Every finding on record at Northern Regional Hospital

Based on record review, observations, and staff interviews, the facility failed to remove food items stored and available for use that were past the expiration date or had signs of spoilage from 1 of 2 walk-in coolers. The facility also had 3 of 4 kitchen staff members who failed to fully cover their hair during meal preparation. This deficient practice had the potential to affect food and beverages served to residents. The findings included: The initial tour of the kitchen with the Dining Services Manager on 3/25/25 at 10:32 AM revealed the following: 1a. One 16 ounce (oz) container of Chicken Base with an expiration date December 2024 stored in the walk-in cooler and available for use. b. Three 16 oz containers of Chicken Base with an expiration date of January 2025 stored in the walk-in cooler and available for use. c. Four 16 oz containers of Chicken Base with an expiration date of February 2025 stored in the walk-in cooler and available for use. d. One 16 oz container Chicken Base with expiration date February 2025, with opened date March 13, 2025, was observed to be one fourth used covered in clear wrap was stored in the walk-in cooler available for use. e. Ten of twenty-five medium red onions observed with white fuzzy matter in a covered plastic container stored in the walk-in cooler available for use. During an interview on 3/25/25 at 10:44 AM the Dining Services Manager stated produce should be checked daily for signs of spoilage. The Dining Services Manager verbalized the supervisors in the kitchen were assigned to complete the daily checks of the walk-in cooler and specifically observe the produce for signs of spoilage. The Dining Services Manager further stated the supervisors were also assigned to check expiration dates. The Dining Services Manager voiced expiry dates and produce checks for signs of spoilage were completed daily inclusive of weekends. The Dining Services Manager indicated she did not have any concerns reported to her from the weekend (3/22/25 and 3/23/25) as well as on Monday (3/24/25). The Dining Service Manager continued to state dietary staff were educated on checking for expiry dates and signs of spoilage but did not have documentation of the education provided. On 3/28/25 at 12:05 PM the Director of Nursing revealed food items should be appropriately discarded. 2. An observation on 3/27/25 at 11:50 AM in the presence of the Dining Services Manager revealed Dietary Aide #1's hair on her forehead was not covered by the hair net. Dietary Aide #2 and Dietary Aide #3's hair net covered the bun in the back of their head with the rest of their hair exposed. The three staff members were observed pouring the residents' beverage selections in cups and transporting tea to the beverage area. During the interview with the Dining Services Manager on 3/27/25 at 2:30 PM, the Dining Services Manager stated all employees' hair should be fully covered at all times while in the kitchen. On 3/28/25 at 12:05 PM the Director of Nursing stated all kitchen staff should have hair fully covered.

Based on observations, record review and staff interviews, the facility failed to maintain a medication error rate of less than 5% as evidenced by 3 medication errors out of 29 medication opportunities resulting in a medication error rate of 10.34% for one resident (Resident #36) observed during medication pass. Findings included: A review of Resident #36 ' s physicians orders for (MONTH) 2019 revealed she was prescribed [MEDICATION NAME] 5-325 milligrams one tablet by mouth 5 times a day along with [MEDICATION NAME] (immediate release) 5 milligrams by mouth five times a day to equal [MEDICATION NAME] 10-325 milligrams. Resident #36 was also prescribed [MEDICATION NAME] 10 milligrams daily. A medication administration pass was observed on 5/23/19 at 7:44 AM with Nurse #1. Nurse #1 prepared and administered to Resident #36 [MEDICATION NAME] 10 milligrams, [MEDICATION NAME] 5-325 milligrams and [MEDICATION NAME] 5 milligrams by mouth. After Resident #36 received the medication, Nurse #1 was observed exiting the room and sanitized her hands. Nurse #1 was not observed reconciling the controlled substance count sheet to reflect the administration of [MEDICATION NAME] 10 milligrams, [MEDICATION NAME] 5-325 milligrams and [MEDICATION NAME] 5 milligrams. An observation on 5/23/19 at 10:46 AM of the controlled substance count sheet revealed Nurse #1 had not reconciled the count for the administration of [MEDICATION NAME] 10 milligrams, [MEDICATION NAME] 5-325 milligrams and [MEDICATION NAME] 5 milligrams. The controlled substance count sheets revealed [MEDICATION NAME] 10 milligrams was last administered on 5/22/19 at 8:30 PM, [MEDICATION NAME] 5-325 milligrams was last administered on 5/22/19 at 11:30 PM and [MEDICATION NAME] 5 milligrams was last administered on 5/23/19 at 12:00 AM. An interview on 5/23/19 at 10:44 AM with Nurse #1 revealed she had not signed out the medications she administered to Resident #36 yet. Nurse #1 revealed she should have scanned the medications, administered them and then reconciled the count on the controlled substance count sheets. Nurse #1 revealed she did not reconcile the administered medications immediately because she had had a bad habit of waiting until after the medication pass. An interview on 5/23/19 at 11:30 AM with the Director of Nursing revealed her expectation was for nurses administering controlled substances to reconcile the count on the controlled substance count sheet immediately after administration.

Based on record review and staff interviews, the facility failed to accurately document code status in both the electronic medical record and the paper chart and failed to obtain a physician's order [REDACTED].#16) residents reviewed for advanced directives. The findings included: Resident #16 was re- admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a significant change in assessment dated [DATE] revealed Resident 16 was cognitively intact. A review of the care plan dated 4/18/19 revealed Resident #16 desired a do not resuscitate status in the event of [MEDICAL CONDITION]. The goal was for the medical record to reflect proper paperwork related to her request. A review of the physicians orders for (MONTH) 2019 revealed no order for a do not resuscitate. A record review revealed a portable Do Not Resuscitate document signed by the physician in Resident #16 ' s paper chart. A review of the electronic medical record revealed a code status was not reflected. An interview on 5/22/19 with Nurse #2 revealed code status was addressed upon admission. She stated an order was obtained by the physician for code status and entered into the computer system. She stated entering it in would then reflect the code status on the screen in red. She stated Resident #16 ' s code status was not put it the computer and stated it must not have gotten put in the computer when Resident #16 was admitted . An interview on 5/23/19 at 3:01 PM with the Director of Nursing revealed she knew Resident #16 was a do not resuscitate, that she had been a do not resuscitate for a long time. She stated Resident #16 had a portable do not resuscitate that was signed by the physician. She stated when Resident #16 was readmitted from the acute floor, the code status must not have been put back in. An interview on 5/23/19 at 3:03 PM with Nurse #3 revealed she did not know the policy for advanced directives. She stated she was unsure if the portable do not resuscitate document was a physician's order [REDACTED].>

Based on observations, record review and staff and resident interviews, the facility failed to implement pressure reducing interventions for a resident with a current pressure ulcer and at risk for pressure ulcer development for 1 of 5 residents (Resident #34) reviewed for pressure ulcers. The findings included: Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review revealed a nursing admission assessment indicating Resident #34 was cognitively intact and required assistance with her activities of daily living. Resident #34 was admitted with an unstageable pressure ulcer to her left heel. A record review revealed a skin risk assessment dated [DATE] revealing a skin risk score of 17, indicating mild risk. A review of the baseline care plan revealed Resident #34 was admitted to the facility with an unstageable pressure ulcer to her left heel. The baseline care plan summary indicated staff will keep a pillow under ankles to keep pressure off of heels since you can ' t wear heel protectors. On 5/22/19 at 1:05 PM, an observation was made of wound care to Resident #34 ' s left heel wound. Nurse #2 completed the treatment to Resident #34 ' s left heel and placed her heel directly on the mattress. Nurse #2 was not observed asking Resident #34 if she wanted her heel floated or attempting any type of pressure reducing intervention before leaving the room. An observation on 5/23/19 at 9:17 AM revealed Resident #34 lying in bed with heels directly on mattress. An interview with Resident #34 was completed on 5/23/19 at 12:58 PM. She stated she can ' t wear the heel protectors but was agreeable to using a pillow under her leg to float her heel. She stated the staff don ' t always do it and she isn ' t able to do it herself. An interview with Nurse #1 on 5/23/19 at 2:07 PM revealed when a resident is admitted with a wound, orders and other interventions go in the computer system and are also on the care plans. She stated nurses give nursing assistants information also in report. She did not know why Resident #34 did not have her heel floated. An interview with Nursing Assistant #1 on 5/23/19 at 2:13 PM revealed she didn ' t have time to check every resident for pressure reduction devices when she came on shift in the morning. She stated she didn ' t know why Resident #34 didn ' t have her heels floated this morning. An interview with the Director of Nursing on 5/23/19 at 11:30 AM revealed it was her expectation that Resident #34 ' s heels be floated.

Based on staff and pharmacist interviews and record review, the facility failed to follow a gradual dose reduction (GDR) for an anti-anxiety medication as recommended by the pharmacist and ordered by the physician for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #26). Findings included: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #26's comprehensive minimum data set (MDS) assessment dated [DATE] revealed she was cognitively intact and had no negative behaviors. Further review of the assessment revealed Resident #26 received an anti-anxiety medication for seven days out of a seven day look back period. A review of Resident #26's current medications for the month of (MONTH) 2019 revealed she received [MEDICATION NAME] (a medication used to treat anxiety), 2.5 milligrams (mg) every night (started 10/29/18). A review of a pharmacy recommendation dated 5/2/19 revealed the pharmacist recommended the [MEDICATION NAME] be changed from scheduled to as needed for [MEDICAL CONDITION], then reassess in four weeks for possible discontinuation. Further review of the pharmacy recommendation revealed the physician (MD) reviewed the recommendation on 5/8/19 and documented that he agreed to change the [MEDICATION NAME] to as needed. The recommendation form was noted to have been faxed by a facility nurse to the pharmacy. A review of a MD's note dated 5/8/19 revealed, .She is seen today for follow up anxiety. This appears stable and no recent exacerbations. She has been on [MEDICATION NAME] ([MEDICATION NAME]) 2.5mg scheduled at bedtime. We will change to as needed at bedtime as attempt at GDR and reassess in four weeks . A review of the medical record on 5/23/19 revealed the order for [MEDICATION NAME] had not been changed from scheduled to as needed. On 5/23/19 at 11:06 AM an interview was completed with Pharmacist #1. She said that typically orders for medications were faxed to the pharmacy. She reported she was unable to locate an order that changed the [MEDICATION NAME] from scheduled to as needed. On 5/23/19 at 12:52 PM an interview was completed with Nurse #2. She stated the process that was followed when an order for [REDACTED]. Nurse #2 said typically there were several orders faxed at one time. She said Resident #26 was not her resident on the day the order was faxed to the pharmacy, but the order was one of several orders she faxed at one time that day. Nurse #2 indicated that she wrote her initials on the order once she faxed it to the pharmacy. She further stated she had not followed up with the pharmacy since she had not worked with Resident #26 on 5/8/19. On 5/23/19 at 12:57 PM an interview was completed with Pharmacist #2. He said the process of GDR recommendations was once the MD agreed with the recommendation the nurse faxed the signed recommendation to the pharmacy. Pharmacist #2 stated he was unsure what happened and thought the order was inadvertently missed once it was faxed to the pharmacy. On 5/23/19 at 2:02 PM an interview was completed with the Director of Nursing. She stated the process for GDR's was that once the MD addressed the pharmacy recommendation the nurse immediately faxed it to the pharmacy. She said she thought the order was faxed on 5/8/19 after the MD visited with Resident #26 and stated, I know the process was done correctly.

Based on observations, record review and staff interviews, the facility failed to prevent cross contamination by using the same pair of gloves to perform wound care to two separate wounds for 1 of 4 (Resident #34) reviewed for wound care. The findings included: Resident #34 was admitted to the facility on [DATE] with an unstageable pressure ulcer to her left heel and a laceration to her left lower leg. A record review revealed Minimum Data Assessment and comprehensive care planning had not been completed. A review of the Baseline Care Plan dated 5/18/19 revealed Resident #34 was cognitively intact, had an unstageable pressure ulcer to her left heel and a laceration to her left lower leg. An observation of wound care for Resident #34 by Nurse #2 on 5/22/19 at 1:09 PM revealed Nurse #2 removed the dirty dressing to the wound on Resident #34 ' s left lower leg, applied [MEDICATION NAME] and a clean dressing without changing her gloves. Nurse #2 then removed the dirty dressing to the pressure ulcer on Resident #34 ' s left heel, cleaned the wound and applied an [MEDICATION NAME] foam dressing while wearign the same pair of gloves. An interview with Nurse #2 on 5/23/19 at 9:17 AM revealed she completes the treatments as ordered: she gathers her supplies, tells the resident what she is going to do, puts gloves on and does the treatment using clean technique. When asked why she didn ' t change her gloves after removing the soiled dressing on Resident #34 ' s left lower leg or after she completed the left lower leg dressing before moving to the left heel pressure ulcer treatment, she replied that it wasn ' t a sterile technique and she would only change her gloves if the dressing was heavily soiled. An interview with the Director of Nursing on 5/23/19 at 3:05 PM revealed she would have expected Nurse #2 to change her gloves after removing dirty dressings and between wounds.

Based on observations and staff interviews the facility failed to maintain sanitary conditions in the kitchen by not ensuring pans, and food slicing knives were stored/stacked clean and dry; and, by not ensuring food service equipment were maintained clean and free from debris. Findings included: 1. During the observation of the meal tray line service in the kitchen on 2/10/17 at 12:15pm, 2 of 2-plate warmers located next to the meal serving line contained stained, dried brown debris on the inside where clean plates were stacked. Also observed in the kitchen was a table top meat slicer. There were brown crumbs noted beneath the meat slicer. The DM revealed that the plate warmers were cleaned weekly by the dietary staff and acknowledged the inside of both plate warmers were dirty. 2. During the kitchen observation with the DM (Dietary Manager) on 2/10/17 at 12:20pm 4-large muffin tins and 2-large pans containing dried brown stains were stacked on the storage rack. Also, the knife rack contained 4-slicing knives that were stained with dried debris. The DM removed these items from storage to the three compartment sink, instructing staff to re-wash them.

Based on record review and interviews with the facility staff, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place in March of 2016. This was for five recited deficiencies which were originally cited in February of 2016 on a recertification survey and subsequently recited on the current recertification survey. The deficiencies were in the areas of comprehensive care plan development (F279), care plan revision (F280), unnecessary drugs (F329), medication regimen review (F428), and labeling/storage of medications (F431). The continued failure of the facility during two federal surveys of record show a pattern of the facility ' s inability to sustain an effective Quality Assurance Program. The findings included: This tag is cross referred to: a) F279: Develop Comprehensive Care Plans. Based on observations, record reviews, and staff interviews, the facility failed to develop a comprehensive care plan for 1 of 3 sampled residents (Resident #30) reviewed for range of motion; and, for 2 of 3 sampled residents (#29 and #30) reviewed for activities. During the recertification survey of 2/19/16, the facility was cited for F279 for failure to develop a care plan with critical interventions, including monitoring target behaviors and non-pharmacological interventions, for 1 of 6 residents receiving [MEDICAL CONDITION] medications (Resident #12). On the current recertification survey, the facility was recited for failing to develop a care plan to address range of motion for 1 of 3 sampled residents and activities for 2 of 3 sampled residents reviewed. An interview was conducted on 2/10/17 at 5:30 PM with the facility ' s Director of Nursing (DON) and Vice President (VP) of Patient Services. The areas of recited deficiencies identified by the current recertification survey were discussed during the interview. The DON reported the QAA Committee has been working on the area of care plans since 11/7/16, with care plans being reviewed on a quarterly basis. The DON stated the last staff meeting (held on 1/5/17 with 90% attendance) emphasized the need for staff input on care plans. Additionally, the DON noted residents ' care plans completed in October, November and December of 2016 were reviewed at the QAA meeting on 1/19/17. Upon inquiry, the DON stated the care plan QAA project did not specifically address a timeline and the action plan itself was described as, ongoing. b) F280: Care Plan Revision. Based on observation, record reviews and staff interviews, the facility failed to revise the care plan of 1 of 3 residents reviewed for significant weight loss (Resident #16). During the recertification survey of 2/19/16, the facility was cited for F280 for failure to update a care plan with the current [MEDICAL CONDITION] medications and dosages for 1 of 6 residents receiving [MEDICAL CONDITION] medications (Resident #16). On the current recertification survey, the facility was recited for failing to revise the care plan for a resident reviewed for significant weight loss. An interview was conducted on 2/10/17 at 5:30 PM with the facility ' s Director of Nursing (DON) and Vice President (VP) of Patient Services. The areas of recited deficiencies identified by the current recertification survey were discussed during the interview. The DON reported the QAA Committee has been working on the area of care plans since 11/7/16, with care plans being reviewed on a quarterly basis. The DON stated the last staff meeting (held on 1/5/17 with 90% attendance) emphasized the need for staff input on care plans. Additionally, the DON noted residents ' care plans completed in October, November and December of 2016 were reviewed at the QAA meeting on 1/19/17. Upon inquiry, the DON stated the care plan QAA project did not specifically address a timeline and the action plan itself was described as, ongoing. c) F329: Drug Regimen is Free From Unnecessary Drugs. Based on record reviews, and staff and pharmacist interviews, the facility failed to identify and attempt a Gradual Dose Reduction (GDR) or document the continued need for an antidepressant ([MEDICATION NAME]), an antianxiety ([MEDICATION NAME]), and a hypnotic ([MEDICATION NAME]) medication ordered for 1 of 5 sampled residents reviewed for unnecessary drugs (Resident #27). During the recertification survey of 2/19/16, the facility was cited for F329 for failure to ensure that Resident #12's drug regimen was free of unnecessary drugs, as they failed to identify and monitor target behaviors and failed to attempt a dose reduction of an antipsychotic medication for 1 of 6 residents. On the current recertification survey, the facility was recited for failing to identify and attempt a GDR, or document the resident ' s continued need for an antidepressant, antianxiety, and hypnotic medication. An interview was conducted on 2/10/17 at 5:30 PM with the facility ' s Director of Nursing (DON) and Vice President (VP) of Patient Services. The areas of recited deficiencies identified by the current recertification survey were discussed during the interview. Upon inquiry, the DON reported a spread sheet was developed and put into place by the consultant pharmacist after the facility ' s last recertification to address the areas of unnecessary medications and gradual dose reductions. Data from the information collected was reviewed by the DON and reported to the QAA committee quarterly. d) F428: Medication Regimen Review. Based on record reviews, and staff and pharmacist interviews, the consultant pharmacist failed to identify and address a Gradual Dose Reduction (GDR) for an antidepressant ([MEDICATION NAME]), an antianxiety ([MEDICATION NAME]), and a hypnotic ([MEDICATION NAME]) medication ordered for 1 of 5 sampled residents reviewed for unnecessary drugs (Resident #27). During the recertification survey of 2/19/16, the facility was cited for F428 for failure of the consultant pharmacist to recommend a gradual dose reduction and/or a risk versus benefit rationale for the continued use of an antipsychotic medication for 1 of 6 residents reviewed for unnecessary medications (Resident #12). On the current recertification survey, the facility was recited for the consultant pharmacist failing to identify and address a GDR for a resident continuing to receive an antidepressant, antianxiety, and hypnotic medication. An interview was conducted on 2/10/17 at 5:30 PM with the facility ' s Director of Nursing (DON) and Vice President (VP) of Patient Services. The areas of recited deficiencies identified by the current recertification survey were discussed during the interview. Upon inquiry, the DON reported a spread sheet was developed and put into place by the consultant pharmacist after the facility ' s last recertification to address the areas of unnecessary medications and gradual dose reductions. Data from the information collected was reviewed by the DON and reported to the QAA committee quarterly. e) F431: Labeling and Storage of Drugs. Based on observation, record review and staff interviews, the facility failed to date a medication when opened to allow for the determination of its shortened expiration date in 1 of 1 medication storage room and 1 of 2 medication carts (Cart 2 for Rooms 337-352); and, failed to store medications as specified by the drug manufacturer in 2 of 2 medication carts (Cart 1 for Rooms 320-336 and Cart 2 for Rooms 337-352). During the recertification survey of 2/19/16, the facility was cited for F431 for failure to remove an expired medication from one of two medication carts and failure to date a multi dose insulin vial when opened in one of one medication rooms. On the current recertification survey, the facility was recited for failing to date medications when opened to allow for the determination of a shortened expiration date; and, for failing to store medications as specified by the drug manufacturer. An interview was conducted on 2/10/17 at 5:30 PM with the facility ' s Director of Nursing (DON) and Vice President (VP) of Patient Services. The areas of recited deficiencies identified by the current recertification survey were discussed during the interview. Upon inquiry, the DON reported the deficiency related to medication labeling and storage from the facility ' s last recertification had more to do with expired medications. She indicated the medication labeling/storage concerns identified during the current recertification survey were different from the previous survey.

Based on record review and staff interviews, the facility failed to code active [DIAGNOSES REDACTED].#7 and Resident #27); and, failed to accurately code the MDS to reflect the medications administered during the 7-day look back period for 2 of 5 sampled residents reviewed for unnecessary medications (Resident #7 and Resident #27). The findings included: 1a) Resident #7 was admitted to the facility on [DATE] with re-entry from the hospital on [DATE]. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #7 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section I (Active Diagnoses) did not identify the presence of any active [DIAGNOSES REDACTED]. Also, the option of checking None of the above active [DIAGNOSES REDACTED]. No additional active [DIAGNOSES REDACTED]. An interview was conducted on 2/9/17 at 3:33 PM with the MDS Nurse. Upon inquiry, the MDS Nurse reviewed Resident #7 ' s active [DIAGNOSES REDACTED]. The nurse reported [MEDICAL CONDITION] should have been checked as an active [DIAGNOSES REDACTED]. The MDS Nurse also stated she should have reported additional [DIAGNOSES REDACTED]. The additional [DIAGNOSES REDACTED]. An interview was conducted on 2/10/17 at 7:40 AM with the facility ' s Director of Nursing (DON). During the interview, the DON stated she would expect the MDS assessments to be coded properly. 1b) Resident #27 was admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #27 ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed Section I (Active Diagnoses) did not identify the presence of any active [DIAGNOSES REDACTED]. Also, the option of checking None of the above active [DIAGNOSES REDACTED]. No additional active [DIAGNOSES REDACTED]. An interview was conducted on 2/10/17 at 7:40 AM with the facility ' s Director of Nursing (DON). During the interview, the DON stated she would expect the MDS assessments to be coded properly. An interview was conducted on 2/10/17 at 11:42 AM with the MDS Nurse. During the interview, the nurse reported she had contacted the support service for the facility ' s MDS software earlier that morning. The MDS nurse reported she was told Section I of the MDS was auto-populated so it would show up on the computer screen as if it had been completed. The nurse stated she believed this was the reason why she had missed filling out Section I of the MDS assessment. 2a) Resident #7 was admitted to the facility on [DATE] with re-entry from the hospital on [DATE]. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #7 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section N (Medications) reported the resident received both antianxiety and hypnotic medications on 7 out of the 7 days during the look back period. Section N did not indicate the resident received an antidepressant, an anticoagulant, nor an antibiotic medication during the 7-day look back period. A review of the resident ' s December 2016 Medication Administration Record [REDACTED]½ tablet (7.5 mg) by mouth once daily at bedtime; and 100 mg [MEDICATION NAME] (an antibiotic) given as one capsule by mouth every night at bedtime. An interview was conducted on 2/9/17 at 3:33 PM with the MDS Nurse. Upon inquiry, the MDS Nurse reviewed Resident #7 ' s electronic and paper charts. After her review, the nurse confirmed that while Section N of the MDS was coded accurately for the antianxiety medication, other medications were not. The MDS nurse reported Resident #7 did receive an anticoagulant (Eliquis) and antidepressants ([MEDICATION NAME], and [MEDICATION NAME]) on 7 out of 7 days during the look back period. The nurse was uncertain as to why she had reported the resident received a hypnotic medication but believed she may have counted [MEDICATION NAME] as a hypnotic instead of an antidepressant medication. Failure to code [MEDICATION NAME] in Section N of the MDS as an antibiotic given 7 out of 7 days was not specifically addressed during the interview. An interview was conducted on 2/10/17 at 7:40 AM with the facility ' s Director of Nursing (DON). During the interview, the DON stated she would expect the MDS assessments to be coded properly. 2b) Resident #27 was admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #27 ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed Section N (Medications) reported the resident received an antipsychotic, antianxiety and hypnotic medication on 7 out of the 7 days during the look back period. Section N did not indicate the resident received an antidepressant during the 7-day look back period. A review of the resident ' s January 2017 Medication Administration Record [REDACTED]. An interview was conducted on 2/10/17 at 7:40 AM with the facility ' s Director of Nursing (DON). During the interview, the DON stated she would expect the MDS assessments to be coded properly. An interview was conducted on 2/10/17 at 11:42 AM with the MDS Nurse. Upon inquiry, the MDS Nurse reviewed Resident #27 ' s electronic and paper charts, including the January 2017 MAR. After her review, the nurse confirmed Resident #27 did receive an antidepressant ([MEDICATION NAME]) on 7 out of 7 days during the look back period. The MDS Nurse reported use of the antidepressant should have been reported in Section N of the MDS.

Based on record review, observation, and staff interview, the facility failed to maintain residents' dignity by standing over 4 of 4 sample residents (Resident #11, Resident #29, Resident #6, and Resident #21) while assisting them to eat a meal. The findings included: 1) Resident #11 was admitted to the facility on [DATE] from the community. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #11 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. The resident required total assistance from staff for all of her Activities of Daily Living (ADLs), with the exception of requiring limited assistance with personal hygiene. On 2/7/17 at 12:56 PM, Resident #11 was observed as she was fed her noon meal by Nursing Assistant (NA) #1. Resident #11 was lying in bed with the head of the bed elevated. NA #1 was observed standing over the resident next to the bed as she assisted her with the meal. The nursing assistant was observed to be standing above eye level for Resident #11. On 2/9/17 at 8:17 AM, NA #1 was observed as she entered Resident #11 ' s room and assisted Resident #11 with her breakfast meal. NA #1 was observed standing over the resident next to the bed as she assisted her with the meal. The NA was observed to be standing above eye level while assisting Resident #11. An interview was conducted with NA #1 on 2/9/17 at 2:34 PM. During the interview, the NA reported Resident #11 would try to feed herself on occasions, but typically needed assistance from staff to help finish the meal. Upon further inquiry, NA #1 stated she tries to sit in the chair next to the bed and face the resident, but whether or not this worked depended on the position of the resident. The NA reported she usually tried to raise the resident ' s bed to eye level so she was not standing over her. The NA stated, (The) facility doesn ' t want us to stand over them really. An interview was conducted on 2/10/17 at 10:20 AM with the facility ' s Director of Nursing (DON) in regards to the observations made of staff standing over residents while assisting them with meals. During the interview, the DON reported the beds in the facility were hospital beds (versus standard nursing facility beds). She stated the beds were higher than a standard nursing facility bed and could not be lowered enough to allow staff to sit at eye level while feeding a resident. The DON stated she has recognized this issue and would rather have the staff standing so they can better reach the resident, be eye level to resident, and able to talk and encourage them to eat. 2) Resident #29 was admitted to the facility on [DATE] from the community. His cumulative [DIAGNOSES REDACTED]. A review of Resident #29 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #29 required total assistance from staff for all of his Activities of Daily Living (ADLs), with the exception of requiring limited assistance with personal hygiene. On 2/7/17 at 12:55 PM, Resident #29 was observed as he was fed his noon meal by Nursing Assistant (NA) #4. Resident #29 was lying in bed with the head of the bed elevated. NA #4 was observed standing over the resident next to the bed as she assisted him with the meal. The NA was observed to be standing above eye level for Resident #29. On 2/9/17 at 8:18 AM, NA #3 was observed standing over Resident #29 ' s bed as she assisted the resident with his breakfast meal. The NA was observed to be standing above the resident ' s eye level while assisting him. Upon inquiry, the NA reported Resident #29 had a good appetite and was eating well. An interview was conducted with NA #4 on 2/10/17 at 9:11 AM. During the interview, the NA was asked what the facility policy was in regards to standing while assisting a resident with a meal. The NA reported the facility preferred staff to sit when feeding a resident. However, NA #4 reported she had back and shoulder issues so if she sat by the side of the bed, she would experience pain from having to twist around. A telephone interview was conducted with NA #3 on 2/10/17 at 10:05 AM. Upon inquiry, the NA stated she has a habit of standing when feeding residents. NA #3 reported she was unsure as to what the facility policy was, but thought they encouraged sitting while assisting a resident to eat. An interview was conducted on 2/10/17 at 10:20 AM with the facility ' s Director of Nursing (DON) in regards to the observations made of staff standing over residents while assisting them with meals. During the interview, the DON reported the beds in the facility were hospital beds (versus standard nursing facility beds). She stated the beds were higher than a standard nursing facility bed and could not be lowered enough to allow staff to sit at eye level while feeding a resident. The DON stated she has recognized this issue and would rather have the staff standing so they can better reach the resident, be eye level to resident, and able to talk and encourage them to eat. 3) Resident #6 was admitted to the facility on [DATE], with re-entry from the hospital on [DATE]. The resident was referred and admitted to Hospice on 2/8/17. A review of Resident #6 ' s admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognitive skills for daily decision making. The resident was totally dependent on staff for all of her Activities of Daily Living (ADLs), with the exception of requiring extensive assistance with dressing and personal hygiene. She was noted to be independent with eating. A review of Resident #6 ' s Nutrition Care Plan dated 1/9/17 included an intervention for staff to assist the resident with feeding as needed. On 2/7/17 at 12:58 PM, Resident #6 was observed as she was fed her noon meal by Nursing Assistant (NA) #2. Resident #6 was lying in bed with the head of the bed elevated. NA #2 was observed standing over the resident next to the bed as she assisted her with the meal. The NA was observed to be standing above eye level for Resident #6. An attempt was made to interview Resident #6 on 2/8/17 at 10:20 AM. The resident appeared very sleepy and did not verbally respond to questions posed. On 2/9/17 at 8:20 AM, NA #2 was observed as she entered Resident #6 ' s room. At 8:26 AM, the NA was observed standing over the resident next to the bed as she assisted Resident #6 with her breakfast meal. NA #2 was observed to be standing above eye level while assisting the resident to eat. An interview was conducted on 2/9/17 at 9:24 AM with Nurse #2. Nurse #2 had been assigned to care for Resident #6. Upon inquiry, Nurse #2 confirmed the resident was verbal at times but was not interviewable due to her recent decline in health and mental status. An interview was conducted with NA #2 on 2/10/17 at 10:00 AM. When asked if she usually assisted residents with their meals while sitting or standing, the NA stated, It all depends on the position .I prefer to sit on the edge of the bed to feed the resident. The NA reported the facility ' s policy indicated the staff member should be at eye level when assisting residents to eat. However, the NA stated there was not always a place to sit when she assisted a resident at mealtime. An interview was conducted on 2/10/17 at 10:20 AM with the facility ' s Director of Nursing (DON) in regards to the observations made of staff standing over residents while assisting them with meals. During the interview, the DON reported the beds in the facility were hospital beds (versus standard nursing facility beds). She stated the beds were higher than a standard nursing facility bed and could not be lowered enough to allow staff to sit at eye level while feeding a resident. The DON stated she has recognized this issue and would rather have the staff standing so they can better reach the resident, be eye level to resident, and able to talk and encourage them to eat. 4) Resident #21 was admitted to the facility on [DATE] from the community. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #21 ' s quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Resident #21 required total assistance from staff for all of her Activities of Daily Living (ADLs). On 2/10/17 at 8:40 AM, Nursing Assistant (NA) #4 was observed standing over Resident #21 next to the bed as she made multiple attempts to assist the resident with her breakfast. The NA was observed to be standing above the resident ' s eye level. Resident #21 appeared to be resistant to eating her meal at the time of the observation. An interview was conducted with NA #4 on 2/10/17 at 9:11 AM. During the interview, the NA was asked what the facility policy was in regards to standing while assisting a resident with a meal. The NA reported the facility preferred staff to sit when feeding a resident. However, NA #4 reported she had back and shoulder issues so if she sat by the side of the bed, she would experience pain from having to twist around. An interview was conducted on 2/10/17 at 10:20 AM with the facility ' s Director of Nursing (DON) in regards to the observations made of staff standing over residents while assisting them with meals. During the interview, the DON reported the beds in the facility were hospital beds (versus standard nursing facility beds). She stated the beds were higher than a standard nursing facility bed and could not be lowered enough to allow staff to sit at eye level while feeding a resident. The DON stated she has recognized this issue and would rather have the staff standing so they can better reach the resident, be eye level to resident, and able to talk and encourage them to eat.

Based on observations, record reviews, and staff interviews, the facility failed to develop a comprehensive care plan for 1 of 3 sampled residents (Resident #30) reviewed for range of motion; and, for 2 of 3 sampled residents (#29 and #30) reviewed for activities. Findings included: 1. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS (minimum data set) dated 11/23/16 indicated Resident #30 was cognitively impaired and had limited range of motion of her bilateral lower extremities. There was no plan of care available with measurable goals and interventions to address the care and treatment related to Resident #30's range of motion needs. During an observation on 2/7/17 at 12:30pm, Resident #30 was sitting up in her bed, feeding herself lunch. The resident was alert but answered questions with confused responses. During an interview on 2/9/17 at 4:39pm, the MDS Nurse revealed Resident #30 had not been ambulatory since admission. She acknowledged the resident was not, but should have been care planned for ADLs (activities of daily living) which would have included the resident's limited range of motion of her lower extremities. 2. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS (minimum data set) dated 11/22/16 indicated Resident #29 was severely cognitively impaired. There was no plan of care with measurable goals and interventions to address care and treatment related to Resident #29's participation in activities. During an observation on 2/7/17 at 12:55pm, Resident #29 was lying in bed assisted with his meal by a nursing assistant. The resident was not verbal, unable to answer questions. During an interview on 2/10/17 at 2:45pm, the Activity Director indicated Resident #29 was always in bed, sleeping most of time and did not respond to verbal stimuli. She revealed the activity she provided with the resident was one on one talking to the resident once every five days. She also revealed that she did not maintain an Activity Attendance Log for residents. During an interview on 2/10/17 at 5:02pm, the MDS Nurse confirmed there was no Activity Care Plan available for Resident #29, but there should have been. 3. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS (minimum data set) dated 11/23/16 indicated Resident #30 was cognitively impaired and had activity preferences which included going outside and religious services. There was no plan of care with measurable goals and interventions to address care and treatment related to Resident #30's activity preferences. During an observation on 2/7/17 at 12:30pm, Resident #30 was sitting up in her bed, feeding herself lunch. The resident was alert but answered questions with confused responses. During an interview on 2/9/17 at 10:50am, Resident #30's daughter revealed she volunteered at the facility working with the Activity Director on Monday through Saturday, but still visited the resident on Sundays, after church. She revealed the resident used to get out of bed for group Bingo but currently refused. She also revealed that she visited with the resident every day to talk about current events. During an interview on 2/9/17at 3:00p, the MDS Nurse acknowledged Resident #30 should have been care planned for activities, stating I missed it.

Based on hospital and facility record reviews, and staff, pharmacist and Physician Assistant (PA) interviews, the facility failed to provide the extended release formulation of an antihypertensive medication as ordered ([MEDICATION NAME]) to a resident over a period of 30 days. This occurred for one of one resident (Resident #33) reviewed who had been recently discharged from the hospital after experiencing a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). The findings included: Resident #33 was admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #33 ' s December 2016 and January 2017 Physician order [REDACTED]. A review of the resident ' s medical record revealed that on 1/5/17, Resident #33 complained of dizziness and stated, I ' m [MEDICAL CONDITION]. She was lowered to the floor by a Nursing Assistant. The resident ' s vital signs were taken and included an initial blood pressure of 221/88 with a follow up blood pressure of 200/83 (an optimal blood pressure is typically less than 120/80). The resident was transported to the Emergency Department and admitted to the hospital with [REDACTED]. Resident #33 was readmitted to the facility on [DATE]. A review of the resident ' s hospital Discharge Medication list dated 1/11/17 revealed her new medications included 25 mg [MEDICATION NAME] to be given as one tablet by mouth once daily. The hospital Discharge Medication list also noted her discontinued medications included 25 mg [MEDICATION NAME] given twice daily. According to Lexi-Comp, a comprehensive on-line drug information resource, [MEDICATION NAME] is an immediate release formulation of an antihypertensive medication. Therefore, the total daily dosage of [MEDICATION NAME] should be given in 2 – 3 divided doses each day. However, Lexi-Comp indicates [MEDICATION NAME] is an extended release formulation of the antihypertensive medication. The total daily dosage of [MEDICATION NAME] is given as one dose daily. A review of Resident #33 ' s Physician order [REDACTED]. Both the physician orders [REDACTED]. The 1/11/17 handwritten orders did not specify whether the [MEDICATION NAME] was to be provided as [MEDICATION NAME] or [MEDICATION NAME]. The handwritten orders were not initialed or signed to identify who transcribed the orders. Resident #33 ' s Admission Minimum Data Set ((MDS) dated [DATE] was reviewed and revealed the resident had moderately impaired cognitive skills for daily decision making. She was independent with eating, required limited assistance from staff for transfers, walking in her room, toileting and personal hygiene. The resident was reported as needing extensive assistance for bed mobility and dressing. A review of the resident ' s type-written February 2017 Physician order [REDACTED]. However, both the instructions twice daily and the 5:00 PM scheduled dose were crossed out on the forms and, a handwritten notation which read daily was written next to the medication. The notation was not initialed. An interview was conducted on 2/10/17 at 2:37 PM with the facility ' s consultant pharmacist. During the interview, the pharmacist reviewed the resident's paper and electronic chart. Upon inquiry, the pharmacist confirmed the resident had received the [MEDICATION NAME] formulation (instead of [MEDICATION NAME]) since she was readmitted to the facility on [DATE] and reported this was apparently an error. The pharmacist indicated he would need to contact the physician to determine whether the [MEDICATION NAME] dosing should be changed to twice daily or the medication changed to [MEDICATION NAME] given once daily. At the time of the interview on 2/10/17 at 2:37 PM, the consultant pharmacist was observed as he wrote a note to the resident ' s physician, explaining the situation. The note indicated Resident #33 was discharged from acute care on 1/11/17 after experiencing a [MEDICAL CONDITION] infarction. He noted the discharge physician had discontinued the 25 mg [MEDICATION NAME] given twice daily and ordered 25 mg [MEDICATION NAME] to be given once daily. The pharmacist also noted the pharmacy had continued to provide 25 mg [MEDICATION NAME] given once daily since the resident ' s discharge from the hospital. On 2/10/17 at 2:55 PM, the Director of Nursing (DON) and consultant pharmacist contacted Resident #33 ' s Physician Assistant (PA) by telephone to clarify the [MEDICATION NAME] order and dosing. A telephone interview was conducted on 2/10/17 at 3:00 PM with the PA. During the telephone interview, the PA confirmed he had just clarified the order and reported the resident should receive 25 mg [MEDICATION NAME] to be given as one tablet by mouth once daily. Upon inquiry as to whether or not the resident may have had an adverse effect from receiving [MEDICATION NAME] only once daily for the past month, the PA stated the answer would be based on the resident ' s symptomology. He reported the resident seemed to be doing okay, and therefore the error did not appear to have caused harm to the resident. An interview was conducted on 2/10/17 at 4:45 PM with the facility ' s DON. Upon inquiry, the DON stated she would expect medication orders to be transcribed correctly from the hospital discharge summary.

Based on record reviews, and staff and pharmacist interviews, the consultant pharmacist failed to identify and address a Gradual Dose Reduction (GDR) for an antidepressant (citalopram), an antianxiety (lorazepam), and a hypnotic (temazepam) medication ordered for 1 of 5 sampled residents reviewed for unnecessary drugs (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #27 ' s March 2016 physician's order [REDACTED]. capsule by mouth every night at bedtime. A review of Resident #27 ' s medical record revealed the facility ' s consultant pharmacist completed monthly Medication Regimen Reviews on the following dates: --On 3/22/16, the resident was noted to receive the following medications, in part: haloperidol and lorazepam for anxiety/agitation, citalopram for Generalized Anxiety Disorder (GAD), and temazepam for insomnia. The pharmacist noted mirtazapine (an antidepressant) had been recently discontinued. No other changes related to psychotropic medications were noted at that time. No recommendations regarding psychotropic medications were made. A psychotropic medication is any drug that affects brain activities associated with mental processes and behavior. Psychotropic medications include antipsychotic, antidepressant, antianxiety, and hypnotic medications. --On 4/18/16, no changes related to psychotropic medications were noted. No recommendations regarding psychotropic medications were made. --On 5/12/16, no maintenance medication changes were noted. There were no recommendations made at this time. --On 6/21/16, no maintenance medication changes were noted. There were no recommendations made at this time. --On 7/20/16, no changes related to psychotropic medications were noted. There were no recommendations made at this time. --On 8/19/16, the consultant pharmacist noted haloperidol was added at 2 mg scheduled twice daily during the past month. No other medication changes were noted to have been made within the last 60 days. No recommendations were made at this time. --On 9/26/16, the consultant pharmacist notes indicated no maintenance medication changes had been made in the past 30 days. No recommendations were made at this time. --On 10/18/16, no medication changes were noted to have been made within the last 60 days. No recommendations were made at this time. On 10/26/16, the consultant pharmacist wrote an Observation/Recommendation Note for Resident #27 ' s physician which read: CMS (Centers for Medicare & Medicaid Services) requires gradual dose reduction trials for antipsychotic medications. (Resident #27) is currently getting haloperidol 2 mg po (by mouth) BID (twice daily) (scheduled). She has been on this dose since July. Can a dose reduction trial of 1 mg po BID be initiated or if not could you please provide a clinical note as to why? A review of the resident ' s medical record revealed the physician agreed with the pharmacist ' s recommendation and reduced the dose of haloperidol from 2 mg to 1 mg given twice daily. Further review of Resident #27 ' s medical record revealed the facility ' s consultant pharmacist completed additional monthly Medication Regimen Reviews on the following dates: --On 11/15/16, the consultant pharmacist noted Resident #27 ' s haloperidol dose was reduced from 2 mg to 1 mg by mouth twice daily with no adverse behaviors noted since the dose reduction. No other medication changes were made in the past 30 days. No recommendations were made at this time. --On 12/26/16, no adverse behaviors were noted since the haloperidol dose reduction. No maintenance medication changes were made in the past month and no recommendations were made at this time. --On 1/18/16, no adverse behaviors were noted since the haloperidol dose reduction. No maintenance medication changes were made in the past month and no recommendations were made at this time. A review of Resident #27 ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. She was independent with eating, required limited assistance from staff for her bed mobility and personal hygiene, and required extensive assistance for dressing and toileting. Section E of the MDS indicated the resident did not exhibit any behaviors nor rejection of care. A review of Resident #27 ' s February 2017 physician's order [REDACTED]. Further review of Resident #27 ' s medical record revealed there was no documentation of GDRs having been addressed for the citalopram, lorazepam, or temazepam currently prescribed. An interview was conducted on 2/10/17 at 2:09 PM with the facility ' s consultant pharmacist. Upon inquiry, the pharmacist reported he would expect to address GDRs for lorazepam and temazepam every 3-4 months, and an antidepressant such as citalopram less often than that. A follow-up interview was conducted on 2/10/17 at 4:30 PM with the consultant pharmacist. At that time, the pharmacist reported he reviewed his records and found GDRs had not been attempted at any time for the citalopram, lorazepam, nor temazepam prescribed for Resident #27. The pharmacist reported he had already telephoned the resident ' s PA and received new MEDICATION ORDERS FOR [REDACTED]yes. A copy of the Observation and Recommendation Note written by the consultant pharmacist on 2/10/17 for Resident #27 included the following actions taken and new medication orders received from the resident ' s PA: --Leave scheduled lorazepam as is; --Decrease PRN (as needed) lorazepam to 0.5 mg po (by mouth); --Decrease temazepam to 7.5 mg po q HS (every night at bedtime) PRN sleep; --Decrease citalopram to 10 mg po daily. An interview was conducted on 2/10/17 at 4:45 PM with the facility ' s Director of Nursing (DON). A review of Resident #27 ' s history of psychotropic medications without GDRs addressed was discussed. Upon inquiry, the DON stated she would expect GDRs to be monitored and addressed. She indicated she would expect a discussion to be held with the physician and documented attempts for the GDRs made, or alternatively, a reason documented as to why the attempts could not be made.

Based on observation, record reviews and staff interviews, the facility failed to revise the Care Plan of 1 of 3 residents reviewed for significant weight loss. (Resident #16). Findings included: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS (minimum data set) dated 11/16/16 indicated Resident#16 was severely, cognitively impaired; was independent with eating; had weight gain; and received a therapeutic diet. The Weights for this resident in six months were: Weight on 1/2/17 was 99 lbs. (pounds); Weight 30 days ago (12/05/2016): 108 lbs. (which is 9 lbs. less than on the first date or a 9.1% loss) Weight 90 days ago (10/06/2016): 99 lbs. (which is 0 lbs. more than on the first date or a 0.0% gain) Weight 180 days ago (08/04/2016): 105 lbs. (which is 6 lbs. less than on the first date or a 6.1% loss) The review of Resident #16's Care Plan was not updated to include the resident's fluctuations in weight status. During an observation and interview on 2/10/17 at 9:00am, Resident #16 was completing her breakfast assisted by NA#2 (nursing assistant). NA#2 indicated the resident was able and would feed herself some of her meal and stop; then she (NA#2) would assist the resident with the remaining meal. During an interview on 2/10/17 at 10:16am, the RD (Registered Dietitian) revealed Resident #16 received a no added salt, lactose free diet with finely chopped meats. The RD stated that the resident's desirable weight range for her height of 52.5 inches was 73-89 lbs. She revealed the resident has had weight variations in the past (three months prior), then her weight would level off between 107 lbs. to 109 lbs. for two months then begin to fluctuate again for a few months. During an interview on 2/10/17 at 5:35pm, the RD confirmed the Nutrition Care Plan was not updated and acknowledged it should have been to include Resident #16's weight fluctuations.

Based on record reviews, and staff and pharmacist interviews, the facility failed to identify and attempt a Gradual Dose Reduction (GDR) or document the continued need for an antidepressant ([MEDICATION NAME]), an antianxiety ([MEDICATION NAME]), and a hypnotic ([MEDICATION NAME]) medication ordered for 1 of 5 sampled residents reviewed for unnecessary drugs (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE]. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #27 ' s March 2016 physician's order [REDACTED]. A review of Resident #27 ' s quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making. She was independent with eating, required limited assistance from staff for her bed mobility and personal hygiene, and required extensive assistance for dressing and toileting. Section E of the MDS indicated the resident did not exhibit any behaviors nor rejection of care. A review of Resident #27 ' s February 2017 physician's order [REDACTED]. Further review of Resident #27 ' s medical record revealed there was no documentation of GDRs having been addressed for the [MEDICATION NAME], or [MEDICATION NAME] currently prescribed. An interview was conducted on 2/10/17 at 2:09 PM with the facility ' s consultant pharmacist. Upon inquiry, the pharmacist reported he would expect to address GDRs for [MEDICATION NAME] and [MEDICATION NAME] every 3-4 months, and an antidepressant such as [MEDICATION NAME] less often than that. A follow-up interview was conducted on 2/10/17 at 4:30 PM with the consultant pharmacist. At that time, the pharmacist reported he reviewed his records and found GDRs had not been attempted at any time for the [MEDICATION NAME], nor [MEDICATION NAME] prescribed for Resident #27. The pharmacist reported he had already telephoned the resident ' s PA and received new MEDICATION ORDERS FOR [REDACTED]yes. A copy of the Observation and Recommendation Note written by the consultant pharmacist on 2/10/17 for Resident #27 included the following actions taken and new medication orders received from the resident ' s PA: --Leave scheduled [MEDICATION NAME] as is; --Decrease PRN (as needed) [MEDICATION NAME] to 0.5 mg po (by mouth); --Decrease [MEDICATION NAME] to 7.5 mg po q HS (every night at bedtime) PRN sleep; --Decrease [MEDICATION NAME] to 10 mg po daily. An interview was conducted on 2/10/17 at 4:45 PM with the facility ' s Director of Nursing (DON). During the interview, failure to address GDRs for the [MEDICATION NAME], and [MEDICATION NAME] for Resident #27 ' s was discussed. Upon inquiry, the DON stated she would expect GDRs to be monitored and addressed. She indicated she would expect a discussion to be held with the physician and documented attempts for the GDR made or, alternatively, a reason documented as to why the attempt could not be made.

Based on observations, record review, and staff interviews, the facility failed to have a medication error rate less than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8%, for 2 of 3 residents (Resident #1 and Resident #15) observed during medication pass. The findings included: 1) On 2/8/17 at 4:05 PM, Nurse #1 was observed preparing medications for administration to Resident #1. The medications pulled for administration included a [MEDICATION NAME] HFA inhaler with 110 micrograms (mcg) per actuation (puff). The nurse was observed as she administered two puffs of [MEDICATION NAME] HFA to the resident. [MEDICATION NAME] HFA is a corticosteroid inhaler used for the management of asthma. A review of Resident #1 ' s physician medication orders included a current order for [MEDICATION NAME] HFA 110 mcg inhaler to be given as 2 puffs in the morning and 1 puff in the evening (scheduled for 5:00 PM). An interview was conducted with Nurse #1 on 2/8/17 at 4:30 PM. Nurse #1 reviewed Resident #1 ' s February 2017 Medication Administration Record (MAR) and the administration instructions written on the pharmacy labeling of the [MEDICATION NAME] HFA 110 mcg inhaler used. Upon review of the MAR and pharmacy labeling, Nurse #1 acknowledged the directions written on each indicated only 1 puff of the [MEDICATION NAME] HFA should have been given to Resident #1 in the evening. The nurse stated she did not notice these directions and acknowledged she administered two puffs of [MEDICATION NAME] HFA to the resident during the medication pass observation, instead of one puff as prescribed. An interview was conducted with the facility ' s Director of Nursing (DON) on 2/10/17 at 4:45 PM. Upon inquiry, the DON indicated her expectation was to have a medication error rate of less than 5%. 2) On 2/9/17 at 8:19 AM, Nurse #3 was observed preparing medications for administration to Resident #15. The medications pulled for administration included one - 500 microgram (mcg) Vitamin B12 tablet. The nurse was observed as she administered the medication to the resident. A review of Resident #15 ' s physician medication orders and the resident ' s February 2017 Medication Administration Record revealed there was a current order for two – 500 mcg Vitamin B12 tablets to be given daily. An interview was conducted with Nurse #3 on 2/10/17 at 12:40 PM. During the interview, Nurse #3 reported she made a mistake during the medication pass observation when she gave Resident #15 one Vitamin B12 tablet instead of the two tablets ordered. An interview was conducted with the facility ' s Director of Nursing (DON) on 2/10/17 at 4:45 PM. Upon inquiry, the DON indicated her expectation was to have a medication error rate of less than 5%.

Based on observation, record review and staff interviews, the facility failed to date a medication when opened to allow for the determination of its shortened expiration date in 1 of 1 medication storage room and 1 of 2 medication carts (Cart 2 for Rooms 337-352); and, failed to store medications as specified by the drug manufacturer in 2 of 2 medication carts (Cart 1 for Rooms 320-336 and Cart 2 for Rooms 337-352). The findings included: 1) Accompanied by Nurse #2, an observation of the medication store room was made on 2/9/17 at 5:00 PM. The observation revealed a carton of 0.25 mg / 2 ml budesonide inhalation suspension (a corticosteroid medication to be inhaled via use of a nebulizer) dispensed for Resident #4 was stored on a shelf in the medication room. The carton included an opened foil pouch containing 4 vials of inhalation suspension. The manufacturer labeling of the budesonide inhalation suspension included storage instructions which read, in part: Once the foil envelope is opened, use the vials within 2 weeks. The foil pouch was not dated. A review of Resident #4 ' s Physician order [REDACTED]. An interview was conducted on 2/9/17 at 5:05 PM with Nurse #2. When asked how she would know when the foil pouches of budesonide inhalation suspension had been opened, Nurse #2 stated she would not know. An interview was conducted on 2/10/17 at 4:45 PM with the Director of Nursing (DON). During the interview, the DON reported she would expect pharmacy to make nursing staff aware of any special storage needs for medications. 2) An observation of the medication cart for Rooms 337-352 was made on 2/9/17 at 4:50 PM. The observation revealed one vial of 0.25 mg / 2 ml budesonide inhalation suspension (a corticosteroid medication to be inhaled via use of a nebulizer) was stored in an opened foil pouch laying on its side in the medication cart drawer labeled for Resident #4. The manufacturer labeling of the budesonide inhalation suspension included storage instructions which read, in part: Store unopened vials in the foil envelope placed upright in the carton .Once the foil envelope is opened, use the vials within 2 weeks. The foil pouch was not stored upright; and, the foil pouch was not dated to indicate when it had been opened. A review of Resident #4 ' s Physician order [REDACTED]. An interview was conducted on 2/9/17 at 5:05 PM with Nurse #2 after observations of both the medication cart (Rooms 337-352) and medication storage room were conducted. When asked how she would know when the foil pouches of budesonide inhalation suspension had been opened, Nurse #2 stated she would not know. Nurse #2 also indicated she was not aware the vials of budesonide inhalation suspension needed to be stored upright. An interview was conducted on 2/10/17 at 4:45 PM with the Director of Nursing (DON). During the interview, the DON reported she would expect pharmacy to make nursing staff aware of any special storage needs for medications. 3) An observation of the medication cart for Rooms 320-336 was made on 2/9/17 at 4:25 PM. The observation revealed 1 - 10 milliliter (ml) bottle of Pred Forte 1% ophthalmic suspension (a corticosteroid suspension used as an eye drop) dispensed for Resident #30 was stored laying down on its side in a drawer of the medication cart. The manufacturer ' s instructions for storage were covered by the pharmacy labeling. Upon peeling back the pharmacy label, the manufacturer ' s labeling on the bottle of the Pred Forte 1% ophthalmic suspension became visible and read, in part: Store in upright position. A review of Resident #30 ' s Physician order [REDACTED]. An interview was conducted on 2/9/17 at 4:30 PM with Nurse #3. Nurse #3 was assigned to the medication cart for Rooms 320-336. During the interview, Nurse #3 reviewed the labeling on the Pred Forte eye drops and reported she would need to find an alternative way to store these eye drops. An interview was conducted on 2/10/17 at 4:45 PM with the Director of Nursing (DON). During the interview, the DON reported she would expect pharmacy to make nursing staff aware of any special storage needs for medications.

Based on observations, record review and staff interviews, the facility failed to include all of the required information on the daily nursing staff postings, including the name of the facility, for 60 of the past 60 days reviewed (12/9/16 through 2/9/17). The findings included: An observation made on 2/7/17 at 11:15 AM revealed the nurse staffing information dated 2/7/17 was posted in the hallway near the nursing station. The name of the facility was not included on the nursing staff posting. An observation made on 2/8/17 at 8:30 AM revealed the nurse staffing information dated 2/8/17 was posted in the hallway near the nursing station. The name of the facility was not included on the nursing staff posting. An observation made on 2/9/17 at 9:10 AM revealed the nurse staffing information dated 2/9/17 was posted in the hallway near the nursing station. The name of the facility was not included on the nursing staff posting. An interview was conducted with facility ' s Director of Nursing (DON) on 2/9/17 at 3:21 PM. The DON reported she was not aware it was required to include the facility name on the nursing staff posting. On 2/10/17 at 7:58 AM, a review of the nursing staff postings from the past 60 days was completed. None of the nursing staff postings reviewed included the name of the facility.

Based on record review and staff interviews the facility failed to develop a care plan with critical interventions, including monitoring target behaviors and non-pharmacological interventions, for a resident receiving [MEDICAL CONDITION] medications for 1 of 6 residents, Resident #12. The findings included: Resident #12 was admitted to the facility 4/21/2013. [DIAGNOSES REDACTED]. Progress notes dated 12/16/2015, 7/17/2015 and 1/6/2016 included [DIAGNOSES REDACTED]. Resident #12 ' s Minimum (MDS) data set [DATE] indicated that she had received 7 days of antianxiety medication, 7 days of antidepressants, and 7 days of antipsychotic medication. A review of physician orders [REDACTED]. [MEDICATION NAME] 20 mg, an antidepressant, was ordered to be given daily. [MEDICATION NAME] 1 mg, an antianxiety, was ordered to be given by mouth three times a day. A review of the Medication Administration Record [REDACTED]. No behavioral monitoring was noted in the resident ' s medical record. No non-pharmacological interventions were documented for this resident. The resident ' s care plan identified a concern of [MEDICAL CONDITION] medication use, including [MEDICATION NAME], and [MEDICATION NAME]. The goal stated, The resident will remain free of [MEDICAL CONDITION] drug related complications, including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation or cognitive/behavioral impairment. The interventions included, Administer [MEDICAL CONDITION] medications as ordered by physician. Monitor for side effects and effectiveness every shift. It did not include any non-pharmacological interventions. It did not list any target behaviors to monitor for the use of [MEDICATION NAME]. The care plan was initiated 5/14/2014 and updated 1/23/2016. The Director of Nursing was interviewed 2/19/2016 at 11:46 am. She identified herself as the nurse responsible for the care plan. When asked about non-pharmacological interventions, she agreed that they were not included on the care plan. She explained that the resident gets tearful at times and wants her family. She indicated that the nurses will give her tasks to do, like folding linen to distract her. She explained that nurses who know this resident will do these interventions automatically, without being included on the care plan.

Based on record review and staff interview the facility failed to update a care plan with the current [MEDICAL CONDITION] medications and dosages for one of six residents receiving [MEDICAL CONDITION] medications. Resident #16. The findings included: Resident #16 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], a quarterly, indicated Resident #16 had short and long term memory impairment and moderate impairment with daily decision making abilities. This MDS included use of an antipsychotic medication in his treatment. Re-admission orders [REDACTED]. Review of the care plan with an update of 9/23/15 included a problem for use of [MEDICATION NAME] 1.0 mg at 2:00 PM, [MEDICATION NAME] 0.5mg daily and [MEDICATION NAME] 0.5mg as needed at bedtime related to anxiety issues and dementia disease process. Target behaviors for use of the [MEDICATION NAME] included agitation. Interview on 02/18/2016 at 2:44 PM with the Director of Nursing revealed she completed and updated care plans for Resident #16. She explained she missed updating the medications and dosages when Resident #16 was readmitted and on subsequent care plan reviews. Further interview revealed Resident #16 has physical aggression at times and would hit or kick at staff. The target behaviors were not included on the care plan due to nurses knew his behaviors.