Every finding on record at The Lodge at Lane

47191 Based on interviews and record reviews, the facility failed to ensure the resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately: 1. Coded the discharge status for 1(#39) of 2 (#27 and #39) residents reviewed for hospitalization s. 2. Coded a resident reviewed for PASRR for 1 (#13) of 2 (#13 and #18) residents reviewed for PASRR. Findings: 1. Review of Resident #39's clinical record revealed that she was admitted to the facility on [DATE] and discharged from the facility on 12/11/2024. Review of Resident #39's MDS Discharge Assessment, dated 12/11/2024, revealed the resident was discharged to an acute hospital. Review of Resident #39's Nurses Notes revealed the following: in part: 12/11/2024 Resident #39 scheduled for discharge today with home health services. On 02/04/2025 at 4:17 p.m., an interview was conducted with S2MDS. She reviewed Resident #39's MDS Discharge Assessment, dated 12/11/2024, and confirmed it indicated Resident #39 discharged to an acute hospital. She further reviewed Resident #39's medical record and confirmed the resident was discharged home. She confirmed Resident #39's MDS Discharge Assessment was not coded correctly and should have been coded discharge to home. On 02/04/2025 at 4:22 p.m., an interview was conducted with S1DON. She was made aware of the findings and confirmed the MDS Discharge Assessment should be accurate. 2. Review of Resident #13's clinical record revealed that she was admitted to the facility on [DATE] with a 142 Form Notification of Medical Certification with approval of admission by the state Level II authority dated 10/16/2023 through 10/14/2024. Review of Resident #13's annual MDS assessment dated [DATE] revealed section A1500 PASRR: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as 0. No. Section A1510 level II PASRR conditions was blank. Review of Resident #13's current care plan revealed the following: Focus: Level II PASRR On 02/05/2025 at 9:58 a.m., an interview was conducted with S2MDS. She reviewed Resident #13's Annual MDS Assessment, dated 09/24/2024, and confirmed section A1500 should have been coded as 1-Yes, and was not. On 02/05/2025 at 10:00 a.m., an interview was conducted with S1DON. She reviewed Resident #13's Annual MDS assessment dated [DATE]. S1DON further reviewed Resident #13's Form 142 which indicated Resident #13 was approved for nursing home admission and approved by level II authority effective 10/16/2023 through 10/14/2024. S1DON confirmed section A1500 should have been coded as 1-Yes, and was not.

Based on record review, observations, and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 36 residents who were served meals from the kitchen. Findings: Review of the facility's policy titled Date Marking for Food Safety revealed the following: Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines for Staffing: 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The discard day or date may not exceed the manufacturer's use-by date, or four days whichever is earliest. The date of opening or preparation counts as day one. On [DATE] at 8:25 a.m., an observation was conducted of the kitchen's dry storage room and the following items were found to be labeled with the month and date but no year: Ground basil 12oz opened container labeled ,d+[DATE] Opened 25oz container garlic salt labeled ,d+[DATE] The following items were found with expired open dates: Opened 32oz container lemon juice labeled [DATE] Opened 18oz container chili powder labeled [DATE] The following items were found open with no open date label: Opened 8oz container kosher salt Opened 19oz container garden seasoning Opened 32oz container imitation almond extract Opened 32oz container kitchen bouquet Opened 3oz container chili powder Opened 24oz container seasoning blends On [DATE] at 8:45 a.m., an observation was conducted of the walk in freezer, and the following items were found to be opened and unlabeled: Opened 48oz container vanilla ice cream Indivual wrapped 1.65oz ice pops-3 orange, 4 purple, 3 red were noted out of the original box in a plastic container On [DATE] at 9:05 a.m., an observation was conducted of the cooking area, the following items were found to be opened and unlabeled: Opened 5lb bag grits On [DATE] at 8:55 a.m., an interview was conducted with S3DM. She confirmed all 36 resident eat from the kitchen. She confirmed the above observations, and stated open food items were to be labeled with the open date including the month, date and year and were not. She also confirmed the above items with open dates of 2022 should have been discarded and were not.

Based on record review and interviews, the facility failed to complete quarterly assessments for 1 (#18) of 2 (#18 and #22) residents reviewed for resident assessment. Findings: Review of Resident #18's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/2024 revealed no completion date. An interview was conducted on 02/28/2024 at 11:08 a.m. with S2MDS. She stated she was responsible for completing MDS assessments. She reviewed the quarterly MDS for Resident #18 dated 02/08/2024. She confirmed Resident #18's quarterly MDS assessment was not complete. She confirmed the quarterly MDS assessment was 6 days late. An interview was conducted on 02/28/2024 at 11:25 a.m. with S1DON. She reviewed the quarterly MDS for Resident #18 dated 02/08/2024. She confirmed Resident #18's quarterly MDS assessment was not complete. She confirmed the quarterly MDS assessment was 6 days late.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable disease and infection by failing to ensure staff were knowledgeable and cleaned residents' whirlpools according to manufacturer's guidelines. This deficient practice had the potential to affect 32 female residents who used the whirlpool in the facility as documented on the facility's Whirlpool Assignment Sheet. Findings: Review of facility's policy titled, Whirlpool Tub and Bathroom Cleaning revealed the following, in part: It is the policy of this facility to establish policies, procedures and guidelines to provide a clean and sanitary environment for residents, staff and visitors in order to prevent cross contamination and transmission of healthcare-associated infection (HAI) Procedure: 1. Working from clean areas to dirty areas: h. Clean tub faucets, walls and railing, scrubbing as required to remove soap scum. Inspect grout for mold, apply disinfectant to interior surfaces of shower/tub, including soap dish, faucets and shower head. Allow sufficient contact time for disinfectant according to manufacturer's recommendations. Rinse and wipe dry. Review of the Whirlpool System Cleaning instructions titled, RS8 Geneva (Fixed Height) Operating and Disinfecting Procedure revealed the following, in part: Pull the drain plug. Rinse and dry the resident while the tub is draining. Unlock and open the Disinfectant Cabinet door. Remove the disinfectant wand from its holder and point spray head into the tub. Turn the disinfectant valve to the disinfect position. Spray the interior surface of the tub. Use brush or sponge if needed. Turn the disinfectant wand to the off position. Allow disinfectant solution to remain on the interior surface of the tub for the period of time recommended by the manufacture. Turn the disinfectant valve to the rinse position. Thoroughly rinse the interior of the tub. Turn the disinfectant valve to the off position. Return the disinfectant wand to its holder and lock the disinfectant cabinet door. Review of [NAME] disinfectant solution's label instructions used to disinfect the whirlpool revealed: leave on the surface for 10 minutes and rinse off. On 01/24/2018 at 9:57 a.m., an observation was conducted of bathing room a. There was a large sign next to the whirlpool bath with instructions for disinfecting the whirlpool, which read, in part, the instructions from the Whirlpool System Cleaning Instructions titled, RS8 Geneva (Fixed Height) Operating and Disinfecting Procedure. On 01/24/2023 at 1:15 p.m., an interview was conducted with S4CNA. She said she had worked at the facility for one week and she was responsible for bathing residents in the whirlpool room. She said she was not sure what to use to disinfect the whirlpool. An observation was conducted of Whirlpool Room A at that time. She demonstrated what she does when she bathed residents. She said she used the liquid soap by the whirlpool and rinses it out. She said she was supposed to use a special cleaner but did not know where it was. On 01/24/2023 at 1:45 p.m., an interview was conducted with S5CNA. She said she worked in the bathing room and does whirlpool baths. She verified 32 female residents were bathed in the whirlpool in bathing room a. On 01/24/2023 at 2:01 p.m., an interview and observation was conducted with S6CNA. She said she had worked at the facility since October 2022. She said she cleaned the whirlpool with the disinfectant in the whirlpool and let it set for about 5 minutes while she got the resident out of the tub and then she rinsed it off. She said she did not realize the disinfectant was supposed to set for 10 minutes. On 01/24/2023 at 1:20 p.m., an interview was conducted with S2DON. She said she expected the staff to clean the whirlpool per policy and manufacture's guideline.

Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for 1 (#6) of 5 (#6, #7, #11, #15, #20) residents reviewed for unnecessary medications. The facility failed to ensure: 1. A gradual dose reduction was attempted for a psychotropic medication for Resident #6; and 2. An antipsychotic medication was used only when there was an acceptable diagnosis for Resident #6. Findings: Review of the facility's policy titled Use of Psychotropic Medication revealed the following, in part: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medications beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 5. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. 12. (c.) New Admissions: ii. The physician in collaboration with the consultant pharmacist shall re-evaluate the use of the medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission. Review of Resident #6's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, Anxiety Disorder, and Major Depressive Disorder, Recurrent. Review of the Quarterly MDS with an ARD of 11/02/2022 for Resident #6 revealed the following: BIMS =01(severe cognitive impairment) Section-N-Medications Medications received: days: antipsychotic-7 days a week Review of the current Physician Orders for Resident #6 revealed the following: Start Date 07/27/2022- Quetiapine Fumarate Tablet 100 mg Give 1 tablet by mouth two times a day related to Anxiety Disorder. Review of the MAR dated July 2022 - January 2023 for Resident #6 revealed she received Quetiapine twice daily at 8:00 a.m. and 6:00 p.m. starting on 07/27/2022. Review of The Gradual Dose Reduction dated 08/30/2022 for Resident #6 from the facility's pharmacist revealed the following: Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rationale for the continued use. 8. Seroquel 100mgBID 9. Please provided an appropriate diagnosis for the use of Seroquel as Anxiety is not appropriate according to the CMS guidelines. Review of Antipsychotic Diagnosis Verification sheet dated 01/20/2023 for Resident #6 from S2DON revealed the following: Quetiapine Fumarate Tablet 100 mg give 1 tab by mouth two times a day related to anxiety disorder, unspecified. The use of Seroquel for the treatment of anxiety is considered inappropriate according to the CMS guidelines. Please consider an alternate medication. Further review of the clinical record for Resident #6 revealed there was no documentation of an acceptable diagnosis for the use of an antipsychotic or an attempt of a gradual dose reduction. An interview was conducted on 01/25/2023 at 1:55 p.m. with S2DON. She reviewed Resident #6's Physician Orders and Progress Notes and verified there was no documented diagnosis to justify the administration of Quetiapine100mg po twice daily. She also reviewed the Psychoactive Gradual Dose Reduction for Resident #6 and verified there was no attempt of a gradual dose reduction for Quetiapine100mg po twice daily.

Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances for 1 (#10) of 2 (#10 and #26) residents reviewed for grievances. The facility failed to ensure a grievance was promptly investigated when Resident #10 reported a missing cell phone to staff. Review of the facility policy reveals, in part: Resident and Family Grievances Policy Explanation and Compliance Guidelines: 1. Administrator has been designated as the Grievance Official. 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. Procedure: b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. Findings: Review of the clinical record revealed Resident #10 was admitted to the facility on [DATE]. Resident #10 had diagnoses which included Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes. Review of Resident #10's Quarterly MDS with an ARD of 01/06/2023 revealed Resident #10 had a BIMS Summary score of 15, which indicated Resident #10 was cognitively intact. Review of the facility's Grievance Log dated August 2022 through January 2023 revealed no entries for Resident #10. On 01/23/2023 at 10:40 a.m., an interview was conducted with Resident #10. She said she had a missing cell phone. She said she reported it to S6CNA about a week ago. She said her cell phone remained missing. On 01/24/2023 at 08:22 a.m., an interview was conducted with S5CNA. She said Resident #10 reported her phone missing to her. She said she reported the missing phone to S3LCSW. She confirmed Resident #10's cell phone remained missing. On 01/24/2023 at 8:35 a.m., an interview was conducted with S3LCSW. She said she was made aware Resident #10's phone was missing since last week. She confirmed she did not file a grievance for the missing phone. On 01/24/2023 at 9:00 a.m., an interview was conducted with S1NFA. He verified a grievance report should have been started when Resident #10's phone was reported missing.

Based on record review, observation, and interviews, the facility failed to ensure expired medications were not available for use and administration to residents as evidenced by expired medications being stored in Cart A. Findings: Review of facility policy titled Medication Storage revealed, in part: Policy Explanation and Compliance Guidelines: 1. General Guidelines: d. All medications are checked monthly for expiration dates by the night nurse. Expired medications are immediately removed from the medication cart and properly disposed of. On 03/02/2022 at 11:00 a.m., an observation was conducted of Cart A with S2LPN. The following cart stock medications were expired: 3 tablets of Loperamide 2 mg tablets with an expiration date of 08/2021, 1 Chloraseptic 6 oz. bottle with an expiration date of 07/2021, 1 Milk of Magnesia 12 oz. bottle with an expiration date of 12/2021. The following medication for Resident #25 was expired: Tussin DM syrup 4 oz. bottle 10-100 mg/5ml give 10 ml by mouth every 6 hours as needed for cough with an expiration date of 03/2021. On 03/02/2022 at 11:05 a.m., an interview was conducted with S2LPN. She confirmed the above medications were expired. She confirmed the medications were intended for resident use. She confirmed these medications should have been removed from the cart and disposed of. On 03/02/2022 at 11:20 a.m., an interview was conducted with S1DON. She said once a month and as needed, the night shift nurse checked the medication carts for expired medications. She confirmed the above expired medications should have been immediately removed from Cart A and properly disposed of.

Based on record reviews and interviews, the facility failed to ensure staff: 1. Notified the resident representative of a change in condition for 1 (#19) of 12 residents investigated. 2. Notified the nurse of a resident's change in condition for 1 (#19) of 12 residents investigated. Findings: Review of the policy titled, Notification of Change revealed the following, in part: Expected Outcomes: The resident and family members or legal representative listed will receive notification of significant changes. Standards: 1. The facility will notify the resident, consult with the physician, legal representative if known, or a family member when: a. There is a significant change in resident's physical, mental, or psychosocial status. Review of the clinical record for Resident #19 revealed he was admitted to the facility on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) for Resident #19 with an Assessment Reference Date (ARD) of 12/16/2021 revealed the resident had a Brief Interview for Mental Status (BIMS) of 00, which indicated the resident had severe cognitive impairment. Review of Nurses' Notes dated 02/17/2022 to 02/27/2022 revealed no notifications of the resident's change in condition to his resident representative. On 03/03/2022 at 8:45 a.m., an interview was conducted with Resident # 19's daughter who was his resident representative. She said she was not notified her father had a change in condition until 02/28/2022 when they sent him to the hospital. On 03/03/2022 at 9:15 a.m., an interview was conducted with S3CNA. He said Resident #19 used to be continent of urine during the day, and he never wet his brief. He said last week Resident #19 was incontinent of urine all the time, wetting his brief and clothes, and his urine had a strong odor. He said the urine smelled so strong he had to shower him each day over the weekend. He said he did not notify the nurse of Resident #19's strong urine odor and continued incontinence. On 03/03/2022 at 9:20 a.m., an interview was conducted with S2LPN. She said S3CNA notified her Resident #19 had blood in his brief on 02/18/2022. She said when she notified a resident representative, she documented a note in the resident's chart. She confirmed there was no documentation that she notified Resident #19's daughter of his change in condition. She confirmed the expectation would be that she would notify a resident's representative of a change in condition. On 03/03/2022 at 12:20 p.m., an interview was conducted with S1DON. She confirmed when a resident had a change in condition, she would have expected the nurse to notify the resident's representative. She confirmed she would have expected the CNA to report any changes in a resident's condition to the nurse.

Based on observation and interview, the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 9 (#2, #4, #8, #15, #25, #26, #31, #32, #36) of 9 (#2, #4, #8, #15, #25, #26, #31, #32, #36) residents in the dining room requiring assistance with meals who were not served with the other residents in the dining room, and for 5 (#8, #27, #31, #32, #36) of 5 (#8, #27, #31, #32, #36) residents left out in the hallway with a towel over their wet hair waiting on the beauty shop. This failed practice had the potential to affect the 35 residents in the facility. Findings: On 01/09/19 at 7:55 AM observation of the dining room revealed the residents that could feed themselves were served their trays first. Further observation revealed there were 2 tables used for residents requiring assistance with eating. Observation revealed there were 2 residents in Brodie chairs at each table with no food in front of them while the other residents in the dining room were eating. At 8:05 AM S3 CNA started feeding resident #4 while resident #32 was sitting at the same table with no food. At 8:10 AM S4 CNA started feeding resident #32. Further observation at the same time revealed resident #26 was sitting at another feeding assistance table eating while resident #36 was at the same table with no food. At 8:20 AM S5 CNA started feeding resident #36. At 8:20 AM S6 CNA started feeding resident #8 off of a bedside table in the sitting area and S7 Activity Director started feeding #31 off of a bedside table in the sitting area. Further observation of the dining service revealed S3 CNA and S4 CNA were having a personal conversation while resident #4 and #32 were seated in between S3 CNA and S4 CNA and not paying attention to the resident's needs. At 8:25 AM resident #15 continued to sit in a Brodie chair at a feeding assistance table alone without a tray. At 8:30 AM observation of the tray cart from the kitchen revealed resident #15's tray was still on the cart. At 8:35 AM observation revealed S8 CNA brought the tray from the cart to the table and then took the tray to the refreshment room and then brought it back to the table and started feeding resident #15. On 1/10/19 at 11:30 AM observation revealed the lunch trays were brought to the dining room. At 11:35 AM staff were serving trays to residents that could feed themselves. At 11:52 AM resident #4 and #32 were served their trays at the feeding assistance table. At 12:00 PM resident #25 was fed in the sitting area off of an over bed table. At 12:00 PM resident #2 was fed in the sitting area off of an over bed table. On 1/11/19 at 9:00 AM interview with resident #2 confirmed there are times when her food is cold by the time she gets it but she was not aware she could request to have the food warmed so she just ate it cold. On 1/11/19 at 12:00 PM interview with S1 DON confirmed the serving process could be more efficient. She further confirmed their are resident's served off of over bed tables in the sitting area because the Brodie chairs are so large there is not enough room at each feeding assistance table for all of the residents in the Brodie chairs. On 1/9/19 at 11:00 AM observation of the hallway outside of the beauty shop revealed resident #8, #27, #31, #32 and #36 were all seated in Brodie chairs with towels over their heads and their hair was damp. Interview with S9 CNA revealed the beauty shop assistant washes the resident's hair with no rinse shampoo and places the towel over their head so the beautician only has to dry and style the hair. Interview with resident #27 revealed she did not like to sit out in the hallway with the towel over her head and she was cold. Observation again at 11:45 AM revealed residents #8, #31, #32, #36 continued to sit out in the hallway with a towel over their head and hair damp. Observation again at 11:52 AM revealed resident #31 and #32 continued to sit out in the hallway with a towel over their head. On 1/11/19 at 12:00 PM interview with S1 DON confirmed the resident's should not have been sitting out in the hallway with a towel over their head while their hair was damp waiting to see the beautician.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by a staff member failing to change gloves and sanitize hands after incontinent care and prior to pressure ulcer care for 1 (#31) of 2 (#19 and #31) residents observed for pressure ulcers. Findings: Resident #31 Observation on 01/11/19 at 9:30 AM of S2 LPN's performance of pressure ulcer care to Resident #31's left buttock revealed: S2 LPN donned 3 pair of gloves prior to cleaning the resident's perineal area. She cleaned the resident's perineal area, removed the soiled brief and replaced it with a clean brief. S2 LPN then removed one pair of gloves and began cleaning Resident #31's left buttock pressure ulcer with gauze and wound cleaner. After cleaning the wound, she removed all the gloves, went to the bathroom and washed her hands. She returned to the bedside, donned 2 pair of clean gloves and applied zinc oxide paste to the wound. . During an interview with S2 LPN on 01/11/19 at 9:40 AM, she revealed that before she begins wound care she puts on at least 3 pair of gloves so that after she cleans the wound she can remove the dirty pair of gloves and continue with the wound care. She stated that when she provides wound care, she does not wash her hands between wound care steps; she just removes the dirty gloves and proceeds to the next step with the gloves she was already wearing under the removed pair. S2 LPN confirmed she did not change gloves after cleaning Resident #31's perineal area and before cleaning the left buttock pressure ulcer and she should have. She confirmed she should have worn only one pair of gloves and she should have removed the gloves and sanitized her hands after performing perineal care and she did not. Review of the Use of Gloves For Routine Patient Care and Isolation Precautions policy revealed .Hands must be decontaminated or washed before and after using gloves .When taking care of a patient, after direct contact with his/her secretions or excretions, gloves will be changed to complete the care .Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use .Wash/decontaminate hands after removing gloves . During an interview with S1 DON (Director of Nursing) on 01/11/2019 at 10:30 AM, she confirmed S2 LPN should have performed hand hygiene prior to donning a clean pair of gloves, between each task of the wound care and upon completion of the wound care.

Based on record review and staff interview, the facility failed to notify the resident and the resident's representative of a transfer and the reason for the move in writing for 3 (#11, #18 and #40) of 3 (#11, #18 and #40) resident records reviewed for hospitalization . Findings: Resident #11 Review of Resident #11's record revealed he was sent to the hospital emergency department on 12/25/18 and admitted to the hospital with [REDACTED]. Further review of the record revealed no documented evidence that the facility provided a written notice of transfer to the resident or his responsible party. During an interview with S1 DON (Director of Nursing) on 01/09/2019 at 3:30 PM, she confirmed that the resident and the responsible party were not notified in writing of the transfer to the hospital on [DATE]. S1 DON confirmed the facility only sent written notices to the Office of the State Long-Term Care Ombudsman, and not the resident or the resident's representative. Resident #18 Review of Resident #18's record revealed she was sent to the hospital emergency department on 12/06/18 and admitted to the hospital with [REDACTED]. Further review of the record revealed no documented evidence that the facility provided a written notice of transfer to the resident or his responsible party. During an interview with S1 DON on 01/09/2019 at 3:45 PM, she confirmed that the resident and the responsible party were not notified in writing of the transfer to the hospital on [DATE]. S1 DON confirmed the facility only sent written notices to the Office of the State Long-Term Care Ombudsman, and not the resident or the resident's representative. Resident #40 On 1/11/19 at 9:27 AM record review for resident #40 revealed an admitted [DATE] for rehab skilled therapy following [PR[NAME]EDURE] surgery. Further review of the record revealed on 12/2/18 resident #40 had an exacerbation of [MEDICAL CONDITION] and was sent to the emergency room and admitted to hospital. On 1/11/19 at 9:45 AM record review revealed resident #40 and resident representative were not notified in writing of the transfer to the emergency room . On 1/11/19 at 9:56 AM interview with S1 DON confirmed the facility did not provide a written notification to the resident and the resident's representative upon transfer of resident.

Based on observations, interviews and record reviews the facility failed to ensure services provided met professional standards of quality for 1 (Resident #6) of 3 (Resident #6, Resident #10, Resident #35) residents observed during medication administration facility task by failing to ensure the total prescribed dosage of an eye drop medication was administered into Resident #6's right eye as ordered by the physician. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part .3. development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgment, prudence, ethical thinking and behaviors, problem solving and critical thinking abilities .7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and working as a member of the interdisciplinary health care team . Review of facility policy- Administration of Medications Purpose: To administer drugs accurately and safely 1. Nurse verifies that the medication is being administered at the proper time in the prescribed dose. Review of Resident #6's record revealed in part she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's January 2016 physician's orders [REDACTED].>[MEDICAL CONDITION] of Both Eyes: - [MEDICATION NAME] 0.2% Eye Drop - Instill 1 drop into each eye twice daily. An observation was made during medication administration on 01/25/2017 at 8:25 a.m. S4LPN was observed administering Alphagon 0.2% eye drops into both eyes of Resident #6. It was observed that the total eye drop administered in Resident #6's right eye did not go into the eye. A portion of the eye drop went into the right eye and the other portion fell on to the tissue. An interview was conducted with S4LPN on 01/25/2017 at 8:25 a.m. She stated the total drop of Alpagon 0.2% did not go into Resident #6's right eye. She further acknowledged the other portion of the eye drop fell on to the tissue. An interview was held with S1DON on 01/26/2017 at 10:20 a.m. She stated S4LPN informed her that the entire dosage of Alphagon 2% eye drop that was administered did not go into Resident #6's right eye.

Based on observation, record reviews and interviews, the facility failed to ensure the clinical record was accurate and complete by failing to ensure: 1. Intervention of a wandergard placement was included in the resident's care plan for 2 (#14, #43) of 2 (#14, #43) residents; and 2. Exhibition of wandering behavior was included on the care plan for 1 (#43) of 2 (#12, #43) residents reviewed for wandergard placement. Findings: Resident #14 A review of Resident # 14's clinical record revealed in part, Resident #14 was admitted to the facility on [DATE]. Resident #14 had [DIAGNOSES REDACTED]. A review of the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/29/16 revealed in part, Resident #14 exhibited a wandering behavior. A review of Resident #14's care plan revealed in part: Behavioral Symptoms Goal: Resident will demonstrate no wandering from facility. The care plan was last reviewed by the Interdisciplinary Team on 12/7/16, 9/7/16, 6/8/16 and 3/9/16. Review of the facility's Nurse's Notes dated 3/3/16, 6/6/16 and 12/3/16 revealed entries that indicated Resident # 14 had a wandergard in place on her person. On 1/26/17 at 10:12 a.m., an interview was held with S6CNA. S6CNA stated Resident #14 was wearing a wandergard on her ankle. During the interview, S6CNA showed the surveyor Resident #14 was wearing the device on her left ankle. Resident #43 A review of the Resident #43's clinical record revealed in part, Resident #43 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #43's care plan did not contain documentation of Resident #43 exhibiting a wandering behavior. Further review of the care plan did not contain documentation of wandergard placement as an intervention. The care plan was last reviewed by Interdisciplinary Team on 1/25/17, 10/26/16, 8/3/16, 5/4/16, 2/3/16, 11/18/15 and 8/5/15. A review of the facility's Nurse's Notes revealed in part, an entry on 7/28/15 indicating Resident #43 had a monitor on his leg due to having a tendency to wander off. On 1/26/2017 at 11:53a.m., an interview was held with S2RN. She stated Residents #14 and #43 were the only residents currently wearing a wandergards. She said both residents exhibited wandering behaviors. S2RN explained that she and the floor nurses were responsible for updating the resident's care plan. She further explained as a part of assessing a resident, she would review nurses' notes, new orders, conduct resident observations and interviews. S2RN reviewed the care plans and verified Residents #14 and #43's care plan did not included wandergard placement as an intervention. She also verified Resident #43's care plan did not included the resident exhibiting wandering behaviors. S2RN said she was not aware of the initiation of either resident having the wandergard placed and verified the care plan should have included the wandergard placement. S2RN also verified Resident #43's wandering behavior should have been documented on the care plan. During the interview with S2RN on 1/26/17 at 11:53 a.m., S1DON joined the interview. She acknowledged Residents #14 and #43 were the only residents with a wandergard in place. S1DON was made aware of the missing information on Resident #14's and Resident #43's care plan and confirmed both care plans should have been updated to include the wandergard placement and the wandering behavior for Resident #43.

Based on record review and interviews, the facility failed to develop a comprehensive care plan that includes measurable objectives and timetables to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (#12) of 3 (#7,#12 & #25) residents reviewed for the use of physical restraint. There were a total of 16 residents in the Stage 2 Resident Sample. Review of the clinical record for Resident #12 revealed an admission date of [DATE]. Admit [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/15 revealed a Brief Interview for Mental Status (BIMS) score of 8 indicating her cognition was moderately intact. Functional status for Resident #12 revealed she required limited assistance with walking in room, walking in corridor, locomotion off unit and locomotion on unit. Further review of the MDS Section P: Restraints revealed a trunk restraint was being used daily while in the chair or out of the bed. Review of the facility's policy, titled: Physical Restraints, dated 9/15, revealed the following documentation: Definition: Physical Restraints: The use of any manual method or physical/mechanical device, material or equipment attached to or adjacent to the resident's body that he/she cannot remove easily which restricts freedom of movement or normal access of one's body. Standard: 2. C. Contribution to the care plan is made at that time. Review of Resident #12 ' s Care Plan revealed no development of an individualized problem specific to the use of physical restraints to include specific resident conditions, risks, needs, behaviors, measureable objective and specific interventions. Review of the Quarterly Nursing Summary, dated 9/2/15, revealed the following documentation: restraints/lap belt while in wheelchair. On 11/12/15 at12:13 pm, an interview was conducted with S5LPN. She stated that the nurses updated the care plan on the residents. After review of Resident #12's Care Plan, S5LPN verified there was no problem identified for the use of physical restraint. On 11/12/15 at12:28 pm, an interview was conducted with S2MDS. She stated the resident care plans were updated by Minimum Data Set (MDS) and the nurses. After review of Resident #12's Care Plan, S2MDS verified there was no problem identified for the use of physical restraint.

Based on record review, observations, and interviews, the facility failed to ensure 1(#12) of 3 (#7, #12, and #25) residents reviewed for physical restraints out 16 Staged 2 Sampled Residents had the right to be free of any physical restraint imposed for purposes of discipline or convenience, and not required to treat the resident ' s medical symptoms by using a lap seat belt to restrain a resident while in a wheelchair to prevent falls. Findings: Review of the clinical record for Resident #12 revealed an admission date of [DATE]. Admit [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/15 revealed a Brief Interview for Mental Status (BIMS) score of 8 indicating her cognition was moderately intact. Functional status for Resident #12 revealed she required limited assistance with walking in room, walking in corridor, locomotion off unit and locomotion on unit. Further review of the MDS Section P: Restraints revealed a trunk restraint was being used daily while in the chair or out of the bed. Review of the facility's policy, titled: Physical Restraints, dated 9/15, revealed the following documentation: Definition: Physical Restraints: The use of any manual method or physical/mechanical device, material or equipment attached to or adjacent to the resident's body that he/she cannot remove easily which restricts freedom of movement or normal access of one's body. Standard: 2. D. A trail of alterative measures is attempted prior to restraint application when possible. Alternatives that may be used include: Frequent monitoring with visual and verbal cues for safety reminders. F. The use of restraint is based on the residents assessed needs, including precipitating factors and medical symptoms. H. Documentation of reason for restraint and intervention used is required in the medical record. Review of the Monthly physician's orders [REDACTED]. Review of Resident #12 ' s care plan revealed the following documentation: Problem: Fall- 7/31/15 - Seatbelt for safety while in wheelchair; 8/2/15, Approaches/Interventions: Ok to use safety belt while up in wheelchair. Review of the Pre-Restraining Evaluation, dated 8/22/15, revealed the following documentation: Physical Consideration - Ambulation: Gait - Steady with assist only; Balance - Stable with assist only; Other History of falls; Transfers - Stable when making transfers, and Sitting - Stable, maintains upright positon. Medical Consideration - History of [MEDICAL CONDITIONS], and [MEDICAL CONDITION] was checked yes; Restraint Alternatives: Devices: Non-slip grips, wheelchair, and walker was checked; Environment: Call system in reach, Alarm doors, and grab bars were checked. Recommendations: Alternative to restraints: 8/25/15 - Resident was in wheelchair today and was rocking in the wheelchair and moving to the front of the chair so seatbelt was needed and kept on while out of bed. Review of the Patient Status Report, dated 8/2/15, revealed the following documentation: Resident was sitting in a recliner and got up and got her wheelchair. Took 2 steps and fell on her . to the floor. Able to ambulate to her room without pain. Can we have an order for [REDACTED]. Review of the Rehabilitation Screening form, dated 8/24/15, revealed Resident #12 required 1 helper when walking using a rolling walker. Further documentation revealed no Physical Therapy needs were identified. Review of the Quarterly, Nursing Summary, dated 9/2/15, revealed the following documentation: restraints/lap belt while in wheelchair. On 11/9/15 at 2:38 pm, an observation was made of Resident #12 sitting in a wheelchair with a seat belt restraint attached across her lap and fastened to the back of the wheelchair. Further observation revealed there was no way Resident #12 could have released the lap seat belt restraint. She was observed using her feet to self-propel the wheelchair. Resident #12 had been observed throughout the day with the lap seat belt restraint attached and fastened to the back of the wheelchair. On 11/09/15 at 2:40pm, an interview was done with Resident #12 regarding the use of the lap seat belt restraint. Resident #12 stated she had been falling so, the lap seat belt restraint was placed on to prevent her from getting up. Resident #12 stated she did not like the lap seat belt restraint because; it prevented her from getting up. She stated she did not consent to having the lap seat belt restraint. Resident #12 also stated the lap seat belt restraint was kept on all day while she was up in the wheelchair. On 11/09/15 at 2:39 pm, an interview was conducted with S7CNA regarding Resident #12. S7CNA stated Resident #12 was able to stand up with assistance. S7CNA stated the lap seat belt restraint was being used because; Resident #12 would get up on her own and fall. On 11/10/15 at 8:45 am, an observation was made of Resident #12 sitting in her wheelchair with the lap seat belt restraint attached and fastened to the back of the wheelchair. On 11/10/15 at 9:07 am, an observation was made of Resident #12 ambulating up the hallway with S10RT. S10RT was observed using a gait belt and a rolling walker. On 11/11/15 at 9:51 am, an observation was made of Resident #12 sitting in a wheelchair with the lap seat belt restraint attached and fastened at the back on the wheelchair. On 11/10/15 at 2:23pm, an interview was conducted with S8CNA regarding Resident #12. S8CNA stated the lap seat belt restraint was being used to prevent Resident #12 from falling. S8CNA stated Resident #12 keeps the lap seat belt restraint on at all times when she's up in the wheelchair. On 11/11/15 at 9:05 am, an interview was conducted with S9CNA regarding Resident #12. S9CNA stated the purpose of the lap seat belt restraint, while in up in the wheelchair was because of her falls. On 11/11/15 at 10:12 am, an observation was made of Resident #12 sitting in her wheelchair with lap seat belt restraint positioned across her waist and fastened to the back of the wheelchair. At this time, Resident #12 was asked to release the seat belt. Resident #12 stated she could not. On 11/11/15 at 10:26 am, an interview was conducted with S6CNA. S6CNA stated they had to use the restraint to keep her in the wheelchair and to keep her from falling. S6CNA stated Resident #12 was not able to unfasten the lap seat belt restraint. S6CNA stated the lap seat belt restraint was being used to keep Resident #12 from falling. On 11/11/15 at 11:05 am, an interview was conducted with S2MDS. S2MDS stated the lap seat belt was a restraint but, it was keeping Resident #12 from falling. On 11/11/15 at 11:19 am, an interview was conducted with S1Unit Dir. She stated the lap seat belt restraint was being used for Resident #12 to keep her from falling. S1UnitDir stated Resident #12 had had numerous falls and since the lap seat belt restraint was implemented she had no more falls. S1UnitDir stated, the object of the restraint was for Resident #12 not to be able to remove or release it.

Based on record reviews and interview, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiency regarding the use of psychoactive (antipsychotic) medications being used without clinical indication or justification. There were 2 (#3 and #20) out of 5 (#3, #5, #20, #25, and #28) residents reviewed for unnecessary medications affected by this deficient practice out of a total sample of 16 Stage 2 Residents. Findings: Review of the Resident Census and Conditions of Residents form submitted by the facility on 11/9/15 revealed there were 14 residents on antipsychotic medications. Review of the facility ' s Annual Survey, Form CMS-2567 (Centers for Medicare and Medicaid-2567), dated 1/15/15, revealed deficient practice related to unnecessary medications involving psychoactive (antipsychotic) drugs. The plan of correction was dated for 2/27/15. Review of the clinical record for Resident #3 revealed no clinical indication or justification for the use of [MEDICATION NAME] 100 milligrams by mouth twice daily. Review of the clinical record for Resident #20 revealed no clinical indication or justification for the use of [MEDICATION NAME] 0.5 milligrams (antipsychotic) by mouth every night. On 11/12/2015 at 2:43 pm, an interview was conducted with S1Unit Dir. She stated she was responsible for Quality Assurance and Assessment (QA&A) along with 2 other nurses. She stated psychoactive (antipsychotic) medications were already identified by the facility's QA&A Committee as an area of quality deficiency. S1UnitDir stated quality deficiencies identified by the facility ' s QA&A Committee were monitored for compliance on an on-going basis. S1UnitDir verified that the clinical record for Resident #3 and Resident #20 had no clinical indication or justification for the use of psychoactive (antipsychotic) medication in regards to unnecessary medications.

Based on observation and interview the facility failed to prepare food under sanitary conditions by failing to ensure that food was properly thawed. This deficient practice had the potential to affect 36 of 38 residents who received meals from the kitchen. Findings: On 11/09/15 at 11:10 a.m., an observation made in the kitchen with S3DM revealed three 2 pound bags of sliced turkey and two bags of 2 pound sliced ham standing in a sink with running hot water. At that time, S3DM stated the meat was being thawed for the evening meal. The water temperature was measured with a thermometer by S11DA which documented a temperature of 100 degrees Fahrenheit. S3DM stated the meat should be defrosting under running cold water. A review of the facility's Food Preparation Method Policy revealed the following: 2. Frozen foods are thawed under refrgiration or cold running water.

Based on observations, interviews and record reviews, the provider failed to ensure that each resident's drug regimen was free from unnecessary drugs for 2 (#3, #20) of 5 (#3, #5, #20, #25, #28) resident's reviewed for unnecessary medications out of a total sample of 29 Stage 2 sampled residents. They failed to ensure: 1) 2 (#3, #20) of 5 (#3, #5, #20, #25, #28) Residents that received antipsychotic's had an adequate indication for its use on the clinical record. 2) A gradual dose reduction was attempted for 1 (#3) of 5 (#3, #5, #20, #25, #28) Resident's antipsychotic drug regimen within a year. 3) Non-pharmacological interventions were implemented for 1 (#3) of 5 (#3, #5, #20, #25, #28) residents prior to increasing the dose of the resident's antipsychotic medication dose. Findings: Resident #3 Review of the clinical record for Resident #3 revealed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Further review of the MDS (Minimum Data Set) observation form for 7 days for the MDS assessment revealed from 8/22/15-8/28/15 the resident never displayed any behaviors of verbal behavioral symptoms or wandering during the 7 day look back period. Review of the November 2015 Physician order [REDACTED]. [MEDICATION NAME] 20 milligram tablet once daily [MEDICATION NAME] 50 microgram tablet once daily [MEDICATION NAME] 150 milligram in Morning and 150 mg at night [MEDICATION NAME] 2 tablets at bedtime Review of the behaviors monitoring record for February 2015 revealed the resident displayed behaviors of Delusions and going in others rooms on 2/21/15. There was no other documentation the resident displayed any behaviors that month. Review of the nurse's notes for the month of January 2015 and February 2015 revealed documentation on 2/2/15 that the resident had increased agitation. Further review revealed Resident #3 displayed some behaviors of yelling on 2/20/15 and 2/21/15. There was no documentation of non-pharmacological interventions implemented. Review of the patient status report sheet on 2/3/15 for Resident #3 revealed the following: Resident #3 had increased agitation- Urinalysis was Negative- Resident gets much worse as the day goes on, anxious, grabbing staff, calling out, pushing at other residents to move out of her way, looks angry a lot. Meds: [MEDICATION NAME] 50 mcg (micrograms) every day, [MEDICATION NAME] 10 mg (milligrams) every day, [MEDICATION NAME] every day, [MEDICATION NAME] 75 mg twice a day and [MEDICATION NAME]. By 4 pm she is asking to go to bed and the once in she's climbing out. Please advise. Physician Response: [MEDICATION NAME] increase to 20 mg every day and [MEDICATION NAME] to 100 mg by mouth twice a day. Review of the Physician orders [REDACTED].#3's [MEDICATION NAME] to 20 mg once a day and [MEDICATION NAME] to 100 mg twice a day. Review of the clinical record revealed no behavior monitoring form for the month of March 2015. Review of the behavior monitoring record for April 2015 through July 2015 revealed the resident was being monitored for delusions and crying out. Further review revealed the resident did not display any behaviors during that time period. Review of the monthly pharmacist drug regimen review revealed a recommendation to reduce the residents [MEDICATION NAME] to 75 mg twice daily which was done on 11/11/14. Further review of the Request for Gradual Dose Reduction form completed on 6/22/15 by the pharmacist revealed the following: Recommendations to consider attempt at gradual dose reductions on the following meds: [MEDICATION NAME] 20 mg by mouth daily and [MEDICATION NAME] 100 mg twice daily. Review of the response completed by the physician on 6/23/15 revealed the following: Do NOT attempt to taper the dose of this drug. In my professional opinion, and/or by diagnosis, to do so is clinically contraindicated (must state why its contraindicated). Further review revealed no clinical indication for the resident to not attempt a GDR (Gradual Dose Reduction) Review of the behavior monitoring record for August 2015 revealed the resident displayed a behavior of hitting 3 times on 8/30/15. Review of the behavior monitoring record for September 2015 through November 2015 revealed the resident was being monitored for delusions and hitting. Further review revealed the resident displayed a behavior of hitting on 2 occasions on 10/16/15. There was no other documentation the resident had displayed any other behaviors. Review of the nursing notes for October 2015 for Resident #3 revealed the following: 10/3/15- No documentation of resident displaying behaviors. 10/6/15- Resident appreared to be anxious. 10/7/15- No documentation of resident displaying behaviors. 10/9/15- No documentation of resident displaying behaviors. 10/10/15- no documentation of resident displaying behaviors. 10/15/15- comes to nurse constantly and says come on, come on, calls me by different names, constantly coming to nurses station, will report to monitor. 10/16/15- Sent a fax to Resident #3's physician to see if Resident's [MEDICATION NAME] needs to be because of her needy behaviors and anger. Review of nursing home patient status report revealed the following on 10/16/15: Request to increase Resident #3's [MEDICATION NAME]. Resident was on 100 mg AM (in the morning) and HS (bedtime) and was hitting and cursing at other residents. She was very needy and following staff around all day, staff would back into her when they were at our carts because she would coming up behind them and sitting in wheelchair behind them. Review of a telephone physician's orders [REDACTED]. An interview was held with S4LPN on 11/11/15 at 1:20 p.m. She stated Resident #3 did not usually have any behaviors. She said the resident would just roll around in her wheelchair. She stated the resident would get agitated on the days when should would have to ride in the van but she would only be agitated that day. An interview was held with S6CNA on 11/11/15 at 1:30 p.m. She stated she cared for Resident #3 for about a year. She stated when the resident first came to the facility, she was acting out and they put her on some medicine. She stated once they put her on the medicine, she was better. She stated Resident #3 and another resident would occasionally curse at each other. She stated that was about a year ago. She explained Resident #3 had not had any behaviors recently. An interview was held with S12RT on 11/12/15 at 9:30 a.m. She stated she cared for Resident #3 3-4 times a week. She stated the resident was very cheerful. She said the resident would sometimes get agitated but it was rare. She stated about a month ago the resident was agitated because she did not get along with certain residents. She stated they would just keep those residents away from each other. She said Resident #3 was very friendly and did not get agitated that often. An interview was held with S2MDS, on 11/12/15 at 10:00 a.m. She stated she was in charge of the MDS assessments and stated the resident had a care pan that was generated from that. When asked if they had identified any issues during the care plan meetings with Resident #3 regarding her antipsychotic drug use, she stated she was not sure she would have to go look in her notes. When she reviewed the notes from the meetings, she said she could not show where is was discussed to reduce Resident #3's antipsychotic drug regimen. An interview was held with S1UnitDir on 11/12/15 at 10:40 a.m. She stated Resident #3 was monitored by the physician every 60 days. She said they would discuss the resident's drug regimen during the care plan meetings. She stated the resident was not having any behaviors because she was on her medication. When asked if they attempted to titrate the resident's medication due to her lack of behaviors, she stated she would have to review the record. She reviewed the master list of the resident's [DIAGNOSES REDACTED]. She stated the resident used to have behaviors where she would hit other residents. When she reviewed the resident's behavior monitoring sheet, Resident #3 had not displayed consistent behaviors. She reviewed the GDR form for Resident #3 from 6/22/2015 and confirmed there was no clinical indication for the need to keep Resident #3 on the same antipsychotic drug regimen. She stated sometimes the nurses would document in the nurses notes if the residents had behaviors. She stated if there were zeros documented on the behavior monitoring sheet, then the resident did not display any behaviors. She stated she was not aware that a discussion had taken place to attempt to reduce the resident's antipsychotic medication and she had not personally discussed with the physician residents medication being reduced with the physician. An interview was held with Resident #3's primary care physician on 11/12/15 at 1:15 p.m. He stated he had recently been notified regarding the resident displaying some behaviors. He stated the resident would roll up and down the hallway in her wheelchair. He stated she had some behaviors when he was first admitted to the facility but she was currently stable. He stated the resident was currently stable on her drug regimen. He stated he had not been contacted by the nursing staff recently regarding reducing the dose of her [MEDICATION NAME]. He stated he would certainly review her medication regimen when he would next see the resident. Review of the clinical record revealed Resident #20 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date of 8/18/15 and 5/19/15 both revealed the use of antipsychotic medication. Review of the Monthly physician's orders [REDACTED]. Review of the Consultant Pharmacist Report, dated 6/22/15, revealed a recommendation to decrease [MEDICATION NAME] 10 milligrams by mouth twice daily and [MEDICATION NAME] 1 milligram by mouth every night. Review of the Monthly Medication Administration Record, [REDACTED]. Review of the 7-Day MDS Observation, dated 8/12/15 - 8/18/15 and 5/13/15 - 5/19/15, revealed no documentation of behavioral symptoms or [MEDICAL CONDITION]. Review of the Behavior Monitoring Psychoactive Flow Record, dated May 2015 - Nov. 2015, revealed no documented evidence of behavioral symptoms. Review of the Physician's Progress Notes revealed the following documentation: 6/30/15 - Action/Plan: 3. Dementia - stable without behavioral issues. 8/26/15 - Action/Plan: 3. Dementia - stable without behavioral issues. On 11/11/15 at 10:59 am, an observation was made of the resident sitting in the dayroom. On 11/11/15 at 10:57 am, an interview was conducted with S6CNA. She stated the resident had not shown any unusual behaviors, delusions, or hallucinations. On 11/12/15 at 12:34 pm, an interview was conducted with Resident # 20. She stated was doing okay and did not have any problems. On 11/12/15 12:05 pm, an interview was conducted with S4LPN. She stated Resident #20 had no behavioral issues, [MEDICAL CONDITION], or delusions. S4LPN stated she did not know why the Resident #20 was taking [MEDICATION NAME]. On 11/12/15 at 12:50 pm, an interview was conducted with S1UnitDir. After review of the clinical record for Resident #20, S1UnitDir verified there was no clinical indication or justification for use of [MEDICATION NAME] documented in the clinical record. On 11/12/15 at 1:25 pm, a telephone interview was conducted with Resident #20 ' s physician. He stated Resident #20 was previously placed on [MEDICATION NAME] for sleep. He stated Resident #20 had no behavioral issues and had been doing well. Resident #20's physician verified there was no need to continue the [MEDICATION NAME]. He stated he would give an order to discontinue the [MEDICATION NAME].

Based on observation, interview, and record review, the facility failed to have an established system of detailed records that included accurate reconciliation on all controlled drugs for 2 of 2 medication carts maintained within the facility. Findings: Review of the facility's policy entitled, "Scheduled II Drugs", revealed in part: Standards: 7. Upon discontinuance of Schedule II drug, remaining medication will be destroyed by the consultant pharmacist in accordance with LA (Louisiana) regulations. 8. Schedule II drugs are counted daily. A. Two nurses count the Schedule II drugs on each cart and in the refrigerator. B. Both nurses sign each sheet verifying the count. On 3/11/15 at 11:10 a.m. an observation was made of B hall medication cart with S4LPN. The following controlled medications were observed to have a sheet wrapped around the medication card: Restoril 15mg - 30 tablets Klonopin 0.5mg - 30 tablets Klonopin 1mg - 22 tablets Klonopin 0.5mg - 5 tablets Tramadol 50mg - 10 tablets Tramadol 50mg - 10 tablets Sonata 5mg - 30 tablets Tramadol 50mg - 60 tablets Norco 5/325 mg - 30 tablets At this time, an interview was held with S4LPN. She stated the above controlled medications were not being counted by the nursing staff. She explained the reason the medication cards had sheets wrapped around them was because the nurses were not using them during that time. She said some of the medications had been discontinued and some of the medications were refills. An observation was made of the refrigerated controlled medications with S4LPN on 3/11/15 at 11:20 a.m. During the observation, four vials of Ativan 1mg/ml injectables were observed in the refrigerator for Resident #32. S4LPN could not locate a count or reconciliation sheet for the medication. Review of Resident #32's March 2015 physician's orders [REDACTED]. Review of the Narcotic Count Verification sheet for Hall A and B revealed only one nurse's signature for the narcotic count on the following days: 1/30/15, 2/9/15, 2/13/15, 2/14/15, 2/25/15, 3/3/15, and 3/6/15. An interview was held with S1DON on 3/11/15 at 1 p.m. S1DON stated that she was unaware the nurses were not reconciling all controlled medications. She stated the nurses should be counting all controlled medications once daily. On 3/11/15 at 11:50 a.m., an observation of the bottom drawer on the A Hall medicine cart revealed two (2) blister packs containing hydrocodone-acetaminophen 7.5-325mg tablets, secured by a rubber band, folded inside a blank form titled "Record of Narcotics and Controlled Drugs". The blister pack labeled number "1 of 2" contained sixty (60) tablets, and the blister pack labeled number "2 of 2" contained thirty (30) tablets. A review of the narcotic count logs revealed a "Record of Narcotics and Controlled Drugs" was initiated on 2/19/15 for Norco 7.5mg/325mg tablets. The last entry, on 3/11/15 at 6:00 a.m., noted the remaining amount of Norco was twenty (20) tablets. On 3/11/15 at 11:55 a.m., an interview with S5LPN revealed that she was the nurse using the A hall medication cart. She stated that when a narcotic was received for a resident, a form titled "Record of Narcotics and Controlled Drugs," was initiated and used to document any changes that affected the amount of medication available. She further stated a narcotic count was performed every morning, by the night nurse and a day shift nurse. Both nurses would then sign a narcotic count log, indicating all narcotic counts were correct. After review of the narcotic count logs, S5LPN confirmed the "Record of Narcotics and Controlled Drugs" indicated that the remaining amount of Norco was twenty (20) tablets. She then confirmed there were two (2) blister packs, containing a total of ninety (90) hydrocodone-acetaminophen 7.5-325mg tablets, which were not being included in narcotic counts. .

Based on observation and interview, the facility failed to promote care for residents in a manner that maintained each resident's dignity by failing to serve all residents seated together, at a table, at the same time, for 8 of the 38 residents that received meals in the main dining room. FINDINGS: An observation was made in the main dining room on 1/12/15 beginning at 11:30 am of residents seated at dining tables. Two tables were observed during this meal service. Seated at Table 1 were Resident #10 who was served at 11:51 am, Resident #1 who was served at 12:10 pm and Resident #16 who was served at 12:15 pm. Resident #10 completed her meal and left the table at 12:05 pm and the other residents had not yet received their meals. Seated at Table 2 were Resident #45 who was served at 11:50 am, Resident #29 who was served at 12:02 pm, Resident #15 who was served at 12:03pm, Resident #28 who was served at 12:08 pm and Resident # 26 who was served at 12:34 pm. An interview was conducted with S7, CNA on 1/12/15 at 12:15 pm who was feeding Resident #28. She stated that Resident # 26 would have to wait to be fed until staff were available to feed her. S7, CNA stated, "we feed the residents as we go." Resident #26 remained seated at the table watching the others eating until she was fed at 12:34 pm An interview was conducted with S8, CNA on 1/12/15 at 12:34 pm who was feeding Resident #26. She stated that residents who required staff to feed them were fed one at a time and that staff left the trays on the cart to ensure that they remained warm. S8, CNA stated that trays were served to residents that could feed themselves first and then to those that required feeding by staff. S8, CNA stated that they did not have enough staff to feed all of the feeders at one time. An interview was conducted with S9, CNA on 1/12/15 at 12:45 pm who stated that the residents who required feeding had to wait until staff were available to feed them one at a time. She stated that they were seated at tables with other residents and were fed at different times. An interview was conducted with S1, DON on 1/12/14 at 3:00 pm who stated that she was not aware that there was a problem with meals being served to residents seated together at different times. She stated that she had not considered this to be a problem.