Every finding on record at PruittHealth- Estill

Based on observations, record reviews, and interviews, the facility failed to prevent a potential accident hazard by failing to maintain hot water temperatures below 120 degrees Fahrenheit (F) to prevent potential scalding for one of three sampled residents, (Resident (R) 87). Findings include: Record review of R87's Face Sheet located under the Face Sheet tab of the Electronic Medical Record (EMR) revealed an admission date of 06/04/26 with a diagnosis of dementia. Record review of R87's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/10/26 revealed a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. R87 was independent with walking 10 feet. R87 had a diagnosis of non-Alzheimer's dementia. Observation of R87 on 06/23/26 at 4:03 PM revealed he was ambulating independently in the facility on the unit he resided on. Observation on 06/23/26 at 4:04 PM revealed the hot water in the sink of R87's bathroom felt hot to the touch with an inability to keep a bare hand in the hot water for more than two seconds without discomfort. A temperature check of the hot water with a digital thermometer revealed the temperature was 124.5 degrees Fahrenheit (F). Observation on 06/24/26 at 9:54 AM with the Administrator and the Maintenance Director (MD) revealed the hot water temperature was 121.5 degrees F with the laser thermometer used by the MD. The Administrator placed his hand in the running hot water and he confirmed that the hot water was too hot for safe use by the facility residents. Interview with the Administrator on 06/24/26 at 10:25 AM revealed the facility did not have a policy or procedure in place for maintaining the facility hot water temperatures at a safe level. Interview with the MD on 06/24/26 at 10:35 AM revealed the facility had four boilers; one for each resident unit (two), one for the laundry, and one for the kitchen. The MD revealed the boiler that provided the hot water to the unit R87 resided on was set at 135 degrees F. The MD confirmed the hot water setting on the boiler had to be lowered to 118 degrees F to be at the safe temperature. Interview with Certified Nursing Assistant (CNA)1 on 06/24/26 at 10:57 AM revealed R87 used the bathroom for toileting and handwashing.

Based on interviews, record reviews, and policy review, the facility failed to ensure residents and/or their resident representative (RR) received written information regarding the right to accept or refuse medical and surgical treatments for one of two residents (Resident (R) 8) out of 23 sampled residents. This failure had the potential for the residents' wishes not to be followed if they were unable to speak for themselves. Findings include:Review of the facility policy titled, Advance Directives: South Carolina, dated 04/09/24 did not indicate the facility should provide the resident and/or the RR with written information regarding the right to accept or refuse medical and surgical treatments. Review of R8's Face Sheet, located under the Resident tab in the electronic medical record (EMR), revealed R8 was admitted on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, unspecified mood disorder, post-traumatic stress disorder, and bipolar disorder. Review of R8's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/26/26 and located under the Resident Assessment Instrument (RAI) tab of the EMR, revealed R8 had a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment. Review of R8's undated Social Services form titled, SC [South Carolina] Advance Directive for Healthcare, located under the Resident tab in the EMR under the Documents section, revealed it did not include information regarding the resident and/or the resident representative receiving written information regarding the right to accept or refuse medical and surgical treatments. During an interview and record review on 06/23/26 at 4:38 PM, the Social Service Director (SSD) verified the SC Advance Directive form did not indicate that R8 or her RR received written information regarding the right to accept or refuse medical and surgical treatments. During an interview and record review on 06/24/26 at 11:00 AM, the Administrator confirmed the R8's SC Advanced Directive form did not include information regarding the right to accept and or refuse medical and surgical treatments.

Based on interview and record review, the facility failed to maintain a comprehensive Facility Assessment that adequately addressed the care needs of residents with serious mental illness. Per the 2025 Facility Assessment review, the facility did not properly evaluate or establish the necessary care protocols, services, and staff competency requirements essential for managing residents with serious mental health conditions. This failure to assess and provide the resources needed for resident care, including mental health services, based on their acuity levels and diagnoses, had the potential to impact all 79 current residents. Findings include: Review of the electronic medical record (EMR) Face Sheet tab revealed R32 was admitted to the facility on [DATE] with a diagnosis, which included unspecified intellectual disabilities, Schizophrenia with behavioral disturbances and hallucinations, and psychotic and combative behavior. Review of R32's referral documents dated 09/26/23, in the resident's EMR from the hospital discharge summary to the facility, indicated R32 had a history for seizure disorder and intellectual disability who presented to the hospital emergency room with altered mental status, intellectual delay, and confusion. A review of R32's EMR Minimum Data Set (MDS) with an Assessment Reference Date of 09/06/24 assessment revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. During an interview on 04/29/25 at 10:27 AM with the Administrator and Senior Nurse Consultant (SNC), it was indicated that the Facility Assessment captured the facility for the periods of 08/01/23 through 07/31/24. R32 was admitted to the facility on [DATE]. The SNC confirmed that the FA would have captured 11 months of the resident in the facility. While the report stated that the facility can accommodate patients with psychiatric conditions and mood disorders, it failed to address their ability to manage residents with more severe mental illnesses and behaviors, such as those exhibited by R32. Cross Reference: F742 Treatment and Services for Mental and Psychosocial Concerns.

Based on observation, interviews, and record review, the facility failed to ensure one of four residents reviewed for behaviors (Resident (R)32) received appropriate treatment and services for his diagnosis of serious mental illnesses and for his behaviors out of a total sample of 27 residents. This failure increased the risk of psychosocial harm and/or physical harm from other residents to R32 and increased the risk of psychosocial harm to the residents coping with R32's behaviors. Findings include: Review of the electronic medical records (EMR), Face Sheet tab, indicated R32 was admitted to the facility on [DATE] with diagnosis including but not limited to unspecified intellectual disabilities, Schizophrenia with behavioral disturbances and hallucinations, and psychotic and combative behaviors. Review of the EMR, Documents tab revealed hospital referral documents, dated 09/26/23, that indicated R32 had a history of seizure disorder and intellectual disability and presented to the hospital emergency room with altered mental status, intellectual delay, and confusion. Review of R32's EMR, admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/29/23, revealed a zero of 15 score on his Brief Interview for Mental Status (BIMS) assessment that indicated severe cognitive impairment. Further review of the MDS revealed R32 was at risk for decline of psychosocial well-being. The care plan Care Area Assessment (CAA) document located in the EMR, MDS tab, dated 09/29/23, stated consideration was made for R32's psychosocial well-being but a care plan for psychosocial well-being was declined with the rationale that R32 was always up and out of his room. The MDS documented the seriousness of his behavioral symptoms and that R32 is an immediate threat to self-due to his long-standing mental health problem associated with the behavioral disturbances of schizophrenia, bipolar disorder, depression, and anxiety disorder. Factors identified in the MDS to exacerbate his behaviors included alarm use. The MDS identified R32 was at risk for elopement and behaviors. R32 had a wander guard device on his right wrist that activated an alarm each time he approached an exit door of the facility. The MDS CAA analysis of findings documented for activities indicated R32 had been involved in several group activities and was ambulatory throughout the facility but did not identify his specific activity interest or structured activities specific to his needs, as required. Review of R32's EMR, Documents tab, revealed a Pre-admission Screening and Resident Review (PASARR) Level II South Carolina Intellectual Disability Authority Determination, dated 01/19/24, that R32 did not have an Intellectual Disability (ID) as defined under the current Pre-admission Screening and Resident Review (PASARR) regulation. The document indicated, based on R32's psychiatric diagnosis, that the nursing facility was required to contact the South Carolina Mental Health Authority to conduct a review of R32's Level II PASARR. Review of R32's EMR, Documents tab, revealed a document titled Level II State Mental Health Authority Determination, dated 09/11/24, that determined R32's needs could be met in a nursing facility with specific psychiatric/mental services required for structured socialization activities, psychotherapy, crisis intervention services, development and training of necessary daily living skills and development of personal support networks. The document also stated that the nursing facility rehabilitation services were less intensive than specialized services that must be provided or arranged for by the nursing facility through a Mental Health Facility/Center named Coastal Empire. The facility could not provide documentation that specialized services were provided to R32. During an interview with the facility Administrator on 04/29/25 at 1:00 PM, he indicated he was not aware of the mental health services required for R32 as stipulated in the South Carolina Mental Health Authority review. Review of R32's EMR, MDS tab, quarterly MDS with an ARD of 02/27/25 revealed R32 required a wander/elopement alarm that monitors resident movement and alerts the staff when movement to elope is detected. R32 takes antipsychotics on a routine basis and that a GDR (Gradual Dose Reduction) had not been attempted. Documentation indicated R32's diagnoses included seizure disorder, psychotic disorder (other than schizophrenia), Schizophrenia, metabolic encephalopathy, parkinsonism, and unspecified intellectual disabilities. Documented behavioral symptoms not directed at others included pacing, rummaging, public disrobing, smearing bodily wastes, and verbal/vocal symptoms like screaming, and disruptive sounds occurred daily. Documented was no evidence of an acute change in mental status from R32's baseline and that his inattention, disorganized thinking, and altered level of consciousness was present and fluctuated in severity. A BIMS was conducted and concluded with a summary score of 00 out of 15 indicating severe cognitive impairment. Review of the EMR, MDS tab revealed a Care Plan, dated 03/09/25, for behavioral symptoms of hallucinations related to psychosis, the care plan goal stated R32: will not harm self or others secondary to hallucinations with interventions to include administering medications as ordered, and to evaluate/record/report effectiveness and any adverse side effects. Also documented intervention was to communicate with R32's provider to determine the need for hospitalization and to determine if hallucinations pose danger to R32 or others. Also documented as an approach/intervention stated do not confront, argue against, or deny R32's hallucination, and to keep distance between R32 and others during hallucinations, and to encourage resident to discuss feelings, impulses, and hallucinations to validate reality. The Care Plan also documented R32 has a risk for impaired verbal communication related to disordered thinking secondary to schizophrenic disorder as evidenced by inappropriate speech. The care plan for R32's behavioral symptoms problem documented the following: presents with behavioral symptoms, wanders unsafely, refuses medication at times, shows aggression in attempts to knock medication from nurse hand, refuses ADL care at times, consistently ask and look for cigarettes and snacks, spits/urinates/defecates on floor, pushes/hits staff, attempts to bite staff, wanders in other resident rooms and takes their food/turns the lights on in other resident rooms and shakes them, sleeps in empty beds other than his own, he is difficult to redirect and is at risk for behaviors towards others. Interventions documented in his care plan included educate R32 on appropriate behavior and importance of keeping hands to self and to intervene/redirect as needed to protect the rights and safety of others, approach in a calm manner, divert attention, remove from situation, and take to another location as needed. Review of the EMR, Orders tab, revealed physician orders for R32 included a monthly injection of 2.5 mg Haldol decanoate, and 7.5 mg injection of Risperdal every two weeks. Review of the Medication Administration Report (MAR) for the month of March and April 2025, revealed the following refusals by R32: R32's order for Valproic acid solution for Schizophrenia 10 ml oral three times each day was refused 63 times of 90 scheduled to be administered. R32 also refused valproic acid solution 10 mg three times each day 82 times of 90 scheduled doses for April 2025. R32 refused all benztropine (used to treat abnormal body movements caused by antipsychotic medications) tabs 2 mg for the entire month of March 2025 and April 2025. R32's lactulose 30 mg one time each day for metabolic encephalopathy was refused for the entire month of March and April 2025. R32 refused all levetiracetam (to treat seizures)10 mg every 12 hours for epilepsy for the month of March and April 2025. Review of R32's EMR, Progress Notes tab, nursing progress notes documented R32 was discharged to the hospital five times in the previous 120 days related to his mental health diagnoses. Progress notes indicated hospital discharges related to R32's mental health occurred on 01/01/25, 02/08/25, 02/20/25, 04/21/25, and 04/26/25. R32 returned to the facility less than 24 hours after each discharge. The progress notes also documented two room changes related to his mental health behaviors that occurred on 03/31/25 and 04/18/25. During an interview with Licensed Practical Nurse (LPN)2 on 04/28/25 at 11:38 AM, she stated R32 consistently wandered in and out of other resident rooms where he urinates and defecates on the floor multiple times each day. She also stated R32 also urinates and defecates on the floor in many other areas of the nursing facility including the hallways and the dining room. LPN2 said R32 was not easily redirected and displayed combative behaviors when an attempt was made to redirect him from unsafe wandering and wandering into other resident rooms. LPN2 stated R32 constantly removed food from other residents' rooms, from staff lunch bags, and from resident food trays during meal service. She stated that R32 wandered independently without one-to-one supervision. Review of R32's EMR, Progress Notes tab, nursing progress notes, revealed R32 wandered around disrobing inappropriately, urinating and defecating on the floor throughout the facility and in other resident rooms, taking other residents' belongings, removing food from resident rooms and from meal trays during meal service, and attempting to bite staff upon redirection, on 04/12/25, 03/17/25, 03/13/25, 01/30/25, 01/25/25 , 01/07/25, 12/31/24, 12/24/24, 12/18/24, 12/17/24, 12/16/24, 12/13/24, 12/11/24, 12/10/24, 12/02/24, 11/30/24, 11/27/24, 11/16/24, and 11/01/24. Observation of R32 on 04/27/25 at 7:30 AM identified R32 was sleeping in his bed and appeared clean and dry with no evidence of discomfort. Observation of R32 on 04/28/25 at 11:00 AM identified R32 sitting in the activity room with a staff member with his head lying on the table with staff member stroking his back. R32 did not respond to verbal interaction. Observation of R32 on 04/28/25 at 4:00 PM identified R32 sitting in the activity room with a staff member with his head lying on the table with a staff member stroking his back. R32 did not respond to verbal interaction. R32 was discharged to the hospital on [DATE] at 9:00 PM and was not present in the facility for additional observations during the survey. During a resident council meeting conducted by a surveyor on 04/28/25 at 2:30 PM, R69 reported that R32 came into her room a few weeks ago during the night and turned the light on and asked her for a cookie. R3 stated R32 has come into his room, put his hand on his face, and woke him up during the night. R27 stated the facility usually has two certified nurse aides at night and they just can't keep up with him, and that [R32] urinates and defecates anywhere he wants and has gotten outside a couple of time by pushing his way through the door.

Based upon observations and interviews, the facility failed to post the daily staffing report in a prominent place accessible to all residents and visitors. This failure had the potential for residents, family, friends, or other visitors to not know the ratio of nursing staff to residents, causing uncertainty of the ability and availability of the staff for residents' needs. Findings include: Observations on 04/28/25 at 9:56 AM and at 12:46 PM of the facility revealed no staffing report posted in the facility. Interview on 04/28/25 at 4:18 PM with the Administrator regarding the staffing posting, the Administrator took this surveyor to an area that was the employee entrance only. At the entrance, there was a bulletin board with announcements for staff. On that board was the staffing posting. The Administrator acknowledged that the staffing posting was not visible to the resident's family, friends, or other visitors.

Based on interviews and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's Brief Interview for Mental Status (BIMS) for one of 24 sampled residents (Resident (R) 51). The failure placed the resident at possible unmet needs. Findings include: Review of R51's undated admission Record, located in the resident electronic medical record (EMR) under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with a diagnosis that included, chronic obstructive pulmonary disease with (acute) exacerbation, major depressive disorder, single episode, moderate and anxiety disorder, unspecified. Review of R51's quarterly MDS with an Assessment Reference Date (ARD) of 05/12/24 located in the resident's EMR under the MDS tab, revealed the BIMS score of 13 out of 15, indicating cognitively intact. An annual MDS with an ARD of 07/29/24 revealed a BIMS score of 00 out of 15, which indicated severely impaired cognition A quarterly MDS with an ARD of 10/23/24 revealed a BIMS score of 15 out of 15, which indicated intact cognition. A quarterly MDS with an ARD of 01/17/25 revealed a BIMS score of 00 out of 15, which indicated severely impaired cognition. A quarterly MDS with an ARD of 04/14/25 revealed a BIMS score of 15 out of 15, which indicated R51 was cognitively intact. During an interview on 04/28/25 at 6:09 PM with the Minimum Data Set Coordinator (MDSC), about the accuracy of R51's BIMS, the MDSC was unable to give any rationale for why the scores were so different. During an interview on 04/28/25 at 6:28 PM at the Administrator, verified that the BIMS scores of R51 were incorrect. The Administrator stated that the Social Service Director (SSD), who completes the BIMS score, was not coding 1x, which would capture the refusal to answer instead of unable to answer. During an interview on 04/29/25 at 3:39 PM, the SSD stated I was doing the score incorrectly when the resident refused to respond. I have been in-service on the appropriate way to document the refusal. R51 at times would refuse to answer questions for the assessment, and I would make a 0 instead of a 1x that would capture refusal instead of being unable to answer.

Based on manufacturer's recommendations, observations and interviews, the facility failed to ensure an excessive amount of lint was removed from 2 of 2 clothes dryers, which has the potential to cause a fire. Findings include: Review of the manufacturer's recommendations for the clothes dryers, titled, Important Safety Instructions, states under number 12. Always clean the lint filter daily. Number 13, states, Keep area around the exhaust opening and adjacent surrounding area free from the accumulation of lint, dust, and dirt. During an observation on 09/19/23 at 3:10 PM, of the laundry room revealed 2 of 2 clothes dryers with an excessive amount of lint in the lint basket, on all 3 upper sides of the clothes dryer, and on the wiring. During an interview on 09/19/23 at 3:10 PM, Laundry Worker (LW)1 stated, when brought to her attention, we only keep the floor of the dryer clean, maintenance cleans around the wiring and the upper insides of the dryers. During an interview on 09/19/23 at 3:30 PM, the Housekeeping Supervisor stated that Maintenance cleans the wiring over the lint basket and upper insides of the dryers, and the backs of the dryers. During an interview on 09/19/23 at 3:45 PM, the Maintenance Director, provided a check off sheet where occasionally he cleans the inside of the dryers from lint.

Based on review of the facility policy, observations and interviews, the facility failed to ensure that food was properly stored and labeled in 2 of 2 unit nourishment rooms. Findings include: Review of the facility policy titled Labeling, Dating, and Storage revised 11/11/22 revealed, It is the policy of PruittHealth for all partners who assist in handling, preparing, serving, and storing food and beverage items follow the proper procedures for labeling, dating and storage to ensure proper food safety. During an observation and interview on 09/18/23 at approximately 9:35 AM, the [NAME] Wing nourishment room refrigerator revealed that it was empty and unplugged from electrical outlet with an unopened 8 ounce container of whole milk sitting on counter which was warm to touch and labeled by manufacturer Keep refrigerated 33 degrees F (Fahrenheit) - 48 degrees F. These findings were confirmed on Certified Nursing Assistant (CNA)6 who stated she did not know why the refrigerator was unplugged. Further observation of the [NAME] Wing nourishment room on 09/18/23 at approximately 9:48 AM revealed the following: two clear, hand knotted, approximately 4 x 4 inch plastic bags containing an unidentified light brown colored chips, not properly labeled. A snack box located beside the refrigerator and one large opened bag of Blue Ribbon brown rice, inside a zip lock bag, not properly labeled. These findings were confirmed by Licensed Practical Nurse (LPN)6. During an observation on 09/18/23 at approximately 9:55 AM, the Palmetto Wing nourishment room was unlocked with wandering residents nearby and the refrigerator door identified as NOURISHMENT REFRIGERATOR'S with a statement which read: .Resident's personal foods may be stored (space permitted) if 1. The item is labeled with resident's name and the item is dated. Labels are available with the temperature log. NO STAFF PERSONAL ITEMS ARE ALLOWED IN THESE REFRIGERATOR'S: PLEASE USE THE REFRIGERATOR IN THE BREAK ROOM . and included a handwritten noted which stated please put 3 day date if you have anything in here. There was a Food Refrigerator Freezer Temperature Log labeled Palmetto Nourishment Refrig which showed that it was not being consistently checked each AM (morning) and PM (evening) temperatures as specified on the log. The refrigerator contained one container of a thick orange liquid in clear plastic cup which was not properly labeled, one plastic bag containing a Styrofoam clam shell container which was not properly labeled. Observation of the refrigerator freezer compartment revealed one large unidentified Styrofoam cup with a straw, which contained a frozen brown liquid not properly labeled, one unopened container of TGI (thank goodness it's) Friday Loaded Potato Skins not properly labeled, one opened container of [NAME] Strawberry Cheesecake ice cream not properly labeled, one unopened frozen cone of Blue Bunny Vanilla ice cream not properly labeled, one plastic bag containing a frozen bread-like material which was not properly labeled, and one opened and eight ounce container of Diet Shasta Ginger Ale not properly labeled. Further observation of the Palmetto Wing cabinets and counter top revealed one green plastic container with lid containing a multi-colored fruit loop like substance which was not properly labeled. During an interview on 09/18/23 at approximately 10:11 AM, these findings were confirmed by CNA5 who proceeded to discard the unidentified thick orange liquid in the sink.

Based on observations, interviews, record reviews and reviews of facility policy and procedure the facility failed to ensure prompt and thorough incontinent care was provided for two Residents (R)6 and R62. Furthermore, the facility failed to ensure R33 received baths for 3 of 5 residents reviewed for Activities of Daily Living (ADLs). Findings Include: Review of facility procedure guide titled Elimination and Toileting: Incontinence Prevention revealed, manage incontinence according to the client's care plan not for staff convenience. Furthermore Providing Peri-Care states urine and feces are very irritating to the skin and mucous membrane and will cause irritation and breakdown if not thoroughly and promptly removed. Review of the undated facility policy titled, Documentation: Charting Activities of Daily Living (ADLs) states, It is required for Activities of Daily Living (ADL) care given by a Certified Nursing Assistants and Nurses to be documented under Care Assist in patient's/resident's Electronic Health Record (EHR). For all healthcare centers not utilizing EHR, all documentation will be completed using the CNA ADL Flow Sheet Form. Review of R6's Face Sheet revealed R6 was admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's disease, dysphagia, dementia, moderate protein calorie malnutrition and type 2 diabetes. Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/23 revealed a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating R6 was severely cognitively impaired. During an observation on 09/17/23 at 11:55 AM revealed, R6 was laying in a urine-soaked bed without an absorbent pad underneath. R6 appeared to be wearing a visibly soaked tee shirt. During an observation on 09/18/23 at 9:41 AM revealed, R6 again lying in urine-soaked linens and clothes. Review of R62's Face Sheet revealed R62 was admitted to the facility on [DATE] with diagnoses including but not limited to: dementia, vascular dementia with behavioral disturbances, type 2 diabetes, acute cerebrovascular insufficiency, weakness and difficulty walking. Review of R62's annual MDS with an ARD of 06/28/23 revealed a BIMS score of 10 out of 15 indicating R62 was moderately cognitively impaired. During an observation on 09/17/23 at 11:55 AM revealed, R62 was sitting in bed and the sheets appeared to be covered in dried feces. A strong unpleasant odor was emanating from the room. During an interview on 09/17/23 at 12:05 PM, R62 stated that someone had been in his room that morning and stated that they would return to get him cleaned up but they never came back. During an observation on 09/18/23 at 9:41 AM revealed, R62 lying in a urine-soaked bed with a puddle of urine under his bed and on both sides of the bed, with a foul odor coming from the room. During an interview with on 09/17/23 at 12:25 PM, Certified Nursing Assistant (CNA)4 stated that this was her first time rounding and that she was unsure when the night shift had last rounded on the residents. CNA4 further stated that she had begun her shift at 7:00 AM but that there were only three staff members to care for the residents on this hall. During an interview on 09/18/23 at 10:07 AM, Licensed Practical Nurse (LPN)5 stated that she makes the CNAs schedule and normally has it posted by 6:30 AM, if there are no changes to be made. Furthermore, LPN5 states that CNAs are to make rounds on residents soon after getting a report from previous staff and then every two hours. During an interview on 09/19/23 at 3:28 PM, the Director of Health Services (DHS) states that he was unaware that residents did not receive proper ADL and incontinence care on 09/17/23. The DHS also states that it is his expectation that residents are cleaned in a timely manner and rounded on appropriately. 31846 Review of R33's Face Sheet revealed, the facility admitted R33 with diagnoses including, but not limited to: anoxic brain damage, hallucinations, repeated falls, muscle weakness, lack of coordination ad communication deficit. During an observation on 09/17/23 at 11:20 AM, revealed R33 laying in bed. R33's hair was not clean and the resident was wearing a hospital gown. The hospital gown had dried food on the chest area of the gown and R33 had food around her mouth. Review on 09/19/23 at 2:11 PM of the documentation for R33's bathing revealed in June 2023, R33 did not receive a bath on 06/01/2023, 06/02/2023, 06/03/2023, 06/05/2023, 06/06/2023, 06/07/2023, 06/09/2023. Also R33 did not receive any type of bath on 06/10/2023, 06/11/2023, 06/14/2023, 06/18/2023, 06/19/2023, 06/20/2023, 06/25/2023 or 06/28/2023. In July 2023, R33 had no documentation to ensure she received a bath on 07/02/2023, 07/03/2023, 07/04/2023, 07/09/2023, 07/10/2023, 07/12/2023, 07/17/2023, 07/21/2023, 07/23/2023, 07/25/2023, 07/26/2023 and on 07/31/2023. Furthermore, for the month of August 2023 R33 did not receive a bath of any type on 08/02/2023, 08/04/2023, 08/05/2023, 08/06/2023, 08/07/2023, 08/08/2023, 08/09/2023, 08/10/2023, 08/15/2023, 08/16/2023, 08/18/2023, 08/20/2023, 08/22/2023, 08/23/2023, and 08/24/2023. Further review of the documentation for baths revealed in September 2023, R33 was not documented as receiving a bath on 09/02/2023, 09/07/2023, 09/08/2023, 09/14/2023, 09/16/2023 and 09/17/2023. During an interview on 09/19/23 at 3:04 PM, the Director of Nursing (DON) offered no reasoning for the missed baths and stated it just may be the documentation was not done.

Based on record reviews and interviews the facility failed to implement and/or develop a comprehensive plan of care for Resident (R)33, R44 and R41 for 3 of 6 residents reviewed for care plans. Findings include: The facility admitted R33 with diagnoses including, but not limited to anoxic brain damage, cognitive communication deficit, and pseudobulbar affect. Review of R33's comprehensive plan of care dated 07/21/22 revealed a problem that states, Resident is limited in ability to take showers due to past history of abuse. Resident should only take bed baths. The long term goal is, Resident will be bathed only by bed baths. The approach dated 07/21/22 states, Monitor for presence of pain/intolerance during grooming/personal hygiene and signs of discomfort. Review of a form titled Point of Care ADL Report for the months June, July, August and September revealed R33 did not receive a bath daily, however R33 did receive a shower for 18 days. On 09/19/23 at 3:15 PM when brought to the attention of staff no additional information was provided as to why R33 was receiving showers. The facility admitted R44 with diagnoses including, but not limited to, malignant neoplasm of the prostate, major depressive disorder, dementia with behavior disturbance and chronic pain. Review of R44's activity attendance from 06/19/23 through 09/19/23 revealed R44 attended choir practice on 08/09/23 and on 08/21/23 R44 received a hair cut, shave and shampoo. No other activities were documented for June, July, August or September. Review of R44's comprehensive plan of care dated 11/07/19 under the category of activities states, He needs to be invited and assisted to activities of interest. He enjoys TV, music, singing, football and outside activities. The goals stated, Allow his preference of independent activities of choice through next review. Resident will attend group activities twice, weekly through next review. The interventions state, Staff will discuss with resident the monthly calendar to see which planned activities interest him and then remind him when scheduled. Resident has declined all group invitations. Will continue to invite and encourage participation. Invite and assist to activities of interest. During an interview on 09/20/23 at 11:40 AM the Activity Director stated that she is only one person and she has not invited him to activities as much as she should have. 48810 Review of R41's Face sheet indicated the facility admitted R41 with diagnoses including but not limited to, schizoaffective disorder and bipolar type. Review of R 41's medical record indicated a diagnosis of schizoaffective disorder, dated 07/03/21. Review of R41's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/21, revealed R41 had a Brief Interview for Mental Status (BIMS) score of 9 our of 15, which indicated R41 had moderate cognitive impairment. R41 required extensive assistance with bed mobility and toileting. R41 required limited assistance with transfers and required supervision with meal setup. Review of 41's comprehensive care plan, revealed no Care Plan to address R41's diagnosis of Schizophrenia. During an interview on 09/20/23 at 11:07 AM, the MDS Coordinator stated that she was not aware of R41's mental illness and she was not aware of R41 not being care planed for the mental illness. The MDS Coordinator stated that the resident's mental illness could go untreated if the resident is not care planned for the mental illness. During an interview on 09/20/23 at 12:04 PM, the Administrator stated that he expected all major mental illness to be care planned so that the resident can be treated correctly with medications or referrals to psychiatry.

Based on interviews and record reviews, the facility failed to ensure that Resident (R)41 had an accurate level-1 Preadmission Screening and Resident Review (PASARR) assessment for 1 of 3 residents reviewed for PASARR. Findings include: In an interview on 09/20/23 at 10:00 AM, the Director of Health Services (DHS) stated that the facility did not have a policy for assuring PASSARs are completed accurately. The DHS stated that they follow state regulations and he expects PASSARs to be completed correctly and accurately. The DHS further stated that the documents should be done prior to the resident coming into the facility and that Social Services is responsible for the accuracy of the PASSARs and making sure that all diagnosis and major mental illnesses are listed on the PASSAR once the resident is in the facility. A review of R41s Face sheet indicated the facility admitted R41 with a diagnosis that included schizoaffective disorder, bipolar type upon admission. A Review of R41's admission Minimum Data Set (MDS), with an Assessment Reference Date of 07/09/21, revealed R41 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R 41 had moderate cognitive impairment. Further review of the MDS revealed R41 had an active diagnosis of Schizophrenia. A review of R41's Medical Record indicated a diagnosis of schizoaffective disorder, dated 07/03/21. A review of R41's Level-1 PASARR dated 07/02/21, indicated R41 did not have a mental illness. Psychotropic Drugs Prescribed to the resident, listed on the Level-1 PASSAR included Restoril 30 milligrams (mg) by mouth (PO) at bedtime and Xanax .5mg every (Q) 8 hours. During an interview on 09/20/23 at 10:08 AM, Social Services stated that the admissions director should make sure that the PASSAR are completed and accurate. She stated that she is not trained to do PASSARs yet, therefore she is unable to touch PASSARs. She stated that she was unaware of R41's PASSAR not being updated with a mental illness of Schizophrenia upon admission. She stated that a possible outcome if the PASSAR is not completed correctly is that the resident will not receive the correct care. She stated that she expects the PASSARs to be completed correctly and the resident to be treated correctly. During an interview on 09/20/23 at 11:07 AM, the MDS Coordinator stated that she does not update the PASSAR. She stated that she looks to see if they have one. She stated that she does reports in the morning meetings if one is missing. She stated that she was not aware of R41's mental illness upon admission. During an interview on 09/20/23 at 12:04 PM, the Administrator stated that he expected PASSARs to be completed and accurate.

Based on review of facility policy, observations, interviews and record review, the facility failed to ensure Resident (R)26 was free from potential entrapment of bedrails for 1 of 1 residents reviewed for bedrails. Findings include: Review of a facility policy titled, Bed Rails with a revised date of 02/01/18, documented, Policy Statement: As further described in this policy, prior to using bed rails, the risk of doing so for a particular patient should be evaluated by appropriate staff of the healthcare center (as described herein) and discussed with the patient and/or the patient's representative. Scope: This policy applies to the healthcare center nursing staff. Definition: Bed rails (also referred to as side rails) are adjustable metal or rigid plastic bars that attach along the side of a patient's bed for the purpose of preventing a patient from falling out of the bed or for assisting a patient independently to turn or maneuver themselves in the bed. Bed rails are available in a variety of types, shapes, and sizes, ranging from full, to one-half, one-quarter, or one-eighth lengths of a bed. While some bed rails are designed by a manufacturer as a component part of a patient bed, others are not, and may be installed along the side of a bed. Entrapment is an event in which a patient is caught, trapped, or entangled in the space in or about a bed rail. Procedure: 3. Prior to installing or using bed rails on a patient's bed, the patient should be assessed by the admitting nursing and/or the inter-disciplinary team (IDT) to determine whether the use of bed rails would constitute an enabler or a restraint for the patient. All factors of a patient's functional ability should be taken into consideration when making this determination. When it has been determined by the admitting nurse and/or IDT that bed rails are medically necessary for a patient's care the following procedures should be followed prior to their use: 1. The patient and/or the patient's representative should be educated on the proper use of bed rails as well as the risks of using bed rails, which should include, but not be limited to, the risk of entrapment. 2. The nurse should complete the initial/annual observation for physical device form in determining whether the bed rails should be considered an enabler or a restraint for the patient. 3. A partner from the Maintenance Department should examine the bed and determine that the dimensions of the bed are appropriate for the patient and confirm that the bed rails to be installed or used, by raising the bed rails if the bed rails are a component part of the bed), are appropriate for the size and weight of the patient using the bed. In addition, this partner will confirm that the manufacturer's instructions have been followed to ensure a proper fit and that the bed rails are in proper working order. 4. The nursing and maintenance staff should regularly inspect the mattress and bed rails for areas of possible entrapment. A review of R26's Face Sheet indicated the facility admitted R26 with diagnoses including but not limited to: Alzheimer's disease, syncope and collapse, muscle weakness, unsteadiness on feet, repeated falls, contracture, left hand-post left wrist fracture, abnormalities of gait and mobility, and anorexia. Review of R26's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/23, revealed R26 had a Staff Assessment for Mental Status (SAMS) score of 3, indicating that R26 is severely impaired for cognitive skills for daily decision making. R26 required limited assistance with bed mobility, extensive assistance with transfer, eating, and toileting and totally dependent on staff for bathing. Review of R26's Care Plan, initiated 07/30/19, revealed R26 is total care and requires assistance with Activities of Daily Living (ADL) functions per staff with interventions that included 1/4 side rails for turning and repositioning to assist with bed mobility. Review of R26's Physician Orders, for the month 08/2023, revealed an order, dated 05/05/22 for 1/4 side rails for turning and repositioning. Review of Joerns Bed Frames UltraCare XT, the manufacture's guidelines for the bedrails/bedframe revealed Warning: Possible Injury. Improper installation could result in the pendent holder producing a hazard by protruding from the bed. Carefully follow all installation and user instructions. Failure to do so could result in injury or death. Head End Mattress Side Stop 1. Mattress Side Stop is designated to help keep mattress from sliding laterally on the mattress support platform. Please read important warnings related to Mattress Side Stop and follow all instructions below, prior to use. 3. Replace mattress, making sure mattress fills width between stops. Review of consent for the use of bed rails, signed by R26's Representative (RP), dated 04/06/22, revealed R26's RP's signature of consent for the use of bed rails. During an observation on 09/17/23 at 12:25 PM, R26 was observed in bed lying on their right side in a fetal position, R26 was sucking their thumb and mumbling to self. R26's bed rails were observed with approximately 6 gap between the mattress and bedrail. R26's head was leaning against the bed rail with the corner of a white pillow tucked partially between the mattress and bed rails. During an interview on 09/19/23 at 2:23 PM, the Director of Health Services (DHS) stated that they did not have a bed evaluation for R26. During an interview on 09/19/23 at 1:22 PM, Registered Nurse (RN)6 (the resident's hospice nurse) stated that the resident is unable to move themselves. RN6 stated that the resident is seen by hospice two times weekly. During an interview on 09/17/23 at approximately 12:30 PM, the DHS stated that there was a gap between the mattress and the bed rails. He stated that it was unsafe for the resident. The DHS also stated that it could potentially become an entrapment hazard for the resident. During an interview on 09/20/23 at 12:04 PM, the Administrator stated that he expected a bed assessment to be completed on all residents for the safety use of bedrails before the resident was placed in the bed. The Administrator further stated that he also expected a consent to use the bedrails be signed by the resident or the residents RP before use. The Administrator stated that he expects the bedrails to be properly fitted and placed on the bed and for all residents to be free from entrapment with the use of bedrails.

Based on review of facility policy, record reviews, observations, and interviews, facility failed to ensure that the enteral feeds for Resident (R)6 were running at the correct rate, was properly labeled, and properly connected for 1 of 1 resident reviewed for tube feeding. Findings Include: Review of the facility procedure guide titled Enteral tube feeding, duodenal and jejunal dated 11/18/20 in the Preparation of Equipment section states, Make sure the enteral formula is labeled clearly with patient identification information, the type of formula, the method of administration, the date and time of preparation, and the name of the person preparing the formula (If appropriate). Verify the enteral formula label with the practitioner's order. Furthermore, the implementation Section states, Trace the tube from the patient to its point of origin to make sure it's connected to the proper port before beginning the tube feeding. Review of R6's Face Sheet revealed R6 was admitted to the facility on [DATE] with diagnoses including: Parkinson's disease, dysphagia, dementia, moderate protein calorie malnutrition and type 2 diabetes. Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/23 revealed a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating R6 was severely cognitively impaired. Review of R6's Physicians Orders dated 03/14/23 states Jevity 1.2 @ 75 ml/hr. x 22 hours per day off at 4 am and back on at 6 am. During an observation on 09/17/23 at 11:55 AM, revealed R6's tube feed was observed without a date, time or initials. During an observation on 09/18/23 at 9:41 AM, revealed R6's tube feed was observed without a date, time or initials During an interview on 09/19/23 at 3:58 PM, the Director of Health Services (DHS) stated that it is his expectations that his staff verify tube feed rates when beginning their shift with the previous nurse and that nurses are responsible for managing and maintaining residents tube feeds. During an observation on 09/19/23 at 10:37 AM, revealed R6 lying in bed, with Jevity tube feed running at 80 milliliters (mls)/hour(hr.), furthermore R6's tube feed was not properly connected and was leaking out onto his bed and shirt, and was not properly labeled. During an observation on 09/20/23 at 7:54 AM, revealed R6 lying in bed, with Jevity tube feed running at 80mls/hr. During an interview on 09/20/23 at 7:57 AM, Registered Nurse (RN) 3 stated that typical tube feed rates are verified with the previous shift nurse and that she had not verified the rate or had she been in the resident room to check his tube feed rate. During an interview on 09/20/23 at 8:54 AM Licensed Practical Nurse (LPN)2 stated that she was responsible for ensuring R6's tube feed was started at 6 am. LPN 2 states that R6's tube feed should be turned off at 4:00 AM for 2 hours and restarted at 6 AM at 75mls/hr. LPN 2 was unable to provide a reason as to why R6's feed was running at an incorrect rate at 80 mls/hr.

Based on record reviews, observations, interviews and medical literature in Facts and Comparisons, Epocrates and Drugs.com, the facility failed to coordinate psychiatric care for Resident (R)67 with LifeSource, Inc. for 1 of 6 residents reviewed for unnecessary medications. Findings include: Review of R67's Face Sheet revealed R67 was admitted to the facility on [DATE] with diagnoses including but not limited to schizophrenia and dementia. A review of January - September, 2023 progress notes for R67 revealed the Consultant Pharmacist stated Medication regimen reviewed for problems an/or irregularities, Recommendation made. on 01/30/23, 02/20/23, 03/29/23, 04/16/23, 05/16/23, 06/21/23, 07/22/23, 08/6/23 and 09/15/23. Further review of the progress notes revealed an entry dated 08/16/23 related to CMS-F757: Duplicate Antipsychotic Drugs which stated This patient is currently receiving duplicate antipsychotic drugs Quetiapine 400mg (milligram) BID (twice daily) and Brexpiprazole 1mg QD (daily). The typical treatment pathway is to maximize the dose of a single agent prior to adding a second drug. Consider tapering to D/C (discontinue) Brexpiprazole and may increase the Quetiapine if needed. The recommendation further included specific recommendations for action. During an interview on 09/19/23 at 2:22 PM the Medical Director (MD) stated that the resident is being seen by a psychiatric service and the facility places the orders for psychotherapeutic agents made by the psychiatric service under his name. He did not recall seeing pharmacist recommendations made on 08/16/23 related to duplicate antipsychotic drugs Seroquel and Rexulti for R67 and was unaware of a potential need for blood pressure monitoring. During an interview on 09/19/23 at 2:32 PM, the Administrator stated that psychiatric services are provided by LifeSource and that the Social Services Director enters their orders into the computer system under the Medical Director's name. When asked to whom at the facility pharmacist recommendations are given to, he stated to the Director of Nursing (DON) and that he would have the DON come see me. During an interview on 09/19/23 at approximately 3:40 PM, the DON stated he was unaware of a pharmacist recommendation made on 08/16/23 related to duplication of therapy related to two antipsychotic drugs (Seroquel and Rexulti) for R67 and was unaware that LifeSource orders for Seroquel and Rexulti had been faxed to the pharmacy with the Medical Director as the prescriber, not LifeSource. The DON stated that the Medical Director defers to LifeSource when it comes to prescribing psychiatric medications. Stated he would provide a copy of policy and procedures related to LifeSource and its recommendations/orders and handling of pharmacist recommendations and would provide copies of all other pharmacist recommendations. During an interview on 09/20/23 at approximately 9:30 AM, the DON was unable to provide copies of other recommendations made by the Consultant Pharmacist or a copy of the requested policy and procedure related to LifeSource.

Based on record reviews and interviews, the facility failed to ensure Resident (R)44 was afforded the opportunity to participate in activities of choice and further failed to ensure R44 was invited to out of room activities related to his preferences and interest for 1 of 4 reviewed for activities. Findings include: Review of R44's Face Sheet revealed, the facility admitted R44 with diagnoses including, but not limited to, cognitive deficits, difficulty walking, anemia, bradycardia and psychosis. Review of R44's activity attendance sheets for 06/20/23 through 09/19/23, revealed R44 was included in choir practice on 08/09/23 and on 08/22/23 R44 had his hair cut and shampooed, and was shaven and received a massage. No other activities were documented on the attendance sheets for the 3 month period. Review on 09/19/23 at 4:00 PM of the Comprehensive Plan of Care for R44 included independent activities and watching TV, music, singing, football and outside activities. No documentation was found in the medical record to ensure R44 was invited to any activities that he may have enjoyed. During an interview on 09/20/23 at 10:42 AM, the Activity Director stated that she had not invited R44 to any activities.

Based on review of the facility policy, observations and interviews, the facility failed to follow a procedure during wound care for Resident (R)21 to prevent infection and to promote wound healing for 1 of 4 residents reviewed with pressure ulcers. Findings include: Review of the undated facility policy titled, Procedure: Guidelines for Cleansing and observing a Wound, states, in the procedure, 7. Gently clean the wound with the ordered cleanser or normal saline. 8. Work from clean areas to less clean areas. 9. To cleanse an injury or pressure ulcer, work in half circles or full circles, beginning in the center of the wound and working outward. Cleanse the skin at least one inch beyond the edge of the dressing. Use a new sponge for each circle. 10. Avoid rubbing back and forth. Rinse using the same technique. 11. Use each gauze sponge once, then discard it. Review of R21's Face Sheet revealed the facility admitted R21 with diagnosis including, but not limited to pressure ulcers. Review of R21's physician's order stated, Cleanse wound with wound cleanser, pat dry, apply medihoney and then calcium alginate 3 times weekly and cover and secure. During an observation of wound care on 09/19/23 at 10:40 AM, for R21 by Licensed Practical Nurse (LPN)1 revealed the following: LPN1 knocked on the door and R21 invited us in. LPN1 explained the procedure to R21. Neither LPN1 or the Certified Nursing Assistant (CNA) washed their hands. The CNA applied gloves, and LPN1 cleansed her hands with hand sanitizer from a dispenser inside the resident's room. LPN1 applied a pair of gloves. The CNA raised the bed, and LPN1 removed the tape from the resident's brief, opened the brief and the CNA and LPN1 positioned R21 onto his right side facing the wall ensuring that R21 was over far enough using the draw sheet to assist him over. LPN1 removed the soiled dressing which was observed with a moderate amount of drainage. LPN1 then removed her gloves and cleaned her hands with hand sanitizer and then applied gloves. LPN1 then opened a drape over the over bed table and proceeded to open the gauze and then sprayed them with wound cleanser and took several in hand and rubbed across the wound going back and forth across both wounds several times using the same wound cleanser soaked gauze. LPN1 then removed her gloves and cleansed her hands with sanitizer, applied gloves, she then opened the medihoney and squeezed a large amount onto a 2x2 gauze and rubbed the 2x2 of medihoney onto one wound and then the other wound using the same 2x2 gauze of medihoney. LPN1 then opened a 4x4 square of Maxorb II, Alginate and placed the entire sheet over the 2 wounds and then covered the wounds with a foam dressing. LPN1 then took a marker and wrote the date, time and her initials on the outer dressing. LPN1 then aided the CNA in ensuring the resident was comfortable and then she removed her gloves and cleansed her hands before leaving R21's room. During an interview on 09/19/23 at 11:00 AM, LPN1 confirmed that she had used the same 2x2 soaked gauze with wound cleanser and cleaned back and forth across both wounds.

Based on record reviews and interviews, the facility failed to ensure a quarterly, Minimum Data Set (MDS) assessment for Resident (R)54 was coded correctly for dialysis for 1 of 1 residents reviewed for Dialysis. Findings include: The facility admitted R54 with diagnoses including, but not limited to, diabetes mellitus type 2, gastroparesis and end stage renal disease. R54 is dependent on hemodialysis and is scheduled for it on Mondays, Wednesdays, and Fridays. Review on 09/18/2023 at 11:30 AM of the quarterly MDS dated [DATE] revealed section O for special treatments, procedures and programs was not coded for dialysis for R54. During an interview on 09/18/2023 at 11:45 AM with Licensed Practical Nurse (LPN)6 reviewed and confirmed that dialysis was not coded on the quarterly MDS.

Based on record review and interviews, the facility failed to ensure Resident (R)54 with decisional capacity to make his own health care decisions was afforded the right to formulate an advance directive for 1 of 1 residents reviewed for Advance Directives. Findings include: The facility did not provide the policy for Advance Directives. The facility admitted R54 with diagnoses including, but not limited to, end stage renal disease, falls, hypertension and glaucoma. Review of the Minimum Data Set (MDS) assessment dated at the time of admission revealed a Brief Interview for Mental Status (BIMS) is score of 15 out of 15, indicating R54 was cognitively intact. Record review on 09/19/23 at 11:42 AM revealed a form titled, Decisional Capacity, dated 04/05/2023. The physician checked the box which states, This resident DOES have the capacity to make healthcare decisions for self. Further review of the medical record on 09/19/23 at 11:42 AM revealed a form titled, Intro to Admission. The form identified an admission to another facility, in another town, and was signed by the family member for R54. The form did not mention the current facility that R54 is a resident of and the representative's relation to R54 is unknown. The section titled, Patient/Resident Signature (to be signed by Patient/Resident only), was not signed by R54. During an interview on 09/19/23 at 11:55 AM with Social Services, she provided the document of Intro to Admission, and stated that the consent for the family member to sign was verbal. During an interview on 09/19/23 at 1:42 PM, the Director of Nursing stated the consent was verbal and went on to say that the resident may have been too sick to sign the form at the time of admission.

Based on review of facility policy, record review, and interviews, the facility failed to ensure Resident (R)54 and her representative received notice of transfer or discharge in writing and in a language they could understand, and the reason for transfer, for 1 of 5 residents reviewed for hospitalization . Findings include: Review of the facility policy titled, Involuntary Transfers and Discharges, revealed under section III, Required Notice Before Involuntary Transfer or Discharge, Number 1 states, The healthcare center must provide notice to the patient, guardian, or representative, and the patient's physician in writing and language that they understand. The facility must keep a copy of the notice in the medical record. The facility admitted R54 with diagnoses including, but not limited to, endstage renal disease, congestive heart failure, atrial fibrillation, acute myocardial infarction, depression and anxiety. Review of R54's medical record on 09/18/23 at 11:42 AM, revealed a form titled, SNF/NF to Hospital Transfer Form filled out, but no documentation to ensure R54 or R54's representative received a copy of the form. Further review of the form revealed, no signatures or indication that the reason for transfer was explained to the resident or the representative. There is no signature as to who filled out the form, or who received a copy of the form. Further review of the medical record for R54 revealed an additional hospital transfer on 05/29/23, with no signature as to who filled out the form, or who received a copy of the form. During an interview on 09/18/23 at 12:20 PM with the Director of Nursing (DON) stated that he would have to check for additional information. The DON provided no further information concerning the hospitalization for R54.

Based on record reviews, observations, interviews and review of the medical literature in Facts and Comparisons, Epocrates and Drugs.com, the facility failed to ensure Resident (R)67 did not have multiple drug therapies that could cause central nervous system depression for 1 of 6 residents reviewed for unnecessary medications. Findings include: Review of R67's Face Sheet revealed R67 was admitted to the facility on [DATE] with diagnoses including but not limited to schizophrenia and dementia. A review of R67's physician orders by the Medical Director (MD) revealed the following orders: Trazodone (an antidepressant) 50 mg (milligram) at bedtime prescribed 01/19/23 open ended (no end date) for insomnia. Melatonin 3 mg x2 at bedtime prescribed 01/24/23 open ended for insomnia. Hydrocodone - acetaminophen 5-325 mg twice daily PRN (as needed) prescribed 02/10/23 open ended for pain, do not exceed 2 per day. Memantine 10 mg twice daily prescribed 04/04/23 open ended for dementia. Seroquel (quetiapine 400 mg) twice daily prescribed 08/03/23 open ended for vascular dementia with behavioral disturbance/Schizophrenia. Rexulti (brexpiprazole) 1 mg once daily prescribed 08/11/23, open ended for Schizophrenia. Depakote (divalproex) Sprinkles 250 mg once daily and 125 mg at bedtime both prescribed 08/14/23 open ended for Mood. Further review of the physician orders failed to find an order for monitoring of vital signs. A review of R67's progress notes dated 03/21/23 at 7:50 PM revealed, resident was in an altercation resident found aggressive toward her roommate. resident did not sustained any injury. A review of R67's progress notes revealed Psychiatry/LifeSource notes were being entered into the medical record progress notes 2-15 days after the date of the visit as follows: -Psychotherapy Comprehensive Clinical Assessment performed on 04/07/23 and R67 found not to be appropriate for CBT (cognitive behavioral therapy) due to her cognitive decline and inability to hold a conversation and entered into the medical record (EITMR) on 04/13/23. -04/20/23 LifeSource Service(s): Discharge Summary which stated A comprehensive psychological assessment of the resident took place on April 7, 2023. The final treatment plan was dated and patient was last seen on April 7, 2023. Discontinue psychotherapy services only . EITMR 04/25/23 -04/24/23 Psychiatry Initial Visit with recommendations/plan to Start Depakote 20 mg po QHS (at bedtime), EITMR 04/26/23 -06/19/23 with recommendation/plan, Patient continues to exhibit behaviors as documented in HPI (history of present illness) section; recommend increasing Depakote to 250 mg po BID x 3 days, then Dose should be Depakote 250mg po qd and Depakote 500 mg po QHS. Increase seroquel to 400 mg po BID (twice daily) (max dose is 800 mg a day), EITMR 07/05/23 -07/31/23 with recommendations/Plan Start rexulti 0.5 mg po x 7 days then increase to 1 mg po daily., EITMT 08/14/23 and -08/31/23 with no recommended changes to current dose of medication. EITMR 9/7/23 During an observation on 09/17/23 at approximately 11:18 PM and 12:15 PM, R67 was in room with door open laying on the bed, bed in a low position. R67 was wrapped in sheet/blanket, laying in the fetal position near foot of bed. R67 had no response to questions and only made an occasional sound. There were no staff members noted on that hall. During an observation on 09/18/23 at approximately 9:26 AM, 10:35 AM, 1:32 PM and 3:44 PM, R67 was in room with door open, laying at foot of the low bed next to door. R67 was wrapped in a sheet, laying in the fetal position, making no sound. During an interview on 09/18/23 at approximately 1:41 PM, Certified Nursing Assistant (CNA)6 stated R67 seems to lie in that position most of the time. During an observation on 09/19/23 at approximately 10:35 AM, 11:26 AM and 1:27 PM, R67 was in with door partially closed, laying on foot of low bed next to door. R67 was wrapped in a sheet, laying in the fetal position, making an occasional sound. During an interview on 09/19/23 at approximately 2:06 PM, CNA 5 stated R67 had been in bed all day, but had eaten a hearty lunch. On 09/18/23 at approximately 3:10 PM a review of the Facts and Comparisons, Epocrates and Drug.com medical literature revealed potential moderate drug interactions between trazodone, divalproex, melatonin, quetiapine, brexpiprazole due to central nervous system depressant effects which may be additively or synergistically be increased in patients taking multiple drug that cause these effect, especially in elderly or debilitated patients. Sedation and impairment of attention, judgement, thinking, and psychomotor skills may increase. Vital signs (blood pressure, orthostatics, temperature and pulse) for brexpiprazole should be monitored during first 3-4 weeks of treatmenrt and every 4 weeks after dose change. Monitor blood pressure due to combination which may increase risk of CNS depression, psychomotor impairment, hyperthermia, hypotension, including orthostasis, syncope. During observations on 09/17/23 - 09/19/23, R67 was in bed and not involved in activities. Review of R67's progress notes dated May 2023 - September 2023 revealed R67 frequently charted as sleeping in bed and failed to show R67 being involved in any activities. A review of R67's January 2023 - September 2023 progress notes revealed the Consultant Pharmacist had stated Medication regimen reviewed for problems an/or irregularities, Recommendation made. on 01/30/23, 02/20/23, 03/29/23, 04/16/23, 05/16/23, 06/21/23, 07/22/23, 08/6/23 and 09/15/23. Further review of the progress notes revealed an entry dated 08/16/23 related to CMS-F757: Duplicate Antipsychotic Drugs which stated This patient is currently receiving duplicate antipsychotic drugs Quetiapine 400mg (milligram) BID (twice daily) and Brexpiprazole 1mg QD (daily). The typical treatment pathway is to maximize the dose of a single agent prior to adding a second drug. Consider tapering to D/C (discontinue) Brexpiprazole and may increase the Quetiapine if needed. The recommendation further included specific recommendations for action. During an interview on 09/19/23 at approximately 2:22 PM, the Medical Director (MD) called and stated that the resident is being seen by a psychiatric service and the facility places the orders for psychotherapeutic agents made by the psychiatric service under his name. The MD did not recall seeing pharmacist recommendations made on 08/16/23 related to duplicate antipsychotic drugs Seroquel and Rexulti for R67 and was unaware of a need for blood pressure monitoring. During an interview on 09/19/23 at approximately 3:40 PM, the DON stated that pharmacist recommendations come to him and the nursing staff sends them to the prescribing physician if he hasn't picked them up, but was otherwise unclear as to the process as it related to Licensure orders for medications. The DON was unaware of a pharmacist recommendation made on 08/16/23 related to duplication of therapy related to two antipsychotic drugs (Seroquel and Rexulti) for R67 and was unaware that LifeSource orders for Seroquel and Rexulti had been faxed to the pharmacy with the MD as the prescriber, not LifeSource. The DON stated that the MD defers to LifeSource when it comes to prescribing psychiatric medications. The DON further stated he would provide a copy of policy and procedures related to, 1) LifeSource and its recommendations/orders and 2) handling of pharmacist recommendations and would provide copies of all other pharmacist recommendations. On 09/20/23 at approximately 9:30 AM, the DON had been unable to provide copies of other recommendations made by the Consultant Pharmacist or a copy of the requested policy and procedure related to LifeSource, but did provide a copy of the 08/16/23 Consultant Pharmacist Communication to Physician (Medical Director) which had been checked Duplicate agents are being used due to differing mechanisms of action that result in augmention in managing behavior symptoms. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. and Duplicate agents with differing degrees of D (dopamine receptor) 2 binding are being used in an attempt to use lower dosages of each individual agent. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. and Duplicate agents are being used for different indications/symptoms (please specify below) and the risk vs benefit has been considered. The OTHER below had been checked and signed by the Medical Director on 09/20/23 stating Rexulti is approved (FDA) (Food and Drug Administration) for agitation dementia to target . (unable to decipher) . in notes sent . (unable to decipher) .

On the day of the complaint inspection, based on record review and interview, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Facility staff did not know where written resident care information was located. The findings included: Resident #1 sustained a laceration during a pivot transfer. During an interview with the surveyor on 8/9/12 Certified Nurse Aide (CNA) #2 confirmed she had provided care to the resident for 6 months and had never been told before the incident that she was transferring the resident incorrectly. The facility had CNA Care Records to give guidance to the type of care and assistance required by the residents. The CNAs who provided the care were unaware of the Care Records. The facility offered inservice on lifts on 8/5/12, thirteen days following the incident with Resident #1. Resident #1 was admitted to the facility 8/12/09. Review of the resident's record on 8/8/12 at approximately 1:30 p.m. revealed a physician's orders [REDACTED]." Review of the UniGuard Physician Communication Tool dated 7/23/12 revealed "while resident was being transfer from bed to wheel chair when pivoted around to sit resident hit L(eft) leg on bar of the leg rest received a gash..." Review of the Resident Incident Report dated 7/23/12 revealed that Certified Nurse Aide (CNA) #2 reported the incident. CNA #2 provided a written statement that they sat the resident up on the side of the bed and adjusted the bed so the resident's feet would reach the floor. The CNA then placed the wheelchair and took the right arm off the chair and helped the resident pivot into the wheelchair. When CNA #2 stepped back, they saw the blood on the floor, wrapped a towel around the cut and called for the resident's nurse. Review of the resident's Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 that indicates a moderately impaired cognitive pattern. During interview on 8/8/12 at approximately 3:50 p.m., the resident stated that she did remember hitting her leg on the wheelchair piece and receiving a cut. Resident #1 also stated that staff does not use a lift to transfer her, they help her stand and turn to transfer between the bed and wheelchair. She stated that the staff has used a lift for transfer before, but not recently. Information provided by the facility for the reportable incident included a CNA Care Records form. The form provided care information about activities of daily living including mobility and transfers. Resident #1's CNA Care Record indicated that the resident required a "mechanical lift with two" for transfer. During interview on 8/8/12 at approximately 3:25 p.m., CNA #5 stated that staff on duty tells oncoming staff resident care information at the start of each shift. CNA #5 also stated that staff knows which residents need to be transferred using a lift. CNA #5 stated she thought that written care information, including how to transfer residents, was located at the nurse's station. CNA #5 also demonstrated the kiosk computer system and stated that it is used to enter resident care information at the end of the shift, but does not have information on what type of care to provide to the residents. CNA #5 demonstrated the kiosk by using the transfer information screen and showed that she entered how much assistance a resident needs to transfer and how many staffs required. On 8/8/12 at 12:45 PM, CNA (Certified Nurse Aide) #4 was interviewed. When asked how the CNA knew what care her residents needed, she stated, "I have a normal group. The nurses report changes. I ask the other CNA's and Nurses. I document on the computers. The CNA was shown a CNA Care Record. The CNA stated she had never seen one. CNA #1 was interviewed on 8/8/12 at 1:00 PM. When asked how she knew what care her residents needed she stated, "They (nurses) will tell you. They tell you who has vital signs and who is going out. We are told if they are not able to do for themselves and to get help. We have stand up lift and Hoyer lift. The lift program book/ADL (activity of daily living) sheets, are at the desk. They tell you who are incontinent and how much assistance is needed. The care plans are kept at the desk. When asked about the CNA Care Record, the CNA denied use of the form. CNA #3 was interviewed on 8/8/12 at 1:10 PM. The CNA stated there was an ADL book that told them what to do for the residents. The CNA was asked to show the surveyor the book. The CNA brought the Lift Program Book that had been updated on 8/6/12, following the Lift Inservice on 8/5/12. There were no ADL's or care guides in the book. The CNA denied knowing what a CNA Care Record was. When shown the care record, the CNA denied ever seeing a care record. RN #1 was interviewed on 8/8/12 at 1:45 PM. She stated she was not aware of the type of transfer Resident #1 was to have. When asked how the CNA's knew what they were to do to provide care to their assigned residents, the RN stated, I think a new resident is reported off on. It's on their ADLs (computer). It tells how many and what kind of transfer. I don't know who updates." The surveyor showed a CNA Care Record to RN #1, she denied having ever seen the record. CNA #2 was interviewed on 8/9/12 at 10:10 AM. The CNA stated she had taken care of Resident #1 for 6 months and had transferred her the same way. "This is normal routine. They told me after it happened that she was suppose to have a lift. I told them I had never used a lift on her." When asked by the surveyor, how she knew what to do for her residents, she stated, "We find out by talking to another CNA and they tell us how they did it. I would go by what the Senior CNA told me. We have the ADLs on the computer. I don't know anything of a CNA Care Record. I didn't even know there was a book I could go to to find out what to do for a patient." The CNA was asked about inservices regarding providing care to the residents. She stated, "If I had an inservice it was over a year ago. It has been about 6 months since I had any inservice." The Director of Health Services was interviewed on 8/8/12 at 4:00 PM. When asked how the CNAs know what kind of care to provide to their assigned residents, she stated, "They get report. We have the ADL sheet and it has the assistance needed. The ADL sheets are updated with changes. The CNA that is responsible does the care and ADL sheets. The ADL sheets are gone over in orientation. Every admit has an ADL sheet within 8-24 hours."