Every finding on record at Millard County Care and Rehabilitation

Based on interview and record review, it was found that for 4 out of 20 sampled residents, the facility failed to ensure that a licensed pharmacist performed a drug regimen review at least once a month and failed to act upon the pharmacist's reports of any irregularities to the attending physician and the facility's medical director and director of nursing. Irregularities included, but were not limited to, any drug that met the criteria set forth in paragraph (d) of this section for an unnecessary drug. (ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that was sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. (iii) The attending physician must document in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. If there was to be no change in the medication, the attending physician should have documented his or her rationale in the resident's medical record. Specifically, the facility failed to maintain documentation in the medical records to demonstrate that a pharmacist reviewed the residents' medications, identified potential irregularities, or provided recommendations to the attending physician and one resident had a recommendation by the pharmacist in November 2025 and it was not acted upon until February 2026. Resident Identifiers: 4, 6, 8, and 54.1. Resident 6 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Parkinson's disease without dyskinesia. Review of resident 6's medical record was completed on 4/27/26 through 4/30/26.Resident 6's monthly pharmacist medication regimen review notes were reviewed. There were no monthly notes for the months of March 2026 or April 2026. 2. Resident 4 was admitted [DATE], and readmitted on [DATE] with diagnoses including, but not limited to unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety disorder unspecified.Resident 4's medical record was reviewed from 4/27/26 through 4/30/26.Resident 4's monthly pharmacist medication regimen review notes were reviewed. There were no monthly notes for the months of March 2026 or April 2026. 3. Resident 54 was admitted [DATE], and readmitted on [DATE] with diagnoses including, but not limited to Alzheimer's disease with early onset and dementia in other diseases classified elsewhere.Resident 54's medical record was reviewed from 4/27/26 through 4/30/26. Resident 54's monthly pharmacist medication regimen review notes were reviewed. There were no monthly notes for the months of March 2026 or April 2026. On 4/30/26 at 1:08 PMm an interview was conducted with the Director of Nursing (DON). The DON stated that monthly pharmacist review notes should be uploaded into each resident's electronic medical record. The DON stated that the facility pharmacist had not completed pharmacy reviews for the months of March 2026 and April 2026. 4. Resident 8's medical record was reviewed 4/27/26 through 4/30/26.Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, psychotic disorder with delusions due to known physiological condition, dementia, and major depressive disorder.A nurse's note on 11/1/25 at 4:31 PM indicated, .The pharmacist called and asked how she was doing on the Seroquel vs the Abilify. I told him that she has done better with her behaviors, but she does have episodes where she gets irritable or emotional and does get the PRN [as needed] Haldol at times and her MD [medical doctor] is notified. He felt that she may benefit from a low dose of Seroquel during the day. She does tend to get more anxious towards the afternoon or when there is a lot of commotion around her.A nurse's note on 2/3/26 at 5:10 PM indicated, .[Physician name redacted] came to see resident at shift change. He asked if there were any concerns. I talked to him about her recent behaviors (yelling, hitting and resistant to care). I reminded him that he was sent a message, and I also told him that a while back, the pharmacist was doing a review of her medications, and at that time she had the PRN Haldol. I told him that PRN psychotropics can only be for 14 days and that he recommended an alternative option by a low dose of Seroquel during the day since she has done better at night with it. He wrote an order for Seroquel 25mg [milligrams] PO [by mouth] QAM [every morning] .A physician's order dated 2/4/26 at 6:00 AM indicated quetiapine fumarate [generic name for Seroquel; an antipsychotic/antimanic medication] oral tablet 25 MG once a day.An interview was conducted on 4/30/26 at 10:08 AM with Licensed Practical Nurse (LPN) 1 and she stated that she did not talk to the doctor about the recommendation from the pharmacist in November 2025 because resident 8 had not needed PRN haldol around that time.An interview was conducted on 4/30/26 at 1:14 PM with the Director of Nursing (DON) and she stated that it did not look like the pharmacist's recommendation from November 2025 was completed until February 2026 when a nurse mentioned it to the physician. The DON stated that she does not have time to stay on top of that because she was too busy.

Based on interview and record review, it was found that for 3 out of 20 sampled residents, the facility failed to ensure all alleged violations involving abuse and injuries of unknown sources were thoroughly investigated. Specifically, the facility failed to initiate or document an investigation into an allegation of sexual abuse and three separate incidents involving major injuries to determine the cause, identify responsible parties, or implement corrective actions to prevent further potential abuse. Resident Identifiers: 3, 6, and 59.1. Resident 59 was admitted to the facility on [DATE], readmitted on [DATE], and discharged [DATE] with diagnoses which included hemiplegia and hemiparesisReview of resident 59's medical record was completed on 4/27/26 through 4/30/26.A Quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 59 had a Brief Interview of Mental Status (BIMS) score of 6 which indicated severely impaired cognition.On 1/31/26 at 5:22 PM, a Nursing Note revealed the following, his roommate called the bell to say he had fallen, staff found him on the floor between his bed and the window. He had tried to get out of bed by himself and hurt his knees and felt a pop in themboth. Staff assisted him up and onto the gurney to take him to the ER [emergency room] for eval [evaluation] of injuries. DON [Director of Nursing], Son [name redacted] and Dr. [name redacted] notified. He was taken over to the [name redacted] Hospital for eval at 1600 [4:00 PM].On 2/1/26 at 5:20 PM, a Nursing Note revealed the following, He got back from the ER [emergency room] at 1407 [2:07 PM] via hospital bed and staff X [times] 2 and one of our staff. He is comfort cares and had his regular meds DC'd [discontinued].He moaned out in pain when transferred to his bed on readmit.He has immobilizing braces on both legs d/t [due to] fractures of both femurs post fall yesterday and an indwelling. He has heel protectors on both feet. His bones are not strong enough to have surgery so is now on comfort cares. He opened his eyes a couple of times but has not replied back with words to staff- just grunting.On 4/30/26 at 12:44 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he was made aware of resident 59's bilateral femur fractures. The ADM stated that resident 59 was totally dependent for any type of transfer. The ADM stated that looking back, resident 59 had a change in condition and thought he could get up, which could have caused the fall. The ADM stated that he did not feel there was any neglect or abuse that caused the major injury for resident 59. The ADM stated that he did not investigate the cause of the injury regarding resident 59.2. Resident 6 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Parkinson's disease without dyskinesia.Review of resident 6's medical record was completed on 4/27/26 through 4/30/26.A Quarterly MDS dated [DATE] revealed that resident 6 had a BIMS score of 0 which indicated resident us rarely/never understood.On 11/1/25 at 6:30 PM, an Incident Nursing Note revealed the following, resident was sitting in w/c [wheelchair] in [sic] north side dining room. resident alarm went off, found in supine position on floor, denies hitting head, denies injury, assisted off ground and into chair, able to bear weight, no signs of injury noted. resident moved to nurses station deskOn 11/4/25 at 1:51 PM, a Nursing Note revealed the following, When aides were trying to get [resident 6] out of bed, they stated that he was c/o [complaining of] of [sic] pain in his left leg. I went in to assess and he did has [sic] some tenderness and wince when moving the left leg. 2 person assist to get resident up out of bed and into the bathroom. Resident was able to bear weight on both legs.Transferred to recliner, noticed that he is still complaining of pain in his left leg, rubbing his upper thigh .Notfied [sic] MD [medical doctor], to see if we could get an xray of his left hip and leg d/t [due to] increased complaint of pain when transferring or moving left leg.On 11/4/25 at 4:59 PM, a Nursing Note revealed the following, Notified daughters that [name redacted] was c/o [complaining of] pain in his left leg and asked if it was ok to have xrays done .Dr. [name redacted] gave order to xray left hip and upper leg. Transferred into w/c [wheelchair] and taken to hospital forxrays [sic]. Xray results sent to Dr. [name redacted], there is a femur fracture .They don't want to do any surgery.On 4/30/26 at 12:44 PM, an interview was conducted with the ADM. The ADM stated that he was made aware of resident 6's left femur fracture. The ADM stated that he did not feel there was any neglect or abuse that caused the major injury for resident 6. The ADM stated that he did not investigate the cause of the injury regarding resident 6.3. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease and scoliosis. Review of resident 3's medical record was completed on 4/27/26 through 4/30/26.A Quarterly MDS dated [DATE] revealed that resident 3 had a BIMS score of 7 which indicated severely impaired cognition.On 4/6/25 at 3:31AM, an Incident Nursing Note revealed the following, 0310 [3:10 AM] resident bed alarm went off, when staff went down, resident found in kneeling [sic] position leaning into her recliner. resident [sic] states her walker didn't go where she was going. resident [sic] states she was getting up from bed to go to bathroom [sic]. able to stand, c/o [complaint of] left knee, left elbow pain- no visible injury, right pinky pain no visible injury, right ring finger abrasion.On 4/16/25 at 4:24 PM, a Nursing Note revealed the following, Resident had ORIF [Open Reduction and Internal Fixation] to R [right] 4/5 [fourth and fifth] MC [metacarpal] Fx [fractures], at [name redacted] this AM. She returned to [name redacted] from surgery at 12:50.On 4/30/26 at 12:44 PM, an interview was conducted with the ADM. The ADM stated that he was made aware of resident 3's fractures to her right wrist. The ADM stated that resident 3 is very independent and she would want to be able to wander the facility at her leisure. The ADM stated that he did not feel there was any neglect or abuse that caused the major injury. The ADM stated that he did not investigate the cause of the injury.

Based on interview and record review, it was found that for 4 out of 20 sampled residents, the facility failed to ensure all alleged violations of abuse, including injuries of unknown source, were reported immediately to the State Survey Agency and other officials in accordance with State law. Specifically, the facility failed to report an allegation of sexual abuse and incidents involving major injuries to the State Agency, which prevented a timely investigation and oversight of resident safety. Resident Identifiers: 3, 6, 19, and 59.1. Resident 59 was admitted to the facility on [DATE], readmitted on [DATE], and discharged [DATE] with diagnoses which included hemiplegia and hemiparesis.Review of resident 59's medical record was completed on 4/27/26 through 4/30/26.A Quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 59 had a Brief Interview of Mental Status (BIMS) score of 6 which indicated severely impaired cognition.On 1/31/26 at 5:22 PM, a Nursing Note revealed the following, his roommate called the bell to say he had fallen, staff found him on the floor between his bed and the window. He had tried to get out of bed by himself and hurt his knees and felt a pop in themboth. Staff assisted him up and onto the gurney to take him to the ER [emergency room] for eval [evaluation] of injuries. DON [Director of Nursing], Son [name redacted] and Dr. [name redacted] notified. He was taken over to the [name redacted] Hospital for eval at 1600 [4:00 PM].On 2/1/26 at 5:20 PM, a Nursing Note revealed the following, He got back from the ER [emergency room] at 1407 [2:07 PM] via hospital bed and staff X [times] 2 and one of our staff. He is comfort cares and had his regular meds DC'd [discontinued].He moaned out in pain when transferred to his bed on readmit.He has immobilizing braces on both legs d/t [due to] fractures of both femurs post fall yesterday and an indwelling. He has heel protectors on both feet. His bones are not strong enough to have surgery so is now on comfort cares. He opened his eyes a couple of times but has not replied back with words to staff- just grunting.On 4/30/26 at 12:44 PM, an interview was conducted with the Administrator (ADM).The ADM stated that he reported the incident involving resident 59 on the state's patient safety website, but not to the State Survey Agency's incident reporting website. 2. Resident 6 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Parkinson's disease without dyskinesia. Review of resident 6's medical record was completed on 4/27/26 through 4/30/26.A Quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 6 had a Brief Interview of Mental Status (BIMS) score of 0 which indicated resident us rarely/never understood.On 11/1/25 at 6:30 PM, an Incident Nursing Note revealed the following, resident was sitting in w/c [wheelchair] in [sic] north side dining room. resident alarm went off, found in supine position on floor, denies hitting head, denies injury, assisted off ground and into chair, able to bear weight, no signs of injury noted. resident moved to nurses station deskOn 11/4/25 at 1:51 PM, a Nursing Note revealed the following, When aides were trying to get [resident 6] out of bed, they stated that he was c/o [complaining of] of [sic] pain in his left leg. I went in to assess and he did has [sic] some tenderness and wince when moving the left leg. 2 person assist to get resident up out of bed and into the bathroom. Resident was able to bear weight on both legs.Transferred to recliner, noticed that he is still complaining of pain in his left leg, rubbing his upper thigh .Notfied [sic] MD [medical doctor], to see if we could get an xray of his left hip and leg d/t [due to] increased complaint of pain when transferring or moving left leg.On 11/4/25 at 4:59 PM, a Nursing Note revealed the following, Notified daughters that [name redacted] was c/o [complaining of] pain in his left leg and asked if it was ok to have xrays done .Dr. [name redacted] gave order to xray left hip and upper leg. Transferred into w/c [wheelchair] and taken to hospital forxrays [sic]. Xray results sent to Dr. [name redacted], there is a femur fracture .They don't want to do any surgery.On 4/30/26 at 12:44 PM, an interview was conducted with the ADM.The ADM stated that he reported the incident involving resident 6 on the state's patient safety website, but not to the State Survey Agency's incident reporting website. 3. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease and scoliosis. Review of resident 3's medical record was completed on 4/27/26 through 4/30/26.A Quarterly MDS dated [DATE] revealed that resident 3 had a BIMS score of 7 which indicated severely impaired cognition.On 4/6/25 at 3:31AM, an Incident Nursing Note revealed the following, 0310 [3:10 AM] resident bed alarm went off, when staff went down, resident found in kneeling [sic] position leaning into her recliner. resident [sic] states her walker didn't go where she was going. resident [sic] states she was getting up from bed to go to [sic] bathroom. able to stand, c/o [complaint of] left knee, left elbow pain- no visible injury, right pinky pain no visible injury, right ring finger abrasion.On 4/16/25 at 4:24 PM, a Nursing Note revealed the following, Resident had ORIF [Open Reduction and Internal Fixation] to R [right] 4/5 [fourth and fifth] MC [metacarpal] Fx [fractures], at [name redacted] this AM. She returned to [name redacted] from surgery at 12:50.On 4/30/26 at 12:44 PM, an interview was conducted with the ADM. The ADM stated that he reported the incident involving resident 3 on the state's patient safety website, but not to the State Survey Agency's incident reporting website. 4. Res 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, adjustment disorder with anxiety, hearing loss, visual loss, and age-related physical debility.A 1-page document was located in the facility's abuse binder titled with resident 19's name, a date of 2/23/24 [sic], and Outside person - possible molest. It indicated that on 2/23/25 at 5:34 PM, resident 19's nephew called the Administrator (ADM) and notified him that his mother, who was resident 19's sister, was riled up and anxious and had told him that she felt like [resident 19] had reported she had been molested. He then stated he, [nephew's name redacted] felt his mother was emotionally ill right now and not able to be reasonable or competent and was not far from having a breakdown. He stated several times that in the conversation that he did not think [resident 19] had been molested, sexually or otherwise. He just said he felt like the nurse who addressed the concerns with his mother, [resident 19's sister's name redacted] had tried to reassure her and told her, [resident 19's sister's name redacted] that she had been delusional several times the last month and that she had almost never been in her room the last few days and that she probably had not been molested, but then offered several ideas for watching her and monitoring for risk. [Resident 19's nephew's name redacted] felt like that conversation had just made things worse for his mothers' lack of well-being. He didn't blame the nurse, he just stated that we needed to try to help his mom feel heard, rather than be dismissive. This because there had been some sexual misconduct in [resident 19's] life several decades ago by a person in a position of authority. I confirmed with [resident 19's nephew's name redacted] that he thought [resident 19] was delusional and confused and had not been sexually assaulted and that his mother was not in a good place emotionally right now. I assured [resident 19's nephew's name redacted] I would nonetheless, investigate, in a non-urgent way as it was not a viable allegation. It further indicated, I have known [resident 19's nephew's name redacted] for over 30 years and known [resident 19's sister] superficially for same. Because [resident 19's nephew's name redacted] reported he did not think the report he got from his mom was credible, [name redacted] did not report initially to any of the agencies or law enforcement. After talking to the resident, [resident 19] it is felt the sister is not in a good place emotionally and may have been triggered by something and reliving a memory from decades ago. [Resident 19's] interview does not support any credible allegation of sexual abuse/molestation. The document was signed by the ADM.Resident 19's medical record was reviewed 4/27/26 through 4/30/26 and there was nothing documented regarding this incident.On 4/29/26 at 1:54 PM, an interview was conducted with the ADM who stated resident 19's nephew called to tell him that his mother, who was resident 19's sister and POA (Power of Attorney), was getting confused and had worsening dementia and requested to have resident 19's sister, his mother, taken off as POA and the nephew took over as POA during that call. The ADM stated that he believed the main reason for the call was to change resident 19's POA, and that the abuse allegation was reported just to show how confused his mom, resident 19's sister, was getting. The ADM stated he interviewed resident 19 and she denied it and that nobody had touched her. The ADM stated that resident 19's sister came into the facility and that she was unable to provide any more details besides resident 19 reporting that a man had groped her breast. The ADM stated he specifically asked resident 19 if a man had groped her breast and she said no. The ADM stated that resident 19 had said a housekeeper was mean to her and that he asked to clarify that it was a housekeeper here and she said, no, it was up in [City name redacted]. The ADM stated he did not report it because he felt it was not a credible allegation of abuse because there was more story to it, about resident 19's sister's dementia progressing and that he could not get anymore information out of resident 19's sister and because resident 19 denied it. The ADM stated that resident 19's nephew had told him that resident 19 had been assaulted at another facility in [City name redacted] when resident 19's sister was her POA and that resident 19's nephew thought resident 19's sister was just reliving that and getting that confused.

Based on interview and record review, it was determined that for 3 out of 20 sampled residents, that the facility did not ensure that residents who use psychotropic drugs received gradual dose reductions and did not ensure that PRN (as needed) orders for anti-psychotic drugs were limited to 14 days. Specifically, the facility did not document a gradual dose reduction attempt of psychotropic medications for two residents prior to January 2026 and one resident had an antipsychotic medication prescribed for more than 14 days. Resident identifiers: 4, 8, and 54. 1. Resident 4 was admitted on [DATE], and readmitted on [DATE] with diagnoses including, but not limited to unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety disorder unspecified.Resident 4's medical record was reviewed from 4/27/26 through 4/30/26. The facility completed a psychotropic medication review and gradual dose reduction attempt in January 2026. There were no other documented gradual dose reduction attempts in the residents medical record.2. Resident 54 was admitted on [DATE], and readmitted on [DATE] with diagnoses including, but not limited to Alzheimer's disease with early onset, dementia in other diseases classified elsewhere mild with anxiety, and psychotic disorder with hallucinations due to known physiological conditions.Resident 54's medical record was reviewed from 4/27/26 through 4/30/26. The facility completed a psychotropic medication review and gradual dose reduction attempt in January 2026. There were no other documented gradual dose reduction attempts in the residents medical record.On 4/29/26 at 9:34 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the most recent psychotropic review and gradual dose reduction attempts at the facility were conducted in January 2026. The DON stated that the facility did not complete any gradual dose reduction attempts or psychotropic reviews prior to January 2026, but that they should be completed quarterly. 3. Resident 8's medical record was reviewed 4/27/26 through 4/30/26.Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, psychotic disorder with delusions due to known physiological condition, dementia, and major depressive disorder.A physician's order dated 2/8/26 at 9:10 AM indicated haloperidol lactate (an antipsychotic/antimanic agent) injection solution 5 MG/ML (milligrams/milliliter). Inject 0.2 ml intramuscularly every 12 hours as needed (PRN) for delusions, hallucinations, paranoia, and agitation. No end date was given in the order.The medication administration record (MAR) was reviewed for the months of February 2026, March 2026, and April 2026 the MARs indicated resident 8 received the PRN haloperidol lactate injection on 2/8/26 at 9:15 AM and 4/21/26 at 4:35 PM. No end date was documented on the MAR.On 4/30/26 at 8:48 AM, an interview was conducted with the Director of Nursing (DON) who stated her PRN haldol was more than 14 days because it was only used for extreme reasons, but that it should have been limited to 14 days and that the doctor did not document a reason for the extended order.

Based on record review and interview, it was found that for 4 out of 20 sampled residents, the facility failed to ensure that each resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Specifically, five residents or resident representatives were not informed of risks and benefits, treatment or treatment alternatives or options in advance of starting psychotropic medications. Resident identifiers: 4, 6, 8, and 54. 1. Resident 8's medical record was reviewed 4/27/26 through 4/30/26.Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, psychotic disorder with delusions due to known physiological condition, dementia, and major depressive disorder.Physician orders were reviewed and indicated resident 8 was started on the following psychotropic medications:Haloperidol lactate injection solution on 2/8/26 at 9:10 AM,Donepezil HCl (hydrochloride) oral tablet on 4/15/26 at 3:51 PM,Buspirone HCl oral tablet on 7/30/25 at 2:00 PM,Quietiapine fumarate oral tablet on 9/18/25 at 6:00 PM, andSertraline HCl oral tablet on 4/19/25 at 6:00 AM.No documentation that indicated the resident or resident representative was informed of the risks and benefits, treatment or treatment alternatives or options in advance of starting any psychotropic medications was found in the medical record or provided by staff.On 4/30/26 at 8:35 AM, an interview was conducted with the Director of Nursing (DON) who stated they notify the family when residents start or change the medication doses, but they do not discuss risks and benefits, give alternative options or have them sign a consent.2. Resident 4 was admitted [DATE], and readmitted [DATE] with diagnoses including, but not limited to unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety disorder unspecified.Resident 4's medical record was reviewed from 4/27/26 through 4/30/26.Physician orders were reviewed and indicated resident 4 was started on the following psychotropic medications:Zaleplon Oral Capsule on 1/22/26 at 6:00pmQuetiapine Fumarate Oral Tablet on 1/22/26 at 6:00pm, andBusprione HCl (hydrochloride) Oral Tablet on 2/23/26 at 2:00pmNo documentation that indicated the resident or resident representative was informed of the risks and benefits, treatment or treatment alternatives or options in advance of starting any psychotropic medications was found in the medical record or provided by staff.3. Resident 54 was admitted [DATE], readmitted [DATE] with diagnoses including, but not limited to Alzheimer's disease with early onset and dementia in other diseases classified elsewhere.Resident 54's medical record was reviewed from 4/27/26 through 4/30/26.Physician orders were reviewed and indicated resident 54 was started on the following psychotropic medications:Sertraline HCl (hydrochloride) oral tablet on 9/19/24 at 6:00am, andQuetiapine Fumarate oral tablet on 3/10/26 at 6:00pm No documentation that indicated the resident or resident representative was informed of the risks and benefits, treatment or treatment alternatives or options in advance of starting any psychotropic medications was found in the medical record or provided by staff.4. Resident 6 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Parkinson's disease without dyskinesia. Review of resident 6's medical record was completed on 4/27/26 through 4/30/26.Physician orders were reviewed and indicated resident 6 was started on the following psychotropic medications:Buspirone HCl Oral Tablet on 6/27/25,Seroquel Oral Tablet on 1/22/26, andSertraline HCl Oral Capsule on 6/27/25.No documentation that indicated the resident or resident representative was informed of the risks and benefits, treatment or treatment alternatives or options in advance of starting any psychotropic medications was found in the medical record or provided by staff.

Based on record review and interview, it was determined that for 3 out of 20 sampled residents, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized. Specifically, one resident's progress notes were entered late, at least 13 times with one being documented 48 days late, and 2 resident's pharmacy reviews were not readily available. Resident identifiers: 4, 23, 54 1. Resident 23's progress notes were reviewed:An Incident Note was documented on 10/24/25 at 1:39 PM for 9/30/25 at 4:50 PM, which was 24 days late;A Nurses Note was documented on 11/18/25 at 9:36 AM for 11/2/25 at 4:36 PM, which was 16 days late;A Social Services Note was documented on 1/5/26 at 10:25 AM for 11/18/25 at 10:23 AM, which was 48 days late;A Nurses Note was documented on 2/6/26 at 9:36 PM for 1/29/26 at 4:36 PM, which was 8 days late;A Nurses Note was documented on 3/2/26 at 9:49 AM for 2/28/26 at 4:48 PM, which was 2 days late;A Social Services Note was documented on 3/27/26 at 3:30 PM for 2/25/26 at 3:30 PM, which was 30 days late;A Nurses Note was documented on 3/5/26 at 12:38 PM for 3/2/26 at 4:37 PM, which was 3 days late;A Nurses Note was documented on 3/8/26 at 6:38 PM for 3/6/26 at 4:37 PM, which was 2 days late;A Nurses Note was documented on 3/20/26 at 7:23 PM for 3/19/26 at 4:22 PM, which was 1 day late;A Nurses Note was documented on 3/27/26 at 1:06 PM for 3/23/26 at 4:55 PM, which was 4 days late;A Nurses Note was documented on 4/6/26 at 9:42 AM for 4/4/26 at 4:41 PM, which was 2 days late;An Incident Note was documented on 4/17/26 at 12:28 PM for 4/16/26 at 12:17 PM, which was 1 day late; andA Nurses Note was documented on 4/22/26 at 9:23 AM for 4/17/26 at 4:45 PM, which was 5 days late.On 4/30/26 at 9:50 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1 and she stated she needed time to think about her notes because she wanted to put in a thorough note. LPN 1 further stated that she had time to finish her nursing duties but she was just a slow charter.2. Resident 4 was admitted [DATE], and readmitted on [DATE] with diagnoses including, but not limited to unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety disorder unspecified.Resident 4's medical record was reviewed from 4/27/26 through 4/30/26. Resident 4's monthly pharmacist medication regimen review notes were reviewed. There were no monthly notes for the months of March 2026 or April 2026.3. Resident 54 was admitted [DATE], and readmitted on [DATE] with diagnoses including, but not limited to Alzheimer's disease with early onset and dementia in other diseases classified elsewhere.Resident 54's medical record was reviewed from 4/27/26 through 4/30/26. Resident 54's monthly pharmacist medication regimen review notes were reviewed. There were no monthly notes for the months of March 2026 or April 2026. On 4/30/26 at 1:08 PM an interview was conducted with the Director of Nursing (DON). The DON stated that monthly pharmacist review notes should be uploaded into each resident's electronic medical record.

Based on observation and interview, it was determined that the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. Specifically, two open insulin pens were not labeled with a resident's name. Resident identifier: 56. On 4/29/26 at 10:50 AM, an observation of the south medication fridge was made where a plastic bin with resident 56's first name written on it was located, two open insulin pens were loose in the plastic bin and there was no resident name labeled on the medications. A concurrent interview was conducted with Registered Nurse (RN) 1 who stated the two insulin pens belonged to resident 56 and that they always put the names of the resident on the pen. RN 1 stated they were unsure why the labels had not been affixed. RN 1 was observed to place resident 56's identification label on both insulin pens.On 4/29/26 at 2:17 PM, an interview was conducted with the Director of Nursing (DON) who stated she threw the two previously unlabeled insulin pens away to avoid any medication errors and that the insulin pens should have been labeled.

Based on interview and record review the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility had no established facility-wide system to ensure the appropriate indication, dose, and duration for antibiotic prescriptions, nor a process for monitoring usage and resistance data.On 4/29/26 at 8:20 AM, the facility's Infection Control Surveillance Logs were requestedIt should be noted the facility's Infection Control Surveillance Logs, including any prescribed antibiotic tracking information, were unavailable.On 4/30/26 at 12:28 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that she also served as the facility's designated Infection Preventionist. The DON stated that she did not track resident antibiotic utilization, including the specific clinical indications for the medications or the prescribed durations of treatment.

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed handling oral medications with bare hands during administration, and the facility failed to maintain documentation for tracking and investigating infections to identify patterns or trends. Resident identifier: 23.1. On 4/30/26 at 11:47 AM, an observation of Licensed Practical Nurse (LPN) revealed that while preparing medications for resident 23, LPN 1 popped a pill directly into her bare hand before placing it into a medication cup. LPN 1 was then observed administering the contaminated medication to resident 23. On 4/30/26 at 1:29 PM, an interview with the DON was conducted. The DON stated that staff members were expected to pop pills directly from blister packs into medication dispenser cups and to never touch medications with bare hands. The DON stated that if a medication came in contact with a staff member's bare hand, that medication was to be disposed of and replaced with a newly dispensed dose. 2. On 4/29/26 at 8:20 AM, the facility's Infection Control Surveillance Logs were requested. The DON stated that the facility had several residents contract influenza during the 2025 holiday season due to increased number of visitors.The DON stated that she kept those residents with symptoms contained to their room to reduce further spreading. The DON stated that she did not have a list of residents or rooms affected regarding the influenza outbreak. It should be noted, the requested Infection Control Surveillance Logs were unavailable for review. On 4/30/26 at 12:28 PM, an interview with the Director of Nursing (DON) was conducted.The DON stated that she also served as the facility's designated Infection Preventionist (IP). The DON stated that the facility lacked an infection control surveillance manual or organized tracking system.

Based on record review and interview, it was determined that as part of their performance improvement activities, the facility failed to take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements were realized and sustained. Specifically, the facility was cited a deficiency for F756 when it failed to maintain documentation in the medical records to demonstrate that a pharmacist reviewed the residents' medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents which was identified as a deficiency in the previous health survey in 2024.On 4/30/26 at 1:14 PM, an interview was conducted with the Director of Nursing and she stated that she did not have time to maintain documentation in the medical records to demonstrate that a pharmacist reviewed the residents' medications, identified potential irregularities, or provided recommendations to the attending physician for four sampled residents because she did not have time. This was cited during the previous survey at F756 and again on the current surveyOn 4/30/26 at 2:07 PM, an interview was conducted with the Administrator (ADM) and he stated that he did not have a performance improvement project but he had QAPI minutes that captured some of the improvement plans that they had worked on. The ADM further stated that he felt they did achieve compliance with F756, which was cited during the previous survey, and that it should have been corrected.Documents to show compliance were requested at that time but were not received as of 5/13/26.

Based on observation, interview and record review it was determined, for 1 of 20 sampled residents, that based on the comprehensive assessment of a resident the facility did not provide care, consistent with professional standards of practice, to prevent pressure ulcers. In addition, a resident with pressure ulcers did not receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident had no treatment orders when a new pressure ulcer was identified. The same resident did not have wound measurements of her heel wound since November 2023 and December 2023 for two additional wounds. The heel wound increased in size and there was no re-assessment of the treatment orders. Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, moderate protein-calorie malnutrition, open wound left foot, major depressive disorder and cutaneous abscess of left lower limb. On 2/5/24 at 1:52 PM, an interview was conducted with resident 21. Resident 21 stated she thought she had sores on her body. Resident 21 stated she did not have pain from her sores. Resident 21 stated her sores were kept covered with dressings. On 2/5/24 at 4:10 PM, the facility provided the CMS-802 form. Resident 21 was listed to have a stage 2 and a stage 4 pressure ulcer. Resident 21's medical record was reviewed 2/5/24 through 2/7/24. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 21 had a Brief Interview of Mental Status (BIMS) score of 7 which suggested severe cognitive impairment. The MDS further revealed resident 21 had 1 or more unhealed stage 1 or higher pressure ulcer, three stage 3 pressure ulcers and one stage 4 pressure ulcer. The MDS revealed skin and ulcer treatments were pressure reducing device for bed, turning/repositioning program, nutrition or hydration interventions to manage skin problems, pressure ulcer care, application of nonsurgical dressing other than to feet, applications of ointments/medications other than to feet, and application of dressing to feet. A care plan dated 1/19/21 and revised on 12/4/23 revealed, The resident has potential impairment to skin integrity of the peri area/buttocks r/t [related to] contact dermatitis d/t [due to] incontinence. Scratches & picks at her skin. Multiple wounds at various stages of healing. Stage 4 L heel with h/o [history of] Osteomyelitis. The goal was The resident will maintain or develop clean and intact skin by the review date. Interventions included the following: a. Antibiotics per Medical Doctor (MD) order was initiated on 6/1/23. b. Encourage good nutrition and hydration in order to promote healthier skin was initiated on 1/19/21 and revised on 3/17/21. c. Follow facility protocols for treatment of injury was initiated on 1/19/21 and revised on 3/17/21. d. Keep skin clean and dry. Use lotion on dry skin was initiated on 1/19/21 and revised on 3/17/21. e. The resident needs pressure relief pad to protect the skin while IN BED was initiated on 1/19/21 and revised on 3/17/21. f. The resident needs pressure relief pad to protect the skin while up IN CHAIR was initiated on 1/19/21 and revised on 3/17/21. g. Wound care per MD order was initiated on 5/13/21. A physician's order dated 6/25/21 revealed, left lateral calf Q3D [every 3 days] Clean skin with wound cleanser or normal saline and gauze. If open: Skin prep where drsg will cover. May use santyl on slough, or xenaderm, calcium alginate, Cover with Adhesive foam drsg. Change every 3-7 days, until healed. D/C [discontinue] when healed. one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday]. Another physician's order dated 6/25/21 revealed, (right distal and lateral calf) Q3D Clean skin with wound cleanser or normal saline and gauze. If open: Skin prep where drsg will cover. May use santyl on slough, or xenaderm, calcium alginate, Cover with Adhesive foam drsg. Change every 3-7 days, until healed. D/C when healed. one time a day every Mon, Wed, Fri. A physician's order dated 6/25/21 revealed, Assess wound (right calf distal and medial)for: (A. Increased redness, B. Increased drainage, C. warm to the touch, D. Bleeding, E. Dressing intact, F. Draining thru dressing, G. Need to change the drsg, H. No Drainage, I. Increased pain, J. Notify physician, K. Notify family every shift). A physician's order dated 6/25/21 revealed, Assess wound left lateral calf for: (A. Increased redness, B. Increased drainage, C. warm to the touch, D. Bleeding, E. Dressing intact, F. Draining thru dressing, G. Need to change the drsg, H. No Drainage, I. Increased pain, J. Notify physician, K. Notify family every shift). A physician's order dated 1/15/24 revealed, Juven Oral Packet (Nutritional Supplements) Give 1 packet by mouth every morning and at bedtime related to MODERATE PROTEINCALORIE MALNUTRITION .; UNSPECIFIED OPEN WOUND, LEFT FOOT, SEQUELA. A physician's order dated 1/15/24 revealed, Premier Protein 11oz two times a day related to UNSPECIFIED PROTEINCALORIE MALNUTRITION. A physician's order dated 6/8/21 revealed, Med Pass 2.0 after meals (4OZ) for added nutrition. According to a hospital discharge summary dated 6/7/21, resident 21 had pressure ulcers of bilateral lower extremities with an open wound to right foot and lower leg. A nursing progress note dated 9/9/23 at 4:34 PM, revealed .The wounds on both feet had saturated dressings on them. I removed the dressings, legs are extremely dry, scaly and a lot of dead skin. I washed her legs and patted them dry. I cleansed the wounds on the left shin and heel. The sore on the left shin measures 2.5 cm X 2.5cm in diameter. It is beefy red and good blood flow. I placed a poly memfoam pad and covered with a dressing. The left heel has improved, it measures 5.0cm (L) x 5.5cm (W); has beefy red wound bed and good blood flow. I placed a silver poly mem foam pad and covered with a heel dressing. The right foot, the 5th toe had a lot of drainage and the area on the bottom of food [sic]has several open areas. I cleansed it with wound cleanser, patted it dry. I put silver poly mem between 4th and 5th toe; applied poly mem around the base of the toe and bottom of foot and covered with a foam dressing and tape. Will have DON assess the foot and give us suggestions for wound treatment. Booties put on both feet. A nursing progress note dated 11/14/23 at 4:38 PM, revealed .Pillows for support, booties on both feet. She was medicated for pain with scheduled and PRN [as needed] pain medication with good effect. Her appetite has been fair today. She was given additional snacks and fluids. She drank the nutritional supplements. I changed the dressing on her left heel again today, cleansed with NS [normal saline] and patted dry, polymem foam applied to wound bed and foam dressing covering the wound. The wound measured 4.5cm [centimeter] (L) [length] x [by] 4.0cm (W)[width]. Minimal drainage noted. A nursing progress note dated 12/10/23 at 4:35 PM, revealed .Resident had personal care given and repositioned in bed. Pillows for support and booties on her feet. She has been assisted with her meals. Medicated for pain with scheduled and PRN pain medication with good effect. I changed the dressings on the R [right] foot. The two are ason [sic] the outer bottom of the foot are almost healed. I put a dressing on them for protection. The sore on the bottom of the R small toe was cleansed and patted dry. It measured approximately 2.0 cm(L) x 1.5 cm (w). I put a piece of polymem foam in the wound bed and covered it with a dressing. I changed the dressing on the left shin. The wound was cleansed with NS [normal saline] and patted dry. I put a small piece of poly mem foam and covered with a foam dressing. It measured 2.0 cm (L) X 2.0 cm (W). The left heel dressing was changed. I cleansed the area with NS and patted it dry, applied poly mem foam to the wound bed and covered it with a foam dressing. The wound is filling in from the outer perimeters. She had a medium loose BM this shift. Had 450cc output. A physician's visit dated 12/12/23, revealed resident 21 had chronic wounds on her legs. The physician documented, I am actually pretty surprised at home [sic] much improvement we have seen in the wounds. She had a very big gaping wound on her left heel that was infected months ago and that is actually close down quite a bit to where she just has about a 4 cm [centimeters] wound which is pretty crazy. I think care center is been doing a good job changing her dressing and monitoring her wounds as she has made some steady improvement. We will continue with these interventions hopefully get theses healed up all the way and then at that point preventions again to be the biggest key. A nursing skilled charting assessment dated [DATE], revealed resident did not weight bear, had decreased sensation, required assistance with bed mobility, and required assistance with eating. The assessment further revealed Resident is bed-ridden; requires all care done by staff. The Skin/Wound section revealed, Old hematomas on arms from scratching; lotion applied; Nystatin to abdominal fold. Wounds in various stages of healing on both legs; feet and dressing changed as per treatment orders. On 2/6/24 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a Certified Nursing Assistant (CNA) noticed a wound on a resident, the nurse was notified, and then the nurse would assess the wound and notify the physician to obtain orders to treat the wound. The DON stated resident 21 had wounds on the back of her legs and a wound on her left shin for about 3 to 4 years. The DON stated she had a pressure sore on her left heel and a wound under her right pinky toe. The DON stated the wound under the pinky toe was the size of the tip of a pen. The DON stated resident 21 was on hospice under wounds on her hips had healed. The DON stated she dressed resident 21's pinky toe wound on 2/3/24. The DON stated she used a foam dressing and it was to be changed weekly or when saturated. The DON stated that CNA reported to the nurse if a dressing was saturated. The DON stated there were no physician's orders for the pinky toe wound. The DON stated that nurses would call and ask her what dressings to use. The DON stated she Failed on documentation. The DON stated she did not have measurements on resident 21's wounds for a long time. On 2/6/24 at 1:23 PM, a follow-up interview was conducted with the DON. The DON stated there were no physician orders for the wound below the pinky toe. The DON stated she changed all of resident 21's dressings on Saturday night. The DON stated she did not know when resident 21's wound below the pinky toe opened. The DON stated she did not have a policy and procedure for wounds. On 2/6/24 at 1:29 PM, a phone interview was conducted with Physician 1's Medical Assistant (MA). The MA stated she talked to Physician 1 and Physician 1 stated he was not aware of a new wound on resident 21. The MA stated Physician 1 stated that he was aware that resident 21 had chronic wounds. The MA stated that staff usually texted Physician 1 regarding new skin issues and then Physician 1 provided treatment orders. On 2/6/24 at 1:43 PM, an interview was conducted with CNA 1. CNA 1 stated when a resident was bathed she looked at their skin. CNA 1 stated if there were skin issues, she reported to the nurse to have the nurse look at the resident. CNA 1 stated resident 21 had a left heel wound, left calf wound, and something on her right foot. CNA 1 stated resident 21 had her feet and legs in booties so they were floating and not touching the bed. CNA 1 stated resident 21 had a body pillow that they used to rotate her every 2 hours. CNA 1 stated resident 21 had an air mattress. An observation was made of resident 21's legs and feet with CNA 1. Resident 21 was observed in bed with a sheet over her feet and legs. CNA 1 removed the sheet and there were booties on each foot. There was a bandage on the left shin. CNA 1 lifted resident 21's left leg and there was a bandage on the left heel. CNA 1 lifted resident 21's right foot and there was a bandage on the bottom of the foot below the pinky toe. The bandages were dated 2/3/24. On 2/6/24 at 10:56 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the nurses changed wound dressings when the dressing was soiled or leaked through. RN 1 stated that the DON changed bandages when she did wound rounds. RN 1 stated that the DON completed measurements on wounds. On 2/7/24 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the DON had changed resident 21's wound dressings on Tuesday night 2/6/24. On 2/7/24 at 8:09 AM, an interview was conducted with the DON. The DON stated she changed resident 21's dressings on Tuesday night 2/6/24. The DON stated she measured the wounds because the measurements had not been done for a while. The DON stated she took pictures and talked to Physician 1 to obtain wound orders. The DON stated resident 21's wounds were healing and did not know when the pinky toe wound opened up. The DON stated she was going to be measuring wounds on Tuesdays so she changed the wound dressings orders to Tuesday and Friday. The DON stated that she had not been tracking measurements of wounds. The DON provided the measurements obtained on 2/6/24. The left heel measured at 8.5 cm (L) x 6.5 cm (W) x 0.1 cm depth (D). The left shin was 2.8 cm (L) x 2.5 cm (W) x 0.1 cm (D). The wound below the right pinky toe on the ball of foot was 0.4 cm (L) x 0.4 cm (W) x 0.1 cm (D). The note dated 12/10/23 was the last note of measurements. The left shin measurements were 2.0 cm (L) X 2.0 cm (W). The sore on the bottom of the R small toe measured approximately 2.0 cm(L) x 1.5 cm (w). The previous measurement for the left heel were dated 11/14/23. The measurements were 4.5cm (L) x 4.0cm (W). It should be noted the left heel increased in size with no changes to the wound dressing orders since 6/25/21. On 2/12/24 at 11:32 AM, a phone interview was conducted with the DON. The DON stated she was not aware that resident 21's heel wound was larger than the previous measurement in November 2023. The DON stated there were no changes to the treatment orders since June 2021 for the heel and shin wound. The DON did not provide information for why treatments were not changed or different treatments tried since June 2021. On 2/13/24 at 8:30 AM, a phone interview was conducted with the DON. The DON stated on the left heel wound she measured the picture and not the outline of the wound on 2/6/24. The DON stated the wound was actually 4.9 cm (L) by 5 cm (W). The DON confirmed the previous measurements were completed in November 2023 for the left heel wound.

Based on observation, interview and record review, it was determined the facility did not designate one or more individuals as the infection preventionist (IP) who are responsible for the facility's infection control program. Findings include: The facility's Infection control documentation was requested. No Infection Control Surveillance Logs were available from the previous survey 5/5/22 to current. On 2/6/24 at 4:34 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had not had an IP since the previous survey. The DON stated she had not completed the IP training. The DON stated she was unable to fill the IP position because then it would take a nurse from patient care. The DON stated she did not have infection control tracking or trending. The DON stated she should have infection control tracking and trending for each month. [Cross refer to F880]

Based on observation, interview and record review it was determined that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, a staff member tested positive for COVID-19 and was not excluded from working in the facility. Findings include: On 2/5/24 upon entering the facility, an interview was conducted with the Administrator. The Administrator stated the Maintenance Director tested positive for COVID-19 that morning. The Administrator stated he fixed the facility washing machine and then tested positive. The Administrator stated he was not feeling well and he was sent home. The Administrator stated the Maintenance Director did not feel good Friday and left early. The Administrator stated the Maintenance Director did not work Saturday or Sunday. On 2/6/24 at 10:05 AM, an observation was made of the Maintenance Director. The Maintenance Director was wearing a black surgical mask. The Maintenance Director was observed pushing a cart with tools wearing a mask through the 100 hallway. At 11:11 AM, the Maintenance Director was observed walking to the 200 hallway. At 11:14 AM, the Maintenance Director was walking through the 200 hallway with chairs on a flat bed. The Maintenance Director walked past the nurses station and dining room in the 100, 200 and 300 hallway. On 2/6/24 at 3:00 PM, an interview was conducted with the Administrator. The Administrator stated that he sent the Maintenance Director home because he looked like he was sick. The Administrator stated that because the Life Safety surveyor did not come, he went home and would be back tomorrow. On 2/6/24 at 3:07 PM, a phone interview was conducted with the Maintenance Director (MD). The MD stated he did not feel good Friday 2/2/24. The MD stated on Saturday 2/3/24, he did some stuff around his house and his bones were hurting. The MD stated he had a fever on Sunday 2/4/24. The MD stated he went to the facility Monday morning 2/5/24 because a washing machine had broken down. The MD stated the Director of Nursing (DON) tested him on Monday and he was positive. The MD stated he wore a mask, used sanitizer and washed his hands when he was in the facility. The MD stated the DON told him to go home for the day and to not come back until his fever was gone. The MD stated his fever broke on 2/5/24 at midnight. The MD stated he did not feel good and went home on 2/6/24 after working a half day. The MD stated the Administrator instructed him to to do what he could and then he could go home. The MD stated he fixed a call light in a resident room that was vacant. The MD stated he put gloves on and fixed the call light. The MD stated he left the facility between 11:30 AM and 12:00 PM. On 2/6/24 at 4:01 PM, an interview was conducted with the DON. The DON stated if a staff member tested positive for COVID-19, the policy was for the staff member to go home. The DON stated the staff member should stay home until they tested negative after 5 days. The DON stated the facility was having a staffing shortage, so if a staff member was positive they wore a KN94 mask. The DON stated residents were tested if they had symptoms. The DON stated if a staff member was exposed, they wore a KN94 mask. The DON stated it was the Korean brand of KN95 masks. The DON stated the MD tested positive at about 7:30 AM and he came into the facility after the DON. The DON stated the MD talked to the Administrator about something and then he was tested . The DON stated the MD was not tested Friday because he was not having symptoms. The DON stated the MD worked a couple of hours Friday before going home. The DON stated the MD may have checked the washing machine on 2/5/24. The DON stated the MD worked on 2/6/24 and wore a KN94 mask. The DON stated she did not contact the County Health Department or the HAI (Healthcare Associated Infections) team for recommendations. The DON stated the MD was at the facility on 2/6/24 to get ready for his survey. The DON stated the concern with a staff member working with COVID-19 was that it could transfer it to residents or other staff members. The DON stated she tested positive for COVID-19 on New Year's Eve and worked the night shift. The DON stated she used the KN94 mask, performed hand hygiene, and was assigned half of the facility on New Year's Eve. The KN94 masks were observed. The mask was labeled KF94 and were flat masks with pleats in it, like a surgical mask. On 2/6/24 at 4:18 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if a resident was coughing and had a fever she would test the resident for COVID-19 and notify the physician. RN 1 stated no residents had tested positive for COVID-19 since October or November 2023. On 2/6/24 at 4:26 PM, an interview was conducted with the Administrator. The Administrator stated the Human Resource(HR)/Payroll Director was the last staff member to test positive on 12/31/23. The Administrator stated she was really sick and tested positive for COVID-19. The Administrator stated he did not know if she worked at the facility before or after testing positive for COVID-19 because she worked from home. On 2/6/24 at 4:26 PM, an interview was conducted with the HR/Payroll Director. The HR/Payroll Director stated she tested positive for COVID-19 after Christmas. The HR/Payroll Director stated she had a cough, sore throat, body aches, fever, chills, coughing, headache and felt awful. The HR/Payroll Director stated she went to work at the facility on 1/2/24 until 1:00 PM because she needed to pick up paperwork to close out payroll. The HR/Payroll Director stated she could not remember if she tested positive on 1/2/24. According to the Center for Disease Control updated 9/23/22 the Return to Work Criteria for HCP [Healthcare Professional] with SARS-CoV-2 [COVID-19] Infection. The following are criteria to determine when HCP with SARS-CoV-2 infection could return to work and are influenced by severity of symptoms and presence of immunocompromising conditions. After returning to work, HCP should self-monitor for symptoms and seek re-evaluation from occupational health if symptoms recur or worsen. If symptoms recur (e.g., rebound) these HCP should be restricted from work and follow recommended practices to prevent transmission to others (e.g., use of well-fitting source control) until they again meet the healthcare criteria below to return to work unless an alternative diagnosis is identified. The CDC continued: HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. *Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since the date of their first positive viral test if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). *Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later HCP with severe to critical illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 10 days and up to 20 days have passed since symptoms first appeared, and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. The test-based strategy as described below for moderately to severely immunocompromised HCP can be used to inform the duration of work restriction. https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html

Based on observation and interview it was determined that the facility failed to store all drugs and biologicals in locked compartments. Specifically, two refrigerators that contained medications were unlocked. Findings include: On 2/6/24 at 2:05 PM, an observation was made of the north side nursing station medication refrigerator. The medication refrigerator was unlocked and contained insulin medications. On 2/6/24 at 2:22 PM, an observation was made of the south side nursing station medication refrigerator. The medication refrigerator was unlocked and contained insulin medications. On 2/6/24 at 2:22 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the medication refrigerator contained insulin and suppository medications. RN 1 further stated the south side medication refrigerator did not have a lock on it. On 2/6/24 at 2:35 PM, an interview was conducted with RN 2. RN 2 stated the medication refrigerator always needed to be locked. RN 2 stated the refrigerator contained insulin, eye drops, and suppository medications. On 2/6/24 at 4:35 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the medication refrigerators contained insulin and suppository medications. The DON stated the refrigerators should be locked at all times and that the south side medication refrigerator did not have a locking mechanism on it.

Based on interview and record review it was determined, for 5 of 20 sampled residents, that the facility did not ensure that residents who used psychotropic drugs received a gradual dose reduction (GDR), and behavioral interventions, unless it was clinically contraindicated. Specifically, residents prescribed psychotropic drugs did not have a GDR attempted. In addition, documentation for contraindication for GDR's were not documented. Resident identifier: 14, 19, 20, 22 and 32. Findings include: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, hypoxemia, pain in thoracic spine, unsteady on feet, wedge compression fracture, low back pain, pain in hip, heart failure, hypertension and osteoporosis. Resident 20's medical record was reviewed 2/5/24 through 2/7/24. Resident 20's physician's order dated 4/30/2020 revealed, Pristiq 100 milligrams (mg) to administer 1 tablet by mouth one time a day related to anxiety. Resident 20's physicians order dated 3/24/2020 revealed, Anti-anxiety behaviors: Monitor for 1. restless, 2. Verbalizes anxiety, 3. Wringing of hands, 4. Nervous pacing, 5. Irritability, 6. Verbalizes worry, 7. shortness of breath every shift. A care plan dated 6/5/2020 and revised on 2/6/24 revealed, The resident is resistive to care r/t [related to] Anxiety. The goal was, The resident will cooperate with care through next review date. Interventions included the following: a. Allow the resident to make decisions about treatment regime, to provide sense of control. b. Encourage as much participation/interaction by the resident as possible during care activities. c. Provide resident with opportunities for choice during care provision. Another care plan dated 5/7/2020 and revised on 2/6/24 revealed, The resident has a psychosocial well being problem r/t Anxiety. The goal was, The resident will demonstrate adjustment to nursing home placement by/through review date. The interventions included the following: a. The resident will verbalize feelings related to emotional state by review date. b. Encourage participation from resident who depends on others to make own decisions. c. Provide opportunities for the resident and family to participate in care. A physician's visit dated 1/10/24 revealed resident 20 had a review of systems, Psychiatric: anxiety, personality change, depression and emotional problems (Generalized anxiety disorder. Depression. Managed with medications.) The current medications listed did not include Pristiq. There was a note, It is medically contraindicated to made [sic] changes to her psychotropic medications at this time. There was no further information why it was contraindicated for resident 20. On 2/5/24 at 11:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated she had been working with patient care and was unable to complete her DON duties. The DON stated she had not had a psychotropic drug meeting since July 2023. On 2/6/24 at 8:00 AM, an interview was conducted with the DON. The DON stated she completed her psychotropic meeting on 2/5/24 with the pharmacist. The DON provided the Psychotropic Drug Review form dated 2/5/24. The form revealed the drug was Pristiq 100 mg 1 tablet once daily. The diagnosis was F43.22 (Adjustment disorder with anxiety) and the Interdisciplinary Team recommendations were to maintain with the comments, No changes stable. There was one signature at the bottom of the form for the IDT and it was the Pharmacist. The form did not have targeted behaviors, number of behavioral episodes and if the behaviors had changed. On 2/7/24 at 12:12 PM, a follow-up interview was conducted with the DON. The DON stated there should be a progress note from the physician regarding why resident had not had a GDR. The DON provided the Physician's note from 1/10/24 regarding why resident 20 was contraindicated for a GDR. 43212 2. Resident 14 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of endocrine pancreas, type 2 diabetes, neoplasm related pain, anxiety disorder, nausea with vomiting, thrombocytopenia, and occlusion and stenosis of aortic artery. Resident 14's medical records were reviewed between 2/5/24 and 2/7/24. Physician orders included: a. Venlafaxine HCL (Hydrochloride) ER (extended release) oral capsule 75 mg (milligrams); Give 2 capsules by mouth in the morning related to anxiety disorder. b. Olanzapine oral tablet 5 mg; Give 1 tablet by mouth at bedtime. d. Mirtazapine oral tablet 7.5 mg; Give 1 tablet by mouth at bedtime. e. Ativan oral tablet 2 mg; Give 1 tablet by mouth every 8 hours as needed for anxiety/agitation. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 14 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. A review of the admission Care Area Assessment (CAA) dated 1/1/24 revealed care areas triggered were cognitive loss/dementia and psychotropic drug use. A review of resident 14's care plan initiated on 12/18/23, revealed no care focus areas addressing his use of psychotropic medications, monitoring for behaviors or having dementia. No pharmacy reviews of psychotropic medications were found in resident 14's medical record. On 2/5/24, psychotropic reviews were completed by the Director of Nursing [DON} and the pharmacist. Resident 14 discharged on [DATE] and a psychotropic review was not completed for this resident. 3. Resident 19 was admitted to the facility initially on 4/17/22 and then again on 11/17/23 with diagnoses that included fracture of coccyx, muscle weakness, displace fracture of left humerous, encephalopathy, chronic kidney disease, type 2 diabetes, major depressive disorder and dementia. Resident 19's medical records were reviewed between 2/5/24 and 2/7/24. Physician orders included: a.Quetiapine Fumarate tablet 100 mg; Give 1 tablet by mouth at bedtime related to major depressive disorder. b. Sertraline oral capsule 100 mg; Give one capsule by mouth one time a day related to major depressive disorder. (Discontinued 2/6/24) c. Sertraline oral capsule 150 mg; Give one capsule by mouth one time a day related to major depressive disorder. (Started 2/6/24) Physician orders for monitoring of antidepressant target behaviors and antidepressant medication side effects were not found in resident 19's medical record. An admission MDS assessment dated [DATE] revealed that resident 19 had a BIMS score of 11, which indicated moderate cognitive impairment. A review of resident 19's CAA dated 11/21/23 revealed care areas triggered were cognitive impairment/dementia and use of psychotropic drugs. A care plan created on 1/16/24 revealed, Resident has delusions, paranoia or hallucinations. The goal was, Resident will not make delusional or paranoid statements. Interventions included the following: a. Do not argue, criticize or correct the resident. b. Help resident to feel safe. c. Remind resident that resident is safe. A care plan created on 1/26/24 revealed, Resident has mental health issue/depression. The goal was, Resident will verbalize relief of symptoms of mental illness when asked. Interventions included the following: a. Encourage pursuit of activities and hobbies. b. Offer music of resident's choice. A care plan created on 1/22/23 revealed, Resident has cognitive function/dementia. The goal was, The resident will be able to communicate basic needs on a daily basis through the review date. Interventions included: a. Administer medications as ordered. Monitor/document for side effects and effectiveness. b. Communicate with the resident/family/caregivers regarding residents capabilities and needs. c. COMMUNICATION: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions-turn off TV, radio, close door, etc. d. Cue, reorient and supervise as needed. e. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. A care plan created on 1/22/23 revealed, Resident uses psychotropic medications (Seroquel, Zoloft) r/t dementia and depression. The goal was, The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Interventions included: a. Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q-shift. b. Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications, unsteady gait, tardive dyskinesia, EPS [Extra pyramidal side effects] (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. c. Monitor/record occurrences of for target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc. and document per facility protocol. The admission MDS assessment dated [DATE] revealed no Gradual Dose Reductions [GDR] had been attempted and no physician statement for contraindication to GDR had been documented. 4. Resident 22 was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbance, psychophysiologic insomnia, mood disorder with depressive features, and anxiety disorder. Resident 22's medical records were reviewed between 2/5/24 and 2/7/24. Physician orders included: a. Seroquel (Quetiapine Fumarate) 25 mg; Give .5 tablet by mouth at bedtime related to dementia with behavioral disturbance. b. Exelon patch 24 hr (hour) 13.3 mg/24 hr; Apply 1 patch transdermally in the morning related to dementia with behavioral disturbance. c. Lexapro Tablet 20 mg; Give 1 tablet by mouth in the morning related to mood disorder. d. Buspirone HCL tab 10 mg; Give 1 tablet by mouth three times a day related to anxiety disorder. Physician orders dated 3/14/19 revealed, antidepressant side effects: {Monitor for significant side effects: common side effects: (A) Sedation, (B) Drowsiness, (C) Dry Mouth, (D) Blurred vision, (E) Urinary Retention, (F) Tachycardia, (G) Muscle Tremor, (H) Agitation, (I) Headache, (J) Skin Rash, (K) Photosensitivity/skin, (L) Weight Gain, (M) Suicidal Thinking/Behaviors, (N) Other. Physician orders dated 3/14/23 revealed, antipsychotic behaviors: 1. Hallucination, 2. Delusions, 3. Paranoid Statements, 4. Continuously crying out (greater than 15 minutes= 1 episode). Physician orders dated 3/14/23 revealed, Antidepressant target behaviors: 1. Symptoms of anxiety (SOB V Worry, nervous pacing, irritability, restlessness V anxiety, wringing of hands) 2. V. Sadness, 3. Tearfulness/crying, 4. V. Hopelessness, 5. Negative comments about self or situation. Physician orders dated 3/14/19 revealed, Anti-anxiety behaviors monitor for 1. Restlessness, 2. Verbalizes anxiety, 3. wringing of hands, 4. nervous pacing, 5. Irritability, 6. Verbalizes worry, 7. Shortness of breath. An annual MDS assessment dated [DATE] revealed resident 22 had a BIMS score of 99, which indicated severe cognitive impairment and inability to be evaluated. A quarterly MDS assessment dated [DATE] revealed the last GDR attempt was 6/6/22. A review of resident 22's CAA dated 9/7/23 revealed care areas triggered were cognitive loss/dementia, behavior symptoms, and use of psychotropic medications. A care plan created on 6/13/19 revealed, Resident has anxiety and depression r/t dementia. The goal was, The resident will exhibit indicators of depression, anxiety, or sad mood less than daily by review date. Interventions included: a. Administer medications as ordered. Monitor/document for side effects and effectiveness. b. Monitor/document/ report PRN any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. c. SS [Social Services] will meet with resident for supportive visits as needed. Staff will help identify personal strengths and abilities. Praise resident for accomplishments. d. The resident needs time to talk as needed. Encourage the resident to express feelings. A care plan created on 6/6/23 revealed, Resident has hallucinations. The goal was, Resident will not make paranoid statements. Interventions included: a. Help resident to feel safe. b. Remind resident that they are safe. A care plan created on 3/21/19 revealed, The resident is resistive to cares r/t Anxiety, Dementia. The goal was, The resident will cooperate with care through next review date. Interventions included: a. Allow the resident to make decisions about treatment regime, to provide sense of control. b. Encourage as much participation/interaction by the resident as possible during care activities. c. If resident resists with ADL's (activities of daily living), reassure resident, leave and return 5-10 minutes later and try again. A care plan created on 8/21/20 revealed, The resident is/has potential to be physically and verbally aggressive r/t dementia. The goal was, The resident will have less than 3 delusions per week through the review date .The resident will not harm self or others through the review date. Interventions included: a. Redirect resident away from any residents who upset resident. If resident becomes upset, redirect resident to a quiet place away from others so resident can calm down. b. If resident handles a difficult situation calmly without yelling or hitting tell resident that resident did very well. c. Explain to resident what you are there to do before you touch the resident. A physician progress note dated 11/8/23 revealed, It is medically contraindicated to make changes to her psychotropic medications at this time. Also documented, I am aware of the black box warning for the psychotropic drug. The benefits of the medication however, outweigh the risks, especially for this patient. Continue current care . 5. Resident 32 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included type 2 diabetes, major depressive disorder, macular degeneration, dementia, anxiety disorder, insomnia, pneumonia, and influenza A with respiratory manifestations. Resident 32's medical records were reviewed between 2/5/24 and 2/7/24. Physician orders included: a. Seroquel Tablet 100 mg; Take 1 tablet by mouth at bedtime for dementia. b. Seroquel Tablet 50 mg; Take 1 tablet by mouth in the afternoon for encephalitis. c. Buspirone HCL oral tablet 5 mg; Take 1 tablet by mouth every morning and at bedtime for dementia. Physician orders dated 8/22/23 revealed, Antipsychotic medication-monitor for dry mouth, constipation blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V (nausea/vomiting), lethargy, drooling, EPS, symptoms (Tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue). Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'other/See Nurses Notes' and progress notes findings. Physician orders dated 8/22/23 revealed, Antipsychotic side effects/observe closely for significant side effects-COMMON SIDE EFFECTS-): Sedation, (B) drowsiness, (C) Dry mouth, (D) Constipation, (E) Blurred Vision, (F) Extra Pyramidal Reaction, (G) Weight Gain, (H) Edema, (I) Postural Hypotension, (J) Sweating, (K) Loss of appetite, (L) Urinary Retention. ATTENTION FOR: (M) Tardive Dyskinesia, (N) Seizure disorder, (O) Chronic constipation, (P) Glaucoma, (Q) Diarrhea, (R) Skin Pigmentation, (S) Jaundice, (T) other. An MDS dated [DATE] revealed resident 32 had a BIMS score of 8, which indicated moderately impaired cognition. A care plan dated 12/7/23 revealed, Resident is anxious at times. The goal was Resident will calm down within 10 minutes of becoming anxious. Interventions included: a. Assist resident to breathe more slowly. b. Assist resident to think about something calm and peaceful (guided imagery). A care plan dated 10/13/21 revealed, The resident has impaired cognitive function/dementia or impaired thought processes r/t dementia. The goal was, The resident will develop skills to cope with cognitive decline and maintain safety by the review date. Interventions included: a. Administer medications as ordered. Monitor/document for side effects and effectiveness. b. Communicate with the resident/family/caregivers regarding residents capabilities and needs. c. COMMUNICATION: Use the residents preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Provide the resident with necessary cues-stop and return if agitated. d. Cue, reorient, and supervise as needed. e. Discuss concerns about confusion, disease process, NH (nursing home) placement with resident/family/caregivers. f. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. g. Provide the resident with a homelike environment. No psychotropic reviews were found in resident 32's medical record. Additionally, no documentation was found regarding a GDR for psychotropic medications, or a physician's documentation of contraindication for attempting a GDR.

Based on interview and record review, it was determined for 5 of 20 sampled residents, that the facility did not ensure that each resident's drug regimen was reviewed once a month by the licensed pharmacist, and that any irregularities were reported to the physician and were acted upon. Specifically, monthly pharmacy reviews were not being conducted between July 2023 and January 2024. Resident identifiers: 14, 19, 20, 22 and 32. Findings include: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of endocrine pancreas, type 2 diabetes, neoplasm related pain, anxiety disorder, nausea with vomiting, thrombocytopenia, and occlusion and stenosis of aortic artery. Resident 14's medical record was reviewed between 2/5/24 and 2/7/24. No pharmacy reviews were located in resident 14's medical record. 2. Resident 19 was admitted to the facility initially on 4/17/22 and then again on 11/17/23 with diagnoses that included fracture of coccyx, muscle weakness, displace fracture of left humerous, encephalopathy, chronic kidney disease, type 2 diabetes, major depressive disorder and dementia. Resident 19's medical record was reviewed between 2/5/24 and 2/7/24. Resident 19's last pharmacy review was completed on 1/30/23. There were no other pharmacy reviews located in resident 19's medical record. 3. Resident 22 was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbance, psychophysiologic insomnia, mood disorder with depressive features, and anxiety disorder. Resident 22's medical record was reviewed between 2/5/24 and 2/7/24. Resident 22's last pharmacy review was completed on 7/20/23. There were no other pharmacy reviews located in resident 22's medical record after 7/20/23. 4. Resident 32 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included type 2 diabetes, major depressive disorder, macular degeneration, dementia, anxiety disorder, insomnia, pneumonia, and influenza A with respiratory manifestations. Resident 32's medical record was reviewed between 2/5/24 and 2/7/24. Resident 32's last pharmacy review was completed 5/24/23. There were no other pharmacy reviews located in resident 32's chart after 5/24/23. 30563 5. Resident 20 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation, hypoxemia, pain in thoracic spine, unsteady on feet, wedge compression fracture, low back pain, pain in hip, heart failure, hypertension, and osteoporosis. Resident 20's medical record was reviewed 2/5/24 through 2/7/24. Resident 20's last pharmacy review was completed on 7/28/23. There were no other pharmacy reviews located in resident 20's medical record. Pharmacy reviews were requested. The Pharmacist provided a binder with 3 recommendations from July 2023. On 2/6/24 at 8:17 AM, an interview was conducted with the Pharmacist and the Administrator. The Pharmacist stated he had a medical emergency in August 2023 and had not completed medication reviews since then. The Pharmacist stated the last time he was at the facility to document his medication regimen reviews was July 2023. The Administrator stated there was no Pharmacist to fill in while the facility Pharmacist was unavailable. On 2/7/24 at 12:12 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she had not received any pharmacy recommendations since August 2023. The DON stated no other Pharmacist had been asked to complete reviews while the facility pharmacist was not available. The DON stated the Pharmacist signed the order summaries every month but there were no recommendations from those.

Based on observation, interview and record review, it was determined that, for 5 of 20 sampled residents, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, care plans were not updated when there was a change in the resident's condition and therefore were not reflective of the services required for the residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident identifiers: 9, 14, 21, 22, and 34. Findings include: 1. Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included mental disorder, polyosteoarthritis, type 2 diabetes mellitus, sensorineural hearing loss, paralytic syndrome, chronic pain, hypoxemia, lagophthalmos left eye, hallucinations, and malignant neoplasm of brain. On 2/5/24 at 12:15 PM, an observation was made of resident 9. Resident 9 was sitting at a table in the dining room. Resident 9 fed himself lunch from a divided plate of food, which consisted of three items of pureed food and a bowl of jello. Resident 9's medical record was reviewed from 2/5/24 through 2/7/24. The MDS (Minimum Date Set) Annual assessment dated [DATE] revealed resident 10 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated a cognitive status of moderately impaired. The MDS further revealed resident 9 did not have swallowing disorders, received a mechanically altered diet and therapeutic diet. The Care Area Assessment (CAA) section revealed nutrition was triggered from the MDS and would be care planned. A physician's order dated 1/27/22 at 12:35 AM, indicated, CCHO [controlled carbohydrate diet] diet, Regular texture, Regular consistency, Fortified Meals. The Care Plan dated 5/27/22 indicated, The resident has oral/dental health problems r/t [related to] had all of his teeth extracted, bone graft placed & posts for future dentures placed on 05/24/22. The goal was, The resident will be free of infection, pain or bleeding in the oral cavity by review date. Interventions included, Diet as Ordered. Consult with dietitian and change if chewing/swallowing problems are noted. Another intervention dated 5/24/22 and revised on 7/11/22 on pureed diet while mouth is healing. A Nutrition Risk Review dated 10/5/23, indicated, CCHO, reg (regular), reg prefers puree d/t (due to) mouth pain. A Risk Assessment for Eating and Swallowing problems dated 12/16/23 indicated, Does the resident have difficulty chewing, choking or coughing when eating? Pureed, was marked, Yes. A Multidisciplinary Care Conference document dated 12/22/23 at 1:29 PM, indicated that resident 9's current diet was, CCHO diet. Puree consistency. Divided plate. On 2/7/24 at 9:37 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 9 had all of his teeth pulled but that he did not wear his dentures because of the pain they caused. RN 1 stated resident 9's family and dentist decided to keep resident on a pureed diet because the resident had tolerated it. RN 1 further stated resident 9 had been on a pureed diet for a long time and believed that was the physician's order. On 2/7/24 at 10:09 AM, an interview was conducted with the Dietary Manager (DM). The DM reviewed resident 9's meal ticket which indicated resident 9 was on a fortified, puree diet. The DM stated resident 9 had oral surgery and declined to use his dentures. The DM stated a mechanical soft diet was attempted but the resident requested to have a pureed diet. The DM stated there should have been an order for the change in diet. On 2/7/24 at 10:14 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 9 had no teeth and he refused to wear his dentures. The DON further stated that he refused to eat a mechanical diet. The DON further stated that the diet served should match what the physician ordered and that if resident 9 was served a regular diet he could choke. On 2/7/24 at 12:40 PM, a follow-up interview was conducted with the DON. The DON stated that resident 9's care plan had not been updated since 5/27/22 and should have been updated. 43212 2. Resident 14 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of endocrine pancreas, type 2 diabetes, neoplasm related pain, anxiety disorder, nausea with vomiting, thrombocytopenia, and occlusion and stenosis of aortic artery. On 2/5/24 at 2:08 PM, an interview was conducted with resident 14 who stated that in the previous week, he was assisted by a Certified Nursing Assistant (CNA) out of the tub after bathing. Resident 14 stated that the CNA gathered up the wet towels and wash cloths and turned around to put them in the dirty linen container. As she did this, resident 14 stated he went to dry his legs and the towel he was standing on slipped out from under him and he fell back into the chair he had been sitting on. Resident 14 stated he had pain on his backside after falling back. Resident 14's medical records were reviewed between 2/5/24 and 2/7/24. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 14 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS further revealed resident 14 had a fall in the month prior to admission to the facility and no falls since admission. Resident 14's care plan was reviewed. On 2/1/24, a care area was initiated revealing, The resident has had an actual fall (2/1/24) with minor injury d/t [due to] poor balance, weakness. Goals included, The resident will resume usual activities without further incident through the review date. No interventions were listed to prevent additional falls. Resident progress notes revealed an incident note dated 2/1/24 at 10:35 AM. The note stated, Pt [patient] sitting in weight chair after getting out of tub. Pt drying off with towels. [CNA name removed] put a towel under pt's feet r/t [related to] weight chair and pt dripping with water. [CNA's name removed] states that she took the wet washcloths and towels over to the laundry hamper which were a few steps away from pt and heard the weight chair move. She turned around as pt was climbing out of weight chair and pt's feet slid out from under him while standing on towel. Pt fell backwards and hit his Lt [left] hip and Lt elbow on weight chair. Both pt and CNA state that pt did not hit his head. Pt able to stand, put pressure on Lt hip, and walk. Pt also able to bend and use Lt arm and elbow. Red marks noted to both Lt hip and Lt elbow. Pt assisted with getting dressed. VS [vital signs] taken. BP [blood pressure] 167/87, HR [heart rate] 89, RR [respirations] 20, Temp [temperature] 97.8* F [Fahrenheit], O2 sat [oxygen saturation] 97% RA [room air]. Nursing called [residents family member] and #1 contact, at 0900 (9:00 am) and let her know about fall, pt hitting Lt hip/elbow, and no injuries noted. [Director of nursing name removed] notified at 0904 [9:04 AM], also of pts fall and hit Lt elbow/hip, no other injuries. [Physician name removed] notified at 0918 [9:18 AM]. MD [Medical Doctor] notified of pt's fall, Pt hit Lt elbow/hip, able to stand, move, and ambulate all joints. No other injuries noted. No orders at this time. On 2/7/24 at 9:11 AM, an interview was conducted with RN 3. RN 3 stated that she did not update the resident's care plan. RN 3 stated after an incident report was completed, she thought it would be provided to the Minimum Data Set (MDS) coordinator, who reviewed the report and updated the resident's care plan. On 2/7/24 at 1:00 PM, an interview was conducted with the DON. The DON stated they tried to put a new intervention into the care plan every time a resident had a fall. The DON stated the nurses documented what happened in a progress note and an incident report, and the reports would go to the MDS coordinator who would update the care plan. The DON stated the intervention should be relevant to the resident and something they would be able to follow to avoid additional falls. 3. Resident 22 was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbance, psychophysiologic insomnia, mood disorder with depressive features, and anxiety disorder. On 2/5/24 at 12:10 PM, an observation was made of resident 22 in the dining room for the lunch meal. Resident 22 received a pureed diet in a divided plate and a cup of jello. Resident 22 also had water and juice to drink with her meal. A Certified Nursing Assistant (CNA) was sitting between resident 22 and another resident and was assisting resident 22. Resident 22 was unable to feed herself. Resident 22's medical record was reviewed between 2/5/24 and 2/7/24. A quarterly MDS dated [DATE] revealed that resident 22 received a mechanically altered diet. The MDS revealed resident 22 did not have a swallowing disorder. The MDS revealed resident 22 did not have a BIMS score. The MDS further revealed resident 22 had short and long-term memory problems. A physician's diet order dated 6/29/23 and revised on 1/11/24 revealed, Regular diet, mechanical soft texture, regular consistency. Resident 22's care plan included: a. The resident has an ADL (activities of daily living) self-care performance deficit r/t dementia, initiated on 2/9/2020 and revised on 6/12/23. The goal The resident will maintain the current level of function in ADL ability through the review date. Interventions included, EATING: The resident requires max assist by one staff to eat. b. The resident has a nutritional problem or a potential nutritional problem r/t dementia and refuses to let staff assist her to eat, initiated on 3/4/21 and revised on 6/15/22. The goal The resident will have gradual weight gain to within 10% of IBW [ideal body weight] for sex and height by review date. Interventions included, RD (registered dietitian) to evaluate and make diet change recommendations PRN (as needed). Initiated on 3/4/21; Provide nutrition supplements as ordered: Ensure, initiated 3/4/21. No information was located in resident 22's care plan indicating difficulty swallowing or the need for a pureed diet. [Note: It should be noted that the last update to the nutrition area of resident 22's care plan was on 6/15/22,] Resident 22's progress notes were reviewed and there was no documentation indicating a reason for a change in diet texture, or that resident 22's care needs had changed. Additionally, a progress note dated 12/12/23 revealed, Med Pass has been d/c'd (discontinued) per family request. An IDT (Interdisciplinary Team) care conference dated 12/9/23 revealed, resident intake is 76-100%, with resident 22's diet order documented as mechanical soft regular diet. On 2/7/24 at 9:23 AM, an interview was conducted with CNA 3. CNA 3 stated that CNA's could look at the resident's care plan to see what information was there to assist then with caring for the residents. CNA 3 stated that the DON and nursing staff kept the CNA's up to date with changes. Additionally, CNA 3 stated the MDS coordinator and resident advocate also let the staff know if there was a change in the resident's care. On 2/7/24 at 11:44 AM, an interview was conducted with RN 3. RN 3 stated resident 22 did not have difficulty chewing or swallowing food. RN 3 stated the aids in the dining room were complaining that it was taking too long for resident 22 to eat. RN 3 stated it was not like she would not have eaten, it's just a time factor and has been going on for weeks. 30563 4.Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, moderate protein-calorie malnutrition, open wound left foot, major depressive disorder and cutaneous abscess of left lower limb. On 2/5/24 at 1:52 PM, an interview was conducted with resident 21. Resident 21 stated she thought she had sores on her body. Resident 21 stated she did not have pain from her sores. Resident 21 stated her sores were kept covered with dressings. On 2/5/24 at 4:10 PM, the facility provided the CMS-802 form. Resident 21 was listed to have a stage 2 and a stage 4 pressure ulcer. Resident 21's medical record was reviewed 2/5/24 through 2/7/24. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 21 had a Brief Interview of Mental Status (BIMS) score of 7 which suggested severe cognitive impairment. The MDS further revealed resident 21 had 1 or more unhealed stage 1 or higher pressure ulcer, three stage 3 pressure ulcers and one stage 4 pressure ulcer. The MDS revealed skin and ulcer treatments were pressure reducing device for bed, turning/repositioning program, nutrition or hydration interventions to manage skin problems, pressure ulcer care, application of nonsurgical dressing other than to feet, applications of ointments/medications other than to feet, and application of dressing to feet. A care plan dated 1/19/21 and revised on 12/4/23 revealed, The resident has potential impairment to skin integrity of the peri area/buttocks r/t [related to] contact dermatitis d/t [due to] incontinence. Scratches & picks at her skin. Multiple wounds at various stages of healing. Stage 4 L heel with h/o [history of] Osteomyelitis. The goal was The resident will maintain or develop clean and intact skin by the review date. Interventions included the following: a. Antibiotics per Medical Doctor (MD) order was initiated on 6/1/23. b. Encourage good nutrition and hydration in order to promote healthier skin was initiated on 1/19/21 and revised on 3/17/21. c. Follow facility protocols for treatment of injury was initiated on 1/19/21 and revised on 3/17/21. d. Keep skin clean and dry. Use lotion on dry skin was initiated on 1/19/21 and revised on 3/17/21. e. The resident needs pressure relief pad to protect the skin while IN BED was initiated on 1/19/21 and revised on 3/17/21. f. The resident needs pressure relief pad to protect the skin while up IN CHAIR was initiated on 1/19/21 and revised on 3/17/21. g. Wound care per MD order was initiated on 5/13/21. A physician's order dated 6/25/21 revealed, left lateral calf Q3D [every 3 days] Clean skin with wound cleanser or normal saline and gauze. If open: Skin prep where drsg will cover. May use santyl on slough, or xenaderm, calcium alginate, Cover with Adhesive foam drsg. Change every 3-7 days, until healed. D/C [discontinue] when healed. One time a day every Mon [Monday], Wed [Wednesday], Fri [Friday]. Another physician's order dated 6/25/21 revealed, (right distal and lateral calf) Q3D Clean skin with wound cleanser or normal saline and gauze. If open: Skin prep where drsg will cover. May use santyl on slough, or xenaderm, calcium alginate, Cover with Adhesive foam drsg. Change every 3-7 days, until healed. D/C when healed. one time a day every Mon, Wed, Fri. A physician's order dated 1/15/24 revealed, Premier Protein 11oz two times a day related to UNSPECIFIED PROTEINCALORIE MALNUTRITION. It should be noted this was not added to the care plan. A nursing progress note dated 9/9/23 at 4:34 PM, .The wounds on both feet had saturated dressings on them. I removed the dressings, legs are extremely dry, scaly and a lot of dead skin. I washed her legs and patted them dry. I cleansed the wounds on the left shin and heel. The sore on the left shin measures 2.5 cm X 2.5cm in diameter. It is beefy red and good blood flow. I placed a poly memfoam pad and covered with a dressing. The left heel has improved, it measures 5.0cm (L) x 5.5cm (W); has beefy red wound bed and good blood flow. I placed a silver poly mem foam pad and covered with a heel dressing. The right foot, the 5th toe had a lot of drainage and the area on the bottom of food [sic]has several open areas. I cleansed it with wound cleanser, patted it dry. I put silver poly mem between 4th and 5th toe; applied poly mem around the base of the toe and bottom of foot and covered with a foam dressing and tape. Will have DON assess the foot and give us suggestions for wound treatment. Booties put on both feet. It should be noted there was another wound documented in this note and was not addressed on the care plan. A nursing progress note dated 11/14/23 at 4:38 PM revealed, .Pillows for support, booties on both feet. She was medicated for pain with scheduled and PRN [as needed] pain medication with good effect. Her appetite has been fair today. She was given additional snacks and fluids. She drank the nutritional supplements. I changed the dressing on her left heel again today, cleansed with NS [normal saline] and patted dry, polymem foam applied to wound bed and foam dressing covering the wound. The wound measured 4.5cm [centimeter] (L) [length] x [by] 4.0cm (W)[width]. Minimal drainage noted. A nursing progress note dated 12/10/23 at 4:35 PM revealed, .Resident had personal care given and repositioned in bed. Pillows for support and booties on her feet. I changed the dressings on the R [right] foot. The two are ason [sic] the outer bottom of the foot are almost healed. I put a dressing on them for protection. The sore on the bottom of the R small toe was cleansed and patted dry. It measured approximately 2.0 cm(L) x 1.5 cm (w). I put a piece of polymem foam in the wound bed and covered it with a dressing. I changed the dressing on the left shin. The wound was cleansed with NS [normal saline] and patted dry. I put a small piece of poly mem foam and covered with a foam dressing. It measured 2.0 cm (L) X 2.0 cm (W). The left heel dressing was changed. I cleansed the area with NS and patted it dry, applied poly mem foam to the wound bed and covered it with a foam dressing. The wound is filling in from the outer perimeters. She had a medium loose BM this shift. Had 450cc output. A nursing skilled charting assessment dated [DATE] revealed resident did not weight bear, had decreased sensation, required assistance with bed mobility, and required assistance with eating. The assessment further revealed Resident is bed-ridden; requires all care done by staff. The Skin/Wound section revealed, Old hematomas on arms from scratching; lotion applied; Nystatin to abdominal fold. Wounds in various stages of healing on both legs; feet and dressing changed as per treatment orders. On 2/6/24 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a Certified Nursing Assistant (CNA) noticed a wound on a resident, the nurse was notified, and then the nurse would assess the wound and notify the physician to obtain orders to treat the wound. The DON stated resident 21 had wounds on the back of her legs and a wound on her left shin for about 3 to 4 years. The DON stated she had a pressure sore on her left heel and a wound under her right pinky toe. The DON stated the wound under the pinky toe was the size of the tip of a pen. The DON stated resident 21 was on hospice under wounds on her hips had healed. The DON stated she dressed resident 21's pinky toe wound on 2/3/24. The DON stated she used a foam dressing and it was to be changed weekly or when saturated. The DON stated that CNA reported to the nurse if a dressing was saturated. The DON stated there were no physician's orders for the pinky toe wound. The DON stated that nurses would call and ask her what dressings to use. The DON stated she Failed on documentation. The DON stated she did not have measurements on resident 21's wounds for a long time. On 2/6/24 at 1:23 PM, a follow-up interview was conducted with the DON. The DON stated there were no physician orders for the wound below the pinky toe. The DON stated she changed all of resident 21's dressing on Saturday night. The DON stated she did not know when resident 21's wound below the pinky toe opened. The DON stated she did not have a policy and procedure for wounds. On 2/6/24 at 1:29 PM, a phone interview was conducted with Physician 1's Medical Assistant (MA). The MA stated she talked to Physician 1 and Physician 1 stated he was not aware of a new wound on resident 21. The MA stated Physician 1 stated that he was aware that resident 21 had chronic wounds. The MA stated that staff usually texted Physician 1 regarding new skin issues and then Physician 1 provided treatment orders. On 2/7/24 at 8:09 AM, an interview was conducted with the DON. The DON stated she changed resident 21's dressings on Tuesday night 2/6/24. The DON stated she measured the wounds because the measurements had not been done for a while. The DON stated she took pictures and talked to Physician 1 to obtain wound orders on 2/6/24. The DON stated resident 21's wounds were healing and did not know when the pinky toe wound opened up. The DON stated she would be measuring wounds on Tuesdays and that the wound dressing change orders had been changed to Tuesday and Friday for that purpose. The DON stated that she had not been tracking measurements of wounds. The DON provided the measurements obtained on 2/6/24. The left heel measured at 8.5 cm (L) x 6.5 cm (W) x 0.1 cm depth (D). The left shin was 2.8 cm (L) x 2.5 cm (W) x 0.1 cm (D). The wound below the right pinky toe on the ball of foot was 0.4 cm (L) x 0.4 cm (W) x 0.1 cm (D). The note dated 12/10/23 was the last note of measurements. The left shin measurements were 2.0 cm (L) X 2.0 cm (W). The sore on the bottom of the R small toe measured approximately 2.0 cm(L) x 1.5 cm (w). The previous measurement for the left heel were dated 11/14/23. The measurements were 4.5cm (L) x 4.0cm (W). It should be noted the left heel increased in size with no changes to the wound dressing orders since 6/25/21. On 2/12/24 at 11:32 AM, a phone interview was conducted with the DON. The DON stated she was not aware that resident 21's heel wound was larger than the previous measurement in November 2023. The DON stated there were no changes to the treatment orders since June 2021 for the heel and shin wound. The DON did not provide information for why treatments were not changed or different treatments tried since June 2021. On 2/13/24 at 8:30 AM, a phone interview was conducted with the DON. The DON stated on the left heel wound she measured the picture and not the outline of the wound on 2/6/24. The DON stated the wound was actually 4.9 cm (L) by 5 cm (W). The DON confirmed the previous measurements were completed in November 2023 for the left heel wound. 5. Resident 34 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and hemiparesis, subluxation of left shoulder, heart failure, insomnia, cerebral infarction due to unspecified occlusion or stenosis of cerebral artery, muscle weakness, and type 2 diabetes mellitus. On 2/5/24 at 2:51 PM, an interview was conducted with resident 34. Resident 34 stated she needed her dentures realigned. Resident 34 stated she was not sure if she had enough money. Resident 34 stated she was able to wear her top dentures and had to have her food cut up for her to be able to eat it. Resident 34's medical record was reviewed 2/5/24 through 2/7/24. An annual Minimum Data Set (MDS) dated [DATE] revealed no dental issues. The MDS revealed resident 34 had Brief Interview of Mental Status (BIMS) score of 15 which indicated cognition was intact. The MDS revealed resident did not have a loss of natural teeth or tooth fragments (edentulous). Nursing Progress notes revealed the following: a. On 10/17/23 at 4:29 PM, Resident asked me to cancel the dental appointment for her d/t [due to] her not feeling well. We will reschedule when she is feeling better. b. On 10/18/23 at 2:31 PM, [Resident 34] has a blister on her upper left gum from getting food caught between her gum and denture. She doesn't want anyone to see her w/o [without] her dentures, so she has been staying in her room and drinking soda and soups so that her gum can heal. On 2/7/24 at 9:26 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 34 had not complained about her dentures for a while because she was taking them out at night. CNA 1 stated she thought resident 34's dentures fit. CNA 1 stated resident 34 complained of sores in her mouth a while ago because she was not willing to take her dentures out at night. CNA 1 stated resident 34 completed her own oral hygiene. On 2/7/24 at 9:28 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she had not heard of any problems with her mouth or dentures. On 2/7/24 at 10:16 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 34 did not have chewing or swallowing problems. The DON stated resident 34 had not been to the dentist and had not complained of her dentures not fitting. The DON stated the MDS coordinator worked offsite. The DON stated resident 34 had dentures with no teeth and it should have been on the MDS that way. On 2/7/24 at 8:28 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the MDS coordinator updated care plans, baseline care plans and comprehensive care plans. The DON stated staff tried to complete baseline care plans. The DON stated care plans were not updated.

Based on interview and record review, for 1 of 20 sampled residents, it was determined the facility did not develop and implement a baseline care plan that included the instructions needed to provide effective and person centered care of the resident that met professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, the resident's care plan was developed 5 days after the resident was admitted to the facility. Resident identifier: 19. Findings include: Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included fracture of coccyx, muscle weakness, displaced fracture of left humerous, encephalopathy, chronic kidney disease, type 2 diabetes, major depressive disorder and dementia. Resident 19's medical records were reviewed between 2/5/23 and 2/7/23. A review of resident 19's careplan revealed focus areas initiated on 11/22/23 included: a. The resident had an ADL (activities of daily living) performance deficit r/t (related to) unsteadiness, dementia. Interventions included, BATHING/SHOWERING: The resident needs max assist of one staff; BED MOBILITY: The resident requires max assist with one staff to turn and reposition in bed; DRESSING: Allow sufficient time for dressing and undressing; EATING: The resident is able to feed self after setup help from staff; PERSONAL HYGIENE: The resident requires max assist with one staff with personal hygiene and ora care; TOILET USE: The resident requires mod (moderate) assist of one staff for toileting; TRANSFER: The resident requires limited assist with one staff. b. The resident had impaired cognitive function/dementia. Interventions included, Administer medications as ordered. Monitor/document for side effects and effectiveness; Communicate with the resident/family/caregivers regarding resident's capabilities and needs; COMMUNICATION: use the resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distrations, turn off TV (television), radio, close the door, etc.; Cue, reorient, and supervise as needed; Keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion; Prefers to be called [name removed]. c. The resident had diabetes mellitus. Interventions included, Diabetes medications & insulin as ordered by doctor, Monitor/document for side effects and effectiveness; Fasting serum blood sugar as ordered by doctor; Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. d. The resident was at HIGH risk for falls r/t unsteady h/o (history of) falling at home resulting in fracture. Interventions included, Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Follow facility fall protocol; PT (physical therapy) evaluate and treat as ordered or PRN; The resident needs a safe environment with even floors free from spills and/or clutter, adequate glare free light, a working and reachable call light, the bed in low position at night, Slide fails as ordered, handrails on walls, personal items within reach; The resident uses bed electronic alarm, ensure the device is in place as needed. e. The resident used psychotropic medications (Seroquel and zoloft) r/t dementia with depression. Interventions included, Administer PSYCHOTROPIC medications as ordered by physician, monitor for side effects and effectiveness Q-shift (every shift); Monitor/document/report PRN (as needed) any adverse reactions of PSYCHOTROPIC medications, unsteady gait, tardive dyskinesia, EPS (extrapyramidal side effects), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavioral symptoms not usual to the person; Monitor/record occurance of for target behavior symptoms, pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression toward staff/others, etc. and document per facility protocol. f. The resident had acute pain r/t fracture coccyx. Interventions included, The resident's pain is alleviated/relieved by: rest & current meds; Administer analgesia as per orders. Give 1/2 hours before treatment or care; Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; Monitor and record pain characteristics: Quality, Severity, Anitomical location, onset, duration, Aggrivating factors, Relieving factors; Report to nurse any change in usual activity attendence patterns or refusal to attend activities related to s/sx (signs or symptoms) or c/o (complaints of) pain or discomfort; The resident is able to ask for medication, tell you how much pain is experienced, tell you what increases or alleviates pain. g. The resident had potential impairment of skin d/t (due to) incontinence, poor mobility, edema, DM (diabetes mellitus). Interventions included, Encourage good nutrition and hydration in order to promote healthier skin, follow facility protocol for treatment of injury, keep skin clean and dry, use lotion on dry skin. h. The resident had impaired visual function. Interventions included, Remind resident to wear glasses when reading. Ensure resident is wearing glasses which are clean, free from scratches and in good repair. Report any damage to nurse/family. [Note: Resident 19's care plan was created 3 days past the 48 hour requirement for baseline care plans] On 2/7/24 at 9:29 AM, an interview was conducted with Registered Nurse (RN) 1 who stated when a resident was admitted , there was a checklist that she followed to ensure all the important information was collected. RN 1 stated one of the items on the checklist triggered the baseline care plan. RN 1 stated the baseline care plan should be saved in the resident's medical record. On 2/7/24 at 8:29 AM, an interview was conducted with the Director of Nursing (DON) who stated care plans were created and updated by the MDS (Minimum Data Set) coordinator. The DON stated that the MDS coordinator tried to complete a baseline care plan as soon as the resident was admitted . The DON stated the baseline care plan should be initiated within 48 hours of the resident's admission.

Based on interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not provide or obtain routine dental services. Specifically, a resident stated her dentures did not fit and needed to be adjusted. Resident identifier: 34. Findings include: Resident 34 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and hemiparesis, subluxation of left shoulder, heart failure, insomnia, cerebral infarction due to unspecified occlusion or stenosis of cerebral artery, muscle weakness, and type 2 diabetes mellitus. On 2/5/24 at 2:51 PM, an interview was conducted with resident 34. Resident 34 stated she needed her dentures realigned. Resident 34 stated she was not sure if she had enough money. Resident 34 stated she was able to wear her top dentures and her food was cut up for her to be able to eat it. Resident 34's medical record was reviewed 2/5/24 through 2/7/24. An annual Minimum Data Set (MDS) dated [DATE] revealed no dental issues. The MDS revealed resident 34 had Brief Interview of Mental Status (BIMS) score of 15 which indicated cognition was intact. Nursing Progress notes revealed the following: a. On 10/17/23 at 4:29 PM, Resident asked me to cancel the dental appointment for her d/t [due to] her not feeling well. We will reschedule when she is feeling better. b. On 10/18/23 at 2:31 PM, [Resident 34] has a blister on her upper left gum from getting food caught between her gum and denture. She doesn't want anyone to see her w/o [without] her dentures, so she has been staying in her room and drinking soda and soups so that her gum can heal. On 2/7/24 at 9:26 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 34 had not heard her complain about her dentures for a while because she was taking them out at night. CNA 1 stated she thought resident 34's dentures fit. CNA 1 stated she complained of sores in her mouth a while ago because she was not willing to take her dentures out at night. CNA 1 stated resident 34 completed her own oral hygiene. On 2/7/24 at 9:28 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated she had not heard of any problems with her mouth or dentures. On 2/7/24 at 10:16 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 34 did not have chewing or swallowing problems. The DON stated resident 34 had not been to the dentist and had not complained of dentures not fitting. The DON stated the MDS coordinator worked offsite. The DON stated resident 34 had dentures with no teeth and it should have been on the MDS that way.

Based on observation, interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not notify the resident's physician when there was a signigicant change in the resident's physical, mental or psychosical status or when there was a need to alter treatment significantly. Specifically, a resident developed a new wound and the physicain was not notified. In addition, the resident did not have physician's orders to treat the wound. Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, moderate protein-calorie malnutrition, open wound left foot, major depressive disorder and cutaneous abscess of left lower limb. On 2/5/24 at 1:52 PM, an interview was conducted with resident 21. Resident 21 stated she thought she had sores on her body. Resident 21 stated she did not have pain from her sores. Resident 21 stated her sores were kept covered with dressings. On 2/5/24 at 4:10 PM, the facility provided CMS-802 form. Resident 21 was listed to have a stage 2 and a stage 4 pressure ulcer. Resident 21's medical record was reviewed 2/5/24 through 2/7/24. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 21 had a Brief Interview of Mental Status (BIMS) score of 7 which suggested severe cognitive impairment. The MDS further revealed resident 21 had 1 or more unhealed stage 1 or higher pressure ulcer, three stage 3 pressure ulcers and one stage 4 pressure ulcer. The MDS revealed skin and ulcer treatments were pressure reducing device for bed, turning/repositioning program, nutrition or hydration interventions to manage skin problems, pressure ulcer care, application of nonsurgical dressing other than to feet, applications of ointments/medications other than to feet, and application of dressing to feet. A care plan dated 1/19/21 and revised on 12/4/23 revealed, The resident has potential impairment to skin integrity of the peri area/buttocks r/t [related to] contact dermatitis d/t [due to] incontinence. Scratches & picks at her skin. Multiple wounds at various stages of healing. Stage 4 L heel with h/o [history of] Osteomyelitis. The goal was The resident will maintain or develop clean and intact skin by the review date. Interventions included the following: a. Antibiotics per Medical Doctor (MD) order was initiated on 6/1/23. b. Encourage good nutrition and hydration in order to promote healthier skin was initiated on 1/19/21 and revised on 3/17/21. c. Follow facility protocols for treatment of injury was initiated on 1/19/21 and revised on 3/17/21. d. Keep skin clean and dry. Use lotion on dry skin was initiated on 1/19/21 and revised on 3/17/21. e. The resident needs pressure relief pad to protect the skin while IN BED was initiated on 1/19/21 and revised on 3/17/21. f. The resident needs pressure relief pad to protect the skin while up IN CHAIR was initiated on 1/19/21 and revised on 3/17/21. g. Wound care per MD order was initiated on 5/13/21. A physician's order dated 6/25/21 revealed left lateral calf Q3D [every 3 days] Clean skin with wound cleanser or normal saline and gauze. If open: Skin prep where drsg will cover. May use santyl on slough, or xenaderm, calcium alginate, Cover with Adhesive foam drsg. Change every 3-7 days, until healed. D/C [discontinue] when healed. one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday]. Another physician's order dated 6/25/21 revealed, (right distal and lateral calf) Q3D Clean skin with wound cleanser or normal saline and gauze. If open: Skin prep where drsg will cover. May use santyl on slough, or xenaderm, calcium alginate, Cover with Adhesive foam drsg. Change every 3-7 days, until healed. D/C when healed. one time a day every Mon, Wed, Fri. A physician's order dated 6/25/21 revealed, Assess wound (right calf distal and medial) for: (A. Increased redness, B. Increased drainage, C. warm to the touch, D. Bleeding, E. Dressing intact, F. Draining thru dressing, G. Need to change the drsg, H. No Drainage, I. Increased pain, J. Notify physician, K. Notify family every shift). A physician's order dated 6/25/21 revealed, Assess wound left lateral calf for: (A. Increased redness, B. Increased drainage, C. warm to the touch, D. Bleeding, E. Dressing intact, F. Draining thru dressing, G. Need to change the drsg, H. No Drainage, I. Increased pain, J. Notify physician, K. Notify family every shift). A physician's order dated 1/15/24 revealed, Juven Oral Packet (Nutritional Supplements) Give 1 packet by mouth every morning and at bedtime related to MODERATE PROTEINCALORIE MALNUTRITION .; UNSPECIFIED OPEN WOUND, LEFT FOOT, SEQUELA. A physician's order dated 1/15/24 revealed, Premier Protein 11oz two times a day related to UNSPECIFIED PROTEINCALORIE MALNUTRITION. A physician's order dated 6/8/21 revealed, Med Pass 2.0 after meals (4OZ) for added nutrition. According to a discharge summary dated 6/7/21, resident 21 had pressure ulcers of bilateral lower extremities with an open wound to right foot and lower leg. A nursing progress note dated 9/9/23 at 4:34 PM, revealed .The wounds on both feet had saturated dressings on them. I removed the dressings, legs are extremely dry, scaly and a lot of dead skin. I washed her legs and patted them dry. I cleansed the wounds on the left shin and heel. The sore on the left shin measures 2.5 cm X 2.5cm in diameter. It is beefy red and good blood flow. I placed a poly memfoam pad and covered with a dressing. The left heel has improved, it measures 5.0cm (L) x 5.5cm (W); has beefy red wound bed and good blood flow. I placed a silver poly mem foam pad and covered with a heel dressing. The right foot, the 5th toe had a lot of drainage and the area on the bottom of food [sic]has several open areas. I cleansed it with wound cleanser, patted it dry. I put silver poly mem between 4th and 5th toe; applied poly mem around the base of the toe and bottom of foot and covered with a foam dressing and tape. Will have DON assess the foot and give us suggestions for wound treatment. Booties put on both feet. A nursing progress note dated 11/14/23 at 4:38 PM, revealed .Pillows for support, booties on both feet. She was medicated for pain with scheduled and PRN [as needed] pain medication with good effect. Her appetite has been fair today. She was given additional snacks and fluids. She drank the nutritional supplements. I changed the dressing on her left heel again today, cleansed with NS [normal saline] and patted dry, polymem foam applied to wound bed and foam dressing covering the wound. The wound measured 4.5cm [centimeter] (L) [length] x [by] 4.0cm (W)[width]. Minimal drainage noted. A nursing progress note dated 12/10/23 at 4:35 PM, revealed .Resident had personal care given and repositioned in bed. Pillows for support and booties on her feet. She has been assisted with her meals. Medicated for pain with scheduled and PRN pain medication with good effect. I changed the dressings on the R [right] foot. The two are ason [sic] the outer bottom of the foot are almost healed. I put a dressing on them for protection. The sore on the bottom of the R small toe was cleansed and patted dry. It measured approximately 2.0 cm(L) x 1.5 cm (w). I put a piece of polymem foam in the wound bed and covered it with a dressing. I changed the dressing on the left shin. The wound was cleansed with NS [normal saline] and patted dry. I put a small piece of poly mem foam and covered with a foam dressing. It measured 2.0 cm (L) X 2.0 cm (W). The left heel dressing was changed. I cleansed the area with NS and patted it dry, applied poly mem foam to the wound bed and covered it with a foam dressing. The wound is filling in from the outer perimeters. She had a medium loose BM this shift. Had 450cc output. A physician's visit dated 12/12/23, revealed resident had chronic wounds on her legs. The physician documented, I am actually pretty surprised at home [sic] much improvement we have seen in the wounds. She had a very big gaping wound on her left heel that was infected months ago and that is actually close down quite a bit to where she just has about a 4 cm [centimeters] wound which is pretty crazy. I think care center is been doing a good job changing her dressing and monitoring her wounds as she has made some steady improvement. We will continue with these interventions hopefully get theses healed up all the way and then at that point preventions again to be the biggest key. A nursing skilled charting assessment dated [DATE], revealed resident did not weight bear, had decreased sensation, required assistance with bed mobility, and required assistance with eating. The assessment further revealed Resident is bed-ridden; requires all care done by staff. The Skin/Wound section revealed, Old hematomas on arms from scratching; lotion applied; Nystatin to abdominal fold. Wounds in various stages of healing on both legs; feet and dressing changed as per treatment orders. On 2/6/24 at 11:24 AM, an interview was conducted with the Director of Nursing (DON). The DON stated skin evaluations were completed by a Certified Nursing Assistant (CNA) when they performed bathing. The DON stated if the CNA noticed a wound on a resident, the nurse was notified, and then the nurse would assess the wound and notify the physician to obtain orders to treat the wound. The DON stated resident 21 had wounds on the back of her legs and had a wound on her left shin for about 3 to 4 years. The DON stated she had a pressure sore on her left heel and a wound under her right pinky toe. The DON stated the wound under the pinky toe was the size of the tip of a pen. The DON stated she dressed resident 21's pinky toe wound on 2/3/24. The DON stated she used a foam dressing and it was to be changed weekly or when saturated. The DON stated that the CNA reported to the nurse if a dressing was saturated. The DON stated there were no physician's orders for the pinky toe wound. The DON stated that nurses would call and ask her what dressings to use. The DON stated she Failed on documentation. The DON stated she did not have measurements on resident 21's wounds for a long time. On 2/6/24 at 1:23 PM, a follow-up interview was conducted with the DON. The DON stated there were no physician's order for the wound below the pinky toe. The DON stated she changed all of resident 21's dressing on Saturday night. The DON stated she did not know when resident 21's wound below the pinky toe opened. The DON stated she did not have a policy and procedure for wounds. On 2/6/24 at 1:29 PM, a phone interview was conducted with Physician 1's Medical Assistant (MA). The MA stated she talked to Physician 1 and Physician 1 stated he was not aware of a new wound on resident 21. The MA stated Physician 1 stated that he was aware that resident 21 had chronic wounds. The MA stated that staff usually texted Physician 1 regarding new skin issues and then Physician 1 provided treatment orders. On 2/6/24 at 1:43 PM, an interview was conducted with CNA 1. CNA 1 stated when a resident was bathed she looked at their skin. CNA 1 stated if there were skin issues, she reported to the nurse to have the nurse look at the resident. CNA 1 stated resident 21 had a left heel wound, left calf wound, and something on her right foot. CNA 1 stated resident 21 had her feet and legs in booties so they were floating and not touching the bed. CNA 1 stated resident 21 had a body pillow that they used to rotate her every 2 hours. CNA 1 stated resident 21 had an air mattress. An observation was made of resident 21's legs and feet with CNA 1. Resident 21 was observed in bed with a sheet over her feet and legs. CNA 1 removed the sheet and there were booties on each foot. There was a bandage on the left shin. CNA 1 lifted resident 21's left leg and there was a bandage on the left heel. CNA 1 lifted resident 21's right foot and there was a bandage on the bottom of the foot below the pinky toe. The bandages were dated 2/3/24. On 2/6/24 at 10:56 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the nurses changed wound dressings when the dressing was soiled or leaked through. RN 1 stated that the DON changed bandages when she did wound rounds. RN 1 stated that the DON completed measurements on wounds. On 2/7/24 at 8:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the DON had changed resident 21's wound dressings on Tuesday night 2/6/24. On 2/7/24 at 8:09 AM, an interview was conducted with the DON. The DON stated she changed resident 21's dressings on Tuesday night 2/6/24. The DON stated she measured the wounds because the measurements had not been done for a while. The DON stated she took pictures and talked to Physician 1 to obtain wound orders. The DON stated resident 21's wounds were healing and did not know when the pinky toe wound opened up. The DON stated she was going to be measuring wounds on Tuesdays, so the dressing changes were changed to Tuesday and Friday, instead of Monday, Wednesday, Friday. The DON stated that she had not been tracking measurements of wounds. The DON provided the measurements obtained on 2/6/24. The left heel measured at 8.5 cm (L) x 6.5 cm (W) x 0.1 cm depth (D). The left shin was 2.8 cm (L) x 2.5 cm (W) x 0.1 cm (D). The wound below the right pinky toe on the ball of foot was 0.4 cm (L) x 0.4 cm (W) x 0.1 cm (D). The note dated 12/10/23 was the last note of measurements. The left shin measurements were 2.0 cm (L) X 2.0 cm (W). The sore on the bottom of the R small toe measured approximately 2.0 cm(L) x 1.5 cm (w). The previous measurement for the left heel were dated 11/14/23. The measurements were 4.5cm (L) x 4.0cm (W). It should be noted the left heel increased in size with no changes to the wound dressing orders since 6/25/21. On 2/12/24 at 11:32 AM, a phone interview was conducted with the DON. The DON stated she was not aware that resident 21's heel wound was larger than the previous measurement in November 2023. The DON stated there were no changes to the treatment orders since June 2021 for the heel and shin wound. The DON did not provide information for why treatments were not changed or different treatments tried since June 2021.

Based on observation, interview, and record review it was determined, for 4 of 25 sample residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, three residents had multiple falls with inadequate interventions in an attempt to decrease the number of falls. The findings for resident 47 were found to have occurred at a harm level. Resident identifiers: 3, 6, 8, and 47. Findings include: 1. Resident 47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 47's medical record was reviewed on 12/3/19. An admission Minimum Data Set (MDS) assessment indicated that resident 47 had a short term and long term memory problem, with a Brief Interview for Mental Status (BIMS) of 6. Incident reports were reviewed for resident 47 and revealed the following: a. On 1/9/19, resident 47 was standing in front of her sink. The staff member with her turned away, the resident fell on her buttocks - hurting her lower back. Interventions listed to prevent further incidents included bed tender (bed alarm) remains in place - pt (patient) checks started - standby assist - pt teaching. b. On 3/13/19, resident 47 was found on the floor crawling on her hands and feet. The report indicated that resident 47 had left her walker in her bedroom. The reports also indicated that Resident has dementia and is confused, needs verbal reminders and cueing. There were no interventions listed on the incident report to prevent further falls. c. On 4/18/19, staff found resident 47 on her butt in the south dining room. No interventions were listed to prevent further incidents. (Note: A replacement care plan was initiated in a new electronic medical records system on 5/22/19. This care plan included interventions to prevent falls such as anticipate and meet the resident's needs, make sure the call light is in reach, follow the facility protocol for falls, and ensure the bed alarm is in place.) d. On 6/12/19, resident 47 went to sit on couch after walking back from breakfast. She couldn't pick her feet up (shuffles while walking) and lost footing when she hit the sticky spill. Interventions listed to prevent further incidents included cleaning up the spill. The resident's care plan was updated to include continue interventions, monitor for 72 hours, and determine the cause of falls. e. On 7/13/19, resident 47 was found laying on lt (left) side in front of couch in south dining area. No interventions were listed to prevent further incidents. Resident 47's care plan was not updated to include additional interventions to prevent further incidents. f. On 7/17/19, resident 47 was found on the floor with back against the closet (and) walker near by . Resident stated she got herself off the toilet and went (down) onto her butt. Interventions listed to prevent further incidents included Do not leave resident unattended in BR (bathroom); supervision when ambulating. Resident 47's care plan was not updated to include additional interventions to prevent further incidents. g. On 8/29/19, resident 47 was found laying on the floor in front of her closet, her chair cushion along with her alarm was on the floor with her. Interventions listed to prevent further incidents included Resident in view of staff when not in bed. Resident 47's care plan was not updated to include additional interventions to prevent further incidents. h. On 10/17/19, staff was assisting resident in transferring from chair to standing position down in dining room. Staff then placed resident's walker in front of her with gaitbelt in place. Staff proceeded with transferring resident. Staff asked resident to stand still while she handed another resident her walker so she could leave dinning (sic) room as well. Resident standing stated ok in response to staff's instructions. Staff then removed hand from standing resident's gaitbelt while standing next to resident. Staff handed other resident her walker when staff heard resident say Oh! Was unable to stop resident from falling . Resident hit head L (left) hip L elbow forearm on wall. Interventions listed to prevent further incidents included training on ambulating one person at a time (with) gait belt (and) walker. Nurses notes for resident 47 on 10/17/19 indicated the following: CNA (Certified Nursing Assistant) reported at 0900 (9:00 AM), staff was assisting resident in transferring from chair to a standing position down in dining room resident. Staff then placed resident's walker in front of her with the gait belt in place staff proceeded with transferring the resident. Staff asked resident to stand still while she handed other resident her walker so she could leave the dining room as well. Resident standing stated ok in response to staff's instructions. Staff then removed hand from standing residents gait belt while standing right next to standing resident handed other resident walker when staff hear OH! from standing resident staff was unable to stop standing residents fall. Standing resident fell landing on left hip left arm hitting her head on dining room wall. Staff notified nurse. I was giving a resident her AM medications, I told them to leave her until I got down there to assess her. I went down as soon as I was done giving the medications to another resident. (Resident 47) was very anxious and in pain. V/S taken . Pain at a 10. I had her raise her arms and she did so, I had her grip my hands and she did. DON (Director of Nursing) got there and I asked resident to move her legs and she stated I can't they hurt. No bruising noted on the back of her head at this time. She does have a light bruise showing up on her left elbow. We assisted resident into a wheelchair. She would not bear any weight on her left leg. DON notified (name of physician). all documents were sent with resident and staff to take to (name of local hospital) for medical evaluation and x-ray of Left hip d/t (due to) pain. A review of the emergency department notes from the hospital revealed that resident 47 sustained a left [MEDICAL CONDITION], and the family declined surgical intervention. The resident returned to the facility the same day. On 12/3/19 at 2:30 PM, an interview was conducted with Certified Nursing Assistant (CNA) 4. CNA 4 stated that on 10/17/19, she was assisting resident 47 out of the dining room, while holding on to a gait belt around resident 47's waist. CNA 4 stated that resident 47 was standing up, and was holding on to her walker. CNA 4 stated that just as we got to the corner of the table, another resident asked for help. CNA 4 stated that she spoke with the other resident while holding on to resident 47's gait belt. CNA 4 then changed her statement, saying that she actually let go of resident 47's gait belt, but did have one hand on resident 47's walker. CNA 4 stated that resident 47 dropped to the ground suddenly with no warning. CNA 4 stated that she later received training not to let go of a resident's gait belt. CNA 4 stated that despite resident 47's previous falls while ambulating with a walker, resident 47 was doing better on the walker that day. CNA 4 stated that resident 47 would use a wheelchair or a walker based on how cognitive she was and how well she stood on a particular day. On 12/4/19 at 8:09 AM, an interview was conducted with CNA 5. CNA 5 stated that she witnessed resident 47's fall on 10/17/19. CNA 5 stated that CNA 4 came to the dining room to assist resident 47 back to the resident's room. CNA 5 stated that CNA 4 was assisting resident 47 by holding on to the resident's gait belt as resident 47 ambulated with her walker. CNA 5 stated that CNA 4 let go of the gait belt and turned her back on the resident to assist another resident. CNA 5 stated that resident 47 lost her balance and tipped over to the left, hitting the wall and sliding down onto the floor. CNA 5 stated that resident 47 did not just fall all of a sudden. On 12/3/19 at 3:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that after resident 47's fall on 10/17/19, staff had been inserviced on the proper use of gait belts. 2. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/2/19 at 3:35 PM resident 6 was observed sitting in the wheelchair in the common area in his unit. On 12/3/19 at 1:30 PM resident 6's medical record was reviewed. Record revealed that resident 6 had falls on following dates: 6/8/19, 6/9/19, 7/30/19, 7/31/19, 8/7/19, 9/6/19, 10/1/19, 10/3/19, 10/8/19, 10/16/19, 10/21/19, 10/27/19 and 10/28/19. Records revealed following: a. The Incident Report from 6/8/19 revealed that, Bed alarm went off. CNA's (Certified Nursing Assistant) down to room, upon entering found resident sitting on the floor leaning against his bed. Resident unable to give description. This incident report revealed that resident did not sustain an injury. He was assessed and his vital signs (VS) were taken. There was no intervention listed on the form. b. The Incident Report from 6/9/19 revealed that, Call light sounding and staff ran (sic) to room and (Resident 6) was 1/2 lying and 1/2 sitting on the floor. Resident unable to give description. This incident report revealed that resident did not sustain injury. Resident 6's VS were taken, head to toe assessment completed and he was put back in bed. There was no intervention listed on the form. c. The Event Report Worksheet from 7/30/19 revealed that resident 6 had fall at 6:30 AM. Per this report, aide walked by room and found him (Resident 6) on floor. Bed-alarm on and working, but his arm (Resident 6's) was on it so did not go off.; (Resident 6) unable to explain, was assessed and assisted up. The intervention listed on the report was,Unable to prevent him sliding out of bed at his will. The report revealed that Care Plan was updated and Red star was placed on residents door. d. The Event Report Worksheet from 7/31/19 revealed that resident 6 had fall at 6:00 AM. Per this report, heard bell go off, found him (Resident 6) on floor next to his bed same as yesterday.; (Resident 6) unable to explain, was assessed, help up into bed, V/S. The intervention listed was, ?Fall cushion pad next to bed?. The report revealed that Care plan was updated and Red star was placed on residents door. e. The Event Report Worksheet from 8/7/19 revealed that resident 6 had fall at 6:30 AM. Per this report, pt found on floor at side of bed.; Dementia-pt unable to verbalize occurrence. The intervention listed was, staff assisted pt up and ambulate to BR (bedroom). Assessed for injury. VS taken. PT up and ambulated to south dining area for observation. f. The Event Report Worksheet from 9/6/19 revealed that resident 6 had fall at 8:15 AM. Per this report,(Resident 6) was sitting on his butt and back against bed when I got there. While waiting for help resident rolled onto left side.; (Resident 6) confused. The intervention listed was,assessed for injuries, ROM (range of motions) and gait, assisted back on bed, V/S taken, resident showered, notified all parties. The report revealed that Care Plan was updated and Red star placed on residents door. g. The Event Report Worksheet from 10/1/19 revealed that resident 6 had fall at 7:15 AM. Per this report, Bed alarm went off, found him {Resident 6) wrapped in his blankets sliding to floor-assisted him to floor. No injuries. The intervention listed was, assisted up onto bed, toileted.; Unable to prevent, keep monitoring. The report revealed that Red star was placed on residents door. h. The Event Report Worksheet from 10/3/19 revealed that resident 6 had fall at 4:00 PM. Per this report, (Resident 6) was found just inside staff breakroom on the floor. Per this report, (Resident 6) sustained 1 centimeter (cm) lac (laceration) on r(right) back of head. The intervention listed was, assess for injury, obtain vitals. Ensure that he has a chair alarm at all times. The report revealed that Care Plan was updated and Red star was placed on residents door. i. The Event Report Worksheet from 10/8/19 revealed that resident 6 had fall at 8:00 AM. Per this report, (Resident 6) was found on the floor of his room next to his bed kneeling. The intervention listed was, assess for injury, obtain vitals. Frequent monitoring in the morning. The report revealed that Red star was placed on residents door. j. The Event Report Worksheet from 1016/19 revealed that resident 6 had fall at 9:20 PM. Per this report, Alarm sounding, (Resident 6) sitting on floor (upright) next to bed with right hand on side rail. Resident 6's description of the incident was was, I was waiting for you, I guess. The intervention listed was, Skin assessment, VS, given fluids, tucked back into bed with warm blanket. The report revealed that Red star was placed on residents door. k. The Event Report Worksheet from 10/21/19 revealed that resident 6 had fall at 3:50 AM. Per this report, (Resident 6) was on the side of bed with arms and torso mostly on left side, legs on floor also on left side. There was no interventions listed. l. The Event Report Worksheet from 10/27/19 revealed that resident 6 had fall at 1:00 AM. Per this report, no witness to the fall. Post fall witness CNA's found pt. on floor with head resting on bed. The intervention listed was, assess, V/S, motor function. Need to find how resident fall so fast. m. The Event report Worksheet from 10/28/19 revealed that resident 6 had fall at 8:45 PM. Per this report, when light and alarm went off and the time we got there, pt. is already with body on the floor almost in sitting position. The intervention listed was, assess, notify DON, family and DR. Continue to identify how to prevent this from happening. The report revealed that Care Plan was updated. Records revealed Care Plan dated 5/24/19 with following focus:The resident is at HIGH risk for falls r/t (related to) severe weakness, recent acute illness. The goal listed was, The resident would be free of falls through the review date. The interventions listed were, The resident uses bed & chair electronic alarm. Ensure the device is in place as needed.; Pt. evaluate and treat as ordered or PRN (as needed).;Low bed to decrease risk of injury.; Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.; Anticipate and meet the resident's needs. Record revealed Care Plan dated 10/29/19 with following focus:(Resident 6) frequently slides out of bed. Family, staff and MD are aware of this problem. The goal listed was, (Resident 6) will not sustain injury from sliding out of bed. The interventions listed were, If (Resident 6) slides out of low bed, help him of the floor, and write a progress note about the incident. No need to notify family/ MD or to complete the facility fall protocol.; Utilize low bed and leave it locked at lowest position when (Resident 6) is in bed. Records revealed that the facility created separate care plans for each resident 6's fall. The goal listed for all falls was, The resident will resume usual activities without further incident through the review date. The interventions listed for all falls were, Continue interventions on the at-risk plan.; For no apparent acute injury, determine and address causative factors of the fall.; Monitor/document/report PRN x 72h (hours) to MD for s/sx: Pain, bruises, change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. An interview with the Director of Nursing (DON) was conducted on 12/03/19 at 3:52 PM. She stated that resident 6 had few falls and they were all when he slid of the bed. The DON stated that they moved resident 6 closer to nursing station, lowered his bed to low position, implemented bed and chair alarm usage. The DON stated that resident 6 was stationed close to nursing station during the day so the staff kept an eye on him. The DON stated that resident 6 was confused and not able to explain how the falls occurred or to follow education/ directions provided. The DON stated that she did not have time to put all interventions on resident 6's care plan. 3. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. and a history of traumatic fracture On 12/2/19 at 1:01 PM an interview was conducted with resident 3. Resident 3 stated that she had fallen a few times. On 12/3/19 the resident's medical record was reviewed. Event reports revealed that resident 3 had falls on the following dates: 2/21/19, 6/21/19, 7/1/19, 7/4/19, 8/2/19, 9/10/19, 9/20/19, 9/30/19, 10/5/19, 11/7/19. Records revealed: a. The Event Report Worksheet (ERW) from 2/21/19 revealed that (resident 3) was found sitting on the floor. Resident 3 stated that resident 3 tried to sit on a chair and ended up on the floor. The ERW revealed that resident 3 was assessed for injuries and vital signs were taken. No injuries were noted. No intervention was listed on the form. b.The ERW from 6/21/19 revealed that (resident 3) was found on the ground with the chair on the side of her tipped over. Resident 3 stated that she was trying to pick up a puzzle piece. The ERW revealed that resident 3 was assessed for injuries, assisted resident 3 up and vital signs were taken. No injuries were noted. No intervention was listed on the form. c. The ERW from 7/1/19 revealed that the nurse down to room to take (resident 3) her medication. Upon entering room (resident 3) was found sitting on the floor in front of her recliner. Resident 3 stated that she was trying to out something out of her dresser, when she lost her balance as she was turning. Resident 3 then grabbed hold of the foot board of her bed to help guide herself to the floor, where she landed on her butt. The ERW revealed that resident 3 was assessed for injuries. Range of motion performed and vital signs taken. Resident 3 had a skin tear 1 centimeter (cm) x 3.5 cm. Area cleansed with Normal saline, edges approximated well, skin prep to wound and sterri-strips applied. Foam dressing in place over sterri-strip. d. The ERW from 7/4/19 revealed that (resident 3) was found sitting on the floor. Resident 3 stated 'I tried to get up and my legs are swollen. I lost my balance and slide down front of recliner. The ERW revealed that a head to toe assessment was done and the (resident 3) was taken to the bathroom. No injuries were noted and Resident 3 was advised to call and accept more help even though she doesn't like to. No intervention was listed on the form. e.The ERW from 8/2/19 revealed that the nurse found resident 3 was found sitting on the bathroom floor next to the door. Resident 3 stated that she was finishing her shower; she slid down the wall to her bottom. Resident 3 was assessed for injuries and vital signs were done. Resident 3 had a skin tear on her left wrist. No intervention was listed on the form other than resident 3 was reminded to call every time and not do anything on her own. f. The ERW from 9/10/19 revealed that staff was helping resident 3's roommate when (resident 3) yelled for help. When staff went to resident 3's side of the room the found resident 3 sitting in the closet. Resident 3 stated I was getting my clothes in my closet and I lost my balance. I am shaky. Resident 3 was assessed for injuries and vital signs were taken. No injuries were noted. Staff checked her bed alarm which resident 3 had removed from her bed. No intervention was listed on the form. g. The ERW from 9/20/19 revealed that resident 3 was found on the floor in front of her chair. Resident 3 stated that she was trying to get up from her wheel chair and slide to close to the edge. Resident 3 was assessed for injuries, pain, range of motion, staff identified if there was a problem. Resident 3 had a skin tear about 2.5 cm by 1 cm. Staff asked resident 3 to call for help when resident 3 needed it. No intervention was listed on the form. h. The ERW from 9/30/19 revealed that resident 3 was found sitting on the floor between her wheel chair and the recliner in resident 3's room. Resident 3 stated she was transferring from the wheel chair to the recliner when the wheel chair rolled back. Resident 3 stated that she forgot to set the brakes. Resident 3 was assessed for injuries and vital signs were taken. No injuries were noted. Staff placed bed alarm back on chair. i. The ERW from 10/5/19 revealed that resident 3 was trying to set a paper on her table when she lost her balance and leaned against the wall after losing her balance. Resident 3 stated that she didn't fall but, slid to the floor. CNA was in the room because she heard the bed alarm but, didn't make it in time to stop resident 3 from sliding to the floor. Resident 3 was assessed for injuries, assisted to her wheel chair, and vital signs were taken. Resident 3 had a 1.5 cm x1.5 cm skin tear on her elbow the skin tear was cleaned with normal saline and sterri-strips and dressing applied. Reminded resident 3 to let staff help her with transfers and ambulation. Resident 3 stated she was standing working on the puzzle when she turned to sit down and missed the wheel chair. Resident 3 was assessed for injuries. No injuries were noted j. The ERW from 11/7/19 revealed that resident 3 was found crawling on the floor by the desk down the hall. Resident stated she stood up to fix her puzzle turned around to sit down and missed the wheel chair. Staff reminded resident to call for help when resident 3 needed it and to lock the wheel chair breaks Care plan stated the following for falls on 6/21/19, 7/1/19, 7/4/19, 9/10/19, 10/5/19, 6/11/19: Focus: The resident had has an actual call (date) with (Specify) poor balance, poor communications/comprehension, and unsteady gait. Goals: The resident will resume usual activities without further incident through the review date. (OVERDUE) Intervention/Tasks: Continue interventions on the at-risk plan. For no apparent acute injury, determine and address causative factors of the fall Monitor/document/report (As need) PRNx 72hours to MD for (Signs and symptoms) s/sx: Pain, bruises, change in mental status. New onset: Confusion, sleepiness, inability to maintain posture, agitation. There are no assigned tasks. The Care plan addressed the fall after resident 3 had fallen but, once the care plan had been developed it was never reviewed or revised to prevent future falls. The care plan has not been updated since 7/6/19. 4. Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/3/19 the resident's medical record was reviewed. Event reports revealed that resident 8 had falls on the following dates: 6/11/19, 8/9/19, 8/30/19. Record reveals: a. The Event Report Worksheet (ERW) from 6/11/19 revealed that resident 8 was found sitting on the floor by the doorway to the bathroom with her brief around her ankles. Resident stated that she slipped and fell . The ERW revealed that resident 8 was assesses for injuries, vital signs were taken, range of motion was assessed. Resident was helped to the bathroom and was given a shower. No injuries were noted and no interventions were listed. b. The ERW from 8/9/19 revealed that call light was going off when CNA went to answer the call light resident 8 CNA found resident 8 on the floor. Resident 8 stated that she missed the toilet. The ERW revealed that resident 8 was assisted to the toilet and then bed, vital signs taken. No injuries noted. Intervention was to remind her to use the call light. c. The ERW from 8/30/19 revealed that resident 8 had picked up a box of the floor and threw it which caused resident 8 to loss her balance and fall. Due to dementia resident was unable to explain the fall. The ERW revealed that resident 8 was assessed for injury, vitals were taken. No injuries and interventions were noted. d. The ERW from 11/21/19 revealed that resident 8 was picking eggs up off the floor and slipped. Resident 8 landed on her buttocks. Resident 8 stated that she was picking up eggs off the floor and that resident 8s wrist hurt. The ERW revealed that resident 8 was assisted up, vital signs were taken, and range of motion was checked. Resident 8 was placed on the couch to rest. No injury or interventions were noted. Care plan initiated on 6/5/19 and revised on 7/28/19 stated the following: Focus: The resident 8 has limited physical mobility, history of falls and forgets her walker. Goals: The resident will maintain current level of mobility, able to walk with four wheel walker and supervision. Interventions: Ambulation: The resident 8 is able to walk with four wheel walker but requires supervision and reminders to use her walker. Resident 8 has had three falls sense the care plan was updated. On 12/3/19 at 2:47 PM CNAs 1, CNA 2, and CNA 3 during a simultanous interview stated that bed and wheel chair alarms were placed on resident 3's wheel chair and bed when resident 3 fell the first time. On 12/3/19 at 3:22 PM Registered nurse (RN) 1 during an interview stated that nurses are supposed to update the care plan after each fall. On 12/3/19 at 3:25 PM, the Assistant Director of Nursing (ADON) during an interview stated that after a resident has a fall the nurse on shift should update the care plan. A review of the care plans showed that the falls were documented but no interventions were added to prevent future falls.

Based on interview and record review, it was determined that for 4 of 36 sample residents, the facility did not ensure that the residents' drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate drug therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, a resident was prescribed and given regularly scheduled [MEDICATION NAME], both narcotics, while an undetected non-facility prescribed narcotic patch was in place resulting in multiplication of pain medication therapy and the need for [MEDICATION NAME], a narcotic reversing medication, at the emergency room (resident 36). Additionally, 3 other residents were given anti psychotic medications that contained black box warnings, without adequate diagnostic indications and no effort for medication reductions (resident 20, 25, 34). The deficient practice identified for resident 36 was found to have occurred at a Harm Level. The deficient practice identified for resident 20, 25, and 34, was found to have occurred at a potential for harm. Resident identifiers: 20, 25, 34, and 36. Findings include: HARM 1. Resident 36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 36's medical records were reviewed on 8/29/17. A review of resident 36's Medication Administration Record [REDACTED] a) 7/21/17 [MEDICATION NAME] SULFATE 30 MG (milligrams) TAB . Oral TWICE DAILY for Chronic pai[DIAGNOSES REDACTED]. b) 7/21/17 [MEDICATION NAME] 325 MG-5 MG TAB ([MEDICATION NAME]/[MEDICATION NAME]) Oral TWICE DAILY for Chronic pai[DIAGNOSES REDACTED]. A review of resident 36's progress notes revealed the following: a) 7/21/17 16:53 (4:53 PM) . (resident) is tired and falls asleep easily in the recliner. b) 7/22/17 22:19 (10:19 PM) (Resident) does wake up when you talk to her but for just a bit then she falls back asleep. c) 7/23/17 16:45 (4:45 PM) At (6:30 AM), I gave her a [MEDICATION NAME] to help with pain management before we got her up. When we got her up this morning, she would have muscle jerking and involuntary muscle movement. She was diaphoretic. When we waked her to the bathroom, she was just in front of the toilet when she stated that her knees were going to buckle. She was very flaccid and resident was assisted on to the toilet. She has not ate well, she is more lethargic and has been unable to hold a glass, as she will almost drop it. She was given the rest of her AM (medications) at (8:30 AM). (Resident's son) came in to go to church and asked what was going on with her. I told him that when I took her (blood pressure) this AM after her (medications) were given, it was 70/47 on the machine; (Blood pressure) checked manually (and) it was 84/52. That I was concerned about it being so low and was going to call her (physician) after church services were out. I also reported that she has a moist cough. I told him there was a change just from yesterday in her behavior and condition. He replied he would come back later this afternoon to see what I found out. Resident did not eat anything for lunch. She was assisted back to bed. At (2:00 PM), I rechecked (blood pressure) (and) was 88/50; (heart rate) was 85. I called her (physician) but got no answer. At (2:35 PM), I notified my (Director of Nursing) resident's condition and she asked if I though it was the new pain medication. I told her that I was not sure, that her pain was managed. I told her the conversation with her son and asked if I could have them hold her (blood pressure ) medication ([MEDICATION NAME]) tonight and she said yes. She also told me to check to see if the resident's [MEDICATION NAME] was removed. (Resident's son) came back (and) he showed me where the patch was, on her and it was promptly removed. He asked that we hold her (blood pressure) medication and to have them only give her 1 tab of [MEDICATION NAME] at bedtime if he could request that. I told him I would put a note on the drug card and make a nursing note. We will monitor resident's condition and reassess her in the AM. Resident's son will be back out tomorrow to see how his mom is doing. d) 7/23/17 21:15 (9:15 PM) Resident has been very sleepy throughout shift. When it came time to give her evening pills (9:00 PM), she could not wake up enough to take the pills, Vitals were taken . (oxygen saturation) around 77 on (room air) (was promptly put on 2 (liters) of (oxygen) which brought it up to 93) . (Director of Nursing) was notified of condition of patient and informed nurse to call (resident's son) and ask what he wants done and if he wants the Doctor notified. (Resident's son) was called and informed of situation and said that due to previously discussed things and a [MEDICATION NAME] that was still on he figured it was something that she would get past, and that we didn't need to worry about giving her pills tonight and to just continue to watch her throughout the night and not worry about calling the doctor at this point. e) 7/26/17 15:32 (3:52 PM) (Resident) received a new order today to decrease her [MEDICATION NAME] 15 (milligrams twice a day). She has been sleepy. f) 7/27/17 15:26 (3:26 PM) . (Resident) still wants to lay down often. g) 7/29/17 17:03 (5:03 PM) . (Resident) napped in her recliner and in bed off and on today. h) 8/3/17 16:25 (4:25 PM) (Resident) was sleeping soundly this morning and did not get her morning medications till 10 AM. She has been sleepy today. i) 8/4/17 04:48 (4:48 AM) Resident has had a decline over the last 10 days of admission. Very sleepy, slightly lethargic acting, unable to swallow pills without crushing them on night shift. [MEDICATION NAME] and (Tylenol) on hold at this time. j) 8/5/17 03:01 (3:01 AM) Resident sleeping at (6:00 PM) and did not arouse for dinner or meds. About (8:00 PM) she was awake enough to give (night time) meds. At (10:00 PM) (vital signs) . respirations 26 . (oxygen saturation) 84% on (room air). Applied oxygen at 2 (liters per minute) via nasal canula. Called (Director of Nursing) to update on resident change of condition. Per (Director of Nursing) request, updated (physician) and (resident's son). (Resident's son) came to care center and spoke with (physician) via phone. Decision made to send (resident) to (emergency room ) for (evaluation and treatment). resident being admitted with (diagnosis) of Pneumonia and will be started on anti-biotics. Also advised that she was given some [MEDICATION NAME] and she is now awake. k) On 8/3017 at 6:00 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she had assessed resident 36 on admission. RN 1 stated the facility had trained her on how to perform a skin assessment on a resident but could not recall when the training had occurred. RN 1 stated that resident 36 was clothed during her skin assessment but that she was able to visualize all areas by lifting resident 36's clothes. RN 1 stated that she did not visualize a [MEDICATION NAME] on resident 36 during assessment but had 'heard' at a later time the [MEDICATION NAME] had been found on resident 36. l) On 8/30/17 at 6:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility was aware that resident 36 had used a [MEDICATION NAME] prior to admission to the facility and had not been prescribed one by the facility physician. The DON confirmed that the [MEDICATION NAME] had been missed at resident 36's physical admission assessment. The DON stated that the facility physician should have been notified of the discovery of the [MEDICATION NAME] on resident 36. The DON stated that she would normally follow up on a medication error such as duplication of medication therapies and educate staff but had not done so on this incident. 2. Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 20's records were reviewed on 8/31/17. A review of Physician's Telephone Orders for Resident 20 revealed the following: On 6/15/17, [MEDICATION NAME] 25 mg (by mouth three times a day). According to the Nursing 2016 Drug Handbook, Wolters Kluwer; pg. 1215-1218; [MEDICATION NAME] is an antipsychotic used to treat [MEDICAL CONDITIONS] I disorder, [MEDICAL CONDITION], Depression associated with [MEDICAL CONDITION] disorder, Major [MEDICAL CONDITION]. Additionally, [MEDICATION NAME] had a Black Box Warning that Drug isn't indicated for use in elderly patients with dementia-related [MEDICAL CONDITION] because of increased risk of death from CV (cardiovascular) disease or infection. (Note: An admitting [DIAGNOSES REDACTED].) A review of resident 20's Pharmacy Reviews revealed that a dose reduction for [MEDICATION NAME] had not been recommended nor had irregularities for [MEDICATION NAME] been identified by the pharmacist. 3. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 25's records were reviewed on 8/30/17. A review of resident 25's medical orders revealed the following: [MEDICATION NAME] 25 mg AM, 50 mg (at bed time). According to the Nursing 2016 Drug Handbook, Wolters Kluwer; pg. 1215-1218; [MEDICATION NAME] is an antipsychotic used to treat [MEDICAL CONDITIONS] I disorder, [MEDICAL CONDITION], Depression associated with [MEDICAL CONDITION] disorder, Major [MEDICAL CONDITION]. Additionally, [MEDICATION NAME] had a Black Box Warning that Drug isn't indicated for use in elderly patients with dementia-related [MEDICAL CONDITION] because of increased risk of death from CV (cardiovascular) disease or infection. (Note: An admitting [DIAGNOSES REDACTED].) A review of resident 25's Pharmacy Reviews revealed that a dose reduction for [MEDICATION NAME] had not been recommended nor had irregularities for [MEDICATION NAME] been identified by the pharmacist. 4. Resident 34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 34's records were reviewed on 8/30/17. A review of resident 34's medical orders revealed the following: [MEDICATION NAME] 50 mg AM and 200 mg (at bed time). According to the Nursing 2016 Drug Handbook, Wolters Kluwer; pg. 1215-1218; [MEDICATION NAME] is an antipsychotic used to treat [MEDICAL CONDITIONS] I disorder, [MEDICAL CONDITION], Depression associated with [MEDICAL CONDITION] disorder, Major [MEDICAL CONDITION]. Additionally, [MEDICATION NAME] had a Black Box Warning that Drug isn't indicated for use in elderly patients with dementia-related [MEDICAL CONDITION] because of increased risk of death from CV (cardiovascular) disease or infection. (Note: An admitting [DIAGNOSES REDACTED].) A review of resident 34's Pharmacy Reviews revealed that a dose reduction for [MEDICATION NAME] had not been recommended nor had irregularities for [MEDICATION NAME] been identified by the pharmacist. On 8/30/17 at 6:30 PM, an interview was conducted with the DON. The DON stated that the facility did not have policy, procedures, or interdisciplinary team meetings for reviews or recommendations for [MEDICAL CONDITION] medication reductions. The DON stated that the facility did request dose reductions for [MEDICAL CONDITION] medications but not in a formal way. The DON stated the facility physician may look at [MEDICAL CONDITION] medications in a general way but did not make gradual dose reductions or recommendations. The DON confirmed that residents 20, 25, and 34 did not have [DIAGNOSES REDACTED]. (Cross refer to F428)

Based on interview and record review it was determined for 3 of 36 sample residents that the facility did not ensure that each resident's environment remained as free from accident hazards as was possible or provide adequate supervision and assistance devices to prevent accidents. Specifically, one resident was not adequately supervised and did not receive assistance while ambulating and experienced a fall which resulted in a refractured hip (resident 23). Another resident had episodes of coughing after consuming food and liquids (resident 20). Additionally, a resident had repeated falls for which the facility did not implement interventions (resident 42). The deficient practice identified for resident 23 was found to have occurred at a Harm Level. The deficient practice identified for resident 20 and 42 was found to have occurred at a potential for harm. Resident identifiers: 20, 23, and 42. Findings include: HARM 1. Resident 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 23's medical records were reviewed on 8/31/17. A review of resident 23's fourteen day Minimum Data Set (MDS) Assessment, dated 7/15/17 revealed that resident 23 was assessed by the facility as requiring a one person physical assistance while walking in her room. A review of resident 23's plan of care included, Fall Risk: Based on fall risk assessment, (patient) is found to be at risk . High risk for falls. The Goal included, Staff and patient to practice injury prevention measures for (patient) during facility stay. Interventions included, Assist with all transfers. Assess need for adaptive equipment, rehab (rehabilitation) or therapy. A review of nurses notes for resident 23 dated 7/17/17 at 8:59 PM, revealed the following, RN (Registered Nurse) called to resident room at (10:20 PM) by (Certified Nurse Assistant) stating that (resident) fell on the floor in her bathroom. (Certified Nurse Assistant) said that resident was ambulating in front of her and resident lost her balance and she was not able to grab her or lower her to the floor. Resident fell on left hip and hit the back of her head. She has a small goose egg on the posterior side of her head. She did not lose consciousness. (Medical Director) updated and verbal order to send to (emergency room ) to (evaluate), hip xray, and treat. (Director of Nursing) updated. Husband updated who said he will meet (resident) at the (emergency room ). A review of a facility Event Report Worksheet for resident 23 dated 7/17/17 revealed the following, Witness observations: (Certified Nurses Assistant) in room with resident. Resident few steps ahead to go to bathroom. Resident lost balance and (Certified Nurses Assistant) unable to catch or lower to floor. A review of nurses notes for resident 23 dated 7/17/17 at 10:45 PM, revealed the following, Resident returned to care center with no new order. X-rays negative for injury. She does (complain of) 'mild' hip pain. She had 2 pain pills just after (8:00 PM). Will give her 2 more around (midnight), if she still wants/needs them to help (sic) managed her pain. Toileted and tucked into bed. Continues on neuro and 15-minute checks per protocol. A review of resident 23's updated plan of care dated 7/18/17 included the following, Falls investigation worksheet and immediate intervention for patient safety. A review of nurses notes for resident 23 dated 7/20/17 at 5:20 PM, revealed the following, Resident was gotten (sic) up (and) worked with (physical therapy) this morning (and) tolerated it well, she did report to them that at times it felt like her left hip was popping, but she had no complaints of pain. (resident) rang her bell at around (9:00-9:30 AM) and asked if I could help her straighten her left leg, I noticed that it was turned in more. Resident cried out in pain when leg was moved. I gave resident Oxycodone 2 tabs at (9:30 AM), applied some heat to left hip area (and) notified (Director of Nursing) about resident having increased pain, she went over the x-ray with me. She said she would contact (physician) and see if he wanted her evaluated by his (physician's assistant). (Physician's assistant) came over (and) assessed resident, at which time she had repeated to him what she had told me prior to him coming over. She stated that when she was bringing her legs up on to the bed, she felt a shooting pain like muscle spasms or Charlie horses (cramps) in her muscles. I had given her some Tylenol at (11:00 AM and) pain was decreased when resident elevated her head of bed (and) was not laying flat. (Physician's assistant) ordered a x-ray of the left hip . faxed the results of the x-ray to (physician) . received a call back from (physician's assistant and) we are shipping resident to (hospital) to be seen by the orthopedic surgeon for putting the hip back in place, possibly a knee brace to wear when up and an abduction pillow when in bed. We notified her family, and the ambulance crew came (and) picked resident up at 1715. resident's son asked that we notify him when we get resident back this evening. All papers and documentation was sent with ambulance crew. On 8/31/17 at 10:00 AM, an interview was conducted with the Administrator (Admin). The Admin stated that staff were trained by physical therapy on how to assist residents to transfer and ambulate safely. The Admin was unable to provide documentation indicating any specific training given to staff and which staff attended training. On 8/31/17 at 11:00 AM, an interview was conducted with the Physical Therapist (PT). The PT stated that resident 23 at the time of the incident was a one person assist with a gait belt. The PT stated that all residents at the facility should be assisted with the use of a gait belt during transfers and ambulation. On 8/31/17 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 23 was a one person assist, walk by. The DON could not confirm that a gait belt was used for resident 23 during the fall on 7/17/17. The DON stated that the facility did not have a policy for when a gait belt should be used. The DON stated resident 23 probably should have had a gait belt when she fell on [DATE]. The DON stated that an investigation was not made after resident 23's fall to determine the root cause of the fall. The DON stated that no further training was given to the staff after resident 23's fall to ensure the use of a gait belt for residents during transfers and ambulation. 2. Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/30/17, resident 42's medical record was reviewed. Nurses progress notes for resident 42 were reviewed and revealed the following: a) On 6/7/17, resident 42 . slid out of his recliner onto the floor. b) On 6/10/17, . he has however been sliding down in his w/c (wheelchair) all morning long today. Resident has to be readjusted in w/c multiple times. c) On 6/12/17, . Resident continues to slide down in his w/c et (and) recliner He is frequently pulled back up in a sitting position. d) On 7/2/17, . He sometimes has episodes of trying to crawl out of bed or slipping down in his chair due to trying to get up. e) On 7/24/17, . He continues to slide down in his w/c et and (sic) the recliner at times. f) On 7/28/17, I went into room 401/2 and found (name of resident) stuck in his wheelchair with his right arm stuck under the handle and he slid down to the point where his extremities were starting to become a concern due to their darkened color. I had an aide help me get him up in the chair, but I was concerned due to his circulation. He was really stiff and fragile, so in order to ensure that no harm came to him in the moving process, I cut the back of the wheelchair so that we could slide him back and free his arm. Due to the restrictions caused by his arm wedged behind the handle, I accidentally nicked his upper right bicep causing him to have a small open wound . g) On 8/6/17, . He sometimes has episodes of trying to crawl out of bed or slipping down in his chair due to trying to get up. h) On 8/13/17, . Resident is frequently monitored d/t (due to) him sliding down in his w/c or recliner. Incident reports for resident 42 were reviewed and revealed the following: a) On 6/7/17, resident 42 was found laying on floor after sliding out of w/c (wheelchair. The intervention listed to prevent this from reoccurring was place resident in recliner. b) On 7/27/17, went to give night meds (medications) in the (name of resident)'s room. (Resident 42) was stuck in his wheelchair with his right arm stuck in his wheelchair and he slowly was sliding downwards. Staff attempted to move him, but his circulation was concerning (and) I wanted to prevent major injuries. I cut the back of the wheelchair to free him so we could do a 2-person assist. Accidentally knicked (sic) his right upper arm with scissors. The intervention listed to prevent this from reoccurring was talked with nurse in detail about the need to call for assistance, to utilize the other staff on duty to help with any situation she is unsure of . The intervention did not address prevention of the resident sliding out of his wheelchair. Resident 42's physician orders [REDACTED]. (Note: Coumadin is an anticoagulant that would put resident 42 at increased risk of bleeding if he experienced a fall.) Resident 42's care plan was reviewed. Facility staff developed a care plan for resident 42 and his falls on 6/7/17. The care plan indicated that resident 42 had experienced an actual fall. Interventions listed included: reporting the fall to the physician and family, assess for 72 hours after the fall, update the fall risk assessment, assess for injuries, and complete a falls investigation worksheet. None of the interventions listed on the care plan indicated what the facility was implementing to prevent further falls. In addition the facility did not update the care plan after the resident slid down in his wheelchair and was found stuck in his wheelchair on 7/27/17. On 8/31/17 at 10:35 AM, an interview was conducted with CNA 3. CNA 3 stated that resident 42 had a cushion in his wheelchair, but the CNA did not know the purpose of the cushion. CNA 3 stated that resident 42 slid down or out of his wheelchair at least 20 times a day and needed to be repositioned in his wheelchair after sliding down or out. On 8/31/17 at 10:00 AM, resident 42 was observed. Resident 42 was seated in his wheelchair in his room. No staff were in the area. On 8/31/17 at 10:05 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated that resident 42 often scoots himself out of the wheelchair, and can't get back up, but that he had never fallen out of the wheelchair. RN 4 stated that staff needed to reposition resident 42 frequently and watch him closely. When asked about the interventions that had been implemented to prevent the resident from sliding down in his wheelchair, RN 4 stated that staff did frequent monitoring because if you're Johnny on the spot, he's safe. On 8/31/17 at 11:30 AM, an interview was conducted with Physical Therapist (PT) 1. PT 1 stated that he had not worked with resident 42 in at least 6 months. PT 1 stated that he was unaware of the 2 incidents listed on the incident reports referenced above. PT 1 stated that resident 42 had [DIAGNOSES REDACTED] which made his body lock up on one side. When asked about interventions that had been attempted to prevent the resident from sliding down in his wheelchair, PT 1 stated that they had not attempted any cushions or wedges in the wheelchair because they were considered restraints. (Note: No documentation could be located to indicate that the facility had implemented interventions to prevent the resident from sliding down in his wheelchair, despite 2 separate incidents.) 3. Resident 20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/30/17, resident 20 was observed while he ate his breakfast meal. The resident was observed to be seated in a wheelchair at a table around the corner from the main hall where the majority of the residents were dining. The resident was observed to be drinking a cream of wheat hot cereal out of a cup. At 7:40 AM, resident 20 was observed to swallow the cereal and then cough after swallowing the cereal. There were no staff present while resident 20 was coughing after swallowing. This same cycle of swallowing and coughing with no staff present occurred again at 7:45 AM, 7:48 AM, 7:54 AM, 7:59 AM, and 8:04 AM. At 8:04 AM, resident 20 pushed himself away from the table and down the hall. At no time during the observation were staff observed to be present during resident 20's coughing. On 8/30/17 at 2:25 PM, an interview was conducted with the DON. The DON stated that she was unaware that resident 20 was coughing after swallowing that morning. The DON stated that residents were usually referred to a speech therapist upon admission, or if a staff member noticed a resident was having swallowing difficulties during dining. (Cross refer F387)

Based on observation and record review it was determined, for 1 of 36 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, a resident was admitted with a [MEDICATION NAME] (a narcotic medication for pain) that was not detected by the facility during an admission assessment. The resident was prescribed two additional narcotic pain medications by the facility physician resulting in a duplication in pain medication. Furthermore, the resident was not assessed by a physician after a change of condition. The resident was admitted to an emergency room and received [MEDICATION NAME], a narcotic reversing medication. The resident was admitted to the hospital. The deficient practice identified for the resident was found to have occurred at a Harm Level. Resident identifier: 36. Findings include: Resident 36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 36's medical record was reviewed on 8/29/17. A review of resident 36's July 2017 Medication Administration Record [REDACTED] a) 7/21/17 [MEDICATION NAME] SULFATE 30 MG (milligrams) TAB (tablet). Oral TWICE DAILY for Chronic pai[DIAGNOSES REDACTED]. b) 7/21/17 [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) 325 MG-5 MG TAB Oral TWICE DAILY for Chronic pai[DIAGNOSES REDACTED]. A review of resident 36's progress notes revealed the following: a) 7/21/17 16:53 (4:53 PM) . (resident) is tired and falls asleep easily in the recliner. b) 7/22/17 15:30 (3:30 PM) .Resident has had a moist cough this afternoon. c) 7/22/17 22:19 (10:19 PM) (Resident) does wake up when you talk to her but for just a bit then she falls back asleep. d) 7/23/17 16:45 (4:45 PM) At (6:30 AM), I gave her a [MEDICATION NAME] to help with pain management before we got her up. When we got her up this morning, she would have muscle jerking and involuntary muscle movement. She was diaphoretic. When we walked her to the bathroom, she was just in front of the toilet when she stated that her knees were going to buckle. She was very flaccid and resident was assisted on to the toilet. She has not ate well, she is more lethargic and has been unable to hold a glass, as she will almost drop it. She was given the rest of her AM (morning medications) at (8:30 AM). (Resident's son) came in to go to church and asked what was going on with her. I told him that when I took her (blood pressure) this AM after her (medications) were given, it was 70/47 on the machine; (Blood pressure) checked manually (and) it was 84/52. That I was concerned about it being so low and was going to call her (doctor) after church services were out. I also reported that she has a moist cough. I told him there was a change just from yesterday in her behavior and condition. He replied he would come back later this afternoon to see what I found out. Resident did not eat anything for lunch. She was assisted back to bed. At (2:00 PM), I rechecked (blood pressure) (and) was 88/50; (heart rate) was 85. I called her (physician) but got no answer. At (2:35 PM), I notified my (Director of Nursing) resident's condition and she asked if I thought it was the new pain medication. I told her that I was not sure, that her pain was managed. I told her the conversation with her son and asked if I could have them hold her (blood pressure) medication ([MEDICATION NAME]) tonight and she said yes. She also told me to check to see if the resident's [MEDICATION NAME] was removed. (Resident's son) came back (and) he showed me where the patch was, on her and it was promptly removed. He asked that we hold her (blood pressure) medication and to have them only give her 1 tab of [MEDICATION NAME] at bedtime if he could request that. I told him I would put a note on the drug card and make a nursing note. We will monitor resident's condition and reassess her in the AM. Resident's son will be back out tomorrow to see how his mom is doing. e) 7/23/17 21:15 (9:15 PM) Resident has been very sleepy throughout shift. When it came time to give her evening pills (9:00 PM), she could not wake up enough to take the pills, Vitals were taken . (oxygen saturation) around 77 (percent) on (room air) (was promptly put on 2 (liters) of (oxygen) which brought it up to 93 (percent)) . (Director of Nursing) was notified of condition of patient and informed nurse to call (resident's son) and ask what he wants done and if he wants the Doctor notified. (Resident's son) was called and informed of situation and said that due to previously discussed things and a [MEDICATION NAME] that was still on he figured it was something that she would get past, and that we didn't need to worry about giving her pills tonight and to just continue to watch her throughout the night and not worry about calling the doctor at this point. f) 7/26/17 15:32 (3:52 PM) (Resident) received a new order today to decrease her [MEDICATION NAME] 15 (milligrams twice a day). She has been sleepy. g) 7/27/17 07:50 (7:50 AM) . (Resident) has been coughing a lot more than usual though. h) 7/27/17 15:26 (3:26 PM) . (Resident) still wants to lay down often. i) 7/29/17 17:03 (5:03 PM) . (Resident) napped in her recliner and in bed off and on today. j) 8/3/17 16:25 (4:25 PM) (Resident) was sleeping soundly this morning and did not get her morning medications till 10 AM. She has been sleepy today. k) 8/4/17 04:48 (4:48 AM) Resident has had a decline over the last 10 days of admission. Very sleepy, slightly lethargic acting, unable to swallow pills without crushing them on night shift. [MEDICATION NAME] and (Tylenol) on hold at this time. l) 8/5/17 03:01 (3:01 AM) Resident sleeping at (6:00 PM) and did not arouse for dinner or meds (medications). About (8:00 PM) she awake enough to give (night time) meds. At (10:00 PM) (vital signs) . respirations 26 . (oxygen saturation) 84% on (room air). Applied oxygen at 2 (liters per minute) via nasal canula (sic). Called (Director of Nursing) to update on resident change of condition. Per (Director of Nursing) request, updated (physician) and (resident's son). (Resident's son) came to care center and spoke with (physician) via phone. Decision made to send (resident) to (emergency room ) for (evaluation and treatment). resident being admitted with (diagnosis) of Pneumonia and will be started on antibiotics. Also advised that she was given some [MEDICATION NAME] and she is now awake. On 8/3017 at 6:00 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she had assessed resident 36 on admission. RN 1 stated the facility had trained her on how to perform a skin assessments but could not recall when the training had occurred. RN 1 stated that resident 36 was clothed during her skin assessment but that she was able to visualize all areas by lifting resident 36's clothes. RN 1 stated that she did not visualize a [MEDICATION NAME] on resident 36 during assessment but had 'heard' at a later time the [MEDICATION NAME] had been found on resident 36. On 8/30/17 at 7:00 PM, an interview was conducted with RN 2. RN 2 stated that he cared for resident 36 the evening of 7/23/17. RN 2 stated he did not notify the facility physician because he spoke with the resident's son who told him not to call the physician. RN 2 stated that he would normally call the facility physician when a resident had a change in condition but the resident's son, is here everyday so I felt like it was ok. On 8/31/17 at 7:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she cared for resident 36 the morning of 7/23/17. LPN 1 stated that she did not call the physician on the morning of 7/23/17 when resident 36 had a change in condition because resident 36's son informed her that the physician was at church and she did not want to call him while he was at church. LPN 1 stated that normally she would have called the physician if the resident had gotten worse but it was a holiday weekend and she did not call him. LPN 1 confirmed that the physician was not notified on 7/23/17. LPN 1 stated that when a resident had a change in condition she would normally call the DON (Director of Nursing), the family, and the physician. On 8/30/17 at 6:20 PM, an interview was conducted with the DON. The DON stated that she was aware that resident 36 had used a [MEDICATION NAME] prior to admission to the facility and had not been prescribed one by the facility physician. The DON confirmed that the [MEDICATION NAME] had been missed during resident 36's physical admission assessment. The DON stated that the facility physician should have been notified of the discovery of the [MEDICATION NAME] on resident 36. The DON stated that she would normally follow up on a medication error such as duplication of medication therapies and educate staff but had not done so on this incident. On 8/31/17 at 1:00 PM, a second interview was conducted with the DON. The DON confirmed that resident 36 was not assessed by the facility physician between the dates of 7/21/17 and 8/5/17. The DON confirmed that the physician was not notified when resident 36 had changes in condition related to sedation and coughing until 8/5/17 when she was sent to the emergency room . The DON confirmed that facility staff usually called her first prior to calling the facility physician. (Cross refer to F329)

Based on interview, observation, and record review, the facility did not ensure that 2 of 36 sample residents received appropriate interventions to prevent or treat pressure ulcers. Specifically, one resident acquired a pressure sore during his stay at the facility, while a second wound worsened. This finding will be cited at a harm level. In addition, another resident did not receive appropriate treatment for [REDACTED]. Resident identifiers: 12 and 52. HARM: 1. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/30/17 resident 52 was continuously observed. The following observations were made: a) At 8:52 AM, resident 52 was wheeled in his wheelchair into the south dining room, where a staff member assisted him with his meal. Resident 52 was observed to have his upper lateral left calf resting directly on a metal bar on the wheelchair. b) At 9:22 AM, resident 52 was wheeled out of the dining room, and into his room in front of the television. The staff member did not reposition resident 52 or move resident 52 to his recliner or bed. c) At 9:47 AM, Registered Nurse (RN) 3 was observed to enter resident 52's room to administer a nutritional supplement. RN 3 did not reposition resident 52 or move resident 52 to his recliner or bed. Resident 52 was observed to have his upper lateral left calf resting directly on a metal bar on the wheelchair. d) At 10:52 AM, resident 52 remained in his wheelchair, with his upper lateral left calf resting directly on a metal bar on the wheelchair. e) At 11:10 AM, resident 52 remained in his wheelchair, with his upper lateral left calf resting directly on a metal bar on the wheelchair. f) At 11:26 AM, resident 52 wheeled himself out of his room, and stationed himself near the nurses station, which was adjacent to his room. g) At 11:31 AM, resident 52 stated that his left leg hurts like hell. h) At 11:41 AM, resident 52 was observed to move the leg rests of the wheelchair up, and attempt to place his feet on the floor. Resident 52's chair was at a height that prevented resident 52 from placing his feet directly on the floor. Part of resident 52's left foot was touching the floor, but resident 52's right foot and leg were dangling from the chair seat. The resident then attempted to wheel himself down the hallway, but his arms became partially stuck in the wheel. i) At 11:44 AM, a staff member adjusted the footrests on resident 52's wheelchair, and wheeled resident 52 to the dining room. The staff member positioned resident 52's wheelchair at a table. j) At 12:57 PM, the continuous observation ended. At that time, resident 52 was still seated at the dining room table, eating lunch. At no time during the continuous four hour and five minute observation was resident 52 observed to be repositioned, or reposition himself. Also, resident 52 had his left leg resting directly on the metal bar of the wheelchair throughout most of the observation. On 8/30/17 at approximately 2:00 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 confirmed that she was assigned to resident 52 that day, and had not repositioned the resident at any time from 8:52 AM through 12:57 PM during the time of the continuous observation by the surveyor. On 8/31/17 at 10:35 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that resident 52 was dependent on staff for repositioning both in bed and in his wheelchair. CNA 3 stated that usually after meals, facility staff would assist resident 52 into his recliner as a way to help the resident change position. CNA 3 stated that resident 52 was supposed to be repositioned at least every 2 hours by facility staff. On 8/28/17, resident 52's medical record was reviewed. Resident 52's Admission Nursing Assessment indicated that resident 52 was admitted with a stage II pressure ulcer to his left buttocks, that was 2.5 centimeters by 2 centimeters in size. No other wounds were documented as being present on admission. Resident 52's Progress notes indicated the following: LEG WOUND a) On 6/30/17, the Physical Therapist (PT) documented that resident 52 was dependent on staff for transfers, and was non-ambulatory. b) O 7/15/17, the nurse documented put new dressing on left calf where there was a wound roughly the size of 2cm (centimeters) x (by) 3 cm. (Note: This is the first mention in the nurses progress notes of a wound on resident 52's leg. No documentation could be located to indicate the stage of the pressure ulcer, the possible cause of the ulcer, the orders to treat the ulcer, or that the nurse had notified the physician of the new ulcer.) c) On 7/25/17, the PT documented that resident 52 had a left lateral calf wound: 1.6 cm (centimeters) x (by) 2.3 cm stage III pressure ulcer. Edges adhered, no odor, minimal drainage. Wound bed 60 (percent) slough. Wound cleansed with [MEDICATION NAME], washed with saline, dressed with bordered gauze. (resident 52) has another wound on his lateral L (left) lower leg due to resting the side of his leg against the bar for his foot rest. We got pt (patient) a new seat cushion to adjust his sitting position and this seemed to keep his leg off the at (sic) it previously rested on. (Note: This was the first note by the PT indicating that resident 52 had a pressure ulcer on his leg, which was approximately 10 days after nursing had identified it. No other physical therapy notes could be located to indicate that facility staff had identified the pressure ulcer on resident 52's left leg until it was already at a stage III. In addition, no treatments were implemented by the PT besides the saline wash and bordered gauze.) d) On 7/26/17, the PT noted that resident 52's left lower leg was again rested on the wheelchair in a position to put pressure on the wound. Nursing was notified and we will continue to monitor pressure relief in that area. e) On 7/28/17, the PT noted Wound over L (left) fibular head is closed with a scab but min (minimum) drainage on dressing and dark [DIAGNOSES REDACTED] around the wound perimeter. Covered with bordered foam for pressure prevention and reported to nursing and PT that patient needs to be closely monitored for pressure over that point. I discussed with him that he needs to be very cautious with resting the outside of his lower leg against the bar for his foot pedal. (Note: Bordered foam is typically used to provide a type of padding for protection, and is not a typical treatment used for healing a wound.) f) On 8/1/17, the PT noted Wound on Left fibular head, 2.7 x 1.6 cm. Covered with scab, min amount of serosanguinous drainage on the dressing. Covered with bordered foam. appears to be keeping his L leg off of the foot rest bar that caused his pressure ulcer . g) On 8/14/17, the PT noted Wound on Left fibular head, 2.5 x 1.6 cm. Covered with bordered foam. h) On 8/17/17, the PT noted L lateral calf ulcer 2.5 cm x 1.6 cm. Wound bed covered in slough, unstageable. wounds are both pressure ulcers. Dressed with santyl and bordered foam. (Note: This was an increase severity of the pressure ulcer, as the ulcer had worsened from a stage III to an unstageable. In addition, the PT documented at this time, that santyl was being implemented as a chemical debridement. This was the first treatment of [REDACTED].) i) On 8/29/17, the PT noted L lateral calf ulcer 2.5 cm x 1.6 cm. Wound bed covered in slough, unstageable. Both wounds cleaned with [MEDICATION NAME], washed with saline. Dressed with santyl and bordered foam. (Note: These were the exact measurements that had been taken on both 8/14/17, and 8/17/17.) (Note: At no time in the PT notes, did the PT staff identify ways to protect the resident's leg from resting directly on the metal bar of the wheelchair to prevent worsening of the wound after 7/25/17, even though the leg continued to rest on the metal bar.) BUTT(NAME)K WOUND a) On 7/20/17, the PT noted resident 52's nurse informed therapy of his pressure sore on his left hip area. To be further assessed tomorrow at AM by PT. (Note: This was approximately three weeks after resident 52 was admitted . No other PT notes regarding this pressure ulcer could be located prior to this date.) b) On 7/22/17, the PT noted resident 52's left hip wound has not healed with (sic) just the removal of his brace and the pressue (sic) it was causing. The PT identified that the hip wound was 2.3 cm x 2.4 cm in size. c) On 7/28/17, the PT noted resident 52's hip wound was now being described as being on the left proximal buttock. d) On 8/1/17, the PT noted resident 52's hip wound was now being described as being on his left lower back. e) On 8/30/17, the PT noted the left hip ulcer was measured at 2.4 cm x 2.4 cm. On 7/7/17, facility staff completed an admission Minimum Data Set (MDS) Assessment. The Assessment indicated that resident 52 had a stage II pressure ulcer upon admission, and that a care plan should be developed. There was no care plan in place for resident 52's wounds, either when the resident was first admitted with a pressure ulcer on his buttocks, or later when he developed a pressure ulcer on his leg. The physician's recertification orders were reviewed. No orders for the treatment of [REDACTED]. physician progress notes [REDACTED]. On 8/31/17 at 8:05 AM, Physical Therapist (PT) 1 was observed while changing the dressings on resident 52's buttocks and leg. PT 1 donned gloves and positioned resident 52 on his right side. An Allyvan foam dressing was removed. The Allyvan foam dressing was saturated with a serousangineous drainage. PT 1 then cleansed the open area with [MEDICATION NAME] without changing his gloves. PT 1 donned clean gloves and used the head of the cotton swab to debride yellow slough. PT 1 cleansed the open area with normal saline and threw the old dressing and supplies in the garbage. During this time, resident 52 stated, Ouch! That hurts! PT 1 stated that the wound measured 3.5 cm x 3.25 cm with an inner area of yellow slough and an area of eschar on the upper medial aspect of the buttocks. PT 1 then removed the old dressing on resident 52's left lateral calf without changing his gloves. PT 1 then cleansed the wound with a saline soaked gauze pad to debride the brownish gray substance that covered the wound. PT 1 applied an antibiotic ointment, and then covered the wound with a bordered gauze. PT 1 stated that the wound measurement was 3.2 cm X 2.8 cm X 0.4 cm. (Note: PT 1 did not change his gloves or wash his hands prior to completing the wound care on resident 52's left lateral calf area. In addition, both wounds were significantly larger than they had been measured as being on 8/30/17.) PT 1 was immediately interviewed. PT 1 confirmed that he did not change his gloves after removing soiled dressings or before treating additional wounds. Lab results for resident 52 were reviewed and the results were as follows: a) On 7/20/17, resident 52 was identified as having staphylococcus aureus in his buttock wound. b) On 8/22/17, resident 52 was identified as having staphylococcus aureus and [MEDICATION NAME] clocae in his wound, although the results did not list which wound. On 8/31/17 at 7:22 AM, PT 1 was re-interviewed. PT 1 also stated that it required 4 pounds of pressure for 4 hours to cause a pressure ulcer. PT 1 stated that when a resident had a pressure ulcer, the PTs were responsible for monitoring, measuring, and treating the wounds. PT 1 stated that resident 52 must have bumped or scraped his leg on something that caused it to bruise and then progress to a stage 2 ulcer. PT 1 stated that the wound on resident 52's leg was not caused by pressure, despite the multiple PT entries stating that it was a pressure ulcer caused by the wheelchair. When asked about nutritional support for resident 52, PT 1 stated that resident 52 stated he felt force fed with the nutritional supplements. PT 1 stated that neither he nor other facility staff had made attempts at increasing resident 52's nutritional status with things like increased protein, vitamin C, zinc, multivitamin, or a fortified diet. PT 1 stated that facility staff had been trying to get him (resident 52) to eat more. PT 1 also stated that there were no physician orders for dressing changes because as a PT he could prescribe those changes. PT 1 stated that he had not spoken with the physician regarding resident 52's wounds. On 8/31/17 at 8:52 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that she participated in Interdisciplinary Team (IDT) meetings. The DM stated that during the IDT meetings, facility staff decreased resident 52's nutritional supplement because he was drinking it six times a day, and was upset about it. The DM stated that the facility staff had not implemented alternative treatments to improve resident 52's calorie/protein intake and healing potential, such as a fortified diet/snacks or Vitamin C/Zinc/Multivitamins. The DM stated that the Registered Dietitian was responsible for making those suggestions. On 8/31/17 at 11:15 AM, a telephone interview was conducted with the facility Registered Dietitian (RD). The RD stated that he was present for most Interdisciplinary Team (IDT) meetings. The RD stated that the IDT meetings involved discussions about resident assessments, activities, wounds, etc. When asked about other interventions to improve wound healing in residents, the RD stated that we stick to med pass (a nutritional supplement). When asked if the RD ever recommended protein supplements, Vitamin C, a multivitamin or zinc, the RD stated, I guess we haven't done too much of that. When asked if the facility had attempted a fortified diet for resident 52 the RD stated, What do you mean by a fortified diet? After the surveyor explained that a fortified diet typically included increasing the caloric and nutrient content of foods the resident was already eating (such as adding extra butter, cheese, fortified milk, etc to foods), the RD stated, We don't do fortified diets here. On 8/31/17 at 7:45 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed she did not have any orders in place for dressings, there was no care plan for resident 52's wounds, and no documentation that the physician had been notified. The Pressure Ulcers/Skin Breakdown - Clinical Protocol was reviewed. The protocol documented the following: Assessment and Recognition . 2. In addition, the nurse shall assess and document /report the following: a. Vital signs b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. c. Pain assessment . e. Resident's mobility status. f. Current treatments, including support surfaces g. All active [DIAGNOSES REDACTED].>Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown . Treatment/Management 1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. 2. The physician will help identify medical interventions related to wound management . Monitoring . 2. The physician will help the staff review and modify the care plan as appropriate especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. (Cross refer to F157, F279 and F441) 2. Resident 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/29/17 at approximately 11:00 AM, Registered Nurse (RN) 1 was interviewed related to pressure ulcers. RN 1 stated that resident 12 had a pressure ulcer on his right heel that was not healed. RN 1 further stated that resident 12 was on hospice services. On 8/30/17 the following observations were made of resident 12: a) At 9:32 AM, resident 12 was observed sitting in an electric wheelchair and appeared to be asleep. The right foot was planted on the floor and the left was on the footrest of the wheelchair. Both feet were covered by socks and slippers. The right foot did not appear to have a dressing in place. b) At 10:06 AM, resident 12 was observed sitting in an electric wheelchair with both heels on the footrest of the chair. The resident's feet were covered by socks and slippers. The right foot did not appear to have a dressing in place. c) At 10:50 AM, resident 12 was observed sitting in an electric wheelchair with both heels on the footrest of the chair. The resident's feet were covered by socks and slippers. The right foot did not appear to have a dressing in place. d) At 11:30 AM, resident 12 was observed in his wheelchair at lunch. His feet were covered by socks and slippers. Both feet were observed on the footrest of the wheelchair. His right foot did not appear to have a dressing in place. e) At 12:05 PM, resident 12 was observed in his wheelchair at lunch. His feet were covered by socks and slippers. Both feet were observed on the footrest of the wheelchair. His right foot did not appear to have a dressing in place. f) At 12:35 PM, resident 12 was observed at lunch in his wheelchair. His feet were covered by socks and slippers. Both feet were on the footrest of the wheelchair. His right foot did not appear to have a dressing in place. g) At 2:45 PM, resident 12 was observed in his room in his wheelchair and both feet were on his footrest. His feet were covered by socks and slippers. His right foot appeared to be half off the foot rest, forcing pressure to the back of his foot. His right foot did not appear to have a dressing in place. h) At 3:50 PM, resident 12 was observed in his room in his wheelchair and both feet were on his footrest. His feet were covered by socks and slippers. His right foot appeared to be half off the footrest, forcing pressure to the back of his foot. His right foot did not appear to have a dressing in place. i) At 6:15PM, resident 12 was observed in his room in his wheelchair and both feet were on the footrest. His feet were covered by socks and slippers. His right foot appeared to be half off the footrest, forcing pressure to the back of the foot. His right foot did not appear to have a dressing in place. Resident 12's medical record was reviewed on 8/30/17. On 4/27/17 the licensed nursing staff completed a Minimum Data Set (MDS) assessment. Resident 12 was assessed as being at risk of pressure ulcers, that he had a pressure reducing device for chair and bed, and had a stage II pressure ulcer present on admission. Per hospice documentation, resident 12's right heel pressure ulcer was first observed 2/27/17. Per facility's care plan: The Care plan was initiated 4/29/17 which identified Resident has Stage 2 pressure ulcer on R (right) heel. Goal: Pressure ulcer will show signs of healing and be free of infection. Interventions: Treatment as ordered, monitor and report if ineffective (initiated 4/29/17); Observe for changes in pressure ulcer, report to MD if there is an increase in size or stage and follow up as indicated (initiated 4/29/17); Turn and reposition frequently as needed (initiated 4/29/17); Reduce pressure to affected area by frequently repositioning (initiated 4/29/17); and Pressure relieving device when in chair (4/29/17). Per hospice's Plan of Care and Physician's Orders from 7/13/17 to 9/10/17, the treatment to resident 12's right heel was to include to cleansing the wound with normal saline and air dry, apply skin protector, apply a foam pad to the area, and cover with [MEDICATION NAME] or [MEDICATION NAME] tape. The orders were to change the dressing every 2-7 days until healed. The facility licensed nursing staff documented the following regarding resident 12's wound care of his right heel: a. 6/16/17 He was assisted to bed and feet were elevated and heels floated. b. 7/15/17 I also talked to resident about sitting up in the morning or afternoon to help with the sore on his heel. Resident will have heels floated by pillows but does not keep them on them. c. 8/14/17 Skin (sic) is applied to heels BID (twice daily) et (and) his heels are floated when he's in bed. d. 8/27/17 Staff c/t (continue to) skin prep resident's heel et (and) float them. The hospice staff documented the following related to resident 12's wound care of his right heel: a. On 4/26/17 the hospice RN charted talked with staff nurse about pt's (patient's) needs. Talked with her about pt's heel pain in the night. She will report to night nurse to help make sure that heels are propped off the mattress and pain is managed. b. On 5/1/17 hospice RN charted wound care discussed with nurse (nurse's name). She will watch for drainage and cover if present. RN also charted facility provides wound care, hospice provides wound care. The following wound dimensions were documented: length 1.25 centimeters (cm), width 1.5 cm, no depth, and no eschar. c. On 5/3/17 the hospice RN charted right heel wound appears to be healing assessed right heel. No dressing was on it when I arrived .wound cleaned and foam dressing applied .instructed staff to keep a foam dressing on pt's heel. Wound dimensions were not recorded this visit. d. On 5/8/17 RN charted Pt with new pressure sore to back of heel despite caregiver keeping pt leg elevated and up on pillow. RN charted caregiver/family provides wound care, hospice provides wound care. The following wound dimensions were documented: length 1.5 cm, width 1.5 cm, no depth, and no eschar. e. On 5/10/17 hospice RN charted right heel wound continues to heal and wound care provided to right heel, discussed plan of care with staff nurse. f. On 5/15/17 the hospice RN charted pt's wound to right heel is about the same and charted wound care managed by: hospice. Wound dimensions were not recorded this visit. g. On 5/18/17 the hospice RN facility provides wound care, hospice provides wound care. The following wound dimensions were documented: length 1 cm, width 1 cm, no depth, and no eschar. h. On 5/23/17 the hospice RN charted hospice provides wound care. Wound dimensions were not recorded this visit. i. On 5/30/17 the hospice RN charted wound care provided to R heel and foam dressing applied and caregiver/family provides wound care. Wound dimensions were not recorded this visit. j. On 6/1/17 the hospice RN charted wound care provided to right heel and right arm. Dressing applied to right heel. The following wound dimensions were documented: length 0.75 cm, width 1 cm, depth 0.25 cm, and no eschar. RN also charted caregiver/family provides wound care, hospice provides wound care. k. On 6/8/17 the hospice RN charted assessed right heel. No dressing was on it when I arrived .wound cleaned and foam dressing applied .instructed staff to keep a foam dressing on pt's heel. l. On 6/12/17 the hospice RN charted right heel wound care done and foam dressing applied .SN taught pressure prevention to pt and discussed care with staff nurse at (facility name). RN also charted hospice provides wound care. Wound dimensions were not recorded this visit. m. On 6/15/17 the hospice RN charted wound care provided to right heel .dressing applied to right heel. Wound dimensions were not recorded this visit. n. On 6/19/17 the hospice RN charted pt's (patient's) wound is closed. Still has a little depth, but is not open at this time. RN also charted: hospice provides wound care. Wound dimensions were not recorded this visit. o. On 6/22/17 the hospice RN charted right heel wound noted to be dry and intact still with a small amount of depth. Wound dimensions were not recorded this visit. p. On 6/26/17 the hospice RN charted pt's wound today is scabbed and has no depth. RN also charted hospice provides wound care. Wound dimensions were not recorded this visit. q. On 6/30/17 the hospice RN charted right heel wound noted to be dry and completely closed. r. On 7/5/17 RN charted pt c/o (complains of) right heel today. Area assessed and noted to be worsening. Discussed P(NAME) (point of care) with staff nurse (nurse's name) to work on pressure prevention .instructed pt to let staff know when he is having pain so they can check on pressure to heel. RN also charted: hospice provides wound care. The following wound dimensions were documented: length 2 cm, width 2.5 cm, depth 0.1 cm, eschar-greater than 25%, and slough-greater than 25% s. On 7/7/17 the hospice RN charted: (patient) states that his right heel feels a little better and staff has been helping to keep pressure off of it. The following wound note was documented: eschar-greater than 25%, slough-greater than 25%. t. On 7/10/17 the hospice RN charted pt with pressure sore to right heel that continues to worsen despite pressure sore to right heel that continues to worsen despite caregiver keeping heel floated off the bed and pt receiving optimal wound care. RN also charted hospice provides wound care. The following wound information was documented: eschar greater than 25%, slough less than 25%, foam dressings, skin prep, gloves, NS (normal saline). u. On 7/14/17 the hospice RN charted right heel wound assessed, noted to be improving with BID (twice a day) deep tissue wound care per facility staff as ordered. The following wound information was documented: eschar less than 25%, slough less than 25%. Wound dimensions were not recorded this visit. v. On 7/17/17 the hospice RN charted: facility provides wound care. Wound dimensions were not recorded this visit. w. On 7/20/17 the hospice RN charted: assess right heel wound which is noted to be dry. Wound dimensions were not recorded this visit. x. On 7/25/17 the hospice RN charted facility provides wound care, hospice provides wound care. Also RN charted wound continues to heal with BID deep tissue wound care per facility. The following wound information was documented: eschar- less than 25%. Wound dimensions were not recorded this visit. y. On 7/27/17 the hospice RN charted the following wound information: eschar-none, slough- greater than 25%. Wound dimensions were not recorded this visit. z. On 8/1/17 the hospice RN charted: heel wound noted to continue to heal. Also RN charted: facility provides wound care. The following wound information was documented: eschar-none, slough-none. Wound dimensions were not recorded this visit. aa. On 8/8/17 the hospice RN charted: facility provides wound care. The following wound information was documented: eschar-none, slough-less than 25%. Wound dimensions were not recorded this visit. bb. On 8/15/17 the hospice RN charted hospice provides wound care, facility provides wound care. The following wound information was documented: eschar-none, slough-none. Wound dimensions were not recorded this visit. cc. On 8/29/17 the hospice RN charted facility provides wound care. Also RN charted: reddened area around site again, looking like previous deep tissue injury. SN (skilled nursing) discussed P(NAME) (point of care) with (nurse name) about floating heels and continuing with skin prep BID as ordered. Wound dimensions were not recorded this visit. On 8/30/17 at 9:40 AM, RN 1 was interviewed. RN 1 stated the hospice RN came twice a week. RN 1 reported that during the hospice RN's visits, she took vitals, looked at wounds, checked if pain was in control, etc. On 8/30/17 at 2:15 PM, Registered Nurse (RN) 1 was observed while providing a treatment to resident 12's right heel. Resident 12's right foot was planted on the right foot pedal of the wheelchair. RN 1 removed resident 12's shoe and sock. Resident 12 did not have a dressing or pressure relieving device in place. Resident 12's right heel had an area of approxiately 2 cm (centimeters) X (by) 1.5 cm area of purplish discoloration with an area of approximately 1 cm X 1 cm that was blackish in appearance. RN 1 cleansed the heel with skin prep then reapplied resident 12's sock and shoe. Resident 12 stated that his right heel hurt. RN 1 was immediately interviewed related to the unstageable pressure ulcer on resident 12's right foot. RN 1 stated that the pressure ulcer developed because of pressure. RN 1 stated that resident 12's heels were elevated with pillows at night. On 8/30/17 at 3:10 PM, the Director of Nursing (DON) was interviewed. The DON stated that she hadn't seen resident 12's right heel and was not aware that resident 12 had an unstageable pressure ulcer. (Cross refer to F157, F441, and F500)

Based on interview and record review, it was determined that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs for 2 of 21 sample residents. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued; provide adequate monitoring for medication and the facility did not attempt a gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue antipsychotic drugs. Specifically, a resident did not have adequate laboratory monitoring for an anticogulatant resulting in the resident receiving additional medications to counteract the anticoagulant. In addition, another resident did not have a dose reduction for an antipsychotic drug. Resident identifiers: 24 and 61. Findings include: 1. Resident 61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 61's medical record was reviewed on 3/17/15. Resident 61's admission orders [REDACTED]. Make sure your cardiovascular surgeon, cardiologist, or primary care physician is aware of the results of the PT/INR draws. The admission orders [REDACTED]. (appointment)) PT/INR on 12/15/14 at lab at hospital. Resident 61's Medication Administration Record [REDACTED]. Resident 61's Nurses Notes revealed the following entries: a. 12/26/2014 at 11:58 PM, .Looks really tired and worn out. Did not sleep well at all last night and voiced this to family and staff. b. 12/27/2014 at 6:59 AM, .Aspirin 81 mg. Held due to (sic) held d/t (due to) bleeding from peri area. c. 12/27/2014 at 12:15 PM, received order to draw labs on (resident 61) d/t bleeding from vaginal area. order for pt/inr, cbc (complete blood count), cmp (comprehensive metabolic panel). Labs drawn at 1210 (12:10 PM) and taken up to (local hospital) lab. Resident out to lunch at this time, no complaints other than being tired. d. 12/27/2014 at 3:01 PM, 1300 (1:00 PM) call from (name) at (local hospital) lab with a critical lab value for inr of 11. Call to (physicians name) with critical lab value information. He stated to hold [MEDICATION NAME] and do a daily pt/inr until inr is less than 3.5. Give 5 mg of vitamin k now, and reduce total weekly [MEDICATION NAME] dose by 20%. Don't start the [MEDICATION NAME] until inr is (less than) 3.5. Resident 61's telephone orders revealed the following: a. On 12/27/14, Draw labs today PT/INR, CBC, CMP. b. On 12/27/14, 1. hold [MEDICATION NAME] and draw daily PT/INR until INR is less than 3.5. 2. give Vit. (Vitamin) K 5 mg po (orally) now 3. reduce total weekly [MEDICATION NAME] dose by 20% 4. start [MEDICATION NAME] 4 mg po q (one time) day when INR is less than 3.5. c. On 12/31/14, . PT/INR weekly started 1/6/14. Resident 61's Laboratory results were reviewed and revealed the following: (Note: Normal range according to the Laboratory Results form was PT: 11.9-14.4 and INR: Moderate 2.0-3.0, high 2.5-3.5.) a. 12/12/14: PT was 19.8 high and INR was 1.7 b. 12/15/14: PT was 27.5 high and INR was 2.6 c. 12/27/14: PT was greater than 100.0 and INR was greater than 11.0. A note on the Laboratory Results form revealed, . Critical value notification. On 3/17/15 at 1:35 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that PT/INRs were obtained every Tuesday for residents with orders for [MEDICATION NAME]. The DON stated that PT/INRs were obtained on Tuesdays and Fridays if the laboratory results were not stable. The DON stated that an outside laboratory tested and provided the results to the facility. The DON stated that the laboratory values were sent to the facility on Tuesday and reported by the facility DON to the physicians the same day. The DON stated that the physicians provided orders to recheck residents laboratory and orders for medication changes. The DON stated that a PT/INR was ordered because resident 61 had vaginal bleeding. The DON stated that resident 61's PT/INR were critically high and the physician ordered Vitamin K. On 3/18/15 at 8:40 AM, a follow up interview was conducted with the DON. The DON stated that the facility had resident 61's PT/INR done on 12/15/14. The DON stated that the next laboratory draw was obtained on 12/27/14. The DON stated that resident 61 did not have laboratory values obtained according to admission orders [REDACTED] 2. Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 24's medical record was reviewed on 3/17/15. On 3/30/15, an order was received by resident 24 physician to administer [MEDICATION NAME] 50 milligrams (mg) po (oral) BID (twice a day). No further documentation was found showing that the facility staff had attempted a GDR (Gradual Dose Reduction) of [MEDICATION NAME] in two separate quarters within the first year or annually after the first year. On 3/17/15 at 1:20 PM, the DON was interviewed. The DON stated that resident 24's [MEDICATION NAME] dosage had not been reduced since it was ordered by the physician on March 30, 2013. The DON stated that resident 24 still had behavior problems.

Based on observation, interview and record review, it was determined the facility did not ensure each resident's drug regimen was free of drugs which were used without adequate monitoring or without adequate indications for their use, for 4 of 12 sample residents, one of whom was hospitalized as a result. Resident Identifiers: 4, 5, 7 and 9. Findings include: 1. Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 5's History and Physical, dated 2/27/10, included information the resident had initially presented with "significant large [MEDICAL CONDITION] embolism bilaterally including a satellite lesion" (on 2/10/10). "She became unstable and necessitated transfer" to another hospital on [DATE]. On 3/16/10, resident 5 was admitted to this facility from the hospital. The resident's initial drug regimen included daily [MEDICATION NAME] 2 milligrams (mg) daily and [MEDICATION NAME] 50 micrograms (mcg). On 3/23/10, [MEDICATION NAME] 875 mg was ordered to be administered twice daily for a period of two weeks for the resident's urinary tract infection. On 4/21/10, Bactrim DS was ordered to be administered twice daily for a period of two weeks. On 4/23/10, a daily dose of [MEDICATION NAME] 40 mg was initiated. [MEDICATION NAME], thiazides and antibiotics can potentiate the effects of [MEDICATION NAME] (reference Lippincott Williams & Wilkins, Nursing 2009 Drug Handbook). Resident 5's [MEDICATION NAME] Time and International Normalized Ratio (PT/INR) were checked on 3/18/10. The resident's PT/INR were, respectively, 25.9 (reference range from 11.9 to 14.4 seconds) and 2.4 (therapeutic range is 2.0 to 3.0, high range is 2.5 to 3.5). The resident's PT/INR was not monitored at the facility after the initial test. Resident 5's laboratory tests, dated 3/18/10, included results of a complete blood count. The resident's hemoglobin was 12.0 (reference range 12.0 to 16.0) and hematocrit was 36.6 (reference range 36.0 to 46.0). On 4/22/10, a laboratory test revealed resident 5's hemoglobin was low at 9.0 and hematocrit was low at 27.7. On 4/30/10, resident 5 was transferred back to the hospital, from the facility, following two days of increased pain, low grade fever with nausea and vomiting and an episode of black, tarry stools. The hospital's Discharge Summary, dated 5/5/10, included information that resident 5 had presented at the hospital with a GI bleed. The resident's hemoglobin was 4.0 and her hematocrit was 13. The resident's PT was greater than 100.0 and INR was greater than 13.2; both were "Critical" values. Resident 5 received vitamin K, fresh frozen plasma and 5 units of transfused blood. On 8/12/10, at 7:25 AM, Registered Nurse (RN) 2 was asked if the facility had a protocol for monitoring PT/INR for residents on anticoagulants. The nurse stated, there was a protocol to check every so often but she did not know details. The nurse stated to check with Licensed Practical Nurse (LPN) 3. On 8/12/10 at 7:26 AM, LPN 3 was asked if the facility had a protocol for monitoring PT/INRs. The nurse stated there was a protocol and the Director of Nursing (DON) would have it. On 8/12/10 at 7:30 AM, the DON said she could get the policy and she referred the surveyor to the physician. On 8/12/10 at 4:00 PM, a nurse at the physician's office returned the surveyor's call regarding the protocol used to monitor PT/INR for residents on anticoagulants. The nurse stated their therapeutic goal was usually an INR of 2.0 to 3.0. The nurse stated if the INR was within therapeutic range, it would be rechecked in one month. On 8/13/10 at 3:44 PM, the physician's nurse called to clarify the physician's protocol. The nurse faxed a copy of the "(a city name) Medical Clinic Physicians Anticoagulation Management Guide". The guide included instructions for adjusting the anticoagulant dose to maintain the target INR of either 2.0 - 3.0 or 2.5 - 3.5. Instructions included that, if a resident's INR was within the target range (once), no dosage changes were to be made and the next INR should be completed in one month. The guide included instructions that "(This sheet must be faxed to the Physician's office on same day changes are made)". The guide did not include different instructions for monitoring new residents or residents who had been unstable in the recent past. 2. Resident 7 was admitted to the facility 3/16/10 with [DIAGNOSES REDACTED]. On 4/1/10, resident 7's physician ordered the facility to administer [MEDICATION NAME] 2.5 mg every day and to obtain a PT/INR in one week. Resident 7, by documentation on the MAR (medication administration record) and the nursing notes, refused to take the [MEDICATION NAME] as ordered by the physician on 4/2/10 through 4/14/10 when the resident agreed to take one-half of a 5 mg tablet beginning on or around 4/14/10. Within the medical record for resident 7, was an INR result of 6.2 seconds dated 5/6/10 (this was almost one month past the physician ordered PT/INR). On 5/6/10, the physician was contacted regarding the INR results and the physician ordered the facility to stop [MEDICATION NAME] for 4 days and recheck the PT/INR on 5/10/10. On 8/11/10 at 1:45 PM, an interview was held with the DON. The DON identified the facility protocol for obtaining labs as ordered by the physician, and the review process she completes monthly to assure all orders are completed. Regarding the missed PT/INR on 4/8/10, the DON stated, the facility staff was working with the refusals and the education for resident 7 as to the importance of the medication. The specific order for the lab was missed due to the medication refusal. Once the missed lab was identified, the physician was contacted and a PT/INR was obtained. 3. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed from 8/9/10 through 8/12/10. On 8/19/09, resident 4's primary care physician ordered [MEDICATION NAME] 1 mg by mouth daily related to the [DIAGNOSES REDACTED]. The facility "Behavior Monitoring Form" for May 2010 through August 2010 was reviewed. The facility staff indicated target behaviors of (1) cussing and swearing and (2) hitting at staff for the month of May 2010. The facility nursing staff documented no behaviors during the month of May 2010. The June 2010 and July 2010 target behavior was spitting or slapping at staff. The facility nursing staff documented no behaviors for June through July 2010. The August 2010 target behavior was slapping at staff with cares. The facility nursing staff documented no behaviors from 8/1/10 through 8/9/10. On 8/10/10 the facility DON was interviewed. The DON stated that the facility had not attempted any gradual dose reductions since the [MEDICATION NAME] 1 mg was ordered on [DATE]. 4. Resident 9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 9's medical record was reviewed on 8/11/10. On 9/3/09, resident 9's primary care physician ordered [MEDICATION NAME] 25 mg to be taken at hour of sleep for a [DIAGNOSES REDACTED]. The facility "Behavior Monitoring Form" from May 2010 through August 2010 indicated a target behavior as "difficulty sleeping". The facility nursing staff documented no episodes of difficulty sleeping from May 2010 through August 10, 2010. On 8/11/10, the facility DON was interviewed. The DON stated that the last gradual dose reduction attempt for resident 9 was on 9/3/09 and that no further attempts had been made.