Als Woodstock Inc

Based on record review, review of a facility self-reported incident (SRI) and staff interviews, the facility failed to develop a plan of care to address a resident's behaviors. This affected one (#11) of three residents reviewed for care planning. The facility census was 42.

Findings include:

Review of medical record for Resident #11 revealed admission date of 04/23/25 with diagnoses including Diabetes Mellitus, stroke, ataxia following stroke, depression and anxiety. The resident was discharged on 06/05/25 to another skilled nursing facility.

The discharge Minimum Data Set (MDS) dated 06/5/25 revealed with a Brief Interview Mental Status (BIMS) score of 15 indicating intact cognition. The resident was required set up of touching assistance for Activities of Daily Living.

Review of Resident #11's physician orders revealed an order dated 05/23/25 for one-on-one (1:1) supervision until further notice.

Review of Resident #11's Health Status Note dated 06/01/25 at 8:54 A.M. revealed resident continues to be 1:1 with staff. No situations or concerns this morning shift. Will continue to monitor. A Health Status Note dated 06/01/25 at 5:31 P.M. revealed resident continues 1:1 care per staff member with no situations or issues to report for this. Resident #11 has been very compliant today with redirection when needed for simple tasks. A Health Status Note dated 06/03/25 at 5:53 P.M., revealed the resident was on strict 1:1 per order this shift.

Further review of Resident #11's plan of care revealed there was no care plan or intervention for the resident's behaviors or related to 1:1 supervision.

Review of a facility SRI dated 05/30/25 regarding sexual abuse revealed on 05/23/25, it was reported by staff that a Resident #11 made a gyration motion in the doorway of Resident #1's room. Resident #11 was immediately placed on 1:1 supervision. This Administrator advised him that he was not to go into any resident rooms without invitation. On 05/30/25, Resident #1's daughter came to take the resident to a medical appointment and resident divulged to her that Resident #11 had actually exposed himself. Police were called. An investigation was conducted the allegation was unsubstantiated by the facility.

Interview on 06/17/25 at 3:32 P.M. with the Administrator revealed Resident #11 had inappropriate behaviors and an allegation of misappropriate sexual behavior by Resident #11 toward Resident #1 which prompted an order for 1:1 supervision. The Administrator stated Resident #11 was not a registered sexual offender but the facility was aware of a pending court hearing for sexual misconduct for Resident #11 prior to his admission.

Interview on 06/17/25 at 4:16 P.M. with MDS Coordinator #109 revealed she was aware of an allegation of sexual misconduct by Resident #11 and she verified there was no behavioral care plan. MDS Coordinator #109 confirmed Resident #11 had behaviors and acknowledged given the 1:1 supervision order a behavioral care plan should have been created.

This deficiency is based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview, and policy review, the facility failed to notify a resident representative of change of condition. This affected one (#39) out of the three residents reviewed for change of condition. The facility census was 39.

Findings include:

Review of the medical record for Resident #39 revealed an admission date of 04/20/21 with medical diagnoses of Alzheimer's disease, alcohol dementia, behavioral disturbances, Wernicke's encephalopathy, and peripheral vascular disease.

Review of the medical record for Resident #39 revealed a quarterly Minimum Data Set (MDS) assessment, dated 01/01/25, which indicated Resident #39 had moderate cognitive impairment and required supervision with oral care, toilet hygiene, and bathing. The MDS indicated Resident #39 was independent with eating, bed mobility, and transfers.

Review of the medical record for Resident #39 revealed a nurse's note, dated 11/26/24 at 1:40 P.M., which stated Resident #39 tested positive for Coronavirus Disease 2019 (COVID-19) and the physician was notified. Review of the medical record revealed no documentation to support Resident #39's representative was notified positive COVID-19 test result.

Review of the medical record for Resident #39 revealed a nurse's note, dated 01/02/25 at 3:13 P.M. which stated Resident #39 had increased behaviors and the physician was notified and ordered Resident #39 to be sent to the hospital for evaluation. Review of the medical record revealed Resident #39 was sent to the hospital on 01/02/25 and returned to the facility on 01/02/25 at 5:54 P.M. Review of the medical record revealed no documentation to support the facility notified Resident #39's representative on 01/02/25 that Resident #39 was sent to the hospital. Review of the medical record for Resident #39 revealed a nurse's note, dated 01/03/25 at 11:32 A.M., which stated Resident #39's representative was notified Resident #39 was sent to the hospital for evaluation on 01/02/25. The note stated Resident #39's representative expressed concern that he was not notified of clinical changes.

Interview on 01/21/24 at 3:50 P.M. with Regional Nurse #140 confirmed the medical record for Resident #39 did not contain documentation to support Resident #39's representative was notified on 11/26/24 of COVID-19 positive test results. Regional Nurse #140 also confirmed the medical record did not contain documentation to support Resident #39's representative was notified on 01/02/25 of Resident #39's transfer to the hospital for evaluation due to behaviors.

Review of the facility policy titled, Change in Resident's Condition

Based on observations, staff and resident interviews, review of the facility activity calendar, and review of the facility policy, the facility failed to ensure group activities were conducted as scheduled. This had the potential to affect 22 residents residing in the facility who regularly attend group activities, the facility identified 17 (#02, #03, #04, #05, #06, #08, #10, #14, #16, #19, #22, #24, #25, #26, #30, #34, and #35) residents who chose not to attend and/or are not physically able to attend group activities. The facility census was 39.

Findings include:

Review of the activity calendar for 01/21/25 revealed documentation to support the facility had a group activity scheduled for 9:00 A.M. The activity planned was coffee time in the activity room. Review of the activity calendar on 01/21/25 at 10:30 A.M. revealed a planned group activity of exercise in the facility dining room.

Observation on 01/21/25 at 9:07 A.M. revealed the activity room door to be closed and locked. Observation of the facility common areas and dining room revealed no group activity taking place.

Observation on 01/21/25 at 9:23 A.M. revealed the activity room door to be closed and locked. Observation of the facility common areas and dining room revealed no group activity taking place.

Observation with interview on 01/21/25 at 9:25 A.M. with Assistant Director of Nursing (ADON) #130 confirmed the 9:00 A.M. group activity planned for 01/21/25 had not occurred because the activity staff were out of the facility bringing a resident to an appointment.

Interview on 01/22/25 at 7:30 A.M. with Licensed Practical Nurse (LPN) #100 confirmed group activities are canceled at times so the activity staff can bring residents to their appointments.

Interview on 01/22/25 at 7:36 A.M. with Resident #29 confirmed group activities are canceled at times because there is not any activity staff in the building.

Interview on 01/22/25 at 9:18 A.M. with Activity Director (AD) #135 confirmed the group activity on 01/21/25 at 9:00 A.M. did not start until after 10:30 A.M. because he was out of the building bringing a resident to an appointment. AD #135 confirmed the group activity of exercise planned for 01/21/25 at 10:30 A.M. did not occur because residents were having coffee in the activity room at that time. The facility identified 22 residents residing in the facility who regularly attend group activities and 17 (#02, #03, #04, #05, #06, #08, #10, #14, #16, #19, #22, #24, #25, #26, #30, #34, and #35) residents who chose not to attend and/or are not physically able to attend group activities.

Review of the facility policy titled, Activities

Based on staff interviews, employee file reviews, and review of the facility Activity Director (AD) job description, the facility failed to ensure the employee in the role of AD was qualified as required. This had the potential to affect all 39 residents residing in the facility. The facility census was 39.

Findings include:

Interview on 01/22/25 at 9:18 A.M. with AD #135 confirmed he was hired at the facility as the AD on October 15, 2024, and was currently enrolled in an activity training course. AD #135 confirmed he was not a qualified therapeutic specialist or an activities professional who was licensed by the state or had a minimum of two years' experience in social or recreational program within the past five years or was a qualified occupational therapist or occupational therapist assistant or completed a training course approved by the State.

Interview on 01/22/25 at 9:30 A.M. with Regional Nurse #140 confirmed the employee in the role of AD was currently enrolled in a training course for activities certification and had started some of the online training but had not completed the course yet.

Interview on 01/22/25 at 9:50 A.M. with Administrator stated she is a contracted employee and was hired at the facility on 11/27/24 and oversaw the activities department. Administrator stated she had completed the certification for activities prior to starting at the facility. Administrator confirmed the facility contract for her employee did not contain documentation to support her role as the AD.

Review of the facility Activity Director job description the purpose of the position was to plan, organize, develop, and direct he overall operations of the Activities Department in accordance with current federal, state, and local standards, guidelines, and regulations, our established policies and procedures, and as may be directed by the Administrator, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. The policy stated the qualifications for the position included: must possess a high school diploma and must be a qualified therapeutic specialist or an activities professional who is licensed by the state and is eligible for certification as a recreation specialist or as an activities professional; or must have, as a minimum of two years' experience in social or recreational program within the past five years, one o which was full-time in a patient activities program in a health care setting; or must be a qualified occupational therapist or occupational therapist assistant; or must have completed a training course approved by the State.

Review of the employee file for AD #135 revealed a hire date of 10/15/24. The employee file contained confirmation form with enrollment into activity training course but no documentation to support he completion of the course.

Review of the employee file for Administrator revealed a company contract which stated Administrator was hired effective 11/27/24. The contract did not contain documentation to support that the Administrator would also serve as the AD. Review of the file revealed documentation to support Administrator had completed the AD's course on 11/04/05.

This deficiency was based on incidental findings discovered during the course of this complaint investigation.

Based on medical record review, staff interview, and policy review, the facility failed to develop comprehensive care plans as required. This affected one (#31) of three residents reviewed for care plans. The facility census was 35. Findings include: Review of the medical record for Resident #31 revealed an admission date of 01/03/23 with diagnoses including Parkinson's disease, type two diabetes, major depressive disorder, bipolar disorder, hypertension, anxiety, seizures, and varicose veins of the left lower extremity with an ulcer of the ankle. Review of Resident #31's Minimum Data Set (MDS) assessment dated 09/02/24 revealed the resident was cognitively intact with one stage one pressure ulcer (non-blanchable erythema of intact skin). Review of Resident #31's care plan dated 07/02/24 revealed there was no care plan developed regarding the wound to the left medial ankle or seeing the wound clinic. Interview on 10/29/24 at 2:52 P.M. with the Director of Nursing (DON) verified Resident #31 did not have a care plan regarding the wound to the left medial ankle prior to 10/29/24 when the facility was made aware of the omission. Review of a policy titled, Care PlanningBased on medical record review, staff interview, and policy review, the facility failed to develop comprehensive care plans as required. This affected one (#31) of three residents reviewed for care plans. The facility census was 35.

Findings include:

Review of the medical record for Resident #31 revealed an admission date of 01/03/23 with diagnoses including Parkinson's disease, type two diabetes, major depressive disorder, bipolar disorder, hypertension, anxiety, seizures, and varicose veins of the left lower extremity with an ulcer of the ankle.

Review of Resident #31's Minimum Data Set (MDS) assessment dated 09/02/24 revealed the resident was cognitively intact with one stage one pressure ulcer (non-blanchable erythema of intact skin).

Review of Resident #31's care plan dated 07/02/24 revealed there was no care plan developed regarding the wound to the left medial ankle or seeing the wound clinic.

Interview on 10/29/24 at 2:52 P.M. with the Director of Nursing (DON) verified Resident #31 did not have a care plan regarding the wound to the left medial ankle prior to 10/29/24 when the facility was made aware of the omission.

Review of a policy titled, Care Planning

Based on observation, medical record review, and resident and staff interview, the failed to ensure physician orders were in place to address wound treatments. This affected one (#31) of one residents reviewed for wounds. The facility census was 35.

Findings include:

Review of the medical record for Resident #31 revealed an admission date of 01/03/23. Diagnoses included Parkinson's disease, type two diabetes, major depressive disorder, bipolar disorder, hypertension, anxiety, seizures, and varicose veins of the left lower extremity with an ulcer of the ankle.

Review of Resident #31's Minimum Data Set (MDS) assessment dated 09/02/24 revealed the resident was cognitively intact with one stage one pressure ulcer (non-blanchable erythema of intact skin).

Review of a health status note dated 07/24/24 revealed Resident #31 was seen by a physician regarding the wound on the left ankle. A new order was received to send the resident to the wound clinic and an appointment was scheduled on 07/30/24 at 3:00 P.M. The resident was aware.

Review of wound clinic documentation dated 08/20/24 revealed Resident #31 missed the appointment the previous week due to ride issues and wore the same dressing for the entire time. On 09/10/24, documentation revealed Resident #31 did not come to the schedule appointment the previous week due to ride issues and the wound dressing remained in place for two weeks. Review of wound clinic documentation dated 10/22/24 revealed Resident #31 had not been seen for over a month with no indication of when the last dressing change was completed.

Review of a wound clinic note dated 10/29/24 revealed Resident #31's diabetic foot ulcer wound to the left medial ankle was cleansed with soap and water. The wound measured 1.2 centimeters (cm) long by 1.5 cm wide by 0.4 cm in deep. There were no orders but moderate thick yellow drainage was present. The order for the week of 10/29/24 revealed Resident #31's left medial ankle wound was cleansed with mild soap and water, rinsed with normal saline, patted dry with four inch long by four inch wide gauze, apply Desitin and Clobetasol to the peri-wound, apply Stimulen to the wound, then apply silver nitrate damp gauze to the wound, cover the wound with silver alginate, wrap both legs, and secure with tape. Instructions were to leave the wound treatment on for one week and keep dry. Resident #31 was to follow up with certified nurse practitioner (CNP) in one week at the wound care center.

Review of Resident #31's current physicians orders dated October 2024 revealed there were no orders in place to direct staff on treatments to apply to the resident's wound if the dressing were to be soiled or come off.

Interview and observation on 10/28/24 at 10:34 A.M. with Resident #31 revealed he has wounds on his bilateral lower legs and the facility provided no treatments for them. Resident #31 stated only the wound clinic managed his wounds. Observation at the time of the interview revealed Resident #31's bilateral lower extremities had dressing wraps on them and were covered with stockings.

Interview on 10/29/24 at 2:52 P.M. with the Director of Nursing (DON) verified Resident #31 did not have any orders in the medical record to direct staff on what treatment to apply if the wound dressing was soiled or came off prior to the next wound clinic appointment, or if the resident missed appointments at the wound clinic. The DON verified the facility did not measure or document regarding the status of the resident's wound as the resident goes to the wound clinic.

Based on medical record review, staff interview, and policy review, the facility failed to ensure sufficient smoking assessments were completed to determine resident capabilities and deficits regarding smoking safety. This affected four (#2, #13, #16, and #26) of five residents reviewed for smoking. The facility census was 35. Findings include: 1. Review of the medical record for Resident #26 revealed an admission date of 04/20/21. The resident was admitted with diagnoses including Alzheimer's disease, vascular dementia, and panlobular emphysema (BLE). Review of Resident #26's Minimum Data Set (MDS) assessment dated 10/04/24 revealed the resident was assessed with moderately impaired cognition. Review of Resident #26's most recent smoking evaluation dated 09/03/24 revealed the resident was assessed to use tobacco products; however, there was no additional assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking. 2. Review of the medical record for Resident #2 revealed an admission date of 02/19/18 with diagnoses including cerebral palsy, type two diabetes, major depressive disorder, epilepsy, borderline personality disorder, anxiety, paraplegia, and unspecified convulsions. Review of Resident #2's MDS assessment dated 10/01/24 revealed the resident was cognitively intact and required partial to moderate assistance for activities of daily living (ADLs). Review of Resident #2's smoking evaluations dated 06/15/24 and 08/23/24 revealed the resident was assessed to utilize tobacco productions, and on the 06/15/24 the resident was determined to have balance problems while sitting or standing. Further review of the smoking evaluations revealed no assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking. 3. Review of the medical record for Resident #13 revealed an admission date of 06/09/15 with diagnoses including paranoid schizophrenia, obsessive-compulsive disorder, nicotine dependence, and unspecified psychosis. Review of Resident #13's MDS assessment dated 10/03/24 revealed the resident was cognitively intact and required supervision or touching assistance for ADLs. Review of Resident #13's smoking evaluation dated 03/18/24 revealed the resident was assessed to utilize tobacco products, followed the facility policy on smoking, and was able to light and hold cigarettes by himself without safety concerns. Review of subsequent smoking evaluations dated 05/01/24 and 08/10/24 revealed the facility identified the resident utilized tobacco products but there was no additional assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking. 4. Review of the medical record for Resident #16 revealed an admission date of 11/28/13 with diagnoses including cerebral palsy, paranoid schizophrenia, extrapyramidal and movement disorder, and other specified disorders of the brain. Review of Resident #16's MDS assessment dated 09/17/24 revealed the resident was cognitively intact and required supervision or touching assistance to partial/moderate assistance for ADLs. Review of Resident #16's smoking evaluation dated 04/30/24 revealed the resident was assessed to utilize tobacco products, had balance problems while sitting or standing, and followed the facility policy for smoking. Review of Resident #16's subsequent smoking evaluations dated 08/02/24 and 08/19/24 revealed the resident was assessed to utilize tobacco products but there was no additional assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking. Interview on 10/29/24 at 3:30 P.M. with the Director of Nursing (DON) verified the smoking assessments for Resident #2, Resident #13, Resident #16, and Resident #26 were not entirely completed and lacked assessment of each resident's capabilities or deficits to determine whether or not supervision was required for smoking. Review of an undated policy titled, SmokingBased on medical record review, staff interview, and policy review, the facility failed to ensure sufficient smoking assessments were completed to determine resident capabilities and deficits regarding smoking safety. This affected four (#2, #13, #16, and #26) of five residents reviewed for smoking. The facility census was 35.

Findings include:

1. Review of the medical record for Resident #26 revealed an admission date of 04/20/21. The resident was admitted with diagnoses including Alzheimer's disease, vascular dementia, and panlobular emphysema (BLE).

Review of Resident #26's Minimum Data Set (MDS) assessment dated 10/04/24 revealed the resident was assessed with moderately impaired cognition.

Review of Resident #26's most recent smoking evaluation dated 09/03/24 revealed the resident was assessed to use tobacco products; however, there was no additional assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking.

2. Review of the medical record for Resident #2 revealed an admission date of 02/19/18 with diagnoses including cerebral palsy, type two diabetes, major depressive disorder, epilepsy, borderline personality disorder, anxiety, paraplegia, and unspecified convulsions.

Review of Resident #2's MDS assessment dated 10/01/24 revealed the resident was cognitively intact and required partial to moderate assistance for activities of daily living (ADLs).

Review of Resident #2's smoking evaluations dated 06/15/24 and 08/23/24 revealed the resident was assessed to utilize tobacco productions, and on the 06/15/24 the resident was determined to have balance problems while sitting or standing. Further review of the smoking evaluations revealed no assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking.

3. Review of the medical record for Resident #13 revealed an admission date of 06/09/15 with diagnoses including paranoid schizophrenia, obsessive-compulsive disorder, nicotine dependence, and unspecified psychosis.

Review of Resident #13's MDS assessment dated 10/03/24 revealed the resident was cognitively intact and required supervision or touching assistance for ADLs.

Review of Resident #13's smoking evaluation dated 03/18/24 revealed the resident was assessed to utilize tobacco products, followed the facility policy on smoking, and was able to light and hold cigarettes by himself without safety concerns. Review of subsequent smoking evaluations dated 05/01/24 and 08/10/24 revealed the facility identified the resident utilized tobacco products but there was no additional assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking.

4. Review of the medical record for Resident #16 revealed an admission date of 11/28/13 with diagnoses including cerebral palsy, paranoid schizophrenia, extrapyramidal and movement disorder, and other specified disorders of the brain.

Review of Resident #16's MDS assessment dated 09/17/24 revealed the resident was cognitively intact and required supervision or touching assistance to partial/moderate assistance for ADLs.

Review of Resident #16's smoking evaluation dated 04/30/24 revealed the resident was assessed to utilize tobacco products, had balance problems while sitting or standing, and followed the facility policy for smoking. Review of Resident #16's subsequent smoking evaluations dated 08/02/24 and 08/19/24 revealed the resident was assessed to utilize tobacco products but there was no additional assessment information to determine resident safety or clinical suggestions related to smoking needs in regard to determining if the resident required supervision with smoking.

Interview on 10/29/24 at 3:30 P.M. with the Director of Nursing (DON) verified the smoking assessments for Resident #2, Resident #13, Resident #16, and Resident #26 were not entirely completed and lacked assessment of each resident's capabilities or deficits to determine whether or not supervision was required for smoking.

Review of an undated policy titled, Smoking

Based on medical record review and staff interview, the facility failed to ensure pharmacy recommendations were reviewed and responded to timely from the physician. This affected four (#2, #7, #9, and #33) of five residents reviewed for unnecessary medications. The current census was 35.

Findings include:

1. Record review for Resident #2 revealed the resident was admitted to the facility on 02/19/18. Diagnoses for Resident #2 include cerebral palsy, hypertension, chronic obstructive pulmonary disease, and epilepsy.

Review of Resident #2's Minimum Data Set (MDS) assessment dated 10/01/24 revealed the resident had intact cognition and was receiving antidepressant medications during the assessment period.

Review of Resident #2's medication orders revealed on 03/22/23 the resident received orders to be administered citalopram 10 milligrams (mg) daily for depression and on amitriptyline 10 mg daily for depression.

Review of Resident #2's pharmacy recommendation dated 06/12/24 revealed a recommendation made to the physician to consider a reduction dose for the amitriptyline 10 mg daily and the citalopram 10 mg daily or provide documentation regarding the benefit of continuing the medication as it was originally ordered.

Further review of Resident #2's medication records, treatment records, progress notes, physician response documentation, and physician orders revealed there was no documentation of a response from the physician to the pharmacy or facility staff regarding the recommendation of reduction of the medications.

Interview on 10/30/24 at 11:10 A.M. with the Medical Doctor (MD) revealed if there was no documented response he was not notified of the pharmacy recommendation for the resident. The MD verified there was no response to the recommendations for Resident #2.

Interview on 10/30/24 at 11:25 A.M. with Assistant Director of Nursing (ADON) #133 verified there was no evidence in Resident #2's medical record that the physician was made aware of the pharmacy recommendation from 06/12/24.

2. Record review for Resident #7 revealed the resident was admitted to the facility initially on 07/12/17 and readmitted to the facility on 05/24/24. Diagnoses for Resident #7 include Parkinson's disease, chronic obstructive pulmonary disease, bipolar disorder, depression, and schizoaffective disorder.

Review of Resident #7's quarterly MDS assessment dated 10/01/24 revealed the resident had intact cognition, and received an antipsychotic and antidepressant medications.

Review of Resident #7's physician orders revealed on 02/20/20 the resident was ordered to receive buspirone 10 mg three times a day for behaviors, Depakote 250 mg daily for seizures, Zoloft 200 mg daily for depression, and Trazadone 100 mg at bedtime.

Review of the pharmacy monthly medication review dated 11/12/23 for Resident #7 revealed the pharmacy recommended a gradual dose reduction of buspirone to five (5) mg, discontinue Depakote or reduce Zoloft to 75 mg daily, reduce Trazadone to 50 mg at bedtime, or to explain why the gradual dose reduction would be contraindicated.

Further review of the medical records for Resident #7 including progress notes, medication orders, and physician progress notes revealed no evidence the physician responded to the 11/12/23 pharmacy recommendation for Resident #7.

Interview on 10/30/24 at 9:45 A.M. with ADON #133 verified there was no documented evidence in Resident #7's medical records the physician responded to the 11/12/23 pharmacy recommendation.

Interview on 10/30/24 at 11:10 A.M. with the MD verified no responses and stated, if there was no documented response the physician was not notified of the pharmacy recommendation.

3. Record review for Resident #9 revealed the resident was admitted to the facility on 06/20/08. Diagnoses for Resident #9 include paranoid schizophrenia, diabetes type two, depression, anxiety, and muscle weakness.

Review of Resident #9's quarterly MDS assessment dated 10/11/24 revealed the resident had impaired cognition. Per the assessment the resident received anti-anxiety and antidepressant medications during the assessment period.

Review of Resident #9's physician orders dated 11/01/23 revealed the resident was ordered to receive the anti-anxiety medication lorazepam one (1) mg as needed every eight hours for anxiety with no stop date for the lorazepam included in the order.

Review of Resident #9's physician orders dated 03/01/24 revealed the resident was ordered to receive Depakote sprinkles 250 mg twice a day, Zyprexa 15 mg twice a day, Zoloft 100 mg at 5:00 A.M., and Trazadone 50 mg at bedtime.

Review of Resident #9's pharmacy recommendation dated 03/11/24 revealed the pharmacist recommended a gradual dose reduction for Depakote sprinkles to 125 mg twice a day, Zyprexa to 10 mg twice a day, Zoloft to 50 mg in morning, and Trazadone to 25 mg at bedtime, or for the physician to document contraindications for reducing the medication.

Further review of Resident #9's medical records including physician orders, progress notes, and medication administrations revealed no response from the physician in regards to the pharmacist's 03/11/24 recommendations.

Review of Resident #9's pharmacy recommendation dated 06/12/24 revealed the recommendation was for the physician to either discontinue the lorazepam or document a rationale or time frame.

Review of the medical records for Resident #9 revealed there was no physician response for the 06/12/24 recommendation.

Interview on 10/30/24 at 11:10 A.M. with MD revealed he believed the facility was giving him recommendations monthly for Resident #9. Per MD, if no there was no responses from him it meant there were no recommendation notification from the pharmacy or facility staff.

Interview on 10/30/24 at 12:00 P.M. with the Director of Nursing (DON) verified there was no physician response for the 03/12/24 and 06/12/24 pharmacist recommendations for Resident #9.

4. Record review for Resident #33 revealed the resident was admitted to the facility on 06/25/25. Diagnoses for Resident #33 include Parkinson's disease, epilepsy, hypertension, heart disease, insomnia, and post-traumatic disorder.

Review of Resident #33's quarterly MDS assessment dated 10/01/24 revealed the resident has intact cognition. Per the assessment the resident was receiving antidepressant, antipsychotic, and hypnotic medications.

Review of Resident #33's physician orders as of 03/01/24 revealed the resident was ordered to receive Trazadone 150 mg and Remeron 30 mg at bedtime for insomnia.

Review of Resident #33's pharmacy recommendation dated 03/11/24 revealed the pharmacist recommended to discontinue the Trazadone, discontinue the Remeron, or document no change to medications.

Further review of the pharmacy recommendations dated 05/12/24 revealed the pharmacist made a recommendation for Resident #33; however, there was no documentation of what the recommendation was noted in the medical record.

Further review of Resident #33's medical records revealed no documented response from the physician for the 03/11/24 recommendation.

Interview on 10/30/24 at 12:00 P.M. with the DON verified there was no document from the pharmacy for Resident #33's May 2024 medication review. Per the DON, the pharmacy did review Resident #33's medications on 05/12/24 and made a recommendation to the physician; however, the DON stated there was no documented evidence of what the recommendation was in the medical records and the facility had no documented evidence the recommendation was given to the physician. The DON also verified there was no documentation from the physician for the 03/11/24 pharmacist recommendation for Resident #33.

Based on medical record review and staff interview, the facility failed to ensure psychotropic as needed medications had an appropriate stop date or rationale for extending the usage as required. This affected one (#9) of five residents reviewed for unnecessary medications. The census was 35.

Findings include:

Record review for Resident #9 revealed the resident was admitted to the facility on 06/20/08. Diagnoses for Resident #9 include paranoid schizophrenia, diabetes type two, depression, anxiety, and muscle weakness.

Review of Resident #9's quarterly Minimum Data Set (MDS) assessment dated 10/11/24 revealed the resident had impaired cognition. Per the assessment, the resident received anti-anxiety and antidepressant medications during the assessment period.

Review of Resident #9's physician orders dated 11/01/23 revealed the resident was ordered to receive the anti-anxiety medication lorazepam one (1) milligram (mg) as needed every eight hours for anxiety with no stop date included in the order.

Review of the pharmacy recommendation dated 11/12/23 for Resident #9 revealed the recommendation was for the physician to either discontinue the lorazepam (Ativan) or document a rationale or time frame for usage.

Review of the physician response dated 12/03/24 revealed the physician responded to continue the lorazepam writing, She is on prn (pro re nata, or as needed), keep. There was no duration for the order written on the response.

Review of the pharmacy recommendation dated 02/12/24 for Resident #9 revealed the recommendation was for the physician to either discontinue the lorazepam (Ativan) or document a rationale or time frame.

Review of the physician response dated 03/07/24 revealed the physician responded to continue the lorazepam for three months.

Review of the pharmacy recommendation dated 04/10/24 for Resident #9 revealed the recommendation was for the physician to either discontinue the lorazepam (Ativan) or document a rationale or time frame.

Review of the physician response dated 04/20/24 revealed the physician responded to continue the lorazepam for 30 more days. There was no rationale for extending the use noted in the medical record.

Review of the pharmacy recommendation dated 06/12/24 for Resident #9 revealed the recommendation was for the physician to either discontinue the lorazepam (Ativan) or document a rationale or time frame.

Review of the medical records for Resident #9 revealed there was no physician response for the 06/12/24 recommendation.

Review of the pharmacy recommendation dated 08/13/24 for Resident #9 revealed the recommendation was for the physician to either discontinue the lorazepam (Ativan) or document a rationale or time frame.

Review of the physician response dated 09/04/24 revealed the physician responded to continue the lorazepam for three months. There was no rationale for extending the use noted in the medical record.

Interview on 10/30/24 at 11:10 A.M. with the Medical Doctor (MD) revealed he believed the facility was giving him recommendations monthly for Resident #9. The MD stated Resident #9's as needed Ativan needed to continue due to the increased behaviors of the resident when the medication was reduced or discontinued. The MD stated he will continue the as needed medications per guidelines, and verified he did not include a explanation or rationale in the documentation but stated he does tell the staff why he wants to continue to medications.

Based on medical record review, resident and staff interview, pharmacy delivery document review, and policy review the facility failed to administer an antibiotic as ordered by the physician. This affected one (#7) of one resident reviewed for urinary tract infections. The facility census was 35.

Findings include:

Review of the medical record for Resident #7 revealed an admission date of 05/24/23 with diagnoses including Parkinson's disease, type one diabetes, bipolar disorder, major depressive disorder, hypertension, schizoaffective disorder, and generalized anxiety disorder.

Review of Resident #7's Minimum Data Set (MDS) assessment dated 10/01/24 revealed the resident was cognitively intact.

Review of Resident #7's physician orders for October 2024 revealed the resident was ordered the antibiotic piperacillin/tazobactum (Zosyn) 3-0.375 gram (gm)/50 milliliter (ml) every six hours for seven days from 10/18/24 through 10/24/24. Resident #7 was ordered Zosyn 3-0.375 gm four times daily for eight administrations from 10/25/24 through 10/27/24. Resident #7 was again ordered Zosyn 3.375 gm intravenously (IV) four times daily for eight administrations from 10/27/24 through 10/28/24 and Zosyn 3.375 gm IV four times daily for two days for eight administrations from 10/29/24 through 10/31/24.

Review of Resident #7's medication administration record (MAR) for October 2024 revealed the Zosyn ordered 10/18/24 through 10/24/24 was not documented as administered on 10/18/24 at 12:00 P.M. Further review revealed there was no documentation of the resident receiving the ordered Zosyn on 10/18/24 at 12:00 A.M., 10/23/24 at 6:00 A.M., and 10/23/24 at 12:00 P.M. Resident #7 was documented as not being in the facility for doses due on 10/20/24 at 6:00 P.M. and 10/21/24 at 12:00 P.M., and a dose was held on 10/24/24 at 12:00 P.M.

Further review of Resident #7's MAR for October 2024 revealed Zosyn IV that was ordered from 10/25/24 through 10/27/24 was not documented as administered on 10/25/24 at 9:00 P.M. and 10/26/24 at 3:00 A.M. A dose was held on 10/26/24 at 3:00 P.M.

Further review of Resident #7's MAR for October 2024 revealed Zosyn IV that was ordered from 10/27/24 through 10/28/24 was not administered on 10/28/24 at 1:00 A.M., 7:00 A.M., 1:00 P.M. and 7:00 P.M. due to the medication being unavailable from pharmacy.

Further review of Resident #7's health status notes revealed no communication to the physician of each dose held prior to 10/25/24 to include the seven doses that were missed.

Review of pharmacy packing slip proof of delivery documents dated 10/17/24 revealed 28 vials of Zosyn were delivered to the facility along with 28 100 ml normal saline bags to reconstitute the IV prior to administration.

Review of Resident #7's health status note dated 10/25/24 revealed the physician was notified the resident missed seven doses of IV antibiotics over the seven day course that completed on 10/24/24 and staff were awaiting response as to extend the order to complete the seven missed doses or not.

Review of Resident #7's health status note dated 10/28/24 revealed the IV antibiotic was not available to administer that shift. Pharmacy was contacted and indicated the pharmacy was out of the medication (Zosyn IV) with notation the pharmacy could send the premixed type of the same medication if pre-authorization was signed and returned to pharmacy. A pre-authorization was signed and returned to pharmacy. The physician was notified and stated to administer two days of four doses per schedule when the medication arrived, and he would review during his visit.

Review of pharmacy packing slip proof of delivery documents dated 10/29/24 revealed Zosyn 400 ml was delivered to the facility.

Interview on 10/28/24 at 1:32 P.M. with Resident #7 revealed the facility ran out of her IV medication (Zosyn) and she was taking the medication for treatment of a urinary tract infection (UTI).

Interview on 10/29/24 at 3:34 P.M. with the Director of Nursing (DON) verified Resident #7's Zosyn IV doses were not marked as given on 10/18/24, 10/25/24, and 10/26/24. The DON also verified there was no documentation of communication with the physician regarding the seven missed doses prior to the note on 10/25/24.

Interview on 10/30/24 at 9:53 A.M. with Pharmacist #142 verified the pharmacy sent 28 vials of Zosyn to the facility. Pharmacist #142 verified that amount would have been enough doses to complete the order for four times daily for seven days. Pharmacist #142 verified they did not receive any returns of the medication from the facility. Pharmacist #142 verified the pharmacy sent 400 mls of Zosyn IV on 10/29/24 which would complete the eight administrations that were remaining on the current order.

Interview on 10/30/24 at 10:51 A.M. with the DON verified 27 of the 28 doses originally sent from the pharmacy were administered between 10/18/24 through 10/27/24. The DON verified she could not explain why the seven missed doses were not administered from the original order of four times daily for seven days to start on 10/18/24 and end on 10/25/24 which would have equaled the 28 vials sent from the pharmacy.

Interview on 10/30/24 at 11:00 A.M. with Assistant Director of Nursing (ADON) #133 stated she cleaned the medication room on 10/26/24 and found normal saline (NS) used to mix the powder for the IV antibiotic with the seal broken, but she did not find any vial of antibiotic powder. ADON #133 stated she assumed the staff attempted to mix the Zosyn with the NS and was unable to do it, so they wasted the vial of medication, but there was no proof to back her intuition.

Review of policy titled, Administration Procedures For All Medications

Based on medical record review, resident and staff interview, review of dental visit documentation, review of hospital documentation, and review of facility policy, the facility failed to ensure residents were provided with timely dental services to address non-restorable and decaying teeth. Actual harm occurred to Resident #33 when the dentist identified the resident's teeth required extraction (removal) and the facility failed to follow up with a referral to an oral surgeon. This resulted in the resident developing fever and chills which prompted a visit to the emergency department where the resident was diagnosed with system inflammatory response syndrome and bacteremia caused by a tooth infection. This affected one (#33) of one residents reviewed for dental services. The census was 35.

Findings included:

Review of the medical record for Resident #33 revealed an admission date of 06/25/20. Diagnoses included Parkinson's disease and diabetes mellitus. Further review of the medical record revealed the resident was discharged to the hospital on 08/11/24 and returned to the facility on 08/16/24.

Review of the annual Minimum Data Set (MDS) assessment dated 07/03/23 revealed Resident #33 had obvious or likely cavities or broken natural teeth.

Review of the quarterly MDS assessment dated 09/20/24 revealed Resident #33 was assessed as cognitively intact. Further review of the MDS assessment revealed the resident had no mouth or facial pain, discomfort, or difficulty with chewing. The resident was on a therapeutic diet.

Review of Resident #33's care plan related to oral and dental alteration revealed a notation dated 05/12/21, that the resident had a dental evaluation, and the doctor determined all teeth need extracted and dentures placed. The resident was referred to a dentist. An intervention included coordination of arrangements for dental care, transportation as needed or ordered, and daily oral care per routine and as needed.

Review of a dental visit note dated 12/19/23 revealed Resident #33 was seen to have an examination (exam) completed, and the resident was determined to need all remaining teeth extracted with a referral made to an oral surgeon. Review of a dental note dated 02/21/24 revealed Resident #33 was not seen that day by the dental provider because the resident was out of the facility. Review of a dental visit note dated 06/20/24 revealed all remaining teeth needed to be extracted due to being non-restorable and decaying. Further review of the note revealed Resident #33 would like to have only tooth #18 extracted for now. Physician clearance was left at the facility.

Review of Resident #33's social services progress note dated 06/25/24 at 7:11 P.M. revealed Resident #33 was seen by the dentist on this date. Physician clearance was left with the Medical Director for tooth #18 to be extracted and Resident #33 was notified. Further review revealed there were no new orders or follow-up related to the request to extract tooth #18.

Review of a dental visit note dated 07/15/24 revealed Resident #33 was seen by a dental hygienist only and services provided that day were preventative only.

Review of Resident #33's medical record revealed no documentation of the facility addressing the resident's need to have any teeth extracted as care planned on 05/12/21 and as assessed during dental visits on 12/19/23 and 06/20/24. Further review of the medical record revealed no documented evidence of Resident #33 being referred to an oral surgeon or that teeth extraction could not be performed because the resident's blood glucose levels were too high.

Review of Resident #33's progress note dated 08/11/24 at 6:22 P.M. revealed the resident was not feeling well and voiced feeling cold and shaking. Emergency Medical Services (EMS) were called, and the resident was sent to the hospital. Review of a progress note dated 08/12/24 at 1:06 P.M. revealed a nurse spoke with the emergency room nurse who indicated the resident was being admitted to the hospital for sepsis.

Review of hospital documentation revealed Resident #33 presented to the emergency room on 08/11/24 with complaints of fever and chills with associated generalized weakness. On assessment, the resident had an elevated temperature (100 degrees Fahrenheit), elevated pulse (103 beats per minute), elevated respirations (26 breaths per minute), was ill-appearing, and diaphoretic (sweating). The resident was given the pain medication and fever-reducing medication Tylenol, and a full septic workup was completed. The resident was found to have an elevated white blood cell count. Resident #33 was diagnosed with system inflammatory response syndrome (SIRS) and bacteremia (bacteria in the blood) as three out of four blood cultures were positive for streptococcus and staphylococcus. Further review revealed the most likely cause of the bacteremia was a tooth infection and Resident #33 needed immediate follow up with a dentist once discharged from the facility. The resident reported difficulty with eating and swallowing and was noted with poor dentition. Resident #33 was discharged on 08/16/24 with orders for the antibiotic Augmentin 875-125 milligrams (mg) by mouth two times daily for 14 days.

Review of a progress note dated 08/16/24 at 1:15 P.M. revealed Resident #33 returned from hospital at 12:30 P.M. with orders for Augmentin 875-125 mg twice daily for 14 days.

Interview with Resident #33 on 10/28/24 at 11:17 A.M. revealed he had a badly infected tooth and could not get permission for oral surgery. The resident stated he still had sensitivity to hot and cold foods.

Interview with the Medical Director (MD) on 10/30/24 at 11:18 A.M. stated the oral surgeons would not do surgery on Resident #33's teeth with a high hemoglobin A1C (a blood test that measures the average blood sugar levels over the past two to three months) due to the increased opportunity for infections. The MD stated the oral surgeons suggested the hemoglobin A1C level to be at least down to 7.5 percent (%) to 8% (normal levels are below 5.7%).

Interview with Assistant Director of Nursing (ADON) #133 on 10/31/24 at 9:00 A.M. verified there was no documentation of a referral from the MD to an oral surgeon for Resident #33 to have teeth extraction until 10/30/24. ADON #133 also verified there was no documented evidence of oral surgeons refusing to remove Resident #33's teeth due to elevated hemoglobin A1C levels.

Review of the facility policy titled, Dental Services from 2016, revealed routine and emergency dental services are available to meet resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services are provided to facility residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to a resident's personal dentist, referral to a community dentist, or referral to other health care organizations that provide dental services.