Based on record review and interview, the facility failed to follow physician orders for 1 (#4) of 3 sampled residents reviewed for physician orders. The administrator identified 83 residents resided in the facility. Findings:A physician order, dated 04/21/25, showed the following medications were to be held starting 04/21/25:aspirin EC 9enteric coated) delayed release 81 mg (an antiplatelet medication used to prevent blood clots) for a procedure scheduled on 04/24/25.Plavix oral tablet 75 milligrams (antiplatelet medication used to prevent blood clots). A physician order, dated 04/24/25, showed Plavix )an anti-platelet) oral tablet was to be held on 04/26/25 for pacemaker placement. A review of the discontinued medications for Resident #4 showed these medications were not discontinued or held as ordered. A quarterly clinical assessment, dated 06/25/25, showed Resident #4 had diagnoses which included metabolic encephalopathy and cerebral ischemia. The assessment showed Resident #4 had a BIMS score of 6 which indicated severe cognitive impairment for decision making. On 07/30/25 at 2:48 p.m. the DON reported Resident #4 had two scheduled procedures to place a pacemaker and because a medication, ordered to be held prior to the procedure, was not withheld for the appropriate length of time, the resident was not able to have the pacemaker placed. The procedures were scheduled for 04/24/25 and 04/25/25. Resident #4 had the pacemaker placed on 05/08/25. The DON reported they were not informed of the first missed procedure, but were notified after the second missed procedure. The DON reported education was provided to all staff who provided medications to residents, and a system was put into place to monitor for resident procedures to ensure this situation did not reoccur. The DON reported the importance of following physician orders was addressed in the quality assurance committee and also at their weekly stand-up meeting. The DON reported the monitoring had begun on 05/01/25 and would continue indefinitely. On 07/30/25 at 4:09 p.m. the administrator provided documentation of:QAPI meeting held on 6/17/25 that addressed following physician ordersEducation dated 05/12/25 for medication aides and nurses that addressed following physician orders. Monitoring documentation for scheduled surgeries that document physician orders reviewed and entered correctly. On 07/30/25, interviews were conducted with LPN #1, CMA #1 and CMA #2. All reported education had been received and demonstrated their knowledge of following physician orders and policy and procedures in place for when residents have scheduled procedures.

Based on record review and interview, the facility failed to ensure that 1 (#1) of 3 residents reviewed for elopement received adequate supervision to prevent elopement. The Administrator reported a census of 83.Findings:A facility incident report, dated 7/22/23, showed Resident #1 eloped from the locked unit and was returned to the facility by local law enforcement. A tour of the facility was conducted on 07/22/23 to observe the corrective changes made in the window mechanisms. A review of the facility's investigation did not indicate how far the resident went after leaving the facility or the exact time frame the resident had left the facility. Resident records were reviewed for updated elopement status. Maintenance logs were reviewed for daily checks on windows in the locked unit and weekly checks on the windows in the rest of the building.A quarterly assessment, dated 07/14/25, for Resident #1 showed a diagnosis of unspecified dementia and BIMS score of 3 which indicated severe cognitive impairment.On 07/23/25 at 1:53 p.m., the administrator reported they were notified around 6:00 a.m. by the DON Resident #1 could not be located. They were told the facility was being searched and the police had been notified. The administrator reported the resident was returned to the facility at 6:30. The resident reported they had left the facility through a window. The administrator stated they took immediate actions on 07/22/25 to ensure the safety of all residents, and provided documentation of the following:A census audit was conducted on all residents to ensure they were in the building. All windows in the facility were checked to ensure they were safe. All residents were reassessed for elopement.Maintenance replaced all the screws that enabled windows to be partially opened. These screws were put in place on the outside of the window to ensure they could not be tampered with from the inside of the facility.Weekly audits on windows were increased to every day for the locked unit. All staff were educated on elopement risks and how to identify elopement behavior. Resident #1 was assessed for any physical injury and checks were conducted every 15 minutes. On 07/23/25 at 2:35 p.m., Resident #1 stated they left because they wanted to go to (name-withheld city) to get to the bank. Resident #1 did not recall how they got out of the building or how far away from the facility they were when found by law enforcement.On 07/23/25 at 3:00 p.m., interviews with 5 staff from different departments were conducted regarding knowledge of elopement risks and behaviors, and to confirm re-education by the facility.

Based on observation, record review, and interview, the facility failed to ensure proper PPE was used for 1 (#24) of 3 sampled residents observed for EBP. The administrator identified 75 residents resided in the facility. Findings: On 05/29/25 at 8:39 a.m., the door frame to Resident #24's room was observed to have EBP signage and a tube feeding was observed hanging on a pole next to the resident's bed. On 05/29/25 at 8:57 a.m., LPN #1 entered Resident #24's room, closed the door, turned off the tube feeding, and checked placement with a stethoscope and syringe. LPN #1 had on gloves, but did apply a gown prior to accessing the resident's feeding tube. On 05/29/25 at 9:00 a.m., LPN #1 exited Resident #24's room to get water from a cart, returned to the resident's room, applied gloves, but still no gown was applied. PPE was observed inside the resident's room, on the back of the door, which included yellow gowns, gloves, and masks. A policy titled Enhanced Barrier Precautions, dated 05/15/24, read in part, The facility may expand the use of PPE [and] refer to the use of gown [and] gloves during high-contact resident care activities that provides the opportunities for transfer of MDROs [multidrug-resistant organism] to hands/clothing. Examples of High-Contact Resident Care Activities requiring Gown [and] Glove Use for EBP .Device Care .Enteral Tube. On 05/29/25 at 9:08 a.m., LPN #1 stated Resident #24 was on EBP for a tracheostomy and catheter. LPN #1 was asked about the feeding tube. They stated, Oh, yes. On 05/29/25 at 9:09 a.m., LPN #1 stated the policy and procedure for EBP was to wear a yellow gown and gloves. LPN #1 stated they did not apply the required PPE. On 05/29/25 at 9:10 a.m., the DON stated the requirements for EBP was to wear gloves, a gown, and a mask. The DON stated they had given all staff badges with the EBP information on it and had completed in-services with all the staff.

Based on record review and interview, the facility failed to conduct a thorough investigation after an allegation of resident to resident abuse for 1 (#2) of 3 sampled residents reviewed for abuse. The administrator identified 79 residents resided in the facility. Findings: An Abuse Prevention policy, revised 10/21/22, read in part, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents .Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident. Resident #2 had diagnoses which included cognitive communication and unspecified intellectual disabilities. Resident #2's quarterly assessment, dated 10/30/24, showed a brief score for mental illness scored of three, indicating the resident's cognition was severely impaired. An unlabeled document, dated 11/19/24, read in part, Upon thorough investigation collecting statements from staff and residents, it appears [name withheld] mumbled a statement to the effect of 'get away from me'. [Name withheld] proceeded to self-propel up to [name withheld] and grab [them] by the neck and was verbally aggressive until a staff member had to physically release [name withheld] had off of [name withheld] neck. The staff member deescalated the situation and separated the two residents immediately. A Final State Reportable Incident form, received 11/21/24, read in part, A staff member and other witnesses claim to have witnessed resident [name withheld] grab [name withheld] by the neck as [name withheld] was wheeling past [them] in the dining room. There was no documentation of staff or resident interviews. On 03/06/25 at 10:04 a.m., the administrator stated they did not have any other staff or resident statements or interviews other than the one provided with the final report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure infection control was maintained and EBP were followed during the provision of wound care for 1 (#6) of 3 sampled residents reviewed for pressure ulcers. The administrator identified 30 residents required enhanced barrier precautions. Findings: On 03/04/25 at 2:24 p.m., the wound care nurse was observed to enter Resident #6's room, wash their hands, don gloves, and provide wound care to Resident #6 who required EBP precautions. The wound care nurse did not wear a gown or mask to provide the care. An Enhanced Barrier Precautions, policy, dated 02/28/23, read in part, The Use of Gown & Gloves during High Contrast Resident Care Activities as indicated, when Contact Precautions do not otherwise apply, for Facility Residents with Wounds. Resident #6 admitted on [DATE] with diagnoses which included pressure ulcer of sacral region and resistance to multiple antimicrobial drugs. Resident #6's care plan, created on 02/10/25, showed enhanced barrier precautions approach to reduce multi-drug resistant organisms in a healthcare setting. On 03/04/25 at 2:53 p.m., the wound care nurse stated the sign outside Resident #6's room was to alert staff to take more precautions in the room. They stated like a gown and a mask. On 03/04/25 at 2:54 p.m., the wound care nurse stated they did not don a gown or put on a mask prior to entering the resident's room.

Based on record review and interview, the facility failed to ensure a resident was free from abuse for one (#1) of three sampled residents reviewed for abuse. The administrator identifed 75 residents resided in the facility. Findings: An Abuse Prevention policy, revised 10/21/22, read in part, The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: visitors, and any other individual Abuse: The willful infliction of injury, unreasonable confinement, intimidation with refusing physical harm, and pain. Abuse may be visitor-to-resident. 1. Resident #1 had diagnoses which included anxiety, repeated falls, nicotine dependence, and alcoholic polyneuropathy. A Quarterly Resident Assessment, dated 11/13/24, documented Resident #1's cognition was severly impaired. It documented the resident made themselves understood and was able to understand others. A Incident Report OSDH form, dated 11/18/24, read in part, At approximately 3:45 a.m. resident noted yelling out from room, nurse immediately went to room and noted resident being physically restrained by roommates [visitor]. Nurse immediately told [visitor] to let go of resident right now. [Visitor] let go and stated no [they] is fine, [they] fine. Staff escorted resident [Resident #1] out of room and to nurses desk, assessments for pain and skin done immediately. Staff offered resident a new room and resident declined. Staff went to room and told visitor they would have to leave facility, visitor refused to leave and local police were called. Police escorted visitor out of building. A 911 service detail report, dated 11/18/24 at 4:18 a.m., read in part, when [visitor]refused the roommate attempted to get a nurse to remove [visitor]] and the [visitor] held the roommate down and refused to let them leave the room .subject was being loud and .[Resident #1] asked [visior] to leave. An Alert Note dated 11/18/24 at 5:22 a.m., read in part, At approximately 3:45a.m. resident noted yelling out from room, nurse immediately to room and noted resident being physically restrained by roommate's [visitor]. Nurse immediately told visitor to let go of resident right now. [Visitor] let resident go and stated, No, no [they are] fine [they] fine. [They are] ok. Escorted resident to nurses desk, assessments done .Verbal altercation per resident occurred, resident attempted to eave room. That's when [visitor] physically tried to restrain resident from leaving the room per residents statement. This nurse noted that resident was standing up next to doorway when [visitor] was noted holding both arms. This nurse asked resident if [they] would like a new room to go to. Declined new room, stating that [they] wanted to stay in [their] current room. This nurse [sic] residents' room, educated [visitor] that [they] needed to leave the building .[visitor] refused to leave room. ADON and DON notified. Police were called. [Visitor] escorted by police from [facility name withheld]. Skin and Pain assessment. On 11/20/24 at 2:24 p.m., Resident #1 was interviewed and stated their roommate had a visitor come into the facility to visit around 3:45 a.m. The resident stated the visitor was being loud in their room and they asked the visitor to not be so loud. The resident stated the visitor was asked several times and would not be quite. The resident stated they got up from their bed to get staff for help and the visitor grabbed both of their wrists at the doorway and would not let go. The resident stated staff heard them yelling for help and came immediately. The resident stated the visitor was not twisting their wrists, just holding both of them. On 11/21/24 at 5:24 a.m., CNA #1 was interviewed regarding the incident that occurred on 11/18/24 between Resident #1 and their roommates visitor. CNA #1 stated they heard LPN #1 telling the visitor of the roommate they would need to leave the facility. CNA #1 stated they heard Resident #1 saying the visitor pulled them away from the door to prevent them from leaving. CNA #1 stated then the police came. On 11/21/24 at 5:33 a.m., LPN #1 was interviewed regarding the incident that occurred on 11/18/24. LPN #1 stated a visitor of Resident #1's roommate came in about 3:40 a.m. and went to their room. LPN #1 stated they kept hearing Resident #1's voice. LPN #1 stated they went to the room and the roommate's visitor had Resident #1 by their wrist at the doorway. LPN #1 stated the visitor was not letting Resident #1 leave the room. LPN #1 stated they escorted Resident #1 to the nurses desk for safety. LPN #1 stated they did offer another room to Resident #1 and the resident declined another room. LPN #1 stated they went back to the room and told the visitor they would have to leave the facility and the visitor refused. LPN #1 stated they then called the police, DON, and ADON. LPN #1 stated the police got to the facility quick and escorted the visitor out of the building. On 11/21/24 at 9:21 a.m., the DON was asked what was the facility policy for abuse. The DON stated they were to report abuse immediately, call the police, APS, and the family. The DON was asked about the incident on 11/18/24 regarding Resident #1 and roommates visitor. They stated the roommate's visitor was not allowed back in facility at this time and had not been back since incident happened. The DON also stated the facility changed all the codes to entrance and exit doors and an in person inservice was completed regarding aggressive visitors.

Based on record review and interview, the facility failed to ensure resident's rights to receive visitors of the resident's choice for one (#1) of three residents reviewed for visitation. The DON reported the census was 71. Findings: A Visitation Policy, revised 02/17, read in part, .Our facility permits residents to receive visitors subject to the resident's wishes .The facility provides 24-hour access to all individuals visiting with the consent of the resident . Resident #1 had diagnoses which included hypertension and anxiety disorder. A progress note, dated 03/25/24 at 2:19 pm, documented that a friend of Resident #1 called and wanted to visit the resident. The note further documented the facility contacted Resident #1's POA and the POA did not want the friend to visit. The note also documented that the friend was called back by the facility and informed the POA did not want him to visit. A progress note, dated 04/03/24 at 9:26 am, documented that a friend of Resident #1 called and wanted to visit the resident. The note further documented the facility contacted Resident #1's POA and the POA instructed the facility to call the police if the friend tried to visit Resident #1. The note also documented that the resident was notified that the friend would not be allowed to visit. On 07/10/24 at 1:30 pm, LPN #1 stated the facility should not restrict visitation based on the wishes of the POA. On 07/10/24 at 1:40 pm, the SSD stated that after they had the care plan meeting last week, they are no longer restricting Resident #1's visitors. On 07/10/24 at 1:50 pm, the DON stated that the ombudsman had informed them during the care plan meeting last week that the facility could not restrict visitation based on the wishes of the POA. On 07/10/24 at 2:17 pm, the Corporate Administrator stated they could not restrict visitation based on the wishes of a POA.

Based on record review and interview, the facility failed to provide a bed hold policy to a resident prior to transfer for one (#49) of one resident reviewed for hospitalization. The administrator reported the census was 71. Findings: A notification of Bed Hold policy, dated December 2018, read in part .When a resident/patient is discharged to a hospital, the facility will notify the resident/patient and responsible party of bed hold days remaining .Document communication in the medical records . Resident #49 had diagnoses which included anxiety disorder and anemia. A physician order, dated 02/07/24 at 11:45 a.m., documented the resident was to be sent to the hospital for evaluation and treatment. A review of Resident #49's health record did not document the resident, or their representative had been given notice of the bed hold policy at the time of transfer. On 02/15/24 at 11:38 a.m., the administrator stated they did not have documentation the resident or their representative had been provided with a copy of the bed hold policy at the time of transfer.

Based on record review and interview, the facility failed to ensure a level II PASRR referral was made to the Oklahoma Health Care Authority for one (#15) of four residents who were reviewed for PASARR. The administrator reported the census was 71. Findings: A Policy titled PASRR Determination, dated November 2023, read in part .Level 2 screens are conducted when necessary to insure that a beneficiary requires nursing facility level of care and/or specialized services within the nursing facility .It is the responsibility of the NF to ensure a Level II is completed on a beneficiary that meets previous criteria .A yes answer to any of the six questions in Section E of the LTC-300R form .Requires a Screening for Level II PASRR . Resident #15 had diagnoses which included unspecified intellectual disabilities and anemia. A PASRR level 1 form, dated 12/08/23, documented the social worker from the hospital Resident #15 was admitted from contacted the OHCA regarding a 30-day PASRR exemption letter as the resident was being admitted for skilled care. The level I PASRR also documented in section E that Resident #15 had a diagnosis of mental retardation or a related condition. On 2/15/24 at 11:35 a.m., the administrator stated a Level II PASRR was not completed because of the 30-day exemption. A review of the resident's record documented the resident had been in the facility 46 days.

Based on observation and interview, the facility failed to ensure that expired medications were removed from the medication room. The administrator reported the census was 71. Findings: A Medication Storage in the facility policy, dated April 2018, read in part, .Outdated, contaminated, or deteriorated medications .are immediately removed from inventory . On 02/15/24 at 9:23 a.m., a tour of the medication storage room for halls A and B was conducted with RN #1. A medication card containing ondansetron 4 mg for Resident #8 was observed to have an expiration date of 01/17/24. On 02/15/24 at 9:25 a.m., RN #1 stated the expired medication should have been removed from the medication room. On 2/15/24 at 9:30 a.m., the DON stated expired medications should be disposed of.

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed for the need and an informed consent was obtained prior to the use of shepherds hook bed rails for two (#14 and #38) of two residents reviewed for bed rails. The administrator identified six residents whose beds were equipped with a bed rail of any type. Findings: A Bed Mobility Assistive Devices/Bed Rails policy, dated July 2018, read in parts, .If a bed rail is determined to be the most effective intervention for resident positioning/safety, the following requirements must be met: Bed/Bedrail assessment .Review of risks and benefits of bed rails with the resident or resident representative .Obtain informed consent prior to installation . 1. Res #14 had diagnoses which included heart failure, anxiety, and repeated falls. A physician order, dated 01/17/23, documented the resident may have a shepherd hook on bed for turning and repositioning. A quarterly assessment, dated 11/17/23, documented Res #14 was severely impaired in cognition, required supervision or touch assistance with bed mobility, and had not fallen. On 02/12/24 at 12:28 p.m., Res #14 was observed sitting on the side of the bed. A shepherd hook bed rail was observed on the upper left side of the bed closest to the wall. Res #14 stated they did not use the bed rail for transfers or positioning and did not know why it was there. 2. Res #38 had diagnoses which included heart failure, muscle wasting, and depression. A physician order, dated 01/17/23, documented the resident may have a shepard hook on bed for turning and repositioning. An annual assessment, dated 11/03/23, documented Res #38 was intact in cognition, required substantial to maximum assistance with bed mobility, and did not ambulate. On 02/12/24 at 1:08 p.m., Res #38 was observed lying in bed. [NAME] hook bed rails were observed on both sides of the upper bed. Res #38 stated they had the bed rails for a while now to assist with turning left and right in the bed. On 02/15/24 at 11:24 a.m., the DON stated there was no documentation of an assessment of the appropriateness of the shepherds hook bed rails and no documentation of informed consent prior to installation for Res #14 and Res #38. On 02/15/24 at 11:33 a.m., the administrator stated an assessment for appropriateness and informed consent should have been obtained prior to installation of the shepherds hook bed rails for Res #14 and Res #38.

Based on record review and interview, the facility failed to ensure an abuse allegation was thoroughly investigated for one (#24) of one resident reviewed for allegations of abuse. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: The facility's abuse policy read in parts, .Investigation .d. Conduct interviews of alleged victim/resident representative .f. Conduct interviews of all actual/potential witnesses .h. Conduct record review to include .4. Complete Documentation of the investigation . An incident report form 283, dated 07/19/22, documented a resident reported to the administrator she had witnessed a CNA being rough with her roommate Res #24 while providing personal care. Res #24 had diagnoses which included psychosis, diabetes mellitus, Dementia, and Parkinson's disease. A quarterly assessment, dated 12/08/22, documented the resident was severely impaired in cognition and required total assistance with most activities of daily living. The documentation regarding the incident did not contain documented interviews from staff other than the accused. The investigation did not document other resident interviews. The 283 form documented there were interviews but they were not provided. On 01/17/23 at 2:12 p.m., the administrator stated she thought she had interviews attached with the investigation. She stated she would look for the interviews. On 01/17/23 at 2:22 p.m., the administrator stated she did not have any statements or interviews from residents or staff members.

Based on record review, observation, and interview, the facility failed to accurately capture the mental health diagnoses on a resident PASRR I assessment for one (#48) of one residents reviewed for PASRR. The Resident Census and Conditions of Residents form documented 36 residents had mental health diagnoses excluding dementia and depression. Findings: Res #48 was admitted with diagnoses which included unspecified mood disorder, agoraphobia with panic disorder, social phobia, post traumatic stress disorder, depression, and anxiety disorder. A PASRR level I assessment, dated 01/10/23, documented Res #48 did not have mental health diagnoses such as evidence of serious mental illness including possible disturbances in orientation or mood, a serious mental illness such as a schizophrenic, paranoid, panic, mood or other severe anxiety or depressive disorder, somatoform disorder, personality disorder, or other psychotic disorder, or another mental disorder that may lead to a chronic disability. On 01/18/23 at 9:06 a.m., the DON stated he did not think the resident had a pertinent mental health diagnosis when he was admitted . When asked if the diagnoses on the resident's list was diagnoses which could have caused chronic disability, he stated he would call OHCA and see if the resident required a PASRR II evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to conduct routine pressure ulcer assessments and follow physician orders for pressure ulcer treatment for one (#34) of three residents sampled for pressure ulcers. The Resident Census and Conditions of Residents form documented five residents with pressure ulcers resided in the facility. Findings: Res #34 had diagnoses which included cellulitis of right lower limb and pressure ulcer of the sacral region. A physician order, dated 07/21/22, documented to cleanse sacral wounds with NS and pat dry; fill deficits with saline moistened gauze; apply calmaseptine cream to peri wound area; and cover daily related to pressure ulcer of sacral region, stage IV. A wound note, dated 10/14/2022 at 2:49 p.m., documented the resident had two sacral wounds which measured 0.4 x 0.3 x 0.3 cm and 4.0 x 0.8 x 0.3 cm. The EHR documented on 10/15/22 the resident went to the hospital. A care plan, last reviewed 10/18/22, documented the resident had damage to the skin and subcutaneous tissue associated with friction and shearing secondary to immobility. A hospital wound assessment, dated 11/21/22, with a fax date of 11/25/22, documented the current wound treatment to apply alginate an cover with foam dressing. An admission note, dated 11/25/22, documented Res #34 arrived back to the facility. The note documented the residents skin was warm and dry, skin color WNL, and turgor was normal. The assessment did not document the resident had a pressure ulcer or wound treatment. The November 2022 TAR, documented the resident did not have a wound treatment on November 26th and 27th. The TAR documented a treatment was done on the 28th from the 07/21/22 wound order. A physician order, dated 11/29/22, documented to apply alginate and cover wounds daily. An admission MDS assessment, dated 12/07/22, documented the resident was intact with cognition and had one stage four pressure ulcer. From the resident's admission date, 11/25/22 until 12/15/22, there was no wound assessments documented in the resident's record. A wound note, dated 12/15/22, documented the resident had two sacral wounds measuring 0.5 x 1.0 x 0.3 cm and 1.5 x 0.5 cm. The note documented the wound peri area had redness and excoriation and the current treatment in place was to cover wounds with alginate and cover daily. A physician order, dated 01/08/23, documented to cleanse sacral wounds with NS, pat dry, apply collagen to wound beds, then cover with calcium alginate, and secure with dressing daily related to pressure ulcer of sacral region stage IV. A physician order, dated 01/10/23, documented the wound physician may consult related to sacral wound. On 01/11/23 at 11:56 a.m., Res #34 stated she came into the facility with pressure ulcers. She stated the wounds were healing. Res #34 stated she had been to the hospital for wound treatment. She stated the wound doctor was coming today to see her. She stated she was glad to be off the air bed because she did not like it. A physician order, dated 01/12/23, documented to cleanse sacral wounds with NS, pat dry, apply collagen to wound beds, then cover with calcium alginate and secure with dressing every shift for pressure ulcer of sacral region stage IV. On 01/13/23 at 10:24 a.m., corporate nurse stated there was not a skin assessment completed when the resident was readmitted from the hospital on [DATE]. On 01/13/23 at 10:45 a.m., LPN #1 stated when the resident returned from the hospital she did not take a photo or measure the wound until 12/15/22. She stated they continued the orders from the hospital which was wet to dry with alginate and that order was discontinued on 11/28/22. On 01/13/23 at 12:58 p.m., LPN #1 stated the wound care orders should have been changed on the day the resident returned to the facility from the hospital. She stated she did not change the order until 11/28/22 after she did the resident wound care. She stated on the 26th and 27th of November, if the wound care was not documented it was not done. On 01/13/23 at 2:07 p.m., LPN #1 was observed performing wound care. The pressure ulcers were treated with collagen powder and alginate dressing. On 01/13/23 at 2:43 p.m., LPN #1 stated the resident had a new small open area on Monday and but had no measurements. She stated the facility was supposed to notify the physician of new areas. She stated the wound doctor was going to start seeing the resident again.

Based on record review, observation, and interview, the facility failed to ensure respiratory orders were followed for one (#8) of one resident sampled for respiratory care. The Resident Census and Conditions of Residents form documented 23 residents with respiratory treatments resided in the facility. Findings: Res #8's physician order, dated 12/20/22, documented oxygen at two to three liters continuously every shift to maintain oxygen saturation greater than 90% for shortness of breath. An admission assessment, dated 12/13/22, documented the resident was severely impaired with cognition and required extensive assistance with ADLs. The assessment documented the resident required oxygen and was on hospice care. A care plan could not be located in the resident record. The December 2022 TAR, did not document the resident's oxygen saturation for nine of 31 shifts as ordered by the physician. The January 2023 TAR, did not document the resident's oxygen saturation for 22 of 33 shifts as ordered by the physician. On 01/11/23 at 3:25 p.m., Res #8 was observed on a low bed with oxygen at 2L per nasal cannula tubing, which was not dated. On 01/18/23 at 11:04 a.m., the DON stated the O2 sat should have been performed as ordered three times a day.

Based on record review, observation, and interview, the facility failed to ensure a resident was assessed for the need, an order was obtained, an informed consent was obtained, and a care plan was completed, prior to the use of a shepherds hook bed rail, for one (#27) of one resident reviewed for bed rails. The administrator identified eight residents whose beds were equipped with a bed rail of any type. Findings: Res #27 had diagnoses which included dementia, retention of urine, muscle wasting and atrophy, and abnormalities of gait and mobility. A post fall progress note, dated 11/16/22, documented the resident had experienced an unwitnessed fall in her room. The resident slid from her bed and her head was stuck on the shepherds hook causing a skin tear. The post fall note documented the resident did not have to go to the hospital from the injury. A quarterly assessment, dated 12/08/22, documented Res #27 was severely impaired in cognition, required extensive assistance with ADLs, was always incontinent of urine, and had not fallen. On 01/11/23 at 12:22 p.m., the resident was observed in her room laying on a mattress with bolsters. A fall mat was observed at the side of the bed and a geri chair was present in the room. On 01/17/23 at 3:43 p.m., corporate nurse #1 stated there was no documentation of an assessment of the appropriateness of the shepherd's hook for the resident, no order, no documentation of an informed consent, and no care plan for the use of the shepherd's hook. She confirmed the facility should have obtained the above prior to installation of the shepherd's hook bed rail. The corporate nurse stated there was no documentation on when the resident's bed was equipped with the bed rail.

Based on record review, observation, and interview, the facility failed to designate a facility staff member as an interdisciplinary team member to work with the hospice representatives and failed to ensure the hospice agreement documented the required components for one (#27) of one resident reviewed for hospice services. The Resident Census and Conditions of Residents form documented 12 residents who resided in the facility received hospice services. Findings: A physician order for Res #27 documented to admit the resident to hospice services for a diagnosis of Lewy Body Dementia. The hospice agreement between the hospice and the facility was reviewed and did not document a provision stating the facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the facility became aware of the alleged violation. The agreement did not document a provision for the hospice to provide bereavement services to the facility staff. On 01/17/23 at 1:29 p.m., the administrator and corporate nurse confirmed the facility did not have a interdisciplinary team member designated to coordinate care with the hospice representatives. The administrator and the corporate nurse confirmed the hospice agreement did not document all the required components.

Based on record review, observation, and interview, the facility failed to ensure conduct regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment and failed to ensure when rails and mattresses are purchased separately from the bed frame the bed rails, mattress, and bed frame are compatible. The administrator identified eight residents whose beds were equipped with a bed rail of any type. Findings: Res #27 had diagnoses which included dementia, retention of urine, muscle wasting and atrophy, and abnormalities of gait and mobility. A post fall progress note, dated 11/16/22, documented the resident had experienced an unwitnessed fall in her room. The resident slid from her bed and her head was stuck on the shepherds hook causing a skin tear. The post fall note documented the resident did not have to go to the hospital from the injury. On 01/11/23 at 12:22 p.m., the resident was observed in her room laying on a mattress with bolsters. A fall mat was observed at the side of the bed and a geri chair was present in the room. On 01/17/23 at 3:43 p.m., corporate nurse #1 stated the facility had not conducted regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment.

Based on record review and interview, the facility failed to ensure an Oklahoma DNR consent form was: a. followed-up on when residents were admitted to the facility for #48. b. was signed by an eligible person to make decisions for Res #24. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #24 had diagnoses which included psychosis, dementia, and Parkinson's disease. A DNR form, dated 08/09/21, was in the resident's medical record. The DNR was not signed. The form documented a consent was obtained from a resident representative over the telephone. The DNR was completed while the resident was in the hospital. A physician order, dated 08/31/21, documented the resident's status was DNR. A quarterly assessment, dated 12/08/22, documented the resident was severely impaired in cognition and required total assistance with most activities of daily living. On 01/17/23 at 10:27 a.m., corporate nurse #1 stated there was no POA documentation for the resident in the record. She stated the staff should always follow-up when a DNR was received from the hospital for a resident without a signature. 2. Res #48 had diagnoses which included acute pancreatitis with uninfected necrosis, chronic kidney disease, and heart failure. A physician signed DNR form, dated 12/19/22, documented the resident was not to be resuscitated in the event on cardio pulmonary arrest. Physician orders, dated 12/21/22, documented the resident was to be admitted to hospice services and a signed DNR was on the resident's chart. An admission assessment, dated 01/02/23, documented Res #48 had intact cognition and required supervision and set up for most ADLs. On 01/11/23 at 12:07 p.m., the resident was observed sitting in a chair in his room. He stated he had little memory of being in the hospital and just came back to himself after he was admitted to the facility. On 01/18/23 at 9:05 a.m., the DON and administrator were interviewed. They stated they had not checked with the resident after his admission to assess if being a DNR was his wishes. On 01/18/23 at 9:20 a.m., the administrator stated she had spoke with the resident and he told her he did not know if he wanted to be a DNR or not. She stated he would speak with his family and get back to her.

Based on record review, observation, and interview the facility failed to ensure assessments accurately reflected the resident's status for four (#24, 27, 34, and #55) of 22 residents who were reviewed for resident assessments. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #24 had diagnoses which included psychosis, diabetes mellitus, dementia, and Parkinson's disease. A physician order, dated 10/21/22, documented to administer quetapine an (antipsychotic medication) 25mg at bedtime. A quarterly assessment, dated 12/08/22, documented the resident was severely impaired in cognition and required total assistance with most activities of daily living. The assessment documented the resident received an antipsychotic medication 7 days during the 7 day look back period. The assessment also documented the resident had not received antipsychotics on a regular basis. A care plan, last reviewed 12/07/22, did not document the resident was receiving an antipsychotic medication. On 01/17/23 at 4:39 p.m., the MDS coordinator stated the assessment should have been coded as the resident received antipsychotics. She stated she would do a correction. 2. Res #34 had diagnoses which included cellulitis of right lower limb and pressure ulcer of the sacral region. A wound note, dated 10/14/22 at 2:49 p.m., documented the resident had two sacral wounds which measured 0.4 x 0.3 x 0.3 cm. and 4.0 x 0.8 x 0.3 cm. An admission assessment, dated 12/07/22, documented the resident had one stage IV pressure ulcer. A wound note, dated 12/15/22 at 2:47 p.m., documented the resident had two sacral wounds which measured 0.5 x 1.0 x 0.3 cm and 1.5 x 0.5 cm. On 01/13/23 at 4:40 p.m., the MDS coordinator stated the wound section of the MDS was incorrect. 3. Res #55 had diagnoses which included aphasia following cerebral infarction and gastrostomy status. On 12/16/22 at 9:01 a.m., the resident weight was documented in the EHR as 133.4 pounds. A dietary note, dated 12/19/22 at 1:38 p.m., documented the resident's weight was 133 pounds and had a weight gain of 13 pounds since last months weight report. A quarterly assessment, dated 12/23/22, documented the resident's cognition was intact and the resident's weight was 112 pounds. On 01/11/23 at 2:40 p.m., Res #55 stated she had started gaining weight. She stated she has been on a feeding tube about a year. She said she could eat food also and have thickened liquids. On 01/13/23 at 4:39 p.m., the MDS coordinator stated she did not fill out the weight section on the MDS. She stated the dietitian did that section. The MDS coordinator stated the weight in the computer for the look back period was 133.4 pounds. 4. Res #27 had diagnoses which included dementia, retention of urine, muscle wasting and atrophy, and abnormalities of gait and mobility. A post fall progress note, dated 11/16/22, documented the resident had experienced an unwitnessed fall in her room. A quarterly assessment, dated 12/08/22, documented Res #27 was was always incontinent of urine and had not fallen. On 01/11/23 at 12:22 p.m., the resident was observed in her room laying on a mattress with bolsters. A fall mat was observed at the side of the bed. The resident was observed to have an indwelling catheter. On 01/17/23 at 2:32 p.m., the MDS coordinator reviewed the quarterly MDS and stated she had incorrectly coded the resident as incontinent of urine when she had a catheter. She stated she also should have captured the resident had a fall with minor injury.

2. Res #55 had diagnoses which included aphasia following cerebral infarction and gastrostomy status. A physician order, dated 06/28/22, documented a regular diet, pureed texture, nectar thick consistency and a dietary waiver was signed. A care plan, last reviewed 12/20/22, documented the resident had a gastrostomy tube secondary to swallowing disorder (dysphagia) associated with cerebral infarction. The care plan documented the resident was NPO. A physician order, dated 12/21/22, documented Nutren 2.0 at 50 ml/hr. On 01/11/23 at 11:28 a.m., a CNA asked Res #55 if she wanted her noon meal. Res #55 stated she did. The tube feeding was observed running at 50ml/hr. On 01/11/23 at 2:40 p.m., Res #55 stated she had started gaining weight. She stated she has been on a feeding tube about a year. She said she could eat food also and have thickened liquids. On 01/13/23 at 4:52 p.m., the care plan coordinator stated the care plan should be updated when an order changes. She stated under the anemia care plan she talked about po foods. She stated its in care plan all over the place where she is getting po intake just not in gastroscopy care plan it still had NPO. The LPN stated the resident refused po intake for a long time. 3. Res #34 had diagnoses which included cellulitis of right lower limb and pressure ulcer of the sacral region. A wound note, dated 10/14/2022, documented the resident had two sacral wounds. A care plan, last reviewed on 10/18/22, documented the resident had damage to the skin and subcutaneous tissue associated with friction and shearing secondary to immobility. An admission assessment, dated 12/07/22, documented the resident was intact with cognition and had one stage four pressure ulcer. A wound note, dated 12/15/2022 at 2:47 p.m., documented the resident had two sacral wounds. On 01/13/23 at 5:00 p.m., the care plan coordinator stated the resident should have had a care plan which included pressure ulcers. She stated she had been out of the facility for 10 days and had missed updating the doing the care plan. Based on record review, observation, and interview, the facility failed to update resident care plans to reflect the residents' current needs for three (#34, 55, and #62) of 18 residents whose care plans were reviewed. The facility failed to update the care plans to reflect: a. pressure ulcers for Res #34. b. the diet status of Res #55. c. behaviors including pilfering in other resident rooms for Res #62. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #62 had diagnoses which included myocardial infarction, anemia, and chronic lymphocytic leukemia of B-cell type. A nurse note, dated 08/05/22, documented the resident had been taking food off the other residents' plates. The note documented the resident had walked into another resident room and ate her dinner. A nurse note, dated 08/8/22, documented the resident was frequently found removing items from other resident rooms. A nurse note, dated 08/10/22, documented the resident wandered around the facility and into other resident rooms removing other resident belongings without permission particularly television remotes. A nurse note, dated 08/20/22, documented the resident frequently roamed into other resident rooms and was confused. A nurse note, dated 08/27/22, documented the resident was easily confused and had a pleasant disposition. The note documented the resident was frequently confused of taking things from other resident rooms. A nurse note, dated 08/28/22, documented the resident was frequently noted to take items from the rooms of other residents. The note documented the resident was easily confused and did not remember taking the items. A nurse note, dated 09/3/22, documented the resident could be found frequently wandering the halls, going from room to room, and had been accused of taking items from other resident rooms. A significant change assessment, dated 10/20/22, documented Res #62 was severely impaired in cognition and required set up and supervision with ADLs. The assessment documented the resident did not have any behaviors during the seven day assessment period. On 01/12/23 at 9:17 a.m., Res #62 was observed lying in her bed watching television. The resident stated she did not like it when the facility chopped her food up. She stated sometimes if another resident did not want their food, such as a piece of chicken, they would give it to her to eat. She stated the facility gave out candy once a month too and she would get the candy and keep it in her room. She stated she thought she had gained weight at the facility. On 01/13/23 at 4:10 p.m., the DON stated he had no knowledge of the resident taking things from resident rooms. He stated if he had known he would have done a behavior care plan. On 01/13/23 at 4:19 p.m., CNA #1 reported the resident used to go in other resident rooms but they had not seen her do that recently. On 01/13/23 at 4:20 p.m., the care plan coordinator stated she had no knowledge of the resident entering other resident rooms and taking things. She stated had she been notified she would have initiated a behavior care plan.

Based on record review, observation, and interview, the facility failed to provide medications to residents per physician order and facility policy for two (#20 and #40) of seven residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #20 had diagnoses which included diabetes mellitus. A physician order, dated 07/29/22, documented the facility was to administer Aspart Insulin by sliding scale with a FSBS of 0-150 = 0u; 151-200 = 2u; 201-250 = 4u; 251-300 = 6u, subcutaneously as needed for elevated blood sugar. A review of the resident's insulin administration records documented the resident had a FSBS of 279 on 10/21/22 and should have received 6 units of Aspart insulin. The records indicated the resident did not receive insulin at that time. A quarterly assessment, dated 12/16/22, documented the resident was severely impaired in cognition and received insulin seven days of the seven day assessment period. A care plan, last reviewed on 12/16/22, documented the resident had diabetes and to administer medications as prescribed. A review of the resident's insulin administration records documented the resident had a FSBS of 175 on 12/14/22 and should have received 2 units of Aspart insulin. The records indicated the resident did not receive insulin at that time. On 01/12/23 at 5:00 p.m., LPN #2 reviewed Res #20's insulin records and confirmed the resident should have received Aspart insulin on the above dates but did not. On 01/12/23 at 5:14 p.m., the DON stated Res #20's insulin orders had not been put in the computer correctly and the FSBS was not populating the order for Aspart insulin. He stated it did not instruct the staff to administer Aspart based on the FSBS reading and the staff did not administer the insulin as ordered. 2. A facility policy, titled Specific Medication Administration Procedures, dated April 2018, read in part: .F. Administer medication and remain with resident while medication is swallowed . Res #41 had diagnoses which included insomnia. A physician order, dated 11/15/22, documented to administer Melatonin 10 mg by mouth at bedtime. An admission assessment, dated 11/22/22, documented Res #41 was intact in cognition and required supervision to limited assistance with ADLs. On 01/13/23 at 7:57 a.m., during observation of a medication pass, Res #41 was observed to grab a medication cup sitting on his window sill, which contained two small white tablets, and stated he forgot to take his medication the previous night. On 01/13/23 at 8:08 a.m., LPN #3 stated she would have to look up the tablets to see what they were. On 01/13/23 at 8:15 a.m., LPN #3 reported the tablets were melatonin tablets. On 01/13/23 at 4:06 p.m., the DON stated he had heard about the melatonin tablets which the resident had not taken and were found in a medication cup on the resident's windowsill. He confirmed the facility policy was for staff to stay with the resident until the medications were swallowed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined the facility failed to ensure a physician responded to the monthly pharmacist recommendations in a timely manner for three (#20, 21 and #24) of five residents sampled for unnecessary medications. The Resident Census and Conditions of Residents report documented 71 residents resided in the facility. Findings: The facilities Drug Regimen Review policy, dated December 2018, read in part .9. The resident's physician will be notified of the Pharmacy Recommendations. The facility will allow 10 days for the physician response to the recommendations. Any recommendations not completed within 10 days will be referred to the Medical Director . 1. Resident #21 was admitted to the facility on [DATE] and had diagnoses which included psychosis, paranoid schizophrenia, depression, abnormal involuntary movement, and anxiety disorder. A pharmacist MRR, dated 08/13/22, documented a recommendation to decrease Trazodone 50 mg to 25 mg. The MMR documented the physician agreed to the GDR on 09/01/22. A quarterly assessment, dated 10/05/22, documented the resident was moderately impaired with cognitive skills. The assessment documented the resident had verbal aggression behaviors. The assessment documented the resident received an antipsychotic, antidepressant, antianxiety, diuretic, and opioid medications every day of seven day assessment period. On 01/13/23, at 10:30 A.M. the corporate nurse was asked about the GDR for resident #21 and and what the policy and procedure stated in regards to the time the physician had to respond. The corporate nurse stated that the physician should have responded in 10 days. 2. Res #24 had diagnoses which included psychosis, dementia, and Parkinson's disease. A physician order, dated 10/21/22, documented to administer quetapine an (antipsychotic medication) 25mg at bedtime for anxiety related to unspecified psychosis not due to a substance or known physiological condition. A pharmacy MRR, dated 11/09/22, documented Res #24 was receiving Seroquel 25mg at bed time for anxiety. Please clarify the diagnosis to one of the following, which are considered appropriate diagnoses/conditions per CMS guidelines: Tourette's, psychosis, schizophrenia or schizophrenic condition, dementia/refractory depression/unresolved delirium, delusional disorder, ect. with documented and ongoing behaviors that are deemed dangerous to self or others. If none of these conditions apply, please consider instituting a gradual dose reduction process and ultimate discontinuation of this therapy. A quarterly assessment, dated 12/08/22, documented the resident was severely impaired in cognition and received an antipsychotic medication seven days during the look back period. A physician order, dated 01/02/23, documented quetiapine 25mg at bedtime for unspecified psychosis not due to a substance or known physiological condition. On 01/05/23, the MRR, dated 11/09/22, documented the physician agreed and signed to change the diagnosis to unspecified psychos. The MRR was noted on 01/05/23. On 01/17/23 at 9:41 a.m., the corporate nurse consultant stated there was not a response within ten days per policy. 3. Res #20 had diagnoses which included hypertension and depression. A consultant pharmacist MRR, dated 04/16/22, documented a request for the physician to consider a switch of the long acting metoprolol to a non-extended release metoprolol which could be crushed. The physician agreed to the request on 05/05/22. A consultant pharmacist MRR, dated 08/13/22, documented a request for the physician to reduce the resident's dose of Zoloft from 50 mg to 25 mg. An agreement response was received by the physician on 09/01/22. A quarterly assessment, dated 12/16/22, documented Res #20 was severely impaired in cognition and received antidepressant medication for seven days of the seven day assessment period. On 01/13/23 at 10:40 a.m., the corporate nurse and the DON confirmed the physician responded to the medication regimen reviews beyond the time frame described in the facility policy.

2. Res #8 had diagnoses which included peripheral vascular disease, diabetes mellitus, and chronic pain syndrome. An admission assessment, dated 12/13/22, documented the resident was severely impaired with cognition and required extensive assistance with ADLs. The assessment documented the resident required oxygen and was on hospice care. A care plan could not be located in the resident record. On 01/11/23 at 3:25 p.m., Res #8 was observed on a low bed with oxygen at 2L per nasal cannula tubing, which was not dated. On 01/18/23 at 9:58 a.m., the corporate nurse consultant stated Res #8's care plan was one of three care plans that disappeared when electronic record updated. She stated she would continue to try and get the resident's care plan. On 01/18/23 at 11:10 p.m., the care plan coordinator stated the facility had called the electronic record company because the resident's care plan was gone. She stated a staff member who worked for the company was working to get the missing care plans back. She stated the update happened on 12/22/22 and there would be another update on 01/19/23. Based on record review, observation, and interview, the facility failed to ensure resident records were accurately documented and readily accessible for two (#8 and #39) of 20 residents whose records were reviewed. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: 1. Res #39 had diagnoses which included congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease. An admission assessment, dated 12/29/22, documented Res #39 was severely impaired in cognition and required extensive assistance with ADLs. A nurse note, dated 01/07/23, documented the resident was found unresponsive and was sent to the hospital for evaluation. A nurse note, dated 01/08/23, documented the resident had been sent to a separate hospital for a possible cerebral vascular accident. No notes were documented after date of 01/08/23 and the resident had not returned to the facility at the time of the survey. The resident task records documented cares were being provided to the resident until the date of 01/15/23. On 01/18/23 at 11:10 a.m., the DON reported the resident had chose not to come back to the facility and had went somewhere else. The DON was shown the resident's task records and stated he did not know why the CNAs were documenting cares on the resident until 01/15/23. The DON stated the CNAs should not have documented they had provided cares to a resident when the resident was not at the facility.

Based on interview and record review, the facility failed to implement their infection control policy related to water management for the prevention of Legionnaires' disease. The Resident Census and Conditions of Residents form documented 71 residents resided in the facility. Findings: A facility procedure, titled Legionnaires' Disease, dated September 2019, read in part, .Assess the facility's wear [sic] system risk of Legionella. Develop a water management strategies to reduce the risk of the growth and spread of Legionella if a risk assessment determines the facility to be at risk .1. Complete a facility assessment of the water system. A map/diagram will be developed which will show how the water enters and travels through the building. 2. Develop water management strategies for the facility's hot and cold water distributions system . On 01/18/23 at 2:58 p.m., the corporate administrator reported the facility did not know anything about water management for the prevention of Legionella. She confirmed the Legionnaires' Disease policy had not been implemented.

Based on record review, and interview, it was determined the facility failed to ensure an antibiotic stewardship program was consistently implemented for two (#21 and #24) of five residents whose medications were reviewed. The DON identified 22 residents who had received antibiotics in the last three months. Findings: 1. Resident #21 had diagnoses which included edema, infectious gastroenteritis and colitis, and urinary tract infection. An annual assessment, dated 04/04/22, documented the resident was moderately impaired with cognitive skills and received antibiotics every day of the seven day assessment period. A physician order, dated 10/31/22, documented the resident was to receive Keflex 500mg four times a day for seven days related to urinary tract infection. A nurse note, dated 11/25/22, documented the resident was complaining of left ear pain. A physician order, dated 11/25/22, documented the resident was to receive Augmentin 500/125 mg three times a day for ten days related to seasonal allergic rhinitis. On 01/17/23 at 9:27 a.m., the IP was interviewed and reported the facility had implemented an antibiotic stewardship program but it had fallen through the cracks. The IP reported the nursing staff had been in-serviced to fill out the criteria forms for antibiotic use. The nursing staff on the floor were originally suppose to do it and inform the IP, but they would only do it sometimes. The IP stated she forgot about implementing the criteria forms for the antibiotic stewardship program. 2. Res #24 had diagnoses which included UTI and seasonal allergic rhinitis. A quarterly assessment, dated 12/08/22, documented the resident was severely impaired in cognition and had an antibiotic four days during the look back period. Res #24's EHR documented the resident received Azithromycin (an antibiotic medication) 250mg for COVID 19 in December 2022. There was no documentation antibiotic stewardship was conducted for the resident. On 01/17/23 at 9:53 a.m., the IP stated the facility had not been utilizing the McGreer's system. She stated it was hit and miss during COVID.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure dignity during meals was maintained for one (#37) of ten sampled resident observed for dignity. The facility identified 10 residents who required assistance with eating. Findings: Resident #37 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, osteoporosis, and dementia. A quarterly assessment, dated 06/17/21, documented the resident was severely impaired with cognition and required extensive assistance with eating. On 08/04/21 at 11:21 a.m., while observing the noon meal, licensed practical nurse (LPN) #3 was observed standing while assisting resident #37 eating her meal. LPN #3 was observed to stand while assisting the resident during the entire meal. On 08/16/21 at 1:05 p.m., the assistant director of nursing (ADON) stated the staff should stay eye level and sit while assisting a resident to eat. She stated it made the residents feel more comfortable. On 08/16/21 at 1:18 p.m., LPN #3 was asked how she would assist a resident with eating. She stated she would sanitize her hands, help the resident with an apron, and sit while she assisted the resident. LPN #3 was asked why she stood and assisted resident #37. She stated stated she thought it was easer to maneuver and that was why she stood. She stated she did not think to move to the other side of the table and sit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to complete a significant change assessment for one (#53) of 24 sampled residents who experienced declines in two or more areas of activities of daily living. This had the potential to affect 64 residents who resided at the facility. Findings: Resident #53 was admitted to the facility on [DATE] with diagnoses that included respiratory failure, anxiety, vascular dementia, and adult failure to thrive. A quarterly assessment, dated 04/05/21, documented the resident: ~ required limited assistance with bed mobility; ~ required limited assistance with transfers; ~ required limited assistance with locomotion both on and off the unit; and ~ was occasionally incontinent of bowel and bladder. A quarterly assessment, dated 07/06/21 documented the resident: ~ required extensive assistance with bed mobility; ~ required extensive assistance with transfers; ~ was dependent on staff for locomotion both on and off the unit; and ~ was frequently incontinent of bowel and bladder. A comparison of the two quarterly assessments revealed the resident had experienced a decline in four areas of activities of daily living. This indicated a significant change assessment should have been completed for the resident. Review of the resident's clinical record revealed no significant change assessment. Review of the resident's clinical record revealed the resident suffered seven falls between 02/11/21 and 08/09/21 when she was attempting to transfer herself. On 08/16/21 at 3:30 p.m., the assessment coordinator was asked what dictated when a significant change assessment should be completed. She stated two changes in the areas of activities of daily living would require a significant change assessment. She stated a significant change assessment should have been completed for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to develop a comprehensive care plan related to hospice services for one (#43) of two sampled residents who were reviewed for hospice services. The facility identified 20 residents as receiving hospice services. Findings: Resident #43 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, congestive heart failure, and cancer of the lips and oral cavity. Review of the resident's clinical record revealed the resident was admitted to hospice services on 06/08/21. Review of the resident's care plan revealed the care plan did not address hospice as a problem. There was no goal. There were no interventions. On 08/09/21 at 2:46 p.m., the care plan coordinator stated hospice services had not been added to the care plan as a problem, and it should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide assistance with nail care for two (#4 and #16) of three sampled residents who were reviewed for activities of daily living. The facility identified 39 residents as requiring assistance with activities of daily living. Findings: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included a contracture of the right hand, chronic pain syndrome, and Parkinson's disease. A quarterly assessment, dated 07/30/21, documented the resident was severely impaired with cognition and required extensive to total assistance with activities of daily living (ADLs). The resident's care plan, dated 08/04/21, documented the resident required extensive assistance with ADLs. On 08/04/21 at 10:09 a.m., the resident was observed in his bed. The resident was unshaven, his eyes were matted, and his face was not washed. There was food on the resident's shirt, and his fingernails were long. On 08/09/21 at 3:56 p.m., the resident was observed in the dining room in a geriatric chair. The resident was clean, shaved, and he had glasses on. The resident's fingernails were still long. On 08/12/21 at 8:49 a.m., the resident was observed in bed with food on his face and chest. The resident's hair was not combed, and he had not been shaved. The resident's fingernails were long. On 08/12/21 at 9:00 a.m., certified nurse aide (CNA) #1 was observed assisting the resident with his ADL needs. The CNA dressed the resident and obtained assistance to get the resident to the geriatric chair using the lift. The CNA then used a wash cloth and washed the resident's face and ears. The CNA placed a pillow on the resident's right side for positioning. CNA #1 then brushed the resident's hair. CNA #1 asked the resident if he wanted shaved this morning and went to get shaving supplies. On 08/12/21 at 09:21 a.m., CNA #1 stated the CNAs did not clip nails. He stated the nurses did. On 08/12/21 at 2:02 p.m., licensed practical nurse (LPN)#1 stated nails were cut as needed for the residents. LPN #1 stated CNAs and medication aides were able to cut nails for the residents who are not diabetic. The LPN stated the facility had a restorative aide who did fingernail care for the residents and painted the ladies' fingernails if they wanted. LPN #1 stated the resident should have had his nails cut by the CNAs by now. On 08/12/21 at 2:57 p.m., LPN #2 stated she did nail care for the residents. She stated all nurses could, and the CNAs could also perform nail care for residents who were not diabetic. LPN #2 stated the CNAs did not feel comfortable doing nail care for resident #4 because of the way his right hand was contracted. She stated the resident's nails grew very fast. She stated she did not keep a record of when she cuts nails. On 08/12/21 at 3:15 p.m., LPN #2 looked at the residents's fingernails and stated they were long but his nails grew fast. She stated the resident's nails would be trimmed before she left on this day. 2. Resident #16 was admitted to the facility on [DATE] with diagnoses that included cerebral artery occlusion and stenosis, fetal alcohol syndrome, and epilepsy. A quarterly assessment, dated 05/24/21, documented the resident was severely impaired with cognition and required extensive assistance with most activities of daily living. The resident's care plan, dated 06/04/21, documented, . Keep fingernails short . On 08/09/21 at 8:45 a.m., the resident was observed in the hall in his wheel chair. The resident's fingernails were long and dirty. On 08/12/21 at 3:22 p.m., the resident's fingernails were observed by LPN #2. She stated the resident's nails were long and needed to be cut. She stated his nails grew fast, and she would cut them on this day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure a resident with a gastrostomy tube received the appropriate treatment and services for one (#16) of one sampled residents reviewed for tube feedings. The facility identified seven residents as receiving tube feedings. Findings: Resident #16 was admitted to the facility on [DATE] with diagnoses that included fetal alcohol syndrome, epilepsy, and a gastrostomy tube. A nursing admission assessment, dated 10/30/20, documented the resident was to receive a tube feeding diet of Isosource HN 50 cc/hr (cubic centimeters per hour) with 50cc/hr water flush. It was documented the resident did not receive any nutrition by mouth. A quarterly assessment, dated 05/24/21, documented the resident was severely impaired with cognition and required extensive assistance with most activities of daily living. The assessment documented the resident had a feeding tube. The resident's care plan, dated 06/04/21, documented, . I have a PEG [percutaneous endoscopic gastrostomy] tube . Feeding: Keep HOB [head of bed] elevated at 45 degrees at all times. Maintaining HOB may help decrease risk of aspiration . Enteral Feeding: Stop/hold continual feeding temporarily when turning, repositioning, or moving the resident . A physicians order, dated 06/28/21, documented the resident was to receive Isosource HN 50 cc/hr with 50 cc/hr water flush via his PEG tube three times a day. On 08/04/21 at 9:38 a.m., the resident was observed in bed with the enteral feeding running through a pump at 35 cc/hr and a water flush at 40 cc/hr. On 08/04/21 at 2:55 p.m., the resident was observed in his wheelchair in the hallway. The resident did not have his continuous tube feeding. A dietary note, dated 08/06/21, documented, . 113# [pounds], BMI [body mass index]=18 (UW) [underweight]; Reg [regular] diet/puree/honey/ in addition to Isosource HN 50cc with 50cc flush provides 1440 kcal; + [increase] 13# in one month which was needed; Resident has had several teeth pulled and continues to have more teeth pulled; Mouth sores make feeding difficult; Currently meeting needs with TF [tube feeding] and PO [by mouth] diet; Gastronomy . feeding difficulties; Continue to monitor weight gain and adjust TF as necessary . On 08/09/21 at 8:45 a.m., the resident was observed in his wheelchair in the hallway. The resident did not have his continuous tube feeding. On 08/09/21 at 3:54 p.m., the resident was observed in bed with his eyes closed. His tube feeding was running at 50 cc/hr with a 40 cc/hr water flush. On 08/12/21 at 8:43 a.m., the resident was observed in his wheelchair in the hallway. The resident did not have his continuous tube feeding. On 08/12/21 at 1:40 p.m., certified nurse aide (CNA) #1 stated the resident was on a continuous tube feeding except when he was up to eat. The CNA stated the resident went back on his tube feeding after his meals. On 08/12/21 at 1:44 p.m., registered nurse #2 stated the resident was on a continuous tube feeding and he also ate very well by mouth. She stated the tube feeding was stopped for his meals, and he ate almost 100% of all meals. She stated he likes to wheel around in his wheelchair for a little while before going back on his tube feeding. On 08/16/21 at 9:50 a.m., licensed practical nurse (LPN) #3 reviewed the resident's diet order and stated the tube feeding was supposed to be continuous. She stated he received the tube feeding and a puree diet by mouth. She stated she was not taking the resident off of his tube feeding or decreasing the feeding. She stated if the resident was full or if he was having issues like vomiting, she would check the residual and call the physician on what needed to be done. On 08/16/21 at 12:45 p.m., the ADON stated the resident's tube feeding was continuous and that meant it was not supposed to be unplugged. She stated it should be running while he ate. She was asked why his tube feeding had been turned down to 35 cc/hr. She reviewed the clinical record and stated she did not see a nurse's note stating why it was turned down. She stated there was not an order for the resident's feedings to be stopped. The ADON stated staff should have brought the feeding pump with the resident when he came to the dining room or in the common areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to have a medication error rate of less than 5% for two (#7 and #23) of 10 residents observed during the medication passes. Two errors out of 35 opportunities were observed, resulting in a medication error rate of 5.71%. The facility identified 61 residents as receiving medications. Findings: The facility's eye drop administration policy, dated 04/2018, documented, . To administer ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner . If the eye drop is a suspension (read label), shake well . 1. Resident #23 was admitted to the facility on [DATE] with diagnoses that included dry eyes. A physician's order dated 10/07/20, documented to administer one drop in both eyes two times a day of LiquiTears Solution 1.4 %. On 08/11/21 at 9:00 a.m., licensed practical nurse (LPN) #2 was observed to administer eye drops to the resident. She administered three drops in the left eye. 2. Resident #7 was admitted to the facility on [DATE] with diagnoses that included allergies. A physician's order, dated 03/24/21, documented to administer one drop in both eyes two times a day of Artificial Tears Solution 1.4 % (Polyvinyl Alcohol), for allergies. On 08/11/21 at 9:46 a.m., LPN #2 was observed to administer eye drops to the resident. She administered three drops in the left eye and two drops in the right eye. On 08/12/21 at approximately 1:00 p.m., LPN #2 stated she messed up and gave too many drops.

Based on observation and interview, it was determined the facility failed to ensure the facility's emergency suction machine was in a safe operating condition. This had the potential to affect 64 of 64 residents who resided at the facility. Findings: The facility's policy and procedure regarding emergency medical equipment, dated March 2019, documented, . Emergency Medical Equipment/Cart . will include suction machine . Emergency cart will be stored in a central location so it can be accessed quickly by staff in the event of an emergency . The Emergency cat will be checked daily by Licensed Staff daily to ensure equipment is clean and available for immediate use. (Suction machine clean/oxygen cylinder set up etc) . On 08/16/21 at 9:45 a.m., the crash cart was observed on D hall in the supply closet. The suction machine was observed sitting on the top of the crash cart. The dial on the machine was broken and there was no top to the suction canister. Licensed practical nurse (#3) was asked if the suction machine worked. She stated she did not know. On 08/16/21 at 12:59 p.m., the assistant director of nursing (ADON) looked at the crash cart. The ADON stated, Oh yeah, that's broke. The suction machine dial is broken and missing the cap to the suction bottle. She was asked what the staff would do if they had an emergency and needed the suction machine. The ADON stated the staff would probably get another suction machine. She stated she could get another suction machine for it now. The ADON tried to open the storage closet, but it was locked. The ADON asked the nurse working that hall to open the storage closet door. The nurse did not have a key to open the door. She stated if there was an emergency, they would have had to get a suction machine from another hall. On 08/16/21 at 1:12 p.m., LPN #2 brought a different suction machine from another hall for the crash cart. On 08/17/21 at 12:03 p.m., the administrator stated the crash cart should be inspected every shift. She stated she thought there was a check off list in the drawer of the cart.

Based on interview and record review, it was determined the facility failed to notify eight (#3, #21, #30, #31, #35, #40, #41, and #58) of 25 residents or representatives, whose payer source was Medicaid, when their resource balances were within $200 of the amount allowed for each resident. The facility identified 40 residents as having Medicaid as a payer source. Findings: Review of residents' trust fund account balances, effective 08/16/21, revealed the following: ~ resident #21 had a balance of $6,303.66; ~ resident #41 had a balance of $5,076.32; ~ resident #3 had a balance of $4,309.46; ~ resident #31 had a balance of $5,937.16; ~ resident #35 had a balance of $7,082.60; ~ resident #58 had a balance of $5,677.27; ~ resident #30 had a balance of $6,806.55; and ~ resident #40 had a balance of $4,370.99. On 08/16/21 at 12:45 p.m., the business office manager stated all the residents had Medicaid as their payer source. She stated the residents had all received stimulus checks, and those credits had increased the balances of their trust accounts. When deducting the amounts of the credits for the stimulus checks, it was noted the residents had the following balances: ~ resident #21 - $4303.66; ~ resident #41 - $3076.32; ~ resident #3 - $2309.46; ~ resident #31 - $3937.16; ~ resident #35 - $5082.60; ~ resident #58 - $4277.27; ~ resident #30 - $4806.55; and ~ resident #40 - $2970.99. These amounts were still over the $2000.00 resource limit allowed by Medicaid, and there was no documentation to show the residents or their representatives had been notified the accounts were within $200 of reaching the resource limit. On 08/16/21 at 1:03 p.m., the business office manager was asked what the resource limit was for a resident receiving Medicaid services as a payer source. She stated, I hear it is $2000, but I keep hearing they are being lenient on it. She was asked why the account balances were greater than $2000 for each resident, even after deducting for the stimulus checks. She stated, We don't have anything to spend the money on. She stated many of the residents already had burial arrangements taken care of, and the facility had not identified anything the residents needed, or they said they did not want anything. The business office manager stated she was not aware the residents could lose Medicaid as their payer source if they exceeded their resource limit. On 08/16/21 at 12:55 p.m., the administrator stated she was not aware of any leniency or that the account balances were so high.

Based on interview and record review, it was determined the facility failed to provide assurance of the funds deposited in the residents' trust fund account. This had the potential to affect 25 of 25 residents whose funds were held in the trust account. Findings: Review of the facility's Long-Term Care Facilities Residents Fund Bond, dated 08/23/16, revealed the facility had a surety bond covering the residents' trust fund account in the amount of $10,000. Review of bank statements for the residents' trust fund account revealed the following: ~ 05/2021 - the high daily balance in the account was $93,791.62 on 05/03/21; ~ 06/2021 - the high daily balance in the account was $79,674.61 on 06/03/21; and ~ 07/2021 - the high daily balance in the account was $71,882.89 on 07/06/21. On 08/16/21 at 2:30 p.m., the administrator was asked how much the surety bond was for. She stated it was for $10,000. On 08/17/21 at 2:15 p.m., the corporate administrator stated the insurance company had been contacted, and they were in the process of securing a new bond with an amount high enough to cover the high daily balances in the trust account.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility failed to inform, provide written information, and/or assist in formulating advance directives for six (#4, #7, #16, #19, #51 and #64) of seven residents sampled for advance directives. This had the potential to affect 64 who resided at the facility. Findings: The facility's policy on advance directives, dated 12/2018, documented, . Provide information about the facility's resident/patient's rights policies to all residents/patients and/or the authorized representatives or sponsors . prior to or upon admission . Inquire as to the existence of an Advance Medical Directive at the time of admission . Document in the resident/patient's medical record whether or not an Advance Medical Directive has been executed by the resident/patient . Place a copy of such Advance Medical Directive in the permanent medical record . 1. Resident #7 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, chronic obstructive pulmonary disease, and acute and chronic respiratory failure. On 08/05/21 at 3:22 p.m., resident #7 was asked if she had an advance directive. She stated yes, the facility did go over that with her. Review of the resident's medical record revealed no documentation of an advance directive. On 08/13/21 at 10:00 a.m., the business office manager was asked to locate the resident's advance directive. She stated the facility had a form that was signed by a resident when they were offered the advance directive. She stated a few resident did not get the form. At 10:47 a.m., the business office manager stated resident #7 did not have a do not resuscitate (DNR) order or a signed paper for the advance directive. 2. Resident #51 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, heart failure, and end stage renal disease. On 08/05/21 at 1:13 p.m., resident #51 stated she had an advance directive. Review of the resident's medical record revealed she had a DNR but not an advance directive. On 08/13/21 at 10:00 a.m., the business office manager was asked to locate the resident's advance directive. At 10:45 a.m., the business office manager stated the resident had a DNR in her file, but no advance directive or document showing she had been offered an advance directive. 4. Resident #4 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome, Parkinson's disease, and post traumatic stress disorder. Review of the resident's medical record revealed no advance directive. There was no documentation the resident or representative had been offered information or assistance with formulating an advance directive. The record revealed the resident was a full code. On 08/13/21 at 9:56 a.m., the office manager stated she offered information on advance directives to residents on admission. She stated if a resident wanted an advance directive, she would get a nurse to help the resident formulate one. She stated when she first started as the business manager, she was unaware the resident needed to decline and have a copy of the declination in the chart. She stated she had started trying to get those declinations for all residents, including those who had been at the facility for some time. On 08/13/21 at 10:47 a.m., the office manager stated she had a hard time getting the family of resident #4 to sign the admission paperwork for the resident. She stated she did not find any documentation of an advance directive or refusal in the resident's chart. 5. Resident #16 was admitted to the facility on [DATE] with diagnoses that included cerebral artery occlusion and stenosis, fetal alcohol syndrome, and epilepsy. Review of the resident's medical record revealed no documentation of an advance directive. There was no documentation the resident or representative had been offered information or assistance with formulating an advance directive. The record revealed the resident was a full code. On 08/13/21 at 10:48 a.m., the office manager stated the resident did not have an advance directive, nor was there any documentation the resident or representative had been offered information or assistance in formulating one. 6. Resident #19 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, metabolic encephalopathy, and vascular dementia. Review of the resident's medical record revealed no documentation of an advance directive. There was no documentation the resident or representative had been offered information or assistance with formulating an advance directive. The record revealed the resident was a full code. On 08/05/21 at 9:50 a.m., registered nurse (RN) #2 was asked to provide the resident's advance directive or the form documenting one had been refused. She reviewed the clinical record and stated she did not find either form. On 08/13/21 at 10:46 a.m., the office manager stated the family member of resident #19 had taken the paperwork home, and he had not returned it. 3. Resident #64 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, congestive heart failure, hypertension, and a femur fracture. An Advance Directive Acknowledgement form, dated 07/16/21, documented the resident requested assistance in completing an advance directive and/or Oklahoma DNR form. Review of the resident's clinical record revealed no documentation of either an advance directive or DNR form. Physician's orders, dated 07/16/21, documented the resident was a full code, meaning she would receive cardiopulmonary resuscitation in an emergency event. On 08/13/21 at 10:28 a.m., the business office manager stated there was a form in the admission packet where residents could notate if they wanted help filling out an advance directive. She stated if a resident requested help, the form was given to the nurse so they could assist the resident. At 10:48 a.m., the business office manager stated it appeared the facility did not follow through with assisting resident #64 in filling out an advance directive. She stated she was putting a system in place to ensure this was done in the future.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and recored review, it was determined the facility failed to Findings: Resident #19 FTag Initiation [NAME] Resident #19 Writing tag F605 for chemical restraints admit date : [DATE] Unnecessary Medications 08/09/21 08:46 AM resident was laying in her bed this morning facility the wall under the covers. She stated she would rather take her nap this morning than do the interview. 08/09/21 04:00 PM The resident was observed sitting on the side of her bed with the overbed table in from of her waiting on her dinner. DX: I63.9 CEREBRAL INFARCTION, UNSPECIFIED SLP Acute Neurologic 2/12/2020 Primary Admitting Dx 2/12/2020 jwade view F29 UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION Medical Management 5/6/2021 Secondary History 5/6/2021 cbraden K59.00 CONSTIPATION, UNSPECIFIED N/A, not an acceptable Primary Diagnosis 8/24/2020 Secondary During Stay 8/24/2020 sharbison R19.7 DIARRHEA, UNSPECIFIED N/A, not an acceptable Primary Diagnosis 2/13/2020 Secondary During Stay 2/13/2020 jwade G43.009 MIGRAINE WITHOUT AURA, NOT INTRACTABLE, WITHOUT STATUS MIGRAINOSUS N/A, not an acceptable Primary Diagnosis 2/12/2020 Secondary History 2/12/2020 jwade F33.3 MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS Medical Management 2/12/2020 Secondary admission 4/21/2021 cbraden R27.0 ATAXIA, UNSPECIFIED Acute Neurologic 2/12/2020 Secondary admission 2/12/2020 jwade I69.319 T UNSPECIFIED SYMPTOMS AND SIGNS INVOLVING COGNITIVE FUNCTIONS FOLLOWING CEREBRAL INFARCTION SLP Medical Management 2/12/2020 Secondary admission 2/12/2020 jwade R53.83 OTHER FATIGUE N/A, not an acceptable Primary Diagnosis 2/12/2020 Secondary admission 2/12/2020 jwade I48.91 UNSPECIFIED ATRIAL FIBRILLATION Cardiovascular and Coagulations 2/12/2020 Secondary admission 2/12/2020 jwade Z91.81 HISTORY OF FALLING N/A, not an acceptable Primary Diagnosis 2/12/2020 Secondary History 2/12/2020 jwade G47.00 INSOMNIA, UNSPECIFIED N/A, not an acceptable Primary Diagnosis 2/12/2020 Secondary admission 2/12/2020 jwade I10 ESSENTIAL (PRIMARY) HYPERTENSION N/A, not an acceptable Primary Diagnosis 2/12/2020 Secondary admission 2/12/2020 jwade R56.9 UNSPECIFIED CONVULSIONS Medical Management 2/12/2020 Secondary admission 2/12/2020 jwade B02.9 ZOSTER WITHOUT COMPLICATIONS Acute Infections 2/12/2020 Secondary History 2/12/2020 jwade F41.9 ANXIETY DISORDER, UNSPECIFIED Medical Management 2/12/2020 Secondary admission 2/12/2020 jwade R55 SYNCOPE AND COLLAPSE Medical Management 2/12/2020 Secondary History 2/12/2020 jwade view E86.0 DEHYDRATION Medical Management 2/12/2020 Secondary History 2/12/2020 jwade R42 DIZZINESS AND GIDDINESS N/A, not an acceptable Primary Diagnosis 2/12/2020 Secondary admission 2/12/2020 jwade R41.82 ALTERED MENTAL STATUS, UNSPECIFIED N/A, not an acceptable Primary Diagnosis 2/12/2020 Secondary admission 2/12/2020 jwade G93.41 METABOLIC ENCEPHALOPATHY Acute Neurologic 2/12/2020 Secondary History 2/12/2020 jwade F03.90 UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE Medical Management 2/12/2020 Secondary admission 2/12/2020 jwade Z79.01 LONG TERM (CURRENT) USE OF ANTICOAGULANTS N/A, not an acceptable Primary Diagnosis 2/12/2020 Secondary admission 2/12/2020 jwade I48.3 TYPICAL ATRIAL FLUTTER Cardiovascular and Coagulations 2/12/2020 Secondary admission 2/12/2020 jwade E78.5 HYPERLIPIDEMIA, UNSPECIFIED Medical Management 2/12/2020 Secondary admission 2/12/2020 jwade F01.51 VASCULAR DEMENTIA WITH BEHAVIORAL DISTURBANCE N/A, not an acceptable Primary Diagnosis 2/12/2020 Secondary admission 2/12/2020 jwade F48.2 PSEUDOBULBAR AFFECT Medical Management 2/12/2020 Secondary admission **************** MEDICATIONS: Keppra Tablet 500 MG (levETIRAcetam) Give 1 tablet by mouth two times a day related to UNSPECIFIED CONVULSIONS (R56.9) Pharmacy Active 2/12/2020 19:00 5/19/2021 Apixaban Tablet 5 MG Give 1 tablet by mouth two times a day related to UNSPECIFIED ATRIAL FIBRILLATION (I48.91) Pharmacy Active 2/12/2020 19:00 5/19/2021 Atorvastatin Calcium Tablet 40 MG Give 1 tablet by mouth at bedtime related to HYPERLIPIDEMIA, UNSPECIFIED (E78.5) Pharmacy Active 2/12/2020 20:00 2/12/2020 Digoxin Tablet 125 MCG Give 1 tablet by mouth one time a day related to UNSPECIFIED ATRIAL FIBRILLATION (I48.91);TYPICAL ATRIAL FLUTTER (I48.3) hold if apical pulse less than 60 Pharmacy Active 2/12/2020 13:00 2/12/2020 Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) hold for SBP less than 100 or pulse less than 60 Pharmacy Active 2/12/2020 19:00 7/3/2021 Milk of Magnesia Suspension 7.75 % (Magnesium Hydroxide) Give 30 ml by mouth every 24 hours as needed for constipation Pharmacy Active 2/13/2020 19:00 2/13/2020 Tylenol Extra Strength Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Pain;Elevated Temperature Pharmacy Active 2/15/2020 11:15 2/15/2020 Antacid & Antigas Suspension 200-200-20 MG/5ML (Alum & Mag Hydroxide-Simeth) Give 20 ml by mouth every 2 hours as needed for gas/bloating;Indigestion Pharmacy Active 2/14/2020 14:30 2/14/2020 traZODone HCl Tablet 50 MG Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES (F33.2) Pharmacy Active 3/26/2020 20:00 3/26/2020 Melatonin Tablet 5 MG Give 2 tablet by mouth at bedtime related to INSOMNIA, UNSPECIFIED (G47.00) Give two tabs to = 10mg Pharmacy Active 5/12/2020 20:00 5/12/2020 Zofran Tablet 8 MG (Ondansetron HCl) Give 1 tablet by mouth every 8 hours as needed for Nausea and Vomiting Pharmacy Active 6/13/2020 15:45 6/13/2020 Colace Capsule 100 MG (Docusate Sodium) Give 1 capsule by mouth two times a day related to CONSTIPATION, UNSPECIFIED (K59.00) Pharmacy Active 8/24/2020 19:00 5/19/2021 Meclizine HCl Tablet 25 MG Give 1 tablet by mouth three times a day related to DIZZINESS AND GIDDINESS (R42) Pharmacy Active 11/5/2020 13:00 5/19/2021 Tums Tablet Chewable 500 MG (Calcium Carbonate Antacid) Give 1 tablet orally three times a day for Indigestion Pharmacy Active 12/9/2020 19:00 5/19/2021 Paxil Tablet 20 MG (PARoxetine HCl) Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS (F33.3) Pharmacy Active 2/24/2021 07:00 5/19/2021 SEROquel Tablet 100 MG (QUEtiapine Fumarate) Give 1 tablet by mouth at bedtime related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION (F29) Take 1 tablet by mouth nightly Pharmacy Active 4/26/2021 20:00 5/6/2021 LORazepam Tablet 0.5 MG Give 1 tablet by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED (F41.9) Pharmacy Active 6/1/2021 19:00 6/1/2021 busPIRone HCl Tablet 10 MG Give 1 tablet by mouth three times a day related to ANXIETY DISORDER, UNSPECIFIED (F41.9) Pharmacy Active 6/1/2021 13:00 6/1/2021 Benadryl Allergy Capsule 25 MG (diphenhydrAMINE HCl) Give 1 capsule by mouth every 24 hours as needed for Redness/irritation Pharmacy Active 6/12/2021 02:45 Ocean Nasal Spray Solution 0.65 % (Saline) 2 spray in both nostrils every 6 hours as needed for Nasal Dryness Pharmacy Active 6/19/2021 17:15 ************************** ORDERS: FULL CODE No directions specified for order. Other Active 2/13/2020 Obtain VS weekly one time a day every Thu Other Active 5/13/2021 06:00 5/11/2021 MAY HAVE COVID 19 TESTING No directions specified for order. Other Active 5/27/2021 DIGOXIN VALPORIC ACID AND KEPPRA LEVEL Q 3 MONTHS DUE IN APRIL JULY OCT JAN one time a day every 3 month(s) starting on the 1st for 1 day(s) related to CEREBRAL INFARCTION, UNSPECIFIED (I63.9);UNSPECIFIED CONVULSIONS (R56.9);METABOLIC ENCEPHALOPATHY (G93.41);UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE (F03.90);LONG TERM (CURRENT) USE OF ANTICOAGULANTS (Z79.01) Laboratory Active 4/1/2021 06:00 3/31/2021 7/02/21 Keppra level was done 14 (5-45) normal 4/2/21 Digoxin 0.85 (0.80-2.00) normal 4/2/21 VPA <12.5 Resident was changed to Keppra 02/12/20. CMP CBC Q 6 MONTHS IN APRIL OCT one time a day every 6 month(s) starting on the 1st for 1 day(s) related to CEREBRAL INFARCTION, UNSPECIFIED (I63.9);UNSPECIFIED ATRIAL FIBRILLATION (I48.91);ESSENTIAL (PRIMARY) HYPERTENSION (I10);METABOLIC ENCEPHALOPATHY (G93.41) Laboratory Active 4/1/2021 06:00 3/31/2021 Lab obtained 04/22/21 normal TSH LIPIDS VIT D YEARLY IN APRIL one time a day every 12 month(s) starting on the 1st for 1 day(s) related to CEREBRAL INFARCTION, UNSPECIFIED (I63.9);UNSPECIFIED ATRIAL FIBRILLATION (I48.91);ESSENTIAL (PRIMARY) HYPERTENSION (I10);METABOLIC ENCEPHALOPATHY (G93.41);TYPICAL ATRIAL FLUTTER (I48.3);HYPERLIPIDEMIA, UNSPECIFIED (E78.5) Laboratory Active 4/1/2021 06:00 Lab obtained for CMP, CBC 04/22/21 normal Lipid Panel HDL 49 low range >60, Triglycerides 157 high range is <150 *********************** MDS: 02/24/21 Annual 05/26/21 Quarterly BIMS 10 07 Mood 01 01 Behaviors - none Physical & verbal behaviors 1to3 days Bed mobility 1/1 1/1 Transfer 1/1 1/1 Walk in room/corridor 1/1 1/1 Locomotion on/off unit 1/1 1/1 Dressing 2/2 2/2 Eating 1/1 1/1 Toilet use 1/1 1/1 Personal hygiene 1/1 1/1 Bathing 2/2 2/2 Urinary always continent always continent Bowel - not rated always continent Pain - no scheduled pain medication/ PRN pain meds/no pain has not received PRN pain medications. Medications: Antipsychotic 7 days 7 days Antianxiety 7 days 7 days Antidepressant 7 days 7 days Anticoagulant 7 days 7 days Med review: No- anti were not received - routine YES GDR - NO SP TX: none none ********************* Care Plan: 08/09/21 Labile Emotional Control. Diagnosis of PSEUDOBULBAR EFFECT. I have a chemical imbalance in the brain that effects my emotions secondary to diagnosis of SIGNS AND SYMPTOMS INVOLVING COGNITIVE FUNCTIONING FOLLOWING CEREBRAL INFARCTION. I have a reduced stress threshold secondary to VASCULAR DEMENTIA, CVA. I have diminished mental capacity secondary to DEMENTIA, CVA. I have feelings of anxiety, fear, confusion associated with DEMENTIA, CVA, ALTERED MENTAL STATUS. H [Behavior] · Resident will have behavioral problems identified and preventive measures implemented to minimize labile emotions by the review date. H · Resident will experience improved emotional control or maintain current level of emotional control through the review date. H · Resident will have safe, stable environment with routine scheduling of activities to decrease anxiety and confusion through the review date. H · Administer medications as prescribed. ANAFRANIL CAPSULE 50mg. [CMA/T,LPN,RN] H · Allow the resident the freedom to sit in a chair new the window or nurse station, etc., utilize books, magazines or diversion activities as desired/appropriate. [CNA,RNA,LPN,RN] H · Allow wandering in a controlled environment as appropriate or within acceptable limitations. This increases the resident's security and decreases hostile and agitated behaviors within the confines of a safe, supervised environment. [CNA,RNA,LPN,RN] H · Approach the resident in a consistent manner in all interactions. A consistent approach to resident interaction enhances feelings of security and provides structure. [LPN,RN,SS,CNA,ACTD] H · Assess and document ability to cope with events, interests in surroundings and activity in surroundings every shift. [LPN,RN,CNA,SS,RNA] H · Assist with establishing cues and reminders for resident assistance. [CNA,RNA,ACTD,LPN,RN] H · Avoid or terminate emotionally charged situations or conversations. Avoid anger and expectation of resident to remember or follow instructions. Do not expect more than the resident is capable of doing. [CNA,LPN,RN,RNA,ACTD] H · Guard against personal feelings of frustration and lack of progress. [RN,LPN,SS,CNA,RNA] H · If labile emotional control is demonstrated, provide a calm, quiet environment with minimal sensory stimuli for the resident. Speak calmly, clearly in a soothing voice. Provide reassurance. Provide appropriate diversion activity as needed. [CNA,RNA,LPN,RN,SS] H · Limit decisions the resident makes. Be supportive and convey warmth and concern when communicating with the resident. [CNA,CMA/T,RNA,LPN,RN] H · Maintain consistent scheduling with allowances for resident's specific needs. Avoid situations that may lead to overstimulation. [CNA,LPN,RN,RNA,ACTD] H · Orient to person and environment as needed. Utilize calendars, radios, newspapers, television, etc. as appropriate. [CNA,RNA,LPN,RN,SS] H · Provide time for reminiscing if resident desires to do so. [ACTD,CNA,RNA] H · Refer to psych. to treat and evaluate as ordered. [RN,LPN,SS] H · Altered Thought Processes Risk. I have damage to cerebral tissues associated with cerebral ischemia secondary to CVA, DEMENTIA. H [Behavior][Psychotropics] · Resident will demonstrate improvement in thought processes evidenced by improved level of orientation by the review date. H · Resident will reduce the frequency of inappropriate responses/behaviors through the review date. H · Administer medications as prescribed. Monitor effectiveness of medications and s/s adverse drug reactions. [CMA/T,LPN,RN] H · Assess/monitor/document s/s altered thought processes (e.g., shortened attention span, impaired memory, decreased ability to problem solve, confusion, inappropriate responses, inappropriate behaviors). [LPN,RN,SS] H · Assist resident to problem solve as necessary. [CNA,RNA,LPN,RN,SS] H · Consult physician/appropriate health care provider if altered thought processes continue and/or worsen. [LPN,RN,SS] H · Discuss physiological basis for altered thought processes with resident and significant others; inform them that cognitive and emotional functioning may improve. Encourage/support in methods of dealing with resident's altered thought processes. [LPN,RN,SS] H · Implement measure to minimize emotional outbursts and inappropriate responses/behaviors if they occur (e.g., provide distraction, redirect, use calm, quiet language/approach, don't argue/confront, turn on music/television, give familiar object, etc.). [CNA,RNA,LPN,RN] H · Keep environmental stimuli to a minimum but avoid sensory deprivation. [CNA,RNA,LPN,RN,ACTD] H · Maintain a consistent and regular, structured routine. Maintain onsistent caregivers when possible. [CNA,LPN,RN] H · Place familiar objects, clock and calendar within the resident's view. [ACTD,SS,RNA,CNA,LPN] H · Reorient to person, place and time as indicated/necessary. [CNA,RNA,LPN,RN] H · Repeat instructions as necessary using clear, simple language and short sentences. Allow ample time for communication. [CNA,RNA,LPN,RN,SS] H · ANTIDEPRESSANTS. Disturbed Thought Process/Risk. I am exhibiting decreased problem-solving capability, hypovigilance, impaired interpretation of environment, inappropriate behaviors associated with DEPRESSION, ANXIETY, PSEUDOBULBAR AFFECT. I am experiencing changes in sleep habits, loss of appetite, decreased energy level, inability to concentrate associated with DEPRESSION, INSOMNIA, ANXIETY, MIGRAINE. H [Behavior][Psychotropics] · Resident will be free from SE and/or adverse drug reaction from use of antidepressant medications PAXIL, SEROQUIL, TRAZADONE through the review date. H · Resident will demonstrate improved mood evidenced by absence of crying, decreased anxiety, improved sleep pattern, participation in preferred activities by the review date. H · Resident will demonstrate improved sleep pattern and interest in self-care, preferred activities by the review date. H · Administer medications as prescribed. Monitor for effectiveness, side effects and adverse drug reactions. PAXIL 20mg. TRAZADONE 50mg. [CMA/T,LPN,RN,PHARM] H · ADVERSE REACTIONS: Monitor for s/s CNS effects that may increase the risk for falls: dizziness, nausea, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, increased appetite. [RN,LPN,CMA/T,CNA,SS] H · Allow ample time to finish ADLs, activities, eating, routines. Understand that demands to hurry only increase anxiety and slow down ability to think and respond clearly. [CNA,CMA/T,RNA,LPN,RN] H · Allow plenty of time to think and frame responses. [CNA,CMA/T,LPN,RN,SS] H · DOSAGE: Use of two or more antidepressants simultaneously may increase risk of SE. Provide documentation of expected benefits that outweigh the associated risks and monitoring for increase in SE with use of two or more antidepressants simultaneously. [RN,LPN,CMA/T,PHARM,SS] H · Move the resident to a quiet area with minimal stimulus, dim lighting, small area, relaxing music, comfort items with s/s anxious behavior and/or escalating behavior. [LPN,RN,CNA,CMA/T,SS] H · Observe for increasing anxiety. Assume a calm manner. Decrease environmental stimulation, Provide temporary isolated environment as indicated. Early detection and intervention facilitates a method of minimizing the escalation of anxiety/behaviors. [SS,RN,LPN,CNA,ACTD] H · Provide reassurance and comfort measures to relieve s/s anxiety. [RN,LPN,CNA,CMA/T,SS] H · SIDE EFFECTS: MENTAL STATUS CHANGE: Monitor s/s, SE mental status changes: mood changes, sensorium, suicidal tendency, increase in psychiatric symptoms, depression, panic, flat affect. Report new onset SE to physician. [CMA/T,LPN,RN,PHARM,SS] H · SIDE EFFECTS: SEROTONIN SYNDROME: Monitor for s/s, SE of serotonin syndrome: increased heart rate, sweating, dilated pupils, tremors, twitching, hyperthermia, agitation, hyperreflexia, nausea, vomiting, diarrhea, hallucinations, coma (SSRIs, SNRIs, TRIPTANS). [LPN,RN,CMA/T] H · Teach caregivers s/s of escalating anxiety and ways to interrupt its progression (i.e., relaxation techniques, deep breathing, physical exercise, brisk walks, meditation, diversion, etc.). These techniques provide resident confidence in having control over his/her anxiety. [SS,RN,LPN,CNA,ACTD] H · Teach/Remind resident and caregivers of safety precautions with RX: Use caution when performing activities that require alertness r/t SE drowsiness, dizziness, blurred vision. Report s/s bleeding to prescribing physician. [LPN,RN,PHARM,CMA/T,CNA] H · Use simple, concrete words to communicate. [CNA,CMA/T,LPN,RN,SS] H · ANTIPSYCHOTICS. Altered Though Process. I am experiencing confusion, inappropriate behaviors associated with AMS, DEMENTIA, CVA, DEPRESSION. H [Psychotropics][Behavior][Falls] · Resident will be free from SE and/or adverse reaction from antipsychotic (SEROQUEL) use through the review date. H · Administer medication as prescribed. Assess/Monitor/Document for effectiveness and/or adverse drug reaction. SEROQUEL 100mg. [RN,LPN,PHARM,CMA/T] H · ADVERSE REACTION/CARDIOVASCULAR: Assess/Monitor/Document s/s cardiac arrhythmias, orthostatic hypotension. [LPN,RN,PHARM,CMA/T] H · ADVERSE REACTION/GENERAL: Assess/Monitor s/s of anticholinergic effects, falls, excessive sedation. [LPN,RN,PHARM,CMA/T] H · ADVERSE REACTION/NEUROLOGIC: Assess/Monitor/Document s/s: akathisia, neuroleptic malignant syndrome, parkinsonism, tardive dyskinesia, cerebrovascular events (stroke, TIA) in individuals with dementia. [LPN,RN,PHARM,CMA/T] H · BLACK BOX WARNING: Increased mortality in elderly resident with dementia-related psychosis. [RN,LPN,PHARM,CMA/T] H · Encourage frequent repositioning. [CNA,RNA,ACTD,PT,RNA] H · Encourage resident's independence by allowing/encouraging/reinforcing completion of tasks to his/her highest functional level. [LPN,RN,CNA,RNA,PT] H · Evaluate recent medication changes for possible drug interactions, adverse side effects, particularly if the behavior is new. [LPN,RN,PHARM,CMA/T] H · Provide a quiet, calm environment. Decrease environmental stimuli. Provide a cool room temperature. Dim the lights. Limit procedures and personal visits during periods of rest. [LPN,RN,CMA/T,CNA,ACTD] H · Provide activities/entertainment to maintain social and cognitive stimulation throughout the day and evening hours. [PT,ACTD,RNA,CNA,SS] H · Provide consistent caregivers. [LPN,RN,CMA/T,CNA,RNA] H · Provide the resident with reassurance, a sense of security. [LPN,RN,CMA/T,CNA,RNA] H · Remove the resident for the environment that is contributing to stress(ors). Provide a quiet, calm environment. Provide for reassurance, meet immediate needs. [ACTD,LPN,RN,CNA,RNA] H · Bowel Incontinence. I have cognitive impairment secondary to CVA, DEMENTIA, AMS. I have nerve damage secondary to CVA. H · Resident will have less than two episodes of incontinence per day through the review date. H · Resident will be continent during daytime through the review date. H · Administer medications as prescribed. [CMA/T,LPN,RN] H · Assess and document risk factors and history for bowel incontinence. [LPN,RN,CNA] H · Assess and document s/s and frequency of bowel incontinence. [CNA,LPN,RN] H · Check resident every two hours and assist with toileting as needed [CNA] H · Observe pattern of incontinence, and initiate toileting schedule if indicated. H · Provide bedpan/bedside commode [CNA] H · Provide loose fitting, easy to remove clothing [CNA] H · Provide pericare after each incontinent episode Constipation Risk Chronic Perceived. I have decreased peristalsis secondary to impaired mobility, activity intolerance. I have inadequate food and fluid intake secondary to diminished appetite. H · will pass soft, formed stool at the preferred frequency of every third day through the review date. H · Resident will have a normal bowel movement at least every third day through the review date. H · Administer medication as prescribed. Colace 100mg CAPSULE BID. MILK OF MAGNESIA 30ml PRN. H · Assess/monitor/document bowel sounds. Report pattern of diminishing sounds or sounds that do not return to normal when expected. [LPN,RN] H · Assist me to the bathroom or bedside commode. Pace me in high Fowler's position on bedpan for bowel movements unless contraindicated. Provide privacy. [CNA] H · Encourage resident to defecate whenever the urge is felt. [CNA,LPN,RN] H · Encourage resident to sit on toilet to evacuate bowels if possible. [CNA] H · Establish a regular time for bowel movements, preferably one hour after meals. [CNA] H · Follow facility bowel protocol for bowel management. H · Monitor medications for side effects of constipation. Keep physician informed of any problems. H · Record bowel movement pattern each day. Describe amount, color and consistency. [CNA] H · Decision-Making. I am experiencing inadequate preparation for stressors secondary to DEPRESSION, AXIETY, CONFUSION, IMPAIRED MEMORY, PAIN, DEBILITY. I experience confusion in appraisal of threat associated with FATIGUE, DEBILITY, ANXIETY, DEPRESSION. H [Advance Directive] · Resident will verbalize feelings related to emotional state by the review date. H · Resident will communicate needs and negotiate with others to meet needs through the review date. H · Convey feelings of acceptance and understanding. Avoid false reassurances. [SS,DON,LPN,RN] H · Determine the resident's understanding of the stressful situation. [SS,LPN,RN] H · Evaluate resources and support systems available to the resident. [SS] H · Identify specific stressors. [SS,LPN,RN,CNA] H · Observe for causes of ineffective coping such as poor self-concept, grief, lack of problem-solving skills, lack of support, or recent change in life situation. [SS,LPN,RN,CNA] H · Observe for strengths such as the ability to relate the facts and to acknowledge the source of stressors. [SS,LPN,RN,CNA] H · Provide diversion activities. Encourage use of cognitive behavioral relaxation. [SS,LPN,RN] H · Provide information the resident wants and needs. Do not give more than the resident can handle. Decreased Cardiac Output Risk. Resident has a pre-existing compromise in cardiac function associated with HYPERLIPIDEMIA, HTN. Resident has an alteration in heart rate, rhythm and conduction secondary to AFIB, ATRIAL FLUTTER. H · Resident will remains free of side effects from medications used to achieve adequate cardiac output through the review date. H · Resident will maintain adequate cardiac output as evidenced by urine output at least 30ml/hour through the review date. H · Resident will demonstrate adequate cardiac output evidenced by BP, pulse rate and rhythm WNL, strong peripheral pulses and ability to tolerate activity without symptoms of dyspnea, syncope or chest pain through the review date. H · Administer medications as prescribed. Monitor for side effects and toxicity. [CMA/T,LPN,RN] H · Assess monitor/document peripheral pulses and capillary refill. Report s/s decreased cardiac output: weak pulses, capillary refill >3seconds or absent refill to the physician. [LPN,RN] H · Assess/monitor/document bowel function. Provide stool softeners as prescribed. Teach/instruct resident to avoid straining with BM. [CNA,CMA/T,LPN,RN] H · Assess/monitor/document complaints of fatigue and reduced activity tolerance. Report abnormal findings and/or changes from baseline to physician. [LPN,RN] H · Assess/monitor/document heart sounds. Auscultate apical pulse, assess heart rate, rhythm. [LPN,RN] H · Assess/monitor/document oxygen saturation wi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide complete and accurate assessments for five (#8, #16, #19, #56, and #68) of 24 sampled residents whose assessments were reviewed. This had the potential to affect 64 residents who resided at the facility. Findings: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses that included periodontal disease. An admission assessment, dated 11/10/20, documented the resident did not have any problems with his teeth. The assessment also documented the resident had limited range of motion only to one upper side. A physician's order, dated 03/11/21, documented the resident was to receive peridex oral solution to his gums twice daily related to periodontal disease. A quarterly assessment, dated 05/24/21, documented the resident did not have any broken teeth or /pain. The assessment also documented the resident had limited range of motion only to one upper side. On 08/04/21 at 2:59 p.m., the resident was observed to have missing and rotted teeth. On 08/12/21 at 3:22 p.m., the resident was asked if he could straighten out his hands. The resident tried and was not able to. The resident could move his left thumb and first finger, and his right hand was contracted at the knuckles. On 08/16/21 at 3:43 p.m., the minimum data set (MDS) assessment coordinator stated she probably should have marked the assessment for cavities on the admission. She stated she did not remember the resident complaining of any pain in the look back period for the quarterly assessment. She stated she did not put his contractures for both hands in the range of motion field. 2. Resident #19 was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis, major depressive disorder, anxiety disorder, pseudobulbar affect, dementia without behavioral disturbances, and vascular dementia with behavioral disturbances. A physician's order, dated 06/12/20, documented the resident was to receive Seroquel, an antipsychotic medication, 100 milligrams daily. An annual assessment, dated 02/24/21, documented the resident did not receive antipsychotic medications regularly. On 08/16/21 at 3:37 p.m., the MDS coordinator stated she either missed that area or hit the wrong area. She stated either way, when the resident was on an antipsychotic medication routinely, that area on the MDS should be marked. 3. Resident #56 was admitted to the facility on [DATE] and had diagnoses that included dementia and Parkinson's disease. A physician's order, dated 06/28/21, documented the resident was to be admitted to hospice services. A significant change assessment, dated 07/12/21, documented the resident was severely impaired with cognition. It did not document the resident was receiving hospice services. On 08/17/21 at 10:50 a.m., the MDS coordinator stated she did a significant change for the resident because the resident went on hospice, and one was required. She reviewed the assessment and stated she missed marking hospice on the assessment. 4. Resident #8 was admitted to the facility on [DATE] with diagnoses that included chronic pain, depressive disorder, and fluid overload. A quarterly assessment, dated 05/11/21, documented the resident had received an opioid pain medication on seven of the preceding seven days. Review of the resident's clinical record revealed no documentation the resident received a opioid during 05/2021. On 08/16/21 at 3:23 p.m., the assessment coordinator was asked what opioid had been administered to the resident. She reviewed the clinical record and stated she did not see where an opioid had been administered. 5. Resident #68 was admitted to the facility on [DATE] with diagnoses that included atrial flutter, deep vein embolism and thrombosis. Physician orders, dated 05/13/21, documented the resident was to receive Eliquis, an anticoagulant, 5 milligrams (mgs) twice daily. Medication administration records, dated 05/16/21 through 05/25/21, documented the resident received Eliquis each day, for a total of 10 days. An admission assessment, dated 05/25/21, documented the resident had not received an anticoagulant during the seven day look back period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility failed to ensure a resident with limited range of motion (ROM) received services to improve or prevent potential decline in ROM for one (#16) of two sampled residents reviewed for mobility. The facility failed to provide restorative services for a resident who had impairment in both of his hands. The facility identified six residents with limited range of motion. Findings: Resident #16 was admitted to the facility on [DATE] with diagnoses that included cerebral artery occlusion and stenosis, fetal alcohol syndrome, epilepsy, and contractures. A nursing assessment, dated 10/30/20, documented the resident had a contracture, but the location of the contracture was not noted. An admission assessment, dated 11/10/20, documented the resident was severely impaired with cognition, required extensive assistance with most activities of daily living, and had impaired mobility on one side of the upper body. A care plan, dated 06/04/21, documented . I have diagnosis of joint contracture . Resident will improve muscle strength and joint ROM by the review date . Progress from passive to active ROM as tolerated to prevent joint contractures and muscle atrophy . On 08/04/21 at 2:59 p.m., the resident was observed with contractures to both his hands. No splints were in use. On 08/12/21 at 3:22 p.m., licensed practical nurse (LPN) #2 observed the resident's hands. The resident was asked if he could straighten out his hands. The resident tried and was not able to. The resident moved the thumb and first finger on his left hand. The resident's right hand was contracted at the knuckles. The resident was able to squeeze the LPN's fingers with both hands. The LPN stated the resident had contractures to both of his hands. On 08/16/21 at 12:52 p.m., the assistant director of nursing ( ADON) stated the nursing assessment, dated 10/30/20, documented the resident had contracture but the assessment did not document where the contracture was. She stated she was aware a couple of his fingers were contracted. The ADON stated the resident had not received restorative care. On 08/16/21 at 4:20 p.m., the ADON was asked why the resident was not on a restorative program. She stated she had not asked therapy to do an evaluation for the resident. The ADON stated she believed the resident would benefit from the restorative program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide oxygen therapy as ordered by the physician and/or change oxygen tubing per current standards of practice for three (#41, #51 and #53) of three sampled residents reviewed for respiratory concerns. The facility identified eight residents as receiving respiratory treatments. Findings: 1. Resident #51 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD). The resident's physician order, dated 01/30/19, documented the resident was to receive oxygen at a flow rate of two liters per minute via nasal cannula at night. It was documented the oxygen was to be off in the mornings. The resident's care plan, dated 04/20/21, documented a problem related to impaired gas exchange risk related to COPD. A goal was documented, . resident will be free from s/s [signs and symptoms] of respiratory distress through the review date with interventions of administer humidified oxygen . Monitor for evidence of hypoventilation by increased somnolence after initiating or increasing oxygen therapy . Avoid high concentration of oxygen in patients with COPD unless otherwise ordered . The resident's health status note, dated 08/05/21 at 11:57, documented, . 115/62 [blood pressure] 68 [heart rate] 16 [respirations] 97.0 [temperature] 97% [oxygen saturation] 02 [oxygen] 2L [two liters] Resident resting quietly, respirations even and unlabored. Resident has no complaints of not feeling well today . On 08/05/21 at 1:05 p.m., the resident was observed in bed wearing her oxygen nasal cannula. The concentrator was set at a flow rate of seven liters, and the tubing was undated and not connected to the water bottle for humidification. The resident was asked how many liters of oxygen she was on. She stated she was on two liters. She was asked if she knew it was on seven liters. She stated no, the nurse must have turned it up. She was asked if she was to have humidified oxygen. She stated she did not like it connected to the water because the water got in her nose through the tubing. A nurse's note, dated 08/06/21 at 2:16 a.m., documented, . Alert and oriented . with confusion noted. Resp [respirations] with ease. LCTA [lungs clear to auscultation]. O2 [oxygen] @ [at] 3L/M [three liters per minute] in use via NC [nasal cannula] . On 08/10/21 at 9:29 a.m., the resident was observed in her bed, lying flat on her back, and wearing her nasal cannula. The tubing was undated and not connected to the water bottle. The concentrator was observed to be set to a flow rate of seven liters. On 08/10/21 at 9:37 a.m., LPN #1 was asked how many liters of oxygen the resident was to receive. He stated two liters. He was asked if she had the oxygen on now. He said he did not know. He entered the resident's room and observed her to be wearing her oxygen cannula and observed her concentrator. He stated, She has it on, and it is set to seven liters. He then turned off the concentrator. The resident stated, Hey, I need that on. The nurse turned it back on and turned the flow rate down to two liters. He did not assess the resident or ask any questions. He was asked when her blood oxygen saturation was last checked. He stated, Well, not today, and left the room. He returned with a blood oxygen saturation meter. He obtained a reading and stated it was 96%. At 9:47 a.m., he was asked what the diagnosis was for her oxygen orders. He stated one order was for comfort and respiratory distress, and the other was for COPD. He was asked if there were risks or dangers associated for a resident with COPD to be on high levels of oxygen. He stated, Yes, I'm going to contact the doctor or nurse practitioner. 2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease and chronic respiratory failure. A physician's order, dated 12/29/20, documented the resident was to have oxygen at 2 liters/minute per nasal cannula continuously. Review of physician orders and treatment sheets, dated 05/2021 through 07/2021, revealed no order to change the resident's oxygen tubing or documentation the tubing had been changed. On 08/04/21 at 3:35 p.m., 08/09/21 at 1:51 p.m., and 08/10/21 at 3:00 p.m., the resident was observed in her room. Her oxygen tubing was not dated. On 08/16/21 at 4:25 p.m., the assistant director of nursing (ADON) stated the facility's policy on changing oxygen tubing was to change it weekly. She stated the tubing should be labeled with the date, time, and initials of the person changing it. 3. Resident #41 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease. Physician orders, dated 06/07/21, documented to change the resident's oxygen tubing on the 10th and 25th of every month; however, there were no orders for oxygen therapy. Treatment sheets, dated 06/2021 and 07/2021, documented the oxygen tubing was changed as ordered by the physician. On 08/04/21 at 9:51 a.m., the resident was observed in his room. An oxygen concentrator was noted, with oxygen tubing dated 05/10/21. A physician's order, dated 08/10/21, documented the resident was to receive oxygen at 2 liters per minute, as needed, for shortness of breath. On 08/16/21 at 4:41 p.m., the ADON stated she did not know why staff had documented the oxygen tubing had been changed when it was not. She stated the facility's policy was to change the tubing weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide resident-centered dementia care to one (#19) of five sampled residents who were reviewed for unnecessary medications received care and services. The facility identified 12 residents as having a dementia diagnosis. Findings: The facility policy and procedure, dated [DATE], documented . Dementia Management . when a person with dementia behaves differently, this is often mistakenly seen as a direct result of dementia or simply as another symptom of the condition. However, this is often not the case. The behavior (such as memory loss, language or orientation problems), but also mental and physical health, habits, personality, interactions with others and the environment. Dementia can make the word a confusing and frightening place as the person struggles to understand what is going on around them. Though it may confuse the caregiver, the behavior will have meaning to the person with dementia . The person with dementia may be influenced by an environment that is unable to support or meet their needs. Disorientation is common feature of dementia, so an environment that is difficult to navigate and confusing can increase distress .Behavior may be an attempt to meet a need . When managing a situation where a person with dementia is behaving out of character, it is important not to see the behavior as just another symptom that needs treating. A problem-solving approach is needed to try to work out why the person's behavior has changed . It used to be that antipsychotic drugs were frequently prescribed to people with challenging behavior. while these may be appropriate and helpful in some situations they can suppress behavior without addressing the cause, and may add to the person's confusion . Resident #19 was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis, major depressive disorder, anxiety disorder, pseudobulbar affect, dementia without behavioral disturbances, and vascular dementia with behavioral disturbances. A nurse's note, dated [DATE] at 9:48 p.m., documented, . alert, oriented to name, speech clear, denies pain at this time, repetitive w/ [with] requests for help/assistance to bathroom, continues to turn call light on within only minutes of staff leaving room asking to be assisted with going to the bathroom and back to bed, does not void or have bm [bowel movement] with each trip to bathroom. staff strives to offer comfort and reassurance . staff strives to keep call light and personal items w/i [within] easy reach . A physician's order, dated [DATE], documented the resident was to receive Seroquel, an antipsychotic medication, 12.5 milligrams (mgs) by mouth at bedtime for dementia. A behavior note, dated [DATE] at 2:03 a.m., documented, . Resident AOX2 [alert and oriented to person and place] anxious, noted constantly for the past 2 nights ambulating from room to BNS [back nurses' station] every 5 minutes or so to ask this Nurse and staff if she can go back to bed and sleep, resident denies pain or needs, speech is clear, no s/s [signs or symptoms] of grimacing, distress, pain noted, resident noted confused, resident constantly redirected and encouraged, resident educated that she does not [sic] permission to get into her own bed and sleep, resident has been offered to sit at BNS lobby to watch TV to which she refuses stating she needs to go to bed- resident does go to room only to come back in approximate every 5 minutes to ask the same question of if she's allowed to go to bed and sleep . A physician order, dated [DATE], documented the resident was to receive Seroquel 25 mg by mouth at bedtime for dementia. A physician order, dated [DATE], documented the resident was to receive Buspar, an antianxiety medication, 10 mgs twice daily for anxiety. Review of the resident's clinical record revealed no documentation the facility attempted to identify or implement any resident specific, non-pharmalogical interventions before requesting an increase in the resident's Seroquel dose or the addition of Buspar. A behavior note, dated [DATE] at 2:30 a.m., documented, . Resident noted anxious coming from her room and up C -hall awakening several residents and up to BNS several times throughout the night, repeating 'can you help me' 'can you help me' 'I cant find my room' 'I get confused' resident has been assisted and oriented to room, resident insists staff to help her back in bed of which she got up from several times on her own, resident has been encouraged to do for herself while supervising by this Nurse and staff through the night, once resident is in bed, resident does not remain in bed and once again is noted in hallway coming up to staff keeping staff and this Nurse from working while invading their personal space, resident has been educated about personal space and to utilize c/l [call light]for staff assistance with little effect as resident again noted in hallway keeping this Nurse from moving nurse cart to perform job duties and resident care. several residents have complained stating 'that woman is keeping me up' resident c/o [complain of] shoulder pain of which prn [as needed] pain relief was administered, resident educated and encouraged to get rest as prn pain relief will not work if resident continues using shoulder- education and encouragement unsuccessful . Review of the resident's clinical record revealed a faxed communication to the resident's physician. The fax, dated [DATE], documented, . resident has been up all night noted anxious repeatedly at BNS stating she needs finding her room & needing help back into bed of which she has gotten up from by herself - resident does not rest - has been keeping residents up this night-attached - behavior note current meds - buspirone [Buspar] 10 mg Seroquil [sic] 25 mg at HS, melatonin 5 mg 1 tab at HS Lexapro 10 mg at HS . A physician's order, dated [DATE], documented to increase the resident's Buspar to 15 mgs twice daily for anxiety. Review of the resident's clinical record revealed no documentation the facility attempted to identify or implement any resident specific, non-pharmalogical interventions before requesting an increase in the resident's Buspar dosage. A behavior note, dated [DATE] at 3:02 a.m., documented, . Resident noted to be following staff around interrupting them and also following staff into other residents' rooms while staff is attempting to provide care. Denies pain/discomfort, no grimacing or guarding noted at this time. Skin clean and dry, brief is clean and dry and resident doesn't require any assistance to the restroom as she is ambulatory and continent of bowel and bladder and denies offer for help to restroom. Staff frequently assists resident back to own room and resident continues to come up to nurses station and to interrupt staff attempting to work. Difficult to redirect . A health status note, dated [DATE] at 5:27 a.m., documented, . Faxed [physician name withheld] r/t [related to] increased anxiety and resident request for new medication . Review of the resident's clinical record revealed a faxed communication to the resident's physician. The fax, dated [DATE], documented, . Resident c/o anxiety and restlessness. Asks if there is something she can take for her anxiety and insomnia. Resident noted to be up all hours of the night multiple nights a week. Resident is inconsolable. Any suggestions ??? . A physician's order, dated [DATE], documented the resident was to receive Trazodone, an antidepressant, 50 mgs at bedtime for depression and to increase the resident's Buspar dosage to 10 mg every six hours for anxiety. Review of the resident's clinical record revealed no documentation the facility attempted to identify or implement any resident specific, non-pharmalogical interventions before requesting pharmalogical intervention. A behavior note, dated [DATE] at 12:15 a.m., documented, . Resident noted restless and pacing up and down the hallways asking for help, staff assists resident and within 10 minutes resident is interrupting staff while they are working to ask for help in same area. E.G. Staff makes bed for resident, resident comes back to nurses station insisting bed has no linens, however bed has fresh clean linens, recently placed by staff. Argues with staff about assistance provided. Inconsolable. Staff strives to assist resident with needs, resident is continent, has a clean brief on. No s/s of pain and verbally denies pain. Staff will continue to monitor . A physician's order, dated [DATE], documented the resident was ordered Vistaril (hydroxyzine), an antihistamine medication, 25 mgs one every six hours to treat anxiety. A health status note, dated [DATE] at 5:03 a.m., documented, . Focused assessment r/t COVID 19 ISOLATION. Resident noted to be noncompliant with isolation, repeatedly comes off of unit to ask for assistance with simple things such as pulling blankets back up, resident demonstrated to this nurse that she can, in fact, pull her own blankets up, despite constant requests to staff . Skin warm and dry, afebrile. Fresh fluids and call light within easy reach . Review of the resident's clinical record revealed a faxed communication to the resident's physician. The fax dated [DATE], documented, . [resident name withheld] . 605 Am Telling staff she fell in the floor. Discoloration to knees light purple. Raised area to back of head . unsure if this is new . A behavior note, dated [DATE] at 8:41 a.m., documented, . Resident unable to stay in her room, she is in contact isolation. Following nurseing [sic] staff around from room to room. States that she needs to lay down and that she needs help. Staff provide assistance, however before staff can make it out of the room resident uncovers herself and walks out of the room following staff. Resident has been out of the isolation unit multiple times. [Nurse practitioner name withheld] notified and stated that as soon as the facility can the resident needed to go to geri psych [geriatric psychiatric] for eval [evaluation]. Also gave verbal orders for hydroxyzine HCl Tablet 25 MG Give 2 tablet by mouth every 6 hours related to anxiety disorder . Resident redirected as much as possible to say [sic] in her room . An activities progress note, dated [DATE] at 9:05 a.m., documented, . [nurse practitioner name withheld] called facility to have this nurse call pharmacy for recommendation [sic] on medication changes. Pharmacy [name withheld] notified of residents anxiety and behaviors. Stated to left [sic] [nursing practitioner name withheld] know that she can increase Buspar to 15 mg and/or increase his [sic] Trazodone to 100 mg. [Nurse practitioner name withheld] stated to just increase the Buspar for right now and we can see how she does . A physician order, dated [DATE], documented to increase the resident's Buspar dosage to 15 mgs every six hours for anxiety. Review of the resident's clinical record revealed no documentation the facility attempted to identify or implement any resident specific, non-pharmalogical interventions before requesting pharmalogical intervention for the resident's behaviors. A behavior note, dated [DATE] at 3:24 a.m., documented, . resident noted coming out of isolation room and out of isolation hall (E unit) into D hall hallway 9 times this night, despite being oriented and educated that resident must remain in contact isolation as precautions r/t global pandemic COVID-19, resident alert, oriented X 3 with ongoing episodes of restlessness and anxiety nods head in 'Yes' goes back into isolation hallway only to come out again stating she needs help to get back into room of which she has been taken to by staff and this nurse various times, resident has been educated to utilize call light for staff assistance of which resident has demonstrated to use prior, resident again educated and reoriented to remain in isolation as per order without success . Review of the residents clinical record, documented the resident was hospitalized to a psychiatric hospital from [DATE] to [DATE]. A physician's order, dated [DATE], documented the resident was to receive lorazepam, an antianxiety medication, 0.5 mgs three times daily for anxiety and Seroquel 100 mg every day for major depressive disorder. The lorazepam was an additional medication to the resident's medication regimen. The diagnosis for the use of Seroquel was changed from dementia to major depressive disorder, and the time of administration was changed from bedtime to daily. A health status note, dated [DATE] at 8:18 p.m., documented, . Res up and down the hallway repetitively, asking staff to put her to bed, after being assisted to bed resident gets up and finds someone to put her to bed again. Resident was put to bed multiple times without success. CMA [certified medication aide] gave medication for the night, then CNA [certified nurse aide] assisted resident. Ambulated outside facility with CNA supervision for some fresh air and re-direction away from being put to bed. CNA provided one on one for 15 min and resident then assist back to bed . A health status note, dated [DATE] at 7:34 pm., documented, . One on one sitter for part of this 2-10 shift, sitting in sun room for evening meal, denies pain, tolerated well. Stayed with the sitter without complaints . A behavior note, dated [DATE] at 6:39 p.m., documented, . Resident up and down the hallways following staff. [Nurse practitioner name withheld] notified of residents behaviors and that resident often has a sitter. New orders for Lorazepam Tablet 0.5 MG Give 1 tablet by mouth every 24 hours as needed for anxiety related to anxiety disorder . CMA notified and PRN to be given. [Nurse practitioner name withheld] stated that she can still have her routine Lorazepam when it is due and that there is no need to wait to give the medication . A physician's order, dated [DATE], documented the resident was to receive Lorazepam, 0.5 mg one tab every 24 hours as needed for anxiety, in addition to her routine dosages. Review of the resident's clinical record revealed when the resident specific intervention of one on one with staff was implemented, the resident had a decrease in behaviors. There was no documentation to show any resident specific, non-pharmalogical interventions were in place when the staff notified the nurse practitioner on [DATE]. There was no documentation to show any other resident specific, non-pharmalogical interventions were identified or implemented for the resident. A pharmacy medication regimen review, dated [DATE], documented the resident received the following medications: ~ Trazodone - 50 mg at bed time; ~ Buspar - 15 mg four times daily; ~ Hydroxyzine 50 mg every six hours; ~ Lorazepam 0.5 mg three times daily; and ~ Seroquel 100 mg nightly. The medication regimen review documented, . This resident is at risk for falls based on the current medication profile. Please consider reducing one of the following meds which are being administered at bedtime . Facility inservice records, dated [DATE], documented the facility held an educational session on pain and dementia. Review of the resident's clinical record revealed a faxed communication to the resident's physician. The fax dated [DATE], documented, . Res with increasing anxiety, restlessness Res is following staff into other patients room. Res with repetitive questions/statements about anxiety, restlessness, stomach c/o prn meds given with minimal effectiveness. Staff attempts to do redirect unsuccessful. Unwilling to do any activities is staying in her room. Only comes out of room when she hears staff in the hallway. Please Advise . On [DATE], the nurse practitioner responded to the pharmacist's request on [DATE] with an order to decrease the resident's Buspar to 10 mgs four times daily. Review of the resident's clinical record revealed a faxed communication to the resident's physician. The fax dated [DATE], documented, . Resident has shown increased agitation, has been following staff into other resident rooms, and yelling at staff to assist her to bed. Multiple attempts have been made to redirect resident -w no success. Resident was found jogging down the hall in attempt to catch up to a staff member. Resident has been flailing arms around causing resident to lose balance, and has been grabbing staff members by the arm. I've attached a medication list to review. Thanks . The physician responded . 1/ DC [discontinue]Trazodone 2/ increase Anafranil [antidepressant] to 50 mg at HS [hour of sleep] . A health status note, dated [DATE] at 12:38 p.m., documented, . Agitated. Resident is concerned her room mate is being harmed. Refuses to go back to her room at the moment. Is not tolerating room change well. Staff will continue to monitor . An initial behavior progress note, dated [DATE] at 3:07 p.m., documented, . Resident pacing and screaming at staff that she can not stay there and live the way she does. Very argumentative upon trying to redirect. Non-medication Interventions attempted: Redirection, distraction with activities painting nails and listening to music . Response to intervention: As long as activity was going on no behaviors, as soon as activity was over became very argumentative and very defensive . [nurse practitioner name withheld] notified . A physician's order, dated [DATE], documented the resident was to receive Lorazepam, 0.5 mg one time only. A health status note, dated [DATE] at 1:40 a.m., documented, . Lying in bed with eyes closed easily aroused with verbal stimuli. Alert and oriented x 2. Speech clear. Resident stated 'one of my dx [diagnosis] has come back I have diarrhea I'm sorry.' No c/o's [complaints] voiced r/t room change. staff strives to keep call light and water in easy reach . A behavior note, dated [DATE] at 8:15 a.m., documented, . resident keeps putting on call light and complaining about breakfast and not being able to eat it. observed that resident had eaten all of her cereal and part of boiled egg. States that the cereal is too mushy and the milk is sour. milk is not expired and attempted to show resident and she got hatful [sic] and started getting loud. asked if she would like something else and she stated 'no, just take this away' . A health status note, dated [DATE] at 9:56 a.m., documented, . continuously agitated this shift and demands anxiety medication. was given anxiety medication routinely as prescribed this morning by CMA [certified medication aide] already and was informed that she can only have it as it is prescribed . A health status note, dated [DATE] at 10:57 a.m., documented, . Resident demanding to go to hospital for her head. she states that she is having a stroke. resident has had a stroke in the past and ever since has been very worried that she is having another one. Nurse does not observe any s/s of stroke at this time . have redirected resident to dining room for lunch after calling her [family member] and calming down a little . A behavior note, dated [DATE] at 11:06 a.m., documented, . resident stated that she has not been given a bath in 3 wks [weeks] or been taken care of at all. demands to go to the hospital so she can get a bath. have redirected numerous times that there is not a reason for her to go to the hospital right now. she is now demanding that she starts therapy today or she is going to find another place to live . A behavior note, dated [DATE] at 11:33 a.m., documented, . focused assessment r/t residents behavior. resident kept coming to the desk stating she needed to go to the hospital because her stomach hurt, just like it did when she had her stroke. resident medicated for upset stomach, she then stated she hadn't had a BM in a couple of days, and she needed to go to the hospital. resident medicated for constipation. residents room mate keeping resident stirred up . An annual assessment, dated [DATE], documented the resident was moderately impaired with cognition and required limited assistance with activities of daily living (ADLs). The assessment documented the resident had no behaviors during the assessment period. The assessment documented the resident received an antipsychotic, antianxiety, and an antidepressant medication on seven days out of the seven day look back period. The assessment documented the resident had following diagnoses: cerebrovascular accident, dementia, anxiety disorder, depression, insomnia, and pseudobulbar affect. A social services progress note, dated [DATE] at 2:43 p.m., documented, . res [resident] enjoys coloring & doing word puzzles as tolerated, at times confused & needs much redirecting but carries good conversation, ambulates well, this SSD [social services director] offers water/snacks, assists with phone calls to [family member] & carries casual conversation with res in room, SS [social services] will monitor for social depression during this time of social distancing & continue to provide one on one visits . A physician's order, dated [DATE], documented the resident was to receive Seroquel 100 mg at bedtime for psychosis. This was a change in diagnosis for the use of the medication from depressive disorder. A behavior note, dated [DATE] at 7:31, documented, . resident yelling at staff to, 'send me out, I don't wanna be here.' resident then yelled at nearby aide, 'i don't know why you don't put me in bed.' encouraged resident that she is capable enough to help herself to bed as she is independent enough to do so. resident became frustrated and began crying demanding that she be released. resident states, 'Do you want me to break down that door,' while holding up both fists. this nurse asked resident to take a walk until she can calm down. resident has already received all medication. continues to cry and states, 'I didn't do anything.' . A quarterly assessment, dated [DATE], documented the resident was severely impaired with cognition and required limited assistance with activities of daily living. The assessment documented the resident had physical and verbal behaviors on one to three days during the assessment period. The assessment documented the resident received an antipsychotic, antianxiety, and an antidepressant medication on seven days out of the seven day look back period. A behavior note, dated [DATE] at 5:48 p.m., documented, . resident following staff and yelling, 'I need a shower.' explained to resident that she'll have to wait until a staff member is available to assist her. allowed resident to make outgoing call to her [family member]. resident hung up phone and walked away from desk. resident noted to be stopping aides that were assisting other residents and asking them to take her to her room. when told that she is independent enough to take herself back to her room, she began to cry. this nurse stepped away from desk to assist another resident, reported by nearby aide that resident was at the phone making another outgoing call but hung up quickly when she was approached. received call from Muskogee Police Department shortly after that resident had made a call with the statement, 'I'm lost, I need help back to my room.' and hung up. when asked about the situation, resident raised hand and said, 'yes, I guess that was me that did it.' . A physician order, dated [DATE], documented Lorazepam, 0.5 mg twice daily for anxiety and Buspar, 10 mg three times daily for anxiety. This was a reduction in dosages for both medications even though the resident was continuing with the same behaviors the medications were originally prescribed for. Facility inservice records, dated [DATE], documented the facility held an educational session on pain and dementia. The resident's care plan, dated [DATE], documented a problem related to the resident having feelings of anxiety, fear, confusion associated with dementia, cerebrovascular accident (CVA), and altered mental status. The care plan documented the resident will have behavioral problems identified and preventive measures implemented to minimize labile emotions by the review date. The care plan documented to administer medications as prescribed, monitor for effectiveness, side effects and adverse drug reactions. The care plan documented a problem related to the diagnosis of pseudobulbar effect. It was documented, I have a chemical imbalance in the brain that effects my emotions . The goals included the resident would experience improved emotional control through the review date. Interventions included to administer medications as ordered, allow the resident the freedom to sit in a chair near the window or nurses' station, allow wandering in a controlled environment, approach the resident in a consistent manner, avoid or terminate emotionally charged situation or conversations, and avoid the expectation of the resident to remember or follow instructions. Another problem was documented as altered thought processes. It was documented, . I am experiencing confusion, inappropriate behaviors . The goal was the resident would be free from side effects and/or adverse reactions from antipsychotics through the review date. Interventions included to administer medications as prescribed and to monitor for adverse drug reactions. Review of the resident's clinical record revealed no psychotropic medication side effect monitoring for 01/2020, 04/2020, 09/2020, 11/2020, or 12/2020. From 01/2021 through 07/2021, the only month when side effect monitoring occurred was 04/2021. Review of the resident's clinical record revealed from 02/2020 through 07/2021, revealed no resident specific, non-pharmalogical interventions had been identified or implemented to help the resident with her behaviors, except for two instances when the resident was provided one on one interaction with the staff. Each time, it was documented the intervention was successful. A behavior note, dated [DATE] at 4:27 a.m., documented, . this Nurse in process of passing routine medication. resident again in hallway asking assistance into bed and with blankets of which resident has proven to do with no issue when encouraged and watched while she does so. this time resident has been following this Nurse and has been standing behind Nurse while this Nurse is pulling medication out while resident continues to ask assistance into bed again. resident educated that staff is not to be interrupted while in process of meds/giving meds with no success as resident continues to follow event stopping at other roommates doorway to stand there. doors of other resident's closed for privacy as per procedure. resident once again assisted into bed only to note resident out in hallway in search of staff to ask assistance with getting into bed. at this time, encouragement, education, orientation all unsuccessful as resident continues with said behavior . A behavior note, dated [DATE] at 3:37 a.m., documented, . [3:35 a.m.] resident noted walking in hallway from FNS [front nurses' station] desk to BNS. resident AOX2, calm with no s/s if [sic] pain, needs or distress noted is now stating 'I can't sleep, my blankets are all twisted up, I'm just not sleepy. resident encouraged to sit at BNS where TV was turned on for entertainment, resident reluctantly agreed but for only a brief moment stating she wanted to go back to bed. resident now in bed being assisted with blankets but encouraged to help as resident AOX2, ambulatory is able to so with no issue. resident's roommate again noted annoyed stating she would like to rest. roommate again apologized to for continuously need to entering room and use of call light. resident's c/l and fluids within reach. 0335 and 0338 resident again noted in hallway, call light room not on, resident again stating her blankets are all twisted up 0351 resident again encouraged and welcomed to sit BNS, only to sit for a very short brief moment, stating I'm going back to my room, can you help me? resident assisted to room X 3 times and encouraged to get some rest as well as to allow roommate some rest. c/l and fluids within reach. [linked] Nursing A behavior note, dated [DATE] at 2:14 a.m., documented, . Since the beginning of shift change, resident AOX2, has been noted on call light, each time call light is answered, resident is noted stating to either forger [sic] reason for call light or is noted thinking of a reason then. Each time that call light is answered resident denies pain/discomfort, no s/s of pain, grimacing, distress noted each time. this Nurse in room to answer call light after CNA notified this Nurse that resident stated she was wanting more 'Tums'. resident stated she had went to the restroom but only has a small bowel movement and so she needed tums. resident educated/oriented that order for tums of which she has is routine and that last dose was at [7:00 p.m.]. resident also educated that tums were not for her bowel movements. resident was asked if she was experiencing s/s of constipation of which she denied. [12:42 a.m.] this Nurse in room to pass medication for resident's roommate. upon assessment of roommate's VS, resident is over heard in bed calm AOX2, 'can I ask you a question', 'can I ask you a question' resident notified by this Nurse that once done with roommate's assessment and medication pass, this Nurse would be over to her side of the room to address question/needs. this Nurse now over to resident's room side. resident in bed AOX2, calm, stating 'uh, uh, oh! I'm feeling feverish and I don't know what to do' speech is clear. denies pain at this time. skin is warm and dry with no s/s of excess skin warmth . resident notified of current temp and VS, resident then stating she would now be getting some rest, c/l and fluids within reach. [2:15 a.m.] this Nurse answers call light, notes resident in bed stating 'oh that's me hun, I pressed the call light' resident then states 'I don't know what's wrong with me' speech is clear. denies pain but states 'maybe I can have some that milk of mag' resident asked if she is straining to have an bowel movement, to which resident states 'well I haven't gone to the restroom since last time' resident educated that milk of magnesium is a laxative and should only be taken for constipation. resident encouraged to voice s/s of constipation; straining. c/l and fluids within reach. [2:45 a.m.] resident's call light noted just on and then resident walking inti [sic] hallway towards Nurse's station. resident educated that call light would promptly be answered. resident AOX2 at Nurses' station rubbing at stomach, arms and looking down at feet. resident asked if she was in pain anywhere, resident then states 'ugh I don't know, I just can't relax' resident offered and welcomed to come at BNS lobby to watch TV if she is not sleepy, resident refused. resident then asked to bed assisted back to room by CNA. c/l and fluids within reach . On [DATE] at 8:46 a.m., the resident was laying on her bed under the blanket facing the wall. She stated she was tired and would rather take her nap this morning than do an interview. On [DATE] at 2:09 p.m., the resident was observed in the hallway. She asked, Do I go wait for dinner? The surveyor informed the resident it was not time for dinner. The [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #33 was admitted to the facility on [DATE] with diagnoses that included constipation. A physician order, dated [DATE], documented to administer one suppository of biscodyl 10 milligrams (mg) every four hours as needed for constipation. On [DATE] at 8:52 a.m., registered nurse (RN) #1/care plan coordinator, was at a treatment cart next to the resident's room. She was asked if she had any medications to administer. She stated yes, she had a suppository to administer and picked it up off the cart to show. She was asked to provide the bag for the suppository, with its' labeling. She checked the refrigerator in the medication room and did not locate a bag for the resident. She was asked where she had gotten the suppository. She stated it was loose in the refrigerator. She was asked if she was going to administer the medication to the resident. She stated, Yes, but I didn't. On [DATE] at 9:28 a.m., the assistant director of nursing (ADON) was asked when the resident had last received a biscodyl suppository. She reviewed the resident's medication administration records (MARs) and stated, He has never received the medication. It must have come from the hospital. She was asked when it was last ordered. She stated [DATE]. She was asked what should happen to loose medications. She stated, It should have been destroyed. She was asked what happened if an as needed (PRN) medication had not been administered over a period of time. She stated usually the pharmacist will recommend to discontinue them. She was asked if the resident's order was active. She stated yes. She was informed that RN #1 had obtained a suppository that was loose in the medication refrigerator and had it on her cart to administer to resident #33. She was asked if the nurse was going to administer it. She stated she hoped not. She was asked if the care plan coordinator nurse had received any training on the floor. She stated, She had one day of one on one training and I've tried to help her as I could today. 3. Resident #7 was admitted to the facility on [DATE] with diagnoses that included diabetes type two. A physician's order, dated [DATE], documented the resident was to administer 25 units of Novolog solution three times a day subcutaneously related to diabetes type two. A physician's order, dated [DATE], documented to administer Novolog solution per a sliding scale subcutaneously before meals and at bedtime related to diabetes type two. On [DATE] at 11:22 a.m., RN #1/Care Plan Coordinator asked resident #7 if she had already had lunch. The resident stated she had. The nurse proceeded to check the resident's blood sugar level. RN #1 stated the blood sugar level was 431. She stated, This resident has a Flex pen, they use it for both the sliding scale and her routine insulin. RN #1 stated the resident was to receive a total of 37 units of insulin, according the her blood sugar reading, sliding scale, and routine order. She stated, I don't like using the Flex pen, I don't feel they [the resident] get the correct dose. She cleaned the tip of the pen with an alcohol wipe, and used an insulin syringe to pierce the end of the pen. She injected air from the insulin syringe into the Flex pen, and withdrew up 37 units of insulin from the pen. She then administered the medication to the resident. She recapped the flex pen and placed it back in the drawer next to another resident's pen. It was not placed into an individual bag. On [DATE] at approximately 1:00 p.m., the director of nursing (DON) was informed of the nurse drawing insulin out of an insulin pen instead of using the pen to inject the resident with the insulin. He stated he was unaware the practice was not acceptable. He stated he had done the same in the past. Based on observation, interview, and record review, it was determined the facility failed to: ~ obtain anticoagulant medications for administration as ordered by the physician for one (#68) of six residents whose medications were reviewed. The facility identified 61 residents as receiving medications; ~ ensure unlabeled medications were not administered for one (#33) of 10 sampled residents who were observed receiving medications. The facility identified 61 residents as receiving medications; and ~ ensure insulin was administered using safe medication practices for one (#33) of four sampled residents who were observed receiving fingerstick blood sugar checks. The facility identified 17 residents as receiving fingerstick blood sugar checks. Findings: The Institute for Safe Medication Practices [Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults. Institute for Safe Medication Practices. (2017, [DATE]). http://www.ismp.org.] website documented, . The manufacturers do not recommend the withdrawal of medication from the pen, except in an emergency with a malfunctioning pen. In these instances, the pen should then be discarded, even if insulin remains in the pen . Large pockets of air have been observed in cartridges of insulin pen injectors after aspirating some of the drug with a needle. If the pen injector or cartridge is not discarded, and the air is not eliminated before delivering a subsequent dose, the patient could receive less than the desired dose of insulin as well as a subcutaneous injection of air . 1. Resident #68 was admitted to the facility on [DATE] with diagnoses that included atrial flutter, chronic embolism, and deep vein thrombosis. A hospital history and physical report, dated [DATE] and located in the facility's scanned documents, documented, . PMH [past medical history] of . atrial fibrillation previously on Eliquis who presents . with CC [chief complaint] of numbness and tingling to her left lower leg . intermittent numbness and tingling to left lower leg and occasionally similar symptoms to the right lower leg and bilateral wrists. Her symptoms have been progressive. Over the last month, she has had more constant numbness and tingling to the left lower leg and foot. She now reports a cold feeling to the limb. She had not previously sought medical attention after losing her job and health insurance . No chest pain or shortness of breath . palpitation intermittently. She stopped taking her Eliquis about 3 to 5 days ago after running out of medication . A hospital discharge documentation, dated [DATE] and located in the facility's scanned documents, documented, . Your Diagnosis[:] Atrial Flutter, physical deconditioning, right leg deep vein thrombosis (DVT) . multiple rib fractures due to CPR, pneumonia, acute hypoxemic respiratory failure, cardiogenic shock, acute intraoperative massive pulmonary embolism - s/p [status post] catheter direct TPA [tissue plasminogen activator, used to dissolve blood clots] thrombolysis, subacute thrombotic occlusion of the left iliac artery and left femoral-popliteal trifurcation vessels, acute kidney injury, anemia, hypertension, hypertension, hypokalemia,, moderate aortic regurgitation, ventricular septal defect, multiple fractures of ribs . Discharge physician orders documented the resident was to receive Apixaban (Eliquis, an anticoagulant) 5 milligrams (mgs) twice daily for the prevention of blood clots. A medication administration note, dated 05//13/21 at 8:23 p.m., documented, . waiting on pharmacy . A medication administration note, dated [DATE] at 9:10 a.m., documented, . Apixaban Tablet 5 MG Give 1 tablet by mouth two times a day related to chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity . A medication administration note, dated [DATE] at 9:44 a.m., documented, . Pharmacy notified that medication Apixaban has not made it to facility, pharmacist stated the medication needed insurance approval and he would be sending a form over to the facility to fill out. Apixaban Tablet 5 MG placed on hold until paperwork can be submitted to insurance . Review of facility medication administration records revealed the resident did not receive Eliquis, as ordered by the physician from admission on [DATE] until 8:00 p.m. on [DATE]. On [DATE] at 10:36 a.m., the director of nursing (DON) and assistant director of nursing (ADON) were asked when the resident received her first dose of Eliquis. The ADON stated, The number 5 means it wasn't here. She stated the resident received the first dose of Eliquis at 8:00 p.m. on [DATE]. They were asked why the resident had physician orders for Eliquis. The ADON stated, DVT [deep vein thrombosis]. They were asked what kind of consequences could occur if a resident did not receive the ordered Eliquis. The ADON stated a blood clot could to go the brain, the heart, or cause a stroke. On [DATE] at 11:09 a.m., the resident's physician was asked if the facility notified him the pharmacy had not delivered the resident's Eliquis and that the resident had missed dosages from admission until the 8:00 p.m. dose on [DATE]. He stated he did not recall, but they may have. He was asked what the dangers were of the resident not receiving her Eliquis. He stated, They certainly could have a PE [pulmonary embolism] or stroke. On [DATE] at 11:21 a.m., the administrator stated the pharmacy would generally call her and inform her if a medication was not approved by insurance, and she would authorize them to send the medication, and the facility would absorb the cost. She stated she always approved a medication, and had never let cost or anything else prevent her from giving the authorization. She was asked if the staff had informed her the resident did not have her Eliquis. She stated, Not that I recall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to identify and implement non-pharmalogical interventions before initiating psychotropic medications and/or failed to monitor for adverse consequences of psychotropic medications for two (#19 and #53) of five sampled residents reviewed for unnecessary medications. The facility identified 62 residents as receiving psychotropic medications. Findings: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis, major depressive disorder, anxiety disorder, pseudobulbar affect, dementia without behavioral disturbances, and vascular dementia with behavioral disturbances. A nurse's note, dated [DATE] at 9:48 p.m., documented, . alert, oriented to name, speech clear, denies pain at this time, repetitive w/ [with] requests for help/assistance to bathroom, continues to turn call light on within only minutes of staff leaving room asking to be assisted with going to the bathroom and back to bed, does not void or have bm [bowel movement] with each trip to bathroom. staff strives to offer comfort and reassurance . staff strives to keep call light and personal items w/i [within] easy reach . A physician's order, dated [DATE], documented the resident was to receive Seroquel, an antipsychotic medication, 12.5 milligrams (mgs) by mouth at bedtime for dementia. A behavior note, dated [DATE] at 2:03 a.m., documented, . Resident AOX2 [alert and oriented to person and place] anxious, noted constantly for the past 2 nights ambulating from room to BNS [back nurses' station] every 5 minutes or so to ask this Nurse and staff if she can go back to bed and sleep, resident denies pain or needs, speech is clear, no s/s [signs or symptoms] of grimacing, distress, pain noted, resident noted confused, resident constantly redirected and encouraged, resident educated that she does not [sic] permission to get into her own bed and sleep, resident has been offered to sit at BNS lobby to watch TV to which she refuses stating she needs to go to bed- resident does go to room only to come back in approximate every 5 minutes to ask the same question of if she's allowed to go to bed and sleep . A physician order, dated [DATE], documented the resident was to receive Seroquel 25 mg by mouth at bedtime for dementia. A physician order, dated [DATE], documented the resident was to receive Buspar, an antianxiety medication, 10 mgs twice daily for anxiety. Review of the resident's clinical record revealed no documentation the facility attempted to identify or implement any resident specific, non-pharmalogical interventions before requesting an increase in the resident's Seroquel dose or the addition of Buspar. A behavior note, dated [DATE] at 2:30 a.m., documented, . Resident noted anxious coming from her room and up C -hall awakening several residents and up to BNS several times throughout the night, repeating 'can you help me' 'can you help me' 'I cant find my room' 'I get confused' resident has been assisted and oriented to room, resident insists staff to help her back in bed of which she got up from several times on her own, resident has been encouraged to do for herself while supervising by this Nurse and staff through the night, once resident is in bed, resident does not remain in bed and once again is noted in hallway coming up to staff keeping staff and this Nurse from working while invading their personal space, resident has been educated about personal space and to utilize c/l [call light]for staff assistance with little effect as resident again noted in hallway keeping this Nurse from moving nurse cart to perform job duties and resident care. several residents have complained stating 'that woman is keeping me up' resident c/o [complain of] shoulder pain of which prn [as needed] pain relief was administered, resident educated and encouraged to get rest as prn pain relief will not work if resident continues using shoulder- education and encouragement unsuccessful . Review of the resident's clinical record revealed a faxed communication to the resident's physician. The fax, dated [DATE], documented, . resident has been up all night noted anxious repeatedly at BNS stating she needs finding her room & needing help back into bed of which she has gotten up from by herself - resident does not rest - has been keeping residents up this night-attached - behavior note current meds - buspirone [Buspar] 10 mg Seroquil [sic] 25 mg at HS, melatonin 5 mg 1 tab at HS Lexapro 10 mg at HS . A physician's order, dated [DATE], documented to increase the resident's Buspar to 15 mgs twice daily for anxiety. Review of the resident's clinical record revealed no documentation the facility attempted to identify or implement any resident specific, non-pharmalogical interventions before requesting an increase in the resident's Buspar dosage. A behavior note, dated [DATE] at 3:02 a.m., documented, . Resident noted to be following staff around interrupting them and also following staff into other residents' rooms while staff is attempting to provide care. Denies pain/discomfort, no grimacing or guarding noted at this time. Skin clean and dry, brief is clean and dry and resident doesn't require any assistance to the restroom as she is ambulatory and continent of bowel and bladder and denies offer for help to restroom. Staff frequently assists resident back to own room and resident continues to come up to nurses station and to interrupt staff attempting to work. Difficult to redirect . A health status note, dated [DATE] at 5:27 a.m., documented, . Faxed [physician name withheld] r/t [related to] increased anxiety and resident request for new medication . Review of the resident's clinical record revealed a faxed communication to the resident's physician. The fax, dated [DATE], documented, . Resident c/o anxiety and restlessness. Asks if there is something she can take for her anxiety and insomnia. Resident noted to be up all hours of the night multiple nights a week. Resident is inconsolable. Any suggestions ??? . A physician's order, dated [DATE], documented the resident was to receive Trazodone, an antidepressant, 50 mgs at bedtime for depression and to increase the resident's Buspar dosage to 10 mg every six hours for anxiety. Review of the resident's clinical record revealed no documentation the facility attempted to identify or implement any resident specific, non-pharmalogical interventions before requesting pharmalogical intervention. A behavior note, dated [DATE] at 12:15 a.m., documented, . Resident noted restless and pacing up and down the hallways asking for help, staff assists resident and within 10 minutes resident is interrupting staff while they are working to ask for help in same area. E.G. Staff makes bed for resident, resident comes back to nurses station insisting bed has no linens, however bed has fresh clean linens, recently placed by staff. Argues with staff about assistance provided. Inconsolable. Staff strives to assist resident with needs, resident is continent, has a clean brief on. No s/s of pain and verbally denies pain. Staff will continue to monitor . A physician's order, dated [DATE], documented the resident was ordered Vistaril (hydroxyzine), an antihistamine medication, 25 mgs one every six hours to treat anxiety. A health status note, dated [DATE] at 5:03 a.m., documented, . Focused assessment r/t COVID 19 ISOLATION. Resident noted to be noncompliant with isolation, repeatedly comes off of unit to ask for assistance with simple things such as pulling blankets back up, resident demonstrated to this nurse that she can, in fact, pull her own blankets up, despite constant requests to staff . Skin warm and dry, afebrile. Fresh fluids and call light within easy reach . Review of the resident's clinical record revealed a faxed communication to the resident's physician. The fax dated [DATE], documented, . [resident name withheld] . 605 Am Telling staff she fell in the floor. Discoloration to knees light purple. Raised area to back of head . unsure if this is new . A behavior note, dated [DATE] at 8:41 a.m., documented, . Resident unable to stay in her room, she is in contact isolation. Following nurseing [sic] staff around from room to room. States that she needs to lay down and that she needs help. Staff provide assistance, however before staff can make it out of the room resident uncovers herself and walks out of the room following staff. Resident has been out of the isolation unit multiple times. [Nurse practitioner name withheld] notified and stated that as soon as the facility can the resident needed to go to geri psych [geriatric psychiatric] for eval [evaluation]. Also gave verbal orders for hydroxyzine HCl Tablet 25 MG Give 2 tablet by mouth every 6 hours related to anxiety disorder . Resident redirected as much as possible to say [sic] in her room . An activities progress note, dated [DATE] at 9:05 a.m., documented, . [nurse practitioner name withheld] called facility to have this nurse call pharmacy for recommendation [sic] on medication changes. Pharmacy [name withheld] notified of residents anxiety and behaviors. Stated to left [sic] [nursing practitioner name withheld] know that she can increase Buspar to 15 mg and/or increase his [sic] Trazodone to 100 mg. [Nurse practitioner name withheld] stated to just increase the Buspar for right now and we can see how she does . A physician order, dated [DATE], documented to increase the resident's Buspar dosage to 15 mgs every six hours for anxiety. Review of the resident's clinical record revealed no documentation the facility attempted to identify or implement any resident specific, non-pharmalogical interventions before requesting pharmalogical intervention for the resident's behaviors. A behavior note, dated [DATE] at 3:24 a.m., documented, . resident noted coming out of isolation room and out of isolation hall (E unit) into D hall hallway 9 times this night, despite being oriented and educated that resident must remain in contact isolation as precautions r/t global pandemic COVID-19, resident alert, oriented X 3 with ongoing episodes of restlessness and anxiety nods head in 'Yes' goes back into isolation hallway only to come out again stating she needs help to get back into room of which she has been taken to by staff and this nurse various times, resident has been educated to utilize call light for staff assistance of which resident has demonstrated to use prior, resident again educated and reoriented to remain in isolation as per order without success . Review of the residents clinical record, documented the resident was hospitalized to a psychiatric hospital from [DATE] to [DATE]. A physician's order, dated [DATE], documented the resident was to receive lorazepam, an antianxiety medication, 0.5 mgs three times daily for anxiety and Seroquel 100 mg every day for major depressive disorder. The lorazepam was an additional medication to the resident's medication regimen. The diagnosis for the use of Seroquel was changed from dementia to major depressive disorder, and the time of administration was changed from bedtime to daily. A health status note, dated [DATE] at 8:18 p.m., documented, . Res up and down the hallway repetitively, asking staff to put her to bed, after being assisted to bed resident gets up and finds someone to put her to bed again. Resident was put to bed multiple times without success. CMA [certified medication aide] gave medication for the night, then CNA [certified nurse aide] assisted resident. Ambulated outside facility with CNA supervision for some fresh air and re-direction away from being put to bed. CNA provided one on one for 15 min and resident then assist back to bed . A health status note, dated [DATE] at 7:34 pm., documented, . One on one sitter for part of this 2-10 shift, sitting in sun room for evening meal, denies pain, tolerated well. Stayed with the sitter without complaints . A behavior note, dated [DATE] at 6:39 p.m., documented, . Resident up and down the hallways following staff. [Nurse practitioner name withheld] notified of residents behaviors and that resident often has a sitter. New orders for Lorazepam Tablet 0.5 MG Give 1 tablet by mouth every 24 hours as needed for anxiety related to anxiety disorder . CMA notified and PRN to be given. [Nurse practitioner name withheld] stated that she can still have her routine Lorazepam when it is due and that there is no need to wait to give the medication . A physician's order, dated [DATE], documented the resident was to receive Lorazepam, 0.5 mg one tab every 24 hours as needed for anxiety, in addition to her routine dosages. Review of the resident's clinical record revealed when the resident specific intervention of one on one with staff was implemented, the resident had a decrease in behaviors. There was no documentation to show any resident specific, non-pharmalogical interventions were in place when the staff notified the nurse practitioner on [DATE]. There was no documentation to show any other resident specific, non-pharmalogical interventions were identified or implemented for the resident. A pharmacy medication regimen review, dated [DATE], documented the resident received the following medications: ~ Trazodone - 50 mg at bed time; ~ Buspar - 15 mg four times daily; ~ Hydroxyzine 50 mg every six hours; ~ Lorazepam 0.5 mg three times daily; and ~ Seroquel 100 mg nightly. The medication regimen review documented, . This resident is at risk for falls based on the current medication profile. Please consider reducing one of the following meds which are being administered at bedtime . Review of the resident's clinical record revealed a faxed communication to the resident's physician. The fax dated [DATE], documented, . Res with increasing anxiety, restlessness Res is following staff into other patients room. Res with repetitive questions/statements about anxiety, restlessness, stomach c/o prn meds given with minimal effectiveness. Staff attempts to do redirect unsuccessful. Unwilling to do any activities is staying in her room. Only comes out of room when she hears staff in the hallway. Please Advise . On [DATE], the nurse practitioner responded to the pharmacist's request on [DATE] with an order to decrease the resident's Buspar to 10 mgs four times daily. Review of the resident's clinical record revealed a faxed communication to the resident's physician. The fax dated [DATE], documented, . Resident has shown increased agitation, has been following staff into other resident rooms, and yelling at staff to assist her to bed. Multiple attempts have been made to redirect resident -w no success. Resident was found jogging down the hall in attempt to catch up to a staff member. Resident has been flailing arms around causing resident to lose balance, and has been grabbing staff members by the arm. I've attached a medication list to review. Thanks . The physician responded . 1/ DC [discontinue]Trazodone 2/ increase Anafranil [antidepressant] to 50 mg at HS [hour of sleep] . A health status note, dated [DATE] at 12:38 p.m., documented, . Agitated. Resident is concerned her room mate is being harmed. Refuses to go back to her room at the moment. Is not tolerating room change well. Staff will continue to monitor . An initial behavior progress note, dated [DATE] at 3:07 p.m., documented, . Resident pacing and screaming at staff that she can not stay there and live the way she does. Very argumentative upon trying to redirect. Non-medication Interventions attempted: Redirection, distraction with activities painting nails and listening to music . Response to intervention: As long as activity was going on no behaviors, as soon as activity was over became very argumentative and very defensive . [nurse practitioner name withheld] notified . A physician's order, dated [DATE], documented the resident was to receive Lorazepam, 0.5 mg one time only. A health status note, dated [DATE] at 1:40 a.m., documented, . Lying in bed with eyes closed easily aroused with verbal stimuli. Alert and oriented x 2. Speech clear. Resident stated 'one of my dx [diagnosis] has come back I have diarrhea I'm sorry.' No c/o's [complaints] voiced r/t room change. staff strives to keep call light and water in easy reach . A behavior note, dated [DATE] at 8:15 a.m., documented, . resident keeps putting on call light and complaining about breakfast and not being able to eat it. observed that resident had eaten all of her cereal and part of boiled egg. States that the cereal is too mushy and the milk is sour. milk is not expired and attempted to show resident and she got hatful [sic] and started getting loud. asked if she would like something else and she stated 'no, just take this away' . A health status note, dated [DATE] at 9:56 a.m., documented, . continuously agitated this shift and demands anxiety medication. was given anxiety medication routinely as prescribed this morning by CMA [certified medication aide] already and was informed that she can only have it as it is prescribed . A health status note, dated [DATE] at 10:57 a.m., documented, . Resident demanding to go to hospital for her head. she states that she is having a stroke. resident has had a stroke in the past and ever since has been very worried that she is having another one. Nurse does not observe any s/s of stroke at this time . have redirected resident to dining room for lunch after calling her [family member] and calming down a little . A behavior note, dated [DATE] at 11:06 a.m., documented, . resident stated that she has not been given a bath in 3 wks [weeks] or been taken care of at all. demands to go to the hospital so she can get a bath. have redirected numerous times that there is not a reason for her to go to the hospital right now. she is now demanding that she starts therapy today or she is going to find another place to live . A behavior note, dated [DATE] at 11:33 a.m., documented, . focused assessment r/t residents behavior. resident kept coming to the desk stating she needed to go to the hospital because her stomach hurt, just like it did when she had her stroke. resident medicated for upset stomach, she then stated she hadn't had a BM in a couple of days, and she needed to go to the hospital. resident medicated for constipation. residents room mate keeping resident stirred up . An annual assessment, dated [DATE], documented the resident was moderately impaired with cognition and required limited assistance with activities of daily living (ADLs). The assessment documented the resident had no behaviors during the assessment period. The assessment documented the resident received an antipsychotic, antianxiety, and an antidepressant medication on seven days out of the seven day look back period. The assessment documented the resident had following diagnoses: cerebrovascular accident, dementia, anxiety disorder, depression, insomnia, and pseudobulbar affect. A social services progress note, dated [DATE] at 2:43 p.m., documented, . res [resident] enjoys coloring & doing word puzzles as tolerated, at times confused & needs much redirecting but carries good conversation, ambulates well, this SSD [social services director] offers water/snacks, assists with phone calls to [family member] & carries casual conversation with res in room, SS [social services] will monitor for social depression during this time of social distancing & continue to provide one on one visits . A physician's order, dated [DATE], documented the resident was to receive Seroquel 100 mg at bedtime for psychosis. This was a change in diagnosis for the use of the medication from depressive disorder. A behavior note, dated [DATE] at 7:31, documented, . resident yelling at staff to, 'send me out, I don't wanna be here.' resident then yelled at nearby aide, 'i don't know why you don't put me in bed.' encouraged resident that she is capable enough to help herself to bed as she is independent enough to do so. resident became frustrated and began crying demanding that she be released. resident states, 'Do you want me to break down that door,' while holding up both fists. this nurse asked resident to take a walk until she can calm down. resident has already received all medication. continues to cry and states, 'I didn't do anything.' . A quarterly assessment, dated [DATE], documented the resident was severely impaired with cognition and required limited assistance with activities of daily living. The assessment documented the resident had physical and verbal behaviors on one to three days during the assessment period. The assessment documented the resident received an antipsychotic, antianxiety, and an antidepressant medication on seven days out of the seven day look back period. A behavior note, dated [DATE] at 5:48 p.m., documented, . resident following staff and yelling, 'I need a shower.' explained to resident that she'll have to wait until a staff member is available to assist her. allowed resident to make outgoing call to her [family member]. resident hung up phone and walked away from desk. resident noted to be stopping aides that were assisting other residents and asking them to take her to her room. when told that she is independent enough to take herself back to her room, she began to cry. this nurse stepped away from desk to assist another resident, reported by nearby aide that resident was at the phone making another outgoing call but hung up quickly when she was approached. received call from Muskogee Police Department shortly after that resident had made a call with the statement, 'I'm lost, I need help back to my room.' and hung up. when asked about the situation, resident raised hand and said, 'yes, I guess that was me that did it.' . A physician order, dated [DATE], documented Lorazepam, 0.5 mg twice daily for anxiety and Buspar, 10 mg three times daily for anxiety. This was a reduction in dosages for both medications even though the resident was continuing with the same behaviors the medications were originally prescribed for. The resident's care plan, dated [DATE], documented a problem related to the resident having feelings of anxiety, fear, confusion associated with dementia, cerebrovascular accident (CVA), and altered mental status. The care plan documented the resident will have behavioral problems identified and preventive measures implemented to minimize labile emotions by the review date. The care plan documented to administer medications as prescribed, monitor for effectiveness, side effects and adverse drug reactions. The care plan documented a problem related to the diagnosis of pseudobulbar effect. It was documented, I have a chemical imbalance in the brain that effects my emotions . The goals included the resident would experience improved emotional control through the review date. Interventions included to administer medications as ordered, allow the resident the freedom to sit in a chair near the window or nurses' station, allow wandering in a controlled environment, approach the resident in a consistent manner, avoid or terminate emotionally charged situation or conversations, and avoid the expectation of the resident to remember or follow instructions. Another problem was documented as altered thought processes. It was documented, . I am experiencing confusion, inappropriate behaviors . The goal was the resident would be free from side effects and/or adverse reactions from antipsychotics through the review date. Interventions included to administer medications as prescribed and to monitor for adverse drug reactions. Review of the resident's clinical record revealed no psychotropic medication side effect monitoring for 01/2020, 04/2020, 09/2020, 11/2020, or 12/2020. From 01/2021 through 07/2021, the only month when side effect monitoring occurred was 04/2021. Review of the resident's clinical record revealed from 02/2020 through 07/2021, revealed no resident specific, non-pharmalogical interventions had been identified or implemented to help the resident with her behaviors, except for two instances when the resident was provided one on one interaction with the staff. Each time, it was documented the intervention was successful. On [DATE] at 8:46 a.m., the resident was laying on her bed under the blanket facing the wall. She stated she was tired and would rather take her nap this morning than do an interview. On [DATE] at 2:09 p.m., the resident was observed in the hallway. She asked, Do I go wait for dinner? The surveyor informed the resident it was not time for dinner. The resident asked if the surveyor could get her back to bed. She stated she needed help with her bed. At this time, a CNA approached the resident and asked her if she wanted to have her nails painted. The resident walked to her room, and the CNA began to paint her nails. At 3:01 p.m., the resident walked out of her room and showed the surveyor her fingernails. She stated she liked the color. On [DATE] at 1:55 p.m., CNA #1 stated staff walked the resident to lunch and helped her with a shower. CNA #1 stated the resident would tell staff when she went to the bathroom and when she had a bowel movement. CNA #1 stated there resident really did not have behaviors but had anxiety, getting up and down out of bed. CNA #1 stated the resident would ask for help to lie back down, and he would assist her, and she was good. On [DATE] at 2:01 p.m., licensed practical nurse (LPN) #3 stated the resident got agitated and anxious. She stated the resident was attention seeking and acted out. LPN #3 stated the resident like [NAME] and having her hair braided. She stated the resident was up and down and hard to console. On [DATE] at 2:07 p.m., the activities director (AD) stated the resident loved music, dancing, and one on one conversations, if staff would sit and interact with her. She stated the resident had a short attention span and needed a lot of praise. The AD stated the resident had chose to have her nails done on the previous day. On [DATE] at 3:06 p.m., the director of nursing (DON) and assistant director of nursing (ADON) were asked what non-pharmalogical interventions had been identified and implemented for the resident. The ADON stated the resident attended quite a few activities, and the staff had done some one on one with the resident. They were asked what they were doing to determine the source of the resident's behaviors. The DON stated she had a mental disease. The ADON stated it was due to a stroke affecting her brain. The DON and ADON were asked what they had done to find the root cause of the resident's behaviors regarding her bed linens. The ADON stated the resident was in and out of the bed several times a night, and the aides would go and straighten the bed linens five to six times per night. The ADON stated they would try distraction and redirection for the resident. She was asked how they communicated their findings to all staff members, including the night shift. She stated, We pass it on from one shift to the next. She stated the resident got up during the night and had the same behaviors. The ADON was asked if the resident could help her behaviors. She stated, No. She stated the resident's family member reported she had the same behaviors when at home. The DON and ADON was asked what training the staff received on dementia care. The ADON stated, We have in-services at least two times a year for dementia. They were asked why the resident was receiving psychotropic medications. The DON stated, Because the doctor ordered it. They were asked who had requested the resident have the medications. The ADON stated the nurses called to get the medications because of the behaviors the resident was having. The DON and ADON were asked if the staff had exhibited a level of frustration with the resident. The ADON stated not that she knew of. She stated, I know they redirect her. They were asked who monitored for adverse consequences to the medications. The ADON stated the nurses did. She stated the monitoring would be documented in the behavior notes and in the assessments. The DON and ADON were asked why the staff consistently instructed the resident to go take care of something herself and why they did not attempt any non-pharmalogical interventions before asking for an increase in her medications. The ADON stated the staff did not tell her that. She stated she would not ask for an increase in medications when it could cause the resident to fall. The DON stated he did not think they had called for an increase in her medications for a while. The ADON stated the resident needed encouragement. She stated she had good long term memory, but her short term memory was around 45 minutes to an hour. The DON stated her behaviors got worse the later it got, like sundowners. Details of nursing notes were shared with the DON and ADON. The ADON stated the staff was not properly taking care of a resident with dementia. They were asked again what specific non-pharmalogical interventions had been attempted with the resident. The ADON stated one on one with a staff member and the resident liked to take walks. The ADON stated, She liked to sing. The DON and ADON were asked what their expectation was for the staff and this resident. The ADON stated, The staff is not meeting the resident's needs. She stated the resident should have been assisted every time she asked. On [DATE] at 8:35 a.m., the resident was observed in bed with covers up to her neck facing the wall, her breakfast tray was on the overbed table. The resident's roommate stated the resident had already eaten her breakfast. The roommate was asked if the resident received help from staff to go back to bed when she asked. The roommate stated, At times she does. She stated the resident would not go back to bed if the linens on the resident's bed were messed up. The roommate stated she straightened the resident's bed linens at least five to six times a day. On [DATE] at 1:01 p.m., the director of nursing (DON) stated the side effect monitoring was done monthly. The assistant director of nursing (ADON) stated she would expect her staff to perform side effect monitoring once a month. The DON stated their electronic charting system was not generating the form for side effect monitoring to be completed monthly. The DON was asked who was responsible for ensuring side effect monitoring was being completed. The DON stated the administrative nursing staff. 2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, restlessness, and anxiety. A physician's order, dated [DATE], documented the resident was to received Lorazepam, 0.5 mg, every two hours as needed for anxiety. An admission assessment, dated [DATE], documented the resident had received an anxiolytic medication on one of the preceding seven days. Medication administration records (MARs), dated 01/2021, documented the resident received Lorazepam on [DATE] and [DATE]. The resident's care plan, initiated on [DATE],

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to ensure: ~ one of four medications carts was secure when unattended; and ~ failed to ensure medications were stored at safe temperatures in one (B Hall) of two medication rooms. The facility identified 61 residents as receiving medications. Findings: The website https://www.helmerinc.com/articles/usp-chapter-outlines-good-drug-storage-and-shipping-practices which contained an article from [NAME] Scientific titled, USP CHAPTER <1079> OUTLINES GOOD DRUG STORAGE AND SHIPPING PRACTICES, documented, . The United States Pharmacopoeia (USP) chapter 1079 from 2016 . temperature ranges for drugs stored at the following requirements: Room Temperature Storage: 20°C - 25°C [68 degrees Fahrenheit - 77 degrees Fahrenheit] (Excursions permitted between 15°C and 30°C [59 degrees Fahrenheit - 86 degrees Fahrenheit]) . 1. On 08/11/21, from 10:54 through at 11:09 a.m., registered nurse (RN) #1/Care Plan Coordinator was observed to check the blood sugar and inject insulin for residents #23, #41, and #45. Each time she would enter a resident room, she would leave the cart unlocked and out of her sight. At 11:17 a.m., RN #1 pushed the medication cart from A Hall to the walkway in front of the back nurses' station. She left the cart unlocked and unattended and walked into the dining room. The director of nursing (DON) walked past the cart, locked it, and pushed it against the nurses' station wall. At 11:22 a.m., RN #1 entered the room of resident #7 to check her blood sugar. She left the medication cart unlocked and unattended. At 11:39 a.m., she went into resident #25's room to check his intravenous (IV) antibiotic and left the medication cart unlocked and unattended. At 11:45 a.m., RN #1 entered the room of resident #58 to check her blood sugar. She left the medication cart unlocked and unattended. 2. On 08/12/21 at 4:34 p.m., the temperature in the medication room on hall B was observed to be 82 degrees Fahrenheit. Two fans were observed on the counter. A sign titled Recommended minimum medication storage parameters was on the wall under the thermostat. It documented a recommended temperature of 77 degrees Fahrenheit with some medications to have excursions up to 86 degrees Fahrenheit. On 08/12/21 at 4:45 p.m., licensed practical nurse (LPN) #4 stated she checked the temperatures first thing in the morning, but she had not checked them on this day. She stated the medication room temperature was not checked in the evenings or afternoons. She was asked if she knew what the temperature was at that time. She stated no. She was asked what the temperature should be for a medication storage room. She stated no higher than 75 or 76 degrees. She was informed the temperature was 82 degrees. She stated that was too hot.

Based on observation and interview it was determined the facility failed to store food in a sanitary manner. This had the potential to affect 59 of 59 residents who ate food from the kitchen. Findings: On 08/04/21 at 9:16 a.m., during an initial tour of the kitchen, scoops, with their handles touching the food, were observed in the cornmeal, flour, bread crumbs, sugar, and rice crisp cereal containers. At 9:27 a.m., the dietary manager stated the scoops should not be left in the containers and removed them. She stated it was an infection control concern.