Every finding on record at Premier Place at the Glenview

Based on record review, staff interview, and review of facility policy, the facility failed to provide a written copy of the transfer notice to residents and the Office of the State Long Term Care Ombudsman (LTCO) for 2 (Residents #388, and #389) of 28 sampled residents transferred to the hospital and subsequently discharged from the facility. The findings included: The facility policy dated October 2022 titled Transfer or Discharge, Facility Initiated stated, Residents have the right to remain in the facility. Facility initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy . Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long term care ombudsman when practicable; Notice of Facility Bed Hold and Return policies are provided to the resident and representative within 24 hours of emergency transfer; Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. On 2/28/24 at 1:00 p.m., review of the Hospital Tracking Portal log provided by the Director of Nursing (DON) showed 28 residents were transferred to an acute care hospital from 12/9/23 to 2/28/24. On 2/28/24 at 2:10 p.m., in an interview the Social Services Coordinator said she notifies the office of the Long Term Care Ombudsman each month of all residents discharged home. On 2/28/24 at 2:21 p.m., the Social Services Coordinator provided a fax cover sheet, and discharge information addressed to the office of the LTCO for all residents discharged home. The discharge notifications did not include residents transferred to acute care hospitals. The Social Service Coordinator said she did not know the LTCO had to be notified of transfers to the hospital. She verified the LTCO was not notified of residents transferred to an acute care hospital and had not returned to the facility. Review of Resident #388's clinical record revealed an admitted [DATE]. Diagnoses included Acute Renal Failure. The Nursing progress note dated 1/16/24 stated Resident #2 was unable to follow commands, she was still sleepy, and had not been able to drink fluids or eat food. The physician issued an order to transfer the resident to an acute care hospital. Further review of Resident #388's medical record revealed no documentation a Nursing Home Transfer and Discharge Notice form was completed and given to the resident and the LTCO was notified of Resident #388's transfer to the hospital. The clinical record showed the resident was discharged from the facility on 1/16/24. Review of Resident #389's medical record revealed a date of admission of 12/26/2023 with a primary diagnosis of Sepsis. The Nursing progress notes dated 12/29/23 stated Resident #3 had increased sob (shortness of breath), palpitations, and tachycardia (Heart rate over 100 beats a minute). The resident was sent to the hospital via Emergency Medical Services. Further review of Resident #389's clinical record revealed no documentation a Nursing Home Transfer and Discharge Notice form was completed and given to the resident and the LTCO was notified of Resident #389 transfer to the hospital. Resident #389 was discharged from the facility on 12/29/23. On 2/29/24 in an email communication the representative of the LTCO office said the facility only sends a list of residents discharged home on a monthly basis. The facility does not send a list of residents transferred to the hospital. On 2/29/24 at 11:15 a.m., in an interview the Director of Nursing (DON) verified the facility was not providing discharge notices to residents transferred to the hospital before discharging the residents from the facility. He also verified the facility has not been sending a copy of the hospital transfer notices to the office of the LTC Ombudsman.

Based on observation, staff interview and record review, the facility failed to ensure 1 (Resident #19) of 1 resident reviewed for activities, attended activities of their choice to ensure they maintained and/or improved their psychosocial well-being and independence. The findings included: On 2/26/24, observation of Resident #19 at 10:30 a.m., 11:16 a.m., 12:35 p.m., and 3:00 p.m. revealed she was in her room during those observations without the television or radio on. Resident #19 was not observed in any of the facility activities during the day. On 2/27/24, observation of Resident #19 at 8:30 a.m., 9:30 a.m., and 11:00 a.m. revealed she was in her room during those observations without the television or radio on. Resident #19 was not observed in any of the facility activities during those observations. On 2/27/24, a review of Resident #19's medical record revealed she was admitted to the facility on [DATE] with medical diagnoses of Parkinsonism, muscle weakness, and dementia without behavioral disturbance. A review of Resident #19's activity plan of care dated 11/22/2023 stated Resident #19 would benefit from associate support for resident programs to maintain involvement in cognitive stimulation with independent or assisted leisure and social activities as desired. Interventions included to invite Resident #19 to scheduled programs, lunch and dinner in the dining room, live entertainment, outdoors, dog visits and violinists. Review of the Activity Coordinator's progress note revealed 12 entries from 11/20/23 through 2/21/24 of 1:1 room visits by the violinist, Golden Paws service dogs, podiatrist, and Nurse [NAME] who plays the guitar. On 2/27/24 at 11:58 a.m., during an interview with Resident #19's daughter, she said due to her mother's Parkinson's disease, her mother needed a lot of assistance from staff. She said her mother was an active person prior to coming to the facility and one of her concerns was when she visited her mother she was always in her room without the television or the radio being on. She said she had asked the facility from the beginning to take her mother outside to enjoy the sunlight and fresh air. She said since the facility was not taking her mother out of her room for activities, she had another meeting with the Director of Nursing (DON) and the Activity Coordinator (AC) several weeks ago, reminding them to ensure her mother attended out-of-room activities and going outside to enjoy the sunshine and fresh air. The Activity Programs policy last revised on June 2018 stated the activity program was provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. On 2/27/24 at 12:34 p.m., in an interview with the Activity Coordinator, she said she had been working at the facility for one year. She said as part of her job she was to promote the physical, mental and psychosocial well-being of the residents, conduct an activity evaluation upon admission and at least quarterly and document any change of condition that could affect the resident's participation in the activity care plan. She said the Activity Coordinator was responsible for completing, directing, and/or delegating the completion of the activity interventions noted in each resident's activity plan of care. The Activity Coordinator confirmed after reviewing Resident #19's medical records, Resident #19's plan of care for activities dated 11/22/2023 stated Resident #19 would benefit from associate support for resident programs to maintain involvement in cognitive stimulation with independent or assisted leisure and social activities as desired. Interventions included inviting Resident #19 to scheduled programs, lunch and dinner in the dining room, live entertainment, outdoor activities, dog visits, and violinists. She said she had documented 12 activity progress notes from 11/20/23 through 2/21/24 of 1:1 room visits by the violinist, Golden Paws service dogs, the podiatrist, and Nurse [NAME], who plays the guitar. She said she was unable to find documentation that Resident #19 had done activities outside of her room as noted in the 11/22/23 activity plan of care and requested again several weeks ago in a meeting with the DON and Resident #19's daughter.

Based on observation, interviews, and review of facility's policies and procedures, the facility failed to maintain, clean, and store respiratory care equipment in a sanitary manner and in accordance with manufacturer's specifications for 1(Resident #27) of 2 sampled residents with physician's orders for oxygen and breathing treatments. The findings included: Review of the clinical record revealed Resident #27 was admitted to the facility on [DATE] with primary diagnoses of Chronic Obstructive Pulmonary Disease and Emphysema (a lung disease that damages the tiny air sacs in the lungs). On 2/26/24 at 10:55 a.m., Resident #27 was observed receiving oxygen through a nasal cannula connected to an oxygen concentrator (medical device that delivers extra oxygen). The concentrator machine and the filter at the vented area were dusty. An Oxygen cylinder was observed on the back of the resident's wheelchair with a nasal cannula stored uncovered on the seat. A nebulizer (a medical device to administer aerosol medication) machine mask and medication cup with tubing were observed stored uncovered on the resident's nightstand. Photographic Evidence Obtained On 2/27/24 at 9:40 a.m., the nebulizer mask and medication cup were observed stored uncovered on the nightstand. The oxygen tubing with nasal cannula connected to the oxygen cylinder was hanging over the armrest of the wheelchair touching the wheel. On 2/28/24 at 9:37 a.m., the resident's nasal cannula was observed stored hanging uncovered over the back of the wheelchair. The concentrator vented area remained dusty. Photographic Evidence Obtained. On 2/28/24 at 10:26 a.m., in an interview, Registered Nurse (RN) Staff C stated, When a resident is using a nebulizer, the tubing gets changed weekly or as needed and dated. The nebulizer would get washed with soapy water, rinsed and air dried. It would be placed in a bag when dry. A policy provided by the facility titled, Nebulizer Cleaning Policy and Procedure indicated device will be cleaned and dried after each nebulizer treatment and placed in a bag. Take apart medication cup and mouthpiece or mask, use soap and water, rinse, and place on clean towel to dry. Place in plastic bag when dry. On 2/28/24 at 10:35 a.m., in an interview, the DON stated, The nasal cannula should be placed in a bag when not in use. The concentrators are owned and maintained by a contracted company. We do not have a policy to maintain the machines. They come weekly and they maintain the cleaning of machines and filters. The DON stated, the company was just here yesterday (2/27/24). On 2/28/24 at 10:40 a.m., the DON observed and confirmed Resident #27's oxygen concentrator, and the vented filter area were dusty. She also verified the oxygen tubing was stored uncovered. The DON provided the maintenance logs from the contracted company from 1/9/24 through 2/27/24. The logs included multiple brand names of oxygen concentrators but did not include Resident #27's brand of oxygen concentrator. Review of the manufacturer's oxygen concentrator manual for Resident #27 provided by the facility noted, Ensure the air intake filter and exhaust locations are not clogged or restricted. If a gross particle filter is in place, it should be inspected and cleaned once a week. On 2/29/24 at 9:43 a.m., in an interview, RN Staff D said after administering a nebulizer treatment to a resident, the mask and container are washed with warm soapy water, air dried and placed in a bag and the bag is dated. On 2/29/24 at 10:12 a.m., in an interview, the DON verified after administration of a nebulizer treatment, the medication cup and mask should be washed with soap and water, air dried and bagged until next use.

Based on observation, staff interview, review of facility's policy and procedure and manufacturer's specification, the facility failed to ensure appropriate storage and labeling of prescribed medications in one (400 hall cart) of two medication carts observed. The findings included: The facility's Storage of Medications policy (revised November 2020) read, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. The facility's Administering Medications (Revised April 2019) read, . When opening a multi-dose container, the date opened is recorded on the container. On 6/21/22 at 9:30 a.m., observation of the 400-hall medication cart with Registered Nurse (RN) Staff A revealed an insulin [MEDICATION(S)] kwikpen stored in a clear plastic bag. The pharmacy label affixed to the bag had Resident #8's name. [MEDICATION(S)] was handwritten on the bag. Part of the pharmacy label on the storage bag was crossed out in black making it unreadable. The insulin pen in the bag was opened but not dated. Photographic evidence obtained A second opened undated [MEDICATION(S)] insulin kwikpen was stored on the top drawer. On 6/21/22 at 10:40 a.m., RN Staff A verified both insulin pens were opened and not dated. She said once opened the insulin is only good for one month. RN Staff A removed both insulin pens from the cart. Review of the insulin [MEDICATION(S)] patient's instructions for use revealed to throw away the pen in use after 28 days, even if it still has insulin left in it. On 6/21/2022 at 1:00 p.m., the Director of Nursing (DON) verified the insulin pen should have been labeled with the date opened to be discarded within 28 days.

Based on observation, policy review, record review, and staff interview, the facility failed to accurately document the care and services provided to 1 (Resident #3) of 1 resident reviewed for intravenous therapy. This failure led to a delay in care that had potential for infection to occur. The findings included: The facility's policy on Central Venous Catheter Dressing Changes (Revised April 2016) stated . Change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (as needed) (when wet, soiled, or not intact). Review of the clinical chart revealed a physician order [REDACTED]. On 11/17/20 at 8:56 a.m., Resident #3 was observed with a midline present. The dressing to midline was dated 10/25/20. Photographic evidence obtained. On 11/18/20 at 2:49 p.m., the Assistant Director of Nursing (ADON), said residents that are admitted with peripheral venous access sites are monitored every shift. The ADON said dressing changes occur every seven days or as needed. The ADON confirmed that a dressing dated 10/25/20 was not in compliance with facility policy. Review of the Treatment Administration Record (TAR) showed a dressing change to the midline was documented as completed on 11/3/20 and 11/10/20. On 11/19/20 at 4:00 p.m., Registered Nurse (RN) Staff L verified her initials on TAR dated 11/3/20. She said she did not do Resident #3's dressing. She said she signed off treatment and intended to do it later. She stated she did not remember why she did not do it and did not believe she reported to it to the oncoming shift. On 11/19/20 at 4:13 p.m., RN Staff M confirmed familiarity with Resident #3 and confirmed she worked on 11/10/20. RN Staff M said she signed the TAR for the dressing change prior to completing. RN Staff M said when she attempted to do the dressing change, Resident #3 was unavailable. She said she intended to go back but got busy and forgot to change the dressing.

Based on observation, review of facility policy and procedure, and staff interview, the facility failed to assure 1 of 3 medication carts were locked and under direct observation of authorized staff in an area where residents and staff could access it. This has the potential to cause harm for residents if they were to ingest medications. In addition, the facility failed to implement a system to account for periodic receipt, reconciliation, and disposition of all controlled substances. The findings included: 1. The facility policy Storage of Medications (revised April 2019) specified drugs and biologicals used in the facility were stored in locked compartments. Access to controlled medications was limited to authorized personnel. Personnel access to controlled medications is recorded. On 11/16/20 at 10:10 a.m., observation of the 400-hall medication cart revealed the cart was not locked. Two certified nursing assistants, two therapy staff members, one resident and the Assisted Director of Nursing (ADON) were observed walking past the unlocked medication cart. On 11/16/20 at 10:16 a.m., Registered Nurse (RN) Staff K was observed exiting from a room with a closed door and approached the unlocked medication cart. On 11/16/20 at 10:17 a.m., RN Staff K verified the medication cart was not locked and was not in direct view. RN Staff K confirmed the medication cart should have been locked when it was not in direct view. 2. On 11/17/20 at 10:01 a.m., the ADON said when a controlled medication was discontinued, she collected them from the medication carts, or the nurse would bring them to her. The ADON said she checked the amount of medications with the controlled medication count sheet and then she signed the count sheet indicating the count was accurate for the medication. The ADON said she brought the medications to the Director of Nursing (DON) office and the count sheet and the medication were placed in a locked box on the wall in the DON's office. The ADON said she did not know what medications were currently in the locked box and said, I won't know until we remove them for destruction. On 11/17/20 at 10:08 a.m., the ADON confirmed there was no documentation to reconcile the identification and drug count for controlled medications that were in the locked cabinet. On 11/19/20 at 4:20 p.m., the DON said he did not know what medications were in the locked box in his office. The DON confirmed he had no documentation to periodically reconcile the medications in the locked box.

Based on interview and record review the facility failed to properly display federally required staffing data. The findings included: A review of the federal postings dated 6/8/15, 6/9/15, 6/10/15, and 6/11/15 revealed the facility did not have their name indicated on the form. The forms were also incomplete for date and resident census for the 3:00 p.m. - 11:00 p.m., and 11:00 p.m.- 7:00 p.m. shifts. On 6/11/15 at 9:36 a.m., the facility's administrator confirmed that the posting lacked facility name, date, and census numbers at the beginning of each shift.

Based on record review and interview the facility Quality Assurance and Performance Improvement (QAPI) committee failed to ensure that action plans are fully implement to correct deficiencies and that action plans are revised, in a timely manner, in response to discrepancies identified through monitoring activities. The findings include: 1. Upon interview at 4:30 p.m., on 8/28/12, the Administrator, head of the QAPI committee, and the Director of Nursing, a member of the committee, stated that the committee developed a plan of correction in relationship to citations identified during a 7/19/2012 certification and licensure survey. The plan had a correction date of 8/15/12. The Director of Nursing (DON) was responsible for auditing to ensure that the plan was correctly implemented. The Risk Manager was responsible for training of the direct caregiver staff. Upon interview at this time, the DON stated audits were done of "care tracker" (computer program) that revealed irregularities in relationship to the plan of correction regarding vital signs. The problems were not identified via documentation and there was no change in the plan of correction to address the "irregularities" at this time. The DON stated he could not readily find the audits and could not readily identify what the "irregularities" were. The Administrator stated "There won't be a QAPI meeting until this Thursday." When asked if "irregularities" had to wait until the monthly QAPI meeting to be corrected; there was no response from the DON or the Administrator. When asked who takes the vital signs that are entered into the "care tracker" computer program, the DON stated the Certified Nursing Assistants. When asked if that included Blood Pressures, the DON stated "yes". 2. In-service training records were presented to the surveyor regarding: AIMS Test for [MEDICATION NAME] and Atypical Neuroleptics Documenting Pain and Response to Interventions Influenza Vaccination Policy and Procedure Cleaning the Stethoscope, Pulse Oximeter and Thermometer Medication Errors Pain Assessment Medication Administration Time Behavior Monitoring Form (to document monitoring of Signs or Symptoms of Tardive Dyskinesia and Behaviors. a.. Although a plan was developed regarding the implementation of 24 hr., behavior monitoring for residents receiving [MEDICATION NAME] and Atypical Neuroleptics and training was provided to direct caregiver; the plan was not implemented for the only resident in the facility who was ordered to receive this type of medication. No auditing documentation was available for review. b. Although the plan of correction stated that "nurses will be retrained in a targeted training session, on or before August 10, 2012 concerning follow-up temperature within 30 to 60 minutes following the administration of antipyretic medications, including [MEDICATION NAME].": -- There was no documentation that this took place. -- The only reference found in the Survey Training Documentation was found under "Medication Pass - 28. Medications requiring monitoring of vital signs are to be administered after vital signs are obtained." There was no reference to monitoring a temperature after administration of a prn antipyretic. -- Records regarding auditing febrile illness could not be located for review although the DON stated that the audits showed "irregularities". c. Although the Survey Correction Training contained a Medication Pass policy stating "28. Medications requiring monitoring of vital signs are to be administered after vital signs are obtained.", audits regarding vital sign "irregularities" were not addressed in a timely manner resulting in failure to monitor blood pressures per physician orders. d. The DON also stated that he audited all charts for pain, [MEDICATION NAME] & others (medication) in that classification, and audited the medication cart for any type of antipsychotic. The DON did not have any documentation of those audits. No report is available for review at this time and the next QAPI meeting will be on 8/30/12 per Administrator. e. The pharmacy consultant report, dated July 26, 2012, was reviewed by the surveyor and physician recommendations were recorded and responded to. When asked if there was a Pharmacy Consultant report for August 2012, the DON stated that the consultant was contacted and stated "it was in the mail". The pharmacy consultant audit should have identified the blood pressure monitoring irregularities, but it was not available to the facility in a timely manner to implement/revise the plan of correction.

Based upon observation and interview the nurse failed to clean and/or disinfect resident care equipment (forehead thermometer) between residents for 3 (Residents #55, #129 and #100) of 8 medication pass residents sampled. The findings include: An observation of staff A during medication pass on 7/18/12, beginning from 8:55 a.m., to approximately 9:15 a.m., revealed she used the forehead thermometer for sampled Resident's #55, #129 and #100 during med pass and did not clean or disinfect it between the residents. During an interview with Staff A after medication pass, she confirmed that she should have cleaned and/or disinfected the thermometer between residents.

Based on record review and staff interview the pharmacist failed to identify and report the risks or the potential for adverse side effects related to the use of Metoclopram (Reglan) for 1 (Resident #100) of 10 resident's reviewed for medication use. The findings include: 1. Resident #100 was admitted to the facility on [DATE]. The resident is [AGE] years old, alert and oriented. The resident was admitted with a prescription for Metoclopram (Reglan) 10 milligrams (mg.), one tablet three times a day (a total of 30 mg./day) for gastroparesis. A record review documented that Resident #100 has [DIAGNOSES REDACTED]. A review of the History and Physical, completed on 4/20/12, documents that the resident has Ataxia, which is the the inability to coordinate the movements of muscles. The physician orders [REDACTED]./day). Per the Federal Drug Administration a Black Bow warning was issued on 2/26/09 for the use of metoclopramide. This medication has been linked to tardive dyskinesia (TD), which may include involuntary and repetitive movements of the body, even after the drugs are no longer taken. On 7/20/12 at 10:05 a.m., the "Consultant Pharmacist Recommendation to Physician" form, dated 5/25/12, was reviewed. The one recommendation made to the physician was for the use of Ambien. At that time, the Director of Nursing was asked if this was the only review available and he said it was the one completed, Resident #100 is here for short term rehabilitation. There were no recommendations from the pharmacist to monitor the resident for the side effects of TD.

Based on record review, observation and interview, the facility failed to ensure that 3 (Resident #11, #23, #37) of 4 residents sampled, were free from unnecessary drugs. This is due to the facility failure to monitor for potential side effects. The finding include: 1. At 9:30 a.m., 11:00 a.m., 12:30 p.m. and 3:00 p.m., on 8/28/12 the Director of Nursing was asked for a list of residents receiving psychoactive medications. At 3:00 p.m., the Director of Nursing stated that there was one (Resident #37), with an order for [REDACTED]. A review of the physician orders [REDACTED].o. (by mouth) twice daily prn. (as necessary) for [MEDICAL CONDITION], agitation" dated 8/26/12. On 8/27/12, a physician order [REDACTED]. #1 [MEDICATION NAME] 12.5mg po., qhs (every night at bedtime), #2 D/[MEDICATION NAME], #3 [MEDICATION NAME] 12.5mg po prn one time a day or 24h (hours) in addition to qhs Dx (diagnosis) [MEDICAL CONDITION]." The [MEDICATION NAME] was documented as given on prn on 8/26/12, without a time indicated; and on 8/27/12 at 2100 (9:00 p.m.). A review of the facility "Survey Corrections Training" records dated August 2010 (relating to the facility plan of correction) revealed the following procedures: "Drugs Known to cause Tardive Dyskinesia: Atypical Neuroleptics Quetiapine/[MEDICATION NAME] ([MEDICATION NAME])" "Behavior Monitoring Form: To document monitoring of Signs or Symptoms of Tardive Dyskinesia (T.D.) and Behaviors. On this form, select Number 16 to document signs or reported symptoms of Tardive Dyskinesia. All types of behaviors are to be documented using this form, including signs or symptoms which may indicate the resident is suffering from side effect of T.D. This is the form for shift to shift monitoring of the side effects, not the AIMS test." A review of the record for Resident #301 containing a Behavior Monitoring Record that identified "First Behavior Symptom (symptom) #3 (Paranoia), Second Behavior Symptom #4 ([MEDICAL CONDITION]), Third Behavioral Symptom #8 (Agitation)." Documentation was recorded for 6 shifts in each category encompassing the time period 8/26/12 through 8/27/12. The record did not identify "Number 16 Tardive Dyskinesia" and there was no documentation relating to this "Suspected Side Effect Code(s)". Resident #37 was observed at 3:30 p.m., on 8/28/12 sitting in her room in a wheelchair. The resident smiled and made eye contact when spoken to by the surveyor. The resident did not initiate conversation, but responded in an appropriate manner to brief questions. An interview of the Director of Nursing, at this time, revealed that Resident #37 requires total care in activities of daily living, has very limited mobility and is cognitively impaired. Upon interview on 8/28/12, at 4:00 p.m., the Director of Nursing acknowledged that there was no documentation monitoring for the potential side effects of the [MEDICATION NAME] medication known to cause Tardive Dyskinesia. 2. A review of the medical record for Resident #11 documented a physician order [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Upon interview on 8/28/12, at 1:45 p.m., Staff A stated, "I take the blood pressure and record it on a piece of paper." When asked if the blood pressure is recorded in the resident's medical record, Staff A said "I only have it on this piece of paper and I don't save it. We document in the nurse's notes, but that is not every day." Upon interview on 8/28/12, at 1:45 p.m., the Director of Nursing stated that the blood pressures are on the computer, but was unable to view or print them. At 4:15 p.m., the Director of Nursing said that the blood pressures for Resident #11 were on the computer and printed a form entitled "Corp - Vital Detail Report". A review of this form documented that there was one blood pressure recorded on 8/27/12 at 11:02 a.m., 2 hours after the medication is scheduled to be given, as 168/88 for the time period 8/15/12 to 8/28/12. When asked who took the blood pressure and recorded it in the computer, the Director of Nursing stated "The CNA's (Certified Nursing Assistant)". When asked if the licensed nurse, giving the medication, records it anywhere; the Director of Nursing stated "Yes, in the nurse's notes." Upon review of the nurse's notes, at this time, the Director of Nursing acknowledged there were no blood pressures recorded for this time period. There was no documentation that the [MEDICATION NAME] medication was given on 8/17/12, at 0900 (9:00 a.m.) The Director of Nursing and Staff A concurred that there was no entry documenting that the drug was given. 3. A review of the medical record for Resident #23 documented a physician order [REDACTED]. Upon interview at 1:45 a.m., on 8/28/12, the Director of Nursing stated, "There would only be entries if the medication was given, this is prn (as necessary)." When asked how he would know if the medication was necessary, the Director of Nursing stated "According to the blood pressure, they are on the computer." Staff A was interviewed at this time and stated he had not taken any blood pressures on Resident #23 this date or any other time he has been administering medications when working the 7:00 a.m. - 7:00 p.m., shift (12 hours). He stated he would only give the medication if it was needed. When asked what every 8 hours represents; he stated he wasn't sure but agreed it would mean at least once on his shift. Resident #23 is receiving Losarth Pot 25 mg one tablet by mouth daily for the [DIAGNOSES REDACTED]. At 4:15 p.m., the Director of Nursing again said that the blood pressures for Resident #23 were on the computer and printed a form entitled "Corp - Vital Detail Report", however, a print out of the blood pressures (for this resident) was not provided to the surveyor. When asked who took the blood pressure and recorded it in the computer, the Director of Nursing stated, "The CNA's (Certified Nursing Assistant)". When asked if the licensed nurse, who would be giving the prn medication, records it anywhere; the Director of Nursing stated "Yes, in the nurse's notes." Upon review of the nurse's notes, at this time, the Director of Nursing acknowledged that there were 3 blood pressures recorded, rather than the required 37 to determine if the [MEDICATION NAME] was needed during the time period under discussion.

Based staff interview and record review the facility failed to ensure that two (Residents #28 and #100) of ten residents sampled were free from unnecessary medication. This is due to the facility failure to monitor for potential side effects and the effectiveness of medications. The findings include: 1. Resident #100 was admitted to the facility on [DATE]. The resident is [AGE] years old, alert and oriented. The resident was admitted with a prescription for Metoclopram ([MEDICATION NAME]) 10 milligrams (mg.) one tablet three times a day (a total of 30 mg. /day) for gastroparesis. A review of record noted that Resident #100 has [DIAGNOSES REDACTED]. A review of the History and Physical, completed on 4/20/12, documented that the resident has Ataxia, which is the inability to coordinate the movements of muscles. The physician orders [REDACTED]. /day). Per the Federal Drug Administration, on 2/29/09, a Black Box Warning was issues for the use of Metoclopram. The FDA information at: "http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm 3.htm" documents the following: 2/29/09: "The U.S. Food and Drug Administration announced today that manufacturers of [MEDICATION NAME], a drug used to treat gastrointestinal disorders, must add a boxed warning to their drug labels about the risk of its long-term or high-dose use. Chronic use of [MEDICATION NAME] has been linked to tardive dyskinesia (TD), which may include involuntary and repetitive movements of the body, even after the drugs are no longer taken. The FDA wants patients and health care professionals to know about this risk so they can make informed decisions about treatment, said Janet Woodcock, M.D., director of the FDA's Center for Drug Evaluation and Research. The chronic use of [MEDICATION NAME] therapy should be avoided in all but rare cases where the benefit is believed to outweigh the risk." Per Rxlist.com, information for Metoclopram shows "Tardive dyskinesia: (U.S. Boxed Warning): May cause tardive dyskinesia, which is often irreversible; duration of treatment and total cumulative dose are associated with an increased risk. Therapy durations >12 weeks should be avoided (except in rare cases following risk: benefit assessment). Risk appears to be increased in the elderly women and diabetics; however, it is not possible to predict which patients will develop tardive dyskinesia. Therapy should be discontinued in any patient if signs/symptoms appear. The elderly may be at greater risk for tardive dyskinesia." A review of Resident #100's clinical record documented that an assessment for the side effects of Metoclopram has not been completed for this resident. During an interview with the Director of Nurses, on 7/19/12, at approximately 3:45 p.m., he revealed that he was not aware that it is recommended that persons receiving Metoclopram ([MEDICATION NAME]) be monitored for the side effects of Tardive dyskinesia (TD). The DON said that the consultant pharmacist has not mentioned this to him. On 7/20/12 at 10:05 a.m., the "Consultant Pharmacist Recommendation to Physician" form, dated 5/25/12 was reviewed. The one recommendation made to the physician was for the use of Ambien. At that time, the DON was asked if this was the only review available and he said it was the only one completed, the resident is only here for short term rehabilitation. There were no recommendations from the pharmacist to monitor Resident #100 for the side effects of TD. There was no documentation in Resident #100's record of monitoring for signs/symptoms of tardive dyskinesia. 2. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation the temperature was taken after the Tylenol was administered to monitor the effectiveness.

Based on record review and interview the facility failed to ensure that the medical record contains accurate and complete documentation relating to influenza vaccine for 3 (Resident #1, #25, #33) out of a sample of 5 residents reviewed. The finding includes: A review of the medical record on 7/18/12 revealed that that Resident #33 signed a form, on 8/22/11, declining to give permission for the influenza vaccination. A review of the medical record on 7/18/12 revealed that Resident #25 signed a form, on 9/5/11, giving permission to received the influenza vaccine; but there is no documentation that the vaccine was given. A review of the medical record on 7/18/12 revealed that Resident #1 had no record indicating that she was offered the influenza vaccine during the 2011 through 2012 flu season. Upon an interview on 7/19/12 at 10:00 a.m., the Director of Nursing (DON) stated that the vaccines were given to Resident #1 and #25; but agreed that there was no documentation in the medical record. The DON continued to state that the Visiting Nurses Association (VNA) gave the influenza vaccine and proceeded to contact the VNA to obtain a record of consent/administration. A record of consent/administration of the influenza vaccine was faxed to the facility this date for Resident #1 and #25; along with a list of all facility residents that received the influenza vaccine on 10/3/11. The listing contained the name of Resident #33. On 7/20/12 at 10:30 a.m., the DON was asked if he had obtained all the records from the this list, and he said "No". The DON was requested to obtain the record, for Resident #33, from the VNA. The record was obtained on 7/19/12 and documented a verbal consent was given by the resident's family member and the influenza was given on 10/3/11. There were 16 random residents on this list indicating that they had received the influenza vaccination on 10/3/11, residing at the facility. The DON stated, on 7/20/12, that he did not obtain any of these records to incorporate into the random residents' records. Facility policy entitled "Influenza Vaccine", dated 4/1/11, states "All residents will be offered the influenza vaccine annually, in the fall" and "Appropriate entries must be documented in the residents' medical records indicating the date of the receipt or refusal of the annual influenza vaccination".