Every finding on record at The Nicol Home

Based on observation, record review, and interview, the facility failed to provide a written notice for a transfer for Resident (R)5, R7, and R26 (or their representatives) when they were transferred to the hospital or the bed hold policy. The facility also failed to complete a discharge summary with a recapitulation (a concise medical document required during discharge from a long-term care facility or nursing home. It summarizes the resident's course of treatment, diagnoses, and medical progress) of R33's stay when R33 was discharged from the facility. Findings included:- R7's Nurse's Note, dated 04/25/2025 at 02:50 PM, documented the resident admitted to the hospital.R7's clinical record lacked evidence that the resident or representative was provided with a written notification of transfer, or a copy of the bed hold policy. Upon request, the facility was unable to provide evidence.2. R5's Nurse's Note, dated 01/23/2026 at 08:35 PM, documented R5 admitted to the hospital for observation and urinary tract infection (UTI-an infection in any part of the urinary system).R5's Nurse's Note, dated 02/08/202026 at 09:42 PM, documented R5 admitted to the hospital for a UTI.R5's clinical record lacked evidence that the family received written notification of the transfer or a copy of the bed hold policy for the transfers on 01/23/26 and 02/08/2026. Upon request, the facility was unable to provide evidence.3. R26's Nurse's Note, dated 05/14/2026 at 06:12 PM, documented R26 admitted to the hospital for kidney failure.R26's clinical record lacked evidence that the resident or representative was provided with a written notification of transfer or a copy of the bed hold policy. Upon request, the facility was unable to provide evidence.4. R33's Nurse's Note, dated 04/29/2026 at 09:45 AM, documented R33 transferred to another facility.R33's Discharge Summary, dated 04/29/2026 at 09:45 AM, documented that the resident was discharged to another facility to be closer to the spouse. Report was given to the nurse at the receiving facility, and vital signs were checked. The summary documented R33 was alert and oriented to person and place, required extensive assistance with most activities of daily living (ADLs). R 33 had multiple scabbed areas on the extremities and a pressure area on the right buttocks, with a dressing change done. R33 continued to have a urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) with cloudy yellow urine and required a lot of encouragement to drink fluids to try and prevent UTIs. All belongings were sent with the family at the time of discharge. The summary lacked a recapitulation of R33's stay, which included medication reconciliation (a formalized process of creating the most accurate and complete list of a patient's current medications-including dosages, frequencies, and routes-and comparing it to their newly prescribed medications).On 06/10/26 at 10:44 AM, Social Service Designee (SSD) II and Administrative Nurse BB verified the facility failed to provide R5, R7, and R26 or their representative with a bed hold form or written notification of transfers to the hospital on the above dates. SSD II and Administrative Nurse BB stated they were unaware they were required to provide a written notice to residents or their representatives when they transferred to the hospital; the nurse who transferred them was responsible for notifying them. SSD II and Administrative Nurse BB stated the bed hold policy was provided to the residents or their representatives on admission.The facility's Bed-Holds and Returns Policy, revised October 2022, documented all residents /representatives would be provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave)The facility's Transfer or Discharge, preparing a Resident for Policy, revised 12/2016, documented that when a resident was scheduled for transfer or discharge, the nursing services would be responsible for the following:Obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment Preparing the discharge summary and post-discharge plan Preparing the medications to be discharged from the resident (as permitted by law) Providing the resident or representative with required documents (discharge summary and plan) Packing and collecting personal possessions Assisting with transportation as applicableEscorting the resident to transportationCompleting the discharge note in the medical record.The business office was responsible for informing the resident or his or her representative of the facility's bed-holding policy.

Based on observation, record review, and interview, the facility failed to initiate interventions to prevent the development of a Stage 2 pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction) for Resident (R) 26. Findings included:- R26's Electronic Health Record (EHR) revealed diagnosis of chronic kidney disease (long term condition where the kidneys are damaged and gradually lose their ability to filter waste), hyperkalemia (greater than normal amount of potassium in the blood), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), heart failure, and muscle weakness. R26's Significant Change Minimum Date Set (MDS), dated [DATE] recorded R26 had a Brief Interview for Metal Status (BIMS) score of 12, indicating moderately impaired cognition. The assessment revealed R27 required extensive staff assistance of two for bed mobility, personal hygiene, dressing, repositioning, and transfers. The resident was at risk for pressure ulcer development but had no skin issues or pressure ulcers. The MDS documented that the resident had a pressure-reducing device in her chair. R26's Skin Care Plan dated 02/23/26, documented R26 had potential for skin impairment due to fragile skin, impaired mobility, and bowel and bladder incontinence. The care plan documented staff would encourage good nutrition and hydration to promote healthier skin, encourage R26 to reposition often when sitting for long periods of time. The care plan documented staff to use caution with transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. R26's Activities of Daily Living (ADL) Care Plan dated 02/23/26, recorded R26 required extensive assistance of one to two staff with most ADLs. The Braden Scale for Predicting Pressure Ulcer assessment dated [DATE] documented a score of 15, which indicated the resident was at mild risk for pressure ulcer development.The Nurse Notes dated 05/11/26 at 10:59 AM, documented R26 had an intact blister on her left heel, and staff would float her heels and placed a pressure relieving boot on her left foot to prevent any further pressure to her left heel. The Nurse Notes dated 05/14/26 at 01:58 PM, documented the resident had labs and diagnosed with acute kidney failure and was sent to the hospital for further treatment. The Nurse Notes dated 05/18/26 at 12:00 PM, documented the resident returned to the facility and the left heel blister was intact. The Skin Notes dated 05/18/26 at 02:34 PM, documented blister to left heel progressed to an open area, facility acquired. The area measured 2.74 centimeters(cm) in length, by 2.4 cm in depth, with no tunneling. Small amount of serosanguineous (semi-thick blood-tinged drainage) drainage. Staff to use wound cleanser with a Silvercel (a specialized antimicrobial wound dressing that is used to manage heavy wound drainage while actively releasing silver ions to kill bacteria and prevent infection) dressing and border foam dressing (an advanced wound care bandage with an absorbent polyurethane foam pad in the center surrounded by soft, self-adhering border) two times a week. The Skin Notes dated 06/02/26 at 10:27 PM, documented an open area on the left heel, 1.36 cm in length by 1.32 cm in width, with no tunneling, mixture of serosanguineous drainage. Staff use wound cleanser with Silvercel dressing and covered with a border foam two times a week. R26's EHR documented a physician order dated 05/26/26 which directed staff to apply Silvercel to wound bed and cover with Mepilex Border Foam and change dressing every 72 hours and as needed if it becomes soiled or dislodged until the wound healed. On 06/09/26 at 03:20 PM, observation revealed R26 lying on her back in bed. Licensed Nurse (LN) A assisted Administrative Nurse BB to keep R26 left foot and leg elevated while she performed wound care to R26's left heel. Administrative Nurse BB cleansed R26's left heel with wound cleansed, then applied Silvercel wound dressing and covered with a Border Foam pad, there was no drainage noted. Administrative Nurse BB then applied a pressure relieving boot to R26's left heel and elevated it on a pressure relieving cushion. On 06/10/26 at 10:45 AM, Administrative Nurse BB verified R26's pressure ulcer was facility acquired and stated she developed it after she had a decline in condition. Administrative Nurse BB verified the resident had a pressure relieving cushion in her chair but did not have a pressure relieving boot or offloading interventions prior to when she acquired the pressure area. The facility's Pressure Injury Risk Assessment policy, dated March 2020, documented the purpose of the pressure injury risk assessment was to identify a risk factor and then to determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify. The facility would complete the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the residents' condition. Risk factors that increase a resident's susceptibility to develop or not heal a pressure injury include nutrition, malnutrition, and hydration deficits, impaired and decreased mobility and decreased functional ability. Once the assessment is conducted and risk factors are identified and characterized, a resident center care plan can be created to address and modifiable risks for pressure injuries.

The facility had a census of 30 residents. The sample included 13 residents. Based on the interview and record review, the facility failed to submit complete and accurate information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit accurate staffing hour date for all direct care personnel as required. This placed the residents at risk for unidentified issues with inadequate staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2024 Quarter 2 documented the metric for Registered Nurse (RN) hours and Licensed Nurse (LN) Coverage 24hours/Day was suppressed for the facility and quarter. The PBJ report for FY 2023 Quarter 4 documented 13 dates the facility did not have LN coverage. A review of the nursing schedule and timesheet payroll for FY 2023 Quarter 4 and FY 2024 Quarter 2 revealed LN and RN coverage. On 07/31/24 at 08:05 AM, Administrative Staff A reported he was responsible for submitting the PBJ information and verified he had an inaccurate submission for FY 2023 Quarter 4. Administrative Staff A verified he did not make the submission deadline for FY Quarter 2. The facility's Reporting Direct Care Staffing Information(Payroll-Based Journal) policy, dated 08/2022, documented direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system. Direct care staffing information is submitted on the schedule specified by CMS, but no less frequently than quarterly. Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. The facility failed to submit accurate information to CMS PBJ. This placed the residents at risk for unidentified issues with inadequate staffing.

The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan that addressed the individual resident needs for Resident (R)17, R12, R5, R13, and R26. This placed the residents at risk for impaired care due to uncommunicated needs. Findings included: - R17's Electronic Medical Record (EMR) documented diagnoses of muscle weakness, fluency (speech) disorder following nontraumatic subarachnoid hemorrhage (bleeding in the space just outside the brain), atrial fibrillation (rapid, irregular heartbeat), major depressive disorder (major mood disorder which causes persistent feelings of sadness), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), abnormalities of gait and mobility, and dementia (progressive mental disorder characterized by failing memory, confusion) The Quarterly Minimum Data Set, dated dated [DATE], documented R17 had severe cognitive impairment, functional range of motion of one side of the upper and lower extremities, used a wheelchair for mobility, and was dependent on staff with functional abilities. R17 was always incontinent of urine and bowel and at risk for pressure ulcers. R17's Care Plan, dated 06/26/24, documented the resident had a self-care deficit related to confusion and stroke, directing staff to place heel protectors on while in bed or chair. The care plan lacked documentation and instruction for R17's left heel and great toe wounds. The Skin Progress Note, dated 05/23/24 at 09:58 AM, documented a care plan meeting was held with a family member and they spoke about any skin breakdown which R17 had none. The Skin Progress Note, dated 05/26/24 at 05:15 PM, documented an unstageable area noted outer left foot, Skin-prep (liquid skin barrier) was applied, heel protectors were in place and R17's feet were floated on pillows. The Skin Progress Note, dated 06/09/24 at 01:00 PM documented that R17's great toenail was lifting and had drainage underneath the nail bed. R17's EMR documented physician notification of skin injuries and provided orders for treatment. On 07/01/24 the physician providing routine foot and wound care to the feet documented that staff were unable to feel pulses in either foot; R17's feet were dusky in color. R17 had been taken off of insulin due to a family request as R17 had been on hospice services, and blood sugars had been running higher than the machine could read. The family was educated on diabetic blood sugar control and wound healing and chose to resume insulin orders. The note further documented a non-pressure chronic ulcer to the left foot, with peripheral circulation disorder associated with diabetes mellitus. On 07/30/24 at 09:25 AM, observation revealed Administrative Nurse E provided wound care to R17's left foot. R17 feet had been elevated off the bed with a pillow. R17 wore foam-protective pressure-reducing boots, had a blanket lifter/foot cradle at the foot end of the bed, and a pressure-reducing winged mattress on the bed. R17 had slept through the procedure of wound care without indications of discomfort. On 07/31/24 at 11:57 AM, Certified Nurse Aide (CNA) P reported R17 was dependent on staff for all care, was repositioned every two hours, wore padded boots at all times, and was positioned with her legs on pillows to prevent the feet from laying on the bed. On 07/31/24 at 12:53 PM, Administrative Nurse E verified she had not included the wounds, treatment, and interventions on R17's Care Plan. The facility's Care Plans Goals and Objectives policy, dated 04/2009, documented care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives are defined as the desired outcome for specific resident problems. Goals and objectives are entered into the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcome is being achieved. Goals and objectives are reviewed and or revised when there has been a significant change in the resident's condition when the desired outcome has not been achieved, when the resident has been readmitted to the facility, and at least quarterly. The facility failed to develop a comprehensive care plan related to R13's wound care. This placed the resident at risk for impaired care due to uncommunicated care needs. - R12's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN-elevated blood pressure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), occlusive and stenosis (narrowing or constricted) of unspecified carotid artery, hypothyroidism (a condition characterized by decreased activity of the thyroid gland), pure hypercholesterolemia (greater than normal amounts of cholesterol in the blood), chronic kidney disease and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R12 had severe cognitive impairment and wandered daily. R12 required substantial/maximal assistance with dressing and personal hygiene, partial to moderate assistance with toileting hygiene, and supervision/touch assistance with mobility with the use of a walker. R12 had frequent incontinence of urine and bowel and no diagnosis of urinary tract infection (UTI). R12 received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), antibiotic (class of medication used to treat infections), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used to treat pain). The MDS further documented an antipsychotic was received on a routine basis only but had no gradual dose reduction (GDR), and no physician documentation as clinically contraindicated. R12's Care Plan, dated 06/20/24, documented R12's medications had Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) with potential reactions and adverse side effects. This included the use of the following: Ativan (antianxiety) could be associated with an increase in confusion, loss of balance, and cognitive impairment that looks like dementia and increases the risk of falls, broken hips, and legs. R12's Care Plan lacked mention of nonpharmacological approaches to try before the use of as-needed (PRN) Ativan. R12's EMR documented tA Physician's Order dated 05/19/23 for Ativan 0.5 milligrams (mg) every eight hours PRN for agitation. On 07/30/24 at 08:01 AM, R12 was in the dining room, dressed and groomed appropriately for the day. 07/31/24 at 11:57 AM Certified Nurse Aide (CNA) P reported staff provides reassurance when she is anxious, is less tearful, but is easily frustrated, usually redirectable. On 07/31/24 AM Licensed Nurse (LN) H reported staff tried non-pharmacologic interventions for the use of PRN Ativan and stated staff and physician discussed the issue of pain involvement related to behaviors. LN H stated staff had not documented the use of non-pharmacological interventions which should be found in the care plan. On 07/31/24 at 12:53 PM, Administrative Nurse D verified R12 received PRN Ativan which did not have a stop date, and the care plan lacked directions to staff of non-pharmacological interventions prior to use prior to administering PRN Ativan. The facility's Care Plans Goals and Objectives policy, dated 04/2009, documented care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives are defined as the desired outcome for specific resident problems. Goals and objectives are entered into the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcome is being achieved. Goals and objectives are reviewed and or revised when there has been a significant change in the resident's condition when the desired outcome has not been achieved, when the resident has been readmitted to the facility, and at least quarterly. The facility failed to complete a comprehensive care plan related to R12's use of PRN Ativan placing the resident at risk for impaired care due to uncommunicated care needs. - R5's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic atrial fibrillation (rapid, irregular heartbeat), major depressive disorder (major mood disorder which causes persistent feelings of sadness), chronic kidney disease and morbid obesity. R5's Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had intact cognition. R5 required supervision or touching assistance with toileting hygiene and was frequently incontinent of urine and occasionally incontinent of bowel. The MDS recorded R5 had no urinary tract infection (UTI) and received an antidepressant (class of medications used to treat mood disorders), anticoagulant (medication to prevent blood from clotting), and diuretic (a medication to promote the formation and excretion of urine). R5's Care Plan, dated 06/27/24, documented R5 had a self-care deficit due to age and weakness and instructed staff to assist with morning and evening care. The care plan lacked interventions related to the use of antibiotics daily for UTIs. The Physician Order dated 04/19/24 directed staff to administer Macrodantin (an antibiotic) 100 milligrams (mg) at bedtime for chronic UTIs. The Physician Order, dated 05/31/24, directed staff to administer cefdinir 300 mg two times a day for 10 days for UTI. R5's EMR recorded only one UTI for the year during the period of 07/2023 to 07/2024 on 05/32/24. On 07/30/24 at 11:13 AM, observation revealed R5 sat in her room, in her recliner. R5 reported she was able to identify symptoms of UTIs and would report them to staff. She stated she had frequent UTIs in the past, but it was less frequent in the facility. She also reported she did not know what her medication regimen was, and she had confidence the staff was administering them correctly. On 07/31/24 at 10:33 AM, Licensed Nurse (LN) H recognized R5 had ongoing antibiotic use and R5 was able to report to staff signs of UTI. On 07/31/24 at 11:57 AM, Certified Nurse Aide (CNA) P reported R5 toileted herself but did ask for assistance when needed. CNA P reported staff ensure the resident is cleansed properly when assistance is requested. On 07/31/24 at 12:53 PM, Administrative Nurse D verified R5's Care Plan lacked identifying the long-term use of an antibiotic for UTIs and should be addressed with interventions. The facility's Care Plans Goals and Objectives policy, dated 04/2009, documented care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plan goals and objectives are defined as the desired outcome for specific resident problems. Goals and objectives are entered into the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcome is being achieved. Goals and objectives are reviewed and or revised when there has been a significant change in the resident's condition when the desired outcome has not been achieved, when the resident has been readmitted to the facility, and at least quarterly. The facility failed to develop a comprehensive care plan related to R5's use of daily antibiotic use for a history of UTI placing the resident at risk for impaired care due to uncommunicated care needs. 32360 - The Electronic Medical Record (EMR) for R13 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) without behavioral disturbance, hypertension (elevated blood pressure), and depression (abnormal emotional state characterized by exaggerated feelings of sadness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had severely impaired cognition. R13 required substantial assistance for toileting, dressing, and personal hygiene. R13 required supervision with transfers and ambulation. The MDS documented R13 received an antidepressant (medication used to treat mood disorders and relieve symptoms of depression). R13's Care Plan, dated 06/20/24 and initiated on 03/09/20, documented R13 had dementia and would sometimes wander and directed staff to cue, reorient, and supervise as needed. R13's Care Plan lacked interventions for the use of antipsychotic (used to treat psychosis and other mental or emotional conditions) medication and any related Black Box Warning (BBW-a warning from the Food and Drug Administration for serious adverse reactions or special problems that could occur that may lead to death or serious injury). The Physician's Order, dated 07/26/24, directed staff to administer Risperdal (an antipsychotic medication), 0.25 milligrams (mg), by mouth, twice per day for dementia without behavioral disturbance. On 07/30/24 at 10:32 AM, observation revealed Certified Nurse Aide (CNA) M placed a gait belt around R13's wait, and CNA M and CNA P assisted R13 to stand up in front of her walker to ambulate to the bathroom. Staff assisted R13 with personal care, stood her up, and assisted her back to her recliner without resistance with care. On 07/30/24 at 09:00 AM, Certified Nurse Aide O stated R13 had behaviors and was at times resistant to care. On 07/31/24 at 09:20 AM, Licensed Nurse (LN) H stated R13 had advanced dementia; R13 was resistant to care with staff and was recently placed on Risperdal. Licensed Nurse H further stated R13 also received Ativan( antianxiety medication) as needed on her shower days. On 07/31/24 at 12:45 PM Administrative Nurse D stated staff saw that the Risperdal had not flagged on the care plan for a BBW but they had not had the opportunity to document the medications and side effects on the care plan. The facility's Goals and Objectives, Care Plans policy, dated 04/09, documented care plan should incorporate goals and objectives that lead to the resident's highest obtainable level of independence and are defined as the desired outcome for a specific resident problem. Care plan goals and objectives were derived from information contained in the resident's comprehensive assessment. The facility failed to develop a comprehensive care plan for R13's use of an antipsychotic medication. This placed her at risk for impaired care due to uncommunicated care needs. - The Electronic Medical Record (EMR) documented R26 had diagnoses of diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough sepsis made or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion, and weakness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R26 had severely impaired cognition and required partial to moderate assistance with toileting, dressing, set-up assistance with mobility, transfers, and supervision with ambulation. The MDS documented R26 required insulin (a hormone that lowers the level of glucose in the blood) daily. R26's Care Plan lacked documentation a diabetes care plan was implemented to provide direction to staff to care for the resident with a diagnosis of diabetes and of R26's insulin pump (an insulin-delivering device). The Physician's Order, dated 08/09/23, directed staff to obtain an accucheck (a test that measured the amount of glucose, or sugar in a blood sample). The Physician's Order, dated 07/02/24, directed staff to document R26's total carbohydrates (compounds that include sugars, starch, and cellulose used in the body for energy) for each meal in the insulin pump so that it would deliver a bolus of insulin based on carbohydrate count at meals. The Physician's Order, dated 07/03/24, directed staff to charge the insulin pump every day for 15 minutes. The Physician's Order, dated 07/03/24, directed staff to check the placement of the insulin pump every shift. The Physician's Order, dated 07/07/24, directed staff to change the insulin pump cartridge and site every 48 hours. The Physician's Order, dated 07/07/24, directed staff to administer Ozempic (an injectable medication that helps manage blood sugar levels), 2 milligrams (mg) sq in the morning every Sunday for DM. The Physician's Order, dated 07/08/24, directed staff to administer Humalog (rapid-acting insulin), 1.7 units every hour via insulin pump for a total of 20.4 units every 12 hours for DM. The Physician's Order, dated 07/08/24, directed staff to administer insulin aspart (a short-acting manmade versus of human insulin), 25 units at lunch if the insulin pump failed. The Physician's Order, dated 07/08/24, directed staff to administer Novolog (a fast-acting insulin), 35 units at breakfast and supper if the insulin pump failed. The Physician's Order, dated 07/07/24, directed staff to administer Tresiba (long-acting insulin), 100 units, every 24 hours as needed for blood sugar control and administer 100 units at bedtime if the insulin pump failed. The Physician's Order, dated 07/11/24, directed staff to change the placement of the insulin pump every 10 days in the afternoon. On 07/31/24 at 10:20 AM, observation revealed R26 was lying on her bed with the insulin pump beside her. R26 stated she loved having the pump and that she was happy that she did not get stuck all the time and it was working well for her. On 07/31/24 at 10:20 AM, Licensed Nurse (LN) H stated the insulin pump worked great for R26 and she was doing well with it. LN H further stated that her daughter was one of the nurses on staff and had done a lot of research on insulin pumps and was able to find a doctor who would be in charge of the pump and provided the facility with training and a manual to use if needed. On 07/31/23 at 12:45 PM, Administrative Nurse D stated R26 should have a diabetes care plan and the insulin pump should be addressed on the care plan to provide staff direction for care. The facility's Goals and Objectives, Care Plans policy, dated 04/09, documented care plan should incorporate goals and objectives that lead to the resident's highest obtainable level of independence and are defined as the desired outcome for a specific resident problem. Care plan goals and objectives were derived from information contained in the resident's comprehensive assessment. The facility failed to develop a comprehensive care plan for R26 ' s DM and insulin pump. This placed her at risk for impaired care due to uncommunicated care needs.

The facility had a census of 30 residents. The sample included 13 residents, with seven reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure an appropriate indication, or a documented physician rationale, which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for continued use for Resident (R)4, R13, R2, and R12s' antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication and failed to ensure a 14-day stop date or specified duration for R13 and R12's ongoing as needed (PRN) antianxiety (a class of medications that calm and relax people with excessive anxiety, nervousness, or tension). This placed the residents at risk for unintended effects related to psychotropic (alters mood or thought) drug medications. Findings included: - The Electronic Medical Record (EMR) for R4 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) without behavioral disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 had moderately impaired cognition and was dependent upon staff for toileting, dressing, and transfers. R4 required substantial assistance from staff for personal hygiene and mobility, and R4 did not ambulate. The MDS documented R4 had periods of feeling down about herself, had no behaviors, and received antidepressants (medication used to treat mood disorders and relieve symptoms of depression) daily. R4's Care Plan, dated 05/10/24, initiated on 08/18/22, directed staff to administer medications as ordered by the physician and monitor for side effects, consult with the pharmacy to consider dosage reduction and monitor for target behaviors. The Physician's Order, dated 06/21/24, directed staff to administer Rexulti (atypical antipsychotic medication), 0.25 milligram (mg), by mouth, in the evening for dementia. The medication was discontinued on 07/10/24. The Physician's Order, dated 07/10/24, directed staff to administer Rexulti, 0.5 mg, by mouth, in the evening for dementia. R4's EMR lacked a documented physician rationale which included unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued Rexulti use. On 07/30/24 at 09:15 AM, observation revealed R4 in the doorway of her room. R4 was very pleasant and stated she was very happy with her care. On 07/30/24 at 09:00 AM, Certified Nurse Aide (CNA) O stated R4 did not have the typical behaviors but did obsess about a male resident in the facility that she was friends with and always wanted to be with. On 07/31/24 at 09:20 AM. Licensed Nurse (LN) H stated R4 would get upset if she wanted to watch the news out in the living room area and other residents were watching something else but said she had never been aggressive with other residents. On 07/31/24 at 12:45 PM, Administrative Nurse D stated the family requested she be placed on the medication due to the obsessive calls to her family. Administrative Nurse D further stated the Consultant Pharmacist recommended a reduction in the medication due to the obsessive phone calls to family were less frequent and that the medication was not appropriate for residents with dementia, so the physician did decrease the dose. The facility's Antipsychotic Use policy, dated 07/22, documented that residents would not receive medications that were not clinically indicated to treat a specific condition and would be prescribed at the lowest possible dosage, for the shortest period of time and are subject to gradual dose reduction and re-review. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Residents would be informed of the recommendations, risks, benefits, purpose, and potential adverse consequences of the medication use. The facility failed to ensure R4 did not receive antipsychotic medication without an appropriate indication or required documentation for its use. This placed R4 at risk for adverse side effects. - The Electronic Medical Record (EMR) for R13 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) without behavioral disturbance, hypertension (elevated blood pressure), and depression (abnormal emotional state characterized by exaggerated feelings of sadness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had severely impaired cognition. R13 required substantial assistance for toileting, dressing, and personal hygiene. R13 required supervision with transfers and ambulation. The MDS documented R13 received an antidepressant (medication used to treat mood disorders and relieve symptoms of depression). R13's Care Plan, dated 06/20/24 and initiated on 03/09/20, documented R13 had dementia and would sometimes wander and directed staff to cue, reorient, and supervise as needed. The care plan directed staff to administer medications as ordered, document for side effects and effectiveness, and report any signs of depression or anxiety. The Physician's Order, dated 05/30/24, directed staff to administer Ativan (an antianxiety medication), 1 milligram, by mouth, four times per day, as needed for agitation. The order lacked a stop date. The Physician's Order, dated 07/26/24, directed staff to administer Risperdal (an antipsychotic medication), 0.25 milligrams (mg), by mouth, twice per day for dementia without behavioral disturbance. R13's EMR lacked a documented physician rationale which included unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued Risperdal use. On 07/30/24 at 10:32 AM, observation revealed Certified Nurse Aide (CNA) M placed a gait belt around R13's wait, and CNA M and CNA P assisted R13 to stand up in front of her walker to ambulate to the bathroom. Staff assisted R13 with personal care, stood her up, and assisted her back to her recliner without resistance with care. On 07/30/24 at 09:00 AM, Certified Nurse Aide O stated R13 had behaviors and was at times resistant to care. On 07/31/24 at 09:20 AM, Licensed Nurse (LN) H stated R13 had advanced dementia, was resistant to care with staff, and was recently placed on Risperdal. Licensed Nurse H further stated R13 also received Ativan as needed on her shower days. On 07/31/24 at 12:45 PM Administrative Nurse D stated she was unaware that the Ativan required a 14-day stop date and of the inappropriate indication for Risperdol. Administrative Nurse D stated she would work with the physician on the Risperdal. The facility's Antipsychotic Use policy, dated 07/22, documented that residents would not receive medications that were not clinically indicated to treat a specific condition and would be prescribed at the lowest possible dosage, for the shortest period of time and are subject to gradual dose reduction and re-review. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Residents would be informed of the recommendations, risks, benefits, purpose, and potential adverse consequences of the medication use. Residents who received as-needed psychotropic medication would not be renewed beyond 14 days unless the healthcare practitioner had evaluated the resident for the appropriateness of that medication and documented the rationale for continued use. The facility failed to ensure R13 did not receive antipsychotic medication without an appropriate indication or the required documentation for its use and failed to ensure R13's Ativan had a 14-day stop date or specified duration. This placed the resident at risk for adverse side effects. 37450 - R12's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN-elevated blood pressure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), occlusive and stenosis (narrowing or constricted) of unspecified carotid artery, hypothyroidism (a condition characterized by decreased activity of the thyroid gland), pure hypercholesterolemia (greater than normal amounts of cholesterol in the blood), chronic kidney disease and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R12 had severe cognitive impairment and wandered daily. R12 required substantial/maximal assistance with dressing and personal hygiene, partial to moderate assistance with toileting hygiene, and supervision/touch assistance with mobility with the use of a walker. R12 had frequent incontinence of urine and bowel and no diagnosis of urinary tract infection (UTI). R12 received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), antibiotic (class of medication used to treat infections), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used to treat pain). The MDS further documented an antipsychotic was received on a routine basis only but had no gradual dose reduction (GDR), and no physician documentation as clinically contraindicated. R12's Care Plan, dated 06/20/24, documented R12's medications had Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) with potential reactions and adverse side effects. This included the use of the following: Venlafaxine (antidepressant) could lead to worsening of suicidal thoughts and behaviors Ativan (antianxiety) could be associated with an increase in confusion, loss of balance, and cognitive impairment that looks like dementia and increases the risk of falls, broken hips, and legs. Olanzapine (antipsychotic) is not approved for the treatment of patients with dementia-related psychosis and has an increased risk of death. R12's EMR documented the following physician orders: 02/16/24 venlafaxine 50 milligrams (mg) two times a day for depression. 05/19/23 Ativan 0.5 mg every eight hours PRN for agitation (no stop date). 03/31/23 Olanzapine two times a day for behaviors. R12's Medication Administration Record (MAR) revealed the use of as-needed (PRN) Ativan three times in March 2024, six times in April 2024, eight times in May and June 2024, and four times in July 2024. On 05/14/24 at 10:38 AM, Progress Note documented R12 had increased behaviors requiring the use of PRN Ativan, and a verbal order was received for a urine analysis. On 07/30/24 at 08:01 AM, R12 was in the dining room, dressed and groomed appropriately for the day. On 07/31/24 at 12:53 PM, Administrative Nurse D verified that R12 received an antipsychotic without an approved indication and the required physician documentation. Administrative Nurse D verified R12's PRN Ativan did not have a stop date, and there was no documentation of non-pharmacological interventions prior to use. The facility's Psychotropic Medication Use policy, dated 07/2022, documented that residents will not receive medication that is not clinically indicated to treat a specific condition. Consideration of the use of any psychotropic medication is based on a comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions) unless clinically contraindicated, in an effort to discontinue these medications. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are NOT antipsychotics, if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. When determining whether to initiate, modify, or discontinue medication therapy, the IDT conducts an evaluation of the resident. The facility failed to ensure R12 did not receive antipsychotic medication without appropriate indications for or required documentation for its use and failed to ensure R12's PRN Ativan had a 14-day stop date or specific duration. This placed the resident at risk for adverse side effects. - R2's Electronic Medical Record (EMR) documented diagnoses of chronic kidney disease, polyosteoarthritis (many sites of inflammation of a joint characterized by pain, swelling, redness, and limitation of movement), weakness, and displaced fracture (broken bone) of the humerus (upper arm bone). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had severe cognitive impairment without delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment perception), or behaviors. R2 required setup or clean-up assistance and had frequent incontinence of urine and occasional incontinence of bowel. R2 received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication to treat pain). The MDS further documented an antipsychotic was received on a routine basis only, had no gradual dose reduction (GDR) attempt, and no physician documentation of GDR as clinically contraindicated. R2's Care Plan, dated 06/06/24, documented R2 was dependent on staff for meeting emotional, intellectual, physical, and social needs due to immobility and lacked the use of quetiapine (antipsychotic) and Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) or mood state with non-pharmacological interventions. The Physician Order, dated 10/25/23, directed staff to administer quetiapine 25 milligrams (mg) twice a day for anxiety. The Consultant Pharmacist (CP) medication review on 04/17/24 documented that R2 received quetiapine twice a day and recommended attempting a gradual dose reduction twice within the first year, then yearly. The CP requested the physician to evaluate the current therapy and document accordingly. The CP recommendation did not identify the inappropriate indication associated with the use of quetiapine. On 04/18/24, the CP documented the physician requested no changes and would consider GDR next year. The documentation lacked the reason for continued use without a GDR. The Progress Note dated 10/24/23 at 05:55 PM, documented a physician visit with R2 due to pain and increased tearfulness, and orders were received to obtain an x-ray of the left hip and lumbar spine, start morphine (opioid) PRN for pain for two days only. The progress note further documented R2 was upset and thought nobody cared about her and was very tearful. R2's clinical record lacked evidence of documented nonpharmacological interventions attempted and failed or the risks versus benefits of continued use without GDR. On 07/31/24 at 10:33 AM Licensed Nurse (LN) H, reported R2's mood had been good, and she had a history of tearfulness and anxiousness. LN H reported that R2 had been coming out of her room more lately. LN H also stated R2's mood seemed to be related to pain and the physician had made changes to her medication and this had helped. On 07/31/24 at 11:33 AM, Certified Nurse Aide (CNA) P reported R2 was less tearful and anxious. On 07/31/24 at 12:53 PM, Administrative Nurse D verified the antipsychotic was started without documentation of nonpharmacological interventions attempted prior and verified the physician had not provided a rationale for the continued use or lack of GDR. The facility's Psychotropic Medication Use policy, dated 07/2022, documented that residents will not receive medication that is not clinically indicated to treat a specific condition. Consideration of the use of any psychotropic medication is based on a comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions) unless clinically contraindicated, in an effort to discontinue these medications. The facility failed to ensure R2 did not receive antipsychotic medication without appropriate indications or the required documentation for its use and failed to provide a rationale for the lack of a GDR. This placed the resident at risk for adverse side effects related to psychotropic medication use.

The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise the resident's care plan to reflect the resident's current health needs for Resident (R)3. This placed the resident at risk for impaired care due to uncommunicated care needs. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough sepsis made, or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), edema (swelling resulting from an excessive accumulation of fluid in the body tissues) and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition. R3 required substantial assistance for transfers, partial assistance for dressing and personal hygiene, and set-up assistance for toileting, mobility, and ambulation. The MDS documented R3 had no skin issues. R3's Care Plan, dated 06/27/24 and initiated on 10/19/22, directed staff to inspect R3's skin during showers for any redness, open areas, scratches, cuts, or bruises, and report any changes to the nurse. The care plan lacked direction to staff on the prevention or treatment of skin tears. The Skin/Wound Note, dated 06/27/24 at 01:34 PM, documented R3 obtained three skin tears to his left forearm from a dog during pet therapy while he gave the dog a treat. The area was cleansed, approximated (edges brought together), and Steri-strips (adhesive wound closures) applied. The note further documented the area was covered with a dressing and wrapped with gauze for protection. The Skin/Wound Note. dated 07/14/24 at 08:37 PM, documented R3 bumped his hand on his drawer and obtained a skin tear above his left thumb. The area was cleansed, and Steri-strips were applied. On 07/29/24 at 10:15 AM, observation revealed a skin tear with multiple Steri-strips on R3's right hand by his thumb. R3 stated he bruised easily and explained he hit his hand on his walker and obtained a skin tear on his right hand. R3 stated he always had bruises or skin tears. On 07/30/29 at 09:00 AM, Certified Nurse Aide (CNA) O stated she was aware of a previous skin tear from a dog and said R3's skin was very fragile. CNA O further stated she was unsure of where R3's current skin tear came from. CNA O said R3 did not wear anything to protect his skin from further injury. On 07/31/24 at 08:46 AM, Administrative Nurse E stated she was unaware of R3's current skin tear and was unable to find any information or a skin assessment related to it. On 07/31/24 at 09:00 AM, Licensed Nurse (LN) H stated residents were assessed in the shower for any skin tears, bruises, or skin changes. LN H stated they had not been made aware of the skin tear on R3's right hand. On 07/31/24 at 12:45 PM Administrative Nurse D stated a skin assessment should have been completed and placed on R3's care plan for interventions to prevent further skin tears. The facility's Goals and Objectives, Care Plans policy, dated 04/09, documented care plan should incorporate goals and objectives that lead to the resident's highest obtainable level of independence and are defined as the desired outcome for a specific resident problem. Care plans are reviewed and/or revised when there is a significant change in condition when the desired outcome has not been achieved, when readmitted after a hospital stay, and at least quarterly. The facility failed to revise the care plan for R3's skin tears. This placed R3 at risk for impaired care due to uncommunicated care needs.

The facility had a census of 30 residents. The sample included 13 residents, with three reviewed for quality of care. Based on observation, record review, and interview, the facility failed to implement interventions to prevent skin tears for Resident (R) 3 and failed to provide general skincare and services for R29, who had multiple sores on his arms. This placed the residents at risk for further skin injury and related complications. Findings included: - The Electronic Medical Record (EMR) for R3 documented diagnoses of diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough sepsis made, or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), edema (swelling resulting from an excessive accumulation of fluid in the body tissues) and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition. R3 required substantial assistance for transfers, partial assistance for dressing and personal hygiene, and set-up assistance for toileting, mobility, and ambulation. The MDS documented R3 had no skin issues. R3's Care Plan, dated 06/27/24 and initiated on 10/19/22, directed staff to inspect R3's skin during showers for any redness, open areas, scratches, cuts, or bruises, and report any changes to the nurse. The care plan lacked direction to staff on the prevention or treatment of skin tears. The Skin/Wound Note, dated 06/27/24 at 01:34 PM, documented R3 obtained three skin tears to his left forearm from a dog during pet therapy while he gave the dog a treat. The area was cleansed, approximated (edges brought together), and Steri-strips (adhesive wound closures) applied. The note further documented the area was covered with a dressing and wrapped with gauze for protection. The Skin/Wound Note. dated 07/14/24 at 08:37 PM, documented R3 bumped his hand on his drawer and obtained a skin tear above his left thumb. The area was cleansed, and Steri-strips were applied. On 07/29/24 at 10:15 AM, observation revealed a skin tear with multiple Steri-strips on R3's right hand by his thumb. R3 stated he bruised easily and explained he hit his hand on his walker and obtained a skin tear on his right hand. R3 stated he always had bruises or skin tears. On 07/30/29 at 09:00 AM, Certified Nurse Aide (CNA) O stated she was aware of a previous skin tear from a dog and said R3's skin was very fragile. CNA O further stated she was unsure of where R3's current skin tear came from. CNA O said R3 did not wear anything to protect his skin from further injury. On 07/31/24 at 08:46 AM, Administrative Nurse E stated she was unaware of R3's current skin tear and was unable to find any information or a skin assessment related to it. On 07/31/24 at 09:00 AM, Licensed Nurse (LN) H stated residents were assessed in the shower for any skin tears, bruises, or skin changes. LN H stated they had not been made aware of the skin tear on R3's right hand. On 07/31/24 at 12:45 PM Administrative Nurse D stated a skin assessment should have been completed and placed on R3's care plan for interventions to prevent further skin tears. The facility's Skin Tears-Abrasions and Minor Breaks, Care of policy, dated 09/13, directed staff to record information about the wound in the medical record, complete the in-house investigation of causation, implement interventions, or modify current interventions to prevent further incidents. The policy further documented that staff should complete a Report of Incident/Accident notify the responsible family member and physician and report other information in accordance with facility policy and professional standards of practice. The facility failed to implement interventions including dressing and wound care to prevent and treat skin tears for R3. This placed the resident at risk for further skin injuries. - The Electronic Medical Record (EMR) for R29 documented diagnoses of diabetes mellitus type 2 (DM-when the body cannot use glucose, not enough sepsis is made or the body cannot respond to the insulin), chronic pain, muscle weakness, and hypertension (high blood pressure). The Quarterly Minimum Data Set, (MDS), dated [DATE], documented R29 had intact cognition. R29 required substantial assistance for toileting, dressing, personal hygiene, and supervision for mobility and ambulation. The MDS further documented R29 had no skin issues. R29's Care Plan, dated 06/18/24 and initiated on 08/31/23, directed staff to inspect R29's skin per policy during his showers and to observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. The Physician's Orders, dated 11/15/23, directed staff to use A&D ointment with zinc (ointment used as a moisturizer to treat and prevent dry itchy skin and minor skin irritations and protect wounds from moisture and bacteria) for skin preventive care. The Skin Observation Tool, dated 07/25/24, documented R29 had scabs on both forearms and old scabs on his knees. R29's EMR lacked orders or treatments related to R29's skin sores. On 07/29/24 at 08:30 AM, observation revealed R29 had four unopened sores the size of a pencil eraser on his right forearm, one unopened sore between the first and second finger by the knuckle on his left hand, and five unopened sores the size of a pencil eraser on his left forearm. On 07/29/24 at 08:30 AM, R29 stated the sores were from scratching his arms because they itched. R29 said he puts lotion on them during the day. On 07/30/24 at 07:30 AM, Certified Nurse Aide (CNA) O stated she did not know what R29's sores were from but said R29 liked to pick at his skin. On 07/31/24 at 09/20/24, Licensed Nurse (LN) H stated R29's sores were open to the air and he received a daily shower. LN H stated staff applied lotion to his arms after his shower. On 07/31/24 at 12:45 PM, Administrative Nurse D stated staff should offer R29 Geri-sleeves (arm skin protectors) and said she would contact the physician for medicated lotion for his arms. The facility's Skin Tears-Abrasions and Minor Breaks, Care of policy, dated 09/2013 documented to obtain a physician's order as needed, reviewing the care plan, and checking the treatment record. The policy further documented if the resident refused treatment, and explained the risks of refusing and the benefits of accepting alternatives. The facility failed to provide treatment for the sores on R29's arms. , and failed to implement interventions to prevent sores on R29's arms. This placed R29 at risk for ongoing skin sores and related complications.

The facility had a census of 30 residents. The sample included 13 residents of which eight residents were reviewed for falls. Based on observation, record review, and interview, the facility failed to identify and implement interventions to prevent Resident (R) 25 and R13 from falling which placed the residents at risk for further falls and injuries. Findings included: - R25's Electronic Medical Record (EMR) included diagnoses of unspecified falls, altered mental status, weakness, unsteadiness, abnormality of gait and mobility, major depressive disorder (major mood disorder that causes persistent feelings of sadness), and heart failure. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R25 had severe cognitive impairment and wandering behavior which occurred one to three days during a seven-day observation period. R25 had no functional range of motion impairment and used a walker and wheelchair for mobility, R25 required partial to moderate assistance with dressing, putting on and taking off footwear, and toileting hygiene. The MDS further documented R25 required setup or clean-up assistance with bed mobility, transfers, and walking 10 to 150 feet. R25 had not fallen since the prior assessment. R25's Care Plan, dated 06/11/24, documented R25 was at high risk for falls due to confusion, gait, and balance problems. The care plan directed staff to anticipate and meet R25's needs, be sure the call light was within reach, and encourage use for assistance. Staff were to respond promptly and ensure a safe environment with even floors, free of spills and clutter. The care plan further directed staff to review information on past falls and attempt to determine the cause of falls and record possible root causes. R25's care plan lacked documentation of falls or immediate actions placed to prevent the resident from falling. The Progress Notes recorded the following falls: On 06/07/24 at 09:25 AM, R25 was found in her room on the floor in front of the bed. She stated she was getting up from the wheelchair to bed to lie down, did not make it, and slid out of bed. On 06/07/24 at 10:19 AM, R25 was found on the floor in front of her recliner. R25 stated she was fearful of falling and put herself on the floor. The facility's investigation form recorded the immediate action was to bring the resident to the living room to be more closely monitored. On 06/08/24 at 04:06 PM, staff called the nurse to R25's room due to finding the resident on the floor beside the bed with her wheelchair beside her. R25 reported she slipped. The facility's investigation form documented the immediate action was to bring R25 closer to staff for close monitoring. On 06/14/24 at 09:45 AM, R25 was found on the floor of her bathroom, with her wheelchair behind her. The facility's investigation form lacked documentation of an immediate action. On 06/23/24 at 01:27 PM, R25 was found on the floor in her room, sitting by the door and/or hallway. R25 reported she was in her recliner and went to get into her wheelchair and did not lock the brakes, so she went onto her knees and crawled to the doorway. The facility's investigation documented the immediate action taken was to assist R25 into her wheelchair as requested. On 07/30/24 at 11:30 AM, observation revealed R25 in the dining room in her wheelchair for church service. On 07/31/24 at 10:33 AM, Licensed Nurse (LN) H reported staff assessed the resident for injuries following the falls and documented findings in the EMR. LN H reported all nursing staff could add intervention to prevent further falls if identified. LN H stated care plan oversight was done by the leadership team. On 07/31/24 at 11:57 AM, Certified Nurse Aide (CNA) P reported fall intervention for R25 consisted of assisting the resident with care and toileting if the resident allowed it; staff tried to keep an eye on her whereabouts. CNA P reported fall information was passed on during shift change reports. On 07/31/24 at 12:53 PM, Administrative Nurse D verified that R25's falls had not been recorded in the care plans, nor had interventions been implemented. Administrative Nurse D verified the facility had not done a root cause analysis to determine the reasons for falling. The facility's Managing Falls and Fall Risk policy, dated 03/2018, documented based on previous evaluation and current data, the staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If falling recurs despite interventions, staff will implement additional or different interventions, or indicate why the current approaches remain relevant. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on an assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. The facility failed to identify and implement interventions to prevent R25 from falling which placed the resident at risk for further falls and injuries. 32360 - The Electronic Medical Record (EMR) for R13 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) without behavioral disturbance, weakness, abnormalities of gait and mobility, and repeated falls. The Annual Minimum Data Set (MDS), dated [DATE], documented R13 had severely impaired cognition. R13 required substantial assistance for toileting, dressing, personal hygiene, and transfers. R13 required supervision with ambulation. The MDS documented R13 had no functional impairment and was frequently incontinent of bladder and occasionally incontinent of bowel. R13 had a wander alarm and had one fall since the prior assessment. The Quarterly MDS, dated [DATE], documented R13 had severely impaired cognition. R13 required substantial assistance for toileting, dressing, and personal hygiene. R13 required supervision with transfers and ambulation. The MDS documented R13 had no functional impairment and was frequently incontinent of bladder and bowel. R13 had a wander alarm and had two or more falls since the prior assessment. The Morse Fall Scale, dated 02/20/24, 02/21/24, 03/04/24, 03/26/24, 03/30/23, 04/04/24, 05/11/24, 05/21/24, 07/05/24, 07/09/24, and 07/22/24 documented R13 had a high risk for falls. R13's Care Plan, dated 06/20/24 and initiated on 09/17/21, directed staff to assist or ask if R13 needed to use the restroom every two hours. The update, dated 10/09/22, directed staff to continue education for the use of the call lights. The update, dated 08/12/22, directed staff to educate the elder to wait for assistance at night and to not get herself up after a fall. The update dated 09/12/23 directed staff to assist her to the bathroom before and after meals. The update, dated 11/12/23, directed staff to assist R13 as needed to the bathroom. The update, dated 03/26/24, directed staff to take R13 to the bathroom before she laid down in bed, so she doesn't have an accident. The update, dated 02/23/24, directed staff to continue to follow all fall interventions. The update, dated 03/30/24, directed the nurse to reeducate the staff on duty on the importance of periodically checking residents and toileting promptly to prevent falls. The update, dated 07/05/24, documented the reeducation of staff to take R13 to the bathroom after all meals. The update, dated 07/10/24, directed staff to use a wheelchair for longer distances. The Fall Investigation, dated 02/20/24 at 05:55 PM, documented R13 fell in front of her recliner and was unable to tell staff what happened. R13 did not sustain any injury. The Fall Investigation, dated 03/30/24 at 07:41 PM, documented R13 was on the floor between the bed and recliner with her feet extended outward. The investigation further documented R13 did not sustain any injury and staff were educated on the importance of periodically checking on residents more often to make sure they were toileted and changed regularly. The Fall Investigation, dated 04/18/24 at 11:30 AM, documented R13 fell in her room and was unable to tell staff what happened. The investigation further documented R13 was confused, had a gait imbalance, and ambulated without assistance; R13 did not sustain any injury. The Fall Investigation, dated 05/10/24 at 07:23 PM, documented staff observed R13 on the floor in the bathroom doorway with no pants on, one shoe on, and her feet extended out towards the bed, with a wet incontinence brief on. The investigation further documented she had not sustained any injury, was unable to tell staff what happened, and the staff was educated on making sure she had proper footwear on and was checked on more periodically to prevent falls. The Fall Investigation, dated 07/05/24 at 10:31 PM, documented R13 on the floor by her bed and was unable to tell staff what happened. R13 was incontinent and did not sustain any injury. The Fall Investigation, dated 03/26/24 at 10:00 PM, documented staff observed R13 on the floor with her back against the bed, feet extended out, blanket over her, in a wet incontinence brief, and no pants. The investigation further documented that staff were educated on the importance of checking on elders periodically and making sure they were not in wet clothing or getting up without assistance. The Fall Investigation, dated 07/09/24 at 05:41 PM, documented R13's knees buckled, and staff lowered her to the ground. The investigation further documented R13 did not sustain any injury. The Fall Investigation, dated 07/10/24 at 11:30 AM, documented R13's knees buckled, and staff lowered her to the ground, The investigation further documented R13 was able to move all extremities per her baseline and did not sustain any injury. On 07/30/24 at 10:32 AM, observation revealed Certified Nurse Aide (CNA) M placed a gait belt around R13's wait, and CNA M and CNA P assisted R13 to stand up in front of her walker to ambulate to the bathroom. Staff assisted R13 with personal care, stood her up, and assisted her back to her recliner. On 07/30/24 at 10:32 AM, CNA M stated R13 had fallen and she was checked on frequently; staff ensured she wore proper footwear. CNA M said R13 had been using a wheelchair more often as her knees were shaky, and staff toileted her more often. CNA M further stated two staff assisted R13 with ambulation but sometimes when she was not weak, they used one staff. CNA M stated when R13 had falls, staff were informed of fall interventions during shift- report or by the leadership team. On 07/31/24 at 09:21 AM, Licensed Nurse (LN) H stated R13 used a wheelchair for longer distances as her knees buckled and staff were to have her call light within reach and make sure she had on proper footwear. On 07/31/24 at 12:45 PM, Administrative Nurse D stated they had not done root cause analysis for R13's falls but did have Resident at Risk meetings to discuss falls and fall interventions. Administrative Nurse D further stated R13 should have a toileting plan to help with fall reduction. The facility's Falls and Fall Risk, Managing policy, dated 03/2018, documented based on previous evaluations and current data, staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff would monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If interventions have been successful in preventing falls, staff would continue the interventions or consider whether these were still needed if the problem was resolved. If the resident continued to fall, staff would re-evaluate the situation and whether it was appropriate to continue or change the current intervention. The facility failed to identify the root cause of R13's falls and implement meaningful person-centered interventions to prevent further falls. This placed R13 at risk for further falls and injury.

The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 2 with the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. This placed the resident at risk for unmet mental health care needs. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of chronic kidney disease, polyosteoarthritis (many sites of inflammation of a joint characterized by pain, swelling, redness, and limitation of movement), weakness, and displaced fracture (broken bone) of the humerus (upper arm bone). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had severe cognitive impairment without delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment perception), or behaviors. R2 required setup or clean-up assistance and had frequent incontinence of urine and occasional incontinence of bowel. R2 received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication to treat pain). The MDS further documented an antipsychotic was received on a routine basis only, had no gradual dose reduction (GDR) attempt, and no physician documentation of GDR as clinically contraindicated. R2's Care Plan, dated 06/06/24, documented R2 was dependent on staff for meeting emotional, intellectual, physical, and social needs due to immobility. The plan lacked resident-specific interventions based on the resident's preferred activities or to address her difficulty adjusting to the facility and loss of independence. The Progress Note dated 10/15/24 at 11:36 PM, documented R2 was tearful and stated her leg hurt, R2 accepted pain medication. The Progress Note dated 10/18/24 at 08:00 AM, documented R2 would not acknowledge therapy or nursing staff though staff assisted her in sitting up and taking her medication. She then sat in her recliner without verbalizing to or with the staff providing care. The Progress Note dated 10/21/24 at 01:17 PM, documented R2 refused to leave her room all day, would not be weighed, refused breakfast and medications, and ignored staff when they tried to talk to her. R2 was up in her room independently getting things out of her closet and going to the bathroom. The Progress Note, Dated 10/21/24 at 06:09 PM, documented R2 refused assistance to get ready for supper stating she would do it herself. The nurse on duty went and helped. R2 stated she didn't know she lived in a prison and was upset. The nurse spent 50 minutes talking with R2 when she shared with staff she was upset because she could not go back to her apartment where she enjoyed sitting on her porch to watch the sun go down and look at the flowers she had planted on her patio. She felt she had gotten worse and not better due to increased pain. R2 was very repetitive and hung up on things in the past that she was unable to let go of and move forward. R2 stated she cries every time she goes to the dining room and does not want others to see her that way The Progress Note dated 10/23/23 at 09:56 AM documented R2 was assisted to the dining room and was upset and tearful, reporting Please let me die. The note further documents a call was placed to the physician requesting something for R2's anxiety. The Progress Note, dated 10/24/24 at 09:15 AM documented R2 was screaming and crying, stating no one cared about her and she was having pain and requesting to see the physician. Staff offered pain medication, heat, and ice packs but refused interventions related to pain reporting they did not help. The Physician Order, dated 10/25/23, directed staff to administer quetiapine 25 milligrams (mg) twice a day for anxiety. The Physician Order, dated 10/30/23, directed staff to administer trazodone 50 mg at bedtime for depression. The Progress Note dated 10/24/23 at 05:55 PM, documented a physician visit with R2 due to pain and increased tearfulness, and orders were received to obtain an x-ray of the left hip and lumbar spine, start morphine (opioid) PRN for pain for two days only. The progress note further documented R2 was upset and thought nobody cared about her and was very tearful. The Physician Order, dated 10/25/23, directed staff to administer quetiapine 25 milligrams (mg) twice a day for anxiety. The Physician Order, dated 10/30/23, directed staff to administer trazodone 50 mg at bedtime for depression. R2's clinical record lacked evidence of nonpharmacological interventions implemented or action taken to address R2's verbalizations of loss, embarrassment, sadness, and feelings of wanting to die. On 07/31/24 at 10:33 AM Licensed Nurse (LN) H, reported R2's mood had been good, and she had a history of tearfulness and anxiousness. LN H reported that R2 had been coming out of her room more lately. LN H also stated R2's mood seemed to be related to pain and the physician had made changes to her medication and this had helped. On 07/31/24 at 11:33 AM, Certified Nurse Aide (CNA) P reported R2 was less tearful and anxious. On 07/31/24 at 12:50 PM, Social Service X stated she had not spent time with the resident regarding her anxiety and depression. On 07/31/24 at 12:53 PM, Administrative Nurse D verified the lack of social service involvement or mental health support provided to R2 prior to starting medications to treat her mental health. The facility did not provide a policy for behavioral or mental health services. The facility failed to provide R2 with the appropriate mental health support and services before administering psychotropic medication to attain the highest practicable mental and psychosocial well-being. This placed the resident at risk for unmet mental health care needs.

The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and observation, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 12 and 13's as needed (PRN) antianxiety medication without a stop date and the lack of an approved indication, or the required documentation, for the use of an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medications for R12 and R2. This placed the residents at risk for inappropriate and/or unnecessary medication. Findings included: - R12's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN-elevated blood pressure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), occlusive and stenosis (narrowing or constricted) of unspecified carotid artery, hypothyroidism (a condition characterized by decreased activity of the thyroid gland), pure hypercholesterolemia (greater than normal amounts of cholesterol in the blood), chronic kidney disease and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R12 had severe cognitive impairment and wandered daily. R12 required substantial/maximal assistance with dressing and personal hygiene, partial to moderate assistance with toileting hygiene, and supervision/touch assistance with mobility with the use of a walker. R12 had frequent incontinence of urine and bowel and no diagnosis of urinary tract infection (UTI). R12 received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), antibiotic (class of medication used to treat infections), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used to treat pain). The MDS further documented an antipsychotic was received on a routine basis only but had no gradual dose reduction (GDR), and no physician documentation as clinically contraindicated. R12's Care Plan, dated 06/20/24, documented R12's medications had Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) with potential reactions and adverse side effects. This included the use of the following: Venlafaxine (antidepressant) could lead to worsening of suicidal thoughts and behaviors Ativan (antianxiety) could be associated with an increase in confusion, loss of balance, and cognitive impairment that looks like dementia and increases the risk of falls, broken hips, and legs. Olanzapine (antipsychotic) is not approved for the treatment of patients with dementia-related psychosis and has an increased risk of death. R12's EMR documented the following physician orders: 02/16/24 venlafaxine 50 milligrams (mg) two times a day for depression. 05/19/23 Ativan 0.5 mg every eight hours PRN for agitation (no stop date). 03/31/23 Olanzapine two times a day for behaviors. R12's Medication Administration Record (MAR) revealed the use of as-needed (PRN) Ativan three times in March 2024, six times in April 2024, eight times in May and June 2024, and four times in July 2024. On 05/14/24 at 10:38 AM, Progress Note documented R12 had increased behaviors requiring the use of PRN Ativan, and a verbal order was received for a urine analysis. The CP reviewed R12's medical record monthly and documented R12's medication reviewed and no recommendations with the exception of 02/19/24 which identified venlafaxine required an attempt for GDR twice a year, and then yearly thereafter. The physician's response was stable. The CP reviews lacked recommendations for the of olanzapine without an approved indication and did not identify the lack of a stop date or specified duration for the use of PRN Ativan. On 07/30/24 at 08:01 AM, R12 was in the dining room, dressed and groomed appropriately for the day. On 07/31/24 at 12:53 PM, Administrative Nurse D verified the CP did not identify and report the unapproved indication of anxiety for the use of quetiapine. The facility's Pharmacy Services-Role of the Provider Pharmacy policy, dated 04/2019, documented the provider pharmacy to provide services that comply with applicable facility policies and procedures, accepted professional standards of practice, and laws and regulations, including (but not limited to) help the facility comply with its legal and regulatory requirements related to medication and medication management, maintain a medication profile for each resident that includes all pertinent information including that which is required by law and regulations. Screen new medication orders for key parameters, including appropriate indications, proper dose, and duration, correct route of administration, potential for adverse consequences including medication interactions, and possible duplication therapy. The facility failed to ensure the CP identified and reported R12's unapproved indication or lack of required physician documentation for the ongoing use of antipsychotic medication. This placed R12 at risk for inappropriate use of antipsychotic medications. - R2's Electronic Medical Record (EMR) documented diagnoses of chronic kidney disease, polyosteoarthritis (many sites of inflammation of a joint characterized by pain, swelling, redness, and limitation of movement), weakness, and displaced fracture (broken bone) of the humerus (upper arm bone). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had severe cognitive impairment without delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by a gross impairment perception), or behaviors. R2 required setup or clean-up assistance and had frequent incontinence of urine and occasional incontinence of bowel. R2 received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antidepressant (class of medications used to treat mood disorders), diuretic (medication to promote the formation and excretion of urine), and opioid (medication to treat pain). The MDS further documented an antipsychotic was received on a routine basis only, had no gradual dose reduction (GDR) attempt, and no physician documentation of GDR as clinically contraindicated. R2's Care Plan, dated 06/06/24, documented R2 was dependent on staff for meeting emotional, intellectual, physical, and social needs due to immobility and lacked the use of quetiapine (antipsychotic) and Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) or mood state with non-pharmacological interventions. The Physician Order, dated 10/25/23, directed staff to administer quetiapine 25 milligrams (mg) twice a day for anxiety. The Consultant Pharmacist (CP) medication review on 04/17/24 documented that R2 received quetiapine twice a day and recommended attempting a gradual dose reduction twice within the first year, then yearly. The CP requested the physician to evaluate the current therapy and document accordingly. The CP recommendation did not identify the inappropriate indication associated with the use of quetiapine. On 04/18/24, the CP documented the physician requested no changes and would consider GDR next year. The documentation lacked the reason for continued use without a GDR. The Progress Note dated 10/24/23 at 05:55 PM, documented a physician visit with R2 due to pain and increased tearfulness, and orders were received to obtain an x-ray of the left hip and lumbar spine, start morphine (opioid) PRN for pain for two days only. The progress note further documented R2 was upset and thought nobody cared about her and was very tearful. R2's clinical record lacked evidence of documented nonpharmacological interventions attempted and failed or the risks versus benefits of continued use without GDR. On 07/31/24 at 12:53 PM, Administrative Nurse D verified the CP did not identify and report the unapproved indication of anxiety for the use of quetiapine. The facility's Pharmacy Services-Role of the Provider Pharmacy policy, dated 04/2019, documented the provider pharmacy to provide services that comply with applicable facility policies and procedures, accepted professional standards of practice, and laws and regulations, including (but not limited to) help the facility comply with its legal and regulatory requirements related to medication and medication management, maintain a medication profile for each resident that includes all pertinent information including that which is required by law and regulations. Screen new medication orders for key parameters, including appropriate indications, proper dose, and duration, correct route of administration, potential for adverse consequences including medication interactions, and possible duplication therapy. The facility failed to ensure the CP identified and reported R2's unapproved indication or lack of required physician documentation for the ongoing use of antipsychotic medication. This placed R2 at risk for inappropriate use of antipsychotic medications. 32360 - The Electronic Medical Record (EMR) for R13 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) without behavioral disturbance, hypertension (elevated blood pressure), and depression (abnormal emotional state characterized by exaggerated feelings of sadness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R13 had severely impaired cognition. R13 required substantial assistance for toileting, dressing, and personal hygiene. R13 required supervision with transfers and ambulation. The MDS documented R13 received an antidepressant (medication used to treat mood disorders and relieve symptoms of depression). R13's Care Plan, dated 06/20/24 and initiated on 03/09/20, documented R13 had dementia and would sometimes wander and directed staff to cue, reorient, and supervise as needed. The care plan directed staff to administer medications as ordered document for side effects and effectiveness and report any signs of depression or anxiety. The Physician's Order, dated 05/30/24, directed staff to administer Ativan (an antianxiety medication), 1 milligram, by mouth, four times per day, as needed for agitation. The order lacked a stop date. The CP's Medication Regimen Review, dated 06/19/24 and 07/10/24, failed to address the as-needed Ativan. On 07/30/24 at 10:32 AM, observation revealed Certified Nurse Aide (CNA) M placed a gait belt around R13's wait, and CNA M and CNA P assisted R13 to stand up in front of her walker to ambulate to the bathroom. Staff assisted R13 with personal care, stood her up, and assisted her back to her recliner without resistance with care. On 07/30/24 at 09:00 AM, Certified Nurse Aide O stated R13 had behaviors and was at times resistant to care. On 07/31/24 at 09:20 AM, Licensed Nurse (LN) H stated R13 had advanced dementia, would be resistant to care with staff, and was recently placed on Risperdal. Licensed Nurse H further stated R13 also received Ativan as needed on her shower days. On 07/31/24 at 12:45 PM Administrative Nurse D stated she was unaware that the Ativan required a 14-day stop date and said she had not been notified by the pharmacist. The facility's Pharmacy Services-Role of the Provider Pharmacy policy, dated 04/19, documented the Pharmacist would help the facility comply with its legal and regulatory requirements related to medications and medication management. The Pharmacist would establish a reliable way to identify the facility in a timely fashion of issues and concerns related to medications and prescriptions. The CP failed to identify and report the lack of a stop date for R13's PRN Ativan. This placed the resident at risk for inappropriate use of psychotropic medication.

The facility had a census of 30 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to implement antibiotic use protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk of adverse events, including antibiotic resistance, when the facility failed to monitor effectiveness and evaluate appropriateness for the extended administration of prophylactic antibiotics for Resident (R) 5 and R12. This placed the resident at risk for complications related to antibiotic use including the development of antibiotic-resistant organisms. Findings included: - R5's Electronic Medical Record (EMR) documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), chronic atrial fibrillation (rapid, irregular heartbeat), major depressive disorder (major mood disorder which causes persistent feelings of sadness), chronic kidney disease and morbid obesity. R5's Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had intact cognition. R5 required supervision or touching assistance with toileting hygiene and was frequently incontinent of urine and occasionally incontinent of bowel. The MDS recorded R5 had no urinary tract infection (UTI) and received an antidepressant (class of medications used to treat mood disorders), anticoagulant (medication to prevent blood from clotting), a diuretic (a medication to promote the formation and excretion of urine) and an antibiotic (class of medications used to treat infections). R5's Care Plan, dated 06/27/24, documented R5 had a self-care deficit due to age and weakness and instructed staff to assist with morning and evening care, the care plan lacked the use of antibiotic use daily for UTI. The Physician Order dated 04/19/24 directed staff to administer Macrodantin (an antibiotic) 100 milligrams (mg) at bedtime for chronic UTIs. The Physician Order, dated 05/31/24, directed staff to administer cefdinir 300 mg two times a day for 10 days for UTI. R5's EMR recorded one UTI for the year during the period of 07/2023 to 07/2024 on 05/32/24 which was treated with cefdinir. R12's EMR lacked a physician rationale and benefits statement regarding the ongoing use of antibiotics or the concurrent use with other antibiotics for the same issue. On 07/30/24 at 11:13 AM, observation revealed R5 sat in her room, in her recliner. R5 reported she was able to identify symptoms of UTIs and would report them to staff. She stated she had frequent UTIs in the past, but it was less frequent in the facility. She also reported she did not know what her medication regimen was, and she had confidence the staff was administering them correctly. On 07/31/24 at 10:33 AM, Licensed Nurse (LN) H recognized R5 had ongoing antibiotic use and R5 was able to report to staff signs of UTI. On 07/31/24 at 11:57 AM, Certified Nurse Aide (CNA) P reported R5 toileted herself but did ask for assistance when needed. CNA P reported staff ensure the resident is cleansed properly when assistance is requested. On 07/31/24 at 12:53 PM, Administrative Nurse D verified the CP should have identified and reported the ongoing antibiotic use without signs and symptoms of infections. The facility's Antibiotic Stewardship policy, dated 12/2016, documented antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Programs. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. Training and education will include an emphasis on the relationship between antibiotic use and gastrointestinal disorders, opportunistic infections, medication interactions, and the elevation of drug-resistant pathogens. The facility failed to identify and address the ongoing use of antibiotics for R5 which placed the resident at risk for adverse effects and antibiotic resistance. - R12's Electronic Medical Record (EMR) documented diagnoses of hypertension (HTN-elevated blood pressure), major depressive disorder (major mood disorder which causes persistent feelings of sadness), peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), dementia (progressive mental disorder characterized by failing memory, confusion), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), occlusive and stenosis (narrowing or constricted) of unspecified carotid artery, hypothyroidism (a condition characterized by decreased activity of the thyroid gland), pure hypercholesterolemia (greater than normal amounts of cholesterol in the blood), chronic kidney disease and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R12 had severe cognitive impairment and wandered daily. R12 required substantial/maximal assistance with dressing and personal hygiene, partial to moderate assistance with toileting hygiene, and supervision/touch assistance with mobility with the use of a walker. R12 had frequent incontinence of urine and bowel and no diagnosis of urinary tract infection (UTI). R12 received an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), antibiotic (class of medication used to treat infections), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used to treat pain). The MDS further documented an antipsychotic was received on a routine basis only but had no gradual dose reduction (GDR), and no physician documentation as clinically contraindicated. R12's Care Plan, dated 06/20/24, documented R12's medications had Black Box Warnings (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration)with potential reactions and adverse side effects. R12's Care Plan lacked mention of nitrofurantoin (antibiotic) which could lead to resistive infective organisms. R12's EMR documented a Physician's Order dated 06/23/22 for nitrofurantoin (antibiotic) 80 milligrams in the morning for urinary health. R12's EMR recorded two urine analyses completed on 03/05/24 and 05/15/24 which resulted in no active infection or reason for cultures. R12's EMR lacked a physician rationale and benefits statement regarding the ongoing use of antibiotics without symptoms or infection present. On 05/14/24 at 10:38 AM, Progress Note documented R12 had increased behaviors requiring the use of PRN Ativan, and a verbal order was received for a urine analysis. On 07/30/24 at 08:01 AM, R12 was in the dining room, dressed and groomed appropriately for the day. On 07/31/24 at 12:53 PM, Administrative Nurse D confirmed R12 had ongoing antibiotic use without signs and symptoms of infections. The facility's Antibiotic Stewardship policy, dated 12/2016, documented antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Programs. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Orientation, training, and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. Training and education will include an emphasis on the relationship between antibiotic use and gastrointestinal disorders, opportunistic infections, medication interactions, and the elevation of drug-resistant pathogens. The facility failed to identify and address the ongoing use of antibiotics for R12 which placed the resident at risk for adverse effects and antibiotic resistance.

The facility identified a census of 26 residents, with three reviewed for falls. Based on observation, record review, and interview the facility failed to ensure Resident (R) 1 was free from falls when facility staff failed to follow R1's care plan for two staff assistance with bathing. On 11/16/22 at approximately 07:05 PM, Certified Nurse's Aide (CNA) M assisted R1 in the shower. R1 was in the shower chair when CNA M turned to get wash cloths and left R1 alone on the shower chair, which led to R1 falling off of the shower chair and sustaining a laceration to the top of her scalp measuring 2.2 centimeters (cm) by 2.3 cm. R1 was transported to the emergency department and it was determined that R1 sustained a subdural hematoma (collection of blood on the surface of the brain). This deficient practice placed R1 at risk for fall and injury. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), and transient cerebral ischemic attacks (TIA - episode of cerebrovascular insufficiency). R1's Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) assessment could not be completed as R1 was rarely/never understood. The MDS documented R1 had short and long-term memory problems. The MDS documented R1 required total assistance of one to two staff for bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and bathing. The Activity of Daily Living Care Plan, dated 04/05/22, documented R1 was totally dependent upon two staff assistance for bathing five times a week. The Dementia/Cognitive Loss Care Area Assessment (CAA), dated 05/24/22 documented R1 had a decreased ability to make herself understood or to understand others and exhibited confusion, disorientation, and forgetfulness. The Falls CAA, dated 05/24/22, documented R1 had internal risk factors for falls including cerebral vascular accident (an interruption in the blood flow to cells in the brain), TIA, incontinence, delirium, and Alzheimer's disease. The Nurses Note, dated 08/27/22 documented R1 was noted to have seizure like activity. R1 had a fixed stare with her head hung down, drooling, jerking/twitching movements, and was unable to be aroused. The activity noted was the same seizure-like activity that presented in the past related to R1's seizure disorder. The Skin/Wound Note, dated 10/10/22, documented R1 had blood coming from her mouth. Upon assessment two teeth marks were noted to the inside of R1's bottom lip. R1's daughter notified and R1's daughter stated R1 probably had a seizure. The Morse Fall Scale, dated 10/12/22, documented R1 had a score of 15, which indicated R1 was a low risk for falling. The Health Status Note, dated 11/07/22, documented R1 was yelling and then her face tensed up. R1's mouth was clenched up and saliva was drooling out of her mouth. The Health Status Note, dated 11/14/22, documented R1 was not acting herself, was very sleepy, her eyes were open in a fixed stare, and R1 was twitching. The note documented R1 responded in this manner prior to or after seizure activity. The Health Status Note, dated 11/15/22, documented staff heard R1 yell and R1 was lightly blowing out of her mouth and slight drool in the corner of her mouth and R1 was shivering. The episode was documented as lasting three minutes. The Health Status Note, dated 11/16/22, documented R1's responsible party was notified of R1's seizure activity. The Incident Note, dated 11/16/22 at approximately 07:05 PM, R1 was in the shower room with CNA M. R1 fell out of the shower chair when CNA M's back was turned. R1 was face down on the floor of the shower room in front of the shower chair. CNA M stated, she turned around to grab a washcloth and R1 fell out of the shower chair. Blood was noted to pooling out of the left side of R1's forehead. A laceration was noted above R1's left eye and ice was applied. R1 was alert and disoriented. R1 remained on the floor with continuous head support. Emergency Medical Staff arrived at 07:45 PM. R1 was noted to be having seizure activity the night before and appeared to have another seizure that resulted in her fall. The Health Status Note, dated 11/16/22, documented the facility had received an update regarding R1's status from the hospital. R1 was in the intensive care unity with four to five brain bleeds. The Health Status Note, dated 11/17/22, documented the hospital was going to keep R1 for a couple of days as she had brain bleeds. R1 will have another scan in a couple of days and will be placed on seizure medication. The Skin/Wound Note, dated 11/23/22, documented R1 had a sutured laceration to the top of her scalp that measured 2.2 cm by 2.3 cm. On 12/28/22 at 11:30 AM, CNA M stated that she had turned around to get a washcloth while R1 was sitting in the shower chair and out of the corner of her eye she saw R1 jerk and shake before falling out of the shower chair. On 12/28/22 at 11:45 AM, CNA N stated R1 was a two-person assist getting into the shower chair but then was a one-person assist with the actual shower. On 12/28/22 at 01:30 PM, Administrative Nurse D verified that R1's Care Plan documented R1 was to have two staff assistance with bathing. Administrative Nurse D stated with R1 having frequent seizure activity, there should always have been two staff assistance with R1 in the shower. The facility's Fall Policy, revised March of 2018, documented nursing staff will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The facility's undated Assisting Resident with a Spa Bath or Whirlpool Bath, policy, documented all resident's residing in the facility will receive care, treatment and services according to the resident's individualized care plan. The facility failed to prevent R1 from falling in the shower room due to not following her individualized care plan regarding bathing which resulted in acute injury requiring intensive care in the hospital. The facility completed education regarding following appropriate level of assistance and following residents' care planned directives for all staff on 11/21/22 so the deficient practice was determined to be past noncompliance. -

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)12, and R29's insulin (hormone which allows cells throughout the body to uptake glucose) vial with the date opened and expiration date, failed to discard R2's expired insulin pen and failed to discard expired stock medications in one medication cart. This placed the affected residents at risk for ineffective medications. Findings included: - On 07/27/22 at 08:10 AM, observation of the medication cart, revealed the following: R12's [MEDICATION(S)] (a rapid acting insulin) vial lacked a date opened, and date of expiration. R 29's [MEDICATION(S)] (a short acting insulin) vial lacked a date opened, and date of expiration. R2's [MEDICATION(S)] (rapid acting insulin) flex pen expired 05/28/22. On 07/27/22 at 08:20 AM, observation of the medication cart revealed one bottle of aspirin (pain reliever) 325 (mg) milligram, 100 tablets, expired 6/22, and one bottle of Vitamin C ([MEDICATION(S)] supplement) 500 mg, 100 tablets, expired 2/22. On 07/27/22 at 08:25 AM, Licensed Nurse (LN) G verified the stock medications in the medication cart were expired. LN G stated the nurses were to look at the bottles and verify expiration dates before administering the medications and to the discard expired medications. LN G verified the nurses were to date the insulin pens/vials when opened and discard the expired insulin. On 08/02/22 at 12:30 PM, Administrative Nurse D verified the nurses should label and date the insulin pens and vials with the resident's name and discard expired items. Administrative Nurse D verified expired stock medications were to be discarded. The facility's Storage of Medications policy, dated April 2007, documented the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall not use discontinued, outdated or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. The facility failed to label and date the residents insulin vials, discard expired insulin flex pen and discard expired stock medications, placing the residents at risk for ineffective medications.

The facility had a census of 31 residents. The sample included 12 residents with five reviewed for immunizations. Based on interview and record review the facility failed to assess four sampled residents for the eligibility to receive the pneumococcal (pneumonia infection that inflames air sacs in one or both lungs which may fill with fluid) )vaccine, Resident (R) 3, R5, R14, R28. This placed the residents at risk for illness and pneumonia infection. Findings included: - Review of R3's medical record lacked documentation the resident received a pneumococcal vaccine and/or lacked evidence of an informed declination. Review of R5's medical record lacked documentation the resident received a pneumococcal vaccine and/or lacked evidence of an informed declination. Review of R14's medical record lacked documentation the resident received a pneumococcal vaccine and/or lacked evidence of an informed declination. Review of R28's medical record lacked documentation the resident received a pneumococcal vaccine and/or lacked evidence of an informed declination. The facility's Physician Standing Orders, dated 04/07/22, directed staff to offer residents the pneumococcal vaccine every five years unless contraindicated. On 07/28/22 at 03:50 PM, Administrative Nurse E stated the facility had no records for the residents' pneumococcal vaccine status and had not offered the vaccine to the resident and/or family representative. The facility's Pneumococcal Vaccine Policy, dated August 2016, directed staff to assess the resident's pneumococcal vaccine status at admission, offer the vaccine as needed, and record the pneumococcal vaccine information in the resident's medical record. The facility failed to assess R3, R5, R14 and R28 for the eligibility to receive the pneumococcal vaccine, placing the residents at risk for illness and pneumonia infection.

The facility had a census of 31. The sample included 12 residents. Based on record review, interview and observation the facility failed to treat residents with respect, dignity, and privacy during medication administration. This placed the resident at risk for impaired psychosocial wellbeing. Findings included: - On 07/28/22 at 12:05 PM, observation revealed Licensed Nurse (LN) G obtained Resident (R)2's blood sugar reading using a glucometer (a blood glucose meter monitor device that you test the amount of glucose [sugar] in the blood) from R2's left index finger at the table in the main dining room, with two other resident seated at the table and 13 other residents seated in the dining room eating lunch. On 08/02/22 at 10:15 AM, Administrative Nurse D stated staff should not check residents' blood sugar at the dining room table; they should take the resident to the room or to a private area. The facility's Quality of Life policy, dated August 2009, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Resident shall always be treated with dignity and respect. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal cares and during treatment procedures. The facility failed to promote care for R2 in a manner to maintain and enhance dignity and respect placing the resident at risk or impaired psychosocial wellbeing.

The facility had a census of 31 residents. The sample included 12 residents with five reviewed for unnecessary medication. Based on observation, interview and record review the facility failed to care plan the use of antipsychotic medications (class of medications used to manage delusions, hallucinations, and paranoia). This deficient practice placed Resident (R)3 at risk for unmet care needs related to the use of the antipsychotic medications. Findings included: - R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10 and no behaviors. The MDS documented the resident required limited to extensive assistance with most activities of daily living (ADLs). The MDS documented R3 received an antipsychotic medication seven days during the lookback period. The Medication Care Plan, dated 07/20/22, directed staff to provide medications whole, monitor for side effects, and effectiveness. The care plan directed staff to obtain and monitor lab work as ordered, report results to the physician and follow up as indicated. The care plan lacked mention of antipsychotic medications. The Physician Order, dated 06/30/22, directed staff to administer [MEDICATION(S)] (antipsychotic) 50 milligrams (mg) at bedtime for sleep. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/28/22 at 03:30 PM, observation revealed R3 sat in her wheelchair in the living room visiting with family and other residents. Further observation revealed R3 leaned to one side, her right arm dangled toward the floor, and her eyes were closed. On 08/01/22 at 145 PM, Certified Nurse Aid O stated R3 falls asleep in her chair. She stated staff encouraged R3 to sleep in her bed when staff saw her slumping in her wheelchair. On 08/02/22 at 11:55 AM, Administrative Nurse E verified the use of [MEDICATION(S)] had not been care planned and no targeted behaviors were monitored. The facility's Pharmacy Services policy, dated April 2007 recorded the facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medication and biologicals, and the services of a licensed pharmacist. The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but not limited to, collaborating with the facility and Medical Director to: Help the facility develop procedures and evaluate pharmacy services related to recommend current resources to help staff to understand and identify medications and related information such as contraindications, adverse consequences, and appropriate monitoring, and help the facility identify and address educational and informational needs about medications for staff, practitioners, residents, and families The facility failed to care plan the use of [MEDICATION(S)] and behavior interventions to provide for R3, placing the resident at risk to not have her needs met.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to complete a safe-smoking evaluation for one sampled resident, Resident (R) 6. This placed the resident at risk for unsafe smoking practices and accidents while smoking. Findings included: - The Physician Order Sheet (POS), dated 06/03/22, documented diagnoses of anxiety (mental health disorder characterized by worry and fear that interferes with daily life), depression (mental health disorder characterized by persistent depressed mood that impairs daily life), [CONDITION(S)] ([CONDITION(S)]-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain), and [CONDITION(S)] (paralysis of one side of the body). The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R6 had a Brief Interview for Mental Status (BIMS) score of 10 (moderately impaired cognition). The MDS recorded R6 required extensive staff assistance with transfers, had impaired range of motion of the extremities on one side of the body, and used a wheelchair for mobility. The Smoking Care Plan, dated 05/11/22, directed staff to provide R6 with a copy of the facility's Smoking Policy, and educate the resident about smoking times, locations, safety concerns, and staff supervision. Review of R6's medical record lacked documentation the facility completed a safe smoking evaluation for the resident since 2019. On 07/28/22 at 10:15 AM, observation revealed R6 smoked outside with staff supervision. On 07/28/22 at 11:00 AM, Administrative Nurse E stated the facility had not completed a smoking assessment for R6 since 2019. The facility's Smoking Policy, dated 07/2017, directed staff to complete a safe smoking evaluation for residents quarterly, upon a significant change, and as determined by staff. The facility failed to complete a safe smoking evaluation for R6, placing the resident at risk for unsafe smoking practices and accidents while smoking.

The facility had a census of 31 residents. The sample included 12 residents with one reviewed for bladder incontinence. Based on observation, interview and record review the facility failed to develop and initiate a toileting program for Resident (R) 4 who was assessed as being a good candidate for bladder retraining to improve urinary continence. This deficient practice placed R4 at risk for increased incontinence. Findings included: - R4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. The MDS documented R4 required supervision for eating, limited staff assistance for transfers, toileting, hygiene and walking. The MDS documented R4 was on a toileting program, had frequent urinary incontinence, and received diuretic (class of medicine which promotes the formation and excretion of urine) medication seven days of the lookback period. The Urinary Care Area Assessment (CAA), dated 04/14/22, was blank. The Quarterly MDS, dated [DATE], documented a toileting trial had been attempted, was not used currently, and R4 was always continent. The Care Plan, dated 6/30/22, directed staff to provide stand-by assistance for toileting. The care plan documented the resident stated he would call if he needed to go to the bathroom and may need assistance with getting pants up and down and personal hygiene in the morning and before bed. R4 wore incontinence briefs for his incontinent episodes The Bowel and Bladder Assessment, dated 04/08/22, documented R4 did not always appropriately void without incontinence, but at least daily he was able to get to the toilet with assistance of one staff. The assessment documented R4 was a good candidate for urinary retraining. The Bowel and Bladder Assessment, dated 07/08/22, documented R4 did not always appropriately void without incontinence, but at least daily he was able to get to the toilet independently but slowly; he was forgetful and usually aware of the need to toilet. The assessment documented R4 was a good candidate for urinary retraining. The clinical record lacked evidence of a toileting program and/or urinary retraining for R4. The facility documentation tracking for toileting documented R4 was incontinent at least one time each day and required supervision to limited staff assistance with toileting. On 07/28/22 at 12:40 PM, observation revealed R4 sat at the dining table with his walker nearby. At 12:50 PM, he ambulated with his walker, back to his room. Licensed Nurse (LN) H assisted him the rest of the way down the hall and did not offer toileting assistance or cue him to toilet. The resident then went to the living room and sat at the big table for a visit with his family. On 07/28/22 at 01:33 PM, observation revealed R4 up with walker and LN H assisted him back to his room, guided him to his recliner, and assisted him to sit. She asked if he needed anything else and he replied no, thank you. On 07/28/22 at 03:27 PM, Certified Nurse Aide (CNA) M looked into R4's room and then stated she was going to give him a shower. At 03:50 PM, they came back from the shower. CNA M stated R4 had been continent, but she thought he went to the bathroom on his own before she went to his room. On 07/28/22 at 220 PM, CNA N stated she cued the resident to toilet, but he was sometimes incontinent. CNA N stated she tried to cue him to go to the bathroom before meals. On 07/28/22 at 04:07 PM, Administrative Nurse E stated staff usually do a 7-day voiding pattern on admission. The facility lacked documentation of the voiding assessment and Administrative Nurse E verified they had no analysis of the voiding pattern and toileting schedule even though the resident was documented as a good candidate for retraining. On 08/01/22 at 01:45 PM, CNA O stated R4 had no toileting plan, and was not on a scheduled toileting. The facility's Urinary Continence and Incontinence policy, dated 12/2010, documented the staff and practitioner would appropriately screen for and manage individuals with urinary incontinence. As appropriate, based on assessment, the staff would provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence. The facility failed to develop and initiate a toileting program for R4 who was assessed as being a good candidate for bladder retraining, placing R4 at risk for increased incontinence.

The facility had a census of 31 residents. The sample included 12 residents with five reviewed for unnecessary medication. Based on observation, interview and record review the facility failed to ensure the Consultant Pharmacist (CP) identified and reported to the physician and the director of nursing (DON) that antipsychotic medications (class of medications used to manage delusions, hallucinations, and paranoia) had an inappropriate diagnosis per CMS (Center for Medicare/Medicaid Services) guidelines. The facilty further failed to ensure the phsyician responded to the CP's recommendation. This deficient practice placed Residents (R)3, R14, and R26 at risk for adverse effects from the use of the antipsychotic medications. Findings included: - R3's Physician Order Sheet (POS), dated 04/12/22, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance and major recurrent depressive disorder. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10 and no behaviors. The MDS documented the resident required limited to extensive assistance with most activities of daily living (ADLs). The MDS documented R3 received an antipsychotic medication seven days during the lookback period. The Medication Care Plan, dated 07/20/22, directed staff to provide medications whole, monitor for side effects, and effectiveness. The care plan directed staff to obtain and monitor lab work as ordered, report results to the physician and follow up as indicated. The Physician Order, dated 06/30/22, directed staff to administer [MEDICATION(S)] (antipsychotic) 50 milligrams (mg) at bedtime for sleep. The Medication Administration Record (MAR), dated July 2022, directed staff to monitor for side effects of antipsychotic medications ([MEDICATION(S)]) such as but not limited to: stiffness of neck, dry mouth, blurred vision, constipation, [CONDITION(S)], drowsiness, increased falls or dizziness, [CONDITION(S)] (inability to sleep), and confusion. The CP's Drug Regimen Review, dated 03/01/22, requested an antipsychotic gradual dose reduction (GDR). The review stated the resident currently receives [MEDICATION(S)] ([MEDICATION(S)]) 50mg. It is recommended to attempt a gradual dose reduction twice within the first year, then yearly. Please evaluate current therapy and document accordingly. The physician did not respond to the recommendation or provide a risk versus benefit statement. The consultant pharmacist did not note the inappropriate diagnosis of sleep. On 07/28/22 at 03:30 PM, observation revealed R3 sat in her wheelchair in the living room visiting with family and other residents. Further observation revealed R3 leaned to one side, her right arm dangled toward the floor, and her eyes were closed. On 08/01/22 at 01:45 PM, Certified Nurse Aid O stated R3 falls asleep in her chair. She stated staff encouraged R3 to sleep in her bed when staff saw her slumping in her wheelchair. On 08/02/22 at 09:05 AM, Administrative Nurse D verified the diagnosis of sleep was inappropriate for the use of [MEDICATION(S)]. She verified the consultant pharmacist had not identified the inappropriate diagnosis. On 08/02/22 at 11:55 AM, Administrative Nurse E verified the use of [MEDICATION(S)] had not been care planned and no targeted behaviors were monitored. The facility's Pharmacy Services policy, dated April 2007 recorded the facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medication and biologicals, and the services of a licensed pharmacist. The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but not limited to, collaborating with the facility and Medical Director to: Help the facility develop procedures and evaluate pharmacy services related to recommend current resources to help staff to understand and identify medications and related information such as contraindications, adverse consequences, and appropriate monitoring, and help the facility identify and address educational and informational needs about medications for staff, practitioners, residents, and families The facility failed to ensure the Consultant Pharmacist identified and reported to the facility, Director of Nursing (DON), medical director, and physician the inappropriate diagnosis for the use of R3's [MEDICATION(S)], placing the resident at risk for adverse side effects. - R14's Physician Order Sheet (POS), dated 06/03/22, documented diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) anxiety disorder (persistent feeling of anxiety or dread), and psychotic disorder with delusions (severe mental disorders that cause abnormal thinking and perceptions). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R14 had short- and long-term memory problems and severe cognitive impairment. The MDS documented R14 required total staff assistance with most activities of daily living and received antipsychotic medications seven days of the lookback period. The Care Area Assessment (CAA), dated 05/24/22, for [CONDITION(S)] (altering mood or thought) and cognitive loss was blank. The Medication Care Plan, dated 05/04/22, documented R14 received medications with a Black Box Warning (BBW-a warning of potential serious adverse effects) including [MEDICATION(S)] ([MEDICATION(S)]- an antipsychotic). The BBW stated elderly patients with dementia-related [CONDITION(S)] treated with antipsychotic drugs are at an increased risk of death. Administer medications as ordered, monitor for side effects and effectiveness, review medications and record possible causes of cognitive decline. The Physician Order, dated 04/27/22, directed staff to administer [MEDICATION(S)], 40 mg, twice daily, for preventative related to dementia. The CP's Drug Regimen Review, dated 08/26/21, recommended an antipsychotic GDR for [MEDICATION(S)] 40mg twice daily. It is recommended to attempt a gradual dose reduction twice within the first year, then yearly. Please evaluate current therapy and document accordingly. The physician did not respond to the recommendation or provide a risk versus benefit statement. The CP's Drug Regimen Review, dated 01/26/22, stated the resident was currently taking [MEDICATION(S)] 40mg daily, with diagnosis listed as dementia with behavioral disturbances. This was not an approved diagnosis for antipsychotic use in elderly patients. Please review current therapy and document accordingly. The physician did not respond to the recommendation or provide a risk versus benefit statement. On 08/01/22 at 08:03 AM, observation revealed R14 in a low bed with a fall mat in front of the bed. The lights were off and R14 was covered. She did not respond to a knock at the door. On 08/02/22 at 08:52 AM, Administrative Nurse D agreed that preventative was an inappropriate diagnosis for the use of [MEDICATION(S)]. She stated staff were to send recommendations again to the physician if they do not respond to the requests for an appropriate diagnosis. The physician did not follow through with the requests for an appropriate diagnosis for the [MEDICATION(S)]. The facility's Pharmacy Services policy, dated April 2007 recorded the facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medication and biologicals, and the services of a licensed pharmacist. The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but not limited to, collaborating with the facility and Medical Director to: Help the facility develop procedures and evaluate pharmacy services related to recommend current resources to help staff to understand and identify medications and related information such as contraindications, adverse consequences, and appropriate monitoring, and help the facility identify and address educational and informational needs about medications for staff, practitioners, residents, and families The facility failed to ensure the physician responded to the CP's recommendation regarding the inappropriate diagnosis for the use of R14's [MEDICATION(S)], placing the resident at risk for adverse side effects. - R26's Physician Order Sheet (POS), dated 06/23/22 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear.) R26's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired cognition with inattentive behaviors that come and go. The MDS recorded the resident required extensive assistance of one to two staff for bed mobility, locomotion on the unit, dressing and personal hygiene. The MDS documented R26 received an antipsychotic (a class of medications used to manage delusions, hallucinations, and paranoia) medication seven days during the lookback period. R26's Behavioral Care Area Assessment, dated 01/08/22 recorded the resident wandered 1-3 days a week and had a diagnosis of dementia. R26's Medication Care Plan, dated 06/15/22 directed staff to monitor the resident's behaviors. R26 may call 911 (police/emergency phone number) when she does not get her pain medication and antianxiety medications when requested. The care plan documented the resident would get bossy with roommates and could be verbally aggressive towards others. R26's Abnormal Involuntary Movement Scale (AIMS) Assessment, (assessment for detection of involuntary movements related to use of antipsychotic) dated 06/11/22, recorded a score of zero. (A score of two or higher indicates the resident has involuntary movements) The Physician Order, dated 06/22/22, directed the staff to administer R26 [MEDICATION(S)] (antipsychotic medication) for a diagnosis of dementia with delusions. The Pharmacy Consult review on 04/26/22 recommended the physician attempt a gradual dose reduction (GDR) twice within the first year then yearly and to evaluate current therapy. The physician declined the pharmacist recommendation for a GDR. The recommendation lacked evidence the CP identified and reported the inappropriate diagnosis for [MEDICATION(S)]. On 07/28/22 at 08:00 AM, observation revealed the resident stood at her doorway and was confused. She did not know where to go, if she had eaten breakfast, or which way the dining room was. R26 told the staff she felt good that morning and staff assisted her to the dining room to eat breakfast. On 08/01/22 at 10:20 AM, Administrative Staff E verified the inappropriate diagnosis of dementia with delusions for R26's use of the [MEDICATION(S)] medications. Administrative Nurse E further acknowledged there were no recommendations from the pharmacist for an appropriate diagnosis for the use of the [MEDICATION(S)]. The facility's [CONDITION(S)] Medication Monitoring policy, undated, documented the facility would use and administer [CONDITION(S)] medications appropriately working with the interdisciplinary team to ensure the appropriate use, evaluation and monitoring. The facility would make every effort to comply with State and Federal regulations related to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dose, side effects, risk and/or benefits. The facility supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness while recognizing that the use of psychopharmacologic medications for dementia related behaviors is inappropriate in most cases but rather the use of non-pharmacological interventions based on individual needs of the resident needs, preferences and routines is the most appropriate and first -line treatment for dementia related behaviors. The facility's Pharmacy Services policy, dated April 2007 recorded the facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medication and biologicals, and the services of a licensed pharmacist. The facility shall contract with a licensed Pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but not limited to, collaborating with the facility and Medical Director to: Help the facility develop procedures and evaluate pharmacy services related to recommend current resources to help staff to understand and identify medications and related information such as contraindications, adverse consequences, and appropriate monitoring, and help the facility identify and address educational and informational needs about medications for staff, practitioners, residents, and families The facility failed to ensure the CP identified and reported to the facility, Director of Nursing (DON), medical director, and physician the inappropriate diagnosis for R26's use of antipsychotic medication, [MEDICATION(S)]. This placed the resident at risk for inappropriate use of an antipsychotic medication.

The facility had a census of 31 residents. The sample included 12 residents with five reviewed for unnecessary medication. Based on observation, interview and record review the facility failed to ensure antipsychotic medications (class of medications used to manage delusions, hallucinations, and paranoia) were used for an appropriate diagnosis per CMS (Center for Medicare/Medicaid Services) guidelines. This deficient practice placed Residents (R)3, R14, and R26 at risk for adverse effects from the use of the antipsychotic medications. Findings included: - R3's Physician Order Sheet (POS), dated 04/12/22, documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance and major recurrent depressive disorder. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10 and no behaviors. The MDS documented the resident required limited to extensive assistance with most activities of daily living (ADLs). The MDS documented R3 received an antipsychotic medication seven days during the lookback period. The Medication Care Plan, dated 07/20/22, directed staff to provide medications whole, monitor for side effects, and effectiveness. The care plan directed staff to obtain and monitor lab work as ordered, report results to the physician and follow up as indicated. The Physician Order, dated 06/30/22, directed staff to administer [MEDICATION(S)] (antipsychotic) 50 milligrams (mg) at bedtime for sleep. The Medication Administration Record (MAR), dated July 2022, directed staff to monitor for side effects of antipsychotic medications ([MEDICATION(S)]) such as but not limited to: stiffness of neck, dry mouth, blurred vision, constipation, [CONDITION(S)], drowsiness, increased falls or dizziness, [CONDITION(S)] (inability to sleep), and confusion. On 07/28/22 at 03:30 PM, observation revealed R3 sat in her wheelchair in the living room visiting with family and other residents. Further observation revealed R3 leaned to one side, her right arm dangled toward the floor, and her eyes were closed. On 08/01/22 at 145 PM, Certified Nurse Aid O stated R3 falls asleep in her chair. She stated staff encouraged R3 to sleep in her bed when staff saw her slumping in her wheelchair. On 08/02/22 at 09:05 AM, Administrative Nurse D verified the diagnosis of sleep was inappropriate for the use of [MEDICATION(S)]. On 08/02/22 at 11:55 AM, Administrative Nurse E verified the use of [MEDICATION(S)] had not been care planned and no targeted behaviors were monitored. The facility's [CONDITION(S)] Medication Monitoring policy, undated, documented the facility would use and administer [CONDITION(S)] medications appropriately working with the interdisciplinary team to ensure the appropriate use, evaluation and monitoring. The facility would make every effort to comply with State and Federal regulations related to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dose, side effects, risk and/or benefits. The facility supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness while recognizing that the use of psychopharmacologic medications for dementia related behaviors is inappropriate in most cases but rather the use of non-pharmacological interventions based on individual needs of the resident needs, preferences and routines is the most appropriate and first -line treatment for dementia related behaviors. The facility failed to ensure an appropriate diagnosis for the use of R3's [MEDICATION(S)], placing the resident at risk for adverse side effects. - R14's Physician Order Sheet (POS), dated 06/03/22, documented diagnoses of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) anxiety disorder (persistent feeling of anxiety or dread), and psychotic disorder with delusions (severe mental disorders that cause abnormal thinking and perceptions). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R14 had short- and long-term memory problems and severe cognitive impairment. The MDS documented R14 required total staff assistance with most activities of daily living and received antipsychotic medications seven days of the lookback period. The Care Area Assessment (CAA), dated 05/24/22, for [CONDITION(S)] (alters mood or thought) and cognitive loss was blank. The Medication Care Plan, dated 05/04/22, documented R14 received medications with a Black Box Warning (BBW-a warning of potential serious adverse effects) including [MEDICATION(S)] ([MEDICATION(S)]- an antipsychotic). The BBW stated elderly patients with dementia-related [CONDITION(S)] treated with antipsychotic drugs are at an increased risk of death. Administer medications as ordered, monitor for side effects and effectiveness, review medications and record possible causes of cognitive decline. The Physician Order, dated 04/27/22, directed staff to administer [MEDICATION(S)], 40 mg, twice daily, for preventative related to dementia. On 08/01/22 at 08:03 AM, observation revealed R14 in a low bed with a fall mat in front of the bed. The lights were off and R14 was covered. She did not respond to a knock at the door. On 08/02/22 at 08:52 AM, Administrative Nurse D agreed that preventive was an inappropriate diagnosis for the use of [MEDICATION(S)]. She stated staff were to send recommendations again to the physician if they do not respond to the requests for an appropriate diagnosis. The facility's [CONDITION(S)] Medication Monitoring policy, undated, documented the facility would use and administer [CONDITION(S)] medications appropriately working with the interdisciplinary team to ensure the appropriate use, evaluation and monitoring. The facility would make every effort to comply with State and Federal regulations related to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dose, side effects, risk and/or benefits. The facility supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness while recognizing that the use of psychopharmacologic medications for dementia related behaviors is inappropriate in most cases but rather the use of non-pharmacological interventions based on individual needs of the resident needs, preferences and routines is the most appropriate and first -line treatment for dementia related behaviors. The facility failed to ensure an appropriate diagnosis for the use of R14's [MEDICATION(S)], placing the resident at risk for adverse side effects. - R26's Physician Order Sheet (POS), dated 06/23/22 documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance, and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear.) R26's Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired cognition with inattentive behaviors that come and go. The MDS recorded the resident required extensive assistance of one to two staff for bed mobility, locomotion on the unit, dressing and personal hygiene. The MDS documented R26 received an antipsychotic (a class of medications used to manage delusions, hallucinations, and paranoia) medication seven days during the lookback period. R26's Behavioral Care Area Assessment, dated 01/08/22 recorded the resident wandered 1-3 days a week and had a diagnosis of dementia. R26's Medication Care Plan, dated 06/15/22 directed staff to monitor the resident's behaviors. R26 may call 911 (police/emergency phone number) when she does not get her pain medication and antianxiety medications when requested. The care plan documented the resident would get bossy with roommates and could be verbally aggressive towards others. R26s Abnormal Involuntary Movement Scale (AIMS) Assessment, (assessment for detection of involuntary movements related to use of antipsychotic) dated 06/11/22, recorded a score of zero. (A score of two or higher indicates the resident has involuntary movements) The Physician Order, dated 06/22/22, directed the staff to administer R26 [MEDICATION(S)] (antipsychotic medication) for a diagnosis of dementia with delusions. On 07/28/22 at 08:00 AM, observation revealed the resident stood at her doorway and was confused. She did not know where to go, if she had eaten breakfast, or which way the dining room was. R26 told the staff she felt good thats morning and staff assisted her to the dining room to eat breakfast. On 08/01/22 at 10:20 AM, Administrative Nurse E verified dementia with delusions was not an appropriate diagnosis for a resident who received [MEDICATION(S)]. She verified the pharmacist had not addressed the inappropriate diagnosis, and the physician had failed to change the diagnosis for the medication. The facility's [CONDITION(S)] Medication Monitoring policy, undated, documented the facility would use and administer [CONDITION(S)] medications appropriately working with the interdisciplinary team to ensure the appropriate use, evaluation and monitoring. The facility would make every effort to comply with State and Federal regulations related to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dose, side effects, risk and/or benefits. The facility supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness while recognizing that the use of psychopharmacologic medications for dementia related behaviors is inappropriate in most cases but rather the use of non-pharmacological interventions based on individual needs of the resident needs, preferences and routines is the most appropriate and first -line treatment for dementia related behaviors. The facility failed to ensure an appropriate diagnosis for the use of R26's [MEDICATION(S)] placing the resident at risk for adverse side effects.

The facility had a census of 30 residents. The sample included 12 residents, of which 1 resident was reviewed for abuse. Based on observation, interview, and record review the facility failed to provide supervision to protect 1 of 1 sampled resident, #15, from resident to resident abuse when Resident #17, made verbal threats toward him/her. Approximately 17 hours later, during a second incident, Resident #17 hit Resident #15 in the mouth, which placed the resident in immediate jeopardy. Findings included: - The facility admitted Resident #17 on 9/30/17 and the physician orders [REDACTED]. the mind created), dementia (progressive mental disorder characterized by failing memory, confusion), and amnesia (loss of memory caused by brain damage or severe emotional trauma). The admission (MDS) Minimum Data Set assessment, dated 10/11/17, documented moderately impaired cognition, other behaviors 4-6 days of the look back period, and daily wandering. The assessment documented the resident was independent with most (ADLs) activities of daily living, had no range of motion impairment, and ambulated without assistive devices. The assessment documented the resident received an antipsychotic (used to treat [MEDICAL CONDITION] and other mental emotional conditions) medication. The 3/30/18 quarterly MDS documented the same except he/she had no behaviors, wandered 1-3 days, required extensive staff assistance with hygiene, and received an antidepressant (used to treat mood disorders and relieve symptoms of depression) medication. The 6/22/18 quarterly MDS documented the same except the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The 12/11/17(CAA) Care Area Assessment summary for behavioral symptoms documented the resident was at risk for impaired social interaction due to dependence on staff for cognitive stimulation and social interaction to maintain a positive psychosocial well-being. The summary documented the resident had chronic confusion related to a head injury, and impaired decision-making skills. The 6/20/18 care plan documented the resident was at risk for decreased activity participation, directed staff to invite the resident to planned activities, and documented the resident liked happy hour, being outdoors, and to work on things. The care plan recorded the resident had a history of [REDACTED]. when he/she was unable to locate a toilet. The care plan directed staff to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, TV, or a book. Sometimes he/she just wanted a drink, and beer or mixed drinks which were available for him/her at the facility. The care plan instructed staff to redirect the resident if he/she attempted to wander into other rooms, ensure the Wanderguard alert (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) was in place on his/her wrist, and when conflict occurred, remove the resident to a calm, safe environment. Nursing note (NN) dated 5/17/18 at 8:22 AM, recorded Resident #17 came up behind another resident that was ambulating up the hallway and kicked the back of his/her shoe. Staff separated Resident #17 from the other resident and started (1:1) one to one supervision immediately. While staff talked to Resident #17 and attempted to get him/her to walk to his/her room, he/she hit another resident with his/her open hand. Staff held Resident #17's arm and attempted to stop him/her from swinging, but he/she was still able to make contact. A second staff member was called to assist with the 1:1 and staff took Resident #17 outside for a walk, with both staff members present to walk with him/her. NN on 5/17/18 at 9:24 AM, recorded 2 staff continued 1:1 supervision outside with the resident, and he/she kept saying that guy killed my dad. NN on 5/17/18 at 3:14 PM, documented the behavioral unit nurse called and notified facility staff they were ready for the resident, so staff drove him/her to the behavioral health unit. On 5/23/18 at 12:40 PM, the (SSD) Social Services Designee documented he/she attended Resident #17's team meeting at the behavioral health unit, and the doctor and staff reported the resident was doing very well, had no behaviors they were concerned about, and the resident was a lot calmer compared to his/her last visit at the unit. The behavioral health unit staff said they were planning to discharge the resident on 5/25/18. NN on 6/29/18 at 11:20 PM, documented this nurse heard a loud noise and inappropriate language and observed Resident #17 walking out of another resident's room. This nurse talked to him/her to see what was going on and tried to redirect Resident #17 to his/her room. Resident #17 followed this nurse to check on the other resident, who was attempting to get off the floor. The belongings of the other resident were thrown on the floor, a wall shelf taken down, and cords to the TV and cable box were ripped out of the wall. This nurse was between the two residents as Resident #17 was upset and stated he/she stole my ****, why is he/she in here. This nurse assured Resident #17 that this was not his/her room and called down the hall for staff to help with Resident #17. Staff placed the resident on 2 to 1 supervision due to the resident being able to overtake 1 staff member. NN on 8/11/18 at 6:10 PM, documented Resident #17 was combative to other residents and staff. The resident continued to go into other residents' rooms and became angry with staff when they tried to get him/her out. At supper, the resident kept trying to unzip his/her pants to urinate behind the dining room door. Staff intervened, and the resident went down the hall and tried to urinate in the day room. NN on 8/13/18 at 3:12 AM, documented staff heard a resident yelling. When staff entered Resident #15's room, they found Resident #17 standing at the head of the opposite gender resident's bed in his/her underwear. Resident #15 was yelling for Resident #17 to get out of his/her room. When staff tried to redirect Resident #17 out of the resident's room when he/she stated, I want to just punch that person in (his/her) mouth. Staff asked Resident #15 if Resident #17 touched him/her and he/she stated no, but he/she scared him/her. The note recorded Resident #15's room was next to Resident #17's room and this was not the first time he/she had gone into the resident's room. Resident #17 wandered about the facility for approximately an hour, staff gave him/her something to eat, and he/she returned to his/her room without further incident. (the clinical record lacked evidence staff initiated 1:1 supervision for Resident #17 at this time.) NN on 8/13/18 at 1:40 PM, documented the day shift nurse reported the resident slept most of the morning but was up off and on during the night. The resident was laid in bed with his/her eyes closed. NN on 8/13/18 at 6:30 PM, documented the Office Manager/(CMA) Certified Medication Aide had taken Resident #17 out of the facility for supper. Staff returned the resident to the facility at 6:30 PM and left the resident unattended at the nurse's station drinking a cola. NN on 8/13/18 at 7:55 PM, documented at 7:30 PM, unsupervised by staff, Resident #17 went into Resident #15's room and hit the resident in the mouth, lower left lip. A (CNA) Certified Nurse Aide informed the nurse that he/she found Resident #17 shaking his/her fist at Resident #15, but the CNA could not understand what he/she was saying. The nurse noted blood on Resident #17's right hand knuckles and initiated one-on-one supervision. NN on 8/13/18 at 9:09 PM, documented the nurse called the mental health practitioner, who stated the resident did not need anything at this time. Resident #17 continued to rest in bed with eyes closed, and one on one supervision. NN on 8/14/18 at 5:54 AM, documented the resident continued to rest in bed with his/her eyes closed, and one on one supervision continued. NN on 8/14/18 at 9:15 AM, documented the resident woke up around 8:00 AM this morning, walked up and down the halls with a nurse aide, and had breakfast in the living room with staff. NN on 8/14/18 at 9:30 AM, documented Resident #17 left the facility with his/her family member who reported he/she would provide lunch to the resident and bring him/her back to the facility this afternoon. NN on 8/14/18 at 2:00 PM, documented Resident #17 returned to the facility and staff informed the family member the resident would be transferred to a behavioral health unit. NN on 8/14/18 at 2:50 PM, documented staff sat outside with the resident, 1 on 1, since he/she arrived back to the facility at 2:00 PM. The resident rested off and on in a chair outside, stayed calm, and carried on small conversation, when initiated by others. NN on 8/14/18 at 3:00 PM, documented staff transferred Resident #17 to the behavioral unit. On 8/14/18 at 8:45 AM, observation revealed Resident #15 sat at a dining table and his/her bottom lip on the left side was swollen and had reddish purple bruising. On 8/14/18 at 3:55 PM, Nurse Aide M stated the resident would have been aggressive with other residents if staff had not intervened. He/she stated the resident was physically and verbally aggressive to staff and he/she had to place himself/herself between Resident #17 and other residents. On 8/15/18 at 10:23 AM, Nurse Aide Q verified he/she removed the resident from other residents' rooms, and he/she was hesitant, but did not argue or fight. On 8/15/18 at 4:47 PM, Nurse G stated he/she worked the day shift Monday, (MONTH) 13, (YEAR), and the 8/12/18 night nurse reported to him/her Resident #17 threatened to hit an (opposite gender) person in the mouth but the nurse was not specific who the resident threatened. Nurse G reported Resident #17 had not threatened to hit other residents, just staff, and his/her mood or behavior quickly changed at times. He/she stated if the resident threatened another resident, staff should place Resident #17 on one to one supervision. On 8/16/18 at 7:05 AM, Nurse H stated Resident #17 wandered the halls, set off exit alarms, and staff observed him/her, but did not place him/her under one on one supervision until after the resident hit Resident #15. Nurse H stated the resident sat quietly in the living room with 3 other residents and walked up and down the hall 2-3 times before staff heard Resident #15 hollering for help. Nurse H stated Resident #17 left the room after punching Resident #15. Nurse H stated he/she was unaware that Resident #17 threatened to hit the other resident. Nurse H stated staff has had to remove Resident #17 from Resident #15's room several times. Nurse H stated staff had not informed him/her of the threat or he/she would have had staff provide one on one supervision with Resident #17. 8/16/18 at 10:59 AM, Nurse I stated on Sunday night, staff reported Resident #17 threatened to punch someone in the mouth and Nurse I stated Nurse Aide R, who diffused the situation between Residents #17 and #15 early Monday morning, never specified who Resident #17 made that comment toward. Nurse I stated the aide removed him/her from Resident #15's room and gave him/her a sandwich. Nurse I stated all staff watched the resident as much as they could, and he/she did not feel Resident #15 was in any danger of being harmed. Nurse I stated once Resident #17 became fixated on something it was hard to distract him/her, and if someone got into his/her personal space it agitated him/her. Nurse I stated Resident #17 was fast with his/her hands and had hit the staff. He/she wandered at night and went into other residents' rooms. Nurse I stated he/she reported the incident to the next shift nurse. 8/16/18 at 1:03 PM, Nurse Aide R stated he/she found Resident #17 in Resident #15's room when he/she was in bed, early Monday morning, 8/13/18, about 3:00 AM. Nurse Aide R stated he/she heard Resident #15 screaming at someone to get out of his/her room and stated he/she found Resident #17, in his/her underwear, standing at the side of the bed about 1 foot away from Resident #15's face. Nurse Aide R stated he/she had trouble redirecting the resident, called for another staff, who was able to get Resident #17 out of Resident #15's room, and Resident #15 reported the other resident had not touched him/her. Nurse Aide R stated Resident #17 looked at him/her (the aide) and said, I just wanna punch (him/her) in the mouth. Nurse Aide R stated Resident #17's clothes were on the bedside table, which was odd as he/she usually slept in his/her clothes. Nurse Aide R stated he/she reported what Resident #17 said to the nurse, and during the rest of the night staff could not see Resident #17, as the resident closed his/her door. 8/16/18 at 1:37 PM, Nurse Aide S stated Monday evening, 8/13/17, he/she heard Resident #15 screaming, he/she responded, found Resident #15's door shut, and when he/she opened the door Resident #15 was in his/her recliner chair with blood dripping from the left side of his/her mouth. Resident #17 was shaking his/her fist, pointing his/her finger at Resident #15, and scolding him/her. Nurse Aide S stated the nurse guided Resident #17 out of room. Resident #15 reported he/she tried to use his/her walker to create space between them and it was on the floor on it's front when I went in. Resident #15 reported Resident #17 hit him/her and said he/she had not done anything to him/her except told him/her to get out of his/her room. Resident #15 was a little on edge the rest of the night, but staff had a person providing one to one supervision with Resident #17 all night. 8/16/18 at 2:33 PM, Nurse Aide M stated on Sunday 8/12/18, 3 staff had to remove Resident #17 from Resident #9's room after he/she had grabbed Resident #9's wheelchair in the hallway and pushed him/her. Resident #9 did not like that and became agitated. Nurse Aide M stated he/she asked Resident #17 several times to let go of the wheelchair, but he/she would not let go and pushed the resident into Resident #9's room. Nurse Aide M stated he/she called for help and staff transferred the resident out of the wheelchair and into his/her recliner. Resident #17 went into the resident's bathroom, with staff following, then eventually left the resident's room. Nurse Aide M stated Resident #17 pulled up floor vents and wandered around with them, pulled the hand railing off the wall, pulled the door code boxes off at the doors, wandered in and out of resident rooms, and urinated in their rooms. He/she stated the residents were scared of Resident #17. Nurse Aide M stated on Monday evening 8/13/18, he/she checked on Resident #15 who was holding a wash cloth with ice to his/her lip. Nurse Aide M stated he/she observed blood on the resident's pants and front of his/her shirt, and helped the resident clean up and change since he/she was still shaky. Nurse Aide M stated the resident's mouth had blood in it and asked him/her if his/her teeth were loose, to which he/she replied no. Nurse Aide M stated Resident #15 told him/her when Resident #17 smacked him/her, he/she tried to reach his/her walker and defend himself/herself and that's when Resident #17 kicked him/her. Nurse Aide M stated he/she observed a laceration on the resident's lip, a new bruise on his/her left leg, about 6 inches long and his/her right leg had 2 red spots and a skin tear the size of the end of a thumb, and he/she reported those concerns to the nurse. Nurse Aide M stated Resident #17 tried to hit other residents, but staff intervened. The facility's 11/2016 policy for Preventing Resident Abuse documented the facility's program included the following: 1) Training all staff how to resolve conflicts appropriately. 2) Assisting or rotating staff working with difficult or abusive residents. 3) Training staff to understand and manage a resident's verbal or physical aggression. 4) Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect. 5) Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues. involving qualified psychiatrists and other mental health professional to help the staff manage difficult or aggressive residents. 6) Striving to maintain adequate staffing on all shifts to ensure the needs of each resident are met and encouraging all staff to report any signs or suspected incidents of abuse to facility management immediately. The facility's undated Protection of Residents During Abuse Investigation documented if the alleged abuse involved another resident, the accused resident's representative and physician would be informed and there may be restrictions placed on the accused resident's ability to visit other residents' rooms unattended. The policy lacked specific interventions such as 1:1 supervision. The facility failed to provide supervision to protect Resident #15 after Resident #17 verbally threatened to punch that person in the mouth, placing the resident in immediate jeopardy. Approximately 17 hours later, Resident #17 hit Resident #15 in the mouth, causing bleeding and swelling. The facility abated the immediate jeopardy on 8/13/18, when the facility provided one on one supervision for Resident #17. The facility transferred Resident #17 to a behavioral health facility on 8/14/17. The deficient practice remained at a scope and severity of a G.

The facility had a census of 23 residents. Based on observation, record review, and interview, the facility failed to ensure 4 sampled residents rooms (#4,#10,#14,#32), 3 unsampled residents rooms (#3,#5,#6), and 1 of 1 shower room for the facility located on the West Hall , were free from unsafe water temperatures above 120 degrees Fahrenheit, (132-141) degrees. This deficient practice placed the residents in immediate jeopardy. Findings included: - On the second day of the onsite visit on 8/19/14, observation on the West Hall, revealed the following water temperatures: 8:18 AM,132 degrees in Resident #30 and Resident #14's shared room. 8:30 AM, 138 degrees in Resident #30 and Resident #14's shared room. 9:00 AM, 141 degrees in Resident #3's room. 9:05 AM, 138 degrees in Resident #4's room. 9:10 AM, 136 degrees in Resident #6's room. 9:15 AM, 136 degrees in an unoccupied room. 9:45 AM, 139 degrees in the shower room During an interview, on 8/19/14 at 9:20 AM, Administrative Staff B verified the unsafe water temperatures and stated he/she would call someone to come right away to adjust the water heater. Administrative Staff B further stated, the facility had recently installed a new water heater that provided the water to the West Hall rooms. At 9:45 AM, Administrative Nurse A stated the staff would not give any showers until the water temperature in the shower room was under 120 degrees. . At 10:00 AM, Administrative Nurse A obtained a water temperature of 136 degrees in the shower room,using a facility thermometer. At 10:15 AM, Administrative Staff B stated he/she contacted a vendor who would adjust the water heater. At 12:45 PM, Local Contractor G, stated he/she did not take any water temperatures prior to adjusting the water temperature. Contractor G further stated, the knob on the water heater had an indention as to where 120 degrees Fahrenheit was and the knob was set higher than 120 degrees. The invoice, dated 7/7/14, indicated the contractor installed a water heater on 7/8/14. Review of the Facility's Water Temperature log for The West Hall on 7/10/14 revealed the following temperatures: 135 degrees in Resident #3's room 134 degrees in Resident #4's room 137 degrees in Resident #6's room 137 degrees in an unoccupied room 127 degrees in shared Resident #14 and Resident #32's room. 137 degrees in shared Resident #5 and Resident #10's room. Review of the Facility's Water Temperature log for The West Hall on 7/11/14 revealed the following temperatures: 138 degrees in Resident #3's room 138 degrees in Resident #4's room 140 degrees in Resident #6's room 137 degrees in an unoccupied room 137 degrees in shared Resident #14 and Resident #32's room 135 degrees in shared Resident #5 and Resident #10's room Further review of the Facility's Water Temperature logs revealed staff did not obtain any further water temperatures in the resident rooms after 7/11/14 . Review of the Facility's Shower Room Temperature Log revealed a water temperature on 7/14/14, of 133 degrees. On 8/19/14 at 2:15 PM, Nurse Aide I stated the nurse aide who gave the first shower of the day was to obtain and document the water temperatures on the shower log. On 8/21/14 at 9:15 AM, Nurse Aide H stated, the nurse aides obtain the water temperatures in the residents' rooms monthly. Nurse Aide H further stated he/she did not notify administration of the elevated water temperature that he/she had taken on 7/10/14 and 7/11/14. On 8/21/15 at 4:00 PM, Administrative Nurse A verified, he/she was unaware of the unsafe water temperatures in the resident rooms and further verified the staff did not take water temperatures in the shower room on the West Hall daily. Administrative Nurse A stated the staff had been aware to contact administration of any water temperatures over 120 degrees. The August 2014 Facility Safety of Water Temperature Policy stated the water heaters that service resident rooms and shower rooms shall be set to temperatures of no more than 120 degrees Fahrenheit. The policy further stated the shower room temperatures will be checked prior to the first shower given each day, and recorded on the temperature log. The policy stated checks of the water temperatures in the residents rooms are done periodically, and if the water felt hot enough to be painful, to report to the immediate supervisor. The facility failed to ensure that the resident environment remained as free of accident hazards as that possible regarding elevated water temperatures in the West Hall shower room and 5 resident rooms which affected 7 residents. The facility abated the immediate jeopardy on 8/19/14 when the water heater was drained and refilled, and adjusted to 120 degrees. The facility held an in-service for all available staff, and in serviced the remaining staff on 8/20/14, at which time 100% of staff had in-service prior to working their next scheduled shift. The in-service included the risk factors for burns in the elderly and education of how to appropriately check water temperatures. The nurse aide in-service stated the nurse aide was responsible for checking thermostats and temperature controls of the water in the facility and to record the checks in the maintenance log per facility policy. The policy stated to check the water temperature in the resident rooms the 1st Sunday of each month and record the documentation in the safety log. The nurse aide would check the shower and each day record on the temperature log. The Director of Nursing or designee would be responsible to follow-up monthly and review the water safety log. (The facility completed the education 42 days after a contractor installed the water heater) This deficient practice remains at the scope and severity of an F.