME] such as tardive dyskinesia and [DIAGNOSES REDACTED]. During an interview at 4:00PM on 9/15/10, the physician stated she was not aware of the allergy to [MEDICATION NAME] even though it was documented in the medical record. Interview with the pharmacist at 2:15PM on 09/15/10 revealed that when the order was sent to the pharmacy, the [MEDICATION NAME] flagged as an allergy but someone at the facility noted that the physician was aware and to send the medication. Interview with the Director of Nursing (DON) on 09/15/10 revealed that the practice of the nursing staff in June 2010 was to "click off" on the allergy flag from the pharmacy and not to call the physician to verify if the medication was safe to be given or not. According to the DON this practice is no longer allowed. The nursing staff must notify the physician of any known allergies [REDACTED]. An interview was conducted on 09/15/10 with the nurse who wrote the notes concerning the resident's behaviors and confusion on 06/17/10, 06/23/10, and 08/02/10. The nurse stated that the resident was confused and resisting care but did not exhibit any confusion or agitation that would have resulted in physical harm to herself or others. The nurse also stated that she was unaware of the allergy to [MEDICATION NAME] even though it was documented in the medical record. During further interview on 09/15/10, the physician could not state her rational for choosing 5mg of [MEDICATION NAME] to treat the documented confusion and behaviors. The physician prescribed and the nursing staff administered an excessive dose of an antipsychotic medication, [MEDICATION NAME], without a medical indication for it's use resulting in the resident developing intermittent muscular spasms of the head and neck, clenching of the teeth, and cogwheeling (an abnormal rigidity in muscle tissue characterized by jerky movements when the muscle is passively stretched) [MEDICATION NAME] greater than 24 hours that required treatment with [MEDICATION NAME] and [MEDICATION NAME]. 2. The nursing staff failed to recognize that a B-12 injection was not being adminstered as ordered resulting in the resident receiving extra needle sticks and extra medication. Resident 68 was admitted to the facility with multiple [DIAGNOSES REDACTED]. According to the medical record the resident requires extensive assistance from the staff for care, comfort and safety. B-12 is a vitamin that is usually administered by injection. The vitamin plays a key role in normal functioning of the brain and muscles. Review of the medical record revealed a physician's orders [REDACTED]. According the physician's orders [REDACTED]. Review of the medication record revealed that the resident received the medication starting on 7/12/10 and continued to receive the medication weekly through July as ordered, but then continued to receive the B-12 weekly through the month of August. Further review of the MEDICATION ORDERS FOR [REDACTED]. The resident received the B-12 medication twice within 2 days. Due to the nursing staff failing to recognize that the B-12 was not being adminstered as ordered resulted in the resident receiving extra needle sticks and extra medication.

Based on medical record review and interviews with staff, it was determined the physician failed to completely and accurately assess residents' status when planning care in three of 27 sampled resident records reviewed in the Stage II investigation. The findings included: 1. The physician prescribed a potent antipsychotic medication, [MEDICATION NAME], when notified by nursing of a resident's agitation and confusion on 06/17/10 (wanting to go to her bathroom and talking about going to a wedding) and then failed to assess the appropriateness of it's continued use for mild confusion and agitation. The continued use of 5mg of [MEDICATION NAME] for mild confusion and agitation resulted in the resident developing muscle spasms of the neck and head, clenching of the teeth and muscle rigidity of the extremities. Resident #103 has multiple [DIAGNOSES REDACTED]. Resident #103 has a history of [MEDICAL CONDITION] caused by underlying infections. Review of the medical record revealed that at 8:00PM on 06/17/10 the physician ordered 5mg of [MEDICATION NAME] to be given now and 5mg every 12 hours as needed. During an interview at 4:00PM on 09/15/10, the physician could not state her rational for choosing 5mg of [MEDICATION NAME] to treat the documented confusion and behaviors of 06/17/10. When asked if 5mg of [MEDICATION NAME] was appropriate for treating behaviors of packing belongings, talking about going to Kmart, etc the physician stated that the use of [MEDICATION NAME] for those behaviors was a "nursing issue" and that she (the physician) was not aware that nursing was administering 5mg of [MEDICATION NAME] for mild confusion. Review of the medical record revealed that the physician was in to see the resident on 06/18/10 and 07/16/10 and had the opportunity to assess the resident's behaviors and confusion and the appropriateness of the nursing staff's use of 5mg of [MEDICATION NAME]. An interview was conducted by this surveyor on 09/15/10 with the nurse who wrote the notes concerning the resident's behaviors and confusion on 06/17/10, 06/23/10, and 08/02/10. The nurse stated that the resident was confused and resisting care but did not exhibit any confusion or agitation that would have resulted in physical harm to herself or others. The physician chose a potent antipsychotic drug at an excessive dose for a [AGE] year old resident who displayed mild agitation and confusion without a thorough assessment of the resident's behaviors and then failed to reassess the appropriateness of the use of [MEDICATION NAME] for intermittent mild confusion and agitation resulting in the resident developing serious side effects requiring treatment with additional medications. See Cross Reference CMS 2567, F329 (Resident #103). 2. The physician failed to accurately assess a resident's skin upon admission to the facility. Resident #186 was admitted to the facility on [DATE] following a hospitalization . Review of the medical record revealed a nursing assessment done on admission that documented a Stage II pressure ulcer on the resident's left buttock. A pressure ulcer is a lesion caused by unrelieved pressure resulting in damage to the tissues. Pressure ulcers are staged according to the extent of tissue damage. The stages range from Stage I (intact skin with persistent redness), Stage II (superficial skin loss such as a blister or shallow crater), Stage III (deep crater of skin and subcutaneous tissue damage) or Stage IV (extensive destruction with damage to muscle and bone). Further review of the medical record revealed a Admission History and Physical done on 08/25/10 by the physician. Review of the History and Physical revealed that the physician assessed the resident's skin and documented diffuse ecchymosis (bruising) but did not document the Stage II pressure ulcer. 2. The admitting physicians's history and physical of a newly admitted resident was inaccurate. Subsequently,the physician did not order treatments for the resident's pressure ulcers/nutritional status. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Resident # 180 was admitted to the facility on [DATE] with metastatic [MEDICAL CONDITION]. Upon admission, the nursing staff documented the resident as having the following pressure ulcers: (1) STDI (Suspected Deep Tissue Injury) on the right buttock, (1) Stage IV ulcer on her coccyx (tailbone) and (2) Stage II ulcers on the left buttocks . (Refer to F314 for definitions/details) The resident's physician performed an Admission History and Physical on 9/1/10 and noted "no rashes, no [MEDICAL CONDITION], no ulcers". Therefore, no treatment was prescribed for the resident's ulcers. (refer to F314). Interview of the physician on 9/15/10 as to why no treatments were prescribed for the resident's ulcers revealed that the physician stated, "The staff did not tell me about the ulcers." Subsequently, after initial resident assessment, the physician did not order treatments for this resident. Additionally, the resident's admission blood work-up obtained on 9/1/10 indicated the resident had a low [MEDICATION NAME] level. The resident's [MEDICATION NAME] level was 2.2 g/dl (grams/Deciliter). The normal level is 3.2 -4.6 g/dl. Low [MEDICATION NAME] levels can indicate low protein stores. Adequate protein is necessary for wound healing. The physician did not order protein supplements until 9/7/10. The physician failed to adequately assess this resident's skin condition upon admission, therefore no treatments were prescribed for this resident to address her pressure ulcers and compromised nutritional status.