Every finding on record at Perham Living

Based on interview and document review, the facility failed to ensure the consulting pharmacist (CP) identified and acted upon an irregularity for psychotropic medications for 1 of 1 resident (R2) reviewed who was on a psychotropic medication. Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], identified R2 had intact cognition and was dependent on staff for activities of daily living (ADLs). R2 had not exhibited any behavioral symptoms. Diagnoses included Parkinson's disease, paraplegia, dysfunction of bladder, cardiomyopathy, dysphagia, hallucinations, and unspecified mental disorder due to known physiological condition. R2's Physician Progress Note for Nursing Home Visit dated 2/5/26, identified R2 was being seen by R2's primary care provider (PCP)-A for gastrointestinal concerns and tremors. The assessment/plan was identified as splenic infarct-ultrasound of abdomen complete, anemia- complete blood count with differential, hallucinations - quetiapine (Seroquel) 25 milligrams (mg) one time per day, and gastroesophageal reflux disease- omeprazole 20 mg one time per day. The plan identified R2 would resume Seroquel 25 mg per day as it had seemed R2 was better on the medication. A complete blood count (CBC) was ordered and a scheduled ultrasound. After the visit, an abnormal CBC and hemoglobin was identified and R2 was sent to the emergency department for further evaluation. Although R2 PCP-A restarted the Seroquel there was no identification of new onset of symptoms warranting the antipsychotic medication. R2's physician order dated 2/9/26, identified and order for quetiapine fumarate (Seroquel and antipsychotic) 25 milligrams (mg) to be given one time per day related to hallucinations.R2's Pharmacy Consultant Medication Review/Recommendations dated 2/23/26, identified R2 had medication changes as well as recent hospitalization. Seroquel, low dose, was restarted as R2 seemed better with it. Warfarin adjusted, vitamin K added, potassium increased, and omeprazole restarted. Multiple lab results noted and hypokalemia resolved. No recommendations. R2's medical record lacked evidence of R2 having any hallucinations, delusional thoughts, inappropriate communication or removing his clothing nor was there any ongoing behavioral monitoring.During interview on 3/24/26, at 3:46 p.m. RN-A stated staff and R2's spouse had been noting an increase in R2's tremors since his Seroquel had been stopped. RN-A thought R2 had been using his PRN carbidopa/levodopa more frequently, nearly daily since the Seroquel had been stopped. She had addressed the increase tremors with R2's PCP, and he had restarted the Seroquel. RN-A was sure there was weekly psychotropic medication monitoring for side effects but was unable to find any documentation of targeted behaviors such as hallucinations. RN-A thought the spouse had reported the behaviors, but it had not been documented. During telephone interview on 3/24/26, at 4:54 p.m. the consulting pharmacist (CP)-B stated he usually looked at the resident discharge summary and would have looked to see if the physician indicated the psychotropic medication was restarted for a psychotic episode or delusions. CP-B knew R2 had a diagnosis of hallucinations for the medication, and the medication was at a low dose. R2's physician would have never started Seroquel for tremors. CP-B had not reviewed if behavior or hallucinations had been monitored and/or documented for R2. CP-B did not review the physician indications for the restart of the medication and had just noted the medication had been restarted with a diagnosis of hallucinations. CP-B would have certainly commented if the indication for the restart of Seroquel was listed as tremors.The facility policy Psychotropic Medications dated 3/10/26, identified physicians and mid-level providers would use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. The facility would support the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications could be utilized to meet the needs of the individual resident. The pharmacist and/or consulting pharmacist would monitor psychotropic drug use in the facility to ensure that medications were not used in excessive doses or for excessive duration. The CP would participate in the interdisciplinary quarterly review of residents on psychoactive medications and notify the physician and the nursing unit if/when a psychotropic medication was past due for review.

Based on observation, interview and document review, the facility failed to comprehensively assess and develop interventions following a fall to reduce the risk of falls for 1 of 3 residents (R1) reviewed for accidents. Findings include: R1's Fall Assessment and Interview dated 3/5/36, identified R1 had falls during the last month, as well as in the last two-to-six-month period. R1 took diuretic, hypoglycemic, antiseizure, non-steroid anti-inflammatory and cathartic medications. R1 had good memory, and vision and was continent of bowel and bladder. No behavior was identified and R1 used an assistive device with ambulation. R1's risk score was six which represented a moderate risk for falls. R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition and was independent with activities of daily living. R1 was continent of bladder and had a colostomy. R1 had occasional complaints of pain. Diagnoses included congestive heart failure, heart disease, diabetes, Parkinson's disease, dementia and use of hypoglycemic medications. R1's progress note dated 3/15/26, identified R1 had placed his call light on. R1 was found lying in bed and reported to staff he had fallen. A skin tear was noted on his right elbow and bruising noted to his left inner upper arm. R1 stated he did not call staff as he thought he could do it himself, however, the note did not identify what it was R1 had been trying to do. Later, R1 complained his bottom hurt. R1's care plan dated 3/18/26, identified R1 was at risk for falls related to Parkinson's symptoms with impaired balance. Staff were directed to anticipate and meet his needs; be sure his call light was within his reach and encourage R1 to use the call light for assistance when needed. Staff were directed to promptly respond to all requests for assistance. Staff were to educate R1 and family about safety reminders and what to do if a fall occurred, encourage R1 to change positions slowly, ask for assistance when walking off the unit when needed and encourage to call if a fall occurred. Staff were to ensure R1 was wearing appropriate footwear with ambulation, and monitor blood glucose and sleepiness to see if other symptoms developed. R1 had a necklace style pendant to use for emergencies when he needed staff assistance. The most recent interventions had been added on 2/5/26. R1's physician progress note dated 3/20/26, identified R1 was seen by his primary physician (PCP)-C. R1 complained of persistent pain in his buttocks following a fall that had occurred two days previously. No open wounds or fractures were reported, and the discomfort was being managed with acetaminophen as needed. R1 also reported ongoing bilateral lower back pain that had begun after his recent fall. Pain was localized to the lower back. R1's mobility was maintained but R1 had continued complaints of muscle pain and repeated falls, which were attributed to weakness and deconditioning. acetaminophen did provide relief and R1 was considering Aspercreme for additional pain management. The assessment and plan identified R1 complained of back pain, possibly from frequent falls. PCP-C examined R1 and noted the pain appeared to be at the level of lumbar five, in the middle, but no deformities were noted. PCP-C ordered Aspercreme and to work with physical therapy. R1's medical record lacked evidence the fall on 3/15/26 was assessed for potential factors that may result in a fall including but not limited to: Environmental hazards, such as wet floors, poor lighting, incorrect bed height and/or width, or improperly fitted or maintained wheelchairs; Unsafe or absent footwear and loose or improperly worn clothing; Underlying chronic medical conditions, such as arthritis, heart failure, anemia and neurological disorders; Acute change in condition such as fever, infection, delirium; Medication side effects; Orthostatic hypotension; Lower extremity weakness; Balance disorders; Poor grip strength;, Functional impairments (difficulty rising from a chair, getting on or off toilet, etc.); Gait disorders; Cognitive impairment; Visual deficits; Pain; and Incontinence.; along with an analysis and interventions, if warranted, to reduce the incidents of future falls. On 3/23/26, at 2:18 p.m. R1 was observed just getting up to a sitting position on the side of his bed. R1 stated he had fallen the week previous in his room and had hurt his back. R1 was not sure why or how he fell. R1 stated he had just been walking across his room and fell. R1 stated he had then got himself up off the floor and proceeded to the bathroom, where he experienced another fall. R1 stated his back really hurt. On 3/23/26, at 5:37 p.m. The door to R1's room was partially open and R1 was observed getting up to a sitting position on the side of his bed. R1 was barefoot. R1 stated his back was really hurting from a fall that had occurred a few days ago. When interviewed on 3/24/26, at 11:49 a.m. nursing assistant (NA)-A stated R1 was independent with all of his care. The staff did not do anything for R1 except for on his bath day, which they help him with. R1 did have falls in the past but had not had any recent falls that she was aware of. R1 did spend a lot of time in his room with the door closed, and there were times NA-A would try to prop his door open but then R1 would get up and close it. The staff did not check on R1 at all, but he would ring his call light if he needed anything. R1 was pretty independent. During interview on 3/24/26, at 12:03 p.m. registered nurse (RN)-C stated the charge nurse on duty who discovered a resident had fallen would try to figure out what had occurred and report to the unit manager who would then update the care plan if any new interventions were added. RN-C was not sure why R1's last fall did not have a post fall analysis completed and would need to ask the unit manager. When interviewed on 3/24/26, at 12:15 p.m. RN-A stated R1's last fall of 2/27/26 and it was reviewed at the facility's interdisciplinary fall team (fall IDT) meeting that met weekly. A new intervention was added to offer R1 a snack when he was visiting with his spouse on another unit. RN-A was aware R1 had fallen the week previously as she had just noticed it documented in the nurse progress notes. RN-A planned to follow up with the nurse that discovered the fall and have her put in a post fall analysis report under the assessment tab as well record it in risk management. The weekly fall IDT team reviewed risk management for all the falls that had occurred. The IDT team did not review R1's fall when they met on 3/18/26, because it had not been recorded in risk management and so they were not aware a fall had occurred. RN-A stated she planned to have IDT discuss the fall during the current week meeting. RN-A stated an analysis of R1's fall had not been completed because the nurse that discovered the fall did not complete all the required steps for recording the occurrence and did not follow the facility's fall procedures. On 3/24/25, at 3:05 p.m. the assistant administrator stated the facility did weekly fall meetings and AA-C felt the team went over resident falls pretty thoroughly. AA-C would expect staff to document resident falls objectively and put all the information into the documentation to obtain the correct interventions, in order to keep residents safe. During interview on 3/24/26, at 3:15 p.m. the assistant director of nursing (ADON)-D stated when a resident fell, an email notification went out to the registered nurse case manager group to notify them of the fall. The fall IDT obtained resident fall information by reviewing the post fall analysis forms that were completed any time a resident had a fall. ADON-D would have expected the RN case manager to follow up on a note that was documented in a resident chart regarding a fall. If a post fall analysis form had not been completed following a resident fall, then the facility's fall procedure had not been followed and as a consequence, the fall IDT group would not have reviewed the fall to try to determine the root cause of the fall and/or identify any interventions that could have been attempted to prevent future falls. The facility policy Fall Protocol dated 3/10/26, identified the purpose was to ensure timely, accurate, and appropriate assessment and documentation of all fall events, while identifying and addressing potential risk factors to prevent recurrence and enhance resident safety. Following a fall the staff would conduct a post fall huddle involving all staff present or involved and gather and document relevant details. The nurse would document the fall event under the risk management tab in the facility system. The nurse would ensure the who, what, where, why and how the fall occurred was included. The nurse would complete the post fall analysis report and update the resident's care plan and Kardex to reflect new fall prevention interventions.

Based on observation, interview and document review, the facility failed to ensure clinical justification and behavior monitoring for the use of an antipsychotic medication for 1 of 1 resident (R2) reviewed who was on a psychotropic medication. Findings include:R2's significant change Minimum Data Set (MDS) dated [DATE], identified R2 had intact cognition and was dependent on staff for activities of daily living (ADLs). R2 had not exhibited any behavioral symptoms. Diagnoses included Parkinson's disease, paraplegia, dysfunction of bladder, cardiomyopathy, dysphagia, hallucinations, and unspecified mental disorder due to known physiological condition. R2's Physician Progress Note for Nursing Home Visit dated 2/5/26, identified R2 was being seen by R2's primary care provider (PCP)-A for gastrointestinal concerns and tremors. The assessment/plan was identified as splenic infarct-ultrasound of abdomen complete, anemia- complete blood count with differential, hallucinations - quetiapine (Seroquel) 25 milligrams (mg) one time per day, and gastroesophageal reflux disease- omeprazole 20 mg one time per day. The plan identified R2 would resume Seroquel 25 mg per day as it had seemed R2 was better on the medication. A complete blood count (CBC) was ordered and a scheduled ultrasound. After the visit, an abnormal CBC and hemoglobin was identified and R2 was sent to the emergency department for further evaluation. Although R2 PCP-A restarted the Seroquel there was no identification of new onset of symptoms warranting the antipsychotic medication.R2's Psychotropic Medication Use Care Area Summary (CAA) dated 2/27/26, identified R2 was restarted on an antipsychotic medication by PCP-A for increased tremors. R2 had a history of hallucinations, and his PCP indicated his mental status seemed to be better when on the antipsychotic medication. The summary indicated the care plan reflected interventions to remain free from adverse effects of the antipsychotic medication and R2 would maintain relief from hallucinations and tremors. Staff were to monitor for side effects per protocol and update the PCP with any concerns. The CAA indicated target symptoms were noted in plan of care with non-pharmacological interventions.R2's care plan dated 3/5/26, identified R2 was administered the psychotropic medication Seroquel related to hallucinations. Staff were directed to administer the medication as ordered, consult with pharmacy and PCP to consider dose reduction when appropriate, educate resident and family about the risks, benefits and side effects and/or toxic symptoms of the drug being given and discuss with PCP and family regarding the ongoing need for the use of the medication. Staff were also directed to monitor and record occurrences of targeted behaviors symptoms, which included disrobing, inappropriate response to verbal communication, attempts to reach items that were not present and decrease hallucinations or delusional ideations and document. However, there were no non-pharmacologic approaches and interventions related to the target behaviors being monitored.R2's most recent Physician Order Report dated 3/24/26, identified quetiapine fumarate (Seroquel) 25 milligrams (mg) to be given one time per day related to hallucinations, with a start date 2/9/26. On 3/23/26, at 7:12 p.m. R2 was observed being wheeled into his room by his spouse. R2 stated he had just returned from a physician appointment and then a visit with his wife at his home. R2 stated he had lost some weight recently but was stabilizing. R2 had been in the hospital recently with a very bad urinary tract infection and had been on four different antibiotics. R2 stated the antibiotics had messed with his stomach and so he was not eating well. R2 was fully dressed and groomed. R2's left arm was hanging down over the wheelchair arm, with hand towards floor. R2 was eventually able to lift his arm up and over the arm of the wheelchair. Both of R2's hands were lightly closed and had difficulty moving his arms easily. No significant tremor was noted during the conversation. R2 answered questions appropriately and clearly. R2's nursing progress notes 11/1/25 to 3/23/26, identified the following:-12/5/25, R2 was a little bit confused as he answered football to questions two times. When further questioned, R2 answered all questions to person, time and place correctly. Staff would continue to monitor.-12/6/25, R2 went into urgent care for increase confusion and decrease urinary output. Returned with treatment ordered for a urinary tract infection. -1/5/26, R2 was seen on routine doctor rounds. It was noted R2 had been using his as needed (PRN) carbidopa/levodopa (a medication to treat Parkinson's disease) since around 12/10/25, for increase tremors, would try to stop that PRN medication and see how it went. -2/5/26, R2 had an upcoming appointment with his PCP that day for acute issues of upset stomach, decreased appetite, with question if should go back on omeprazole (to treat excess stomach acid), R2's weight was down. R2 had increased tremors with question to discuss going back on Seroquel. -2/5/26, R2 was seen in the clinic for a follow up visit on abdominal symptoms and start of anticoagulation related to splenic infarction. Omeprazole and Seroquel were ordered. A CBC was ordered to be drawn that day, an ultrasound scheduled and speech therapy ordered. R2's medical record lacked any behavioral monitoring or evidence of R2 having any hallucinations, delusional thoughts, inappropriate communication or removing his clothing, prior to the restarting of the Seroquel.During interview on 3/24/26, at 3:29 p.m. registered nurse (RN)-B stated she helped manage psychotropic medications in the facility including managing orders and physician follow up. RN-B was aware R2 was on Seroquel and then they had tapered the medication down and stopped the medication in December 2025. RN-B stated R2 had hallucinations of water dripping on him and getting him wet, which distressed him. R2 reported his hallucinations to his spouse. RN-B was aware R2's Seroquel was restarted and then he went to the hospital and was still on the medication upon his hospital return. RN-B stated R2 did have targeted behaviors that were care planned, which included disrobing, inappropriate response to communication, attempt to reach for objects not present and hallucinations. RN-B stated there should be some type of behavior monitoring or staff should chart if there were any behaviors present. RN-B reviewed R2's medical record and stated she was unable to find any behaviors documented for R2. During interview on 3/24/26, at 3:46 p.m. RN-A stated staff and R2's spouse had been noting an increase in R2's tremors since his Seroquel had been stopped. RN-A thought R2 had been using his PRN carbidopa/levodopa more frequently, nearly daily since the Seroquel had been stopped. She had addressed the increase tremors with R2's PCP, and he had restarted the Seroquel. RN-A was sure there was weekly psychotropic medication monitoring for side effects but was unable to find any documentation of targeted behaviors such as hallucinations. RN-A thought the spouse had reported the behaviors, but it had not been documented. During telephone interview on 3/24/26, at 4:36 p.m. PCP-A stated he did not think he would have stated he was restarting R2's Seroquel for increase tremors, as increase tremors was not an indication of use for that medication. PCP-A would never prescribe any medications for treatment of R2 symptoms related to his Parkinson's disease, as R2 was being seen by a neurologist for his Parkinson's symptoms. PCP-A stated it had seemed R2 was mentally better when he was on the Seroquel and the medication was prescribed at a low dose. PCP-A stated he did restart the Seroquel before his labs came back that identified an infection and R2 was hospitalized . PCP-A stated he would have treated the infection first before restarting the Seroquel. The facility policy Psychotropic Medications date 3/10/26, identified physicians and mid-level providers would use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. The facility would support the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications could be utilized to meet the needs of the individual resident. Nursing would monitor for the presence of identified behaviors by charting occurrence and using behavior template. Nursing would review the use of the medication with the physician on a quarterly basis to determine the continued presence of targe behaviors and/or the presence of any adverse effects of the medication use.

Based on observation, interview and document review, the facility failed to implement appropriate donning/doffing of personal protective equipment (PPE) practices and to ensure PPE was readily available for use to prevent the spread of infection for 4 of 4 residents (R14, R3, R33, R58) observed for enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). In addition, the facility failed to ensure personal laundry was transported and delivered in a manner that prevented risk of contamination for 1 of 6 units observed for personal laundry transportation. Findings include: Review of Centers for Disease Control (CDC) guidance dated 4/1/24, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions (EBP) included: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R14 R14's quarterly Minimum Data Set (MDS) dated [DATE], identified R14 was cognitively intact and had diagnoses which included: diabetes mellitus, obstructive uropathy (disorder of urinary tract that obstructs urinary flow) and urinary tract infection. Indicated R14 had an indwelling urinary catheter. R14's care plan revised 4/25/24, identified R14 had a suprapubic catheter (a urinary catheter that drained urine from the bladder through a small incision in abdomen) secondary to benign prostatic hyperplasia (enlarged prostate) (BPH) with urinary retention and urinary obstruction. R14's care plan lacked EBP interventions to be used related to R14's indwelling device, the suprapubic catheter. R14's Order Summary Report dated 6/12/24, identified the following: -Suprapubic catheter change -20 french (F) Council Tip 5 cubic centimeters (cc) balloon: use 10 cc sterile water in balloon. One time a day every 28 day(s). During an observation and interview on 6/10/24 at 8:06 a.m., R14's room lacked signage of EBP and PPE was not available inside or outside R14's room. R14 confirmed he had a catheter and indicated staff wore gloves when caring for his catheter however, did not wear gowns. During an observation on 6/11/24 at 2:39 p.m., R14 placed his call light on in his room and stated he needed to have his catheter emptied. R14's room continued to lack signage of EBP and PPE was not available inside or outside R14's room. At 2:42 p.m. nursing assistant (NA)-A knocked and entered R14's room and R14 asked to have his catheter bag emptied. NA-A applied gloves and gathered equipment of a graduate (plastic container used to measure liquids), paper towel and alcohol wipes. NA-A placed the paper towel on the floor next to R14's left foot and placed the graduate on the paper towel. NA-A opened an alcohol wipe and placed that on the paper towel next to the graduate. NA-A opened R14's catheter bag, drained the urine into the graduate, clamped the tubing, wiped the opening with alcohol, closed the tubing, went to the bathroom and emptied the urine into the toilet. NA-A returned to R14 and repeated the process to finish emptying the urinary catheter. NA-A disposed of the paper towel, emptied the graduate, rinsed the graduate, removed her gloves and completed hand hygiene. NA-A did not wear a gown during the high contact activity of emptying R14's urinary catheter. During an interview on 6/11/24 at 2:48 p.m., NA-A stated was unaware of what EBP was, and indicated had not been instructed to wear a gown when accessing R14's catheter or completing high contact resident care activities. 48583 R3 R3's quarterly MDS dated [DATE], identified R3 was cognitively intact and had diagnoses which included: diabetes mellitus, cancer, peripheral vascular disease (a condition where narrowed blood vessels outside the heart cannot deliver sufficient oxygen and nutrients to the body) and neurogenic bladder (the nervous system and bladder function is disrupted by injury or disease). Indicated R3 had open pressure ulcers to both feet and an opening draining wound on right foot. R3's care plan revised 6/7/24, identified R3 had a recent surgical procedure (transmetatarsal amputation of the right foot), was partial weight bearing on right foot and was required to wear a Prevalon boot to right foot along with a [NAME] boot to left foot. R3 had activities of daily living deficits secondary to weakness. R3 required maximum assistance of one to dress and undress below the waist, transferring on and off the toilet, washing back side and adjusting clothing. During an observation on 6/10/24 at 1:16 p.m., NA-F was observed assisting R3 out of the bathroom after resident had placed his call light on for assistance. When entering the room, NA-F assisted R3 from toilet to wheelchair in bathroom. NA-F was not wearing gloves or a gown during R3's transfer. NA-F pushed R3 out of the bathroom into his room in his wheelchair. R3 was wearing a white stocking under a Prevalon boot to right foot. [NAME] stocking had visible red discoloration that was coming from underneath the stocking towards the end of R3's right foot. NA-F picked up R3's right foot and helped place it on the right foot pedal of the R3's wheelchair. NA-F was not wearing any gloves or gown while assisting with R3's foot placement. NA-F asked R3 if there was anything else that R3 needed and R3 declined any additional needs or assistance. NA-F exited R3's room, walked across the hallway and entered another resident's room to provide assistance. NA-F was not observed to wash her hands or use any hand sanitizer when leaving R3's room or entering another resident's room. During an interview on 6/12/24 at 2:02 p.m., NA-F confirmed she assisted R3 in the bathroom with adjusting his pants and assisted R3 to transfer to R3's wheelchair. In addition, NA-F confirmed she placed R3's leg onto his wheelchair foot pedal without wearing a gloves or a gown. NA-F indicated she was not aware she needed to wear any EBP items when assisting R3. NA-F stated she was aware of the cart in R3's room containing EBP PPE in R3's room however was not aware why it was in there or what she was expected to do with it. NA-F stated she read the policy on EBP on her own while working to educate herself on the facility's expectations and guidelines however had not received any formal training on EBP. 49620 R33 R33's quarterly MDS dated [DATE], identified R33 was cognitively intact and had diagnoses which included: diabetes mellitus, chronic kidney disease stage five, end stage renal disease, dependence on renal dialysis. Indicated R33 had a central port. R33's care plan revised 8/25/20, identified R33 had a central line dialysis access to the right side of chest. A central venous catheter (CVC) is a type of access used for hemodialysis. Tunneled CVC's are placed under the skin and into a large central vein. Dialysis (a blood purifying treatment given when kidney function is not optimum). R33's care plan lacked enhanced barrier precautions (EBP) interventions to be used related to R33's indwelling devise, the central venous catheter. R33's Order Summary Report dated 5/21/24, identified the following: -Dressing change to central line right sided chest wall as needed. Change if dressing was not intact. Was routinely changed at dialysis. R58 R58's quarterly MDS dated [DATE], identified R58 was cognitively intact and had diagnoses which included: venous stasis ulcers to bilateral lower extremities (wounds that develop because of problems with blood circulation) and urinary retention (disorder of urinary tract that obstructs urinary flow). Indicated R58 had an indwelling urinary catheter. R58's care plan revised 4/07/24, identified R58 had an indwelling foley catheter (a urinary catheter that drained urine from the bladder inserted through the penis) secondary to urinary retention. R58's care plan revised 6/5/24, identified R58 had venous stasis ulcers. Treatment and dressing change as ordered. R58's care plan lacked EBP interventions to be used related to R58's indwelling device, the indwelling foley catheter and venous ulcer wounds to bilateral feet. R58's Order Summary Report dated 5/30/24, identified the following: -Apply betadine to right lateral foot sore, cover with telfa and kerlix gauze, one time a day. -Iodine topical solution apply to bilateral foot ulcers one time a day. R58's Order Summary Report dated 5/30/24, lacked documentation for care of the urinary foley catheter. During an observation and interview on 6/10/24 at 1:22 p.m., R33 confirmed he had a CVC used for dialysis. R33 stated he returned from dialysis today and the EBP bins and a sign on the inside of his door were placed in his room while he was at dialysis. R33 stated staff informed him they would now wear gowns and gloves when completing cares. R33 confirmed the facility staff had not been using gowns and gloves prior to that time. During an observation and interview on 6/11/24 at 6:39 p.m., R58 confirmed he had a foley catheter and wounds present on both feet. R58 stated the EBP bins and sign on the inside of his door in his room were placed a few days ago and he had been informed by staff they would start to wear gowns and gloves when completing cares. During an interview on 6/12/24 at 1:05 p.m., NA-E stated she was unsure when EBP were initiated for R33 and R58. NA-E asked clinical manager-B who verified EBP were initiated on 6/10/24, for R33 and R58. During an interview on 6/12/24 at 1:24 p.m., licensed practical nurse (LPN)-A stated EBP were initiated within the past week for R33 and R58. LPN-A stated EBP for all residents that required EBP would not go into effect until July sometime. 49014 LAUNDRY During an observation on 6/11/24 at 1:50 p.m., NA-B carried and delivered two shirts on hangers to R279's room and had clean laundry under both arms pressed against her uniform and delivered these laundry items to R73's room. During an interview on 6/11/24 at 1:54 p.m., NA-B verified she held clean laundry items against her uniform. NA-B stated the normal process was to deliver clean laundry to rooms in baskets and carry it away from the body to prevent cross contamination. NA-B stated she should have placed the clean laundry in baskets to deliver to R279 and R73. During an interview on 6/11/24 at 4:34 p.m., director of nursing (DON) confirmed the facility had not implemented EBP procedures and planned to implement them on 7/1/24. DON indicated they had a family council meeting to inform them of EBP procedures and stated the family members were not happy about it. DON stated they had started education on EBP implementation however, not all staff had received education at that time and not every resident who required EBP had PPE supplies for their rooms. During a follow-up interview on 6/12/24 at 12:12 p.m., DON stated her expectations of transporting clean laundry was that staff would have carried clothing items in baskets, covered them with a cloth/towel or delivered them on the covered linen carts. DON further stated staff should not have held clean laundry against their uniform to prevent the spread of infection. During an interview on 6/12/24 at 1:04 p.m., registered nurse infection preventionist (IP)-A confirmed she had been aware of EBP and had first received information about EBP on 7/22. IP-A stated Centers for Medicare & Medicaid Services (CMS) had sent out QSO 24-08 Enhanced Barrier Precautions In Nursing Homes To Prevent The Spread Of Multidrug-Resistant Organisms (MDROs) dated 3/20/24, which she referred to, and confirmed the effective date for implementation was 4/1/24. In addition, IP-A referred to the CMS survey pathway for Infection Prevention, Control & Immunizations, and stated that was available on 4/1/24. IP-A confirmed the facility had not implemented EBP yet at the facility and were in the process of working on it. IP-A verified residents who required EBP included those identified with MDROs' colonized or not, anyone with indwelling devices and wounds such as diabetic wounds and pressure ulcers. IP-A confirmed R14 had an indwelling device, a suprapubic catheter. The untitled, undated facility form provided by the facility identified columns which included: Resident Name, Unit Name, MDRO, MDRO, and Concerns. The column of resident names identified some of the residents as (does not meet criteria) under the resident's name. The residents identified on the form who did not have (does not meet criteria) under their name, included the following: -Pine Harbor-one resident,concern: ostomy -Harvest Glen-two residents-concerns: suprapubic catheter in place, and indwelling catheter -Timbergrove-two residents-concerns: G-tube present with water flushes, and indwelling catheter -[NAME]-four residents-concerns: central port dialysis catheter in place, ostomy, indwelling catheter, daily antibiotics, and indwelling catheter with wounds to lower extremity (LE) -Prairie [NAME]-one resident-concern: hemodialysis catheter -Transitions-two residents-concerns: multiple wounds to LE, open wounds to toes, wound vac on his stump post-op (following surgery) The facility policy titled Enhanced Barrier Precautions (EBP) undated, identified it was intended to prevent the transmission of drug resistant pathogens. The policy identified EBP included the use of PPE, specifically gowns and gloves during high contact activities for residents. High contact activities were defined as dressing/bathing, transferring, changing linens, assisting with toileting, accessing indwelling medical devises, providing wound care, and other activities that provide opportunities for transfer of MDROs to staff hands and clothing. An indwelling medical devise included central lines, PICC lines (line inserted into vein in arm that passed to larger veins near the heart), urinary catheters, and feeding tubes. Review of a facility policy titled Linens: Collecting, Sorting, Transport & Storage reviewed 6/2020, identified package, transport and store clean textiles and fabrics by methods that will ensure their cleanliness and protect them from dust and soil during loading, transport and unloading. Further identified Clean linens shall be transported to patient/resident care areas by use of covered carts by hospital or nursing home staff.

Based on observation, interview and document review, the facility failed to maintain wheelchairs in a clean and sanitary manner for 1 of 2 residents (R62) whose wheelchair cushion was visibly soiled and armrests were torn. In addition, the facility failed to maintain standing lifts shared by residents in a clean and sanitary manner. Findings include: R62's quarterly Minimum Data Set (MDS) dated [DATE], identified R62 had moderate cognitive impairment and had diagnoses which included progressive supranuclear ophthalmoplegia (eye aim is off and can cause loss of balance), hypertension (elevated blood pressure), and osteoporosis (softening of bones). Identified R62 required substantial assistance with activities of daily living (ADLs) which included bed mobility, transfers, and toileting. Further identified R62 utilized wheelchair for mobility. During an observation on 6/10/24 at 8:10 a.m., R62 was being walked by staff with wheelchair following. Both arm rests on R62's wheelchair were cracked and wheelchair cushion was soiled with a dry white substance. During an observation on 6/10/24 at 8:15 a.m., two standing lifts located in the hallway cubby of the facility had brown, crumb-like debris on both foot plates. During an observation on 6/11/24 1:45 p.m., R62 was lying in bed, both arm rests on R62's wheelchair continued to be cracked and wheelchair cushion continued to be soiled with a dry white substance. During an observation on 06/11/24 at 1:48 p.m., two standing lifts located in the hallway cubby of facility continued to have brown, crumb-like debris present on the foot plates. During an interview on 6/11/24 at 12:10 p.m., nursing assistant (NA)-B verified brown crumb-like particles on both standing lift footplate's. NA-B further verified R62's arm rests were both torn and wheelchair cushion was soiled. NA-B stated staff were expected to fill out a maintenance slip for wheelchair repairs. NA-B stated staff wiped lifts down with cleansing wipes after each use and there was a cleaning process and checklist for the night shift to complete. NA-B was unsure the last time the lifts or R62's wheelchair cushion had been cleaned. During an interview on 6/11/24 at 12:10 p.m., registered nurse (RN)-B verified the foot plates to both standing lifts had a brown crumb like substance present. RN-B indicated there was a handheld vacuum to clean the plates and/or cleansing wipes to wipe them down with. RN-B stated it was the night shift's responsibility to clean the lifts and wheelchair cushions. RN-B indicated it was her expectation that staff would have filled out a maintenance slip for the repair of R62's wheelchair. During an interview on 6/11/24 at 2:22 p.m., maintenance director (MD) verified both arm rests were cracked on R62's wheelchair. MD stated his expectation was that staff would have filled out a maintenance slip so he could have replaced the arm pads to R62's wheelchair. During an interview on 6/12/24 at 12:12 p.m., director of nursing (DON) stated nursing staff were responsible for cleaning the lifts and wheelchairs and for completing a maintenance slip for wheelchairs that required repair. DON indicated her expectation was staff would have followed the process for cleaning of equipment and repair of wheelchairs. A facility task sheet titled Night Task Sheet undated, identified staff were to clean wheelchairs and wipe off EZ lifts and stands on Wednesdays. Further identified all staff were to wipe off EZ lifts and stands as needed. A facility policy titled Wheelchair Repair revised 10/16/23, indicated when staff identified a wheelchair needed repair staff were to fill out a maintenance request and maintenance would have repaired the wheelchair or ordered parts if needed.

Based on observation, interview and document review, the facility failed to ensure an evaluation of causal factors was completed after each fall. In addition, the facility failed to consistently develop and implement relevant interventions for 1 of 2 residents (R73) who had repeated falls in the facility and remained at high risk for falls. Findings include: R73's quarterly Minimum Data Set (MDS) dated [DATE], identified R73 had diagnoses which included cerebral infarction (stroke), visuospatial deficit (a term used to describe a range of cognitive impairments that affect the ability to perceive, process, and use visual and spatial information) and spatial neglect following cerebral infarction, incontinence, and hypertension (high blood pressure). Identified R73 had severe cognitive impairment and required extensive assistance with activities of daily living (ADLs), which included: bed mobility, transfers, and toileting. Indicated R73 required touching/steadying assist to complete ambulation. Identified R73 had two or more falls. R73's Significant Change Care Area Assessment (CAA) dated 3/7/24, identified R73 had completed skilled therapies and had progressed in ADL self-care, she had been working with staff on mobility ambulating to/from bathroom and at times out of room. R73's care plan initiated 2/4/24, identified R73 was at moderate risk for falls related to recent CVA (stroke), and decreased mobility, had cognitive impairment, required partial to moderate assistance with transfers to and from bed to chair (or wheelchair). Identified various interventions for fall prevention which included: anti-roll back applied to wheelchair, continue to intervene by having R73 seated in an area where staff could observe and intervene frequently, such as in the living room. Provide activities she enjoyed, such as wheeling to the courtyard, happy hour in the afternoon. Place wheelchair on resident right side, so can see and use it to hold onto if attempted to transfer. Wheelchair next to bed, when it bed. When in bathroom stay with resident, or stay just outside the bathroom to supervise her. Review of R73's resident fall assessment and interview form dated 5/31/24, identified R73 had the following conditions and factors present: forgetful and was not always able to make needs known, did not use call light appropriately, severe cognitive impairment, history of falls, one to two medications that had possible side effects that could increase risk for falls, and three or more predisposing diseases: visual deficits, balance issues, cognitive condition. Form indicated R73's fall risk score was 19, identifying R73 was at high risk for falls. Review of R73's falls incident reports and post fall analysis reports from 2/2/24 to 6/10/24, revealed the following: - on 2/24/24, incident report identified R73 had an unwitnessed fall and was found lying on her back in the middle of her room. She appeared to have slipped out of her wheelchair. She had gripper socks on and her call light was in reach. No injuries noted and R73 was unable to give description. Identified predisposing environmental and physiological factors: lost strength/balance, slipped, gait imbalance, weakness, incontinence, and impaired memory. - on 2/24/25, post fall analysis identified R73 had an unwitnessed fall in her room. It appeared R73 slipped out of her wheelchair, gripper socks on and call light was in reach. Identified R73 risk factors increasing fall risk: 14 (moderate risk), no falls since admission. Diagnoses identified visuospatial deficit, stroke, and high blood pressure. Identified R73 was forgetful and did not utilize call light, struggled with making her needs known. Identified root cause of R73 not remembering to use call light and attempted to self transfer. Identified intervention of continuing current fall interventions and PT to evaluate and treat as ordered or as needed (PRN). - on 3/22/24, incident report identified R73 had an unwitnessed fall and was found seated next to her bed, on her bottom, attempting to undress her undergarments. R73 was in a night gown, sleeping in per her usual, had both gripper socks on, shoes over, and wheelchair within reach of her bed. Her call light was also on her bed within reach. She was incontinent of urine in her brief, it appeared she was attempting to reach the toilet. No injuries noted and R73 unable to give description. Identified predisposing situation factor of ambulating without assist, but no predisposing environmental or physiological factors listed. - on 3/22/24, post fall analysis identified R73 had an unwitnessed fall and was found seated next to her bed on her bottom, attempting to undress undergarments. Gripper socks on, shoes, wheelchair and call light in reach. R73 was incontinent of urine. Identified risk factors increasing fall risk: 19 (high risk), with previous history of fall on 2/24/24. Diagnoses of visuospatial deficit, stroke, and high blood pressure. Identified root cause of R73 not remembering to use call light and attempted to self transfer. Identified therapies were completed on 2/29/24, and was unable to progress further due to short and shuffled gait pattern, and dependence on staff for steering her walker. - on 3/30/24, incident reported identified R73 had an unwitnessed fall and was found seated on the floor in her room, next to her bed. Back against the side of her bed with legs in front of her. R73 was not wearing any pants or brief. The pants and brief were next to her, brief was wet. Appeared she stood up, took off the brief and pants and then sat back down on the floor. No injuries noted and R73 unable to give description. Identified predisposing physiological and situation factors of incontinent, gait imbalance, and ambulating without assist. - on 3/30/24 at 755 a.m., post-fall analysis identified R73 was found seated on the floor in her room, next to her bed. Back against the side of her bed with legs in front of her. R73 was not wearing any pants or brief. The pants and brief were next to her, brief was wet. Appeared she stood up, took off the brief and pants and then sat down on the floor. The report revealed no injuries, no pain. Identified risk factors increasing fall risk: fall risk score of 19 (high risk), previous history of falls on 3/22/24, and diagnoses of visuospatial deficit and spatial neglect, stroke, and high blood pressure. Identified root cause: impulsive at times and doesn't always remember to use call. Appeared to have been incontinent and took off wet brief, had poor vision and left sided weakness related to stroke. Wheelchair was not in reach. Identified placing wheelchair next to bed as intervention. - on 4/19/24, incident report identified R73 had an unwitnessed fall and resident had slipped out of her wheelchair onto the floor. Upon entering pine harbor writer found R73 on the floor on her buttocks with her back against her wheelchair and her legs straight out in front of her. she was wearing shoes. No injuries noted and R73 unable to give description. Identified predisposing environmental, physiological, and situation factors: lost strength, slipped, gait imbalance, impaired memory, weakness/fainted, ambulating without assist and during transfer. -on 4/19/24 at 2:30 p.m., post-fall analysis identified R73 had slipped out of her wheelchair onto the floor. Upon entering Pine Harbor writer found R73 on the floor on her buttocks with her back against her wheelchair and her legs straight out in front of her. She was wearing shoes. Identified no injuries. Identified risk factors increasing fall risk: fall risk score of 19 (high risk), previous history of falls, diagnoses visuospatial deficit and spatial neglect, CVA (stroke), high blood pressure. She spoke fluent Spanish and staff utilized an interpreter to communicate. She was forgetful and did not utilize her call light and struggled with making her needs known. Root cause identified: was scooting in her wheelchair and scooted out onto her buttocks. Intervention identified as review information on past falls and attempt to determine cause of falls. Record possible root causes. -on 4/28/24 at 12:30 p.m., incident report identified R73 had an unwitnessed fall. Trained medication aide (TMA) notified nurse that resident had fallen. When writer got to resident, resident was already off the floor and seated in her wheelchair. TMA explained that resident was using the bathroom and the aide stepped just outside of the door for just a couple minutes to give her a little privacy, as she was having a bowel movement, and when she went back in just a couple minutes later resident was found on the floor in front of the toilet and attempted to get herself off the floor using the hand rails. No injuries noted and R73 unable to give description. Identified predisposing physiological factors: gait imbalance, impaired memory. No environmental or situation factors identified. Identified staying in bathroom with R73 or just outside of the bathroom to supervise. - on 4/29/24 at 2:04 p.m., post fall analysis identified R73 fell in bathroom after having a bowel movement, staff left R73 alone to provide privacy. R73 attempted to get off the floor using the hand rails. Identified risk factors increasing fall risk: fall risk score 19 (high risk), previous history of falls, diagnoses visuospatial deficit, CVA (stroke), high blood pressure. R73 spoke fluent Spanish and staff utilized interpreter for communication. R73 was forgetful and is not always able to make needs known and did not use call light appropriately. R73 was impulsive at times and did not use call light. -on 5/13/24, incident report identified R73 had an unwitnessed fall. R73 had self transferred into bed and had a bloody nose. R73 indicated that she bumped her nose on the side rail of the bed. No other injuries noted. Identified predisposing environmental, physiological, and situation factors: other, gait imbalance, and ambulating without assist. Review of R73's medical record lacked evidence of a post fall risk analysis for R73's fall on 5/13/24. -on 5/20/24, incident report identified R73 had an unwitnessed fall. R73 was found seated next to bed on the floor with her pants down. It appeared as if she was attempting to walk to the bathroom, back was resting against side table. No injuries noted. R73 stated she did not hit her head and was not dizzy, but she did have a headache. She did not complain of any other pain, resident stated she was trying to get to the bathroom. Identified predisposing environmental and physiological factors: poor lighting, lost balance, confused, gait imbalance, and weakness/fainted. - on 5/20/24 at 9:45 a.m., post fall analysis identified R73 was found sitting next to bed on the floor with her pants down attempting to find the bathroom. Translator was contacted through her iPad to have a better understanding of what happened, R73 stated she did not hit her head, but she does have a headache. R73 did not complain of any other pain and stated was trying to get to the bathroom. Identified risk factors increasing fall risk: fall risk score of 19 (high risk), previous history of falls, diagnoses visuospatial deficit and spatial neglect, CVA (stroke), high blood pressure. She spoke fluent Spanish and staff utilized an interpreter to communicate. R73 was forgetful and did not utilize her call light and struggled with making her needs known. Identified cause of fall R73 was impulsive at times and did not utilize call light. R73 was self transferring to get to bathroom. Identified intervention of moving call light closer to R73, on her when in bed. Check in on her around 7:30 a.m. to see if she needs to use the bathroom. - on 5/25/24 at 8:00 p.m., post fall analysis identified R73 was found sitting on floor between wheelchair and couch, with back resting against couch. No injuries noted. Identified risk factors increasing fall risk: fall risk score 19 (high risk), history of falls with last fall on 5/20/24. Diagnoses of visuospatial deficit, stroke, high blood pressure. Cognitive functioning identified R73 as forgetful, was not always able to make needs known and did not use call light appropriately. Identified root cause of R73 attempted to self transfer from wheelchair to couch. Identified intervention of having R73 sit in an area where staff could observe and intervene frequently. -on 5/29/24, incident report identified R73 had an unwitnessed fall. R73 was found sitting on floor between wheelchair and couch, with back resting against couch. No injuries noted and R73 was unable to give description. Identified R73 had increase in confusion since family visited earlier in the day, had been looking for family to return home with them. Identified predisposing environmental, physiological, and situation factors: slipped, confused, gait imbalance, impaired memory, and during transfer. - on 6/10/24 at 3:36 p.m., post fall analysis identified R73 had a fall and was found lying on her left side holding onto her call light. R73 indicated she did not hit her head and was trying to get up, no injuries. Identified risk factors increasing fall risk: fall risk score of 19 (high risk), previous history of falls, diagnoses of visuospatial deficit, stroke, and high blood pressure. R73 spoke fluent Spanish and an interpreter was utilized for communication. R73 was forgetful and was not always able to make needs known, did not use call light appropriately. Identified root cause of R73's fall as self transfer attempt. Identified interventions of continuing with current interventions at this time. Review of R73's medical record lacked evidence of an incident report for R73's fall on 6/10/24. Review of R73's progress note dated 6/10/24 at 3:34 p.m., identified R73 had a fall and was found lying on her left side holding her call light. R73 indicated she was trying to get up and stated she did not hit her head. No injuries noted. During an observation on 06/11/24 at 1:33 p.m., R73 was observed sitting in living room recliner, wheelchair was approximately ten feet from R73 in front of fire place. No staff were observed to be present in the living room at the time. During an observation on 06/11/24 at 2:24 p.m., R73 continued to be sitting in living room recliner wheelchair continued to be approximately 10 feet away from R73 in front of the fire place. During an observation on 06/11/24 at 4:47 p.m., R73 was observed lying on her back in bed with wheelchair approximately 8 feet away. R73 was restless and calling out for help. R73 grabbed U shaped rail on bed with both hands and sat up independently to side of bed with legs dangling. During a joint interview on 6/11/24 at 4:51 p.m., registered nurse (RN)-A and nursing assistant (NA)-C verified R73 was sitting up at the edge of her bed with wheelchair approximately 8 feet away. RN-A indicated she was unaware of R73's care plan interventions and would need to refer to her chart to find fall interventions. NA-C stated R73's care plan fall intervention was for wheelchair to be positioned next to her bed and next to the recliner in living room. During an interview on 6/12/24 at 08:21 a.m., clinical manager (CM)-A verified R73 was a high fall risk and had multiple falls at the facility. CM-A verified care plan fall interventions and stated her expectation was staff would have followed care planned fall interventions. CM-A confirmed the facility had not completed a post fall analysis after the 5/13/24, fall to determine the cause of the fall and to develop or revise interventions to prevent future falls. During an interview on 6/12/24 at 12:19 p.m., director of nursing (DON) verified R73 was a high fall risk and had multiple falls at the facility. DON stated her expectations was that staff would have followed care plan interventions to prevent falls. Review of a facility policy titled Fall Protocol reviewed 1/8/24, identified that a post-fall huddle would be initiated after each fall to gather pertinent information. The charge nurse would update the individualized care plan and care card with post-fall interventions and would communicate changes to staff in regards to the updated plan of care.

Based on observation, interview, and document review the facility failed to follow standards of practice related to medication administration for 1 of 2 residents (R 31) observed to receive an inhalation medication. Findings include: R31's Admission Record printed 8/17/23, indicated diagnoses of congestive heart failure (CHF), pulmonary hypertension (a condition that affects the blood vessels in the lungs), and paroxysmal atrial fibrillation (a rapid, erratic heart rate begins suddenly and then stops on its own). R31's physician orders dated August 2023, included budesonide inhalation solution (medication used to prevent swelling in the lungs) 0.5 mg (milligram)/2ml (milliliter) inhale one nebulizer two times a day, rinse mouth with water after use. During an observation on 8/16/23 at 7:40 a.m., trained medication aide (TMA)-A gave R31 a budesonide inhalation solution via a nebulizer with a face mask. TMA-A removed the mask, rinsed the mask and solution cup, and placed them out to dry, then gave R31 the call light. During an interview on 8/16/23 at 8:10 a.m., TMA-A stated she did not have R31 rinse her mouth out after the budesonide nebulizer medication. During an interview on 8/17/23 at 12:59 p.m., the director of nursing (DON) stated staff should have followed the order to rinse the mouth after the use of the budesonide nebulizer medication. The DON stated the pharmacy consultant made sure there were directions for rinsing the mouth after the budesonide nebulizer was given to the residents to prevent yeast infections orally. During interview on 8/17/23 at 1:56 p.m., pharmacist stated staff should aways have the residents rinse their mouth out after a budesonide nebulizer. Pharmacist stated it was important to rinse after the budesonide nebulizer to prevent thrush (a fungal (yeast) infection that can grow in your mouth and throat). The facility policy Medication Inhalers dated 11/8/22, indicated if the inhale is a corticosteroid (reduce swelling (inflammation) in your airways), have the resident rinse/gargle with water after the administration.

Based on observation, interview, and document review the facility failed to follow implementation of a comprehensive person-centered care plan for 1 of 1 residents (R36) reviewed for ambulation. Findings included: R(36) quarterly Minimal Data Set (MDS) dated [DATE], indicated fully intact cognition (able to fully understand). Diagnoses of medically complex conditions (more than one complicated medical diagnosis) Anemia, (not enough red blood cells), Renal insufficiency (poor kidney function), and received dialysis (blood filtering treatment for poor kidney function). R36 walked in room and corridor once or twice and required two staff physical assistance. Locomotion on and off facility unit required at least 1 staff person with extensive assistance with activity. R36 needed assistive devices of a walker and wheelchair. Care Plan identified R36 was able to ambulate using a walker with the assistance of staff. To maintain his current mobility level, R36 was to be walked by staff with limited to extensive assistance for distance as tolerated. On 8/15/23 at 3:09 p.m., R36 was in room watching television, seated in recliner with space darkened. On 8/17/23 at 11:13 a.m., certified nursing assistant (CNA-A) asked R36 if he would like to go for a walk today. She apologized R36 had not yet been walked today, or the other day. On 8/17/23 at 11:22 a.m., R36 stated he was supposed to walk on days he didn't go to dialysis. He sometimes asked, but felt staff should ask and remind him as it was their job. R36 felt he had not been walked more than 5 times in the last month. On 8/17/23 at 11:27 a.m., CNA-A stated R36 walked on days when he didn't go to dialysis. Walks should be offered Tuesdays, Thursdays, Saturdays, and Sundays. CNA-A stated R36 refused at times. Documentation indicated refusals, and NA. CNA-A stated NA meant staff did not do it because R36 usually hadn't refused. On 8/17/23 at 11:44 a.m., CNA-B stated R36 went for walks on days when he didn't to to dialysis. She had assisted with walking in the past but could not recall how often. On 8/17/23 at 11:46 a.m., Licensed Practical Nurse (LPN)-A reviewed chart and verified all dates identified were not dialysis days. R36 had been offered to walk 4 times. LPN-A continued R36 had the right to refuse, but walking should have been offered. On 8/17/23 at 11:53 a.m., Registered Nurse (RN)-A stated R36 had been walked 4 times according to documentation. RN-A confirmed there was a space to document R36 refusal. She expected staff to offer walking, even if the resident refused it. On 8/17/23 at 3:04 p.m., Director of Nursing (DON), stated R36 was care planned for walking. She expected staff to offer a walk, and chart on it. Facility Document, titled, [NAME] Health Job Description with date of 1/26/2023 for Nursing Assistants/ Registered, under general description indicated, All care is provided according to each individual resident care plan and wishes, and to complete assigned documentation daily.

Based on interview and document review, the facility failed to provide a written notice of a bed hold was provided after an emergent transfer to the hospital for 1 of 2 residents (R22) reviewed for hospitalization . Findings include: R22's Admission Record printed 8/17/23, indicated diagnoses of diabetes and anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). R22's Minimum Data Set (MDS) dated [DATE], indicated R22's cognition was intact. R22's progress notes indicated R22 was hospitalized on [DATE] to 5/15/23, then returned to the facility. During an interview on 8/17/23 at 12:20 p.m., registered nurse (RN)-A stated she was unable to find any notes in R22's chart about a bed hold when R22 was hospitalized . During an interview on 8/17/23 at 1:36 p.m., the director of nursing (DON) stated there was no transfer group email (email sent to administration when a resident was sent to the hospital). The DON stated she took the call from the hospital about R22's admission and did not proceed with a bed hold at the time. The DON told staff she would take care of it. The DON stated she should have emailed the transfer group and put a progress note in R22's medical record that he was in the hospital. The DON stated this was not the normal process for bed hold notification. The facility policy Bed Hold and Return from LOA (leave of absence) dated 2/16/23, indicated the bed hold policy and procedure notice will be provided to the resident/responsible part at admission and prior to leaving the facility. In an emergency transfer, i.e., hospitalization , the resident/responsible party would be provided with the written bed hold policy and procedure notice.

Based on observation, interview and document review, the facility failed to maintain the water and ice machines and coffee machines in a sanitary manner to prevent potential food borne illness for 57 of 61 residents who currently received water, ice and coffee from the machines. In addition, the facility failed to maintain 1 of 2 bakers freezers in a sanitary manner to prevent potential food borne illness for 64 of 66 residents who currently received food from the baker freezer. Findings include: On 4/18/22, at 12:59 p.m. an initial tour was conducted with the dietary manager (DM). The following concerns were identified with the DM present: - The baker freezer number two located in the main kitchen area had large chunks of ice on the top shelf and the DM pulled one large chunk of ice off that was stuck on the shelf and disposed of it. The freezer had five loaves of orange poppy bread and three fruit pies on the top shelf which had ice frozen in-between the loaves of bread and water present all over them. Additionally, the freezer had 15 loaves of raisin bread on the second shelf which had ice frozen in between the loaves of bread and water running all over them. The pipe fitting in the back of the freezer was leaking water down the back of the freezer and had ice pieces attached to the back of the freezer as well and was running onto the breads and pies in the freezer. On 4/19/22, at 2:13 p.m. a kitchen tour was conducted with the DM. The DM indicated baking freezer number two was taken out of service due to the ice build up and the freezer leaking water. The freezer had a sign posted on the outside which identified it was out of service. On 4/20/22, at 11:24 a.m. a tour of the kitchenette on Timber Grove and [NAME] units was conducted with home maker (HM)-A. -The coffee machine located on the counter in the [NAME] unit had a heavy encrusted build up of white mineral deposits on the tip of the hot water dispenser. The grate inside of the tray of the coffee maker had a small amount of mineral deposit build up on top of the grate where the water and coffee were dispensed from. -The coffee machine located on the counter in the Timber Grove unit had a heavy encrusted build up of white mineral deposits on the tip of the hot water dispenser. The grate inside of the tray of the coffee maker had a small amount of mineral deposit build up on top of the grate where the water and coffee were dispensed from. - The water and ice machine located in the the middle of Timber Grove and [NAME] located on the counter were observed to have encrusted mineral deposits built up under the ice and water dispenser. The tray and the grate inside of the tray of the ice machine had a heavy build up of white mineral deposits where the ice and water were dispensed from. The entire tray and grate were white with mineral deposits. HM-A indicated the coffee makers were cleaned every time they switched the coffee inside which was about every 12 weeks and stated it depended on the coffee use, too. On 4/20/22, at 11:42 a.m. a tour of the kitchenette on Harvest Glen unit was conducted. - The water and ice machine located in the the middle of Harvest Glen and Pine Harbor located on the counter were observed to have encrusted mineral deposits built up under the ice and water dispenser. The tray and the grate inside of the tray of the ice machine had a heavy build up of white mineral deposits where the ice and water were dispensed from. The entire tray and grate were white with mineral deposits. On 4/20/22, at 11:50 a.m. food service supervisor (FSS) confirmed the above findings and indicated the water and ice machines and the coffee machines were cleaned weekly. The FSS indicated they had tried to de-lime the machines however it was not effective. The FSS verified she had no cleaning schedules for the ice and water machines and coffee machines. The FSS indicated an ice buildup in the freezers were not normal and the freezer developed a leak and was freezing. The FSS confirmed the freezers had ice buildup and a leak which had the potential to damage the products in the freezer and the residents had the potential to develop food borne illness as a result. The FSS indicated she would expect staff to report when equipment was not functioning properly to maintenance. Additionally, she expected staff would ensure the ice, water machines and the coffee machines were properly cleaned. On 4/21/22, at 9:49 a.m. the DM confirmed the above findings and indicated staff were to check the freezers everyday. The DM indicated she would expect staff to check the freezers daily for ice build up or leaks and to check the product as well. The DM stated it was important for staff to ensure the products were safe due to safety concern of potential food borne illness. The DM indicated she would expect staff to clean the ice and water machines and coffee machines weekly by de-liming and sanitizing them. Review of facility policy titled, Equipment Cleaning dated 3/14/22, indicated staff were to monitor unit/department equipment and environment cleaning. Each unit/department was responsible for their area and equipment unless other wise specified to assure clean equipment and environment to prevent the transmission of microorganisms which included ice machines. Review of facility policy titled, Nutrition and Food Services revised 3/31/22, indicated food must be stored properly after delivery to keep products safe and to preserve quality.

Based on interview and document review, the facility failed to ensure all residents were consistently offered and provided a substantial evening snack for 5 of 5 residents (R38, R31, R36, R54, R3) who voiced a concern while attending the resident council group meeting. This deficient practice had the potential to affect all 64 residents residing in the facility who were provided oral meals and snacks. Findings Include: On 4/21/22, at 10:00 a.m. a resident council group meeting was held with 5 residents, R38, R31, R54, R36, and R3, who regularly attended the facility resident council meetings. At 10:21 a.m. all the residents indicated afternoon snacks were offered, however confirmed evening snacks were not offered on their units, which included [NAME], Pine Harbor and Harvest Glen neighborhoods. R36 was the only resident present who stated she would not take a snack if offered in the evening because she went to bed early. R38's quarterly Minimum Data Set (MDS) dated [DATE], identified R38 had severe cognitive impairment. R31's quarterly MDS dated [DATE], identified R31 was cognitively intact. R54's quarterly MDS dated [DATE], identified R54 was cognitively intact. R36's quarterly MDS dated [DATE], identified R36 was cognitively intact. R3's quarterly MDS dated [DATE], identified R3 was cognitively intact. R33's MDS had not been completed at time of survey. On 4/21/22, at 10:40 a.m. during a follow up interview R54 indicated snacks were not regularly offered in the evening on Harvest Glen neighborhood. R54 indicated he believed it was extra work for the staff to offer snacks and did not wish to bother anyone. R54 stated he would like to be offered a snack in the evening. On 4/21/22, at 10:52 am. during a follow up interview R38 confirmed snacks were not offered in the evening on Pine Harbor neighborhood. R38 stated she never asked staff for a snack in the evening, however it would be wonderful if the staff offered her a snack. On 4/21/22, at 1:27 p.m. during a follow up interview R31 stated evening snacks were not routinely offered on [NAME] neighborhood. On 4/21/22, at 1:55 p.m. R33 indicated on Transitions neighborhood he was offered a snack about twice weekly in the evening and stated he was not offered a snack routinely every evening. On 4/21/22, at 1:58 p.m. dietary manager (DM)-A stated afternoon snacks were prepped by the dietary staff, and evening snacks were prepped on the households by nursing staff with items they had on each neighborhood. DM-A confirmed she expected snacks to be offered to the residents on all the neighborhoods before bed time. DM-A indicated it was important snacks were offered in the evening to prevent too large of a gap between the supper meal and breakfast meal. DM-A stated it was important to offer snacks to the residents, since residents would likely be more receptive to a snack when offered, then if they had to ask for one. The facility policy titled Supplements And Snacks revised 1/15/20, identified the purpose was to promote weight maintenance through providing snacks and supplements. The policy identified snacks were to be available on the households, for any time of the day the resident was requesting a snack. The policy indicated snacks would be offered in the afternoon for coffee/social hour in the dining rooms and at HS to all residents. The policy identified HS snack would be a nutritious snack consisting of two choices from the four basic food groups. A list of appropriate snacks for PM were posted in each area to use for a guide for PM snacks. The facility policy titled Preparing Between Meal Snacks revised 6/15/20, identified PM snacks would be offered to all residents. A list of appropriate snacks for PM were posted in each area to use for a guide for PM snacks. The facility form titled Household Ideas For Resident Snacks And Extra Meal Items, undated, included a list of food items.

Based on observation, interview and document review the facility failed to provide routine shaving and grooming assistance for 1 of 1 residents (R1) who was dependent on staff for activities of daily living (ADL's). Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan revised on 11/18/21, identified R1 had an ADL self care performance related to dementia and chronic pain. The care plan indicated R1 required extensive assistance of one staff with personal hygiene cares. R6's Nursing Aid Care Sheets dated 4/12/22, indicated R1 required staff assistance of one with grooming tasks. During observations on 4/18/22, at 3:15 p.m. R1 walked down the hallway with her walker independently with her friend who came to visit R12 at the facility. R1 had several long white facial hairs present on her lower chin area that were approximately 1/4 inch long and her hair was pasted to the back of her head with the rest of her hair sticking straight up. R1 and her visitor walked down to the living room area and sat down and began to visit. -at 3:29 p.m. R1 was seated out in the living room area with other residents and her facial hair and hair remained the same. - at 3:39 p.m. R1 continued to be seated in the living room area and her facial hair and hair remained the same. - at 5:59 p.m. R1 was seated out in the dining room area with other residents eating supper and her facial hair and hair remained the same. During observations on 4/19/22, at 9:31 a.m. R1 was seated out in the living room area watching TV with other residents. R1 continued to have several long white facial hairs present on her lower chin area that were approximately 1/4 inch long and her hair was pasted to the back of her head with the rest of her hair sticking straight up. - at 9:47 a.m. continued to be seated in the living room area and her facial hair and hair remained the same. - at 1:46 p.m. R1 walked back onto the unit with her walker independently and sat down in the living room area with other residents and watched TV. R1's facial hair and hair remained the same. - at 2:02 p.m. R1 continued to watch TV with other residents and her facial hair and hair remained the same. - at 2:44 p.m. R1 continued to be seated out in the living room area and had a visitor seated next to her visiting with her. R1's facial hair and hair remained the same. During observations on 4/20/21, at 9:07 a.m. R1 was seated the dining room area with her head lowered and her eyes were closed. NA-A approached R1, woke her up and pushed her up to the table and informed R1 it was time to eat her breakfast. R1 began to eat her breakfast independently. R1 continued to have several long white facial hairs present on her lower chin area that were approximately 1/4 inch long and was not shaven. On 4/20/22, at 11:01 a.m. family member (FM)-A indicated staff assisted R1 with cares and personal hygiene, and indicated she would expect staff to help R1 with grooming task. FM-A stated R1 always wanted her hair to look nice and would not like to have chin hair present on her face. On 4/20/22, at 11:10 a.m. nursing assistant (NA)-A confirmed R1 required assistance with personal hygiene, grooming and shaving. NA-A indicated the NA's were responsible for making sure residents were shaved on their bath days. NA-A indicated she did not think R1 really needed to be shaved at other times and was not aware of R1 having whiskers on her face. NA-A indicated staff should have assisted R1 with shaving and combing her hair per her care plan. On 4/20/22, at 11:17 a.m. licensed practical nurse (LPN)-A confirmed R1 required staff assistance with personal hygiene and grooming. LPN-A indicated she would expect staff to follow the care plan and to make sure R1 had her hair combed and was cleanly shaven. On 4/21/22, at 8:50 a.m. the director of nursing (DON) confirmed the above findings and indicated she would expect staff to assist R1 with grooming and personal hygiene such as shaving and combing her hair. The DON indicated she would expect staff to follow the care plan as written. Review of the facility policy titled, Resident Dignity-[NAME] dated 5/18/21, indicated it was the policy of [NAME] Living to promote the right of each resident to a dignified existence. The policy stated staff should address preferences with personal hygiene, assisting with grooming such as combing and styling hair and facial hair removal.

Based on interview and document review, the facility failed to thoroughly investigate an allegation of resident to resident abuse for 1 of 4 residents (R1) reviewed for allegations of abuse. In addition, the facility failed to report to the State agency (SA) the results of the investigation within 5 working days for 1 of 4 allegations of abuse reviewed. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R1 required staff supervision for eating, bed mobility, ambulation and required extensive assist of one staff for dressing, toileting, personal hygiene, bathing and was independent with transfers. The MDS further indicated R1 had behavior symptoms directed towards other physically and verbally 1 to 3 days and wandered 4 to 6 days but less than daily. Review of R1's progress notes from 1/7/21, revealed the following: - at 9:11 p.m. R1 was found in R5's room. R5 was upset, stating R1 had hit her with a pillow, slapped her and twisted her arm. R5 was very frightened. When trying to redirect R1, she pulled the blankets off R5's bed and pushed registered nurse (RN)-A and threw the blanket on the floor and walked out of the room. R1 was very angry. Interventions used: redirection and will watch R1 closely. After further review of R1's medical record, there was no documentation of when the SA was notified of the alleged resident to resident abuse and when the investigation was submitted to the SA for the alleged incident. The facility was unable to provide any internal investigation in regards to the allegation. On 3/4/21, at 12:01 p.m. the director of nursing (DON) was notified of the alleged allegation on 1/7/21, and stated she was not aware of the incident. In a follow up interview at 4:40 p.m., the DON indicated she would expect staff to start the investigation and submit the investigation to the SA within 5 days. On 3/4/21, at 4:40 p.m. the administrator confirmed the above findings and indicated she had not been notified immediately when the resident to resident altercation occurred and indicated staff should have contacted her or the DON. The administrator indicated she would expect staff to follow the facility vulnerable adult policy and to investigate the allegation and submit the investigation to the SA within 5 days. Review of the facility policy titled, Vulnerable Adult Reporting revised on 10/1/2020, indicated the facility must report any incidents of actual or suspect maltreatment to the Office of Health Facility Complaints (OHFC) immediately upon becoming knowledgeable of the incident. Immediately is interpreted by surveyors with MDH to be as soon as possible, but not later than 2 hours after the allegation is mad, if the event that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse or do not result in serious bodily injury. The policy also indicated staff were to make sure the resident was safe, call the administrator as soon as possible, report to OHFC, put intervention into place immediately and begin the investigation by getting written witness statements from staff.

Based on interview and document review, the facility failed to immediately report to the administrator and no later than 2 hours, to the State Agency (SA) an allegation of resident to resident abuse for 1 of 4 residents (R1) who was reviewed for allegations of abuse. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R1 required staff supervision for eating, bed mobility, ambulation and required extensive assist of one staff for dressing, toileting, personal hygiene, bathing and was independent with transfers. The MDS further indicated R1 had behavior symptoms directed towards other physically and verbally 1 to 3 days and wandered 4 to 6 days but less than daily. Review of R1's progress notes from 1/7/21, revealed the following: - at 9:11 p.m. R1 was found in R5's room. R5 was upset, stating R1 had hit her with a pillow, slapped her and twisted her arm. R5 was very frightened. When trying to redirect R1, she pulled the blankets off R5's bed and pushed registered nurse (RN)-A and threw the blanket on the floor and walked out of the room. R1 was very angry. Interventions used: redirection and will watch R1 closely. After further review of R1's medical record, there was no documentation of when the SA was notified of the alleged resident to resident abuse. The facility was unable to provide any documentation that the SA had been notified within 2 hours of the resident to resident altercation. On 3/4/21, at 11:37 p.m. RN-A indicated R1 had gone into R5's room, pulled out her pillow, grabbed and slapped R5 and had attempted to pull R5 out of bed. RN-A indicated R5 was clearly upset and told her what had happened when R1 entered her room. RN-A indicated she tried to redirect R1 out of R5's room, but R1 was angry and did not respond to her redirection. RN-A indicated R1 started to shove her and she was able to escort R1 out of R5's room. RN-A stated R1 was placed on 15 minute checks after the incident. RN-A indicated the incident happened around 8:30 p.m. or 9:00 p.m. but was not sure of the actual date. RN-A indicated she had reported the incident to the charge nurse that was working that evening and RN-A assumed the charge nurse was going to report the incident to the SA. On 3/4/21, at 1:17 p.m. RN-C confirmed it had been reported that R1 entered R5's room in the evening and had frightened her. RN-C indicated R1 grabbed R5's arm and was physically touching her. RN-C confirmed the allegation did not get reported to the SA due to R5 being confused and unreliable at the time. RN-C confirmed the allegation of resident to resident abuse occurred and indicated it should have been reported to the SA immediately. On 3/4/21, at 12:01 p.m. the director of nursing (DON) was notified of the alleged allegation on 1/7/21, and stated she was not aware of the incident. At 2:49 p.m., the DON confirmed the above finding and indicated she had not been notified of the allegation of resident to resident abuse by staff and the allegation had not been reported to the SA. The DON indicated she would have expected staff to notify her and the administrator immediately whenever an allegation of abuse occurred and within 2 hours to the SA. On 3/4/21, at 4:40 p.m. the administrator confirmed the above findings and indicated she had not been notified immediately when the resident to resident altercation occurred and indicated staff should have contacted her or the DON. The administrator indicated she would expect staff to follow the facility vulnerable adult policy and report any allegations of abuse within 2 hours to the SA. Review of the facility policy titled, Vulnerable Adult Reporting revised on 10/1/2020, indicated the facility must report any incidents of actual or suspected maltreatment to the Office of Health Facility Complaints (OHFC) immediately upon becoming knowledgeable of the incident. Immediately is interpreted by surveyors with MDH to be as soon as possible, but not later than 2 hours after the allegation is made, if the event that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse or did not result in serious bodily injury.

Based on observation, interview and document review, the facilty failed to implement a comprehensive infection control program to include recommended COVID-19 staff and visitor health screening procedures. This deficient practice had the potential to affect all 84 residents residing in the facility and all facility staff. Findings include: During observations on 4/28/20, at 11:00 a.m. on the right side of the front entrance was a desk, a plastic container was observed, which held homemade masks, sanitizer, a thermometer, and a binder lying on the desk. The binder had an unlabeled form, dated 4/28/20. The form had spaces for name, fever, symptoms, close contact, worked in another facility, ok to work, excluded from duty and and initials of person completing the screen. - at 11:01 a.m activity aid (AA)-A entered the front door entrance of the building wearing a mask, stepped up to the desk on the right side of the entrance, took her own temperature, filled out the questions on the form, santitizer her hands and proceeded to enter the facility. - at 1:10 p.m. registered nurse (RN)-A entered the front entrance of the building using her badge and put a homemade mask on. Two males out in the entry way followed RN-A into the building as she stood in front of the table to the right of the main entrance and waited behind her. RN-A proceeded to take her own temperature, filled out the questions on the form, sanitized her hands and entered the facility. During this time Visitor (V)-A stepped up to the desk on the right side of the entrance, took his own temperature, filled out the questions on the form, sanitized his hands, put on a homemade mask, while V-B stood behind him in line. V-A proceeded to wait off to the left side of the entrance while V-B stepped up to the desk on the right side of the entrance, took his own temperature, filled out the questions on the form, sanitized his hands, put on a homemade mask and proceeded to enter the facility with V-A. - The administrator came around the corner of the hallway, approached V-A and V-B and asked them if they had symptom screening. Both V-A and V-B indicated the screening had been done, indicated they had come to the facility to work on the sprinkler system in the building and proceeded to enter the facility. On 4/28/20 at approximately 1:15 p.m. the administrator confirmed facility staff were not present at the entrance and V-A and V-B had not been screened by facility staff. She indicated this was not normal practice and the facility had trained screeners to screen anyone who entered the building. The administrator indicated she would expect the screeners to screen everybody that came into the building including all employees and all visitors. On 4/28/20 at 1:20 infection control preventionist, (ICP) indicated everyone was to be screened at the front entrance of the building. The ICP indicated the facility has staff assigned as screeners at the front door from 5:00 a.m. to 9 a.m. and 1:30 p.m. to 5:00 p.m. and off hours charge nurses help out or they should call for assistance to be screened. The ICP indicated someone should be at the front entrance to screen people at all times and indicated the screener takes the employees or visitors temperature and asks the screening questions on the sign in sheet. The ICP indicated she would expect the screener to screen the people entering the building or they should be calling someone to complete the screening prior to the visitors entering the facility. On 4/28/20 at 1:43 RN-A confirmed the above findings and indicated she had screened herself when she entered the building to come to work. RN-A indicated she entered the building using her badge, put a mask on, took her own temperature, filled out the form with questions, signed her name, sanitized her hands and proceeded to go to work. RN-A indicated that is her process for symptom screening for COVID-19, if no staff are present at the front desk and indicated she has had to screen herself at times in the past. On 4/28/20 at 3:28 p.m director of nursing (DON) indicated she would expect staff to be evaluated by the screener or another individual trained when entering the front door. The DON indicated she did not know what happened and indicated she was aware in the past, staff were not at the front desk to screen staff members as they entered the building during these times and they had screened themselves. In a follow up interview via telephone call on 4/29/20 at 8:21 a.m., the ICP indicated staff and visitors should not be screening themselves and would expect the trained screener to conduct the symptom screening. The ICP indicated the facility expected another person was screening to ensure the integrity of the screening process and to keep the symptoms out of the facility. Review of facility policy titled, COVID UPDATE undated, indicated under employee screening: all employees should stay home if they are ill, COVID symptoms we screen include fever, cough, shortness of breath and sore throat. If you do not pass the screening log prior to enter to the facilty leave work, call the charge RN. Under visitors: only visitors allowed in the facility are family members during end-of-life situations. The policy indicated visitors will be screened at the door and will not be allowed into the facility if they do not pass the screening.

Based on interview and document review, the facility failed to ensure appropriate monitoring for efficacy of a [MEDICAL CONDITION] medication was completed for 1 of 5 residents (R11) reviewed for unnecessary medications. Findings include: R11's admission Minimum Data Set ((MDS) dated [DATE], indicated R11 had [DIAGNOSES REDACTED]. The MDS identified R11 was cognitively intact and required extensive assistance with all activities of daily living (ADLs), except ate independently. The MDS further identified R11 had no behaviors, but had trouble falling or staying asleep, or slept too much. R11's quarterly MDS dated [DATE], indicated R11 had [DIAGNOSES REDACTED]. The MDS identified R11 had moderate cognitive impairment and had no trouble falling or staying asleep, or sleeping too much. R11's Care Area Assessments (CAA) dated 6/24/18, indicated R11 received Trazadone (antidepressant) on a schedule to aid sleep, and indicated R11 slept without difficulty. The CAA further indicated R11 received antidepressants and monitoring was in place and/or had been set up in plan of care. R11's care plan, last reviewed 4/8/19, indicated R11 used [MEDICAL CONDITION] medication Trazadone to assist with [MEDICAL CONDITION]. R11's care plan listed various interventions which included administer the medication as ordered, monitor and document for side effects and effectiveness, consult with pharmacy and doctor to consider dosage reduction when clinically appropriate, monitor/record occurrence of target behavior symptoms of sleeplessness and document, and monitor and record/report to physician as needed side effects and adverse reactions of psychoactive medications. Review of R11's Medication Administration Record [REDACTED]. Review of R11's Hypnotic/Sedative Medication Review dated 9/13/18, indicated R11 received Trazadone 50 mg for [MEDICAL CONDITION], with last dose change prior to admission. The form allowed areas to document non-pharmacological measures tried, benefits of the medication, or risks, however these areas were left blank. R11's physician indicated the medication worked for sleep, and R11 did not want to change. However, the form lacked an assessment of R11's sleep pattern. On 6/13/19, at 9:03 a.m. registered nurse (RN) clinical manager (CM)-B indicated R11 received Trazadone for [MEDICAL CONDITION] and had received Trazadone since prior to admission. CM- B stated R11 was due for a Gradual Dose Reduction (GDR) as she had been at the facility almost a year and the last GDR recommendation was on 9/13/18. CM-B stated staff do not monitor R11's sleep while taking Trazadone. CM-B indicated the facility did not have a policy or procedure for monitoring residents which received a [MEDICAL CONDITION] medication (Trazadone) for [MEDICAL CONDITION]. Review of R11's Pharmacist's Monthly Drug Regimen Review Form from 7/11/18 to 5/6/19, revealed the following: -7/11/18, R11 admitted receiving [MEDICATION NAME] (antidepressant), Trazadone, and [MEDICATION NAME] (antianxiety medication) for a history of depression, [MEDICAL CONDITION] and anxiety. Will allow time for resident to adjust to new living arrangements before addressing any potential dose reductions. -9/12/18, Consider reducing Trazadone or [MEDICATION NAME] ([MEDICATION NAME]), increase [MEDICATION NAME] ([MEDICATION NAME]) . No further comment or recommendation regarding Trazadone efficacy monitoring. On 6/13/19, at 9:33 a.m. during an interview with the director of nursing (DON) and the assistant director of nursing (ADON), the ADON indicated nursing assistants completed flow sheets in each household that included hours of sleep for residents and these forms are reviewed daily, but not kept as part of the resident record. The ADON stated if a resident had specific sleep difficulties; the nurse would review that information in the Treatment Administration Record. The ADON indicated a lot of resident information came through shift to shift reports and if a resident was not sleeping well then that information would be brought up to the CM. Review of R11's TAR from (MONTH) 2019 to (MONTH) 2019, indicated R11's side effect monitoring was completed monthly on the sixth of each month, however the TAR lacked any monitoring of R11's sleep or effectiveness of R11's Trazadone. On 6/13/19, at 3:28 p.m. during a follow up interview with the DON and ADON, the ADON indicated nursing staff would monitor the effectiveness of an antidepressant used to treat [MEDICAL CONDITION] by completing sleep studies, or reviewing hourly rounding sheets completed by nursing assistants. On 6/13/19, at 12.33 p.m. during a telephone interview with consultant pharmacist (CP)-A, CP-A indicated if a resident received a [MEDICAL CONDITION] medication for [MEDICAL CONDITION], then she would expect to find monitoring of sleep. CP-A was unsure of the facility's process for monitoring the effectiveness of [MEDICAL CONDITION] medication used for [MEDICAL CONDITION], but would expect the facility's policy would define the appropriate procedure. CP-A stated the facility CM write a detailed summary every quarter and would expect to find a summary of sleep monitoring for a resident on [MEDICAL CONDITION] medication for [MEDICAL CONDITION]. Review of R11's RN Clinical Coordinator (RNCC) Quarterly Summary from 12/1/18 to 6/12/19, included: -12/20/18, [MEDICAL CONDITION] medication use: (R11) sleeps well at night, takes trazadone 50 mg at bedtime to assist with [MEDICAL CONDITION]. (R11) denies pain affecting her sleep. Will continue medications a(t) current dosage. Last GDR for [MEDICATION NAME] and Trazadone was 9/14/18 with no dose reductions advised. -3/29/19, Quarterly review: Uses [MEDICATION NAME] 50 mg daily for sleep ([MEDICAL CONDITION]) .GDRs have beendone (sic) previously with no change in medication dosing. No side effects noted. Reports she sleeps well at night .Plan: GDR when appropriate. Continue to monitor anxiety and depression. Continue to monitor side effects. No behaviors noted. Review of R11's medical record lacked an assessment of R11's sleep to determine the effectiveness of Trazadone, or to provide documentation to support or deter a GDR. Review of the facility policy titled [MEDICAL CONDITION] Medications last revised 7/24/18, indicated providers would use [MEDICAL CONDITION] medications appropriately working with the interdisciplinary team (IDT) to ensure appropriate use, evaluation and monitoring. The policy further indicated a psychiatrist/mental health may assist the facility in establishing appropriate guidelines for use, dosage and monitoring of [MEDICAL CONDITION] medications. The policy identified nursing staff would monitor [MEDICAL CONDITION] drug use daily, noting any adverse effects, monitor for the presence of target behaviors on a daily basis charting by exception and review the use of the medication with the physician and the IDT on a quarterly basis to determine the continued presence of target behaviors. The policy further identified the CP would monitor [MEDICAL CONDITION] drug use in the facility to ensure that medications are not used in excessive doses or duration and would notify the physician and the nursing unit if/whenever a [MEDICAL CONDITION] medication was past due for review. However, the policy lacked a procedure for assessing the effectiveness of [MEDICAL CONDITION] medications used for [MEDICAL CONDITION].

Based on interview and document review, the facility failed to notify the Long Term Care (LTC) Ombudsman of a facility initiated transfer for 1 of 3 residents (R86) reviewed for hospitalization . Findings include: R86's significant change Minimum Data Set (MDS), dated [DATE], indicated R86 had [DIAGNOSES REDACTED]. The MDS identified R86 had severe cognitive impairment and required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene and bathing. Review of R86's progress notes from 4/18/19, revealed the following: - on 4/18/19, at 10:33 a.m. R86 was noted to have minimal responsiveness. - on 4/18/19, at 10:59 a.m. R86's daughter was notified of R86's minimal intake and discussion was had whether R86 should be transferred to the hospital or not to be evaluated. R86's daughter requested time for her to have further discussions with other family members to determine if R86 should have been transferred to the hospital. - on 4/18/19, at 2:49 p.m. the rest of R86's family members arrived and a decision was made to transfer R86 to the hospital to be evaluated. - on 4/18/19, at 3:10 p.m. ambulance arrived to transport R86 to the hospital. R86's family expressed a desire to have intravenous therapy administered due to minimal intake as well as further testing to be completed. The progress notes lacked any documentation the Ombudsman had been notified of R86's transfer to the hospital. Review of the Action Summary form sent to the Ombudsman for (MONTH) 2019, and (MONTH) 2019, indicated R86 was not on the list of residents transferred to the hospital. On 6/13/19, at 3:28 p.m. licensed social worker (LSW)-B stated the Ombudsman was provided a listing of residents transferred to the hospital on a monthly basis. LSW-B reviewed the summary form and confirmed R86 had not been listed on the form. LSW-B stated the facility had been contacted by the family sometime after the transfer to the hospital to inform them R86 would not be returning to the facility and as a result the facility had not included R86 on the list. On 6/13/19, at 4:17 p.m. director of nursing (DON) stated the expectation was all residents who were transferred to the hospital to be included on the list to the Ombudsman. DON explained the business office compiled the summary reports sent to the Ombudsman. DON confirmed the progress notes lacked documentation of the Ombudsman receiving notification and confirmed R86 had not been included on the summary list sent to the Ombudsman for (MONTH) 2019 or (MONTH) 2019.

Based on interview and document review, the facility failed to provide notification to the resident and/or resident representative of the facility's bed hold policy at the time of the emergency transfer for 1 of 3 residents (R86) reviewed for hospitalization . Findings include: R86's significant change Minimum Data Set (MDS), dated [DATE], indicated R86 had [DIAGNOSES REDACTED]. The MDS identified R86 had severe cognitive impairment and required extensive assistance with bed mobility, transfers, locomotion, dressing, toileting, personal hygiene and bathing. Review of R86's progress notes from 4/18/19, revealed the following: - on 4/18/19, at 10:33 a.m. R86 was noted to have minimal responsiveness. - on 4/18/19, at 10:59 a.m. R86's daughter was notified of R86's minimal intake and discussion was had whether R86 should be transferred to the hospital to be evaluated. R86's daughter requested time for her to have further discussions with other family members to determine if R86 should have been transferred to the hospital. - on 4/18/19, at 2:49 p.m. the rest of R86's family members arrived and a decision was made to transfer R86 to the hospital to be evaluated. - on 4/18/19, at 3:10 p.m. ambulance arrived to transport R86 to the hospital. R86's family expressed a desire to have intravenous therapy administered due to minimal intake as well further testing to be completed. The progress notes lacked documentation a bed hold notice had been provided to R86 or R86's representative upon transfer to the hospital. On 6/13/19, at 3:28 p.m. licensed social worker (LSW)-B stated the usual practice was to provide a bed hold notice to the resident and/or representative anytime a resident was transferred to the hospital. LSW-B confirmed there had been no bed hold notice provided to R86 or R86's representative at the time of the emergency transfer. On 6/13/19, at 4:17 p.m. director of nursing (DON) stated the expectation was all residents and/or representatives were to be provided a bed hold notice at the time of emergency transfer. DON confirmed the progress notes lacked documentation of the bed hold notice provided to R86 and/or representative and additionally confirmed R86 and/or representative had not received a bed hold notice. A policy of bed hold notice had been requested and not provided.

Based on observation, interview and document interview, the facility failed to comprehensively assess smoking safety for 1 of 1 residents (R20) with currently smoked. Findings include: R20's [DIAGNOSES REDACTED]. R20's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R20 was cognitively intact and required extensive staff assistance with transfers, toileting, and bathing and required limited assistance with bed mobility, personal hygiene, dressing. The MDS further indicated R20 had limited range of motion of lower extremity on one side and utilized a wheelchair and walker. R20's care plan, revised 6/10/19, indicated R20 had impaired cognitive function and or impaired thought processes related to dementia and history of inappropriate use of cigarette use within facility against policy secondary to cognitive impairment and was an elopement risk/wanderer secondary to his smoking addiction and cognitive impairment. The care plan listed various interventions which included: staff would give reminders, cues, reorientation, coaching conversations and/or discussion regarding alternative measures that may need to take place when R20 does not comply with request to be safe. Staff were to offer activities of interest such as structured activities, conversations, food, TV and books to deter R20 from asking about smoking. Staff were to ensure R20 handed in his cigarettes and lighting device upon each return from an outing and staff would locked up them up. Staff were to assist R20 in calling FM-A when he wanted to smoke. R20's care plan did not address the use of a wanderguard device. Review of R20's medical record did not include an assessment for R20's safety and smoking. A smoking assessment was requested for R20 and none was not provided. During observations on 6/11/19 at approximately 4:30 p.m. R20 was seated in his wheelchair in the hallway talking to trained medication aid (TMA)-A about going out to have a cigarette and stated to the TMA-A he had gotten some cigarettes from the gas station. On 6/12/19 at 8:29 a.m. R20 was seated on the edge of his bed with RN-A present. R20 stated I will be going shopping for cigarettes. R20 requested she bring him his wallet back out of the medication drawer and stated I need to get some cigarettes. RN-A gave R20 his wallet and proceeded to collect the dirty linen and garbage and exited the room. -at 12:28 p.m. R20 was seated in his wheelchair next to FM-A's pickup, in the parking area outside in the main entrance of the building, smoking a cigarette with FM-A present. On 6/13/19 at 9:29 a.m. RN-A confirmed R20's family members take R20 out to smoke and indicated FM-A had given R20 cigarettes in the past. RN-A indicated R20's lighter and cigarettes were to be locked up and indicated the facility was a non- smoking facility. RN-A indicated staff do not go out with R20 to smoke and that FM-A took R20 off of the premises to smoke. In a follow up interview at 1:27 p.m., RN-A indicated FM-A has been educated on R20's cigarettes needing to be locked up and indicated since then she was aware R20 has had cigarettes and lighters at times when he was not supposed to have them. RN-A indicated R20 had smoked in the building at times, and had seen R20 carry used cigarette butts in the breast pocket of his shirt. She indicated she was aware R20 would hide his cigarettes in his socks and other places. RN-A indicated she felt R20 was a smoking hazard and was not sure where R20 has been getting his cigarettes, lighter or matches. RN-A indicated she was not aware of R20 smoking on the premises. RN-A indicated she was not sure if a smoking assessment had been completed on R20 for safety. On 6/13/19 at 1:42 clinical manager (CM)-A stated she was aware R20 had smoked in his bathroom in the past. CM-A confirmed R20's current care plan and confirmed an assessment had not been completed for R20's safety with smoking. CM-A indicated she felt R20 was a safety risk if he is smoking on the premises, having cigarettes and lighters and indicated she did not know if a smoking assessment would change anything. On 6/13/19 at 10:59 a.m. TMA-A confirmed R20 was a current smoker and indicated R20's cigarettes and lighter were to be locked up in the medication room because the facility was a tobacco free campus. TMA-A indicated R20 would have cigarettes on him but not always a lighter and indicated R20 would always be looking for a lighter. TMA-A indicated staff were to try and distract R20 by offering coffee, conversing and that will usually help R20 to get it off his mind. On 6/13/19 at 11:22 a.m. NA-A indicated staff have caught R20 with cigarettes and lighters on several occasions and have taken them away from him. NA-A indicated R20 has a wanderguard on because he had tried to go outside to smoke at times. NA-A has seen R20 with his cigarettes and lighter. She confirmed R20 had smoked in the building in the past. Review of R20 Progress Notes from 4/22/19 to 6/13/19 identified the following: - 4/22/19 at 11:07 p.m. R20 was in the hallway asking staff for a light, R20 indicated he wanted to light his cigarette as he held it in his hand. Staff told R20 the facility was a smoke free campus and he could not smoke inside or on the premises. R20 responded by saying that's crap, I've done it before. R20 asked to have a cigarette a couple more times that evening and went to bed. - 5/2/19 at 8:06 p.m. R20 was out in the hallway asking staff for light for his cigarette as he held it in his hand. Staff told him this was a smoke free campus. - 5/10/19 at 1:28 p.m. last night R20 attempted to leave the unit to go the gas station to get a lighter or matches so he could smoke his cigarettes. R20 did have a pack of cigarettes on him and has not tried to leave the unit today. At 3:37 p.m. R20 left the unit and was stopped by staff. R20 was asked where he was going he indicated he was going to go outside to smoke. Staff explained to R20 this was a non smoking facility and they would call his son. Staff called family member (FM)-A and left message and will continue to observe. At 6:36 p.m. R20 left the unit and staff asked where he was going, R20 indicated he was going outside to have a cigarette. Staff redirected by telling R20 it was supper time and R20 was agreeable. Question use of wander guard on R20's wheel chair appropriate, will route to register nurse and will continue to monitor. At 6:39 p.m. R20 left the unit and staff asked where he was going, R20 indicated he was going outside to have a cigarette. Staff indicated to R20 it was supper time, R20 replied he needed to smoke more than he needed to eat and indicated he would die if he did not have a smoke. Staff followed R20, retrieved him and reminded him this was a no smoking facility. R20's response was bullshit. - 5/11/19 at 2:14 p.m. R20 requested to go outside for smoke, staff explained to R20 he could not go outside to smoke unless his FM-A took him and R20 stated well that's stupid. Staff called FM-A and indicated he was just at the facility and would be up later to take R20 out to smoke later in the evening. At 7:00 p.m. R20 has been at the door in the town center repeatedly, staff retrieve R20 brought back to unit and R20 stated just get the hell away from me, I ' m going out to smoke. Staff explained to R20 that he could not go out to smoke and R20 stated just get the hell back in there and leave me alone. R20 was noted to be hiding behind the divider wall and peaking around looking for staff, so he could sneak out the door of the facility. R20's FM-A here and took R20 outside for a little while. At 10:54 p. m. R 20 was telling staff he was going to light up the pack of cigarettes his family left him. Staff thinks R20 also has a lighter, which he denies and R20 will not allow staff to check his pockets. Message left with FM-A to inquire if they left lighter with R20. - 5/12/19 at 2:09 p.m. R20 attempted twice to go outside to smoke this shift, doors locked due to wander guard and staff told R20 he could only go out to smoke when his FM-A was here. R20 stated well that stupid and wheeled himself back to his room. At 8:39 p.m. removed a pack of Pall Mall cigarettes, R20 had them laying out while at his bath and placed at nurses station. - 5/15/19 at 10:15 a.m. R20's FM-A took cigarettes home, will review our policy with FM-A and R20. R20 was doing well in the past with nicotine patched to help with his smoking sensation. The warmer weather, being outside and smoking out of facility with family may also contribute to smoking cravings. Will offer and encourage smoking sensation options if having smoking cravings and will review use wander guard quarterly or as needed due to R20's smoking cravings that are contributing to his exit seeking. - 5/19/19 at 9:10 p.m. R20 came out of room with cigarette tucked behind his ear and headed out to exit the building to find a match to lite his cigarette. R20 redirected and asked if he wanted FM-A called. Message left for FM-A, R20 went down to living room area, asked another resident if he had a match, resident stated no and R20 went back to his room. R20 then came back out of his room, asked another person if he had a match and proceeded to go back to his room for medications. - 5/22/19 at 10:41 a.m. R20's FM-A requested staff talk to him about not smoking on the premises and the policy. Staff explained to R20 that he cannot even have a cigarette in the building. R20's FM-A indicated he would take R20 out for a drive so he could have a cigarette. At 10:26 p.m. nurse was in den area when a smell of a freshly lit cigarette was notice. Nurse went into the hallway to find out where the smell was coming from. Nurse asked nursing assistant (NA) if she smelled the same thing and NA confirmed the smell of a lit cigarette smoke. Nurse followed the smell coming from R20's room, R20 was in his bathroom and asked R20 what that smell was and R20 replied it was the smell of a cigarette. Nurse asked R20 if he lit a cigarette in the bathroom and he replied he forgot he could not have a cigarette in his room. Nurse told R20 this was a non smoking facility and grounds, it was dangerous and hazardous to smoke in the bathroom. Nurse then asked R20 to hand over his cigarettes, R20 complied and nurse hid R20's cigarettes in the nursing den. At 10:47 p.m. R20 was entering nursing den looking for his cigarettes, nurse relocated R20's cigarettes and locked them in the medication room. - 5/25/19 at 2:38 p.m. R20 attempting to exit unit to go out to smoke, R20 had a pack of cigarettes and lighter on him and staff told R20 he could not have cigarettes and lighter on him at all. Cigarettes and light taken from R20 and locked up. R20's FM-A was called, message left alerting him to findings and was updated that this was a smoke free facility and this was a safety concern. R20 was out with FM-A last evening for a car ride and will continue to monitor. At 4:37 p.m. R20 entered nursing den and want to know if staff had his cigarettes, R20 was informed that his cigarettes were locked up, R20 asked why staff took his cigarettes from him and staff told R20 they were not allowed on the grounds and they could not risk him lighting up in the building again. R20 asked when he was able to have his cigarettes back and staff told him when FM-A gets here. - 6/4/19 at 9:29 p.m. licensed pratical nurse (LPN) found unlit, broken cigarette in the hallway. Staff called R20's FM-A, he indicated he did not leave any cigarettes with R20 and indicated last week he found a lighter and matches on R20. R20's FM-A indicated R20 would not tell him where he got the matches and the lighter from. R20's son indicated he would stop up tomorrow to search R20's room to ensure that he does not have any cigarettes, lighter or matches in his room. R20's son wondering if other people are bringing R20 cigarettes, lighters and matches into the facility. - 6/10/19 at 11:47 p.m. R20 very anxious before and after supper wanting a cigarette. R20 was at the unit door many times sounding wander guard alert and trying to get out. R20 redirected and continued to attempt to get outside. R20's cigarettes remained locked up in the medication room. On 6/13/19 at 2:32 p.m. during a group interview with the director of nursing (DON) and social worker (SW)-A, SW-A confirmed R20 currently smokes and has been a life long smoker. The DON confirmed the facility does not complete smoking assessments because they are a smoke free campus and do not allow smoking. The DON indicated they have confiscated cigarettes from R20 many times and have re-educated and tried to reinforce R20 not smoking. The DON indicated she has never seen R20 smoking and indicated she understood FM-A would take R20 for a drive to smoke. The DON indicated staff have never reported to her that R20 has been smoking on the campus grounds. The DON verified the parking area outside the main entrance was facility property and indicated R20 and FM-A should be following the facility policy. The DON and SW-B confirmed R20 was a smoking risk with R20 and FM-A not following the facility policy. Review of the facility policy titled, Resident and Family Smoking revised on 2/27/18, indicated residents/families are not allowed to use any form of smoking tobacco on Perham Living grounds. Resident who do smoke must be able to travel off campus to public property under their own power to smoke. If chewing tobacco or any of its forms including but not limited to dip, smokeless tobacco, snuff, and, spit tobacco is used spitting on Perham Health grounds was not permitted.

Based on interview and document review, the facility failed to ensure the consultant pharmacist (CP) identified and reported an irregularity related to the lack of [MEDICAL CONDITION] medication efficacy monitoring for 1 of 5 residents (R11) reviewed for unnecessary medications. In addition, the facility failed to ensure CP recommendations were acted upon in a timely manner for 1 of 5 residents (R70) reviewed for unnecessary medications. Findings include: R11's admission Minimum Data Set ((MDS) dated [DATE], indicated R11 had [DIAGNOSES REDACTED]. The MDS identified R11 was cognitively intact and required extensive assistance with all activities of daily living (ADLs), except ate independently. The MDS further identified R11 had no behaviors, but had trouble falling or staying asleep, or slept too much. R11's quarterly MDS dated [DATE], indicated R11 had [DIAGNOSES REDACTED]. The MDS identified R11 had moderate cognitive impairment and had no trouble falling or staying asleep, or sleeping too much. R11's Care Area Assessments (CAA) dated 6/24/18, indicated R11 received Trazadone (antidepressant) on a schedule to aid sleep, and indicated R11 slept without difficulty. The CAA further indicated R11 received antidepressants and monitoring was in place and/or had been set up in plan of care. R11's care plan, last reviewed 4/8/19, indicated R11 used [MEDICAL CONDITION] medication Trazadone to assist with [MEDICAL CONDITION]. R11's care plan listed various interventions which included administer the medication as ordered, monitor and document for side effects and effectiveness, consult with pharmacy and doctor to consider dosage reduction when clinically appropriate, monitor/record occurrence of target behavior symptoms of sleeplessness and document, and monitor and record/report to physician as needed side effects and adverse reactions of psychoactive medications. Review of R11's Medication Administration Record [REDACTED]. Review of R11's Hypnotic/Sedative Medication Review dated 9/13/18, indicated R11 received Trazadone 50 mg for [MEDICAL CONDITION], with last dose change prior to admission. The form allowed areas to document non-pharmacological measures tried, benefits of the medication, or risks, however these areas were left blank. R11's physician indicated the medication worked for sleep, and R11 did not want to change. However, the form lacked an assessment of R11's sleep pattern. On 6/13/19, at 9:03 a.m. registered nurse (RN) clinical manager (CM)-B indicated R11 received Trazadone for [MEDICAL CONDITION] and had received Trazadone since prior to admission. CM- B stated R11 was due for a Gradual Dose Reduction (GDR) as she had been at the facility almost a year and the last GDR recommendation was on 9/13/18. CM-B stated staff do not monitor R11's sleep while taking Trazadone. CM-B indicated the facility did not have a policy or procedure for monitoring residents which received a [MEDICAL CONDITION] medication (Trazadone) for [MEDICAL CONDITION]. CM-B stated the CP reviewed resident medications and if monitoring for effectiveness for Trazadone was not in place, CM-B would expect the CP to identify the lack of monitoring and recommend to put monitoring in place. Review of R11's Pharmacist's Monthly Drug Regimen Review Form from 7/11/18 to 5/6/19, revealed the following: -7/11/18, R11 admitted receiving [MEDICATION NAME] (antidepressant), Trazadone, and [MEDICATION NAME] (antianxiety medication) for a history of depression, [MEDICAL CONDITION] and anxiety. Will allow time for resident to adjust to new living arrangements before addressing any potential dose reductions. -9/12/18, Consider reducing Trazadone or [MEDICATION NAME] ([MEDICATION NAME]), increase [MEDICATION NAME] ([MEDICATION NAME]) . No further comment or recommendation regarding Trazadone efficacy monitoring. On 6/13/19, at 9:33 a.m. during an interview with the director of nursing (DON) and the assistant director of nursing (ADON), the ADON indicated nursing assistants completed flow sheets in each household that included hours of sleep for residents and these forms are reviewed daily, but not kept as part of the resident record. The ADON stated if a resident had specific sleep difficulties; the nurse would review that information in the Treatment Administration Record. The ADON indicated a lot of resident information came through shift to shift reports and if a resident was not sleeping well then that information would be brought up to the CM. Review of R11's TAR from (MONTH) 2019 to (MONTH) 2019, indicated R11's side effect monitoring was completed monthly on the sixth of each month, however the TAR lacked any monitoring of R11's sleep or effectiveness of R11's Trazadone. On 6/13/19, at 3:28 p.m. during a follow up interview with the DON and ADON, the DON indicated the CP's role was to identify and report medication irregularities. The ADON indicated nursing staff would monitor the effectiveness of an antidepressant used to treat [MEDICAL CONDITION] by completing sleep studies, or reviewing hourly rounding sheets completed by nursing assistants. On 6/13/19, at 12.33 p.m. during a telephone interview with CP-A, CP-A indicated her normal process at the facility included reviewing resident medication therapies, and make recommendations and identify irregularities and report those irregularities to facility staff. CP-A indicated if a resident received a [MEDICAL CONDITION] medication for [MEDICAL CONDITION], then she would expect to find monitoring of sleep. CP-A was unsure of the facility's process for monitoring the effectiveness of [MEDICAL CONDITION] medication used for [MEDICAL CONDITION], but would expect the facility's policy would define the appropriate procedure. CP-A stated the facility CM write a detailed summary every quarter and would expect to find a summary of sleep monitoring for a resident on [MEDICAL CONDITION] medication for [MEDICAL CONDITION]. Review of R11's RN Clinical Coordinator (RNCC) Quarterly Summary from 12/1/18 to 6/12/19, included: -12/20/18, [MEDICAL CONDITION] medication use: (R11) sleeps well at night, takes trazadone 50 mg at bedtime to assist with [MEDICAL CONDITION]. (R11) denies pain affecting her sleep. Will continue medications a(t) current dosage. Last GDR for [MEDICATION NAME] and Trazadone was 9/14/18 with no dose reductions advised. -3/29/19, Quarterly review: Uses [MEDICATION NAME] 50 mg daily for sleep ([MEDICAL CONDITION]) .GDRs have beendone (sic) previously with no change in medication dosing. No side effects noted. Reports she sleeps well at night .Plan: GDR when appropriate. Continue to monitor anxiety and depression. Continue to monitor side effects. No behaviors noted. Review of R11's medical record lacked an assessment of R11's sleep to determine the effectiveness of Trazadone, or to provide documentation to support or deter a GDR. R70 R70's admission Minimum Data Set ((MDS) dated [DATE], indicated R70 had [DIAGNOSES REDACTED]. The MDS identified R70 was cognitively intact and required extensive assistance with dressing, supervision for toilet use, personal hygiene, eating, and was independent with all other activities of daily living (ADL). R70's Care Area Assessments (CAA) undated, indicated R11 had a [MEDICAL CONDITION] problem. R70's care plan last reviewed 5/29/19, indicated R11 had a [DIAGNOSES REDACTED]. plan did not address R11's [MEDICAL CONDITION]. Review of R11's admission History and Physical (HP), dated 11/13/18, indicated R11 was admitted to the facility five days prior. R11's Active Problem List included a [DIAGNOSES REDACTED]. The HP further indicated [MEDICAL CONDITION] medication should be continued without change given recent [MEDICAL CONDITION] lab which was normal in (MONTH) (YEAR). Review of R70's Order Summary Report indicated no currently ordered [MEDICAL CONDITION] medication. Review of R70's Pharmacist's Monthly Drug Regimen Review Form from 12/14/18 to 5/6/19, indicated the following: -5/6/19: Clarify whether (R70) should be receiving [MEDICATION NAME] ([MEDICAL CONDITION] medication) per PN (physician/progress note) 4/19. Review of R70's physician progress notes [REDACTED]. -12/22/18, [MEDICAL CONDITION]-stable. -1/21/19, acquired [MEDICAL CONDITION]. -4/1/19, 4) [MEDICAL CONDITION]-continue replacement. -6/10/19, note indicated R70 was reviewed for pain and under the Active Problem List indicated acquired [MEDICAL CONDITION]. The provider note lacked documentation that the pharmacist's recommendations was reviewed or actions taken to address the recommendations. Review of R70's progress notes on 5/30/19, indicated R70 was seen by physician on rounds. R70's medications and [DIAGNOSES REDACTED]. On 6/12/19, at 11:37 a.m. registered nurse (RN) clinical manager (CM)-B stated awareness of CP-A's recommendation from 5/6/19, regarding R11's physician progress notes [REDACTED]. CM-B stated she had checked R11's medical records through the hospital's electronic health record (EHR) that the facility was affiliated with, and there were no records R11 ever received medication therapy for [MEDICAL CONDITION]. CM-B indicated R11's medical records in the EHR did not go back too far, as prior to admission R11's primary physician worked with another hospital system, and CM-B did not have access to that system's EHR. CM-B stated R11's record lacked any TSH levels since admission, and stated she had not tried contacting R11's former primary provider from prior to admission. CM-B stated R11 was seen for regular rounds on 5/30/19, and again for a concern visit on 6/10/19, and CP-A's recommendation was not addressed with either provider visits. CM-B stated I probably missed that on the last rounds, (R70) was just seen. On 6/13/19, at 3:18 p.m. director of nursing (DON) stated CP-A reviewed resident medical records and identified any medication irregularities which are reported to nursing staff. The DON indicated CM-B would have received the recommendations from CP-A and would address the recommendation with the provider on the next physician rounds. Review of facility policy titled Consultant Pharmacist Drug Regimen Review Policy, revised 3/14/18, indicated the CP would review the medical records and medication regiments of each resident for appropriateness using CMS (Centers for Medicare and Medicaid Services) Guidelines on Unnecessary Medications. The policy identified an unnecessary drug is any drug when used: without adequate monitoring, and indicated any irregularities noted by the pharmacist during the review would be documented on a written report and provided to the attending physician, facility medical director, and DON. The facility further indicated irregularities requiring physician attention are intended to be addressed prior to or at the next scheduled physician (or designee) visit for the resident. Review of the facility policy titled [MEDICAL CONDITION] Medications last revised 7/24/18, indicated providers would use [MEDICAL CONDITION] medications appropriately working with the interdisciplinary team (IDT) to ensure appropriate use, evaluation and monitoring. The policy further indicated a psychiatrist/mental health may assist the facility in establishing appropriate guidelines for use, dosage and monitoring of [MEDICAL CONDITION] medications. The policy identified nursing staff would monitor [MEDICAL CONDITION] drug use daily, noting any adverse effects, monitor for the presence of target behaviors on a daily basis charting by exception and review the use of the medication with the physician and the IDT on a quarterly basis to determine the continued presence of target behaviors. The policy further identified the CP would monitor [MEDICAL CONDITION] drug use in the facility to ensure that medications are not used in excessive doses or duration and would notify the physician and the nursing unit if/whenever a [MEDICAL CONDITION] medication was past due for review. However, the policy lacked a procedure for assessing the effectiveness of [MEDICAL CONDITION] medications used for [MEDICAL CONDITION].