Holton Health Care Center

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure adequate staffing levels on the weekends to meet the needs of the residents. This placed the residents at risk for impaired mental and physical wellbeing.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents and two Certified Nurse Aides (CNA) reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure two of the two CNA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 34 residents. The facility had one kitchen and a dining kitchenette. Based on interviews and record review, the facility failed to provide the services of a full-time certified dietary manager for the 34 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility identified a census of 34 residents. The facility had one kitchen and a dining area kitchenette. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to dirty dishes and food storage. This deficient practice placed the residents at risk for food-borne illness.

Inspectors wroteThe facility identified a census of 34 residents. The facility identified six residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to store Resident (R) 2 and R22's respiratory equipment in a sanitary manner. The facility additionally failed to supply the laundry room with a gown to sort dirty laundry and failed to transport laundry with the laundry being covered in a sanitary manner. The facility further failed to ensure it had trends and tracking for Legionella. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to develop and implement the core elements of antibiotic stewardship to ensure an effective infection prevention and control program, including antibiotic stewardship for the residents of the facility.

Inspectors wroteThe facility had a census of 34 residents. Two Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure two of the two CNA staff reviewed had the required 12 hours of in-service education. This placed the residents at risk for decreased quality of life and/or inadequate care.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents. Based on observations and interviews, the facility failed to provide a clean, home-like environment for the residents who resided in the facility.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with seven residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician had clarified the indication for Resident (R) 14's psychotropic (alters mood or thought) medication. The facility failed to ensure that the physician had clarified R6's gradual dose reeducation (GDR) for R6's antipsychotic (a class of medications used to treat major mental conditions that caused a break from reality) medication, R2's as-needed (PRN) Lorazepam (antianxiety medication(a class of medications that calm and relax people)), and R9's PRN Ativan (antianxiety medication) had a 14-day stop date. [...]

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to complete the Care Area Assessment (CAA- analysis of findings) related to a Minimum Data Set (MDS), within the required time frame, for Resident (R) 4, R19, R2, and R9 to address the underlying cause, risk factors, and other contributing factors to ensure the resident received care based on their individual needs. This deficient practice placed the residents at risk for unidentified care needs.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with four residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to secure the facility's electrical panel, a razor, and cleaning chemicals in a safe, locked area, and out of reach of eight cognitively impaired, independently mobile residents. The facility also failed to assess R5 for smoking safety. This deficient practice placed the residents at risk for preventable accidents and injuries.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with seven residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure that the physician reviewed and addressed the Consultant Pharmacist (CP) recommendations for a gradual dose reduction (GDR) for Resident (R) 6's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication and R14's psychotropic (alters mood or thought) medication indication. The facility also failed to ensure the CP identified and reported as needed diuretic (a medication to promote the formation and excretion of urine) medication lacked administration parameters. [...]

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, two medication carts, one Licensed Nurse (LN) medication cart, and one medication room. Based on observation, record review, and interview, the facility failed to store drugs and biologicals for the residents in the medication cart and the medication room that were labeled with opened on dates for the liquid vials and not expired oral medications. This deficient practice placed the residents at risk for an ineffective medication regimen.

Inspectors wroteThe facility identified a census of 34 residents. The facility had one main kitchen and a dining kitchenette. Based on observation, record review, and interview, the facility failed to ensure that the facility had sufficient staff with the appropriate competencies and skill sets to carry out the functions of the Food and Nutrition Services. This deficient practice resulted in poor sanitary conditions in the kitchen and placed the residents at risk of potentially impaired nutrition.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with five residents reviewed for immunizations. Based on observation, record review, and interviews, the facility failed to provide Resident (R) 6 with the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial lung infections) and the Influenza vaccine as consented. The facility further failed to offer the PCV20, and Influenza vaccines for R24 and R14. This placed the residents at increased risk for complications related to pneumococcal (a type of bacterial infection).

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer or obtain informed declinations or a physician-documented contraindication for the COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccinations for Resident (R) 2, R14, and R24. This deficient practice placed these residents at increased risk for COVID-19.

Inspectors wroteThe facility had a census of 34 residents. Based on observation, interview, and record review, the facility failed to ensure effective pest control. This deficient practice placed the residents of the facility at risk for decreased health and wellness.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with two residents sampled for reasonable accommodations of resident needs and preferences. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 22's call light was within her reach and further failed to ensure R6 was not pushed by staff without foot pedals. This deficient practice left R22 vulnerable for unmet care needs due to the inability to call for staff assistance and the possibility of falls and placed R6 at risk for preventable injury and avoidable accidents.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on the record review and interview, the facility failed to provide the cost for continued services information on the Advanced Beneficiary Notice (ABN Centers for Medicare and Medicaid Services (CMS) form 10055) for skilled services for Resident (R) 9. This placed the resident at risk for uninformed care decisions.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with 12 residents reviewed for comprehensive care plans. Based on observation, record review, and interviews, the facility failed to develop a comprehensive care plan for Resident (R) 33 for chronic pain, diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), activities of daily living (ADL), vision, bowel and bladder, activities, falls, psychosocial, dehydration, risk for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, [...]

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, and 12 residents were reviewed for care plan revision. Based on observation, record review, and interviews, the facility failed to revise Resident (R) 19's care plan to include the dialysis (a procedure where impurities or wastes are removed from the blood) provider, frequency of visits, and chair time at dialysis. These deficient practices placed R19 at risk for impaired care due to uncommunicated care needs related to dialysis.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with two residents sampled for activities of daily living (ADL). Based on observations, interviews, and record review, the facility failed to ensure Resident (R) 9's plan of care reflected assistance and monitoring while eating. This defiant practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity. [...]

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 22's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask was stored in a sanitary container. This placed R22 at an increased risk for respiratory infection and complications. [...]

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to monitor Resident (R) 19's access site for complications at least daily and document arteriovenous (AV- a surgically created connection between artery and a vein used for hemodialysis) fistula for thrill (palpable vibration) and bruit (an audible vascular sound associated with turbulent blood flow usually heard with stethoscope that may occasionally also be palpated as a thrill) every day. This deficient practice placed R19 at risk of adverse outcomes and physical complications related to dialysis.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with one resident reviewed for trauma informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 4's post-traumatic stress disorder (PTSD- mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R4 at risk for decreased psychosocial well-being and ineffective treatment.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 12 residents, with four residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 24 and R2. This placed the resident at risk for inappropriate end-of-life care.

Inspectors wroteThe facility identified a census of 34 residents. Based on record review, and interviews, the facility failed to maintain the posted daily nurse staffing data for the required 18 months.

Inspectors wroteThe facility identified a census of 32 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to prevent an avoidable accident on 12/16/24 when Certified Nurse Aide (CNA) M propelled Resident (R) 1 in her wheelchair without utilizing foot pedals. R1 planted her feet, leaned forward, and then fell out of the wheelchair, hitting the floor. The facility sent R1 to the emergency room (ER) where they discovered via a computed tomography (CT scan- a test that used X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) that she had mildly displaced bilateral (both sides) nasal bone fractures as a result of the fall. This deficient practice also placed R1 at risk for pain.

Inspectors wroteThe facility identified a census of 28 residents. The sample included three residents. Based on record review and interviews, the facility failed to ensure Resident (R) 1 received care consistent with the standards of practice when staff failed to report abnormal x-ray findings and obtain physician involvement for treatment. On 06/04/24, R1 had a fall in the facility's van. On 06/06/24, R1 complained of right shoulder pain and staff obtained an order for an x-ray. The x-ray showed a medial subluxation (dislocation) of R1's right glenohumeral joint (ball and socket joint at the shoulder). Staff failed to notify R1's physician of the results. On 06/27/24, after continued complaints of right shoulder pain affecting R1's activities of daily living (ADLs), staff obtained an order for a referral to an orthopedic (specializing in bones) doctor. [...]

Inspectors wroteThe facility identified a census of 28 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to ensure staff provided safe activities of daily living (ADLs) care to Resident (R) 2, consistent with her level of need. This deficient practice resulted in a fracture across the right distal femur (fracture of the thigh bone near the knee) for R2.

Inspectors wroteThe facility identified a census of 28 residents. The sample included three residents. Based on record review and interviews, the facility failed to prevent accidents for Resident (R) 1 when on 06/04/24 during a van transport to an appointment, R1's seatbelt came unfastened. Her electric wheelchair tipped towards the right to the lift gate, and she hit her right arm/shoulder on the lift gate. R1 complained of right shoulder pain on 06/06/24 and the facility obtained an x-ray. This deficient practice resulted in a medial subluxation (dislocation) of R1's right glenohumeral joint (ball and socket joint at the shoulder).

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to provide trauma-informed care for Resident (R) 17 who had an extensive history of trauma. On 05/11/23, the facility performed a social services assessment on R17 which revealed an extensive history of traumatic relationships, experience with disaster, profound feelings of helplessness, history of serious accidents and/or injuries and a history of abuse and sexual harassment. Despite this information, the facility did not develop a plan of care which identified and addressed triggers in order to prevent recurring traumatization. On 11/01/23 R17 told Activity Staff Z about her history of traumatization, previous suicide attempts, and her feelings of wanting to shoot herself. R17 cried and stated she felt sad and suicidal. [...]

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to implement immediate protective measures when Resident (R) 17 verbalized suicidal intent and/or ideations. The facility further failed to assess R17's underlying causes of distress and failed to implement person-centered interventions to address the distress and prevent recurring or ongoing distress. On 11/01/23 R17 told Activity Staff Z about her history of traumatization, previous suicide attempts, and her feelings of wanting to shoot herself or jump to her death. R17 cried and shared the reasons she felt this way with Activity Staff Z. Activity Staff Z told Administrative Staff A. At 02:45 PM Administrative Staff A and Administrative Nurse D spoke with R17 who confirmed the information. [...]

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents. Based on record review and interview the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours seven days a week. This placed all residents who resided in the facility at risk for lack of assessment and inappropriate care.

Inspectors wroteThe facility reported a census of 18 residents. Based on observation, record review and interviews, the facility failed to provide administration services in a manner that enabled effective and efficient use of resources to attain/maintain each resident's highest practicable physical, mental and psychosocial well-being, as evidenced by the deficiencies cited on the health resurvey. This had the potential to affect all 18 residents.

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents. Based on interview and record review the facility failed to identify how the facility's Medical Director would fulfill his/her responsibilities to effectively implement resident care policies and coordinate medical care for residents in the facility The facility lacked a medical director's job description or separate facility policy. This placed all 18 residents at risk for inadequate care and decreased quality of life.

Inspectors wroteThe facility had a census of 18 residents. Based on observation, interview, and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility identified a census of 18 residents. Based on observation, interview, and record review the facility failed to ensure procedures were implemented to address the facility's Quality Assessment and Performance Improvement (QAPI) plan and program. The current QAPI program failed to gather and analyze data, implement, and re-evaluate to address adverse events and potential deficient practices specific to the facility. This had the potential to affect all 18 residents residing in the facility. Findings Included: - The facility failed to promote care in a manner to maintain and enhance dignity and respect placing the affected residents at risk for impaired psychosocial well-being (Refer to F550) The facility failed to provide notification to and include the resident and/or DPOA of the quarterly care plan meetings for Resident (R)13. [...]

Inspectors wroteThe facility identified a census of 18 residents. Based on observation, interview, and record review the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) team meet quarterly with the required members in attendance. This deficient practice placed all the residents at risk for ineffective care. Findings Included: - A review of the facility's Quality Assurance Performance Improvement (QAPI) team meeting sign-in sheet for 2023 indicated a QAPI meetings were held each month. The sign in sheets revealed the facility Medical Director did not attend any of the QAPI meetings in 2023. The review also revealed that the Director of Nursing and Infection Preventionist did not attend any of the meetings for the last quarter of 2023. On 01/29/24 at 04:14 PM Administrative Staff A stated the QAA committee met monthly. [...]

Inspectors wroteThe facility had a census of 18. The sample included 16 residents. Based on record review, interview, and observation the facility failed to treat residents with respect, dignity, and privacy related to blood glucose testing, insulin (a hormone that lowers the level of glucose in the blood) administration, eye drop administration, and unintentional skin exposure from too-large clothing. This placed the affected residents at risk for impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accidents and hazards for four cognitively impaired, independently mobile residents who resided in the facility.

Inspectors wroteThe facility identified a census of 18 residents. The sample included 16 residents with five residents reviewed for immunizations, Resident (R)3, R4, R6, R14, and R16, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and is caused by infection) vaccinations. Based on record review and interviews, the facility failed to provide the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV 20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from the pneumococcal disease.

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents. Based on interview and record review, the facility failed to inform Resident (R) 13, and/or her Durable Power of Attorney (DPOA) orally or in writing the date and time of R13's quarterly care plan meetings. This placed the resident at risk for impaired care and decreased autonomy.

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents, with three reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide CMS form 10055, Advanced Beneficiary Notice, (ABN) which included the estimated cost to continue skilled services to the resident or their representative for Resident (R) 10 and R17. This placed the two residents at risk for unanticipated costs or uninformed decisions.

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to investigate Resident (R)13's bruises of unknown origin. This placed the resident at risk for unidentified and ongoing abuse and/or neglect.

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to develop an individualized comprehensive person-centered care plan for Resident (R)17 and R4. This placed the residents at risk for unmet mental health care needs related to past trauma.

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R) 16's use of an antipsychotic (medications used to treat any major mental disorder characterized by gross impairment in reality) and failed to identify and report the lack of a 14-day stop date or specific duration for R16's as needed (PRN) psychotropic (alters mood or thought) medication. This placed the resident at risk for unnecessary psychotropic medication and related side effects.

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)16's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) and failed to ensure a 14-day stop date or specified duration with rationale for R16 and R17's ongoing as needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R16 and R17 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications.

Inspectors wroteThe facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to implement acceptable infection control practices when staff failed to properly store Resident (R)13 and R6's oxygen tubing and nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help)in a sanitary manner, and staff failed to properly store R15's used urinary catheter (tube inserted into the bladder to drain urine) bag when not in use during the day. This placed the residents at increased risk for infection and communicable diseases.

Inspectors wroteThe facility identified a census of 25 residents. The sample included three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure staff immediately reported allegations of abuse to the facility administrator. On 10/07/23 at approximately 04:45 PM Dietary Staff (DS) CC heard a loud verbal interaction between Administrative Nurse D and Resident (R)1 which DS CC perceived as verbal abuse. DS CC reported the alleged verbal abuse to DS BB on the evening of 10/08/23 and DS BB reported the event to Administrative Staff A on 10/09/23 at approximately 06:10 AM, almost two days later. Certified Nurse Aide (CNA) M also perceived the interaction as alleged abuse but did not report to the facility administrator because CNA M did not know who to report to, in Administrative Staff A's absence. [...]

Inspectors wroteThe facility had a census of 30 residents. The facility identified 29 residents positive for Covid-19 ( highly contagious, potentially life threatening respiratory virus). The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for the 30 residents who resident in the facility. The facility failed to assess and ensure water temperatures were adequate to ensure the laundry, bedding, and linens were sanitized and disinfected for the 30 residents who resided in the facility. The facility failed to disinfect shared blood glucose glucometer between uses. [...]

Inspectors wroteThe facility had a census of 30 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview and record review the facility failed to store, prepare and serve meals in a sanitary manner for the residents at the facility. This deficient practice placed the affected residents who received meals from the kitchen at risk for food borne illness.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview and record review the facility failed to provide a safe, clean, sanitary environment. This deficient practice placed the affected residents at risk for impaired well-being.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents with two reviewed for urinary catheter (tube inserted into the baldder to drain urine). Based on observation, interview and record review the facility failed to care plan Resident (R) 29's urinary catheter leg bag. This deficient practice placed R29 at risk for unmet care needs.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents with one reviewed for urinary catheter (tube inserted directly into the bladder to drain urine). Based on observation, interview and record review the facility failed to provide adequate care and services for catheters for Resident (R) 29. This deficient practice placed R29 at risk urinary infections.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to act upon the Consultant Pharmacist (CP) recommendations the facility staff complete an abnormal movement assessment for the continued use of antipsychotic (class of medications used to treat any major mental disorder characterized by a gross impairment in reality testing and other mental emotional conditions) medication, Risperdal, for Resident (R)19. The facility further failed to ensure the CP identified and reported an inappropriate diagnosis for the use of an antipsychotic medication for R18 and the lack of a stop date for as needed psychotrpoic medications (class of medications which alter mood or thought). [...]

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate side effect monitoring for two of the five sampled residents, Resident (R)19's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment in reality testing) medication Risperdal and R18's olanzapine ( antipsychotic). The faility further failed to ensure R18's as needed (PRN) Ativan (an antianxiety medication that calm and relax people with excessive restlessness, nervousness and tension) had the required 14 day stop date or a rationale for continued use. This placed R19 and R18 at increased risk for side effects related to medications and unnecessary medication use.

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to ensure Resident (R)27, reviewed during medication administration pass, remained free of medication errors. This placed the resident at risk for adverse reaction from the medication and resulted in a facility medication error rate of 7.14 percent (%).

Inspectors wroteThe facility had a census of 30 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R)20's expired insulin (hormone which allows cells throughout the body to uptake glucose) flex pen in one medication cart, and failed to discard expired stock medications in one medication room. This placed the affected residents at risk for ineffective medications.