Every finding on record at Westwood Nursing and Rehabilitation Center

Based on observations, staff interviews, and record review, the facility failed to provide maintenance services to maintain resident bedrooms in good repair for 1 of 11 sampled resident bedrooms. (room [ROOM NUMBER])The findings include:An observation of the wall near the window in room [ROOM NUMBER] was conducted on 8/3/26 at 3:01 PM. The wall was observed to be damaged and in disrepair. There was enough of a crack in the wall where the end on an ink pen could be inserted through the wall. Further observation of the wall in room [ROOM NUMBER] was conducted on 8/5/26 at 10:16 AM with the Maintenance Director. The Maintenance Director stated he was aware of the damage on the wall as the resident in the room had reported the damage to him about 2 weeks ago. He stated he was sure it was caused by the air conditioning leaking. The wall damage covered about 6 square feet and went up the wall about 12 inches. (Photographic evidence obtained.) The Administrator observed the wall damage on 8/5/26 at 10:25 AM and stated she was not aware of the damage. She stated they have room rounds. She stated the facility did not have a specific audit where they inspect the walls and structural integrity of the room. The Administrator stated the Maintenance Director confirmed he was informed of the wall damage two weeks ago, but she was not made aware of the damage. The facility policy Safe Environment (date implemented 1/1/24) states, The resident has a right to a safe, clean, comfortable, and homelike environment. The facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Areas of concern with environmental repairs/upkeep will be addressed and corrected in a timely manner depending on the scope of each project and the impact on resident safety will take priority over cosmetic repairs.

Based on observation, resident interview, staff interviews, and record review, the facility failed to provide appropriate treatment and services to maintain and prevent further decrease in range of motion for 1 of 1 residents sampled for limited range of motion. (Resident #8) The findings include: The facility policy Prevention of Decline in Range of Motion (implemented 7/2/25) states, Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systemic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion.An observation of Resident #8 was conducted on 8/3/26 at 2:56 PM. His left hand was observed to be contracted, but no splint was on the left hand. At this time, the resident stated he has a splint, but the staff rarely put the splint on him. Further interview was conducted with Resident #8 on 8/4/26 at 3:10 PM. He stated the staff attempted to put his splint on today (8/4/26) but it was too painful. He stated that staff do not usually attempt to apply his splint so now his hand became stiff again, making it more painful to put the splint on. Review of Resident #8's electronic medical record revealed that the resident had a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (a condition which can result in weakness or paralysis on the left side of the body, impacting mobility, coordination, and daily functioning). The current physician orders revealed no orders for a splint, brace, or range of motion to the left hand. The quarterly minimum data set (MDS) (with an assessment reference date of 7/19/26) revealed the resident had a brief interview of mental status score of 13 indicating the resident was cognitively intact. The MDS also stated a functional limitation in range of motion impairment on one side of upper extremities, no physical therapy or occupational therapy (OT), and no splint or brace assistance and no restorative nursing program. The OT evaluation and plan of treatment dated 6/16/26 revealed a contracture involving the right upper shoulder, elbow, wrist, and fingers. A review of the OT discharge summary revealed the short term goal, Patient will safely wear a resting hand splint on left hand for up to 4 hours with minimal signs and symptoms of redness, swelling, discomfort, or pain. Discharge recommendations included a functional maintenance program to be implemented for Splint and Brace use, which includes, Splint to be worn 2 hours on and 2 hours off. Patient able to doff (remove) brace, CNA (Certified Nursing Assistant) trained in donning and wearing schedule.The resident's current comprehensive plan of care revealed no care plan related to limited range of motion or splint use. The record revealed no evidence of a program to apply the resident's splint to the left hand. A review of the list of residents receiving restorative nursing care provided by the Director of Nursing on 8/5/26 revealed Resident #8 was not on the list. An interview was conducted with the Occupational Therapist on 8/5/26 at 2:39 PM, the therapist who made the recommendation for the splint. She stated nursing was made aware of recommendations verbally and she normally notifies the resident's primary nurse. She had also notified the Director of Rehabilitation, and any recommendations are discussed in meetings. She stated her intent was for the resident to wear the splint 2 hours per day. An interview was conducted with Employee B (Certified Nursing Assistant for Resident #8) on 8/5/26 at 2:53 PM. She stated he used a splint on his hand but she was not sure how long he wore the splint. She stated restorative, a nurse, or a CNA (Certified Nursing Assistant) usually applied the splint. An interview was conducted with Resident #8's assigned nurse, Employee C (Registered Nurse) on 8/5/26 at 3:07 PM. She stated he did not have use of his left upper extremity and did not have a brace or splint for the left upper extremity. An interview was conducted with the Director of Therapy on 8/5/26 at 3:17 PM. She stated the therapist will inform the nursing staff on duty of any recommendations from therapy and nursing will care plan the recommendations. She did not believe the recommendations were communicated to the Director of Nursing (DON). An interview was conducted with the DON on 8/5/26 at 3:40 PM. The DON stated therapy should be informing nursing of any recommendations in the facility's morning meeting so they can place physician orders in the electronic medical record. She had no idea that Resident #8 was supposed to wear a splint. The DON stated a form should be completed in writing by therapy for a referral to restorative.

Based on observations, interviews, and record review, the facility failed to provide a comprehensive plan of care for 2 of 2 residents sampled for care plans. (Resident #21 and #24) The findings include: Resident #21 A record review of Resident #21's electronic medical record (EMR) revealed that the resident is dependent on staff for activities for daily living. A review of the care plan developed by the facility for Resident #21 did not include an intervention to address the need for assistance in activities for daily living. On 4/23/2025 at approximately 1:00 PM, an interview was conducted with the Minimum Data Set Coordinator (MDS) and Care Plan Coordinator. The Care Plan Coordinator confirmed that there was not a care plan for Resident #21 in regards to activities of daily living. The Care Plan Coordinator further indicated that the information did trigger from the MDS and should have been included in the care plan. Resident #24 A record review was conducted on Resident #24's EMR concerning End Stage Renal Disease (ESRD) and dependence on hemodialysis services. The care plan developed by the facility for Resident #24 did not include goals and interventions to manage ESRD and hemodialysis services. The Care Plan Coordinator confirmed that there was not a care plan for Resident #24 for ESRD/Dialysis. She further indicated that it had triggered for a care plan from the MDS and should have been included in the care plan. The Care Plan Coordinator acknowledged that she missed developing a care plan for both of these residents. On 4/23/2025 at approximately 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON indicated that it is her expectation that, if the MDS triggers care areas, then the care plan should be updated to include those areas. The facility policy titled Comprehensive Care Plans stated: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally-competent and trauma-informed. 3. The Comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would be otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. c. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations.

Based on observation, record review, staff interviews, and policy review, the facility failed to ensure staff provide appropriate care and services to promote healing and prevent cross contamination of pressure ulcers for 1 of 1 sampled residents with pressure ulcers. (Resident #43) The findings include: A review of Resident #43's medical record was conducted which revealed she had a stage 3 pressure ulcer on her sacrum. An observation of wound care for Resident #43 was conducted on 9/20/2022 at 12:51 PM with Employee A (Licensed Practical Nurse). Employee A gathered supplies for the wound care from the treatment cart to include a bottle of wound cleanser dated 9/3/2022, took the supplies to the resident's room, and placed them on the over bed table with no barrier on the table. Employee A washed her hands and applied clean gloves, removed the old dressing from the resident's sacrum, removed the bottle of wound cleanser from the over bed table and set it on the resident's bed, then picked up the bottle of wound cleanser and used it to clean the wound. Employee A then applied gauze with Iodosorb to the wound bed, then removed her gloves and applied clean gloves and applied the adhesive dressing to the wound. Employee A did not wash her hands and change gloves after removing the soiled dressing and did not wash hands after cleansing the wound. After completing the wound care, Employee A returned the wound cleanser to the treatment cart by placing it back in the cart. She did not sanitize the bottle of wound cleanser before placing it back in the cart. An interview was conducted with Employee A on 9/20/2022 at 12:59 PM. She stated the bottle of wound cleanser she used was used on multiple residents and they use bleach wipes to clean the bottle. She then removed the bottle of wound cleanser from the treatment cart and cleansed the bottle of wound cleanser with a bleach wipe before placing it back in the same area of the treatment cart. Review of the facility policy for Clean Dressing Change (revised 1/5/2022) revealed it is the policy of this facility to provide wound care in a manner to decrease the potential for infection and/or cross contamination. Multi-use wound care supplies will be maintained as clean after initial use. Set up a clean field on the over bed table with needed supplies for wound cleansing and dressing application. Place a disposable cloth or linen saver on the over bed table. Place only the supplies to be used per wound on the clean field at one time. Wash hands and put on clean gloves, loosen the tape and remove existing dressing, remove gloves pulling inside out over the dressing and discard, wash hands and put on clean gloves, cleanse the wound as ordered, wash hands and put on clean gloves, apply topical ointments or creams and dress the wound as ordered, secure the dressing. An interview was conducted with the Director of Nursing (DON) on 9/20/2022 at 1:33 PM. She stated the wound cleanser should be maintained and placed on a barrier, then cleansed with sanitizing wipes before you place it back in the cart. She stated staff would be expected to wash hands, apply gloves, remove the old dressing, remove gloves, wash hands and apply clean gloves, cleanse the wound as ordered, remove gloves, wash hands and apply clean gloves, then apply the dressing as ordered.

Based on observations, interviews, record review, and policy review, the facility failed to implement safety precautions related to smoking to ensure the resident environment remained as free of accident hazards as possible for 1 of 1 sampled residents who smoked tobacco products. (Resident #8) The findings include: An observation was conducted for Resident #8 on 9/19/2022 at 1:10 PM. The resident was outside on the smoking patio, which is located outside the dining room, smoking a cigarette. No staff were present on the patio at this time. He was observed to have his cigarettes and lighter in a plastic bag and lit his own cigarette. He was again observed to be smoking on the patio on 9/21/2022 at 8:50 AM with no staff present. An interview was conducted with Resident #8 on 9/21/2022 at 11:41 AM. He stated he keeps his cigarettes and lighter in his room in the dresser drawer. I observed the resident remove his cigarettes and lighter from an unlocked dresser drawer in his room. No locking mechanism was observed on the dresser drawer. He stated he had been in the facility so long they trusted him. Review of Resident #8's medical record revealed a smoking assessment dated [DATE] indicating the resident had no cognitive loss and the resident needs the facility to store his lighter and cigarettes. The current care plan for risk for injury due to smoking initiated on 6/29/2018 and revised 6/15/2022 indicated Resident #8's cigarettes and lighter will be kept on the nurse's cart with staff/family supervision while smoking. An interview was conducted with Employee B (Certified Nurse Aide) on 9/20/2022 at 4:34 PM. She stated all resident smoking materials are kept locked up in the soiled utility room. An interview was conducted with the Director of Nursing (DON) on 9/20/2022 at approximately 4:45 PM. She stated Resident #8 did not require supervision to smoke. He has been assessed and his smoking materials are kept in the lock box and when he wants to go smoke the staff give them to him. She stated supervision was on the care plan in error. Further interview was conducted with the DON on 9/21/2022 at 11:45 AM. She stated she remembered this morning that the resident is allowed to keep his cigarettes and lighter in a lock box in his room, however it was not care planned or documented. Review of the facility policy for smoking (Attachment Q1 dated 4/22/2015) revealed the facility shall establish and maintain safe resident smoking practices. All residents that desire to smoke will be assessed upon admission, quarterly and as needed for level of safety awareness to determine if the resident is safe or unsafe and what restrictions, if any, will be placed on the resident's smoking privileges. Any resident who has been assessed as unsafe will not be permitted to smoke without the direct supervision of a responsible staff member, visitor, or volunteer. Smoking articles for residents who are assessed to be safe with independent smoking privileges: a. Residents who have independent smoking privileges shall be permitted to keep, cigarettes, pipes, tobacco, and other tobacco products in their possession. b. Residents may not have or keep lighter fluids, including butane gas, or any other forms of gas or fluids, or matches at any time. c. Residents who are safe may request a lighter from the nursing staff but it must be returned promptly after smoking has been completed.

Based on observation, record review, and interview the facility failed to provide a resident who was unable to carry out activities of daily living (ADLs) with the necessary services to maintain good personal and hygiene for 1 of 3 residents sampled for ADL care (resident #12). The findings include: On 12/09/19 at approximately 2:11 PM during observation and interview with resident #12's family member, the female resident was observed to grab an area of facial hair, say excuse my blemishes and cover the area with her hand. The family member expressed that the resident was uncomfortable with the facial hair and that request to staff had been made for the hair to be tweezed or shaved. On 12/10/19 at approximately 11:53 AM during review of resident #12's medical record showed that the resident was admitted about 1 year ago with a pertinent [DIAGNOSES REDACTED]. The resident's care plan dated 10/21/2019 identified that the resident had a terminal [DIAGNOSES REDACTED]. abilities. On 12/11/2019 at approximately 9:00 AM during interview and observation with the resident's Certified Nursing Assistant (CNA), staff J, expressed that the shaving or removal of facial hair on a female resident should be done anytime that it is observed and in conjunction with the resident's preferences. The CNA expressed that the resident does not normally refuse care. During observation of the resident, the CNA confirmed that the resident had visible facial hair, and at that time the resident consented to having the hair shaven by the CN[NAME] On 12/11/2019 at approximately 10:54 AM in interview with the facility Director of Nursing, it was expressed that the resident was totally dependent on staff for care and that the expectation for facial hair on women was that the hair should be trimmed in accordance with the resident's preferences. On 12/12/19 at approximately 01:33 PM during interview with staff J, CNA, the CNA stated the resident's facial was able to be trimmed on 12/11/2019 with no concerns.

Based on record review and interview the facility failed to ensure that the pharmacist identified and reported irregularities identified during the review for 1 of 4 residents sampled for unnecessary medications (resident #19). The findings include: On 12/11/19 at approximately 10:16 AM during record review of resident #19's medical record it was identified that the resident was admitted over a year ago and was receiving the medication [MEDICATION NAME] 20 mg twice a day by mouth (an antidepressant) started on 11/28/2018 at 10 mg and increased to 20 mg on 12/18/2019. During review of the medication regimen review, no evidence of a gradual dose reduction (GDR) for [MEDICATION NAME] could be found. A review of pharmacy recommendations since (MONTH) (YEAR) failed to find a recommendation for a dose reduction for [MEDICATION NAME]. On 12/11/2019 at approximately 11:46 AM during interview with the resident's Psychiatric Nurse Practitioner, Staff H, Advanced Registered Nurse Practitioner (ARNP), stated that she does not consider GDR's on medications until she has received a recommendation from the pharmacist and that she cannot keep up with that for 2000 medications. On 12/12/2019 at approximately 2:15 PM in interview with the facility Pharmacist staff I, the Pharmacist expressed that it was his responsibility to prompt for a GDR and that he was aware of the requirements to identify the need for and recommend a GDR. The pharmacist stated that he missed it in reference to there being no recommendation for a GDR for the antidepressant resident #19 was receiving. Additionally, the Pharmacist stated that he relied on the notes of the Psychiatric ARNP in making his judgment on whether a GDR was to be recommended or not.

Based on observation, record review, staff interview and policy review, the facility failed to ensure staff perform appropriate hand hygiene after caring for 1 of 1 residents sampled for contact isolation precautions. (resident #95) The findings include: An observation of resident #95 was conducted on 12/9/19 at approximately 1:15 PM. Employee D (licensed practical nurse) entered the room with gown and gloves on to administer medication to the resident. The nurse gave the resident the medication then discarded her gown and gloves in the trash and left the room. The nurse did not wash her hands before leaving the room. Review of the medical record revealed a current physician order for [REDACTED]. An interview was conducted with employee D on 12/9/19 at 1:34 PM. She confirmed resident #95 was on contact isolation for [DIAGNOSES REDACTED]icile. She stated staff should put on gown and gloves when entering the room and wash your hands or use hand sanitizer outside the door after care. She stated she used the hand sanitizer outside the door when she left and she believes it is effective against [DIAGNOSES REDACTED]icile. An interview was conducted with the Director of Nursing (DON) on 12/9/19 at 2:35 PM. She stated after caring for a resident with [DIAGNOSES REDACTED]icile, staff should remove personal protective equipment and wash their hands before leaving the room. Review of the facility policy for [MEDICAL CONDITION] (revised 2014) reveals preventative measures will be taken to prevent the occurrence of [DIAGNOSES REDACTED]icile infections among residents and precautions will be taken while caring for residents with [DIAGNOSES REDACTED]icile (to prevent transmission of [DIAGNOSES REDACTED]icile to others). When caring for residents with diarrhea or fecal incontinence caused by [DIAGNOSES REDACTED]icile, staff will maintain vigilant hand hygiene. Hand washing with soap and water is superior to alcohol based hand rub for the mechanical removal of [DIAGNOSES REDACTED]icile spores from hands. Glove use when caring for residents with [DIAGNOSES REDACTED]icile infection, washing hands with soap and water before exiting the room of a resident with [DIAGNOSES REDACTED]icile infection and strict adherence to hand hygiene in general is considered best practice.

Based on observations, record review, staff interview and policy review, the facility failed to notify the physician of a significant change in the resident's physical condition related to [MEDICAL CONDITION] (swelling) for 1 of 1 sampled resident (#37). The findings include: Observations of resident #37 were conducted on 3/13/18 at 11:03 AM and 3/14/18 at 1:10 PM. The resident was observed both times to be sitting in her wheelchair and had [MEDICAL CONDITION] (swelling) observed to her lower extremities (legs/feet). Review of the medical record for resident #37 revealed a nurse's note dated 3/13/18 at 3:07 PM indicating the resident had 3+ [MEDICAL CONDITION] to her left lower extremity. The note also indicated the extremity was white and waxy and the nurse was not able to find a pedal pulse. There was no documentation indicating the resident previously had this [MEDICAL CONDITION], nor was there documentation to show the staff had notified the physician of the [MEDICAL CONDITION] and lack of pedal pulse. An interview was conducted with the Director of Nursing (DON) on 3/14/18 at 3:47 PM. The DON stated she would expect the nurses to report [MEDICAL CONDITION] and lack of pedal pulse to the physician. Review of the facility policy for Change in a Resident's Condition or Status revealed the facility shall promptly notify the attending physician of a significant change in the resident's condition.

Based on record review and staff interview the facility failed to provide the appropriate transfer notice to the resident and responsible party for 2 of 2 sampled residents reviewed for transfer and hospitalization (#44 and #46). The findings include: Resident #44 Review of resident #44 ' s record revealed she was transferred to the hospital on [DATE] for emergent care. The resident was admitted to the hospital and returned to the nursing home on 2/28/18. The record contained no evidence a transfer notice, with all required components, was provided to the resident and the resident's representative. An interview was conducted with the Director of Nursing (DON) on 3/15/18 at 12:36 PM. She stated they had not been providing a transfer notice with appeal rights to the resident and resident representative at the time of transfer, and she had no evidence a transfer notice was provided to the resident and responsible party as soon as practicable after the transfer. Resident #46 A clinical record review was conducted for resident #46, and revealed that on 2/15/18 the resident was sent to the hospital via Emergency Medical Services (EMS), per physician order, for elevated lab results. The record review had documentation that the resident returned to the facility on [DATE]. On 03/16/18 at approximately 9:38 AM, an interview was conducted with the Administrator-In-Training (AIT). The AIT was asked to confirm if the resident or her Power of Attorney (POA) were given the required transfer notice when she was transferred to the hospital. The AIT stated that she would have to speak to the DON about that because she had no knowledge of the requirement or the process. On 03/16/18 at approximately 10:01 AM an interview was conducted with the POA/spouse of the resident. When asked if he or his wife were ever presented with a Transfer Notice by the facility he replied, no. On 03/16/18 at approximately 10:24 AM a joint interview was conducted with the AIT and the DON. They were asked if the facility provided a transfer notice to resident #46 or her POA (spouse) upon discharge of the resident on 2/15/17. The AIT provided what was explained as the admission folder which was provided to each resident/POA upon admission. The AIT stated that when a discharge to the hospital occured, the bed hold policy was explained to the resident/POA. The AIT further stated that the admission folder was then reviewed with the resident/POA and that the folder included a copy of the bed hold along with contact information for various agencies including the Ombudsman, the State Survey Agency and other resources, which were posted at entrances and exits to the facility for official agencies to obtain assistance and/or file complaints. The DON confirmed that there was no actual transfer notice given, but all of the information which would be contained in a transfer notice was available in the folder or otherwise posted at the entrances and exits to the facility.

Based on record review and staff interview, the facility failed to provide the resident and resident representative the appropriate notice of bed-hold policy at the time of transfer for hospitalization for 1 of 2 residents reviewed for transfer and hospitalization . (#44) The findings include: Review of resident #44's record revealed she was transferred to the hospital on [DATE] for emergent care. The resident was admitted to the hospital and returned to the nursing home on 2/28/18. The record contained no evidence the facility bed-hold policy was provided to the resident and the responsible party at the time of the transfer. An interview was conducted with the Director of Nursing (DON) on 3/15/18 at 12:36 PM. The DON stated she had no evidence the bed hold policy was provided to the resident at the time of the transfer or as soon as practicable thereafter.

Based on record review, staff interviews and policy review, the facility failed to assess a resident post fall in accordance with professional standards of practice for 1 of 2 sampled residents reviewed for falls with major injury (#37). The findings include: Review of the medical record for resident #37 revealed a nurse's note, dated 2/18/18 at 6:50 AM, indicating the resident was observed on the floor in her room leaning against the wall. According to the documentation, the nurse and another staff transferred the resident from the floor to her wheelchair. The note stated the resident complained of pain in her right hip, but had no visible injuries or bruises, and they assisted the resident to the bathroom and then back to bed. There was no further documentation of a resident assessment conducted by the nurse. The resident was transferred to the hospital later on 2/18/18, and was discovered to have a fractured left hip. According to The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities, last updated (MONTH) (YEAR), and published by the Agency for Healthcare Research and Quality, backed by the U.S. Department of Health and Human Services, immediate evaluation by a nurse after a resident falls should include a review of the resident systems and description of injuries. The document goes on to explain that the nurse should stabilize the resident and provide immediate treatment if necessary. A telephone interview was conducted with employee A (licensed practical nurse) on 3/14/18 at 3:17 PM. Employee A stated the resident fell on the floor near her bed prior to shift change. He first asked her if she was okay. The resident stated she was in some pain and her hip was hurting. He stated himself and another staff member then transferred the resident to the wheelchair and assisted her to the bathroom. They placed the resident back in bed and he then assessed her for skin tears and injuries. An interview was conducted with the Director of Nursing (DON) on 3/14/18 at 3:47 PM. The DON stated the nurse should have assessed the resident for injuries prior to moving the resident from where he found her on the floor. Review of the facility policy on Incident Reports revealed the first step to follow when a resident sustained [REDACTED].

Based on observations, interviews and record review, the facility failed to provide appropriate services and equipment to maintain or improve mobility for 1 of 2 (#6) residents sampled for limited range of motion (ROM). Findings include: On 3/13/18 at approximately 10:30 AM an observation was made of resident #6 in which her right upper extremity was noted to be contracted inward toward her body, bent at the elbow with her wrist flexed inward and her fingers closed into a fist. At the time of the observation a brace was not noted. On 3/13/18 a chart review for resident #6 was conducted which revealed a nursing maintenance program form, dated 2/15/18, by the occupational therapy (OT) staff, in which the following recommendation was made: Resting hand splint. Caregivers will perform ROM to right shoulder, elbow, wrist and digits for 10 minutes daily. Don right hand splint while in bed. Caregivers will take off after 4 hours. This form documented that staff education was provided on 2/20/18. On 3/14/18 at approximately 1:00 PM an interview was conducted with CNA F in which she stated she was not aware of the resident having a brace but that she did provide range of motion (ROM) twice daily. She stated that if the resident was required to have a brace applied it would be noted on the task sheets within the electronic medical record. She stated there was not a task sheet for the resident to have a brace. On 3/14/18 at 1:00 PM an interview was conducted with the Staff Development Coordinator, in which she was asked to provide information related to the resident's right hand splint ordered by occupational therapy on 2/15/18. She stated she was not aware of a splint order, but if the certified nursing assistants (CNAs) were applying the splint, it would be either in the restorative notebook or on the task sheet in Point Click Care, their electronic medical record system. She looked in both locations and was unable to find documentation and stated it has not been done. She was able to locate the splint in the room; however, was not able to provide documentation of its use. On 03/16/18 at 09:00 AM,l an interview was conducted with the Certified Occupational Therapy Assistant (COTA), in which she stated that when a resident was discharged from OT and sent to the facility's nursing maintenance program, staff were trained on proper therapy after care. She stated that the record supported that this plan was created on 2/20/18 and that staff were trained on the use of the brace on that day. She stated that after the training was completed, the restorative nurse would create a task within Point Click Care (PCC) for documentation purposes. On 3/16/18 at 9:05 AM, an interview was conducted with the Director of Nursing (DON), in which she stated that the restorative nurse had left her position as of Monday 3/12/18 and the DON took over those responsibilities until a replacement could be found. She stated that the staff was not aware of resident #6 having a plan in place because the restorative nurse did not create the task, but once the staff became aware on 3/14/18, the task was created.

Based on observations, record review, staff interview and review of facility policy and procedure, the facility failed to ensure 1 of 3 residents reviewed for dementia care, (#44), received appropriate treatment and services to address behaviors related to dementia prior to the initiation of antipsychotic medications. The findings include: Observations of resident #44 were conducted on 3/14/18 at 11:21 AM, 1:12 PM, 4:47 PM and 3/15/18 at 9:26 AM, 11:30 AM and 4:16 PM. The resident did not display any hallucinations or behaviors at the times of the observations. Review of resident #44's record revealed the physician ordered Klonopin 0.5mg by mouth twice a day for anxiety on 3/4/18. On 3/5/18 the physician ordered to discontinue the Klonopin and start [MEDICATION NAME] 25mg by mouth every night for anxiety. A clarification physician order [REDACTED]. Behaviors of restlessness were documented in the nurse's notes on 3/4/18 at 1:45 AM, 3/5/18 at 2:07 AM and 3/12/18 at 3:10 AM. An interview was conducted with the Director of Nursing (DON) on 3/15/18 at 1:51 PM. The DON stated the psychiatrist was supposed to see the resident last week but did not see her. He had an extensive list of residents to see and he put off the people who had been recently admitted until the next visit. She stated she was not aware resident #44 had started taking [MEDICATION NAME] and confirmed there were no documented hallucinations in the resident's record. Review of the facility procedure for dementia care (June (YEAR)) revealed the intent was to provide dementia care and services to attain the highest practicable well-being for the resident with procedures to include: Evaluate behaviors prior to the initiation and during the use of [MEDICAL CONDITION] medications; Assessment will be completed on admission of resident prior routines, preferences, triggers and any effective interventions known by family/caregivers; If behaviors represent a sudden change or worsening from baseline, contact the physician for medical evaluation; Nursing will collaborate with physician to identify risk and causal/contributing factors for behavior such as co-existing medical or psychiatric conditions or decline in cognitive function or adverse consequence related to current medication; Behavior documentation and interventions will be reviewed weekly by the DON or designee; Interdisciplinary team will meet periodically to review residents with dementia [DIAGNOSES REDACTED].

Based on observations, record review, staff interview and facility policy and procedure review, the facility failed to ensure adequate indications for the initiation and use of an antipsychotic medication for 1 of 5 sampled residents reviewed for unnecessary medications (#44). The findings include: Observations of resident #44 were conducted on 3/14/18 at 11:21 AM, 1:12 PM, 4:47 PM and 3/15/18 at 9:26 AM, 11:30 AM and 4:16 PM. The resident did not display any hallucinations or behaviors at the times of the observations. Review of resident #44's record revealed the physician ordered Klonopin 0.5mg by mouth twice a day for anxiety on 3/4/18. On 3/5/18 the physician ordered to discontinue the Klonopin and start [MEDICATION NAME] 25mg by mouth every night for anxiety. A clarification physician order [REDACTED]. Behaviors of restlessness were documented in the nurse's notes on 3/4/18 at 1:45 AM, 3/5/18 at 2:07 AM and 3/12/18 at 3:10 AM. An interview was conducted with the Director of Nursing (DON) on 3/15/18 at 1:51 PM. The DON stated the psychiatrist was supposed to see the resident last week but did not see her. He had an extensive list of residents to see and he put off the people who had been recently admitted until the next visit. She stated she was not aware resident #44 had started taking [MEDICATION NAME] and confirmed there were no documented hallucinations in the resident's record. Review of the facility procedure for dementia care (June (YEAR)) revealed the intent was to provide dementia care and services to attain the highest practicable well-being for the resident with procedures to include: Evaluate behaviors prior to the initiation and during the use of [MEDICAL CONDITION] medications; Assessment will be completed on admission of resident prior routines, preferences, triggers and any effective interventions known by family/caregivers; If behaviors represent a sudden change or worsening from baseline, contact the physician for medical evaluation; Nursing will collaborate with physician to identify risk and causal/contributing factors for behavior such as co-existing medical or psychiatric conditions or decline in cognitive function or adverse consequence related to current medication; Behavior documentation and interventions will be reviewed weekly by the DON or designee; Interdisciplinary team will meet periodically to review residents with dementia [DIAGNOSES REDACTED].

Based on record review, and staff interviews the facility failed to implement the plan of care related to the use of [MEDICAL CONDITION] medications for 2 of 5 sampled residents reviewed for unnecessary medications. (residents #63 and 50) The findings include: Review of resident #63's record revealed the resident received [MEDICATION NAME] (an anti-anxiety medication) 0.25 mg by mouth every morning beginning on 9/7/2016. The resident had a [DIAGNOSES REDACTED]. The care plan interventions included to assess the resident for anxiety triggers and patterns to attempt to eliminate them. The nurses notes dated 8/29/16 through 9/14/16 revealed no documentation of resident behaviors. The Medication Administration Record [REDACTED]. At the time of the survey, the resident was receiving [MEDICATION NAME] 0.25 mg by mouth twice a day for anxiety. The behavior monitoring forms indicated the resident had behaviors of being afraid, pacing, and panic. The record revealed no documented assessment of the behaviors in an attempt to identify patterns, trends, causative factors, or interventions to minimize or eliminate these behaviors. Resident #63 had 6 falls from 9/14/16 to 5/17/17. According to the Federal Drug Administration (FDA), dizziness and unsteadiness are potential adverse reactions to this medication. An interview was conducted with the Director of Nursing (DON) on 5/24/17 at approximately 12:52 PM. The DON stated the facility had no formal process or policies related to the evaluation and initiation of a [MEDICAL CONDITION] medication for a patient with a [DIAGNOSES REDACTED]. Resident #50 was admitted to the facility on [DATE] taking the anti-psychotic medication [MEDICATION NAME] 25 mg (milligrams) at bedtime. She was sent to the hospital from 7/19/16 through 7/21/16, and returned to the facility on [DATE] with a continuation order for the [MEDICATION NAME] and the addition of medication [MEDICATION NAME] 25 mg at bedtime for [MEDICAL CONDITION]/antidepressant. The resident had pertinent [DIAGNOSES REDACTED]. There was a progress note in the resident's chart that revealed the resident's daughter insisted on continued use of the [MEDICATION NAME], stating that otherwise, intense hallucinations occur. A review of the care plan for resident #50 revealed a care plan for the use of anti-psychotic medications for [MEDICAL CONDITION] with [MEDICAL CONDITION], and included the following interventions: dose reduction as needed, monitor for mood and behavior and report to the medical doctor (MD) as needed, and obtain psychiatric evaluation as needed. She also had a care plan for the potential to demonstrate verbally disruptive behaviors related to her dementia with interventions to include: analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Monitor/document observed behavior and attempted interventions, psychiatric consult as indicated. Both care plans were initiated 6/3/16 and updated 5/10/17. Review of the nursing notes and behavior monitoring forms for resident #50 showed no documentation of any behaviors from August 2016 to May 2017. An interview was conducted with the Director of Nursing on 05/23/2017 at 4:36 pm. She stated the daughter wanted resident #50 on [MEDICATION NAME] because of hallucinations. She was requested to provide documentation of pharmacy reviews and evidence of a gradual dose reduction (GDR). A follow-up interview was conducted on 5/24/17 at 8:11 am with the DON. She confirmed that there was no documentation of the resident having behaviors, there was no documented analysis to indicate key times, places, circumstances, or triggers for resident behavior, and that no psychiatric evaluation had ever been conducted in the facility for resident #50. She further stated that she had talked to staff, and they all reported that the resident's daughter did not want her taken off the [MEDICATION NAME] and she was on the lowest dose available. An interview was conducted with Certified Nursing Assistant (CNA) Employee A on 5/24/17 at 11:43 am. She stated resident #50 yelled a lot and laughed out at inappropriate times. She then stated, A couple of days ago she yelled no, no, no because she did not want to be changed and she was wet. She then said the resident had hit her about a month ago. She reported that most of the resident's behaviors seemed to occur when vital signs were being done, and when she needed to be changed. She further stated that 9 out of 10 times, the resident fights during care, and they try to calm her and will report to the nurse. The Registered Nurse(RN) Employee B was interviewed on 5/24/17 at 11:56 am. She stated that resident #50 had very few behaviors. She then stated, Yesterday she was yelling, and I could not seem to find the reason for it. She indicated that she would document behaviors on the behavior monitoring forms and chart on the progress notes for anything out of the ordinary. When asked if she had recorded the yelling from yesterday, she stated that she had not. She then further explained that she only recorded on the behavior monitoring form when she was required to give a resident an as needed medication for behaviors.

Based on clinical record review and staff interview, the facility failed to ensure that each resident received the necessary dementia care and services to attain the highest practicable well-being. The facility failed to develop and implement policies and procedures related to dementia care to evaluate behaviors prior to the initiation and during the use of [MEDICAL CONDITION] medications for 2 of 5 sampled residents reviewed for unnecessary medications. (residents #63 and 50) The findings include: Review of resident #63's record revealed the resident received [MEDICATION NAME] (an anti-anxiety medication) 0.25 mg by mouth every morning beginning on 9/7/2016. The resident had a [DIAGNOSES REDACTED]. The care plan interventions included to assess the resident for anxiety triggers and patterns to attempt to eliminate them. The nurses notes dated 8/29/16 through 9/14/16 revealed no documentation of resident behaviors. The Medication Administration Record [REDACTED]. At the time of the survey, the resident was receiving [MEDICATION NAME] 0.25 mg by mouth twice a day for anxiety. The behavior monitoring forms indicated the resident had behaviors of being afraid, pacing, and panic. The record revealed no documented assessment of the behaviors in an attempt to identify patterns, trends, causative factors, or interventions to minimize or eliminate these behaviors. Resident #63 had 6 falls from 9/14/16 to 5/17/17. According to the Federal Drug Administration (FDA), dizziness and unsteadiness are potential adverse reactions to this medication. An interview was conducted with the Director of Nursing (DON) on 5/24/17 at approximately 12:52 PM. The DON stated the facility had no formal process or policies related to the evaluation and initiation of a [MEDICAL CONDITION] medication for a patient with a [DIAGNOSES REDACTED]. Resident #50 was admitted to the facility on [DATE] taking the anti-psychotic medication [MEDICATION NAME] 25 mg (milligrams) at bedtime. She was sent to the hospital from 7/19/16 through 7/21/16, and returned to the facility on [DATE] with a continuation order for the [MEDICATION NAME] and the addition of medication [MEDICATION NAME] 25 mg at bedtime for [MEDICAL CONDITION]/antidepressant. The resident had pertinent [DIAGNOSES REDACTED]. There was a progress note in the resident's chart that revealed the resident's daughter insisted on continued use of the [MEDICATION NAME], stating that otherwise, intense hallucinations occur. A review of the care plan for resident #50 revealed a care plan for the use of anti-psychotic medications for [MEDICAL CONDITION] with [MEDICAL CONDITION], and included the following interventions: dose reduction as needed, monitor for mood and behavior and report to the medical doctor (MD) as needed, and obtain psychiatric evaluation as needed. She also had a care plan for the potential to demonstrate verbally disruptive behaviors related to her dementia with interventions to include: analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Monitor/document observed behavior and attempted interventions, psychiatric consult as indicated. Both care plans were initiated 6/3/16 and updated 5/10/17. Review of the nursing notes and behavior monitoring forms for resident #50 showed no documentation of any behaviors from August 2016 to May 2017. An interview was conducted with the Director of Nursing on 05/23/2017 at 4:36 pm. She stated the daughter wanted resident #50 on [MEDICATION NAME] because of hallucinations. She was requested to provide documentation of pharmacy reviews and evidence of a gradual dose reduction (GDR). A follow-up interview was conducted on 5/24/17 at 8:11 am with the DON. She confirmed that there was no documentation of the resident having behaviors, there was no documented analysis to indicate key times, places, circumstances, or triggers for resident behavior, and that no psychiatric evaluation had ever been conducted in the facility for resident #50. She further stated that she had talked to staff, and they all reported that the resident's daughter did not want her taken off the [MEDICATION NAME] and she was on the lowest dose available. An interview was conducted with Certified Nursing Assistant (CNA) Employee A on 5/24/17 at 11:43 am. She stated resident #50 yelled a lot and laughed out at inappropriate times. She then stated, A couple of days ago she yelled no, no, no because she did not want to be changed and she was wet. She then said the resident had hit her about a month ago. She reported that most of the resident's behaviors seemed to occur when vital signs were being done, and when she needed to be changed. She further stated that 9 out of 10 times, the resident fights during care, and they try to calm her and will report to the nurse. The Registered Nurse(RN) Employee B was interviewed on 5/24/17 at 11:56 am. She stated that resident #50 had very few behaviors. She then stated, Yesterday she was yelling, and I could not seem to find the reason for it. She indicated that she would document behaviors on the behavior monitoring forms and chart on the progress notes for anything out of the ordinary. When asked if she had recorded the yelling from yesterday, she stated that she had not. She then further explained that she only recorded on the behavior monitoring form when she was required to give a resident an as needed medication for behaviors.

Based on staff interview, and clinical record review, the facility failed to monitor resident behaviors, and failed to attempt a gradual dose reduction for 1 of 5 residents (#50) who was reviewed for unnecessary medication review. The findings are: Resident #50 was admitted to the facility on [DATE] taking the anti-psychotic medication [MEDICATION NAME] 25 mg (milligrams) at bedtime. She was sent to the hospital from 7/19/16 through 7/21/16, and returned to the facility on [DATE] with a continuation order for the [MEDICATION NAME] and the addition of medication [MEDICATION NAME] 25 mg at bedtime for [MEDICAL CONDITION]/antidepressant. The resident had pertinent [DIAGNOSES REDACTED]. There was a progress note in the resident's chart that revealed the resident's daughter insisted on continued use of the [MEDICATION NAME], stating that otherwise, intense hallucinations occur. A review of the care plan for resident #50 revealed a care plan for the use of anti-psychotic medications for [MEDICAL CONDITION] with [MEDICAL CONDITION], and included the following interventions: dose reduction as needed, monitor for mood and behavior and report to the medical doctor (MD) as needed, and obtain psychiatric evaluation as needed. She also had a care plan for the potential to demonstrate verbally disruptive behaviors related to her dementia with interventions to include: analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Monitor/document observed behavior and attempted interventions, psychiatric consult as indicated. Both care plans were initiated 6/3/16 and updated 5/10/17. Review of the nursing notes and behavior monitoring forms for resident #50 showed no documentation of any behaviors from August 2016 to May 2017. A review of the pharmacy recommendations failed to reveal any gradual dose reduction for the [MEDICATION NAME] until March, 2017. An interview was conducted with the Director of Nursing on 05/23/2017 at 4:36 pm. She stated the daughter wanted resident #50 on [MEDICATION NAME] because of hallucinations. She was requested to provide documentation of pharmacy reviews and evidence of a gradual dose reduction (GDR). A follow-up interview was conducted on 5/24/17 at 8:11 am with the DON. She confirmed that there was no documentation of the resident having behaviors, there was no documented analysis to indicate key times, places, circumstances, or triggers for resident behavior, and that no psychiatric evaluation had ever been conducted in the facility for resident #50. She further stated that she had talked to staff, and they all reported that the resident's daughter did not want her taken off the [MEDICATION NAME] and she was on the lowest dose available. An interview was conducted with Certified Nursing Assistant (CNA) Employee A on 5/24/17 at 11:43 am. She stated resident #50 yelled a lot and laughed out at inappropriate times. She then stated, A couple of days ago she yelled no, no, no because she did not want to be changed and she was wet. She then said the resident had hit her about a month ago. She reported that most of the resident's behaviors seemed to occur when vital signs were being done, and when she needed to be changed. She further stated that 9 out of 10 times, the resident fights during care, and they try to calm her and will report to the nurse. The Registered Nurse(RN) Employee B was interviewed on 5/24/17 at 11:56 am. She stated that resident #50 had very few behaviors. She then stated, Yesterday she was yelling, and I could not seem to find the reason for it. She indicated that she would document behaviors on the behavior monitoring forms and chart on the progress notes for anything out of the ordinary. When asked if she had recorded the yelling from yesterday, she stated that she had not. She then further explained that she only recorded on the behavior monitoring form when she was required to give a resident an as needed medication for behaviors. An interview was conducted with the consultant pharmacist on 5/24/17 at 12:27 pm . He agreed that a gradual dose reduction should have been attempted twice in the past year. He did mention documentation that the daughter wanted her mother on the [MEDICATION NAME], but then said, I must have just missed it as the reason for not having another recommendation for GDR.

Based on record review and interview, the facility failed to complete a gradual dose reduction according to guidelines for 1 of 5 residents (#50) reviewed for unnecessary medications. The findings are: Resident #50 was admitted to the facility on [DATE] taking the anti-psychotic medication Seroquel 25 mg (milligrams) at bedtime. She was sent to the hospital from 7/19/16 through 7/21/16, and returned to the facility on [DATE] with a continuation order for the Seroquel and the addition of medication Trazodone 25 mg at bedtime for insomnia/antidepressant. The resident had pertinent [DIAGNOSES REDACTED]. There was a progress note in the resident's chart that revealed the resident's daughter insisted on continued use of the Seroquel, stating that otherwise, intense hallucinations occur. Review of the nursing notes and behavior monitoring forms for resident #50 showed no documentation of any behaviors from August 2016 to May 2017. A review of the pharmacy recommendations failed to reveal any gradual dose reduction for the Seroquel until March, 2017. The facility received a recommendation on 3/26/17 requesting that the doctor update the clinical record with the necessary supporting information for the continuation of Seroquel 25 mg and Trazodone 25 mg at bedtime. The recommendation reviewed the guidelines: when used to treat behavioral symptoms related to dementia, failed previous attempt within the facility AND physician documentation of clinical rationale must be present. Clinical rationale must include physician documentation as to why an attempted dose reduction at the time would be likely to impair the resident's function or cause psychiatric instability by exacerbation of an underlying medical or psychiatric disorder. The physician responded on 4/18/17 stating: Trazodone provided for insomnia, low dose 25 mg provides minimal SSRI (selective serotonin re-uptake inhibitor) effect; though still provides sedation effect. Continue current dosing. There was no mention of the Seroquel. An interview was conducted with the consultant pharmacist on 5/24/17 at 12:27 pm . He agreed that a gradual dose reduction should have been attempted twice in the past year. He did mention documentation that the daughter wanted her mother on the Seroquel, but then said, I must have just missed it as the reason for not having another recommendation for GDR.

Based on observation of residents with urinary collection bags, and staff interview, the facility failed to prevent possible cross contamination for 2 of 2 residents observed with indwelling urinary drainage tubing and urinary collection bags ( #79 and #80). The findings are: On 5/22/17 at 12:00pm resident #80 was interviewed in his room. He stated he had a supra-pubic catheter (tube from an opening in his abdomen to his bladder) for a number of years. His collection bag for his urine was observed to be covered with a dignity bag. The bag was dragging on the floor. On 5/23/17 at 9:30am the resident was observed propelling himself in his wheelchair in the hallway. His collection bag was observed dragging on the floor. On 5/23/17 at 9:37 resident #79 was observed to be leaving his room with a urinary collection bag in a dignity bag observed to be dragging on the floor as the resident went from his room to the dining room. At 3:21 pm the same resident was observed to be coming from the dining room, being pushed in his wheelchair by staff. The tubing from the indwelling catheter was observed to be dragging on the floor as he was pushed into his room. On 5/24/17 at 10:00 am resident #79 was observed in the dining room with staff during an activity. His collection bag was again observed to be sitting on the floor inside the dignity bag. An interview was conducted with certified nursing assistant (CNA) A, who was asked to observe resident #79 at 11:37 am on 5/24/17, while he was still in the dining room. She was asked where the urine collection bag should be, and stated,It should be off the floor.' She confirmed that the urine bag was dragging on the floor and immediately asked the resident to go with her to his room so it could be adjusted. The registered nurse (RN) employee (B) was interviewed on 5/24/16 at 11:56 am. She was asked about the infection control practices that are followed for urinary collection bags and tubing. She said she would make sure the urine collection bag was in a dignity covering, and that the tubing and collection bag was secured in such a way as to prevent them from touching the floor. An interview was conducted with the (DON) on 5/24/17 at 12:16 am. She stated there was no specific policy for care and use of urinary collection devices and tubing. She said it was a standard of care to make sure the bags and tubing were not dragging on the floor.