Ohman Family Living At Briar

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview review of the Stand Up (Chorus) Patient Lift Manual and facility policy review, the facility failed to provide adequate supervision/assistive devices to prevent avoidable accidents/falls. This affected one resident (Resident #10) out of four reviewed for accidents/falls. This had the potential to affect 48 residents (Resident # #3, #4, #5, #6, #10, #11, #14, #15, #17, #18, #19, #20, #23, #25, #26, #28, #30, #31, #32, #36, #38, #39, #41, #44, #46, #50, #52, #55, #57, #60, #61, #65, #70, #71, #73, #75, #77, #80, #82, #83, #84, #85, #87, #89, #95, #96, #103, #106) that required a Chorus (operated lift designed to safely transition individuals with limited mobility from sitting to standing for transfers) or mechanical lift for transfer. The facility census was 92.Findings include:Record review revealed Resident #10 admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling.) to the left buttock, neuromuscular bladder, tremor, unspecified convulsions, repeated falls, mild vascular dementia, and cognitive communication deficit.Review of the physician orders dated 01/12/22 revealed Resident #10 required a Chorus lift with two staff assistance for transfers and a wheelchair for mobility.Review of the Fall Risk Evaluation V2 dated 11/11/25 and completed by Former Licensed Practical Nurse (LPN) #483 revealed Resident #10 was at high risk for falls as he was confined to a chair, unable to stand, had diagnoses that placed him at high risk for falls as well as was on medications that increased his risk of falls.Review of the nurse's note dated 12/01/25 and completed by LPN #318 revealed Resident #10 had a witnessed fall and was lowered to the ground by Agency Certified Nurse Aide (CNA) #480. LPN #318 was informed by Agency CNA #480 that while transferring Resident #10 from the bed to the wheelchair, he lost strength and she was unable to hold him up and had to lower him to the floor. The nursing note revealed he had no injuries and/or signs of pain. Review of the fall investigation dated 12/01/25 and completed by LPN #318 revealed Resident #10 lost strength in his upper extremities during transfer and was lowered to the floor by Agency CNA #480.Review of the Kardex (brief overview of each resident) dated 12/01/25 revealed Resident #10 was to have two staff assist with the Chorus lift transfers.Review of CNA Transfer Inservice dated 12/23/25 and completed by Staff Development/ Registered Nurse (RN) #329 revealed education was provided to follow transfer orders in the Kardex in the electronic medical record or ask the nurse if needed.Review of the nurse's note dated 01/11/26 and completed by LPN #318 revealed Resident #10 had a witnessed fall when Agency CNA #481 lowered him to the floor due to him not being able to maintain balance while using the Chorus lift. The nursing note revealed he had no injuries and/or signs of pain. Review of the fall investigation dated 01/11/26 and completed by LPN #318 revealed Resident #10 was lowered to the floor by Agency CNA #481 due to not being able to maintain his balance. LPN #318 was called to the room and observed the resident sitting on the floor on his buttocks in front of his wheelchair. Resident #10 stated his footing was not correct and while transferring he was unable to hold on.Review of the Kardex dated 01/11/26 revealed Resident #10 was to have two staff assist with the Chorus lift transfers.Review of the email from Assistant Director of Nursing (ADON) #394 to Agency CNA #481 dated 01/12/26 revealed instructions to check the Kardex or ask staff for transfer status of residents. Agency CNA #481 responded she did ask for help, but everyone was busy. ADON #394 replied she would need to wait for help and follow the orders in the Kardex.Review of Physical Therapy Evaluation and Treatment Plan and completed by Physical Therapist (PT) #375 dated 01/29/26 revealed Resident #10 was performing bed mobility with physical therapy; the resident had not attempted out of bed activity.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact. He was dependent on staff for rolling and required maximum assistance for bed mobility. Resident #10 was dependent on staff for sit-to-stand and transfers.Review of the Care Plan dated 02/19/26 revealed Resident #10 was at risk for falls related to impaired mobility, impaired balance, medication use, diagnoses of morbid obesity, COPD, congestive heart failure (CHF), anxiety, depression, and tremors. Interventions included monitoring and medicating for pain, monitoring for signs of dizziness, pharmacy review of medications monthly, referring to physical and occupational therapy to evaluate and treat as needed.Review of Quarterly Fall Risk Evaluation V2 dated 02/19/26 and completed by MDS/ LPN #324 revealed Resident #10 continued to be at high risk for falls, was confined to a chair, unable to stand, had diagnoses that placed him at high risk for falls as well as was on medications that increased his risk of falls.Review of the nurse's notes dated 02/22/26 authored by LPN #318 revealed Resident #10 had a witnessed fall with Agency CNA #482 who yelled for help when attempting to transfer Resident #10 from the bed to the wheelchair. He was unable to stand and began sliding down. Resident #10 was lowered to the ground by Agency CNA #482 and LPN #318. Staff then assisted him off the floor with use of a mechanical lift (used to safely transfer residents who cannot bear weight and limited mobility between positions) into his wheelchair with two staff assist. The nursing note revealed he had no injuries and/ or signs of pain. Review of the fall investigation dated 02/22/26 revealed Agency CNA #482 yelled for someone to assist her. LPN #318 arrived at Resident #10's room and observed the resident on the edge of his wheelchair still attached to the Chorus lift. Agency CNA #482 stated she was attempting to transfer Resident #10 from his bed to his wheelchair when he was unable to continue to stand and began sliding down. LPN #318 and Agency CNA #482 lowered Resident #10 to the ground.Review of the Kardex dated 02/22/26 revealed Resident #10 required two staff assistance for all Chorus lift transfers.Review of the physician's order dated 02/22/26 revealed Resident #10 was changed from a Chorus lift to a mechanical lift for transfers.Review of Physical Therapy (PT), PT Recert, Progress Report and Updated Therapy Plan dated 03/02/26 signed by PT #375 revealed transfers and sit/stand not attempted due to medical or safety concerns. Interview with Resident #10 on 03/02/26 at 10:00 A.M. and on 03/03/26 at 9:16 A.M. revealed he had fallen three times because the agency aides were not locking the wheelchair causing the chair to move back as he went to sit down, and he stated only one staff member assisted him each time instead of two. He revealed he does not want to use the mechanical lift as he wanted to continue to utilize the Chorus lift.Interview with Director of Rehab #466 on 03/03/26 at 11:01 A.M. revealed Resident #10 had always required either a mechanical lift or a Chorus lift to transfer. She verified Resident #10 was to be have two staff assist for both types of transfers for this resident.Interview with the Director of Nursing (DON) 03/03/26 at 12:42 P.M. verified Resident #10 was to have two-staff assist with the Chorus lift. She verified that only one staff member had transferred him on 12/01/25, 01/11/26, and 02/22/26 and that he had fallen and/or was lowered to the floor. Interview with LPN #318 on 03/03/26 at 2:45 P.M. revealed she was working when Resident #10 fell on [DATE], 01/11/26 and 02/22/26 and verified only one aide went into the room to transfer Resident #10 with Chorus lift each time. She verified aides have access to and are supposed to check the Kardex prior to resident care. She stated all three aides were from agency. She revealed she attempted to give report to aides before they do resident care but sometimes, they get into the room before she was done with nursing report from the previous shift. She revealed Resident #10 was lowered to the ground each time and did not complain of any injuries. She stated one of the three incidents was because the aide did not lock the wheelchair. Review of undated facility policy, Falls Prevention Program revealed the purpose of the program is to identify the root cause of a fall, so that an intervention being put in place is effective. Falls risk assessment to be completed and falls weekly meeting held. There was nothing in the policy in regard to the facility monitoring that interventions per physician orders and/ or in their plan were implemented. Review of the Stand Up (Chorus) Patient Lift Manual dated 05/07/18 revealed individuals that use the patient sling must be able to support the majority of their own weight; otherwise injury may occur.This deficiency represents non-compliance investigated under Master Complaint Number 2747582.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, the facility did not ensure an allegation of verbal abuse was reported as required. This affected one resident (#68) of three residents reviewed for abuse. The facility census was 89.Findings included: Review of medical record for Resident # 68 revealed an admission date of 08/03/23 with diagnoses of schizoaffective disorder, malnutrition, epilepsy, and dementia.Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 had severely impaired cognition and required staff assistance for all activities of daily living (ADLs).Review of the care plan for Resident #68, dated 06/09/25, revealed Resident #68 had impaired cognition related to dementia, schizoaffective disorder, mood problems related to dementia and intellectual disability. Interventions included to reorient as needed, keep explanations simple and use yes or no questions and if resident resists care, assure safety, back off and reapproach later. Review of the 08/20/25 psychiatric evaluation revealed Resident #68 was alert but disoriented to person, place, time and situation. Memory was poor, impaired attention and concentration; insight, judgement and impulse control poor. Resident #68 reported no concerns during the evaluation. Review of the facility investigation, date initiated 09/06/25, revealed on 09/06/25 Licensed Practical Nurse (LPN) #282 and LPN #321 wrote a witness statement indicating Resident #68 told them an aide asked Resident #68 why am I still breathing. Review of an unsigned statement dated 09/08/25 revealed Resident #68 was interviewed and indicated an aide with curly brown hair and glasses asked her why is she still breathing. The aide was working in the facility at that time and when the writer pointed out the aide to Resident #68, Resident #68 said that it was her, however, that aide was not working in the facility at the time the incident was said to have occurred. When Resident #68 was asked about Certified Nursing Assistant (CNA) #240, Resident #68 stated she's good. Review of a statement written by Unit Manager (UM) #290 revealed an interview with CNA #240 who denied she had ever made any such statement to Resident #68. Other resident interviews included in the facility investigation revealed no findings related to abuse allegations. An interview on 09/11/25 at 9:25 A.M. with Licensed Practical Nurse (LPN) #321 revealed she was not a witness to the verbal abuse allegation and stated she saw Resident #68 in the morning following the alleged incident. LPN #321 stated Resident #68 wanted help to call her sister and let her know what had occurred during the night. LPN #321 assisted Resident #68 with the phone call and overheard Resident #68 stating the aide wanted her to stop breathing, and wanted her dead. LPN #321 stated no other residents came to her with any complaints of disrespect or verbal abuse. LPN #321 stated she reported the incident to the Unit Manager #290 in the morning.An interview on 09/11/25 at 11:02 AM with LPN #282 revealed during the morning following his shift on 09/06/25, CNA #201 reported to him that another CNA (CNA #240) had been verbally mean to Resident #68, however; CNA #201 did not witness it. LPN #282 stated he had worked at the time the incident allegedly occurred, and it was not brought to his attention at that time. LPN #282 stated he was unaware of any complaints of verbal abuse or complaints from residents aside from the allegation made by Resident #68. An interview on 09/11/25 at 11:48 A.M. with CNA #201 revealed that Resident #68 told her that CNA #240 said to Resident #68 to stop breathing. She stated she did not witness it, but CNA #240 could come across with a tone in her voice, aggressive and needed to have more patience with the residents. CNA #201 verified she reported the incident to the nurse. An interview on 09/11/25 at 3:00 P.M. with Unit Manager (UM) #290 revealed she spoke with LPN #282 and Resident #68 regarding the allegation. UM #290 stated Resident #68 could not identify the aide in question. UM #290 also interviewed the other residents on the floor which denied any inappropriate comments or verbal abuse. UM #290 verified Resident #68 had made an allegation of verbal abuse from an aide, identified by staff as CNA #240, and it had been investigated. An interview on 09/11/25 at 3:44 P.M. with the Director of Nursing (D.O.N.) revealed she spoke with Resident #68 about the incident but Resident #68 could not identify the aide. The DON stated she also spoke with the other residents and could not validate the alleged comments. The DON confirmed she did not report the allegation to Ohio Department of Health (ODH) and did not submit a Self- Reported Incident Form (SRI). The DON verified all allegations of abuse are required to be reported to the state agency. The DON verified an investigation had been done to determine if abuse had occurred. Review of the ODH Certification and Licensure System (CALS) on 09/11/25 confirmed no SRI was completed regarding the allegation of verbal abuse from staff to Resident #68. Review of facility policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 2022, revealed the policy was to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property. Staff should immediately report all such allegation to the Administrator and to the Ohio Department of Health (ODH) in accordance with the procedures in this policy. This deficiency represents non-compliance investigated under Complaint Number 2614720 and 2612128.

Based on personnel file review, narcotic destruction log review, facility policy review and interview, the facility failed to ensure a thorough investigation to prevent the possibility of drug diversion and ensure the safety of all residents after the Administrator received a text message alleging a staff member was using drugs. This had the potential to affect all residents residing in the facility. The census was 92.
Findings include:
Review of Registered Nurse (RN) #200's personnel file revealed RN #200 received a Notice of Disciplinary Suspension dated 12/21/23. The notice indicated RN #200 was suspended as a result of an investigation of the narcotic destruction process. Review of a termination letter dated 12/27/23 revealed RN #200 was terminated effective immediately due to violation of narcotic destruction process policy, asking a staff member to falsify documents, and exercising poor nursing judgement.
Interview on 12/12/24 at 1:58 P.M. with the Administrator revealed in December of 2023, there was no diversion of narcotics. RN #200 had a back log of narcotics that needed to be destroyed and destroyed the narcotics without a witness then asked the supervisor to falsify documents stating she was present when the narcotics were destroyed. The Administrator stated it was a one-time incident but RN #200 was terminated for using poor nursing judgement. The Administrator re-hired RN #200 on 05/13/24 with conditions which included random drug screening and having three staff present when narcotics were destroyed. The condition did not indicate the frequency of the random drug screening.
Follow up interview on 12/12/24 at 3:32 P.M. with the Administrator revealed he received a random text message on 11/06/24 indicating RN #200 was using drugs. The Administrator spoke to three staff members including the Clinical Manager, Staff Development Coordinator and the Assistant Director of Nursing who denied having any issues or concerns with RN #200 or the narcotic counts. No further actions were taken. The Administrator did not interview direct care staff, residents, or review narcotic count sheets or narcotic destruction logs. The Administrator did not try to contact the person who sent the text message. Review of facility drug screening documentation revealed RN #200 had drug screens completed on 05/09/24 and 07/10/24. The Administrator verified no further drug screening was completed for RN #200. Review of the narcotic destruction sheets for the past three months with the Administrator revealed two staff signed and dated the destruction logs. Two additional staff signed at the bottom of the logs although the signatures did not include a date or time. The Administrator verified two staff signed the destruction of narcotics and the signatures on the bottom did not include a date and time.
Review of the facility policy titled Controlled Medications-Disposal, dated 2019 noted narcotics must be destroyed in the presence of two licensed nurses.
Review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation, dated 2016 revealed staff who were suspected would be removed from the facility and schedule pending the investigation. The Administrator was to complete an investigation of the alleged violation which was to be completed within five days unless there were special circumstances. The Administrator was to interview residents, staff members, possible witnesses, and review personnel files if a staff member was suspected.
This deficiency represents non-compliance investigated under Complaint Number OH00159787.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, review of medical record and review of Policy for Central Line Dressing Changes revealed the facility failed to ensure Resident #27's central line dressing was changed as ordered. This affected one resident (Resident #27) out of one resident reviewed in a sample of two residents, (Resident #27 and #241) with intravenous access. The facility census was 88.
Findings included:
Review of medical record for Resident #27 revealed an admission date of 09/09/22 and his diagnoses included infection and inflammatory reaction due to internal right hip prosthesis, acute and chronic respiratory failure with hypoxia, diabetes, and hypertension.
Review of quarterly Minimum Data Set (Minimum Data Set (MDS)) dated 03/29/23 revealed Resident #27 was cognitively intact. He required extensive assistance of one person with bed mobility and extensive assistance of two people with transfers. He was unable to ambulate. He received intravenous medications.
Review of undated care plan revealed Resident #27 was on intravenous medications for septic joint infection. Intervention included change dressing to [NAME] (a type of central line usually used to administer medications intravenously through the venous system) catheter twice a week on Tuesdays and Fridays, check dressing at site daily, and monitor for any side effects of intravenous antibiotic use.
Review of April 2023 Treatment Administration Record (TAR) revealed Resident #27 had an order to change his midline (A vascular access device placed into a peripheral vein in the upper arm) dressing and caps every week (every Tuesday on night shift) per protocol. The TAR revealed Resident #27's midline dressing change was to be changed on 04/11/23 but that the documentation for this date on the TAR was blank.
Review of physician order dated 04/11/23 revealed Resident #27 was to have his midline dressing and caps changed every week.
Observation on 04/18/23 at 8:52 A.M. revealed Resident #27 had a midline intravenous catheter to his right arm. The central line dressing to the midline catheter was noted to be partially coming off as it was peeling from the bottom and the dressing was dated 04/05/23 (13 days since last changed).
Interview on 04/18/23 at 8:52 A.M. with Resident #27 revealed he was unsure when the last time they had changed his central line dressing and/ or how often it was to be changed.
Interview on 04/18/23 at 8:54 A.M. with Agency Licensed Practical Nurse (LPN) #706 verified Resident #27's central line dressing to his right midline was partially peeling up from the bottom of the dressing and was not completely intact. She also verified the central line dressing was dated 04/05/23. She verified Resident #27 had an order to have his central line dressing changed once a week.
Interview on 04/18/23 at 9:02 A.M. with the Director of Nursing also verified Resident #27's central line dressing to his right arm was dated as last changed on 04/05/23. She verified his central line dressing was to be changed once a week and had been scheduled to be changed per the TAR on 04/11/23 but was not changed as ordered.
Interview on 04/20/23 at 1:00 P.M. with MDS/ Registered Nurse (RN) #669 verified Resident #27's care plan was not updated as previously he had a [NAME] catheter and the dressing change at that time was to be completed twice a week but Resident #27 had a midline to his right arm and his central line dressing change to his midline was to be completed once a week.
Review of policy Central Line Dressing and Cap Changes dated 07/22/23 revealed a central line dressing change was a sterile procedure and should be changed at a minimum every seven days. The policy revealed if at any time the dressing peels, becomes wet underneath, or becomes dirty it should be changed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to ensure Resident #70 were not medicated with as needed Haloperidol (anti-psychotic medication) prior to non- pharmacological interventions being attempted. This affected one of five residents reviewed for use of unnecessary medications. The facility census was 71.
Findings include:
Review of the medical record for Resident #70 revealed an admission date of 05/16/19 and diagnoses including dementia with behavioral disturbances, major depression, anxiety disorder and psychosis.
Review of the care plan dated 05/17/19 revealed Resident #70 received psychotropic medications related to behavioral management and depression. Interventions included: administer medications as ordered and monitor for side effects, redirect, give one on one, as needed prior to use of as needed medications and chart results.
Review of the pharmacy medication review dated 06/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had an order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were only to be used for 14 days. He recommended to discontinue the Haloperidol or place a 14-day duration with rational for the medication. The pharmacy medication review was blank and the physician and the facility did not address the recommendation.
Review of the pharmacy medication review dated 08/28/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were to be used only for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy recommendation until 10/18/19 and checked the box that he agreed but provided no rationale.
Review of the pharmacy medication review dated 09/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy as anti-psychotic agents needed to be only used for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy medication review until 10/18/19 and noted he renewed for 14 days but provided no rationale.
Review of the physician orders for October 2019 revealed Resident #70 had an order for Haloperidol tablet two milligrams by mouth every 12 hours as needed for agitation.
Review of the Medication Administration Record (MAR) for October 2019 revealed Resident #70 received Haloperidol tablet two milligrams by mouth every 12 hours as needed for agitation on 10/07/19 at 7:07 A.M., 10/08/19 11:12 A.M., 10/13/19 4:16 A.M., and at 1:57 P.M., 10/14/19 at 9:54 A.M., 10/17/19 at 7:39 A.M. and 10/22/19 at 9:41 A.M.
Review of the nursing note by Licensed Practical Nurse (LPN) #600 dated 10/07/19 at 9:13 A.M. revealed Resident #70 was raising his fist at another resident. The nurse medicated the resident with Haloperidol for behaviors. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol.
Review of the nursing note by LPN #955 dated 10/08/19 at 12:16 P.M. revealed Resident #70 was medicated with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol.
Review the of nursing note by LPN #964 dated 10/13/19 at 5:09 A.M. revealed Resident #70 was medicated with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol.
Review of the nursing note by LPN #955 dated 10/13/19 at 2:32 P.M. revealed Resident #70 was medicated with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol.
Review of the nursing note by LPN #901 dated 10/17/19 at 9:33 P.M. revealed Resident #70 was medicated with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol.
Review of the nursing note by LPN #955 dated 10/22/19 at 10:07 A.M. revealed Resident #70 was medicated with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #70 had impaired cognition. He had physical behaviors one to three days and he wandered one to three days.
Review of the Abnormal Involuntary Movement Scale (AIMS) test dated 11/22/19 for Resident #70 revealed he scored a six and had lip smacking present and his tongue thrusted moderately as adverse effects of the psychotropic medications.
Review of Resident #70's physician orders for current month of December 2019 revealed he had an order for Haloperidol tablet one milligram by mouth every six hours as needed for agitation.
Review of Resident #70's Medication Administration Record (MAR) for December 2019 revealed he received Haloperidol tablet one milligram by mouth every six hours as needed for agitation on 12/06/19 at 10:38 A.M. and on 12/10/19 at 6:04 A.M.
Review of the nursing note per LPN #600 dated 12/06/19 at 11:22 A.M. revealed she medicated Resident #70 with as needed Haloperidol at 10:38 A.M. for agitation with positive effect noted. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol.
Review of the nursing note per LPN #600 dated 12/10/19 at 6:54 A.M. revealed she medicated Resident #70 with as needed Haloperidol for agitation. The nursing note did not include any non-pharmacological interventions attempted prior to the administration of the as needed Haloperidol.
Interview on 12/10/19 at 3:15 P.M. with Resident #70's wife revealed she was concerned the facility was administering too many psychotropic medications especially the Seroquel (anti-psychotic) and Haloperidol as at times when she visited, he was in a like a stupor state. She revealed she talked to the pharmacist who stated he agreed and stated he recommended to the facility to look at his psychotropic medications, but she did not believe they had. She revealed she did not feel they attempted other non-medication interventions prior to administering his as needed medications. She revealed she was concerned as he had lip smacking which he did almost daily and was told that the lip smacking was from a side effects of his psychotropic medications.
Interview on 12/11/19 at 3:45 P.M. with LPN #955 revealed Resident #70 does have lip smacking daily as a side effect of his psychotropic medications. He revealed at times one on one or activities would help calm him down and decrease his behaviors.
Interview with the Director of Nursing on 12/10/19 at 2:24 P.M. revealed prior to the nurse administering a as needed psychotropic medication they were to attempt non-pharmacological interventions prior to administration. The nurse was to document the non-pharmacological interventions in the nursing notes that had been attempted prior to administration of the as needed psychotropic medication. She verified non-pharmacological interventions for Resident #70 prior to him receiving his as needed Haloperidol were not documented in the nursing notes for October 10/07/19 at 7:07 A.M., 10/08/19 11:12 A.M., 10/13/19 4:16 A.M., and at 1:57 P.M., 10/14/19 at 9:54 A.M., 10/17/19 at 7:39 A.M. and 10/22/19 at 9:41 A.M. and on 12/06/19 at 10:38 A.M. and on 12/10/19 at 6:04 A.M. She verified she did not have documentation of non- pharmacological interventions attempted prior to the administration of the Haloperidol.
Review of facility policy labeled, Use of Psychoactive Medications dated August 2019 revealed psychotropic medication therapy was to be only used when it was necessary to treat a specific condition. Nursing staff was to document in detail an individual's behavioral symptoms. Non-pharmacological interventions would be attempted and documented following the resolution of the acute psychiatric situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to ensure pharmacy medication review recommendations were addressed and followed up on. This affected three residents (Residents #37, #53, and #70) of five residents reviewed for use of unnecessary medications. The facility census was 71.
Findings included:
1. Review of medical record for Resident #53 with an admission date of 10/04/18 revealed diagnoses including generalized anxiety, major depression, post- traumatic stress disorder, and dementia without behaviors disturbances.
Review of care plan dated 10/09/18 for Resident #53 revealed he received psychotropic medications related to anxiety, depression, and post- traumatic stress disorder. Interventions included administer medications as ordered and monitor for side effects and effectiveness, observe for possible side effects such as excess sedation, dizziness, unsteadiness, gastrointestinal upset, headache, and drowsiness, and the pharmacist was to review his drug regimen monthly.
Review of pharmacy medication regimen review dated 02/22/19 for Resident #53 per Pharmacy Consultant #951 revealed the pharmacist recommended adding a duration of therapy for Resident #53's ongoing as needed Hydroxyzine order for anxiety. The pharmacist stated if the as needed Hydroxyzine remained necessary after the initial 14-day duration, then current guidelines require a new duration of therapy and clinical rationale. The form was blank and not addressed by the physician or facility.
Review of form labeled Note To attending Physician/ Prescriber dated 7/26/19 per Consultant Pharmacist #951 revealed since Resident #53 was readmitted recently with an order for as needed Hydroxyzine and the pharmacist recommended to the facility comply with current guidelines to add to the order a duration of therapy if the medication remained necessary. The form was blank and not addressed by the physician or facility.
Review of pharmacy medication regimen review dated 10/22/19 from Pharmacy Consultant #951 for Resident #53 revealed Resident #53 was re-admitted late September and continued to have an as needed Hydroxyzine physician order without a stop date as of late October. The Pharmacy Consultant #951 recommended to discontinue the Hydroxyzine used for anxiety or obtain a stop date/ duration of therapy. The form was blank and not addressed per the physician or facility.
Review of physician orders for December 2019 revealed Resident #53 continued to have an order for Hydroxyzine hydrochloride tablet 25 milligrams (mg) by mouth every six hours as needed for anxiety with a start date of 09/24/19 and no stop date or duration of therapy was noted per the order.
Interview with the Director of Nursing on 12/12/19 at 10:37 A.M. verified the pharmacy recommendations for Resident #53 dated 02/22/19, 07/26/19, and 10/22/19 regarding Resident #53's order for as needed Hydroxyzine was not addressed per the physician. She revealed they leave the pharmacy recommendations in the physician's folder, but he does not address the pharmacy recommendations. She verified Resident #53 had a Hydroxyzine as needed order without a stop date that was re-ordered on his readmission on [DATE] and continued to have a Hydroxyzine as needed physician order used for anxiety without a stop date per the order or rationale documented in his clinical record for a duration of therapy.
2. Review of medical record for Resident #37 revealed an admission date of 02/19/19 and diagnoses including alcoholic hepatitis without ascites, post-traumatic stress disorder and anxiety.
Review of care plan dated 04/30/19 for Resident #37 revealed he used anti-anxiety medications related to anxiety disorder. Interventions included follow up with psychiatrist, give anti-anxiety medications as ordered and monitor for side effects.
Review of pharmacy medication regimen review dated 06/27/19 from Pharmacy Consultant #951 for Resident #37 revealed he recommended the facility comply with current guidelines as the facility needed to update the duration of therapy for Resident #37's as needed Lorazepam (anti-anxiety medication). The form was blank and not addressed per the physician or facility.
Review of pharmacy medication review recommendation dated 09/27/19 from Pharmacy Consultant #951 revealed Resident #37 had physician orders recently titrated Lyrica (anti-convulsant medication) 50 milligram three times a day and Gabapentin (anti-convulsant) 600 milligrams four times a day. The pharmacist revealed each medication had similar mechanism of action and administration of both these medications could represent a therapeutic duplication. He revealed Resident #37 had renal dysfunction that could result in the accumulation of both the Lyrica and Gabapentin increasing the risk of central nervous system effects such as sedation, confusion, falls and dizziness. He recommended to review for dose or regimen titration's that were indicated. The recommendations were blank and not addressed per the physician or the facility.
Review of form labeled, Pharmacy Communication as Needed Psychotropic Notice Form dated 11/08/19 revealed Resident #37 had an order for Lorazepam .5 milligram (mg) one tablet by mouth every eight hours as needed for agitation. The communication form recommended the medication should be limited to 14 days unless the prescriber documented the rationale for the medications and a duration for the medication. The Primary Care Physician #952 documented on the form on 11/14/19 that the medication was being managed by psychiatry. No rationale of the medication or duration was added to the order.
Review of Psychiatry Consult dated 11/22/19 revealed Psychiatrist #708 evaluated Resident #37 and recommended to either discontinue the Lorazepam or give the Lorazepam a two-week limitation.
Review of physician orders for current month December 2019 revealed Resident #37 continued to have an order for Lorazepam 0.5 milligram (mg) give one tablet by mouth every eight hours as need for agitation or loss of temper. There was no stop date or duration of this medication per Psychiatrist #708's recommendation on 11/22/19. Resident #37 had an order for Lyrica capsule 100 milligrams by mouth three times a day and Gabapentin capsule 600 milligram by mouth two times a day.
Review of Medication Administration Record (MAR) for December 2019 revealed he received the Lorazepam 0.5 mg by mouth every eight hours as needed for agitation or loss of temper on 12/06/19 at 2:17 A.M. and 12/10/19 12:54 A.M. after the medication was to be discontinued.
Interview with Director of Nursing on 12/11/19 at 12:27 P.M. verified Resident #37's Lorazepam was not discontinued or given a duration of two weeks per Psychiatrist #708's recommendation on 11/22/19. She verified the order continued without a stop date or duration as of today, 12/11/19. She verified Resident #37 was given Lorazepam 0.5 mg one tablet as needed for agitation on 12/06/19 and 12/10/19 after the medication was to be discontinued per Psychiatrist #708's recommendation on 11/22/19 to either stop the Lorazepam or continue only for 14 days. She verified the Lorazepam for Resident #37 was never stopped or given a 14-day duration per recommendation. She verified the pharmacy recommendation dated 09/27/19 regarding the Lyrica and Gabapentin dose or regimen titration's was not addressed per the physician as she did not have documentation and verified the recommendation was blank.
3. Review of medical record for Resident #70 revealed an admission date of 05/16/19 and diagnoses including dementia with behavioral disturbances, major depression, anxiety disorder and psychosis.
Review of care plan dated 05/17/19 revealed Resident #70 received psychotropic medications related to behavioral management, and depression. Interventions included: administer medications as ordered and monitor for side effects, redirect, give one on one, as needed prior to use of as needed medications and chart results.
Review of Resident #70's physician orders for June 2019, July 2019, August 2019, September 2019 and October 2019 revealed he had a physician order for Haloperidol (anti-psychotic) tablet two milligrams (mg) by mouth every 12 hours as needed for agitation that started on 06/07/19. There was no stop date or duration of this medication per the order during these months until the medication was discontinued on 10/22/19.
Review of pharmacy medication review dated 06/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had an order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were only to be used for 14 days. He recommended to discontinue the Haloperidol or place a 14-day duration with rational for the medication. The pharmacy medication review was blank and the physician or the facility did not address the recommendation.
Review of pharmacy medication review dated 08/28/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were to be used only for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy recommendation until 10/18/19 and checked the box that he agreed but provided no rationale.
Review of pharmacy medication review dated 09/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy as anti-psychotic agents needed to be only used for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy medication review until 10/18/19 and noted he renewed for 14 days but provided no rationale.
Review of Resident #70's current physician orders for December 2019 revealed he had an order for Haloperidol tablet one milligram give one milligram by mouth every six hours as needed for agitation that did not include a duration of 14 days.
Interview on 12/10/19 at 3:15 P.M. with Resident #70's wife revealed she was concerned the facility was administering too many psychotropic medications especially the Seroquel (anti-psychotic) and Haloperidol as at times when she visited, he was in a like a stupor state. She revealed she talked to the pharmacist who stated he agreed and stated he recommended to the facility to look at his psychotropic medications, but she did not believe they had. She revealed she did not feel they attempted other non-medication interventions prior to administering his as needed medications. She revealed she was concerned as he had lip smacking which he did almost daily and was told that the lip smacking was from a side effects of his psychotropic medications.
Interview with the Director of Nursing on 12/11/19 at 12:37 P.M. verified Resident #70 had an order for Haloperidol tablet two milligrams give by mouth every 12 hours as needed for agitation. She verified he had this order from 06/07/19 to 10/22/19 without a duration or rationale documented. She verified Resident #70's pharmacy medication review dated 06/27/19 was not addressed by the physician. She also verified Resident #70's pharmacy medication review dated 08/18/19 was not addressed until 10/18/19. She verified Resident #70's as needed Haloperidol was an anti-psychotic medication and should have been limited to a 14- day duration and rationale should have been documented justifying the use of the as needed Haloperidol. She also verified Resident #70 was recently ordered Haloperidol one milligram by mouth every six hours as needed for agitation on 12/06/19 and there was not a stop/ duration of 14 days added to the order.
Interview with the Director of Nursing on 12/12/19 at 10:37 A.M. revealed the facility did not have a policy or procedures for the monthly drug regimen review that included, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident or how the physician addresses the drug regimen review recommendation.
Review of facility policy labeled, Use of Psychoactive Medications dated August 2019 revealed psychotropic medication therapy was to be only used when it was necessary to treat a specific condition. The facility policy did not address psychotropic medications limited to 14 days or indicated duration for the medications other than anti-psychotic medications that were limited to 14 days. The policy revealed all as needed anti-psychotic drugs were limited to 14 days and cannot be renewed unless the attending physician evaluated the resident for the appropriateness of that medication. The physician was to respond appropriately by changing or stopping problematic doses of medications or clearly document why the benefits of the medication outweigh the risks. The facility consultant pharmacist would assist by identifying gradual dose reductions and prompting prescriber's for periodic re-evaluation of medication and to prompt the facility to update their documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents were free of unnecessary medications as their as needed psychotropic orders were not limited to 14 days and/ or a documented physician rationale was not in the resident's medical record to indicate the duration of the as needed psychotropic medication order. This affected three residents (Residents #37, #53, and #70) out of five residents reviewed for use of unnecessary medications. The facility census was 71.
Findings included:
1. Review of the medical record for Resident #53 with an admission date of 10/04/18 revealed diagnoses including generalized anxiety, major depression, post-traumatic stress disorder and dementia without behaviors disturbances.
Review of the care plan dated 10/09/18 revealed he received psychotropic medications related to anxiety, depression and post- traumatic stress disorder. Interventions included: administer medications as ordered and monitor for side effects and effectiveness, observe for possible side effects such as excess sedation, dizziness, unsteadiness, gastrointestinal upset, headache, and drowsiness, and the pharmacist was to review his drug regimen monthly.
Review of the pharmacy medication regimen review dated 02/22/19 completed by Pharmacy Consultant #951 revealed the pharmacist recommended adding a duration of therapy for Resident #53's ongoing as needed Hydroxyzine order for anxiety. The pharmacist stated if the as needed Hydroxyzine remained necessary after the initial 14-day duration, then current guidelines require a new duration of therapy and clinical rationale. The form was blank and not addressed by the physician or facility.
Review of the form labeled, Note To attending Physician/ Prescriber dated 7/26/19 completed by Consultant Pharmacist #951 revealed since Resident #53 was readmitted recently with an order for as needed Hydroxyzine and the pharmacist recommended to the facility comply with current guidelines to add to the order a duration of therapy if the medication remained necessary. The form was blank and not addressed by the physician or facility.
Review of the pharmacy medication regimen review dated 10/22/19 completed by Pharmacy Consultant #951 for Resident #53 revealed Resident #53 was re-admitted late September and continued to have an as needed Hydroxyzine physician order without a stop date as of late October. Pharmacy Consultant #951 recommended to discontinue the Hydroxyzine used for anxiety or obtain a stop date/ duration of therapy. The form was blank and not addressed per the physician or facility.
Review of the physician orders for December 2019 revealed Resident #53 continued to have an order for Hydroxyzine hydrochloride tablet 25 milligrams (mg) by mouth every six hours as needed for anxiety with a start date of 09/24/19 and no stop date or duration of therapy was noted per the order.
Interview with the Director of Nursing on 12/12/19 at 10:37 A.M. verified the pharmacy recommendations for Resident #53 dated 02/22/19, 07/26/19 and 10/22/19 regarding Resident #53's order for as needed Hydroxyzine was not addressed by the physician. She revealed they leave the pharmacy recommendations in the physician's folder, but he does not address the pharmacy recommendations. She verified Resident #53 had a Hydroxyzine as needed order without a stop date that was re-ordered on his readmission on [DATE], and he continued to have a Hydroxyzine as needed physician order used for anxiety without a stop date per the order or rationale documented in his clinical record for a duration of therapy.
2. Review of the medical record for Resident #37 revealed an admission date of 02/19/19 and diagnoses including alcoholic hepatitis without ascites, post-traumatic stress disorder and anxiety.
Review of the care plan dated 04/30/19 for Resident #37 revealed he used anti-anxiety medications related to anxiety disorder. Interventions included: follow up with psychiatrist, give anti-anxiety medications as ordered and monitor for side effects.
Review of the pharmacy medication regimen review dated 06/27/19 completed by Pharmacy Consultant #951 for Resident #37 revealed he recommended the facility comply with current guidelines as the facility needed to update the duration of therapy for Resident #37's as needed Lorazepam (anti-anxiety medication). The form was blank and not addressed by the physician or facility.
Review of the form labeled, Pharmacy Communication as Needed Psychotropic Notice Form dated 11/08/19 revealed Resident #37 had an order for Lorazepam 0.5 milligram (mg) one tablet by mouth every eight hours as needed for agitation. The communication form recommended the medication should be limited to 14 days unless the prescriber documented the rationale for the medications and a duration for the medication. Primary Care Physician #952 documented on the form on 11/14/19 that the medication was being managed by psychiatry. No rationale of the medication or duration was added to the order.
Review of the Psychiatry Consult dated 11/22/19 revealed Psychiatrist #708 evaluated Resident #37 and recommended to either discontinue the Lorazepam or give the Lorazepam a two-week limitation.
Review of the orders for current month December 2019 revealed Resident #37 continued to have an order for Lorazepam 0.5 milligram (mg) give one tablet by mouth every eight hours as need for agitation or loss of temper. There was no stop date or duration of this medication per Psychiatrist #708's recommendation on 11/22/19.
Review of the Medication Administration Record (MAR) for December 2019 revealed he received the Lorazepam 0.5 mg by mouth every eight hours as needed for agitation or loss of temper on 12/06/19 at 2:17 A.M. and 12/10/19 12:54 A.M. after the medication was to be discontinued.
Interview with the Director of Nursing on 12/11/19 at 12:27 P.M. verified Resident #37's Lorazepam was not discontinued or given a duration of two weeks per Psychiatrist #708's recommendation on 11/22/19. She verified the order continued without a stop date or duration as of today, 12/11/19. She verified Resident #37 was given Lorazepam 0.5 mg one tablet as needed for agitation on 12/06/19 and 12/10/19 after the medication was to be discontinued per Psychiatrist #708's recommendation on 11/22/19 to either stop the Lorazepam or continue only for 14 days. She verified the Lorazepam for Resident #37 was never stopped or given a 14-day duration per recommendation.
3. Review of the medical record for Resident #70 revealed an admission date of 05/16/19 and diagnoses including dementia with behavioral disturbances, major depression, anxiety disorder and psychosis.
Review of the care plan dated 05/17/19 revealed Resident #70 received psychotropic medications related to behavioral management and depression. Interventions included: administer medications as ordered and monitor for side effects, redirect, give one on one, as needed prior to use of as needed medications and chart results.
Review of Resident #70's physician orders for June 2019, July 2019, August 2019, September 2019 and October 2019 revealed he had a physician order for Haloperidol tablet (anti-psychotic) two milligrams (mg) by mouth every 12 hours as needed for agitation that started on 06/07/19. There was no stop date or duration of this medication per the order during these months until the medication was discontinued on 10/22/19.
Review of the pharmacy medication review dated 06/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had an order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were only to be used for 14 days. He recommended to discontinue the Haloperidol or place a 14-day duration with rational for the medication. The pharmacy medication review was blank and the physician or the facility did not address the recommendation.
Review of the pharmacy medication review dated 08/28/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy that was needed for anti-psychotic agents as they were to be used only for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy recommendation until 10/18/19 and checked the box that he agreed but provided no rationale.
Review of the pharmacy medication review dated 09/27/19 revealed Consultant Pharmacist #951 stated Resident #70 had a physician order for as needed Haloperidol without a duration of therapy as antipsychotic agents needed to be only used for 14 days. He recommended to have the physician renew for 14 days and have Resident #70 assessed and provide rationale of the as needed Haloperidol in the clinical record. Primary Care Physician #953 did not review the pharmacy medication review until 10/18/19 and noted he renewed the medication for 14 days but provided no rationale.
Review of Resident #70's current physician orders for December 2019 revealed he had an order for Haloperidol tablet one milligram by mouth every six hours as needed for agitation that did not include a duration of 14 days.
Interview on 12/10/19 at 3:15 P.M. with Resident #70's wife revealed she was concerned the facility was administering too many psychotropic medications especially the Seroquel (anti-psychotic) and Haloperidol as at times when she visited, he was in a like a stupor state. She revealed she talked to the pharmacist who stated he agreed and stated he recommended to the facility to look at his psychotropic medications, but she did not believe they had. She revealed she did not feel they attempted other non-medication interventions prior to administering his as needed medications. She revealed she was concerned as he had lip smacking which he did almost daily and was told that the lip smacking was from a side effects of his psychotropic medications.
Interview with the Director of Nursing on 12/11/19 at 12:37 P.M. verified Resident #70 had an order for Haloperidol tablet two milligrams give by mouth every 12 hours as needed for agitation. She verified he had this order from 06/07/19 to 10/22/19 without a duration or rationale documented. She verified Resident #70's pharmacy medication review dated 06/27/19 was not addressed by the physician. She also verified Resident #70's pharmacy medication review dated 08/18/19 was not addressed until 10/18/19. She verified Resident #70's as needed Haloperidol was an anti-psychotic medication and should have been limited to a 14-day duration and rationale should have been documented justifying the use of the as needed Haloperidol. She also verified Resident #70 was recently ordered Haloperidol one milligram by mouth every six hours as needed for agitation on 12/06/19 and there was not a stop/ duration of 14 days added to the order.
Review of facility policy labeled, Use of Psychoactive Medications dated August 2019 revealed psychotropic medication therapy was to be only used when it was necessary to treat a specific condition. The facility policy did not address psychotropic medications limited to 14 days or indicated duration for the medications other than anti-psychotic medications that were limited to 14 days. The policy revealed all as needed anti-psychotic drugs were limited to 14 days and cannot be renewed unless the attending physician evaluated the resident for the appropriateness of that medication. The physician was to respond appropriately by changing or stopping problematic doses of medications or clearly document why the benefits of the medication outweigh the risks. The facility consultant pharmacist would assist by identifying gradual dose reductions and prompting prescribers for periodic re-evaluation of medication and to prompt the facility to update their documentation.

Based on interview, observation, record review and policy review, the facility failed to ensure insulin's were dated when opened for Resident #24 and Resident #46. This affected two medication carts with undated insulin for Residents #24 and Resident #46 of three medications carts reviewed for medications storage and labeling. This had the potential to affect 11 residents (Residents #11, #22, #24, #33, #36, #37, #46, #47, #65, #70 and #274) receiving insulin. The facility census was 71.
Findings include:
1. Review of medical record for Resident #46 with an admission date of 03/31/16 and diagnoses of type one diabetes mellitus with diabetic autonomic neuropathy.
Review of Resident #46's current physician orders for December 2019 revealed she had an order for Tresiba FlexTouch Solution Pen-injector 100 units per milliliter (ml) inject 52 units subcutaneously at bedtime for diabetes.
Observation of medication storage on 12/09/19 at 4:45 P.M. of North Floor One medication cart with Licensed Practical Nurse (LPN) #600 revealed Resident #46 had a opened Tresiba FlexTouch Solution Pen-injector 100 unit per milliliter (ml) (insulin) in the medication cart undated when it was opened.
Interview on 12/09/19 at 4:47 P.M. with LPN #600 verified Resident #46's Tresiba FlexTouch Solution Pen-injector 100 unit per milliliter (ml) (insulin) was not dated when the insulin was opened and revealed when the insulin was opened the nurse should have dated the insulin.
2. Review of medical record for Resident #24 with an admission date of 03/11/19 and diagnoses of diabetes mellitus with hyperglycemia.
Review of Resident #24's current physician orders for December 2019 revealed she had an order for Lantus Solution Pen- injector 100 units per milliliter (ml) inject 36 units subcutaneously one time a day for diabetes.
Observation of medication storage on 12/09/19 at 4:55 P.M. with LPN #601 of [NAME] Cart Two revealed Resident #24 had a opened Lantus Solution Pen- injector 100 units per milliliter (ml) had a black smudge on the side of the pen but was unable to read a date when the pen was opened.
Interview on 12/09/19 at 4:57 P.M. with LPN #601 verified Resident #24's Lantus Solution Pen- injector 100 units per milliliter (ml) had a black smudge on the side of the pen but was unable to read a date when the pen was opened.
Review of facility policy titled, Medication Administration dated 06/17/17 revealed insulin was a high risk drug and warranted additional precautions for the safe and effective administration. The nurse was to ensure that all opened insulin was dated when opened by documenting on the vial or pen. The policy revealed vials and pens without an open date recorded should be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to routinely assess and monitor one resident, Resident #17, at risk for elopement. This affected one of two residents identified by the facility as having an alarming bracelet due to elopement risk. The facility census was 71 residents.
Findings include:
Review of Resident #17's medical record revealed an admission date of 05/27/17 and diagnoses including dementia, chronic kidney disease, peripheral vascular disease, Alzheimer's disease, hypertension, wandering in diseases classified elsewhere and vitamin D deficiency.
Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had a memory problem, had continuous inattention and wandered daily in the look back period.
Review of elopement risk assessments for Resident #17 revealed entries on 05/27/17 and 07/21/17. Review of the assessment dated [DATE] revealed Resident #17 was physically capable of leaving the facility; was confused to time and place; wanders, roams and paces; a listed intervention in place included a Roam Alert watchlet (keeps wander-prone residents safe by triggering an alert when a protected resident approaches a monitored exit). No further assessments were available for review.
Review of physician's orders revealed an order dated 01/15/19 to check the Roam Alert placement every shift.
Review of a care plan dated 07/20/17 revealed Resident #17 was an elopement risk due to wandering behavior. A goal indicated Resident #17 would not elope from the facility over the next 90 days. Interventions included: keep a watchful eye on resident's whereabouts (07/20/17), notify physician of any attempts from resident to leave facility (07/20/17) and Roam Alert to wrist, check placement daily (10/12/17).
Review of nurses' note written by Licensed Practical Nurse (LPN) #406 and dated 08/25/19 at 1:00 P.M. revealed another resident's family made staff aware Resident #17 exited the building into the parking lot. LPN #406 and another nurse ran down the hallway and brought Resident #17 back in to the facility. The note stated the alarm light was flashing but there was no sound.
Further review of Resident #17's medical record revealed the order for checking roam alert placement was completed as ordered from August 2019 through December 2019, however, no orders or indication the device was checked for functioning at any point was noted in the record.
An interview was conducted on 12/11/19 at 2:25 P.M. with the Director of Nursing (DON). The DON stated Resident #17 had made it out to the porch of the facility on 08/25/19. The DON indicated Resident #17's Roam Alert had needed to be replaced, and Resident #17 was moved to the second floor of the facility as a result of the incident. The DON stated the MDS staff were responsible for completing elopement assessments.
An interview was conducted on 12/11/19 at 3:25 P.M. with the Director of Maintenance (DOM) #401. DOM #401 stated eight doors were checked with a Roam Alert pendant each month to ensure the system would chirp then alarm. DOM #401 explained the system was passive, and the individual Roam Alert watchlet's did not have a battery.
An interview was conducted on 12/11/19 at 3:46 P.M. with LPN #402. LPN #402 explained nursing staff were to sign off in the treatment administration record (TAR) the Roam Alert was physically on a resident daily, and the individual Roam Alert device was checked for functioning weekly.
Interviews were conducted on 12/11/19 at 4:07 P.M. with MDS Nurse #403 and MDS Nurse #404. Both nurses shared elopement risk assessments were completed upon admission and various staff completed these assessments thereafter.
A follow-up interview with the DON on 12/11/19 at 4:31 P.M. verified no further assessment of Resident #17's elopement risk was available for surveyor review. The DON verified nursing staff were to check a resident's individual Roam Alert device weekly to ensure proper function and sign off in the TAR. The DON confirmed Resident #17 did not have an order in her medical record for staff to check her Roam Alert device weekly to ensure proper function and shared no further information regarding Resident #17 being found in the parking lot was available for review.
An interview was conducted on 12/12/19 at 10:31 A.M. with LPN #406. LPN #406 verified her nurses' note from 08/25/19 and shared Resident #17 had been on the steps outside the front door of the facility that led to the parking lot. LPN #406 recalled the light had been blinking on the Roam Alert keypad, but it did not emit any sound. LPN #406 thought night shift was to check the Roam Alerts for functioning. She stated she was told to write a nurses' note and had not completed any further documentation regarding this incident.
Review of the facility policy, Roam Alert Resident Bracelet revised 08/16/17 revealed a Roam Alert bracelet would be initiated when a resident experienced a decrease in the ability to guard self from accident or injury due to elopement. A resident would be evaluated upon admission and quarterly thereafter. Elopement was defined as when a patient or resident who was cognitively impaired left the facility unnoticed and/or prior to their scheduled discharge. A listed procedure included monthly testing of Roam Alert bracelets/system completed monthly by maintenance and once initiated, the Roam Alert function was to be checked weekly.
Review of maintenance records revealed once a month, maintenance staff checked the operation of door monitors of the patient wandering system.
Review of facility policy and procedure on elopement, revised 06/01/16 defined elopement as unauthorized leave from the facility premises without prior communication by the resident or responsible party to facility staff. Charge nurse was to document pertinent medical information in the clinical records; if found off-premises and/or any injuries sustained, an incident report would be completed. Post-elopement, the elopement risk assessment form would be reviewed and updated; the plan of care would be reviewed and updated; the watchlet policy would be reviewed and initiated; the resident could be moved to the second floor of the facility if not already residing there; a post-elopement investigation and documentation was to be completed by Administrator/designee.
Review of the Roam Alert instruction manual dated October 1999 revealed the function of the Roam Alert system was to monitor areas within a building for the presence of Roam Alert transponders. A transponder was sensed when it entered a radio frequency (RF) exciter field that was set up using the Roam Alert controller. Roam Alert was designed to assist nursing staff in providing a higher degree of safety for wandering patients but was not intended as the sole means of protection in preventing a wandering patient leaving the premises.
Review of the Roam Alert controller instruction manual dated August 2012 revealed the manufacturer's systems were designed to assist staff in providing a high degree of safety for people and assets and therefore should be used as a component on a comprehensive security programs of policies, procedures and processes. As with any security system one must perform regular system operational checks to verify functional integrity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to monitor Resident #70's bowel movements and implement bowel medications per physician orders to prevent constipation. This affected one resident (Resident #70) of one resident reviewed for constipation. The facility census was 71.
Findings included:
Review of medical record for Resident #70 revealed an admission date of 05/16/19 and diagnoses including dementia with behavioral disturbances, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and constipation.
Review of Resident #70's care plan dated 06/05/19 revealed he had a potential for constipation related to altered mobility and medication usage. Interventions included administer Colace (stool softener), Milk of Magnesia (laxative), Dulcolax (laxative) and Senna (laxative) per physician orders, assess abdomen at least daily for tenderness, distension, bowel sounds and firmness, follow facility bowel protocol for bowel management, record bowel movement pattern each day, and monitor, document, report to physician as needed sign and symptoms of complications related to constipation.
Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had impaired cognition and required extensive assist of two people for bed mobility, transfers and toileting. He was always incontinent of bowel and bladder.
Review of physician orders for the months of November 2019 and December 2019 revealed Resident #70 had a physician order to receive Milk of Magnesia 30 milliliters (ml) by mouth every 24 hours as needed for constipation if no bowel movement in two days. He also had an order for Bisacodyl suppository (Dulcolax) insert ten milligram (mg) suppository rectally every 24 hours as needed for lack of bowel movement.
Review of Medication Administration Record (MAR) for November 2019 revealed Resident #70 received Milk of Magnesia 30 milliliters (ml) by mouth as needed on 11/16/19, 11/17/19, and 11/29/19. He did not receive a Bisacodyl suppository.
Review of form labeled, POC (Plan of Care) Response History dated from 11/11/19 to 12/10/19 revealed staff documented Resident #70's bowel movements. Resident #70 had no bowel movements recorded from 11/13/19 through 11/16/19 (four days), from 11/18/19 through 11/21/19 (four days), and from 11/25/19 through 11/29/19 (five days).
Interview with the Director of Nursing on 12/10/19 at 2:21 P.M. verified Resident #70 was to receive Milk of Magnesia as needed if he did not have a bowel movement after two days per his physician order. She verified he should have received Milk of Magnesia on 11/15/19, 11/20/19 and 11/27/19 per physician order as he did not have a bowel movement for two days. She verified Resident #70's physician order was not followed.
Review of undated facility policy labeled, BM (Bowel Movement) Protocol revealed the facility was to assist with maintaining a good bowel regimen and prevent constipation. Bowel movements would be marked everyday by the nurse's aides and then the nurse would review the bowel record on 6:00 P.M. to 6:00 A.M. shift and note which residents needed Milk of Magnesia and pass on in report to the day shift.
Review of facility policy labeled, Medication Administration dated 06/21/17 revealed the facility did not ensure medications were administered per acceptable standards of practice. The nurse was to open the medication administration record and note any changes on the medication administration record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the physician was notified when Resident #8's medication was not administered. This affected one (Resident #8) out of three residents observed for medication administration. The facility census was 78.
Findings include:
Resident #8 was admitted on [DATE] with diagnoses including diabetes mellitus, cardiac disease, vascular disease, gastrointestinal disease, anemia, anxiety, osteoporosis, breast cancer and depression. A review of Resident #8's clinical record indicated a physician order dated 05/07/18. The physician order indicated to administer Mucinex (expectorant) 1,200 milligrams orally two times a day. The physician order indicated to swallow the tablets whole and not to chew or crush. On 09/25/18 the physician order was changed and indicated the Mucinex medication could be crushed for administration. A review of Resident #8's Medication Administration Record (MAR) dated 10/01/18 to 10/18/18 indicated on 10/03/18 to 10/05/18, 10/08/18, 10/09/18, 10/12/18 to 10/15/18 the Mucinex dosage scheduled for 7:00 P.M. to 11:00 P.M. and on 10/05/18 and 10/15/16/18 the Mucinex dosage scheduled from 7:00 A.M. to 11:00 A.M. were not administered. The MAR did not indicate why the Mucinex medication had not been administered. Upon further review of the clinical record there was no documentation the physician was notified when Resident #8 did not receive the Mucinex medication.
An observation of Resident #8's medication administration performed by Licensed Practical Nurse (LPN) #9 on 10/16/18 at 9:15 A.M. indicated the Mucinex medication was not administered due to the medication was not available in the medication cart. An inspection of Resident #8's MAR with LPN #9 indicated several dosages of the Mucinex medication were not administered and there was no documentation on the MAR or in Resident #8's clinical record to explain why the medication was not administered. The facility census was 78.
An interview with the Director of Nursing (DON) on 10/16/18 at 11:00 A.M. verified Resident #8 had not received the Mucinex medication due to she was unable to swallow the medication from 10/03/18 to 10/08/18. DON was not able to state a reason for why the Mucinex medication was not administered for the times listed above from 10/12/18 to 10/15/18. On 10/17/18 at at 3:45 P.M. an interview with DON indicated there was no documentation or other evidence of the notification of the physician when the staff did not administer Resident #8's Mucinex medication.
A review of the facility policy and procedure titled Medication Administration effective 06/21/17 indicated the procedure for the administration of medications. Item #9 indicated if a medication was unavailable , contact the pharmacy and document accordingly. Item #15 indicated if a resident refused or ingested less than 100% of the dose of the medication to document on the MAR in the designated area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #30 was admitted on [DATE] with diagnoses including dementia with behavioral disturbance, Alzheimer's dementia, anxiety, depression, macular degeneration, osteoarthritis and low back pain. A review of Resident #30's annual Minimum Data Set (MDS) assessment dated [DATE] indicated severe cognitive impairment. The MDS assessment indicated Resident #30 needed extensive assistance of one staff member for locomotion on and off the nursing unit and the extensive assistance of two staff members for transfers.
An observation of Resident #30 on 10/17/18 at 9:20 A.M. indicated Resident #30 was seated in front of the television in a wheelchair. Resident #30 was calling out to the staff requesting assistance to go to her room. Several staff members were walking in the hallway and in the common room and ignored Resident #30. At the time of the observation Licensed Practical Nurse (LPN) #6 was administering medications to Resident #5. Resident #5 was seated directly behind Resident #30. Resident #30 continued to ask for help to go to bed. LPN #6 did not respond or acknowledge Resident #30 until Resident #30 pushed back her wheelchair and bumped in to LPN #6's leg. LPN #6 then responded she could not go to her room right now and stated Okay, Kiddo?. An interview with LPN #6 upon completion of the medication administration to Resident #5 verified she had addressed Resident #30 as Kiddo and verified the above observation.
A review of the facility policy and procedure titled Resident Rights and Facility Responsibilities dated 11/28/16. The policy indicated the facility would abide by all resident rights and to communicate theses right to the residents and designated representative. Nursing facility residents are granted specific rights under Federal law and indicated a duplication of the Federal regulation for reference. The facility duplicated Federal regulations and indicated item (e) Respect and Dignity: The resident had the right to be treated with respect and dignity.
Based on observation, record review, policy review and interview, the facility failed to ensure Resident #58 had a dignified dining experience and failed to ensure Resident #30 was treated with respect while sitting in a common area. This affected one (Resident #58) of 29 residents who ate in the second-floor dining room and one (Resident #30) of three residents reviewed for dignity. The facility census was 78.
Findings include:
1. Record review of Resident #58 indicated an admission date of 09/18/18 with diagnoses of dementia with behavioral disturbances and cognitive communication deficit. Review of the 09/25/18 Minimum Data Set (MDS) 3.0 admission assessment indicated Resident #58 was severely cognitively-impaired, needed set-up help with her meal and supervision with eating. Review of the 09/27/18 care plan indicated Resident #58 was confused at times, may yell or call out related to dementia and can become annoyed or agitated at times with an intervention to assess and anticipate resident ' s needs such as food and thirst.
Review of the undated dining room seating chart policy indicated all the residents who are seated together at one table may be served at one time, in order to promote a more home-like atmosphere.
Observation on 10/15/18 at 12:25 P.M. in the second-floor dining room revealed Resident #15, Resident #62, Assisted Living (AL) Resident #5 and Resident #58 were sitting at a dining room table together. Resident #15 and Resident #62 were served lunch and State-tested Nurse Aide (STNA) #1 assisted them with their meals; AL Resident #5 and Resident #58 were not served their lunch.
Observation on 10/15/18 at 12:34 P.M. revealed Resident #15 and Resident #62 were feeding themselves and AL Resident #5 and Resident #58 hadn ' t received their meals. Resident #58 said to STNA #1 and STNA #3, who were walking by her to serve other residents their meal, I ' m waiting for my lunch . STNA #1 and STNA #3 did not respond to Resident #58.
Observation on 10/15/18 at 12:35 P.M. Resident #58 said again to STNA #1 and STNA #3, who were walking by her to serve other residents their meal, when do I get mine? I ' m waiting for my lunch . STNA #1 and STNA #3 did not respond to Resident #58.
Observation on 10/15/18 at 12:36 P.M. revealed AL Resident #5 and Resident #58 were served their lunch. Resident #58 started feeding herself.
Interview on 10/15/18 at 12:39 P.M. with STNA #3 verified Resident #58 was served her meal 11 minutes after Resident #15 and Resident #50 was served.

Based on observation, record review, admissions agreement review and interview, the facility failed to ensure Resident #51 ' s concerns about her roommate were addressed. This affected one (Resident #51) of one resident reviewed for participation in care planning. The facility census was 78.
Findings include:
Record review of former Resident #77 indicated Resident #77 passed away on 10/05/18.
Record review of Resident #51 indicated an original admission date of 03/11/15 with diagnoses of dementia with behavioral disturbances, major depressive disorder and anxiety disorder. Review of the 09/18/18 Minimum Data Set (MDS) 3.0 quarterly assessment indicated Resident #51 was moderately cognitively-impaired. Review of the care plan, updated 10/06/18, indicated Resident #51 was grieving related to the passing of her husband (former Resident #77) and still coping with her daughter passing earlier this year with an intervention of Resident #51 needing assistance/supervision/support to accept individual responses to loss of her husband and daughter. Resident #51 and former Resident #77 were married and shared a room.
Review of the undated admission agreement indicated when there was a room or roommate change decision made by the facility, the facility would take reasonable steps to transfer with the least disruption and shall access, monitor and adjust care as needed subsequent to the transfer.
Review of the 10/11/18 health status note timed 5:35 P.M. indicated Resident #51 got a new roommate (Resident #58) and stated that she could have gotten a roommate that was alive and not dead. Licensed Practical Nurse (LPN) #6 suggested Resident #51 give it a few days to see how her roommate was and Resident #51 complied.
Review of the 10/12/18 health status progress note timed 1:10 A.M. indicated Resident #51 was administered an as needed 1 milligram Xanax (an antianxiety medication) for crying and increased anxiety. Resident #51 was upset because she had a roommate who was almost dead and Resident #58 was in former Resident #77 ' s place. Resident #51 came to the nurses ' station crying then began swearing because of roommate (Resident #58)
Review of the 10/12/18 health status note timed 6:06 P.M. indicated Resident #51 was very sad with passing of husband (former Resident #77) and did complaint of having a roommate that was in her husband ' s old bed.
Review of the 10/13/18 health status note timed 7:44 P.M. indicated Resident #51 was very sad and grieving her husband. Resident #51 ' s roommate made her more upset because she made comments in front of her and Resident #58 was screaming and too much for Resident #51.
Review of the 10/16/18 social service note timed 11:33 A.M. indicated Resident #51 was very upset, angry and did not feel that the facility allowed her time to grieve husband ' s passing. Resident #51 was upset regarding having a roommate.
Review of the 10/16/18 health status note timed 1:17 P.M. indicated Resident #51 was anxious and requested an as needed Xanax at 12:00 P.M.
Observation on 10/15/18 at 10:58 A.M. revealed Resident #51 was sitting in her bed, brushing her hair, visibly upset, shaking, had tears in her eyes and a scowl on her face. Interview, during the observation, with Resident #51 revealed her husband (former Resident #77), who Resident #51 shared a room with, had passed away last week and the facility staff moved Resident #58 (Resident #51 ' s current roommate) into her room a couple of days after former Resident #77 passed away. Resident #51 felt moving Resident #58 into her room only a couple days after former Resident #77 was very insensitive.
Interview on 10/15/18 at 3:11 P.M. with Registered Nurse (RN) #4 revealed on 10/13/18, Resident #51 was complaining about not liking her roommate (Resident #58) due to Resident #58 yelling and screaming in the bed next to her and Resident #51 felt she didn ' t have time to grieve after former Resident #77 passed away. RN #4 stated she notified the Director of Nursing and RN #5 of Resident #51 ' s complaints.
Interview on 10/15/18 at 4:23 P.M. with Director of Admissions (DA) #8 revealed she was notified on 10/14/18 of Resident #51 ' s concerns about her roommate and Resident #51 hadn ' t been offered a room change. DA #8 also revealed Resident #51 was not taken to meet Resident #58 prior to Resident #58 moving into Resident #51 ' s room.
Interview on 10/15/18 at 4:52 P.M. with the Director of Nursing (DON) revealed there were open beds available in the facility.
Interview on 10/17/18 at 4:30 P.M. with the DON verified Resident #51 ' s concerns about her roommate were not addressed until 10/17/18 when the facility spoke with Resident #51 and Resident #58 ' s family about the roommate conflict.
Interview on 10/18/18 at 3:04 P.M. with Licensed Social Worker (LSW) #7 revealed when she spoke to Resident #51 on 10/16/18 at 11:33 A.M., LSW #7 did not offer Resident #51 a room change.