Every finding on record at Oak Hill Health & Rehabilitation

Based on interview and record review, the facility failed to ensure treatment and care was provided to all facility residents for physician prescribed medications for 2 of 4 residents, Resident #1 and #4, reviewed for medication administration.Findings include:Review of Resident #1's admission data revealed the resident was admitted on [DATE] with medical diagnoses to include a history of urinary (tract) infections and chronic kidney disease.Review of Resident #1's physician orders documented, Bactrim DS [double strength] oral tablet 800-160 mg [milligrams]. Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/17/2025 at 1700 [5:00 PM]; D/C [discontinue] date 12/19/2025 at 0645 [6:45 AM].Review of the Medication Administration Record (MAR) documented dated 12/17/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/18/2025 at 0600 (6:00 AM) the entry was blank. Dated 12/18/2025 at 1700 and 12/19/2025 at 0600 was documented with a 9 - Other/See Nurse Notes.Review of the Progress Notes documented an eMAR (electronic) Medication Administration Note dated 12/18/2025 and 12/19/2025 that read, Bactrim DS Oral Tablet 800 - 160 MG (Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2 times a day for UTI for 14 days. Awaiting delivery. Review of Resident #1's physician orders documented, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/19/2025 at 1700 [5:00 PM]; D/C date 12/22/2025 at 1104 [11:04 AM].Review of the MAR documented dated 12/19/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/20/2025, 12/21/2025, and 12/22/2025 at 0600 was documented with a 9 - Other/See Nurse Notes.Review of the Progress Notes documented an eMAR (electronic) Medication Administration Note dated 12/20/2025 and 12/21/2025 that read, Bactrim DS Oral Tablet 800 - 160 MG (Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2 times a day for UTI for 14 days. Awaiting delivery. Review of Resident #1's physician orders documented, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI for 14 days. Start Date: 12/22/2025 at 1700; D/C date 12/23/2025 at 1654 [4:54 PM].Review of the MAR documented dated 12/22/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/23/2025 at 0600 was documented with a 9.Review of the Progress Notes dated 12/23/2025 did not provide for documentation for the 0600 note of 9.Review of Resident #1's physician orders read, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI for 14 Days, Start Date 12/23/2025 at 2100 (9:00 PM).Review of a Progress Note dated 12/24/2025 read, Nurse spoke with pharmacy in regards to Bactrim, pharmacy to stat out. Facility to use [name of medication dispensing system] supply until delivered. MD [Medical Doctor] and family notified.During an interview on 2/18/2026 at 1:35 PM the DON (Director of Nursing) said the nurses should be documenting on the MAR if they are unable to administer a medication, such as if it was not available from the pharmacy, and they should notify the provider. Bactrim was also available in the [name of the automated medication dispensing system] machine.Review of Resident #4's admission data documented the resident was admitted on [DATE] with medical diagnoses to include primary generalized osteo arthritis; cerebellar ataxia in diseases classified elsewhere; pneumonia, unspecified organism; muscle weakness (generalized).Review of Resident #4's MDS (Minimum Data Set) assessment, an admission assessment dated [DATE], documented a BIMS score of 15 out of 15 = cognitively intact.Review of Resident #4's physician orders documented Cyanocobalamin [Vitamin B-12] Injection Kit 1000 mcg/ml [micrograms per milliliter] (Cyanocobalamin) Inject 1000 mcg intramuscularly [into the muscle] one time a day for neuropathy [damage to the nerves outside the brain and spinal cord] for 7 days. Start Date 02/11/2026 0900 [9:00 AM].Review of Resident #4's MAR for Cyanocobalamin administration documented on 02/12/2026 and 02/13/2026 at 0900 12 = Not Applicable. Dated 02/17/2026 at 0900 was documented with a 9 = Other/See Nurse Note.Review of Resident #4's Progress Notes did not contain documentation for 02/12/2026 and 02/13/2026 for the code of 12, or for 02/17/2026 for a code of 9.During an interview on 2/18/2026 at 4:20 PM Resident #4 said she was participating in therapy but some days it really wore her out. She didn't have as much energy as she usually did and thought it might be because she had not received all of the B-12 injections she was supposed to get. The facility was having some problems getting the shots. During an interview on 2/18/2026 at approximately 5:50 PM the DON said the pharmacy had sent Resident #4's B-12 injections in a kit and not all of the doses had arrived. The nurses should have contacted Resident #4's physician when the medication wasn't available and they should have checked with the pharmacy. Review of the policy and procedure titled, Medication Monitoring, read, Policy: this facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences. Policy Explanation and Compliance Guidelines: 5. Licensed nurses, with periodic oversight by nurse managers, shall: Report refusals of medications, frequent holding of medications, or signs of adverse consequences of medications to the physician.Review of the policy and procedure titled, Medication Administration, read, Policy: medications are administered by licensed nurses, other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 22. Report and document any adverse side effects or refusals. 23. Correct any discrepancies and report to nurse manager.

Based on interview and record review, the facility failed to document unavailable medications and notification to physicians of missed doses of ordered medications for 2 (Resident #1 and Resident #4) of 4 residents reviewed for medication administration.Findings include:Review of Resident #1's admission data revealed the resident was admitted on [DATE] with medical diagnoses to include a history of urinary (tract) infections and chronic kidney disease.Review of Resident #1's physician orders documented, Bactrim DS [double strength] oral tablet 800-160 mg [milligrams]. Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/17/2025 at 1700 [5:00 PM]; D/C [discontinue] date 12/19/2025 at 0645 [6:45 AM].Review of the Medication Administration Record (MAR) documented dated 12/17/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/18/2025 at 0600 (6:00 AM) the entry was blank. Dated 12/18/2025 at 1700 and 12/19/2025 at 0600 was documented with a 9 - Other/See Nurse Notes.Review of the Progress Notes documented an eMAR (electronic) Medication Administration Note dated 12/18/2025 and 12/19/2025 that read, Bactrim DS Oral Tablet 800 - 160 MG (Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2 times a day for UTI for 14 days. Awaiting delivery. Review of Resident #1's physician orders documented, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI [urinary tract infection] for 14 days. Start date 12/19/2025 at 1700 [5:00 PM]; D/C date 12/22/2025 at 1104 [11:04 AM].Review of the MAR documented dated 12/19/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/20/2025, 12/21/2025, and 12/22/2025 at 0600 was documented with a 9 - Other/See Nurse Notes.Review of the Progress Notes documented an eMAR (electronic) Medication Administration Note dated 12/20/2025 and 12/21/2025 that read, Bactrim DS Oral Tablet 800 - 160 MG (Sulfamethoxazole-Trimethoprim): Give 1 tablet by mouth 2 times a day for UTI for 14 days. Awaiting delivery. Review of Resident #1's physician orders documented, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI for 14 days. Start Date: 12/22/2025 at 1700; D/C date 12/23/2025 at 1654 [4:54 PM].Review of the MAR documented dated 12/22/2025 at 1700 Bactrim was administered as ordered by the physician. Dated 12/23/2025 at 0600 was documented with a 9.Review of the Progress Notes dated 12/23/2025 did not provide for documentation for the 0600 note of 9.Review of Resident #1's physician orders read, Bactrim DS oral tablet 800-160 mg. Give 1 tablet by mouth two times a day for UTI for 14 Days, Start Date 12/23/2025 at 2100 (9:00 PM).Review of a Progress Note dated 12/24/2025 read, Nurse spoke with pharmacy in regards to Bactrim, pharmacy to stat out. Facility to use [name of medication dispensing system] supply until delivered. MD [Medical Doctor] and family notified.During an interview on 2/18/2026 at 1:35 PM the DON (Director of Nursing) said the nurses should be documenting on the MAR if they are unable to administer a medication, such as if it was not available from the pharmacy, and they should notify the provider. Bactrim was also available in the [name of the automated medication dispensing system] machine.Review of Resident #1's medical record for the period of 12/17/2025 through 12/31/2025 did not contain documentation the physician was notified when the Bactrim DS was not administered as order.Review of Resident #4's admission data documented the resident was admitted on [DATE] with medical diagnoses to include primary generalized osteo arthritis; cerebellar ataxia in diseases classified elsewhere; pneumonia, unspecified organism; muscle weakness (generalized).Review of Resident #4's MDS (Minimum Data Set) assessment, an admission assessment dated [DATE], documented a BIMS score of 15 out of 15 = cognitively intact.Review of Resident #4's physician orders documented Cyanocobalamin [Vitamin B-12] Injection Kit 1000 mcg/ml [micrograms per milliliter] (Cyanocobalamin) Inject 1000 mcg intramuscularly [into the muscle] one time a day for neuropathy [damage to the nerves outside the brain and spinal cord] for 7 days. Start Date 02/11/2026 0900 [9:00 AM].Review of Resident #4's MAR for Cyanocobalamin administration documented on 02/12/2026 and 02/13/2026 at 0900 12 = Not Applicable. Dated 02/17/2026 at 0900 was documented with a 9 = Other/See Nurse Note.Review of Resident #4's Progress Notes did not contain documentation for 02/12/2026 and 02/13/2026 for the code of 12, or for 02/17/2026 for a code of 9.During an interview on 2/18/2026 at 4:20 PM Resident #4 said she was participating in therapy but some days it really wore her out. She didn't have as much energy as she usually did and thought it might be because she had not received all of the B-12 injections she was supposed to get. The facility was having some problems getting the shots. During an interview on 2/18/2026 at approximately 5:50 PM the DON said the pharmacy had sent Resident #4's B-12 injections in a kit and not all of the doses had arrived. The nurses should have contacted Resident #4's physician when the medication wasn't available and they should have checked with the pharmacy. Review of Resident #4's medical record for the period of 02/11/2026 through 02/18/2026 did not contain documentation the physician was notified the medication was not administered as ordered.Review of the policy and procedure titled, Medication Monitoring, read, Policy: this facility takes a collaborative, systematic approach to medication management, including the monitoring of medications for efficacy and adverse consequences. Policy Explanation and Compliance Guidelines: 5. Licensed nurses, with periodic oversight by nurse managers, shall: Report refusals of medications, frequent holding of medications, or signs of adverse consequences of medications to the physician.Review of the policy and procedure titled, Medication Administration, read, Policy: medications are administered by licensed nurses, other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 22. Report and document any adverse side effects or refusals. 23. Correct any discrepancies and report to nurse manager.

Based on interview and record review the facility failed to ensure Preadmission Screening and Resident Reviews (PASRR) were accurately completed for 7 of 7 residents, Residents #9, #15, #23, #28, #31, #44, #59, reviewed for mood and behavior.Findings include:1) Review of Resident #44 Preadmission Screening and Resident Review (PASRR) dated 7/27/2024 did not document serious mental illness or intellectual disability.Review of Resident #44's admission record resident was readmitted on [DATE] with diagnosis including but not limited to anxiety disorder, major depressive disorder and psychosis. Review of Resident #44's physician order dated 7/29/2024 read, Xanax Oral Tablet 0.25 mg [milligram] give 1 tablet by mouth at bedtime for anxiety.Review of resident #44's physician order dated 12/10/2024 read, Zoloft Oral Tablet 50 mg give 1 tablet by mouth at bedtime for depression. Review of Resident #44's psychiatry subsequent note dated 6/3/2025 read, Chief Complaint: Depression, anxiety, insomnia and Parkinson's psychosis. History of Present Illness: Prior to last visit, patient had anxiety. Sleep issues were reported. During last visit, patient was at baseline. Patient's mood was stable. During an interview on 7/1/2025 at 9:10 AM with the Director of Nursing (DON) stated, [Resident #44's name] PASSR needed to be updated upon admission. They will be corrected to include all diagnosis applicable.2) Review of Resident #23's clinical record documented the resident was admitted on [DATE] with diagnosis to include but not limited to bipolar disorder and major depressive disorder. Review of Resident #23's PASRR dated 4/25/2025 did not document any mental illness. Review of Resident #23's physician order dated 6/10/2025 read, Depakote Sprinkles capsule sprinkle 125 mg give 4 capsules by mouth every 12 hour for mood disorder, aripiprazole tablet 5mg give 1 tablet by mouth at bedtime for behavioral/mood disturbances, escitalopram oxalate tablet 5 mg give 1 tablet by mouth one time a day for depression, Remeron oral tablet 15 mg give 1 tablet by mouth at bedtime for depression, and buspirone HCL oral tablet 5 mg give 1 tablet by mouth every 12 hours for anxiety.Review of Resident #23's psychiatry subsequent note dated 5/23/2025 read Chief complaint: The patient has a history of depression, schizoaffective disorder (depressive type with disorganized thinking and hallucination's, and prior opioid and nicotine dependence. She reports no anxiety.3) Review of Resident #31's clinical record documented the resident was readmitted into the facility on [DATE] with diagnosis to include but not limited to major depressive disorder. Review of Resident #31's physician order dated 6/10/2025 read, Fluoxetine HCL oral tablet 60 mg (Fluoxetine HCL) give 1 tablet one time a day for depression.Review of Resident #31's physician order dated 6/11/2025 read, Bupropion HCL ER (XL) [extended release] oral tablet extended release 24-hour 300 mg (Bupropion HCL) give 1 tablet by mouth one time a day for depression.Review of Resident #31's physician order dated 6/25/2025 read, Clonazepam oral tablet 0.5 mg (Clonazepam) give 1 tablet by mouth at bedtime for anxiety.Review of Resident #31's psychiatry note dated 6/20/2025 read, [AGE] year old female with a history of depression, anxiety, dementia, anxiety, psychosis, PTSD [post traumatic stress disorder], and panic disorder.Review of Resident #31's PASRR dated 2/20/2023 did not document any mental illness. 4) Review of the PASRR for Resident #9 dated 6/9/2025 read, Resident #9 did not have or was not suspected of having any mental illness.Review of Residents #9's medical record documented a diagnosis of anxiety disorder.Review of Resident #9 physician order dated 6/29/2025 read, Xanax 0.25 mg, give one tablet by mouth every 8 hours as needed for anxiety for 14 days.5) Review of the (PASRR dated 4/17/2025 read, Resident #15 did not have or was not suspected of having any mental illness.Review of Resident #15's psychiatry subsequent note dated 6/17/2025 read, I saw the patient for medication management as the patient has active psychiatric diagnosis, is on psych med, is in the facility setting .Review of Resident #15's physician order dated 6/13/2025 read, Remeron 30 mg, give one tablet by mouth at bedtime for major depressive disorderReview of Resident #15's physician order dated 6/14/2025 read, Risperdal 1 mg, give one tablet by mouth two times a day for behavior disorder.Review of Resident #15's physician order dated 6/15/2025 read, Clonazepam 2 mg, give one tablet by mouth three times a day for anxiety.6) Review of the PASRR dated 5/17/2024 read, Resident #28 was only suspected to have depression as the only mental illness the Resident is diagnosed with. Review of Resident #28's psychiatry subsequent note dated 6/3/2025 read, This is a [AGE] year old patient with an past psychiatric history of depression and anxiety.Review of Review #28's physician order dated 5/16/2025 read, Duloxetine 60 mg, give one capsule by mouth at bedtime for depression.Review of Resident #28's physician order dated 6/1/2025 read, Lorazepam 0.5 mg, give one tablet by mouth every 3 hours as needed for anxiety, restlessness.7) Review of PASRR dated 3/4/2024 read Resident #59 was only suspected to have depression and anxiety as the only mental illness the Resident is diagnosed with. Review of Resident #59's medical diagnosis related to mental illness read generalized anxiety disorder, major depressive disorder and adjustment disorder.Review of Resident #59's physician order dated 1/22/2025 read, Sertraline 100 milligrams, give one tablet by mouth one time a day for depression.Review of Resident #59's physician order dated 1/22/2025 read, Buspirone 5 mg, give one tablet by mouth two times a day for anxiety. Review of Resident #59's physician order dated 2/5/2025 read, Trazodone 50 mg, give one tablet by mouth at bed time for major depressive disorder. Review of Resident #59's physician order dated 4/8/2025 read, Alprazolam 0.25 mg, give one tablet by mouth every eight hours for anxiety.During an interview on 7/1/2025 at 3:30 PM the Administrator stated, The PASRRs are incorrect. My expectations would be that the PASRRs be correct.During an on 7/1/2025 at 3:30 PM the Administrator stated, The PASRRs are incorrect. My expectations would be that the PASRRs be correct.

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided for intravenous (IV) dressing changes for 2 of 4 residents, Residents #195 and #444, reviewed for IV catheters and infusions, and failed to ensure medication management for 1 of 6 residents, Resident #55, reviewed for medications.Findings include:1) During an observation on 06/29/25 at 10:17 AM Resident #195 had a double lumen PICC (peripherally inserted central catheter) line inserted in his left upper arm. The dressing covering the insertion site was dated 6/17/2025. Review of Resident #195's physician order dated 5/23/2025 read, Change catheter site dressing every week and prn [as needed] with a transparent dressing every shift every Tue [Tuesday] for IV therapy.During an interview on 7/1/2025 at 1:11PM Staff E, Licensed Practical Nurse stated, IV dressing changes should be done every week or as needed. I don't know what happened I thought I had changed the dressing.During an interview won 7/2/2025 at 9:45 AM the Director of Nursing (DON) stated, Central line dressing should be [changed] every seven days and peripheral lines every three day. [Resident #195's name] should have been changed on 6/24/2025.2) Review of Resident #55's physician order dated 3/30/2025 read, Carvedilol Oral Tablet 3.125 mg [milligrams] give 1 tablet by mouth every 12 hours for htn [hypertension] hold medication for SBP <135 [systolic blood pressure less than 135].Review of Resident #55's Medication Administration Record (MAR) for the month of June 2025 documented Carvedilol 3.125 mg was administered outside of the physician ordered parameters at 0900 [9:00AM] on 6/2/2025 SBP was 106, 6/3/2025 SBP was 113, 6/4/2025 SBP was 110, 6/5/2025 SBP was 112, 6/6/2025 SBP was 122, 6/7/2025 SBP was 129, 6/8/2025 SBP was 128, 6/9/2025 SBP was 115, 6/10/2025 SBP was 111, 6/11/2025 SBP was 120, 6/12/2025 SBP was 124, 6/13/2025 SBP was 118, 6/16/2025 SBP was 108, 6/17/2025 SBP was 115, 6/18/2025 SBP was 111, 6/19/2025 SBP was 111, 6/20/2025 SBP was 113, 6/21/2025 SBP was 105, 6/22/2025 SBP was 116, 6/23/2025 SBP was 115, 6/24/2025 SBP was 107, 6/25/2025 SBP was 117, 6/26/2025 SBP was 132, 6/29/2025 SBP was 123, 6/30/2025 SBP was 126. At 2100 [9:00PM] on 6/1/2025 SBP 106, 6/2/2025 SBP was 113, 6/3/2025 SBP was 117, 6/4/2025 SBP was 110, 6/6/2025 SBP was 129, 6/7/2025 SBP was 122, 6/8/2025 SBP was 120, 6/9/2025 SBP was 116, 6/10/2025 SBP was 111, 6/11/2025 SBP was 108, 6/12/2025 SBP was 124, 6/13/2025 SBP was 113, 6/14/2025 SBP was 129, 6/15/2025 SBP was 108, 6/16/2025 SBP was 108, 6/17/2025 SBP was 118, 6/18/2025 SBP was 111, 6/21/2025 SBP was 108, 6/22/2025 SBP was 118, 6/23/2025 SBP was 107, 6/24/2025 SBP was 117, 6/25/2025 SBP was 120, 6/26/2025 SBP was108, 6/29/2025 SBP was 126, and on 6/30/2025 SBP was 126.During an interview on 7/2/2025 at 9:51 AM the DON stated, The nurses were administering medications out of parameters. The staff are expected to follow the physician orders and make the physician aware. I believe it might have been confusion with the less than sign. I always encourage the staff to write out the words instead of using the symbols.During an interview on 7/2/2025 at 10:22 AM Staff E, LPN stated, I always look at the parameters. I know the sign is for less than and you hold the medication. If the entry has a check mark it means it was given. I don't know what happened there, I don't recall. I would always document a progress note if I contacted the provider for any questions regarding medication.During an interview on 7/2/2025 at 2:30 PM Medical Doctor #1 stated, [Resident #55's name] has an extensive cardiac history. I was going to change her parameters. It's a betablocker and she needs the drug. If medication has parameters it should be followed. Review of the policy and procedure titled Medication Administration with a last review date of 12/30/2024 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 3) Review of Resident #444's physician orders dated 6/23/2025 read, Change catheter site dressing every week and PRN with a transparent dressing.During an observation on 6/30/2025 at 09:11 AM Resident #444 was lying in the bed and was noted to have a peripherally inserted central catheter (PICC) in the upper right arm. The transparent dressing covering the PICC was dated 6/22/2025. During an observation on 06/30/2025 at 9:45 AM with Staff B, Licensed Practical Nurse, Resident #444's PICC line dressing was observed. (Photographic evidence obtained) During an interview on 06/30/2025 at 9:45 AM Staff B, Licensed Practical Nurse stated, The dressing is dated on 6/22/2025. Dressing changes are to be done every seven days. It should have been changed yesterday 7/29. During an interview on 6/30/2025 at 1:20 PM the Director of Nursing stated, The dressing should be changed at least every seven days.Review of the policy and procedure titled PICC (peripherally inserted central catheter/MIDLINE/CVAD(central venous access device) Dressing Change dated 12/30/2024 read, It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes.

Based on observation, interview, and record review the facility failed to ensure medications were securely stored when unattended and failed to date and label intravenous (IV) medication infusion bags and tubing. Findings include: 1) During an observation on 6/29/2025 at 11:32 AM Resident #499 was lying in bed. Next to the bed was an intravenous (IV) pole. Hanging on the pole was a Zosyn IV infusion bag. The infusion bag and the tubing were not dated or timed. re was no date or time on the IV infusion bag or tubing. (photographic evidence obtained)2) During an observation on 6/30/2025 at 10:19 AM of Resident #27's room there was CeraVe eczema relief cream on top of the bedside table. (Photographic evidence obtained) 3) During an observation on 7/1/2025 at 8:22 AM Resident #195's IV medication was hanging from an IV pole. The infusion bag and the IV tubing was not labeled with the date and time. Observed on top of Resident #195 bedside table was a Germa Ubre Plus topical analgesic ointment (is a medicated ointment used to relieve minor aches and pains in muscle and joints). During an interview on 7/1/2025 at 8:47 AM Resident #195 stated, I use the ointment if I have a tooth ache. I normally will apply it outside on the side of the mouth area and when I wake up the next morning it feels better.During an interview on 7/1/2025 at 8:50 AM Staff C, Licensed Practical Nurse (LPN), stated, The IV medication should be labeled with the time and date it was hung. I do not see this one [IV medication bag and tubing] has a date and time. I do not see a doctor's approval for Resident #195 to have medication at bedside.During an interview on 7/1/2025 at 9:15 AM the Director of Nursing stated, The residents need to have a medication self-administration assessment and be educated on medication self-administration. Also, the physician would be notified, and the medication should be secured when not in use. The intravenous tubing should be labeled with the time and date when first used.Review of the facility policy and procedure titled Intravenous Therapy with a last review date of 12/30/2024 read, Policy: The facility will adhere to accepted standards of practice regarding infusion practices. Compliance Guidelines: 5. All IV tubing is to be labeled with date, time and initials.Review of the facility policy and procedure titled, Labeling of Medications and Biologicals with a last review date of 12/30/2025 read, Policy: All medications and biologicals used in the facility will be labeled in accordance with current stated and federal regulations to facilitate consideration of precautions and safe administration of medication. 5. Labels for medications prepared or compounded for intravenous infusion must include: f. Initials of compounder and person administering medications if different than compounder.

Based on observation, interview, and record review the facility failed to ensure foods and drinks were served at a safe and appetizing temperature.Findings include: During an interview on 6/29/25 at 10:03 AM Resident #493 stated, My food is always cold.During an interview on 6/29/25 at 10:20 AM Resident #495 stated, My food is sometimes cold. During an interview on 6/29/25 at 10:32 AM Resident #498 stated, The food is lukewarm.During an observation on 7/1/25 beginning at 7:00 AM, a test tray investigation on the 100 hallway was conducted related to resident complaints. At 7:19 AM the last tray/test tray was plated and placed on an enclosed meal delivery cart. At 7:20 AM the meal delivery cart exited the kitchen and headed towards the 100 hallway. At 7:35 AM the test tray/last tray was removed from the insulated meal delivery cart. The CDM (Certified Dietary Manager) tested the temperature of the scrambled eggs with a finding of 101 degrees Fahrenheit, the link sausages with a finding of 120 degrees Fahrenheit, and a glass of orange juice with a finding of 48 degrees Fahrenheit. During an interview on 7/1/25 at 7:40 AM the CDM stated, The hot foods [scrambled eggs and sausage] temp should be higher than 140 [degrees Fahrenheit] for hot foods. Cold foods/drinks should be below 41 [degrees Fahrenheit].Review of the policy and procedure titled, Food Safety Requirements, with a review date of 4/9/24 read, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. 5. Foods and beverages shall be distributed to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone [where bacteria can multiply rapidly, potentially causing foodborne illnesses]. Review of Room Test Tray Evaluation Form read, Acceptable delivery Temperatures: include Entree: cold 40-55* [degrees Fahrenheit] hot foods 135-160.* Cold beverages 40-55.* Food and drinks cannot be held in the Danger Zone 40*- 140* no more than 4 hours.

Based on observation, record review, and interview, the facility failed to ensure food was stored in accordance with professional standards in the kitchen walk-in cooler and walk-in freezer and in the second floor nourishment freezer. Findings include:During the initial observation of the kitchen on 6/30/25 beginning at 9:07 AM in the walk-in freezer, there was a clear plastic bag of tater tots sitting on a shelf. The bag was not labeled or dated. In the walk-in cooler, were two trays of uncovered slices of pie on a rolling cart.During an interview on 6/29/25 at 9:08 AM Staff G, Head [NAME] stated, It [plastic bag of tater tots] should be labeled and dated. The dessert [pie] should be covered. During the interview on 7/2/25 at 12:37PM the Dietary Manager states, Food should be labeled and dated and the desserts [pie] should have been covered.During observation on 6/29/25 at 9:40 AM of the nourishment refrigerator/freezer located on the second floor inside the life enrichment room, there was an ice bucket in the freezer with an ice scooper laying on the ice.During an interview on 6/29/25 at 9:42AM Staff F, Dietary Aide stated, That should not be like that [the scooper laying on the ice]. During an interview on 7/2/25 at 12:38 PM the Dietary Manager stated, I don't know where that scooper came from. Review of policy and procedure titled, Food Safety Requirements, with a review date of 4/9/24 read, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Compliance guidelines: 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to, leftovers, so it is used by its use-by date, or frozen (when applicable) discarded; and v. Keeping food covered or in tight containers.

Based on observation, interview, and record review, the facility failed to maintain complete and accurately documented medical records for 1 of 4 residents, Resident #195, reviewed for central catheters and 2 of 6 residents, Resident #5 and #13, reviewed for medication management.Findings include:1) During an observation on 06/29/25 at 10:17 AM Resident #195 was sitting in wheelchair. Resident #195 was observed to have a peripherally inserted central catheter (PICC) line double lumen inserted in the left upper arm. The site was covered with a dressing that was dated 6/17/2025.Review of Resident #195’s physician order dated 5/23/2025 read, Change catheter site dressing every week and prn [as needed] with transparent dressing every shift every Tue [Tuesday] for IV [intravenous] therapy.Review of Resident #195’s Treatment Administration Record (TAR) for the month of June 2025, documented the PICC line dressing change was completed on 6/24/2025.During an interview on 7/1/2025 at 1:11 PM Staff E, Licensed Practical Nurse (LPN) stated, IV dressing changes should be done every week or as needed. I cannot recall what happened on 6/24/20245 or why the dressing was dated as 6/17/2025.2) Review of Resident #5’s physician order dated 11/7/2024 read, Insulin Glargine Solution 100unit/ml [milliliters] inject 10 units subcutaneously at bedtime for diabetes.Review of Resident #5’s physician order dated 11/8/2024 read, Novolog Injection Solution 100 unit/ml (Insulin Aspart) inject as per sliding scale.Review of Resident #5 Medication Administration Record (MAR) for the month of June 2025 for Insulin Glargine Solution documented on 6/10/2025 at 2100 [9:00PM] coded 10 [No sliding scale required].Review of Resident #5 Medication Administration Record (MAR) for the month of June 2025 for Novolog there was a blank entry on 6/20/2025 at 0600 [6:00AM].During an interview on 7/2/2025 at 9:49 AM the Director of Nursing (DON) stated, The nurses should be documenting accurately the services provided. If there is contact with the provided, they need to document the communication in a progress note.During an interview on 7/2/2025 at 11:11 AM with Staff J, Registered Nurse (RN), stated, I know I called the doctor and asked about the insulin. I normally will call the provider with any concerns and act upon the orders provided.During an interview on 7/2/2025 at 2:03 PM Medical Doctor #2 stated, I oversee many patients and it’s hard to recall all. I think it was communicated to me in person and a lot of things are communicated in person. I remember with her [Resident #5] she had a morning she refused the insulin.Review of the facility policy and procedure titled Documentation in Medical Record with a last review date of 12/30/2025 read, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident’s progress through complete, accurate, and timely documentation.3) Review of Resident #13’s physician order dated 6/13/2025 read, Insulin Aspart FlexPen Subcutaneous Solution Pen-injector 100 units/ml, inject subcutaneously before meals and at bedtime for diabetes mellitus, Inject as per sliding scale: if 150-200=1 unit, 201-250= 2 units, 251-300= 3 units, 301-350= 4 units, 351-400= 5 units, 401-999= 6 units, contact MD [Medical Doctor] and recheck every 1 hour until response or under 300, subcutaneously before meals and at bedtime for DM [Diabetes Miletus].Review of Resident #13's documented blood glucoses dated 6/14/2025 read, blood glucose reading at 6:17 AM of 145 milligrams/deciliters (mg/dl), 12:08 PM of 433 mg/dl, 4:50 PM of 139 mg/dl and 9:11 PM of 399 mg/dl.Review of Resident #13's documented blood glucose dated 6/19/2025 read, blood glucose reading at 11:11 AM of 190 milligrams/deciliters (mg/dl), 11:24 AM of 455 mg/dl, 1:45 PM of 489 mg/dl and 9:23 PM of 115 mg/dl.Review of Resident #13's medical record did not provide for document of notification to the medical doctor of the blood glucose readings greater than 400.During an interview on 7/2/2025 at 10:59 AM the DON stated, I spoke to the doctor and he stated that he was notified of the follow-up glucose. I also spoke with the nurses who were responsible for the follow-up blood glucose checks but they did not document them.

Based on observation, interview, and record review, the facility failed to prevent the possible spread of infection when not following infection control standards to wear appropriate personal protective equipment for 3 of 5 residents, Resident #195, #444, and #499, reviewed for enhanced barrier precautions, and failed to store respiratory equipment when not in use for 1 of 2 residents, Resident #5, reviewed for respiratory services. Findings include: 1) During an observation on 7/1/2025 at 8:22 AM Staff C, Licensed Practical Nurse (LPN) entered Resident #195’s room. Outside on the door frame to Resident #195’s room there was an enhanced barrier sign posted. Staff C entered the room and performed hand hygiene. Staff C donned gloves but did not put on a gown. Resident #195’s IV (intravenous) pump was peeping. Staff C turned the pump off. Staff C walked outside of the room with the gloves on, returned to the medication cart, and grabbed a curos disinfecting cap [a single-use cap designed to disinfect and protect IV access points]. Staff C entered the room, removed her gloves, did not perform hand hygiene, and donned a new pair of gloves. Staff C disconnected the IV tubing and put the curos on the end of the needleless connector, removed her gloves, did not perform hand hygiene, and exited the room to verify the flush order. Staff C walked to the medication room, returned to the medication cart with two 3 milliliters (ml) heparin flush syringes and a 5 ml heparin flush syringe. Staff C did not perform hand hygiene and placed the two 3 ml heparin flushes in the medication cart and then entered Resident #195’s room. Staff C did not perform hand hygiene and donned a pair of gloves. Staff C did not don a gown. Staff C placed the flush on top of Resident#195’s bed. Staff C exited the room wearing the gloves, returned to the medication cart, grabbed alcohol wipes, entered Resident #195’s room, did not remove the gloves, did not perform hand hygiene, removed the green curos cap from the IV needless connector and placed it on top of the resident's bed. Staff C cleaned the needleless connector and flushed the IV tubing. Staff C grabbed the used, single use, green curos cap and placed it on the needleless connector. During an interview on 7/1/2025 at 8:47 AM with Staff C, LPN, stated, For enhanced barrier precaution I just wear gloves. The curos cap as long as you remove it and quickly put it back on is okay. I should have perform hand hygiene more often and in between changing my gloves. 2) During an observation on 7/1/2025 at 2:05 PM Staff D, LPN, entered Resident #499’s room who had an enhanced barrier precaution sign on the frame of the room door. Staff D performed hand hygiene and donned a pair of gloves but did not don a gown. Staff D primed the resident’s IV tubing, cleaned the needleless connector with a alcohol wipe, flushed the needleless connector with normal saline, and started the infusion. During an observation on 7/1/2025 at 2:35 PM Staff D entered Resident #499’s room and performed hand hygiene and donned a pair of gloves but did not don a gown. Staff D disconnected the IV tubing, cleansed the needleless connector with an alcohol wipe, flushed the tubing with normal saline followed by a heparin flush. During an interview on 7/1/2025 at 2:47 PM Staff D, LPN, stated, For enhanced barrier I wear gloves. I normally wear gloves only.During an interview on 7/2/2025 at 9:36 AM the Director of Nursing (DON) stated, The expectation is at least hand sanitizer goes on when nurses remove their gloves. When they come back from the medication room they should do hand hygiene. Reusing a curos cap is not a best practice it should be changed out. As far as EBP [enhanced barrier precautions] the staff if they will be in high contact with a patient they should wear gowns and gloves.During an interview on 7/2/2025 at 9:49 AM the Assistant Director of Nursing (ADON)/Infection Preventionist stated, EBP residents have signs posted on the door. Nurses are expected to follow the instructions on the signs and they should wear a gown and gloves.Review of the facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 12/30/2025 read, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ's targeted gown and gloves use during high contact resident care activities. 4. High-contact resident care activities include: g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC [peripherally inserted central catheter] lines midline catheters.Review of the facility policy and procedure titled Hand Hygiene with a last review date 12/30/2025 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. Hand Hygiene Table: Before applying and after removing personal protective equipment (PPE), including gloves.3) During an observation on 6/29/2025 at 10:03 AM Resident #5 was lying in bed. Lying on the corner cabinet was a nebulizer mask that was not bagged. Review of Resident #5’s physician order dated 11/7/2024 read, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML [milligrams/milliliters] 3 ml inhale orally every 4 hours as needed for SOB [shortness of breath] or wheezing via nebulizer. Review of Resident #5’s Medication Administration Record for the month of June 2025 for Ipratropium Albuterol solution documented administered on 6/23/2025. During an interview on 7/2/2025 at 10:01 AM the DON stated, [Resident #5's name] nebulizer mask should be bagged when not in use. Review of the facility policy and procedure titled “Cleaning and Changing Respiratory Equipment with a last review date of 12/30/2024 read, Policy: It is the policy of this facility to ensure the safety of residents by cleaning and changing respiratory equipment using guidelines that adhere to infection control standards. Procedure: Handheld Nebulizers and mask (if applicable): c. The nebulizer will be kept in a plastic bag when not in use. 4) During an observation on 6/30/2025 at 09:11 AM Staff B, LPN prepared and administered medication and enteral feeding for Resident #444 without wearing the proper personal protective equipment (PPE - gown, gloves and mask). Staff B, LPN administer enteral feeding via gastrostomy tube. Staff B, LPN completed an intravenous flush of Resident #444’s PICC access device.Review of Resident #444's physician orders dated 6/20/2025 read, Enhanced Barrier Precautions (EBP)During an observation of resident #444's door and the surrounding area there was no signage to notify staff of the need for EBP.During an interview on 7/1/2025 at 9:30 AM Staff B, LPN stated, Normally, I look at the door and there is a sign on the door that tells me what type of isolation the resident is on. There is no signage [for Resident #444]. I'm not sure what enhanced barrier precautions are or what I should be wearing.During an interview on 7/1/2025 at 12:20 PM the Director of Nursing stated, They [staff] should follow the orders and wear the appropriate PPE.

Based on observation, interview, and record review, the facility failed to ensure medications were kept secured in the facility in 2 of 4 residents rooms observed, Resident #2 and Resident #4 (Photographic evidence obtained). Findings include: During an observation on 6/28/2024 at 9:30 AM, there were Systane eyedrops on Resident #2's bedside table within resident's reach, and Equate Baby Powder and Equate Arthricream Rub on the shelf inside the resident's room. During an interview on 6/28/2024 at 9:30 AM, Resident #2 stated, I use the eyedrops at least twice a day sometimes 4 times a day. I only use the baby powder and the cream if I need it. Review of Resident #2's physician orders revealed no orders for self-administration of medications. During an observation on 6/28/2024 at 9:55 AM, there was a bottle of Systane eyedrops on the bedside table by the bed within reach in Resident #4's room. During an interview on 6/28/2024 at 9:55 AM, Resident #4 stated, I use the eye drops whenever my eyes get blurry and I used them yesterday. Review of Resident #4's physician orders revealed no orders for self-administration of medications. During an interview on 6/28/2024 at 9:55 AM, Staff A, Licensed Practical Nurse (LPN), verified that Systane eyedrops, baby powder and Arthricream cream were at the bedside and stated, No medications are supposed to be left at the bedside unless they have been approved by the physician and a self-administration form has been completed. [Resident #2's name] does not have any orders for eye drops and cannot self-administer medication. During an interview on 6/28/2024 at 10:57 PM, the Assistant Director of Nursing stated, Residents are not allowed to keep medications at bedside or self-administer medications unless the doctor has written an order for self-administration of medications and a self-administration evaluation has been completed. The Assistant Director of Nursing confirmed that Resident #2 and Resident #4 could not self-administer medications and had no orders or evaluation for self-administration of medications. During an interview on 6/28/2024 at 3:22 PM, the Director of Nursing (DON) stated, Medication cannot be stored at the bedside unless the resident has been cleared by the physician for self-administration of medication and an order obtained for self-administration of medication. [Resident #2 and Resident #4's names] are not allowed to self-administer medications and medications should not have been at the bedside. Review of the facility policy and procedure titled Self-Administration of Medication dated 6/21/2012 read, General guidelines: 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician/clinician.

Based on record review and interview, the facility failed to ensure residents received health care services in accordance with professional standards for 1 of 6 residents reviewed for unnecessary medications, Resident #20, and 1 of 4 residents sampled for oxygen therapy, Resident #18. Findings include: 1. Review of Resident #20's admission record showed the resident was initially admitted on [DATE] with the diagnoses that included type 2 diabetes mellitus without complications. Review of Resident #20's physician order dated 2/12/2024 reads, Insulin Glargine Solution 100 unit/ML [milliliters], Inject 15 unit subcutaneously one time a day for diabetes. Review of Resident #20's Medication Administration Record (MAR) for the period from 2/1/2024 through 2/29/2024 for administration of Insulin Glargine revealed the MAR was coded as 5 (Hold/See Nurses Notes) on 2/13/2024, 2/17/2024, 2/18/2024, and 2/19/2024, coded as 9 (Other/See Nurse Notes) on 2/16/2024, and as 2 (Drug Refused) on 2/25/2024, 2/26/2024, and 2/27/2024. Review of Resident #20's Medication Administration Record (MAR) for the period from 3/1/2024 through 3/12/2024 for administration of Insulin Glargine revealed the MAR was coded as 9 (Other/See Nurse Notes) on 3/2/2024, coded as 2 (Drug Refused) on 3/3/2024, 3/4/2024, 3/5/2024, 3/6/2024, 3/10/2024, 3/11/2024, and 3/12/2024, and coded as 5 (Hold/See Nurses Notes) on 3/9/2024. Review of Resident #20's nurses' progress notes for February 2024 and March 2024 revealed no documentation on Resident #20's physician notification or non-administration of Insulin Glargine. During an interview on 3/12/2024 at 12:53 PM, the Director of Nursing stated that the physician should be notified when medications were refused or not administered as ordered by the physician. During an interview on 3/13/2024 at 9:14 AM, when asked about notification of the status for administration of Resident #20's Insulin Glargine, Resident #20's physician stated, Nobody called me. During an interview on 3/13/2024 at 9:28 AM, the Director of Nursing stated she was unable to find documentation indicating Resident #20's physician had been notified when the medication was not given. She added that she would expect the medical doctor to be notified when a medication is not given if the physician had not specified parameters to hold the medication. Review of the facility policy and procedures titled Physician/Clinician/Family/Responsible Party Notification for Change in Condition, last reviewed on 3/11/2024, showed the policy read, Purpose: To ensure that medical/psychological care problems are communicated to the attending physician/clinician and family/resident representative in a timely, efficient, and effective manner . Policy: 1. The facility must immediately inform the resident; consult with the resident's physician/clinician; and notify, consistent with his or her authority, the resident representative(s) when there is . A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 45576 2. Review of Resident #18's admission record showed the resident was most recently admitted on [DATE] with the diagnoses that included chronic obstructive pulmonary disease, hypertensive heart disease, and chronic diastolic (congestive) heart failure. During an observation on 3/11/2024 at 1:11 PM, Resident #18 was receiving oxygen at 4 liters per minute via nasal cannula (NC). During an observation on 3/12/2024 at 9:42 AM, Resident #18 was receiving oxygen at 4 liters per minute via NC. During an interview on 3/13/2024 at 8:44 AM, Staff B, LPN, stated, There is no order for the oxygen. The oxygen should be set at 4 liters via Nasal Canula. During an interview on 3/13/2024 at 11:15 AM, the Director of Nursing stated, There are no orders for oxygen administration and the orders should have been written. Review of Resident #18's physician orders revealed no order written for oxygen administration. Review of Resident #18's care plan dated 2/29/2024 read, Focus: I have an alteration in my cardiac respiratory status related to heart failure, exacerbation of Chronic Obstructive Pulmonary Disease (COPD) . Goal: My respiratory status will be managed with care plan interventions. Interventions: I will have my oxygen saturation levels obtained as ordered and as needed. I will have the head of my bed elevated to facilitate my breathing due to shortness of breath . I will receive my respiratory medications as ordered and as needed . I will wear my oxygen via nasal cannula as ordered and indicated. Review of the facility policy and procedures titled Administrative Physician's orders last reviewed on 3/11/2024 read, 8. Verbal and Telephone orders will be documented as such in the Electronic Medical Record . All licensed nurses and QMA's [Qualified Medical Assistants] will follow physician orders.

Based on observation, interview, and record review, the facility failed to ensure residents were assessed by registered dietician and measures were put into place to maintain acceptable parameters of nutritional status to prevent weight loss for 1 of 4 residents reviewed for nutritional status, Resident #25. Findings include: Review of Resident #25's admission record showed that the resident was admitted on [DATE] with the diagnoses including fracture of T (thoracic) 9 through T10 vertebrae, fall on same level, repeated falls, urinary tract infection, paroxysmal atrial fibrillation (an irregular heartbeat), unspecified dementia, cognitive communication deficit, mixed receptive expressive language disorder, and essential primary hypertension. Review of Resident #25's weights and vitals summary showed the resident's weight as 230.8 pounds on 1/8/2024, 228.2 pounds on 1/22/2024, 224.6 pounds on 1/29/2024, 221.8 pounds on 2/7/2024, 217.6 pounds on 2/14/2024, 213 pounds on 3/7/2024, and 210.3 pounds on 3/13/2024. This is an 8.93% weight loss in 2 months. Review of Resident #25's mini nutritional assessment dated [DATE] showed a score of 10 (at risk of malnutrition). Review of Resident #25's progress notes dated 2/1/2024 read, Resident with stage 3 sacral wound, noted to be improving. Current nutrition interventions include: Prostat 30 ml [milliliters] 2x/day, Vit C [Vitamin C] and Zinc 1x/day, Has varied oral intake but overall average is > 50% with occasional refusals. Has 8.8 lb [pound] weight loss from 1/8/2024-1/29/2024. BMI [Body Mass Index] is in obese range. No new recommendations at this time. Review of Resident #25's medical record revealed no additional Registered Dietitian assessments. Review of Resident #25's task sheet for meals (food and fluid consumption) from 2/19/2024 through 3/13/2024 showed refusal for breakfast and lunch and 0-25% consumption for dinner on 2/19/2024; 0-25% consumption for breakfast, lunch, and dinner on 2/20/2024; 51-75% consumption for breakfast, 25-50% consumption for lunch, and 0-25% for dinner on 2/21/2024; refusal for breakfast and lunch, and 0-25% for dinner on 2/22/2024; 76-100% consumption for breakfast, 25-50% consumption for lunch, and 51-75% consumption for dinner on 2/23/2024; 51-75% consumption for breakfast, 75-100% consumption for lunch, and refusal for dinner on 2/24/2024; 51-75% consumption for breakfast, 76-100% consumption for dinner, and 0-25% consumption for dinner on 2/25/2024; 0-25% consumption for breakfast, lunch, and dinner on 2/26/2024; 25-50% consumption for breakfast and refusal for lunch and dinner on 2/27/2024; 25-50% consumption for breakfast and lunch and refusal for dinner on 2/28/2024; 25-50% consumption for breakfast, lunch, and dinner on 2/29/2024; refusal for breakfast and lunch and 0-25% consumption for dinner on 3/1/2024; 25-50% consumption for breakfast, lunch, and dinner on 3/2/2024; 0-25% consumption for breakfast, lunch, and dinner on 3/3/2024; 25-50% consumption for breakfast, lunch, and dinner on 3/4/2024; 25-50% consumption for breakfast, refusal for lunch, and 51-75% consumption for dinner on 3/5/2024; refusal for breakfast and lunch, and 51-75% consumption for dinner on 3/6/2024; 25-50% consumption for breakfast and lunch, and 0-25% consumption for dinner on 3/7/2024; refusal for breakfast and lunch, and 0-25% consumption for dinner on 3/8/2024; no documentation for breakfast and lunch, and 0-25% consumption for dinner on 3/9/2024; no documentation for breakfast and lunch, and 0-25% consumption for dinner on 3/10/2024; 75-100% consumption for breakfast and lunch, and refusal for dinner on 3/11/2024; refusal for breakfast and lunch, and 0-25% consumption for dinner on 3/12/2024; and refusal of breakfast and lunch on 3/13/2024. During an interview on 3/13/2024 at 2:35 PM, Staff C, Licensed Practical Nurse (LPN), stated, I had not been told that he [Resident #25] had been refusing meals. I should be told if they have a poor appetite or refuse meals. I don't work with him a lot. During an interview on 3/13/2024 at 2:31 PM, the Registered Dietician stated, I was not aware of his [Resident #25] weight decline. He has not been a subject in our weekly weight meetings, and I have no notes on him. I was not told about his meal refusals, and we have a nutritional risk meeting and look at weights. I did not look at the weights. I should have been notified about his poor intake and his meal refusals. We should have implemented something before today. During an interview on 3/13/2024 at 3:09 PM, the Director of Nursing (DON) stated, The CNAs [Certified Nursing Assistants] should be notifying the nurses if a resident is refusing meals, and they should notify the dietician and doctor. We have weekly meetings related to residents and weight loss. He [Resident #25] did have C diff. [Clostridioides difficile] and had a history of COVID, which could have affected his appetite and weights. But we did not implement any measures to address his weight loss. During an interview on 3/14/2024 at 8:30 AM, Staff C, LPN, stated, I was not aware that [Resident #25's name] was refusing meals. We should be told by the CNAs if they are eating less than 50% of the meals. We should notify the doctor, the dietician, and the residents representative. I don't see any documentation of that. During an interview on 3/14/2024 at 11:00 AM, the Medical Doctor (MD) stated, This is a significant weight loss, truly attributed to his use of antibiotics. But, I was not notified of his weight loss until today and if I had been, I would have put measures such as dietary supplements in place. I was not notified about his poor intake and meal refusals and should have been. Review of the facility policy and procedures titled Weight Monitoring with an implementation date of 11/29/2023 read, Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. This process includes: a. Identifying and assessing each resident's nutritional status and risk factors . c. Developing and consistently implementing pertinent approaches. d. Monitoring the effectiveness of interventions and revising them as necessary . 4. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. 5. A weight monitoring schedule will be developed upon admission for all residents . c. Residents with weight loss-monitor weight weekly . 6. Weight Analysis: The newly recorded weight should be compared to the previous weight. A significant change in weight is defined as: a. 5% weight change in 1 month (30 days), b. 7.5% weight change in 3 months (90 days) . 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions . e. The Registered Dietician or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 1 of 4 residents reviewed for respiratory care, Resident #19. Findings include: Review of Resident #19's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, seizures, essential primary hypertension, unspecified dementia, unspecified mood disorder, and anxiety disorder. Review of Resident #19's physician order dated 1/23/2024 read, Oxygen at 3 lpm [liters per minute] via nasal cannula continuous, every shift for COPD [Chronic Obstructive Pulmonary Disease]. During an observation on 3/11/2024 at 12:35 PM, Resident #19 was in bed, receiving oxygen from the concentrator via nasal cannula at 4 liters per minute. During an observation on 3/13/2024 at 7:46 AM, Resident #19 was in bed, receiving oxygen via nasal cannula at 4 liters per minute. During an observation on 3/13/2024 at 8:33 AM, Staff E, Certified Nursing Assistant (CNA), confirmed that the oxygen was running at 4 liters per minute and stated, I do not adjust or start oxygen. During an interview on 3/13/2024 at 8:35 AM, Staff F, Registered Nurse (RN), stated, Nurses should be checking what oxygen is running at when they administer medications. We should follow physician orders. During an interview on 3/13/2024 at 8:37 AM, Staff G, RN, stated, I gave medications already. I did not verify oxygen amounts. We should check them and follow physicians' orders for it. Review of the facility policy and procedure titled Oxygen Therapy with the last approval date of 3/11/2024 read, Policy: It is the policy of this facility to provide adequate oxygenation to residents with health conditions that require continuous or as needed oxygen therapy . Procedure: 1. Oxygen may be administered when it has been ordered by a physician or in emergency situations, by a licensed nurse/RT [Respiratory Therapist] . 3. The physician order will be written to include the liter flow and delivery device (i.e., nasal cannula, mask) as well as any other specific orders such as saturation levels that may be included . Oxygen Administration- Concentrator: 1. Verify physician order (except in emergency).

Based on record review and interview, the facility failed to ensure residents were from unnecessary medications for 1 of 3 residents reviewed for urinary tract infections, Resident #209. Findings include: Review of Resident #209's admission record showed the resident was most recently admitted on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur, fall, essential primary hypertension, chronic obstructive pulmonary disease, acute kidney failure, diverticulosis, and cognitive communication deficit. Review of Resident #209's interact SBAR (Situation, Background, Assessment, Recommendation) dated 3/8/2024 at 4:45 PM read, Nursing observations, evaluation and recommendations are: Resident expressed feelings of hopelessness and sadness. Resident states she is having PTSD [post-traumatic stress disorder] from experiencing 09/11. MD [Medical Doctor] contact and psych [psychiatric] consult ordered, every 15 minute checks initiated, and UA to be collected. Resident daughter [Resident #209's daughter's Name] called and explained resident is prone to UTIs [urinary tract infections] and believes behavior could be related to UTI. Review of Resident #209's physician order dated 3/8/2024 read, U/A [urinalysis], Urine C&S [culture and sensitivity].- Review of Resident #209's physician order dated 3/9/2024 read, Ciprofloxacin HCL [hydrochloride] 500 mg tab [tablet] (100 EA), Give 1 tablet every 12 hours for UTI for 5 days. Review of Resident #209's urinalysis lab results report with the final report date of 3/10/2024 showed no growth at 24 hours. Review of Resident #209's Medication Administration Record (MAR) showed Resident #209 was receiving Ciprofloxacin 500 mg every 12 hours from 3/9/2024 through 3/13/2024. During an interview on 3/13/2024 at 9:53 AM, Staff C, Licensed Pracctical Nurse (LPN), stated, I was not aware that her culture came back negative. I will need to call and make sure that it [Ciprofloxacin] is needed as she had no symptoms of a UTI. We should have called when we first got the negative urine culture. During an interview on 3/13/2024 at 10:00 AM, the Medical Doctor (MD) stated, I was not told that the culture results were negative. I would have discontinued the antibiotic as soon as I was told. It would be considered not needed because she does not have a UTI. This was started prophylactically when her daughter told staff she can get tearful and sad when she has a urinary tract infection, but once determined that she did not have a UTI, we should have discontinued this medication. During an interview on 3/13/2024 at 11:22 AM, Staff F, Registered Nurse (RN), stated, Typically, it is the nurses' responsibility to notify the physician of the culture results and they [the physician] will make the determination of whether a resident would stay on the antibiotic. I have her on the log [the infection control log] for March as a community acquired UTI. This was within 24 hours of admission. I cannot answer if I was told about the culture result or not. I just don't remember. It [the culture results] should have been followed up on, either by myself or the nurse. Review of the facility policy and procedure titled, Antibiotic Stewardship Program with an implementation date of 11/1/2023 read, Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Policy Explanation and Compliance Guidelines . 4. The program includes antibiotic use protocols and a system to monitor antibiotic use . b. Monitoring antibiotic use: i. Monitor response to antibiotics, laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out) . 5. Nursing will monitor the initiation of antibiotics on residents and conduct an antibiotic timeout within 48-72 hours of antibiotic therapy to monitor response to the antibiotic and review laboratory results and will consult with the practitioner to determine if the antibiotic is to continue or if adjustments need to be made based on the findings.

Based on observation, interview, and record review, the facility failed to ensure medications were securely stored in 1 of 6 residential halls, Hall 500. Findings include: During an observation on 3/11/2024 at 9:52 AM, Resident #101 was in her room. There were one container of eye drops and single doses of eye lubricant stored on Resident #101's bedside table. During an interview on 3/11/2024 at 9:52 AM, Resident #101 stated that the items stored on her bedside table were her over-the-counter eye medications. Review of Resident #101's physician orders revealed an order with the start date of 2/13/2024 for administration of one drop of Xalatan Ophthalmic Solution 0.005% in both eyes at bedtime for dry eyes. Review of Resident #101's care plan initiated on 2/14/2024 revealed no focus on self-administration of medications. During an interview on 3/13/2024 at 9:04 AM, Staff A, Licensed Practical Nurse (LPN), stated, The facility completes a self-administration of medication assessment of a resident and obtains an order from the physician before a resident is able to self-administer medications. Staff A confirmed the facility had not completed a self-administration of medication assessment with Resident #101. During an observation on 3/11/2024 at 9:42 AM, Resident #20 was in his room lying in bed. There was a nasal spray pump stored in a tissue box on Resident #20's bedside table. There was no nurse or other facility staff present in Resident #20's room. During an interview on 3/11/2024 at 9:42 AM, Resident #20 stated the nasal spray pump contained his over-the-counter nasal spray. Review of Resident #20's physician orders revealed an order with the start date of 2/9/2024 for administration of 2 sprays of allergy relief nasal suspension 50 micrograms in both nostrils one time a day for allergies. Review of Resident #20's care plan initiated on 12/12/2023 revealed no focus on self-administration of medications. During an interview on 3/13/2024 at 9:06 AM, Staff A, LPN, stated, that Resident #20 did not have an assessment for self-administration of medication. During an interview on 3/13/2024 at 9:28 AM, the Director of Nursing stated, Usually, the facility contacts the physician to see if the doctor is okay with that [self-administration of medications]. The facility will have the medical doctor write an order for self-administration if the facility obtained physician's approval for a resident to self-administer medications. Review of the facility policy and procedure titled Self-Administration of Medication, last reviewed on 3/11/2024, showed the policy read, General Guidelines: 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician/clinician. 2. Should the resident's attending physician/clinician permit the resident to administer his/her medication(s), the following condition should apply: a. A self-administration of medications evaluation will be completed that indicates that the resident is capable of self-administering drugs. This is to be completed quarterly and as needed with resident cognition or physical ability changes. b. Storage of medications in the resident's room must be such that it will prevent access by other residents; c. Only the medications permitted for self-administration shall be left at the bedside. Review of the facility policy and procedure titled Guidelines for Medication Storage and Labeling, last reviewed on 3/11/2024, showed the policy read, Purpose: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview and record review, the facility failed to adhere to professional standards of infection Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration to help prevent the possible transmission of infections and communicable diseases during 3 of 7 observations of medication administration. Findings include: During an observation of medication administration on 3/13/2024 at 7:59 AM, Staff C, Licensed Practical Nurse (LPN), began preparing Resident #219's medications without performing hand hygiene. Staff C poured three medications into a medication cup. Then, Staff C removed one medication, which was not able to be crushed, with his bare hand and placed it in a different medication cup. Staff C crushed the medications and added the whole medication and mixed with applesauce. Staff C entered Resident #219's room and administered the medications. Staff C exited Resident #219's room and returned to the medication cart. At 8:07 AM, Staff C began preparing Resident #209's medications. Staff C entered Resident #209's room and administered the medications. Resident #209 dropped a medication on her chest and Staff C picked up the medication and placed it in the resident's mouth. After Resident #209 completed taking medications, Staff C exited the room and returned to the medication cart. At 8:15 AM, Staff C prepared Resident #25's medications, entered Resident #25's room, and administered the medications. Staff C did not perform hand hygiene during the medication administration. During an interview on 3/13/2024 at 10:30 AM, Staff C, LPN, stated, I thought I did use hand sanitizer. We should always use hand sanitizer when we do medications. I didn't realize I touched the medications. I should not have touched them. During an interview on 3/13/2024 at 3:24 PM, the Director of Nursing stated, All staff should follow infection control standards at all times. Review of the facility policy and procedures titled Medication Administration with an implementation date of 11/1/2023 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines . 4. Wash hands prior to administering medication per facility protocol and product . 13. Remove medication from source, taking care not to touch medication with bare hand . 15. Observe resident consumption of medication. 16. Wash hands using facility protocol and product. Review of the facility policy and procedures titled, Hand hygiene with an implementation date of 11/1/2023 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . Hand Hygiene Table . Between resident contacts . Before preparing or handling medications.

Based on observation, record review, and interview, the facility failed to ensure medication orders were obtained according to professional standard of quality for 1 of 6 residents reviewed for unnecessary medications, Resident #80. Findings include: Review of Resident #80's admission record showed the resident was most recently admitted on [DATE] with the diagnoses that included urinary tract infection, orthostatic hypotension, and heart failure. Review of Resident #80's physician order dated 3/3/2024 read, Midodrine HCL [hydrochloride] 5 mg [milligram] tablet (100 EA), Give 1 tablet by mouth every 8 hours as needed for hypothyroidism. During an interview on 3/14/2024 at 9:19 AM, Staff H, Licensed Practical Nurse (LPN), stated, The physician order written for Midodrine HCL tablet 5 mg is wrong. It is not given as needed for hypothyroidism. Midodrine is written for low blood pressure and with parameters. During an interview on 3/14/2024 at 11:19 AM, the Medical Doctor stated that the order for Midodrine HCL tablet 5 mg should have been written as needed for hypotension for systolic less than 110 not for hypothyroidism. During an interview on 3/14/2024 at 12:02 PM, the Director of Nursing stated, The order was written wrong. The nurse needs to read back the order if provided on the phone or transcribed. Then, the physician orders are to be checked with another nurse to prevent medication errors.

Based on record review and interview the facility failed to complete and submit a federal report of alleged staff abuse for 1 of 3 residents, Resident #10, reviewed for reportable incidents. Findings include: Record review of Resident #10's investigation records revealed Resident #10 made an allegation on 5/24/2023 that Staff A, Certified Nursing Assistant, rolled her to her side and pushed on her nephrostomy tubes causing her to say ouch. Record review of additional facility investigation documentation, incident date 5/24/2023, showed the investigation was initiated as An event that is reported to law enforcement or it's personnel for investigation. Record review of facility investigation documentation related to the incident involving Resident #10 failed to reveal documentation that showed the facility had completed and submitted federal reports following the allegation. During and interview on 8/3/2023 at 11:03 AM, the Executive Director confirmed the facility had not completed and submitted federal reports following Resident #10's allegation of mistreatment by Staff A. Record review of the facility policy titled Abuse, Neglect and Misappropriation of Resident Property, last reviewed 12/31/2022, showed the policy read 9. When incidents involving injury of unknown origin, suspected abuse, neglect or mistreatment are reported, the facility shall take the following steps: d. Report all alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property immediately but not later than 2 hours. B. If resident sustains injury by an employee or employee is a suspected perpetrator: b. Staff is to notify Administrator immediately of situation, and he/she or designee, must conduct a thorough investigation including interview with employee and resident immediately. This will be reported to appropriate agencies within 2 hours. 12. The results of all investigations will be reported to the Administrator and to other officials in accordance with the law within five (5) working days of the incident.

Based on observation, interview, and record review, the facility failed to ensure 2 of 2 residents who were fed by enteral means, Residents #181 and #183, received properly labeled enteral feeding bag with date, time, and initials of nurse. Findings include: 1. During an observation on 11/1/2022 at 8:15 AM, Resident #183 was frail, eyes closed with a pale complexion and tube fed with [MEDICATION(S)] 1.5. The formula was hung in a clear Enteral Feeding Bag and pump was running at 60 milliliters (ml) per hour (ml/hr). The bag contained approximately 800 ml of formula. The formula appeared thick and lumpy, with cottage cheese like appearance and consistency. The label on the feeding bag was torn and the date, time or nurses' initials of when the formula was hung were not legible (Photographic evidence obtained). During an interview on 11/1/2022 at 8:19 AM, Staff K, Licensed Practical Nurse (LPN), stated, I rounded on my resident this AM and I did not find any concerns. The residents that are tube fed reported no discomfort. Staff K was not able to identify the formula being thick and lumpy, with cottage cheese like appearance and consistency. Staff K stated the label was torn and the bag appeared dirty. During an interview on 11/1/2022 at 8:25 AM, the Director of Nursing (DON) stated the formula bag should have a label and appeared thick. Review of Resident #183's medical records revealed the resident was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #183's physician orders reads, Nothing by mouth (NPO) diet NPO Texture. Order Date: 10/19/2022 . [MEDICATION(S)] 1.5 at 60 ml/hr continuous every shift. Order Date: 10/27/2022. 2. During an observation on 11/1/2022 at 8:35 AM, Resident #181 was in bed, holding his stomach and frowning. The resident was tube being fed with [MEDICATION(S)] 1.5. The formula was hung in a clear Enteral Feeding Bag and pump was running at 80 ml/hr. The bag contained approximately 600 ml. The formula appeared thick and lumpy, with cottage cheese like appearance and consistency. The label on the feeding bag was torn and the date, time or nurses' initials of when the formula was hung were not legible (Photographic evidence obtained). During an interview on 11/1/2022 at 8:35 AM, Resident #181 stated he had a stomachache and was nauseated not feeling well at all. During an observation on 11/1/2022 at approximately 8:40 AM, the Assistant Director of Nursing (ADON) arrived in Resident #181's room and looked at the formula and turned off the feeding pump. During an interview on 11/1/2022 at 8:40 AM, the ADON stated this looked the same as the other formula for Resident #183. Review of Resident #181's medical records revealed the resident was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #181's physician order reads, [MEDICATION(S)] 1.5 cal/Fiber at 80 ml/hr continuous every shift for Enteral Feeding. Review of the facility policy and procedures titled Gastric Tube Feeding Via Continuous Pump last revised in 1/2019, reads, Purpose: To provide nourishment to the resident who is unable to obtain nourishment orally . Procedure: - Label the enteral feeding bag/bottle with date, time, rate and initials of the nurse.

Based on observation, interview, and record review, the facility failed to ensure residents who use [CONDITION(S)] drugs received behavioral interventions for 3 of 3 reviewed residents, Residents #5, #56, and #70, in a total sample of 39 residents. Findings include: 1. Review of Resident #70's medical records revealed the resident was admitted on [DATE] with the diagnoses including [CONDITION(S)], dementia with other behavioral disturbance, paranoid personality disorder, and personal history of [CONDITION(S)]. Review of Resident #70's Medication Administration Record (MAR) revealed the resident was receiving [MEDICATION(S)] 0.25 mg [milligrams] for anxiety, [MEDICATION(S)] for depression, and [MEDICATION(S)] 1 mg at bedtime, and 0.5 mg daily for agitation. Review of Resident #70's care plan reads, Focus: I have a risk for side effects related to the use of [CONDITION(S)] meds. Further review of the care plan did not reveal an intervention to monitor the resident's behavior while receiving [CONDITION(S)] medications. During an interview on 10/31/2022 at 2:15 PM, Staff J, Certified Nursing Assistant (CNA), stated, Approximately 4-5 PM, she has a severe sun downing, where she gets out of her room, wanders in hallway looking for her daughter. She does not remember that her daughter visited her today. I do not see her cry. She can get feisty but not aggressive. During an interview on 11/1/2022 at 10:33 AM, the Regional Nurse Consultant stated, There must be a way for the nurses to document behavior and is just showing a check mark, and record shows Y for yes and N for no. I will check further with IT [Information Technology]. During an interview on 11/1/2022 at 2:30 PM with Staff H, Licensed Practical Nurse (LPN), when asked how she monitored the behavior of a resident who was receiving an antipsychotic, anxiolytic and hypnotic drugs, she stated, In the MAR, we are supposed to write Yes or No, but the computer is not showing that. There is a separate option that we need to add to monitor for behaviors. [Resident #70's name] MAR did not show to monitor for behaviors, and I know as reported to me that she has behavior issues in the evening. 2. During an observation on 10/30/2022 at 9:15 AM, Resident #56 was in bed with flat affect and did not want to engage in conversation. During an observation on 10/31/2022 at 8:16 AM, Resident #56 was in bed and did not want to engage in conversation. During an interview on 10/31/2022 at 8:16 AM, Resident #56 stated she did not want to engage in activity and preferred to stay in room. Review of Resident #56's medical records revealed the resident was admitted on [DATE] with diagnoses including adjustment disorder with depressed mood and depression. Review of Resident #56's physician orders dated 9/21/2022 reads, [MEDICATION(S)] Oral Tablet ([MEDICATION(S)]) Give 10 mg by mouth one time a day for depression. Review of Resident #56's Minimum Data Set (MDS) dated [DATE] revealed Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive response). Review of Section D- Mood revealed total severity score of 12 (moderate depression). Review of Resident #56's physician orders dated 10/20/2022 reads, [MEDICATION(S)] Oral Tablet 2 MG ([MEDICATION(S)]) Give 1 tablet one time a day for depression. Review of Resident #56's MAR for September and October 2022 revealed the resident received [MEDICATION(S)] 5 mg oral tablet at 9 AM on 9/22/22 through 9/24/22 and [MEDICATION(S)] 10 mg oral tablet at 9 AM from 9/26/2022 through 10/31/2022. Further review of the MAR and TAR for the months of September 2022 and October 2022 revealed no monitoring for mood and behavior documented. Review of Resident #56's care plan reads, Focus: I have a risk for side effects related to the use of antidepressants. The interventions of the care plan did not include behavior monitoring. During an interview on 10/31/2022 at 2:35 PM, the Director of Nursing (DON) stated, It is the admitting nurse's responsibility for putting the orders for monitoring behavior and mood once the resident has diagnosis and medication for depression. I expect the nurses to monitor and document mood and behavior. 3. Review of Resident #5's medical records revealed the resident was admitted on [DATE] with the diagnoses including anxiety disorder, major depressive disorder, and dementia. Review of Resident #5's physician orders dated 8/13/2022 reads, [MEDICATION(S)] Oral Tablet Delayed Release 125 MG ([MEDICATION(S)]) Give 1 tablet by mouth two times a day for anxiety . [MEDICATION(S)] Oral Tablet 50 MG Give 1 tablet by mouth at bedtime for behaviors . [MEDICATION(S)] Oral Tablet 50 MG ([MEDICATION(S)]) Give 1 tablet by mouth one time a day for anxiety. Review of Resident #5's physician orders dated 8/17/2022 reads, [MEDICATION(S)] HCl Oral Tablet 10 MG ([MEDICATION(S)] HCl) Give 1 mg by mouth every 12 hours for Agitation . [MEDICATION(S)] Oral Capsule 1.5 MG ([MEDICATION(S)]) Give 1 capsule by mouth every 12 hours for Agitation. Review of Resident #5's order summary report on 11/1/2022 at 11:00 AM revealed no physician orders for monitoring behaviors for resident. Review of Resident #5's Treatment Administration Record for October 2022 revealed no documentation of behavioral monitoring. Review of Resident #5's care plan dated 9/16/2022 reads, Focus: I have a risk for side effects related to the use of [CONDITION(S)] meds [medications]. Further review of the care plan did not reveal an intervention to monitor the resident's behavior while receiving [CONDITION(S)] medications. During an interview on 11/2/2022 at 7:45 AM, Staff C, Registered Nurse (RN), Unit Manager, stated, When residents are on [CONDITION(S)] medication, we monitor for all side effects and signs of behaviors. Normally we will have an order by the doctor, and we will be able to input the information on the TAR [Treatment Administration Record]. We are able to mark No or Yes. If it is Yes, we can then write notes regarding observations. During an interview on 11/2/2022 at 9:45 AM, the Director of Nursing (DON) stated, We were monitoring behaviors, but she went out to the hospital, and I guess the order fell out. Review of the facility policy and procedures titled Psychoactive Medications/ Gradual Dose Reduction (GDR)/ Unnecessary Medications Policy last revised in 10/2022, reads, Procedure . 3. Residents receiving psychoactive medications will have a care plan initiated that contains resident diagnosis and interventions regarding the target behaviors and possible adverse side effects of the medication(s). 4. Nursing will observe for adverse side effects of psychoactive medications every shift and document on the electronic MAR.