Pleasant View Nursing Home

Inspectors wroteBased on record review and interview, the facility did not offer each resident influenza immunization, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza immunization for 1 of 3 residents (R4) reviewed for immunizations. R4's Activated Power of Attorney (APOA) signed the consent for the influenza vaccine, and there is no evidence that R4 received the immunization. Evidenced by:The facility's policy titled Influenza Vaccination dated 7/1/25 states in part .7. Individuals receiving the influenza vaccine, or their legal representative, will be required to consent prior to the administration of the vaccine. The consent will be located in the resident's medical record. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure when COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized for 1 of 3 residents (R3) reviewed. R3 did not receive the 2025-2026 COVID-19 Vaccine. This is evidenced by: The facility's policy and procedure titled, COVID-19 Vaccination, implemented 11/10/25, states in part: Policy: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. Policy Explanation and Compliance Guidelines: 3. COVID-19 vaccination is recommended for the prevention of COVID-19 disease and its complications as follows: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately provide basic life support, including cardiopulmonary resuscitation (CPR) to a resident requiring emergency care for 1 of 3 residents (R1) reviewed for code status. This has the potential to affect 12 full code residents that reside in the facility. R1 is a full code and was found on the floor of his room unresponsive on [DATE]. A Registered Nurse (RN) failed to initiate CPR immediately, the facility failed to ensure that staff were competent in using basic life support equipment, and failed to ensure that there was always a CPR-certified staff member in the building. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a performance review of every nurse aide at least once every 12 months for 5 of 5 Certified Nursing Assistants (CNAs) reviewed. CNA F did not have an annual performance evaluation completed timely. CNA W did not have an annual performance evaluation completed timely. CNA X did not have an annual performance evaluation completed timely. CNA Y did not have an annual performance evaluation completed timely. CNA Z did not have an annual performance evaluation completed timely. This is evidenced by:The Facility's policy titled Performance Evaluations revised September 2020 states, in part: Policy Statement: The job performance of each employee shall be reviewed and evaluated at least annually. Example 1CNA F's hire date was 5/9/23. CNA F's previous annual performance evaluation was completed on 5/9/24. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse were reported to other officials in accordance with State law through established procedures for 1 of 3 residents (R2) reviewed for abuse/neglect. A staff member was aware of a potential allegation of abuse, and it was not immediately reported to the administrator or designee. This is evidenced by:The Facility Policy, titled, Abuse, Neglect, and Exploitation, indicates, in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response. A. The facility will have written procedures that include: 1. [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure 2 of 9 residents (R) sampled for review of Abuse (R1 and R2) were free from involuntary seclusion.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents were free from physical abuse for three of four (Residents (R) R2, R11, and R8) residents reviewed for physical abuse. The facility failed to put consistent interventions into place to prevent one resident (R3) from repeated physical violence towards other residents.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure an allegation of resident-to-resident abuse for one of four residents (R11) reviewed for abuse out of a total sample of 11 was reported to the state survey agency (SSA) within the required time frame.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to conduct a thorough investigation for an incident of potential resident-to-resident abuse for one of four residents (R11) reviewed for abuse out of eleven sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to contact the pharmacy to ensure medications were available for administration for two of three residents (Resident (R) 6 and R9) reviewed for medication administration out of a sample of eleven residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 of 3 residents (R1, R2, and R3) were free from involuntary seclusion. The facility moved R1, R2, and R3 from the unit they resided on and placed them on a different unit within the facility. Facility staff erected a wall and placed R1, R2, and R3 behind this wall. R1, R2, and R3's families were not aware R1, R2, and R3 were being secured behind a wall isolating the residents from others in the facility. Using the reasonable person concept a resident would be fearful, anxious and feel dehumanized, when not afforded the individuality, compassion and civility as others who reside at the facility. [...]

Inspectors wroteBased on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 64 Residents who reside in the facility. Kitchen floor was unclean with visible dirt and food debris on the floor. Dish machine rinse temperature did not reach the 180-degree rinse requirement. Evidenced by: Facility Policy titled 'Sanitization,' states in part: .The food service area shall be maintained in a clean and sanitary manner . 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. 4. Sanitizing of environmental surfaces must be performed with one of the following solutions: a. 50-11 ppm chlorine solution; 150-200ppm quaternary ammonium compound (QAC); or c. 12.5ppm iodine solution.15. [...]

Inspectors wroteBased on interview and record review the facility did not afford the resident or resident's representative the right to refuse to transfer to another room in the facility for 3 of 3 residents (R1, R2 and R3) reviewed for room transfers. R1, R2, and R3 received room change notices and the facility did not afford the residents' representatives the opportunity to refuse the room change. This is evidenced by: The facility's policy titled Room Change/Roommate Assignment revised 3/2021 states in part; changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change. 1. Resident room or roommate assignment may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered. 2. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure that each resident has a safe, clean, comfortable, and homelike environment, including, but not limited to receiving treatment and supports for daily living for 1 (R2) of 3 resident rooms observed. R2's bathroom toilet was soiled with stool and family reported it had been soiled for several days. This is evidenced by: On 10/8/24 at 6:45 PM, Surveyor observed R2's room and bathroom. R2's toilet was soiled with stool. On 10/9/24 8:20 AM, Surveyor observed R2's room and bathroom. R2's toilet was soiled with stool. On 10/9/25 at 8:15 AM, Surveyor met R2's Guardian FM K (Family Member) and Spouse. R2's guardian asked Surveyor if she had observed R2's bathroom. Surveyor observed R2's bathroom and noted the bathroom remained dirty with stool observed around and in the stool. FM K stated this has been like this for several days; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of a facility-initiated discharge, failed to ensure the written notice contained all pertinent information for a discharge notice including the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, and the name and address of the Office of the State Long-Term Care Ombudsman for 2 of 2 facility-initiated discharges reviewed involving 2 Resident (R1 and R2). R1 and R2 received involuntary discharge notices; however, the notices did not contain all necessary information. This is evidenced by: The facility's Transfer and/or Discharge Policy revised 3/2021 states in part: (2) residents are permitted to stay in the facility, and not be transferred or discharged unless: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program to support resident choice of activities, based on the comprehensive assessment and care plan and the preferences of each resident for 3 of 3 Residents (R1, R2, R3) residing on the Way Unit. Activity staff and staff working on the Way Unit were not providing or offering activities for R1, R2, and R3. There is no documentation of R1, R2, and R3 participating or being offered activities since they were moved to the Way Unit. This is evidenced by: Facility Policy entitled 'Individual Activities and Room Visit program,' states in part: .Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities and for those residents who do not wish to attend group activities. [...]

Inspectors wroteBased on interview and record review, the facility failed to assure that there is sufficient, qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for 3 of 3 Residents (R1, R2, & R3). RA (Resident Assistants), who are not Certified Nursing Assistants, were working on the Way Unit alone with R1, R2 and R3 who require increased supervision. This is evidenced by: Facility Employee list shows RA H, RA CC, RA X, and RA AA as being RA's and CNA (Certified Nursing Assistant) Facility staffing schedule indicates the following: On 10/1/24, RA H worked 6:30 AM to 3:00 PM, on the Way Unit and RA CC worked the Way Unit from 3:00 PM to 4:00 PM with another RA training. On 10/2/24, RA CC worked 1:30 PM to 10:00 PM on the Way Unit. [...]

Inspectors wroteUNCORRECTED AT VERIFICATION VISIT. See SOD for Event ID #MK7V11 Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents for 4 of 4 residents (R8, R10, R4, and R7) reviewed for falls/accidents and 4 of 4 residents (R1, R6, R2, and R5) reviewed for resident to resident/supervision. R8 required a two-person transfer with a full body lift, a staff member completed the transfer independently and R8 fell out of the lift. Staff did not follow R10's care plan when they transferred R10 to the restroom. Staff did not have foot pedals on R10's chair and Surveyor observed staff pushing R10 down the hall with his left leg dragging under the wheelchair seat. R7 was observed self transferring without gripper socks. R4 was transferred with the incorrect sling. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive the care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 2 residents reviewed (R8 and R4). R8 did not have neurological checks completed after a fall per facility protocol. R4 was admitted with orders to weigh daily and update the Physician with a weight increase or decrease by 3 lbs. (pounds) in a day or 5 lbs. in a week. R4's weights were not completed daily, and the physician was not always informed when weights fell outside the given parameters. This is evidenced by: The facility has an Unwitnessed Fall Checklist, undated, which state in part; if resident is unable to tell you if they hit their head, assume they did and do neuro (Neurological) checks with vital signs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure hand hygiene and infection control practices were performed to prevent the spread of infection for 1 of 4 residents (R11) observed for hand hygiene and infection control opportunities. Staff were observed not completing hand hygiene per standards of practice, placing dirty washcloths in the wash basin, placing dirty washcloths on the bedside table, not disinfecting the bedside table or mechanical lift. This is evidence by: The facility policy titled Handwashing/Hygiene dated revised 8/2019 states in part; the facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 1 residents reviewed for elopement (R58), 6 of 17 sampled residents (R2, R40, R59, R1, R66, R48) and 6 of 13 supplemental residents (R10, R31, R39, R45, R35, R50) reviewed for wandering, and 1 of 13 supplemental residents reviewed for accidents (R6). R58 has a history of multiple falls, exit seeking behaviors, and elopement. Facility staff did not provide adequate supervision to prevent elopement when R58 was exit seeking. R58 exited through an alarmed door, took his wheelchair down a stairwell, and was found at the bottom of a flight of stairs. Although the door alarm activated and would have sounded for 15 seconds before the stairwell door opened, staff did not respond because there was no staff in the immediate area. [...]

Inspectors wroteBased on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all 69 residents. Staff returned to work to soon after signs and symptoms of GI (gastrointestinal illness). Surveyors observed R24 reach in the kitchenette's ice machine with her bare hands. The facility policy entitled Communicable/Contagious Diseases, Employee, with a revision date of 1/24, states in part: . Policy Statement: Personnel with active communicable infections may not be in contact with residents, resident-care items and equipment, or resident environments (e.g., common areas or resident rooms) until they are no longer clinically infectious or contagious. [...]

Inspectors wroteBased on interview and record review the facility did not ensure prompt resolution of all grievances for 3 of 14 residents reviewed (R2, R40, and R59) for grievances out of a total sample of 17 residents and 5 of 5 supplemental residents reviewed for grievances (R31, R6, R10, R39 and R50). R31, R39, R10, R40 voiced concerns at the Resident Council Meeting regarding the facility not following up on concerns/grievances. R2, R6, R50, and R59 voiced concerns during individual interviews regarding the facility not following up on voiced concerns/grievances. Staff reported they were aware of concerns voiced by R2, R50, R59, R40, R10, R39, R6, and R31 and did not report to the Grievance Official and did not follow the facility's grievance process. Evidenced by: Facility policy, entitled Grievance/Complaint Filing, revised 4/2017, includes, in part: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that all medications were stored and labeled in accordance with standard of practice for 3 of 3 (R25, R8, and R422) supplemental resident's, 2 of 4 medication storage rooms, and 3 of 5 medication carts reviewed. Surveyor observed expired eye drop administration to R25 during medication pass. Surveyor observed expired facility stock supply of acetaminophen 325 mg (milligram) tablets of the 300 wing medication cart during the medication storage task on [DATE]. This medication was previously administered to R8 and R422 on [DATE] morning doses. Surveyor observed an opened multidose vial of Tubersol in the medication room refrigerator located on the 300 wing with an unreadable partial date of unknown identification if the partial date is for the date of opening the vial or the expiration date. Evidenced by: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents choices were honored in meal substitutions and an environment that promotes an enhanced quality of life which affected 1 of 1 resident (R59) out of a total sample of 17 residents. R59 voiced concerns her bed was not always made and her choice to have her bed made was not always honored. R59 also expressed concerns her meal choices were not honored. As evidenced by: Example 1 R59 was admitted to the facility on [DATE] with a diagnosis including paresthesia of skin, which is a tingling or prickly sensation in the arms, hands, legs, or feet. R59's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 6/4/24, indicates R59 has a BIMS (Brief Interview for Mental Status) score of 9 out of 15 indicating R59 is moderately cognitively impaired. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 resident's (R30) out of a total sample of 17 residents observed for self- administration of medications. R30 was observed to have medications on the floor and an empty medication cup on her bedside table. This is evidenced by: The facility's policy titled Administering Medications dated April 2019, states in part, .27. Residents may self- administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team has determined that they have the decision-making capacity to do so safely . The facility policy titled Self-Administration of Medications dated February 2021, states in part, .1. [...]

Inspectors wroteBased on record review, the facility did not ensure adequate indications for use prior to the administration of a high-risk medication for 1 resident of 5 residents reviewed for unnecessary medications out of a total sample of 17 residents (R40). R40 receives Lemborexant (sedative/hypnotic) for insomnia. The facility failed to complete a sleep assessment for R40 prior to prescribing and administering a hypnotic medication. Evidenced by: Facility policy, entitled Psychotropic Medication Use, dated July 2022, states: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy interpretation and implementation: A psychotropic medication is any medication[sic] that affects brain activity associated with mental processes and behavior. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that before offering the influenza and/or pneumococcal immunizations, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization, and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunizations; and that the resident either received the influenza and/or pneumococcal immunizations or did not receive the influenza and/or pneumococcal immunizations due to medical contraindications or refusal. This affected 1 of 5 residents (R40) reviewed for immunizations. R40 was not offered pneumococcal vaccines. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from physical abuse by a resident (R1). This affected 3 of 6 residents (R4, R5, and R6) reviewed for abuse. R1 has a history of resident-to-resident incidents including punching a resident in the back (R4), punching a resident in the face, putting a resident in a choke hold and banging her head on the wall, hitting the resident in the head and chest and pushing her into a chair and grabbing her wrist. The facility failed to update R1's care plan with new interventions after the incidents to prevent further abuse. The facility failed to ensure that R1's line of sight monitoring was completed to prevent further incidents. The facility was aware of R1's behaviors of hitting, punching, grabbing, yelling, and swearing at other residents and staff. [...]

Inspectors wroteBased on record review and interview, the facility's assessment, last reviewed/updated on 8/18/23, does not address the competencies to care for residents with behaviors or what the facility is doing to work with residents with behavioral needs. The facility assessment does not address the number of residents with traumatic brain injuries (TBIs), the resources required for those residents, or the number of staff necessary to care for these residents. The deficient practice has the potential to affect 19 of the 20 residents with dementia on the View Unit.

Inspectors wroteBased on interview and record review, the facility changed R1's living area for staff convenience and did not ensure that R1's representative was notified in writing of the room change for 1 of 1 residents (R1) out of a total sample of 7 residents. R1 was moved back and forth on the View unit and the Dementia Stabilization Unit (DSU) for staff convenience and without giving written notice of the change to R1's representative. This is evidenced by: Facility Policy entitled Room Change/Roommate Assignment, revised March 2021, states, in part: . Policy Statement: Changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change. Policy Interpretation and Implementation: 2. [...]

Inspectors wroteBased on interview and record review, the facility did not permit 1of 1 residents (R1) reviewed for transfer and discharge to stay in the facility and did not transfer a resident from the facility unless the transfer was necessary and the residents needs could not be met by the facility. R1 was transferred to and from the skilled nursing facility to the community based residential facility within the facility campus without giving R1's family proper notice and without proper documentation justifying the transfer.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification to the resident, resident representative and the Office of the State Long-Term Care Ombudsman of a transfer for 1 of 1 residents (R1) reviewed for transfer/discharge out of a total sample of 7. The facility failed to notify R1's representative and the Ombudsman in writing of the reason for transfer to the Dementia Stabilization Unit (DSU). This is evidenced by: The facility policy titled, Transfer or Discharge, Preparing a Resident for, states in part . Policy Statement: Resident will be prepared in advance for discharge. Policy Interpretation and Implementation: 1. When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to ensure safe and orderly transfer or discharge from the facility for 1 (R1) of 1 resident reviewed for discharge. Evidenced by: The facility policy titled, Transfer or Discharge, Preparing a Resident for, states in part . Policy Statement: Resident will be prepared in advance for discharge. Policy Interpretation and Implementation: 1. When a resident is scheduled for transfer or discharge, the business office will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented. 2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not provide evidence that Certified Nursing Assistants (CNAs) had 12 hours of in-service training per year for 1 of 5 CNA's reviewed for in-service training. The survey team randomly selected five (5) facility CNAs who have been employed at the facility for longer than one (1) year. CNA W did not have 12 hours of in-service training.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 5 residents reviewed (R35) of a total sample of 21. R35 has a history of multiple falls. Facility staff did not implement fall interventions. R35 had a fall that resulted in a right pubic rami fracture (pelvic fracture). This is evidenced by: R35 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, Chronic Kidney Disease stage 4, Major Depressive Disorder, Anxiety Disorder, Spinal Stenosis, and Osteoporosis. R35's most recent MDS (Minimum Data Set) dated 12/13/22 states that R35 has a BIMS (Brief Interview of Mental Status) of 4/15 indicating that R35 is severely cognitively impaired. Section G states that R35 requires extensive assist of 2 staff for bed mobility and transfers. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 1 supplemental resident's (R26) observed during medication pass. R26 was observed to have her medications left at bedside. This is evidenced by: The facility's policy titled Medication Administration Policy dated 9/6/19, states in part, .10. Self- Administration of Medications .a. For a resident to administer their own medications, the resident needs to have completed and passed a nursing assessment that will aid in determining if this resident is capable of self- administering their own medications including leaving medications to be taken at their own determined time, completing their own nebulizer treatments, and applying an ointment or cream where and when ordered. b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident is free from physical restraints that are not required to treat the resident's medical symptoms for 2 of 5 residents reviewed for restraints (R35 and R29). R35 had a pommel cushion without an assessment for its use. The facility did not consider this device a restraint. R29 had a wheelchair seatbelt she could not be easily removed by the resident. The facility did not consider this device a restraint. Evidenced by: The facility's policy titled Use of Restraints last revised April 2017, states in part: Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 1 resident (R1) of 1 sampled residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R1 was at risk for pressure injury (PI) development. R1 developed a deep tissue injury (DTI) to the left heel. Facility staff did not ensure PI interventions were in place and did not implement an appropriate offloading device for the left (L) heel. Treatment orders were not completed as ordered.

Inspectors wroteBased on staff interview and record review, the facility did not ensure that pain management was provided consistent with standards of practice for 1 of 2 residents reviewed (R42) out of a total sample of 21. R42 had an order for scheduled and PRN (as needed) pain medication. R42 has chronic pain and feels pain is not controlled. Facility had not been assessing pain with scheduled pain medication to track effectiveness of medications. Evidenced by: The facility policy, entitled Administering Pain Medications, with a revision date of March 2020, states, in part: . Purpose: The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication . General Guidelines: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 4 residents (R64) of a total of 21 residents reviewed had a drug regimen free from unnecessary drugs. R64 did not meet criteria for antibiotic therapy. As evidenced by The facility policy, Antibiotic Stewardship & MDROs (Multi Drug Resistant Antibiotics), dated 2020, indicates in part, the following: Antibiotic stewardship refers to systemic efforts to optimize the use of antibiotics - not just reduce the total volume used - to maximize their benefits to patients, while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. The CDC (Centers for Disease Control) indicates that antibiotics are among the most frequently prescribed medications in nursing homes with up to 70% of residents receiving at least one antibiotic when followed for over one ear. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the influenza and/or pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindications or refusal, this affected 3 of 5 residents (R10, R44, R59) reviewed for immunizations. R10 had no documentation of pneumococcal immunizations in their medical record. R44 had no documentation of pneumococcal immunizations in their medical record. R59 had no documentation of pneumococcal immunizations in their medical record. [...]