Flatrock River Lodge

Based on interview and record review, the facility failed to timely document weekly wound assessment and ensure a primary care provider's visit was completed for 1 of 4 residents reviewed for quality of care concerns. (Resident C) Findings include:The clinical record for Resident C was reviewed on 1/39/2026 at 10:15 a.m. The resident's diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease (progressive, lung disease characterized by chronic airway inflammation, narrowed airways, and damaged air sacs-[COPD]), heart failure, and kidney failure. A Quarterly MDS Assessment, dated 9/15/2025, indicated Resident C was cognitively impaired, did not have behaviors, did not reject care, needed staffs' assistance with hygiene, and did not have pressure areas.a. A behavioral care plan, revised 9/22/2025, indicated staff were to make referrals as needed.A provider's visit note, dated 11/12/2025, indicated Resident C was having behavioral issues. The plan of care reflected medication changes and to follow up in two to three weeks or soon if indicated.During an interview, on 1/30/2026 at 2:45 p.m., Nurse Practitioner (NP) 5 indicated Resident C was not seen after 11/12/2025.b. A skin care plan, revised 9/22/2025, indicated Resident C had skin impairments, the interventions included, but were not limited to, inspected skin every shift and reporting changes in the skin.A weekly wound assessment, dated 11/11/2025, indicated Resident C had a blister to her left leg.The clinical record for Resident C lacked a weekly wound assessment from11/12/2025 through 11/25/2025.A weekly wound assessment, dated 11/26/2025, indicated Resident C had two venous ulcers to her left leg.The clinical record for Resident C lacked a weekly wound assessment from 11/27/2025 through 12/8/2025.A weekly wound assessment, dated 12/9/2025, indicated Resident C had two venous ulcers to her left leg and one venous ulcer to her right leg.A policy, entitled Skin Management, was provided by the Clinical Support Nurse on 1/29/2026 at 11:45 a.m. The policy indicated, .When a resident is admitted with or develops a pressure injury or any other open area, immediate treatment will be initiated.A weekly assessment will be done by the nurse and all ongoing wound documentation will be entered into the Pressure-Injury Assessment fold (for any pressure-injuries) or Non-Pressure Wounds folder 3.1-37This citation relates to Intakes 2710696 and 2715782.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely follow up on fall interventions (Resident D) and notify a family of a fall (Resident E) for 2 of 3 residents reviewed for falls. Findings include:1. The clinical record for Resident D was reviewed on 1/29/2026 at 2:45 p.m. The resident's diagnoses included, but were not limited to, diabetes and dementia (decline in mental abilities).A Quarterly MDS, dated [DATE], indicated Resident D was cognitively intact and needed assistance of staff for transferring with activities of daily living.A incident note, dated 12/23/2025, indicated Resident D had a fall in her room. The immediate intervention indicated, .Requested for OT Eval and Bed Mobility.A physician's order, signed 12/29/2025, indicated for Resident was to have an Occupation Therapy evaluation and treatment as indicated related to her rolling out of bed.During an interview, on 1/29/2026, the Clinical Support 6 indicated the therapy evaluation was not completed and she could not find documentation as to why it was not completed.A nursing note, dated 1/30/2026, indicated that the therapy evaluation was not completed, but was reordered due to her decline after chronic illness.2. The clinical record for Resident E was reviewed on 1/29/2026 at 3:15 p.m. The resident's diagnoses included, but were not limited to, kidney disease (a condition where the kidneys were damaged or cannot filter blood properly) and tachycardia (a heart rate that exceeds 100 beats per minute in adults while at rest).An admission MDS Assessment, dated 11/3/2025, indicated Resident E was cognitively impaired and needed assistance of staff with transferring for activities of daily living.A fall care plan, dated 11/5/2025, indicated Resident E needed assistance of two staff members for transferring.An incident note, dated 11/4/2025, indicated Resident E had a fall in her room. Under family/contact notification, the documentation stated .Res. is own Responsible Party.During an interview, on 1/29/2026 2:50 p.m., Family Member 4 indicated she was only aware of two falls for her family member during the resident's stay at the facility.A policy, entitled Fall Assessment and Prevention Protocol, was provided by the Clinical Support Nurse 6 on 1/29/2026 at 11:45 a.m. The policy indicated, If/when a resident experiences a fall, a root cause analysis will be conducted to assist in planning appropriate evidence-based interventions to prevent further falls. and .Notify the POA or other legal representative.3.1.45(a)This citation relates to Intakes 2710696 and 2715782.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely implement inventions of a pressure relieving boots for 1 of 3 residents reviewed for skin condition. (Resident J)Findings include:The clinical record for Resident was reviewed on 1/30/2026 at 2:05 p.m. The resident's diagnoses included, but were not limited to, dementia (decline in mental abilities) and adult failure to thrive (a decline in physical and mental wellbeing). A skin care plan, revised 1/4/2026, indicated Resident J had an condition on her left heel which progressed to an unstageable ulcer on 12/24/2025. The intervention for the resident's area to the left heel, included staff were to apply heel protectors to both feet while in bed. A nursing assessment, dated 12/24/2025, indicated the area to Resident J's left heel had increased in size from 1.4 x (by) 1.8 cm on 12/17/2025 to 2.4 x 2.9 cm. The interventions, included but were not limited to, use of heel protector boots. A physician's order, dated 12/26/2025, indicated a request for routine treatment. The order was addressed on 12/29/2025 with a response of dressing order as well as, .Apply heel protectors when not up in wc [wheelchair]. The treatment administration record for Resident J, dated December 2025, indicated heel protectors were not started until 12/31/2025. During an interview, on 1/30/2026 at 3:05 p.m., the Clinical Support Nurse 6 indicated it was the expectations that new orders are processed as soon as possible, but at least within 24 hours. A policy, entitled Prescriber Medication Order, was provided by the Director of Nursing on 1/30/2026 at 3:30 p.m. The policy indicated for new handwritten orders, .the nurse on dity at the [NAME] the order is received enter it on the physician order sheet. This citation relates to Intakes 2710696 and 2715782. 3.1-40

Based on observation, interview, and record review, the facility failed to ensure a resident had compression stockings on as ordered for 1 of 1 resident reviewed for edema. (Resident 9)
Findings include:
The clinical record for Resident 9 was reviewed on 4/8/25 at 11:45 a.m. The diagnoses included, but were not limited to, osteoarthritis and diabetes mellitus.
During an observation and interview on 4/8/25 at 9:48 a.m., Resident 9 was fully dressed for the day and indicated she did not have her TED (Thrombo-Embolic Deterrent) hose on.
During an interview with Resident 9 on 4/8/25 at 10:36 a.m., she indicated the facility staff had taken her TED hose to be washed the day before and they have not brought them back.
During an observation and interview on 4/9/25 at 10:49 a.m., Resident 9 did not have her TED hose on. She indicated that staff have not brought them back to her after being washed.
Resident 9 had a physician's order, dated 3/6/23, that indicated to apply TED hose to both lower extremities (for edema) daily, on in the morning and off in the evening.
Resident 9's Treatment Administration Record (TAR) was reviewed on 4/9/25 at 11:30 a.m. The TAR indicated Resident 9 had TED hose applied in the morning, on 4/8/25, and removed, on 4/8/25, in the evening. The TAR also indicated Resident 9 had TED hose applied in the morning of 4/9/25.
A care plan for Resident 9, dated 10/26/23, indicated to apply TED hose in the morning and remove in the evening/bedtime.
During an interview with the Director of Nursing (DON) on 4/9/25 at 1:50 p.m., she indicated nursing was responsible for making sure Resident 9's TED hose were on.
A Medication/Treatment Administration Error Policy was provided by the Nurse Consultant on 4/10/25 at 10:11 a.m. The policy indicated .1. A facility medication/treatment error occurs when .n. Failure to complete a medically related procedure/treatment as ordered by the physician .
3.1-37(a)

Based on interview and observations, the facility failed to date open and/or prepare food products in the walk-in refrigerator. This deficient practices had the potential to aversively affect 34 of 34 residents who receive foods from the dietary department.
Findings include:
During an observation on 3/4/2024 at 6:50 p.m., three small bowls of prepared cottage cheese, a small bowl of prepared tomatoes, a plastic container of what Dietary Aide 2 identified as barbequed beef, a pitcher of orange liquid, and a cart with multiple glasses prepared with various drinks were all noted to not to be dated of when it was opened/prepared or with a use-by date.
During an interview with Dietary Aide 2 on 3/4/2024 at 6:55 p.m., she indicated that they do not label the drinks on the cart because they go through them so quickly.
During an interview with the Dietary Manager on 3/5/2024 at 10:35 a.m., he indicated all 34 residents receive food from the kitchen and food items should be dated.
A policy entitled, Food Storage Standards, was provided by the Clinical Operations Liaison on 3/6/2024 at 3:00 p.m. The policy indicated, .Ready-to-eat refrigerated foods are labeled according to FDA or state standards . A supportive documented to the policy, entitled Food Storage Guide, was provided by the Clinical Operations Liaison on 3/7/2024 at 10:30 a.m. The guide indicated .Date food packages .
3.1-21(i)(3)

Based on observation, interview and record review the facility failed to complete an accurate skin assessment and provide treatment for a resident experiencing bilateral foot and ankle swelling for 1 of 1 resident reviewed for edema (Resident 30).
Finding include:
During an observation and interview with Resident 30 on 3/05/24 at 11:39 a.m., the resident had bilateral feet and ankle swelling. The resident indicated they had been swollen for a week and she needed a water pill. The resident was unable to tie her tennis shoes all the way due to the swelling. The resident indicated her feet and ankles felt tight but she was not experiencing pain.
During an observation and interview with Resident 30 on 3/06/24 at 11:11 a.m., the resident was observed to have bilateral swelling of her feet and ankles and was not able to tie her shoes due to the swelling. The resident indicated the facility had not provided treatment for the swelling. The resident indicated she had reported the swelling to all the staff.
During an observation on 3/07/24 at 1:53 p.m., Resident 30 was observed to have bilateral swelling of her feet and ankles and was unable to tie her shoes due to the swelling.
Review of the record of Resident 30 on 3/6/24 at 11:50 a.m., indicated the diagnoses included, but were not limited to, hypertension, arthritis, L arm post polio contractures and peripheral edema.
The skin and body assessment for Resident 30, dated 3/6/24, indicated the resident had no skin issues and no edema.
The admission Minimum Data (MDS) assessment for Resident 30, dated 1/26/24, indicated the resident was cognitively intact, decisions consistent and reasonable.
During an interview with the Administrator in Training on 3/07/24 at 1:58 p.m., indicated the nurses were responsible to complete a weekly skin assessment for Resident 30. The resident's bilateral feet and ankle swelling was reported at this time.
The physician order for Resident 30, dated 3/7/24 at 3:38 p.m., indicated the resident was ordered [NAME] hose in the morning and off at night.
The skin management policy provided by the Regional Clinical Liaison on 3/8/24 at 9:30 a.m., indicated skin was to monitored routinely during care giving and problems identified would be documented.
3.1-37(a)

Based on observation, interview, and record review, the facility failed to utilize two staff for transfers for Resident 188, resulting in a fall, failed to use a gait belt during a transfer for Resident 188, failed to implement fall interventions for Resident 139, and failed to use a gait belt during a transfer for Resident 140. This affected 3 of 5 residents reviewed for accidents. (Residents 188, 139, and 140)
Findings include:
1. During an interview, on 1/03/23 at 2:10 p.m., Resident 188 indicated she fell and hurt her left lower leg and cut a big gash in her left leg.
Resident 188's record was reviewed on 1/04/23 at 3:11 p.m. and indicated diagnoses that included, but were not limited to, heart failure, atrial fibrillation, chronic obstructive pulmonary disease, with acute exacerbation, depression, and asthma.
An admission Minimum Data Set assessment, dated 12/4/22, indicated Resident 188 was moderately impaired in cognitive skills for daily decision making, received hospice services, had a fall prior to admission, but none since admission, required extensive assistance of 2 for bed mobility, transfers, and toilet use, did not walk, balance was unsteady, she was only able to stabilize with staff assistance.
A baseline care plan, dated 11/21/22, indicated Resident 188 was alert, occasionally confused, had a history of falls within the last 180 days, is a fall risk due to weakness, and was assist of one for transfers and toileting.
Incident documentation of the fall, dated 12/15/22 at 8:40 p.m., indicated Resident 188 had been lowered to the floor on 12/15/22 at 6:00 p.m. She was in the bathroom and the activity at the time was transferring, the equipment involved was a wheelchair. The injury was a skin tear on the left leg 5 centimeters by 0.5 centimeters.
A follow up of incident dated 12/19/22, indicated the resident had a laceration of her left lower leg, she was being toileted by a CNA and her knees became weak and she had to be sat on the floor. A second CNA came to assist the resident up and cut resident's leg on the foot pedal of her wheelchair. First aid was applied and hospice was called. The Interdisciplinary Team had updated the care plan and made the resident an assist of 2.
On 1/06/23 at 9:39 a.m., the Director of Nursing indicated Resident 188 was being toileted with one person assist, she had to lower her to the floor then she got assistance to get her up. When they were helping her stand, her leg was cut on her wheelchair. This happened on 12/15/22. The new intervention was to have her be a two person assist.
On 1/10/23 at 1:18 p.m., Resident 188 was observed as she was transferred from her wheelchair her recliner chair with CNA 3 and CNA 4. CNA 4 took the resident's catheter drainage bag and hooked it to her front pocket, both CNA's took hold of her arms and helped the resident to stand, then sat her back down in her wheelchair. The Director of Nursing then instructed the CNA's to use a gait belt and let the resident hold the catheter drainage bag. They placed the gait belt around the resident's waist and stood her up, then pivoted her into the recliner.
2.) During an observation on 1/3/23 at 12:50 p.m., Resident 139 was in his room sitting in a wheelchair watching TV, there was no staff present. The resident did not have an alarm on his wheelchair or bed.
During an observation on 1/4/23 at 1:50 p.m., , Resident 139 was in his room sitting in a wheelchair watching TV, there was no staff present. The resident did not have an alarm on his wheelchair or bed.
During an observation on 1/5/23 at 1:38 p.m., Resident 139 was in his room sitting in a wheelchair watching TV, there was no staff present. The resident did not have an alarm on his wheelchair or bed.
During an observation and interview on 1/6/23 at 2:42 p.m., with the Director Of Nursing (DON) Resident 139 was laying in bed. The DON verified the resident had no alarm on his bed or wheelchair. The DON indicated she not aware that the resident had been left in his room alone in his wheelchair.
Review of the record of Resident 139 on 1/5/23 at 1:20 p.m., indicated the resident's diagnoses included, but were not limited, reduced mobility, dehydration, kidney disorder, age related physical debility, atrial fibrillation, dementia, fall, diabetes, weakness and heart failure.
The admission Minimum Data Set (MDS) assessment for Resident 139, dated 12/18/22, indicated the resident was severely cognitively impaired for daily decision making. The resident required extensive assistance of two people to transfer. The resident did not ambulate. The resident used a wheelchair as a mobility device. The resident had a fall in the last month and a fracture from a fall in the pas six months prior to admission.
The plan of care for Resident 139, dated 1/4/23, indicated the resident had the potential for falls related unsteady gait and weakness. The interventions included, but were not limited to, chair alarm on when in the chair and bed alarm. The special care remarks indicated the resident was not to be left in his wheelchair in his room alone.
The fall risk assessment for Resident 139, dated 1/3/22, indicated the resident was incontinent, received a hypnotic that could contribute to falls, the resident was unable to ambulate and used a wheelchair as a mobility device
The incident report for Resident 139, dated 12/19/22, indicated the resident was found on the floor in his room. The resident had been moving around in bed. The resident had an abrasion 4 cm by 6 cm (no location)(right knee). Neurological assessment completed. The immediate intervention was the resident's bed in the lowest position.
The incident report for Resident 139, dated 1/3/22 at 4:20 p.m., indicated the resident was found on the floor. The resident had been in bed resting. No apparent injury.
3.) During an observation on 1/4/23 at 1:54 p.m., CNA 1 and CNA 2 transferred Resident 140 from the wheelchair to the toilet by holding her underneath her arms and the back of her pants, no gait belt was used. CNA 1 and CNA 2 transferred the resident from the toilet to the wheelchair by holding her underneath her arms and the back of her brief, there was no gait belt used. The resident was unable to assist with the transfer and was totally dependent on staff for the transfer.
During an interview with Resident 140's family member on 1/5/23 at 12:49 p.m., indicated the resident had not been at the facility long. The reason Resident 140 came to the facility was because she fell at home and broke her clavicle.
During an interview with the DON on 1/10/23 at 10:16 a.m., indicated the protocol was staff were to use a gait belt when transferring Resident 140.
The safe resident handling and mobility program provided by the Administrator on 1/10/23 at 10:25 a.m., indicated the facility would train staff in the use of a gait belt with transfers.
Review of the record of Resident 140 on 1/10/23 at 1:07 p.m., indicated the resident's diagnoses included, but were not limited to, fracture of the right clavicle, right hip contusion, heart failure, unspecified fall, age related debility, diabetes, atrial fibrillation, anxiety disorder, osteoporosis and chest pain.
The admission Minimum Data Set (MDS) assessment for Resident 140, dated 1/4/23, indicated the resident was moderately impaired for daily decision making. The resident required extensive assistance of two people for transfers and did not ambulate. The resident had a fall in the last month prior to admission.
The fall assessment for Resident 140, dated 12/28/22, indicated the resident had 4 diagnoses that contributed to falls, had a history of falls, fell at home and broke her right clavicle, required cueing when to turn around and sit down, used a walker/wheelchair for mobility, had a decline in her functional status in the last 90 days and wears glasses.
The fall care plan for Resident 140, dated 1/3/23, indicated the resident had potential for falls related to unsteady gait manifested by history of falls, unsteady gait (or near fall) in the last 180 days and recent hospital stay. The intervention included, but were not limited to, call light in reach, encourage to ask for assistance and 2 assist with a gait belt (1/10/23).
3.1-45(a)(1)
3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the physician of low and high blood sugars and failed to assess the resident for hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) for 1 of 5 residents reviewed for unnecessary medication (Resident 1).
Finding include:
Review of the record of Resident 1 on 1/6/23 at 10:21 a.m., indicated the resident's diagnosis included, but were not limited to, diabetes mellitus.
The physician order for Resident 1, dated January 2023, indicated the resident was ordered levemir (insulin) 52 units in the morning and at night. The physician order indicated if the resident's blood sugar (BS) was below 70 or above 400 the physician was to be notified.
Review of Resident 1's blood sugar, dated 11/18/22 was 50, 11/25/22 was 454 and 12/6/22 was 58.
During an interview with the Director Of Nursing (DON) on 1/9/23 at 2:49 p.m., indicated there was no documentation the physician was notified of Resident 1's blood sugars on 11/18/22, 11/25/22 or 12/6/22. There was no documentation of any assessment of Resident 1 for hyperglycemia or hypoglycemia symptoms in the resident's record. The DON provided a 24 hour report sheet, dated 12/6/22, with Resident 1's name on it and documentation of BS 58 orange juice given and rechecked and was 79.
The diabetic blood sugar monitoring policy provided by the DON on 1/10/23 at 11:20 a.m., indicated hypo/hyperglycemic episodes will be reported and treated appropriately. Assess for symptoms of hypoglycemia. from milder, more common indicators to most severe, signs and symptoms of low blood sugar include: feeling shaky, being nervous/anxious, sweating, chills, clamminess, confusion, [NAME] heartbeat, lightheaded, dizzy, hunger, nausea, pale skin, sleepy, feeling weak, blurred/impaired vision, tingling or numbness of lips, tongue and cheeks, headaches, coordination problems, nightmares or seizures. If a blood sugar are less than 70 recheck the blood sugar and notify the physician. Hold scheduled insulin/diabetic medication until the physician addresses. If the residents blood sugar is above 300 recheck the blood sugar and notify the physician.
3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a resident's choice for shower times was honored. This affected 1 of 1 resident reviewed for choices. (Resident 30)
Findings include:
During an interview, on 1/03/23 at 12:49 p.m., Resident 30 indicated she didn't get her bath when she wants it, she prefers during the day and gets a shower on second shift around 9:30 - 10:00 p.m.
On 1/09/23, at 1:58 p.m., Resident 30 was lying in bed dressed in street clothes and said she still prefers to have a shower during the day.
Resident 30's record was reviewed on 1/5/23 at 12:59 p.m. The record indicated diagnoses that included, but were not limited to, repeated falls, altered mental status, high blood pressure, anxiety, depression, and vascular dementia.
An Annual Minimum Data Set assessment, dated 4/22/22, indicated Resident 30 was cognitively intact, speech was clear, and had no moods or behaviors.
A Quarterly Minimum Data Set (MDS) assessment, dated 11/28/22, indicated Resident 30 was cognitively intact, speech was clear, makes self understood, understands others, and had no behaviors.
An Annual MDS, dated [DATE], indicated Resident 30 was cognitively intact, speech was clear, makes self understood and understands others, and had no behaviors.
A data collection tool, for preferences for customary routine and activities had not been filled out, and had no date.
On 1/10/23 at 12:18 p.m., the Activity Director indicated the above form was one of two they used, on admission and once a year after that. She said she usually only keeps one copy in the book, and the assessment had been pulled and not turned back in. She said Resident 30 likes to take a shower but wasn't specific on the time, that in the past she told her she didn't care when she got one as long as she got one. She said she would fill out another assessment and place it in her book, which she did and provided a copy of it.
A Policy for Resident Personal Hygiene and Cares was provided by the Administrator on 1/10/23 at 3:25 p.m. The policy indicated, but was not limited to, Purpose: To provide uniform guidance to C.N.A's on standard hygiene and personal care tasks for residents that comprise AM and HS cares and the bathing/showering process .4. Bathing/Showering Process: a. Upon admission to the nursing home, a resident preference interview will be completed with regard to preferred bathing method, frequency and time of day. b. The C.N.A. assignment sheet will be updated to include the information in the Bathing column of the C.N.A assignment sheet
3.1-3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 30's record was reviewed on 1/5/23 at 12:59 p.m. The record indicated diagnoses that included, but were not limited to, repeated falls, altered mental status, high blood pressure, anxiety, depression, and vascular dementia.
An Annual Minimum Data Set (MDS) assessment, dated 4/22/22, indicated Resident 30 was cognitively intact, speech was clear, had no moods or behaviors, did not receive antipsychotic medications.
A Quarterly MDS assessment, dated 11/28/22, indicated Resident 30 was cognitively intact, speech was clear, had moods of feeling down, depressed or hopeless, trouble falling or staying asleep, or sleeping too much, feeling tired or having little energy, poor appetite or overeating, had no behaviors, received an antipsychotic routinely for seven out of seven days of the assessment, a gradual dose reduction had not been attempted, and a gradual dose reduction has not been documented by a physician as clinically contraindicated.
A care plan, dated 6/1/22, indicated a problem of Disruptive verbally. This res is rude to her peers; makes fun of them, laughs at them, tells them what to do, etc. Diagnosis of Mood Disorder .6/15/22 Manifested by: verbal outbursts, verbal intimidation. Approach: Nurses - provide calm environment, administer medications as ordered by physician; Abilify, redirect, do not reorient or argue with [Resident 30], if need be remove her from her peers if able. Nurse Aide - Positive approach with resident, count verbal outbursts, document and report behaviors to nurse and/or social services, maintain safety of resident and other residents, and other staff, if able remove [Resident 30] from the area
Current physician's orders included an order for an antipsychotic medication - Abilify (generic name is aripiprazole) 2 milligrams by mouth every day, for mood disorder, with a start date of 5/5/22.
On 1/10/23 at 10:45 a.m., the Nurse Practitioner said Resident 30 was on Abilify and she doesn't get a report of signs and symptoms but the Director of Nursing will call and let her know what is going on. She wasn't aware that mood disorder was not an accepted diagnosis for the use of an antipsychotic.
An Informed Consent for Medication for the use of Abilify, indicated Completion of this form is voluntary. If not completed, the medication cannot be administered without a court order unless in an emergency. This consent is maintained in the client's record and is accessible to authorized users The consent was signed by the resident on 1/10/23 and the Ability had been administered since 5/5/22. The informed consent included, but was not limited to, side effects and cautions such as changes in thinking, fever, muscle stiffness, low blood pressure when standing, fall risk, weight gain, and seizure. The following was indicated on the Informed Consent for Medication: Warning: [Black Box Warning]: Increased Mortality in Elderly Patients with Dementia Related Psychosis: Elderly patients with dementia related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Analyses of 17 placebo controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in the drug treated patients of between 1.6 to 1.7 times that seen in placebo treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug treated patients was about 4.5% compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis.
3. Resident 4's record was reviewed on 1/04/23 at 1:20 p.m. and indicated diagnoses that included, but were not limited to, cardiac arrhythmia, age-related physical debility, repeated falls, osteoporosis, hypertension, dementia with behavior disturbance, and heart failure.
A Quarterly MDS, dated [DATE], indicated Resident 4 was severely impaired in cognitive skills for daily decision making, had no moods or behaviors, did not walk, and did not receive an antipsychotic medication.
A Significant Change MDS, dated [DATE], indicated Resident 4 was severely impaired in cognitive skills for daily decision making, had a diagnosis of non-Alzheimer's dementia, did not walk, and received an antipsychotic medication.
A care plan, dated 9/15/22, indicated a problem for Potential for adverse medication side effects related to antipsychotic use manifested by: possible side effects: lethargy, loss of appetite, involuntary movements, tremors, chewing and /or tongue movements, muscle twitching, gait changes. Approach: Nurses - Monitor for side effects q (every) shift, notify physician of symptoms. Nurse Aide - report unusual behavior, report change in physical condition, report change in appetite. [Social Services] Involve family, make referrals, referred her to psych services, discuss in the monthly behavior management meeting. Goal: No adverse affects d/t (due to) med regimen, prevent and/or minimize the side effects of the psychotropic medications. Resident will receive the lowest possible dose necessary to control symptoms.
On 1/05/23 at 9:46 a.m., Resident 4 was in bed, eyes closed.
On 1/09/23 at 10:05 a.m., Resident 4 was in bed with her eyes closed.
On 1/09/23 at 01:48 p.m., Resident 4 was up in her wheelchair in the activity room, sitting quietly with other residents, the activity aide was in the room.
Current physician's orders included an order for the antipsychotic Seroquel 25 milligrams by mouth at bedtime for dementia, with a start date of 9/8/22.
A Pharmacy review, dated 9/29/22, indicated: [Resident 4] is receiving the antipsychotic agent Seroquel but lacks an allowable diagnosis to support its use. The following are considered appropriate diagnoses/conditions: .Dementing illnesses with associated behavioral symptoms. The physician selected Agree and chose Dementia with behavioral disturbance. Signed 9/29/22 by the Nurse Practitioner.
During an interview, on 1/10/23 at 10:37 a.m., the Nurse Practitioner indicated they started Resident 4 on the Seroquel when she started to have behaviors with her dementia, they got psych involved, and she wasn't aware that a dementing illness with associated behavioral symptoms was not an accepted diagnosis for the use of an antipsychotic.
A policy for Psychoactive Medication Protocol was provided by the Interim Executive Director on 1/6/23 at 1:22 p.m. The policy included, but was not limited to, Purpose: To ensure appropriate procedures are followed and subsequent documentation is completed prior to the initiation or change of a psychoactive medication and to ensure ongoing targeted behavior tracking for comprehensive assessment and evaluation purposes. Protocol: 1. Psychoactive medications include antipsychotics, antianxiety agents, sedatives/hypnotics, antidepressants and other medications as described below .2. The Interdisciplinary Team will identify target behaviors and develop a care plan to include treatment goals and evaluation of precipitating events, if any, in the resident's environment .3. Enter the appropriate target behaviors in the appropriate [treatment administration record] folder and begin documenting every shift. Make an appropriate corresponding entry in the medical record as warranted. 5. Physician order obtained MUST include an appropriate diagnosis for medication use and the desired therapeutic goal for the medication (i.e. reduction in the frequency or severity of a targeted behavior) for any psychoactive medications
3.1-48(a)(3)
3.1-48(b)(2)
Based on observation, interview and record review the facility failed to have an indication for the use of an antipsychotic medication, failed to implement behavioral interventions, failed to monitor antipsychotic medication and failed to provide education of the risk of using an antipsychotic medication for 3 of 5 residents reviewed for unnecessary medication use (Resident 20, Resident 30 and Resident 4).
Findings include:
1.) Review of the record of Resident 20 on 1/4/22 at 1:20 p.m., indicated the resident's diagnoses included, but were not limited to, Alzheimer's disease, altered mental status, cerebral infarction, history of falling, diabetes mellitus, hypertension, dementia,, osteoarthritis and anxiety.
The CNA behavior communication form for Resident 20, dated 8/18/22, indicated the resident was being physically abusive to the staff and was hitting and kicking. There were no documented interventions attempted.
The CNA behavior communication form for Resident 20, dated 8/30/22, indicated the resident was pulling the staff's hair. The interventions were talk/listen to the resident and reassured. These interventions were successful.
The CNA behavior communication form for Resident 20, dated 8/30/22, indicated the resident was being physically abusive to staff and was scratching the staff's arm. The interventions were talk/listen to the resident and reassured. These interventions were successful.
The CNA behavior communication form for Resident 20, dated 8/31/22, indicated the resident was being physically abusive to staff and was hitting, biting, kicking and scratching. The interventions were talk/listen to the resident and reassured. These interventions were successful.
The CNA behavior communication form for Resident 20, dated 9/1//22, indicated the resident was being physically abusive to staff and was hitting, biting, yelling and scratching. The interventions were talk/listen to the resident and reassured. These interventions were successful.
The CNA behavior communication form for Resident 20, dated 9/3//22, indicated the resident was being physically abusive to staff and was hitting, pinching and kicking. The interventions were talk/listen to the resident and offered a quiet area. These interventions were unsuccessful.
The CNA behavior communication form for Resident 20, dated 9/7//22, indicated the resident was being physically abusive to staff and was pinching and digging her nails in the staff's hand. The intervention was leave the resident alone.
The CNA behavior communication form for Resident 20, dated 9/13//22, indicated the resident was being physically abusive to staff and was scratching and made the staff's hand bleed. The intervention was reassure the resident and it was successful.
The CNA behavior communication form for Resident 20, dated 9/20//22, indicated the resident was being physically abusive to staff and was hitting and pinching staff. The interventions were talk/listen to the resident and reassured. These interventions were successful. There were no further CNA behavior communication forms documented.
The nursing behavior note for Resident 20, dated 9/2/22, indicated the resident had a behavior of pinching and scratching staff. Intervention was 1:1 conversation and reassured. These interventions were successful.
The nursing behavior note for Resident 20, dated 9/3/22, indicated the resident was scratching and punching staff when they tried to get her up in the morning. The staff attempted to take her to activities and the resident scratched the staff's arm and grabbing their shirt and kicking at staff. The staff talked with resident and listened to the resident and offered a quiet area. The resident remained unchanged.
The nursing behavior note for Resident 20, dated 9/13/22, indicated the resident scratched staff hand while in the shower room. The intervention was resident left alone and reapproached.
The nursing behavior note for Resident 20, dated 10/1/22 through 10/15/22 the resident had no documented behavior.
The nursing behavior note for Resident 20, dated 10/16/22, indicated the resident was pinching scratching and spitting at staff. The intervention was 1:1 and talking. The behavior remained unchanged.
The nursing behavior note for Resident 20, dated 10/19/22, indicated the resident was kicking and hitting staff. The intervention was reassured resident. The behavior remained unchanged.
The nursing behavior note for Resident 20, dated 10/20/22 through 11/4/22, the resident had no behaviors.
The nursing behavior note for Resident 20, dated 11/5/22, indicated the resident was kicking and hitting staff. The interventions were reassured the resident and talked with her and walked away. The intervention was successful.
The nursing behavior note for Resident 20, dated 11/6/22 through 11/17/22, the resident had no documented behaviors.
The nursing behavior note for Resident 20, dated 11/18/22, indicated the resident was yelling and crying very loudly in the hallway before dinner. Staff attempted to redirect the resident but this did not work. The resident went into the dining room and continued to yell at others and crying. The resident threw a small vase and broke it. Staff attempted to assist the resident with eating but was unsuccessful. The resident continued to yell at others and crying while making her way out of the dining room. The resident attempted to hit, grab and bite staff. The staff took the resident to her room and once in front of her bed the resident mostly stopped her behaviors. The stated she wanted to go to bed and staff assisted her to bed and covered her up. The resident cried for a couple more minutes, but then completely calmed down and went to sleep. The facility would review the resident's medications and complete a pain assessment, the resident does have dementia.
The physician order for Resident 20, dated 11/22/22, indicated the resident was ordered seroquel (antipsychotic medication) 25 milligrams (mg) at night for dementia with behaviors.
During an observation on 1/4/23 at 2:12 p.m., Resident 20 was laying in bed with her eyes closed.
During an observation on 1/5/23 at 1:46 p.m., Resident 20 was laying in bed with her eyes closed.
During an interview with the Administrator on 1/5/23 at 2:01 p.m., the facility had not been monitoring for side effects of the seroquel for Resident 20, but they would be now. The resident had not seen psychiatric services.
During an observation on 1/6/23 at 11:00 a.m., Resident 20 was laying in bed. CNA 1 asked the resident if she was ready to get up and the resident shook her head no and pointed to the door for staff to leave. CNA 2 was standing there and when queried if the facility attempted different care givers to see if the resident would get up, CNA 2 indicated yes they did. CNA 2 did not attempt to see if the resident would get up for him and no other interventions were attempted.
During an observation on 1/9/23 at 2:16 p.m., Resident 20 was laying in bed with her eyes closed.
During an interview with the Administrator on 1/10/23 at 10:14 a.m., indicated the facility had not provided Resident 20's family education on the risk of seroquel and the education would be mailed to them today. The Administrator provided a copy the education that would be mailed to the resident's family.
During an interview with Resident 20's Nurse Practitioner (NP) on 1/10/23 at 10:36 a.m., indicated the rationale behind why the medication of an antipsychotic was being used to treat Resident 20's dementia, the NP indicated the resident was combative with staff and the facility ruled out infection and started her on seroquel. When queried if the NP had been aware that the non pharmalogical interventions staff were using for Resident 20's behaviors were mostly successful, the NP indicated it was not reported to her that the non pharmalogical interventions had been successful for her behaviors.
The informed consent for the medication seroquel for Resident 20's family dated 1/10/23, indicated warning: [Black Box Warning] Increased mortality in elderly patents with dementia related psychosis: Elderly patients with dementia related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Although the causes of death varied, most of the deaths appeared to be either cardiovascular (e.g. heart failure, sudden death) or infectious (e.g. pneumonia) in nature. This drug is not approved for the treatment of patients with dementia-related psychosis.

Based on observation, interview, and record review, the facility failed to ensure a resident's fluids were in reach for 4 of the 6 survey days. This affected 1 of 1 resident reviewed for accommodation of needs. (Resident 9)
Findings include:
During an observation, on 1/04/23 at 10:59 a.m., Resident 9 did not appear to be dehydrated, but her water was on the bedside table at the end of her bed, out of reach.
On 1/5/23, at 9:50 a.m., Resident 9 was lying in bed, eyes closed, her water pitcher was on her over bed table out of her reach.
On 1/6/23, at 2:41 p.m., Resident 9 was in bed, eyes closed, her water pitcher was on her over bed table out of her reach, about 3 feet from the side of her bed.
On 1/9/23, at 10:07 a.m., Resident 9 was in bed, her water pitcher was out of reach on her over bed table.
Resident 9's record was reviewed on 1/9/23 at 11:45 a.m. and indicated diagnoses, that included, but were not limited to, generalized muscle weakness, high blood pressure, age related physical debility, disorientation, osteoporosis, pain, Alzheimer's disease late onset, and dementia without behaviors, psychosis, mood or anxiety.
An Annual Minimum Data Set assessment, dated 10/4/22, indicated Resident 9 was severely impaired in cognitively skills for daily decision making, and eating was extensive assist of one.
Current physician's orders for fluids indicated an order dated 2/24/21 to encourage fluids with assistance, 240 milliliters three times a day/evening a.m. and p.m. and to monitor intake and output every a.m., p.m., and night with nights obtaining a 24 hour intake.
1/10/23 at 12:20 a.m., Resident 9 was sitting in the dining room eating and drinking independently. Interview with CNA 3 indicated the resident does feed herself and drink independently, that sometimes she starts out feeding herself and at the end of the meal staff will have to help her. She said the resident has good days and bad days.
A Policy for Hydration Management was provided by the Administrator on 1/10/23 at 3:25 p.m. The policy included, but was not limited to, Purpose: Hydration management will be accomplished through an individualized plan to promote adequate hydration based on risk factor identification and assessment and to determine if intake and/or output monitoring is indicated .3. Fluids will be provided consistently throughout the day
3.1-3(v)(1)

Based on observation, interview and record review the facility failed to provide routine dental services for a resident who had poor fitting dentures for 1 of 2 residents reviewed for dental status (Resident 12).
Findings include:
During an observation on 1/3/23 at 11:31 a.m., Resident 12 was laying in bed, the resident had no teeth.
During an observation on 1/4/23 at 2:13 p.m., Resident 12 was laying in bed, the resident had no teeth.
During an observation and interview on 1/5/23 at 12:53 p.m., Resident 12 was laying in her bed with no teeth. Interview with Resident 12's family member indicated the resident did have dentures but she did not always wear them because they fall out. The family member indicated even when staff used denture adhesive they still fell out and it aggravated the resident so she did not wear her dentures often. The family member indicated she needed to see a dentist to see if they could be adjusted or replaced. The resident's family member was unsure how long the resident's dentures had not fit but it had been going on for awhile.
Review of the record of Resident 12 on 1/10/23 at 1:38 p.m., dementia, hypertension, iron deficiency anemia, anxiety, age related debility and chronic pain syndrome.
During an interview with the Administrator on 1/6/23 at 10:29 a.m., the facility could not find documentation that Resident 12 had ever seen a dentist.
During an interview with the Administrator on 1/6/23 at 1:45 p.m., indicated residents at the facility did not receive routine dental visits and were only seen on a as needed basis.
During an interview with the Administrator on 1/9/23 at 10:32 a.m., indicated the dental company the facility used stopped provided services in 2020. The facility is now going to contract with a different dental company. The new dental company had not started at the facility yet, but if a resident needs to be seen the facility would make arrangements with the local dentist.
During an interview with the Administrator on 1/10/23 at 3:26 p.m., Resident 12 would be seen by a dentist on 1/13/23.
The dental services policy provided by the Administrator on 1/6/23 at 1:45 p.m., indicated the dental needs of residents shall be adequately cared for through proper hygiene and regular and emergency dental care.
3.1-24(a)(1)