Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours a day, seven days a week. The administrator reported 36 residents resided in the facility. Findings: A nursing schedule for April 2024 documented the facility did not have RN coverage for eight consecutive hours on 04/05/24, 04/08/24, 04/09/24, and 04/10/24. On 06/05/24 at 1:01 p.m., the DON was requested to provide documentation that an RN had worked eight consecutive hours in the facility on 04/05/24, 04/08/24, 04/09/24, and 04/10/24. On 06/05/24 at 1:30 p.m., the DON reported they did not have RN coverage in the facility on 04/05/24, 04/08/24, 04/09/24, and 04/10/24.

Based on record review and interview, the facility failed to ensure all allegations of abuse were reported within two hours of the reported incident for one (# 1) of three residents sampled for abuse. The DON reported the census was 35. Findings: A facility policy, revised 01/18, titled Abuse - Reportable Events, read in part, .It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law .Abuse 2-hour limit .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse . Resident #1 had diagnoses which included hypertension and generalized anxiety disorder. An annual assessment, dated 02/23/24, documented Resident #1 was cognitively intact for daily decision making and required partial assistance from staff with bathing. A review of the OSDH form 283 dated 03/27/24 contained a fax cover page indicating it was sent to the OSDH at 12:03 p.m. On 03/29/24 at 9:19 a.m., the DON reported that Resident #1's allegation was reported to them at approximately 3:15 p.m. on 03/26/24. They also stated they thought they had 24 hours to report and that it should have been reported within the required 2 hours.

Based on record review and interview, the facility failed to protect residents from potential abuse by allowing an employee named in an allegation of abuse to continue working for one (# 1) of three residents sampled for abuse. The DON reported the census was 35. Findings: A facility policy, revised 01/18, titled Abuse - Reportable Events documented that an employee named in an allegation of abuse will be suspended pending an investigation. Resident #1 had diagnoses which included hypertension and generalized anxiety disorder. An annual assessment, dated 02/23/24, documented Resident #1 was cognitively intact for daily decision making and required partial assistance from staff with bathing. On 03/28/24 at 3:02 p.m., LPN #1 stated they notified the DON of an allegation of abuse at approximately 3:15 p.m. on 03/26/24. The abuse allegation was made by Resident #1 and named CNA #1 as the alleged abuser. LPN #1 also stated CNA #1 was allowed to work their shift on 03/26/24 after the allegation had been reported to the DON. On 03/29/24 at 9:19 a.m., the DON reported that CNA #1 was suspended pending investigation on 03/27/24 but worked on 03/26/24 after the abuse allegation had been reported to the DON.

Based on interview and record review, the facility failed to ensure an RN (Registered Nurse) was on duty for eight hours a day on the weekends, a total of 38 days. This had the potenital of effecting all 38 residents residing in the facility A report titled Labor Analysis-Overtime Report, did not document an RN was on duty for the Saturdays and Sundays for the weeks of 10/1/22 through 04/24/23. On 04/21/23 at 2:12 p.m., ADON #1 was asked why there was no RN coverage on the weekends. They stated they didn't have RN coverage on the those weekends.

Based on observation, record review, and interview the facility failed to maintain a clean ice machine. The Resident Census and Conditions report, dated 04/14/23, documented 36 residents received ice from the ice machine. Findings: On 04/21/23 at 2:00 p.m., the ice machine was observed to have a black substance on the plastic components inside the machine. The ice came in contact with the black substance. A log titled Ice Machine Cleaning Schedule 2022, was reviewed. The ice machine was documented to have been cleaned once in November 2022 and December 18, 2022. There was no documentation of cleaning the ice machine in 2023. On 04/22/23 at 11:15 a.m., [NAME] #1 was asked to identify the black substance on the inside plastic components of the ice machine. They stated it was scum. They were asked if the black substance should be there. The cook stated no, they had tried to clean it in the past but it kept coming back. They were asked who was responsible for cleaning the ice machine. They stated the maintenance staff but they are new and may not know they are to clean it. [NAME] #1 was asked when the last time the ice machine was cleaned. They stated December 18, 2022. They were asked if it should have been cleaned since December. They stated yes. Maintenance employee #1 was asked who was responsible for cleaning the ice machine. They stated, I guess me but I have only been here for 3 weeks and no one has trained me on that yet. Maintenance employee #1 was asked to identify the black substance in the machine. They stated they didn't know what it was, it's probably mold. 04/22/23 at 11:54 a.m., they were asked if it should be there. They replied no.

**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 residents did not receive duplicate antidepressant medications without indications for use for one (#6) of eleven sampled residents who were reviewed for antidepressant medication use. The resident census and condition report documented there were 21 residents in the facility who received antidepressant medications. ~ ensure residents did not receive continued use of hypnotic medications without attempts of a gradual dose reduction for one (#6) of two sampled residents who received hypnotic medications. The resident census and condition report documented two residents received hypnotic medications. ~ ensure residents did not receive unnecessary antipsychotic medications without indications for use for two (#29 and #32) of three sampled residents reviewed for psychotropic medication use. The resident census and condition report documented there were three residents in the building who were receiving antipsychotic medications. The resident census and condition report documented there were 22 residents in the facility who were receiving psychoactive medication. Findings: 1. Resident #6 had diagnoses which included major depressive disorder. An annual assessment, dated 12/18/18, documented the resident was cognitively intact, had no behaviors, had a mood score of six out of twenty seven, required supervision only with most activities of daily living, received an antidepressant and a hypnotic medication seven days out of the seven day look back period. A care plan, dated 12/19/19, documented: Problem: Psychotropic drug use Risk for adverse side effects: Lexapro, Wellbutrin, and Restoril. Goal: The resident will be monitored from any significant side effects with use of medications until next care conference. Interventions: Administer antidepressants and hypnotic per the physician's orders. Monitor and document any significant side effects every shift and as needed. Monitor and document any targeted behaviors. Monitor and document my mood or any negative behaviors every shift and as needed. Monitor for over sedation and/or changes in mental status. Monthly pharmacy review. Notify the physician as needed. Problem: Disturbed sleep pattern Goal: The resident will feel well rested daily. Interventions: Administer Restoril 15 milligrams by mouth every bedtime per the physician's order. Monitor and record effectiveness. Monitor and record any adverse effects. Assist with toileting prior to bed as needed. Do not turn on light during room check. Encourage consistent routines. Encourage daily exercise as tolerated. Monitor for complaints or signs and symptoms of pain. Offer a snack before bed time or if the resident awakes at night. Organize care to limit sleep interruptions. Provide comfortable environment to promote sleep. Reduce environmental disruptions. A pharmacy medication regimen review, dated 03/06/19, documented the pharmacist requested a reduction in Wellbutrin XL 150 milligrams a day per CMS guidelines. The medication review documented the physician disagreed. The medication review documented the physician stated the resident still required the medication due to a history of refractory depression. A pharmacy medication regimen review, dated 04/04/19, documented the pharmacist requested a reduction in Restoril 15 milligrams at bedtime per CMS guidelines. The medication review documented the physician declined to reduce the medication stating the resident still required the medication. A pharmacy medication regimen review, dated 05/09/19, documented the pharmacist requested a reduction in Restoril 15 milligrams at bedtime per CMS guidelines. The medication review documented the physician declined to reduce the medication stating the resident still required the medication. A behavior monitoring sheet, dated 05/01/19 through 05/31/19, documented the resident had no behaviors of crying, rejecting care, or being withdrawn. A behavior monitoring sheet, dated 06/01/19 through 06/30/19, documented the resident had no behaviors of crying, rejecting care, or being withdrawn. A quarterly assessment, dated 06/20/19, documented the resident was cognitively intact, had no behaviors, had a mood score of six out of twenty seven, required supervision only with most activities of daily living, received an antidepressant and a hypnotic seven days out of the seven day look back period. A behavior monitoring sheet, dated 07/01/19 through 07/31/19, documented the resident had no behaviors of crying, rejecting care, or being withdrawn. A pharmacy medication regimen review, dated 07/10/19, documented the pharmacist requested a reduction in Lexapro 20 milligrams a day per CMS guidelines. The physician responded he disagreed. The medication review documented the physician stated the resident still struggled with symptoms of depression. A behavior monitoring sheet, dated 08/01/19 through 08/31/19, documented the resident had no behaviors of crying, rejecting care, or being withdrawn. A behavior monitoring sheet, dated 09/01/19 through 09/30/19, documented the resident had no behaviors of crying, rejecting care, or being withdrawn. On 09/11/19 at 8:37 a.m., the resident was observed in bed. The resident smiled at the surveyor and stated she was doing much better. No behaviors were observed. On 09/12/19 at 8:33 a.m., the resident was sitting on the bedside eating breakfast. The resident smiled at the surveyor and stated she was doing much better. No behaviors were observed. On 09/16/19 at 10:29 a.m., the resident stated she was feeling nauseated. No behaviors were observed. An EMR, dated 09/16/19, documented: Wellbutrin XL 150 milligrams every day for major depressive disorder. Temazepam 15 milligrams at bedtime for insomnia. Lexapro 20 milligrams every day for major depressive disorder. On 09/16/19 at 12:04 p.m., CNA #1 was asked what kind of behaviors, if any, did the resident have related to depression. She stated the resident was a very happy lady. She stated the resident was pleasant and smiled most of the time. She stated she had not observed the resident be depressed. On 09/16/19 at 12:52 p.m., LPN #1 was asked about the resident's behaviors related to depression. She stated she did not remember the resident having any behaviors related to depression. On 09/16/19 at 3:15 p.m., the resident was observed sitting in a recliner with her feet up listening to head phones. The resident smiled and waved at the surveyor. 2, Resident #29 was admitted with diagnoses which included Alzheimer's disease with late onset, depressive episodes, anxiety disorder, dementia with behavioral disturbance, mood affective disorder, and delusional disorders A quarterly assessment, dated 06/13/19, documented the resident as moderately impaired cognitively, had moods of having little energy for several days in a row, had no indications of psychosis or behaviors, required extensive help of two staff for most ADL's, antipsychotics were received six days, and antidepressants were received five days out of the seven day look-back period. A significant change assessment, dated 07/08/19, documented the resident was moderately impaired cognitively, no mood or behaviors were indicated, required total assistance of two staff for most ADL's, received seven days of antipsychotics, and seven days of antidepressants out of the seven day look-back period. A faxed request, dated 07/16/19, documented the DON requested the MD decrease the resident's antipsychotic medications and possibly other medications, due to the resident having lost function, weight loss, requiring more ADL help, and becoming incontinent. The fax request reply, dated 07/17/19, documented the MD replied to reduce the Zoloft to 25 mg Q AM and requested to see the resident again in 2-3 weeks. A pharmacy regimen review note, dated 08/08/19, documented the pharmacists request to the MD to attempt to discontinue Abilify via gradually tapering the dose. The physician's response to the pharmacy request was to decline the GDR due to the resident continuing to have mood disorders. A care plan, last revised 08/17/19, documented: Problem: Psychotropic drug use: Risk for adverse side effects from Antipsychotics and Antidepressants: Goal: Monitor for any significant side effects with use of medications until next care conference on 10/08/19. Approach: Give meds as ordered. Monitor and document any significant side effects Monitor and document the resident's mood or any negative behaviors q shift and prn. Monitor the resident for over sedation and or changes in mental status. Monthly pharmacy review. Notify PCP as needed. An MD visit, dated 08/20/19, documented the resident had a depression screening of 4, minimal depression, the nursing home was concerned the resident was sleeping more over the last few months, and noted the Zoloft was reduced in July and the Temezepam was changed to PRN HS. A review of the ETAR behavior monitoring flowsheets from May 2019 through [DATE], documented no behaviors. A MAR, dated September 2019, documented the antipsychotics, antidepressants, hypnotics and antianxiety medications listed were: Abilify 5mg PO at HS and has target behavior sheet Buspirone 5mg, PO at BID and has a target behavior sheet Restoril 15 mg PO q HS PRN Wellbutrin XL 150 mg PO QD and has target behavior sheet Seroquel 150 mg HS Zoloft 25 mg QD On 09/10/19 at 10:19 a.m., the resident was observed sitting up in bed. She stated she had only been in the facility a short time and had recently returned from the hospital. On 09/12/19, at 10:00 a.m., the resident was observed with her eyes closed. At 11:00 a.m., the resident was observed with her eyes closed and her head resting against the left side rail. At 02:30 p.m. the resident was observed with her head resting against the upper left side rail with her eyes closed. An aide went in to reposition her head and lower the head of the bed. On 09/16/19 at 10:03 a.m., the DON was asked how behaviors were charted. She stated this resident has not had any behaviors but it would be put on the Medication sheets and also in the progress notes if there were any. She was asked if she was aware the MD had documented on 08/20/19 the resident was still having behaviors. She stated yes. She stated she saw that and did not know where the MD was getting that information, as they had told her there were no behaviors noted. She was asked if she had heard about any behaviors. She stated no. She was asked how she would hear. She stated the staff are good about reporting any behaviors and she would also look at the behavior sheets. On 09/16/19, at 10:29 a.m., the DON, stated they tried to get the resident off several medications since she had been back from geri-psych, due to the resident's decline. The MD documented on the last GDR that no reduction was to be done since the resident still had mood disorders. The DON stated the resident had not had any behaviors. At 1:35 p.m., CNA #1 was asked if the resident displayed any behaviors. She stated the resident could be calm and happy one minute, then walk back in and her mood would have changed. She was asked if she had noticed any of the specific behaviors listed on the sheet. She stated no. She stated the resident would fuss more if her husband was around. She was asked who she would notify if the resident displayed behaviors. She stated the nurse. At 1:50 p.m., LPN#2 was asked if the resident had been having behaviors in the past few months. She stated she had not seen the resident having behaviors for at least 6 months. She stated the resident had been yelling out and was aggressive to staff and husband. She was asked if the resident got out of bed every day. She stated since this last hospitalization, she had been in bed more. She stated the nurse aides reported any behaviors. She stated she had not had any reports of any behaviors while she has been working and the resident allowed her to do her vitals with no problems. 3. Resident #32 had diagnoses which included Alzheimer's disease with late onset, dementia with behavioral disturbances, and mood disorder. An admission assessment, dated 02/08/19, documented the resident was moderately impaired cognitively, had no behaviors, required minimal assist of set-up to one person for most ADL's, and received no antipsychotic, anxiety, or hypnotic medications during the seven day look-back period. A GDR request, dated 07/10/19, documented a request from the pharmacist to decrease Seroquel 50 mg BID for mood disorder to 25 mg Q am and 50 mg Q hs. The MD replied on 08/01/19, and documented no changes, without a reason given. A quarterly assessment, dated 08/11/19, documented the resident was severely impaired cognitively, had no behaviors, had a mood score of 01, required minimal assistance of set-up or one person assist for most ADL's, received seven days of antipsychotics and seven days of antidepressants during the seven day look-back period, and a GDR was documented on 08/01/19 as clinically contraindicated. A care plan, dated as revised on 08/15/19, documented: Problem: Psychotropic drug use Risk for adverse side effects on Seroquel and trazodone. Goal: Will be monitored from any significant side effects with the use of medications with gradual dose reduction attempts as appropriate until next care conference. Approach: Administer Seroquel and Trazodone per orders. Monitor and document any significant side effects q shift and prn. Monitor and document any targeted behaviors, interventions and outcomes q shift and prn. Monitor and document his mood or any negative behaviors q shift and prn. Monthly pharmacy review Notify my doctor when needed A review of the eTAR for past six months documented no behaviors. On 09/11/19 at 9:01 a.m., the resident was observed sitting in his room, in a chair, eyes closed, with his finished breakfast tray next to him. An EMR, dated 09/10/19, documented the following psychotropic medications: Aricept 10 mg q HS, Seroquel 50 mg BID Trazodone 50 mg HS On 09/11/19 at 9:01 a.m., the resident was observed sitting in his room, in a chair, eyes closed, with his finished breakfast tray next to him. On 09/16/19 at 12:57 p.m. the resident was observed lying on his bed with his eyes closed. At 1:44 p.m., CNA #1 was asked if she noticed any behaviors from the resident. She stated he had some in the past. She stated he wanted to get down on the floor, as if he wanted to scrub it. She had not seen him be unpleasant towards anyone. He had not exhibited any of the target behaviors on the sheet when she had worked nor had she heard any reports of him having behaviors. At 1:46 p.m., LPN#2 was asked if she was familiar with the resident and had she noticed any behaviors. She said not recently, it had been more than 3 months since he had any behaviors. At 2:05 p.m., the DON was asked if the resident had displayed any behaviors. She stated he had not had any behaviors recently. She stated he had been crawling under the bed, but had not had any aggression or yelling.

Based on observation, interview, and record review, it was determined the facility failed to ensure the medical director attended quarterly QAPI meetings. The resident census and condition report documented there were 38 residents who resided in the facility. A QAPI sign in sheet, dated 05/01/19, documented the physician did not attend the meeting. A QAPI sign in sheet, dated 06/13/19, documented the physician did not attend the meeting. A QAPI sign in sheet, dated 07/17/19, documented the physician did not attend the meeting. On 09/16/19 12:56 p.m., The DON was asked for QAPI meeting sign in sheets. She stated she had taken over the QAPI task from the administrator recently. She stated the medical director had not attended quarterly meetings. She stated they did meet with the physician about concerns, however he had not attended any of the meetings. She stated she was asked to take on the task and was still trying to figure out exactly what all she needed to do.