Idaho State Veterans Home - Boise

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including obesity and below the knee amputation.
On 5/13/25 at 11:30 AM, Resident #17's bed was observed parallel to the window with the headboard facing the wall. There was an 18-inch gap between the side of the bed and the window.
A physical restraint consent, dated 6/23/23, and 9/26/23, documented the right side of the bed should be placed against the wall.
Resident #17's care plan, dated 6/23/23, documented Resident #17 had mobility and fall risk interventions to include having the right side of the bed against the wall so the resident would feel safe and comfortable.
On 5/15/25 at 3:35 PM, RN Manager #2 stated Resident #17 had moved rooms on 4/7/25, where his bed was placed parallel to the window. RN Manager #2 confirmed Resident #17's care plan had not been updated since his move to the new room on 4/7/25.
Based on observation, record review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 2 of 18 residents (#17 and #52) whose care plans were reviewed. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include:
The CMS SOM, Appendix PP, dated 8/8/24 documented a resident's care plan must be reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident and in response to current interventions.
1. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including dementia, anxiety, and PTSD.
Resident #52's physician's orders documented:
-Quetiapine (antipsychotic) was discontinued on 2/24/25.
-Trazodone (antidepressant used as a sleep aid) was discontinued on 2/24/25.
Resident #52's care plan, initiated on 8/29/23 and revised on 8/29/24, documented resident used the psychotropic drug Quetiapine.
Resident #52's care plan initiated on 2/14/25 documented resident used the psychotropic drug Trazodone.
On 5/15/25 at 4:11 PM, RN Manager #1 confirmed Resident #52's care plan should have been updated to reflect a change in physician's orders when Quetiapine and Trazodone were discontinued, and it did not.

Based on policy review, record review, review of the State Agency's Long-Term Care Reporting Portal, review of I&As, and staff interview, it was determined the facility failed to ensure a resident was free from abuse. This was true for 1 of 5 residents (Resident #56) reviewed for abuse. This failure created the potential for residents to experience ongoing abuse and potential harm. Findings include:
The facility's Freedom from Abuse, Neglect and Exploitation policy, revised February 2020, documented each resident has the right to be free from exploitation, verbal, sexual, physical and mental abuse, serious bodily injury, corporal punishment, and involuntary seclusion.
A review of the State Agency's Long-Term Care Reporting Portal, documented Resident #56 experienced abuse from the staff as follows:
1. A facility investigation report, received on 11/26/24, documented that on 11/19/24 at 10:15 PM, CNA #1 was observed standing in front of Resident #56 with his hands on Resident #56's upper arms and pushed him forcefully back down into the recliner and yelled Sit down. The facility's investigation report documented the facility's Abuse Response Team conducted an investigation where five staff where interviewed. One of the staff interviewed reported that [name of the CNA #1] does overall want to make sure everything gets completed, and everyone is cared for, I believe. He can get flustered when residents may not wish to do what he has asked of them. I think he doesn't always have the creativity to think of a different approach, as he gets focused on getting the cares done.
The investigation report substantiated the abuse of Resident #56 and CNA #1 was not allowed to return to the facility.
A review of CNA #1's record documented CNA #1 resigned from his employment from the facility effective 12/15/24.
2. A facility investigation report, received on 1/30/25, documented CNA #2 physically restrained Resident #56 who was attempting to self-transfer. Investigation was conducted and staff and residents were interviewed. One of the staff who witnessed the incident reported CNA #2 yelled that Resident #56 was going to fall and he needed help moving him over to his recliner. The staff stated she helped CNA #2 to sit Resident #56 in his chair. When Resident #56 was seated to his recliner, he tried to get up out of the recliner. CNA #2 pushed Resident #56 back to his recliner and used the controls to elevate the footrest and recline the chair. CNA #2 then sat down next to Resident #56 and when Resident #56 continued to try to get up out of the chair CNA #2 put his elbow and arm over Resident #56's left arm to keep him down in the chair. Another staff reported [name of CNA #2] was not good with 1:1 situations. We all know this.
The investigation report substantiated the allegation CNA #2 restrained Resident #56.
On 5/15/25 at 12:43 PM, the DON stated CNA #2 was put on administrative leave, and after the investigation the abuse was substantiated. The DON stated even though the intention of CNA #2 was to prevent Resident #56 from falling, he restrained Resident #56. The DON stated CNA #2 was no longer working in the facility.
On 5/15/25 at 2:50 PM, the Administrator stated he was the abuse coordinator. He stated abuse training was being provided to the staff upon hire and annually thereafter. The Administrator stated CNA #1 and CNA #2 were no longer employed in the facility.
A review of CNA #2's record documented he was dismissed from his employment in the facility effective 2/18/25.
Based on the corrective action taken by the facility and no incidents of staff to resident abuse and neglect after 2/18/25, the facility was cited for past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #38 was readmitted to the facility on [DATE] with multiple diagnoses including dementia and mild cognitive impairment.
Resident #38's Annual MDS assessment, dated 5/19/24 documented under I5950 in section I, yes for question, Does the resident have a psychotic disorder other than schizophrenia? However, on review of Resident #38's record no diagnoses were identified to meet the criteria for a psychotic disorder.
On 5/15/25 at 3:09 PM, the MDS coordinator stated she had no evidence to support the decision for marking yes for psychotic disorder as Resident #38 did not have a psychotic disorder in May of 2024.
4. Resident #46 was readmitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, PTSD, anxiety, and Major Depressive Disorder.
Resident #46's Annual MDS assessment, dated 3/8/25 documented under A1500 in section A, No for the question, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and or intellectual disability or related condition? However, Resident #46's record included a PASRR level II, dated 8/20/21.
On 5/15/25 at 2:43 PM, the MDS Coordinator stated she misinterpreted question A1500 and should have indicated yes.
5. Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including PTSD, Major Depressive Disorder, and anxiety.
Resident #11's admission MDS assessment, dated 9/9/24 documented under A1500, no selection to the question, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? However, a PASRR level II, dated 9/9/24, was completed and on file in Resident #11's electronic health record (EHR.)
On 5/15/25 at 2:24 PM, the MDS Coordinator stated Resident #11 did have a PASRR level II completed, and the MDS assessment should have been coded yes at A1500.
6. Resident #28 was admitted to the facility on [DATE], and re-admitted on [DATE], with multiple diagnoses including delusional disorders, Major Depressive Disorder, anxiety, and PTSD.
Resident #28's admission MDS assessment, dated 10/26/24 documented, No at A1500, as a response to question, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? However, a PASRR level II, dated 11/3/23, was found in Resident #28's EHR.
On 5/15/25 at 2:24 PM, the MDS Coordinator stated a PASRR level II was completed, and it should have been coded yes at A1500.
7. Resident #29 was admitted to the facility on [DATE], and readmitted on [DATE] with multiple diagnoses including anxiety disorder, Major Depressive Disorder, and PTSD.
Resident #29's admission MDS assessment, dated 3/17/25 did not document at A1500, Resident #29 had a PASRR level II completed. However, a PASRR level II, dated 8/22/24 and 12/2/19 were found in Resident #29's EHR.
On 5/15/25 at 2:24 PM, the MDS Coordinator stated a PASRR level II was completed, and it should have been coded yes at A1500.
Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 7 of 11 residents (#11, #26, #28, #29, #38, #46, and #52) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include:
The RAI, revised 10/1/2024, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR level II screening determines a resident has a serious mental illness and/or mental retardation, or related condition.
1. Resident #26 was admitted to the facility on [DATE], with a diagnoses of dementia with agitation, PTSD, and Major Depressive Disorder.
Resident #26's admission MDS assessment, dated 12/11/23 and Significant Change MDS dated [DATE], documented under A1500 in section A, No for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR level II found in his electronic medical record dated 12/5/23.
2. Resident #52 was admitted to the facility on [DATE] with diagnoses of anxiety and PTSD.
Resident #52's Annual MDS assessment, dated 8/20/24 documented under A1500 in section A, No for the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? However, there was a PASRR level II found in his electronic medical record dated 8/2/23.
On 5/15/25 at 2:25 PM, the MDS Coordinator stated Resident #26 and #52's MDS assessments were coded that the resident did not receive a PASRR level II screening because she misinterpreted the meaning of the MDS A1500 question.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on State Operation Manual Appendix PP, record review, and staff interview, it was determined the facility failed to refer residents for further evaluation when residents were diagnosed with a new major mental illness. This was true for 1 of 11 residents (Resident #46) reviewed for PASRR level II evaluations. This deficient practice had the potential to cause harm if the residents' specialized services for mental health needs were not evaluated by an appropriate state-designated authority to provide coordinated care. Findings include:
The State Operation Manual Appendix PP revised on 8/8/24, documented if a PASRR level I identified a major mental illness, an in-depth evaluation, known as a PASRR level II evaluation is completed by the state-designated authority, which must be completed prior to admission to a nursing facility.
Resident #46 was readmitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, PTSD, anxiety, and Major Depressive Disorder.
Resident #46's PASRR level I, dated 8/20/21, documented PTSD disorder as a major mental illness. It also documented depression as a mental disorder.
However, the PASRR level I did not document bipolar disorder as a major mental illness or anxiety as a mental disorder.
On 5/16/25 at 10:25 AM, the Social Worker #1 stated a new PASRR level I should have been completed to reflect Resident #46's diagnoses and have him properly evaluated for further mental health services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it was determined the facility failed to ensure professional standards of practice were followed for 2 of 2 residents (Resident #38, #43) reviewed for bowel management. This failure created the potential for adverse outcome when standards of practice were not followed for bowel management.
The CDC website's article titled, Guidelines on Bowel Care, accessed on 5/21/25 recommended that long-term care facilities prioritize bowel care and implement practices to prevent and manage constipation and other bowel-related issues, especially in residents at risk. This includes proactive strategies for residents with bowel incontinence or constipation.
1. Resident #38 was readmitted to the facility on [DATE], with multiple diagnoses including mild cognitive impairment and hemorrhoids.
Resident #38's care plan, revised 11/25/19, directed staff to offer bowel interventions and encourage Resident #38 to sit on the toilet to promote bowel movements.
Resident #38's MAR, dated 3/1/25 - 5/14/25 documented the following physician's order:
- Colace capsule 100 mg by mouth in the morning for constipation and hemorrhoids. Discontinued on 5/14/25.
- Senna oral tablet give 17.2 mg by mouth every 12 hours for constipation. Discontinued on 5/14/25.
- MiraLax Oral powder give 1 scoop by mouth as needed for constipation one time a day.
- Bisacodyl oral tablet give 10 mg by mouth as needed for no documented bowel movement following administration of milk of magnesia.
Resident #38's MAR did not include a physician's order for milk of magnesia.
Resident #38's bowel record, dated 3/1/25 - 5/14/25, documented no bowel movement on the following dates:
3/1- 3/3 (3-days)
3/6-3/9 (4-days)
3/13-3/16 (4-days)
3/18-3/23 (6-days)
3/26-3/29 (4-days)
4/4-4/7 (4-days)
4/26-4/29 (4-days)
5/6-5/13 (8-days)
Resident #38's record did not document additional bowel management interventions when Resident #38 did not have a bowel movement for 3 or more consecutive days.
2. Resident #43 was readmitted to the facility on [DATE], with multiple diagnoses including dementia and constipation.
Resident #43's care plan, revised 8/3/24, directed staff to monitor bowel movements and offer dietary bowel interventions.
Resident #43's MAR did not include physician's orders for bowel management.
Resident #43's bowel record, dated 3/1/25 - 5/14/25 documented no bowel movement on the following dates:
3/10-3/12 (3-days)
3/18-3/22 (5-days)
3/26-3/29 (4-days)
4/1-4/4 (4-days)
4/25-4/27 (3-days)
5/11-5/13 (3-days)
On 5/15/25 at 9:01 AM, the DON stated the Licensed Nurse should obtain an order for bowel management and implement the order into the residents MAR for documentation. On review of Resident #38 and Resident #43's records, the DON stated there was no documentation Resident #38 and Resident #43 received bowel interventions when they did not have a bowel movement for 3 or more consecutive days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, it was identified the facility failed to ensure residents were properly monitored for pain management. This was true for 3 of 4 residents (Resident #8, #43, and #46) whose records were reviewed for pain management. This failure had the potential to create harm when residents were not monitored adequately for pain. Findings include:
1. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including chronic pain syndrome and non-pressure related chronic ulcers of bilateral legs.
Resident #8's quarterly MDS assessment, dated 2/25/25, documented he was cognitively intact.
A pain interview for MDS, dated [DATE], documented Resident #8 had moderate pain almost constantly during the past 5 days. The interview also documented Resident #8's day-to-day activities were limited because of pain.
Resident #8's care plan, revised on 6/10/24, documented the following interventions for pain:
- Position for comfort
- Assist with loose, comfortable clothing
Resident #8's record did not include documentation of pain interventions attempted as directed by his care plan.
A physician's order directed staff to apply 1 patch of Buprenorphine (an opioid pain medication) trans dermally one time every 7 days to Resident #8.
Resident #8's MAR dated 3/1/25 - 5/13/25, included a physician's order documenting, yes, to the following physician order for 74 of 74 days:
Pain monitor: Assess resident for pain. Intervene as appropriate every shift for scheduled pain medication use.
A pain assessment dated [DATE], documented Resident #8 had daily moderate pain characterized as arching, stabbing, and throbbing. Resident # 8's pain assessment documented his pain is worse during wound care and when staff move his legs. The pain assessment also documented his pain interferes with daily activity and he does not want to get out of bed because of it.
On 5/12/25 at 3:08 PM, Resident #8 stated he is constantly in pain from the top of his head to the tip of his toes. When asked what he does when his pain is not resolved Resident #8 stated, I just have to put up with it.
2. Resident #43 was readmitted to the facility on [DATE], with multiple diagnoses including chronic pain and dementia.
Resident #43's Significant Change in Condition MDS assessment, dated 3/26/25, documented he was cognitively intact.
Resident #43's care plan, revised on 1/4/21, documented the following care plan interventions for pain:
- Position for comfort
- Observe and report changes in usual routine, sleep patterns, decrease in function, and resistance of care.
Resident #43's record did not include documentation of interventions attempted.
Resident #43's pain assessment, dated 4/25/25 documented he has pain daily and described his pain as moderately aching.
Resident #43's MAR, dated 3/1/25 - 5/13/25, included a physician's order documenting, yes, to the following physician order for 74 of 74 days:
Pain monitor: Assess resident for pain. Intervene as appropriate every shift for scheduled pain medication use.
3. Resident #46 was readmitted to the facility on [DATE] with multiple diagnoses including lower back pain, bilateral foot pain, and anxiety.
Resident #46's care plan, revised 5/25/23, documented the following:
- Resident #46 can use the numeric scale for pain from 1 to 10.
- Apply left hand brace every morning and remove at bedtime.
- Offer non-pharmacological interventions such as change of position, exercise, and warm blankets.
Resident #46's did not include documentation of non-pharmacological interventions were offered.
Resident #46's Annual MDS assessment, dated 3/8/25, documented he was cognitively intact.
A pain assessment, dated 3/6/25 documented Resident #46 had moderate pain daily described as arching and throbbing. Resident #8's assessment also documented his pain interfered with activities of daily living.
On 5/13/25 at 9:03 AM, Resident #46 stated he had pain in his lower back. He also stated the nurse will often give him pain medication if he complains enough.
On 5/15/25 at 4:01 PM, the DON stated the Licensed Nurse is expected to act based on the pain assessment results. She also stated the facility has room for improvement to properly evaluate if a treatment plan is effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, medication error reports, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 15 of 39 residents (#3, #12, #15, #16, #27, #33, #37, #39, #44, #46, #52, #57, #64, #73, and #281) reviewed for medication errors. This deficient practice created the potential for harm when residents received the wrong dosage of medications or did not receive their prescribed medications. Findings include:
The facilities Procedure for Medication Errors/Omissions revised December 2015, documented a medication and treatment error report will be completed upon identification of any of the following:
-wrong resident
-wrong medication
-wrong dose
-wrong frequency
-wrong route
-omitted medication(s)
1. Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, chronic pain syndrome, and rheumatoid arthritis.
Resident #3's physician's order was for Oxycodone (opioid pain medication) 5 mg tablet by mouth twice per day for arthritic pain.
a.) A Medication Error Report documented a medication error occurred on the evening of 5/31/24, when the nurse discovered she had administered 30 mg of Morphine (opioid pain medication) to Resident #3 instead of his ordered 5 mg of Oxycodone.
On 5/14/25 at 11:35 AM, the DON confirmed the nurse administered Resident #3 the wrong medication when Morphine was given instead of Oxycodone.
b.) A Medication Error Report documented a medication error occurred on the morning of 9/12/24, when the nurse administered Lacosamide (anti-seizure medication) 100 mg instead of the ordered Oxycodone 10 mg to Resident #3. The resident was noted to be suffering from blurry, double vision as a result of the error.
On 5/14/25 at 11:40 AM, the DON confirmed the nurse administered Resident #3 the wrong medication when Lacosamide was given instead of Oxycodone.
c.) A Medication Error Report documented Resident #3 did not receive the following medications on the morning of 2/25/25:
-Aerobika 10-15 (treatment used to clear airway secretions)
-Albuterol 2.5 mg/3 ml (nebulizer treatment to prevent or treat airway spasms)
-apixaban 5 mg (anticoagulant - prevents blood clots)
-baclofen 5 mg (a skeletal muscle relaxant)
-Bupropion 75 mg (antidepressant)
-cranberry 500 mg (herbal product)
-finasteride 5 mg (used to treat enlarged prostate)
-lactase 9000 units (a supplement used to treat lactose intolerance)
-oxycodone 5 mg (opioid pain medication)
-prazosin 2 mg (antihypertensive)
-simvastatin 40 mg (lower cholesterol)
-Tylenol 1000 mg (pain and fever reducer)
On 5/14/25 at 11:45 AM, the DON confirmed the nurse failed to administer Resident #3 the entirety of his morning medications on 2/25/25.
2. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including mild cognitive impairment, fracture of left hip, and gout.
Resident #12's physician's order was for Oxycodone 5 mg tablet by mouth twice per day for pain.
The Medication Error Report documented a medication error occurred on 9/5/24, when Resident #12 did not receive his pain medication in the morning as ordered.
On 5/14/25 at 11:50 AM, the DON confirmed the nurse did not administer Resident #12's morning dose of Oxycodone.
3. Resident #15 was admitted to the facility on [DATE], with multiple diagnoses including dementia, hypertension, testicular hypofunction (a condition where the testes do not produce sufficient amounts of testosterone and/or sperm), and edema.
Resident #15's physician's order was for Furosemide (Lasix) 10 mg one time a day for lower extremity edema.
The Medication Error Report documented several nurses made a medication error on 5/10/24, 5/11/24, 5/12/24, 5/13/24, 5/14/24, and 5/15/24 when Resident #15 was administered Lasix 20 mg for each of the daily scheduled doses instead of the Lasix 10 mg that was ordered.
On 5/14/25 at 11:55 AM, the DON confirmed the nurses administered the wrong dose of Lasix to Resident #15 for six days.
4. Resident #16 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, hypertension, and heart disease.
The Medication Error Report documented a medication error occurred on 3/5/25, when the nurse administered Resident #16 another resident's medications. Resident #16 was noted to be suffering from drowsiness as a result of the medication error.
The medications administered were:
-Oxycodone 5 mg
-tamsulosin 0.4 mg ( used to treat enlarged prostates in men)
-gabapentin 400 mg (anti-convulsant)
-Tylenol 1000 mg
On 5/14/25 at 12:00 PM, the DON confirmed the nurse administered Resident #16 the wrong medications when she received another residents medications.
5. Resident #27 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia and diabetes.
Resident #27's physician's order was for Insulin glargine (long acting insulin) 25 units in the morning.
The Medication Error Report documented a medication error occurred on 2/5/25, when the nurse administered Resident #27 Insulin NPH (70/30) (intermediate acting Insulin) in the morning.
On 5/14/25 at 12:05 PM, the DON confirmed the nurse administered Resident #27 the wrong insulin on the morning of 2/5/25.
6. Resident #33 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (the upper chambers of the heart beat irregularly) and diabetes.
Resident #33's physician's order was for diltiazem (heart medication) 90 mg for treatment of atrial fibrillation.
The Medication Error Report documented a medication error occurred on 3/31/25, when the nurse failed to administer Resident #33 his diltiazem medication in the morning.
On 5/14/25 at 12:10 PM, the DON confirmed the nurse failed to administer Resident #33 his prescribed dose of diltiazem on the morning of 3/31/25.
7. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, pain in knee, and Major Depressive Disorder.
Resident #37's physicians order was for lorazepam (antipsychotic) 1 mg every day.
The Medication Error Report documented a medication error occurred on 3/31/25, when the nurse failed to administer Resident #37 Oxycodone 5 mg instead of his ordered lorazepam.
On 5/14/25 at 12:15 PM, the DON confirmed the nurse failed to administer Resident #33 his prescribed dose of lorazepam 1 mg and administered oxycodone 5 mg instead on the morning of 3/31/25.
8. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including stroke and sciatica (nerve pain that travels the longest nerve in the body).
Resident #39's physician's order was for Oxycodone 2.5 mg every 6 hours as needed for pain.
The Medication Error Report documented multiple medication errors occurred on 12/20/24 and 12/21/24 when multiple nurses administered Resident #39 Oxycodone 5 mg instead of the ordered 2.5 mg.
On 5/14/25 at 12:20 PM, the DON confirmed the nurses failed to administer Resident #39 his prescribed dose of oxycodone 2.5 mg on 3 separate occasions between the dates of 12/20/24 and 12/21/24.
9. Resident # 44 was admitted to the facility on [DATE], with multiple diagnoses including fracture of the bone around a prosthetic hip and chronic pain.
Resident #44's physician's order was for Oxycodone 5 mg every 6 hours as needed for pain.
The Medication Error Report documented a medication error occurred on 5/9/24, when the nurse administered Resident #44 Oxycodone 2.5 mg instead of the ordered 5 mg. The resident was noted to be suffering from anxiety from pain and unable to rest as a result of the error.
On 5/14/25 at 12:25 PM, the DON confirmed the nurse failed to administer Resident #44 his prescribed dose of Oxycodone 5 mg on 5/9/24.
10. Resident #46 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, diabetes and history of substance abuse.
Resident #46's physician's order was for Oxycodone 2.5 mg three times a day for pain.
The Medication Error Report documented the nurse reports she may have given Resident #46 an extra dose of Oxycodone 2.5 mg by mistake on 3/7/25. The nurse reported she had a missing dose at end of shift that day.
On 5/14/25 at 12:30 PM, the DON confirmed the nurse may have given Resident #46 an extra dose of oxycodone 2.5 mg on 3/7/25.
11. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including severe dementia and diabetes.
Resident # 52's physician's order was for Lantus (long acting Insulin) 25 Units in the morning.
The Medication Error Report documented a medication error occurred on 2/5/25, when the nurse administered Resident #52 Insulin NPH (70/30) 25 Units.
On 5/14/25 at 12:35 PM, the DON confirmed the nurse administered Resident #52 the wrong insulin on the morning of 2/5/25.
12. Resident # 57 was admitted to the facility on [DATE], with multiple diagnoses including pain in the left leg and pain in the lower back.
Resident #57's physician's order was for Oxycodone 7.5 mg three times a day.
The Medication Error Report documented a medication error occurred on 3/7/25, when the nurse failed to administer Resident #57 her Oxycodone 7.5 mg dose.
On 5/14/25 at 12:40 PM, the DON confirmed the nurse did not know if she gave Resident #57 her scheduled dose of oxycodone 7.5 mg on 3/7/25.
13. Resident #64 was admitted to the facility on [DATE], with multiple diagnoses including Major Depressive Disorder and PTSD.
Resident #64's physician's order was for bupropion 160 mg every day.
The Medication Error Report documented a medication error occurred on 1/4/25 through 1/11/25 (8 days) when multiple nurses administered Resident #64 bupropion 300 mg every day instead of the ordered 150 mg.
On 5/14/25 at 12:45 PM, the DON confirmed multiple nurses administered Resident #64 the wrong dose of bupropion over the span of 8 days before the error was discovered.
14. Resident #73 was admitted to the facility on [DATE], with multiple diagnoses including rhabdomyolysis (a condition that causes muscle pain) and low back pain.
Resident #73's physician's order was for Oxycodone 5 mg three times a day.
The Medication Error Report documented a medication error occurred on 3/7/25, when the nurse reported she was missing an extra dose of Oxycodone 5 mg, and she may have given the extra dose to Resident #73.
On 5/14/25 at 12:50 PM, the DON confirmed the nurse suspected she gave Resident #73 an extra dose of his Oxycodone 5 mg on 3/7/25.
15. Resident #281 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including dementia, diabetes, and fracture of the femur.
The Medication Error Report documented a medication error occurred on the morning of 10/9/24, when the nurse administered Resident #281 another residents medications. Resident #281 was noted to be suffering from somnolence as a result of the error.
The medications administered were:
-amlodipine 10 mg (lowers blood pressure)
-Magnesium oxide 400 mg (supplement)
-clopidogrel bisulfate 75 mg (antiplatelet)
-wixela inhub inhalation aerosol powder 250-50 mcg/act (asthma treatment)
-gabapentin 900 mg
-leflunomide 20 mg (anti-inflamatory)
-Risperdal potassium 2 mg (antipsychotic)
-losartan potassium 50 mg (lower blood pressure)
-sertraline 200 mg (antidepressant)
On 5/14/25 at 12:55 PM, the DON confirmed the nurse administered Resident #281 the wrong medications on 10/9/24.
On 5/14/25 at 1:00 PM, the DON stated the expectation was for the RN Manager assigned to each floor to provide education and training after a medication errror occured. She could not provide any documentation of training or education being provided after these errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of staff schedules, policy review, license review, and staff interview, it was determined the facility failed to ensure nursing staff possessed a license within the state where they provided care. This was true for 3 of 28 CNAs (CNA #4, CNA #5, CNA #6) and 2 of 22 Licensed nurses (LPN #1, and LPN #2) whose certifications and licenses reviewed. This deficient practice had the potential to affect all 77 residents in the facility. This failure created the potential for harm if residents received inappropriate care due to a staff lacking the required credentials to provide nursing care. Findings include:
The facility's policy for Licensed Nurse Credentialing and License Verification, dated [DATE], documented the following:
- Credentials and license are evaluated annually for performance appraisal for each licensed nurse.
- Reverification of license is required at the intervals set by the Board of Nursing of this State. Licensed nurses are required to renew their license prior to the expiration of their license.
- If the licensed nurse has not renewed their license prior to the expiration date, the nurse may not work past midnight of the expiration date of his/her current license.
Review of the CNA's certification and licensed nurses currently employed documented the following:
- CNA #4's certificate expired [DATE].
- CNA #5's certificate expired [DATE].
- CNA #6's certificate expired [DATE].
- LPN #1's license expired [DATE].
- LPN #2's license expired [DATE].
On [DATE] at 8:15 AM, the Administrator and DON confirmed CNA #4, CNA #5, and CNA #6's, certifications were expired, and LPN #1 and LPN #2's licenses were expired, and they should not have been working in the facility.

Based on observation, record review, policy review, I&A report review, review of Quality Assurance Performance Improvement (QAPI) meeting minutes, and staff interview, it was determined the facility failed to ensure a QAPI plan was developed and implemented. This failure impacted 15 of 39 residents (#3, #12, #15, #16, #27, #33, #37, #39, #44, #46, #52, #57, #64, #73, and #281) whose records were reviewed for medication errors and had the potential to affect the other 38 residents residing in the facility. This created the potential for harm if residents received substandard quality of care from lack of identification and correction to quality deficiencies such as medication errors, staff training, and staff certification and licensure. Findings include:
The facility's QAPI Plan, undated, documented:
-Use quality assurance and performance improvement to make decisions to guide day-to-day operations.
-Improve the quality of care and quality of life of residents with the outcome of QAPI.
-QAPI includes all employees, all departments, and all services provided.
-QAPI focuses on systems and processes to identify system gaps versus individuals.
-Decisions are based on data which includes the input and experiences of caregivers, residents, health care practitioners, families, and other stakeholders.
-Goals are set for performance and measured progress towards those goals.
The facility's QAPI Plan, dated October 2024, documented the facility's QAPI Performance Improvement Plan (PIP) goals for the 2024-2025 fiscal year. These PIP goals included:
1. Facility will reduce for Moderate/Severe pain national percentile of 93% to 80% with a final goal of 75% by 12/31/25.
2. Facility acquired pressure ulcers (PU) will be below 2% monthly by 12/31/25.
3. Facility will reduce or eliminate psychotropic medications on new admissions within 14-days post admit except when it is documented to be medically inappropriate by 12/31/25.
The following records were reviewed:
A. I&A reports May 2024 through May 2025:
-Thirty-nine medication errors reviewed, and 15 were identified as significant medication errors.
B. Staff Licensure and Certification:
- Three of 28 CNAs (CNA #3, CNA #4, and CNA #5) did not have current certification.
- Two of 22 Nurses (LPN #1 and LPN #2) did not have a current license.
C. CNA training requirements:
-Two of 28 CNAs (CNA #8 and CNA #9) did not have the 12-hr annual training.
QAPI meeting attendance was reviewed, documenting monthly meetings were attended by the Medical Director, Administrator, DON, IP, Pharmacist, Activity Director, and other facility staff.
On 5/16/25 at 12:59 PM, the Administrator, with the DON present, stated QAPI meetings were held monthly. The Administrator stated any concerns in the facility were brought to and discussed in the QAPI meeting. At each meeting, the Administrator stated the QAPI reports were reviewed which identified trending patterns in multiple areas including facility-initiated discharges, facility incident reports (i.e. falls, falls with injury, medication errors), wounds, catheters, elimination, infection control, antibiotic stewardship, physical restraints, mobility and ADL (activities of daily living), resident mobility safety, and therapy.
The April 2025 QAPI report, reviewed at the 5/14/25, QAPI meeting documented trends from January 2025 through April 2025:
-Medication errors for 2025: January - 3 errors; February - 6 errors; March - 5 errors.
No PIP or QAPI Plan was documented for the medication errors.
-Human resources: No documented concerns with employee certification or licensure were noted. There were no documented concerns regarding required annual nurse aid training.
A review of the May 2025 meeting minutes documented:
-New business updates for PIP related to UTI's and PU's to be provided the week of 5/19/25.
On 5/16/25 at 1:16 PM, the DON, with the Administrator present, was asked how the QAPI meeting used the QAPI report if the metrics were not addressing the identified PIPs approved in October 2024. The DON stated, We review the [monthly] trends, medication type of error, and educate staff individually, if needed, and address the concerns immediately. However, I did not document those [trainings]. Recently, I had an Administration Medication Error in-service, but I cannot remember the date it was provided. The DON stated she should be documenting these monthly corrective action plans and staff education. The DON stated there was no documented record on file for any monthly corrective action plans.
Surveyors exited the facility on 5/16/25 at 3:00 PM. No additional information was provided regarding the Administration Medication Error in-service training which had been provided to the nursing staff.
The facility's QAPI program failed to provide sufficient monitoring and oversight to sustain regulatory compliance as evidenced by the citations the facility received.

Based on observation and staff interview it was determined the facility failed to ensure appropriate infection control measures were maintained. This was true when CNA #7 failed to remove personal protective equipment after coming in contact with a resident on enhanced barrier precautions, and RN#1 failed to perform hand hygiene prior to application of a clean dressing. This failed practice created the potential for adverse outcomes including infection due to cross contamination. Findings include:
1. The CDC website's article titled Consideration For Use Of Enhanced Barrier Precautions accessed on 5/23/25, documented effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE with hand hygiene products at the point of care.
On 5/13/25 at 9:34 AM, during a resident to staff interaction observation CNA #7 was observed leaving the shower room to take a resident back to his room while wearing a gown and a mask. CNA #7 took the resident to his room and removed her gown in his room before exiting. She then proceeded to enter the following room with her mask on to talk to another resident.
On 5/13/25 at 9:40 AM, CNA #7 stated she had not been informed of the proper location to remove her gown and mask after bathing a resident on enhanced barrier precautions. She also stated her understanding of utilizing enhanced barrier precautions was to protect others if the resident may have had a contagious infection in his wound, and she should have removed the gown and mask prior to leaving the shower room.
2. The CDC website's article titled Hand Hygiene for Healthcare Workers accessed on 5/23/25, documented hand hygiene is recommended before moving from working on a soiled body site to a clean body site on the same patient.
On 5/15/25 at 11:22 AM, during a wound care observation RN #1 was observed to performed hand hygiene with application of gloves. She then proceeded to remove the dirty dressing on Resident #8's left lower leg by soaking it with normal saline to discard the dressing. After the dressing was removed RN #1 cleansed the site and used gauze to pat dry. She then proceeded to apply gauze soaked in briotech (a solution used to target and eliminate bacteria as well as help new skin cell growth on wounds). RN #1 was not observed performing hand hygiene before applying the briotech.
RN #1 removed her dirty gloves, performed hand hygiene, and proceeded to remove the dirty dressing from Resident #8's right lower leg. After removing the dirty dressing and cleansing with normal saline RN #3 then applied gauze soaked in briotech around the right lower leg. RN #1 was not observed performing hand hygiene before applying the briotech.
RN #1 was observed once again removing her gloves performing hand hygiene and applying clean gloves. She returned to Resident #8's left lower leg removed the soaked gauze and applied the clean dry dressing around the left lower leg. RN #1 removed her gloves, performed hand hygiene, and applied gloves, she then proceeded to Resident #8's right lower leg. She removed the soaked gauze and applied the clean, dry dressing.
On 5/15/25 at 12:01 RN #1 stated briotech is a clean dressing and hand hygiene should be performed prior to applying the dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to ensure pneumococcal immunizations were administered consistent with the current CDC recommendations. This was true for 2 of 5 residents (#39 and #72) reviewed for pneumococcal immunizations. This failure increased residents' risk for contracting pneumonia with potential negative outcome. Findings include:
The CDC website's article titled Pneumococcal Vaccine Recommendations, dated 10/26/24, and accessed on 5/19/25, documented for routine vaccination, administer PCV 15, PCV 20, or PCV 21 for all adults 50 years or older:
- Who have never received any pneumococcal conjugate vaccine.
- Whose previous vaccination history was unknown.
If PCV 15 was used, administer a dose of PPSV 23 one year later.
If PCV 20 or PCV 21 was used, a dose of PPSV 23 is not indicated. Regardless of which vaccine was used (PCV 20 or PCV 21), their pneumococcal vaccination were complete.
1. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke.
There was no documentation in Resident #39's record he was offered or received the pneumococcal immunization.
On 5/15/25 at 1:20 PM, the DON with the IP present stated they were unable to find documentation Resident #39 was offered the pneumococcal immunization.
2. Resident #72 was admitted to the facility on [DATE], with multiple diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke and heart failure.
There was no documentation in Resident #72's record he was offered or received the pneumococcal immunization.
On 5/15/25 at 1:20 PM, the DON with the IP present stated they were unable to find documentation Resident #72 was offered the pneumococcal immunization.

Based on personnel record review and staff interview it was determined the facility failed to ensure an effective training program was maintained. This was true for 3 of 5 personnel records reviewed for training requirements. This failure created the potential for adverse outcomes including harm when staff were not educated on abuse protocols and did not have the minimum required training to provide direct care to residents in the facility. Findings include:
1. On 5/15/25 at 1:17 PM, during a personnel record review CNA #8's training record documented a total of 11.80 hours was completed out of the minimum annual 12-hour requirement.
2. On 5/15/25 at 1:21 PM, during a personnel record review CNA #9's training record documented a total of 1 hour was completed out of the minimum annual 12-hour requirement.
CNA #9's record did not include training for abuse and neglect, dementia care, resident rights, and effective communication.
On 5/16/25 at 10:01 AM, the Staff Development Coordinator stated CNA #8 and CNA #9 did not complete the training required and should have.
3. On 5/16/25 at 10:45 AM, Housekeeper #1 stated she had been employed with the facility for 2 years and had not received any abuse and neglect training. She also stated if she witnessed or heard a resident being abused, she would not intervene but would notify a supervisor or the nurse on shift.
The facility was unable to provide documentation Housekeeper #1 received abuse and neglect training.
On 5/16/25 at 11:28 AM, the DON stated Housekeeper #1 did not have any abuse and neglect training but she should have.

Based on policy review, observation, and staff interview, it was determined the facility failed to ensure one medication cart and one medication storage room were locked. This deficient practice placed residents at risk if they accessed other residents' medications, alcoholic beverages, or cigarettes stored in these areas. Findings include:
The facility's Medication Administration and Medication Orders policy, revised 12/2015, documented medication carts were locked when not in use. It also documented multi-use medical supplies, prescribed alcoholic drinks, and cigarettes were kept in the locked medication room.
1. On 12/1/21 at 9:01 AM, the medication cart on 2 [NAME] was observed. The drawers on the cart were opened easily with no key. The drawers contained multiple medications for residents and there was a locked narcotic box, a package of cigarettes, and a lighter. Staff were not present at the nurses' station where the medication cart was located. Resident #73 was present at the nurses' station feeding himself.
On 12/1/21 at 9:06 AM, RN #1 returned to the nurses' station, noticed the medication cart was unlocked, and locked the cart. RN #1 stated she was in a hurry caring for another resident and forgot to lock the medication cart. RN #1 confirmed the cart contained scheduled medications for residents.
2. On 12/1/21 at 9:40 AM, the 2 [NAME] medication storage room door was open. The medication storage room contained multi-use stock medications, needles, syringes, cigarettes, lighters, and prescribed alcohol beverages.
On 12/1/21 at 9:42 AM, LPN #1 entered the medication storage room without using a key to unlock the door.
On 12/1/21 at 9:45 AM, LPN #1 stated the door to the medication storage room was not closed all the way, and she did not have to use a key to enter the room.
On 12/1/21 at 3:05 PM, the DON stated the medication carts and medication storeroom were to be locked at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Idaho Vets - Boise F 657 - Revised
Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents' care plans were reviewed and updated as care needs changed. This was true for 1 of 16 residents (Resident #68) whose care plans were reviewed for smoking interventions. This deficient practice placed Resident #68 at risk of injury when his care plan was not updated to reflect his most recent smoking assessment. Findings include:
The facility's Care Plan Development policy, dated 8/2018, documented when a resident's comprehensive assessment identified a change in a resident's physical or mental functioning not identified in the care plan, the care plan would be updated.
This policy was not followed.
Resident #68 was admitted to the facility on [DATE], with diagnoses including
hemiplegia (paralysis of one side of the body), stroke, dementia, and changes in his mental status.
Resident #68's smoking care plan, dated 8/3/21, documented he had a potential for injury related to his smoking behaviors. The care plan documented Resident #68 was to have limited supervision with smoking.
Resident #68's quarterly Smoking Assessment, dated 10/14/21, documented he required supervised smoking.
An MDS assessment, dated 10/17/21, documented Resident #68 had moderate cognitive impairment.
A Behavior Progress Note, dated 11/25/21, documented Resident #68 went to the nurses' station to get his cigarettes. The note documented while the nurse was gone, Resident #68 opened the unlocked keyboard drawer on the medication cart and took his cigarettes and lighter from the cart without her knowledge.
On 11/29/21 at 4:12 PM, Resident #68 was observed smoking unsupervised on the facility's 2 [NAME] smoking patio.
On 11/30/21 at 10:45 AM, Resident #68 asked a nurse for a cigarette. The nurse opened the top drawer of the medication cart and handed a pack of cigarettes to another staff member. The nurse instructed the staff member to take Resident #68 to the smoking patio. At 10:55 AM, Resident #68 was observed on the smoking patio unsupervised holding a cigarette with his left hand.
Resident #68's care plan did not include the updated quarterly smoking assessment documenting Resident #68 was to have supervised smoking.
On 12/1/21 at 9:53 AM, the UM stated Resident #68 was on semi-supervision for smoking. The UM stated semi-supervision was when a resident came to the nurses' station and requested smoking materials, went out to smoke, then returned the smoking materials to the nurse when finished. She stated it was not necessary for staff to monitor Resident #68 while he smoked. The UM reviewed the most recent smoking assessment for Resident #68 and stated she was not aware of the change in his smoking supervision. The UM stated the smoking care plan was not revised to reflect the resident's smoking supervision changes.
On 12/1/21 at 3:15 PM, the DON reviewed the documentation in Resident #68's record related to his cigarettes, lighter, and smoking needs. The DON stated Resident #68's care plan should have been revised to reflect the changes needed for his level of smoking supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, record review, I&A report review, and staff interview, it was determined the facility failed to ensure residents received the level of supervision necessary to ensure tresidents with diminished cognitive ability did not elope from the facility and to ensure safe smoking practices. This was true for 2 of 17 residents (#45 and #68) reviewed for supervision. The facility's failure to implement and maintain supervision measures to prevent elopement placed Resident #45 at risk of physical harm when he eloped undetected from the facility and was found outside after dark in the rain sitting in his wheelchair which was stuck in a gutter.The facility's failure to proide supervision and care plan intervientions placed Resident #68 at risk for physical harm if he should burn himself related to unsafe smoking practices. Findings include:
Findings include:
1. The facility's Elopement Risk Assessment policy documented the following:
* A quarterly elopement risk assessment was completed to coincide with the MDS assessment schedule.
* If residents demonstrated verbally or a physical attempt to elope from the facility, a new elopement risk assessment was completed.
* 15-minute checks would be implemented for 8 hours for residents who were exit seeking unless the resident resided on the SCU. Residents who were exit seeking would have an elopement risk assessment completed and their care plan updated.
* Two or more episodes of exit seeking by a resident would result in one-on-one supervision unless the resident resided on the SCU.
This policy was not followed.
Resident #45 was admitted to the facility on [DATE], with multiple diagnoses including dementia, anxiety disorder, and psychosis (a severe mental disorder where thought and emotions are impaired and the person losses touch with external reality).
Resident #45's elopement risk assessment, dated 9/26/21, documented he was ambulatory, self-mobile in his wheelchair, and cognitively impaired with poor decision-making skills. It documented Resident #45 had a wandering history but no exit-seeking behavior.
Resident #45's elopement care plan, revised 10/7/21, documented if he left the facility, he would have an escort at all times. His elopement interventions documented he was to have a Roam Alert bracelet (part of a system that protects wandering-prone residents by controlling exit doors) under the seat of his wheelchair, and it was to be monitored for proper placement and function.
Resident #45's TAR for October and November 2021 documented staff were to check the Roam Alert operation and placement located under the wheelchair seat every evening and document if it was operational.
A behavior monitoring report, dated 10/1/21 - 11/1/21, documented staff were to monitor Resident #45's behaviors, including wandering.
A progress note, dated 10/21/21, documented Resident #45 left his unit located on the second floor at approximately 11:15 AM, and he was found by the security guard and other staff on the first floor. The note documented he became angry with them and declined to return to the unit. The note doxumented the SW located him and he agreed to come bact to 2 West. Resident #45's behavior monitoring report, dated 10/21/21 did not include documentation of his wandering.
An occupational therapy note, dated 10/27/21, documented due to Resident #45's significant functional and cognitive decline, it was recommended to transfer him to the facility's SCU and to implement pressure alarms for his bed and wheelchair to increase safety during self-transfers.
A social worker progress note, dated 10/26/21 at 11:30 AM, documented the social worker accompanied Resident #45 to the SCU and observed him for about one hour during lunchtime. The note documented Resident #45 expressed he wanted to go back to his old unit after lunch, and he called it home. The IDT decided not to move Resident #45 to the SCU due to the concern the room change would trigger an increase in Resident #45's anxiety and behavior symptoms.
An I&A report, dated 11/1/21, documented Resident #45 was found around 7:15 PM outside the facility in the dark and rain. His wheelchair was stuck in the gutter drainage grid in the front parking lot of the facility. A staff member assisted him back to his unit through the front entrance door. When Resident #45 passed by the front entrance door to enter the building, the Roam Alert was functional and sounded an alarm. Resident #45's behavior monitoring report, dated 11/1/21 did not include documentation of his wandering.
A progress note dated 11/2/21, documented Resident #45 was having episodes of exit seeking and his guardian/daughter agreed to move him to a room in the SCU on 11/2/21.
The facility's investigation report, dated 11/2/21 - 11/4/2, documented Resident #45 had episodes of exit-seeking behavior and used a Roam Alert bracelet. The report documented on 11/1/21 at 6:30 PM, the DON noticed the Roam Alert was sounding an alarm, and Resident #45 was attempting to leave the facility from the entrance door. The DON escorted Resident #45 back to his unit located on the second floor and reported this attempt to leave the facility to his staff nurse.
Resident #45's record did not include an elopement risk assessment after the 11/1/21 elopement. His record did not include documentation he was placed on15-minute safety checks or one-on-one supervision after each exit-seeking behavior occurred according to the facility's policy.
On 12/3/21 at 10:25 AM, the DON stated Resident #45 had wandering behaviors. She said the facility should have monitored and documented Resident #45's episodes of exit-seeking behavior.
The facility failed to provide Resident #45 with sufficient supervision and monitoring to prevent elopement from the facility.
2. The facility's Smoking policy, revised 6/2020, documented residents were assessed for their safety and ability to handle their smoking materials. The policy stated residents' smoking abilities were re-assessed in the event of a change in condition, change in function, start or change of portable oxygen, or quarterly.
The facility's Smoking Regulation policy, undated, stated smoking was only allowed in designated areas, and smoking in resident rooms was strictly prohibited. The policy stated all staff members were responsible for ensuring smoking regulations were enforced at all times.
These policies were not followed.
Resident #68 was admitted to the facility on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body), stroke, dementia, and changes in his mental status.
An MDS assessment, dated 10/17/21, documented Resident #68 had moderate cognitive impairment.
Resident #68's care plan for smoking, initiated 8/23/21, documented the following:
* Nursing staff were to keep his smoking materials and give them to Resident #68 as he was leaving to smoke
* Remind him to return the smoking materials when he finished smoking
* Observe him for unsafe smoking behaviors such as sleeping with lit cigarettes, not wearing a smoking apron, or smoking in non-designated smoking areas.
A behavior progress note, dated 8/28/21, documented Resident #68 had 3 partially smoked cigarettes in his room. The note documented the UM was notified of the cigarettes, and the UM educated Resident #68 on smoking and the facility's smoking policy.
Resident #68's quarterly Smoking Assessment, dated 10/14/21, documented he required supervised smoking.
A behavior progress note, dated 11/25/21, documented when the nurse was not present in the unit, Resident #68 opened the keyboard drawer on the medication cart and took his cigarettes and lighter.
On 11/29/21 at 4:12 PM, Resident #68 was observed smoking on the 2 [NAME] smoking patio. He was not wearing a smoking apron.
On 12/2/21 at 9:53 AM, the UM stated Resident #68 could come to the nurses' station and request smoking materials, smoke, and return the smoking materials to the nurse when he was finished
On 12/1/21 at 10:10 AM, the UM stated the interventions for smoking in Resident #68's care plan were not followed.
On 12/1/21 at 3:05 PM, the DON said she was unaware Resident #68 accessed the medication cart to get his cigarettes. She stated Resident #68's cigarettes should be placed in a more secure location.
The facility failed to ensure safe smoking practices were implemented for Resident #68.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and policy review, it was determined the facility failed to ensure all allegations of potential abuse were thoroughly investigated. This was true for 1 of 3 residents (#76) who were reviewed for potential abuse and neglect. The failure created the potential for harm when suspected abuse was not immediately reported to the Administrator or designee, a resident was not protected, and an investigation of potential abuse for Resident #76 was not investigated. Findings include:
An undated facility policy titled, Freedom from Abuse, Neglect and Exploitation, documented a person who had knowledge of potential acts of abuse, neglect, exploitation or misappropriation of resident property would report the information to an immediate supervisor or the charge nurse. The policy documented the charge nurse would report the incident to the Administrator. The policy documented all alleged violation would be thoroughly investigated by the facility. The policy documented all suspected cases of abuse would be investigated following the guidelines set forth by the Bureau of Facility Standards. The policy documented after an allegation was received, the facility would protect the resident from potential further crimes. The policy documented the facility would interview staff and obtain written, dated and signed statements from direct care staff assigned to the resident. The policy documented the residents' clinical record should reflect the following questions answered of who, what, where, and when related to the incident.
Resident #76 was admitted to the facility on [DATE], with diagnoses which included vascular dementia without behavioral disturbance, chronic pain, hemiplegia (paralysis/weakness on one side of the body), and urinary incontinence.
An admission MDS assessment, dated 9/18/18, documented Resident #76 had short and long-term memory problems and was severely cognitively impaired. The MDS assessment documented he exhibited physical behaviors that included hitting, kicking, pushing, scratching, grabbing, and these behaviors significantly interfered with resident cares. The MDS assessment documented he exhibited rejection of care in 1-3 of 7 days. The MDS assessment documented Resident #76 required 2-person extensive assist with cares including bed mobility, transfers, and toilet use.
Physician Orders, dated November 2018, documented Resident #76 received Celexa (antidepressant) 20 mg daily for anxiety, depression, and dementia, and Seroquel (antipsychotic) 25 mg three times daily for worsening behaviors related to vascular dementia.
The care plan area addressing Resident #76's self care, dated 9/12/18, documented it was difficult to obtain Resident #76's cooperation with bathing and staff were to re-approach with different staff members as needed and at various times
The care plan area addressing Resident #76's behaviors, dated 9/12/18, documented he had the potential to be physically aggressive during cares. The care plan documented Resident #76 complied best when caregivers did things slow and verbalized what they were doing. The care plan documented Resident #76 benefited from conversations and 1:1 time and if he was angry and frustrated talking to his family sometimes helped.
On 11/8/18 at 1:50 PM, a person who wished to remain anonymous wanted to speak privately with a surveyor. The anonymous person (AP) stated she spoke with CNA #3 about an incident involving Resident #76. The AP stated CNA #3 told him/her one evening she was working with CNA #1 and they were assisting Resident #76 with cares. The AP stated CNA #3 said Resident #76 was combative and they held the resident hands to transfer him and held his hands down to change him. The AP stated he/she said to CNA #3 that the CNAs should have reapproached Resident #76. The AP told RN #1 immediately after hearing about the incident. RN #1 instructed the AP to write it up, sign and date it, and this was done by the AP. The AP could not find RN #1 to give him the signed document as requested, so he/she gave it to LMSW #1.
On 11/8/18 at 2:12 PM, the AP stated the incident occurred on 10/23/18 on the evening shift. The AP said RN #1 and LMSW #1 had the written statement.
On 11/8/18 at 2:38 PM, LMSW #1 identified LSW #1 as the lead investigator for the incident involving Resident #76. He said LSW #1 assisted with investigations and reported them and any allegations should be reported to the State Survey Agency. When LMSW #1 was asked if there was an abuse allegation/incident involving Resident #76, he responded yes he thought there was something and would look for documentation. LMSW #1 stated he had not received a written summary from staff members that he could recall.
On 11/8/18 at 2:45 PM, LMSW #1 reviewed the allegation/incident log with the surveyor and said there was no allegation of abuse documented for Resident #76 during the week of 10/23/18.
On 11/8/18 at 2:56 PM, RN #1 stated he reported suspected abuse immediately to LMSW #1 and the DON and then completed a risk management report. RN #1 stated if an allegation of abuse occurred he would ensure the resident was safe and remove the staff member from the floor if need be. RN #1 stated there was not an abuse allegation involving Resident #76 that he could recall.
On 11/8/18 at 3:15 PM, CNA #1 said Resident #76's behaviors changed fast, he could go from nice to swinging at CNA's quickly. CNA #1 stated Resident #76 liked it when staff members sat next to him. CNA #1 stated Resident #76's cares included the use of a sit-to-stand lift (used when residents are unable to transition from a seated position to standing position on their own). CNA #1 stated Resident #1 would sometimes swing and cuss if staff touched him. CNA #1 stated the aides tried to keep him safe and re-approach him multiple times. CNA #1 stated Resident #76 was incontinent, had pain issues, and switched gears fast. CNA #1 stated if he heard of an allegation of abuse, he would notify the nurse and he was unaware of an allegation of potential abuse involving Resident #76.
On 11/8/18 at 3:43 PM, CNA #3 said Resident #76 was confused, combative and did not know what was happening around him. CNA #3 stated if he was combative staff would talk to him and staff would take their time when providing cares. CNA #3 stated Resident #76 did not like peri-care provided and he would swear, punch, and kick staff. CNA #3 stated he was a two person assist partly because of his behaviors. CNA #3 was asked to describe the incident in October 2018 and she said she (CNA #3) and CNA #1 held his hands while they assisted Resident #76 into bed. After they (CNA #1 and CNA #3) assisted Resident #76 into bed, he allowed them to change him and Resident #76 thanked them. CNA #3 stated they did not utilize a sit to stand but a gait belt with a pivot transfer (stand, turn or pivot, then sit), so they could hold his hands and hold the gait belt. CNA #3 stated Resident #76 held the aides' hands with no screaming and crying. CNA #3 stated she received a phone call from RN #1 and LSW #1 about the cares during the incident. CNA #3 stated if a resident reported abuse, she would immediately go to her unit manager and tell them what occurred.
On 11/8/18 at 4:10 PM, CNA #1 said on the night of the incident, he never transferred Resident #76 with a gait belt. CNA #1 said the staff only used a sit to stand (lift) because Resident #76 would cry out and scream. CNA #1 stated someone walking by could hear him. CNA #1 stated if a gait belt was used to transfer Resident #76 he would be able to strike out at staff easier, however, a sit to stand gave Resident #76 something to hold onto (the handle bars). CNA #1 stated he did not receive a phone call about the incident from facility staff.
On 11/8/18 at 4:23 PM, RN #1 said he thought about things and did recall an incident involving Resident #76 and two CNAs that occurred approximately 10-15 days ago. RN #1 stated CNA #2 overheard other CNAs speaking, and the CNA's used bad wordage. RN #1 said he heard it from CNA #2 that the CNAs held Resident #76 down. RN #1 stated he called the DON and LSW #1. RN #1 stated he and LSW #1 called CNA #3 for clarification of the conversation and they did not call CNA #1. RN #1 said he concluded it was bad wordage.
On 11/8/18 at 5:19 PM LMSW #2, the Administrator, and the DON stated the following:
* LMSW #2 said the story she received was that CNA #2 overheard a staff member talking about how they assisted Resident #76 with cares, and Resident #76 became aggressive and the CNAs held him down to complete cares. The LMSW #2 said she would look for documentation on the incident. LMSW #2 stated as a social worker, she looks for willful intent. LMSW #2 stated RN #1 informed her there was no willful intent. LMSW #2 stated there were three social workers who each had their own unit to manage. LMSW #2 said the incident did not occur on her floor, so she reported the incident to the unit's social worker (LSW #1) for the unit's social worker to complete the investigation and report to the Administrator and the State Survey Agency. LMSW #2 stated an abuse investigation consisted of acquiring documentation from anyone involved, talk to other residents, other staff, and peers. LMSW #2 stated the staff examine the resident, complete an assessment, and then discuss the incident with the staff members. LMSW #2 said LSW #1 did not feel the incident should be reported and it was not reported.
* The Administrator stated he was not aware of the incident until surveyors started asking questions about it during the survey. The Administrator stated he would expect those involved in the investigation to talk to every staff member, including both staff members involved. The Administrator said the allegation reported was hearsay, and it was not made a formal allegation.
* The DON stated she was made aware of the situation. The DON said she received a text 10/27/18 from RN #1 that said a staff member overheard Resident #76 was held down. The DON said she trusted the staff had done what they needed to, so she did not follow up with the LSW #1 or RN #1. The DON said all allegations of abuse should be reported to the facility Administrator, however from talking to the staff, this incident did not appear to be potential abuse and did not need to be reported to the Administrator.
On 11/9/18 at 9:06 AM, LSW #1 said Resident #76 had a severe cognitive impairment related to alcohol use. LSW #1 stated Resident #76 had suffered from stokes and needed assistance with all ADLs. LSW #1 stated Resident #76 displayed behaviors of being combative, fearful, yelling, screaming, and cursing, but he could be nice. LSW #1 stated Resident #76 could get startled and then he was mean. LSW #1 stated Resident #76 did well with music and picture books. LSW #1 stated when Resident #76 was combative and refused cares, staff were to re-approach and/or get different staff members to assist. LSW #1 stated the allegation occurred when a staff member (CNA #2) overheard CNA #3 say Resident #76 was combative during cares, and the staff held him down during cares. LSW #1 stated CNA #2 was concerned and wrote up a statement as directed by social services. LSW #1 stated he and RN #1 spoke with CNA #3 over the phone and did not call CNA #1. LSW #1 stated CNA #3 detailed what occurred and stated the resident was combative, and CNA #1 and CNA #3 were blocking punches while they were performing cares, and not holding him down. LSW #1 said he did not document the phone call with CNA #3. LSW #1 said he discussed the call with LMSW #1, CNA #3, and RN #1, and they discussed how best to approach Resident #76, and deal with his combative behaviors. LSW #1 stated he received CNA #2's written statement from LMSW #1 after LMSW #1 had reviewed it.
On 11/9/18 at 9:39 AM, LMSW #1, said he reviewed CNA #2's written statement and it did not rise to the level of needing an investigation. LMSW #1 stated he did not know where the statement was located now.
On 11/9/18 at 12:45 PM, LMSW #2 said she could not find documentation regarding the incident/allegation related to Resident #76.
There was no documentation available of an investigation completed by the facility into the allegation of abuse for Resident #76.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and policy review, it was determined the facility failed to ensure all allegations of a potential abuse or neglect were reported to the Administrator and State Survey Agency within 2-24 hours. This was true for 1 of 3 residents (#76) reviewed for abuse/neglect and had the potential to adversely affect any resident experiencing a potential incident of abuse or neglect. The deficient practice created the potential for harm if potential abuse was not reported and investigated completely. Findings include:
An undated facility policy titled, Freedom from Abuse, Neglect and Exploitation, documented a person who had knowledge of potential acts of abuse, neglect, exploitation or misappropriation of resident property would report the information to an immediate supervisor or the charge nurse. The policy documented the charge nurse would report the incident to the Administrator. The policy documented all suspected cases of abuse would be investigated following the guidelines set forth by the State Survey Agency.
Resident #76 was admitted to the facility on [DATE], with diagnoses which included vascular dementia without behavioral disturbance, chronic pain, hemiplegia (paralysis/weakness on one side of the body), and urinary incontinence.
An admission MDS assessment, dated 9/18/18, documented Resident #76 had short and long-term memory problems and was severely cognitively impaired. The MDS assessment documented he exhibited physical behaviors that included hitting, kicking, pushing, scratching, grabbing, and these behaviors significantly interfered with resident cares. The MDS assessment documented he exhibited rejection of care in 1-3 of 7 days. The MDS assessment documented Resident #76 required 2-person extensive assist with cares including bed mobility, transfers, and toilet use.
Physician Orders, dated November 2018, documented Resident #76 received Celexa (antidepressant) 20 mg daily for anxiety, depression, and dementia, and Seroquel (antipsychotic) 25 mg three times daily for worsening behaviors related to vascular dementia.
The care plan area addressing Resident #76's self-care, dated 9/12/18, documented it was difficult to obtain Resident #76's cooperation with bathing and staff were to re-approach with different staff members as needed and at various times
The care plan area addressing Resident #76's behaviors, dated 9/12/18, documented he had the potential to be physically aggressive during cares. The care plan documented Resident #76 complied best when caregivers did things slow and verbalized what they were doing. The care plan documented Resident #76 benefited from conversations and 1:1 time and if he was angry and frustrated talking to his family sometimes helped.
On 11/8/18 at 1:50 PM, a person who wished to remain anonymous wanted to speak privately with a surveyor. The anonymous person (AP) stated she spoke with CNA #3 about an incident involving Resident #76. The AP stated CNA #3 told him/her one evening she was working with CNA #1 and they were assisting Resident #76 with cares. The AP stated CNA #3 said Resident #76 was combative and they held the resident's hands to transfer him and held his hands down to change him. The AP stated he/she said to CNA #3 that the CNAs should have re-approached Resident #76. The AP told RN #1 immediately after hearing about the incident. RN #1 instructed the AP to write it up, sign and date it, and this was done by the AP. The AP could not find RN #1 to give him the signed document as requested, so he/she gave it to LMSW #1.
On 11/8/18 at 2:12 PM, the AP stated the incident occurred on 10/23/18 on the evening shift. The AP said RN #1 and LMSW #1 had his/her written statement.
On 11/8/18 at 2:38 PM, LMSW #1 identified LSW #1 as the lead investigator for the incident involving Resident #76. He said LSW #1 assisted with investigations and reported them and any allegations should be reported to the State Survey Agency. When LMSW #1 was asked if there was an abuse allegation/incident involving Resident #76, he responded yes he thought there was something and would look for documentation.
On 11/8/18 at 2:45 PM, LMSW #1 reviewed the allegation/incident log with the surveyor and said there was no allegation of abuse documented for Resident #76 during the week of 10/23/18.
On 11/8/18 at 2:56 PM, RN #1 stated he reported suspected abuse immediately to LMSW #1 and the DON and then completed a risk management report. RN #1 stated if an allegation of abuse occurred he would ensure the resident was safe and remove the staff member from the floor if need be. RN #1 stated there was not an abuse allegation involving Resident #76 that he could recall.
On 11/8/18 at 3:15 PM, CNA #1 said Resident #76's behaviors changed fast, he could go from nice to swinging at CNA's quickly. CNA #1 stated Resident #76 liked it when staff members sat next to him. CNA #1 stated Resident #76's cares included the use of a sit-to-stand lift (used when residents are unable to transition from a seated position to standing position on their own). CNA #1 stated Resident #1 would sometimes swing and cuss if staff touched him. CNA #1 stated the aides tried to keep him safe and re-approach him multiple times. CNA #1 stated Resident #76 was incontinent, had pain issues, and switched gears fast. CNA #1 stated if he heard of an allegation of abuse, he would notify the nurse and he was unaware of an allegation of potential abuse involving Resident #76.
On 11/8/18 at 3:43 PM, CNA #3 said Resident #76 was confused, combative and did not know what was happening around him. CNA #3 stated if he was combative staff would talk to him and staff would take their time when providing cares. CNA #3 stated Resident #76 did not like peri-care provided and he would swear, punch, and kick staff. CNA #3 stated he was a two person assist partly because of his behaviors. CNA #3 was asked to describe the incident in October 2018 and she said she (CNA #3) and CNA #1 held his hands while they assisted Resident #76 into bed. After they (CNA #1 and CNA #3) assisted Resident #76 into bed, he allowed them to change him and Resident #76 thanked them. CNA #3 stated they did not utilize a sit to stand but a gait belt with a pivot transfer (stand, turn or pivot, then sit), so they could hold his hands and hold the gait belt. CNA #3 stated Resident #76 held the aides' hands with no screaming and crying. CNA #3 stated she received a phone call from RN #1 and LSW #1 about the cares during the incident. CNA #3 stated if a resident reported abuse, she would immediately go to her unit manager and tell them what occurred.
On 11/8/18 at 4:10 PM, CNA #1 said on the night of the incident, he never transferred Resident #76 with a gait belt. CNA #1 said the staff only used a sit to stand (lift) because Resident #76 would cry out and scream. CNA #1 stated someone walking by could hear him. CNA #1 stated if a gait belt was used to transfer Resident #76 he would be able to strike out at staff easier, however, a sit to stand gave Resident #76 something to hold onto (the handle bars). CNA #1 stated he did not receive a phone call about the incident from facility staff.
On 11/8/18 at 4:23 PM, RN #1 said he thought about things and did recall an incident involving Resident #76 and two CNAs that occurred approximately 10-15 days ago. RN #1 stated CNA #2 overheard other CNAs speaking, and the CNA's used bad wordage. RN #1 said he heard it from CNA #2 that the CNAs held Resident #76 down. RN #1 stated he called the DON and LSW #1. RN #1 stated he and LSW #1 called CNA #3 for clarification of the conversation and they did not call CNA #1. RN #1 said he concluded it was bad wordage.
On 11/8/18 at 5:19 PM LMSW #2, the Administrator, and the DON stated the following:
* LMSW #2 said the story she received was that CNA #2 overheard a staff member talking about how they assisted Resident #76 with cares, and Resident #76 became aggressive and the CNAs held him down to complete cares. The LMSW #2 said she would look for documentation on the incident. LMSW #2 stated as a social worker, she looks for willful intent. LMSW #2 stated RN #1 informed her there was no willful intent. LMSW #2 stated there were three social workers who each had their own unit to manage. LMSW #2 said the incident did not occur on her floor, so she reported the incident to the unit's social worker (LSW #1) for the unit's social worker to complete the investigation and report to the Administrator and the State Survey Agency. LMSW #2 said LSW #1 did not feel the incident should be reported and it was not reported.
* The Administrator stated he was not aware of the incident until surveyors started asking questions about it during the survey. The Administrator said the allegation reported was hearsay, and it was not made a formal allegation.
* The DON stated she was made aware of the situation. The DON said she received a text 10/27/18 from RN #1 that said a staff member overheard two CNAs saying they held Resident #76 down. The DON said she trusted the staff had done what they needed to, so she did not follow up with the LSW #1 or RN #1. The DON said all allegations of abuse should be reported to the facility Administrator, however from talking to the staff, this incident did not appear to be potential abuse and did not need to be reported to the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, observation, and record review, it was determined the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARR) were complete and accurate for 2 of 3 residents (#64 and #84) reviewed for PASARRs. The deficient practice had the potential to cause harm if residents required, but did not receive, specialized services for mental health needs while residing in the facility. Findings include:
1. Resident #64 was readmitted to the facility on [DATE], with diagnoses which included quadriplegia, major depressive disorder, bipolar disorder, anxiety disorder, and alcohol dependence in remission.
An admission MDS assessment, dated [DATE], documented Resident #64 was cognitively intact and he had minimal signs and symptoms of depression. The MDS documented Resident #76 had no signs of delirium, psychosis, behaviors, rejection of care or wandering. The MDS documented a level 2 PASARR evaluation was not completed despite qualifying diagnoses.
On [DATE] at 2:42 PM, Resident #64 was observed in bed watching television. Resident #64 stated he went to VA service providers when scheduled and he had no concerns.
Resident #64's Level 1 PASARR, dated [DATE], documented his PASARR was good for 30 days.
Resident #64's [DATE] Physician Orders included Paxil 20 mg for depression and Trazodone 150 mg for sleep.
The care plan area addressing Resident #64's PASARR I, dated [DATE], documented he met the requirements for NF (nursing facility) level of care per his PASARR screen level. The care plan documented staff were to ensure his PASARR reflected a thorough evaluation of Resident #64 and he was appropriately placed in a nursing facility with appropriate care and services.
On [DATE] at 8:20 AM, LMSW #2 stated the Resident #64 transferred from another nursing facility and his PASARR came with him and she did not question its accuracy. LMSW #2 reviewed the PASARR with the surveyor and LMSW #2 stated the PASARR showed the level 1 expired in 30 days in the prior nursing facility and a new PASARR should have had been completed. LMSW #2 stated Resident #64 had bipolar disorder and would require a Level 2 PASARR.
On [DATE] at 3:30 PM, LMSW #1 said the facility only received completed level 1 and level 2 PASARRs from transferring facilities. LMSW #1 said if the PASARR was incorrect or not done, the facility contacted the admission's director to obtain a correct/completed form from the transferring facility before the resident was admitted to the facility. LMSW #1 stated this was not completed prior to Resident #64's transfer.
2. Resident #84 was readmitted to the facility on [DATE], with diagnoses which included major depressive disorder and post-traumatic stress disorder (PTSD).
A Quarterly MDS assessment, dated [DATE], documented Resident #84 was cognitively intact. The MDS assessment documented he had no documented evidence of delirium, psychosis, behaviors, rejection of care, or wandering.
On [DATE] at 2:03 PM, Resident #84 was observed propelling himself down the hallway in his wheelchair.
Resident #84's PASARR Level 1, dated [DATE], documented all questions were answered No (including the question on psychoactive medications). The PASARR was signed by the physician on [DATE].
Resident #84's [DATE] Physician Orders, documented he received Lexapro 20 mg daily, ordered on [DATE].
The care plan area addressing Resident #84's PASARR, dated [DATE], documented he meet the requirements for NF level of care per his PASARR 1 screen. The care plan documented staff were to ensure his PASARR reflected a thorough evaluation of Resident #84 and he was appropriately placed in a nursing facility with appropriate care and services. The care plan documented his current PASARR was a level 1.
On [DATE] at 7:53 AM, LMSW #2 stated she was the social worker for the unit where Resident #84 lived. LMSW #2 said Resident #84 was on Lexapro and the form should have been sent to the state for review. LMSW #2 stated she did not have time to update PASARRs when there was a psychoactive medication change because she would be completing them all the time. LMSW #2 stated she spoke with the state about when the PASARR did not match with the medications and they told her that was ok, she did not need update the PASARR. LMSW #2 stated she should have sent a new PASARR to the state for Resident #84.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #87 was readmitted to the facility on [DATE], with which diagnoses included dementia and urinary and cardiac issues.
A Quarterly MDS assessment, dated 9/29/18, documented Resident #87 had severe cognitive impairment.
Resident #87's physician order dated 11/7/18, documented his medication duloxetine (a medication used to treat depression and pain) was increased from 20 milligrams (mg) orally every day to 60 mg each day.
Resident #87's current care plan documented he experienced pain, difficulty concentrating, fear of others causing him harm, and changes in sleep patterns.
Resident #87's care plan lacked specific behaviors staff were to monitor Resident #87 for and lacked interventions related to the use of the psychoactive medication, duloxetine.
On 11/8/18 at 1:25 PM, the Pharmacist confirmed the facility failed to develop and implement a resident specific care plan that described resident specific behaviors and included inventions related to his use of duloxetine.
Based on observation, record review and staff interview, it was determined the facility failed to develop resident-specific care plans. This was true for 3 of 6 residents (#30, #87, and #261) reviewed for psychotropic medications. The residents' care plans did not include resident specific behaviors related to the use of psychotropic medicatons and/or did not include behaviors for which the psychotropic medications were administered. This failure created the potential for residents to receive inappropriate or inadequate care with a subsequent decline in health. Findings include:
1. Resident #261 was admitted to the facility on [DATE], with diagnoses including dementia with Lewy bodies and behavioral disturbances, depression, and REM sleep disorder. Resident #261 passed away at the facility on 6/14/18.
A significant change MDS assessment, dated 6/7/18, documented Resident #261 was severely cognitively impaired and he was totally dependent or required extensive assistance from one to two staff members with cares. The MDS documented Resident #261 had signs and symptoms of mild depression and he exhibited delusions and hallucinations. The MDS documented Resident #261 had physical, verbal, and other behaviors 4-6 days a week.
Resident #261's June 2018 Physician Orders included:
- Ativan (antianxiety) 1 mg/ml by mouth every eight hours for agitation, ordered 6/6/18 and discontinued 6/14/18.
- Clonazepam (benzodiazepine, a central nervous system depressant used to treat seizure disorders and panic disorders) 0.5 mg by mouth two times a day for comfort and seizure control, ordered 6/1/18 and discontinued 6/6/18.
- Depakote (anticonvulsant) extended release 500 mg by mouth at bedtime for Lewy bodies dementia with hallucinations and agitation, order 6/1/18 and discontinued 6/12/18.
- Seroquel (antipsychotic) 50 mg two times a day for dementia with hallucinations, ordered 5/23/18 and discontinued 6/12/18.
- Seroquel 200 mg at bedtime for dementia with hallucinations, ordered 5/31/18 and discontinued 6/12/18.
- Topamax (anticonvulsant) 25 mg at bedtime for unstable mood, ordered 3/30/18 and discontinued 6/12/18.
- Ativan 0.5 mg by mouth every 1 hour PRN for agitation, ordered 6/5/18 and discontinued 6/14/18.
- Ativan 1 mg intramuscularly every 24 hours PRN for agitation, ordered 5/31/18 and discontinued 6/4/18.
- Ativan 1 mg intramuscularly every 24 hours PRN for agitation, ordered 6/4/18 and discontinued 6/14/18.
- Morphine Sulfate (narcotic) 10 mg sublingually every 2 hours PRN for pain and air hunger, ordered 6/1/18 and discontinued 6/14/18.
- Trazadone 50 mg (antidepressant) every 8 hours PRN for anxiety, ordered 5/23/18 and discontinued 6/12/18.
The care plan area addressing Resident #261's behaviors and mood documented he was cognitively impaired and had dementia. The care plan documented he had behavioral issues with hallucinations and delusions. The care plan documented Resident #261 had poor safety awareness, attempted to walk without assistance, experienced suicidal ideation, hit staff, was unable to walk, and required 1:1 supervision. Resident #261's care plan did not identify if Resident #261's hallucinations and delusions were tactile [touch], visual, auditory, or olfactory [smell]) and how they presented. The care plan did not include resident specific behaviors related to the hallucination and delusions and did not identify if they were harmful to Resident #261.
The care plan area addressing Resident #261's cognition documented he had impaired cognition related to Lewy body dementia, was rarely understood, and had difficulty understanding others. The care plan did not document how his dementia presented.
Resident #261 care plan did not identify how Resident #261's anxiety, agitation, and depression presented, or otherwise address them.
On 11/9/18 at 10:19 AM, LMSW #1 stated the specific behavior the resident exhibited should be documented in the resident's clinical record for all PRN psychotropic medication administrations. LMSW #1 stated the care plan should identify resident specific behaviors for dementia, hallucinations, and delusions and if they were harmful.
2. Resident #30 was readmitted to the facility on [DATE], with diagnoses including dementia.
A quarterly MDS assessment, dated 8/13/18, documented Resident #30 was severely cognitively impaired and he had no signs and symptoms of depression. The MDS documented he experienced no behaviors, hallucinations, delusions, rejection of cares, or wandering.
Resident #30's October 2018 Physician Orders included:
- Zyprexa (antipsychotic) 5 mg by mouth in the afternoon and evening for dementia, order 10/22/18.
- Trazadone (antidepressant) 100 mg at bedtime for insomnia, ordered 4/2/18.
- Trazadone 25 mg in the afternoon for anxiety, ordered 10/19/18.
The care plan area addressing Resident #30's behaviors/cognition, revised 5/23/18, documented he was cognitively impaired and had dementia. The care plan documented Resident #30 was angry and frustrated at times.
Resident #30''s care plan did not include resident specific behaviors, goals, and interventions related to dementia and anxiety.
On 11/9/18 at 9:56 AM, LMSW #1 stated Resident #30's dementia presented at confusion and increased anxiety. LMSW #1 stated Resident #30 care plan should address anxiety and the care plan area related to dementia should specify specify resident specific behaviors. LMSW #1 stated with the care plan missing this information it would make it difficult for agency staff to observe for those behaviors and document it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, and policy review, it was determined the facility failed to ensure residents were provided with bathing care consistent with their needs. This was true for 2 of 5 (#30 and #41) residents reviewed for bathing. This failure created the potential for residents to experience embarrassment, isolation, decreased sense of self-worth, skin impairment, and compromised physical and psychosocial well-being. Findings include:
The facility's Bathing policy and procedure, dated 10/2015, documented staff were to provide residents with bathing services at least once weekly or per resident preference.
a. Resident #41 was admitted to the facility on [DATE], with diagnoses including scoliosis, arthritis, and intervertebral disc disorder. Intervertebral disc disorder is a common condition characterized by the breakdown (degeneration) of one or more of the discs that separate the bones of the spine.
An admission MDS assessment, dated 8/22/18, documented Resident #41 was cognitively intact and was totally dependent or required extensive assistance from one to two staff members with all cares except eating.
The care plan area addressing Resident #41's bathing, revised on 10/3/18, documented staff were to assist her with bathing twice weekly.
Resident #41's ADL Bathing Record, dated 9/1/18 through 11/7/18, documented the staff were to complete showers twice weekly. Resident #41's record documented she was not provided a bath or shower between 9/21/18 and 10/1/18 (9 days), 10/4/18 and 10/11/18 (6 days), and 10/29/18 and 11/6/18 (7 days).
On 11/6/18 at 8:41 AM, Resident #41 stated the facility needed more staff. Resident #41 stated she did not always receive her showers twice a week. Resident #41 stated a staff member assisted her with her first shower in 8 days that morning (11/6/18).
b. Resident #30 was readmitted to the facility on [DATE], with diagnoses including dementia, osteoarthritis, and history of transient ishemic attacks (temporary blockages of blood flow to the brain).
A quarterly MDS assessment, dated 8/13/18, documented Resident #30 was severely cognitively impaired and he required extensive assistance from one to two staff members with all cares.
The care plan area addressing Resident #30's bathing documented Resident #30 preferred bathing on the PM shift.
Resident #30's ADL Bathing Record, dated 5/1/18 through 11/7/18, documented staff were to complete showers twice weekly. Resident #30's record documented he was not provided a bath or shower between 5/22/18 and 5/29/18 (6 days), 5/29/18 and 6/6/18 (7 days), 6/12/18 and 6/19/18 (6 days), 6/19/18 and 6/26/18 (6 days), 6/26/18 and 7/3/18 (6 days), 7/3/18 and 7/10/18 (6 days), 7/21/18 and 7/28/18 (6 days), 9/21/18 and 9/28/18 (6 days), and 10/5/18 and 10/16/18 (10 days).
c. The facility tracked baths on a secondary document titled the Bath List. The April through June 2018 Bath List documented multiple days when the bath aide was reassigned to work the floor. The days the shower aide was reassigned to work the floor were 4/11/18, 4/12/18 part of the day, 5/1/18, 5/2/18 part of the day, 5/8/18, 5/9/18, 5/16/18, 5/17/18, 5/21/18, 5/27/18, 5/29/18 part of the day, 6/1/18 part of the day, 6/5/18 part of the day, 6/12/18, 6/17/18, 6/18/18, 6/21/18 part of the day, 6/24/18 part of the day, and 6/25/18.
The October 2018 Bath List documented multiple days when the bath aide was reassigned to work the floor. The days the shower aide was reassigned to the floor were 10/7/18, 10/9/18, 10/17/18, 10/23/18, 10/24/18 for half the day, and 10/30/18.
On 11/8/18 at 1:21 PM, CNA #6 stated she was currently working as a RNA. CNA #6 stated she was reassigned to work the floor often and had been reassigned as a bath aide for most of October 2018. CNA #6 stated when she was working as a bath aide, residents had complained about not receiving showers. CNA #6 stated there were days she could not complete all showers and she would attempt to complete the residents' showers the next day if they missed one.
On 11/8/18 at 1:26 PM, CNA #9 stated she worked as a bath aide and she was reassigned to work the floor approximately two to three times a week during bad weeks. CNA #9 stated she was expected to complete the residents' showers if she was reassigned and she could not always complete all the showers. CNA #9 stated if residents were unable to receive a shower she attempted to complete the task on the make up day. CNA #9 stated she tried to provide at least 1 shower a week and she ensured residents with skin or incontinence issues received their showers twice a week if she was reassigned.
On 11/8/18 at 10:02 AM, the DON stated residents should have baths twice weekly at least unless the resident requests differently. The DON stated some residents request one shower a week and others request showers more often. The DON stated the shower aides were reassigned to work the floor when CNAs called in or were sick. The DON stated the nurse managers on the floors decided who to reassign to the floor duty. The DON stated she was aware of the shower aides being reassigned to work the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, policy review, and record review, it was determined the facility failed to ensure residents received treatment and services to prevent further decrease in range of motion (ROM). This was true for 3 of 5 residents (#27, #30, and #41) reviewed for treatment and services related to ROM. This deficient practice placed residents at increased risk of experiencing a decrease in mobility and function due to lack of active ROM (AROM) or passive ROM (PROM) services. Findings include:
The facility's undated, Restorative policy and procedure documented staff were to provide restorative services to prevent contractures, restore normal movement, maintain function and prevent further deterioration of joints and muscles, and develop and retrain muscles.
a. Resident #27 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including obesity, spinal cord injury, paraplegia, and subluxation of the distal radioulnar joint of the left wrist (partial dislocation of wrist joint).
A significant change MDS assessment, dated 8/12/18, documented Resident #27 was cognitively intact and he required extensive assistance from one to two staff members with all cares except eating. The MDS assessment documented Resident #27 had a ROM impairment to one of his lower extremities.
The care plan area addressing Resident #27's AROM, dated 1/24/18, documented he was to do AROM to his upper and lower extremities 6-7 days a week. The care plan documented the staff was to assist Resident #27 with AROM exercises of 10 repetitions for his cervical flexion, extension, and rotation twice daily and 10 repetitions to his bilateral upper and lower extremities twice daily.
The care plan area addressing Resident #27's PROM, dated 1/24/18, documented he was to do PROM to his upper and lower extremities 6-7 days a week. The care plan documented staff was to assist Resident #27 with 10 repetitions of PROM to his bilateral upper and lower extremities twice daily. The care plan documented staff should perform gentle stretches to each joint twice daily.
Resident #27's ADL AROM documentation, dated 10/1/18 through 11/7/18, documented staff completed AROM for 15 minutes on 10/3/18, 10/5/18, 10/16/18, 10/19/18, 11/1/18 through 11/4/18, 11/6/18, and 11/7/18. Resident #27 did not receive AROM 24 days during the time frame.
Resident #27's ADL PROM documentation, dated 10/1/18 through 11/7/18, documented staff completed PROM for 15 minutes on 10/3/18, 10/5/18, 10/16/18, 10/19/18, 11/1/18 through 11/4/18, 11/6/18, and 11/7/18. Resident #27 did not receive PROM 24 days during the time frame.
On 11/5/18 at 2:25 PM, Resident #27 stated he did not receive his restorative therapy daily. Resident #27 stated the staff did not always have time to complete his restorative therapy.
b. Resident #41 was admitted to the facility on [DATE], with diagnoses including scoliosis, arthritis, and intervertebral disc disorder. Intervertebral disc disorder is a common condition characterized by the breakdown (degeneration) of one or more of the discs that separate the bones of the spine.
An admission MDS assessment, dated 8/22/18, documented Resident #41 was cognitively intact and was totally dependent or required extensive assistance from one to two staff members with all cares except eating. The MDS assessment documented Resident #41 had bilateral ROM impairments to her lower extremities.
The care plan area addressing Resident #41's AROM, dated 9/6/18, documented she was to do 10 repetitions of AROM to her upper extremities using 2 pound hand weights of biceps curls, shoulder raises, and arm stretched out to her side daily.
The care plan area addressing Resident #41's PROM, dated 9/6/18, documented she was to do 3 repetitions of PROM to her bilateral lower extremities of hip abduction exercises, hip flexion and extension, knee flexion stretches, and ankle stretches with a 30 second hold daily.
Resident #41's ADL AROM documentation, dated 9/1/18 through 11/7/18, documented staff completed AROM for 15 minutes on 9/7/18, 9/10/18, 9/16/18, 9/17/18, 9/21/18, 9/23/18, 9/25/18, 9/26/18, 10/1/18, 10/3/18-10/5/18, 10/9/18, 10/12/18, 10/14/18, 10/16/18, 10/19/18, 10/23/18-10/25/18, 10/28/18, 10/29/18, 11/2/18-11/7/18. Resident #41 did not receive AROM 34 days during the time frame.
Resident #41's ADL PROM documentation, dated 9/1/18 through 11/7/18 documented the staff completed PROM for 15 minutes on 9/7/18, 9/10/18, 9/16/18, 9/17/18, 9/21/18, 9/23/18, 9/25/18, 9/26/18, 10/1/18, 10/3/18-10/5/18, 10/9/18, 10/12/18, 10/14/18, 10/16/18, 10/19/18, 10/23/18-10/25/18, 10/28/18, 10/29/18, 11/2/18-10/7/18. Resident #41 did not receive PROM for 34 days during the time frame.
On 11/6/18 at 8:41 AM, Resident #41 stated she did not receive her restorative therapy daily. Resident #41 stated she received restorative therapy for approximately 10 minutes at a time and staff assisted her approximately two to three times a week on average.
c. Resident #30 was readmitted to the facility on [DATE], with diagnoses including dementia, osteoarthritis, and history of transient ishemic attacks (temporary blockages of blood flow to the brain).
A quarterly MDS assessment, dated 8/13/18, documented Resident #30 was severely cognitively impaired and he required extensive assistance from one to two staff members with all cares. The MDS assessment documented Resident #30 had bilateral ROM impairments to his upper extremities.
The care plan area addressing Resident #30's restorative bed mobility documented staff were assist Resident #30 with 3-5 repetitions of log rolls while in bed daily.
The care plan area addressing Resident #30's PROM, dated 3/26/18, documented staff were to provide 3-5 repetitions of gentle PROM stretches to his upper and lower extremities daily.
Resident #30's ADL Bed Mobility documentation, dated 5/1/18 through 11/7/18, documented staff were to complete his log rolls 3-5 times daily. Resident #30's record documented he was not assisted with the log rolls as follows:
- May 2018: 12 out of 31 opportunities,
- June 2018: 8 out of 30 opportunities
- July 2018: 20 out of 31 opportunities,
- August 2018: 7 out of 31 opportunities,
- September 2018: 16 out of 30 opportunities,
- October 2018: 12 out of 31 opportunities,
- 11/1/18 through 11/7/18: 1 out of 7 opportunities.
- Resident #30 did not receive assistance with the log rolls 76 days during the time frame.
Resident #30's ADL PROM documentation, dated 5/1/18 through 11/7/18, documented staff were to provide 3-5 reps of gentle PROM stretches to his upper and lower extremities daily. Resident #30's record documented he was not assisted with his PROM as follows:
- May 2018: 12 out of 31 opportunities,
- June 2018: 8 out of 30 opportunities
- July 2018: 19 out of 31 opportunities,
- August 2018: 7 out of 31 opportunities,
- September 2018: 15 out of 30 opportunities,
- October 2018: 12 out of 31 opportunities,
- 11/1/18 through 11/7/18: 1 out of 7 opportunities.
- Resident #30 did not receive assistance with his PROM 74 days during the time frame.
Staff Interviews:
On 11/8/18 at 10:07 AM, LPN #1 stated the restorative program was run 7 days a week. LPN #1 stated the RNAs worked daily from 6:00 AM to-2:30 PM and there was one RNA on each floor and a float RNA. LPN #1 stated there were currently 81 residents on the caseload. LPN #1 stated it was difficult for all the residents to receive their restorative therapy daily.
On 11/8/18 at 10:07 AM, CNA #4 stated she was an RNA on one of the floors. CNA #4 stated it was difficult to get through all of her caseload each day and it was increasingly difficult when she was reassigned to work the floor. CNA #4 stated if she was reassigned to work the floor the restorative therapy was not always be completed. CNA #4 stated she was reassigned to work the floor more frequently over the last year.
On 11/8/18 at 1:05 PM, CNA #5 stated she was an RNA and it was difficult to complete her caseload each day. CNA #5 stated she was reassigned to work the floor as a CNA multiple times due to a staffing issue. CNA #5 stated if she was reassigned to work the floor the restorative services were not completed for all residents.
On 11/8/18 at 1:21 PM, CNA #6 stated she was currently working as an RNA. CNA #6 stated it was difficult to complete her caseload daily and she was reassigned for most of October 2018 to work the floor and restorative therapy was provided when she could.
On 11/8/18 at 10:02 AM, the DON stated she was aware RNAs were reassigned to work the floor.
On 11/8/18 at 10:24 AM, the DON stated the staffing was difficult to manage and that was why the facility utilized staffing agencies. The DON stated when staff called in they could not always get replacements. The DON stated the staff agencies did not always have staff available when she needed them.

Based on review of facility grievances, resident records, and facility policies, and resident, resident family, and staff interview, it was determined the facility failed to ensure there were sufficient numbers of staff to meet the supervision, restorative, and ADL needs of residents. This was true for 8 of 22 residents (#27, #30, #41, #67, #77, #93, #100, and #261) reviewed for staffing concerns, and had the potential to affect all residents residing in the facility. This deficient practice created the potential for physical and psychosocial harm if residents did not receive appropriate care or received a delay of care. Findings include:
a. Residents did not receive baths/showers consistent with their needs and bathing schedules.
The facility's Bathing policy and procedure, dated 10/2015, documented staff were to provide residents with bathing services at least once weekly or per resident preference.
i. On 11/6/18 at 11:17 AM, Resident #93 said he did not receive showers as he should. Resident #93 stated it was due to the facility being short staffed. Resident #93 stated it irks him when he does not receive his scheduled shower twice weekly. Resident #93 stated he had spoken with staff about his concerns often and nothing had changed.
On 11/8/18 at 7:21 AM, Resident #93 stated he did not receive his shower the night of 11/7/18 because there was not enough staff. Resident #93 stated the shower aide was reassigned to work the floor. Resident #93 stated he had fallen asleep in his chair while waiting to get his shower and woke up at 2:30 AM without staff notifying him he would not receive his shower. Resident #93 stated he needed staff assistance because he was legally blind.
ii. Resident #41's care plan documented she was to receive 2 baths a week. Resident #41's Bathing Record showed she did not receive a bath 5 out of 18 bathing opportunities between 9/1/18 and 11/6/18.
On 11/6/18 at 8:41 AM, Resident #41 stated the facility needed more staff. Resident #41 stated she did not always receive her showers twice a week. Resident #41 stated a staff member assisted her with her first shower in 8 days that morning (11/6/18).
iii. On 11/6/18 at 11:22 AM, Resident #67's family member said she often found Resident #67 wet with urine that soaked through his clothing, bedding, and wheelchair pad. Resident #67's family member said the facility frequently failed to provide bathing for Resident #67, due to lack of staffing.
iv. On 11/5/18 at 2:42 PM, Resident #77 stated his only concern with the facility's care was the lack of bathing. Resident #77 stated he was to receive a bath twice weekly and it did not happen all the time. Resident #77 stated sometimes his family picked him up to allow him to bathe at home due to staffing concerns.
v. On 11/5/18 at 2:58 PM, Resident #100 stated she did not always receive her showers as scheduled. Resident #100 stated sometimes she turned her call light on for things like showers and the staff answered the call light, did not meet her needs, and then did not return because they had gotten busy with other residents.
vi. Resident #30 was severely cognitively impaired. His care plan did not specify how often he was to receive a bath. Resident #30's Bathing Record showed he did not receive a bath 11 out of 52 bathing opportunities between 5/1/18 and 11/7/18.
vii. A 9/26/18 grievance documented an anonymous resident complained of not receiving a shower in 7-10 days. The grievance documented the anonymous residents was provided a shower on 9/27/18.
viii. The facility tracked baths on a secondary document titled the Bath List. The April through June 2018 Bath List documented multiple days when the bath aide was reassigned to work the floor. The days the shower aide was reassigned to work the floor were 4/11/18, 4/12/18 part of the day, 5/1/18, 5/2/18 part of the day, 5/8/18, 5/9/18, 5/16/18, 5/17/18, 5/21/18, 5/27/18, 5/29/18 part of the day, 6/1/18 part of the day, 6/5/18 part of the day, 6/12/18, 6/17/18, 6/18/18, 6/21/18 part of the day, 6/24/18 part of the day, and 6/25/18.
The October 2018 Bath List documented multiple days when the bath aide was reassigned to work the floor. The days the shower aide was reassigned to work the floor were 10/7/18, 10/9/18, 10/17/18, 10/23/18, 10/24/18 for half the day, and 10/30/18.
b. Residents did not receive restorative therapy as directed in their care plans.
The facility's undated Restorative policy and procedure documented staff were to provide restorative services to prevent contractures, restore normal movement, maintain function, prevent further deterioration of joints and muscles, and develop and retrain muscles.
i. Resident #27's care plan documented he was to receive active range of motion (AROM) and passive range of motion (PROM) restorative therapy 6-7 days a week. Resident #27's ADL AROM and ADL PROM documentation showed he was not provided the services 48 out of 76 opportunities between 10/1/18 and 11/7/18.
On 11/5/18 at 2:25 PM, Resident #27 stated he did not receive his restorative therapy daily. Resident #27 stated the staff did not always have time to complete his restorative therapy.
ii. Resident #41's care plan documented she was to receive AROM and PROM restorative therapy 7 days a week. Resident #41's ADL AROM and ADL PROM documentation showed she was not provided the services 68 out of 136 opportunities between 9/1/18 and 11/7/18.
On 11/6/18 at 8:41 AM, Resident #41 stated the facility needed more staff. Resident #41 stated she did not receive her restorative therapy daily as directed in her care plan. Resident #41 stated she received restorative therapy for approximately 10 minutes at a time and staff assisted her approximately two to three times a week on average.
iii. Resident #30 was severely cognitively impaired, and his care plan documented he was to receive restorative services to increase bed mobility and PROM restorative therapy 7 days a week. Resident #30's restorative bed mobility therapy and ADL PROM documentation showed he was not provided the services 150 out of 382 opportunities between 5/1/18 and 11/7/18.
d. Staff Interviews:
i. On 11/7/18 at 11:46 AM, LPN #2 stated every day was different for staffing depending on the need, but it would be better if there were more staff during the meal times.
ii. On 11/7/18 at 12:45 PM, CNA #11 stated it would be helpful to have more staff to assist with getting residents up in the morning, taking them to the bathroom, and at dining times.
iii. On 11/8/18 at 10:07 AM, LPN #1 stated the restorative program ran 7 days a week. LPN #1 stated the RNAs worked daily from 6:00 AM to 2:30 PM, there was one RNA on each floor, and a float RNA. LPN #1 stated there were currently 81 residents on the restorative caseload. LPN #1 stated it was difficult for all the residents to receive restorative therapy daily.
iv. On 11/8/18 at 10:07 AM, CNA #4 stated she was an RNA on one of the floors. CNA #4 stated it was difficult to get through all of her caseload each day and it was more difficult when she was reassigned to work the floor. CNA #4 stated if she was reassigned to work the floor, the restorative therapy was not always completed. CNA #4 stated she was reassigned to work the floor more over the last year. CNA #4 stated the facility could use more staff, so residents' restorative therapy could be completed.
v. On 11/8/18 at 10:50 AM, CNA #3 said residents did not always receive the services of showers and incontinence care due to lack of staffing. CNA #3 stated the facility was generally shorter staffed during the evening and night shifts.
vi. On 11/8/18 at 1:05 PM, CNA #5 stated she was an RNA and it was difficult to complete her caseload each day. CNA #5 stated she was reassigned to work the floor as a CNA multiple times due to staffing issues. CNA #5 stated if she was reassigned to work the floor restorative therapy was not completed for all residents.
vii. On 11/8/18 at 1:14 PM, CNA #8 stated there were quite a few call-ins and other staff members would be reassigned to work the floor.
viii. On 11/8/18 at 1:16 PM, CNA #2 stated she used to be a bath aide and there were times when she was reassigned to work the floor. CNA #2 stated she was still expected to complete all her showers on the days she was reassigned, and it was difficult to complete all the showers. CNA #2 stated the facility could utilize more staff.
ix. On 11/8/18 at 1:21 PM, CNA #6 stated she was currently working as an RNA. CNA #6 stated it was difficult to complete her caseload daily. CNA #6 stated she was reassigned to work the floor often and was reassigned as a bath aide for most of October 2018. CNA #6 stated it depended on the day if the facility needed more staff. CNA #6 stated when she was working as a bath aide, residents complained about not receiving showers. CNA #6 stated there were days she could not complete all showers and she attempted to complete the residents' showers the following day of they missed one.
x. On 11/8/18 at 3:10 PM, CNA #6 said sometimes the facility had a bath aide and sometimes they did not have a bath aide. She said the bath aide often got called to the floor to work. CNA #6 said residents' requiring the use of a Hoyer lift (equipment used to lift and transfer individuals, which requires two staff to operate safely) were the residents who were more likely to not receive baths consistently. CNA #6 stated in the afternoon at approximately 2:00 PM, during shift change, staff had to play catch up and change incontinent residents who were not changed at lunch. CNA #6 stated residents appeared to have been assisted to their rooms and left in their wheelchairs. CNA #6 stated she felt the facility was short staffed, and when concerns were expressed staff would hear, We gotta do the best we can.
xi. On 11/8/18 at 1:26 PM, CNA #9 stated she worked as a bath aide and she was reassigned to work the floor approximately two to three times a week during bad weeks. CNA #9 stated she was expected to complete the scheduled showers if she was reassigned and she could not always complete all the showers. CNA #9 stated she would have to complete approximately 40 showers a day. CNA #9 stated she tried to provide residents at least one shower a week and she ensured residents with skin or incontinence issues received their showers twice a week if she was reassigned to work the floor. CNA #9 stated she was not sure why the bath aide was reassigned, but she suspected it was due to a lack of staff.
xii. On 11/8/18 at 1:29 PM, CNA #10 stated she worked the floor as a CNA and residents had complained to her about not receiving their restorative therapy and showers. CNA #10 stated the facility was short staffed when CNAs called in or did not show up for work. CNA #10 stated when call ins occurred replacements could not always be found.
e. The facility's Shift Assignment sheets for 5/1/18 through 6/14/18 documented if a 1:1 staff member was assigned to a floor. The sheets did not document the assigned resident who required the 1:1 supervision, to ensure the resident received the 1:1 supervision. The staffing sheets and progress notes documented the following staffing concerns:
* 5/1/18: a CNA worked the floor and provided baths.
* 5/2/18, 5/5/18: a CNA worked extra hours because the facility was short staffed. It was unclear if the rest of the shift was covered.
* 5/5/18: a scheduled CNA did not work and the schedule did not document a replacement was found.
* 5/6/18: two CNAs did not show up to work and two CNAs stayed over to assist with getting residents out of bed in the morning. The schedule did not document how long the two CNAs stayed to assist. The schedule documented staffing agencies were called, however, they did not have CNAs available to assist the facility.
* 5/8/18: one CNA was scheduled to work the night shift.
* 5/12/18, 5/13/18, 5/14/18, 5/15/18, 5/17/18, 5/19/18, 5/20/18, 5/21/18, 5/22/18, 5/23/18, and 6/1/18: a CNA was assigned as a 1:1 for 8 hours during the evening shift. The schedule did not document the name of the resident that required the 1:1 supervision, to ensure the resident received the 1:1 supervision.
* 5/21/18: two CNAs did not show up for work, one on day shift and one on evening shift. The schedule documented one CNA stayed over to assist with getting residents out of bed in the morning. The schedule did not document if replacements were found.
* 5/24/18: a CNA was assigned as a 1:1 for 8 hours during the night shift. The schedule did not document the name of the resident requiring the 1:1 supervision, to ensure the resident received the 1:1 supervision.
* 5/25/18: a CNA was assigned each shift to provide 1:1 supervision, to ensure 1:1 coverage for a 24 hour period. The schedule did not document the name of the resident requiring the 1:1 supervision, to ensure the resident received the 1:1 supervision.
* 5/26/18: a CNA was assigned each shift to provide 1:1 supervision, to ensure 1:1 coverage for a 24 hour period. The schedule did not document the name of the resident requiring the 1:1 supervision, to ensure the resident received the 1:1 supervision. The CNA assigned to serve as the night shift 1:1 did not work. Two other CNAs did not work during the day shift and the schedule did not show if a replacement was found for one of the staff members.
* 5/27/18: a CNA was assigned each shift to provide 1:1 supervision, to ensure coverage for a 24 hour period. The schedule did not document the name of the resident requiring the 1:1 supervision, to ensure the resident received the 1:1 supervision. Resident #261's care plan was updated on 5/26/18 to reflect the need for a 1:1 sitter. A Progress Note, dated 5/27/18 at 3:00 AM, documented Resident #261 woke up at 11:00 PM and was sitting on the edge of his bed. The note documented he was moved to the nurses' station due to his 1:1 sitter being unavailable. The note documented a staff member volunteered to assist as Resident #261's 1:1 for 1-2 hours.
* 5/28/18, 5/30/18, 6/2/18, 6/3/18, 6/4/18, 6/5/18, 6/6/18, 6/7/18, 6/8/18, 6/10/18, and 6/11/18: a CNA was assigned each shift to provide 1:1 supervision, to ensure coverage for a 24 hour period. The schedule did not document the name of the resident requiring 1:1 supervision to ensure the resident received the required level of supervision.
* 5/29/18: a CNA was assigned each shift to provide 1:1 supervision, to ensure coverage for a 24 hour period. The schedule did not document the name of the resident requiring the 1:1 supervision to ensure the resident received the required level of supervision. The CNA assigned as the day shift 1:1 worked 7 hours. It was unclear if the resident was provided 1:1 supervision for the one remaining hour.
* 5/31/18: a CNA on the evening shift and a CNA on the night shift were assigned to provide 1:1 supervision. The schedule did not document the name of the resident requiring the 1:1, to ensure the resident received the required level of supervision. The day shift did not document a 1:1 CNA was scheduled. A CNA assigned to bathe residents provided some assistance as a 1:1 for Resident #261 during the day shift in addition to providing showers. The schedule did not document the amount of time the CNA provided showers versus providing 1:1 supervision for Resident #261.
* 6/1/18: a CNA was assigned as a 1:1 for the evening shift. The schedule did not document the name of the resident requiring the 1:1 supervision to ensure the resident received the required level of supervision. The day and night shifts did not document a 1:1 CNA was scheduled. A CNA assigned to bathe residents provided some assistance as a 1:1 for Resident #261 during the day shift in addition to assisting other residents with showers. The schedule did not document the amount of time the CNA provided showers versus providing 1:1 supervision.
* 6/9/18: a CNA was assigned each shift to provide 1:1 supervision, to ensure coverage for 24 hour period. The schedule did not document the name of the resident requiring the 1:1 to ensure the resident received the required level of supervision. The CNA assigned as the evening shift 1:1 worked 2 hours. The schedule documented one CNA was assigned to work the night shift. It was unclear how a resident was provided 1:1 supervision, and the other residents' needs met, when one CNA was assigned to work the shift.
* 6/12/18: a CNA was assigned each shift to provide 1:1 supervision, to ensure coverage for 24 hour period. The schedule did not document the names of the residents requiring the 1:1 supervision, to ensure 1:1 supervision was provided.
* 6/13/18 through 6/30/18 documented CNAs were scheduled to provide 1:1 supervision. The schedule did not document the name(s) of the resident requiring the 1:1 supervision to ensure the resident received the required level of supervision.
On 11/8/18 at 10:24 AM, the DON stated the staffing was difficult to manage and this was why the facility utilized staffing agencies. The DON stated when staff called in they could not always get replacements. The DON stated the staffing agencies did not always have staff available when she needed them. The DON stated the facility could utilize more staff when staff did not show up for work as scheduled.
On 11/9/18 at 12:23 PM, the DON stated 1:1 staff were scheduled and there were occasions when the 1:1 staff did not show up for work. The DON stated her staffing schedule did not document the names of the residents, and she was unable to recall who required 1:1 supervision.
On 11/9/18 at 2:48 PM, the Administrator stated the facility was consistently working on staffing issues through its quality assurance program. The Administrator stated the facility tried to place residents who required more assistance on a floor where more CNAs were scheduled to work. The Administrator stated RNAs got reassigned to work as bath aides if staff members called in.
Also refer to F677 as it relates to the failure of the facility to ensure residents received baths or showers consistent with their need.
Also refer to F688 as it relates to the failure of the facility to ensure residents received restorative therapy consistent with their needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. Resident #87 was readmitted to the facility on [DATE], with diagnoses which included dementia, urinary issues, and cardiac issues.
A Quarterly MDS assessment, dated 9/29/18, documented Resident #87 had severe cognitive impairment.
Resident #87's physician orders, dated 11/7/18, documented his medication duloxetine (a medication used to treat depression and pain) was increased from 20 mg orally every day to 60 mg each day.
Resident #87's current care plan documented he experienced pain, difficulty concentrating, fear of others causing him harm, and changes in sleep patterns. Resident #87's care plan lacked specific behaviors staff were to monitor Resident #87 for and lacked interventions related to the use of the psychoactive medication, duloxetine.
On 11/8/18 at 1:25 PM, the Pharmacist confirmed the facility failed to develop and implement a resident specific care plan that described resident specific behaviors and included inventions related to Resident #87's use of duloxetine.
On 11/8/18 at 10:44 AM, the DON stated she looked for resident specific behaviors and where they may be located. The DON stated residents' sleep habits were evaluated in the GDR meetings verbally and a resident's behaviors were discussed. The DON stated the current GDR form did not document the conversation that took place for the residents.
On 11/9/18 at 10:19 AM, LMSW #1 stated he received alerts from staff when a resident was experiencing increased behaviors and the GDR committee evaluated trends from the alerts. LMSW #1 stated the CNA Behavior Monitoring flowsheets did not include hallucinations and delusions, but staff documented these in the MDS and throughout the progress notes when they were seen by staff. LMSW #1 stated psychotropic medications could increase a resident's fall risk and the facility did not provide PRN psychotropic medications when a 1:1 staff member was unavailable. LMSW #1 stated staff provided the PRN medications when a resident exhibited behaviors. LMSW #1 stated the specific behavior the resident exhibited should be documented in their clinical record for any PRN psychotropic medication administered. LMSW #1 stated the care plan should identify resident specific behaviors for dementia, hallucinations, and delusions and if they were harmful. LMSW #1 stated the current behavior monitors were helpful with gathering information in addition to the alerts he received and the MDS.
On 11/9/18 at 12:23 PM, the DON stated according to the care plan Resident #261 was to have a 1:1 staff member with him on 5/26/18. The DON stated he may have been provided a 1:1 for short durations before that. The DON stated the facility would not provide PRN psychotropic medications when a 1:1 staff member was unavailable, only when residents' behaviors increased. The DON stated the behavior monitors were not resident specific and the staff documented specific instances throughout the progress notes. The DON stated in the GDR meeting the team reviewed each residents' behaviors and evaluated items such as sleep, and what the team discussed was documented in the GDR note
Based on observation, staff interview, record review, and facility policy review, it was determined the facility failed to a) attempt GDR of psychotropic medications, b) monitor behavioral symptoms, c) obtain informed consents for the medications, and d) identify resident specific behaviors on the care plan. This was true for 4 of 6 residents (#2, #30, #87, and #261) reviewed for unnecessary medications. This resulted in harm to Resident #261 when he experienced increased somnolence, sedation, and a decline in ADL's as a result of multiple psychotropic medications. This deficient practice also had the potential for harm of other residents if they receive unnecessary psychotropic medications which were not adequately monitored. Findings include:
A facility policy Mood and Behavior Medication Review Committee, undated, documented the committee identified and evaluated residents use of medication for behaviors or mood and the committee would determine the appropriate interventions and ensure consents, orders, and care plans were completed.
The facility's ADL Behavior Monitor flowsheets documented the following behaviors for every resident in the facility, wandering, verbal abusive, physical abusive, socially inappropriate behavior, resistive or rejection of care.
The facility's ADL Mood Symptoms Monitor flowsheets documented the following behavior for every resident in the facility, little interest or pleasure in doing things, feeling or appearing down/ depressed, trouble falling asleep or staying asleep, feeling tired, poor appetite or overeating, feeling bad about themselves, trouble concentrating, moving extremely slow and speaking slow so that others notice, suicidal ideation, and short tempered. The facility did not have resident specific behaviors for staff to monitor.
a. Resident #261 was admitted to the facility on [DATE], with diagnoses including dementia with Lewy bodies (abnormal protein deposits in the brain) and behavioral disturbances, depression, and sleep disorder.
A significant change MDS assessment, dated 6/7/18, documented Resident #261 was severely cognitively impaired and he was totally dependent or required extensive assistance from one to two staff members with cares. The MDS documented Resident #261 had signs and symptoms of mild depression and he exhibited delusions and hallucinations. The MDS documented Resident #261 had physical, verbal, and other behaviors 4-6 days a week. The MDS documented he did not wander or reject cares.
i. Resident #261's May 2018 Physician Orders included the following scheduled and PRN medications:
Scheduled Medications:
- Depakote (anticonvulsant) 500 mg by mouth one time a day for Lewy bodies dementia with hallucinations and agitation, ordered on 5/31/18 and discontinued the same day.
- Remeron (antidepressant) 15 mg at bedtime for depression and insomnia, ordered on 4/2/18 and discontinued on 6/1/18.
- Seroquel (antipsychotic) 200 mg at bedtime for dementia with hallucinations, ordered on 4/24/18 and discontinued on 5/23/18.
- Seroquel 100 mg two times a day for dementia with hallucinations, ordered on 4/27/18 and discontinued on 5/23/18.
- Seroquel 300 mg at bedtime for dementia with hallucinations, ordered on 5/23/18 and discontinued on 5/31/18.
- Topamax (anticonvulsant) 25 mg at bedtime for unstable mood, ordered on 3/30/18 and discontinued on 6/12/18.
- Zoloft (antidepressant) 200 mg one time a day for depression, ordered on 3/30/18 and discontinued on 6/1/18.
PRN Medications:
- Ativan (sedative and antianxiety) 1 mg intramuscularly (IM) one time only for extreme anxiety, ordered on 5/9/18.
- Ativan 1 mg IM one time only for Lewy bodies dementia related to delirium, ordered on 5/23/18.
- Ativan 1 mg IM one time only for Lewy bodies dementia related to delirium, ordered on 5/24/18.
- Ativan 0.5 mg IM one time only for extreme anxiety, ordered on 5/27/18.
- Ativan 1 mg intramuscularly every 24 hours PRN for agitation, ordered on 5/31/18 and discontinued on 6/4/18.
- Oxycodone (narcotic) 5 mg every 6 hours PRN for pain, ordered on 5/21/18 and discontinued on 6/12/18.
- Seroquel 100 mg one time only for dementia with hallucinations, ordered on 5/23/18.
- Trazadone (sedative and antidepressant) 25 mg every 8 hours PRN for anxiety, ordered on 4/2/18 and discontinued on 5/23/18.
- Trazadone 50 mg every 8 hours PRN for anxiety, ordered on 5/23/18 and discontinued on 6/12/18.
Resident #261 received 2 antidepressant medications, Remeron and Zoloft, daily from 4/2/18 to 6/1/18, and 1 antipsychotic medication, Seroquel, daily from 4/24/18 to 5/31/18. Two medications, Seroquel and Depakote, were prescribed for hallucinations according to the MAR documentation. He also had orders for 2 antianxiety medications PRN, Ativan and Trazadone. Additionally, the medications Seroquel, Remeron, Trazadone, Ativan, and Oxycodone had sedative effects.
Resident #261's June 2018 Physician Orders included the following scheduled and PRN medications:
Scheduled Medications:
- Ativan 1 mg/ml by mouth three times a day for agitation, ordered on 6/5/18 and discontinued on 6/6/18.
- Ativan 1 mg/ml by mouth two times a day for agitation, ordered on 6/6/18 and discontinued the same day.
- Ativan 1 mg/ml by mouth every eight hours for agitation, ordered on 6/6/18 and discontinued on 6/14/18.
- Clonazepam (antianxiety) 0.5 mg by mouth two times a day for comfort and seizure control, ordered on 6/1/18 and discontinued on 6/6/18.
- Depakote extended release 500 mg by mouth at bedtime for Lewy bodies dementia with hallucinations and agitation, ordered on 6/1/18 and discontinued on 6/12/18.
- Seroquel 50 mg two times a day for dementia with hallucinations, ordered on 5/23/18 and discontinued on 6/12/18.
- Seroquel 200 mg at bedtime for dementia with hallucinations, ordered on 5/31/18 and discontinued on 6/12/18.
- Topamax 25 mg at bedtime for unstable mood, ordered on 3/30/18 and discontinued on 6/12/18.
PRN Medications:
- Ativan 0.5 mg by mouth every 2 hours PRN for agitation, ordered on 6/1/18 and discontinued on 6/5/18.
- Ativan 0.5 mg by mouth every hour PRN for agitation, ordered on 6/5/18 and discontinued on 6/14/18.
- Ativan 1 mg IM every 24 hours PRN for agitation, ordered on 5/31/18 and discontinued on 6/4/18.
- Ativan 1 mg IM every 24 hours PRN for agitation, ordered on 6/4/18 and discontinued on 6/14/18.
- Morphine Sulfate (narcotic) 10 mg sublingually every 2 hours PRN for pain and air hunger, ordered on 6/1/18 and discontinued on 6/14/18.
- Oxycodone 5 mg every 6 hours PRN for pain, ordered on 5/21/18 and discontinued on 6/12/18.
- Trazadone 50 mg every 8 hours PRN for anxiety, ordered on 5/23/18 and discontinued on 6/12/18.
Resident #261's antidepressants, Remeron and Zoloft, were discontinued and he had 2 antianxiety medications added to be taken daily, Ativan and Clonazepam. He also had PRN orders for Ativan, and a new order for Morphine Sulfate for pain. Additionally, the medications Ativan, Clonazepam, Seroquel, Morphine Sulfate, Oxycodone, and Trazadone had sedative effects.
ii. Resident #261's 5/1/18 through 6/14/18 MAR documented he was administered a PRN psychotropic medication, Trazadone or Ativan, within 0 to 15 minutes of a PRN pain medication, Oxycodone or Morphine, being administered. Examples include:
- Oxycodone and Trazadone were administered together on 5/23/18 at 2:25 PM and 10:06 PM, 5/24/18 at 3:45 PM, 5/30/18 at 12:33 AM, and 6/4/18 at 3:30 AM.
- Oxycodone and Ativan were administered together on 6/2/18 at 1:12 PM, 6/3/18 at 10:45 AM, and 6/5/18 at 3:03 PM.
- Morphine and Trazadone were administered together on 6/6/18 at 4:00 AM.
- Morphine and Ativan were administered together on 6/1/18 at 1:30 PM, 6/3/18 at 1:40 PM, 6/3/18 at 4:10 PM, 6/4/18 at 6:30 AM, 9:35 AM, and 12:15 PM, 6/6/18 at 3:07 PM, 5:07 PM, and 9:15 PM, 6/10/18 at 10:01 PM, 6/11/18 at 3:32 PM, and 6/12/18 at 1:50 PM.
According to the Nursing 2019 Drug Handbook, Ativan by IM injection takes 15-30 minutes to take effect and when given orally it takes 1 hour. Additionally, the Nursing 2019 Drug Handbook stated Ativan, Trazadone, and Oxycodone side effects include sedation, confusion, insomnia, dizziness, and drowsiness.
This occurred 21 times on 12 days, from 5/23/18 to 6/12/18. The staff did not allow adequate time for the pain medication or the antianxiety medication administered to take effect. It was unclear if Resident #261 was anxious or in pain. According to the Nursing 2018 Drug Handbook the side effects for Ativan, Trazadone, Oxycodone, and Morphine Sulfate included sedation, confusion, insomnia, dizziness, and drowsiness.
The progress notes for Resident #261 for the above listed dates and times included documentation he received Ativan or Trazadone PRN for agitation and/or anxiety. The progress notes did not include documentation of how Resident #261's agitation and/or anxiety presented or specific behaviors related to his agitation and/or anxiety.
iii. Resident #261's May 2018 Behavior flowsheet documented he experienced the following behaviors:
- Wandering- 3 episodes on 5/6/18, 5/17/18, and 5/20/18
- Physically abusive- 1 episode on 5/21/18
- Resistive or rejection of care- 2 episodes on 5/22/18 and 5/23/18
Resident #261's 6/1/18 through 6/13/18 Behavior flowsheet documented he experienced the following behaviors:
- Physically abusive- 1 episode on 6/3/18
- Resistive or rejection of care- 1 episodes on 6/2/18
Resident #261's progress notes did not correlate with his Behavior Monitoring flowsheets for May and June of 2018. Examples include:
- A Progress note, dated 5/14/18 at 9:39 PM, documented Resident #261 was agitated and continued to ambulate without his wheelchair or assistance and a PRN Trazadone was provided at 2:53 PM. The note documented Resident #261 needed 1:1 staff supervision from 1:00 PM to 9:00 PM and a light duty staff member was only available from 4:00 PM to 6:00 PM. Resident #261's care plan was not updated to include the need for 1:1 staff supervision on 5/14/18, and it was unclear if he was to have a 1:1 CNA present for the duration of time between 1:00 PM and 9:00 PM.
- Progress Notes, dated 5/23/18 at 2:25 PM, documented Resident #261 was provided a PRN Trazadone for anxiety and calling out and excessive movement in his wheelchair, PRN Oxycodone for pain, and Seroquel was given early to help with calming anxiety. There was no documentation of Resident #261 calling out or other behaviors related to anxiety in the behavior monitor flowsheet. Additionally, the progress note did not include a description how his anxiety presented.
A subsequent Progress Note, at 11:05 PM on 5/23/18, documented Resident #261 woke up at 8:50 PM and was combative, agitated, and refused his bedtime medications by spitting them out at the nurse. The note documented Resident #261 was also kicking and hitting the nurse and CNAs. Resident #261 refused drink and food and was assisted to the common area to sit in a recliner for better observation by staff. The note documented he required 1:1 supervision because Resident #261 attempted to transfer himself and was constantly repositioning himself in the recliner. The note documented Resident #261 was anxious during most of the shift and rested for a few hours after dinner while his 1:1 supervision CNA was with him. The note documented IM Ativan was not initially effective and PRN Trazadone, Oxycodone, and Seroquel were administered to help settle his delirium/anxiety.
The note did not include a description of how Resident #261 presented with delirium or anxiety. The Behavior Monitoring flowsheet documented Resident #261 was resistive to cares, there was no documentation related to his delirium, anxiety, or hitting and kicking at staff.
The MAR documented he was administered a PRN dose of Ativan IM at 9:53 PM and at 10:06 PM, 13 minutes later, he was administered a dose of PRN Trazadone and PRN Oxycodone. At 10:13 PM, 7 minutes later, he was administered a dose of PRN Seroquel. The staff did not provide adequate time for the antianxiety medication to take effect before administering another 2 psychotropic medications and a pain medication.
- A Progress Note, dated 5/24/18 at 10:53 PM, documented Resident #261 was pleasant and cooperative for most of the shift. The note documented he was administered a PRN pain and antianxiety medication for an increase in symptoms/suspected pain, with successful result. The note documented at 6:45 PM, Resident #261 was restless, yelled and hit staff, and attempted to self-transfer out of his chair, and his scheduled Remeron, Seroquel, and Topamax did not decrease his anxiety. The note documented the physician ordered a one-time dose of IM Ativan which was given and he calmed down afterwards and was observed sleeping in a recliner chair. There was no documentation in his Behavior Monitoring flowsheet Resident #261 hit staff or he exhibited other behaviors.
- A Progress Note, dated 5/27/18 at 3:00 AM, documented Resident #261 woke up and he was calling out he wanted to use the bathroom and go home. Resident #261 was unable to stand up and comprehend instructions with using the mechanical lift and required 3 CNAs to assist with the transfer. He was given a dose of PRN Trazadone related to anxiety, which was ineffective. Resident #261 was moved to the nurses' station and continued to call out. The note documented a 1:1 sitter was not available for the night shift and a staff member assigned to a different unit volunteered to assist as Resident #261's 1:1 for 1-2 hours. Resident #261 was administered a PRN IM Ativan dose at 3:22 AM. There was no documentation describing how Resident #261's anxiety presented.
- A Progress Note, dated 6/4/18 at 10:41 AM, documented Resident #261 had increased confusion and was restless and picked up unseen items on the floor. The note documented he had a change in his previous normal pattern of behavior with an increase in negative behaviors and increased confusion and agitation. Resident #261's 6/4/18 MAR documented he was administered a dose of PRN Ativan and PRN Morphine at 12:15 PM, a dose of PRN Trazadone at 2:00 PM, and a dose of PRN IM Ativan at 2:40 PM. The Behavior Monitoring flowsheet did not include documentation of behaviors or an increase in behaviors. There was also no documentation in the Behavior Monitoring flowsheet about how Resident #261 exhibited agitation.
iv. Resident #261's care plan did not include specific behaviors and did not identify or include depression and anxiety.
Resident #261's care plan addressed cognition, dated 3/27/18, and documented he had impaired cognition related to Lewy body dementia and was rarely understood and had difficulty understanding. The care plan did not document how his dementia presented.
Resident #261's care plan area addressed elopement risk, dated 4/13/18, and documented he verbalized wanting to leave the facility and wandered the facility. Interventions included Resident #261 had a roam alert bracelet on his wheelchair, dated 4/13/18, and staff were to provide 1:1 supervision until Resident #261 stopped attempting to leave the facility, dated 5/26/18. The care plan did not include identification of behaviors associated with the 1:1 intervention initiated on 5/26/18.
The care plan area addressing Resident #261's behaviors and mood, dated 6/28/17, documented he was cognitively impaired and had dementia. The care plan documented he had behavioral issues with hallucinations and delusions. The care plan documented Resident #261 had suicidal ideation, hit staff, and screamed.
Resident #261's care plan did not identify if Resident #261's hallucinations and or delusions were tactile [touch], visual, auditory, and olfactory [smell]), was not resident specific and did not document clearly how his hallucinations or delusions presented. The care plan did not document if his hallucinations or delusions were harmful to him.
Resident #261 did not have a care plan for his anxiety or his depression. The facility did not identify how Resident #261's anxiety, agitation, or depression presented.
v. Resident #261's MAR and Progress Notes documented his hours of sleep increased as medications were added.
The care plan area addressing Resident #261's sleep cycle, dated 6/19/17, documented he was taking medications daily to assist him with sleep. The care plan documented staff were to monitor Resident #261's hours of sleep at night and staff were to encourage him to maintain his home routine of going to bed at 8:00 PM and waking at 6:00 AM.
Resident #261's May 2018 MAR documented he was sleeping from 3 hours to 16 hours a day and averaged 9 hours daily. Examples include:
- On 5/2/18, the MAR documented he slept 11 hours. A progress note, dated 5/2/18, documented Resident #261 was administered a PRN Trazadone as he was unable to sleep and settle down. Resident #261's Trazadone was ordered for anxiety, not sleep.
- Resident #261's MAR documented he slept 9 hours during the 5/8/18 evening shift.
- Resident #261's MAR documented for the night shift on 5/23/18 he slept 7 hours, and during the day shift on 5/24/18 he slept for 4 hours.
- Resident #261's MAR documented for the night shift on 5/27/18 he slept 7 hours, and during the day shift on 5/28/18he slept for 4 hours.
- Resident #261's MAR documented he slept for 10 hours on 5/29/18, on 5/30/18 he slept 7 hours, and on 5/31/18 he slept 10 hours during the 24 hour period.
Resident #261's June 2018 MAR documented he was sleeping from 7 to 24 hours a day and averaging 15 hours daily. Examples include:
- Resident #261's Sleep Monitor flowsheet for 6/4/18 documented he slept 8 hours during the 24 hour period.
- Resident #261's Sleep Monitor flowsheet for 6/5/18 documented he slept 9 hours during the 24 hour period.
- Resident #261's Sleep Monitor flowsheet for 6/6/18 documented he slept 16 hours during the 24 hour period.
- Resident #261's Sleep Monitor flowsheet documented he slept 11 hours on 6/7/18, 16 hours on 6/8/18, 21 hours on 6/9/18, 16 hours on 6/10/18, 21 hours on 6/11/18, and 24 hours on 6/12/18 and 6/13/18.
vi. Resident #261's GDR did not review specific behaviors or evaluate his sleeping habits.
Resident #261's Quarterly GDR review, dated 6/6/18, documented Resident #261 was on Ativan, Trazadone, Seroquel, and Depakote. The GDR review documented he was on these medications for sleep and behavioral disturbances with Lewy Body Dementia. The review documented Resident #261 had hallucinations, increased paranoia, and was on hospice and the committee recommended no changes to his medication regime.
The review did not evaluate Resident #261 for how many episodes/behaviors of hallucinations, depression, and or anxiety he experienced during the look back period. The GDR review did not include an evaluation of the increase in the hours he slept. The review did not include an evaluation what his hallucination or paranoia looked like or identify what other behaviors he was experiencing and how they were harmful to him.
On 11/9/18 at 10:19 AM, LMSW #1 stated Resident #261 was actively delusional and paranoid of people trying to do bad to him. LMSW #1 stated the medications were being managed by a Psychiatrist and he experienced hallucinations as well.
b. Resident #30 was readmitted to the facility on [DATE], with diagnoses including dementia.
A quarterly MDS assessment, dated 8/13/18, documented Resident #30 was severely cognitively impaired and had no signs and symptoms of depression. The MDS documented he did not exhibit inappropriate behaviors, hallucinations, delusions, rejection of cares, or wandering.
Resident #30's October 2018 Physician Orders included:
- Zyprexa 5 mg by mouth in the afternoon and evening for dementia, ordered 10/22/18.
- Trazadone 100 mg at bedtime for insomnia, ordered 4/2/18.
- Trazadone 25 mg in the afternoon for anxiety, ordered 10/19/18.
- Oxycodone 5 mg twice daily for arthritis pain, ordered 9/28/18.
The care plan area addressing Resident #30's sleep cycle, dated 3/9/17, documented he was taking medications daily to assist him with sleep. The care plan documented staff were to monitor Resident #30's hours of sleep at night.
The care plan area addressing Resident #30's behaviors/cognition, revised 5/23/18, documented he was cognitively impaired and had dementia. The care plan documented Resident #30 was angry and frustrated at times. It did not specifically describe how Resident #30's dementia presented.
Resident #30's care plan did not include specific goals and interventions related to his anxiety and did not describe how his anxiety presented.
Resident #30's Quarterly GDR review, dated 9/13/18, documented Resident #30 was receiving Zyprexa and Trazadone. The GDR review documented he was taking the medications for sleep and dementia. The review documented Resident #30 had poor safety awareness and had several falls. The review documented he exhibited anxiety by leaning forward in his Broda chair. The review documented the committee recommended decreasing Resident #30's Zyprexa to 5 mg in the afternoon and 2.5 mg before bed. This was completed and then the medication was increased back to 5 mg twice daily on 10/29/18, when the physician discontinued another psychotropic medication (Lexapro, an antidepressant). Resident #30's GDR did not include a review of specific behaviors or evaluate his sleeping habits.
Resident #30's 8/1/18 through 11/7/18 Behavior Monitoring flowsheets documented he did not exhibit behaviors. The review did not evaluate the number of behaviors and/or symptoms of anxiety Resident #30 experienced during the look back period, to assess the ongoing need for the medications.
Resident #30's 10/1/18 through 11/6/18 MAR documented he was sleeping from 11 to 21 hours a day and averaging 16 hours daily.
On 11/6/18 from 9:50 AM to 10:39 AM, Resident #30 was observed sitting in his Broda chair (tilt-in-space positioning chair) asleep and snoring. Resident 30 was observed asleep in his Broda chair on 11/6/18 at 2:28 PM, 11/7/18 at 11:00 AM and 4:20 PM, and 11/8/18 at 7:00 AM.
On 11/9/18 at 9:56 AM, LMSW #1 stated Resident #30's specific behavior was wandering into other residents' rooms. LMSW #1 stated Resident #30's dementia presented as confusion and increased anxiety. LMSW #1 stated Resident #30 should have a care plan for anxiety and his dementia care plan should describe how his behaviors presented. LMSW #1 stated missing information in Resident #30's care plan made it difficult for contracted agency staff to observe for those behaviors and document them.
c. Resident #2 was readmitted to the facility on [DATE], with multiple diagnoses including insomnia, dementia, PTSD (post-traumatic stress disorder), anxiety, depression, and Alzheimer's disease.
Resident #2's quarterly MDS assessment, dated 7/21/18, documented his cognition was severely impaired, and family or representative participated in the assessment. The MDS documented Resident #2 received antipsychotic and antidepressant medications on a routine basis and documented target behaviors. The MDS target behaviors included delusions, physical, verbal, and other behaviors 1-3 days a week.
Resident #2's care plan related to his behavior and mood, dated 5/3/17, did not identify resident specific behaviors or include interventions related to Resident #2's depression, PTSD, and anxiety. The care plan included Resident #2's dementia, dated 2/20/18, but did not document how his dementia presented or interventions related to the dementia.
Resident #2's physician's orders, included Escitalopram Oxalate (antidepressant) 10 mg by mouth one time a day for depression/PTSD, ordered on 4/3/18; Risperdal 1 mg by mouth two times a day for unstable mood, ordered on 8/9/18; and Trazadone HCl 100 mg by mouth at bedtime for insomnia, ordered on 11/2/18. The orders included monitoring the number of hours of sleep every shift for insomnia, and to observe Resident #2 for side effects every shift related to the use of antidepressant and antipsychotic medications.
Resident #2's Quarterly Mood/Behavior Medication Review, dated 8/7/18, listed his diagnoses for dementia and depression, it did not include his diagnoses for anxiety and PTSD. The review included a section for antidepressant medications and the date initiated. Under this section Escitalopram Oxalate and Trazadone were listed. The review documented Trazadone was used for anxiety and insomnia. Under another section for antipsychotic medications Risperdal was listed. The Trazadone was indicated for insomnia not anxiety according to his physician orders.
The Quarterly Review documented Resident #2 had an increase in aggression directed toward other residents and staff over the past few weeks. There was no documentation how it was determined his aggression increased. The Quarterly Review documented the IDT was unable to determine other causes for Resident #2's increased aggression beyond dementia and psychosis. Resident #2's record did not include a diagnosis of psychosis.
Resident #2's Behavior and Mood Monitoring Flowsheets, dated 10/1/18 through 11/8/18, monitored each shift for general behaviors and mood symptoms. The flowsheets included a section for response to interventions and effectiveness of the interventions, but they were not specific to Resident #2. The flowsheets did not document the effectiveness of Resident #2's use of psychotropic medications and did not identify the behaviors to monitor related to the use of psychotropic medications.

Based on policy review, observation, and staff interview, it was determined the facility failed to ensure staff performed effective hand hygiene and implemented effective infection prevention measures related to urinary catheters. This was true for 9 of 22 residents (#2, #10, #15, #20, #28, #35, #95, #101, #103) reviewed for infection control. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination. Findings include:
a. The facility's Daily Catheter/Peri-Care Competency, undated, documented staff were to wash hands, put on gloves, perform peri-care, remove gloves after performing peri-care, use hand gel sanitizer and apply gloves, provide a clean brief, and then remove gloves and perform hand hygiene. This policy was not followed.
On 11/5/18 beginning at 2:58 PM, CNA #16 and CNA #20 were observed assisting Resident #35 on One East of the main room of the Secured Care Unit. Resident #35 was assisted from his recliner to his wheelchair, then from his wheelchair to his bed to perform peri-care. After cares he was then assisted from his bed to his wheelchair and helped to the dining room.
CNA #16 and CNA #20 did not perform hand hygiene before they assisted Resident #35 to his room, and did not perform hand hygiene before, during, or after performing peri-care. CNA #20 and CNA #16 wore gloves during peri-care but did not change gloves or wash their hands until after Resident #35 was placed in his wheelchair to go to the dining room.
CNA #20 stated she did not wash her hands before she put on the gloves or before she provided CNA #16 a pair of gloves. CNA #16 stated he knew he did not wash his hands before he put on gloves and knew he was supposed to but he was already too far into the care of changing the Resident #35's brief.
b. The facility's policy Performing A Blood Glucose Test, dated August 2017, documented staff were to perform hand hygiene and apply gloves before the procedure, and remove gloves and perform hand hygiene after the procedure.
On 11/6/18 at 2:50 PM, LPN #3 was observed measuring the blood glucose level of Resident #20 and did not perform hand hygiene after measuring Resident #20's blood glucose level. After LPN #3 removed his gloves, he was observed engaging in a conversation with another staff member and resident, and he touched the items on the medicine cart without performing hand hygiene. He then walked over to the nurses' station, touched the desk, picked up a binder and returned to the medicine cart without performing hand hygiene. LPN #3 stated he thought he had used the hand sanitizer after checking Resident #20's blood glucose.
c. The facility's policy Hand Hygiene, dated August 2017, documented staff involved in direct contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy stated hand hygiene was performed between resident contact, after handling contaminated objects, before applying and after removing personal protective equipment (PPE) including gloves, before preparing or handling medications, after handling items potentially contaminated with body fluids, and when during resident care staff moved from a contaminated body site to a clean body site.
The facility's policy Using Gloves, dated August 2017, documented staff were to perform hand hygiene after removing gloves.
These policies were not followed. Examples include:
- On 11/6/18 at 2:30 PM, CNA #15 was observed taking vital signs of residents on One East of the main room of the Secured Care Unit. CNA #15 took Resident #103's vital signs at 2:30 PM, Resident #20's vital signs at 2:34 PM, and Resident #28's vital signs at 2:36 PM. CNA #15 was then observed assisting Resident #95, from a sitting to standing position from his recliner to his walker. He did not perform hand hygiene before and after taking vital signs of each resident and did not perform hand hygiene before assisting Resident #95. CNA #15 stated he knew he should have washed his hands before and after taking the vital signs of each resident.
- On 11/7/18 at 11:15 AM, CNA #11 and CNA #14 were observed helping Resident #10 get up from his recliner to his wheelchair to go to the bathroom. CNA #11 and CNA #14 did not perform hand hygiene before they assisted Resident #10.
CNA #14 performed hand hygiene after he assisted Resident #10 on the toilet and left the room. CNA #14 returned to the room at 11:20 AM and put gloves on but did not perform hand hygiene before he put on gloves. CNA #14 performed hand hygiene after he helped Resident #10 from the toilet to the wheelchair.
CNA #11 did not perform hand hygiene after she removed her gloves, she did not wash her hands before she returned the clean supply items back into the cabinet, and then replaced the dirty garbage bag. CNA #11 then washed her hands and Resident #10's hands and assisted him to the dining room.
- On 11/7/18 at 11:33 AM, CNA #14, was observed assisting Resident #2 from the couch to his wheelchair on One East of the main room to the dining room of the Secured Care Unit for lunch. CNA #14 did not perform hand hygiene before assisting Resident #2 to the dining room.
- On 11/7/18 at 11:35 AM, CNA #11 was observed assisting Resident #28 to the dining room. CNA #11 did not perform hand hygiene before and after assisting Resident #28. CNA #11 then left the dining room and went to Resident #15's room and made his bed. CNA #11 then assisted Resident #35 from his recliner to his wheelchair and helped him to the dining room and did not wash her hands until after she left the dining room.
On 11/7/18 at 12:52 PM, CNA #14 stated he knew he was to wash his hands between taking care of residents, before and after peri-care, and touching equipment. He thought he washed his hands each time but did not realize he sometimes missed opportunities.
On 11/7/18 at 12:54 PM, CNA #11 stated she knew she was to wash her hands before and after cares and between each resident. CNA #11 stated she knew she washed her hands after she moved the clean supplies in the cupboard and stated she should have washed her hands before she moved the clean supplies.
d. The Centers for Disease Control and Prevention (CDC) website, updated October 24, 2016, accessed on November 12, 2018, included recommendations for proper techniques for urinary catheter maintenance. One recommendation stated not to rest the catheter bag on the floor.
The facility's policy Foley Catheter Maintenance, dated March 2006, documented a Foley catheter was a potential source of infection. The policy documented when the resident was up, staff were to make sure the bag was not dragging on the floor area.
Resident #101's care plan, dated 1/12/18, included interventions for an indwelling catheter which documented to keep the catheter bag and tubing off the floor.
On 11/6/18 at 1:50 PM, Resident #101 was observed in bed and the catheter bag was on the floor.
On 11/9/18 at 11:45 AM, CNA #7 stated catheter bags and tubing were not supposed to be on the floor.
On 11/9/18 at 4:00 PM, the DON, stated staff were to make sure catheter bags and tubing were not on the floor.
On 11/7/18 at 4:08 PM, the Infection Control Nurse stated hand hygiene should be performed before and after performing care for residents, between cares with each resident, and catheters should not be on the floor. The Infection Control Nurse stated senior CNAs were assigned to survey other CNAs for hand hygiene but was unsure if they were reporting if there were issues because they did not want to tell on each other. The Infection Control Nurse stated she monitored for infection control. She stated training for hand hygiene and infection control was completed for new employees when they were first hired, annually, and when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents receiving psychoactive medication had consents in place prior to initiation of the medications. This was true for 5 of 6 residents (#2, #30, #87, #100, and #261) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving psychotropic medications without knowledge of the risks and benefits associated with each medication, alternative treatment options, and the right to refuse the medications. Findings include:
A facility policy Mood and Behavior Medication Review Committee, undated, documented the committee identified and evaluated residents' use of medication for behaviors or mood and the committee ensured consents were completed.
a. Resident #261 was admitted to the facility on [DATE], with diagnoses including dementia with Lewy bodies (abnormal protein deposits in the brain) and behavioral disturbances, depression, and sleep disorder.
A significant change MDS assessment, dated 6/7/18, documented Resident #261 was severely cognitively impaired and he was totally dependent or required extensive assistance from one to two staff members with cares. The MDS documented Resident #261 had signs and symptoms of mild depression and he exhibited delusions and hallucinations. The MDS documented Resident #261 had physical, verbal, and other behaviors 4-6 days a week.
Resident #261's May 2018 Physician Orders included the following scheduled and PRN medications:
Scheduled Medications:
- Depakote (anticonvulsant) 500 mg by mouth one time a day for Lewy bodies dementia with hallucinations and agitation, ordered on 5/31/18 and discontinued the same day.
- Remeron (antidepressant) 15 mg at bedtime for depression and insomnia, ordered on 4/2/18 and discontinued on 6/1/18.
- Seroquel (antipsychotic) 200 mg at bedtime for dementia with hallucinations, ordered on 4/24/18 and discontinued on 5/23/18.
- Seroquel 100 mg two times a day for dementia with hallucinations, ordered on 4/27/18 and discontinued on 5/23/18.
- Seroquel 300 mg at bedtime for dementia with hallucinations, ordered on 5/23/18 and discontinued on 5/31/18.
- Topamax (anticonvulsant) 25 mg at bedtime for unstable mood, ordered on 3/30/18 and discontinued on 6/12/18.
- Zoloft (antidepressant) 200 mg one time a day for depression, ordered on 3/30/18 and discontinued on 6/1/18.
PRN Medications:
- Ativan (antianxiety) 1 mg intramuscularly (IM) one time only for extreme anxiety, ordered on 5/9/18.
- Ativan 1 mg IM one time only for Lewy bodies dementia related to delirium, ordered on 5/23/18.
- Ativan 1 mg IM one time only for Lewy bodies dementia related to delirium, ordered on 5/24/18.
- Ativan 0.5 mg IM one time only for extreme anxiety, ordered on 5/27/18.
- Ativan 1 mg intramuscularly every 24 hours PRN for agitation, ordered on 5/31/18 and discontinued on 6/4/18.
- Oxycodone (narcotic) 5 mg every 6 hours PRN for pain, ordered on 5/21/18 and discontinued on 6/12/18.
- Seroquel 100 mg one time only for dementia with hallucinations, ordered on 5/23/18.
- Trazadone (antidepressant, with sedating effects) 25 mg every 8 hours PRN for anxiety, ordered on 4/2/18 and discontinued on 5/23/18.
- Trazadone 50 mg every 8 hours PRN for anxiety, ordered on 5/23/18 and discontinued on 6/12/18.
Resident #261 received 2 antidepressant medications, Remeron and Zoloft, daily from 4/2/18 to 6/1/18, and 1 antipsychotic medication, Seroquel, daily from 4/24/18 to 5/31/18. Two medications, Seroquel and Depakote, were prescribed for hallucinations according to the MAR documentation. He also had orders for 2 antianxiety medications PRN, Ativan and Trazadone. Additionally, the medications Seroquel, Remeron, Trazadone, Ativan, and Oxycodone had sedative effects.
Resident #261's June 2018 Physician Orders included the following scheduled and PRN medications:
Scheduled Medications:
- Ativan 1 mg/ml by mouth three times a day for agitation, ordered on 6/5/18 and discontinued on 6/6/18.
- Ativan 1 mg/ml by mouth two times a day for agitation, ordered on 6/6/18 and discontinued the same day.
- Ativan 1 mg/ml by mouth every eight hours for agitation, ordered on 6/6/18 and discontinued on 6/14/18.
- Clonazepam (antianxiety) 0.5 mg by mouth two times a day for comfort and seizure control, ordered on 6/1/18 and discontinued on 6/6/18.
- Depakote extended release 500 mg by mouth at bedtime for Lewy bodies dementia with hallucinations and agitation, ordered on 6/1/18 and discontinued on 6/12/18.
- Seroquel 50 mg two times a day for dementia with hallucinations, ordered on 5/23/18 and discontinued on 6/12/18.
- Seroquel 200 mg at bedtime for dementia with hallucinations, ordered on 5/31/18 and discontinued on 6/12/18.
- Topamax 25 mg at bedtime for unstable mood, ordered on 3/30/18 and discontinued on 6/12/18.
PRN Medications:
- Ativan 0.5 mg by mouth every 2 hours PRN for agitation, ordered on 6/1/18 and discontinued on 6/5/18.
- Ativan 0.5 mg by mouth every hour PRN for agitation, ordered on 6/5/18 and discontinued on 6/14/18.
- Ativan 1 mg IM every 24 hours PRN for agitation, ordered on 5/31/18 and discontinued on 6/4/18.
- Ativan 1 mg IM every 24 hours PRN for agitation, ordered on 6/4/18 and discontinued on 6/14/18.
- Morphine Sulfate (narcotic) 10 mg sublingually every 2 hours PRN for pain and air hunger, ordered on 6/1/18 and discontinued on 6/14/18.
- Oxycodone 5 mg every 6 hours PRN for pain, ordered on 5/21/18 and discontinued on 6/12/18.
- Trazadone 50 mg every 8 hours PRN for anxiety, ordered on 5/23/18 and discontinued on 6/12/18.
Resident #261's antidepressants, Remeron and Zoloft, were discontinued and he had 2 antianxiety medications added to be taken daily, Ativan and Clonazepam. He also had PRN orders for Ativan, and a new order for Morphine Sulfate for pain.
Resident #261's 5/1/18 through 6/14/18 MAR documented he was administered a PRN psychotropic medication, Trazadone or Ativan, at the same time as PRN pain medications, Oxycodone or Morphine, being administered. Examples include:
- Oxycodone and Trazadone were administered together on 5/23/18 at 2:25 PM and 10:06 PM, 5/24/18 at 3:45 PM, 5/30/18 at 12:33 AM, and 6/4/18 at 3:30 AM.
- Oxycodone and Ativan were administered together on 6/2/18 at 1:12 PM, 6/3/18 at 10:45 AM, and 6/5/18 at 3:03 PM.
- Morphine and Trazadone were administered together on 6/6/18 at 4:00 AM.
- Morphine and Ativan were administered together on 6/1/18 at 1:30 PM, 6/3/18 at 1:40 PM, 6/3/18 at 4:10 PM, 6/4/18 at 6:30 AM, 9:35 AM, and 12:15 PM, 6/6/18 at 3:07 PM, 5:07 PM, and 9:15 PM, 6/10/18 at 10:01 PM, 6/11/18 at 3:32 PM, and 6/12/18 at 1:50 PM.
Resident #261's record did not include consents for his ordered psychotropic medications including Clonazepam, Depakote, Remeron, Seroquel, Topamax, Trazadone, and Zoloft.
b. Resident #30 was readmitted to the facility on [DATE], with diagnoses including dementia.
A quarterly MDS assessment, dated 8/13/18, documented Resident #30 was severely cognitively impaired and had no signs and symptoms of depression. The MDS documented he did not exhibit inappropriate behaviors, hallucinations, delusions, rejection of cares, or wandering.
Resident #30's October 2018 Physician Orders included:
- Zyprexa (antipsychotic) 5 mg by mouth in the afternoon and evening for dementia, ordered 10/22/18.
- Trazadone 100 mg at bedtime for insomnia, ordered 4/2/18.
- Trazadone 25 mg in the afternoon for anxiety, ordered 10/19/18.
- Oxycodone 5 mg twice daily for arthritis pain, ordered 9/28/18.
Resident #30's clinical record did not include a consent for the use of Trazadone.
A Psychoactive Medication Consent, dated 6/29/15, documented Resident #30 received Zyprexa 2.5 mg at twice daily. The consent did not include the black box warning for this medication. The Nursing 2019 Drug Handbook included the following black box warnings for Zyprexa:
* If Zyprexa is used in conjunction with an opioid (oxycodone) this increases the risk of sedation and death.
* Use of Zyprexa may increase the risk of cardiovascular or infection-related deaths in elderly patients with dementia. Zyprexa is not approved to treat patients with dementia related psychosis and is to be used cautiously in the elderly with dementia as it may increase their risk of death.
c. Resident #100 was readmitted to the facility on [DATE], with diagnoses including insomnia and depression.
A quarterly MDS assessment, dated 10/9/18, documented Resident #100 was cognitively intact and had minimal signs and symptoms of depression. The MDS documented she experienced delusions and no other behaviors.
Resident #100's October 2018 Physician Orders included:
- Trazadone 50 mg at bedtime for insomnia, ordered 8/27/18.
- Wellbutrin (antidepressant) 150 mg once daily for depression, 8/27/18.
Resident #100's clinical record did not include consents for the psychotropic medications Trazadone or Wellbutrin.
d. Resident #87 was readmitted to the facility on [DATE], with multiple diagnoses including dementia.
Resident #87's current care plan documented he experienced pain, difficulty concentrating, fear of others causing him harm, and changes in sleep patterns.
Resident #87's physician orders documented he was started on duloxetine (antidepressant, also used to treat pain) 20 milligrams (mg) orally every day. On 11/7/18, the dose was increased to 60 mg each day.
Resident #87's record did not include a consent from Resident #87 or his representative for the use of the duloxetine.
e. Resident #2 was readmitted to the facility on [DATE], with multiple diagnoses including insomnia, dementia, PTSD, anxiety, depression, and Alzheimer's disease.
Resident #2's physician's orders, included:
* Escitalopram Oxalate (antidepressant) 10 mg by mouth one time a day for depression/PTSD, ordered on 4/3/18.
* Risperdal (antipsychotic) 1 mg by mouth two times a day for unstable mood, ordered on 8/9/18.
* Trazadone HCl 100 mg by mouth at bedtime for insomnia, ordered on 11/2/18.
Resident #2's record did not include a consent for the use of psychotropic medications which included Escitalopram Oxalate 10 mg by mouth one time a day for depression/PTSD, and Trazadone HCl 100 mg by mouth at bedtime for insomnia.
On 11/8/18 at 1:25 PM, the DON and Pharmacist confirmed the facility was unaware of the need to obtain resident/responsible party consent to administer psychoactive medications, including antidepressants. The facility failed to obtain consent from the residents and/or responsible parties to treat the resident with psychoactive medications prior to starting the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, policy review, and record review, it was determined the facility failed to ensure a) written notice was provided to residents and/or their representatives prior to room and/or roommate changes, and b) residents were allowed to share a room with a roommate of their choice when practicable. This was true for 3 of 23 residents (#1, #30, and #89) reviewed for a room change and created the potential for harm should the residents experience a diminished sense of self-worth due to lack of control over their environment. Findings include:
The facility's Change of Room or Roommate Policy/Procedure, dated 2/14/18, documented the resident would be provided with advanced written notice of a room transfer or roommate change, and the notice would include the reason for the recommended move. Prior to the room transfer, the resident, his/her roommate, and the resident's representative would be provided with information regarding the decision for the room transfer. The policy documented after the decision to move a resident was made, the facility would involve the resident in the decision and selection of a room or roommate when possible, allow the resident to ask questions, show the resident the new space, introduce any new roommates, and explain to other resident why the change was necessary.
This policy was not followed. Examples include:
a. Resident #1 was admitted to the facility on [DATE], with diagnoses including depression.
A quarterly MDS assessment, dated 10/17/18, documented Resident #1 had moderate cognitive impairment. The assessment also documented Resident #1 had the ability to express ideas and wants and to consider both verbal and nonverbal expressions. The assessment further documented Resident #1 had clear comprehension and the ability to understand others.
On 11/5/18 at 11:21 AM and 11/6/18 at 9:44 AM, Resident #1 was observed in room [ROOM NUMBER]-1.
A Progress Note, dated 11/6/18 at 8:04 AM, documented Resident #1's daughter requested Resident #1 move to a room with a window. The note documented Resident #1 stated to social services he did not need to move but would move. The note documented a room was being prepared for Resident #1.
On 11/6/18 at 10:37 AM, Resident #1 was moved to room [ROOM NUMBER]-2 by the window.
On 11/6/18 at 3:26 PM, Resident #1 stated the facility had not shown him his new room or introduced him to his new roommate until he was moving. Resident #1 stated he was told he had to move. Resident #1 stated he was not sure why he had to move, and he preferred his old room. Resident #1 stated he now had a roommate he did not know, and he left a roommate he had liked.
On 11/14/18, after the completion of the survey, the facility provided a copy of written notice to Resident #1's family regarding the room change. The notice did not include the date the notice was drafted and was not signed by Resident #1's daughter or Resident #1.
b. Resident #30 was readmitted to the facility on [DATE], with diagnoses including dementia.
A quarterly MDS assessment, dated 8/13/18, documented Resident #30 was severely cognitively impaired.
On 11/5/18 at 11:15 AM, Resident #30 was observed in room [ROOM NUMBER]-1.
A Progress Note, dated 11/5/18 at 4:08 PM, documented Resident #30 was moved to room [ROOM NUMBER] today. The note documented Resident #30's wife was notified, and she had no issues with the move.
On 11/6/18 at 9:40 AM, Resident #30 was observed in room [ROOM NUMBER].
On 11/14/18 after the completion of the survey the facility provided a copy of a written notice to Resident #30's family regarding the room change. The notice did not include the date the notice was drafted and was not signed by Resident #30's wife.
c. Resident #89 was admitted to the facility on [DATE], with diagnoses including cerebral infarction (stroke).
A quarterly MDS assessment, dated 9/23/18, documented Resident #89 had moderate cognitive impairment.
On 11/5/18 at 11:15 AM, Resident #89 was observed in room [ROOM NUMBER]-2.
On 11/6/18 at 9:40 AM, Resident #89 was observed in room [ROOM NUMBER]-1.
A Progress Note, dated 11/6/18 at 9:05 AM, documented Resident #89 was moved to a different bed in the same room. The note documented Resident #89's family verbalized no concerns.
A Progress Note, dated 11/6/18 at 9:09 AM, documented Resident #89 received a new roommate and he was introduced to Resident #1.
On 11/7/18 at 3:05 PM, the DON stated Resident #30 was moved to accommodate Resident #1's behavior of wandering and eloping. The DON stated Resident #1's family had requested he be placed near a window, which was what facilitated the move. The DON stated Resident #30's family was out of the country and could not sign a form.
On 11/7/18 at 3:14 PM, LMSW #2 stated she had completed written notices to Resident #1, #30, and #89's families, however, she could not locate the notices. LMSW #2 stated she did not talk to the residents due to their limited cognitive status. LMSW #2 stated she provided a written notice to the families because of the residents' cognitive status.
On 11/14/18, after the completion of the survey, the facility provided a copy of a written notice to Resident #89's family regarding Resident #89's roommate change. The notice did not include the date the notice was drafted and was not signed by Resident #89's family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility did not ensure residents were free from chemical restraints. There was no documented evidence a systematic process of evaluation and care planning was utilized for staff to first implement resident-specific focused non-pharmacological interventions should residents demonstrate aggressive behaviors. This resulted in harm to 1 of 6 residents (Resident #261) reviewed for psychotropic drug use. Resident #261 was harmed when he experienced increased somnolence, sedation, and a decline in ADL's as a result of multiple psychotropic medications. Findings include:
A facility policy, Mood and Behavior Medication Review Committee, undated, documented the committee identified and evaluated residents use of medication for behaviors or mood and the committee would determine the appropriate interventions and ensure consents, orders, and care plans were completed.
The facility's ADL Behavior Monitor flowsheets documented the following behaviors for each resident in the facility, wandering, verbal abusive, physical abusive, socially inappropriate behavior, resistive or rejection of care, or there were no behaviors.
The facility's ADL Mood Symptoms Monitor flowsheets documented the following behavior for each resident in the facility, little interest or pleasure in doing things, feeling or appearing down/depressed, trouble falling asleep or staying asleep, feeling tired, poor appetite or overeating, feeling bad about themselves, trouble concentrating, moving extremely slow and speaking slow so that others notice, suicidal ideation's, and short tempered. The facility did not identify resident specific behaviors for staff to monitor.
Resident #261 was admitted to the facility on [DATE], with diagnoses including dementia with Lewy bodies (abnormal protein deposits in the brain) and behavioral disturbances, depression, and sleep disorder.
A significant change MDS assessment, dated 6/7/18, documented Resident #261 was severely cognitively impaired and he was totally dependent or required extensive assistance from one to two staff members with cares. The MDS documented Resident #261 had signs and symptoms of mild depression and he exhibited delusions and hallucinations. The MDS documented Resident #261 had physical, verbal, and other behaviors 4-6 days a week. The MDS documented he did not wander or reject cares.
Resident #261's May 2018 Physician Orders included the following scheduled and PRN medications:
Scheduled Medications:
- Depakote (anticonvulsant) 500 mg by mouth one time a day for Lewy bodies dementia with hallucinations and agitation, ordered on 5/31/18 and discontinued the same day.
- Remeron (antidepressant) 15 mg at bedtime for depression and insomnia, ordered on 4/2/18 and discontinued on 6/1/18.
- Seroquel (antipsychotic) 200 mg at bedtime for dementia with hallucinations, ordered on 4/24/18 and discontinued on 5/23/18.
- Seroquel 100 mg two times a day for dementia with hallucinations, ordered on 4/27/18 and discontinued on 5/23/18.
- Seroquel 300 mg at bedtime for dementia with hallucinations, ordered on 5/23/18 and discontinued on 5/31/18.
- Topamax (anticonvulsant) 25 mg at bedtime for unstable mood, ordered on 3/30/18 and discontinued on 6/12/18.
- Zoloft (antidepressant) 200 mg one time a day for depression, ordered on 3/30/18 and discontinued on 6/1/18.
PRN Medications:
- Ativan (sedative and antianxiety) 1 mg intramuscularly (IM) one time only for extreme anxiety, ordered on 5/9/18.
- Ativan 1 mg IM one time only for Lewy bodies dementia related to delirium, ordered on 5/23/18.
- Ativan 1 mg IM one time only for Lewy bodies dementia related to delirium, ordered on 5/24/18.
- Ativan 0.5 mg IM one time only for extreme anxiety, ordered on 5/27/18.
- Ativan 1 mg intramuscularly every 24 hours PRN for agitation, ordered on 5/31/18 and discontinued on 6/4/18.
- Oxycodone (narcotic) 5 mg every 6 hours PRN for pain, ordered on 5/21/18 and discontinued on 6/12/18.
- Seroquel 100 mg one time only for dementia with hallucinations, ordered on 5/23/18.
- Trazadone (sedative and antidepressant) 25 mg every 8 hours PRN for anxiety, ordered on 4/2/18 and discontinued on 5/23/18.
- Trazadone 50 mg every 8 hours PRN for anxiety, ordered on 5/23/18 and discontinued on 6/12/18.
Resident #261 received 2 antidepressant medications, Remeron and Zoloft, daily from 4/2/18 to 6/1/18, and 1 antipsychotic medication, Seroquel, daily from 4/24/18 to 5/31/18. Two medications, Seroquel and Depakote, were prescribed for hallucinations according to the MAR documentation. He also had orders for 2 antianxiety medications PRN, Ativan and Trazadone. Additionally, the medications Seroquel, Remeron, Trazadone, Ativan, and Oxycodone had sedative effects.
Resident #261's June 2018 Physician Orders included the following scheduled and PRN medications:
Scheduled Medications:
- Ativan 1 mg/ml by mouth three times a day for agitation, ordered on 6/5/18 and discontinued on 6/6/18.
- Ativan 1 mg/ml by mouth two times a day for agitation, ordered on 6/6/18 and discontinued the same day.
- Ativan 1 mg/ml by mouth every eight hours for agitation, ordered on 6/6/18 and discontinued on 6/14/18.
- Clonazepam (antianxiety) 0.5 mg by mouth two times a day for comfort and seizure control, ordered on 6/1/18 and discontinued on 6/6/18.
- Depakote extended release 500 mg by mouth at bedtime for Lewy bodies dementia with hallucinations and agitation, ordered on 6/1/18 and discontinued on 6/12/18.
- Seroquel 50 mg two times a day for dementia with hallucinations, ordered on 5/23/18 and discontinued on 6/12/18.
- Seroquel 200 mg at bedtime for dementia with hallucinations, ordered on 5/31/18 and discontinued on 6/12/18.
- Topamax 25 mg at bedtime for unstable mood, ordered on 3/30/18 and discontinued on 6/12/18.
PRN Medications:
- Ativan 0.5 mg by mouth every 2 hours PRN for agitation, ordered on 6/1/18 and discontinued on 6/5/18.
- Ativan 0.5 mg by mouth every hour PRN for agitation, ordered on 6/5/18 and discontinued on 6/14/18.
- Ativan 1 mg IM every 24 hours PRN for agitation, ordered on 5/31/18 and discontinued on 6/4/18.
- Ativan 1 mg IM every 24 hours PRN for agitation, ordered on 6/4/18 and discontinued on 6/14/18.
- Morphine Sulfate (narcotic) 10 mg sublingually every 2 hours PRN for pain and air hunger, ordered on 6/1/18 and discontinued on 6/14/18.
- Oxycodone 5 mg every 6 hours PRN for pain, ordered on 5/21/18 and discontinued on 6/12/18.
- Trazadone 50 mg every 8 hours PRN for anxiety, ordered on 5/23/18 and discontinued on 6/12/18.
Resident #261's antidepressants, Remeron and Zoloft, were discontinued and he had 2 antianxiety medications added to be taken daily, Ativan and Clonazepam. He also had PRN orders for Ativan, and a new order for Morphine Sulfate for pain. Additionally, the medications Ativan, Clonazepam, Seroquel, Morphine Sulfate, Oxycodone, and Trazadone had sedative effects.
Resident #261's care plan did not include specific behaviors and did not identify or include depression and anxiety.
Resident #261's care plan addressed cognition, dated 3/27/18, and documented he had impaired cognition related to Lewy body dementia and was rarely understood and had difficulty understanding. The care plan did not document how his dementia presented.
Resident #261's care plan area addressing elopement risk, dated 4/13/18, and documented he verbalized wanting to leave the facility and wandered the facility. Interventions included Resident #261 had a roam alert bracelet on his wheelchair, dated 4/13/18, and staff were to provide 1:1 supervision until Resident #261 stopped attempting to leave the facility, dated 5/26/18. The care plan did not include identification of behaviors associated with the 1:1 intervention initiated on 5/26/18.
The care plan area addressing Resident #261's behaviors and mood, dated 6/28/17, documented he was cognitively impaired and had dementia. The care plan documented he had behavioral issues with hallucinations and delusions. The care plan documented Resident #261 had suicidal ideation, hit staff, and screamed.
Resident #261's care plan did not identify if Resident #261's hallucinations and or delusions were tactile [touch], visual, auditory, and olfactory [smell]), was not resident specific and did not document clearly how his hallucinations or delusions presented. The care plan did not document if his hallucinations or delusions were harmful to him.
Resident #261 did not have a care plan for his anxiety or his depression. The facility did not identify how Resident #261's anxiety, agitation, or depression presented.
Resident #261's Sleep Monitors, MAR, and Progress Notes documented Resident #261's hours of sleep increased as the medications were added, and he experienced falls and increased confusion with the medication changes. Examples include:
- Resident #261's Sleep Monitor for 5/2/18 MAR documented he slept 11 hours. A progress note, dated 5/2/18, documented Resident #261 was administered a PRN Trazadone due to him not being able to sleep and settle down. Resident #261's Trazadone was ordered for anxiety and not sleep.
- A Progress note, dated 5/14/18 at 9:39 PM, documented Resident #261 was agitated and continued to ambulate without his wheelchair or assistance and PRN Trazadone was provided at 2:53 PM. The note documented Resident #261 needed 1:1 staff supervision from 1:00 PM to 9:00 PM and a light duty staff member was only available from 4:00 PM to 6:00 PM. Resident #261's care plan was not updated to include the need for 1:1 staff supervision on 5/14/18, and it was unclear if he was to have a 1:1 CNA present for the duration of time between 1:00 PM and 9:00 PM.
- A Progress Note, dated 5/19/18 at 5:15 AM, documented Resident #261 experienced an unwitnessed fall in his room while attempting to walk in his room.
- A Progress Note, dated 5/22/18 at 1:39 PM, documented Resident #261 had increased behaviors of hitting staff, aggression, paranoia and was not redirectable. The note documented he spoke in word salad (gibberish) and appeared in distress. The note documented pharmacy recommended increasing his psychotropic medications, Topamax and Trazadone, and Resident #261's spouse agreed. Resident #261's clinical record did not document an episode of physical abusive behaviors occurring on 5/22/18. The behavior monitoring documented he experienced one behavior of being physically abusive for the month of May, on 5/21/18.
- A Progress note, dated 5/22/18 at 2:43 PM, documented Resident #261 was easily frustrated and angry at nursing staff. The note documented he wanted to leave the facility and attempted to pick up items off the floor that were not there. The note documented he yelled at staff when they attempted to assist him to the restroom during the day, and later in the evening he was unable to bear weight to transfer onto a toilet and was resistive when they attempted to assist him into bed due to sleepiness.
- A Progress Note, dated 5/23/18 at 5:45 AM, documented Resident #261 experienced a witnessed fall in the TV room. The note documented Resident #261 was sitting in his wheelchair and he was leaning to the side and fell out of his wheelchair before the staff member sitting next to him could stop it. The note documented Resident #261 was up all night and was assisted into a recliner chair using a Hoyer lift, and he immediately fell asleep.
Resident #261's 5/23/18 MAR documented he was administered a dose of PRN oxycodone and PRN Trazadone at 2:25 PM. The MAR documented he was administered a PRN dose of Ativan at 9:53 PM, then at 10:06 PM, he was administered a dose of PRN Trazadone and PRN oxycodone, then at 10:13 PM he was administered a dose of PRN Seroquel. There was 13 minutes between the PRN Ativan and PRN oxycodone, Seroquel, and Trazadone doses.
According to the Nursing 2019 Drug Handbook, Ativan by IM injection take up to 60 minutes to take effect. According to the Nursing 2019 Drug Handbook Ativan, Trazadone, and oxycodone side effects include sedation, confusion, insomnia, dizziness, and drowsiness. The staff did not provide adequate time for the anxiety medication administered to take effect before administering another two psychotropic medications and a pain medication.
- A Progress Note, dated 5/23/18 at 11:05 PM, documented Resident #261 was provided PRN oxycodone at 2:25 PM and at 10:06 PM and they were effective with relieving pain from his fall. The note documented he was anxious the majority of the shift and rested for a few hours after dinner while his 1:1 supervision CNA was with him. Resident #261's care plan was not updated to include the need for 1:1 staff supervision on 5/23/18, and it was unclear if he was to have a 1:1 CNA.
The 5/23/18 note documented the IM Ativan was not initially effective and PRN Trazadone, oxycodone, and Seroquel were administered. The same note documented at 10:30 PM Resident #261 was asleep and snoring in the common area. The note documented Resident #261 required the assistance of 2 staff members with a Hoyer lift for all transfers during the remainder of the shift.
- A Progress Note, dated 5/27/18 at 3:00 AM, documented Resident #261 woke up and he was calling out he wanted to use the bathroom and go home. Resident #261 was unable to stand up and comprehend instructions with using the mechanical lift and required 3 CNAs to assist with the transfer. He was given a dose of PRN Trazadone related to anxiety, which was ineffective. Resident #261 was moved to the nurses' station and continued to call out. The note documented a 1:1 sitter was not available for the night shift and a staff member assigned to a different unit volunteered to assist as Resident #261's 1:1 for 1-2 hours. Resident #261 was administered a PRN IM Ativan dose at 3:22 AM. There was no documentation describing how Resident #261's anxiety presented.
- A Progress Note, dated 6/1/18 at 8:15 AM, documented Resident #261 experienced a witnessed fall in the common room. The note documented Resident #261 was attempting get out of a recliner chair and sat on the footrest causing it to collapse to the floor. The note documented a new care plan intervention was implemented of a 1:1 staff member. It was unclear if Resident #261's 1:1 staff was near him at the time of the fall, or if the 1:1 was currently in place as care planned on 5/26/18.
- A Progress Note, dated 6/2/18 at 10:38 AM, documented a conversation between Resident #261's physician and nursing staff from 5/31/18 through 6/1/18. The note documented Resident #261's psychotropic medications were adjusted. The note documented on 5/31/18 at 11:52 AM, Resident #261 had not slept for 2 days and an IV Ativan was provided per the physician's order and Resident #261 was finally resting.
- A Progress Note, dated 6/4/18 at 10:41 AM, documented Resident #261 had increased confusion and was restless and picked up unseen items on the floor. The note documented he had a change in his previous normal pattern of behavior with an increase in negative behaviors and increased confusion and agitation. Resident #261's 6/4/18 MAR documented he was administered a dose of PRN Ativan and PRN Morphine at 12:15 PM, a dose of PRN Trazadone at 2:00 PM, and a dose of PRN IM Ativan at 2:40 PM. According to the Nursing 2019 Drug Handbook, Ativan, Trazadone, Morphine, and oxycodone side effects include anxiety, irritability, agitation, hostility, anger, sedation, confusion, insomnia, dizziness, and drowsiness.
- A Progress Note, dated 6/5/18 at 3:00 AM, documented Resident #261 was with a 1:1 staff member for safety. The note documented he was agitated and fidgety. The note documented Resident #261 was rubbing his knees for possible pain and attempted to rise from his bed frequently. The note documented he was provided PRN morphine for possible pain and later PRN Ativan for cont [inued] wakefulness/agitation. Resident #261's 6/5/18 MAR documented he was administered a dose of PRN Ativan at 6:49 AM, a dose of scheduled Ativan at 8:00 AM, a dose of PRN Ativan at 10:28 AM, a dose of PRN IM Ativan at 3:03 PM, a dose of PRN oxycodone at 3:15 PM, a dose of scheduled Ativan at 4:00 PM, and a dose of PRN Morphine at 7:36 PM, 9:40 PM, and 11:46 PM.
Resident #261's May 2018 MAR documented he was sleeping from 3 hours to 16 hours a day and averaged 9 hours daily. Examples include:
- On 5/2/18, the MAR documented he slept 11 hours. A progress note, dated 5/2/18, documented Resident #261 was administered a PRN Trazadone as he was unable to sleep and settle down. Resident #261's Trazadone was ordered for anxiety, not sleep.
- Resident #261's MAR documented he slept 9 hours during the 5/8/18 evening shift.
- Resident #261's MAR documented for the night shift on 5/23/18 he slept 7 hours, and during the day shift on 5/24/18 he slept for 4 hours.
- Resident #261's MAR documented for the night shift on 5/27/18 he slept 7 hours, and during the day shift on 5/28/18 he slept for 4 hours.
- Resident #261's MAR documented he slept for 10 hours on 5/29/18, on 5/30/18 he slept 7 hours, and on 5/31/18 he slept 10 hours during the 24 hour period.
Resident #261's June 2018 MAR documented he was sleeping from 7 to 24 hours a day and averaging 15 hours daily. Examples include:
- Resident #261's Sleep Monitor for 6/4/18 documented he slept 8 hours during the 24 hour period.
- Resident #261's Sleep Monitor for 6/5/18 documented he slept 9 hours during the 24 hour period.
- Resident #261's Sleep Monitor for 6/6/18 documented he slept 16 hours during the 24 hour period.
- Resident #261's Sleep Monitor documented he slept 11 hours on 6/7/18, 16 hours on 6/8/18, 21 hours on 6/9/18, 16 hours on 6/10/18, 21 hours on 6/11/18, and 24 hours on 6/12/18 and 6/13/18.
On 11/9/18 at 10:19 AM, LMSW #1 stated Resident #261 was actively delusional, he experienced hallucinations, and was paranoid of people trying to do bad things to him. LMSW #1 stated the medications were managed by a psychiatrist. LMSW #1 stated he received alerts from staff when a resident was experiencing increased behaviors and the GDR committee evaluated the residents from the alerts. LMSW #1 stated the CNA behavior monitors did not include hallucinations and delusions, but staff documented these in the MDS and throughout the progress notes. LMSW #1 stated psychotropic medications could increase a resident's fall risk and the facility did not provide PRN psychotropic medications when a 1:1 staff member was unavailable. LMSW #1 stated staff provided PRN medications when a resident's behavior exhibited. LMSW #1 stated the specific behavior the resident exhibited should be documented in their clinical record for any PRN psychotropic medication administration. LMSW #1 stated the care plan should identify resident specific behaviors for dementia, hallucinations, and delusions and if they were harmful. The LMSW #1 stated the current behavior monitors were helpful with gathering information in addition to the alerts he received along with the resident MDS.
On 11/9/18 at 12:23 PM, the DON stated according to the care plan Resident #261 was to have a 1:1 staff member with him on 5/26/18. The DON stated he may have been provided a 1:1 for short durations before that time. The DON stated the facility did not provide PRN psychotropic medications when a 1:1 staff member was unavailable, only when residents' behaviors increased. The DON stated the behavior monitors were not resident specific and the staff documented specific instances throughout the progress notes. The DON stated when the GDR team met the team reviewed each resident's behaviors and evaluated items such as sleep and what the team discussed was documented on the GDR note.