Every finding on record at Park Place Christian Community

Based on observation, interview, and record review, the facility failed to label/date/seal/store food items, remove expired items, and sanitize the food preparation counter in the facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 36 residents. On [DATE] at 11:00 AM, V4 (Director of Dining Services) said all 36 residents eat from the facility kitchen. 1. On [DATE] at 10:58 AM, V4 (Director of Dining Services) was asked to test the sanitation bucket in the kitchen prep area. V4 picked the bucket of sanitizer solution up from the floor, placed it on the preparation counter next to cook who was prepping desserts, and V4 tested strip. V4 then removed the sanitizer solution bucket from the prep counter and placed it back on the floor and walked away. V4 then returned to the prep area and waited for surveyor to continue kitchen tour. Surveyor then had to ask V4 to sanitize the prep counter where he had placed the sanitizer bucket from the floor. On [DATE] at 12:28 PM, V4 said the food preparation counter should be sanitized after a bucket from the floor is placed on it to minimize the chance of bacteria from counter contaminating food items. The facility's policy titled, Cleanliness and Sanitation of Service Areas last reviewed ,d+[DATE] states, Policy: The cleanliness and sanitation of the serving area is to be maintained . Procedures: .The Dining Services Manager/designee will: 1. Monitor employees to ensure that the meal serving area is properly maintained and all foods are served safely . 2. On [DATE] starting at 10:09 AM, the facility kitchen was toured in the presence of V4 and the following was found: In walk-in cooler: a. Medium sized silver bin of crab salad, no label or date b. Small silver bin of tomato paste with expiration date of [DATE]; expired. c. Small silver bin of ground beef, no label or date. d. Small silver bin labeled straw (strawberry) with expiration date [DATE]; expired. e. A large shallow tray of 18 leftover sausage links, uncovered and sitting in a thick white congealed substance. f. A large tray of leftover prime rib, not sealed, with multiple small remnants of beef in bottom of tray with thick white congealed substance surrounding. In roll-in prep cooler: g. 2 bags of meat, unlabeled and undated. h. A small silver bin of crab salad dated [DATE] good through [DATE]. V4 was asked how long prepared salads are good in the refrigerator for and he said 3 days; crab salad was labeled wrong. In reach-in freezer: i. Five pies, unlabeled, undated, and uncovered. j. Medium sized bin with 5 salmon filets, unlabeled and undated. In dry storage: k. A 25 pound box with bag of semisweet chocolate chips, not sealed and open to air. V4 said the bag being open was risk for contamination. l. A 10 pound box with a bag of graham crumbs, not sealed and open to air. In walk-in produce cooler: m. A medium tray of diced mushrooms, unlabeled and undated. In dairy cooler: n. A 32 ounce carton of heavy whipping cream left opened, not sealed. On [DATE] at 12:28 PM, V4 said all food items in the kitchen should be labeled and dated to make sure they are not serving the residents food that will make them sick. V4 said all opened and leftover food items should be sealed/covered to prevent contamination and foodborne illness. V4 said prepared salads, such as crab salad, is only good for 3 days and there is potential for resident illness if served after 3 days. V4 said expired food items should be removed from food storage as soon as they expire so the kitchen staff doesn't accidentally serve the expired food item and cause resident illness. The facility's policy titled, Food Storage Expiration Dates last reviewed ,d+[DATE] states, Policy: All opened food that is placed into storage shall be labeled with the product name, date opened and/or expiration, or use-by date . Procedures: Foods that expire 3 days after opening: leftover foods, prepared salads . The facility's policy titled, Storage last reviewed ,d+[DATE] states, Policy: All food, chemicals and supplies should be stored in a manner that ensures quality and maximizes safety of the food served .Procedures: .7. Store food in original container if the container is clean, dry and intact. If necessary, repackage food in clean, well-labeled containers using food storage label .Storeroom Sanitation: .2. Dispose of items that are beyond the expiration or use-by dates .

Based on observations, interviews, and record reviews, the facility failed to mitigate the risk of cross contamination during resident care and during handling of soiled clothing/materials. This failure applies to 4 of 4 residents (R24, R16, R84, R8) reviewed for hand hygiene, and all 36 residents in the facility for soiled linen handling. The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 4/23/25 documents that the total census was 36 residents. The findings include: 1. On 04/24/25 at 09:17 AM, V3 (Wound Nurse) and V9 (Nurse) were providing wound care and incontinence care for R24. R24 had a pressure wound to his left gluteal fold. V9 pushed a garbage can toward V3 with her foot. V3 used her right hand and picked up the garbage can and placed the can next to her. V3 then with her unclean gloved hands opens R24's brief and then touches R24's pressure wound spreading the wound open to examine the wound. V3 described the wound drainage and discarded her gloves in the garbage can, cleaned her hands, put on new gloves and provided wound care. After providing wound care the nurses provided incontinence care for R24 because R24 urinated and had a bowel movement while they were providing wound care. After V3 had cleaned stool from R24's buttocks, she removed her gloves, cleaned her hands put on new gloves. V3 pushed a clean brief under R24 and then tucked the soiled brief under R24, then removed the soiled brief. After handling the soiled brief and without changing her gloves or performing hand hygeine, V3 turned R24 in his bed, finished attaching the clean brief, repositioned R24 in the bed, adjusted R24's gown, pulled R24's linen on him, and then adjusted a towel that was placed under R24 chin. On 04/24/25 at 09:45 AM, V3 said that she should not have touched the wound with the gloved hands after she picked up the garbage can to prevent cross-contamination. V3 said that after removing the soiled brief, she should have removed her gloves, cleaned her hands, and put on new gloves to prevent infections. On 04/24/25 at 10:25 AM, V2 (DON) said that V3 should have taken her gloves off and performed hand hygiene and then put new gloves on after picking up the garbage can and before touching the wound for infection control. V2 said that V3 should have removed her gloves and cleaned her hands and put on new gloves after touching the soiled brief before touching clean areas for infection control. The facility's Infection Control Nursing Procedures, Subject: Hand Washing (reviewed date 12/24) showed the purpose of hand washing is considered one of the most effective infection control measures. Frequency: after handling any contaminated items, after contact with inanimate objects or immediate vicinity of a client, before and after contact with a client's intact skin, during client care, after accidental contact with any bodily fluids, mucous membranes, non intact skin or wound dressings, if hands will be moving from a contaminated body site to a clean body site, during client care, before and after using gloves, handling food, client care, and in food service . 2. On 04/23/25 at 12:08 PM, V8 CNA (Certified Nurse's Assistant) was feeding R24 with her right-hand 2 spoonsful of a red drink, the drink had been thickened. Then V8 goes to R16 and starts to feed R16 using her right hand. V8 gave R16 a spoonful of mashed potatoes then a drink, still using her right hand, then gives her a spoonful of a green pureed substance again with her right hand. V8 did not clean her hands between feeding R24 and R16. 3. On 04/23/25 at 12:12 PM, V9 (Nurse) was sitting at a table between R24 and R84 feeding R24 and R84 using her right hand for both residents. V9 did not clean her hands in-between feeding them. V9 using her right hand gave R24 a spoonful of brown pureed food then put a spoonful of green pureed food into R84's mouth, then back to R24 and gave R24 another spoonful of brown pureed food, only using her right hand. V9 used her right hand again to give R84 a drink of a red liquid, and then gave R24 a spoonful of a red thickened drink. V9 did not clean her hands in between feeding the residents. On 04/24/25 at 10:17 AM, V2 DON (Director of Nursing) said that the staff should have cleaned their hands when going from one resident to another. V2 said that this should be done for infection control and cross-contamination. 4. On 04/24/25 at 10:41 AM - 11:14 AM, a tour of the laundry room was conducted with V2 Director of Nursing (DON) present. There were two 50-gallon containers with soiled mop heads and other cleaning items in it and the containers did not have lids on them waiting to be washed. There was an open bag of soiled clothing on the floor by the washing machines. V2 (DON) said that the 50-gallon container should have a lid to contain bacteria and the soiled clothing on the floor should not be there because there is a potential for spreading bacteria, it can get on staff's shoes and then they go out on the floor and spread the bacteria on the floor. Then at 11:06 AM, during the tour of the laundry room, V6 (Housekeeper) brings an open bag of dirty clothing protectors in and drops it on the floor in front of the washing machines. The facility's Soiled Laundry Transport policy dated review date 4/2025 showed soiled linens are to be transported to laundry area in a secure manner. While in laundry room, secure the cover to the soil laundry cart. Place the soiled laundry into a cart or switch with empty cart and immediately re-secure the lid to the cart. 46003 5. On 04/24/25 at 12:55 PM, V11 and V12 (CNAs-Certified Nursing Assistant) assisted during R8's incontinence care. With gloved hands, V11 and V12 removed R8's pants and soiled disposable undergarment. V11 wiped R8's vaginal area with gloved hands, then removed the soiled gloves and retrieved more gloves from a box on the wall and placed them in her right shirt pocket. V11 put on a new pair of gloves and wiped R8's rectum. V11 removed her gloves, washed her hands, and put a new pair of gloves on, and placed a clean disposable brief under R8. V11 took A and D ointment from a jar and applied to R8's vaginal area with her right gloved hand. V11 removed that glove and put on a glove she took from her right shirt pocket. V11 then applied A and D ointment on R8's buttocks and rectum, removed the soiled gloves, and put on gloves from her shirt pocket. V11 and V12 then fastened R8's brief and assisted her to position in bed. V11 and V12 both removed their gloves. V12 then put another pair of gloves on to close R8's window blinds. On 04/24/25 at 01:17 PM, V11 CNA stated she cleans her hands prior to providing care but does not need to clean her hands every time she removes her gloves only when placing a new disposable brief. On 04/24/25 at 03:23 PM, V2 DON (Director of Nursing) stated improper hand hygiene during incontinence care can contribute to the development of urinary tract infections.

Based on observation, interview, and record review, the facility failed to ensure that resident medications were secured. This applies to 6 of 6 residents (R1, R8, R9, R15, R23 and R24) reviewed for medication storage in a sample of 15. Findings include: 1. On 04/23/25 at 10:23 AM, located on the over bed table, R8 had a bottle of chlorpheniramine maleate 4mg (milligram) 100 count bottle, two 1 fl oz (fluid ounce) bottles of Sodium Carboxymethylcellulose, one bottle of Ketotifen fumarate 10ml (milliliter), one bottle of povidone 0.33 fl oz, and one 12 oz bottle of aluminum hydroxide / magnesium hydroxide / simethicone. R8 stated she uses the eye drops at night when her eyes are dry. V8 stated she takes a teaspoon of the aluminum hydroxide / magnesium hydroxide / simethicone before she eats, when she has acid reflux, or heart burn. V8 stated she has acid reflux or heart burn quite often. V8 stated the medications are just over the counter. V8 stated the medications have always been sitting out and the staff never asked her about them or said she couldn't have them or said they needed to be put away. The facility policy Medication Administration dated 5/9/2023 states medications are prepared and administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The medication storage is locked whenever unattended . 2. On 04/23/25 at 11:01 AM, R23 had nystatin 15gm (gram) bottle and miconazole nitrate 3 oz on his nightstand. On 04/23/25 at 11:35 AM, R23 stated the facility staff placed the creams and powders in his room. R23 stated he does not apply any of the items on himself. On 04/23/25 at 12:02 PM, V2 DON (Director of Nursing) stated they were unaware of R8 and R23 having medications at their bedside. On 04/24/25 at 09:09 AM, R23 had two 2.5 oz tubes of miconazole nitrate ointment and on bottle of miconazole nitrate powder 3 oz on his nightstand. V13 RN (Registered Nurse) stated R23's daughter requested they be left at the bedside, but the medications should still be secured. 48944 3. On 4/23/2025 at 10:45 AM, R9 was in bed. R9's bedside table had unsecured bottles of Tylenol (acetaminophen) 500mg (milligram) tablets and Systane eye drops. R9's Tylenol and Systane medications were filled and open. R9 said she had brought the medications from home for her personal use. On 4/24/2025 at 11:40 AM, V2 (DON) said R9's medications should have been properly secured in a locked drawer in her room to ensure the safety of other residents. R9's Order Summary Report dated 4/24/2025 had active orders for Systane Ophthalmic Solution 0.4-0.3% for 1 drop to both eyes two times a day and Tylenol Extra Strength 500 MG give 1 tablet by mouth every 6 hours as needed for pain. The orders indicated R9's medications could be self-administered and kept at the bedside. The facility policy Medication-Self Administration states medication for self-administration will be stored in the medication cart and will be placed in appropriate medication cups and brought to the resident by the licensed nurse for resident administration. If the resident requests medication to be left in the room, a locked, permanently affixed box in the resident room must be provided for this purpose. 41384 4. On 04/23/25 at 11:36 AM, there was 1 bottle of antifungal powder on R1's bedside table, and 1 unopened vial of albuterol sulfate 2.5mg/3ml next to the nebulizing machine in a portable shelving unit. R1's 11/13/24 physician's order showed Albuterol Sulfate inhalation Nebulization Solution (2.5 MG/3ML) 0,083% (Albuterol Sulfate) 3ml inhale orally via nebulizer every 6 hours as needed for wheezing. On 4/24/25 a review of R1's physician's orders did not show an order for antifungal powder. On 04/24/25 at 10:21 AM, V2 Director of Nursing (DON) said the reasons that medications should not be in the residents' rooms are for safety issues, someone else can use the medication and there is a risk of double dosing the medications or a drug interacting with other medications that are being given. 5. 04/23/25 at 11:48 AM, one 3 oz. bottle of antifungal powder was on R15's over the bedside table. R15's 3/23/25 physician's order showed Miconazole External Powder 2% (Antifungal powder) apply to groin and folds as needed for itching (rash/redness) 6. On 04/23/25 at 11:13 AM, there was 1 bottle of medicated shampoo in R24's bathroom. R24's 3/25/24 physician's orders showed Ketoconazole External Shampoo 2%. Apply to scalp topically in the morning every Tuesday and Friday for Seborrheic Dermatitis.

Based on observation, interview and record review, the facility failed to treat residents with dignity while providing care. This applies to 2 of 2 residents (R24 and R16) reviewed for dignity in a sample of 15. The findings include: On 04/23/25 at 12:08 PM, V8 CNA (Certified Nurses' Assistant) was standing over R24 feeding him spoonsful of a red thickened drink. V8 then went to another table and stood over R16 feeding her mashed potatoes, a green pureed food, and gave her a drink of a red liquid. On 04/24/25 at 10:17 AM, V2 DON (Director of Nursing) said that staff should be sitting while feeding residents to have a better visual observation of the resident and for the resident's dignity. The facility's Resident Rights and Responsibilities - Exhibit D policy (no dated shown) showed, These resident rights, policies and procedures ensure that each resident has a right to a dignified experience, self-determination and communication with the access to persons and services inside and outside the facility.

Based on interview and record review, the facility failed to safely transfer a resident during toileting when a gait belt was not used, and required assistance was not provided. This failure resulted in R1 sustaining an acute comminuted fracture of the left femur due to a fall incident occurred during direct care. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: The EMR (Electronic Medical Record) showed R1, a 92-year -old with diagnoses includes dementia, depression, osteopenia, osteoarthritis, stroke, history of breast cancer and pulmonary embolism. R1's surgical history includes right knee replacement. R1 was Covid positive on August 4,2024. R1 was originally admitted to the MMC (Memory Care Center) in the facility on October 11, 2019. R1 was transferred to the skilled section in the facility on September 3, 2024. due to declining condition, multiple falls, and weakness. The incident report log showed R1 had 2 falls for 2 weeks period. The incident report dated September 7, 2024 at 4:40 P.M., showed R1 ended up on the bathroom floor when R1 was getting off the toilet and slid down. The incident report dated September 16, 2024 at 2:00 P.M., showed during toilet assistance by V3 (CNA/Certified Nurse Assistant), R1's was assisted to the floor because R1's knees buckled up during the toilet/transfer assistance. This incident showed R1 had complained of pain to the left lower extremity after the fall. An x-ray was done on same day, with result of acute comminuted impacted supracondylar fracture of the left femur. The progress notes dated 9/16/2024 showed R1 was sent out to the hospital and was admitted due to fracture. On September 20,2024 at 12:14 P.M., V2 (Director of Nursing) said R1's fall on September 7, 2024 was because R1 was left alone in the bathroom as the CNA provided privacy to R1. V2 added R1's fall on September 16,2024 happened when V3 assisted R1 to the toilet, then R1 got weak, and legs buckled up. V2 said V3 assisted R1 to the floor. V2 added R1 then complained of left knee pain after the fall and x-ray was done. V2 said x-ray showed an acute fracture of R1's left femur. On September 20/2024 at 11:15 A.M., V4 (Registered Nurse) said he was the assigned nurse when R1 had a fall on September 16, 2024. V4 said he had also taken care of R1 when R1 was at the MMC. V4 said R1 was transferred to the skilled unit on September 3, 2024 due to R1's decline in level of functioning, was weak due to post Covid infection (August 4,2024). V4 said R1 had been falling at the MMC almost every other day and was then moved to skilled unit for closer supervision and assistance. V4 said when he arrived at the scene when R1 fell on [DATE], R1's knees were bent and R1's feet were caught between the toilet base and the legs of the toilet riser. R1's upper extremity was in upright position and lower extremity in sitting position on the floor, knees bent, and upper body slightly leaned towards the right side. V4 said R1 was assisted back to bed using a total lift mechanical transfer device. V4 said R1 had complained of pain to the left upper knee when touched. V4 said due to R1's declining condition, 2-person assist is required when providing care to ensure safety. On September 20,2024 at 10:38 A.M., V3 said she had assisted R1 to the bathroom on September 16,2024 around 2:00 P.M. V3 said she started assisting R1 in the bathroom from sitting position from the wheelchair. (R1) grabbed the grab bars to pull self-up to standing position. (R1) started to pivot transfer on her own while (V3) was pulling down R1's pants since (R1) had a large bowel movement. During this time, (R1's) legs buckled up, and there was no way to avoid falling to the floor so (V3) eased down (R1) to the floor. (R1's) feet caught in between the toilet base and toilet riser. (R1) complained of left upper leg pain. V3 called (V4) at once and they transferred (R1) to her bed via total lift device. V3 said she did not use gait belt to R1 during toilet transfer. V3 said while she was pulling down R1's pants, R1 had no stability and no assistance since V3 was pulling down R1's pants. On September 20,2024 at 12:44 P.M., V8 (RN/MDS/Care Plan) said R1 requires total assistance for lower body dressing, totally dependent from staff for toilet use, and required substantial assistance for transfer. On September 20,2024 at 2:50 P.M., V5 (CNA) said R1's functional level varies, sometimes R1 resist care and assistance of 2 person was required for safety. On September 20,2024 at 1:10 P.M., V9 (Occupational Therapist) said she had provided occupational treatment to R1 on September 6, 9, 10 and 13, 2024. V9 said R1's functional level varies and is unpredictable. V9 said at times R1 requires 75 % to 100 %, was totally dependent from staff then there were times R1 requires 25 % assistance. V9 added if a task is given one at a time to R1, then 1 person assist is okay since the assistance was focus on a single task, but if 2 or more tasks were provided at the same time, then 2 persons plus assistance was required for R1 to be safe during provision of care. V9 said when R1 was doing pivot transfer and V3 was pulling down R1's pants, V3 was doing assistance for undressing, and a transfer assistance task was not provided. V9 said, One task should be provided at a time with 1-person assist, and with 2 tasks being provided at same time, 2 persons assists were required. Also do not undress during pivot transfer. On September 22,2024 at 12:15 P.M., V2 said transfer belt/gait belt is a must to use when transferring a resident. V2 said 2 person assistance was required when 2 tasks of care is being provided at the same time. On September 20,2024 at 2:27 P.M., V10 (R1's Primary Physician) said she was notified on September 16, 2024 when R1 sustained a fall, landed on knees, and R1's knees were swollen. V10 said R1 sustained acute fracture of the left upper leg (femur) due to the fall incident occurred September 16.2024. The MDS (Minimum Data Set) dated September 9, 2024 showed R1's cognition was moderately impaired with BIMS (Brief Interview Mental Status) score of 8/15. The MDS also showed R1's functional level assessment as follows: -functional limitation in range of motion on both sides for both upper and lower extremities -dependent for toilet hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding, or having a bowel movement) -dependent for lower dressing (ability to dress/undress below the waist) -dependent from sit to stand (ability to come from to a standing position from sitting position in a chair/wheelchair) -dependent for toilet transfer (the ability to get on and off a toilet or commode) The MDS code were as follows: -substantial/maximal assistance: Helper dose MORE THAN HALF the effort. Helper holds or lifts trunk, or limbs and provides more than half the effort. -dependent: Helper does ALL the effort. Resident does none of the effort to comply the activity. The assistance of 2 or more helpers is required for the resident to complete the activity. The care plan dated September 3,2024 showed R1 requires total assistance for lower body dressing, totally dependent from staff for toilet use, and required substantial assistance for transfer. The fall risk assessment dated [DATE] showed R1 was a high risk for fall. The progress notes dated September 20, 2024 showed R1 returned to the facility at 6:30 P.M. R1 was also placed on hospice care. On September 21, 2024 at 10:30 A.M. R1 was observed lying in her bed. R1 was lethargic and barely responsive. R1's left lower extremity was moderately swollen. The facility policy for Lifts and Safe Client Movement Program with review date of September 2024, showed: POLICY: is committed to providing safe care maximizes clients' quality of life while maintaining a safe work environment for employees. The Safe Client Movement Program includes client movement equipment, employee training, client plan of care and a culture of safety approach to safety in the work environment. 6. When a client is being assisted with a transfer and another ADL task is needed a client also needs assistance with such as dressing/undressing The facility policy for Gait Transfer Belt with review date of May 2024, showed: IMPORTANT POINTS: 2. Gait belt use is mandatory with all residents who need assistance in ambulation and /or transfer.

Based on observation, interview and record review the facility failed to ensure that PRN (as needed) antianxiety medication orders had clinician documented rationale for use beyond 14 days, failed to identify and monitor target symptoms/behaviors and failed to implement non- pharmacological interventions prior to PRN medication use. This applies to 1 of 5 residents (R13) reviewed for unnecessary medications in the sample of 12. The findings include: R13's EMR (Electronic Medical Record) showed R13, [AGE] years old, was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease with late onset, personal history of other diseases of the nervous system and sense organs, anemia, primary hypertension, anxiety disorder, arthritis, history of left hip replacement and history of surgical repair of the right ankle. R13's MDS (Minimum Data Set) dated April 4, 2024, showed R13's cognition was severely impaired and was dependent on staff assistance for all ADLs (Activities of Daily Living) including bed mobility, eating, toileting, bathing, dressing, and transfer, and R13 could not sit unsupported requiring the use of a high back wheelchair with built in supports. R13's care plan initiated on September 30, 2022, for use of anti-anxiety medication showed the intervention to monitor/record target behavior of restlessness, anxiety, disrobing, inappropriate response to verbal communication and violence/aggression toward staff and others etc. and document behavior per facility protocol. Interventions included to administer anti-anxiety medication as ordered by the Physician. There were no non-pharmacological interventions to address anxiety, restlessness or agitation in the care plan. R13's pharmacy recommendation dated February 15, 2024, showed R13 was prescribed Lorazepam (anti-anxiety medication) 1 mg (milligram) every 4 hours PRN, greater than 14 days, without a stop date. R13's March 2024 MAR (Medication Administration Record) showed Lorazepam 1 mg, every 4 hours PRN order initiated on February 16, 2024, had a stop date of March 1, 2024. R13 was prescribed Lorazepam 1 mg. every 4 hours PRN on March 7, 2024, through March 21, 2024, without a note written by the prescriber documenting rationale for use. R13 was administered Lorazepam 1 mg on March 9, 2024, at 7:16 PM and March 13, 2024, at 7:43 AM, with No documented for behavior observed prior to administration. R13 was prescribed Lorazepam 1mg. every 4 hours PRN on March 22, 2024, with a stop date of April 5, 2024, without a note written by the prescriber documenting rationale for continued use. R13 was administered Lorazepam 1mg on March 27, 2024, at 9:00 AM with No documented for behavior observed prior to administration. R13's April 2024 MAR showed Lorazepam 1 mg. every 4 hours PRN was prescribed on April 5, 2024, through April 19, 2024. R13 was administered Lorazepam 1 mg PRN dose, without documentation of any behavior observed, prior to administration, on April 5, 2024, at 4:08 PM, April 6, 2024, at 1:23 AM, 8:00 AM and 12:00 PM; and April 10, 2024, at 12:06 AM, 6:51 AM and 12:57 PM. R13's EMR document titled Behavior Monitoring and Interventions for April 2024, showed no behavior observed was documented with a check mark; no behaviors were documented as being observed for the month. R13's EMR document titled Long Term Care Evaluation quarterly assessment, dated April 1, 2024, showed mood was pleasant, no unwanted behaviors witnessed. Resident sleeps through the night. R13's Psychiatric progress note dated April 1, 2024, showed Ativan (Lorazepam) PRN takes long time to work if it did, sometimes does not work. R13's Psychiatric progress note dated April 11, 2024, showed R13's medication regimen was Seroquel 12.5 mg every morning and 50 mg at bedtime, Vistaril 25 mg twice a day, Depakote 250 mg twice a day, and Ativan (Lorazepam)1 mg every 4 hours PRN. The note also showed Ativan is not effective anymore. On May 1, 2024, at 12:00 PM, V6 (Restorative CNA, Certified Nursing Assistant) stated R13 was ok this morning and she did not observe any behaviors. V6 stated V8 (CNA) fed R13 in the dining room for breakfast after getting her up in the wheelchair. V6 stated on a bad day R13 will sing loudly and then fidget with her hands, V6 demonstrated the behavior by rubbing her two hands together. V6 stated she doesn't think R13 was in pain at those times. R13 was observed sitting in the high back supportive wheelchair, in the dining room, with her eyes closed, being fed lunch by her private caregiver. On May 1, 2024, at 12:05 PM, V8 (CNA) stated R13's behavior was good today she got her up for breakfast and fed her in the dining room and stated she ate 50-75%. V8 stated she put R13 back to bed after breakfast. V8 stated she has seen R13 speak to V3 (nurse) but R13 doesn't speak to everyone. V8 stated R13 used to be a pianist and she likes music a lot. V8 described R13's behaviors as singing loudly and she is fidgety, but V8 stated she doesn't think R13's singing means she is agitated. V8 continued, sometimes when R13 is fidgety she thinks R13 may be in pain, and V8 then reports that to the nurse. V8 stated today, on May 1, 2024, at 6:00 AM, when she checked R13 she found her digging in her incontinence brief. V8 stated the incontinence brief was soiled. V8 changed R13's brief and R13 stopped digging, was not fidgeting and rested until V8 got R13 up in the chair for breakfast. On May 1, 2024, at 12:15 PM, V9 (RN Nurse) stated he has worked in the facility for 3 years on this unit. V9 stated he knows R13 well. V9 stated he gave R13 a Lorazepam 1mg dose at around 10:00 AM, this morning. V9 stated he gave the medication because R13 was fidgeting in her wheelchair, moving her arms and legs, and V9 wanted to prevent R13 from falling out of her chair. V9 also stated he did not try any non-pharmacological interventions prior to giving the Lorazepam medication. V9 stated sometimes R13 sings, and she appears anxious and other days R13 can go for a few days without appearing anxious. V9 stated we (facility staff) haven't tried a lot of non- pharmacological interventions. V9 also stated R13's singing may just be a form of self-expression, not a sign of anxiety. V9 stated R13's behavior has unknown triggers. V9 stated sometimes one of the private caregivers requests the staff to give a dose of Lorazepam to R13 and is unsure why the request is made, but the staff comply so as not to upset the caregiver/family. On May 1, 2024, at 2:55 PM, V2 (DON) stated R13 is not on hospice. V2 stated R13 has two caregivers and a very involved family. R13's medical doctor is aware of the psychiatrist's statement that Lorazepam is not effective, and the medical doctor is still prescribing the Lorazepam for R13. V2 was unable to provide documentation of non-pharmacological interventions attempted to reduce R13's anxiety symptoms upon request. V2 stated they have discussed with R13's family, further testing that is available to determine the causes of symptoms/behavior for R13 but that was not pursued due to R13's family being unwilling to pay for the testing. The facility's policy titled Use of Psychotropic Medications, dated 12/23, showed .2. The indications for initiating, withdrawing, or withholding medications as well as the use of non-pharmacological approaches will be determined by: a. assessing the resident's underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment and b. identification of underlying causes (when possible) .4. b. for psychotropic drugs that are initiated after admission to the facility, documentation shall include: ii. Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. iii. non-pharmacological interventions have been attempted, and the target symptoms for monitoring shall be included in the documentation .9. a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the medical record and indicate the duration for the PRN order.

Based on interview and record review, the facility failed to ensure medications were obtained from the pharmacy in a timely manner to prevent residents from missing medication doses as ordered by the physician. This applies to 3 of 3 residents (R3, R4, and R5) reviewed for improper nursing care in delay in medication administration in the sample of 5. The findings include: 1. On September 27, 2023, at 10:51 AM, R3 was lying in bed in her room. R3 said she was admitted to the facility on [DATE], around 3:00 PM. R3 said she receives a medication for her restless leg syndrome every night (Pramipexole Dihydrochloride) two different eye drop medications for her glaucoma (Latanoprost and Timolol Maleate), and medication for her depression (Bupropion). R3 said, The medications were not here in the facility the first night I got here, so I did not receive them. I was most worried about the medication I take for my restless leg syndrome because it is so bad that when I don't take the medication, my arms start to shake as well. I did not get the medications that first night because the nurse said they did not get them from the pharmacy in time to give them to me. The EMR (Electronic Medical Record) shows R3 was admitted to the facility on [DATE]. R3 has multiple diagnoses including, orthopedic aftercare, lumbar region spinal stenosis with neurogenic claudication, post-hemorrhagic anemia, diabetes, heart failure, atrial fibrillation, mild asthma, major depressive disorder, and presence of a cardiac pacemaker. R3's MDS was not completed at the time of this investigation due to her recent admission to the facility. Nursing documentation dated September 21, 2023, shows R3 requires limited assistance by one facility staff member with all ADLs (Activities of Daily Living), including toilet use assistance. R3 has urinary incontinence related to her chronic lumbar spine issues. The EMR shows the following documentation by V14 (RN-Registered Nurse) dated September 21, 2022, related to R3's physician-ordered medications: 6:22 PM - Pramipexole Dihydrochloride oral tablet 0.75 mg. (milligrams). Give 1 tablet by mouth two times a day for Parkinson's Disease - medication not available. 6:22 PM - Bupropion HCl (Hydrochloride) ER (Extended Release) SR (Sustained Release) oral tablet extended release 12-hour 100 mg. Give 1 tablet by mouth two times a day for depression - medication not available. 6:23 PM - Timolol Maleate Ophthalmic Solutions 0.5%. Instill 1 drop in both eyes two times a day for glaucoma - medication not available. 7:01 PM - Fluticasone-Salmeterol 100-50 mcg. (Micrograms) Aerosol Powder, breath activated. Give 1 puff by mouth two times a day for asthma - medication not available. 9:25 PM - Pramipexole Dihydrochloride oral tablet 0.75 mg. Give 2 tablet by mouth at bedtime for Parkinson's disease (2 Tablets = 1.5 mg) - medication not available. 9:25 PM - Latanoprost Ophthalmic Solution 0.005%. Instill 1 drop in both eyes at bedtime for glaucoma - medication not available. The facility does not have documentation to show V14 (RN) contacted R3's physician to notify the medications were not available and the resident missed the medications, and the facility does not have documentation to show the pharmacy service was contacted to obtain a stat delivery of R3's medications. The pharmacy delivery manifest shows R3's medications were delivered to the facility on [DATE], at 2:21 AM. 2. The EMR shows R4 was admitted to the facility on [DATE], and was sent to the local hospital on June 8, 2023. R4 did not return to the facility. R4 had multiple diagnoses including, cellulitis of the left upper limb, atrial fibrillation, hypertension, history of TIA (Transient Ischemic Attack), and presence of a cardiac pacemaker. R4's MDS dated [DATE], shows R4 was cognitively intact, was able to eat with supervision, required limited assistance with transferring between surfaces, and walking, and extensive assistance with all other ADLs. R4 was occasionally incontinent of urine and always continent of stool. The EMR shows the following documentation by V15 (RN) dated June 6, 2023, related to R4's physician-ordered medications: 10:45 PM - Timolol Hemihydrate Ophthalmic Solution 0.5%. Instill 1 drop in both eyes two times a day for glaucoma - medication not available. 10:45 PM - Sotalol HCl Oral tablet 160 mg. Give 1 tablet by mouth every morning and at bedtime for irregular heartbeat - med not available. R4's hospital After Visit Summary, printed on June 6, 2023, at 4:39 PM shows R4 was to start taking Amoxicillin (Antibiotic) 875 mg. on June 6, 2023, at 9:00 PM. The facility's documentation shows R4 received the medication on June 7, 2023, at 8:53 AM, approximately 12 hours after the medication was instructed to be administered by the hospital. The facility does not have documentation to show R4's physician was notified of the missed medication doses or if R4's Amoxicillin dosage could be delayed from June 6, 2023, at 9:00 PM to June 7, 2023, at 9:00 AM. The facility does not have documentation to show a stat delivery was requested from the pharmacy for R4's medications. The pharmacy delivery manifest shows the facility received R4's medications on June 7, 2023, at 1:33 AM. On September 28, 2023, at 9:53 AM, V12 (Pharmacist) said, I looked into the order entry from our end (pharmacy). The order for [R4's] Amoxicillin was put in correctly, as shown on the hospital orders, to start on the evening of June 6, 2023. From our internal audit, it looks like when the nurse at the facility went into the system to approve the order, the administration time got changed on her end and defaulted to start the medication the next day instead of on June 7, 2023, at 9:00 PM. On September 27, 2023, at 2:58 PM, V13 (RN) said R4 did not receive her evening medications, including her Amoxicillin on the night of her admission because the medications were not available in the facility. V13 said, The remote entry person at the pharmacy entered all the medication orders into the system before the resident got to the facility. The orders get put in a queue and then the nurses go in and check the orders and approve the medication orders to be profiled in the system. Since I looked in the STAT safe here at the facility for [R4's] Amoxicillin and it wasn't there, then I thought we would start it the next day (June 7, 2023). I did not call the physician to see if that was okay to do. I was not assigned to this resident and was just helping out the other nurse. On September 27, 2023, at 10:37 AM, V17 (Attending Physician) said, It is my expectation the facility follows the hospital discharge instructions, and also obtains the resident's medications from the pharmacy so the residents do not have to miss any doses of their medications. The facility should let me know if the resident's medications are not available and do everything possible to get the medications. 3. The EMR shows R5 was admitted to the facility on [DATE], with multiple diagnoses including, right pubis fracture, hypoxemia, diabetes, chronic kidney disease, atrial fibrillation, and heart failure. R5's MDS was not completed at the time of this investigation. The EMR shows the following documentation by V16 (RN) dated September 22, 2023, related to R5's physician-ordered medications: 7:39 PM - Jardiance Oral Tablet 10 mg. Give 1 tablet by mouth in the evening for diabetes related to Type 2 Diabetes Mellitus with unspecified complications with dinner - medication is not available. 8:00 PM - Metoprolol Tartrate oral tablet 25 mg. Give 1 tablet by mouth two times a day for hypertension - medication is not available. 8:00 PM - Cephalexin Oral Capsule 500 mg. Give 1 capsule by mouth two times a day for UTI (Urinary Tract Infection) for 5 days - medication is not available. 8:01 PM - Atorvastatin Calcium oral tablet 20 mg. Give 1 tablet by mouth at bedtime for hyperlipidemia - medication is not available. The facility does not have documentation to show R5's physician was notified the medications were not available and the resident missed the medications, and the facility does not have documentation to show the pharmacy service was contacted to obtain a stat delivery of R5's medications. The pharmacy delivery manifest shows R5's medications were delivered to the facility on [DATE], at 2:28 AM. On September 27, 2023, at 11:28 AM, V12 (Pharmacist) said the facility receives two pharmacy deliveries a day. The deliveries leave the pharmacy at 2:00 PM and 1:00 AM. V12 said, The facility can get any medication delivered stat if they request it. There is a two-to-four-hour turnaround time. They just call the pharmacy and request a stat order. The facility's policy entitled, Medication Ordering and Receiving from Pharmacy - Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy dated March 2021 shows: Policy: Medications and related products are received from the dispensing pharmacy on a timely basis. The facility maintains accurate records of medication order and receipt. A. Ordering Medications from the Dispensing Pharmacy: .3) Stat and emergency medications are ordered as follows: a. During regular pharmacy hours, the order is sent electronically or faxed to the pharmacy. The pharmacy is then notified of the emergency or stat order via the telephone. Such medications are delivered and administered within 4 hours. If available, the initial dose is obtained from the emergency kit, when necessary. The pharmacy Order cut-off and delivery times shows: [Pharmacy Service] never closes. To reach a member of our staff after 10:00 PM, Monday through Friday, or after 5:00 PM on weekends and holidays, please dial our main number and follow the prompts. The facility's Policy entitled, Medication Administration effective 10/95 and reviewed 5/9/2023 shows: Medications are prepared and administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.4. Medications are administered as prescribed by the practitioner's order, and in accordance with standards of nursing practice. The nurse administering the medication is responsible to reconcile all concerns with the prescriber prior to administering the medication.If a medication order cannot be followed for any reason, the prescriber is notified as soon as it is reasonable. This communication should be fully documented in the medical record.

Based on observation, interview, and record review, the facility failed to follow standards of infection control practices related to hand hygiene and gloving during provision of incontinence care. This applies to 2 of the 14 residents (R16, R25) reviewed for infection control in the sample of 14. The Findings Include: 1. On 6/06/23 at 1:18 PM, V13 (Certified Nursing Assistant/CNA) rendered peri-care to R25. After R25 voided, V13 proceeded to clean R25's peri-area from front to back, then assisted R25 with repositioning, and pulled R25's brief and pants back up while wearing the same soiled gloves. 2. On 6/06/23 at 1:48 PM, V13 and V14 (CNA) rendered incontinence care to R16 who was wet with urine and had a bowel movement. V13 changed gloves from dirty to clean task without performing hand hygiene all throughout the incontinence care. On 6/06/23 at 2:55 PM, V4 (Director of Nursing/DON) stated every time that staff enters the resident's room, the staff must perform hand hygiene, and don gloves. If at any point of the care, the gloves get contaminated the staff must remove the soiled gloves, perform hand hygiene, wear another set of gloves then continue with the care. When the care is finished, remove the gloves and perform hand hygiene prior to leaving the room to prevent the spread of potential infection. Facility's Hand Hygiene Policy dated 9/14 (September 2014) shows: Purpose: Handwashing is considered one of the most effective infection control measures. Frequency: 6. Before and after having contact with a client's intact skin during client care 7. After accidental contact with any body fluids, mucous membranes, non-intact skin, or wound dressings 8. If hands will be moving from a contaminated body site to a clean body site during client care 9. Before and after using gloves (i.e., handling food, client care)

Based on observation, interview, and record review, the facility failed to ensure dishware was sanitized before reuse. This failure affects all 31 facility residents. The findings include: The facility's Resident Census and Condition of Residents form dated 8/2/22 showed there were 31 residents residing in the facility. On 8/2/22 at 9:59 AM, the dishwasher was in use. There was assorted dishware exited from the dishwasher. There was additional dishware processed through the machine. There was a plastic gallon jug turned upside down above the dishwasher. The jug was labeled as a sanitizer and had a clear tube connecting it to the dishwasher. There were no sanitizer concentration check logs in the kitchen. On 08/02/22 at 09:59 AM, V4 Chef said the Dietary Manager was on vacation. V4 said the dishwasher is usually a high temp dishwasher. The machine didn't get up to temp right this week. The tech came out and determined the booster heater was not working. The tech hooked up some (liquid) sanitizer to the dishwasher. V4 was asked if the high temp dishwasher was adapted to function as a sanitizing washer instead of a high temp dishwasher. V4 said yes. V4 was asked to check the sanitizer concentration and said they did not have any test strips for the new sanitizer. V4 got verbal confirmation from V6 Dishwasher that no test strips were available. On 08/02/22 at 10:22 AM, V6 said we noticed last Tuesday (7/26/22) that the dishwasher wasn't temping right. It was only hitting 155 degrees and it should be 180 degrees. On 08/03/22 at 10:57 AM, V4 said dishware should be sanitized to make it safe to use. If dishware is not sanitized, it could cause food poisoning and people could get sick. V4 was asked how the facility ensured the dishware was sanitized from 7/25/22-8/2/22. V4 said when we realized the dish machine was not holding the temperature consistently, we still checked the temperatures. V4 said, It would kick on and off. They told me the temp machine temperature reading was 180 degrees, but the test strip didn't match. V4 was asked why the facility was checking dishwasher temperatures after they realized there was a problem and didn't check sanitizer levels. V4 said, It's my fault. I didn't educate the staff to check the sanitizer level instead of the temperature until the machine was repaired. The facility's 9/11 Machine Ware Washing-High Temperature Policy showed all silverware, serving dishes, and utensils are washed, rinsed and sanitized after each use. Employees who use the dish machine will be responsible for knowing how to use the machine, document it's use, and properly maintain it after use. Temperatures should be at least: final rinse 165-180 degrees (depending on rack/conveyor and dual or single temperature machines). If the final rinse temperature does not meet the standard, do not run anything through the machine. The facility's 9/11 Machine Ware Washing Policy showed all silverware, serving dishes and utensils are washed, rinsed, and sanitized after each use. The dish machine will be checked prior to each meal period to ensure that it is functioning properly. Employees will be responsible for knowing how to use the machine. Check sanitizer concentration before each use using appropriate test strips. The Dining Services Manager/designee will: verify that the dish machine is functioning properly and check the Chemical Dish Machine Monitoring Form to ensure that sanitizer concentration meets standards. The facility was unable to provide any documentation the dishwasher sanitizer concentration was checked prior to 8/2/22 (after questioning). The July 2022 Dish Machine Record showed the dishwasher reached acceptable (A circled) temperatures three times a day from July 1-31, 2022.

Based on observation, interview, and record review, the facility failed to ensure staff wore personal protective equipment correctly and the correct personal protective equipment during a Covid outbreak, failed to ensure clean linens were covered and dirty linens were not lying on the floor, and failed to ensure staff wore personal protective equipment (PPE) within six feet of a resident on Covid isolation. This failure affects all 31 facility residents. The findings include: The facility's Resident Census and Condition of Residents form dated 8/2/22 showed there were 31 residents residing in the facility. 1. On 08/02/22 at 11:57 AM, V9 Dietary was in the second-floor kitchenette. V9 was not wearing eye protection. V9 plated lunch trays for all the second-floor residents. On 08/02/22 at 11:43 AM, V8 Dietary was in the third-floor dining room plating fruits and desserts to the third-floor resident's lunch trays. V8 wore a surgical mask with an N95 mask over it. The bottom strap of the N95 mask was not behind V8's head but dangled in front of his neck. A facility policy regarding personal protective equipment (PPE) requirements during a Covid outbreak was requested and not received. On 8/3/22 at 9:30 AM, V1 Administrator said the facility is on (Covid) outbreak status since an employee tested positive on 7/28/22. On 08/03/22 at 12:28 PM, V2 Director of Nursing- Infection Preventionist said an N95 mask and eye protection should be worn by all staff in the facility in resident areas while on outbreak status. A gown and gloves should also be worn if entering a resident's room (on isolation). An N95 mask should be worn with both straps behind the head and nothing underneath it so a proper seal is maintained. If both straps are not behind the head, it may cause a gap in the seal and would not be providing the protection as intended. If staff do wear the correct PPE or don't wear it correctly, the residents and staff are not protected from potential disease transmission. The facility's employee Covid tracking form showed an employee tested positive for Covid-19 on 7/28/22. The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 2/2/22 showed to implement the universal use of Personal Protective Equipment (PPE) for Healthcare Personnel (HCP). HCP working in facilities located in counties with substantial or high transmission should use PPE as described: N95or higher-level respirators should be used for situations where additional risk factors are present such as the patient is not up to date with all recommended COVID-19 vaccine doses. To simplify implementation, facilities in counties with substantial or high transmission may consider implementing universal use of N95 or equivalent or higher-level respirators for HCP during all patient care encounters or in specific units or areas of the facility at higher risk for [CONDITION(S)]-CoV-2 transmission. Eye protection (i.e., goggles or face shield that covers the front and sides of the face) should be worn during patient care encounters. The National Healthcare Safety Network (NHSN) showed the week of 7/17/22 (most current available) the facility's county transmission rate was high. 2. On 08/02/22 at 11:39 AM, there was a silver wheeled cart with clean and folded white towels in it uncovered in the third-floor resident hallway. There was a partially filled yellow linen bag with red biohazard symbol and lettering on the carpeted floor in the hallway near the uncovered linen cart. On 08/03/22 at 12:28 PM, V2 Director of Nursing (DON)/ Infection Preventionist (IP) and V3 IP concurred clean laundry should be covered and protected during transport and storage. The environment has the potential to contaminate clean linens. Soiled linen bags should not be in contact with the floor. The floor can become contaminated if dirty items meet it. Soiled linens should be placed in the soiled utility room or soiled linen cart. If soiled linen bags are lying on the floor, it could cause cross contamination and it's not best practice. The facility's 7/07 Soiled Laundry Transport Policy showed soiled linens are transported to the laundry area in a secure manner. The facility's 7/05 Clean Linen Transport Policy showed clean linen is transported in a sanitary manner. On 8/3/22, the facility provided two in-service attendance sheets to show staff were educated that soiled linens cannot be placed on the floor and clean linens must be always covered. 3. R181s Face Sheet showed she was a [AGE] year old female with an admitted [DATE]. On 8/02/22 at 10:46 AM, R181s door had isolation signage showing she was in contact and droplet isolation until 8/6/22. The signage showed the required Personal Protective Equipment (PPE) included an N95 respirator, goggles/face shield, gown, and gloves. On 8/2/22 at 12:21 PM, V10 Physical Therapy Assistant was providing physical therapy in R181's room. V10 was touching and he was within 6 feet of R181. V10 was not wearing a gown or gloves. On 8/04/22 at 10:58 AM, V2 Interim Director of Nursing stated R181 is in isolation because she is a new admission and she had not received all of the recommended booster vaccinations to be considered fully vaccinated for COVID-19. V2 said the required PPE for R181 is N95, face shield/goggles, gown, and gloves. V2 said the purpose of R181s isolation is to prevent the transmission of COVID-19. V2 said V10 should have donned the required PPE prior to entering R181s room. The facility resident matrix showed R181 was admitted to the facility on [DATE]. The facility resident Covid vaccine flowsheet showed R181 did not receive a second Covid booster. The facility's 1/09 Infection Control Program Policy showed the program is established to help prevent the development and transmission of infections in accordance with regulatory requirements. This program will maintain prevention and control measures to protect clients, personnel, visitors and contracted vendors from healthcare-acquired infections. The program will ensure compliance with state and federal regulations related to infection control. Contact Precautions are necessary when an illness is transmitted by direct contact. Requirements include gloves, gown, private room or cohort. Droplet Precautions are necessary when an illness is transmitted by large particle droplet and includes the use of a surgical mask when within three feet of the client. The facility's Contact Precautions signage placed on resident doors showed providers and staff must put on gloves before room entry and put on gown before room entry. The facility's Droplet Precautions signage placed on resident doors showed everyone must make sure their eyes, nose and mouth are fully covered before room entry.

Based on observation, interview, and record review the facility failed to provide activities to meet a resident's needs. This applies to 1 of 1 resident (R29) reviewed for activities in the sample of 12. The findings include: R29's Face Sheet showed an original admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) and stroke. R29's 7/22/22 Minimum Data Set (MDS) showed she was cognitively intact with Brief Interview for Mental Status (BIMS) score of 15 out of 15. R29's MDS showed she required assistance from one staff member for locomotion with her wheelchair. The MDS showed the resident had not moved off the unit to areas such as activities during the look back period for this MDS. On 8/2/22 at 12:05 PM, R29 stated she is there for speech therapy and other issues regarding her stroke. R29 pointed to an educational pamphlet title [CONDITION(S)] as the reason for her therapy. R29 was able to communicate with speech, with head nodding, and with a picture board. R29 stated she is not offered activities daily and activities are something she would enjoy. On 8/03/22 at 12:49 PM, R29 stated she had not been offered activities the day prior or this day. R29 had a magazine on her table. R29 stated the magazine was given to her by her husband. R29 stated she would like to go to activities if she was offered transportation assistance. On 8/04/22 at 10:55 AM, R29 stated she had not been offered activities. R29 said she would enjoy group activities, music, and games. On 8/03/22 at 1:06 PM, V13 Registered Nurse (R29's nurse) stated there is no activity calendar that she is aware of. V13 stated she did not believe activities were done daily, it's limited. V13 stated, activity staff will notify her of activities and tell her, if anyone wants to go make sure they get there. On 8/04/22 at 10:11 AM, V12 Certified Nursing Assistant stated, .because of COVID they have not really done activities; it's more personalized and they do one on one. I have seen them come around on the third floor once in a while. Usually, if the residents want to go to activities, they (residents) will have to tell me then I have to tell the nurse .I'm not aware of any residents on this floor that are getting any one on one activities. On 8/04/22 at 10:36 AM, V11 Activities Director stated group activities are generally conducted on the second floor (R29 is on third.) V11 stated she could not recall if she had personally asked R29 if she would like to attend group activities. V11 was not aware of any residents on the third floor that attend the group activities on the second floor. V11 stated activities are important for resident to give them enjoyment, purpose, and help them pass the time. R29's care plan showed R29 needs social, recreational, and spiritual activity opportunities . R29's Clinical notes showed no documented refusal of activities or that group activities were offered. The facility's Life Enrichment Program policy (reviewed 10/16/21) showed The life enrichment department will provide a variety of recreational and therapeutic opportunities to enhance each clients identity, respect, dignity and level of ability .charting and record keeping will be maintained as appropriate at each level of service .

Based on interview and record review, the facility failed to ensure safe practices when turning a resident in bed. This failure resulted in a resident falling out of bed and sustaining a right femur fracture and a right humerus fracture. This applies to 1 of 3 residents (R2) reviewed for falls in the sample of 3. The findings include: The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses including dementia without behaviors, pneumonia, weakness, history of falling, right humerus fracture, right femur fracture, [CONDITION(S)] (Urinary Tract Infection), dysphagia, anxiety, heart failure, difficulty walking, abnormal gait and mobility, and pain. R2's MDS (Minimum Data Set) dated April 15, 2022 shows R2 has severe cognitive impairment. The MDS continues to show, at the time of the MDS assessment, R2 required extensive assistance by two facility staff members for bed mobility and was totally dependent on two facility staff members for transfers between surfaces. The facility's fall investigation dated June 3, 2022 at 5:55 AM by V5 (RN-Registered Nurse) shows, Around 0655 (6:55 AM) CNA (Certified Nursing Assistant) alerted RN that [R2] was on floor. When CNA was turning resident on R (Right) side to put [mechanical lift] sling under resident, resident slipped off on R side of bed hitting knees on floor first. Resident assessed and placed back in bed via [mechanical lift] for rest. When asked, resident states she hurts all over but particularly R knee. Resident refused to take Tylenol for pain. Resident and CNA deny resident hit head. STAT X-rays ordered for bilateral knees. Neuro checks and vitals WNL (Within Normal Limits) The facility's fall investigation continues to show, X-rays completed and noted with acute mildly displaced supracondylar fracture of right femur (thigh bone).On June 7, 2022, [R2] went to f/u (Follow-Up) appointment with orthopedic MD. At the appointment resident noted to be lethargic with SOB (Shortness of Breath) while on oxygen 3 LPM (Liters Per Minute) via NC (Nasal Cannula). Resident transported to [local hospital]. X-rays and CT scan obtained and admitted with Dx (Diagnosis): Closed fx (fracture) of head of right humerus (right upper arm bone). On July 12, 2022 at 11:12 AM, V4 (CNA) said, I was providing care to [R2], on the day of her fall. [R2] was lying on a thick air mattress. The mattress has a slippery surface. I did not have any staff in the room to help me. I was alone. I was changing her clothes and getting ready to get her out of bed. I had the bed up in a high position, at the height of my waist. I am five feet, seven inches tall, so the bed was up about three to four feet from the floor. There are small side rails up near the resident's head the resident can grab to help with turning, but [R2] was unable to assist with turning that day. She is very heavy, and totally dead weight. I turned [R2] away from me towards the edge of the bed using a pushing motion with one hand, while attempting to put the [mechanical lift] sling under her body with the other hand. I crossed her legs over each other and pushed her in the direction away from me. Her legs were hanging over the side of the bed and she slid off the bed before I could catch her, hitting the floor. First her legs fell , and then the rest of her body followed, hitting the floor. After she fell to the floor, I called her nurse into the room, and she assessed her. On July 12, 2022 at 1:28 PM, V5 (RN) said, I was out doing medication pass in the hallway and [V4] came out to me screaming. When I went in [R2's] room, the resident was lying on the floor on her right side. She was parallel to the bed, between the bed and the wall. [V4] said she was turning the resident and putting the sling under her, and the resident slid off the bed. It looked like she slid off the air mattress. She came off her right side and was lying on her right side on the floor. The bed was up high because [V4] was providing care to the resident in the bed when it happened. [V4] described to me that the resident's knees hit the floor first. She was lying completely on her right side on the floor when I got in the room. No part of her body was up on the bed. On July 12, 2022 at 2:11 PM, V7 (Rehab Director) said, Therapists always recommend rolling the resident towards themselves when providing care alone. The resident can be turned away from you if you have someone else with you while providing care who can ensure the resident can't roll off the side of the bed if they get away from you. On July 12, 2022 at 12:26 PM, V3 said, I cared for [R2] at the facility and during her hospital stay as well. She is well-known to me. [R2] has been bedridden for two or three years. [R2] could not assist with turning. The fall caused the fractures. I don't think there is any doubt. Unfortunately, this fall had a poor outcome for the resident and resulted in fractures. The POA (Power of Attorney) did not want to pursue surgery and decided to put the resident on hospice following the fall. The United States National Library of Medicine [MEDICATION(S)] Plus, reviewed October 23, 2021, shows the following steps should be followed when turning a patient from their back to their side or stomach: Explain to the patient what you are planning to do so the person knows what to expect. Encourage the person to help you if possible. Stand on the opposite side of the bed the patient will be turning towards and lower the bed rail. Move the patient towards you, then put the side rail back up. Step around to the other side of the bed and lower the side rail. Ask the patient to look towards you. This will be the direction in which the person is turning. The American Congress of Rehabilitation Medicine Caregiver Guide and Instructions for Safe Bed Mobility dated 2017 shows, The term bed mobility refers to activities such as scooting in bed, rolling (turning from lying on one's back to side-lying), side-lying to sitting, and sitting to lying down. It also includes scooting to sit on the edge of the bed when preparing to stand or transfer. What are the steps to accomplish safe bed mobility? 2. Place your hands behind the patient's shoulder and hip or thigh on the far side. Have the patient reach with their opposite arm across their body, toward the side of the bed. Important tip: the patient should always roll toward you not away from you. 3. Assist the patient in rolling toward you and have them use their opposite arm to reach across their body into a side lying position.

Based on observation, interviews, and record review, the facility failed to implement the safe disposal of personal protective equipment after use. This applies to 1 resident (R79) in the total sample of 33. On October 18, 2021 at 9:15 AM, there was one resident (R79) on contact/droplet isolation on the second floor of the facility. The Personal Protective Equipment (PPE) cart hanging on the door to the room contained no PPE. The linen disposal bin inside the door to the room was labeled Linens and No Isolation Gowns. On October 18, 2021 at 9:25 AM, V5 (Registered Nurse/Infection Preventionist) stated R79 is on contact/droplet isolation. V5 stated the personal protection equipment is at a station down the hall from R79's room. V5 acknowledged the linen disposal bin in the isolation room is labeled, No Isolation Gowns, and stated the bin for gowns is down the hall near the PPE station. On October 19, 2021 at 10:00 AM, V6 (Nurse Practitioner) obtained gown and face shield and gloves at the PPE station in the hall, donned the PPE near R79's door and entered. At 10:10 AM V6 left R79's room with the rolled-up gown in her hand which she carried down the hall to the disposal bin, passing five resident rooms and staff and residents in the hall. On 10/19/21 at 1:35 PM, V3 (Director of Nurses/Infection Prevention and Control Nurse) stated she was not aware the gown disposal was so far from the room nor that the linen bin in the room was labeled No Isolation Gowns and said it doesn't make sense for it to be located away from the isolation room. The facility was not able to provide policy or procedure guidelines for the disposal of used PPE.

Based on observation, interview, and record review the facility failed to clean the resident's perineal area in a manner that would prevent the potential development of infection and maintain hygiene. This applies to 1 of 2 residents (R17) reviewed for incontinence care. The findings include: On October 20, 2021 at 10:14 AM V9 CNA (Certified Nurse Assistant) and V10 (CNA) provided incontinence care to R17. V9 used a disposable wipe to clean under R17's abdominal fold at waist, moved to the right inner thigh groin area, left inner thigh groin area, and then lifted R17's uncircumcised penis, without retracting the foreskin. V9 cleaned around the tip of the penis, down the shaft and then the scrotum (pouch containing the testicles). Removing gloves and performing hand hygiene was not a concern during this observation. V9 repeated the same procedure starting with the penis and without retracting the foreskin with a wash cloth and soapy water, again with a new wash cloth and rinse water, and lastly she dried the entire area. On October 21, 2021 at 9:56 AM, V3 DON (Director of Nursing) stated after gathering all the supplies, washing hands and putting on gloves, the staff need to explain to the resident what they will be doing. Starting with the perineal area, they need to start at the dirty area and move downward. In a male resident that means starting with the tip of the penis, if uncircumcised they need to pull the foreskin down and clean from the tip of penis down to the testicles. After washing, they need to rinse, and then pat dry. R17's EMR (Electronic Medical Record) shows R17's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17's MDS (Minimum Data Set) date September 25, 2021 shows R17 has severe cognitive impairment and is always incontinent of bowel and bladder. R17 is totally dependent on two staff assistance for toileting and bathing and requires extensive staff assistance for bed mobility, dressing, and personal hygiene. R17's care plan shows R17 has been identified to have substantial to total assist functional deficit with ADLs (Activities of Daily Living). Facility provided policy titled Incontinence Care with revision date of March 2021 shows under procedures .2. wash all soiled skin areas and dry very well, especially between skin folds. Facility provided Perineal/Foley Catheter Care Competency reviewed 6/15, 8/18 shows . For men, retract foreskin, cleanse the penis with a circular motion starting at the meatus, replace the foreskin. Clean the scrotum.

Based on observation, interview and record review, the facility failed to implement fall prevention interventions for a resident who had a history of falls at the facility. This applies to 1 of 6 residents (R1) reviewed for falls in a sample of 12. The findings include: Face sheet, dated 10/20/21, shows R1's diagnoses include fracture of upper end of left humerus, dementia with behavioral disturbance, unsteadiness on feet, anxiety disorder, cardiac pacemaker, vascular dementia without behavioral disturbance, convulsions, sleep disorder. On 10/18/21 at 10:23 AM, R1 was lying in his bed watching television. R1 stated he fell here in the facility which was why his arm was in a sling. R1 had no floor mats on either side of his bed. On 10/20/21 at 10:00 AM, R1 was lying in a bed sleeping and had no floor mats on either side of his bed. On 10/20/21 at 10:08 AM, V7 (Nurse) stated R1 should have had his floor mat next to his bed while R1 was in bed. On 10/20/21 at 10:11 AM, V8 (CNA - Certified Nursing Assistant) stated he had to take R1's floor mat away from the side of R1's bed during breakfast because the tray table did not roll over the floor mats. On 10/20/21 at 10:57 AM, V3 (Director of Nursing) stated the floor mats should have been replaced by R1's bed side while he was in bed after breakfast when the tray table was removed. Fall report, dated 10/2/21, shows R1 fell from his bed at the facility between 2:45 - 3:00 PM in his room. R1 was found on floor next to his bed with a left arm injury. The facility called 911, R1 was transferred to the hospital, and returned at 8:40 AM with a diagnoses of closed fracture of the left shoulder with no surgical intervention. Care plan, created 7/15/21, shows R1 was at risk for falls due to poor activity tolerance, dementia with agitation, anxiety, and multiple [CONDITION(S)] medications. R1's fall interventions, dated 10/2/21, shows R1 was to have floor mats placed by his bed side. Fall Reduction policy, reviewed 5/2021, shows the facility reviews falls at least weekly, discerns a root cause, evaluates factors to recommend new prevention strategies, and communicates the results to the staff via written updates to resident care plans and communications to shift during shift reports.

Based on interview and record review the facility failed to use a gait belt during transfer of a resident per facility's policy. This applies to 1 of 5 residents (R17) reviewed for falls in the sample of 12. The findings include: On 03/10/20 at 12:39 PM, R17 was observed in her room sitting in wheel chair with V5 (daughter). R17 stated that she had a fall last week. V5 stated that V4 CNA (certified nursing assistant) was transferring the resident from the recliner to the wheel chair with out using the gait belt. Nurses notes dated 03/05/2020 at 1: 30 PM showed that V4 notified V3 (nurse) that R17 was on the floor after attempting to transfer R17. Complained of right ankle pain and right hip pain post incident. V6 (R17's daughter in law) was at bedside when incident happened. Per V6's statement R17 was supported by the assigned CNA with one hand under the patient's armpit during the transfer. No gait belt was used nor was the CNA standing in front of her. Patient was unable to pivot and was sat back down again to the recliner. Assigned CNA tried again to transfer R17 but R17 barely made it to the wheelchair and slid off the seat falling on her right knee which bent underneath her. R17's physician was notified about the incident and ordered x-rays to bilateral hip, right knee and ankle. Facility's incident report showed that R17 was lowered to the ground by CNA during transfer, no gait belt in place at the time of incident, and R17 was supported by V4 with only one hand under the resident's armpit while not standing in front of R17. On 03/11/2020 at 12:00 PM, V4 stated she was suppose to use a gait belt when she transferred R17. V4 stated that she forgot her gait belt at home that day and the facility's policy is to use gait belt to all residents during transfer. On 03/11/2020 at 1:30 PM, V3 (nurse) stated she was present after R17 fell and assessed R17 for injuries. V3 stated V4 did not use a gait belt when attempting to transfer R17. On 03/11/2020 at 2:30 PM, V1 (administrator) stated that the CNA definitely should have used the gait belt during the transfer that resulted in R17's fall. MDS (minimum data set ) dated 02/23/2020 showed that R17 requiring extensive assistance with two person physical assist in bed mobility, transfer and toileting. The care plan showed that R17 is at risk for fall secondary to right knee revision, weakness and pain on right lower extremities. The facility's Lifts and Safe Client Movement Program Policy and Procedure with revised date 05/19, shows, Policy: The facility is committed to providing safe care that maximizes client's quality of life while maintaining a safe work environment for employees. The safe client movement program includes client movement equipment, employees training, client plan of care and a culture of safety approach in the work environment. Employee responsibilities: It is the responsibility of the employee to take reasonable care of their own health and safety as well as that of their clients and co-worker during client movement activities. Employees are expected to follow this policy; non compliance will indicate the need for re-training and/or disciplinary action. Procedure: Gait belts will be used unless medically contraindicated.

Based on interview and record review the facility failed to address residents needs after call lights are answered. This applies to 3 of 6 residents (R19, R73 and R123) in the sample of 12 and 3 residents outside the sample (R16, R75 and R173). The Findings Include: On 6/13/2018 at 10:00AM, R19, R73, R123, R16, R75 and R173 all said it takes a while for staff to answer the call light. R16, R19, R73 and R123 were all in wheelchairs and R75 and R173 ambulated via walkers. The residents said after putting the light on staff will come in acknowledge the light and say they will return but when staff return it is often almost 45 minutes later. The residents stated they put the call light on for assistance to the toilet and pain medications. The Resident Council Minutes- Skilled Nursing notes were reviewed from 6/2017 to (MONTH) (YEAR). The following dated minutes ( 6/23/2017, 8/25/2017, 9/29/2017, 11/28/2017, 1/26/2018 3/23/2018 all documented residents had concerns with slow call light response time. On 6/13/2018 at 12:43PM, V3(Nurse) said V1(Administrator) keeps a log of call light response time. On 6/13/2018 at 2PM, V1(Administrator) said the facility does keep a log of call light response time. V1 said the log documents how long the light was on but it does not address when the residents needs were met. V1 said she will provide education for the staff on addressing the residents needs. The Facility's Policy titled: Staff Call Response last reviewed 07/17 states that staff should answer the call, cancel it and provide the residents' needs.

Based on observations, interviews and record reviews, the facility failed to provide incontinence care and services to prevent moisture associated skin damage. This applies to 1 of 9 residents (R1) in the sample reviewed for incontinence. The Findings include: R1's Face Sheet showed R1 is an [AGE] year old with [DIAGNOSES REDACTED]. R1's most recent Minimum Data Set (MDS) Assessment, dated April 13, 2017, showed R1 is always incontinent of bowel and bladder. The care plan for R1, dated February 28, 2017 showed intergluteal cleft fissure opened due to moisture from incontinence was a focus of R1's care in the past. The Braden Scale Risk Assessment completed for R1 on April 26, 2017, showed R1 was at high risk for skin breakdown. This risk assessment identified multiple factors such as: skin moisture, and requires moderate to maximum assistance in moving. R1's plan of care, with a goal date of May 27, 2017, showed R1 is always incontinent of bowel and bladder related to Dementia. The goal in R1's care is for R1 not to develop skin breakdown from incontinence. The nursing interventions were not specific in identifying what staff needed to do to achieve this goal. R1's care plan instructed staff to check R1 for incontinence, but did not identify how often he needed to be checked. On May 3, 2017 and May 4, 2017, R1 was observed up in a reclining wheel chair in the morning (9 AM till after Noon meal). R1 is tall and obese, his body covered the width of the recliner and had no room for repositioning. On May 4, 2017 at 1:20 PM, R1 was placed back in bed by two certified nurses aides (E6 and E7). R1's adult incontinent pad was removed and a large area of redness with small opened area were observed. E3 (Nurse RN) came to R1's bedside to observe his skin condition. E3 measured the redness to R1's skin as 6 x 9 cm and described it as excoriation. E3 stated R1 has a small opened areas, which E3 measured them to be 0.5 x 1 cm. E3 said this was a new opened area. E3 stated that R1 has had excoriation in the past with opened areas, which opened and closed. E3 said the nursing staff usually apply duoderm dressing. Later on May 5, 2017 at 12 PM, E3 stated R1's large redden area was caused by R1 being wet and sitting for long periods of time in his chair. E3 said R1 usually gets up between 6:30 AM and 7:00 AM, and will not be put back to bed until 1:00 PM. E3 stated the family requested he stay up and go to activities. E3 stated the nursing staff should be checking R1 for incontinence every hour. But, R1's care plan was not this specific. At 10:00 AM on May 5, 2017, E2 (director of nursing) said R1 did not have a turning and toileting schedule at this time. E2 also stated a large recliner would be ordered for R1 to allow better positioning of R1. The facility's Incontinence Policy, dated April 2006, showed: Skin Related Complications Skin problems associated with incontinence and moisture can range from irritation to increase risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during reposition. (d) Habit Training / Scheduled Voiding is a behavioral technique that calls for scheduled toileting at regular intervals on a planned basis .

Based on observation, interview, and record review the facility failed to conduct a comprehensive assessment to analyze the root cause of the development and worsening of residents' pressure injuries. Failed to develop a skin care plan to address the residents' specific areas of pressure injuries and implement an individualized interventions based on their specific needs. This applies to 2 of 2 residents (R5 and R4) in the sample of 10 residents reviewed for pressure injuries. The findings include: On May 3, 2017 at 9:40 AM, R5 was noted sitting in his wheelchair, alert, oriented, and hard of hearing. R5's electronic admission record shows he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility presented weekly pressure ulcer report on May 3, 2017 showed, on April 6, 2017 R5 developed a Stage 2 pressure injury on the right upper buttocks measured at 2.5 cm X 1.2 cm X 0.2 cm with slough. The percentage of slough was not identified. On April 20, 2017, R5 acquired another area of pressure injury on the left upper buttocks measured 1.0 cm X 0.5 cm described as dry scab. R5's wound doctor's progress report dated March 24, 2017 showed right buttocks stage 2 which was excoriated. On May 4, 2017 at 9:15 AM, E 2 (Director of Nursing) stated, The acquired Stage 1 on R5's left buttocks was healed on April 28, 2017 and the one on the right buttocks (initially staged as Stage 2) which is now Unstageable (due to slough formation). E2 was unable to present a comprehensive assessment of R5's pressure injury, to show the facility conducted an assessment to analyze R5's root cause and risk factors for the development and worsening of R 5's pressure injuries on his buttocks. R5's skin care plan showed pressure injury, but the care plan did not identify the sites of his pressure injuries. The interventions included: assess and record the size, monitor signs and symptoms of infection, implement treatment, provide care according to protocol for stage 2 and do not massage skin over bony areas . These interventions are generalized and not specific to R5's physical condition. On May 4, 2017 at 3:00 PM, R5 stated, I developed my wounds like they say bed sore (pointed at his bed) from staying too much in bed. They (staff) say had gotten better and started to position me better using those pillows when I am in bed. Those pillows help me a lot not to put too much pressure when I am in bed. On May 4, 2017 at 3:00 PM during skin assessment E5 (Nurse on Duty) identified, described, and provided measurement as following: Right buttocks with compromised area circumference of 4. 0 cm X 5. 0 cm , reddened area and with two open wounds (a) right anterior aspect with 100% tan colored slough and posterior wound with necrotic area at the base of the wound, these open wound was measured at 3.0 cm X 1.5 cm. These were identified as unstageable pressure injuries. A left buttock was identified with 1.0 cm X 1.0 cm, non-blanching reddened area with 0.5 cm X 0.5 cm with an open area on the middle, identified as stage 2. The pressure injuries noted on R5's right buttocks progressed from a stage 2 to an unstageable and a new stage 2 on the left buttocks. On May 3, 2017, the facility identified per their weekly pressure ulcer report R4 having redness (stage 1) 5.0 cm x 9.0 cm on buttocks area. On May 4, 2017 at 9:30 AM, E3 (Nurse RN) changed dressing on R4's pressure injury on his coccyx and right buttocks. E3 measured R4's pressure injury site and identified as following: 1. 9.0 cm x 10.0 cm red-purplish (stage 1) on coccyx area. This area remained red-purple even after 20 minutes of relieving pressure. 2. There were three small areas (1.0 cm x 0.2 cm; 0.2 cm x 0.1 cm; and 0.1 cm x 1.5 cm) of opened excoriation areas on right buttocks. The facility did not identify these areas in the weekly pressure ulcer report. E3 stated these areas are from friction and shearing. On May 4, 2017 at 9:40 AM, E3 stated R4 gets up only on Tuesdays and Thursdays of the week, but recently he has not been willing to get up. There is no documentation to show if the facility explained risks and benefits of R4's non-compliance to treatment, so R4 could make an informed decision to decline or comply with pressure injury prevention interventions. On May 4, 2017 at 9:15 AM, Z1 (R4's care giver) stated R4 is transferred with a sliding board, some times he transfers R4 with one assistance of one facility staff. Z1 also said R4 likes to stay in his bed on his back. Z1 said, R4 tells him when his incontinent brief needs to be changed. Z1 was not aware of R4 having any pressure injury. The facility identified R4 per his October 2016 Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) score of '14,' meaning he is alert and oriented to time, place and person. On May 4, 2017 at 9:50 AM, R4 stated now he (R4) knows the importance of keeping pressure off his back he will, but wanted to know who is going to keep track of his care plan. The facility identified R4 to be at risk for acquiring pressure injury per his May 3, 2017 Braden Scale risk score of '12.' The risk assessment areas indicated: mobility, moisture, friction and shearing, nutrition, and activity. There is no further analysis of these risk factors to develop individualized interventions for the pressure injury prevention. R4's September 30, 2015 pressure injury plan of care interventions are vague, generalized not specific for the prevention or to promote healing of his pressure injury. On May 4, 2017 at 10:00 AM, E2 the Director of Nurses stated R4's open areas are from sliding board transfer and his care plan interventions will be revised.

Based on observation, interview, and record review the facility failed to identify target behaviors and obtain medical justification for the use of anti-psychotic medication. This applies to 1 of 1 resident (R7) reviewed for the use of antipsychotic medication in the sample of 10 residents. The findings include: On May 3, 2017 at 10:20 AM, R7 was alert and oriented. The facility staff claimed R7 has not observed to have any behavior at all. R7's Physician order [REDACTED]. On May 4, 2017 at 11:25 AM, E 2 (Director of Nursing) explained, R7 has no behavior problem. He was admitted from the hospital with this order (on April 28, 2017), we do not discontinue any antipsychotic medication until the patient is seen by a psychiatrist. On May 5, 2017 at 10:00 AM, E 2 stated, we called the attending physician last night (May 4, 2017) and said the reason why the medication was prescribed to him was due to post op (surgical) [MEDICAL CONDITION] and if there's no behavior the medication could be discontinued.