Otterbein New Albany

Inspectors wroteBased on observation, interview and facility record review the facility failed to ensure temperatures were checked prior to serving food and failed to ensure food properly stored and labeled. This had the potential to affect 52 residents. The facility provided a list of two residents who receive nothing by mouth. The facility census was 54.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review the facility failed to ensure Resident #58 was provided with sufficient incontinence care. This affected one of three residents reviewed for incontinence care. The facility census was 54.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review the facility failed to ensure Resident #58 was provided with a safe transfer using a hoyer lift. This affected one of three residents reviewed for Hoyer lift transfer. The facility census was 54.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to timely assess, stage and provide treatment to a pressure ulcer that was identified on admission for a resident. Actual harm occurred on 12/30/25 when Resident #5's pressure ulcer had a documented decline after there was no documented wound assessment or measurements completed by the facility for 20 days. The stage of the pressure ulcer was not documented on admission and the ulcer became larger in size and was unstageable. This affected one resident (Resident # 5) of four residents reviewed for pressure ulcers The facility census was 60.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to store and date food appropriately. This had the potential to affect 36 (Residents #55, #70, #23, #25, #50, #11, #28, #1, #68, #41, #61, #69, #12, #37, #4, #18, #43, #6, #16, #59, #45, #9, #5, #29, #22, #36, #2, #20, #10, #40, #13, #39, #53, #17, #54, and #42) of 48 residents reviewed for food safety. Also, the facility failed to ensure hair restraints were in place when required. This had the potential to affect 12 (Residents #8, #38, #52, #31, #58, #56, #35, #60, #62, #67, #46, and #21) of 12 residents in house one. Finally, the facility failed to ensure all food preparation tools and equipment were fully cleaned and sanitized prior to use. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to have a justified diagnosis for the use of a psychiatric medication. This affected one resident, (Resident #55), out of five residents reviewed for unnecessary medication. The facility census was 60.

Inspectors wroteBased on record review, pharmacy recommendation review, and interview, the facility failed to address pharmacy recommendations. This affected one resident (Resident #55) out of five reviewed for unnecessary medications. The facility census was 60.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide parameters for as needed pain medications. This affected one (Resident #39) of five residents reviewed for unnecessary medications. The census was 60. Findings Include:Resident #39 was admitted to the facility on [DATE]. His diagnoses were acute osteomyelitis, direct infection of right ankle, hypertensive heart and chronic kidney disease, Type II Diabetes, atrial fibrillation, sleep apnea, major depressive disorder, acute kidney failure, hyperlipidemia, hypertension, and pressure ulcer of sacral region (stage IV). Review of his minimum data set (MDS) assessment, dated 01/19/26, revealed he had a mild cognitive impairment. Review of Resident #39's physician orders found the following as needed pain medications orders: [...]

Inspectors wroteBased on observations, medical record review, staff interview, and facility policy review, the facility failed to ensure altered texture diets were prepared in a correct and safe manner. This affected one (Resident #67) of three residents reviewed for altered texture diets. The census was 60. Findings Include:Observation on 02/25/26 from 12:20 P.M. to 12:35 P.M. revealed Neighborhood Concierge (NC) #127 blended cooked chicken in a normal blender; not a food processor. NC #127 blended the chicken for about five to six minutes and then poured the contents into one portion bowl. NC #127 stated the blended chicken was to the standard she wanted it for pureed chicken. There were clear chunks and whole pieces of chicken observed in the bowl. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to display proper Enhanced Barrier Precaution (EBP) signage. This affected two residents (Resident #23 and Resident #70). Furthermore, the facility failed to follow proper infection control procedures during dressing change for #39. This affected three residents of five reviewed for infection control. The facility census was 60.

Inspectors wroteBased on record review, review of self reported incidents (SRI), interview, and policy and procedure review, the facility failed to ensure residents received appropriate assistance with transfers and failed to ensure a sit to stand lift was used appropriately during a transfer. This affected two residents (#29 and #58) of five residents reviewed. The census was 56. Actual physical harm occurred to Resident #29 on 04/15/25 when staff failed to have the sling to the sit to stand lift applied appropriately under the resident during a transfer and the resident sustained bruising, a hematoma, fractured ribs resulting in the resident being transferred and admitted to the hospital with diagnoses of hematoma, bruising, rib fractures, and anemia from blood loss. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to prepare, distribute and serve food following proper infection control. This had the potential to affect the 12 of 12 residents residing in House 6690. The census was 56.

Inspectors wroteBased on medical record review, staff interview and facility policy and procedure review, the facility failed to follow physician orders for obtaining weekly weights to monitor weight gain related to congestive heart failure. This affected one resident (#29) of five resident record reviews. The census was 56.

Inspectors wroteBased on observation, medical record review, staff interview, review of facility menu, and review of a dietary initiative, the facility failed to follow the menus and recipes for meals. This had the potential to affect all residents with the exception of Resident #8 who the facility identified as not eating anything my mouth. The facility census was 52.

Inspectors wroteBased on observation review of food storage temperature logs, and staff interview, the facility failed food was stored in a safe and sanitary manner. This had the potential to affect all 51 residents receiving food from the facility. The facility identified Resident #8 as eating nothing by mouth. The census was 52.

Inspectors wroteBased on observation, medical record review, staff interview and facility policy review, the facility failed to develop a comprehensive plan of care to address resident needs and conditions as required. This affected four (#13, #26, #35, and #42) of 25 sampled residents reviewed. The facility census was 52. Findings Include: 1. Review of the medical record for Resident #13 revealed an initial admission date of 05/05/22 with the latest readmission of 08/8/24. Diagnoses including but not limited to acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), Parkinson's disease, restlessness and agitation, anxiety disorder, major depressive disorder, seizures, hypertension, hyperlipidemia, insomnia, dementia, and atrial fibrillation. [...]

Inspectors wroteBased on observation, medical record review, and resident and staff interview, the facility failed to change and date oxygen tubing and supplies as ordered and failed to store respiratory equipment in a safe and sanitary manner. This affected four (#13, #42, #154, and #155) of seven residents reviewed for respiratory care. The census was 52. Findings Include: 1. Review of the medical record for Resident #154 revealed initial admission date 05/28/24 and re-admission date 08/01/24. Diagnoses included chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and other diseases of the bronchus. Resident #154 had intact cognition and required limited assist from staff for activities of daily living (ADLs) tasks and medication administration. [...]

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to maintain infection control during a dressing change, failed to implement enhanced barrier precautions, and failed to maintain sanitary placement of a urinary catheter bag. This affected seven (#8, #11, #25, #102, #103, #154, and #155) of eight residents reviewed for infection control practices. The facility census was 52. Findings Include: 1. Review of the medical record for Resident #8 revealed an admission date of 10/04/21 with the diagnoses including Down syndrome, obstructive sleep apnea, chronic respiratory failure, asthma, and stage four pressure injury to right buttock. Resident #8 was dependent for all care, personal hygiene needs, and administration of medications and treatments. Resident #8 had impaired cognition and required a wheelchair for mobility. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to provide residents with a dignified dining experience. This affected one (#46) of two residents reviewed for dignity. The facility census was 52.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of invoices, the facility failed to ensure residents had a means to contact staff members of needs and services that were individualized to the resident's needs. This affected one (#102) of one resident reviewed for call lights. The facility census was 52.

Inspectors wroteBased on observation, resident and staff interview, and medical record review, the facility failed to ensure residents were provided the right to chose their eating utensils to promote a homelike dining experience. This affected one (#21) of one residents reviewed for choices. The facility census was 52. Findings Include: Review of the medical record for Resident #21 revealed an initial admission date of 07/31/23 with the diagnoses including but not limited to dementia, colostomy, diabetes mellitus, hypertension, obstructive reflux uropathy, morbid obesity, malignant neoplasm of colon, and osteoarthritis. Review of Resident #21's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of Resident #21's current plan of care revealed no care plan indicating the resident was not able to have a table knife at meals. [...]

Inspectors wroteBased on resident funds account review, medical record review, and staff interview, the facility failed to ensure residents were assisted with spending down their resident trust accounts once the balance reached $200 less than the Medicaid allowable limit. This deficient practice affected one resident (#43) of four residents reviewed for personal funds. The facility census was 52. Findings Include: Review of the medical record for Resident #43 revealed an admission date 08/18/23 with a diagnosis of Alzheimer's disease with late unset. Resident #43 had dual payer sources consisting of Medicaid and a commercial insurance. [...]

Inspectors wroteBased on observation, medical record review, review of maintenance logs, and staff interview, the facility failed to maintain a safe and homelike environment. This affected two (#31 and #36) of nine residents reviewed for environment. The facility census was 52.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to insure residents were free from physical restraints. This deficient practice affected one (#31) of one residents reviewed for physical restraints. The facility census was 52. Findings Include: Review of Resident #31's medical record revealed an admission date of 11/14/21 with diagnoses including dementia, anxiety, osteoarthritis, major depressive disorder, and history of falls. Resident #31 required assistance from staff for transfers and activities of daily living (ADLs) tasks and used a wheelchair for mobility. Resident #31 had impaired cognition and could be redirected during times of agitation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had delusions, was always incontinent of urine and bowel, and was at risk for skin impairment. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) evaluations were updated upon determination or newly evident or possible serious mental disorders. This affected one (#4) of one reviewed for PASARR. The facility census was 52. Findings Include: Review of the medical record for Resident #4 revealed an initial admission date of 11/16/17 with the latest readmission of 02/26/24, and with the diagnoses including but not limited to bipolar disorder, morbid obesity, hypertension, dementia with anxiety, peripheral vascular disease, polyarthritis, cataracts, alcohol dependence with alcohol induced dementia, generalized muscle weakness, difficulty in walking, mixed incontinence, hyperlipidemia, low back pain, sensorineural hearing loss, osteoarthritis, dermatitis, and insomnia. [...]

Inspectors wroteBased on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to thoroughly assess residents for activity preferences, provide activities of resident interest, and failed to ensure activities were completed as planned. This affected three (#6, #42, and #103) of five residents reviewed for activities. The facility census was 52.

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to adequate assess and provide treatments for non-pressure skin injuries, and facility to provide treatment as ordered to prevent edema. This affected three (#13, #42, and #102) of 25 medical records reviewed for care. The facility census was 52.

Inspectors wroteBased on resident and staff interview, medical record review, and review of a facility policy, the facility failed to ensure pressure ulcers were timely assessed and and monitored and failed to ensure treatments were administered as ordered. This affected one (#103) of six residents reviewed for pressure ulcers. The facility census was 52.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to implement an effective intervention to reduce fall risk and determine effectiveness following a fall. This affected one (#4) of six residents reviewed for accidents. The facility census was 52. Findings Include: Review of the medical record for Resident #4 revealed an initial admission date of 11/16/17 with the latest readmission of 02/26/24. Diagnoses including but not limited to bipolar disorder, morbid obesity, hypertension, dementia with anxiety, peripheral vascular disease, polyarthritis, anxiety disorder, cataracts, alcohol dependence with alcohol induced dementia, generalized muscle weakness, difficulty in walking, mixed incontinence, hyperlipidemia, low back pain, sensorineural hearing loss, osteoarthritis, dermatitis and insomnia. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to comprehensively assess a Resident #42's bowel and bladder function and implement interventions and/or a program to restore function and prevent further decline in bowel and bladder function. Additionally, the facility failed to ensure Resident #11 and #102, with urinary catheters received appropriate and timely care of the catheter as ordered. This affected three (#11, #42, and #102) of six residents reviewed for bowel and bladder status and urinary catheters. The facility census was 52.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and facility policy review, the facility failed to obtain resident weighs as ordered, failed to thoroughly assess Resident #103's nutritional status and contributing factors to nutritional deficits, and failed to provided double portioned food items as ordered to prevent malnutrition/weight loss. Additionally, the facility failed to ensure supplements were provided to Resident #20 as ordered and failed to re-weigh the resident following a significant change to the resident's weight per (facility) policy. This affected two (#20 and #103) of six residents reviewed for nutrition. The facility census was 52.

Inspectors wroteBased on medical record review and staff interview, the facility failed to timely address pharmacy recommendations. This affected two (#5 and #26) of five residents reviewed for unnecessary medications. The facility census was 52.

Inspectors wroteBased on medical record review and staff interview, the facility failed to residents were appropriately monitored as ordered when administered medications. This affected two (#102 and #103) of five residents reviewed for unnecessary medications. The facility census was 52.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (#26) of five residents reviewed for unnecessary medications and one (#6) of one residents reviewed for pain management. The facility census was 52.

Inspectors wroteBased on observation, medical record review, and resident and staff interview, the facility failed to secure and store medications appropriately. This affected two (#25 and #44) of five residents observed during medication administration. The facility census was 52. Findings Include: 1. Review of the medical record for Resident #25 revealed admission date 08/06/24 with diagnoses including stomach cancer, adult failure to thrive, esophagus cancer, dysphalgia, and high blood pressure. Resident #25 required assistance from staff for activities of daily living (ADLs) tasks, medication administration, and personal hygiene care. [...]

Inspectors wroteBased on review of the medical record, staff interview, and review of a facility policy, the facility failed to timely obtain laboratory values as ordered. This affected two (#13 and #39) of five residents reviewed for urinary tract infections (UTI). The facility census was 52.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to report results of laboratory results in a timely manner. This affected two (#13 and #20) of 25 residents reviewed for laboratory values. The census was 52.

Inspectors wroteBased on observation and resident and staff interview, the facility failed to ensure appetizing food was served to the resident. This affected one (#39) of 11 resident residing in House #300. The facility census was 52.

Inspectors wroteBased on observation, medical record review, review of menus, staff interview, and review of a dietary initiative, the facility failed to ensure residents were served food items as ordered to meet their needs. This affected two (#33 and #102) of seven residents on a soft and bite sized diet. The facility census was 52.

Inspectors wroteBased on medical record review and staff interview, the facility failed to maintain a complete and accurate medical record. This affected two (#4 and #13) of 25 sampled residents. The facility census was 52. Findings Include: 1. Review of the medical record for Resident #4 revealed an initial admission date of 11/16/17 with the latest readmission of 02/26/24. Diagnoses included bipolar disorder, morbid obesity, hypertension, dementia with anxiety, peripheral vascular disease, polyarthritis, generalized muscle weakness, and difficulty in walking. Review of the fall investigation form dated 04/01/24 at 3:00 A.M. revealed Resident #4 was found in her doorway sitting on the floor. The resident reported she was walking and fell. Review of Resident #4's medical record revealed the fall occurrence on 04/01/24 at 3:00 A.M. was not documented in the resident's medical record. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure residents receiving antibiotics were properly assessed prior to implementation of antibiotic therapy and antibiotics appropriately prescribed. This affected three (#4, #11, and #39) of five residents reviewed for urinary tract infections (UTI). The facility census was 52.

Inspectors wroteBased on personnel record review and staff interview, the facility failed to provide 12 hours of annual in-services for state tested nurse aides (STNAs) as required. This affected two (STNA #45 and STNA #71) out of nine employee records reviewed. This had the potential to affect all 52 residents in the facility. The census was 52 residents.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to report and investigate an injury of unknown origin. This affected one (Resident #17) of one resident reviewed for injury of unknown origin. The facility census was 56.

Inspectors wroteBased on staff interview, observations, medical record review, and facility policy review, the facility failed to implement infection control practices to prevent the potential spread of illness, related to hand hygiene, glove use, personal protective equipment, and tuberculosis screening. This had the potential to affect all 12 residents in House Two (Resident #7, #8, #10, #15, #21, #26, #34, #41, #43, #44, #49, and #103), four residents (Resident #5, #17, #36, and #52) of four residents reviewed for infection control, with the potential to affect all 56 residents residing in the facility.

Inspectors wroteBased on staff interview, observations, medical record review, and facility policy review, the facility failed to ensure resident call lights/pendants were within reach. This affected five residents (Resident #4, #24, #17, #52, and #203) of five reviewed for accomodation of needs.

Inspectors wroteBased on staff interview and facility policy review, the facility failed ensure newly hired employees had a criminal background check prior to beginning to work in the facility. This had the potential to affect all 56 residents residing in the facility.

Inspectors wroteBased on staff interview, resident interview, observations, and facility policy review, the facility failed to sufficiently staff house three to meet the needs of residents. This affected all 12 residents (Resident #4, #5, #6, #9, #17, #24, #30, #36, #38, #52, #203, and #204) of 12 residents residing in House Three.

Inspectors wroteBased on observations, resident interview, staff interviews, and facility meal schedule review, the facility failed to provide an adequate number of dietary staff to ensure food was delivered/served in a palatable and appetizing manner. This had the potential to affect 12 (Residents #4, #5, #6, #9, #17 #24, #30, #36, #38, #52, #203, and #204) of 35 residents observed for meal service. Findings Include: Observations on 07/20/22 from 11:45 A.M. to 12:55 P.M., revealed Elder Assistant (EA) #301 was only staff preparing and cooking all the food items for residents in the 300 house. During the food preparation and cooking period, no residents were being served food, because she was responsible for continuing to cook all the resident food and prepare side dishes, including beginning stages of cutting a watermelon. [...]

Inspectors wroteBased on Observations, resident interview, staff interviews, and facility policy review, the facility failed to serve food at a safe and appetizing temperature. This had to the potential to affect 12 (Residents #4, #5, #6, #9, #17 #24, #30, #36, #38, #52, #203, and #204) of 35 residents observed as being served meals. Findings Include: Observations on 07/20/22, starting at 11:45 A.M., revealed Elder Assistant (EA) #301 started to cook lunch, which included hamburgers, baked beans, and french fries. At 12:12 P.M., the first seven hamburgers were completed and the cooking temperatures were between 172 and 187 degrees Fahrenheit. The hamburgers were placed on a dinner plate and put into the microwave. At 12:34 P.M., seven more hamburgers were cooked, with cooking temperatures being between 164 and 180 degrees. [...]

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to properly store and date foods and failed to use appropriate hand hygiene while serving a lunch meal. The deficient practices had the potential to affect all 24 residents who resided in the 200 and 300 houses (Residents #4, 6, 7, 8, 9, 10, 15, 17, 21, 24, 26, 30, 34, 36, 38, 41, 43, 44, 49, 52, 103, 203, 204, and 312) and nine residents (Residents #45, 46, 153, 154, 155, 156, 157, 158, and 159) who resided in 500 house. One resident (Resident #39) in 500 house was on a nothing by mouth (NPO) diet. Findings Include: Observation of Elder Assistant (EA) #249 on 07/18/22 from 12:06 P.M. to 12:14 P.M. serving lunch in the 500 house showed EA #249 wearing gloves. The EA opened the plastic bag of submarine buns with her gloved hands, reached into the bag, and grabbed a bun from the bag. [...]

Inspectors wroteBased on staff interview, observations, medical record review, and facility policy review, the facility failed to store an indwelling catheter bag and provide incontinence care in a dignified manner per facility policy for Resident #5. This affected one resident (Resident #5) of one resident reviewed for urinary catheters.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to notify the physician of a change in condition for Resident #46. The deficient practice affected one resident (Resident #46) of one reviewed for change of condition. The facility census was 58. Findings Include: Review of the medical record for Resident #46 revealed an original admission date on 04/15/22. The resident was hospitalized on [DATE] and had a readmission date on 06/20/22. Medical diagnoses included benign neoplasm of cerebral meninges, non-traumatic subarachnoid hemorrhage, encephalopathy, sepsis (06/20/22), Type II Diabetes Mellitus, personal history of irradiation, other seizures, and unspecified symptoms involving cognitive functions and awareness. [...]

Inspectors wroteBased on record review, review of minimum data set (MDS) assessments, staff interview, and facility policy review, the facility failed to ensure MDS assessments were completed accurately for two residents (Residents #2 and #55). The deficient practice affected two (Residents #2 and #55) of two residents reviewed for accurate assessments. Findings Include: 1. Review of the medical record for Resident #2 revealed an admission date on 01/15/22 with medical diagnoses including dementia without behavioral disturbance, type II diabetes mellitus with hyperglycemia, major depressive disorder, and anxiety disorder. Review of the the physician orders for July 2022 revealed Resident #2 had orders for Seroquel (an antipsychotic) 50 milligrams (mg) daily dated 02/10/22 and Seroquel 100 mg daily at night dated 02/09/22. [...]

Inspectors wroteBased on observations, medical record review, resident interviews, staff interviews, facility policy review, and resident council minutes review, the facility failed to offer activities to meet the residents needs and preferences. This affected one resident (Resident #5) of three residents reviewed for activities. The census was 56. Findings Include: Review of the medical record for Resident #5 revealed an admission date of 04/09/22 with diagnoses including congestive heart failure (CHF) and acute and chronic respiratory failure with hypoxia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 04/16/22, revealed the resident had impaired cognition with a Brief Interview of Mental Status (BIMS) score of nine out of 15 (moderate cognitive impairment). The resident required extensive to total assistance of two or more staff for all Activities of daily Living (ADL's). [...]

Inspectors wroteBased on observations, staff interview, record review, and facility policy review, the facility failed to monitor bruising on Resident #46's bilateral legs. The deficient practice affected one resident (Resident #46) of one resident reviewed for bruising/skin. Findings Include: Review of the medical record for Resident #46 revealed an original admission date on 04/15/22 and readmission date on 06/20/22 with medical diagnoses including benign neoplasm of cerebral meninges, non-traumatic subarachnoid hemorrhage, encephalopathy, sepsis, type II diabetes mellitus, personal history of irradiation, other seizures, and unspecified symptoms involving cognitive functions and awareness. Review of the readmission skin assessment dated [DATE] revealed Resident #46 did not have any bruising on her legs noted on the assessment. [...]

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to timely investigate a fall with major injury and failed to complete neurochecks per facility protocol for Resident #2. The deficient practice affected one resident (Resident #2) of two residents reviewed for accidents. Findings Include: Review of the medical record for Resident #2 revealed an admission date on 01/15/22. Medical diagnoses included dementia without behavioral disturbance, type II diabetes mellitus with hyperglycemia, major depressive disorder, anxiety disorder, and shortness of breath (SOB). Review of the fall risk assessments dated 01/15/22, 03/31/22, and 06/24/22 revealed the resident was at risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 was rarely or never understood. [...]

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, facility policy review, the facility failed to ensure Resident #4 and Resident #17 received nutritional supplements as ordered. This affected two Residents (#4 and #17) of two residents reviewed for nutrition.

Inspectors wroteBased on staff interview, resident interview, observations, medical record review, facility policy review, the facility failed to ensure oxygen (O2) was administered, stored, labeled, and dated properly. This affected three residents (Resident #4, #5, and #52) of three residents reviewed for respiratory care.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to timely and adequately review pharmacy recommendations. This affected one (Resident #48) of five residents reviewed for unnecessary medications. Findings Include: Resident #48 was admitted to the facility on [DATE] with diagnoses including pain in left knee, muscle weakness, difficulty in walking, type II diabetes, hypertension, lymphedema, anxiety disorder, Alzheimer's disease, major depressive disorder, dementia, and cognitive communication deficit. Review of Resident #48's Minimum Data Set (MDS) assessment, dated 07/01/22, revealed she had a significant cognitive impairment. Review of Resident #48 medical records revealed a pharmacy recommendation made on 09/07/21 to review Duloxetine 60 milligrams (mg) for a gradual dose reduction (GDR). [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to provide proper justification for the use of psychotropic medications. This affected two residents (Resident #2, and Resident #48) of five residents reviewed for unnecessary medications. The census was 56. Findings Include: 1. Resident #48 was admitted to the facility on [DATE]. Her diagnoses were pain in left knee, muscle weakness, difficulty in walking, type II diabetes, hypertension, lymphedema, anxiety disorder, Alzheimer's disease, major depressive disorder, dementia, and cognitive communication deficit. Review of her Minimum Data Set (MDS) assessment, dated 07/01/22, revealed she had a significant cognitive impairment. Review of Resident #48 medical records revealed a physician order for Zyprexa (antipsychotic medication) 2.5 milligrams (mg). [...]