Every finding on record at VI at the Glen

Based on interview and record review, the facility failed to follow its policy in conducting background checks for 10 (R8, R17, R27, R28, R33, R39, R40, R44, R93 and R94) of 10 residents reviewed for admission screening. This deficiency also has the potential to affect the 42 residents currently residing in the facility. Findings include: Per census report, there are 42 residents currently residing in the facility. On 06/11/24 at 2:45 PM during review of documentation pertaining to background checks, the following were presented by facility: R8 is a [AGE] year-old, female admitted in the facility on 03/26/24 with diagnosis of Urinary Tract Infection, Site not Specified and Type 1 Diabetes Mellitus with Hyperglycemia. There were no records on file that her Criminal History Information Response Process (CHIRP) was checked upon admission and department of corrections. Her name was checked in the state sex offender registry on 06/11/24. R17 is a [AGE] year-old, female, admitted in the facility on 05/10/24 with diagnosis of Infection and Inflammatory Reaction due to Internal Left Knee Prosthesis, Subsequent Encounter. Her name was checked under state sex offender website on 06/11/24, which was 32 days after admission. There were no records on file that R17's name was checked in the department of corrections website. R27 is an [AGE] year-old, female, admitted in the facility on 05/02/24 with diagnosis of Unspecified Dementia, Mild, with other Behavioral Disturbance. Her CHIRP was conducted on 05/10/24, which was eight days after admission. Her name was checked under state sex offender registry on 06/11/24. There were no records that her name was checked under department of corrections. R28 is a [AGE] year-old, male, admitted in the facility on 05/10/24 with diagnosis of Essential Hypertension and Liver Cell Carcinoma. His name was checked in the state sex offender registries on 06/11/24, which was 32 days after admission. There was no record showing his name was checked from the department of corrections. R33 is an [AGE] year-old male, admitted in the facility on 04/04/24 with diagnosis of Neurocognitive Disorder with Lewy Bodies. There were no records showing that his name was checked under department of corrections. There was also no CHIRP done on R33. His name was checked in the state sex offender registry on 06/11/24, which was almost two months after admission. R39 is a [AGE] year-old, female, admitted in the facility on 05/09/24 with diagnosis of Metabolic Encephalopathy and Type 2 Diabetes Mellitus without Complications. Her name was checked in the state sex offender registry websites on 06/11/24, which was 33 days after admission. There were no records showing her name was checked from the department of corrections. R40 is an [AGE] year-old, male admitted in the facility on 05/03/24 with diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris. He has no records on file that his name was run for CHIRP or department of corrections. His name was checked in the state sex offender website on 06/11/24, which was 39 days after admission. R44 is a [AGE] year-old, female, admitted in the facility on 05/21/24 with diagnosis of Laceration without Foreign Body of Scalp, Subsequent Encounter. There were no records that her name was ran from the department of corrections. Her name was checked in the state sex offender database on 06/11/24, which was 21 days post admission and her CHIRP on 06/12/24. R93 is an [AGE] year-old, female, admitted in the facility on 06/08/24 with diagnosis of Paroxysmal Atrial Fibrillation. There was no documentation on file in her medical records related to CHIRP or department of corrections. Her name was checked in the state sex offender registry on 06/11/24. R94 is an [AGE] year-old, female, admitted in the facility on 05/29/24 with diagnoses of Dysarthria following Cerebral Infarction and Cerebral Infarction due to Embolism of Left Middle Cerebral Artery. There was no CHIRP done on R94. No document related to department of corrections presented during review of her records. Her name was checked in the state sex offender registry on 06/11/24. On 06/11/24 at 2:48 PM, V3 (Social Worker) was asked regarding background checks on new admissions. V3 replied, I am responsible for the background checks of new admission. Background checks should be done within the 24 hours of admission. I don't have an answer as to why the background checks were done a month after admission. I did not check the department of corrections for these new admitted residents. On 06/11/24 at 2:57 PM, V1 (Interim Administrator) was interviewed regarding new admissions. V1 verbalized, For residents who will admitted in the care center, V3 run the background checks prior or within the 72 hours of admission. She needs to run the CHIRP, state and sex offender registries and Department of Corrections. If there is a hit, we follow our policy. On 06/12/24 at 12:55 PM, V1 stated that they just ran all residents' background checks in the state and sex offender registry websites. Facility presented the following documentation: R27 - checked state sex offender registry on 06/12/24 R93 - checked state sex offender websites on 06/12/24 On 06/13/24 at 10:31AM, V11 (Medical Director) was interviewed regarding background checks on residents. V11 stated, If background checks on residents is a state mandate and if its in their policy, facility has to follow the regulations and their policy. Facility's policy titled Resident Screening dated October 2023 documented in part but not limited to the following: Purpose: This policy outlines the process for screening Skilled Nursing (SN) residents prior to admission. Process: At the community, the Admissions Coordinator or designee will screen all persons seeking admission to SN against the Sex Offender Registry database for the State in which the Community is located and against the National Registry and, as applicable, perform criminal background checks of the person seeking admission in accordance with state law. 1. Sex Offender Registry Screening: Prior to or within 72 hours of admission, unless a shorter timeframe is required by state law, the applicable Community must perform a screening against national and state sex offender registries of the resident, based on the resident's first and last name verified by a government-issued identification. 2. Criminal Background Check. The applicable Community must request a criminal background check when required by law. Communities must request criminal background checks of potential residents 18 or older through the state-specific processes listed below, prior to or within 72 hours of admission, unless a shorter time frame is required by state law, based on the resident's name, date of birth, and other identifiers as required by the specific State Police. While the sex offender screening and background checks (if applicable) are pending, Community will take steps to ensure the safety of residents. Facility's policy titled Abuse/Neglect Prevention, dated May 2007 stated in part but not limited to the following: Process: The Community seeks to protect its residents from abuse by anyone including, but not limited to staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.

Based on observation, interview and record review, the facility failed to implement their grievance policy by not documenting a complaint and applicable resolution as made by a resident. This failure affected 1 (R24) of 27 residents reviewed for grievances. Findings include: R24 is [AGE] years old and admitted to the facility 4/18/23. R24 has diagnoses that include anxiety disorder, weakness, history of falling and difficulty walking. On 6/10/24 at 12:20PM, R24 was observed sitting in an armchair in their bedroom and expressed a complaint that they and their family member made regarding the carpet in R24's room. R24 pointed to a particular area of the carpet in the immediate walkway into the room that was stained. R24 said that they had asked about a month ago to have the carpet replaced, and the administrator and building engineer had informed R24 and the family member that the carpet would only be replaced at their personal expense. R24 insisted that the carpet was not only stained but was torn and said that they almost tripped and was afraid of falling should they trip over the carpet while walking to the bathroom. R24 said that nothing had been completed in writing, but the staff notified R24 by phone. Upon observation by surveyor, the carpet did not appear to be torn, however, some fibers where the carpet was cut were not homogenous which took on a white boarder with a darkened stain in the middle. On 6/11/24 at 3:54PM V1 Administrator said, the carpet in R24's room was replaced about a year ago when R24 first moved in. I, the housekeeping director, and the director of engineering went to evaluate the carpet and could not find any reason to replace it. I informed R24 and their family that we would be happy to replace the carpet if they would like to pay for it. The grievances and concern binder were reviewed from August 2023 to current, however it did not include a grievance for R24's concern. On 6/12/24 at 1:28PM V1 said, R24 made the complaint a few weeks ago and there was no grievance created for the concern because V1 didn't think it was considered a grievance. On 6/13/24, V1 Administrator presented grievance dated 6/13/24 with additional correspondence from R24's family member regarding the issue. Follow up will include deep cleaning which R24 and the family member are amenable. Policy Protocol titled Grievance Resolution Process revised 10/23 states in part; 2. Grievances include written and verbal complaints submitted to the Care Center Administrator, Director of Nursing or designee, as the Grievance Official or any other employee. 2.1 If a resident and/or their responsible agent is unable to complete a written complain, assistance may be provided by the Grievance Official or any other employee. 2.2 Grievances may be filed anonymously. 2.3 Grievance may be submitted using the Grievance Report Form. If a grievance is received verbally, the staff member should complete the Grievance Report Form. 3.5 The resident has a right to obtain a written decision regarding his or her grievance. All written grievance decisions include: (1) The date the grievance was received; (2) A summary statement of the resident's grievance; (3) The steps taken to investigate the grievance; (4) A summary of the pertinent findings or conclusions regarding the resident's concern(s); (6) Any corrective action taken or to be taken by the facility because of the grievance; and (7) The date the written decision was issued. 3.6 All steps of the grievance resolution process are documented on designated forms. 3.8 The facility maintains evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision.

Based on interview and record review the facility failed to update fall care plan interventions after each fall incidents on resident who are at risk for fall. The facility also failed to update resident care plan who is on prophylaxis antibiotic indefinitely. These deficiencies affect four (R11, R21, R26 and R39) of eight residents in the sample of 16 reviewed for care plan revision and updates. Findings include: On 8/23/2023 at 12:20pm V4 (Care Plan Coordinator) observed an unwitnessed fall incident report dated 11/28/2022 resulting in R11 complaining of right hip pain and an unwitnessed fall incident report on 1/25/2023. A care plan review dated on 11/21/2022 with a problem of falls on 11/28/2022 and no fall intervention approach in place. On 8/23/2023 at 12:25pm V4 said the care plan should be updated after every fall incident. Facility Policy: Care Plan Protocol Revised in 2011 Care Plan Protocol This protocol provides care plan guidelines for the Agency. 2. Revision of the plan of care as frequently as necessary to reflect the changing care needs of the patient. 39781 On 8/22/23 at 10:48AM, V10 RN said that R21 had recent witnessed fall on 8/12/23. Observed R21 lying in bed. On 8/23/23 at 12:15PM, Review R21's medical records with V7 Care plan Coordinator. R21 is admitted on [DATE] with diagnosis listed in part but not limited to Unsteadiness on feet, Lack of Coordination, Weakness, Senile Degeneration of brain. V7 said that R21's fall assessment is at high risk. Review R21's Fall incident report on 8/12/23 with V7 indicated: R21 was assisted to the washroom by CNA when her legs gave out. CNA assisted R21 to the floor. No injury or bruises noted on the resident. Review R21's care plan with V7 indicates: R21 is at risk for fall due to debility from recent illness, new surroundings, advancing age with comorbidities, poly pharmacy. V7 said that she did not update R21's fall care plan intervention after her fall on 8/12/23. V7 said that fall care plan intervention should be updated after each fall incident. On 8/22/23 at 10:45am, Observed R26 ambulating with walker with V9 Private Care giver. R26 denied any signs and symptoms of UTI (Urinary Tract Infection). V9 said that R26 did not present signs and symptoms of UTI. On 8/23/23 at 9:35am, Review R26's medical record with V2 Nursing Supervisor. R26 is admitted on [DATE] with diagnosis listed in part but not limited to Chronic lymphocytic leukemia of B-cell type not having achieved remission. V2 said that R26 is on antibiotic (Cephalexin) 250mg 1 cap orally at bedtime since 4/18/23 upon admission as prophylaxis for UTI (Urinary Tract Infection) indefinitely. V2 said that there is no care plan in placed in regards with R26's usage of prophylaxis antibiotics. V2 said that there is no documentation in R26's chart indicating that she is presenting signs and symptoms of UTI. No documentation that R26 is being monitored for sign and symptoms for UTI. On 8/23/23 at 12:08PM, Review R26's comprehensive care plan with V4 Care plan Coordinator. V4 said that she did not develop care plan for R26's usage of antibiotics indefinitely due to prophylaxis for UTI. On 8/22/23 at 10:38AM, Observed R39 lying in bed with V8 Private Caregiver at bedside. V8 said that R39 had fall incident last month and was admitted to hospital due to fractured hip. On 8/23/23 at 10:10AM, Review R39's medical records with V2 Nursing Supervisor. R39 is readmitted on [DATE] with diagnosis listed in part but not limited to Periprosthetic fracture around internal prosthetic left hip joint, Aftercare following joint replacement surgery, Presence of artificial hip joint, Fracture of part of neck of left femur subsequent encounter for closed fracture with routine healing, History of falling, Difficulty in walking, Cognitive decline, Weakness, Abnormalities in gait and mobility, Lack of coordination, Ataxia following Cerebral infraction. V2 said that R39's fall risk assessment indicated that she is at high risk. V2 said that R39 is care plan for at risk for falling related to cognitive impairment, disease process, recent illness, new surroundings, advancing age with comorbidities, poly pharmacy. V2 said that R39 has several fall incidents. Review R39's fall incidents report with V2. Most recent witnessed fall incident dated 7/24/23 at 12:00pm indicated: CNA notified the Nurse on duty that R39 was observed on the floor. V8 Private caregiver, who was with R39 at the that time, turned around to press the call light and in that moment R39 stood up from her wheelchair and fell . R39 hit her head and left hip. R39 was sent to the hospital and admitted with diagnosis of Comminuted Left Intertrochanteric Fracture. R39 had Left hip revision on 7/25/23 and returned to the facility on [DATE]. On 8/23/23 at 12:08PM, V7 Care plan Coordinator said that she updates all the resident care plan in the facility. V7 said that fall care plan is updated after each fall and when there is change of resident condition. Review R39's Fall care plan with V7 Care Plan Coordinator. V7 said that she did not update R39's care plan intervention after she returned from the hospital status post left hip revision from a fall sustaining Comminuted Left Intertrochanteric Fracture. Facility's policy on Care Plan Protocol revised date November 2011 indicates: Standard of Practice: 2. When establishing care plan, in as far as is possible, the dame personnel are assigned to care for each patient. Steps to be taken in developing the care plan include: *Revision of the plan of care as frequently as necessary to reflect the changing care needs of the patient. Facility's policy on Fall Prevention Protocol revised October 2017 indicates: Purpose: This protocol describes mechanism for assessing residents at risk for falls and providing interventions to reduce the likelihood of falls. Desired outcome: To reduce both the number of resident falls and injuries related to those falls. Post fall Guidelines: 3. For residents who are determined to be at risk for falls on admission, a care plan is developed, and the appropriate Minimum Date Set Documentation is completed. These documents are updated for falls that occur after admission.

Based on observation, interview and record review the facility failed to provide psychiatric/ psychological evaluation as ordered and behavioral management interventions for resident who presented delusion of being food poisoned. This deficiency affects one (R26) of three residents the sample of 16 reviewed for Behavioral Management. Findings include: On 8/22/23 at 10:45AM Observed R26 ambulates with rolling walker. She said that somebody has been tampering her food for several months since she was admitted . She does not feel well after she eat because someone is tampering her meals. She has not been eating and has been losing weight. She reported it, but nothing is being done. V9 R26's Private caregiver said that R26 has is confused and thinking that someone is tampering her food or poisoning her. V9 said she needs reassurance and able to convince her if she refused to eat. She has fair to good appetite and did not lose weight. On 8/22/23 at 10:48AM, V10 RN said that she is the nurse assigned to R26. She said that R26 has behavioral problems of refusing care and medications but able to response to redirections. She has delusion and paranoid that her food is being tampered or poisoned. She denied R26 of losing weight. On 8/22/23 at 10:52AM, V11 CNA said that she is the CNA assigned for R26. She said that R26 has behavioral problems of refusing care and medications but able to response to redirections. R26 has delusion and paranoid that her food is being tampered or poisoned. She denied R26 of losing weight. On 8/22/23 at 10:55 AM, V3 Food Service director said that she is aware that R26 has behavioral issues of refusing to eat due to paranoia of food being poisoned. V3 denied R26 of losing weight but rather has gained weight. On 8/22/23 at 10:59AM, Review R26's care plan with V10 RN. Noted there is no behavioral care plan found addressing the issues of delusion and paranoid of food being tampered or poisoned. On 8/22/23 at 11:10AM, Review R26's medical records with V2 Nursing Supervisor. R26 is admitted on [DATE] with diagnosis listed in part but not limited to anxiety disorder due to known physiological condition. Physician order sheet indicates: Psychiatry, Psychology evaluation and treatment as indicated. She is on Quetiapine (Seroquel) for Delirium. Quetiapine 25mg 1 tab orally twice a day for agitation and 25mg orally 1 tab daily as needed, Alprazolam 0.25mg 1 tab orally at bedtime for anxiety. R26's progress notes indicated behavioral of resistance to care, refusing medications, and delusion and paranoia of her food is being tampered or poisoned. R26's dietary notes indicated that she often says that her food is poisoned. R26 is at risk for possible weight. R26's comprehensive care plan did not address her behavioral issues of delusion and paranoid of food being tampered or poisoned. V2 said that R26 is not referred or seen by psychiatrist/psychologist regarding her behavioral issues. R26's Primary Care Physician (PCP) does not come to the facility. R26's last visit to her PCP was last June 2023. R26's PCP notes during her visit no documentation addressing behavioral issues of R26's delusion and paranoid of being food poisoned. On 8/22/23 at 11:18AM V7 Care plan Coordinator said that she formulates and updates the resident's care plan in the facility. V7 said that care plan should be individualized based on the resident needs. Care plan should be addressing the needs/issues of resident. She said that R26 has behavioral problems of refusing care and medications but able to response to redirections or encouragement. She has delusion and paranoid that her food is being tampered or poisoned. V7 said that she did not write behavioral care plan addressing the issues of delusion and paranoid of food being tampered or poisoned. V7 said that she should written care plan intervention addressing the behavioral needs of R26. V7 said that R26 is not seen by psychiatrist or psychologist for her behavioral issues. R26's MDS (Minimum Date set)/Resident Quarterly assessment dated [DATE] indicated: Section E Behavior: E0100 Potentials indication of Psychosis: B. Delusions (Misconception or beliefs that are firmly held, contrary to reality); Section N Medications: N0410 Medications Received: A. Antipsychotic B Antianxiety On 8/22/23 at 2:30PM Informed V1 Administrator and V2 Nursing Supervisor that R26 is on antipsychotic (Quetiapine) medication related to diagnosis of delirium as indicated in physician order sheet. Asked both if this is appropriate diagnosis for usage of Quetiapine. Both said that they will have to review their policy and get back to the surveyor. On 8/23/23 at 10:30am V2 Nursing Supervisor said that she called R26's Nurse Practitioner for appropriate diagnosis for R26 usage of Quetiapine. V2 said that they are not aware that Delirium is not appropriate diagnosis for usage of anti-psychotic medication (Quetiapine). The diagnosis given is Dementia with behavioral disturbance. On 8/24/23 at 2:58pm Informed V1 Administrator informed of above concerns identified. Facility's policy on Behavior Management- Psychotropic/Antipsychotic Drugs revision date October 2017 indicates: Process: 2. Residents will not be given psychotropic drugs unless necessary to treat a specific condition that is documented in the resident's clinical record based upon a comprehensive assessment. 5. Documentation of behavioral monitoring includes: *Symptoms demonstrated which require the use of psychotropic medication *If the symptoms are transient or ongoing *Evaluation of other reason or potential cause of behavior * Ruling out of other medical causes for the behavior 6. In addition to pharmacologic treatments for residents with behavior issues, behavioral management interventions may be utilized either as directed by a health care provider with prescriptive authority or as part of the interdisciplinary plan of care. These interventions may include but not limited to those listed below: *Consultation with a psychologist or psychiatrist for team and for the resident 1. Psychiatrist/psychological consults are documented in the resident's medical record. 3. Changes in the resident's behavior or issues related to the psychotropic medication regime are directed to the psychiatrist. The health care provider with prescriptive authority. The change in plan is also discussed with the resident's responsible agent if needed. Facility's policy on Care Plan Protocol revised date November 2011 indicates: Standard of Practice: 2. When establishing care plan, in as far as is possible, the dame personnel are assigned to care for each patient. Steps to be taken in developing the care plan include: *Revision of the plan of care as frequently as necessary to reflect the changing care needs of the patient.

Based on observation, interview and record review the facility failed to follow its fall prevention protocol by failure to notify the State Agency Illinois Department of Public Health (IDPH) in a timely manner of a resident fall incident that required hospitalization . The facility also failed to ensure effective intervention were in place to reduce the risk of falls. This deficiency affects two (R11 and R39) residents in the sample of 16 reviewed for Resident safety. Findings include: On 8/22/23 at 10:38AM, Observed R39 lying in bed with V8 Private Caregiver at bedside. V8 said that R39 had fall incident last month and was admitted to hospital due to fractured hip. On 8/23/23 at 10:10AM, Review R39's medical records with V2 Nursing Supervisor. R39 is readmitted on [DATE] with diagnosis listed in part but not limited to Periprosthetic fracture around internal prosthetic left hip joint, Aftercare following joint replacement surgery, Presence of artificial hip joint, Fracture of part of neck of left femur subsequent encounter for closed fracture with routine healing, History of falling, Difficulty in walking, Cognitive decline, Weakness, Abnormalities in gait and mobility, Lack of coordination, Ataxia following Cerebral infraction. V2 said that R39's fall risk assessment indicated that she is at high risk. V2 said that R39 is care plan for at risk for falling related to cognitive impairment, disease process, recent illness, new surroundings, advancing age with comorbidities, poly pharmacy. V2 said that R39 has several fall incidents. Review R39's fall incidents report with V2. Most recent witnessed fall incident dated 7/24/23 at 12:00pm indicated: CNA notified the Nurse on duty that R39 was observed on the floor. V8 Private caregiver, who was with R39 at the that time, turned around to press the call light and in that moment R39 stood up from her wheelchair and fell . R39 hit her head and left hip. R39 was sent to the hospital and admitted with diagnosis of Comminuted Left Intertrochanteric Fracture. R39 had Left hip revision on 7/25/23 and returned to the facility on [DATE]. On 8/23/23 at 12:08PM, V7 Care plan Coordinator said that she updates all the resident care plan in the facility. V7 said that fall care plan is updated after each fall and when there is change of resident condition. Review R39's Fall care plan with V7 Care Plan Coordinator. V7 said that she did not update R39's care plan intervention after she returned from the hospital status post left hip revision from a fall sustaining Comminuted Left Intertrochanteric Fracture. On 8/23/23 at 12:32PM, Review R39's Fall incident report of 7/24/23 was reported to IDPH on 7/26/23 with V1 Administrator. V1 said that the fall incident with injury should be reported to IDPH within 24 hours. V1 said she does not know why there was a delayed in reporting to IDPH because she was vacation when it happened. Facility's policy on Fall Prevention Protocol revised October 2017 indicates: Purpose: This protocol describes mechanism for assessing residents at risk for falls and providing interventions to reduce the likelihood of falls. Desired outcome: To reduce both the number of resident falls and injuries related to those falls. Post fall Guidelines: 4. The nursing staff notifies the following individuals of the resident's fall: a. Appropriate State Agency, as required by regulation. Documentation: 1. Documentation of the event, the assessment of the resident and post fall interventions is recorded in the resident's medical record. 2. An incident report is completed and maintained as per the incident report policy 3. For residents who are determined to be at risk for falls on admission, a care plan is developed, and the appropriate Minimum Date Set Documentation is completed. These documents are updated for falls that occur after admission. 40001 On 8/23/2023 at 12:00pm V4 (Care-Plan Coordinator) reviewed with the surveyor the fall log from the facility dated 7/11/2022 to 8/22/2023. R11 had an unwitnessed fall on 11/28/2023 where R11 complained of pain to right hip, and on 1/25/2023 R11 had an unwitnessed fall with no injury. On 8/23/2023 at 12:20pm V4 said that R11 should have had interventions for prevention of falls on 11/28/2023 to try and prevent any further falls which occurred on 1/25/2023. A Physician order report dated 7/25/2023 to 8/25/2023 indicates that R11 has an history of falling. A Fall Risk assessment tool dated on 11/21/2023 indicates that R11 has a score of 11 which is a moderate fall risk. A care-plan dated 11/21/2022 a problem of falls and no approach to fall interventions on 11/28/2022.

Based on observation, interview and record review the facility failed to adequately monitor the resident on antibiotics without adequate indication. This deficiency affects one (R24) of three residents in the sample of 16 reviewed for Unnecessary medication. Findings include: On 8/22/23 at 10:45am, Observed R26 ambulating with walker with V9 Private Care giver. R26 denied any signs and symptoms of UTI (Urinary Tract Infection). V9 said that R26 did not present signs and symptoms of UTI. On 8/23/23 at 9:35am, Review R26's medical record with V2 Nursing Supervisor. R26 is admitted on [DATE] with diagnosis listed in part but not limited to Chronic lymphocytic leukemia of B-cell type not having achieved remission. V2 said that R26 is on antibiotic (Cephalexin) 250mg 1 cap orally at bedtime since 4/18/23 upon admission as prophylaxis for UTI (Urinary Tract Infection) indefinitely. V2 said that R26 is not on antibiotic stewardship program. V2 said that they only put resident on stewardship program when resident was started antibiotic in the facility. R26 was not included because she came in with antibiotics. V2 said that there is no documentation of R26's PCP (Primary Care Physician) regarding justification of antibiotic usage. V2 said that R26's PCP has not been in the facility. R26 goes to her PCP's office. V2 said that R26's urinalysis was done on 6/7 PCP's office, but the test result was not sent to the facility. V2 said that there is no urine culture was done since admission. V2 said that she called R26's PCP to fax his progress notes regarding usage of antibiotics and UA test results. V2 said that there is no care plan in placed in regards with R26's usage of prophylaxis antibiotics. V2 said that there is no documentation in R26's chart indicating that she is presenting signs and symptoms of UTI. No documentation that R26 is being monitored for sign and symptoms for UTI. V2 said that V7 DON (Director of Nursing) is the infection Preventionist and is on vacation, not available for interview. On 8/23/23 at 12:08PM, V4 Care Plan Coordinator said that she responsible for developing and updating care plan for all residents in the facility. Review R26's comprehensive care plan with V4. V4 said that she did not develop care plan for R26's usage of antibiotics indefinitely due to prophylaxis for UTI. Review R26's MDS (Minimum, date set)/ Resident Quarterly assessment dated [DATE] indicated: Section N Medications: N0410 Medications Received. F Antibiotic On 8/24/23 at 2:58pm Informed V1 Administrator informed of above concerns identified. Facility's policy on Antibiotic Stewardship program indicates: Purpose: This policy establishes directives for Antibiotic Stewardship to develop antibiotic use protocols and a system to monitor antibiotic use. Process: 3). The Antibiotic Stewardship Committee will support and promote antibiotic use protocol which include: 1. Assessment of residents for infection using standardized tools and criteria. The criteria used will be adapted from McGeer's Criteria. 2. Therapeutic decisions regarding antibiotics prescriptions based on evidence (Clinical guidelines) appropriate for the care of long-term care facility residents. 3. Specific dose, duration, and indication on all antibiotic's prescriptions. 4. Reassessment of empiric diagnostic test, laboratory reports and or changes in the clinical status of resident. 5. Use of narrow spectrum antibiotics that are appropriate for the condition being treated whenever possible. 4)The Antibiotic Stewardship Committee will develop and maintain a system to monitor antibiotic use which includes: 1. Review of antibiotics prescribed to residents upon admission or transfer to the facility and those prescribed during evaluation by an outside practitioner. 2. Quarterly review of a subset of antibiotic prescriptions for inclusion of dose, duration, and indication (or for length of therapy, documentation of an antibiotic time-out, appropriateness based on antibiotic use protocol and written documentation of clinical justification for antibiotic use that does not comply with the facility antibiotic use protocol). Periodically review rates of prescription for any antibiotics or conditions identified by the committee as being of special interest. Facility's policy on Minimum Criteria for Antibiotic Use Protocol indicates: Purpose: This protocol aims to improve appropriate antibiotic use and establish minimum criteria/clinical guidelines for the use of antibiotics based on McGeer's Criteria for Infection Surveillance/minimum criteria for antibiotic initiation. Desired outcome: Reduce the unnecessary use of antibiotics when the clinical condition being treated does not meet clinical guidelines for the use of an antibiotic.

Based on observation, interview and record review, the facility failed to follow its' policy of the COVID 19 screening process for visitors by staff not taking the visitor's temperature and disinfecting thermometer use, after touching the body of the visitor during the screening process. The deficiency has potential to affect the entire census of 36 residents and staff/employees in the facility. Findings include: On 5/4/21 at 8:55am, V4 Receptionist requested both surveyors take their own temperature and complete the questionnaire. Two private caregivers came in, V5 Caregiver and V6 Care giver. V4 Receptionist also asked them to take their body temp and complete the questionnaire. Both surveyors let both caregivers take their temperature first using a thermometer scanner. V5 Caregiver took the scanner digital thermometer, put it inside her shirt under her armpit, then she looks at the reading. Then she placed the thermometer to her neck, looked at the reading. Next, she placed the scanner thermometer to her forehead, then looked at the reading. No temperature reading registered, so she asked the receptionist for help. V4 Receptionist picked up the thermometer without sanitizing it, shook it and scanned V5's forehead for body temperature. Surveyor called her attention for not disinfecting the thermometer. V1 Administrator stated for COVID temperature screening, the employees take their own temperatures. For visitors, they (staff) take the visitors temperature. Informed V1 Administrator that V4 Receptionist asked both care givers and surveyors to take their own temperature. V1 invited both surveyors to go to the conference room, surveyor informed her that their temperature has not been taken yet. V4 Receptionist took both surveyor's temperature with reading of 93F and 94 F. Asked V1 Administrator what is accepted body temperature, she responded, below 100F. On 5/4/21 at 9:16am, V2 Director Of Nursing (DON) stated acceptable body temperature ranges is between 96.8 to 98.8 F. Reading of 93 or 94 F should be re-taken. Facility's policy in COVID 19 Testing plan and Response Strategy dated May 1, 2020 indicated: Screening and Reporting Protocol: 2. All visitors to the Care Center will be screened prior to entering the facility beyond the screening area in main lobby. The screening will include taking the visitor's temperature, review of any symptoms, review of any prior travel within the preceding 14 day period and review of any potential contact the visitor has had, either with any people with a known case of COVID 19 or through a potential contact within another health-care facility. Any visitor with symptoms or who answers affirmatively to any screening question, will not be approved to enter the facility. Facility's policy on Equipment cleaning revision date October 2017 indicated: Purpose: this policy describes the process for cleaning equipment used in the care of residents in Skilled Nursing . Process: Medical equipment used in the care of the resident is cleaned with community approved disinfectant, before it is stored or used for another resident. 1. Equipment incorporated in this policy includes, but not limited to the following: * Electronic thermometers 2. All equipment is cleaned according to manufacturers' guidelines and/or specifications

Based on observation and interview the facility failed to date open house multi dose stock medications this failure has the potential to affect 36 residents on the unit. Findings Include : On 5/4/2021 At 11:10am, on the Team 2 medication cart with V7 (RN) these floor stock medications where open and not dated. 2 bottles of Vitamin C 500 mg , no open date D3 1000 units, no open date [MEDICATION(S)] 5000 units, no open date B-Complex, no open date Vitamin-C Super, no open date D3 50 mcg 2000 IU, no open date Preser-vision, no open date On 5/4/2021 at 11:40am, V7 (RN) was asked what is the procedure when stock medication is opened for the first time? V7 said it should be dated always. On 5/5/2021 at 10:30am, V2 (DON) was asked what is her expectation of the nurses when they open a new stock medication for the first time? V2 said, I expect all bottles of medication that's stock to be dated when opened. Facility Policy : 5/5/2021- Facility unable to provide a policy on dating open stock medication.

Based on observation, interview, and record review the facility failed to follow facility policy on self-administration of medication for one (R29) of six reviewed for self medication administration in the sample of fifteen. Findings include: On 06/25/19 at 10:15 AM, during medication administration observation for R29, nasal spray was handed by V3 (Registered Nurse) to R29 and was sprayed by R29 multiple times to each nostrils. R29 stated, I don't know if I am doing it right. There is nothing coming out. Then sprayed again multiple times on both nostrils. After which R29 stated, I think that was enough. R29 then stated, I been using the nasal spray by myself for a long time. At this time, V3 stated: She always takes the nasal spray by herself because she usually is independent. During record review of R29's medical record, there was no order found on Physician order [REDACTED]. MAR (Medication Administration Record) dated 6/25/19 documents: [MEDICATION NAME] Nasal Spray for congestion. On 6/26/19 at 9:30 AM, in an interview withV2 (Director of Nursing) discussed concern regarding R29's inability to appropriately self -administrate nasal spray medication. V2 stated, I know this is kind of late because we didn't have a Self-Administration assessment for R29 nor a Plan of Care for Self-Administration, so we will do both. The doctor has also provided an order for [REDACTED]. Revised facility Policy dated (MONTH) (YEAR): On Self Administration of Medication Management, number 9 reads: Self-administration of medications / treatments is permitted only upon the written order of the healthcare provider with prescriptive authority. Additionally, an assessment (utilizing an approved tool) of the residents ability to self-administer medications, is completed by a licensed nurse and the resident assessed as capable. Facility Policy Protocol on Medication - Bedside Storage and Self-Administration, number 4 reads: Items documented in the residents' plan of care include, but are not limited to the following: Assessment confirmation of ability to self-administer; authorization from the healthcare provider with prescriptive authority; and relevant safety issues.

Based on record review and interview, the facility failed to develop a person-centered care plan for self-administration of medication for one resident (R29) of 15 reviewed for care plans in the sample of fifteen. Findings include: On 06/25/19 at 10:15 AM , V3 (Registered Nurse) handed R29 nasal spray ([MEDICATION NAME]) medication. R29 sprayed multiple times to each nostrils. R29 stated, I don't know if I am doing it right. There is nothing coming out. R29 again sprayed multiple times to both nostrils. After which time, R29 stated, I think that was enough. I've been using the nasal spray by myself for a long time. V3 stated, She always takes the nasal spray by herself because she usually is independent. During record review, there was no care plan for self-administration of medication. Revised Policy dated (MONTH) 2011 documents, Medication Protocol on Self-Administration : Items documented in the residents' plan of care include, but are not limited to the following: Assessment confirmation of ability to self-administer; authorization from the healthcare provider with prescriptive authority; and relevant safety issues.

Based on observation, interview and record review, the facility failed to follow medication storage and labeling policy for multi-dose vials. This deficiency was observed in 1 of 2 medication rooms reviewed in the facility. Findings Include: On 06/25/19 at 10:36 A.M., with V4(Registered Nurse/Supervisor) conducted medication storage and labeling observation for team 2 refrigerator. There was a bottle of liquid [MEDICATION NAME] (vitamin B-12) for R32. The bottle did not have an open date nor an expiration date. The medication label indicates fill date of 9-10-2018. On 06/25/19 at 10:39A.M., V4 stated, The vial for vitamin B12 has no date on it. We are supposed to date the vial when we open it. On 06/25/19 at 11:27 A.M., with V4 conducted medication storage and labeling observation for Team 1 refrigerator; found [MEDICATION NAME] vial opened with no open date and no expiration date. On 06/25/2019 at 11:35A.M., V4 stated, I do not see any date on the box or on the vial. It should have been dated when it was opened because it is only good for 30 days. On 6/26/19 at 11:34 A.M. V2 (Director of Nursing) stated, We need to date all vials when we open them. Revised Medication Policy/Protocol dated (MONTH) 2011 documents: Multi-dose vials of medications are dated when opened. Omnicare Policy for Medication Storage dated (MONTH) 2019 remarks: Storage recommendation for multi-dose vials for injections: date when open and discard unused portion after 28 days or in accordance with manufacture's recommendation.

Based on observation, interview and record review the facility failed to follow the procedure for hand hygiene for one resident (R28) of one residents reviewed for pressure ulcers in the sample of 12. Findings: 8/1/18 at12:05 PM, V3 (RN-Registered Nurse) provided wound care to R28. V3 donned gloves and removed R28's sock. V3 did not perform hand hygiene. V3 then donned new gloves and removed the soiled dressing. V3 removed the gloves and did not perform hand hygiene, V3 donned new gloves and cleaned the wound with normal saline. V3 removed the gloves and did not perform hand hygiene, V3 then donned new gloves and applied [MEDICATION NAME] iodine to the wound. V3 removed the gloves and did not perform hand hygiene. V3 donned new gloves and applied an adhesive foam dressing. 8/1/18 at12:30 PM, V3 said I should have washed my hands when I changed gloves. 8/2/18 at 2:00 PM, V4 said that the nurses should perform hand hygiene prior to starting the procedure, when gloves are soiled, when switching gloves and after removing gloves. A policy titled Hand Hygiene reads 5. Hand antisepsis, achieved by hand washing with antimicrobial soaps, detergents or by use of alcohol-based antiseptic hand rubs, is recommended before the performance of invasive procedures. 6. If running water and soap are not immediately available, hand antisepsis may be accomplished with alcohol-based hand rubs (if hands are not visibly soiled): Before and after resident contact; After contact with a source of microorganism, e.g., body fluids and substances, mucous membranes, non-intact skin, and inanimate objects that are likely to be contaminated; and After removing gloves. 8. Gloves are used as an adjunct to, and not substitute for, hand washing. 8.2 Gloves are removed and hands are washed: Between caring for residents; When hand contamination activities are completed; and When the integrity of the gloves is in doubt. 8.2.1 Gloves may need to be changed during the care of a single resident, e.g., when moving from one procedure to another.

Based on interview and record review, the facility failed to ensure that residents' Minimum Data Set (MDS) assessments accurately reflected resident status for two residents (R7, R10) of six residents reviewed for MDS accuracy in the sample of 12. Findings include: R7 is a [AGE] year old resident originally admitted to the facility on [DATE] and diagnosed , in part, with [MEDICAL CONDITION], Dysphagia, Hypertension, and [MEDICAL CONDITION]. R7's Physician order [REDACTED]. R7's most recent MDS dated [DATE] in section J1400 Prognosis under Health Conditions asks, Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? The facility documented, No. R10 is a [AGE] year old resident originally admitted to the facility on [DATE] and diagnosed , in part, with muscle weakness, malignant neoplasm of bronchus, type II diabetes mellitus and pancreatitis. R10's most recent MDS dated [DATE] in section J1400 Prognosis under Health Conditions asks, Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? The facility documented, No. According to the Centers for Medicare and Medicaid Services (CMS) regarding Hospice states in part, To be eligible to elect the Medicare hospice benefit, beneficiaries must be certified by their attending physician (if any) and by the hospice physician as being terminally ill with a prognosis of 6 months or less to live, should the illness run its normal course. The term hospice care means the following items and services provided to the terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan (for providing such care to such individual) established and periodically reviewed by the individual's attending physician and by the medical director and by the interdisciplinary group. On 7/20/17 at 11:30am, E11 (MDS Coordinator) stated, in part, I've been in my position for 5 years. I do both the MDS and Care Plans for the facility. I'm responsible for the entire MDS along with the interdisciplinary team but I'm responsible for it. Asked during the interview about hospice, E11 stated, The only thing I do for residents that are under hospice is do a significant change. There's nothing else I change in the MDS to reflect that. Asked for the facility policy related to MDS assessments and coding, E11 stated, We don't have a policy we just follow the MDS R.A.I. (Resident Assessment Instrument) manual.

Based on observation, interview, and record review, the facility failed to ensure that staff knocked on a resident's door prior to entry. This deficient practice affected one resident (R7) of seven residents reviewed for dignity in a sample of 12. Findings include: On 7/19/17 at 1:30pm, E13 (CNA-Certified Nurse Assistant) and E14 (CNA) were providing incontinence care for R7. E14 removed R7's incontinence brief. R7 laid in the bed bare from the waist down. At 1:34pm, the door to R7's room opened. E8 (CNA) did not knock prior to entry. There was no privacy curtain available to shield R7 from the entry door. On 7/19/17 at 1:45pm, E8 stated, Our facility policy is to knock three times and wait for a response before entering. A facility policy with a revision date of May 2014 and titled, Employee Responsibility re: Residents' Privacy and Confidentiality documents, in part: PROCESS: 3. Prohibited employee conduct includes, but is not limited to: Entering a resident's room without knocking and/or announcing yourself.

Based on interview and record review, the facility failed to ensure that a resident was assessed for a change in bowel habits, failed to notify the physician regarding a change in bowel habits and failed to administer PRN (as needed) medications to treat the constipation. This deficient practice affected one resident (R7) of seven residents reviewed for quality of care/bowel regimen in a sample of 12. Findings include: R7's Face Sheet documented, in part, the following Diagnoses: [REDACTED]. R7's Physician order [REDACTED]. R7's POS documents that [MEDICATION NAME] 25 mg (milligrams) and Venlaxafine 37.5 mg are given to R7 daily. It is documented that constipation is a side effect of these medications. This POS also indicates that R7 receives Senna with [MEDICATION NAME] Sodium 8.6 - 50 mg laxative once a day. R7 was readmitted to the facility on [DATE] after a hospital stay. On 7/20/17, E2 (Director of Nursing-DON) submitted R7's Bowel Logs in completion. The logs indicate that R7 did not have a documented bowel movement (BM) from 1/13/17 to 1/27/17. R7 did not have a documented BM: 4/1/17 through 4/7/17. R7's POS documents that a physician was not notified until 4/7/17 for an order for [REDACTED]. There is no documentation of R7's BM's for the time frame of 5/29/17 through 6/4/17. R7's EMAR does not document that R7 received a [MEDICATION NAME] suppository in that time frame. On 7/19/17 at 4:30pm, E2 indicated that all the handwritten bowel movement logs for R7 were submitted. E2 indicated that the rest could be found in the computerized charting system. The following time frames also document that R7 did not have a bowel movement: 6/5/17 through 6/9/17 and 6/11/17 through 6/26/17. R7's EMAR dated June 2017 does not indicate that R7 was given [MEDICATION NAME] medication during these two episodes of constipation. R7's medical record does not include a Care Plan addressing R7's bowel issues/constipation. R7's Progress Notes dated January 2017 through July 2017 do not document that Z1 (Physician) was notified regarding R7's constipation episodes. On 7/19/17 at 12:20pm, E12 (RN-Registered Nurse) stated, Usually if no bowel movement in 2 - 3 days, give intervention, [MEDICATION NAME] or [MEDICATION NAME]. If no bowel movement for 4 - 5 days, will call the doctor and figure out what to do. That's too long. On 7/20/17 at 11:08am, Z1 (Physician) stated, [MEDICAL CONDITION] definitely puts people at a higher risk for constipation. I have not been called about (R7). More than three days, should be given a laxative or doctor called. Definition of constipation is greater than three days without stool. More than three days without a bowel movement can lead to fecal impaction, [MEDICAL CONDITION], bowel obstruction. If chronic constipation, should not wait three days to administer medication. On 7/20/17, E2 (Director of Nursing-DON) indicated that the facility does not have a bowel regimen policy but does have a bowel protocol. A facility document dated 2/17/17 and titled, B/B (bowel and bladder) Process denotes, in part: 2) Nurse assigned will prepare the due B/B form and file in the B/B binder and inform CNA (Certified Nurse Assistant) at the start of the shift. 3) CNA's to complete the form, initial on the scheduled B/B when done. Leave the form in the binder for the nurse or designee to check if done at the end of the shift. 4) (MDS Coordinator) to collect and check the completed form every morning during weekdays and weekends.

Based on interview and record review, the facility failed to implement its policy regarding controlled substances in order to maintain narcotic count accountability. This applies to one of three residents (R1) reviewed for narcotic medication use in the total sample of 12. The findings include: R1 has [DIAGNOSES REDACTED]. The POS (Physician order [REDACTED]. The Controlled Substances Proof of Use sheet showed that pharmacy had delivered 15 tablets of Ativan 0.5 mg. on September 29, 2016. It also showed that Ativan is a class IV narcotic. The facility's Controlled Drug-Count Record for the month of October 2016 showed that there were three nurses who signed the record on October 1 and 2, 2016. The three nurses were: E14 (night nurse 12 MN to 8:00 A.M. on October 1); E13 (day nurse, 8:00 A.M. to 4:00 P.M. on October 1 and 2) and E12 (evening nurse, 4:00 P.M. to MN on October 1 and 2). The record also showed that by signing this form, the nurses' acknowledges that they have counted the drugs on hand and have found that the quantity of each medication is the same quantity that was recorded on the controlled drug proof of use sheet. On January 30, 2017 at 2:45 P.M., E14 stated that R1 had 15 tablets of Ativan 0.5 mg when counted during the change of shift narcotic count on October 1, 2016 with E13. E14 also stated that R1's Controlled Substance Proof of Use sheet showed that there were 15 tablets of Ativan and that it had matched the actual quantity of 15 tablets when counted. E14 also stated that the count remained the same quantity, which was 15 tablets, when counted with E12 during the PM /MN shift on October 2, 2016. On February 1, 2017 at 2:00 P.M., E12 stated that R1 had 15 tablets of Ativan 0.5 mg when counted during the change of shift narcotic count with E14 on October 1, 2016 (Midnight). E12 also stated that the Ativan remained 15 tablets when counted with E13 on change of shift count on the P.M. shift on October 1, 2016. E12 added that on October 2, 2016 during E13 and E12 count on the P.M. change of shift, the Ativan had 13 tablets remaining. E12 further stated that she asked E13 what happened to the two tablets since there were there during the count on October 1. E12 stated that E13 did not response to her question. On January 30, 2017 at 2:30 P.M., E13 stated that she failed to document on the controlled substance proof of use sheet and the EMAR (Electronic Medication Administration Record) that she gave R1 one tablet of Ativan on October 1, 2016 at 9:30 A.M. E13 also stated that she documented as late entry on October 2, 2016 for the October 1 administration. E13 also stated that she had no explanation of the reason why the controlled of substance proof sheet showed 15 tablets during the count when in fact she took one tablet on October 1 in the morning. A partial investigation made by E1 (Administrator) regarding the questionable accountability of the Ativan showed only one interview that was held by E1 to E13 on October 6, 2016. There was no determination of why the count was 15 tablets and yet one tablet was removed on October 1 as claimed by E13. On January 30, 2017 at 1:45 P.M., E1 stated that E13 failed to timely document on the controlled substance proof of use sheet and EMAR on October 1, 2016 regarding R1's Ativan. E1 also added that she just had to rely on E13's statement that she gave the Ativan to R1. The facility's policy with revision date of June 2011 showed: 1. Schedule II, III, IV and V controlled substances must be accounted for on a controlled substance sign out sheet.3. Upon administration of a controlled substance, the nurse must complete the corresponding line of controlled substance sign out sheet by filling the date, time, signature and amount of medication remaining .6. At shift change, narcotics sheet must be signed by the oncoming and outgoing nurses after completing a controlled substance records at the beginning of each shift. The failure of timely documenting on the controlled substance proof of use sheet resulted to unaccountability of the narcotic use. On January 26, 2017 at 4:15 P.M., Z1 (Pharmacist) stated that the accountability of the Ativan should had been discovered sooner during the earlier count if the quantity of the actual count did not match the proof of use sheet. Z1 also stated that if the Ativan was actually had been removed from the secured box, then during the change of shift narcotic count, the nurses' counting should have discovered the missing document or what happened to the Ativan.

Based on observation, interview, and record review, the facility failed to remove expired medical supplies from one of one crash carts. This has the potential to affect all 44 residents in the facility. Findings include: On [DATE] at 2pm, the crash cart was inspected with E4 (RN, Registered Nurse/ Nurse Supervisor). The following were noted: Two catheter and glove suction kits expired on ,[DATE] One adhesive dressing pad expired on ,[DATE] One adhesive dressing intravenous pad expired on ,[DATE] Four vials of 15 milliliters of normal saline expired on ,[DATE] Two vials of 15 milliliters of normal saline expired on ,[DATE] E4 stated, It is the night nurse's responsibility to check all items in the crash cart and their expiration dates. I'm not sure of the expiration dates on the adhesive dressing pad and intravenous pad. I think that's the date it was manufactured. I will get back to you tomorrow. Let me do an internet search. On [DATE] at 9:00am, E4 stated that she had done an internet search and had confirmed that the adhesive dressing pad and intravenous pads were expired. On [DATE] at 10:45am, during facility presentation, E1 (Administrator) and E3 (Director of Nursing) both stated they have started inservicing their staff on making sure the crash cart is checked three times a day. Facility's policy titled Equipment and Supplies Management denotes in part the following: 2. Equipment and supplies are used according to manufacturers ' guidelines. 2.1 Equipment is maintained, tested , and inspected per manufacturers ' guidelines. The responsibility for ensuring the maintenance of the equipment is completed lies with the area manager.

Based on observation, interview, and record review, the facility failed to follow physician's orders to apply the restorative device/splint, to one resident (R4), inside the sample of 4 reviewed for splints and contracture prevention. Findings include: On 6/29/16, at 9:57am, during observation of memory support group, R4, was observed in group, and did not have the left hand splint in place. At approximately 10:15, E7 CNA (Certified Nurses Assistant) was asked by surveyor why R4 was not wearing the left hand splint. E4 applied the left hand splint after being questioned by surveyor. E4 then indicated that the night shift CNA removes the splint at bedtime, and the CNA that performs the ADL's (Activities of Daily Living) for R4 in the morning should have applied the splint to R4. Review of the POS [REDACTED]. Review of the care plan for R4, dated 4/1/16, indicate that R4 is limited in range of motion to the left upper and lower extremeties related to [MEDICAL CONDITION](Cardiovascular Accident), which left R4 with left [MEDICAL CONDITION]. R4 is on the Contracture Prevention Program, and is to wear a left hand splint daily as scheduled for prevention of [DIAGNOSES REDACTED] and proper alignment. Review of the facility policy state that The goals of Restorative Programs is to prevent contractures via ROM (Range of Motion) activity, and splints/braces.

Based on observation, interviews and record review the facility failed to document the specific Behavioral or Psychological Symptom of Dementia (BPSD) and document the specific behavior monitoring interventions used for the use of [MEDICAL CONDITION] medications in Dementia and dose reduction. This applies for two of two residents (R1 and R9) reviewed for [MEDICAL CONDITION] medication use in a sample of 10 residents reviewed. The findings Include: 1. On 5/12/15 at 10 AM, (R1) was noted to be in the activity room during music therapy. R1 was sitting in her wheelchair leaning to her right side sleeping. R1 was noted sleeping from 10:28 AM through 10:45 AM. In addition, R1 was noted sleeping 5/13/15 at 11:00 AM during activities, 5/13/15 at 1:30 PM, and 5/14/15 at 10 AM. On 5/12/15 at 2:30 PM, R1's chart notes: R1 is on [MEDICAL CONDITION] medications for psychotic behavior. R1 is receiving [MEDICATION NAME] 12.5 milligrams (mg) at bedtime and [MEDICATION NAME] 250 milligrams (mg) at bedtime. [MEDICATION NAME] was originally ordered for R1 on 9/18/13 at 12.5 milligrams by mouth at bedtime for Dementia with Delusional Behavior. On 3/9/14 the [MEDICATION NAME] was increased to 12.5 mgs in the morning and 12.5 mgs at bedtime for Dementia with Delusional Behavior. On 3/26/14, R1 was provided [MEDICATION NAME] 125 milligrams twice a day for mood stabilizing for Dementia with Delusional Behavior. On 4/16/14, R1 was provided [MEDICATION NAME] 125 milligrams in the morning and 250 milligrams at bedtime for Dementia with Delusional Behavior. The specific behaviors are not identified. Per the physician order [REDACTED]. R1's Minimum (MDS) data set [DATE] Section E notes "Potential indicators of [MEDICAL CONDITION] A, Z". Choices for this section were A. Hallucinations, B. Delusions, and Z None of the Above. Section E0200 notes C. (0) No verbal/vocal symptoms like screaming, disruptive sounds. " On Section I of Active [DIAGNOSES REDACTED]. " Depression: [MEDICAL CONDITION], and Anxiety Disorder are not indicated. " R1's Care Plan dated 3/17/15 lists " Problem " , dated 2/26/15 for [MEDICAL CONDITION] Drug Use notes "Resident family perceives that mom is on too many [MEDICAL CONDITION] medication have talked to Primary Care Provider to discontinue medications. Family education provided at the time of conversation. Resident had a hard time falling asleep and staying asleep. She has episodes of confusion, increased anxiety and hallucinations. (R1) had recent falls and [MEDICAL CONDITION] medications adjusted, will monitor for side effects related to their use. 2/26/15, Quarterly Assessment: " [MEDICATION NAME] reduce during Psychiatrist, Z2 follow up visit. Assure that the resident's [DIAGNOSES REDACTED]." On 5/14/15 at 11:10 AM, E18 (Registered Nurse/RN) stated, "Residents are admitted to the facility. The facility completes a Psychosocial Assessment and Behavior Monitoring Sheet if resident placed on [MEDICAL CONDITION] medications." E18 states that she meets with E19 (Social Services Director) to discuss behaviors and medications." E18 stated "I do not document this discussion in the charts. R1 was placed on [MEDICAL CONDITION] with a [DIAGNOSES REDACTED]. We report to Z2 any changes in behavior after reviewing the Behavior Monitoring Sheets." On 5/14/15 at 11:45 AM, E19 (Social Services Director) stated, "E18 and I meet once a week to discuss [MEDICAL CONDITION] medications. E18 creates a list for Z2. I do not document any of the discussions in the chart." On 5/14/15 at 12:10 PM, Z2 stated "R1 was placed on [MEDICATION NAME] for Dementia with Delusions. I discuss with the nurses, aides, E18 (Registered Nurse/RN) and E19 (Social Services Director) their observations of the residents being evaluated. I do not use any numeric data for evaluation of behaviors. After any changes have been made, I recheck with E18 and E19 for any issues after two weeks." On 5/14/15 at 1:00 PM, E2 (Director of Nursing) provided Behavior Management-[MEDICAL CONDITION]/Antipsychotic Drugs Policy and Procedure dated 5/2010 documents: "1. Residents are not given antipsychotic drugs unless such drug therapy is ordered by a healthcare provider with prescriptive authority and the reason for the drug is documented. " " 2. A resident receiving [MEDICAL CONDITION] medications is reviewed for implementation of gradual dose reductions and behavior interventions to reduce/eliminate the medication usage at a minimum every 6 months. " " 3. Documentation of behavioral monitoring includes: symptoms demonstrated which require the use of [MEDICAL CONDITION] medication, If the symptoms are transient or ongoing, Evaluation of other reasons or potential causes of the behavior, and Monitoring the side effects to the [MEDICAL CONDITION] medication." 2. On 5/12/2015 at 2:00 PM observed R9 in his room sitting in a wheelchair, R9 had head tipped to the right with eyes closed. R9 did not respond to greeting. On 5/14/2015 at 8:30AM, R9 was in his room sitting in wheelchair eyes closed. R9 did not respond to greeting. R9 was admitted to facility on 7/30/2014 with the [DIAGNOSES REDACTED]. MDS (Minimum Data Set) dated 2/3/2015, "Behavior E 0100 Potential Indicators of [MEDICAL CONDITION]" documents R9 has "no delusions or hallucinations". Z2, (Psychiatrist) documents on 2/19/2015 in the Physicians Progress Note that a dose reduction of [MEDICATION NAME] 25 milligrams in the AM. Z2, (Psychiatrist) did not document risk versus benefit statement with rationale that indicates that a reduction at that time would be likely to impair the resident's function or increased distressed behavior in the resident's clinical record. On 11/19/2014, Z2 documents in the Physicians Progress Notes that R9 has had periods of agitation in the past, was on [MEDICATION NAME] and [MEDICATION NAME] at last visit, but since then has new needs. New needs are not documented. Z2, (Psychiatrist) documents R9 had a decrease in agitation, anxiety, delusions, anger. Also documented that R9 has had increase in friendliness. Z2 documents in the "Impression of the Physician Notes", "dementia with delusions, but nothing is specified. Use of [MEDICATION NAME] is reasonable as a typical/atypical neuroleptic ". Review of the "Behavior Monitoring Record: Psychopharmacologic Medications" dated March through May 2015 documents no behaviors for R9. Facility missing Behavior Monitoring Records 7/2014 through 2/2015 were requested but not provided. Gradual dose reduction has not been attempted during admittance of 7/30/2014.

Based on observation, interview and record review, the facility failed to prevent the re-development of a Stage II pressure sore for one of two residents (R5) reviewed for pressure sores in the sample of 10. Findings include: On 5/14/15 at 9:50 AM, R5 was seen in bed. E21 (Registered Nurse) was providing wound care for R5 with Duoderm and [MEDICATION NAME] ointment. R5's wound measured 0.4 cm (centimeters) x 0.3 cm. No Air loss mattress or preventive cushion were seen on 5/12/15 at 2:15 PM. R5 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Per E21 (Registered Nurse) on 5/14/15 at 9:50 AM, the Air loss mattress for R5's bed and the preventive cushion were ordered and received on 5/13/15, two months after R5 developed a Stage II pressure ulcer. On 5/14/15 at 9:30 AM" E17 (Registered Nurse) and E16 (Wound nurse) stated "R5 was admitted without a pressure sore on 5/12/2014 and acquired the stage II sacral ulcer on 2/24/15. E16, (Wound Nurse) stated, "R5 has had a history of [REDACTED]. E16 (Wound Nurse) stated "The pressure sore is due to history of stroke, weakness on left side, refusal to ambulate, frequent bowel and bladder incontinence." The Minimum (MDS) data set [DATE] and 2/15/15 documents R5 has frequent incontinence of bowel and bladder. The Braden scale dated 2/24/15 score was 15, which indicated R5 is at moderate risk for a pressure sore. The care plan dated 2/16/15 documents: "R5 has episodes of bowel and bladder incontinence and needs assistance Toileting." Facility's "Toileting Program" directs "Staff to ask/assist resident re: Toileting upon awakening, before and after each meal, bedtime, and upon resident's request." The facility's Pressure Ulcer Prevention and Treatment Protocol dated June 2011 notes: "This Protocol provides guidelines for the assessment of skin integrity; interventions for the prevention and treatment of [REDACTED]." The protocols "Standard of Practice #2" documents: "Avoidable Pressure Ulcer:" "The resident developed a pressure ulcer and the facility did not do one or more of the following:" "Evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; and/or revise the interventions as appropriate."