Every finding on record at Princeton Place-Ruston

Based on observations, record reviews and interviews, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible. The facility failed to ensure CNAs did not place two briefs on 3 (#2, #3, and #4) of 4 residents observed for incontinent care.Findings: Resident 2Review of the medical record for Resident #2 revealed an admission date of 02/09/2026. Resident #2 had diagnoses that included lymphedema, muscle spasm, chronic pain, anxiety, depression, diabetes mellitus and dementia. Review of the admission MDS assessment dated [DATE] revealed Resident #2 had a BIMS of 15 which indicated intact cognition for daily decision making. Resident #2 was dependent on staff for toileting, partial to moderate assistance with personal hygiene, and was at risk for developing pressure ulcers. Review of the current care plan revealed Resident #2 was at risk for complications due to refusing care. Check and encourage resident to use commode and change brief every two hours and as needed. On 03/02/2026 at 8:20 p.m. observation of Resident #2 with S3LPN revealed she was wearing two briefs. Interview with S3LPN confirmed the CNA should not have placed two briefs on Resident #2. Interview with Resident #2 on 03/02/2026 at 8:25 p.m. revealed the CNAs sometimes put two briefs on her but she hasn't said anything to anyone. Further interview with Resident #2 revealed she did not tell the CNA to put two briefs on her. Interview with S4CNA on 03/02/2026 at 9:30 p.m. revealed she placed two briefs on Resident #2 because Resident #2 asked her to put two briefs on her because she didn't like her bed to get wet. S4CNA further revealed she was not supposed to place two briefs on Resident #2. Resident 3Review of the medical record for Resident #3 revealed an admission of 12/21/2020. Resident #3 had diagnoses including hemiplegia and hemiparesis, urinary tract infection, and malignant neoplasm of prostate. Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 15 which indicated intact cognition for daily decision making. Resident #3 was dependent on staff for toileting, setup assistance with personal hygiene, and was at risk for developing pressure ulcers. Review of the current care plan revealed Resident #3 had urinary incontinence, wears adult briefs and staff were to provide pericare as needed. On 03/02/2026 at 8:15 p.m. observation of Resident #3 with S3LPN revealed he was wearing two briefs. Interview with S3LPN confirmed the CNA should not have placed two briefs on Resident #3. Interview with Resident #3 on 03/02/2026 at 8:50 p.m. revealed he did not ask the CNA to put two briefs on him. Interview with S4CNA on 03/02/2026 at 9:30 p.m. revealed she placed two briefs on Resident #3 because Resident #3 asked her to put two briefs on him because he didn't like his bed to get wet. S4CNA further revealed she was not supposed to place two briefs on Resident #3 Resident #4Review of the medical record for Resident #4 revealed an admission date of 09/25/2018. Resident #4 had diagnoses including diabetes mellitus and vascular dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of 7 which indicated severe cognitive impairment for daily decision making. Resident #4 was dependent on staff for toileting hygiene, set up assistance with personal hygiene, and was at risk for developing pressure ulcers. Review of the current care plan revealed Resident #4 had bowel and bladder incontinence related to dementia and used disposable briefs, and the resident needed to be changed every two hours and as needed. On 03/02/2026 at 8:15 p.m., observation of peri care performed by S5CNA and S6CNA for Resident #4 revealed the resident was wearing two briefs. Interview with S6CNA on 03/02/2026 at 9:10 p.m. revealed she placed two briefs on Resident #4 because she was a heavy wetter. S6CNA further stated she was not supposed to place two briefs on Resident #4. Interview with S7LPN on 03/02/2026 at 9:20 p.m. confirmed the CNAs should not place two briefs on the residents. On 03/02/2026 at 9:40 p.m. S1Administrator was notified of the CNAs placing two briefs on Resident #2, #3 and #4. S1 Administrator confirmed the CNAs should not have used two briefs on the residents. Interview with S8CNA Supervisor on 03/03/2026 at 2:10 p.m. confirmed the CNAs should not have placed two briefs on the residents.

Based on observation and interviews, the facility failed to ensure the chemical solution for the dishwasher was maintained at the correct concentration. This deficient practice had the potential to affect 62 residents who received meals served from the kitchen.Findings:Review of the facility's current Dishwashing by Use of Machine policy (undated) revealed the following, in part:10. Check the machine during each procedure to determine if detergent, wetting agent and chemical sanitizer (if appropriate) is being dispensed properly.On 09/08/2025 at 8:48 a.m. observation of the kitchen revealed S5Dietary Manager (DM) checked the chemical solution concentration in the dishwasher. S5DM was unable to establish presence of the chemicals with the sanitizer test strip in the dishwasher drainage area 3 times while the dishwasher was being used to clean and sanitize dishes.On 09/08/2025 at 9:09 a.m. an interview with S5DM revealed the chemical solution container connected to the dishwasher was empty and needed to be replaced.On 09/09/2025 at 3:36 p.m. an interview with S1Administrator confirmed the kitchen staff should know when the chemical solution container needed to be replaced and how to properly test for the correct chemical solution.

Based on record review, policy review, and interviews, the facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for 1 (#2) of 1 residents reviewed for smoking. Findings:Review of the facility's current Smoking Policy-Residents, revised January 2025, revealed the following, in part:Policy Interpretation and Implementation6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: d. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation).8. A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change (physical or cognitive) and as determined by the staff. Review of Resident #2's record revealed an admission date of 05/18/2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, nicotine dependence cigarettes uncomplicated, cerebral infarction, schizophrenia, bipolar disorder, personal history of other mental and behavioral disorders, hypertension, chronic obstructive pulmonary disease, and primary osteoarthritis of right shoulder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #2's current care plan revealed the use of tobacco and the interventions included to assess smoking safety quarterly and as needed, assist with oral care as needed, monitor clothing for burn holes, provide safe receptacles for extinguishing cigarette butts, store cigarettes safely, and store lighter safely. Review of Resident #2's Smoking Safety Evaluation dated 07/28/2025 revealed the facility failed to determine if the resident had the ability to smoke safely with or without supervision on his quarterly re-evaluation. An interview on 09/10/2025 at 10:50 a.m. with S6Licensed Practical Nurse (LPN)/MDS revealed the MDS nurses are responsible for completing the quarterly risks assessments including the Smoking Safety Evaluation for Resident #2. S6LPN/MDS confirmed that Resident #2's Smoking Safety Evaluation dated 07/28/2025 failed to determine that the resident had the ability to smoke safely with or without supervision as per the facility's Smoking Policy. After review of Resident #2's Smoking Safety Evaluation dated 07/28/2025 and the facility's current Smoking Policy with S1Administrator on 09/10/2025 at 11:15 a.m., S1Administrator confirmed the facility failed to determine if Resident #2 was a safe smoker with or without supervision on the Smoking Safety Evaluation as per the facility's policy. An interview on 09/10/2025 at 1:30 p.m. with S2Director of Nursing (DON) confirmed that Resident #2 was not accurately assessed for smoking by failing to identify if Resident #2 had the ability to smoke safely on the Smoking Safety Evaluation on 07/28/2025.

Based on record review and interviews, the facility failed to provide form for Centers for Medicare and Medicaid Services (CMS) 10123-Notice of Medicare Non-Coverage (NOMNC) as required for 1 (#46) of 3 (#46, #62, and #77) residents reviewed for Skilled Nursing Facility (SNF) Beneficiary Notification. The facility had a census of 70 residents.Findings:A review of the facility's current Form Instructions for the NOMNC CMS-10123 policy (undated) revealed the following, in part:Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process per Chapter 4, Section 260 of the Medicare Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare Managed Care Manual. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Alterations to a NOMNC- the NOMNC must remain two pages. The notice can be two sides of one page or one side of two separate pages, but must not be condensed to one page. A review of Resident #46's SNF Beneficiary Notification Review form revealed the facility initiated the resident's discharge from Medicare Part A services when benefit days were not exhausted. Resident #46 was discharged from Medicare Part A services on 03/13/2025. Further review of Resident #46's record revealed a NOMNC was not provided to the resident. On 09/09/2025 at 11:43 a.m., an interview was conducted with S7Social Services Director (SSD). S7SSD confirmed she did not provide the Beneficiary Notifications NOMNC form to the resident #46. S7SSD reported she was not aware Resident #46 should have received a Beneficiary Notification NOMNC form at the time of discharge from services. On 09/09/2025 at 12:50 p.m., an additional interview was conducted with S7SSD. S7SSD acknowledged she was responsible for completing and providing the Beneficiary Notification NOMNC form to residents. S7SSD stated she should have completed and provided Beneficiary Notification NOMNC form to Resident #46.On 09/10/2025 at 10:39 a.m., an interview with S1Administrator, confirmed the Beneficiary Notification NOMNC form was not provided to Resident #46 and should have been.

Based on observation, record review and interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes or enhances his or her quality of life for 1 (#47) of 1 residents reviewed for dignity. The facility failed to ensure Resident #47 was given the opportunity to be weighed in a wheelchair instead of standing. Findings:Review of the medical record for Resident #47 revealed an admission date of 08/28/2025. Resident #47 had diagnoses including chronic atrial fibrillation, heart failure, anxiety, hypokalemia, hypertension, enlarged prostate, hyperlipidemia, and edema. Further review of the record for Resident #47 revealed the resident was blind and hard of hearing. Review of the admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment for daily decision making. On 09/08/2025 at 10:25 a.m., observation of Resident #47 revealed he was sitting in a wheelchair by the chair/standing scale with S3Certified Nursing Assistant (CNA) and S4CNA beside the resident. S4CNA instructed Resident #47 to stand up and get on the scale and Resident #47 stated I am scared. S3CNA and S4CNA stated to Resident #47 we got you and assisted Resident #47 to a standing position. Resident #47 stated again I am scared. Further observation of the encounter revealed S3CNA and S4CNA did not offer Resident #47 to sit down in the wheelchair when he stated two times that he was scared. On 09/08/2025 at 12:30 p.m., an interview with S3CNA revealed they usually use the bed scales to weigh Resident #47, and he wasn't sure why they used the chair/standing scale to weigh him today. When S3CNA was asked if Resident #47 said anything when he was instructed to stand up on the scale to weigh, S3CNA replied I don't think so.On 09/08/2025 at 12:45p.m., an interview with Resident #47 revealed it made him nervous and scared when he had to stand to be weighed. On 09/09/2025 at 8:20 a.m., an interview with S4CNA revealed she did help weigh Resident #47 on 09/08/2025. S4CNA revealed Resident #47 doesn't like to be weighed using the bed lift scale and that is why she asked him to stand with their help to weigh him. When S4CNA was asked if Resident #47 said anything when he was instructed to stand on the scale to weigh S4CNA replied she wasn't sure. On 09/09/2025 at 9:15 a.m., an interview with S2Director of Nursing (DON) confirmed the staff should not have made Resident #47 stand to weigh when the resident stated that he was scared. S2DON further confirmed the staff should have weighed Resident #47 in a wheelchair.

Based on observation and interview the facility failed to maintain all mechanical equipment in safe operating condition by having a buildup of grease inside the deep fryer.Findings:On 09/08/2025 at 8:30 a.m., an observation of the kitchen revealed the large deep fryer contained a buildup of grease on the internal components.On 09/08/2025 at 8:35 a.m. S5Dietary Manger (DM) confirmed the internal components of the deep fryer contained a buildup of grease.

Based on record review and interviews, the facility failed to ensure an alleged violation involving physical abuse witnessed by staff was reported immediately to the Administrator of the facility for 1 (#2) of 7 (#1, #2, #3, #4, #5, #6, #7) sampled residents. Findings: Review of the Abuse Reporting Policy dated 01/05/2024 revealed the following: Policy: All personnel must promptly report any incident or suspected incident of resident abuse, including injuries of unknown origin and misappropriation of resident property. Policy interpretation and implementation: 2. Any alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown origin and misappropriation of resident property, must be reported to the Administrator and Director of Nurses. Physical Abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. 6. The person observing an incident of resident abuse, or suspecting resident abuse, must immediately report such incident(s) to their supervisor. The following information should be reported to the supervisor: The name of the resident(s) involved. The date and time that the incident occurred. Where the incident took place. The name(s) of the person(s) committing the alleged abuse, if known. Review of the record for resident #2 revealed an admitted [DATE] with following diagnoses: Alzheimer's disease, unspecified dementia, anxiety disorder and depression. Review of the Minimum Data Set (MDS) assessment for resident #2 dated 06/21/2024 revealed resident #2 had severely impaired cognitive skills for daily decision making. During an interview with resident #2 on 07/29/2024 at 3:30 p.m., resident #2 was confused and was unable to recall any incident of possible abuse. Observation at this time revealed the resident did not have any bruising. Review of the record for resident #7 revealed an admitted [DATE] with following diagnoses: major neurocognitive disorder due to probable vascular disease, unspecified, with mood disturbance. Review of the MDS assessment for resident #7 dated 07/17/2024 revealed resident #7 had severely impaired cognitive skills for daily decision making. During an interview with resident #7 on 07/30/2024 at 3:00 p.m., resident #7 was confused and was unable to recall any incident with another resident. Review of the care plan for resident #7 revealed problem of unease in dealing with others with onset on 11/01/2023. Further review revealed the following approaches: approach resident warmly and positively, convey acceptance of resident, provide consistent caregivers on all shifts, provide opportunity for resident to express fears/concerns related to socialization with others, listen in non-judgmental manner, monitor resident socialization behavior and document at least daily, and allow resident to select seating at planned activities and in dining room. Interview on 07/30/2024 at 8:29 a.m. with S7 Certified Nursing Assistant (CNA) revealed that she witnessed resident #7 slap resident #2 hard on the left side of her face on 07/13/2024 at approximately 2:00 p.m. S7CNA stated that resident #7 was agitated prior to the incident and was difficult to redirect. S7CNA further revealed she was approximately 40 yards from the residents; therefore, she was unaware of what precipitated resident #7 slapping resident #2. S7CNA stated she did not tell the nurse on duty that resident #7 hit resident #2. S7CNA reported that she has been trained on abuse and neglect reporting but confirmed she failed to report to nurse and/or administrator that she witnessed physical abuse. Interview on 07/30/2024 at 10:00 a.m. with S9Licensed Practical Nurse (LPN) revealed she worked on 07/13/2024 from 7:00 a.m. to 3:00 p.m. S9LPN stated that she was not made aware of any incident involving resident #2 and resident #7. Interview on 07/30/2024 at 11:00 a.m. with S1Adminsitrator revealed she was unaware of any incident involving resident #2 and resident #7. S1Administrator confirmed S7CNA should have reported the alleged abuse regarding resident #2 and resident #7 immediately.

Based on record reviews and interviews the facility failed to ensure that each resident was free from unnecessary medication use for 3 (#32, #42 and #53) of 6 (#29, #32, #37, #42, #49 and #53) residents reviewed for unnecessary medications. The facility failed to monitor side effects for residents #32, #42 and #53 that received psychotropic medications. Findings: Resident #32 Review of the facility's Depression/Anxiety-Clinical Protocol revealed in part the following: the staff and physician will monitor the resident carefully for side effects specific to each class of medication as well as interactions between antidepressants and anti-anxiety medications and other classes of medication. Record of the record revealed an admitted [DATE] with diagnoses including schizophrenia unspecified, major depressive disorder, persistent insomnia, and bipolar disorder. Review of the September 2023 Physician's Orders revealed an order dated 03/15/2023 for Lorazepam (Antianxiety) 0.5 milligram tablet 3 times daily and Trazodone (Antidepressant) 100 milligram tablet by mouth at bedtime. Review of the August 2023 and September 2023 Medication Administration Record (MAR) for resident #32 revealed there was no documented evidence of monitoring for side effects of antidepressant and antianxiety medications. An interview on 09/26/2023 at 4:00 p.m. with S2DON revealed there was no documented evidence of monitoring for side effects of Lorazepam (Antianxiety or Trazodone (Antidepressant) for resident #32 for August 2023 and September 2023. S2DON confirmed that resident #32 should have had monitoring for side effects of the psychotropic medications administered. Resident #53 Review of the record revealed resident #53 was admitted on [DATE] with diagnoses including major depressive disorder recurrent, unspecified dementia, mild cognitive impairment, depression, post-traumatic stress disorder, and anxiety disorder. Review of the September 2023 Physician's Orders revealed an order dated 01/30/2023 for Sertraline (Antidepressant) 50 milligram tablet by mouth once daily and Buspirone (Antianxiety) 5 milligram tablet by mouth twice daily. Review of the August 2023 and September 2023 Medication Administration Record (MAR) revealed no documented evidence that resident #53 was monitored for side effects of Buspirone (Antianxiety) and Sertraline (Antidepressant) medications. An interview on 09/26/2023 at 4:00 p.m. with S2Director of Nursing (DON) revealed there was no documented evidence of monitoring for side effects of Sertraline (Antidepressant) or Buspirone (Antianxiety) for resident #53 for August 2023 and September 2023. S2DON confirmed that resident #53 should have had monitoring for side effects of the psychotropic medications administered. 18118 Resident 42 Review of the medical record for resident #42 revealed an admitted [DATE] with diagnoses including obsessive compulsive disorder, dementia, chronic pain, osteoporosis, degeneration of the nervous system, and depression. Review of the September 2023 Physician's orders revealed an order dated 04/29/2023 for Trazadone 50 milligrams (mg) by mouth at bedtime, and Celexa 20 mg to be given one time a day. Review of the August 2023 and September 2023 MAR revealed no documented evidence that resident #42 was monitored for side effects of Trazadone (Antidepressant) and Celexa (Antidepressant) medications. An interview on 09/26/2023 at 4:00 p.m. with S2DON revealed there was no documented evidence of monitoring for side effects of Trazadone (Antidepressant) or Celexa (Antidepressant) for resident #42 for August 2023 and September 2023. S2DON confirmed that resident #42 should have had monitoring for side effects of the psychotropic medications administered.

Based on record reviews and interviews, the facility failed to ensure the pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing for 3 (#32, #42, and #53) of 6 (#29, #32, #37, #42, #49, and #53) residents reviewed for unnecessary medications. The pharmacist failed to address no monitoring for side effects for residents #32, #42, and #53 while receiving antidepressant and antianxiety medications. Findings: Resident #32 Record of the record revealed an admitted [DATE] with diagnoses including schizophrenia unspecified, major depressive disorder, persistent insomnia, and bipolar disorder. Review of the September 2023 Physician's Orders revealed an order dated 03/15/2023 for Lorazepam (Antianxiety) 0.5 milligram tablet 3 times daily and Trazodone (Antidepressant) 100 milligram tablet by mouth at bedtime. Review of the August 2023 and September 2023 Medication Administration Record (MAR) for resident #32 revealed there was no documented evidence of monitoring for side effects of antidepressant and antianxiety medications. An interview on 09/26/2023 at 4:00 p.m. with S2DON revealed there was no documented evidence of monitoring for side effects of Lorazepam (Antianxiety) or Trazodone (Antidepressant) for resident #32 for August 2023 and September 2023. S2DON confirmed that resident #32 should have had monitoring for side effects of the psychotropic medications administered. Review of the monthly Medication Regimen Review dated 08/11/2023 for resident #32 revealed no documented evidence that pharmacist notified the physician, DON, and medical director regarding resident receiving Lorazepam (Antianxiety) or Trazodone (Antidepressant) and no documented evidence of side effect monitoring with administration of antidepressant and antianxiety medications. An interview on 09/27/2023 at 2:45 p.m. with S2DON confirmed that there was no documented evidence that the pharmacist addressed the facility not monitoring resident #32 for side effects of antianxiety and antidepressant medications. Resident #53 Review of the record revealed resident #53 was admitted on [DATE] with diagnoses including major depressive disorder recurrent, unspecified dementia, mild cognitive impairment, depression, post-traumatic stress disorder, and anxiety disorder. Review of the September 2023 Physician's Orders revealed an order dated 01/30/2023 for Sertraline (Antidepressant) 50 milligram tablet by mouth once daily and Buspirone (Antianxiety) 5 milligram tablet by mouth twice daily. Review of the August 2023 and September 2023 Medication Administration Record (MAR) revealed no documented evidence that resident #53 was monitored for side effects of Buspirone (Antianxiety) and Sertraline (Antidepressant) medications. An interview on 09/26/2023 at 4:00 p.m. with S2Director of Nursing (DON) revealed there was no documented evidence of monitoring for side effects of Sertraline (Antidepressant) or Buspirone (Antianxiety) for resident #53 for August 2023 and September 2023. S2DON confirmed that resident #53 should have had monitoring for side effects of the psychotropic medications administered. Review of the monthly Medication Regimen Review dated 08/11/2023 for resident #53 revealed no documented evidence that pharmacist notified the physician, DON, and medical director regarding resident receiving Sertraline (Antidepressant) and Buspirone (Antianxiety) and no documented evidence of side effect monitoring with administration of antidepressant and antianxiety medications. An interview on 09/27/2023 at 2:45 p.m. with S2DON confirmed that there was no documented evidence that the pharmacist identified the facility regarding not monitoring resident #53 for side effects while taking Sertraline and Buspirone for the August 2023 Medication Regimen Review. 18118 Resident 42 Review of the medical record for resident #42 revealed an admitted [DATE] with diagnoses including obsessive compulsive disorder, dementia, chronic pain, osteoporosis, degeneration of the nervous system, and depression. Review of the September 2023 Physician's orders revealed an order dated 04/29/2023 for Trazadone 50 milligrams (mg) by mouth at bedtime, and Celexa 20 mg to be given one time a day. Review of the August 2023 and September 2023 MAR revealed no documented evidence that resident #42 was monitored for side effects of Trazadone (Antidepressant) and Celexa (Antidepressant) medications. An interview on 09/26/2023 at 4:00 p.m. with S2DON revealed there was no documented evidence of monitoring for side effects of Trazadone (Antidepressant) or Celexa (Antidepressant) for resident #42 for August 2023 and September 2023. S2DON confirmed that resident #42 should have had monitoring for side effects of the psychotropic medications administered. Review of the monthly Medication Regimen Review dated 08/11/2023 for resident #42 revealed no documented evidence that pharmacist notified the physician, DON, and medical director regarding resident receiving Trazadone (Antidepressant) or Celexa (Antidepressant) and no documented evidence of side effect monitoring with administration of antidepressant and antianxiety medications. An interview on 09/27/2023 at 2:45 p.m. with S2DON confirmed that there was no documented evidence that the pharmacist identified the facility regarding not monitoring resident #42 for side effects while taking Trazadone and Celexa for the August 2023 Medication Regimen Review.

Based on interviews and record reviews, the facility failed to promptly notify the ordering physician/practitioner of diagnostic test results by not notifying physican/practioner of MBSS (Modified Barium Swallow Study) results for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified convulsions, diabetic neuropathy, radiculopathy cervical region, intervertebral disc degeneration lumbar region, hemiplegia affecting right dominant side, aphasia following non-traumatic subarachnoid hemorrhage, dysarthria following non-traumatic subarachnoid hemorrhage, dysphagia following cerebral infarction, and cerebral infarction. Review of the October 2022 physician's orders revealed order dated 04/08/2022 for regular no added salt, no concentrated sweets, mechanical soft diet with chopped meats. Review of resident #1's April 2021 careplan revealed the resident needed assistance with feeding and required mechanically altered diet. Staff to supervise dining, monitor for choking, and provide verbal encouragement/cueing as needed. Staff to consult Registered Dietitian as needed. Review of Quarterly MDS dated [DATE] revealed resident #1 required extensive assist with 1 person physical assist with eating. Review of Dietitian Progress Note dated 07/19/2022 revealed resident #1 was on a regular, no added salt/no concentrated sweets mechanical soft diet with chopped meats. Review of the medical record revealed resident #1 was on speech therapy for treatment of dysphagia from 08/24/2022 through 09/22/2022. Review of resident #1's chart revealed a written Physician's Order dated 08/26/2022 and progress note dated 08/26/2022 revealed a swallow study and a consult to Registered Dietitian was ordered by nurse practitioner. Review of MBSS results dated 09/06/2022 revealed resident #1 had aspiration observed during examination, decreased lingual strength, poor lingual control, oral residue, pharyngeal delay, no reflexive cough, ineffective cough, reduced laryngeal closure and elevation. Silent aspiration. Patient able to feed self per objective exam. Recommendation for nectar thick by cup teaspoon size sips for liquids. Recommended strategies included small bites and sips. Precautions recommended included the following: small bites, monitor oral pocketing, supervised po (By Mouth) feeding, position upright 90 for po, patient to be fed by trained staff, monitor patient for adequate nutrition and hydration, crush meds, consider an adjustable flow cup for smaller sips. ST (Speech Therapy) recommended and dietitian due to patient appears thin. An interview on 01/04/2023 at 11:35 a.m. with S3SLP (Speech Language Pathologist) revealed she had resident #1 multiple times for ST since he was admitted , resident had a dysphagia and frequently pocketed his food. S3SLP reported resident knew his swallow strategies and how to clear his mouth, no difficulty with liquids. She further stated resident was on regular mechanical soft diet with chopped meats, but was able to feed himself but needed to be monitored and fed by staff at times. S3SLP stated the most recent time resident #1 was on ST was 08/24/2022-09/22/2022. Review of facility's current Policy and Procedure for Lab and Diagnostic Test Results- Clinical Protocol revealed the nurse was responsible for notifying physician/nurse practitioner of results of lab and other diagnostic test results. An interview on 01/06/2023 at 12:30 p.m. with S3SLP revealed that she did not notify physician/practioner of results for MBSS on 09/06/2022 for resident #1. An interview on 01/06/2023 at 2:45 p.m. with S2DON (Director of Nursing) confirmed that physician/nurse practitioner should have been notified of MBSS results for resident #1 from 09/06/2022. On 01/06/2023 at 3:10PM, notified S1Administrator of deficient practice regarding facility not notifying physician/nurse practitioner of MBSS results from 09/06/2022 on resident #1.

Based on interviews and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to ensure the RD (Registered Dietitian) was consulted for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents, according to the physician's orders, Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, unspecified convulsions, diabetic neuropathy, radiculopathy cervical region, intervertebral disc degeneration lumbar region, hemiplegia affecting right dominant side, aphasia following non-traumatic subarachnoid hemorrhage, dysarthria following non-traumatic subarachnoid hemorrhage, dysphagia following cerebral infarction, and cerebral infarction. Review of the October 2022 physician's orders revealed order dated 04/08/2022 for regular no added salt, no concentrated sweets, mechanical soft diet with chopped meats. Review of resident #1's April 2021 careplan revealed resident needed assistance with feeding and required mechanically altered diet. Staff are to supervise dining, monitor for choking, and provide verbal encouragement/cueing as needed. Staff to consult Registered Dietitian as needed. Review of resident #1's chart revealed a written Physician's Order dated 08/26/2022 and progress note dated 08/26/2022 revealed a swallow study and a consult to RD was ordered by nurse practitioner. An interview on 01/06/2023 at 10:00 a.m. with S4RD revealed she was not aware of an order dated 08/26/2022 for RD consult for resident #1. Review of Dietitian Notes revealed resident #1 was last seen by RD on 07/19/2022. An interview on 01/06/2023 at 2:45 p.m. with S2DON (Director of Nursing) confirmed that the RD should have been consulted for resident #1 based on the physician order dated 08/26/2022. On 01/06/2023 at 3:10PM, S1Administrator was notified of the deficient practice regarding RD not being consulted for resident #1 after consult was ordered on 08/26/2022.

Based on interview and record review the facility failed to provide documentation that a resident or resident's representative were provided written Advance Directive information, and at the residents option, the right to decline or formulate and advance directive for 29 (#1, #2, #3, #4, #5, #6, #8, #10, #11, #12, #15, #18, #19, #28, #29, #33, #35, #38, #39, #40, #45, #49, #54, #58, #61, #62, #63, #161, #361) of 29 sampled residents. Findings: Review of the facility Advance Directives policy revised 12/2016 revealed in part: 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance. b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Review of residents #1, #2, #3, #4, #5, #6, #8, #10, #11, #12, #15, #18, #19, #28, #29, #33, #35, #38, #39, #40, #45, #49, #54, #58, #61, #62, #63, #161, and #361 records revealed no written documentation that the resident or his/her responsible party had been given information or offered the option to formulate an Advance Directive. During an interview on 08/23/2022 at 11:30AM S4Social Services reported the facility was instructed by the Feds advance directive information and statement of acknowledgment or declination form was no longer required so the facility had only been using the LA POST (Louisiana Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 08/24/2022 at 10:00AM S1Administrator reported the facility had not been having residents or the resident's representative sign an acknowledgement/declination form to indicate whether they had received information or implemented advanced directives during admission and were using the resident's LA POST for the code status and to indicate the resident's advance directive wishes.

Based on record review and interview the facility failed to complete a quarterly assessment using the quarterly review instrument specified by the State and approved by CMS (Centers for Medicare and Medicaid Services) no later than 14 days after the Assessment Reference Date (ARD) for 2 (#6, and #11) of 7 (#1, #2, #3, #4, #6, #11, and #12) reviewed for Resident Assessment. Findings: Record review revealed the MDS (Minimum Data Set) quarterly assessments with an ARD date of 07/20/2022 were not completed for 2 (#6, and #11) residents. On 08/24/2022 at 11:33AM, an interview with S3MDS Coordinator confirmed Resident #6 and Resident #11's quarterly assessments with an ARD date of 07/20/2022 should have been completed by 08/03/2022.

Based on record review and interview, the facility failed to ensure resident assessments were electronically transmitted in a timely manner by failing to transmit the resident assessment within 14 days of completion for 5 (#1, #2, #3, #4, and #12) of 7 (#1, #2, #3, #4, #6, #11, and #12) sampled residents reviewed for resident assessments. Findings: Review of the records for residents #1, #2, #3, #4, and #12 revealed each resident had an MDS (Minimum Data Set) completed in March, April, and May in 2022 that was completed but not transmitted to the CMS (Centers for Medicare and Medicaid Services) system. Review of CMS Validation Reports dated 08/25/2022 indicated residents #1, #2, #3, #4, and #12's assessment records were submitted late. On 08/25/2022 at 2:00PM, an interview with S3MDS Coordinator revealed the MDS assessments for residents #1, #2, #3, #4 and #12 should have been submitted in a timely manner.

Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by not ensuring 1) food storage containers were clean, 2) food was labeled, dated, and sealed appropriately, 3) the fryer and toaster oven were clean, and 4) the chemical sanitization levels in the 3 compartment sink was monitored appropriately. According to S5Dietary Manager (DM) 50 residents are served meals from the kitchen. Findings: Review of the facility's policy for 3 Sink Method revealed in part, use the third sink to soak dishes in chemical sanitizing solution per solution directions. Alternately, you can soak dishes for 30 seconds in hot water at 171 degrees Fahrenheit or hotter instead of sanitizing chemicals. Chlorine sanitizer should be maintained at ,d+[DATE]ppm. On [DATE] at 9:25AM, observation of the kitchen revealed the lids on the cereal bins contained grime and debris, and a package of dry noodles was stored in a plastic wrapper that contained grime and debris. Further observation revealed 5 plastic seasoning containers had grime and seasoning on the outside of the bottle, and a box of powdered sugar was not sealed and open to air. On [DATE] at 9:30AM, observation of the freezer and refrigerator revealed a box of biscuits, corndogs, slices of Swiss cheese, sausage patties, a Ziploc bag containing strawberries, a Ziploc bag containing ham, and a plastic bag of salad not labeled or dated. On [DATE] at 9:35AM observation of the fryer revealed food particles and grease buildup on the inside bottom of the fryer. The toaster oven contained an accumulation of burnt food particles covering the inside bottom and the trays of the toaster oven and needed to be cleaned. On [DATE] at 8:32AM, an interview with S5Dietary Manager revealed the kitchen serves 50 residents from the kitchen. On [DATE] at 1:00PM, S5Dietary Manager was notified of the issues in the kitchen. On [DATE] at 1:40PM, observation of the 3 Compartment Sink revealed S6Dietary Worker performed a chemical sanitization strip reading. The test strip reading revealed multicolors yellow/blue/green and was not a clear reading. Further observation revealed the test strips used to test the sanitization level in the 3 compartment sink were expired as of [DATE]. On [DATE] at 1:40PM, an interview with S5Dietary Manger and S6Dietary Worker revealed they were not aware the test strips used to test the sanitization levels in the 3 compartment sink were expired. During the interview S5Dietary Worker revealed the facility did not have any other bottles of the chemical test strips to monitor sanitization levels of the 3 compartment sink. On [DATE] at 1:50PM, S1Administrator was notified of the issues in the kitchen documented above.

Based on record review and interview the facility failed to ensure resident's care plans were reviewed and revised based on the residents' status after each assessment for 3 (#29, #35, #45) of the 29 sampled residents reviewed for care plans. The facility failed to revise the care plan for residents #29 and #45 and failed to address gastrostomy status for resident #35. Findings: Resident #29 Record review of Resident #29's MDS (Minimum Data Set) record revealed the following assessments were completed: an Entry assessment with an ARD (Assessment Reference Date) of 02/02/2022; an Admission assessment with an ARD of 02/10/2022; and Quarterly assessment with an ARD of 05/12/2022. Review of Care Plan revealed Resident #29's care plan had no previous review or revision dates, and no date indicating when next review was required. Resident #35 Record Review of Resident #35's MDS record revealed the following assessments were completed: a Significant Change assessment with an ARD of 02/26/2022; a Quarterly assessment with an ARD of 05/28/2022; and a Significant Change assessment with an ARD of 06/30/2022. Review of Resident #35's Care Plan revealed the care plan had not been revised with the last 3 assessments and indicated the next review date of 02/07/2022. Review of Resident #35's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #35's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nutrition Care Plan revealed Resident #35 had a care plan with an onset date of 03/20/2015 for Alteration in nutrition related to requires supervision and set up assistance with meals with a goal to maintain adequate nutritional status as evidence by weight remaining stable through the next review on 02/7/2022 with interventions to be fed by staff as needed. Resident #45 Record Review of Resident #45's MDS record revealed the following assessments were completed: a Quarterly with an ARD of 03/23/2022, and a Quarterly with an ARD of 06/08/2022. Review of Resident #45's Care Plan revealed the care plan had not been revised with the last two assessments and indicated the next review date was 03/28/2022. On 08/25/2022 at 2:00PM, during an interview S3MDS (Minimum Data Set) coordinator acknowledged Resident #35 did not have a care plan addressing her needs for a peg tube. S3MDS coordinator further acknowledged she did not review and/or revise Resident #29's, Resident #35's, or Resident #45's care plan per requirements with their quarterly and significant change assessments.

Based on observation, record review, and interview, the facility failed to ensure that residents who require [CONDITION(S)] receive such services, consistent with professional standards of practice by failing to assess [CONDITION(S)] graft every shift for 1 (#39) of 1 (#39) residents reviewed for [CONDITION(S)]. Findings: Review of the record revealed resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed resident #39 had a BIMS (Brief Interview of Mental Status) score of 10 indicating moderate cognitive impairment. Further review of the MDS confirmed the resident is receiving [CONDITION(S)]. On 08/23/2022 at 9:15AM, an interview with resident #39 reported she goes to [CONDITION(S)] 3 days per week on Monday, Wednesday, and Friday. Resident #39 reported she has a necklace graft to her upper chest wall, and staff do no monitor graft upon return from [CONDITION(S)]. Review of the facility's policy and procedure for Care of the Patient Receiving Hemodialysis revealed access site to be assessed for bruit and thrill every shift and notify the physician if not heard or felt. Further review of Care of the Patient Receiving Hemodialysis revealed access site to be monitored every shift and notify doctor with any sign and symptoms of infection, such as site being red, swollen, or hot to touch. Review of the June 2022, July 2022, and August 2022 MAR (Medication Administration Record) for resident #39 revealed no documentation for assessing [CONDITION(S)] access for bruit and thrill every shift, and no documentation for monitoring access site every shift for signs and symptoms of infection. On 08/24/2022 at 4:30PM, an interview with resident #39 revealed she went to [CONDITION(S)] today and returned to the facility about 4:00PM. She reported that the nurse had not monitored her [CONDITION(S)] access since she returned to the facility. On 08/25/2022 at 2:55PM, an interview with S7Corporate Administrator, confirmed that resident #39 should have had her [CONDITION(S)] access assessed for thrill and bruit and monitored [CONDITION(S)] access for signs and symptoms of infection each shift per facility's policy and procedure.

Based on policy review, record review and interviews the facility failed to ensure a resident's medical records reflected the resident's wishes for Advanced Directives for 1 (#5) of 1 (#5) residents reviewed for Advance Directives. The facility failed to ensure the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Review of the facility Advance Directives policy revised 12/2016 revealed in part: 20. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Review of resident #5's medical record revealed an admitted [DATE]. Review of resident #5's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #5's comprehensive care plan dated 05/12/2022 revealed resident #5's Code status: Full Code. Present at admission. Review of resident #5's paper medical record binder revealed a full size red first page noting resident #5 was a DO NOT RESUSCITATE - (DNR). Further review revealed the medical record binder was flagged with bright colored stickers designating resident code status as DNR. The second page in resident #5's medical record binder was resident #5's (LA Post) Louisiana Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #5's electronic medical record face sheet and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/24/22 at 11:30 am S2DON (Director of Nursing) and S10LPN (Licensed Practical Nurse) reported if a resident was found unresponsive, S2DON would check the resident's paper medical record (chart) because the code status was on the first page in the front of the chart. S10LPN reported nurses look at the resident's electronic medical record or at the top of the resident's MAR for code status and acknowledged resident #5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . S2DON and S10LPN verified resident #5's code status should have been clarified with resident #5, resident #5's representative and physician and updated according to resident #5's wishes and was not done.

Based on observation, record review, and interview, the facility failed to ensure residents who were unable to carry out activities of daily living receive the necessary services to maintain good personal hygiene by failing to ensure resident's fingernails were trimmed in a timely manner for 1 (#33) of 4 (#19, #33, #40, and #45) residents reviewed for activities of daily living. Findings: Review of the medical record for sampled resident #33 revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS (Minimum Data Set) dated 05/31/2022 revealed the resident had severed cognitive impairment for daily decision making and required one person extensive assist for bed mobility, one person limited assist for eating, and one person total dependence for toileting and transfers. Further review of MDS revealed resident had impaired functional limitation on one side for upper and lower extremities. Review of the care plan dated 04/08/2021 revealed the resident required extensive assistance with activities of daily living. Staff are to assist resident with dressing, grooming, bathing and personal hygiene. On 08/22/2022 at 10:25AM, 08/23/2022 at 9:00AM, 08/24/2022 at 3:30PM, and 08/25/2022 at 12:30PM, observations of resident #33 revealed long fingernails to bilateral hands. An interview on 08/25/2022 at 12:20PM with S8LPN (Licensed Practical Nurse) revealed that resident #33's fingernails are trimmed by nurses on the hall due to resident being diabetic. An interview/observation on 08/25/2022 at 12:30PM with S3LPN, confirmed that resident #33's fingernails are too long and need to be trimmed. An interview on 08/25/2022 at 12:35PM with S2DON (Director of Nurses) confirmed that nurses on hall or Podiatrist are responsible for trimming resident #33's fingernails. S2DON confirmed that resident #33 needed his fingernails trimmed. On 08/25/2022 at 12:51PM S1Administrator was notified that resident #33 had long fingernails that needed to be trimmed and required extensive assist with activities of daily living.

Based on record review and interview, the facility failed to make prompt efforts to resolve grievances for 1 (#5) of 2 (#5, #50) residents reviewed for personal property by failing to timely find or replace the residnets' missing walker and clothing items. Findings: Review of Resident #5's medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Minimum Data Set, dated dated dated [DATE] revealed a brief interview for mental status score of 13, which indicated the resident was cognitively intact. In an interview on 08/23/2021 at 1:05 PM, Resident #5 explained he was sent out to the hospital and when he returned, his walker was missing as well as some black jeans and three tee shirts. Resident #5 reported he notified administration of the missing items and they haven't done anything about it. Review of a grievance filed by Resident #5 revealed he reported to the administrator on 8/12/2021 that he was missing a walker and some clothes. Further review of the grievance revealed the Administrator documented contacting therapy about the walker and laundry about the clothes. Further review failed to reveal if the missing items were located or replaced, or if the issue had been resolved. Review of Resident Inventory Sheet dated 04/12/2021 revealed Resident #5 had one walker and one pair of pants. Review of Resident Inventory Sheet dated 07/30/2021 revealed documentation of a black pair of jeans and one walker that was left here from before. In an interview on 08/25/2021 at 2:15 PM, Resident #5 confirmed he still had not gotten back his missing clothes (black jeans and two shirts) or walker. He explained he reported it to administration and she said she would look into it and never heard back from her. In an interview with S1 Administrator on 8/26/2021 at 10:00 AM, she reported the facility's policy on missing items was to replace them if they are not located. Review of the facility's policy titled Investigating Grievances/Complaints revealed the following, in part: 4. The resident, or person acting in behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 1 working day of the filing of the grievance or complaint. Review of the facility's policy titled Lost or stolen property revealed, in part, the following: 4. If the missing items can't be located, the facility will replace the missing items or provide the resident or family member a refund at cost of missing product. In an interview on 8/26/2021 at 10:50 AM, S1 Administrator reported Resident #5 didn't come to the facility with a walker but only came with a walking stick. S1 Administrator further reported the resident was missing black jeans that she was going to replace when he gives her his pant size. On 8/26/2021 at approximately 3 PM, S1 Administrator was notified of findings and acknowledged Resident #5's walker had been reported missing on 8/12/2021 and was located today.

Based on record review and interview the facility failed to ensure that a drug regimen review was performed or irregularities identified by the consultant Pharmacist were acted upon for 5 (#81, 80, 10, 1, and 85) of 25 (# 32, 6, 53, 78, 90, 85, 12, 1, 95, 2, 81, 74, 31, 46, 10, 3, 80, 29, 48, 72, 56, 44, 67, 77, and 38) residents reviewed for their drug regimen, out of a total 28 sampled residents reviewed for care and services during Stage 2. The facility failed to: 1. monitor the PT/INR (Prothrombin Time/International Normalized Ratio) levels for 2 (#81, 80) of 12 (#48, 72, 81, 56, 1, 44, 67, 46, 80, 78, 77, 38) who received Coumadin therapy; 2. attempt a gradual dose reduction for a resident (#10) who had been on the same dose of Abilify, 15 milligrams daily, since 09/05/12; 3. have consultant Pharmacist communication to Physicians forms dated after 08/13/13, that recommended a gradual dose reduction for Abilify for a resident (#10); 4. ensure a drug regimen review was performed monthly for 2 (#1, 85) residents; and 5. ensure drug regimen review irregularities were acted upon for 1 (#10) resident. The lack of monitoring PT/INR levels resulted in an immediate jeopardy situation for resident #81. The immediate jeopardy began on 09/01/13 when resident #81 began receiving Coumadin after a hospitalization for deep vein thrombosis of the right lower extremity. There were no physician orders for PT/INR levels, and there were no PT/INR lab levels in the medical record. The resident was therefore not being monitored for therapeutic levels of the medication (Coumadin) in order to determine the effectiveness of the anticoagulant in preventing blood clots and to prevent potential bleeding problems. (Coumadin is a blood thinner or anticoagulant which keeps blood flowing smoothly in the body by decreasing the amount of certain substances, clotting proteins, in the blood. A PT/INR test can be used to measure the effectiveness of the medication by determining how long it takes for blood to clot. Low levels may indicate increased potential for clotting, while high levels may indicate increased potential for bleeding.) The consultant pharmacist addressed the lack of routine INR levels in the pharmacist report dated 11/30/13 and a follow up report dated 12/11/13. The physician agreed to the recommended PT/INR monthly on 12/20/13. However, there was no documentation the recommendation was acted upon. The facility was notified of the immediate jeopardy situation on 01/22/14 at 6:13 PM. The facility presented a plan of removal for the immediate jeopardy situation which included; 1. Resident #81 was sent to the hospital for a stat PT/INR to be drawn. 2. Inservice held with nurses on importance of Coumadin therapy, importance of lab draws to monitor levels, notification of MD of lab results at 6:26 PM. 3. The physician was notified of PT/INR results of resident #80 at 6:55 PM. 4. All residents on Coumadin therapy are being reviewed at this time to ensure PT/INR drawn during last 30 days. The MD will be notified immediately of any abnormal levels not already addressed by MD. 5. Nurses will be required to monitor PT/INR results prior to administering any Coumadin. 6. Resident #81 results from hospital within therapeutic range as of 7:22 and MD notified of results. 7. MD orders received for resident #81 and #80 for routine PT/INR levels. 8. Coumadin levels for resident #81 were addressed by the pharmacist in November and December 2013. DON will be counseled regarding follow up on Consultant Pharmacist reports. Coumadin level was addressed by the pharmacist for resident #80 in August 2013. The immediate jeopardy was lifted on 01/22/14 at 8:00PM with the acceptance of the plan of removal. The deficient practice continued at a level 2 pattern. Findings: Resident #81 Record review for sample #81 revealed the [AGE] year old resident was admitted to the facility on [DATE] and had a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the physician orders for January 2014 revealed an order dated 08/29/13 for Coumadin 7.5 mg one PO every day. There was no physician order for [REDACTED]. Review of the September, October, November, and December 2013 MARs revealed the Coumadin was started on 09/01/13 and was given daily through the current date of 01/22/14. Review of the current plan of care revealed the resident was identified as having a potential for injury, excessive bleeding related to the use as an anticoagulant. The nurse was to monitor lab values and report abnormal values to the physician. Review of the lab results revealed there were no PT/INR lab levels in the record. Review of the "Consultant Pharmacist Communication to Physician" form dated 11/30/13 revealed the lack of routine INR orders for the resident was addressed. The physician signed the communication on 12/20/13 and indicated agreement with the recommendation for INR every month. Review of the "Consultant Pharmacist Communication to DON" form dated 12/11/13 revealed no INR levels were in the chart and none were ordered. A recommendation was made to followup with the physician for monthly INR orders. There was no documentation in the record to indicate the recommendation had been acted upon. An interview with S2 DON on 01/22/14 at 3:00PM confirmed there were no orders for PT/INR levels and no lab results were on the chart. She stated that to her knowledge no PT/INR level had been obtained for the resident since she was started on the Coumadin 09/01/13. On 01/22/14 at 6:50PM observation of the resident revealed she was in bed and was alert and talkative. She stated she had been to the hospital this evening to have her lab drawn. Observation at this time revealed no excessive bruising was noted on the resident's arms or legs. On 01/23/14 at 3:37 PM, an interview with S3 Medical Director revealed he was unaware that residents on Coumadin had not been monitored with PT/INR levels. He stated he thought that it was standard protocol to obtain monthly levels for residents on Coumadin therapy. Resident #80 Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record for resident #80 revealed a physician order dated 12/13/12 for Coumadin ( an anticoagulant medication) 5 milligrams on Tuesday, Thursday, Saturday and Sunday and Coumadin 2.5 milligrams on Monday, Wednesday and Friday. Record review revealed there was no PT/INR lab levels to monitor the anticoagulant medication in the medical record. Review of the record revealed a Consultant Pharmacist Communication to DON dated 08/13/13 that revealed DRR (Drug Regimen Review) Recommendations and findings: Coumadin therapy but the last INR I can find is from February. Please follow up with MD on this lab. A Consultant Pharmacist Communication to Nursing dated 11/15/13 revealed that the pharmacist reviewed the signs to monitor for internal bleeding. A Consultant Pharmacist Communication to Physician dated 11/30/13 revealed Coumadin therapy-no routine lab and no results found for an INR. The form was signed by the physician on 12/23/13 and agreed to the routine lab. The form was dated near the bottom on 01/15/14 and signed by S2 DON. On 01/22/14 at 12:47 PM, an interview with the S2 DON was conducted. S2 DON confirmed that the communication form from the Pharmacist dated 11/30/13 to the Physician was not received by her until 01/15/14. S2 DON confirmed that the medication (Coumadin) had not been monitored. She also confirmed that it took 6 1/2 weeks for the pharmacist communication to the physician to be acted upon by the facility which was not an acceptable time frame. Resident #10 Resident #10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed that resident #10 had been on the same dose of Abilify, 15 milligrams daily, since 09/05/12. There was no documented evidence of an attempted dose reduction since the medication was prescribed for the resident on 09/05/12. On 01/22/14 at 9:53 AM, an observation of resident #10 revealed that the resident was sitting in a wheel chair in his room. He was not communicative. On 01/24/14 at 11:40 AM and 3:15 PM, observation of the resident revealed that he was laying in his bed with his eyes open looking toward the wall. One side rail was raised and the bed was against the wall. On 1/24/14/at 12:10 PM, S8 SSD was interviewed and revealed that resident #10 was not communicative. S8 SSD confirmed that she had never witnessed any behaviors from the resident. Review of the mood/behavior /psychotropic drug monitoring record indicated no behaviors for any shift on any day of November/December 2013 or January 2014. Review of the care plan addressed a history of resistance with care and combativeness with staff at HS (night) incontinent care. The goal and target date was 04/16/14. An approach listed was to administer Abilify. Review of the Consultant Pharmacist Communication dated 08/13/13 to the physician requested a GDR (gradual dose reduction) of the medication Abilify. The documented physician response was "No, any reduction is contraindicated due to it will likely lead to greater psychiatric instability and impair function". The form was signed by the physician on 09/24/13. There were no other Consultant Pharmacist Communication to Physicians forms dated after 08/13/13 in the medical record. On 01/23/14 at 2:10 PM, S2 DON confirmed that there was no additional Consultant Pharmacist Communication forms for this resident. On 01/24/14 at 11:50 AM, an interview with S19 LPN, resident #10's nurse, was conducted. S19 LPN confirmed that she had never witnessed any behaviors from the resident. She stated that the resident was quiet and cooperative. She stated that she had been an employee at this facility for 3 years. On 01/24/14 at 12:00 PM, an interview with S2 DON confirmed that she stated she had never witnessed any behaviors and she did not know why resident was taking the Abilify. She also confirmed that there were no additional Consultant Pharmacist Communication forms after 08/13/13. Resident #1 A review of the chart revealed that the resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the documentation for the drug regimen review revealed no documentation for October 2013. An interview with S2DON on 01/24/14 at 12:10 PM revealed that the pharmacist did not have a book of his reviews at the facility or that the facility can not find the book. She confirmed that the printed record of drug regimen review that was emailed to her today and the pharmacist's letters was all she had available. Resident #85 A review of the record revealed that resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the documentation for the drug regimen review revealed no documentation for October 2013. An interview with S2DON on 01/24/14 at 12:10 PM revealed that the pharmacist did not have a book of his reviews at the facility or that the facility can not find the book. She confirmed that the printed record of drug regimen review that was emailed to her today and the pharmacist's letters was all she had available.

Based on record review and interview the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well being of each resident by not monitoring the PT/INR ([MEDICATION NAME] Time/ International Normalized Ratio) levels for 2 (#81, 80) of 12 residents (#48, 72, 81, 56, 1, 44, 67, 46, 80, 78, 77, 38) who received [MEDICATION NAME] therapy, in a total of 54 stage 2 residents. The lack of monitoring PT/INR levels resulted in an immediate jeopardy situation for resident #81. The immediate jeopardy began on 09/01/13 when resident #81 began receiving [MEDICATION NAME] after a hospitalization for [MEDICAL CONDITION] of the right lower extremity. There were no physician orders for PT/INR levels, and there were no PT/INR lab levels in the medical record. The resident was therefore not being monitored for therapeutic levels of the medication in order to determine the effectiveness of the anticoagulant in preventing blood clots and to prevent potential bleeding problems. ([MEDICATION NAME] is a blood thinner or anticoagulant which keeps blood flowing smoothly in the body by decreasing the amount of certain substances, clotting proteins, in the blood. A PT/INR test can be used to measure the effectiveness of the medication by determining how long it takes for blood to clot. Low levels may indicate increased potential for clotting, while high levels may indicate increased potential for bleeding.) The consultant pharmacist addressed the lack of routine INR levels in the pharmacist report dated 11/30/13 and a follow up report dated 12/11/13. The physician agreed to the recommended PT/INR monthly on 12/20/13. However there was no documentation the recommendation was acted upon. The facility was notified of the immediate jeopardy situation on 01/22/14 at 6:13PM. The facility presented a plan of removal for the immediate jeopardy situation which included; 1. Resident #81 was sent to the hospital for a stat PT/INR to be drawn. 2. Inservice held with nurses on importance of [MEDICATION NAME] therapy, importance of lab draws to monitor levels, notification of MD of lab results at 6:26PM. 3. The physician was notified of PT/INR results of resident #80 at 6:55PM. 4. All residents on [MEDICATION NAME] therapy are being reviewed at this time to ensure PT/INR drawn during last 30 days. The MD will be notified immediately of any abnormal levels not already addressed by MD. 5. Nurses will be required to monitor PT/INR results prior to administering any [MEDICATION NAME]. 6. Resident #81 results from hospital within therapeutic range as of 7:22 and MD notified of results. 7. MD orders received for resident #81 and #80 for routine PT/INR levels. 8. [MEDICATION NAME] levels for resident #81 were addressed by the pharmacist in November and December 2013. DON will be counseled regarding follow up on Consultant Pharmacist reports. [MEDICATION NAME] level was addressed by the pharmacist for resident #80 in August 2013. The immediate jeopardy was lifted on 01/22/14 at 8:00PM with the acceptance of the plan of removal. The deficient practice continues at a level 2 pattern. Findings: Resident #81 Record review for sample #81 revealed the [AGE] year old resident was admitted to the facility on [DATE] and had a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the physician orders for January 2014 revealed an order dated 08/29/13 for [MEDICATION NAME] 7.5 mg one PO every day. There was no physician order for [REDACTED]. Review of the September, October, November, and December 2013 MARs revealed the [MEDICATION NAME] was started on 09/01/13 and was given daily through the current date of 01/22/14. Review of the current plan of care revealed the resident was identified as having a potential for injury, excessive bleeding related to the use an an anticoagulant. The nurse was to monitor lab values and report abnormal values to the physician. Review of the lab results revealed there were no PT/INR levels in the record. Review of the "Consultant Pharmacist Communication to Physician" form dated 11/30/13 revealed the lack of routine INR orders for the resident was addressed. The physician signed the communication on 12/20/13 and indicated agreement with the recommendation for INR every month. Review of the "Consultant Pharmacist Communication to DON" form dated 12/11/13 revealed no INR levels were in the chart and none were ordered. A recommendation was made to followup with the physician for monthly INR orders. There was no documentation in the record to indicate the recommendation had been acted upon. An interview with S2 DON on 01/22/14 at 3:00PM confirmed there were no orders for PT/INR levels and no lab results were on the chart. She stated that to her knowledge no PT/INR level had been obtained for the resident since she was started on the [MEDICATION NAME] 09/01/13. On 01/22/14 at 6:50PM, an observation of the resident revealed she was in bed and was alert and talkative. She stated she had been to the hospital this evening to have her lab drawn. Observation at this time revealed no excessive bruising noted on the resident's arms or legs. On 01/23/14 at 3:37PM, an interview with S3 Medical Director revealed he was unaware that residents on [MEDICATION NAME] had not been monitored with PT/INR levels. He stated he thought that it was standard protocol to obtain monthly levels for residents on [MEDICATION NAME] therapy. Resident #80 Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record for resident #80 revealed a physician order dated 12/13/12 for [MEDICATION NAME] ( an anticoagulant medication) 5 milligrams on Tuesday, Thursday, Saturday and Sunday and [MEDICATION NAME] 2.5 milligrams on Monday, Wednesday and Friday. Record review revealed there was no PT/INR levels to monitor the anticoagulant medication in the medical record. Review of the record revealed a Consultant Pharmacist Communication to DON dated 08/13/13 that revealed DRR (Drug Regimen Review) Recommendations and findings: [MEDICATION NAME] therapy but the last INR I can find is from February. Please follow up with MD on this lab. A Consultant Pharmacist Communication to Nursing dated 11/15/13 revealed that the pharmacist reviewed the signs to monitor for internal bleeding. A Consultant Pharmacist Communication to Physician dated 11/30/13 revealed [MEDICATION NAME] therapy-no routine lab and no results found for an INR. The form was signed by the physician on 12/23/13 and agreed to the routine lab. The form was noted near the bottom dated 01/15/14 and signed by S2 DON. On 01/22/14 at 12:47 PM, an interview with the S2 DON was conducted. She confirmed that the communication dated 11/30/13 to the physician was not noted until 01/15/14 by the S2 DON. S2 DON confirmed that the medication had not been monitored. She confirmed that it took 6 1/2 weeks for the pharmacist communication to the physician to be acted upon by the facility which was not an acceptable time frame. On 01/23/14 at 9:50AM, an interview with S2 DON revealed the pharmacy consultant visits monthly and sends letters of recommendation to her for any issues that need to be addressed. She then sends the communication to the physician. On 01/23/14 at 10:50AM, an interview with S4 Pharmacy Consultant revealed he sends a notification directly to the physician and DON in the first month he identifies a need for a diagnosis, justification, lab, or test for any medication. On 01/22/14 at 6:13PM, an interview with S1 Administrator revealed the quality assurance committee had found a problem with lab tests not being done but the system that was put into place did not address the problems noted in this deficient practice. The facility did not address following up on the consultant pharmacists' recommendations nor the lack of monitoring residents that are on anticoagulant therapy ([MEDICATION NAME]).

Based on record review and interview the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 2 (#80 and 81) of 12 (#48, 72, 81, 56, 1, 44, 67, 46, 80, 78, 77, and 38) residents on [MEDICATION NAME] therapy and 2 (#53 and 10) of 5 (#10, 29, 53, 74, and 85) residents reviewed for unnecessary medications; out of a total of 54 Stage 2 residents. The facility failed to: 1. monitor the PT/INR ([MEDICATION NAME] Time/International Normalized Ration) levels for 2 (#80 and 81) of 12 (#48, 72, 81, 56, 1, 44, 67, 46, 80, 78, 77, 38) residents who received [MEDICATION NAME] therapy; 2. have a clinical justification for a resident (#53) receiving [MEDICATION NAME] (anti-psychotic medication); 3. attempt a gradual dose reduction for a resident (#10) receiving [MEDICATION NAME] (anti-psychotic medication) since 09/05/12; 4. document behaviors for 2 (#10 and 53) residents receiving anti-psychotic medications. The lack of monitoring PT/INR levels resulted in an immediate jeopardy situation for resident #81. The immediate jeopardy began on 09/01/13 when resident #81 began receiving [MEDICATION NAME] after a hospitalization for [MEDICAL CONDITION] of the right lower extremity. There were no physician orders for PT/INR levels, and there were no PT/INR levels in the medical record. The resident was therefore not being monitored for therapeutic levels of the medication in order to determine the effectiveness of the anticoagulant in preventing blood clots and to prevent potential bleeding problems. ([MEDICATION NAME] is a blood thinner or anticoagulant which keeps blood flowing smoothly in the body by decreasing the amount of certain substances, clotting proteins, in the blood. A PT/INR test can be used to measure the effectiveness of the medication by determining how long it takes for blood to clot. Low levels may indicate increased potential for clotting, while high levels may indicate increased potential for bleeding.) The consultant pharmacist addressed the lack of routine INR levels in the pharmacist report dated 11/30/13 and a follow up report dated 12/11/13. The physician agreed to the recommended PT/INR monthly on 12/20/13. However there was no documentation the recommendation was acted upon. The facility was notified of the immediate jeopardy situation on 01/22/14 at 6:13PM. The facility presented a plan of removal for the immediate jeopardy situation which included; 1. Resident #81 was sent to the hospital for a stat PT/INR to be drawn. 2. Inservice held with nurses on importance of [MEDICATION NAME] therapy, importance of lab draws to monitor levels, notification of MD of lab results at 6:26PM. 3. The physician was notified of PT/INR results of resident #80 at 6:55PM. 4. All residents on [MEDICATION NAME] therapy are being reviewed at this time to ensure PT/INR drawn during last 30 days. The MD will be notified immediately of any abnormal levels not already addressed by MD. 5. Nurses will be required to monitor PT/INR results prior to administering any [MEDICATION NAME]. 6. Resident #81 results from hospital within therapeutic range as of 7:22 and MD notified of results. 7. MD orders received for resident #81 and #80 for routine PT/INR levels. 8. [MEDICATION NAME] levels for resident #81 were addressed by the pharmacist in November and December 2013. DON will be counseled regarding follow up on Consultant Pharmacist reports. [MEDICATION NAME] level was addressed by the pharmacist for resident #80 in August 2013. The immediate jeopardy was lifted on 01/22/14 at 8:00PM with the acceptance of the plan of removal. The deficient practice continues at a level 2 pattern. Findings: Resident #81 Record review for sample #81 revealed the [AGE] year old resident was admitted to the facility on [DATE] and had a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the physician orders for January 2014 revealed an order dated 08/29/13 for [MEDICATION NAME] 7.5mg one PO (by mouth) every day. There was no physician order for [REDACTED]. Review of the September, October, November, and December 2013 MARs revealed the [MEDICATION NAME] was started on 09/01/13 and was given daily through the current date of 01/22/14. Review of the current plan of care revealed the resident was identified as having a potential for injury, excessive bleeding related to the use an an anticoagulant. The nurse was to monitor lab values and report abnormal values to the physician. Review of the lab results revealed there were no PT/INR levels in the record. Review of the "Consultant Pharmacist Communication to Physician" form dated 11/30/13 revealed the lack of routine INR orders for the resident was addressed. The physician signed the communication form on 12/20/13 and indicated agreement with the recommendation for INR every month. Review of the "Consultant Pharmacist Communication to DON" form dated 12/11/13 revealed no INR levels were in the chart and none were ordered. A recommendation was made to follow-up with the physician for monthly INR orders. There was no documentation in the record to indicate the recommendation had been acted upon. An interview with S2 DON on 01/22/14 at 3:00PM confirmed there were no orders for PT/INR levels and no lab results were on the chart. She stated that to her knowledge no PT/INR level had been obtained for the resident since she was started on the [MEDICATION NAME] 09/01/13. On 01/22/14 at 6:50PM, an observation of the resident revealed she was in bed and was alert and talkative. She stated she had been to the hospital this evening to have her lab drawn. Observation at this time revealed no excessive bruising on the resident's arms or legs. On 01/23/14 at 3:37PM, an interview with S3 Medical Director revealed he was unaware that residents on [MEDICATION NAME] had not been monitored with PT/INR levels. He stated he thought that it was standard protocol to obtain monthly levels for residents on [MEDICATION NAME] therapy. Resident #80 Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record for resident #80 revealed a physician order dated 12/13/12 for [MEDICATION NAME] ( an anticoagulant medication) 5 milligrams on Tuesday, Thursday, Saturday and Sunday and [MEDICATION NAME] 2.5 milligrams on Monday, Wednesday and Friday. Record review revealed there was no PT/INR levels to monitor the anticoagulant medication in the medical record. Review of the record revealed a Consultant Pharmacist Communication to DON dated 08/13/13 that revealed DRR (Drug Regimen Review) Recommendations and findings: [MEDICATION NAME] therapy but the last INR I can find is from February 2013. Please follow up with MD on this lab. A Consultant Pharmacist Communication to Nursing dated 11/15/13 revealed that the pharmacist reviewed the signs to monitor for internal bleeding. A Consultant Pharmacist Communication to Physician dated 11/30/13 revealed [MEDICATION NAME] therapy-no routine lab and no results found for an INR. The form was signed by the physician on 12/23/13 and agreed to the routine lab. The form was noted near the bottom dated 01/15/14 and signed by S2 DON. On 01/22/14 at 12:47 PM, an interview with the S2 DON was conducted. She confirmed that the communication dated 11/30/13 to the physician was not noted until 01/15/14 by the S2 DON. S2 DON confirmed that the medication had not been monitored. She confirmed that it took 6 1/2 weeks for the pharmacist communication to the physician to be acted upon by the facility, which was not an acceptable time frame. Resident #10 Resident #10 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed that resident #10 had been on the same dose of [MEDICATION NAME] (antipsychotic) 15 milligrams daily since 09/05/12. There was no documented evidence of an attempted dose reduction since the medication was prescribed for the resident on 09/05/12. On 01/22/14 at 9:53 AM, an observation of resident #10 revealed that the resident was sitting in a wheel chair in his room. He was not communicative. On 01/24/14 at 11:40 AM and 3:15 PM, observation of the resident revealed that he was laying in his bed with his eyes open looking toward the wall. One side rail was raised and the bed was against the wall. On 1/24/14/at 12:10 PM, S8 SSD was interviewed and revealed that resident #10 was not communicative. S8 SSD confirmed that she had never witnessed any behaviors from the resident. Review of the mood/behavior /[MEDICAL CONDITION] drug monitoring record indicated no behaviors for any shift on any day of November/December 2013 or January 2014. Review of the care plan addressed a history of resistance with care and combativeness with staff at HS (night) incontinent care. The goal and target date was 04/16/14. An approach listed was to administer [MEDICATION NAME]. Review of the Consultant Pharmacist Communication form dated 08/13/13 to the physician requested a GDR (gradual dose reduction) of the medication [MEDICATION NAME]. The documented physician response was "No, any reduction is contraindicated due to it will likely lead to greater psychiatric instability and impair function". The form was signed by the physician on 09/24/13. There were no other Consultant Pharmacist Communication to Physicians forms dated after 08/13/13 in the medical record. On 01/24/14 at 11:50 AM, an interview with S19 LPN, resident #10's nurse, was conducted. S19 LPN confirmed that she had never witnessed any behaviors from the resident. She stated that the resident was quiet and cooperative. She stated that she had been an employee at this facility for 3 years. On 01/24/14 at 12:00 PM, an interview with S2 DON confirmed that she had never witnessed any behaviors from resident #10 and she did not know why resident was taking the [MEDICATION NAME]. Resident #53 Review of the medical record for client #53 revealed she was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current physician orders for January 2014 revealed she was taking the following medications: [REDACTED]. Review of the care plan for resident #53 revealed the following: 11/01/13 - Potential for trauma related to wandering; sleep pattern disturbance r/t [MEDICAL CONDITION] - interventions included calm, quiet environment; decrease noise and stimuli; encourage routine for bedtime nightly; reposition for comfort; med as ordered; Altered thought process/impaired decision making skills related to memory, dementia, and failure to thrive with appropriate interventions including orientation, direction and other measures. 5/28/13 - Potential for adverse reaction related to use of [MEDICAL CONDITION] medications ([MEDICATION NAME]) - approaches included administer meds, assess, monitor, pharmacy review, psychiatric evaluation as needed, AIMS assessment quarterly. 5/28/13 - Socially inappropriate behavior related to risk for injury to self due to resistive to care at times with appropriate approaches Review of the nurse notes revealed the following documentation: 10/20/13 - increased confusion with questionable signs and symptoms of urinary tract infection. 10/24/13 - awake and restless for the last few nights. 11/17/13 - very anxious most days, needs reassurance from staff she is alright. Watches TV in room and doesn't go to activities. 11/08/13 - doesn't sleep during the night - up all hours. Has [MEDICATION NAME] for restlessness that does not help - MD is aware. Constantly calling staff or comes out of room searching for staff stating that she is wet and that she is all messed up when she is dry. 11/10/13 - takes [MEDICATION NAME] qd and [MEDICATION NAME] prn 11/12/13 3:30pm - Physician called regarding anxiousness, restlessness in evening - order given for [MEDICATION NAME] 50mg 1 by mouth at hs - initial dose given at 8:00PM 11/15/13 11:00am - new order from physician - discontinue [MEDICATION NAME] and increase [MEDICATION NAME] to 100mg. 11/28/13 - [MEDICATION NAME] seems to be helping, not as confused, not as anxious or worried all the time - resting better at night. Further review of the nursing documentation revealed no targeted symptoms or behaviors to justify the addition of [MEDICATION NAME] to the medication regimen of resident #53 other than confusion and restlessness/anxiety. Review of the 12/17/13 MD progress note revealed the physician noted that her confusion was somewhat improved with increased [MEDICATION NAME] briefly but now it's beginning to return. No changes were made to her drug regimen. Observation and interview of resident #53 on 01/20/14 at 11:00AM and 5:45PM, and on 1/22/14 at 1:45PM revealed no demonstrated psychotic behaviors. Conversation was pleasant, the resident was oriented and cooperative with interviews. On 01/22/14 at 2:00PM, an interview with S12 LPN, the staff nurse providing care for resident #53, confirmed that resident #53 gets confused, mostly at night or briefly after waking up from a nap. She wanders out of her room to find staff because she is deaf and can not hear them when they respond to her call bell request. If they don't come in her room right away when she presses the call button she will get up and come to the nurse station to find the nurse. She likes to be completely dry, and gets anxious about having her brief changed, even when it is not wet or dirty. She denied that the resident exhibits any moods or behaviors such as crying, refusing care, screaming or hitting at staff, etc. She further stated she does get out of her room and go to the beauty shop and an occasional activity, and socializes well when she is around other people. Review of the Consultant Pharmacist Communications to the Physician and the DON revealed the following: 06/18/13 - request to update the cumulative [DIAGNOSES REDACTED]. 06/18/13 - RE: Antipsychotic ordered PRN **[MEDICATION NAME] 20mg by mouth every 12 hours as needed for restlessness - requested change to a non-psychotic medication for general restlessness. Further review revealed the request for [DIAGNOSES REDACTED]. There was no evidence that the pharmacist had issued a communication to the physician or the DON regarding the use of [MEDICATION NAME] that was ordered 11/12/13. On 01/23/14 at 9:50AM, an interview with S2 DON revealed the pharmacy consultant visits monthly and sends letters of recommendation to her for any issues that need to be addressed. She then sends the communication to the physician. She was unable at this time to produce any communication requests from the pharmacist related to the use of [MEDICATION NAME] by resident #53 and was not able to show documentation of any specific conditions or targeted behaviors to justify the administration of the antipsychotic when it was ordered on [DATE] and increased on 11/15/13. She confirmed that confusion and restlessness were the only symptoms / behaviors noted in the clinical record at the time the [MEDICATION NAME] was ordered. On 01/23/14 at 10:50AM, an interview with S4 Pharmacy Consultant revealed he sends a notification directly to the physician and DON in the first month he identifies a need for a diagnosis / justification for medication use or gradual dose reduction for antipsychotics. In the following month, he leaves a note in the file. In the third month, he sends a letter to the DON for followup. He allows a one month grace period prior to the second letter. At this time, the pharmacist confirmed he sent a letter in November 2013 that requested justification for resident #53 receiving the antipsychotic [MEDICATION NAME]. On 01/23/14 at 4:50PM, a follow-up interview with S2 DON confirmed there was no documented evidence that the resident was exhibiting any psychotic symptoms when the [MEDICATION NAME] was ordered and increased in November 2013.