La Canada Care Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to provide housekeeping services necessary to maintain a clean and homelike environment for residents in three of four resident rooms and hallways. This deficient practice can increase the risk of infection, and not provide the residents with a safe and clean environment. Findings Include:A complaint received on the online complaint portal system, dated January 2, 2026, revealed that the facility did not seem to have enough staff to keep the facility clean, and that the overall cleanliness of the facility is not good. Additionally, the complainant revealed that staff would not clean up the floor after her meal tray spilled. On March 3, 2026, at approximately 8:42 a.m., an observation of room [ROOM NUMBER] was conducted while both residents in Beds A and B were present. During the observation, trash and crumbs were noted on the floor. Multiple visible dark streaks were also observed in high-traffic areas of the flooring. During the observation, the resident in Bed A stated, It takes a lot to get the rooms cleaned around here. The resident in Bed B, stated that the floor and room has been dirty for quite a while. The resident further stated that cleaning staff do not clean the room on a daily basis, but stated he could not estimate how often they come. On March 3, 2026, at approximately 8:54 a.m., an observational tour of the 100 Hall was conducted with the Business Office Manager (Staff #72). During the tour, the manager identified rooms that did not meet the facility's cleanliness expectations and stated the three identified rooms had visible dirt and streaks on the floor (rooms [ROOM NUMBER]); two of the rooms had multiple pieces of trash on the floor (rooms [ROOM NUMBERS]); and one room had visible food crumbs on the floor along with multiple dark streaks and scuff marks in the flooring surface (room [ROOM NUMBER]).On March 3, 2026, at approximately 9:00 a.m., an observation of room [ROOM NUMBER] was conducted with a Certified Nursing Assistant (CNA/Staff #77). During the observation, small pieces of paper, and small loose debris, were noted on the floor along with a few discarded items near the trash can. The CNA stated that housekeeping typically cleans resident rooms daily; however, housekeeping had not yet arrived on the unit that morning, as the meal cart was still present in the hallway. The CNA also stated that the drink cart located in the 300-hallway had multiple areas of visible spillage on the red cooler, on both metallic drink dispenser surfaces, and on the cart surfaces. The CNA indicated that spills should be cleaned when they occur and stated that the cart was being returned to the kitchen to be properly cleaned.On March 3, 2026, at 9:10 a.m., during medication pass with a Registered Nurse (RN/Staff # 75), the nurse identified and stated that room [ROOM NUMBER], failed to meet facility standards due the buildup of streaked dirt, areas of dried spills on the floor, as well as trash on the floor. The RN stated that the room should have been kept clean, and that the current condition of the room was neither home-like nor appropriate for decreasing the risk for spreading infection. The RN stated that trash, messes and spills should be cleaned up immediately and not be allowed to accumulate. An interview was conducted on March 3, 2026, at approximately 3:00 p.m. with the Housekeeping Supervisor (Staff #8). The Housekeeping Supervisor stated that maintaining a clean and home-like environment includes ensuring floors are swept and mopped, trash is removed regularly, and bathroom fixtures such as mirrors, sinks, and toilets are cleaned. She explained that the goal of housekeeping services is to keep the environment organized and smelling clean in order to support a comfortable atmosphere for residents. The supervisor stated that housekeeping staff are instructed to clean under furniture and routinely clean and disinfect high-touch surfaces. She explained that these practices help create a peaceful and comfortable environment for residents. The supervisor stated that she conducts routine walkthroughs throughout the facility to monitor housekeeping performance and ensure resident rooms receive daily cleaning. During these rounds, she stated that areas needing deep cleaning are identified and rooms are checked to ensure they have the supplies and environmental conditions necessary to support a comfortable living environment. The Housekeeping Supervisor stated that housekeeping staff are assigned to specific halls and begin cleaning at the start of each hallway, addressing resident rooms, hallways, and common areas as they proceed. She stated that a floor technician operates the floor machine each morning to maintain hallway floors. The supervisor stated that she also performs morning rounds to observe environmental conditions and address concerns that are identified. The Housekeeping Supervisor stated that previously one housekeeper was assigned to cover two halls; however, she stated that due to an increase in census, staffing assignments are being reassessed so that each hall will have a dedicated housekeeper. The supervisor stated that the facility is in the process of hiring additional staff and reported that one candidate is pending background clearance. She also stated that the facility recently obtained a new washer and continues to implement system improvements to support environmental cleanliness. The supervisor revealed that housekeeping staff are regularly scheduled from 8:00 a.m. to 4:45 p.m., including the supervisor, floor technician, and housekeeping staff assigned to each hall. She explained that while housekeeping staff perform routine cleaning during scheduled hours, all facility staff share responsibility for maintaining a clean environment by reporting spills or debris so they can be addressed promptly. The Housekeeping Supervisor stated that maintaining a clean and homelike environment is the responsibility of all staff within the facility. She stated that spills are expected to be cleaned immediately once identified or reported in order to prevent accidents and maintain a safe environment. The supervisor stated that spills or debris must be reported to housekeeping staff as soon as they occur because if housekeeping is not notified they may not be aware of the issue. She stated that staff typically communicate spills through radio communication so housekeeping staff can respond quickly. The supervisor also stated that maintaining clean floors and surfaces helps prevent illness and infection and reduces the spread of contamination within the facility. The Housekeeping Supervisor stated that the Director of Nursing informed her, of concerns identified with the surveyor during the survey. The supervisor stated that after being notified of the concerns, she personally responded to address the identified issues. The supervisor stated she was instructed to bring room [ROOM NUMBER], up to facility standards, which included cleaning the feces off the toilet. The supervisor revealed that she was also told to address the tube-feeding residue that accumulated on the floor mat in room [ROOM NUMBER]. Following these incidents, the supervisor stated that she spoke with housekeeping staff and reinforced expectations that bathrooms, floors, and other high-use areas must be carefully checked during routine cleaning and that spills, residue, or debris must be addressed promptly. She stated that some resident rooms require closer monitoring because certain residents may have difficulty maintaining cleanliness within their rooms. The Housekeeping Supervisor stated that the findings reported to her by the Director of Nursing on March 3, 2026 did not meet the facility's expectations for environmental cleanliness. She stated that the department is addressing these concerns by hiring additional housekeeping staff, adjusting hall assignments to ensure adequate coverage, and utilizing the new washer to improve cleaning processes. The supervisor stated that the department will continue monitoring the environment and refining processes to ensure the facility consistently maintains a clean, safe, and comfortable environment for residents.An interview was conducted on March 5, 2026, at approximately 9:48 a.m. with the Assistant Director of Nursing (ADON/Staff #83). The ADON stated that maintaining cleanliness and hygiene is an important professional standard within the facility. The ADON further stated that cleanliness is important for residents who are healing, especially those who may be immunocompromised. In addition, the ADON continued to state that a clean, sanitary, and hygienic environment was imperative to both physical health and mental well-being. The ADON also revealed that an unclean environment could potentially contribute to declines in health and negatively impact residents' comfort. The ADON also stated that spills should be cleaned immediately to prevent slip hazards and that overall presentation of the environment should prioritize resident safety. The ADON indicated that situations involving cleanliness concerns provide opportunities for staff education and reinforcement of facility expectations.A follow-up clarification interview was conducted on March 5, 2026, at approximately 10:50 a.m. with the resident in Bed B of room [ROOM NUMBER] to obtain additional clarification regarding his prior statement. During the interview, the resident stated that he was not joking when the Director of Nursing (DON) and the surveyor were previously in the room. The resident reported that even though his roommate has dementia; neither one of them were joking when the DON and the surveyor was present in the room earlier about the need for housekeeping improvement, and that their room is not cleaned on a daily basis. The facility's Infection Control Program policy, with the reviewed date of August 2025, revealed the goal of the infection control program, it to identify and correct problems relating to infection control practices. The facility's Homelike Environment policy, with the reviewed date of May 2022, revealed that it is the policy of the facility to provide a home like environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and facility policy, the facility failed to protect the rights of one of 13 sampled resident's (#600) to be free from abuse by another resident (#525). The deficient practice could result in residents being abused by other residents or staff.Findings include:A facility 5-day incident report, dated April 17, 2023, revealed that on April 9, 2023 at 10:55 p.m. Resident #525 was overheard by a Licensed Practical Nurse (LPN/staff #64) and a Certified Nursing Assistant (CNA/staff #801), using obscenities including the racial profanity nigger towards Resident #600. The facility report included that the abuse was substantiated, resulting in no injury.-Resident #525 (alleged perpetrator):Resident #525 was originally admitted on [DATE] with diagnoses that included malnutrition, hemorrhagic telangiectasia, anxiety disorder, blindness in one eye, and insufficient sleep syndrome. A Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated normal cognition. The assessment also revealed that no behaviors physical or verbal directed toward others had occurred in 1-6 days during the assessment.A Daily Skilled progress note dated April 9, 2023 revealed that the resident was alert and oriented x 3, with no active symptoms or treatments effecting mood or behavior. However, the note included that Resident #525 yelled obscenities at the roommate (Resident #600), was redirected, and proceeded to call the roommate a nigger.-Resident #600 (alleged victim): Resident #600 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, asthma, and depression.A quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated normal cognition.Review of progress notes revealed no evidence regarding the altercation that occurred on April 9, 2023.An interview was conducted on March 4, 2026 at 2:44 pm with an LPN (staff #64), who witnessed the incident that occurred on April 9, 2023. She stated that verbal abuse included yelling, cursing and racial/prejudice remarks. She further stated that the incident included a racial slur toward Resident #600 by Resident #525, who was prejudice.An interview was conducted on March 5, 2026 at 12:30 pm with the Assistant Director of Nursing (ADON/staff #83), who stated that verbal abuse included yelling, profanities, and racial slurs. She further stated that when verbal abuse occurs the residents are separate and the incident is reported to the Abuse Coordinator. The ADON stated that this incident occurred prior to her employment at the facility.An interview was conducted with the Executive Director (ED)/Abuse Coordinator (staff #19), who stated that he expected abuse allegations to be reported immediately. He further stated that verbal abuse included name calling and racial slurs that could cause distress to residents if the person receiving takes offense. The ED/Abuse Coordinator reviewed the facility 5-day report and stated that Resident #525 used colorful language toward Resident #600 that included racial verbiage. The ED/Abuse Coordinator stated that Resident #525 was moved into another room the next day, and there were no reports of any more incidents. The ED/Abuse Coordinator also stated both residents declined to be interviewed, and neither wanted to talk about the incident. The ED/Abuse Coordinator also stated that the facility investigation substantiated the verbal abuse.A policy titled, Abuse: Prevention of and Prohibition Against, revised/reviewed October 2025, revealed that it is the policy of the facility that each resident has the right to be free from abuse. Nursing home residents have a right to be free from verbal, sexual, physical and mental abuse. The policy included that willful abuse means the individual must have acted deliberately. Verbal abuse includes the use of oral or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of age, ability to comprehend, or disability.A policy titled, Resident Rights, revealed that the resident has the right to be free from verbal abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, review of facility documentation and policy and procedures, the facility failed to ensure medications administered to 1 of 3 sampled residents (#20) had physician orders. The census was 101. The deficient practice resulted in resident hospitalization due to a change in resident's condition.Findings include:Resident #20 was admitted [DATE] with diagnoses of metabolic encephalopathy, essential tremor, epilepsy, dementia, spinal stenosis, cognitive communication deficit and syncope and collapse.The history & physical note dated January 12, 2026 included the resident was admitted at the facility for inpatient rehabilitation; and that, all medications were reviewed and reconciled. Assessments included history of TIA (transient ischemic attack); muscle weakness and seizure disorder. Medications included Primidone.A care plan initiated on January 13, 2026, revealed a focus on the resident having hypertension with interventions to give antihypertensive medications as ordered and monitor for side effects such as hypotension and increased heart rate.The eMAR (electronic medication administration record) notes dated January 13, 2026 revealed that prescribed medications for Resident #20 was documented as administered as ordered by a Registered Nurse (RN/Staff #46) on January 13, 2026.The physician order summary report active as of January 16, 2026 included the following medications:Acidophilus (Lactobacillus-probiotics), 1 tablet by mouth one time a day for probioticB-complex w/biotin & folic acid (supplement), 1 tablet by mouth one time a day for supplementClopidogrel bisulfate (antiplatelet) 75 mg (milligrams)1 tablet by mouth one time a day for a history of transient ischemic attackFluconazole (antifungal) 200 mg 1 tablet by mouth one time a day for toe infectionLoratadine (antihistamine) 10 mg 1 tablet by mouth one time a day for allergiesMultivitamin (supplement) 1 tablet by mouth once a day for supplementPolyethylene glycol (laxative)3350 powder 17 grams by mouth daily for bowel regimenPropranolol (beta-blocker) ER (extended release) 120 mg, 1 capsule by mouth one time a day for hypertensionFluticasone propionate (synthetic corticosteroid) nasal suspension, 50 mcg (microgram)/Act (activation) 1 spray in both nostrils every 12 hours for allergiesLamotrigine (anticonvulsant) 100 mg 1 tablet by mouth every 12 hours for seizuresAcetaminophen (analgesic) 1000 mg by mouth every 8 hours for chronic painHeparin (anticoagulant) 5000 unit/ml (milliliter), inject 5000 unit subcutaneously every 8 hours for deep vein thrombosis prophylaxisReview of the clinical record revealed documentation that prescribed medications for Resident #20 were administered as ordered on January 16, 2026A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. Per the assessment, the resident was taking anticoagulants, antiplatelets and anticoagulants with 4 medications being received through injections.A nursing progress note dated January 16, 2026, at 4:00 p.m. included that the resident's family arrived to visit and found the resident #20 slumped over in her chair. It also included that the nurse assessed the resident and noted that the resident did not respond to verbal cues but did respond to physical stimulation. Per the documentation, the resident was unable to state her birthday, the current year, or her location; and, the only question resident could answer was the name of her family. Further, the documentation included that the resident's eyes rolled back while speaking and that the resident fell asleep immediately afterward. According to the documentation, the resident's BP (blood pressure) was 162/81 and the provider was notified. Further, the note included an instruction to send the resident out due to a change in condition.A nursing progress note dated January 16, 2026 at 10:41 p.m. revealed that the resident's family notified the facility that the resident was being admitted to the hospital for observation related to elevated blood pressure.A review of an undated handwritten document written by the License Practical Nurse (LPN/Staff #7) revealed a list of medications of another resident that were given to Resident #20 included the following:-Amiodarone (antiarrhythmic) 200 mg;-Aripiprazole (antipsychotic) 5 mg;-Aspirin (non-steroidal anti-inflammatory) 325 mg;-Citalopram (antidepressant) 40 mg;-Apixaban (direct-acting anticoagulant) 2.5 mg;-Ferrous sulfate (supplement) 325 mg;-Folic acid (supplement) 1 mg;-Lasix (diuretic) 40 mg;-Midodrine (antihypotensive) 10 mg;-Multivitamin with minerals (supplement);-Potassium (supplement) ER 20 mEq (milliequivalent);-Vitamin B12 (supplement) 1000 mcg; and,-Vitamin D3 (supplement) 1000 IU (international units).The clinical record revealed no evidence that Resident #20 had physician orders for medications listed in the handwritten document and documented as administered to her, including amiodarone, aripiprazole, aspirin, citalopram, apixaban, ferrous sulfate, folic acid, Lasix, midodrine, a multivitamin with minerals, potassium ER, vitamin B12, or vitamin D3.Continued review of an undated handwritten document showed a list of morning vital signs documented as prior to event, including a blood pressure of 140/72, pulse of 73, oxygen saturation of 93, respirations of 18, and a temperature of 98 degrees. The documentation indicated that the onsite provider was notified at 12:14 p.m.; the resident, who did not understand at all and was alert and oriented x2ish, was notified at 12:20 p.m.; and, the resident's family, who was described as very angry and requested a list of medications given to Resident #20, was notified at 1:43 p.m. According to the documentation, the physician instructed staff to hold the resident's heparin and propranolol for 24 hours and to monitor vital signs every hour until midnight, then every four hours; and that the monitoring sheet was provided to the CNAs (certified nursing assistants).An undated typewritten facility investigation revealed that on January 16, at approximately 12:10 p.m., the registered nurse (RN/staff #46) and Physical Therapy Assistant (PTA/Staff #57) informed Licensed Practical Nurse (LPN/Staff#7) that Resident #20 was given several medications that were prescribed for a different resident. Per the documentation, the resident reported that she took her medications when she was informed that the nurse had given her additional medications that were not ordered for her. It also included that the resident was leaning to the side and was not responsive to verbal cues, but was responsive to physical stimuli at 4:00 p.m., when the resident's family arrived; and that vital signs were taken and revealed the resident had elevated BP. The documentation included that the provider was notified and orders were received to send Resident #20 to the emergency room; and that, later that evening, the resident's family informed the facility that Resident #20 was admitted for observation for her elevated blood pressure. Further, the documentation included that a follow-up with the hospital on January 21, 2026, confirmed that Resident #20 was still in the hospital and had an admitting diagnosis of unintentional use of medication and pneumonia.A phone interview with the family of Resident #20 was conducted on January 21, 2026, at 1:00 p.m. The family stated that on January 16, 2026, at around 1:45. p.m., the resident's nurse called and informed her that another nurse had gone into the therapy area and asked which therapist was working with another resident. The family said that she was told that the therapist who was working with Resident #20 told the nurse that he had Resident #20, and that the nurse gave the medications to Resident #20 instead of the other resident. The family said the nurse told her the doctor was onsite and staff were monitoring Resident #20, but staff did not immediately inform her which medications were given to Resident #20 or that the resident's vital signs were abnormal. She stated that, eventually, the facility gave her a list of the medications shortly after she arrived at the facility that day. The family stated that when she arrived at the facility, Resident #20 was slumped over in her wheelchair, and there were no staff in the room with the resident. The family said that she immediately left the room to call for help and was able to get the LPN (staff #64) to assess and ask the resident questions. She stated that within a minute, the LPN decided to call the ambulance, and the facility sent Resident #20 to the emergency room by 4:00 p.m. Further, the family said that the blood pressure of Resident #20 skyrocketed, and the resident could not lift her head. The family also said that Resident #20 was given medications to treat schizophrenia.A phone interview was conducted on January 21, 2026, at 1:13 p.m. with an LPN (staff#64) who stated that she was scheduled to start the evening shift at 2:00 p.m. on the day of the incident and learned about the incident during shift change. She said that she was told that a nurse from another hall was going to administer medications to another resident who was not in her room, so the nurse went to the therapy room to locate the resident. The LPN stated she did not know how the nurse identified the resident, but the nurse asked Resident #20 if she was the other resident, and Resident #20 responded yes. The LPN stated that the therapist later informed the nurse that the medication had been given to the wrong resident. She reported that she asked the CNAs for the vital sign monitoring sheet, and that blood pressure and heart rate checks were initiated. According to the LPN, the resident's blood pressure increased slightly with each hourly check. The LPN stated that at approximately 3:30 p.m., while she was administering medications in another room, the family of Resident #20 arrived and asked why the resident was slumped over in her wheelchair. The LPN reported that she went to the resident's room and saw Resident #20 slumped over in her wheelchair and unable to lift her head. She stated that she reassessed the resident's vital signs and noted that the resident was not coherent, stated her birthday as October 25, 2025, and had eyes rolling back. The LPN stated that she contacted the physician, who ordered the resident to be sent to the hospital due to a change in condition and had a BP reading of 162/81.An interview was conducted with another LPN (Staff #7) on January 21, 2026, at 1:35 p.m. The LPN stated that when administering medications, she verifies the resident's name, date of birth , and photo in the electronic medical record and follows the medication rights, including the right medication, right patient, right time, and right route. She stated that she was Resident #20's nurse and that during the Friday day shift, she administered the correct medications to the resident. The LPN reported that later that morning, a nurse from another hall informed her that medications intended for Resident #61 had been administered to Resident #20. She stated that she then contacted the physician who was onsite, reviewed all medications the resident had received with the physician, and obtained the resident's vital signs before notifying the resident, the family, and the Director of Nursing (Staff #27). The LPN stated that the medication error occurred at approximately 12:10 p.m. while the resident was in therapy. She said the nurse who administered the incorrect medications reported verifying the resident's name with both resident #20 and the therapist present in the therapy room. The LPN stated that the physician instructed staff to hold Resident #20's heparin and propranolol the following day so the resident could be monitored.An interview with the Director of Nursing (DON/Staff #7) was conducted on January 21, 2026, at 2:28 p.m. The DON stated that nursing staff were expected to prepare and verify medications according to the physician's orders, confirm the correct resident, and sign the electronic medication administration record (eMAR) after administering medications. She stated that resident identification may be verified by asking the resident their name and date of birth , checking the door tag, and using the resident's photo in the electronic medical record. The DON stated that when medications were administered in error, nurses were expected to immediately observe the resident, notify the provider with a list of the medications given in error, obtain monitoring orders, and notify the resident and the responsible party. She also said that receiving incorrect medications could result in various health outcomes, including hospitalization or the resident receiving medications for conditions they do not have. Regarding Resident #20, the DON stated that the resident received medications prescribed for Resident #61 while participating in a group therapy session. She said that the RN (staff #46) entered the therapy gym looking for the other resident, and the therapist working with Resident #20 told the RN (staff #46) that he had the other resident. The DON stated that Resident #20 also identified herself as the other resident, and the RN (staff #46) administered the medications to Resident #20. The DON said that after the therapy session, the therapist realized the error and informed the RN (staff #46) that he had been working with Resident #20, not the other resident. The DON stated that a nurse then took Resident #20's vital signs, contacted the provider, and notified Resident #20's assigned nurse. She reported that the resident's vital signs were stable for the first few hours; however, later the resident's blood pressure increased, and the resident became slumped over in her chair, requiring staff to support her head to obtain a response. The DON stated that although the blood pressure was not critically high, the decision was made to send Resident #20 to the hospital due to the medication error.A phone interview was conducted on January 21, 2026, at 2:46 p.m. with a registered nurse (RN, Staff #46) who administered medications of another resident to Resident #20. The RN stated that when administering medications, she checks the medications due and verifies the correct medication, dose, time, and resident. She said that she was the nurse for another resident on the day of the incident when the medication error occurred involving Resident #20. The RN stated that she had never worked on the other resident's hall before and had only seen Resident #20 once previously. She reported that she reviewed the other resident's chart, prepared the other resident's medications, and went to administer them, but the other resident was not in her room. The RN stated that she then went to the therapy gym and asked therapists to locate the other resident. According to the RN, a therapist stated that he had the other resident, and Resident #20 also told the RN that she was the other resident. The RN then administered the medications to Resident #20. The RN stated that approximately 20 to 40 minutes later, the therapist informed her that the medications had been given to the wrong resident and apologized, explaining that he was assigned to both Resident #20 and the other resident. The RN stated that she immediately reported the error to the Director of Nursing, the LPN (Staff #7), and the provider (Staff #15). She further stated that she stayed after her shift to complete documentation and heard the ambulance arrive to transport Resident #20 to the hospital. The RN stated that the potential risks of administering medications to the wrong resident range from medication side effects to death.A phone interview was conducted on January 21, 2026, at 2:56 p.m. with a physical therapist assistant (PTA/Staff #57) who stated that he had not met Resident #20 or the other resident prior to the day of the incident. He reported that on the day of the incident, Resident #20 was brought to the therapy gym for scheduled services. The PTA stated that he introduced himself to the resident and reviewed the resident's level of functioning through a chart review. The PTA stated that the RN (Staff #46) entered the therapy gym looking for the other resident, and he told the RN that he had the other resident. He stated that he should have taken more time to verify the resident's identity, but believed the resident he was working with was the other resident. The PTA reported that the RN then administered the other resident's medications to Resident #20. The PTA stated that it was not until he was escorting Resident #20 back to her room that he realized the medications had been given to the wrong resident. He reported that he immediately informed the RN (Staff #46) and the Director of Nursing (Staff #7) of the error.Review of a policy titled, Medication Administration - Oral, with a review date of April 2025, revealed that it was their policy to accurately prepare, administer, and document oral medications. Essential points of the policy included that no medication was to be administered without a physician's order, and the resident must be identified before administering any medications.Review of a policy titled, Quality of Care, with a review date of May 2025, included that it is their policy that residents would be given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, review of facility documentation and policy and procedures, the facility failed to ensure 1 of 3 sampled residents (#20) was free from a significant medication error. The deficient practice could result in harm to the resident.Findings include:Resident #20 was admitted [DATE] with diagnoses of metabolic encephalopathy, essential tremor, epilepsy, dementia, spinal stenosis, cognitive communication deficit and syncope and collapse.The physician order summary report active as of January 16, 2026 included the following medications:Acidophilus (Lactobacillus-probiotics), 1 tablet by mouth one time a day for probioticB-complex w/biotin & folic acid (supplement), 1 tablet by mouth one time a day for supplementClopidogrel bisulfate (antiplatelet) 75 mg (milligrams)1 tablet by mouth one time a day for a history of transient ischemic attackFluconazole (antifungal) 200 mg 1 tablet by mouth one time a day for toe infectionLoratadine (antihistamine) 10 mg 1 tablet by mouth one time a day for allergiesMultivitamin (supplement) 1 tablet by mouth once a day for supplementPolyethylene glycol (laxative)3350 powder 17 grams by mouth daily for bowel regimenPropranolol (beta-blocker) ER (extended release) 120 mg, 1 capsule by mouth one time a day for hypertensionFluticasone propionate (synthetic corticosteroid) nasal suspension, 50 mcg (microgram)/Act (activation) 1 spray in both nostrils every 12 hours for allergiesLamotrigine (anticonvulsant) 100 mg 1 tablet by mouth every 12 hours for seizuresAcetaminophen (analgesic) 1000 mg by mouth every 8 hours for chronic painHeparin (anticoagulant) 5000 unit/ml (milliliter), inject 5000 unit subcutaneously every 8 hours for deep vein thrombosis prophylaxisThese medications were transcribed onto the MAR (medication administration record) for January 2026. Review of the MAR revealed documentation that these medications were administered as ordered.A nursing progress note dated January 16, 2026, at 4:00 p.m. included that the resident's family arrived to visit and found the resident #20 slumped over in her chair. It also included that the nurse assessed the resident and noted that the resident did not respond to verbal cues but did respond to physical stimulation. Per the documentation, the resident was unable to state her birthday, the current year, or her location; and, the only question resident could answer was the name of her family. Further, the documentation included that the resident's eyes rolled back while speaking and that the resident fell asleep immediately afterward. According to the documentation, the resident's BP (blood pressure) was 162/81 and the provider was notified. Further, the note included an instruction to send the resident out due to a change in condition.A nursing progress note dated January 16, 2026 at 10:41 p.m. revealed that the resident's family notified the facility that the resident was being admitted to the hospital for observation related to elevated blood pressure.A review of an undated handwritten document written by the License Practical Nurse (LPN/Staff #7) revealed a list of medications of another resident that was given to Resident #20 included the following:Amiodarone (antiarrhythmic) 200 mg;Aripiprazole (antipsychotic) 5 mg;Aspirin (non-steroidal anti-inflammatory) 325 mg;Citalopram (antidepressant) 40 mg;Apixaban (direct acting anticoagulant) 2.5 mg;Ferrous sulfate (supplement) 325 mg;Folic acid (supplement) 1 mg;Lasix (diuretic) 40 mg;Midodrine (antihypotensive) 10 mg;Multivitamin with minerals (supplement);Potassium (supplement) ER 20 mEq (milliequivalent);Vitamin B12 (supplement) 1000 mcg; and,Vitamin D3 (supplement) 1000 IU (international units).However, review of the clinical record revealed no evidence that Resident #20 had physician orders for the following medications administered to Resident #20 and listed in the handwritten document: amiodarone, aripiprazole, aspirin, citalopram, apixaban, ferrous sulfate, folic acid, Lasix, midodrine, a multivitamin with minerals, potassium ER, vitamin B12, or vitamin D3.Continued review of an undated handwritten document showed a list of morning vital signs documented as prior to event, including a blood pressure of 140/72, pulse of 73, oxygen saturation of 93, respirations of 18, and a temperature of 98 degrees. The documentation indicated that the resident did not understand at all and was alert and oriented x2ish, when she was notified of the error at 12:20 p.m. An undated typewritten facility investigation revealed that on January 16, at approximately 12:10 p.m., the registered nurse (RN/staff #46) and Physical Therapy Assistant (PTA/Staff #57), informed Licensed Practical Nurse (LPN/Staff#7), that Resident #20 was given several medications that were prescribed for a different resident. Per the documentation, the resident reported that she took her medications when she was informed that the nurse gave her additional medications that were not ordered for her. It also included that the resident was leaning to the side and was not responsive to verbal cues, but was responsive to physical stimuli at 4:00 p.m., when the resident's family arrived; and that, vital signs were taken and revealed resident had elevated BP. The documentation included that the provider was notified and orders were received to send Resident #20 to the emergency room; and that, later that evening, the resident's family informed the facility that Resident #20 was admitted for observation for her elevated blood pressure. Further, the documentation included that a follow-up with the hospital on January 21, 2026 confirmed that Resident #20 was still in the hospital; and, had an admitting diagnosis of unintentional use of medication and pneumonia.A phone interview with the family of Resident #20 was conducted on January 21, 2026 at 1:00 p.m. The family stated that on January 16, 2026 at around 1:45. p.m., the resident's nurse called and informed her that another nurse went into the therapy area and asked which therapist was working with another resident. The family said that she was told that the therapist who was working with Resident #20 told the nurse that he had Resident #20; and that, the nurse gave the medications to Resident #20 instead of the other resident. The family said the nurse told her the doctor was onsite and staff were monitoring Resident #20; but, staff did not immediately inform her which medications were given to Resident #20 or that the resident's vital signs were abnormal. She stated that eventually the facility gave her a list of the medications shortly after she arrived at the facility that day. The family stated that when she arrived at the facility, Resident #20 was slumped over in her wheelchair and there were no staff in the room with the resident. The family said that she immediately left the room to call for help and was able to get the LPN (staff #64) to assess and ask the resident questions. She stated that within a minute, the LPN decided to call the ambulance; and the facility sent Resident #20 to the emergency room by 4:00 p.m. Further, the family said that the blood pressure of Resident #20 skyrocketed; and the resident could not lift her head. The family also said that Resident #20 was given medications to treat schizophrenia.A phone interview was conducted on January 21, 2026 at 1:13 p.m. with a LPN (staff#64) who stated that she was scheduled to start the evening shift at 2:00 p.m. on the day of the incident and learned about the incident during shift change. She said that she was told that a nurse from another hall was going to administer medications to another resident who was not in her room, so the nurse went to the therapy room to locate the resident. The LPN stated she did not know how the nurse identified the resident, but the nurse asked Resident #20 if she was the other resident and Resident #20 responded yes. The LPN stated that the therapist later informed the nurse that the medication had been given to the wrong resident. She reported that she asked the CNAs for the vital sign monitoring sheet, and that blood pressure and heart rate checks were initiated. According to the LPN, the resident's blood pressure increased slightly with each hourly check. The LPN stated that at approximately 3:30 p.m., while she was administering medications in another room, the family of Resident #20 arrived and asked why the resident was slumped over in her wheelchair. The LPN reported that she went to the resident's room and saw Resident #20 slumped over in her wheelchair and unable to lift her head. She stated that she reassessed the resident's vital signs and noted that the resident was not coherent, stated her birthday as October 25, 2025, and had eyes rolling back. The LPN stated that she contacted the physician, who ordered the resident to be sent to the hospital due to a change in condition and had a BP reading of 162/81.An interview was conducted with another LPN (Staff #7) on January 21, 2026, at 1:35 p.m. The LPN stated that when administering medications, she verifies the resident's name, date of birth , and photo in the electronic medical record and follows the medication rights, including the right medication, right patient, right time, and right route. She stated that she was Resident #20's nurse and that during the Friday day shift she administered the correct medications to the resident. The LPN reported that later that morning, a nurse from another hall informed her that medications intended for another resident had been administered to Resident #20. She stated that she then contacted the physician who was onsite, reviewed all medications the resident had received with the physician, and obtained the resident's vital signs before notifying the resident, the family, and the Director of Nursing (Staff #27). The LPN stated that the medication error occurred at approximately 12:10 p.m. while the resident was in therapy. She said the nurse who administered the incorrect medications reported verifying the resident's name with both resident #20 and the therapist present in the therapy room. The LPN stated that the physician instructed staff to hold Resident #20's heparin and propranolol the following day so the resident could be monitored.An interview with the Director of Nursing (DON/Staff #7) was conducted on January 21, 2026, at 2:28 p.m. The DON stated that nursing staff were expected to prepare and verify medications according to the physician's orders, confirm the correct resident, and sign the electronic medication administration record (eMAR) after administering medications. She stated that resident identification may be verified by asking the resident their name and date of birth , checking the door tag, and using the resident's photo in the electronic medical record. The DON stated that when medications are administered in error, nurses were expected to immediately observe the resident, notify the provider with a list of the medications given in error, obtain monitoring orders, and notify the resident and the responsible party. She also said that receiving incorrect medications could result in various health outcomes, including hospitalization or the resident receiving medications for conditions they do not have. Regarding Resident #20, the DON stated that the resident received medications prescribed for Resident #61 while participating in a group therapy session. She said that the RN (staff #46) entered the therapy gym looking for the other resident, and the therapist working with Resident #20 told the RN (staff #46) that he had the other resident. The DON stated that Resident #20 also identified herself as the other resident, and the RN (staff #46) administered the medications to Resident #20. The DON said that after the therapy session, the therapist realized the error and informed the RN (staff #46) that he had been working with Resident #20, not the other resident. The DON stated that a nurse then took Resident #20's vital signs, contacted the provider, and notified Resident #20's assigned nurse. She reported that the resident's vital signs were stable for the first few hours; however, later the resident's blood pressure increased, and the resident became slumped over in her chair, requiring staff to support her head to obtain a response. The DON stated that although the blood pressure was not critically high, the decision was made to send Resident #20 to the hospital due to the medication error.A phone interview was conducted on January 21, 2026, at 2:46 p.m. with a registered nurse (RN, Staff #46) who administered medications of another resident to Resident #20. The RN stated that when administering medications, she checks the medications due and verifies the correct medication, dose, time, and resident. She said that she was the nurse for another resident on the day of the incident when the medication error occurred involving Resident #20. The RN stated that she had never worked on the other resident's hall before and had only seen Resident #20 once previously. She reported that she reviewed the other resident's chart, prepared the other resident's medications, and went to administer them, but the other resident was not in her room. The RN stated that she then went to the therapy gym and asked therapists to locate the other resident. According to the RN, a therapist stated that he had the other resident, and Resident #20 also told the RN that she was the other resident. The RN then administered the medications to Resident #20. The RN stated that approximately 20 to 40 minutes later, the therapist informed her that the medications had been given to the wrong resident and apologized, explaining that he was assigned to both Resident #20 and the other resident. The RN stated that she immediately reported the error to the Director of Nursing, the LPN (Staff #7), and the provider (Staff #15). She further stated that she stayed after her shift to complete documentation and heard the ambulance arrive to transport Resident #20 to the hospital. The RN stated that the potential risks of administering medications to the wrong resident range from medication side effects to death.A phone interview was conducted on January 21, 2026, at 2:56 p.m. with a physical therapist assistant (PTA/Staff #57). The PTA stated that he had not met Resident #20 or the other resident prior to the day of the incident. He reported that on the day of the incident, Resident #20 was brought to the therapy gym for scheduled services. The PTA stated that he introduced himself to the resident and reviewed the resident's level of functioning through a chart review. The PTA stated that the RN (Staff #46) entered the therapy gym looking for the other resident, and he told the RN that he had the other resident. He stated that he should have taken more time to verify the resident's identity but believed the resident he was working with was the other resident. The PTA reported that the RN then administered the other resident's medications to Resident #20. The PTA stated that it was not until he was escorting Resident #20 back to her room that he realized the medications had been given to the wrong resident. He reported that he immediately informed the RN (Staff #46) and the Director of Nursing (Staff #7) of the error.Review of a policy titled, Medication Administration - Oral, with a review date of April 2025 revealed that it was their policy to accurately prepare, administer, and document oral medications. Essential points of the policy included that no medication was to be administered without a physician's order, and the resident must be identified before administering any medications.

Based on review of facility documentation and staff interview, the facility failed to ensure that nurse staffing information was posted on a daily basis that included the actual hours worked by licensed and unlicensed nursing staff and the resident census.
Findings include:
An interview was conducted on 2/2/2024 at 12:36 PM with the Staffing Coordinator (staff #18) who said daily staff postings should be accurate. She said that that she gets the numbers from the daily staff tracking form so staff must have left early or late that day. She reviewed the posting for 12/30/2023 and said that it was not accurate.
An interview was conducted on 2/2/2024 at 12:56 PM with the Director of Nursing (DON/staff#13) who said that daily staff postings should be accurate. She said that she'd have to assume that their numbers are accurate but she would have to double check.
An interview was conducted on 2/2/2024 at 1:31 PM with the Administrator (staff #115) who said that he did not know if there was a policy regarding the accuracy of staff postings and that he would check with the Director of Nursing.
A follow up interview conducted on 2/2/2024 at 1:56 PM with the DON included that the facility does not have a policy regarding the accuracy of staff postings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that oxygen was administered per physician orders for one resident (#12). The sample size was 20.
Findings include:
The resident was admitted on [DATE] with diagnosis including anxiety disorder, unspecified dementia, psychotic disturbance, mood disturbance , anxiety, depression, schizophrenia, acute respiratory failure with hypoxia, pleural effusion, other non specific findings of the lung field, pneumonia, chronic obstructive pulmonary disease and a wedge compression fracture.
A review of the MDS (minimum data set) dated December 07, 2023 revealed that the resident had a BIMS (brief interview of mental status) score of 14, indicating that the resident was cognitively intact. The MDS further noted that the resident was on oxygen therapy.
A review of the of the physician's orders dated January 2, 2024 for resident #12 revealed an order for 4 liters of oxygen per minute via nasal cannula. An update to the orders was made on January 30, 2024 at 2:00 PM noting oxygen via nasal cannula for chronic obstructive pulmonary disease and may citrate to keep oxygen saturation (SP02) levels at or above 90%
A review of the resident's care plan initiated on December 29, 2019 revealed a focus that resident #12 has emphysema, and chronic obstructive pulmonary disease and the included intervention that oxygen therapy is to be given as ordered by the physician. Furthermore, the care plan revealed that the resident has oxygen therapy and that the oxygen settings were noted to be at 5 liters per minute continuously via nasal cannula; however, oxygen was observed to be above the ordered liters per minute and above the documented care plan rate for resident #12.
An observation on January 30, 2024 at 9:52 AM revealed that resident #12 was observed to be on 6 liters of oxygen as observed on the oxygen concentrator setting.
An observation on January 30, 2024 at 12:26 PM revealed that resident #12 was still on 6 liters of oxygen.
An interview was conducted on January 30, 2024 at 12:26 P.M. with staff #70 LPN (Licensed Practical Nurse). Staff #70 stated that oxygen settings were as ordered by the physician. She further stated that oxygen settings are checked during rounding every 2 hours. She stated that oxygen setting for resident #12 should be at 4 liters per minute. She stated that the risk for settings outside of the parameters that the physician had established could impact the gas exchange and could impede the resident's breathing.
An interview was conducted with staff #13, DON (Director of Nursing) on January 30, 2024 at 12:40 PM Staff #13 stated that some patients, depending on the physician's order, may have settings designated on a range to maintain oxygen at a certain level. She stated that the nurse assigned to the resident, is required to sign off on the oxygen order every shift. Staff #13 reviewed the medical record for resident #12 and stated that the orders for this resident are at 4 liters per minute. She stated that the expectation is to ensure that the oxygen orders established by the physician are followed. Staff #13 stated that the risk could be that the resident may not get enough oxygen and that the resident's oxygenation could be impeded.
A review of the oxygen administration policy with a review date of May 2023 revealed that oxygen therapy is administered by a licensed nurse as ordered by the physician; however, the oxygen therapy settings observed on 2 separate occasions were not as ordered by the physician and noted to be 2 liters above the ordered setting. It was however observed that the facility did have the order changed on the same day the concern was brought to their attention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interviews, and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for one resident (#24). The sample size was 4. The deficient practice could result in residents being at risk for potential nutritional decline.
Findings include:
Resident #24 was admitted to the facility on [DATE] with diagnoses that included unspecified protein-calorie malnutrition, respiratory failure, hemiplegia and hemiparesis following cerebral infarction, dysphagia and muscle weakness.
A care plan initiated on April 14, 2022 included a problem for moderate malnutrition related to acute illness. The care plan goals stated resident #24 will maintain adequate nutritional status as evidenced by maintaining weight with no signs and symptoms of malnutrition. The intervention included the RD (registered dietician) evaluating and making diet changes recommendations as needed; supplement; and weekly weights for 4 weeks and then monthly if stable.
Review of the weight summary dated April 14, 2022 at 9:29 p.m. stated the resident weighed 135 pounds.
Review of physician's progress notes dated April 19, 2022 at 8:06 p.m. stated the resident was resting comfortably and stated he is still hungry after eating meals.
Review of physician's progress notes dated April 24, 2022 at 3:27 p.m. stated the resident was resting comfortably and asking for second portions for the lunch meal.
Review of physician's progress notes dated May 4, 2022 at 1:49 p.m. included the resident stating that he is hungry.
Review of Speech Therapy notes dated May 4, 2022 stated recommended MBSS (modified barium swallow study) to further assess safest diet, appropriate for PO (by mouth) versus PEG (percutaneous endoscopic gastrostomy) due to continued coughing and difficulty with carryover of safe swallow instructions. The note stated the MBSS was discussed with nursing, and currently waiting scheduling of an appointment.
Review of a LN-Nutrition Interdisciplinary Team Update form dated May 9, 2022 revealed SLP (speech language pathologist) reported the resident continues to struggle even with thickened liquids, awaiting barium swallow to determine next steps.
Review of speech therapy notes dated June 3, 2022 stated pending scheduling for MBSS to analyze most appropriate diet and possible need for alternate nutrition plan, pending as of April 27, 2022.
Continued review of the clinical record revealed no evidence of MBSS follow-up regarding the safest diet for the resident or evidence the resident was offered additional snacks or food items to meet resident #24's complaints.
Review of the clinical record did not reveal another weight for the resident until July 20, 2022 at 1:53 p.m. Resident #24 weighed 111 pounds; a weight loss of 17% in 13 weeks.
A quarterly MDS (minimum data set) assessment dated [DATE] revealed resident #24 BIMS (brief interview of mental status) score was 14, which indicated intact cognition. The MDS assessment stated the resident needed extensive assistance with eating, and had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, and was not on physician-prescribed weight loss regimen.
The weight summary revealed that on October 9, 2022 at 10:26 p.m., the resident's weight was 112 pounds, a weight loss of 17% in about 6 months.
A physician order dated October 10, 2022 revealed an order for a regular diet, pureed texture, nectar thick consistency fluids, and feeding assistance.
A lunch observation was conducted on October 12, 2022 at 12:40 p.m. Resident #24 was in his room seated in the wheelchair, with a lunch tray placed on a bedside table in front of the resident. An SLP was observed assisting resident #24 1:1 with the meal. Resident #24 was observed reaching for the spoon when he wanted the next bites. The SLP (staff #39) stated the resident has a good appetite, but has poor safety awareness. The SLP stated resident #24 takes too much food at once and drinks regular water from the sink at times, that is why the resident has to have assistance with meals.
A follow up interview was conducted on October 12, 2022 at 2:24 p.m. with SLP (staff #39), who stated she was familiar with resident #24. Staff #39 stated on October 10, 2022, she evaluated resident #24's BIMS and scored 15/15, which indicated the resident's cognition was intact. Staff #39 stated the resident has no carry through, he does not have recall overtime, very impulsive, and no safety awareness. Staff #39 stated resident #24 was food seeking, but has ataxic dyskinesia, which causes abnormal movement and impacts the resident ability to swallow, making the resident a very high aspiration risk. Staff #39 stated she requested an MBSS April 2022, and also recommended tube feeding during the last admission to the case manager.
An interview was conducted on October 14, 2022 at 10:41 a.m. with resident #24. Resident #24 stated he has a good appetite and he can eat just about anything. The resident stated most of the time he is still hungry, and that he has not been offered any snacks or fluids in between meals. The resident stated he asked the staff for snacks or fluids, that sometimes the staff brings it and sometimes the staff would not come back. He stated he is constantly craving for more food. The resident stated he lost a lot of weight and it bothers him. The resident stated no staff in the facility has discussed alternative ways of keeping his weight including tube feeding and that he would not mind it if it will help him gain some weight back.
An interview was conducted on October 14, 2022 with the director of nursing (DON/ staff #26), who stated a newly admitted resident is weighed upon admission, then weekly for 4 weeks, then monthly thereafter. Staff #26 stated she did not know why resident #24 was not weighed again until July 2022. The DON stated she does not recall anything about the MBSS, and that she has to access the record. Regarding resident #24 weight loss from April 14, 2022 through July 20, 2022 and no implementation of interventions to address the weight loss, the DON only stated ok.
A facility policy, Nutrition, stated it is the policy of the facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Each resident is to be weighed upon admission, weekly weights for four (4) weeks and monthly weight thereafter unless otherwise specified by the attending physician. The weight will be entered into the resident's clinical record. Once the resident has been evaluated for nutrition status, the Registered Dietitian, Dietary Technician and/or designee will determine if there is a significant change in the resident's condition. If so, additional nutritional interventions will be offered to those residents. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team to determine the cause of weight loss/gain, interventions required and need for further recommendations and/or referral.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documentation, the facility failed to ensure one resident (#397) signed and was issued a written Notice of Medicare Non-Coverage (NOMNC) when there was an ending of Medicare services. The sample size was 3. The deficient practice could result in residents not being informed of their potential liability for payment.
Findings include:
Resident #397 was admitted [DATE], with diagnoses that included unspecified fracture of left femur, muscle weakness, and difficulty walking. The resident was discharged [DATE].
The admission Minimum Data Set assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact.
Review of the resident's face sheet revealed the resident was the financially responsible party.
A weekly skilled nursing note dated April 20, 2022 indicated the resident was discharge ready and that the NOMNC was to be issued. Discharge was set for April 27, 2022.
Review of a weekly skilled review note dated April 27, 2022 revealed the resident's previous NOMNC was rescinded since the provider had not wanted the resident to discharge yet due to changes in range in motion.
Review of the resident's clinical record and request for NOMNC documentation did not reveal any completed NOMNC forms.
A nursing note dated April 30, 2022 stated the resident was discharged home, condition stable, voiced no issues or concerns. Personal belongings, medications and discharge instructions were given to the resident.
Review of Skilled Nursing Facility Beneficiary Protection Notification review forms presented to the facility for completion on October 11, 2022 revealed that the facility did not complete a NOMNC for resident #397. The facility indicated the reason as a clerical error and stated that copies were not found.
During an interview with the Social Service Director/Case Management (staff #5) conducted on October 13, 2022 at 10:04 a.m., she stated that she had only taken over the NOMNC process the previous week. Staff #5 stated that she issues NOMNC three days prior to a resident's scheduled discharge i.e. if the resident is discharging October 14, then that resident would have been issued the NOMNC on October 11. She stated that if the resident has Medicare, then the discharge is driven by therapy, determined by weekly skilled notes, and goes by estimated stay driven by therapy. She stated therapy then lets her know if the resident is discharge ready. She stated she would then print out the NOMNC and present it to the resident. She also stated the resident is informed about the appeal process, and if a resident decides to appeal, they cannot discharge the resident without a decision. Staff #5 stated the facility will provide the resident a financial responsibility form to inform them that they might have to pay out of pocket if the decision is not made before their last day of coverage. In regards to this resident, staff #5 stated that she is not sure what happened or if the resident was provided a NOMNC since she is new. She stated she also is not aware of what happens if the NOMNC is not provided. She could not find documentation regarding NOMNC completion for the resident. Staff #5 stated that since she took over the NOMNC process, she documents NOMNC in the resident's progress note. She also stated that she has a binder where she keeps a copy of the NOMNC as well as putting a copy on the drive so that Medical Records can upload into the resident's electronic record.
In an interview with the Director of Nursing (DON/staff #20) conducted on October 13, 2022 at 1:12 p.m., she stated that if a resident is not provided a NOMNC, it is an incomplete record or documentation. The DON stated that since it is a time-sensitive action, it is not something that can be corrected. The DON stated case management/social services are the ones that receive information about NOMNC.
Review of the facility's NOMNC process implemented on or about April 21, 2022, indicated that once it is determined that a NOMNC needs to be issued, the case manager (CM) determines if the resident can sign for themselves or if a Power of Attorney will need to sign the document. During the presentation of the NOMNC, the CM will explain what the notice entails, go over the last day of coverage, discharge date , and the appeal process. Once signed, a copy is given to the resident and another copy is sent to the Business Office and Medical Records for upload to the resident's record. The original is kept in the Medicare NOMNC binder located in the Social Services Office. The CM then documents this event on a progress note in the resident's record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and review of policy, the facility failed to ensure that Preadmission Screening and Resident Reviews (PASRR) were completed as required for 3 residents (#57, #34, and #41). The sample size was 3. The deficient practice increases the risk for residents being inappropriately placed into nursing facilities and/or not receiving the services they need.
Findings include:
-Resident #57 was readmitted to the facility on [DATE] with diagnoses that included osteomyelitis, acquired absence of right leg below the knee, and bipolar disorder.
Review of the Level 1 PASRR dated 03/06/21 indicated the resident did not have serious mental illness, including bipolar disorder.
Review of the clinical record revealed the resident was discharged from the facility on 12/03/21 and subsequently readmitted on [DATE].
The Level I PASRR evaluation dated 12/06/21 revealed the physician had certified before admission to the facility that the resident required 30 days or less of nursing facility services.
A behavior care plan dated 08/19/22 related to the potential to demonstrate physical behaviors had a goal to not harm self or others. Interventions stated to remove the resident from the situation and take the resident to an alternate location as needed.
The annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. According to the assessment, the resident demonstrated behavioral symptoms, including: physical behaviors directed towards others, verbal behaviors directed towards others, and other behavioral symptoms not directed towards others (e.g., hitting or scratching self, pacing, or public sexual acts) for 1 to 3 days out of the 7-day lookback period. The assessment indicated that the resident's behaviors significantly interfered with the resident's participation in activities or social interactions, put others at significant risk for injury, and significantly disrupted care or the living environment. According to the assessment, the resident's current behavior status was worse compared to the prior assessment.
However, review of the clinical record did not reveal the resident Level 1 PASRR had been updated or that a referral for Level II evaluation and/or services was done.
-Resident #34 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease with acute exacerbation, difficulty walking, and the need for assistance with personal care.
Review of the Level I PASRR screening completed 08/09/19 revealed the physician had certified before admission to the facility that the resident required 30 days or less of nursing facility services.
According to the discharge Minimum Data Set (MDS) records, the resident was discharged on 08/18/19 with return not anticipated.
The resident subsequently readmitted to the facility on [DATE]. However, there was no Level I PASRR associated with the readmission identified in the clinical record.
Review of the resident's diagnoses dated 12/18/19 revealed updates including anxiety disorder and major depressive disorder, recurrent, unspecified.
According to the discharge MDS assessment, the resident was discharged on 12/18/19 with return not anticipated.
Per the clinical record, the resident subsequently readmitted on [DATE]. However, there was no correlating Level I PASRR identified in the clinical record.
Per the resident's diagnoses information, the resident was diagnosed with schizoaffective disorder on 03/01/21. However, the resident's clinical record did not indicate that the resident had been referred to the state-designated authority for Level II PASRR evaluation and review.
The quarterly MDS assessment dated [DATE] revealed the resident scored 12 on the BIMS, indicating moderate cognitive impairment. The resident reported feeling tired or having little energy for 2 to 6 out of the 7-day lookback period. According to the assessment, the active diagnoses included anxiety disorder, depression, and schizophrenia.
On 10/14/22 at 10:06 a.m., an interview was conducted with the Director of Social Services (staff #5) and a Clinical Resource Nurse (staff #115). Staff #5 stated that she did not know when PASRR evaluations were completed. Staff #115 stated that PASRRs were completed before admission or upon admission. She stated that the hospital will typically complete the form. She stated that if the hospital did not complete the form, she thought that admissions would complete it. Staff #115 stated that the interdisciplinary team, case managers, and social services may also review for accuracy. She stated that accuracy and timeliness of assessments were her expectation.
An interview was conducted on 10/14/22 at 10:16 a.m. with the Director of Nursing (DON/staff #20). She stated that ideally, a PASRR will be sent from the hospital when the resident admits. The DON stated if not they will be screened at the facility. She stated that because the Director of Social Services was being trained, admissions complete the screening at this time. She stated that if the resident stays in the facility longer than 30 days, she believed another PASRR needed to be done. She stated that her expectation is that the documentation will be accurate and timely.
-Resident #41 was admitted to the facility on [DATE] with diagnoses that included generalized idiopathic epilepsy and epileptic syndromes, not intractable with status epilepticus, dysphagia, and anxiety disorder.
Review of the Level I PASRR dated 8/29/14 revealed the physician had certified the resident required 30 days or less of nursing facility services.
Review of the Level 1 PASRR dated 8/1/18 revealed a referral for Level II was not necessary.
Physician orders included the following medications:
-Valium Solution 5mg/ml, inject 5 mg intramuscularly as needed for seizure activity may repeat one more after 10 minutes. Ordered 8/1/2018.
-Lorazepam tablet 1 mg, give 1 tablet via G-Tube every 8 hours for anxiety as evidenced by restlessness. Ordered 8/3/2018
A PASRR care plan dated 4/6/2020 revealed focus: has a PASRR level 1 with no recommendations for a PASRR Level II referral. Goal: wishes to continue current activities and medication. Intervention: refer resident for a PASRR Level II if conditions change.
Review of the clinical record revealed resident #41 has a diagnosis Schizoaffective Disorder on 5/10/21.
However, the resident's clinical record did not reflect that a PASRR Level I was updated or PASRR Level II screening had been completed after resident #41 diagnosis with Schizoaffective Disorder.
The annual Minimum Data Set assessment dated [DATE] revealed the resident was rarely or never understood.
Review of the October 2022 Medication Administration Records revealed psychotropic medications were administered in accordance with the physician's orders.
In an interview conducted on 10/14/22 at 7:59 AM with the social services director (staff #5), she stated she does not do anything with PASRR personally. Staff #5 stated she only sees the PASRR from the hospital that the admission department gives to her. Staff #5 stated she did not know how to rate the levels for PASRR.
An interview was conducted with the DON (staff #20) on 10/14/22 at 9:53 AM. The DON stated she is unfamiliar with the process but every resident should have one. The DON stated if PASRR identifies additional services, it has to be requested. The DON stated resident #41 is pulled every year and PASRR was never discussed.
Review of the facility's PASRR Policy revised 5/2022 revealed the following: It is the policy of the facility to ensure that each resident is properly screened using the PASRR specified by the state.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review, review of facility documentation and policy and procedure, the facility failed to ensure that one resident (#191) who was unable to carry out activities of daily living (ADLs) received services to maintain good grooming. The sample size was 10. The deficient practice may result in residents with poor personal hygiene.
Findings include:
Resident #191 admitted to the facility on [DATE] with diagnoses that included COVID-19, alcohol abuse, and chronic obstructive pulmonary disease.
An ADL self-care performance deficit care plan dated 09/28/22 related to decline with function and mobility had a goal to improve independence with ADL tasks and functional mobility. Interventions included required staff participation with bathing.
The admission Minimum Data Set assessment dated [DATE] revealed the resident scored 9 on the Brief Interview for Mental Status, indicating moderately impaired cognition. The assessment also revealed the resident required extensive assistance for most ADLs, including bathing.
On 10/11/22 at 9:38 a.m., an interview with resident #191 was conducted. The resident stated that she had not received any showers since she had been admitted . The resident stated that she usually shaves her whiskers off at home and that she would like them to be shaved off while she was in the facility. During the interview, the resident's hair was observed to appear very greasy and stuck to her head.
Another observation of the resident was conducted on 10/12/22 at 12:45 p.m. The resident continued to appear unwashed and disheveled. The resident's eyes, face, and hair had visible white matter attached to it and her hair appeared to be greasy and uncombed.
Review of the Certified Nursing Assistants (CNAs) Point of Care documentation dated 09/28/22 through 10/12/22 revealed that the resident had received a total of 3 bed baths. Additional review did not indicate that the resident had refused additional opportunities for bathing/showers.
On 10/14/22 at 11:19 a.m., an interview was conducted with a Nursing Assistant (NA/staff #90). She stated that a lot of residents liked to have showers on their scheduled days. She stated that residents will be offered showers, but if they do not feel good, she will offer a bed bath. She stated that resident #191 was fairly new. She stated that yesterday was the resident's shower day, but that the resident wanted to do a bed bath instead. She stated that the CNAs are supposed to document whether or not the resident refused. She stated that she did not know why the resident had only received a couple of bed baths.
An interview was conducted with a Licensed Practical Nurse (LPN/staff #65) on 10/14/22 at 11:45 AM. She stated that she should receive shower sheets when the CNA completes the shower. She stated that CNAs complete the Skin Assessment Shower Sheets in addition to completing the Point of Care documentation. The LPN stated if the resident refused, CNAs should mark refused if the resident refuses. The LPN stated that residents should be offered showers or bed baths twice weekly.
On 10/14/22 at 11:53 a.m., an interview was conducted with the Director of Nursing (DON/staff #20). She stated the shower schedule assigns the residents two showers weekly. The DON stated that it was within the residents' rights to request a different time or day, according to their preference. She stated the residents will usually tell their CNA, the CNA would tell the nurse, and the nurse would notify administration to modify the schedule. She stated the caregivers will document on a flow sheet on their task assignments. The DON stated that CNAs also are expected to document on a shower sheet and to turn the sheets in to their nurse at the end of the shift. She stated that her expectation is that residents will be offered 2 bathing opportunities per week. The DON stated that outcomes of not receiving twice weekly showers or bed baths may include diminished skin integrity, dignity, and comfort.
Review of the facility policy titled ADL, Services to Carry Out, reviewed 08/2022, included it is the policy of the facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with the written plan of care. If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, and personal and oral hygiene will be provided by qualified staff. Bathing will be offered at least twice weekly, and as-needed per resident request. ADL care provided will be documented in the medical record accordingly.

Based on observations, staff interviews, facility documentation and policy review, the facility failed to ensure the posted daily nurse staffing information was accurate. The deficient practice resulted in information not being readily available to residents and visitors.
Findings include:
During an observation conducted on October 13, 2022 at 2:00 p.m., the nurse staffing information was observed posted on a bulletin board in the hallway.
However, the posted staffing information did not include the actual hours worked by the staff.
An interview was conducted with the staffing coordinator (staff #22) on October 14, 2022 at 11:12 a.m., who stated she does not know the hours worked until after the shift is over.
Immediately following the interview, staffing information that was posted for the last 3 months was requested from staff #22.
However, review of the staffing information postings dated August 1, 2022 through October 13, 2022 did not include the actual hours worked by staff.
An interview was conducted with the Director of Nursing (staff #26) on October 14, 2022 at 1:39 p.m. Staff #26 stated the actual hours worked were done electronically and reported directly to CMS (Centers for Medicare & Medicaid Services). Staff #26 stated ever since the PBJ (Payroll Based Journal) started, the actual hours worked are sent directly to the CMS for the 5-star ratings.
A facility policy regarding the posting of 24 hour licensed and unlicensed direct care staff included the following: It is the policy of this facility to post staffing numbers. The procedures stated to post the number of staff hours working who are directly responsible for resident care, and to comply with the Benefits Improvement and Protection Act of 2000, the facility must include hours worked by Registered Nurses, Licensed Practical/Vocational Nurses, and Nursing Assistants for each shift.

Based on review of facility logs and staff interview, the facility failed to provide evidence that temperatures for the reach-in refrigerator was consistently monitored. The deficient practice could result in foodborne illness.
Findings include:
During the initial kitchen observation conducted on October 11, 2022 at 8:12 a.m. the October kitchen log for the freezer and refrigerators were reviewed.
The Kitchen Manager (staff #1110) was present during the walk-through and review of the logs conducted on October 11, 2022 at approximately 8:12 a.m. During the review, it was noticed that the reach-in refrigerator did not have a temperature log. The refrigerator had a thermometer inside and it indicated that the temperature was 40 degrees Fahrenheit. The refrigerator had items inside such as individual serving containers of salad and cottage cheese.
During an interview with the Kitchen Manager (staff #1110) conducted on October 11, 2022 at 8:21 a.m., he stated that they did not have a temperature log for the reach-in refrigerator. When asked if there were logs from previous months, he stated that they did not. He stated that it had completely slipped his mind since they have had kitchen inspections and none of the inspectors had looked at or asked for the reach-in refrigerator's temperature log. He stated that he would fix it immediately and ensure that a log is placed on the refrigerator so that the temperature could be monitored.
A follow-up interview was conducted with staff #1110, on October 12, 2022 at 10:34 a.m. He stated that the reach-in refrigerator is used to store salads, cottage cheese, and salad dressing. He stated that he understands why the refrigerator's temperature had to be monitored. He stated that monitoring the refrigerator temperature helps ensure that the food items stored inside are safe to serve to the residents.
During the final interview with the Kitchen Manager (staff #1110) on October 13, 2022 at 12:48 p.m., he stated that there was not a specific policy with regards to temperature monitoring.

Based on observations, staff interviews, and policy review, the facility failed to ensure narcotic medications and controlled substances were stored via a double-lock system. The resident census was 75. The deficient practice could result in failure to prevent loss or diversion.
Findings include:
An observation was conducted on October 4, 2021 at approximately 12:30 of the Director of Nursing (DON/staff #127)'s office. No one was in the DON's office at this time and the door was open and the DON was not in sight.
Additional observations were conducted on October 6, 2021 at 8:12 AM, 10:32 AM, and 11:15 AM and the same was observed.
An interview was conducted on October 6, 2021 at 7:52 AM with a Licensed Practical Nurse (LPN/staff #9), who said that if they have a resident discharge they are supposed to take the narcotic sheet and the narcotic medication to the DON, who disposes of it.
An interview was conducted on October 6, 2021 at 8:39 AM with the DON (staff #127), who said when resident is discharged , narcotics might go with the resident. The DON stated that if the narcotics are not given to the resident, the total count of narcotics would be confirmed with 2 nurses and would be kept under double lock in her office in a locked cabinet. The DON stated the narcotics are kept behind two locks.
An observation was conducted during the interview with the DON (staff #127) revealed a cabinet in the DON's office that had one lock at the top of the cabinet. Inside was a drawer almost completely full of narcotic medication cards with sheets wrapped around them. A second lock was not on the cabinet and the office had been observed unsecured.
On October 7, 2021 at 10:33 AM, another interview was conducted with the DON (staff #127) who stated narcotics medications are placed in a pharmaceutical waste container and kept in the cabinet until the incinerator comes to pick them up. The DON opened the lock on the cabinet that stored the narcotics and removed a container approximately a gallon in size with a manufacturers label of pharmaceutical waste container, that was approximately 1/3 to 1/2 full of pills. The DON said there was not a second lock on the narcotic cabinet when the door of her office was open and she was not there. She said there was not access to the narcotics because the cabinet is locked, however if the cabinet was not locked there could be adverse consequences for someone who gets their hands on them without a prescription.
A facility policy titled Medication Access and Storage, E-Kit access revealed that It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications This policy included Schedule II-V medications are stored in a separate area under double lock.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -An observation was conducted of the 400 unit on October 5, 2021 at 10:24 AM. room [ROOM NUMBER] was observed to have an isolation cart outside the room and a table was observed towards the end of the hallway on the left wall close to room [ROOM NUMBER] with PPE such as gowns, gloves, surgical mask, etc. Rooms 409 to 414 and room [ROOM NUMBER] had droplet precaution signs outside the rooms. There were three signs posted. One stated Droplet Precaution, one stated Use of PPE, and one stated Donning/Doffing Instructions. The sign titled Use of PPE when caring for patients with confirmed or suspected COVID-19 stated that PPE must be donned correctly before entering the patient area (e.g., isolation room, unit if cohorting). The sign Donning/Doffing Instructions included to gather proper PPE to don, perform hand hygiene, put on isolation gown, N95, face shield/goggles and gloves before entering patient room.
On October 5, 2021 at 10:40 AM, a housekeeper (staff #76) wearing gloves, a N95 mask with no surgical mask over it, and goggles was observed to enter a resident's room on the 400 unit who was on isolation precautions without donning a gown. Staff #76 was observed emptying the trash and sweeping the floor in the room. Staff #76 was also observed to adjust her shirt with her gloved hands while sweeping the floor. Droplet precaution signs were observed outside the resident's room.
On October 5, 2021 at 10:55 AM, staff #76 was observed to enter another resident's room who was on isolation precautions without donning a gown and no surgical mask over her N95 mask. Droplet precaution signs were observed outside the resident's room. After she was finished cleaning that resident's room, staff #76 was observed to enter a resident's room not on isolation precautions with the same N95 mask and goggles.
During an interview conducted with an Occupational Therapy Assistant (OTA/staff #4) on October 5, 2021 at 10:36 AM, she stated that anyone entering a resident room on droplet isolation precautions have to don a gown, gloves, surgical mask over the N95 mask, and goggles.
An interview was conducted with staff #76 on October 5, 2021 at 11:27 AM. She stated that when she has to clean a resident room who is on isolation precautions, she dons a gown, gloves, mask and goggles. The housekeeper stated donning a gown before going into an isolation room is important as the gown keeps her from contaminating herself. She stated that she did not know that those two residents' rooms were on isolation precautions because there was no isolation cart outside those rooms. She stated she was told the rooms with an isolation cart outside the room, such as room [ROOM NUMBER], were the only rooms on isolation. Staff #76 stated that she had received education regarding the isolation rooms during the housekeeping staff meeting and had done online training on infection control.
An interview was conducted with the Infection Preventionist/Assistant Director of Nursing (IP/ADON/staff #40) on October 6, 2021 at 10:37 AM. The IP stated resident rooms have signs posted on the door to let the staff know that the resident in that room is on isolation precautions and what PPE to don before going into the room. She stated a table is set up outside in the hallway with all necessary PPE. The IP stated that to enter a resident's room on isolation precautions, staff need to sanitize their hands, don a gown, gloves, a surgical mask over their N95, and goggles/face shield. The ADON stated all new employees are educated on infection control and PPE during new employee orientation. Regarding staff #76, she stated that staff #76 should have donned a gown. The IP stated all the new admit residents are tested on admission and all were negative. The ADON then stated that it is the facility policy to don proper PPE when entering resident rooms on isolation precautions.
An interview was conducted with the Director of Nursing (DON/staff #127) on October 7, 2021 at 8:22 AM. The ADON stated that they follow the CDC guidance for PPE requirements for residents on isolation precautions and that she expects staff to follow those directions. Staff #127 stated staffs are educated on infection control through routine education, monthly meetings, hurdles and individual department meetings. Regarding staff #76, the DON stated unfortunately sometimes the staff need reeducation. The DON stated donning a gown is important before entering an isolation room as it protects the body from droplets or any potential unknowns.
The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated September 10, 2021 included recommended infection prevention and control practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection. HCP (Health Care Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).
The CDC Strategies for Optimizing the Supply of Eye Protection updated September 13, 2021 stated when using reusable face shields or goggles ensure appropriate cleaning and disinfection after each use. Reusable eye protection should be cleaned and disinfected after each patient encounter.
The CDC Strategies for Optimizing the Supply of Facemasks included a situational update as of May 2021 that the supply and availability of facemasks have increased significantly over the last several months. Healthcare facilities should not be using crisis capacity strategies at this time and should promptly resume conventional practices. The section for conventional capacity strategies stated that in healthcare, facemasks used as PPE to protect their nose and mouth from exposure to splashes, sprays, splatter, and respiratory secretions (e.g., for patients on Droplet Precautions) should be removed and discarded after each patient encounter.
The CDC Summary for Healthcare Facilities: Strategies for Optimizing the Supply of N95 Respirators during shortages included a situational update as of May 2021 that the supply and availability of NIOSH-approved respirators have increased significantly over the last several months. Healthcare facilities should not be using crisis capacity strategies at this time and should promptly resume conventional practices.
Based on observations, staff interviews, policy review, and the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure infection control standards were maintained regarding hand hygiene and Personal Protective Equipment (PPE). The deficient practice could result in the spread of infections.
Findings include:
-A lunch tray distribution observation on hall 300 was conducted on October 4, 2021 at 12:30 p.m. with one nursing staff (staff #68). During the meal tray distribution observation, the staff was observed to not wash their hands prior to distributing the meal trays and in between resident rooms.
On October 4, 2021 at 12:36 p.m., the same nursing staff (staff #68) without washing hands, was observed to enter a resident's room and place the lunch tray on the resident's bedside table. The staff directed his attention to the urinal which contained about 450 cc (cubic centimeters) of urine. He donned a pair of gloves, picked up the urinal and went to the resident's bathroom. The staff returned with an empty urinal then hung the urinal on the resident's walker. Staff #68 doffed the gloves, and without performing hand hygiene, took the cover off the main dish on resident's tray. Then staff #68 stepped out of the room, poured a cup of coffee from a beverage cart, and re-entered the resident's room and served the coffee to the resident. Staff #68 then exited the room without performing hand hygiene and continued with the meal tray distribution.
An interview was conducted with staff #68 on October 4, 2021 at 1:10 p.m. The staff said handwashing should be done after donning and doffing gowns and gloves, and before and after serving a resident's meal tray. He also said handwashing should be done after emptying a urinal and prior to touching or pouring a cup of coffee from the beverage cart. Staff #68 agreed he did not wash his hands after emptying the urinal said he did not always wash his hands or use the alcohol sanitizer in between resident's room. Staff #68 stated that he was in a hurry and was focused on serving the meal trays timely.
In an interview conducted with a registered nurse (RN/staff #42) on October 7, 2021 at 9:08 a.m., the RN stated hand washing should be done before and after resident's care, after bathroom use, before and after passing meal trays, and before and after donning and doffing a pair of gloves when emptying a urinal.
An interview was conducted with the Director of nurses (staff #127/ DON) on October 7, 2021 at 9:20 a.m. The DON stated handwashing should be done on a regular basis before and after resident's care, after donning and doffing a pair of gloves, and when serving meals. The DON stated her expectation is there has to be hand hygiene between each tray. The DON stated that if a urinal needed emptying, donning and doffing of gloves must be followed by handwashing.
A facility policy Handwashing/Hand Hygiene included hand hygiene is the primary means to prevent transmission of possible infectious material. The policy further included that the facility refers to Centers for Disease Control and Prevention's (CDC) most current guidelines for hand washing.
The CDC handwashing guidance included handwashing should be performed immediately before touching a patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure one of two sampled residents (#60) was provided consistent care and treatment regarding pressure ulcers. The deficient practice could result in pressure ulcers not being assessed and monitored, and wound complications.
Findings include:
Resident #60 was readmitted to the facility on [DATE] with diagnoses that included sepsis, paraplegia, and stage 2 pressure ulcer (PU) of the sacral region.
A nursing admission note dated 02/19/21 revealed the resident was admitted back to the facility for physical therapy, occupation therapy, and intravenous antibiotic therapy.
The Braden Scale dated 02/19/21 revealed the resident was at low risk for the development of pressure sores.
A right and left gluteal fold PU care plan dated 02/19/21 had a goal for PUs to show signs of healing and to remain free from infection. Interventions included weekly head to toe skin at risk assessment.
Review of the clinical record revealed weekly skin evaluations were conducted.
Review of physician orders dated 02/22/21 included for a low air-loss (LAL) mattress.
An actual impairment to skin integrity care plan dated 02/22/21 related to pressure wound to the sacrum, MASD/denuded areas on lower buttocks, and wound at the left gluteal fold had goals to be free from injury. Interventions included to follow facility protocols for treatment of injury, to utilize pressure-relieving/reducing Low Air-Loss (LAL) mattress, pillows, and ROHO cushion in wheelchair at all times.
Review of the clinical record did not reveal a physician order for a ROHO cushion.
A Braden Scale dated 02/24/21 included the resident continued at low risk for development of pressure sores.
A physician order dated 03/08/21 revealed for zinc cream to buttocks twice daily and PRN after incontinence episodes, every day and evening shift.
Review of the Skin Pressure Ulcer Weekly Reviews did not reveal a weekly review for 03/11/21.
Review of the March 2021 TAR revealed zinc cream was applied to the resident's buttocks twice daily and PRN in accordance with physician orders, with the exception of 03/13/21 (p.m.) and 03/17/21 (p.m.) where there was no evidence to indicate whether or not the treatment had been provided.
A physician order dated 04/13/21 revealed for a ROHO cushion in wheelchair at all times, every shift.
Continued review of the Skin Pressure Ulcer Weekly Reviews revealed for weekly reviews except for 03/11/21, and 04/13/21 through 04/31/21.
Further review of the clinical record revealed treatments were provided as ordered and interventions were implemented.
An interview was conducted with a Licensed Practical Nurse on 10/06/21 at 9:13 a.m., who stated the floor nurses complete the weekly head-to-toe skin assessments. The LPN stated the wound nurse is responsible for assessing pressure ulcers and ensuring orders are in place for pressure reducing devices.
An interview was conducted on 10/06/21 at 1:27 p.m. with the wound nurse (LPN/staff #57), who stated skin, pressure ulcer, and non-pressure wound assessments are completed weekly. Relative to resident #60, she stated that she provides wound care daily, hand writes the wound assessments, and input the assessments into the system. The wound nurse stated that everything that she has completed is in the system.
On 10/07/21 at 10:44 a.m., an interview was conducted with the DON (staff #61). The DON stated that her expectation is that wound assessments will be completed weekly and with significant changes.
Review of the facility policy titled Wound Management reviewed 05/2021 included that it is the policy of the facility that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. Complete weekly head to toe skin assessment with follow up as applicable. Once a wound has been identified, assessed, and documented, nursing staff shall administer treatment to each affected area as per the physician's order. All wound or skin treatments should be documented in the resident's clinical record at the time they are administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure a Level I Preadmission Screening and Resident Reviews (PASRR) was completed prior to or upon admission for one resident (#60). The sample size was 18. The deficient practice could result in residents not receiving the level of services they require.
Findings include:
Resident #60 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included sepsis, unspecified organism, paraplegia, unspecified, and other psychoactive substance abuse, uncomplicated.
The Initial admission Record dated 02/08/21 included that the resident received psychotropic medications, had behavior problems, and was anxious at times.
The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's memory was ok, the resident was independent with decisions regarding tasks of daily life, and decisions were consistent and reasonable. The assessment included the resident displayed no behaviors, and required limited assistance with most activities of daily living.
However, review of the clinical record did not reveal that a PASRR evaluation/screening had been completed prior to or upon admission to the facility on [DATE].
A nursing progress note dated 2/11/2021 at 9:52 p.m. included the resident had a temperature of 104.3 degrees Fahrenheit (F). The provider was notified and ordered the resident be sent to the ED for further evaluation. Paramedics arrived and the resident left the facility at approximately 8:00 p.m. for transport.
Further review of the clinical record revealed that on 02/17/21 a PASRR evaluation had been completed at the hospital.
A nursing progress note dated 02/19/21 included the resident had been transported back to the facility by medical transport, and the provider had been notified of the admission.
On 10/07/21 at 10:16 a.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #64). She stated that the MDS coordinator is responsible for completing the PASRR screening. She stated the floor nurses will admit the resident, but that they do not complete the PASRR.
An interview was conducted on 10/07/21 at 10:28 a.m. with the Social Services Director (SSD/staff #23). He stated that a PASRR will be completed in the hospital, or he would complete it on special occasions. He stated medical records will review the residents' records and ensure there is one there. Staff #23 stated medical records will notify him if there is not one. Staff #23 stated medical records is responsible for ensuring that a PASRR is uploaded into the resident's record. Staff #23 stated that if there is not one available, that would be the special circumstance where he would complete one. He stated that preadmission is the standard for completion of a PASRR. The SSD reviewed the resident's record and identified an initial PASRR which was completed on 02/17/21. He stated that the resident's admission date was 02/08/21. The SSD stated that PASRRs are typically completed to ensure that the resident had been placed in the correct setting and that the level of care is suitable for the resident's needs. The SSD said that without one, you might not be aware of the resident's needs, and that it is always better to know beforehand. The SSD stated that he thought the 02/08/21 PASRR for resident #60 might have been missed.
On 10/07/21 at 10:44 a.m., an interview was conducted with the Director of Nursing (DON/staff #61). She stated that her expectation was that the PASRR should be completed as close to the date of admission or upon arrival as possible, as best they can. The DON stated that if someone needed Level II services, it would be a concern as additional services would potentially be necessary for that individual.
The facility policy titled PASRR stated it is the policy of the facility to ensure that each resident is properly screened using the PASRR specified by the State. The policy included that if the State mental health authority has determined, based upon physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission that because of the physical and mental condition of the individual, the individual requires the level of services provided by the facility and if the individual requires such level of services, whether the individual requires specialized services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, resident and staff interviews, and policy review, the facility failed to ensure two residents' (#15 and #30) call lights were accessible. The census was 75. The deficient practice could result in residents not being assisted timely with care.
Findings include:
-Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included multiple sclerosis (MS), muscle weakness, and paraplegia.
A care plan was initiated on November 3, 2019 with a focus that stated the resident was at risk for falls related to MS, weakness, malaise, and functional paraplegia. The care plan included an intervention to be sure the call light is within reach and to encourage the resident to use it to call for assistance as needed.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. The assessment included the resident required extensive assistance of one person for bed mobility, transfer, dressing, toilet use, and personal hygiene.
Continued review of the resident's care plan revealed a care plan focus initiated on July 16, 2021 that the resident has potential for pressure ulcer development related to impaired mobility. An intervention was to keep the call light within reach of the resident.
A psychiatric nurse practitioner note dated September 6, 2021 stated the resident's self-care skills are impaired and the resident depends on others to perform them. The resident is dependent on others for domestic tasks.
A physician's progress note dated September 29, 2021 included the resident remained wheelchair bound and required assistance with Activities of Daily Living (ADLs).
Review of the nursing Daily Skilled Notes from September 1, 2021 through October 6, 2021 revealed the resident was alert and oriented to person, place, and time, and had no active symptoms or treatments effecting level of consciousness, cognition, sleep, mood, or behavior. The notes included the resident needed extensive assistance for transfers and toileting.
An interview was conducted on October 6, 2021 at 8:57 am with resident #15 and a family member. The resident's family member stated they were concerned that the resident is not able to reach the call light at times, and might need assistance and not be able to call for help. They stated the resident has MS and is at risk for falling from the wheelchair or choking and needs to be able to call for help.
Another interview was conducted with resident #15 on October 7, 2021 at 10:30 am. The resident was sitting in the wheelchair, and the call light was observed across the room, draped across the seat of a recliner. The resident was not able to reach the call light at that time. The resident stated it is a concern that the Certified Nursing Assistants (CNAs) do not place the call light where it can be accessible which can result in not getting help when needed. The resident also stated a worry of having an accident due to being unable to call for help to get assistance with toileting. The resident stated a grabber is sometimes used to reach the call light. The grabber was observed under the bed and also out of reach at this time.
-Resident #30 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), dysphasia, Alzheimer's disease, difficulty walking, and other weakness.
A care plan was initiated on January 23, 2018 that stated the resident was at risk for falls related to generalized muscle weakness and included staff should be sure the call light is within reach and to encourage the resident to use it to call for assistance as needed. This care plan also included the resident should be educated on the importance of calling for assistance when needed.
Another care plan was initiated on November 19, 2019 which included the resident has a potential for pressure ulcer development related to immobility, incontinence, and advanced age. Interventions included the call light should be within the resident's reach.
Review of the quarterly MDS assessment dated [DATE] revealed a score of 3 on the BIMS indicating the resident had severe cognitive impairment. The assessment included the resident required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene.
A progress note written by a nurse practitioner on September 20, 2021 included the resident is alert, but cognition is impaired related to dementia.
An observation of the resident was conducted on October 4, 2021 at 11:24 am. The resident was in bed and was verbally calling for help. The resident's call light was not observed to be near the resident at this time.
At 11:39 am, 15 minutes after the resident began calling for help, a CNA entered the resident's room and asked the resident why the resident did not use the call light. The CNA looked in the resident's bed and was initially unable to find the call light. The CNA found the call light behind the resident's bed attached to a blanket.
Another observation was conducted on October 5, 2021 at 1:00 pm. The resident was sitting in the bed with lunch on the table in front of the resident. The resident could be heard calling for help and stating that the resident was ready to get up. Further observation revealed the resident's call light was laying across the bedside table approximately 2 feet away. The call light cord was draped over the table so the call button was on the side furthest from the resident, completely out of reach.
The resident was observed again on October 5, 2021 at 2:17 pm. The resident was asleep in the bed and the call light remained draped across the bedside table, out of the resident's reach.
Another observation was conducted on October 7, 2021 at 9:03 am. The resident was awake in the bed, and the call light was again draped over the bedside table, approximately 2 feet away from the resident, and the call button was on the side furthest from the resident.
At 10:35 am on October 7, 2021, the resident was observed to be sitting in the wheelchair in the resident's room. The call light remained draped over the bedside table and was out of the resident's reach.
An interview was conducted on October 7, 2021 at 10:45 am with a CNA (staff #68). Staff #68 stated that when he checks on residents in their rooms, he always makes sure the resident can reach their call light before he leaves the room. He stated the residents might move around in their bed and the call light might move and be out of the residents' reach in those cases. He stated some of the residents need the call light clipped to them or their blankets so it does not fall when the resident is moving around. Staff #68 stated he was not aware of any call lights being out of reach of the residents at that time.
An interview was conducted on October 7, 2021 at 11:06 am with a Licensed Practical Nurse (LPN/staff #64), who stated she was familiar with both resident #15 and resident #30. Staff #64 stated all residents should have their call lights within reach at all times. She stated resident #15 usually has the call light near, but the resident is not able to reach it if it falls. Staff #64 stated resident #30 should have the call light clipped to the resident. Staff #64 stated she was not aware that the residents' call lights had been out of the residents' reach on multiple occasions.
An interview was conducted with the Director of Nursing (DON/staff #127) on October 7, 2021 at 11:27 am. The DON stated it was her expectation that all residents have their call light within reach and that the lights are answered by staff in a reasonable amount of time.
The facility policy titled Call Light/Bell, revised in July 2019 included it is the policy of the facility to provide the resident a means of communicating with nursing staff. It also included staff should place the call device within the resident's reach before leaving the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #72 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, asthma, and major depressive disorder.
Review of the admission MDS assessment dated [DATE] revealed the resident scored a 12 on the BIMS which indicated the resident had moderately impaired cognition.
Review of the physician's orders revealed an order dated September 15, 2021 for Escitalopram (antidepressant) 5 mg by mouth once per day.
Review of the MAR for September 2021 and October 2021 revealed the resident was administered the Escitalopram as ordered.
Further review of the clinical record revealed no evidence that the resident had been informed of the risks and benefits of Escitalopram prior to receiving the medication.
An interview was conducted on October 6, 2021 at 10:24 a.m. with a RN (staff #44). The RN stated that when a psychotropic medication is ordered for a resident, they explain and obtain a consent from the resident before administering the medication to the resident.
During an interview conducted with the Director of Nursing (DON/staff #127) on October 7, 2021 at 9:20 a.m., she stated that it is the expectation that the risks and benefits of a psychotropic medication is explained to the resident prior to the administration of the medication. Later that day, the DON stated that she was unable to find a consent for the Escitalopram.
The facility's policy for Psychoactive Medication revised May 2021, stated it is the policy of the facility to maintain every resident's right to be free from use of psychoactive medication. The use of psychoactive medication must first be explained to the resident, family member, or legal representative. Explain the potential negative outcomes of psychoactive medications. A consent is to be obtained either from the resident or responsible party if the resident unable to give.
Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure two residents (#37 and #72) and/or their representative were informed of the risks and benefits of a psychotropic medication prior to the administration of the medication. The sample size was 5 residents. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and the potential adverse side effects of psychoactive medications.
Findings include:
-Resident #37 was admitted to the facility on [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Anxiety Disorder.
A physician's order dated March 30, 2021, revealed an order for Klonopin (anxiolytic) 0.5 milligrams (mg) tablet, give 2.5 tablet by mouth every 12 hours for anxiety as evidenced by restlessness. This order was discontinued on August 10, 2021.
A physician's order dated August 10, 2021, revealed an order for Klonopin 0.5 mg tablet, give 3 tablet by mouth every 12 hours for anxiety as evidenced by restlessness to equal 1.5 milligrams.
An annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was administered an antianxiety medication all 7 days of the look back period. The assessment also included the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.
Review of the MAR (Medication Administration Record) for July, August, September and October 2021, revealed the resident was administered Klonopin per the physician's orders.
However, continued review of the clinical record revealed no evidence the resident had been informed of the risks and benefits for the use of Klonopin.
An interview was conducted on October 6, 2021 at 10:24 p.m. with a Registered Nurse (RN/staff #44). She reviewed this resident's electronic medical record and stated that the consent for Klonopin was not in the clinical record.
During an interview conducted on October 7, 2021 at 10:33 a.m. with the Director of Nursing (DON/staff #127), she said that for this resident, the staff obtained the consent for Klonopin yesterday. The DON stated that they have searched and were not able to locate a consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and review of policy, the facility failed to ensure one sample resident (#72) was administered oxygen in accordance with the physician order. The deficient practice could result in residents receiving oxygen not according to physician orders.
Findings include:
Resident #72 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, asthma and major depressive disorder.
Review of the clinical record revealed physician orders dated September 7, 2021 and September 14, 2021 for oxygen at 3 liters per nasal cannula every shift for asthma.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) which indicated the resident had moderately impaired cognition. The MDS assessment also included that the resident has shortness of breath, and received oxygen therapy.
A review of the care plan initiated on September 17, 2021 revealed the resident has oxygen therapy related to asthma. The goal was that the resident will have no signs and symptoms of poor oxygen absorption. The interventions included oxygen settings as ordered.
The MAR (Medication Administration Record) for October 2021 revealed the resident's oxygen saturation was 95% on the day shift on October 4, 2021.
The Weights and Vitals Summary revealed that on October 4, 2021 at 9:55 a.m., the resident's oxygen saturation was 95% on oxygen via nasal cannula.
During an observation conducted on October 4, 2021 at 10:33 a.m., the resident was observed resting in bed receiving oxygen at 4.5 liters per nasal cannula. The oxygen humidifier container for 500 cc (cubic centimeters) of water was observed to be completely empty.
Review of the MAR dated October 2021 revealed that the resident's oxygen saturation was 95% on the day shift on October 5, 2021.
On October 5, 2021 at 8:26 a.m., the resident was observed resting in bed receiving oxygen at 4.5 liters per nasal cannula. Again, the oxygen humidifier container was observed to be completely empty.
However, review of the clinical record did not reveal a physician's order had been obtained to increase the oxygen to 4.5 liters.
In an interview conducted with the resident on October 5, 2021 at 8:26 a.m., the resident stated the nurses are in charge of the oxygen and that she receives 3 liters of oxygen. The resident stated she does not touch the oxygen because the nurses do everything.
An interview was conducted on October 6, 2021 at 12:59 p.m. with an LPN (Licensed Practical Nurse/staff #9). The LPN stated oxygen therapy is only administered by the licensed nurses according to the physician order, because oxygen is considered a medication. The nurse stated that she frequently checks on the resident with oxygen to ensure oxygen is being administered as ordered and the tank is not empty if the resident is attending activities.
An interview was conducted on October 7, 2021 at 9:20 a.m. with the DON (Director of Nursing/staff #127). The DON stated that her expectation is that oxygen therapy be administered according to the physician order. She said the flow rate can vary according to the needs of the resident, but there must be an order which includes monitoring of saturation, tubing change every week, and humidifier change as needed. The DON stated the humidifier is only used if oxygen therapy is greater than 4 liters. The DON reviewed the physician order for oxygen but did not comment on why the oxygen was administered at 4.5 liters to the resident.
The facility's policy for oxygen administration reviewed August 2021 stated it is the policy of the facility that oxygen therapy is administered by the licensed nurse as ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure pain medications were administered to one resident (#60) in accordance with the physician's ordered parameters. The sample size was 5. The deficient practice increases the risk for residents to receive unnecessary medications.
Findings include:
Resident #60 was readmitted to the facility on [DATE] with diagnoses that included sepsis, unspecified organism, paraplegia, unspecified, and pressure ulcer (PU) of sacral region, stage 2.
An opioid care plan dated 02/22/21 related to oxycodone for pain management had a goal to remain free from pain or at a level of discomfort acceptable to the resident. Interventions included to administer opioid as prescribed.
A physician order dated 02/26/21 included for oxycodone (opioid analgesic) 10 milligrams (mg); give 2 tablets every 4 hours as needed (PRN) for pain of 7-10 out of 10 on a pain scale.
Review of the June 2021 Medication Administration Record (MAR) included the resident received oxycodone on 4 occasions when the pain level was below 7 out of 10; once on 06/06 for a pain level of 6, once on 06/12 for a pain level of 6, once on 06/18 for a pain level of 6, and once on 06/26 for a pain level of 6.
The July 2021 MAR revealed the resident received oxycodone on more than 10 occasions when the pain level was below 7 out of 10.
Review of the August 2021 MAR revealed the resident received oxycodone on 4 occasions when the pain level was below 7 out of 10; once on 08/03 for a pain level of 2, once on 08/06 for a pain level of 6, once on 08/07 for a pain level of 5, and once on 08/08 for a pain level of 5.
An interview was conducted on 10/07/21 at 10:16 a.m. with a Licensed Practical Nurse (LPN/staff #64). She stated that prior to administering oxycodone to a resident for pain, she will ask the resident to identify what their pain level was and where their pain was located. The LPN stated that it would not be appropriate to administer any narcotic outside of the physician's ordered parameters. She stated that she would consider that a medication error. The LPN stated that if a nurse administered oxycodone outside the order parameters they must let the Director of Nursing (DON) know.
On 10/07/21 at 10:44 a.m., an interview was conducted with the DON (staff #61). She stated that it did not meet her expectation for nursing to administer oxycodone outside of the physician's ordered parameters. The DON stated that nursing should have called the physician and asked to have the order changed.
The facility's policy titled Medication Administration - Oral revised May 2021 included that it is the policy of the facility to accurately prepare, administer, and document oral medications. Verify residents' medication cards with medications orders. Any irregularities in pouring or administering must be reported to the physician. An essential point of medication administration included that if there is any question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies the drug dosage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#72) receiving an antidepressant medication was monitored for efficacy of the medication. The sample size was 5. The deficient practice could result in residents receiving psychotropic medications which are not necessary.
Findings include:
Resident #72 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, and major depressive disorder.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) which indicated the resident had moderate impaired cognition.
Review of the physician's orders revealed an order dated September 15, 2021 for Escitalopram (antidepressant) 5 milligrams (mg) once per day by mouth. The order did not include the target behavior.
A care plan initiated on September 16, 2021 included the use of an antidepressant medication related to depression. Interventions included to monitor/record occurrence of target behavior symptoms (specify) and document per facility protocol.
Review of the Medication Administration Record (MAR) for September 16 and through October 7, 2021 revealed the resident was administered the Escitalopram as ordered.
However, further review of the clinical record revealed no evidence that the target behavior was identified and monitored for.
During an interview conducted with the resident on October 4, 2021 at 10:33 a.m., the resident stated that she is receiving a medication for depression but does not know for what reason.
An interview was conducted with a Licensed Practical Nurse (LPN/staff #9) on October 6, 2021 at 12:02 p.m. The LPN stated if a resident is on a new psychotropic medication, there needs to be an order to document side effects and behavior. Staff #9 stated any resident being administered a psychotropic medication need behavior monitoring.
An interview was conducted on October 6, 2021 at 12:27 p.m. with a Registered Nurse (RN/staff #44), who stated when a resident is started on a psychotropic medication, there should be a monitoring of side effects and behaviors. The RN stated that they have an alert sheet of the medication so nurses that know to monitor the resident for any behaviors and side effects.
During an interview conducted with the Director of Nursing (DON/staff #127) on October 7, 2021 at 9:30 a.m., she stated target behavior and monitoring, and diagnosis should be a part of the physician orders and transcribed onto the MARs. The DON stated the staff document behavior monitoring by the number of times it has occurred every shift. Staff #127 stated that if the order does not include behavior monitoring, the nurse will have to obtain an order from the physician.
Review of the facility policy Psychoactive Medications revised May 2021 revealed the facility maintains every resident's right to be free from the use of psychoactive medication. No psychoactive medications will be utilized without a specific physician order, or without a diagnosed specific condition, and will include the target behavior. The use of the medication will be care planned with the same diagnosis and target behavior for which the medication was ordered. Monitor and track progress towards the therapeutic goal(s). Each resident requiring psychoactive medications will have ongoing assessments and care plan reviews.