ORCHARD PARK POST ACUTE NURSING AND REHABILITATION

Resident #38<BR/>FTag Initiation<BR/>03/29/24 09:42 AM <BR/>Care Plan:<BR/>&bull; I receive antidepressant medication (Zoloft) r/t s/s of major depressive disorder- anxietyH <BR/>&bull;I will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. <BR/>&bull;Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT.<BR/>&bull;Black Box Warning Zoloft<BR/>Warning:<BR/>Suicidality and antidepressant drugs<BR/>Antidepressants increased the risk of suicidal thoughts and behavior in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors.<BR/>&bull;Black Box Warning: Zoloft<BR/>Warning:<BR/>Suicidality and antidepressant drugs<BR/>Antidepressants increased the risk of suicidal thoughts and behavior in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors.<BR/>&bull;Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes<BR/>&bull; I receive antipsychotic medications (olanzapine) r/t<BR/>history of bipolar disorder. <BR/>&bull;I will zero to minimal side effects of medication usage <BR/>&bull;Black Box Warning: olanzapine<BR/>Warning:<BR/>Increased mortality in elderly patients with dementia-related psychosis<BR/>Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients between 1.6 and 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was approximately 4.5%, compared with 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 (eg, heart failure, sudden death) or infectious (eg, 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 patient is not clear. Olanzapine is not approved for treatment of patients with dementia-related psychosis.<BR/>&bull;Monitor behaviors. Notify MD of new or worsening behaviors<BR/>&bull;Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person.<BR/>&bull;Obtain lab work as ordered and notify MD of results<BR/>&bull;Pharmacy consultant to review medications per policy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 10 residents (Resident #38, Resident #36, and Resident #7) reviewed for pharmacy services.<BR/>1.) The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of antipsychotic and anti-depressant medication. <BR/>This failure could affect all residents who require a consent form for medications at risk for lack of proper assessment when their medications are administered. <BR/>Findings included:<BR/>1.Record review of Resident #38's face sheet dated 3/28/2024 reflected a [AGE] year-old male with an admission date of 10/16/2023. Diagnoses included bi-polar disorder (mental illness characterized by extreme mood swings), ) and major depressive disorder (mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest in normal enjoyable activities), transient ischemic attack (mini stroke caused by a brief blockage of blood flow to the brain), and cerebral infarction (stroke caused by blood supply to the brain is blocked or reduced causing death to the brain tissue.). <BR/>Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). <BR/>Record Review of Resident #38's physician orders indicated:<BR/>1.) Olanzapine Oral Tablet 2.5 MG <BR/>Give 1 tablet by mouth two times a day for bipolar disorder.<BR/>Dated:1/26/2024 <BR/>2.) Zoloft Oral Tablet 50 MG (Sertraline HCl) <BR/>Give 1 tablet by mouth at bedtime for depression. <BR/>Dated: 1/26/2024 21:00 <BR/>Record review of Resident #38's care plan dated 11/04/2023 reflected Resident #38 may be physically and verbally aggressive at times due to multiple problems including dementia, bipolar disorder, and major depression. Resident #38 was to be administered medications Olanzapine as ordered. Monitor/document for side effects and effectiveness. Resident #38 did receive antidepressant medication Zoloft r/t s/s of major depressive disorder anxiety.<BR/>Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). <BR/>Record review on 3/28/24 at 1:15pmof Resident #38's clinical record revealed there was no consent form for the medication Zoloft. The and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who has had a responsible party and was cognitively unable to sign the consent form. <BR/>2.Record review of Resident #36's admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), cerebral infarction (stroke), hypertension (high blood pressure), anxiety disorder, heart disease, and obsessive-compulsive disorder (a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others).<BR/>Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #36's Care Plan dated 01/22/24, revealed<BR/>FOCUS: I receive antidepressant medication (fluvoxamine) r/t OCD. Date initiated: 01/27/2024<BR/>INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 01/27/24 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24<BR/>FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24<BR/>INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24.<BR/>FOCUS: I receive anti-anxiety medications (clonazepam, buspirone) r/t anxiety. Date initiated: 01/27/24<BR/>INTERVENTIONS/TASKS: Black box warning for clonazepam. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24.<BR/>Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders:<BR/>-Start date: 01/16/24 Fluvoxamine Maleate Oral Tablet 100mg (Fluvoxamine Maleate) Give 1 tablet by mouth one time a day for OCD (Fluvoxamine Maleate is a Selective Serotonin Uptake Inhibitor [SSRI] antidepressant). <BR/>-Start date: 02/06/24 <BR/>Buspirone HCl oral tablet 5mg (Buspirone HCl) Give 1 tablet by mouth two times a day for anxiety obsessive compulsive disorder (Buspirone is an anxiolytic for treatment of anxiety).<BR/>Start date: 03/14/24<BR/>Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth two times a day for anxiety/restlessness (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety).<BR/>Start date: 03/14/24<BR/>Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism).<BR/>Start date: 03/14/24<BR/>Wellbutrin XL Oral Tablet Extended Release 24 Hour 150mg (Buproprion HCl) Give 1 tablet by mouth two times a day for smoking cessation aid. (Wellbutrin is an antidepressant and smoking cessation aid).<BR/>Start date: 03/14/24<BR/>Memantine HCl Oral Tablet 10mg (Memantine HCl) Give 1 tablet two times a day for dementia. (Memantine HCl is used to treat moderate to severe confusion [dementia] related to Alzheimer's Disease).<BR/>Record review of 02/01/2024 to 02/29/2024 Pharmacy Recommendations revealed, on 02/29/24 Pharmacist wrote under Resident #36, <BR/>Please ensure the state required standardized informed consent for antipsychotics is placed on residents chart for risperidone.<BR/>No consents for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin.<BR/>Consent for Risperdal was signed by resident and not RP. Consent was not dated.<BR/>Record review of Resident #36's February 2024 MAR and March 2024 MAR revealed:<BR/>Fluvoxamine 100mg tablet was administered one time a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24.<BR/>Buspirone HCl 5mg tablet was administered twice a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24.<BR/>Clonazepam 0.5mg tablet was administered twice a day 02/01/24 - 02/16/24. Morning dose on 02/17/24 was administered. The evening dose on 02/17/24 was not checked off. Clonazepam 0.5mg tablet was administered 03/18/24 - morning dose on 03/29/24.<BR/>Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>Wellbutrin XL Extended Release 24 Hour 150mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>3.Record review of Resident #7's admission Record dated 03/26/24, revealed a [AGE] year old female, admitted to facility on 12/22/22. Her diagnosis included: Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause breathing difficulties and airflow blockage. COPD is a progressive disease that damages the lungs or airways, making it hard to breathe), respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), hypertension (high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings,, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and epilepsy (a chronic brain disease that causes recurrent seizures, which are brief episodes of involuntary movement. Seizures are caused by excessive electrical activity in the brain which can affect how it works temporarily).<BR/>Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #7's Care Plan dated 03/22/24, revealed,<BR/>FOCUS: I am receiving anti-anxiety medication (clonazepam, buspirone) r/t anxiety disorder.<BR/>INTERVENTIONS/TASKS: Black box warning for clonazepam. -Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/10/23 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/10/23 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/10/23.<BR/>FOCUS: I am receiving antidepression medication (trazadone) r/t insomnia. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning trazadone. -Administer medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Evaluate other factors potentially causing insomnia, for example, environment (excessive heat, cold or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Date initiated: 01/10/23. -Monitor/document/report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk for falls and fractures, dizziness. Date initiated: 01/10/23. -Precede or accompany hypnotic use by other interventions to try to improve sleep. Date initiated: 01/10/23. <BR/>FOCUS: I have major depression and I am receiving antidepression medication (Paxil). Date initiated: 11/29/23.<BR/>INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 11/29/23 -educate resident/family/caregivers about risks, benefits and side effects and/or toxic symptoms as needed. Date initiated: 11/29/23 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 11/29/23.<BR/>FOCUS: I am receiving antipsychotic medication (Seroquel) r/t schizophrenia. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning. -Discuss side effects of medications with resident/RP as needed. Date initiated: 01/10/23. -Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/10/23. -Monitor vital signs as ordered by MD and PRN. Date initiated: 01/10/23.<BR/>FOCUS: I am at risk for respiratory distress due to sleep apnea, COPD, history of hypoxia/SOB. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning (morphine). -Give medications as ordered by physician. Monitor/document side effects and effectiveness. Atropine sulfate (for excessive secretions), albuterol, Formoterol, Budesonide, ipratropium-albuterol, morphine (see pain care plan for black box warning) Date initiated: 09/28/23. -May suction secretions pre use of Yanker PRN Date initiated: 09/28/23. -Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of lung or section of a lung), hemoptysis (coughing up of blood or blood-tinged sputum from the lungs or tracheobronchial tree), cough, pleuritic (chest) pain, accessory muscle usage, skin color. -Oxygen/CPAP use as ordered. - Promote lung expansion and improve air exchange by positioning with proper body alignment. Date initiated: 09/28/23 <BR/>Record review of Resident #7's Order Summary dated 03/26/24 revealed, Resident #7 had the following orders:<BR/>-Start date: 03/26/23 <BR/>Buspirone HCl oral tablet 10mg (Buspirone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Buspirone is an anxiolytic for treatment of anxiety).<BR/>-Start date: 09/26/23<BR/>Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth every 8 hours related to anxiety disorder (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety).<BR/>-Start date: 10/06/23<BR/>Seroquel Oral Tablet 100mg (Quetiapine Fumarate) Give 1 tablet three times a day related to anxiety disorder (Seroquel is an antipsychotic medication)<BR/>-Start date: 11/28/23<BR/>Paxil Oral Tablet 20mg (Paroxetine HCl) Give 1 tablet by mouth one time a day related to major depressive disorder, single episode, anxiety disorder. (Paxil is used to treat depression and anxiety. It is a SSRI.)<BR/>-Start date: 12/14/23<BR/>Trazadone HCl Oral Tablet 100mg (Trazadone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Trazadone is an antidepressant and sedative)<BR/>-Start date: 03/25/24<BR/>Oxygen at 2 LPM via NC (nasal cannula) continuously while in bed r/t hypoxia.<BR/>Record review of Resident #7's February 2024 MAR and March 2024 MAR revealed:<BR/>-Buspirone HCl 10mg tablet was administered three times a day from 02/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24.<BR/>-Clonazepam 0.5mg tablet was administered every 8 hours 02/01/24 - 03/28/24 at midnight, 08:00 a.m., and 04:00 p.m. Clonazepam 0.5mg tablet was administered at midnight and 08:00 a.m. on 03/29/24.<BR/>- Seroquel 100mg tablet was administered three times a day from 02/01/24 - 02/28/24. On 03/29/24, Resident #7 received the first two administrations of Seroquel 100mg tablet. <BR/>- Paxil 20mg tablet was administered one time a day from 02/01/24 - 03/29/24. <BR/>-Trazadone HCl 100mg tablet was administered three times a day from 02/01/24 - 03/28/24. Trazadone HCl 100mg was administered at midnight and 08:00 a.m. on 03/29/24, pending the 05:00 p.m. dose. <BR/>Record review of psychotropic consent forms for Buspirone HCL 10mg tablet, Clonazepam 0.5mg tablet, Seroquel 100mg tablet, Paxil 20mg tablet, and Trazadone HCl 100mg tablet were signed by Resident #7 and not by Resident #7's RP and consents were undated. There was no consent form for clonazepam 0.5mg tablet.<BR/>In a phone interview on 03/28/24 at 02:35 PM Resident #38s RP stated she could not remember if she signed a consent form for Resident #38's antipsychotic or anti-depressant but does not believe she signed anything for medications. The RP stated she knew Resident #38 did display mood swings and figured he would be taking some kind of medication for the mood swings but could not remember if she signed anything giving consent. <BR/>In an interview on 03/29/24 at 02:14 PM the DON stated, yes there is supposed to be a consent form for appropriate usage for the medication. The DON stated the consent form could have been overlooked or misplaced for the medication Zoloft but could not confirm. The DON stated consent form audits were conducted monthly by herself and the ADON but was now going to be started weekly. The DON stated if a resident was cognitively aware, that resident was able to sign his or her consent form. The DON stated that if a resident does have a responsible party, then the responsible party should have been the one to sign the consent form. The DON stated that the RP for Resident #38 was made aware of the medications Resident #38 was taking but was only told verbally. The DON stated that possible negative outcomes could be the resident could have symptoms from the medication and the family or RP being unaware of what medications that resident was being administered. The DON stated there was no policy for consent forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #216) of 8 residents reviewed for baseline care plans. <BR/>The facility failed to include Resident #216's use of insulin and anticoagulant medications in her baseline care plan. <BR/>This failure could result in residents not receiving needed care and treatment. <BR/>Findings Included: <BR/>Record review of Resident #216's admission Record dated 05/20/2025 revealed she was a [AGE] year-old female admitted [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Heart Failure, Peripheral Arterial Disease (an accumulation of plaque (fats and cholesterol) in the arteries in your legs or arms), Hyperlipidemia (high cholesterol), Muscle Wasting and Atrophy (decrease in muscle size and wasting of muscle tissue), and Dysphagia (difficulty swallowing). <BR/>Record review of Resident #216's 5-day MDS assessment dated [DATE] revealed a BIMS score of 15, indicating intact cognition. <BR/>Record review of Resident #216's Baseline Care Plan initiated 05/11/2025 revealed medications insulin and anticoagulant were not included. <BR/>Record review of Resident #216 ' s Physician Orders dated 5/11/2025 revealed, Tresiba Flex Touch Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Degludec) inject 32 units subcutaneously in the morning for DM #2 hold if BS less than 100 and Eliquis Oral Tablet 2.5mg (Apixaban) Give 1 tablet by mouth two times a day for PAD. <BR/>Record review of Resident #216's electronic Medication Administration Record for May 2025 revealed Eliquis oral tablet 2.5mg 1 tablet by mouth was administered twice a day, started 05/12/2025 and Tresiba Flex Touch Subcutaneous solution Pen injector 100 unit/ml (Insulin Degludec) 32 units injected subcutaneously in the morning, started 05/12/2025.<BR/>During an interview with MDS nurse on 05/19/25 at 3:05 p.m., stated that the baseline care plan was to be completed within 48 hours. She stated that the admitting floor nurses were responsible for completing the baseline care plan upon admission and the registered nurses sign it off. The MDS nurse stated the essential information that should be included in the baseline care plan should be the resident ' s cognition status, ADLs, respiratory, and medications. The MDS stated that it was important to have that information in the baseline care plan because the resident could fall, elope or have a reaction to a medication. <BR/>During an interview with LVN A on 05/19/25 3:15 p.m., she stated the baseline care plan was completed between 24-48 hours. He stated the baseline care plan should include information such as medications like insulin, anticoagulants, antidepressants, and code status. LVN A stated insulin should be in baseline care plan to manage the resident ' s diabetes, so they won ' t go into hypoglycemia or hyperglycemia. To make sure we were not giving too much insulin. He stated that the anticoagulants were important to be on the baseline care plan, so they won ' t bleed out. This information was important for better patient care. The admitting nurse was responsible for completing the baseline care plan. <BR/>During an interview with the DON on 05/19/25 at 3:18 p.m., the DON stated that the nurses were responsible for completing the baseline care plan. She stated that she overlooks the baseline care plans and signs them off. The DON stated the baseline care plans were to be completed within 72hours, but she signs them off before 24hours. She stated that by signing them she acknowledges that it was complete. She stated that the baseline care plan should include the advance directive, allergies, and medications. The DON looked at Residents #216 baseline care plan and under medications, she confirmed that the insulin and anticoagulants were not checked off. She stated that if the resident was currently taking them then the medications needed to be on the baseline care plan. The DON stated the negative outcome was that it would not be care planned and the resident would not have a proper plan of care. <BR/>Record review of the facility policy titled Baseline Care Plan reviewed 10/05/2023 revealed, Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. <BR/>Policy Explanation and Compliance Guidelines: <BR/>The baseline care plan will: <BR/>Be developed within 48 hours of a resident's admission. <BR/>Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: <BR/> i. Initial goals based on admission orders. <BR/>ii. Physician Orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident recieved adequate supervision for one resident (Resident#44) of 2 residents whose records were reviewed for elopements. <BR/>Resident #44 eloped from the facility undetected on 05/05/23. Resident #44 was able to remove her wanderguard bracelet and exit the facility on 06/24/23. Resident #44 eloped from the facility undetected after removing wanderguard bracelet for a second time 06/26/23. <BR/> The non-compliance was identified at PNC (Past non-compliance). The Immediate Jeopardy (IJ) situation began on 06/26/23 and ended 06/27/23 The facility had corrected the noncompliance before the survey began. <BR/>This failure could place the residents with exit seeking behaviors at risk for injury or death. <BR/>Findings included : <BR/>Record review of Resident #44's admission record dated 03/08/24 documented a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses of Primary Osteoarthritis (common form of arthritis; wear and tear arthritis), other Specified Site, Difficulty in Walking, Not elsewhere Noted, Other Abnormalities of Gait, Unspecified Dementia, unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance (group of serious illnesses that affect the mind), Mood Disturbance, and Anxiety.<BR/>Record review of Resident #44's MDS annual assessment dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. <BR/>Record review of the Provider Investigation Report revealed Resident #44 eloped on 05/05/23 at approximately 1:32 pm from the facility. Dietary Aide B witnessed Resident #44 walking on the sidewalk outside the facility and notified LVN G. LVN G redirected resident back to facility and assessed Resident #44. <BR/>Record Review of Progress Note dated 06/27/23 revealed Resident #44 was discharged home with family. <BR/>In an interview on 03/07/24 at 11:55 am LVN G said from what she could recall, on the day of[ Resident #44's] first elopement, Dietary Aide B notified her that Resident #44 was outside the facility. LVN G said she went outside and found Resident #44 walking in the parking lot. LVN G said R#44 was redirected into the facility with no incident. LVN G said that Resident #44 said that wanted to go outside and walk around. LVN G said Resident #44 was placed on 1:1 for 72 hours after this elopement. LVN G added that Resident #44 also had a wander guard placed on her wrist. LVN G said the wander guard was being checked to make sure it was in place and functioning properly every shift. She said it was documented in PCC daily. LVN G said staff was in-serviced on elopement prevention and what to do in case of an elopement. <BR/>In an interview on 03/07/24 at 2:00 pm the DON said Resident #44 did not have a history of wandering or elopement prior to the incident on 05/05/23. She said wandering evaluations were done upon admission and quarterly to find out if a resident poses an elopement risk. The DON said Resident #44 had a wandering evaluation done upon admission and was not noted to be a risk. The DON said after the incident, she was reassessed again as an elopement risk, and received doctor's orders to have a wander guard placed on Resident #44. The DON said other interventions were to engage Resident #44 in activities throughout the day as well as having her by the nurse's station for supervision. The DON said an in-service on elopement was conducted with staff after the incident. <BR/>Record Review of care plan updated on 05/05/23 revealed the following interventions were put in place:<BR/>-1:1 sitter x 72 hours<BR/>-Provide structured activities<BR/>-Offer opportunities for outside recreating in safe areas<BR/>-Complete wandering evaluation tool<BR/>-Wander guard in place. Monitoring and checking device per facility policy, staff education regarding elopement policies and interventions<BR/>Record Review of Resident #44 Skilled Administration Record dated 03/12/24 revealed; Wander guard use, check placement each shift to left wrist was checked off day, evening, and night shifts starting on 05/05/23 to 06/26/23. <BR/>Record review of the facility Provider Investigation Report revealed on 06/26/23 at approximately 5:45 pm Resident #44 eloped from the facility undetected. Resident #44 was located approximately 0.2 miles away from the facility by a busy intersection by the facility SW . SW notified LVN R who was able to redirect Resident #44 back to the facility. <BR/>Further record review of Resident #44's Progress notes revealed an entry dated 06/24/23 which indicated Resident #44 was found outside of building in front patio. As per progress note the nurse assessed the resident and noted that the resident was not wearing the wander guard bracelet. As per progress note Resident #44 stated she had removed and placed the wanderguard bracelet in a drawer. A new wander guard was placed on Resident #44's left wrist . <BR/>In an interview on 03/07/24 at 12:25 pm LVN R said he had not worked at the facility for about 5 or 6 months and did not recall the incident on 06/26/23 with Resident #44 and did not wish to speak to the state surveyor. <BR/>In an interview on 03/07/24 at 2:10 PM the ADON said Resident #44 had been found by the facility SW walking towards the local store about an 8th of a mile from the facility. She said Resident #44 was brought back by LVN R. The ADON said that the investigation found Resident #44 had removed her wander guard. The staff was unable to determine how she did it. After the incident Resident #44 was placed on 1:1 for 72 hours and staff was in-serviced on elopement and wandering . DON said the facility keeps a binder with the names of the residents that have a high risk for elopement. <BR/>In an interview on 03/07/24 at 3:31 pm the DON said she asked Resident #44 how she had removed her wander guard bracelet and she said Resident #44 did not tell her how. The DON said Resident #44 showed her where she had placed it in her dresser drawer in her room. The DON said Resident #44 was assessed after the incident and was found to have no injuries, no skin tears. The DON said a care plan was conducted with Resident #44's family and the facility was recommending placement at a facility with a locked unit. The DON said family decided to take Resident #44. Resident #44 was discharged by family on 06/27/23 the day after the incident . <BR/>In an interview on 03/12/24 at 3:00 pm LVN G said she did not recall the incident that happened on 06/24/23 with Resident #44. LVN G was able to read her progress note documented in PCC and said that the resident was outside sitting in the patio area and LVN G said Resident #44 did not have the wander guard on. She said she believed she asked her where it was or how did she remove it, but Resident #44 did not answer . DON said had in-serviced all the staff on elopement prevention. <BR/>In an interview on 03/12/24 at 3:58 pm the DON said on 6/24/23 Resident #44 was seen sitting outside the facility in the patio area. She said LVN G assessed her and noted that the wander guard was missing. The DON said she asked Resident #44 how she took it off and the resident did not respond. The DON said another wander guard was placed on Resident #44's wrist and the family was notified as well as the nurse practitioner with no new orders given. The DON said staff continued to monitor Resident #44 and continued with activities for her. <BR/>Record Review of facility in-services revealed the following In-services conducted with staff after each incident:<BR/>Topic: 05/05/23 Elopement - Supervise residents at all times, head count of all residents, initiate a code yellow<BR/>Topic: 06/27/23 Elopement - Staff be vigilant in responding to alarms, supervise residents for accidents/elopement and the use and monitor of wander guards. <BR/> There were 4 LNVs, one RN, and 5 CNAs on all three shifts interviewed on facility policy and procedure related to identifying and monitoring residents with exit seeking tendencies, redirecting, and ensuring residents at risk remained engaged . <BR/>Facility Policy titled Elopements and Wandering Residents dated 11/21/22 states; Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 Resident (Resident #36) of 6 residents reviewed for medications in that: <BR/>Resident #36 was administered Risperdal (antipsychotic medication) twice daily for vascular dementia. <BR/>This failure could place residents on psychoactive medications at risk for adverse consequences such as impairment or decline of an individual's mental or physical condition. <BR/>The findings were: <BR/>Record review of Resident #36's admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life).<BR/>Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #36's Care Plan dated 01/22/24, revealed,<BR/>FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24.<BR/>INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24.<BR/>Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders:<BR/>Start date: 03/14/24<BR/>Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism)<BR/>Record review of Resident #36's February 2024 and March 2024 MAR (Medication Administration Record) revealed, Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>In an interview on 03/29/24 at 02:05 p.m., LVN B stated there was not supposed to be an indication of Alzheimer's or Dementia for antipsychotics orders. She said there was usually a black box warning on the antipsychotic for Alzheimer's or Dementia residents receiving it. LVN B stated if she saw that (Alzheimer's or Dementia indication) on an order, she would call the physician or NP to clarify and notify of the order. <BR/>In an interview on 03/29/24 at 02:15 p.m., the DON stated antipsychotics with a diagnosis of Alzheimer's or dementia was an improper diagnosis to put on an order with an antipsychotic.<BR/>Attempted telephone interview on 03/29/24 at 04:07 p.m., with NP D, who prescribed Risperdal for Resident #36, related to dementia. Message stated office was closed for the holiday (Good Friday). No voicemail left.<BR/>Attempted telephone interview on 03/29/24 at 04:08 p.m., with MD E concerning Risperdal 0.5mg tab twice daily prescribed to Resident #36 with an indication of vascular dementia. No answer. Voicemail left. No return call received. <BR/>Record review of facility's policy Psychotropic Medication, date implemented 08/15/22, revealed,<BR/>Policy<BR/>Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 10 residents (Resident #38, Resident #36, and Resident #7) reviewed for pharmacy services.<BR/>1.) The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of antipsychotic and anti-depressant medication. <BR/>This failure could affect all residents who require a consent form for medications at risk for lack of proper assessment when their medications are administered. <BR/>Findings included:<BR/>1.Record review of Resident #38's face sheet dated 3/28/2024 reflected a [AGE] year-old male with an admission date of 10/16/2023. Diagnoses included bi-polar disorder (mental illness characterized by extreme mood swings), ) and major depressive disorder (mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest in normal enjoyable activities), transient ischemic attack (mini stroke caused by a brief blockage of blood flow to the brain), and cerebral infarction (stroke caused by blood supply to the brain is blocked or reduced causing death to the brain tissue.). <BR/>Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). <BR/>Record Review of Resident #38's physician orders indicated:<BR/>1.) Olanzapine Oral Tablet 2.5 MG <BR/>Give 1 tablet by mouth two times a day for bipolar disorder.<BR/>Dated:1/26/2024 <BR/>2.) Zoloft Oral Tablet 50 MG (Sertraline HCl) <BR/>Give 1 tablet by mouth at bedtime for depression. <BR/>Dated: 1/26/2024 21:00 <BR/>Record review of Resident #38's care plan dated 11/04/2023 reflected Resident #38 may be physically and verbally aggressive at times due to multiple problems including dementia, bipolar disorder, and major depression. Resident #38 was to be administered medications Olanzapine as ordered. Monitor/document for side effects and effectiveness. Resident #38 did receive antidepressant medication Zoloft r/t s/s of major depressive disorder anxiety.<BR/>Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). <BR/>Record review on 3/28/24 at 1:15pmof Resident #38's clinical record revealed there was no consent form for the medication Zoloft. The and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who has had a responsible party and was cognitively unable to sign the consent form. <BR/>2.Record review of Resident #36's admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), cerebral infarction (stroke), hypertension (high blood pressure), anxiety disorder, heart disease, and obsessive-compulsive disorder (a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others).<BR/>Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #36's Care Plan dated 01/22/24, revealed<BR/>FOCUS: I receive antidepressant medication (fluvoxamine) r/t OCD. Date initiated: 01/27/2024<BR/>INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 01/27/24 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24<BR/>FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24<BR/>INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24.<BR/>FOCUS: I receive anti-anxiety medications (clonazepam, buspirone) r/t anxiety. Date initiated: 01/27/24<BR/>INTERVENTIONS/TASKS: Black box warning for clonazepam. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24.<BR/>Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders:<BR/>-Start date: 01/16/24 Fluvoxamine Maleate Oral Tablet 100mg (Fluvoxamine Maleate) Give 1 tablet by mouth one time a day for OCD (Fluvoxamine Maleate is a Selective Serotonin Uptake Inhibitor [SSRI] antidepressant). <BR/>-Start date: 02/06/24 <BR/>Buspirone HCl oral tablet 5mg (Buspirone HCl) Give 1 tablet by mouth two times a day for anxiety obsessive compulsive disorder (Buspirone is an anxiolytic for treatment of anxiety).<BR/>Start date: 03/14/24<BR/>Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth two times a day for anxiety/restlessness (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety).<BR/>Start date: 03/14/24<BR/>Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism).<BR/>Start date: 03/14/24<BR/>Wellbutrin XL Oral Tablet Extended Release 24 Hour 150mg (Buproprion HCl) Give 1 tablet by mouth two times a day for smoking cessation aid. (Wellbutrin is an antidepressant and smoking cessation aid).<BR/>Start date: 03/14/24<BR/>Memantine HCl Oral Tablet 10mg (Memantine HCl) Give 1 tablet two times a day for dementia. (Memantine HCl is used to treat moderate to severe confusion [dementia] related to Alzheimer's Disease).<BR/>Record review of 02/01/2024 to 02/29/2024 Pharmacy Recommendations revealed, on 02/29/24 Pharmacist wrote under Resident #36, <BR/>Please ensure the state required standardized informed consent for antipsychotics is placed on residents chart for risperidone.<BR/>No consents for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin.<BR/>Consent for Risperdal was signed by resident and not RP. Consent was not dated.<BR/>Record review of Resident #36's February 2024 MAR and March 2024 MAR revealed:<BR/>Fluvoxamine 100mg tablet was administered one time a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24.<BR/>Buspirone HCl 5mg tablet was administered twice a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24.<BR/>Clonazepam 0.5mg tablet was administered twice a day 02/01/24 - 02/16/24. Morning dose on 02/17/24 was administered. The evening dose on 02/17/24 was not checked off. Clonazepam 0.5mg tablet was administered 03/18/24 - morning dose on 03/29/24.<BR/>Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>Wellbutrin XL Extended Release 24 Hour 150mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>3.Record review of Resident #7's admission Record dated 03/26/24, revealed a [AGE] year old female, admitted to facility on 12/22/22. Her diagnosis included: Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause breathing difficulties and airflow blockage. COPD is a progressive disease that damages the lungs or airways, making it hard to breathe), respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), hypertension (high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings,, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and epilepsy (a chronic brain disease that causes recurrent seizures, which are brief episodes of involuntary movement. Seizures are caused by excessive electrical activity in the brain which can affect how it works temporarily).<BR/>Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #7's Care Plan dated 03/22/24, revealed,<BR/>FOCUS: I am receiving anti-anxiety medication (clonazepam, buspirone) r/t anxiety disorder.<BR/>INTERVENTIONS/TASKS: Black box warning for clonazepam. -Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/10/23 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/10/23 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/10/23.<BR/>FOCUS: I am receiving antidepression medication (trazadone) r/t insomnia. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning trazadone. -Administer medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Evaluate other factors potentially causing insomnia, for example, environment (excessive heat, cold or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Date initiated: 01/10/23. -Monitor/document/report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk for falls and fractures, dizziness. Date initiated: 01/10/23. -Precede or accompany hypnotic use by other interventions to try to improve sleep. Date initiated: 01/10/23. <BR/>FOCUS: I have major depression and I am receiving antidepression medication (Paxil). Date initiated: 11/29/23.<BR/>INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 11/29/23 -educate resident/family/caregivers about risks, benefits and side effects and/or toxic symptoms as needed. Date initiated: 11/29/23 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 11/29/23.<BR/>FOCUS: I am receiving antipsychotic medication (Seroquel) r/t schizophrenia. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning. -Discuss side effects of medications with resident/RP as needed. Date initiated: 01/10/23. -Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/10/23. -Monitor vital signs as ordered by MD and PRN. Date initiated: 01/10/23.<BR/>FOCUS: I am at risk for respiratory distress due to sleep apnea, COPD, history of hypoxia/SOB. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning (morphine). -Give medications as ordered by physician. Monitor/document side effects and effectiveness. Atropine sulfate (for excessive secretions), albuterol, Formoterol, Budesonide, ipratropium-albuterol, morphine (see pain care plan for black box warning) Date initiated: 09/28/23. -May suction secretions pre use of Yanker PRN Date initiated: 09/28/23. -Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of lung or section of a lung), hemoptysis (coughing up of blood or blood-tinged sputum from the lungs or tracheobronchial tree), cough, pleuritic (chest) pain, accessory muscle usage, skin color. -Oxygen/CPAP use as ordered. - Promote lung expansion and improve air exchange by positioning with proper body alignment. Date initiated: 09/28/23 <BR/>Record review of Resident #7's Order Summary dated 03/26/24 revealed, Resident #7 had the following orders:<BR/>-Start date: 03/26/23 <BR/>Buspirone HCl oral tablet 10mg (Buspirone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Buspirone is an anxiolytic for treatment of anxiety).<BR/>-Start date: 09/26/23<BR/>Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth every 8 hours related to anxiety disorder (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety).<BR/>-Start date: 10/06/23<BR/>Seroquel Oral Tablet 100mg (Quetiapine Fumarate) Give 1 tablet three times a day related to anxiety disorder (Seroquel is an antipsychotic medication)<BR/>-Start date: 11/28/23<BR/>Paxil Oral Tablet 20mg (Paroxetine HCl) Give 1 tablet by mouth one time a day related to major depressive disorder, single episode, anxiety disorder. (Paxil is used to treat depression and anxiety. It is a SSRI.)<BR/>-Start date: 12/14/23<BR/>Trazadone HCl Oral Tablet 100mg (Trazadone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Trazadone is an antidepressant and sedative)<BR/>-Start date: 03/25/24<BR/>Oxygen at 2 LPM via NC (nasal cannula) continuously while in bed r/t hypoxia.<BR/>Record review of Resident #7's February 2024 MAR and March 2024 MAR revealed:<BR/>-Buspirone HCl 10mg tablet was administered three times a day from 02/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24.<BR/>-Clonazepam 0.5mg tablet was administered every 8 hours 02/01/24 - 03/28/24 at midnight, 08:00 a.m., and 04:00 p.m. Clonazepam 0.5mg tablet was administered at midnight and 08:00 a.m. on 03/29/24.<BR/>- Seroquel 100mg tablet was administered three times a day from 02/01/24 - 02/28/24. On 03/29/24, Resident #7 received the first two administrations of Seroquel 100mg tablet. <BR/>- Paxil 20mg tablet was administered one time a day from 02/01/24 - 03/29/24. <BR/>-Trazadone HCl 100mg tablet was administered three times a day from 02/01/24 - 03/28/24. Trazadone HCl 100mg was administered at midnight and 08:00 a.m. on 03/29/24, pending the 05:00 p.m. dose. <BR/>Record review of psychotropic consent forms for Buspirone HCL 10mg tablet, Clonazepam 0.5mg tablet, Seroquel 100mg tablet, Paxil 20mg tablet, and Trazadone HCl 100mg tablet were signed by Resident #7 and not by Resident #7's RP and consents were undated. There was no consent form for clonazepam 0.5mg tablet.<BR/>In a phone interview on 03/28/24 at 02:35 PM Resident #38s RP stated she could not remember if she signed a consent form for Resident #38's antipsychotic or anti-depressant but does not believe she signed anything for medications. The RP stated she knew Resident #38 did display mood swings and figured he would be taking some kind of medication for the mood swings but could not remember if she signed anything giving consent. <BR/>In an interview on 03/29/24 at 02:14 PM the DON stated, yes there is supposed to be a consent form for appropriate usage for the medication. The DON stated the consent form could have been overlooked or misplaced for the medication Zoloft but could not confirm. The DON stated consent form audits were conducted monthly by herself and the ADON but was now going to be started weekly. The DON stated if a resident was cognitively aware, that resident was able to sign his or her consent form. The DON stated that if a resident does have a responsible party, then the responsible party should have been the one to sign the consent form. The DON stated that the RP for Resident #38 was made aware of the medications Resident #38 was taking but was only told verbally. The DON stated that possible negative outcomes could be the resident could have symptoms from the medication and the family or RP being unaware of what medications that resident was being administered. The DON stated there was no policy for consent forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #47<BR/>FTag Initiation<BR/>Based on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 3 of 4 residents (Resident #36, Resident #7, and Resident #38) reviewed for resident rights, in that:<BR/>1.Resident #36 did not have a signed (by RP), dated consent for psychotropic medications (Risperdal, clonazepam, buspirone, fluvoxamine, or Wellbutrin XL ER) he received.<BR/>2.Resident #7 did not have signed (by RP), dated consents for psychotropic medications (clonazepam, buspirone, Seroquel, Paxil, and Trazadone) she received.<BR/>3.) The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of antipsychotic and anti-depressant medication for Resident #38.<BR/>This failure could place residents who received psychoactive medications without informed consents and placed 33 additional residents who received psychoactive medications at risk of receiving treatments without informed consent. <BR/>Findings include:<BR/>1.Record review of Resident #36's admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), cerebral infarction (stroke), hypertension (high blood pressure), anxiety disorder, heart disease, and obsessive-compulsive disorder (a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others).<BR/>Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #36's Care Plan dated 01/22/24, revealed<BR/>FOCUS: I receive antidepressant medication (fluvoxamine) r/t OCD. Date initiated: 01/27/2024<BR/>INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 01/27/24 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24<BR/>FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24<BR/>INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24.<BR/>FOCUS: I receive anti-anxiety medications (clonazepam, buspirone) r/t anxiety. Date initiated: 01/27/24<BR/>INTERVENTIONS/TASKS: Black box warning for clonazepam. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24.<BR/>Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders:<BR/>-Start date: 01/16/24 Fluvoxamine Maleate Oral Tablet 100mg (Fluvoxamine Maleate) Give 1 tablet by mouth one time a day for OCD (Fluvoxamine Maleate is a Selective Serotonin Uptake Inhibitor [SSRI] antidepressant). <BR/>-Start date: 02/06/24 <BR/>Buspirone HCl oral tablet 5mg (Buspirone HCl) Give 1 tablet by mouth two times a day for anxiety obsessive compulsive disorder (Buspirone is an anxiolytic for treatment of anxiety).<BR/>Start date: 03/14/24<BR/>Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth two times a day for anxiety/restlessness (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety).<BR/>Start date: 03/14/24<BR/>Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism).<BR/>Start date: 03/14/24<BR/>Wellbutrin XL Oral Tablet Extended Release 24 Hour 150mg (Buproprion HCl) Give 1 tablet by mouth two times a day for smoking cessation aid. (Wellbutrin is an antidepressant and smoking cessation aid).<BR/>Start date: 03/14/24<BR/>Memantine HCl Oral Tablet 10mg (Memantine HCl) Give 1 tablet two times a day for dementia. (Memantine HCl is used to treat moderate to severe confusion [dementia] related to Alzheimer's Disease).<BR/>Record review of 02/01/2024 to 02/29/2024 Pharmacy Recommendations revealed, on 02/29/24 Pharmacist wrote under Resident #36, <BR/>Please ensure the state required standardized informed consent for antipsychotics is placed on residents chart for risperidone.<BR/>No consents for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin.<BR/>Consent for Risperdal was signed by resident and not RP. Consent was not dated.<BR/>Record review of Resident #36's February 2024 MAR and March 2024 MAR revealed:<BR/>Fluvoxamine 100mg tablet was administered one time a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24.<BR/>Buspirone HCl 5mg tablet was administered twice a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24.<BR/>Clonazepam 0.5mg tablet was administered twice a day 02/01/24 - 02/16/24. Morning dose on 02/17/24 was administered. The evening dose on 02/17/24 was not checked off. Clonazepam 0.5mg tablet was administered 03/18/24 - morning dose on 03/29/24.<BR/>Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>Wellbutrin XL Extended Release 24 Hour 150mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>2.Record review of Resident #7's admission Record dated 03/26/24, revealed a [AGE] year old female, admitted to facility on 12/22/22. Her diagnosis included: Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause breathing difficulties and airflow blockage. COPD is a progressive disease that damages the lungs or airways, making it hard to breathe), respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), hypertension (high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings,, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and epilepsy (a chronic brain disease that causes recurrent seizures, which are brief episodes of involuntary movement. Seizures are caused by excessive electrical activity in the brain which can affect how it works temporarily).<BR/>Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #7's Care Plan dated 03/22/24, revealed,<BR/>FOCUS: I am receiving anti-anxiety medication (clonazepam, buspirone) r/t anxiety disorder.<BR/>INTERVENTIONS/TASKS: Black box warning for clonazepam. -Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/10/23 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/10/23 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/10/23.<BR/>FOCUS: I am receiving antidepression medication (trazadone) r/t insomnia. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning trazadone. -Administer medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Evaluate other factors potentially causing insomnia, for example, environment (excessive heat, cold or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Date initiated: 01/10/23. -Monitor/document/report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk for falls and fractures, dizziness. Date initiated: 01/10/23. -Precede or accompany hypnotic use by other interventions to try to improve sleep. Date initiated: 01/10/23. <BR/>FOCUS: I have major depression and I am receiving antidepression medication (Paxil). Date initiated: 11/29/23.<BR/>INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 11/29/23 -educate resident/family/caregivers about risks, benefits and side effects and/or toxic symptoms as needed. Date initiated: 11/29/23 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 11/29/23.<BR/>FOCUS: I am receiving antipsychotic medication (Seroquel) r/t schizophrenia. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning. -Discuss side effects of medications with resident/RP as needed. Date initiated: 01/10/23. -Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/10/23. -Monitor vital signs as ordered by MD and PRN. Date initiated: 01/10/23.<BR/>FOCUS: I am at risk for respiratory distress due to sleep apnea, COPD, history of hypoxia/SOB. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning (morphine). -Give medications as ordered by physician. Monitor/document side effects and effectiveness. Atropine sulfate (for excessive secretions), albuterol, Formoterol, Budesonide, ipratropium-albuterol, morphine (see pain care plan for black box warning) Date initiated: 09/28/23. -May suction secretions pre use of Yanker PRN Date initiated: 09/28/23. -Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of lung or section of a lung), hemoptysis (coughing up of blood or blood-tinged sputum from the lungs or tracheobronchial tree), cough, pleuritic (chest) pain, accessory muscle usage, skin color. -Oxygen/CPAP use as ordered. - Promote lung expansion and improve air exchange by positioning with proper body alignment. Date initiated: 09/28/23 <BR/>Record review of Resident #7's Order Summary dated 03/26/24 revealed, Resident #7 had the following orders:<BR/>-Start date: 03/26/23 <BR/>Buspirone HCl oral tablet 10mg (Buspirone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Buspirone is an anxiolytic for treatment of anxiety).<BR/>-Start date: 09/26/23<BR/>Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth every 8 hours related to anxiety disorder (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety).<BR/>-Start date: 10/06/23<BR/>Seroquel Oral Tablet 100mg (Quetiapine Fumarate) Give 1 tablet three times a day related to anxiety disorder (Seroquel is an antipsychotic medication)<BR/>-Start date: 11/28/23<BR/>Paxil Oral Tablet 20mg (Paroxetine HCl) Give 1 tablet by mouth one time a day related to major depressive disorder, single episode, anxiety disorder. (Paxil is used to treat depression and anxiety. It is a SSRI.)<BR/>-Start date: 12/14/23<BR/>Trazadone HCl Oral Tablet 100mg (Trazadone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Trazadone is an antidepressant and sedative)<BR/>-Start date: 03/25/24<BR/>Oxygen at 2 LPM via NC (nasal cannula) continuously while in bed r/t hypoxia.<BR/>Record review of Resident #7's February 2024 MAR and March 2024 MAR revealed:<BR/>-Buspirone HCl 10mg tablet was administered three times a day from 02/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24.<BR/>-Clonazepam 0.5mg tablet was administered every 8 hours 02/01/24 - 03/28/24 at midnight, 08:00 a.m., and 04:00 p.m. Clonazepam 0.5mg tablet was administered at midnight and 08:00 a.m. on 03/29/24.<BR/>- Seroquel 100mg tablet was administered three times a day from 02/01/24 - 02/28/24. On 03/29/24, Resident #7 received the first two administrations of Seroquel 100mg tablet. <BR/>- Paxil 20mg tablet was administered one time a day from 02/01/24 - 03/29/24. <BR/>-Trazadone HCl 100mg tablet was administered three times a day from 02/01/24 - 03/28/24. Trazadone HCl 100mg was administered at midnight and 08:00 a.m. on 03/29/24, pending the 05:00 p.m. dose. <BR/>Record review of psychotropic consent forms for Buspirone HCL 10mg tablet, Clonazepam 0.5mg tablet, Seroquel 100mg tablet, Paxil 20mg tablet, and Trazadone HCl 100mg tablet were signed by Resident #7 and not by Resident #7's RP and consents were undated. There was no consent form for clonazepam 0.5mg tablet.<BR/>3.) Record review of Resident #38's face sheet dated 3/28/2024 reflected a [AGE] year-old male with an admission date of 10/16/2023. Diagnoses included bi-polar disorder (mental illness characterized by extreme mood swings), and major depressive disorder (mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest in normal enjoyable activities).<BR/>Record Review of Resident #38's physician orders indicated:<BR/>1.) Olanzapine Oral Tablet 2.5 MG <BR/>Give 1 tablet by mouth two times a day for bipolar disorder.<BR/>Dated:1/26/2024 <BR/>2.) Zoloft Oral Tablet 50 MG (Sertraline HCl) <BR/>Give 1 tablet by mouth at bedtime for depression. <BR/>Dated: 1/26/2024 21:00 <BR/>Record review of Resident #38's care plan dated 11/04/2023 reflected Resident #38 may be physically and verbally aggressive at times due to multiple problems including dementia, bipolar disorder, and major depression. Resident #38 was to be administered medications Olanzapine as ordered. Monitor/document for side effects and effectiveness. Resident #38 did receive antidepressant medication Zoloft r/t s/s of major depressive disorder anxiety.<BR/>Record review of Resident #38's MDS dated [DATE] indicated a BIM score of 00 (severe cognitive impairment) and the use of antipsychotic and antidepressant medications. No behaviors were indicated. <BR/>Record review of Resident #38's clinical record revealed there was no consent form for the medication Zoloft and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who had a responsible party and was cognitively unable to sign the consent form. <BR/>In an interview on 03/28/24 at 12:00 p.m., the DON stated there was a binder at the nurse's station with the consents. The DON stated they were not on PCC (electronic charting system) under miscellaneous. <BR/>Observation on 03/28/24 at 01:30 p.m., revealed 35 residents consents undated and some were not signed by the RP. Resident #36 and Resident #7 signed their consent even though they had an RP and were not their own RP. Resident #7 did not have a consent for Clonazepam. Resident #36 did not have a consent for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin. Resident #38 did not have a consent form for the medication Zoloft and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who had a responsible party and was cognitively unable to sign the consent form. <BR/>In a phone interview on 03/28/24 at 02:35 p.m., Resident #38's RP stated she could not remember if she signed a consent form for Resident #38's antipsychotic or anti-depressant but does not believe she signed anything for medications. The RP stated she knew Resident #38 did display mood swings and figured he would be taking some kind of medication for the mood swings but could not remember if she signed anything giving consent. <BR/>In an interview on 03/29/24 at 02:05 p.m., LVN B stated the nurse who gets the order for psychotropics or antipsychotics, was the person who would get the consent (signed and dated), notified the RP and would get their approval (consent) for the medication. LVN B stated RPs gave consent or they do not. LVN B stated the consent form was always dated. LVN B stated she made a progress note concerning getting approval for the medication and then she would put the consent in the tray at the nurse's station for MDS to scan into PCC under miscellaneous. <BR/>In an interview on 03/29/24 at 02:14 PM the DON stated, yes there is supposed to be a consent form for appropriate usage for the medication. The DON stated the consent form could have been overlooked or misplaced for the medication Zoloft for Resident #38, but could not confirm. The DON stated consent form audits were conducted monthly by herself and the ADON but was now going to be started weekly. The DON stated if a resident was cognitively aware, that resident was able to sign his or her consent form. The DON stated that if a resident does have a responsible party, then the responsible party should have been the one to sign the consent form. The DON stated that possible negative outcomes could be the resident could have symptoms from the medication and the family or RP being unaware of what medications that resident was being administered. The DON stated there was no policy for consent forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice for 1 of 3 residents (Resident #1) reviewed for oxygen in that:<BR/>Resident #7's oxygen was administered at 4.0 Lpm instead of 2 Lpm via nasal cannula as ordered by physician.<BR/>This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased qualify of care. <BR/>The findings included:<BR/>Record review of Resident #7's admission Record dated 03/26/24, revealed a [AGE] year old female, admitted to facility on 12/22/22. Her diagnosis included: Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause breathing difficulties and airflow blockage. COPD is a progressive disease that damages the lungs or airways, making it hard to breathe), and respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide).<BR/>Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. MDS Section O Special Treatments, Procedures, and Programs Respiratory Treatments was blank.<BR/>Record review of Resident #7's Care Plan dated 03/22/24, revealed,<BR/>FOCUS: I am at risk for respiratory distress due to sleep apnea, COPD, history of hypoxia/SOB. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning (morphine). -Give medications as ordered by physician. Monitor/document side effects and effectiveness. Atropine sulfate (for excessive secretions), albuterol, Formoterol, Budesonide, ipratropium-albuterol, morphine (see pain care plan for black box warning) Date initiated: 09/28/23. -May suction secretions pre use of Yanker PRN Date initiated: 09/28/23. -Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of lung or section of a lung), hemoptysis (coughing up of blood or blood-tinged sputum from the lungs or tracheobronchial tree), cough, pleuritic (chest) pain, accessory muscle usage, skin color. -Oxygen/CPAP use as ordered. -Promote lung expansion and improve air exchange by positioning with proper body alignment. Date initiated: 09/28/23 . <BR/>Record review of Resident #7's Order Summary dated 03/26/24 revealed: <BR/>-Start date: 03/25/24<BR/>Oxygen at 2 LPM via NC (nasal cannula) continuously while in bed r/t hypoxia.<BR/>Observation on 03/26/24 at 10:49 a.m., the signage on Resident #7's door read Oxygen In Use and the resident's O2 concentrator was set at 4 Lpm. <BR/>In an interview on 03/26/24 at 11:19 a.m., LVN G, the day nurse for Resident #7, went into Resident #7's room and reset Resident #7's oxygen machine to 2 Lpm. LVN G stated when she checked the O2 setting earlier that morning (03/26/24), it was set on 2 Lpm. LVN G stated Resident #7 sometimes resets the O2 so they (the nurses) were continually monitoring it. LVN G stated it was not good for Resident #7 to be on 4 Lpm when the order was for 2 Lpm. She said the resident would be receiving too much oxygen if she were getting 4 Lpm and would become more short of breath. <BR/>In an interview on 03/29/24 at 02:05 p.m., LVN B, 2-10 shift nurse for Resident #7, went into Resident #7's room and checked the O2 setting. LVN B stated she had caught Resident #7 moving the O2 level yesterday (03/28/24), setting it on 4 Lpm. LVN B stated she informed hospice and hospice stated it was ok for her to have it at 4 Lpm and they gave an order for 4 Lpm. LVN B stated the nurses check O2 setting against the doctor's order at the beginning of shift and she checks the O2 settings 2-3 times during her shift. She said yesterday (03/28/24) when she was checking O2 settings on her shift, is when she saw Resident #7 moving her O2 setting and she notified hospice. <BR/>In an interview on 03/29/24 at 02:15 p.m., the DON stated O2 settings are checked by nurses every shift at least once a shift against the physician's order. The DON stated too little oxygen could cause hypoxia or the resident could become short of breath. The DON stated too much oxygen can over inflate the lungs. <BR/>The facility did not provide a policy on Oxygen Administration.

Resident #38<BR/>FTag Initiation<BR/>03/29/24 09:42 AM <BR/>Care Plan:<BR/>&bull; I receive antidepressant medication (Zoloft) r/t s/s of major depressive disorder- anxietyH <BR/>&bull;I will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. <BR/>&bull;Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT.<BR/>&bull;Black Box Warning Zoloft<BR/>Warning:<BR/>Suicidality and antidepressant drugs<BR/>Antidepressants increased the risk of suicidal thoughts and behavior in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors.<BR/>&bull;Black Box Warning: Zoloft<BR/>Warning:<BR/>Suicidality and antidepressant drugs<BR/>Antidepressants increased the risk of suicidal thoughts and behavior in pediatric and young adult patients in short-term studies. Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors.<BR/>&bull;Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes<BR/>&bull; I receive antipsychotic medications (olanzapine) r/t<BR/>history of bipolar disorder. <BR/>&bull;I will zero to minimal side effects of medication usage <BR/>&bull;Black Box Warning: olanzapine<BR/>Warning:<BR/>Increased mortality in elderly patients with dementia-related psychosis<BR/>Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients between 1.6 and 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was approximately 4.5%, compared with 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 (eg, heart failure, sudden death) or infectious (eg, 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 patient is not clear. Olanzapine is not approved for treatment of patients with dementia-related psychosis.<BR/>&bull;Monitor behaviors. Notify MD of new or worsening behaviors<BR/>&bull;Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person.<BR/>&bull;Obtain lab work as ordered and notify MD of results<BR/>&bull;Pharmacy consultant to review medications per policy

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 Resident (Resident #36) of 6 residents reviewed for medications in that: <BR/>Resident #36 was administered Risperdal (antipsychotic medication) twice daily for vascular dementia. <BR/>This failure could place residents on psychoactive medications at risk for adverse consequences such as impairment or decline of an individual's mental or physical condition. <BR/>The findings were: <BR/>Record review of Resident #36's admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life).<BR/>Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #36's Care Plan dated 01/22/24, revealed,<BR/>FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24.<BR/>INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24.<BR/>Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders:<BR/>Start date: 03/14/24<BR/>Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism)<BR/>Record review of Resident #36's February 2024 and March 2024 MAR (Medication Administration Record) revealed, Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>In an interview on 03/29/24 at 02:05 p.m., LVN B stated there was not supposed to be an indication of Alzheimer's or Dementia for antipsychotics orders. She said there was usually a black box warning on the antipsychotic for Alzheimer's or Dementia residents receiving it. LVN B stated if she saw that (Alzheimer's or Dementia indication) on an order, she would call the physician or NP to clarify and notify of the order. <BR/>In an interview on 03/29/24 at 02:15 p.m., the DON stated antipsychotics with a diagnosis of Alzheimer's or dementia was an improper diagnosis to put on an order with an antipsychotic.<BR/>Attempted telephone interview on 03/29/24 at 04:07 p.m., with NP D, who prescribed Risperdal for Resident #36, related to dementia. Message stated office was closed for the holiday (Good Friday). No voicemail left.<BR/>Attempted telephone interview on 03/29/24 at 04:08 p.m., with MD E concerning Risperdal 0.5mg tab twice daily prescribed to Resident #36 with an indication of vascular dementia. No answer. Voicemail left. No return call received. <BR/>Record review of facility's policy Psychotropic Medication, date implemented 08/15/22, revealed,<BR/>Policy<BR/>Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for two of 10 Residents (Resident #219 and Resident #15) that were reviewed for infection control and transmission-based precautions policies and practices, in that:<BR/>1. LVN A did not change gloves after cross-contamination by touching Resident #219's remote prior to glucose check and did not change gloves and perform hand prior to insulin administration. <BR/>2. The facility did not place contact precautions signage outside Resident #15's when there was an order for Resident #15 to be in isolation due to an infection.<BR/>3. Housekeeping C failed to don PPE (Personal Protection Equipment) before he entered Resident #15's room.<BR/>4. The facility failed to have biohazard bin or soiled laundry bin in Resident #15's room to dispose of PPE and soiled linen before leaving room.<BR/>These failures could place residents at risk for infection through cross-contamination of pathogens and infectious diseases. <BR/>The findings include:<BR/>1.Record review of Resident #219's face sheet date 03/2/24 reflected a [AGE] year-old-woman with an admission date of 03/22/24. Diagnosis included type two diabetes (insufficient insulin production of the body).<BR/>Record review of Resident #219's MDS dated [DATE] reflected a BIM score of 4 (severe cognitive impairment. <BR/>Record review of Resident #219's physician orders dated 03/26/24 indicated the resident received Novolog Injection Solution per Sliding scale.<BR/>During a medication administration observation on 03/28/24 at 11:41 AM LVN A performed hand hygiene, put on gloves, grabbed Resident #219's remote with gloved hands, and proceeded to check Resident #219's blood sugar with the glucose monitor without removing contaminated gloves. LVN A then grabbed Resident #219's insulin and administered the medication with the same gloves used to touch Resident #219's remote and blood glucose check. <BR/>In an interview on 03/28/24 at 11:41 AM LVNA stated after touching Resident #219's remote, she should have removed her gloves, performed hand hygiene, and put on new gloves prior to checking Resident #219's blood glucose. LVN A stated she was nervous and should have removed gloves, preformed hand hygiene, and put on new gloves prior to giving Resident #219's insulin injection. LVN A stated in-service on infection control was about two weeks ago. LVN A stated if the object touched by a gloved hand had bodily fluids or bacteria, it could lead to an infection by cross contamination.<BR/>In an interview on 03/29/24 at 10:10 AM the DON stated changing gloves after glove contamination was done to prevent the spread of infection which could potentially cause cross harm to the resident. The DON stated LVN A should have changed gloves after touching Resident #219's remote and after checking Resident 219's blood glucose. The DON stated last in-service on infection control and hand hygiene was about two weeks ago but is ongoing as staff are reminded daily about hand hygiene. <BR/>2. Record review of Resident #15's admission Record dated 03/28/24, revealed a [AGE] year old male, admitted to facility on 07/03/23. His diagnoses included, urinary tract infection, brain cancer, dementia (general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning), hypertension (high blood pressure), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), Parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), heart failure, paraplegia (a chronic condition that causes partial or complete paralysis of the lower half of the body). <BR/>Record review of Resident #15's 02/21/24 Significant Change of status MDS revealed BIMS 09 (moderate cognitive impairment).<BR/>Record review of Resident #15's 02/27/24 Care Plan revealed:<BR/>FOCUS: Resident has infection of the (specify). Date initiated: 03/21/24.<BR/>INTERVENTIONS/TASKS: -Administer antibiotic as per MD orders. Date initiated: 03/21/24 -Administer antipyretic as per MD orders. Date initiated: 03/21/24 -Follow facility policy and procedures for line listing, summarizing, and reporting of infections. Date initiated: 03/21/24. -Maintain universal precautions when providing resident care. Date initiated: 03/21/24. -Provide independent or 1:1 activities as tolerated by the resident. Reduce exposure to other residents while infection is active. Date initiated: 03/21/24.<BR/>Record review of Resident #15's Order Summary dated 03/28/24 revealed: <BR/>Orders dated 03/21/24, <BR/>Contact isolation due to ESBL urinary tract infection.<BR/>Merrem Intravenous Solution Reconstituted 1 GM (Meropenem) Use 1 gram intravenously every 8 hours for ESBL of the urine for 14 days.<BR/>Record review of Resident #15's March 2024 MAR revealed, Resident #15 received antibiotic every 8 hours starting 03/21/24 at 04:00 p.m. through 08:00 a.m. 03/29/24.<BR/>Observation on 03/26/24 at 02:48 p.m., Housekeeping C went into Resident #15's room that had PPE hanging on the door. Housekeeping C entered room without donning PPE. There was not a Contact Precaution signage on the door. <BR/>In an interview on 03/26/24 at 02:57 p.m., LVN F stated the Resident #15 had ESBL to the urine and was on precautions. LVN F stated he was not sure whether Resident #15 was on droplet or contact precautions. LVN F stated everyone entering the room should be wearing mask, gloves, and gown. LVN F stated if someone did not wear the correct PPE, the infection could be spread to other residents. <BR/>In an interview on 03/26/24 at 03:01 p.m., Housekeeping C stated he should have worn PPE going into Resident #15's room, but he forgot. Housekeeping C stated he had been working at the facility for about a month and did not know what could happen if he did not wear PPE in a room that was on precautions. Housekeeping C stated he would ask the floor nurse, LVN F, who was the nurse for that hall and that resident. <BR/>Observation on 03/27/24 at 09:10 a.m., Resident #15 had no bins for soiled laundry or biohazards to discard used PPE in his room.<BR/>In an interview on 03/29/24 at 11:23 a.m., the Housekeeping Manager stated environmental was responsible for putting biohazard, linen, and trash cans in isolation rooms. She stated they had put one in Resident #15's room as soon as he was put on isolation. The Housekeeping Manager stated when surveyor went into room and there was no laundry bin or biohazards bin in Resident #15's room, someone must have taken it out to disinfect it.<BR/>In an interview on 03/29/24 at 02:05 p.m., LVN B stated nurses put the Transmission Based Precaution (TBP) sign on the residents' doors if they have a contact precaution infection. LVN B stated ADONs would put the signage up on weekends. LVN B stated nurses, maintenance or housekeeping put the trash bins or soiled laundry bins in the resident's room, who is on TBP, to dispose of PPE or soiled linens or clothes. LVN B stated the nurses are the ones who notify maintenance or housekeeping of the TBP.<BR/>In an interview on 03/29/24 at 02:15 p.m., the DON stated the ICP (Infection Control Preventionist) was responsible for putting TBP signage on the doors of residents with a transmission based precaution. The DON stated she is the ICP. The DON stated people entering a room on TBP without putting on PPE can become infected. The DON said housekeeping could either get or spread infection from entering the TBP room without PPE. The DON said specific bins in a TBP room for trash and linens are there to prevent cross-contamination or infection spread. The DON stated housekeeping was responsible for putting special bins in the TBP room. <BR/>Review of facility's Infection Prevention and Control Program dated 5/13/23 stated:<BR/>This facility has established and maintains an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease. <BR/>4. Standard Precautions:<BR/> c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.<BR/> d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies.<BR/>5. Isolation protocol (Transmission-Based Precautions):<BR/>a. <BR/> A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.<BR/>b. <BR/> Residents will be placed on the least restrictive transmission-based precaution for the shortest duration possible under the circumstances.<BR/>16. Staff Education<BR/> a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function.<BR/> b. All staff shall demonstrate competence in relevant infection control practices.<BR/> c. Direct care staff shall demonstrate competence in resident care procedures established by our facility.

Observation and interview revealed the facility failed to provide a safe and functional environment for residents, staff, and the public in 1 of 4 resident rooms, and in 1 of 1 patio smoking area, observed for environmental conditions. <BR/>1. Cold water in Resident #38's bathroom was not functioning. <BR/>2. The facility failed to ensure the designated smoking area was free from cigarette butt trash. <BR/>These failures could affect residents by placing them at risk for diminished quality of life due to no running cold water, the lack of a well-kept environment that could place residents at risk, resulting in an environment that is not safe, sanitary, or comfortable for residents, staff, and visitors.<BR/>Findings included: <BR/>1.During an observation on 03/26/24 at 03:25 PM Resident # 38 had no running cold water in his bathroom. <BR/>In an interview on 03/28/24 at 01:42 PM the Maintenance Director stated the water in Resident #38's bathroom was shut off for trouble shooting approximately for a few days due to the sink being clogged. The Maintenance Director stated he removed one of the hoses in Resident #38's bathroom to unclog the drain and forgot to turn the valve on when he was done with the repairs. The Maintenance Director stated every morning an Ambassador (an administrator assigned to a hall) does a hall walk through and check for functionality of water, call lights, etc. The Maintenance Director stated Resident's cold water in the bathroom was fixed on Tuesday, 3/26/24 and the ADON was the Ambassador to check for functionality of water on Resident #38's hall. <BR/>In an interview on 03/28/24 at 01:50 PM the ADON stated she was the Ambassador assigned to Resident #38's hall to make sure equipment and water were functioning. The ADON stated she informed the Maintenance Director on Tuesday 3/26/24, that the cold water in Resident #38's bathroom was not running but only told the Maintenance Director verbally and did not input the work order into the facility's work order system. The ADON stated on Wednesday 3/27/24 when she checked the water in Resident #38's bathroom, it was working but could not remember if she turned on the hot or cold water at that time. The ADON stated she did not check the water in Resident # 38's room on 3/28/24 but knows she was supposed to as part of making sure the water was functioning properly as it was part of the Ambassadors duties. <BR/>In an interview on 03/28/24 at 01:55 PM Resident # 38 stated he does not use the restroom and did not notice there was no running cold water in his bathroom. Resident #38 stated it did not affect him in any way. Resident #38 noted with a Foley catheter and above knee left leg amputation. <BR/>On 03/29/24 at 12:47 PM the Administrator stated there was no policy on environment.<BR/>2.Observation on 03/29/24 at 1:42 p.m. revealed cigarette butts were found inside a trash can designated for trash only in the patio designated for smokers. The trash can did not have a functioning lid and was rusted on the inside as well as the outside. Several cigarette butts were also found in a planter pot. <BR/>In an interview on 03/29/24 at 1:43 p.m. the Maintenance Director said the cigarette butts were not supposed to be thrown in either that trash can or the planter pot. He pointed towards the ashtray and trashcan that were designated for disposal of cigarette butts. The Maintenance Manager said that housekeeping was in charge of cleaning the patio. <BR/>In an interview on 03/29/24 at 3:08 p.m. the Housekeeping Manager said her staff was responsible for cleaning the patio designated for resident who like to smoke. She said they clean the area every other day. She does not have a tracking log documented when it was cleaned or who cleaned the area, she said she designates a person to do the task. The Housekeeping Manager said the area should have been cleaned and does not know what happened, why it was not cleaned. She also said she would have it cleaned immediately and would have staff clean the area daily. <BR/>In an interview on 03/29/24 at 4:19 p.m. the Administrator said cigarette butts should be thrown in the trashcans that are designated for cigarette butts. She said housekeeping staff is in charge of cleaning the designated smoking patio at least twice a week. She also said there is no check off list to document when it was done. The Administrator said t this issue was brought to her attention and that she is having the rusted trash can as well as the planter pot removed immediately. <BR/>On 03/29/24 at 12:47 PM the Administrator stated there was no policy policy on environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 10 residents (Resident #38, Resident #36, and Resident #7) reviewed for pharmacy services.<BR/>1.) The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of antipsychotic and anti-depressant medication. <BR/>This failure could affect all residents who require a consent form for medications at risk for lack of proper assessment when their medications are administered. <BR/>Findings included:<BR/>1.Record review of Resident #38's face sheet dated 3/28/2024 reflected a [AGE] year-old male with an admission date of 10/16/2023. Diagnoses included bi-polar disorder (mental illness characterized by extreme mood swings), ) and major depressive disorder (mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest in normal enjoyable activities), transient ischemic attack (mini stroke caused by a brief blockage of blood flow to the brain), and cerebral infarction (stroke caused by blood supply to the brain is blocked or reduced causing death to the brain tissue.). <BR/>Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). <BR/>Record Review of Resident #38's physician orders indicated:<BR/>1.) Olanzapine Oral Tablet 2.5 MG <BR/>Give 1 tablet by mouth two times a day for bipolar disorder.<BR/>Dated:1/26/2024 <BR/>2.) Zoloft Oral Tablet 50 MG (Sertraline HCl) <BR/>Give 1 tablet by mouth at bedtime for depression. <BR/>Dated: 1/26/2024 21:00 <BR/>Record review of Resident #38's care plan dated 11/04/2023 reflected Resident #38 may be physically and verbally aggressive at times due to multiple problems including dementia, bipolar disorder, and major depression. Resident #38 was to be administered medications Olanzapine as ordered. Monitor/document for side effects and effectiveness. Resident #38 did receive antidepressant medication Zoloft r/t s/s of major depressive disorder anxiety.<BR/>Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). <BR/>Record review on 3/28/24 at 1:15pmof Resident #38's clinical record revealed there was no consent form for the medication Zoloft. The and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who has had a responsible party and was cognitively unable to sign the consent form. <BR/>2.Record review of Resident #36's admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), cerebral infarction (stroke), hypertension (high blood pressure), anxiety disorder, heart disease, and obsessive-compulsive disorder (a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others).<BR/>Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #36's Care Plan dated 01/22/24, revealed<BR/>FOCUS: I receive antidepressant medication (fluvoxamine) r/t OCD. Date initiated: 01/27/2024<BR/>INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 01/27/24 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24<BR/>FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24<BR/>INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24.<BR/>FOCUS: I receive anti-anxiety medications (clonazepam, buspirone) r/t anxiety. Date initiated: 01/27/24<BR/>INTERVENTIONS/TASKS: Black box warning for clonazepam. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24.<BR/>Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders:<BR/>-Start date: 01/16/24 Fluvoxamine Maleate Oral Tablet 100mg (Fluvoxamine Maleate) Give 1 tablet by mouth one time a day for OCD (Fluvoxamine Maleate is a Selective Serotonin Uptake Inhibitor [SSRI] antidepressant). <BR/>-Start date: 02/06/24 <BR/>Buspirone HCl oral tablet 5mg (Buspirone HCl) Give 1 tablet by mouth two times a day for anxiety obsessive compulsive disorder (Buspirone is an anxiolytic for treatment of anxiety).<BR/>Start date: 03/14/24<BR/>Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth two times a day for anxiety/restlessness (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety).<BR/>Start date: 03/14/24<BR/>Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism).<BR/>Start date: 03/14/24<BR/>Wellbutrin XL Oral Tablet Extended Release 24 Hour 150mg (Buproprion HCl) Give 1 tablet by mouth two times a day for smoking cessation aid. (Wellbutrin is an antidepressant and smoking cessation aid).<BR/>Start date: 03/14/24<BR/>Memantine HCl Oral Tablet 10mg (Memantine HCl) Give 1 tablet two times a day for dementia. (Memantine HCl is used to treat moderate to severe confusion [dementia] related to Alzheimer's Disease).<BR/>Record review of 02/01/2024 to 02/29/2024 Pharmacy Recommendations revealed, on 02/29/24 Pharmacist wrote under Resident #36, <BR/>Please ensure the state required standardized informed consent for antipsychotics is placed on residents chart for risperidone.<BR/>No consents for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin.<BR/>Consent for Risperdal was signed by resident and not RP. Consent was not dated.<BR/>Record review of Resident #36's February 2024 MAR and March 2024 MAR revealed:<BR/>Fluvoxamine 100mg tablet was administered one time a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24.<BR/>Buspirone HCl 5mg tablet was administered twice a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24.<BR/>Clonazepam 0.5mg tablet was administered twice a day 02/01/24 - 02/16/24. Morning dose on 02/17/24 was administered. The evening dose on 02/17/24 was not checked off. Clonazepam 0.5mg tablet was administered 03/18/24 - morning dose on 03/29/24.<BR/>Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>Wellbutrin XL Extended Release 24 Hour 150mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>3.Record review of Resident #7's admission Record dated 03/26/24, revealed a [AGE] year old female, admitted to facility on 12/22/22. Her diagnosis included: Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause breathing difficulties and airflow blockage. COPD is a progressive disease that damages the lungs or airways, making it hard to breathe), respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), hypertension (high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings,, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and epilepsy (a chronic brain disease that causes recurrent seizures, which are brief episodes of involuntary movement. Seizures are caused by excessive electrical activity in the brain which can affect how it works temporarily).<BR/>Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #7's Care Plan dated 03/22/24, revealed,<BR/>FOCUS: I am receiving anti-anxiety medication (clonazepam, buspirone) r/t anxiety disorder.<BR/>INTERVENTIONS/TASKS: Black box warning for clonazepam. -Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/10/23 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/10/23 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/10/23.<BR/>FOCUS: I am receiving antidepression medication (trazadone) r/t insomnia. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning trazadone. -Administer medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Evaluate other factors potentially causing insomnia, for example, environment (excessive heat, cold or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Date initiated: 01/10/23. -Monitor/document/report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk for falls and fractures, dizziness. Date initiated: 01/10/23. -Precede or accompany hypnotic use by other interventions to try to improve sleep. Date initiated: 01/10/23. <BR/>FOCUS: I have major depression and I am receiving antidepression medication (Paxil). Date initiated: 11/29/23.<BR/>INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 11/29/23 -educate resident/family/caregivers about risks, benefits and side effects and/or toxic symptoms as needed. Date initiated: 11/29/23 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 11/29/23.<BR/>FOCUS: I am receiving antipsychotic medication (Seroquel) r/t schizophrenia. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning. -Discuss side effects of medications with resident/RP as needed. Date initiated: 01/10/23. -Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/10/23. -Monitor vital signs as ordered by MD and PRN. Date initiated: 01/10/23.<BR/>FOCUS: I am at risk for respiratory distress due to sleep apnea, COPD, history of hypoxia/SOB. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning (morphine). -Give medications as ordered by physician. Monitor/document side effects and effectiveness. Atropine sulfate (for excessive secretions), albuterol, Formoterol, Budesonide, ipratropium-albuterol, morphine (see pain care plan for black box warning) Date initiated: 09/28/23. -May suction secretions pre use of Yanker PRN Date initiated: 09/28/23. -Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of lung or section of a lung), hemoptysis (coughing up of blood or blood-tinged sputum from the lungs or tracheobronchial tree), cough, pleuritic (chest) pain, accessory muscle usage, skin color. -Oxygen/CPAP use as ordered. - Promote lung expansion and improve air exchange by positioning with proper body alignment. Date initiated: 09/28/23 <BR/>Record review of Resident #7's Order Summary dated 03/26/24 revealed, Resident #7 had the following orders:<BR/>-Start date: 03/26/23 <BR/>Buspirone HCl oral tablet 10mg (Buspirone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Buspirone is an anxiolytic for treatment of anxiety).<BR/>-Start date: 09/26/23<BR/>Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth every 8 hours related to anxiety disorder (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety).<BR/>-Start date: 10/06/23<BR/>Seroquel Oral Tablet 100mg (Quetiapine Fumarate) Give 1 tablet three times a day related to anxiety disorder (Seroquel is an antipsychotic medication)<BR/>-Start date: 11/28/23<BR/>Paxil Oral Tablet 20mg (Paroxetine HCl) Give 1 tablet by mouth one time a day related to major depressive disorder, single episode, anxiety disorder. (Paxil is used to treat depression and anxiety. It is a SSRI.)<BR/>-Start date: 12/14/23<BR/>Trazadone HCl Oral Tablet 100mg (Trazadone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Trazadone is an antidepressant and sedative)<BR/>-Start date: 03/25/24<BR/>Oxygen at 2 LPM via NC (nasal cannula) continuously while in bed r/t hypoxia.<BR/>Record review of Resident #7's February 2024 MAR and March 2024 MAR revealed:<BR/>-Buspirone HCl 10mg tablet was administered three times a day from 02/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24.<BR/>-Clonazepam 0.5mg tablet was administered every 8 hours 02/01/24 - 03/28/24 at midnight, 08:00 a.m., and 04:00 p.m. Clonazepam 0.5mg tablet was administered at midnight and 08:00 a.m. on 03/29/24.<BR/>- Seroquel 100mg tablet was administered three times a day from 02/01/24 - 02/28/24. On 03/29/24, Resident #7 received the first two administrations of Seroquel 100mg tablet. <BR/>- Paxil 20mg tablet was administered one time a day from 02/01/24 - 03/29/24. <BR/>-Trazadone HCl 100mg tablet was administered three times a day from 02/01/24 - 03/28/24. Trazadone HCl 100mg was administered at midnight and 08:00 a.m. on 03/29/24, pending the 05:00 p.m. dose. <BR/>Record review of psychotropic consent forms for Buspirone HCL 10mg tablet, Clonazepam 0.5mg tablet, Seroquel 100mg tablet, Paxil 20mg tablet, and Trazadone HCl 100mg tablet were signed by Resident #7 and not by Resident #7's RP and consents were undated. There was no consent form for clonazepam 0.5mg tablet.<BR/>In a phone interview on 03/28/24 at 02:35 PM Resident #38s RP stated she could not remember if she signed a consent form for Resident #38's antipsychotic or anti-depressant but does not believe she signed anything for medications. The RP stated she knew Resident #38 did display mood swings and figured he would be taking some kind of medication for the mood swings but could not remember if she signed anything giving consent. <BR/>In an interview on 03/29/24 at 02:14 PM the DON stated, yes there is supposed to be a consent form for appropriate usage for the medication. The DON stated the consent form could have been overlooked or misplaced for the medication Zoloft but could not confirm. The DON stated consent form audits were conducted monthly by herself and the ADON but was now going to be started weekly. The DON stated if a resident was cognitively aware, that resident was able to sign his or her consent form. The DON stated that if a resident does have a responsible party, then the responsible party should have been the one to sign the consent form. The DON stated that the RP for Resident #38 was made aware of the medications Resident #38 was taking but was only told verbally. The DON stated that possible negative outcomes could be the resident could have symptoms from the medication and the family or RP being unaware of what medications that resident was being administered. The DON stated there was no policy for consent forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident recieved adequate supervision for one resident (Resident#44) of 2 residents whose records were reviewed for elopements. <BR/>Resident #44 eloped from the facility undetected on 05/05/23. Resident #44 was able to remove her wanderguard bracelet and exit the facility on 06/24/23. Resident #44 eloped from the facility undetected after removing wanderguard bracelet for a second time 06/26/23. <BR/> The non-compliance was identified at PNC (Past non-compliance). The Immediate Jeopardy (IJ) situation began on 06/26/23 and ended 06/27/23 The facility had corrected the noncompliance before the survey began. <BR/>This failure could place the residents with exit seeking behaviors at risk for injury or death. <BR/>Findings included : <BR/>Record review of Resident #44's admission record dated 03/08/24 documented a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses of Primary Osteoarthritis (common form of arthritis; wear and tear arthritis), other Specified Site, Difficulty in Walking, Not elsewhere Noted, Other Abnormalities of Gait, Unspecified Dementia, unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance (group of serious illnesses that affect the mind), Mood Disturbance, and Anxiety.<BR/>Record review of Resident #44's MDS annual assessment dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. <BR/>Record review of the Provider Investigation Report revealed Resident #44 eloped on 05/05/23 at approximately 1:32 pm from the facility. Dietary Aide B witnessed Resident #44 walking on the sidewalk outside the facility and notified LVN G. LVN G redirected resident back to facility and assessed Resident #44. <BR/>Record Review of Progress Note dated 06/27/23 revealed Resident #44 was discharged home with family. <BR/>In an interview on 03/07/24 at 11:55 am LVN G said from what she could recall, on the day of[ Resident #44's] first elopement, Dietary Aide B notified her that Resident #44 was outside the facility. LVN G said she went outside and found Resident #44 walking in the parking lot. LVN G said R#44 was redirected into the facility with no incident. LVN G said that Resident #44 said that wanted to go outside and walk around. LVN G said Resident #44 was placed on 1:1 for 72 hours after this elopement. LVN G added that Resident #44 also had a wander guard placed on her wrist. LVN G said the wander guard was being checked to make sure it was in place and functioning properly every shift. She said it was documented in PCC daily. LVN G said staff was in-serviced on elopement prevention and what to do in case of an elopement. <BR/>In an interview on 03/07/24 at 2:00 pm the DON said Resident #44 did not have a history of wandering or elopement prior to the incident on 05/05/23. She said wandering evaluations were done upon admission and quarterly to find out if a resident poses an elopement risk. The DON said Resident #44 had a wandering evaluation done upon admission and was not noted to be a risk. The DON said after the incident, she was reassessed again as an elopement risk, and received doctor's orders to have a wander guard placed on Resident #44. The DON said other interventions were to engage Resident #44 in activities throughout the day as well as having her by the nurse's station for supervision. The DON said an in-service on elopement was conducted with staff after the incident. <BR/>Record Review of care plan updated on 05/05/23 revealed the following interventions were put in place:<BR/>-1:1 sitter x 72 hours<BR/>-Provide structured activities<BR/>-Offer opportunities for outside recreating in safe areas<BR/>-Complete wandering evaluation tool<BR/>-Wander guard in place. Monitoring and checking device per facility policy, staff education regarding elopement policies and interventions<BR/>Record Review of Resident #44 Skilled Administration Record dated 03/12/24 revealed; Wander guard use, check placement each shift to left wrist was checked off day, evening, and night shifts starting on 05/05/23 to 06/26/23. <BR/>Record review of the facility Provider Investigation Report revealed on 06/26/23 at approximately 5:45 pm Resident #44 eloped from the facility undetected. Resident #44 was located approximately 0.2 miles away from the facility by a busy intersection by the facility SW . SW notified LVN R who was able to redirect Resident #44 back to the facility. <BR/>Further record review of Resident #44's Progress notes revealed an entry dated 06/24/23 which indicated Resident #44 was found outside of building in front patio. As per progress note the nurse assessed the resident and noted that the resident was not wearing the wander guard bracelet. As per progress note Resident #44 stated she had removed and placed the wanderguard bracelet in a drawer. A new wander guard was placed on Resident #44's left wrist . <BR/>In an interview on 03/07/24 at 12:25 pm LVN R said he had not worked at the facility for about 5 or 6 months and did not recall the incident on 06/26/23 with Resident #44 and did not wish to speak to the state surveyor. <BR/>In an interview on 03/07/24 at 2:10 PM the ADON said Resident #44 had been found by the facility SW walking towards the local store about an 8th of a mile from the facility. She said Resident #44 was brought back by LVN R. The ADON said that the investigation found Resident #44 had removed her wander guard. The staff was unable to determine how she did it. After the incident Resident #44 was placed on 1:1 for 72 hours and staff was in-serviced on elopement and wandering . DON said the facility keeps a binder with the names of the residents that have a high risk for elopement. <BR/>In an interview on 03/07/24 at 3:31 pm the DON said she asked Resident #44 how she had removed her wander guard bracelet and she said Resident #44 did not tell her how. The DON said Resident #44 showed her where she had placed it in her dresser drawer in her room. The DON said Resident #44 was assessed after the incident and was found to have no injuries, no skin tears. The DON said a care plan was conducted with Resident #44's family and the facility was recommending placement at a facility with a locked unit. The DON said family decided to take Resident #44. Resident #44 was discharged by family on 06/27/23 the day after the incident . <BR/>In an interview on 03/12/24 at 3:00 pm LVN G said she did not recall the incident that happened on 06/24/23 with Resident #44. LVN G was able to read her progress note documented in PCC and said that the resident was outside sitting in the patio area and LVN G said Resident #44 did not have the wander guard on. She said she believed she asked her where it was or how did she remove it, but Resident #44 did not answer . DON said had in-serviced all the staff on elopement prevention. <BR/>In an interview on 03/12/24 at 3:58 pm the DON said on 6/24/23 Resident #44 was seen sitting outside the facility in the patio area. She said LVN G assessed her and noted that the wander guard was missing. The DON said she asked Resident #44 how she took it off and the resident did not respond. The DON said another wander guard was placed on Resident #44's wrist and the family was notified as well as the nurse practitioner with no new orders given. The DON said staff continued to monitor Resident #44 and continued with activities for her. <BR/>Record Review of facility in-services revealed the following In-services conducted with staff after each incident:<BR/>Topic: 05/05/23 Elopement - Supervise residents at all times, head count of all residents, initiate a code yellow<BR/>Topic: 06/27/23 Elopement - Staff be vigilant in responding to alarms, supervise residents for accidents/elopement and the use and monitor of wander guards. <BR/> There were 4 LNVs, one RN, and 5 CNAs on all three shifts interviewed on facility policy and procedure related to identifying and monitoring residents with exit seeking tendencies, redirecting, and ensuring residents at risk remained engaged . <BR/>Facility Policy titled Elopements and Wandering Residents dated 11/21/22 states; Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 4 (Residents #38, #13, #10, and #5) of 9 residents reviewed for MDS transmittal. <BR/>The facility failed to transmit quarterly MDS assessments for Residents #38, #13, and #5 as of 1/27/2023. <BR/>The facility failed to transmit annual MDS assessments for Residents #10 as of 1/27/2023.<BR/>This deficient practice could place residents at risk of not having their assessments transmitted timely.<BR/>Findings included:<BR/>1. Record review of a quarterly MDS dated [DATE] and printed 1/26/2023 revealed Resident #38 was a [AGE] year-old male with an admission date of 5/21/2022 with the primary reason for admission as stroke [occurs when the supply of blood to the brain is reduced or blocked which prevents the brain tissue from receiving oxygen or nutrients]; active diagnoses also included: hypertension [high blood pressure]; obstructive uropathy [structural or functional hinderance of normal urine flow]; diabetes mellitus [group of diseases that affect how the body uses blood sugar]; hemiplegia or hemiparesis [weakness or paralysis of one side of the body]; and seizure disorder [sudden, uncontrolled electrical disturbances in the brain which can cause changes in behavior, movements, feeling and consciousness].<BR/>Record review of Resident #38's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDS's electronic transmittal log.<BR/>2. Record review of quarterly MDS dated [DATE] and printed 1/26/2023 revealed Resident #13 was a [AGE] year-old female with an admission date of 10/20/2016 with the primary reason for admission as stroke; active diagnoses also included: hypertension; diabetes mellitus; hemiplegia or hemiparesis; and seizure disorder. <BR/>Record review of Resident #13's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDS's electronic transmittal log.<BR/>3. Record review of Resident #5's quarterly MDS dated [DATE] and printed 1/26/2023 revealed Resident #5 was a [AGE] year-old male with an admission date of 05/15/2022 with the primary reason for progressive neurological conditions [Parkinson's disease]; active diagnoses also included: hypertension; peripheral vascular disease [progressive circulation disorder of the blood vessels, usually in the arms or legs]; and psychotic disorder [mental disorders characterized by disconnection from reality which results in strange behavior, often accompanied by disturbances of thought, and perception].<BR/>Record review of Resident #5's quarterly MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDS's electronic transmittal log.<BR/>4. Record review of annual MDS dated [DATE] and printed 1/26/2023 revealed Resident #10 was a [AGE] year-old male with an admission date of 04/11/2022 with the primary reason for admission as stroke: active diagnoses also included: hypertension, peripheral vascular disease, transient ischemic attack [temporary period of symptoms similar to those of a stroke], and non-Alzheimer's dementia [group of symptoms that affects memory, thinking and interferes with daily life].<BR/>Record review of Resident #10's annual MDS dated [DATE] was listed as 'export-ready' and not 'submitted' on the MDS's electronic transmittal log.<BR/>During an interview on 1/25/2023 at 9:55 AM with LVN B, she stated that the MDSs that were due since the company buy out [12/15/2022] were completed and ready for export, but until the Change of Ownership (CHOW) was approved, none of the MDS's would be returned as accepted. <BR/>During an interview on 1/26/2023 at 2:55 PM, with the DON, he stated that as an RN he is responsible to sign the MDS assessments as verification the assessment is complete. He stated none of the assessments were late. The DON stated the assessments would not show up in the electronic health record as accepted until the CHOW was processed. <BR/>[MDS policy not received prior to exit.]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #5) reviewed for implementation of care plan.<BR/>Resident # 5's care plan did not list the physician's recommendation that the resident's feet, not be elevated and compression socks placed on the resident as a nursing response to edema.<BR/>The failure could lead to staffing receiving nursing care which are contradicted by a physician's recommendation and could lead to residents experiencing medical complications or harm. <BR/>Findings were:<BR/>Record review of Resident #5's face sheet dated 01/26/23 revealed, Resident #5 was a male age [AGE] re-admitted on [DATE] with diagnoses that included: Parkinson (neurological disease), generalized edema, and peripheral vascular disease (poor blood flow). RP (responsible party) was listed as: a family member.<BR/>Record review of Resident #5's MDS dated [DATE] , revealed: <BR/>o <BR/>BIMS was 11 (0-5=severe impairment 6-12 (moderate impairment) 13-15 (cognitively intact)<BR/>o <BR/>ADLs: B/B (bowel and bladder) frequently incontinent of both. Transfer was extensive two staff and Bed Mobility was extensive one staff.<BR/>Record review of Resident #5's Care Plan, revised 01/25/23 , revealed, the goals and interventions included:<BR/>I (Resident #5) have an abnormal heart rhythm, high blood pressure, coronary heart disease, congestive heart failure and high cholesterol that put me at risk for complications. Interventions included: medications, monitoring for edema, and taking vital signs. [The care plan did not have information about Resident #5's legs not being elevated as an intervention for edema; or not using compression socks]<BR/>Record review of Resident #5's MAR dated January 2023 revealed Lasix 20 mgs daily was given for CHF; changed to 40 mgs on 01/25/23.<BR/>Record review of Resident #5's Change of Condition dated 1/24/23 written by LVN A read: resident with edema to left lower extremity. New NP orders raised the dosage of Lasix to 40 mgs to once per day. <BR/>Record review of Resident #5's Physician' Orders, dated 01/24/23 , revealed an order for Lasix 40 mgs one tab daily.[Response to the swelling on 01/24/23] Previous dosage was 20 mgs per day. <BR/>During an observation on 01/24/23 at 02:13 PM, Resident #5 revealed: a swollen leg on his left leg; the left leg was not elevated and no compression socks were present; the resident had skid socks.<BR/>During an interview on 01/24/23 at 2:15 PM, Resident #5 stated, the left leg hurt and it was swollen. [Resident # 6 did not state how long the leg had been swollen or when the pain started.]<BR/>During an observation and interview on 01/24/23 at 2:20 PM , LVN A revealed: the resident (#5) had edema on the left leg; and it was swollen. LVN A stated , the skin on the left leg that was swollen was not hot . but was not elevated and no support socks present .and (LVNA ) will call the MD. Observation revealed that LVN A lifted Resident #5's legs and rested them on a pillow on the bed the resident was lying on. LVN A stated that she was aware that it was contraindicated that compression socks were not to be placed on Resident #5 because the resident did not want the socks; and the socks would increase the swelling. She/he added that there were no physician or NP orders not to place compression socks on the resident; and she/he was not aware of any orders not to elevate the resident's feet when edema was present; or that the care plan had been updated.<BR/>During an interview on 01/24/23 at 2:54 PM, the DON revealed: Resident #5' had co-morbidities, CHF and vascular disease which were contraindicated for compression socks and the NP did not recommend compression socks . The DON stated, the swelling could have developed acutely .resident was seen between noon and 1 PM and did not complain about swelling. The DON did not want to answer the question about elevating a resident's feet who had a history of edema; or whether the care plan had been updated. The DON stated there were no written orders contraindicating placing compression socks on Resident #5 or elevating the resident's feet as a response to edema. <BR/>During an interview on 01/26/23 at 1:56 PM, LVN B revealed: the care plan indicated the facility was monitoring for edema on Resident #5. LVN B stated that nursing practice for edema was to raise the legs and place compression socks if ordered or the resident wanted the compression socks. Per LVN B , the standard course of treatment was to raise the resident's legs to avoid swelling for a resident with a diagnosis of edema. LVN B stated that the care plan was not updated to reflect the physician's recommendation that Resident #5's legs not be elevated or compression socks placed on the resident's feet. <BR/>During an observation and interview on 01/26/23 at 2:41 PM, Resident #5 was sitting in a wheel chair in his room. LVN C removed the resident's regular sock and revealed that swelling was still present to the left leg below the knee. Resident #5 revealed he still had generalized pain.<BR/>During an interview on 01/26/23 at 2:44 PM, LVN D revealed: interventions to deal with edema included: off-loading (raising the leg to minimize swelling). LVN D stated the swelling Resident #5 was recent (1/24/23) and he had a history of swelling due to DVT (deep vein thrombosis, CHF and vascular disease. LVN D stated that anytime the resident was in bed it is recommended to off-load. LVN D was not aware of any orders dealing with the elevation of the resident's feet or the use of compression socks or any changes to the care plan. <BR/>During a telephone interview on 01/26/23 at 3:11 PM, the NP revealed: Resident #5 had co-morbidities to include edema and back pain; and swelling of the leg could develop within 3-4 hours. The NP did not recommend compression socks given the resident's CHF and vascular disease. The NP stated that the elevation of the resident's feet might not be the best cause of treatment given the resident's history of back pain and CHF. The NP stated they did not want a back flow of blood which could be created by the elevation of the resident's feet.[The NP made no comments about revising the care plan to reflect her latter recommendations]<BR/>During an interview on 01/26/23 at 6 PM, the DON revealed: putting a pillow beneath Resident #5's left leg was contraindicated because of the resident's comorbidities that included CHF and vascular disease. However, The DON stated, there was no doctor's orders for Resident #5's feet not to elevated as an intervention for edema. [The DON was made aware by the surveyor that observation revealed that a nurse had elevated the resident's legs on a pillow once the edema was discovered.] The DON added that the timeline for the edema development was between 1 PM to 2:14 PM when the edema was observed by the surveyor. The DON added that the resident had expressed no pain or showed no signs of edema while being transported from the dining hall on 01/24/23 at 1 PM and laid to rest in his bed; the resident was transported in his wheel chair. [The DON made no comments about revising the care plan to address nursing practice for edema for Resident #5].<BR/>During an interview on 01/27/23 at 8:37 AM, the DON stated, the NP did not write orders for Resident #5's feet not be elevated and not to place compression socks on the resident because it was contraindicated. The DON added he did not follow-up on the NP writing orders because it was outside his realm to question an NP. [The DON made no comments about revising the care plan to address nursing practice for edema for Resident #5].<BR/>During a telephone interview on 01/27/23 at 9:25 AM, the NP revealed that elevating Resident #5's feet was contraindicated because the resident had chronic back problems and CHF. Also, compression socks were contraindicated because the resident could not tolerate the socks. The NP stated, I did not write orders involving not to elevate Resident #5's feet and not to place compression socks. <BR/>[On 1/27/23 at 8:44 AM, the surveyor requested a policy on edema treatment and Nursing Staff following MD orders from the Administrator]<BR/>During an interview on 01/27/23 at 11:00 AM, the DON stated that the facility did not have a policy on nursing staff following MD orders. His expectation was that nursing staff follow physician orders or recommendations.<BR/>Record review of existing facility 's computerized policies dated 2015 did not reveal the existence of a policy on nursing staff following MD orders. <BR/>During an interview on 01/27/2023 at 8:45 am, LVN A stated, I elevated as a nursing intervention Resident #5's feet on 01/24/23. LVN A, added , she/he elevated Resident #5 legs with a pillow. She/he also stated, there were no orders for compression socks and no orders to not elevate the feet. LVN A revealed if nursing interventions were contraindicated then orders should have been present. LNV A called NP on 01-24-2023 and the only order given was to increase Lasix to 40 mg.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for 61 of 61 residents.<BR/>The facility did not have a qualified Activities Professional to direct their activities program.<BR/>This deficient practice could affect any resident and could result in residents not receiving activities that were individualized to match the skills, abilities, and interests/preferences of each resident. <BR/>The findings were:<BR/>Record review on 05/20/25 at 10:30 a.m. of the facility's Administrative and other licensed professional staff Licensure audit revealed the current Activity Director was not certified.<BR/>In an interview on 05/20/25 at 12:00 p.m., the HR Coordinator said the facility's Activity Director was not certified. <BR/>In An interview on 05/20/25 at 12:38 p.m., the AD, said she had been hired as the Activity Director on 01/15/25. She said when she was hired, she was advised by the facility's Administrator she needed to enroll in an AD program within 6 months of being hired. She said she had no previous experience in being an AD. She said she had recently (not sure of date) submitted the required paperwork and fee to enroll in an online AD program. She said as of 05/20/25, she had not been officially enrolled. She said the program consisted of 180 hours to be completed at her own pace.<BR/>In an interview on 05/20/25 at 1:30 a.m., the Administrator said the qualifications to be an Activity Director were to have their AD certificate or be an occupational therapist. She said the current AD started working at the facility on 01/15/25 and did not have the required qualifications. She said she, the current AD, had signed an agreement that stated she would enroll in and begin an AD program within 6 months of her hire date. She said it was her responsibility to ensure the AD had enrolled in an AD program within 6 months. The Administrator said during the morning meeting she had made it a point to ask the current AD on the status of her enrollment in an AD program. The Administrator said the facility did not have a policy on the requirements for an AD, only a job description. The Administrator said the current AD did not have any of the following state requirements:<BR/>licensed or registered,<BR/>eligible for certification as a therapeutic recreation specialist, or<BR/>an activities professional by a recognized accrediting body on or after October 1, 1990,<BR/>had 2 years of experience in a social or recreational program with the last 5 years, one of which was full-time in a therapeutic activities program; or<BR/>was a qualified occupational therapist or occupational therapy assistant; or<BR/>Had completed a training course approved by the state<BR/>Record review of the written agreement signed on 01/20/25 by the Administrator and the current AD reflected:<BR/>This agreement is made on [DATE]th, 2025, between facility and AD. AD is required to enroll in and begin an AD program within 6 months of this agreement. The deadline for enrollment is June 20th, 2025. <BR/>Record review of the facility's job description for the job title of AD reflected:<BR/>Education/Training Requirements:<BR/>Bachelor's Degree in therapeutic recreation or equivalent training experience if preferred.<BR/>Licensing Requirements:<BR/>Certified Therapeutic Recreation Specialist (CTRS).<BR/>Experience Requirements:<BR/>Two years of experience in a social or recreational program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident recieved adequate supervision for one resident (Resident#44) of 2 residents whose records were reviewed for elopements. <BR/>Resident #44 eloped from the facility undetected on 05/05/23. Resident #44 was able to remove her wanderguard bracelet and exit the facility on 06/24/23. Resident #44 eloped from the facility undetected after removing wanderguard bracelet for a second time 06/26/23. <BR/> The non-compliance was identified at PNC (Past non-compliance). The Immediate Jeopardy (IJ) situation began on 06/26/23 and ended 06/27/23 The facility had corrected the noncompliance before the survey began. <BR/>This failure could place the residents with exit seeking behaviors at risk for injury or death. <BR/>Findings included : <BR/>Record review of Resident #44's admission record dated 03/08/24 documented a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses of Primary Osteoarthritis (common form of arthritis; wear and tear arthritis), other Specified Site, Difficulty in Walking, Not elsewhere Noted, Other Abnormalities of Gait, Unspecified Dementia, unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance (group of serious illnesses that affect the mind), Mood Disturbance, and Anxiety.<BR/>Record review of Resident #44's MDS annual assessment dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. <BR/>Record review of the Provider Investigation Report revealed Resident #44 eloped on 05/05/23 at approximately 1:32 pm from the facility. Dietary Aide B witnessed Resident #44 walking on the sidewalk outside the facility and notified LVN G. LVN G redirected resident back to facility and assessed Resident #44. <BR/>Record Review of Progress Note dated 06/27/23 revealed Resident #44 was discharged home with family. <BR/>In an interview on 03/07/24 at 11:55 am LVN G said from what she could recall, on the day of[ Resident #44's] first elopement, Dietary Aide B notified her that Resident #44 was outside the facility. LVN G said she went outside and found Resident #44 walking in the parking lot. LVN G said R#44 was redirected into the facility with no incident. LVN G said that Resident #44 said that wanted to go outside and walk around. LVN G said Resident #44 was placed on 1:1 for 72 hours after this elopement. LVN G added that Resident #44 also had a wander guard placed on her wrist. LVN G said the wander guard was being checked to make sure it was in place and functioning properly every shift. She said it was documented in PCC daily. LVN G said staff was in-serviced on elopement prevention and what to do in case of an elopement. <BR/>In an interview on 03/07/24 at 2:00 pm the DON said Resident #44 did not have a history of wandering or elopement prior to the incident on 05/05/23. She said wandering evaluations were done upon admission and quarterly to find out if a resident poses an elopement risk. The DON said Resident #44 had a wandering evaluation done upon admission and was not noted to be a risk. The DON said after the incident, she was reassessed again as an elopement risk, and received doctor's orders to have a wander guard placed on Resident #44. The DON said other interventions were to engage Resident #44 in activities throughout the day as well as having her by the nurse's station for supervision. The DON said an in-service on elopement was conducted with staff after the incident. <BR/>Record Review of care plan updated on 05/05/23 revealed the following interventions were put in place:<BR/>-1:1 sitter x 72 hours<BR/>-Provide structured activities<BR/>-Offer opportunities for outside recreating in safe areas<BR/>-Complete wandering evaluation tool<BR/>-Wander guard in place. Monitoring and checking device per facility policy, staff education regarding elopement policies and interventions<BR/>Record Review of Resident #44 Skilled Administration Record dated 03/12/24 revealed; Wander guard use, check placement each shift to left wrist was checked off day, evening, and night shifts starting on 05/05/23 to 06/26/23. <BR/>Record review of the facility Provider Investigation Report revealed on 06/26/23 at approximately 5:45 pm Resident #44 eloped from the facility undetected. Resident #44 was located approximately 0.2 miles away from the facility by a busy intersection by the facility SW . SW notified LVN R who was able to redirect Resident #44 back to the facility. <BR/>Further record review of Resident #44's Progress notes revealed an entry dated 06/24/23 which indicated Resident #44 was found outside of building in front patio. As per progress note the nurse assessed the resident and noted that the resident was not wearing the wander guard bracelet. As per progress note Resident #44 stated she had removed and placed the wanderguard bracelet in a drawer. A new wander guard was placed on Resident #44's left wrist . <BR/>In an interview on 03/07/24 at 12:25 pm LVN R said he had not worked at the facility for about 5 or 6 months and did not recall the incident on 06/26/23 with Resident #44 and did not wish to speak to the state surveyor. <BR/>In an interview on 03/07/24 at 2:10 PM the ADON said Resident #44 had been found by the facility SW walking towards the local store about an 8th of a mile from the facility. She said Resident #44 was brought back by LVN R. The ADON said that the investigation found Resident #44 had removed her wander guard. The staff was unable to determine how she did it. After the incident Resident #44 was placed on 1:1 for 72 hours and staff was in-serviced on elopement and wandering . DON said the facility keeps a binder with the names of the residents that have a high risk for elopement. <BR/>In an interview on 03/07/24 at 3:31 pm the DON said she asked Resident #44 how she had removed her wander guard bracelet and she said Resident #44 did not tell her how. The DON said Resident #44 showed her where she had placed it in her dresser drawer in her room. The DON said Resident #44 was assessed after the incident and was found to have no injuries, no skin tears. The DON said a care plan was conducted with Resident #44's family and the facility was recommending placement at a facility with a locked unit. The DON said family decided to take Resident #44. Resident #44 was discharged by family on 06/27/23 the day after the incident . <BR/>In an interview on 03/12/24 at 3:00 pm LVN G said she did not recall the incident that happened on 06/24/23 with Resident #44. LVN G was able to read her progress note documented in PCC and said that the resident was outside sitting in the patio area and LVN G said Resident #44 did not have the wander guard on. She said she believed she asked her where it was or how did she remove it, but Resident #44 did not answer . DON said had in-serviced all the staff on elopement prevention. <BR/>In an interview on 03/12/24 at 3:58 pm the DON said on 6/24/23 Resident #44 was seen sitting outside the facility in the patio area. She said LVN G assessed her and noted that the wander guard was missing. The DON said she asked Resident #44 how she took it off and the resident did not respond. The DON said another wander guard was placed on Resident #44's wrist and the family was notified as well as the nurse practitioner with no new orders given. The DON said staff continued to monitor Resident #44 and continued with activities for her. <BR/>Record Review of facility in-services revealed the following In-services conducted with staff after each incident:<BR/>Topic: 05/05/23 Elopement - Supervise residents at all times, head count of all residents, initiate a code yellow<BR/>Topic: 06/27/23 Elopement - Staff be vigilant in responding to alarms, supervise residents for accidents/elopement and the use and monitor of wander guards. <BR/> There were 4 LNVs, one RN, and 5 CNAs on all three shifts interviewed on facility policy and procedure related to identifying and monitoring residents with exit seeking tendencies, redirecting, and ensuring residents at risk remained engaged . <BR/>Facility Policy titled Elopements and Wandering Residents dated 11/21/22 states; Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 10 residents (Resident #38, Resident #36, and Resident #7) reviewed for pharmacy services.<BR/>1.) The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of antipsychotic and anti-depressant medication. <BR/>This failure could affect all residents who require a consent form for medications at risk for lack of proper assessment when their medications are administered. <BR/>Findings included:<BR/>1.Record review of Resident #38's face sheet dated 3/28/2024 reflected a [AGE] year-old male with an admission date of 10/16/2023. Diagnoses included bi-polar disorder (mental illness characterized by extreme mood swings), ) and major depressive disorder (mental disorder characterized by pervasive low mood, low self-esteem, and loss of interest in normal enjoyable activities), transient ischemic attack (mini stroke caused by a brief blockage of blood flow to the brain), and cerebral infarction (stroke caused by blood supply to the brain is blocked or reduced causing death to the brain tissue.). <BR/>Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). <BR/>Record Review of Resident #38's physician orders indicated:<BR/>1.) Olanzapine Oral Tablet 2.5 MG <BR/>Give 1 tablet by mouth two times a day for bipolar disorder.<BR/>Dated:1/26/2024 <BR/>2.) Zoloft Oral Tablet 50 MG (Sertraline HCl) <BR/>Give 1 tablet by mouth at bedtime for depression. <BR/>Dated: 1/26/2024 21:00 <BR/>Record review of Resident #38's care plan dated 11/04/2023 reflected Resident #38 may be physically and verbally aggressive at times due to multiple problems including dementia, bipolar disorder, and major depression. Resident #38 was to be administered medications Olanzapine as ordered. Monitor/document for side effects and effectiveness. Resident #38 did receive antidepressant medication Zoloft r/t s/s of major depressive disorder anxiety.<BR/>Record review of Resident #38's MDS dated [DATE] reflected a BIM score of 00 (severe cognitive impairment). <BR/>Record review on 3/28/24 at 1:15pmof Resident #38's clinical record revealed there was no consent form for the medication Zoloft. The and the consent form for Olanzapine did not have the medication name on the form, was not dated, and was signed by the resident who has had a responsible party and was cognitively unable to sign the consent form. <BR/>2.Record review of Resident #36's admission Record dated 03/27/24, revealed a [AGE] year old male, admitted to facility on 01/15/24. His diagnosis included: Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), cerebral infarction (stroke), hypertension (high blood pressure), anxiety disorder, heart disease, and obsessive-compulsive disorder (a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others).<BR/>Record review of Resident #36's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #36's Care Plan dated 01/22/24, revealed<BR/>FOCUS: I receive antidepressant medication (fluvoxamine) r/t OCD. Date initiated: 01/27/2024<BR/>INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 01/27/24 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24<BR/>FOCUS: I received antipsychotic medications (Risperdal) r/t vascular dementia. Date initiated: 01/27/24<BR/>INTERVENTIONS/TASKS: - Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions of antipsychotic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24 - Pharmacy consultant to monitor medications at least monthly. Date initiated: 01/27/24.<BR/>FOCUS: I receive anti-anxiety medications (clonazepam, buspirone) r/t anxiety. Date initiated: 01/27/24<BR/>INTERVENTIONS/TASKS: Black box warning for clonazepam. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/27/24 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/27/24 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/27/24.<BR/>Record review of Resident #36's Order Summary dated 03/29/24 revealed, Resident #36 had the following orders:<BR/>-Start date: 01/16/24 Fluvoxamine Maleate Oral Tablet 100mg (Fluvoxamine Maleate) Give 1 tablet by mouth one time a day for OCD (Fluvoxamine Maleate is a Selective Serotonin Uptake Inhibitor [SSRI] antidepressant). <BR/>-Start date: 02/06/24 <BR/>Buspirone HCl oral tablet 5mg (Buspirone HCl) Give 1 tablet by mouth two times a day for anxiety obsessive compulsive disorder (Buspirone is an anxiolytic for treatment of anxiety).<BR/>Start date: 03/14/24<BR/>Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth two times a day for anxiety/restlessness (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety).<BR/>Start date: 03/14/24<BR/>Risperdal Oral Tablet 0.5mg (Risperidone) Give 1 tablet by mouth two times a day for vascular dementia. (Risperidone is an antipsychotic used to treat schizophrenia, bipolar disorder, and irritability caused by autism).<BR/>Start date: 03/14/24<BR/>Wellbutrin XL Oral Tablet Extended Release 24 Hour 150mg (Buproprion HCl) Give 1 tablet by mouth two times a day for smoking cessation aid. (Wellbutrin is an antidepressant and smoking cessation aid).<BR/>Start date: 03/14/24<BR/>Memantine HCl Oral Tablet 10mg (Memantine HCl) Give 1 tablet two times a day for dementia. (Memantine HCl is used to treat moderate to severe confusion [dementia] related to Alzheimer's Disease).<BR/>Record review of 02/01/2024 to 02/29/2024 Pharmacy Recommendations revealed, on 02/29/24 Pharmacist wrote under Resident #36, <BR/>Please ensure the state required standardized informed consent for antipsychotics is placed on residents chart for risperidone.<BR/>No consents for Fluvoxamine, Bupropion HCl, Clonazepam or Wellbutrin.<BR/>Consent for Risperdal was signed by resident and not RP. Consent was not dated.<BR/>Record review of Resident #36's February 2024 MAR and March 2024 MAR revealed:<BR/>Fluvoxamine 100mg tablet was administered one time a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24.<BR/>Buspirone HCl 5mg tablet was administered twice a day from 02/01/24 - 02/29/24, and 03/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24.<BR/>Clonazepam 0.5mg tablet was administered twice a day 02/01/24 - 02/16/24. Morning dose on 02/17/24 was administered. The evening dose on 02/17/24 was not checked off. Clonazepam 0.5mg tablet was administered 03/18/24 - morning dose on 03/29/24.<BR/>Risperdal 0.5mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>Wellbutrin XL Extended Release 24 Hour 150mg tablet was administered twice a day from 02/01/24 through the morning dose on 03/29/24.<BR/>3.Record review of Resident #7's admission Record dated 03/26/24, revealed a [AGE] year old female, admitted to facility on 12/22/22. Her diagnosis included: Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause breathing difficulties and airflow blockage. COPD is a progressive disease that damages the lungs or airways, making it hard to breathe), respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), hypertension (high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings,, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and epilepsy (a chronic brain disease that causes recurrent seizures, which are brief episodes of involuntary movement. Seizures are caused by excessive electrical activity in the brain which can affect how it works temporarily).<BR/>Record review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition.<BR/>Record review of Resident #7's Care Plan dated 03/22/24, revealed,<BR/>FOCUS: I am receiving anti-anxiety medication (clonazepam, buspirone) r/t anxiety disorder.<BR/>INTERVENTIONS/TASKS: Black box warning for clonazepam. -Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Monitor the resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance and cognitive impairment that looks like dementia and increases risk of falls, broken hips, and legs. Date initiated: 01/10/23 - Monitor/document/report PRN any adverse reactions to anti-anxiety therapy: drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Date initiated: 01/10/23 - Monitor/record occurrence of for target behavior symptoms and document per facility protocol. Date initiated: 01/10/23.<BR/>FOCUS: I am receiving antidepression medication (trazadone) r/t insomnia. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning trazadone. -Administer medications as ordered by physician. Monitor for side effects and effectiveness q shift. Date initiated: 01/10/23. -Evaluate other factors potentially causing insomnia, for example, environment (excessive heat, cold or noise), lighting, inadequate physical activity, facility routines, caffeine/medications. Attempt to modify and control these external factors before initiating hypnotic therapy. Date initiated: 01/10/23. -Monitor/document/report PRN for following adverse effects of sedative/hypnotic therapy: daytime drowsiness, confusion, loss of appetite in the morning, increased risk for falls and fractures, dizziness. Date initiated: 01/10/23. -Precede or accompany hypnotic use by other interventions to try to improve sleep. Date initiated: 01/10/23. <BR/>FOCUS: I have major depression and I am receiving antidepression medication (Paxil). Date initiated: 11/29/23.<BR/>INTERVENTIONS/TASKS: - administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness q shift. Date initiated: 11/29/23 -educate resident/family/caregivers about risks, benefits and side effects and/or toxic symptoms as needed. Date initiated: 11/29/23 - Monitor/document/report PRN adverse reactions to antidepressant therapy: change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, , withdrawal, decline in ADL ability, continence, no voiding, constipation, fecal impaction, diarrhea, gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls, dizziness/vertigo, fatigue, insomnia, appetite loss, weight loss, n/v (nausea/vomiting), dry mouth, dry eyes. Date initiated: 11/29/23.<BR/>FOCUS: I am receiving antipsychotic medication (Seroquel) r/t schizophrenia. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning. -Discuss side effects of medications with resident/RP as needed. Date initiated: 01/10/23. -Monitor behaviors. Notify MD of new or worsening behaviors. Date initiated: 01/10/23. -Monitor vital signs as ordered by MD and PRN. Date initiated: 01/10/23.<BR/>FOCUS: I am at risk for respiratory distress due to sleep apnea, COPD, history of hypoxia/SOB. Date initiated: 01/10/23.<BR/>INTERVENTIONS/TASKS: Black box warning (morphine). -Give medications as ordered by physician. Monitor/document side effects and effectiveness. Atropine sulfate (for excessive secretions), albuterol, Formoterol, Budesonide, ipratropium-albuterol, morphine (see pain care plan for black box warning) Date initiated: 09/28/23. -May suction secretions pre use of Yanker PRN Date initiated: 09/28/23. -Monitor for s/sx of respiratory distress and report to MD PRN: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of lung or section of a lung), hemoptysis (coughing up of blood or blood-tinged sputum from the lungs or tracheobronchial tree), cough, pleuritic (chest) pain, accessory muscle usage, skin color. -Oxygen/CPAP use as ordered. - Promote lung expansion and improve air exchange by positioning with proper body alignment. Date initiated: 09/28/23 <BR/>Record review of Resident #7's Order Summary dated 03/26/24 revealed, Resident #7 had the following orders:<BR/>-Start date: 03/26/23 <BR/>Buspirone HCl oral tablet 10mg (Buspirone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Buspirone is an anxiolytic for treatment of anxiety).<BR/>-Start date: 09/26/23<BR/>Clonazepam Oral tablet 0.5mg (Clonazepam) Give 1 tablet by mouth every 8 hours related to anxiety disorder (Clonazepam is a benzodiazepine - sedative - that can treat seizures, panic disorder, and anxiety).<BR/>-Start date: 10/06/23<BR/>Seroquel Oral Tablet 100mg (Quetiapine Fumarate) Give 1 tablet three times a day related to anxiety disorder (Seroquel is an antipsychotic medication)<BR/>-Start date: 11/28/23<BR/>Paxil Oral Tablet 20mg (Paroxetine HCl) Give 1 tablet by mouth one time a day related to major depressive disorder, single episode, anxiety disorder. (Paxil is used to treat depression and anxiety. It is a SSRI.)<BR/>-Start date: 12/14/23<BR/>Trazadone HCl Oral Tablet 100mg (Trazadone HCl) Give 1 tablet by mouth three times a day related to anxiety disorder (Trazadone is an antidepressant and sedative)<BR/>-Start date: 03/25/24<BR/>Oxygen at 2 LPM via NC (nasal cannula) continuously while in bed r/t hypoxia.<BR/>Record review of Resident #7's February 2024 MAR and March 2024 MAR revealed:<BR/>-Buspirone HCl 10mg tablet was administered three times a day from 02/01/24 - 03/29/24. MAR was printed the morning of 03/29/24 so only the morning dose shows as given on 03/29/24.<BR/>-Clonazepam 0.5mg tablet was administered every 8 hours 02/01/24 - 03/28/24 at midnight, 08:00 a.m., and 04:00 p.m. Clonazepam 0.5mg tablet was administered at midnight and 08:00 a.m. on 03/29/24.<BR/>- Seroquel 100mg tablet was administered three times a day from 02/01/24 - 02/28/24. On 03/29/24, Resident #7 received the first two administrations of Seroquel 100mg tablet. <BR/>- Paxil 20mg tablet was administered one time a day from 02/01/24 - 03/29/24. <BR/>-Trazadone HCl 100mg tablet was administered three times a day from 02/01/24 - 03/28/24. Trazadone HCl 100mg was administered at midnight and 08:00 a.m. on 03/29/24, pending the 05:00 p.m. dose. <BR/>Record review of psychotropic consent forms for Buspirone HCL 10mg tablet, Clonazepam 0.5mg tablet, Seroquel 100mg tablet, Paxil 20mg tablet, and Trazadone HCl 100mg tablet were signed by Resident #7 and not by Resident #7's RP and consents were undated. There was no consent form for clonazepam 0.5mg tablet.<BR/>In a phone interview on 03/28/24 at 02:35 PM Resident #38s RP stated she could not remember if she signed a consent form for Resident #38's antipsychotic or anti-depressant but does not believe she signed anything for medications. The RP stated she knew Resident #38 did display mood swings and figured he would be taking some kind of medication for the mood swings but could not remember if she signed anything giving consent. <BR/>In an interview on 03/29/24 at 02:14 PM the DON stated, yes there is supposed to be a consent form for appropriate usage for the medication. The DON stated the consent form could have been overlooked or misplaced for the medication Zoloft but could not confirm. The DON stated consent form audits were conducted monthly by herself and the ADON but was now going to be started weekly. The DON stated if a resident was cognitively aware, that resident was able to sign his or her consent form. The DON stated that if a resident does have a responsible party, then the responsible party should have been the one to sign the consent form. The DON stated that the RP for Resident #38 was made aware of the medications Resident #38 was taking but was only told verbally. The DON stated that possible negative outcomes could be the resident could have symptoms from the medication and the family or RP being unaware of what medications that resident was being administered. The DON stated there was no policy for consent forms.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service safety:<BR/>1. <BR/>There was flaking of ceiling paint in 5 locations in the kitchen<BR/>2. <BR/>A ceiling vent in the kitchen was loose and secured on one side with painter's tape <BR/>3. <BR/>There was a hole in the main dining hall measuring 1 inch by 5 inches [measured by surveyor]<BR/>This deficient practice could place residents who eat meals from the kitchen at risk for spread of infections, food contamination, and food borne illness. <BR/>Findings were:<BR/>Observation on 01/24/23 at 10:10 AM of kitchen revealed: flaking ceiling paint at 5 locations in the ceiling. Some of the flaking paint was above the washing sink and above a corner of the coffee maker. Other flaking paint was near the ceiling at the entrance to the kitchen. <BR/>During a joint interview on 01/24/23 at 11:36 AM, the Maintenance Director revealed: the flaking paint in the ceiling should not be that way because the paint could fall on items in the kitchen. The Maintenance Director added that he had no work orders for repairing the ceiling in the kitchen The Administrator revealed that the flaking paint could pose an infection control issue to the residents if the paint chips/flakes fell in the coffee or on food tray. The Administrator added that he was not aware of the flaking paint in the kitchen.<BR/>During an interview on 01/25/23 at 8:30 AM, the FSS revealed that the flaking paint on the ceiling was reported to the Maintenance Director about one week ago; and a work order might have been submitted. The FSS stated that the flaking paint could pose a hazard to residents if the paint chips or flakes fell in the food or liquids.<BR/>During an observation on 01/25/23 at 10:00 AM, one ceiling kitchen vent above the stove was not properly secured. A blue piece of tape was holding a side of the vent. Also, there was a hole on the plaster board in the main dining hall measuring 2 by 6 inches.[measured by the surveyor with a 12 inch ruler]<BR/>During an interview on 01/25/223 at 10:05 AM, the FSS revealed no work order was made for the unsecured vent above the stove and no work order existed for the hole in the wall in the main dining hall. The FSS stated the unsecured vent was a fall hazard; and the hole in the dining hall wall could create an opening for pests.<BR/>During an interview on 01//25/23 at 10:30 AM, the Dietician revealed that the unsecured vent needed to be repaired because it was a potential fall hazard. Also, the hole in the dining room wall presented an opening for pests. The Dietician was not aware of any work orders for the unsecured vent and the hole in the dining room.<BR/>During an interview on 01/25/23 at 10:35 AM, the Maintenance Director who has been managing the facility for three years was not aware of the unsecured vent and the hole in the dining room. The Maintenance Director denied any work orders had been written by kitchen staff about the unsecured vent and the hole in the wall in the dining room. He added that taping the vent with painter's tape was not the correct way to secure a vent. <BR/>Record review of facility's work order #22 dated 01/25/23 authored by the FSS revealed the work order only addressed ceiling lights and not the repair of the peeling paint in the kitchen. Work order log did not document a work order for fixing the hole in the dining room and securing the ceiling vent in the kitchen.<BR/>Record review of facility's TELS computer program dated 01/25/23 revealed: maintenance areas that need to be checked were: painting, covers/vents, and wall maintenance. The TELS program did not document that the flaking paint in the kitchen ceiling, the unsecured vent in the ceiling, and the hole in the dining room were observed or fixed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 1 ([DATE]) of 90 days reviewed for RN hours, for the months [DATE], through [DATE]<BR/>The facility failed to have RN coverage for 1 day on Saturday, [DATE]. <BR/>This failure could place residents at risk of harm by denying residents the advanced critical thinking skills a registered nurse could provide. <BR/>The findings were:<BR/>Record review of the facility's RN timesheets, no date, reflected the on Saturday [DATE]; the facility only had RN coverage for 3.91 hours. <BR/>During an interview on [DATE] at 1:39 p.m., the DON said it was her responsibility to ensure the facility had RN coverage for 8 consecutive hours every day. She said if the scheduled RN were to call in then it would be her and the ADONs responsibility to look for another RN or one of them would have to cover the shift. The DON said she could not remember what happened on [DATE] that the scheduled RN only worked 3.91 hours. The DON said either she or the ADON might have covered the remainder of the shift on [DATE] but since they were salary, they were not required to clock in to document that day. The DON said the negative outcome of not having an RN in the facility for 8 consecutive hours could be that the certain tasks only an RN could do,(i.e., signing off on baseline care plans, removing midline/picc catheters, and/or pronouncing a resident deceased ) could not be performed. <BR/>In an interview on [DATE] at 1:46 p.m., the Administrator said it was the DON's responsibility to ensure she scheduled an RN for 8 consecutive hours every day but ultimately it was her responsibility the Administrator. The Administrator said the negative outcome of not having an RN work 8 consecutive hours every day could be that the tasks that only an RN could perform like administering certain medications and treatments would not be done. The Administrator said the facility had sufficient RNs to cover their 8 consecutive hours shift every day. <BR/>Record review of the facility's Nursing Services-Registered Nurse (RN) policy dated [DATE] reflected:<BR/>Policy: <BR/>It is the intent of the facility to comply with Registered Nurse requirements as per Social Security Act 1919 and 1819.<BR/>Policy Explanation and Compliance Guidelines:<BR/>1.the facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days a week. (The requirement for 8 consecutive hours of RN services can be met by any RN or multiple RNs.) The hours worked by the DON would be considered applicable towards the requirement.<BR/>Record review of the facility's policy Nursing Services and Sufficient Staff dated [DATE] reflected:<BR/>Policy:<BR/>It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and obtain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessment. <BR/>Policy Explanation and Compliance Guidelines:<BR/>8. Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.