Every finding on record at Pine Heights at Brattleboro Center for Nursing & R

Based on record review and interview the facility failed to notify the long-term care Ombudsman of transfer/discharges for 3 of 3 sampled residents. Findings include:Per record review of Resident #1, Resident #2 and Resident #3's medical record, there was no documentation that the Ombudsman was notified of their transfer/discharge. Per interview on 6/23/26 at 12:15PM, the Administrator confirmed they do not notify the Ombudsman's office for planned transfers/discharges to other skilled nursing facilities.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards of food service safety. This has the potential to impact all residents. Findings include:During the initial tour of the kitchen with the Dietary Manager (DM) on 9/15/2025 at 9:49 AM a frozen turkey in a cardboard box was noted on the floor and an open bag of frozen fish was seen on the shelf. When asked about the frozen turkey on the floor, the DM stated that it was left over from last Thanksgiving, and that she had just not discarded it yet. The DM also confirmed that the bag of fish had been left open and that it should not have been. On 9/15/2025 at approximately 10:15 AM on return to the kitchen, it was noted that clean dishes were being put away and placed on food carts while wet. At this time the DM confirmed that the dishes were being put away wet and that they should not be.

Based on observation and interview, it was determined that the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 2 of 4 medication carts. Findings include:Observation on [DATE] at 8:17 AM for one of the Third Floor Unit medication carts revealed that the Isopto Atropine Solution 1% bottle had expired on 4/2025. Per interview on [DATE] at 8:17 AM with the Licensed Practical Nurse (LPN) assigned to this medication cart, they confirmed that the above medication had expired. They stated the process for checking for outdated medications was a task completed by the night shift.Observation on [DATE] at 11:51 AM for one of the Fourth Floor Unit medication carts revealed that a tube of Glutose 15 had expired on 6/2025. Per interview on [DATE] at 11:51 AM with the LPN assigned to this medication cart, they confirmed that the above medication had expired. They stated the process for checking for outdated medications was a task completed by the night shift.

Based on interview and record review, the facility failed to complete annual evaluations for two of three Licensed Nursing Assistants sampled. Findings include: Per record review of three Licensed Nursing Assistants' (LNA) personnel files that had worked at the facility for over a year, there was no documentation of annual evaluations for 2 of the 3 LNAs to indicate what education or trainings were appropriate for each LNA. Per interview on 9/17/2025 at 12:19 PM, the facility Administrator confirmed that they do not conduct annual evaluations for any staff. Per interview on 9/17/2025 at 12:48 PM, the Director of Nursing confirmed that the facility does not conduct annual evaluations for Licensed Nursing Assistants.

Based on observations, policy review, and staff interviews, the facility failed to implement infection control policies and procedures when staff didn't don personal protective equipment to handle an indwelling device for a resident on enhanced barrier precautions for 1 of 7 residents (Resident #11). Findings include:Per observation on 9/16/2025 at 9:48 AM, a Licensed Practical Nurse (LPN) was observed picking up an indwelling catheter bag (collection bag for urine connected to a catheter, which is a thin, flexible tube that a healthcare provider inserts into the bladder to drain and collect urine) from the floor without wearing any personal protective equipment (PPE). Per interview on 09/17/2025 at 10:34 AM with the Infection Preventionist (IP), she confirmed that indwelling catheter bag handling, whether it is in a privacy pouch or not, requires gloves worn when handling, and Enhanced Barrier Precautions (EBP) should be utilized during care of the catheter. The facility policy Urinary Catheterization policy dated 1/2023/4-24 defines EBP as the use of gown and gloves.Per interview on 9/17/2025 at 10:43 AM with the LPN observed on 9/16/2025 handling the indwelling catheter bag without PPE, she confirmed PPE should've been worn when handling the bag. She stated, Should have, but that wasn't my focus, and I carry gloves with me when I know I'll be providing care, so I didn't have gloves in my pocket. When asked about gloves being available in Resident rooms, she stated there may be some gloves in the bathroom, but she isn't sure.,The Centers for Disease Control and Prevention describes the reasoning for EBP as reducing the opportunities of Multi-Drug Resistant Organisms (MDROs) to be transferred from one resident to another on staff hands and clothing.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice related to care and maintenance of a PICC line for 1 of 1 resident (Resident #23). Findings include:Per record review, Resident # 23 has diagnoses that include acute osteomyelitis, left ankle and foot, and non-pressure chronic ulcer of the other part of the left foot. Resident #23 is receiving wound care and intravenous (IV) antibiotics through a PICC line. On 9/16/25 at 9:35 AM, a Licensed Practical Nurse (LPN) was observed preparing to administer an antibiotic via Resident #23's PICC line. She encountered resistance while trying to clear the catheter line to allow the antibiotic to pass through. This surveyor noticed that the line was very long and coiled, causing it to kink under the dressing, thus preventing the flow of liquid to flush the line. When the line was uncoiled, it measured 42 cm at the indicator marked on the line, indicating that the line could have potentially migrated out of position. An interview conducted minutes later with the Assistant Director of Nursing (ADON) revealed that, after assessing the line, it should have been measured during the admission assessment performed by nursing and each week thereafter.A review of Resident #23's medical record revealed that the resident was admitted to the facility on [DATE] with a PICC line inserted. There was no evidence in the record indicating the length of the line at the insertion site upon admission or any time after. A policy Central Venous Access Device [CVAD] Catheter Dressing Change, dated January 2022 reads, A VAD (Venous Access Device) assessment should occur before, during, and after medication administration, during dressing changes, with each site assessment of the VAD, presence of the following, at a minimum, should be included: erythema (redness) drainage, induration, tenderness warmth, swelling, external catheter length.Per the interview with the ADON on 9/16/2025 at 2:20 PM, the nurse admitting the resident should have measured the line, and the line should have been measured at the insertion site at least weekly during dressing changes. She confirmed that there were no measurements in the medical record that might support whether the line had migrated or not, and that it was safe to use. Caring for your PICC: What you need to know. CEUfast.com Blog. (n.d.). https://ceufast.com/blog/caring-for-your-picc-what-you-need-to-know#:~:text=Measuring%20The%20PICC,proper%20function%20of%20the%20PICC.

Based on interview and record review, the facility failed to ensure resident involvement in the care planning process for 1 of 20 residents (Resident #38). Findings include:Per interview on 9/15/2025 at 11:39 AM, Resident #38 reported that s/he is not involved in her/his care plan development or review. S/he stated that s/he feels that decisions involving her/his care are made without her/him and that s/he does not know when the facility reviews or revises her/his care plan. Review of a Care Conference/Care Plan meeting note dated 7/8/2025 reveals that a Nurse, Social Services, and Recreation was in attendance at the meeting. Section 2. of the form that states Was the resident/responsible party invited to the resident care conference? was left blank. Per interview with the facility Administrator on 9/17/2025 at 2:27 PM, residents and/or their responsible parties are only invited to the comprehensive care plan meetings which are done annually and with a significant change.

Based upon observation and interview, the facility failed to meet food service safety requirements. Findings include: 1.) Per observation on 9/8/24 at 9:30 PM and again on 9/11/24 at 9:45 AM, a fan located above the clean dish drying area in the facility's kitchen was noted to have a notable covering of dark gray dust-like material on the fan blades and the outer surface of the fan guard/grill. On 9/11/24 at 9:45 AM, the fan was noted to be circulating air directly above a tray of clean flatware. The dirt on the fan guard was noted to include a strand of dark, stringlike material extended from the guard while the fan was operating. The observation on 9/11/24 was conducted with the facility's Dietary Manager, who confirmed the fan blowing on the clean flatware represented an unsanitary condition, and stated that Maintenance had been notified about the fan needing cleaning the day before, on 9/10/24, but the cleaning had not been done. 2.) Per observation on 9/9/24 at 12:31 PM, a bag of white bread slices was noted to have visible green mold on it in the facility's 2nd floor kitchenette. Per interview on 9/11/24 at 9:45 AM the Dietary Manager confirmed the bread in the 2nd floor kitchenette was moldy and stated that the facility did not have a process for monitoring and dating bread to ensure it was not used beyond its expiration date.

Based upon observation, interview, and record review, the facility failed to provide Activities of Daily Living [ADL] care and assistance to maintain good nutrition for 1 dependent resident [Res.#39] of 3 sampled residents dependent on ADL assistance. Findings include: Per review of Res.#39's Care Plan, the resident is identified as having as having Dysphagia [Dysphagia is a medical term for difficulty swallowing. Difficulty swallowing can lead to: Malnutrition, weight loss and dehydration. ]*, has risk for weight loss and malnutrition due to variable meal intake and dysphagia as well as cognitive impairment, at risk for dehydration, has impaired cognitive function/dementia or impaired thought processes, has an ADL [Activities of Daily Living] self-care performance deficit related to dementia, and has impaired visual function related to left eye blindness. Care Plan interventions to counteract Res.#39's nutritional risks include EATING: Continual supervision, May need more cues/assist, Provide feeding/dining assistance as needed. Set up for meals, Ensure the resident has access to Beverage of choice, and Ensure all meals and fluid intake occur under staff supervision. A meal observation was conducted on 9/9/24 at 11:45 AM. During the lunch meal observation, Res.#39 was observed seated in a wheelchair with h/her eyes closed at a table with 4 other residents. At 11:45 AM, a meal platter and a drink were placed in front of Res.#39, along with platters in front of the other 4 residents, including a resident seated next to Res.#39. Per observation, a staff Licensed Nursing Assistant [LNA] sat down next to the resident seated next to Res.#39, and the LNA began to feed that resident. Res.#39 was positioned in front of h/her meal and drink and made no attempt to feed h/herself or was cued or assisted by staff for approximately 10 minutes, while the other residents at the table ate their meal and the resident seated next to Res.#39 was being fed by the LNA. At 11:55 AM, another resident, Res.#34, approached the table in their wheelchair, took the drink from in front of Res.#39, drank from it, then wheeled away from the table carrying the drink with them. The LNA seated at the table said nothing to Res.#34 and did nothing to intervene. Res. #39 remained seated at the table in front of h/her meal for another 11 minutes without cueing or assistance, when a second LNA came over to the table and replaced the drink that the other resident had taken. Res.#39 was not offered the drink or cued to drink. At 12:10 PM, 25 minutes after the meal platter was placed in front of Res.#39, after the LNA had finished feeding the resident seated next to Res.#39 and the other residents at the table had finished their meals, the LNA moved their chair next to Res.#39 and offered h/her a bite of the meal. Res.#39 took a spoonful of the food and shook h/her head. The LNA did not question the resident as to why they disliked it, if they wanted an alternative, or if the meal needed reheating after sitting uncovered for 25 minutes. An interview was conducted with the facility's Director of Nursing [DON] on 9/10/24 at 9:30 AM. The DON confirmed that Res.#39 was identified as at risk for weight loss, malnutrition and dehydration, and diagnosed with impaired cognition and dementia along with difficulty swallowing. The DON confirmed Res.#39 is dependent on staff for cueing and assistance with meals, and agreed that based on the observation on 9/9/24 at 11:45 AM, Res.#39 was not offered either while the other residents at the table ate and/or were being fed, another resident took Res.#39's drink with no staff intervention, and after being offered their meal after 25 minutes and declining it, was not offered to re-heat the meal or an alternative.

Based on interview and record review the facility failed to provide services that included supervision, monitoring, and ADL (Activities of Daily Living) care necessary to prevent a fall from a wheelchair for 1 of 10 residents in the applicable sample (Resident #19). Findings include: Per record review Resident #19 was found on the floor of her/his room at 1:45 AM on 8/7/24. Review of Resident #19's care plan reveals that s/he is totally dependent on two staff with a mechanical lift for transfers to and from a wheelchair. The care plan also indicates that s/he has an ADL self-care performance deficit, with interventions that include, ensure resident is assisted to bed by 11 PM unless resident requests otherwise, intentional rounding every 1 hour for repositioning, and monitor positioning while in room. A Health Status Note written on 8/7/2024 states that the Resident was found on the floor next to her/his wheelchair in her/his room at 1:45 AM. The note further states that the call light was out of reach and the mechanical lift was in the room. Another Health Status Note written on 8/7/24 at 3:45 PM states that it appears that the Resident slid out of her/his wheelchair and was on the floor before being found by staff. Review of the facility incident summary written by the Administrator dated 8/7/2024 reveals that Resident #19 was assisted from the dining room to her/his room and was not assisted to bed or reevaluated until s/he was found on the floor by staff at approximately 1:45 AM. The summary also states that the Resident was to be turned and repositioned every 2 hours. Per interview with the facility Administrator on 9/11/24 at 11:36 AM the facility internal investigation of the incident determined that a staff member brought the Resident to her/his room sometime after the evening meal. The Licensed Nursing Assistant (LNA) who was assigned to Resident #19's care had signed documentation that s/he had performed safety checks however, s/he had not. The evening and night shift staff had not done walking rounds at change of shift as is expected. During the onsite survey, it was determined that the facility had implemented actions to correct the noncompliance prior to the start of the re-certification survey, which included evaluation of Resident #19, staff education regarding safety checks, repositioning, intentional walking rounds, and increased monitoring of assistance provided to the residents. The facility was able to demonstrate monitoring of the corrective action and sustained compliance.

Based on interviews, observation, and record reviews, the facility failed to support the resident's right to file grievances anonymously for 5 out of 5 residents in the sample (Resident's #5, #26, #55, #53 and #67). This has the potential to affect all residents in the facility. Findings Include: Per interview at Resident Council (RC) on 9/11/2024 at 10:30 AM, 5 out of 5 residents revealed they did not know how to file a grievance anonymously, or at all, and had no access to forms to be able to file anonymously or independently. All five residents revealed if they had known and understood their rights to file a grievance, they would have done so. Per observation of all units at the facility at 11:45 AM, there was no evidence of grievance forms on any unit for a resident, or his/her representative, to submit a grievance independently or anonymously. Per interview on 9/11/2024 at approximately 12:00 PM with the Administrator, s/he confirmed that there were no forms available for individuals to file a grievance independently or anonymously on any units. The Administrator confirmed during interview there was not a process or form available for the residents or responsible party to file a grievance independently or anonymously. Per facility policy titled Grievance/Concern Policy, it states the following: The residents/responsible party can bring forward their concerns verbally and or by written grievance process. Grievance/Concerns forms are available on the nursing units and in the front lobby where applicable. There is no evidence that forms were made available or that residents/representatives had access to file a grievance independently or anonymously.

Based on observation, interview and record review the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents in a standard survey sample. Per record review for Resident #76, admitted in late June, 2022, the resident had unstageable pressure ulcers to the right and left buttocks on the admission assessment. Interview with unit LPN on 7/12/22 at 10:25 AM, the LPN was unaware of resident #76 having any open skin areas. On 7/12/22 at 10:30 AM, the Unit Manager and Director of Nursing (DON) confirmed the resident did currently have open areas on both right and left buttocks and that these areas were being treated. They were unable to locate any provider orders to treat the pressure ulcers or documentation that the ulcers had been receiving any treatment. On 7/12/22 at 3:45 PM, the DON reported a verbal order for treatment had been previously received; however, it had not been documented in the electronic health record nor had it been put on either the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore, there was no documentation to substantiate the receipt of an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview and record review the facility staff failed to ensure that the person-centered care plan was implemented/followed for ambulation, for 1 of 22 sampled residents, (Resident #38). The detailed findings are as follows: Per record review, Resident # 38 has limited physical mobility related to a right [MEDICAL CONDITION] that required a surgical hip replacement. The person-centered care plan identifies limited physical mobility with an intervention that directs Certified/Licensed Nurse Aides (LNA/CNA) to ambulate the resident with assistance, to walk 60 feet. Per observation during 3/18/19 and 3/19/19 the resident was observed throughout the survey sitting in a wheel chair. Confirmation was made by the Rehabilitation Director on 3/19/19 at approximately 12:42 PM, that the resident was discontinued from therapy because s/he had plateaued. Resident #38 was able to ambulate 60 feet with a rolling walker and assist of one (1). Confirmation was made by two LNA's/CNA's on 03/19/19 that they have not ambulated Resident #38 during the two (2) days identified. They confirm that the resident has not been very steady, but also confirm they have not reported the information to the interim unit manager. Per review of the LNA ambulation log (walk in corridor), the resident has required limited assistance for ambulation twice, during the month of (MONTH) 2019. There is no further evidence that the resident has been assisted to ambulate throughout the month of (MONTH) 2019. Confirmation was made by the Director of Nurses on 3/20/19 that the facility does not have a Restorative Nursing Program.

Based on observation, interview and record review the facility failed to revise the person-centered care plan for 1 of 22 sampled residents at the time when there was a change in medications and a change in the discharge plan, (Resident #38). The detailed findings are as follows: 1. Confirmation was made by Resident #38 on 3/18/19 during the resident interview, that s/he will be staying in the facility long term, s/he is unable to return to the previous setting. Per review of Resident #38's person-centered care plan, identifies that there is a focus in place for a safe and appropriate discharge with a goal to identify feasibility of returning to the community, the resident is unable to return to assisted living. Confirmation was made by the interim unit manager on 03/19/19 at approximately 12:30 PM, that the resident is unable to care for him/herself, unable to return to his/her previous living situation and will be transferring to the third floor, here in the nursing home. Confirmation is made at this time that the person-centered care plan has not been revised since 02/06/19. 2. Per medical record review for Resident #38, identifies the physician ordered [MEDICATION NAME] 250 mg tablets (antibiotic) by mouth (po) one time a day for infection for 4 days ending on 01/24/19. On 02/06/19, the physician ordered [MEDICATION NAME] (a steroid) 20 mg po daily and on 02/07/19, [MEDICATION NAME] 30 mg po daily taper down to 10 mg daily. On 02/20/19 the resident is to receive [MEDICATION NAME] 9 mg po daily ongoing and to be reevaluated by the physician on 4/10/19, for chronic cough that has been going on since (MONTH) 2019. Per review of the person-centered care plan, there is a focus identifying that the resident is on an antibiotic, for an upper respiratory infection. Confirmation was made by the interim unit manager on 3/19/19 at approximately 12:30 PM, that the resident is not on antibiotics, is receiving [MEDICATION NAME] daily and confirms that the person-centered care plan has not been revised since 01/24/19.

Based on staff interview and record review, the facility failed to employ a Food Service Director with the appropriate qualifications to meet the regulation as noted above. Findings include: Per staff interview and review of the Food Service Director's (FSD) credentials, the FSD does not have the requisite qualification to meet the regulation. On 3/20/19 at 9:08 AM the Food Service Director confirmed that s/he does not have the qualifications as required by the regulation. The facility does not employ a Registered Dietician (RD) on a full time bases to over see the FSD. During an interview with the RD on 3/20/19 at 10:30 AM confirmed that s/he only works for the facility as a consultant approximately 20 hours per week. On 3/20/19 at 10:10 AM, the Administrator confirmed that the RD is a consultant and does not work full time hours for the facility. During an interview with the Administrator on 3/20/19 11:50 AM confirmation was made that the FSD does not have the qualifications as required by the regulation.

Based on observation, interview, and record review the facility failed to follow a care plan for fall prevention for 1 of 3 residents in the applicable sample (Resident #3). Findings include: Per record review Resident #3 had an unwitnessed fall on 7/19/18. The care plan was updated on 7/19/18 to use Floor mats on both sides of bed. Per observation on 8/14/18 at 2:04 PM, Resident #3 did not have floor mats on either side of his/her bed. Per interview on 8/14/18 at 2:07 PM with a Licensed Nursing Assistant (LNA), s/he confirmed that there were no floor mats on either side of Resident #3's bed. A Licensed Practical Nurse (LPN) also confirmed this; and stated that s/he was not aware that Resident #3's care plan had been updated with this intervention.

Based on record review and confirmed by staff interview, the facility failed to provide written information pertaining to the bed-hold policy to the resident or resident representative(s) for 4 of 19 applicable residents in the survey sample (Resident #25, 61, 66 and 365). Findings include: 1.) Per record review resident #66 was transferred to an acute care hospital on [DATE] and did not return to the facility. There is no evidence in the clinical records that the resident or resident's representative(s) was provided written notice which specifies the duration of the bed-hold policy after transfer to the hospital. Per interview with the Director of Nursing and the Assistant Director of Nursing on 1/9/18 at approximately 1:30 PM confirmation was made that all residents admitted to the facility are provided the Bed Reservation Policy contained in the Admission Agreement. The facility does not issue the resident or representative a notice of bed-hold at the time of transfer. 2.) Per record review Resident #61 was transferred to the hospital on [DATE] and 12/14/17. For each of these dates, there was no evidence in Resident #61's medical record that the Resident and/or Resident's Representative was notified of the bed-hold policy in writing. During an interview on 1/10/18 at 11:04 AM, the Assistant Director of Nursing (ADNS) confirmed at there was no notice of bed hold provided to the resident or the resident's representative. 3.) Per record review, Resident #25 was transferred to the hospital on [DATE] from the facility after a fall with fracture resulting. There was no documentation that the resident's legal representative was notified in writing of the bed-hold policy. Per interview on 1/8/18 at 3:12 PM, the Director of Nursing confirmed that there was no documentation to show the written notification was made to the family at the time of transfer. 4.) Per record review, Resident #365 was transferred to the hospital on [DATE] from the facility for acute respiratory issues. There was no documentation that the resident or resident's legal representative was notified in writing of the bed-hold policy. Per interview on 1/10/18 at 9:35 AM , the Director of Nursing confirmed that there was no documentation to show the written bed-hold policy notification was made to the resident or legal representative at the time of transfer.

Based on staff interviews and record review the facility failed to notify residents, the resident's representative and the Ombudsman in writing of a transfer or discharge and the reason for the move in writing and in a language and manner they understand, for 4 of 19 applicable residents (Residents #25, 61, 66, and 365). Findings include: 1.) Per record review Resident #61 was transferred to the hospital on [DATE] and 12/14/17. There was no evidence in Resident #61's medical record that the Resident, Resident's Representative, and/or the Ombudsman was notified of each of the transfers in writing. During an interview on 1/10/18 at 11:04 AM, the Assistant Director of Nursing (ADNS) confirmed this. 2.) Per record review resident #66 was transferred to an acute care hospital on [DATE] and did not return to the facility. There is no evidence in the clinical records that the resident or resident's representative(s) or the Ombudsman was notified in writing of the transfer to the hospital. Per interview with the Director or Nursing on 1/09/17 at approximately 1:30 PM confirmation was made that neither the resident, resident representative(s) or the Ombudsman was notified in writing regarding the transfer to the hospital. 3.) Per record review, Resident #25 was sent to the hospital on [DATE] from the facility after a fall with fracture resulting. There was no documentation that the resident, the resident's legal representative or the Ombudsman was notified in writing of the transfer. Per interview on 1/8/18 at 3:12 PM, the Director of Nursing confirmed that there was no documentation to show the written notifications were made. 4.) Per record review, Resident #365 was transferred to the hospital on [DATE] from the facility for acute respiratory issues. There was no documentation that the resident or resident's legal representative or the Ombudsman were notified in writing of the transfer.

Based on observation and staff interview, the facility failed to provide accurately posted phone numbers and address for all pertinent State agencies. Findings include: Per observation on 1/9/18 at 12:40 PM on the third floor and per staff interview, the address for obtaining outside help with a grievance is incorrect and the phone number for the Survey and Certification Division of the Department of Aging and Independent Living is also incorrect. Per Review of the POS [REDACTED]. This was confirmed with the DNS (Director of Nursing Services) on 1/9/18.

Based on record review and confirmed by staff interview, the facility failed to provide written information pertaining to the bed hold policy (specifics as described above), for 1 applicable resident or the resident's representative, at the time of transfer to the acute hospital setting. The findings include the following: Per medical record review on 1/2/18 at approximately 10 AM, nurses' notes identify that on 9/23/17 at 11:55 AM, Resident #1 was found lying on the floor at the foot of his/her bed. The resident was unresponsive for approximately 5 minutes. The resident was transferred to the acute hospital via ambulance at approximately 12:30 PM. Per interview with the Registered Nurse, Director of Nurses on 1/2/18 at approximately 12 noon confirmation was made that all residents admitted to the facility are provided the Bed Reservation Policy contained in the Admission Agreement. The facility does not issue the resident or representative a notice of bed hold at the time of transfer.

Based on clinical record review and interview, the facility failed to provide services to prevent two residents admitted with pressure ulcers from developing additional pressure ulcers while in the facility. This affected two (#4, #3) of four applicable resident records reviewed. Findings include: 1. Per clinical record review on 03/21/12, Resident #4 was admitted on [DATE] with one open area noted to the right buttocks measuring 0.5 centimeters (cm). The Nursing Admission assessment dated [DATE] also indicated the left buttock was reddened and intact. The admission Braden (pressure risk) assessment indicated a score of 17 indicating low risk. The Nurse's Notes dated 03/05/12, and timed 7:00 A.M. to 7:00 P.M., indicated the dressing was changed to the right buttocks open area. The note did not include a description of the area at that time. The Nurse's Notes dated 03/06/12 at 2:00 P.M., indicated Resident #4 had two open areas on the buttocks and coccyx measuring 0.4 cm in diameter and to the left gluteal fold measuring 0.3 cm in diameter. The note indicated the areas were present on admission and no new intervention was implemented. The dietary notes dated 03/07/12 indicated poor intake and recommended diet liberalization and the addition of supplements twice daily. This was implemented on 03/08/12. The Weekly Pressure Ulcer Flow Sheet indicated that the initial assessment of the pressure ulcers by the wound nurse was completed on 03/06/12, and two ulcers were present in close proximity on the right buttock at that time. This was the only assessment documented by the wound nurse and indicated area #1, located to the superior right buttock, measured 0.4 cm by 0.8 cm and was superficial in depth, and area #2 measured 0.3 cm by 0.5 cm and was superficial in depth. Both flow sheets indicated the ulcers were present on admission and were acquired outside of the facility. The Braden (pressure risk) assessment dated [DATE] indicated a score of 15 (mild risk). The nurses notes on 03/09/12 at 1:30 P.M. indicated that the next of kin was notified of a new pressure ulcer noted by the wound nurse on that date. The plan of care for Pressure Ulcers, dated 03/03/12 indicated the presence of actual breakdown acquired prior to admission and urine and fecal incontinence as risk factors. It indicated a Stage II (partial thickness) wound was located on the right ischium. The interventions included: update MD as needed, pressure reducing mattress, turn and reposition every 2 hours, incontinence care every two hours and as needed and treatment as ordered of [MEDICATION NAME] (an occlusive dressing) changed three times a week. A multivitamin was requested by the dietician on 03/07/12. No individualized interventions specific to the Resident #4's hydration, positioning or device needs was noted. The plan of care for a second Pressure Ulcer with a date discovered of 03/06/12, was initiated on 03/09/12. It was identical to the initial plan of care and stated under treatment cleanse and cover with [MEDICATION NAME] used for the other Stage II ulcer. Review of the policy and procedure for pressure ulcers, the National Health Care Association Pressure Ulcer Prevention Management and Treatment Program, revised 10-2007, revealed on page 18, Stage II protocol, intervention number 5, the use of preventative pressure relief non powered devices on the bed and chair. Note: multiple stage II areas on the trunk require a low air loss mattress. The clinical record did not indicate a low air loss mattress or a cushion to the chair was implemented per this protocol. Interview of the Wound Nurse on 03/21/12 at 3:00 P.M., confirmed that there had been one weekly assessment documented on 03/06/12, noting two pressure ulcers. The Wound Nurse stated that it was not unusual for the initial assessment to be completed several days (up to one week) after admission, depending on the timing of the admission, because the wound assessments were completed on Tuesdays. Wound treatments were completed throughout the week and skin was assessed on admission by the various charge nurses. The Wound Nurse verified that the Nursing Admission assessment completed 03/02/12 indicated one open area to the right buttocks and was consistent with the admission paperwork received from the hospital. The wound nurse verified the weekly pressure ulcer flow sheet s/he completed 03/06/12 indicated two pressure ulcers were present on the right buttocks on admission but verified that the wound was not assessed on admission by him/her. No explanation was provided for the discrepancy in the number and location of the wounds or where or when they had developed. This information was confirmed by the Director of Nursing Services (DNS) and the Minimum Data Set assessment Registered Nurse on 03/21/12 at 3:45 P.M. who stated after reviewing the documentation that the Admission assessment indicated a stage II (partial thickness) pressure ulcer to the right buttock and a stage I (red area) ulcer on the left buttock. The stage I ulcer resolved and a new stage II ulcer was documented on 03/06/12. The DNS stated that a low air loss mattress is used when there are multiple stage II pressure ulcers and did not indicate why it was not implemented on 03/06/12 when the second ulcer was documented. The DNS verified that the Braden pressure risk assessment completed 03/09/12 did not accurately reflect the nutritional status, the exposure of skin to moisture or the sensory perception of Resident #4. S/he could not state specific or individualized intervention that had been implemented for Resident #4 as a result of having a pressure ulcer on admission, and risk factors of moisture to the skin, incontinence, and poor nutritional intake to prevent the development of a Stage II pressure ulcer in the facility on 03/06/12. 2. Per clinical record review on 03/21/12, Resident #3 was admitted on [DATE], for a three week respite stay and discharged on [DATE]. A [DIAGNOSES REDACTED]. The Nurse Practitioner documented on 02/09/12, that Resident #3 had a wound to the gluteal fold that was not observed because the Resident was dressed. The history and physical exam also indicated a Foley catheter was in place for wound healing. The Nurse Practitioner requested 02/09/12 that the facility get the wound care plan from the wound center. Orders for bladder retraining to discontinue the catheter were noted. The Foley catheter was discontinued on 02/13/12 at 6:00 A.M. and Resident #3 was incontinent of urine four to seven times daily until it was replaced on 02/18/12 at 5:00 A.M., with no documented continent episodes. The Nurse Practitioner wrote orders on 02/17/12, to refer Resident #3 to the wound clinic. Review of the Weekly Pressure Ulcers Flow Sheet indicated Resident #3 was admitted with a pressure ulcer to the top proximal gluteal cleft on 02/09/12. No measurements were noted. No treatment orders were noted. On 02/14/12 the first wound assessment documented, indicated the area measured 2.5 centimeters (cm) length by 1.5 cm width by 0.3 cm depth. The wound bed was described as beefy red and moist with wound edges pink and intact. The Weekly assessment form did not indicate treatment orders. The Nurse's notes on 2/15/12, day shift, indicated the wound was beefy red with a dark shadow center. It indicated the Wound Nurse and the Nurse Practitioner would assess the wound the next day. No evidence of an assessment was noted on 02/16/12. On 02/17/12, no assessment is documented but a treatment is ordered to include: cleanse the wound to the coccyx, apply [MEDICATION NAME] AG (a [MEDICATION NAME] dressing containing silver), to the wound bed (cut to fit), and cover with [MEDICATION NAME] border (an occlusive dressing). It was to be changed three times a week and as needed until the area resolved. The note dated 02/19/12, night shift, indicated the dressing was changed and the wound appeared beefy red with yellow slough. The second Weekly Pressure Ulcer Assessment was documented on 02/21/12, and indicated the measurements were 2.3 cm length by 1.0 cm width. The assessor was unable to determine a depth and the wound bed was described as covered 100 percent with yellow slough. No changes were noted to be made to the treatment or devices used by the Resident. No collaboration was documented between facility staff and the wound care clinic as requested on 02/09/12 and 02/17/12. The Braden scale (pressure risk assessment) completed 02/16/12 and 02/22/12 indicated a score of 12 (10-12 indicates high risk). No individualized interventions were noted to be in place as a result of the identification of high risk for pressure ulcers. The plan of care for Skin at Risk indicated a goal of no further breakdown during the next 12 weeks. The interventions included a pressure reducing mattress, observe skin integrity during care, protective barrier, turn and reposition ever two hours, toilet or change every two hours and as needed and transfer with lifter to prevent friction. On 02/17/12, the plan of care indicated the addition of a multivitamin and protein shakes three times daily for wound healing. The plan of care for Pressure Ulcers was developed on 02/14/12 and included the pressure reducing mattress, update the MD as needed, turn and reposition every two hours, toilet or incontinence care every two hours and treatment as ordered. Review of the policy and procedure for pressure ulcers, the National Health Care Association Pressure Ulcer Prevention Management and Treatment Program, revised 10-2007, revealed on page 18, Stage II protocol, intervention number 1 states to cleanse the area with cleansing solution (normal saline) and intervention number 5 directs the use of preventative pressure relief non powered devices on the bed and chair. Note: multiple stage II areas on the trunk require a low air loss mattress. On 02/28/12 the wound measurements were 3.0 cm length by 1.5 cm width by 0.6 cm depth with 90 percent of the wound covered with yellow slough, 10 percent beefy red wound bed and reddened wound edges. On 02/28/12 three additional areas were noted to the left buttock measuring #1) 0.2 cm length by 0.2 cm width, #2) 0.3 cm length by 0.5 cm width and #3) 0.4 cm length by 0.7 cm width. All three were described as superficial and beefy red in appearance with bloody drainage. A [MEDICATION NAME] dressing was ordered to cover all three, as they were located in close proximity on the left, lower and inner buttock. Interview of the Wound Nurse on 03/21/12 at 10:45 A.M., before observation of wound care to another Resident, revealed that the facility uses a wound cleanser to clean wounds prior to dressing applications. Interview of the therapy manager on 03/21/12 at 1:15 P.M., revealed that Resident #3 was seen by occupational therapy during her stay to promote upright positioning in a personal customized wheelchair for improved self feeding. The short term goal of two hours and long term goal of four hours had been identified. When questioned about the affect of the wheelchair positioning on the pressure ulcer, the therapy manager indicated no awareness, stating that nursing would be monitoring the Resident's skin. An Occupational Therapy Daily Encounter noted dated 02/22/12, indicated that a waffle cushion was acquired and labeled as Resident #3's personal property because a personal cushion brought to the facility and used by the Resident in the custom chair at home was missing. The therapy manager could not state how long the cushion had been missing. During interview on 03/21/12 at 3:00 P.M., the Director of Nursing Services and the Minimum Data Set Registered Nurse indicated that the measurements of the wound declined from 02/14/12 to 02/28/12, but stated the initial measurement on 02/09/12 was 1.2 cm by 4.5 cm, indicating it had initially improved, and declined due to the [MEDICATION NAME] treatment in place. They stated the facility standard mattress, used for all residents without special orders, is pressure relieving and a low air loss mattress is used when multiple stage II areas are noted. They confirmed that the Foley catheter was discontinued and that Resident #3 had been incontinent for five days when it was replaced, that nutritional supplements were ordered on [DATE] and increased on 02/17/12, but no changes had been made to the turn and reposition schedule, the devices used by the Resident in the bed or chair to redistribute pressure, or limitations made to the amount of time Resident #3 spent sitting up on the wound as it declined. They verified that three additional Stage II pressure areas developed the day prior to Resident #3's discharge home.

Based on record review and staff interviews the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one resident. (Resident # 1) Findings include: Per record review on 5/11/11 Resident # 1 who is elderly and has had a long history of diarrhea and chronic kidney disease was administered an opioid narcotic at an incorrect dose resulting in a period of hospitalization between 5/1/11 and 5/9/11, with a [DIAGNOSES REDACTED]. On the afternoon of 4/29/11 Opium Tincture was delivered to the facility by the contracted pharmacy for Resident # 1. Because there was no written physician or telephone order (s) at the facility for this narcotic medication, it was sent back to the pharmacy. During the evening of 4/29/11 at 6 PM the physician visited the facility and wrote an order to 'Proceed with Tincture of Opium - trial as ordered.' The physician conferenced with the staff nurse regarding the resident's codeine allergy and stated that after consulting with the pharmacist s/he would proceed with the Opium trial for the resident's symptoms of acute diarrhea. Per interview with the staff nurse on 5/11/11 at 1:20 PM who was on duty the evening of 4/29/11, s/he asked the physician to clarify the Opium order. The physician was unable to clarify the order stating to the nurse that 'they could not remember the 'strength of the dose' that s/he had ordered from the pharmacy. The nurse asked the physician if s/he should write the telephone order based on the label and the physician said 'yes.' The medication arrived the evening of 4/29/11 with the label stating, 'Opium Tincture 10 mg/ml, take 6 mls (milliliters) PO (by mouth) QID (four times per day).' The nurse confirmed that s/he wrote a telephone order to this effect and sent it to the physician. In addition,, s/he confirmed that although they were unfamiliar with the drug, s/he failed to call the on-call pharmacist for drug dosage parameters when the Nurses Drug Handbook (2009 Edition) failed to have any information listed for the medication. Per interview on 5/11/11 at 1:40 PM the nurse confirmed that, 'looking back, I should not have done that.' (taking the information off the label and sending it to the physician as a telephone order) In addition, the nurse confirmed s/he 'could have called the on-call pharmacist' to get information regarding the usual dosing instructions, but did not. Per interview on 5/11/11 at 11:15 AM the DNS (Director of Nursing Services) confirmed that they had obtained a copy of the prescription the physician had faxed to the pharmacy and received by the pharmacy, which this surveyor reviewed. The prescription the physician sent to the pharmacy was written as .6mls (point 6 mls) PO QID without a zero in front of the decimal point. The DNS confirmed that the prescription filled by the pharmacy was 6 mls (six mls) PO QID. In addition, this surveyor viewed the bottle sent by the pharmacy, which was still locked in the medication cart. The label read, ' Opium Tincture 10 mg/ml. Take 6 mls (six mls) by mouth four times a day.' Per review of the Nursing Drug Handbook 2004 edition, 6 mls of Opium Tincture is the maximum daily dose for a 24 hour period. On 4/30/11 the resident received a total of 2 doses of the Opium Tincture (at 6 mls), equaling 12 mls total. During that evening s/he became lethargic, his/her limbs were cold, s/he had involuntary twitching and his/her blood pressure and pulse were low. S/He was transferred to the hospital, returned to the facility the next morning, and was transferred back to the hospital where he was admitted for 9 days for an opium overdose. Reference: 1. Per Nursing Drug Handbook 2004 edition: Opium Tincture: Adults dosage: 0.6 ml PO QID. Maximum, 6 ml daily. 2. Geriatric Dosage Handbook (Lexi-Comp-The official drug reference for the American Pharmacists Association) 12th Edition. Todd P. Semla, PharmD, BCPS, FCCP. Page 17 states: Always place a zero in front of a naked decimal (0.5 ml is correct, .5ml is incorrect)

Based on record review and staff interviews, the facility failed to ensure that one resident (Resident # 1) received the correct dosage of a narcotic medication to prevent an unanticipated decline in the resident's status, which resulted in a hospitalization .. Findings include: Per record review on 5/11/11 Resident # 1 who is elderly and has had a long history of diarrhea and [MEDICAL CONDITION] was administered an opioid narcotic at an incorrect dose resulting in a period of hospitalization between 5/1/11 and 5/9/11, with a [DIAGNOSES REDACTED]. On the afternoon of 4/29/11 [MEDICATION NAME] was delivered to the facility by the contracted pharmacy for Resident # 1. Because there was no written physician or telephone order (s) at the facility for this narcotic medication, it was sent back to the pharmacy. During the evening of 4/29/11 at 6 PM the physician visited the facility and wrote an order to 'Proceed with [MEDICATION NAME] of [MEDICATION NAME] - trial as ordered.' The physician conferenced with the staff nurse regarding the resident's [MEDICATION NAME] allergy and stated that after consulting with the pharmacist s/he would proceed with the [MEDICATION NAME] trial for the resident's symptoms of acute diarrhea. Per interview with the staff nurse on 5/11/11 at 1:20 PM who was on duty the evening of 4/29/11, s/he asked the physician to clarify the [MEDICATION NAME] order. The physician was unable to clarify the order stating to the nurse that 'they could not remember the 'strength of the dose' that s/he had ordered from the pharmacy. The nurse asked the physician if s/he should write the telephone order based on the label and the physician said 'yes.' The medication arrived the evening of 4/29/11 with the label stating, '[MEDICATION NAME] 10 mg/ml, take 6 mls (milliliters) PO (by mouth) QID (four times per day).' The nurse confirmed that s/he wrote a telephone order to this effect and sent it to the physician. In addition,, s/he confirmed that although they were unfamiliar with the drug, s/he failed to call the on-call pharmacist for drug dosaging parameters when the Nurses Drug Handbook (2009 Edition) failed to have any information listed for the medication. Per interview on 5/11/11 at 1:40 PM the nurse confirmed that, 'looking back, I should not have done that.' (taking the information off the label and sending it to the physician as a telephone order) In addition, the nurse confirmed s/he 'could have called the on-call pharmacist' to get information regarding the usual dosing instructions, but did not. Per interview on 5/11/11 at 11:15 AM the DNS (Director of Nursing Services) confirmed that they had obtained a copy of the prescription the physician had faxed to the pharmacy and received by the pharmacy, which this surveyor reviewed. The prescription the physician sent to the pharmacy was written as .6mls (point 6 mls) PO QID without a zero in front of the decimal point. The DNS confirmed that the prescription filled by the pharmacy was 6 mls (six mls) PO QID. In addition, this surveyor viewed the bottle sent by the pharmacy, which was still locked in the medication cart. The label read, ' [MEDICATION NAME] [MEDICATION NAME] 10 mg/ml. Take 6 mls (six mls) by mouth four times a day.' Per review of the Nursing Drug Handbook 2004 edition, 6 mls of [MEDICATION NAME] is the maximum daily dose for a 24 hour period. On 4/30/11 the resident received a total of 2 doses of the [MEDICATION NAME] (at 6 mls), equaling 12 mls total. During that evening s/he became lethargic, his/her limbs were cold, s/he had involuntary twitching and his/her blood pressure and pulse were low. S/He was transferred to the hospital, returned to the facility the next morning, was transferred back to the hospital where he was admitted for 9 days for an [MEDICATION NAME] overdose. Reference: 1. Per Nursing Drug Handbook 2004 edition: [MEDICATION NAME]: Adults dosage: 0.6 ml PO QID. Maximum, 6 ml daily. 2. Geriatric Dosage Handbook (Lexi-Comp-The official drug reference for the American Pharmacists Association) 12th Edition. Todd P. Semla, PharmD, BCPS, FCCP. Page 17 states: Always place a zero in front of a naked decimal (0.5 ml is correct, .5ml is incorrect)

Based on record review and staff interviews, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental and psychosocial well-being for one resident. (Resident # 1) Findings include: Per record review on 5/11/11 Resident # 1 who is elderly and has had a long history of diarrhea and [MEDICAL CONDITION] was administered an opioid narcotic at an incorrect dose resulting in a period of hospitalization between 5/1/11 and 5/9/11, with a [DIAGNOSES REDACTED]. On the afternoon of 4/29/11 [MEDICATION NAME] was delivered to the facility by the contracted pharmacy for Resident # 1. Because there was no written physician or telephone order (s) at the facility for this narcotic medication, it was returned to the pharmacy. During the evening of 4/29/11 at 6 PM the physician visited the facility and wrote an order to 'Proceed with [MEDICATION NAME] of [MEDICATION NAME] - trial as ordered.' The physician conferenced with the staff nurse regarding the resident's [MEDICATION NAME] allergy and stated that after conferring with the pharmacist s/he would proceed with the [MEDICATION NAME] trial for the resident's symptoms of acute diarrhea. Per interview with the staff nurse on 5/11/11 at 1:20 PM who was on duty the evening of 4/29/11, s/he asked the physician to clarify the [MEDICATION NAME] order. The physician was unable to clarify the order stating to the nurse that s/he could not remember the 'strength of the dose' that s/he had ordered from the pharmacy. The nurse asked the physician if s/he should write the telephone order based on the label and the physician said 'yes.' The medication arrived the evening of 4/29/11 with the label stating, '[MEDICATION NAME] 10 mg/ml, take 6 mls (milliliters) PO (by mouth) QID (four times per day).' The nurse confirmed that s/he wrote a telephone order to this effect and sent it to the physician. In addition,, s/he confirmed that although s/he was unfamiliar with the drug, s/he failed to call the on-call pharmacist for drug dosage parameters when the Nurses Drug Handbook (2009 Edition) failed to have any information listed for the medication. Per interview on 5/11/11 at 1:40 PM the nurse confirmed that, 'looking back, I should not have done that.' (taking the information off the label and sending it to the physician as a telephone order) In addition, the nurse confirmed s/he 'could have called the on-call pharmacist' to get information regarding the usual dosing instructions, but did not. Per interview on 5/11/11 at 11:15 AM the DNS (Director of Nursing Services) confirmed that they had obtained a copy of the prescription the physician had faxed to the pharmacy and it was was written as .6mls PO QID. (point 6 mls by mouth four times a day) The fax that the pharmacy received from the physician, although difficult to read because of the faxed copy, was filled as 6 mls PO QID. (six mls by mouth four times a day) In addition, this surveyor viewed the bottle sent by the pharmacy, which was still locked in the medication cart. The label read, '[MEDICATION NAME] [MEDICATION NAME] 10 mg/ml. Take 6 mls by mouth four times a day.' Per review of the Nursing Drug Handbook 2004 edition, 6 mls of [MEDICATION NAME] is the maximum daily dose for a 24 hour period. On 4/30/11, the resident received a total of 2 doses of the [MEDICATION NAME] (at 6 mls), equaling 12 mls total. During that evening s/he became lethargic, his/her limbs were cold, s/he had involuntary twitching and his/her blood pressure and pulse were low. S/He was transferred to the hospital, sent back to the facility, then transferred back to the hospital when s/he was subsequently hospitalized for [REDACTED]. Reference: Per Nursing Drug Handbook 2004 edition: [MEDICATION NAME]: Adults dosage: 0.6 ml PO QID. Maximum, 6 ml daily.

Based on record review and staff interviews, the facility failed to provide services that meet professional standards of quality for one resident. (Resident # 1) Findings include: Per record review on 5/11/11 Resident # 1, who is elderly and has had a long history of diarrhea and [MEDICAL CONDITION], was administered an opioid narcotic at an incorrect dose resulting in a period of hospitalization between 5/1/11 and 5/9/11, with a [DIAGNOSES REDACTED]. On the afternoon of 4/29/11 [MEDICATION NAME] was delivered to the facility by the contracted pharmacy for Resident # 1. Because there was no written physician or telephone order (s) at the facility for this narcotic medication, it was sent back to the pharmacy. During the evening of 4/29/11 at 6 PM the physician visited the facility and wrote an order to 'Proceed with [MEDICATION NAME] of [MEDICATION NAME] - trial as ordered.' The physician conferenced with the staff nurse regarding the resident's [MEDICATION NAME] allergy and stated that after consulting with the pharmacist s/he would proceed with the [MEDICATION NAME] trial for the resident's symptoms of acute diarrhea. Per interview with the staff nurse on 5/11/11 at 1:20 PM who was on duty the evening of 4/29/11, s/he asked the physician to clarify the [MEDICATION NAME] order. The physician was unable to clarify the order stating to the nurse that s/he could not remember the 'strength of the dose' that s/he had ordered from the pharmacy. The nurse asked the physician if s/he should write the telephone order based on the pharmacy label and the physician said 'yes.' The medication arrived the evening of 4/29/11 with the label stating, '[MEDICATION NAME] 10 mg/ml, take 6 mls (milliliters) PO (by mouth) QID (four times per day).' The nurse confirmed that s/he wrote a telephone order to this effect and sent it to the physician. In addition, s/he confirmed that although s/he was unfamiliar with the drug, s/he failed to call the on-call pharmacist for drug dosage parameters when the Nurses Drug Handbook (2009 Edition) failed to have any information listed for the medication. Per interview on 5/11/11 at 1:40 PM the nurse confirmed that, 'looking back, I should not have done that.' (taking the information off the label and sending it to the physician as a telephone order) In addition, the nurse confirmed s/he 'could have called the on-call pharmacist' to get information regarding the usual dosing instructions, but did not. Per interview on 5/11/11 at 11:15 AM the DNS (Director of Nursing Services) confirmed that they had obtained a copy of the prescription the physician had faxed to the pharmacy as well as the fax that had been received by the pharmacy, and both faxed copies were reviewed by this surveyor. The prescription the physician sent to the pharmacy was written as .6 mls (point 6 mls) PO QID without a zero in front of the decimal point. The pharmacy filled the prescription as 6 mls (six mls) PO QID. The DNS confirmed that the prescription filled by the pharmacy was 6 mls (six mls) PO QID. In addition, this surveyor viewed the bottle sent by the pharmacy, which was still locked in the medication cart. The label read, '[MEDICATION NAME] 10 mg/ml. Take 6 mls by mouth four times a day.' Per review of the Nursing Drug Handbook 2004 edition, 6 mls of [MEDICATION NAME] is the maximum daily dose for a 24 hour period. On 4/30/11 the resident received a total of 2 doses of the [MEDICATION NAME] at 6 mls, equaling 12 mls total. During that evening s/he became lethargic, his/her limbs were cold, s/he had involuntary twitching and his/her blood pressure and pulse were low. S/He was transferred to the hospital, sent back to the facility, then transferred back to the hospital when s/he was subsequently hospitalized for [REDACTED]. Reference: 1. Per Nursing Drug Handbook 2004 edition: [MEDICATION NAME]: Adults dosage: 0.6 ml PO QID. Maximum, 6 ml daily 2. Geriatric Dosage Handbook (Lexi-Comp, the official drug reference for the American Pharmacists Association) 12 th Edition. Todd P. Semla PharmD BCPS, FCCP. Page 17. 'Safe Prescription Writing" states: "Always Place a zero before a naked decimal (0.5 ml is correct, .5 ml is incorrect." .