Crenshaw Nursing Home

F-F756.

This deficient practice placed Residents 16 and 41 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use.

Findings:

1. During a review of Resident 16's Admission Record, the Admission Record indicated, Resident 16 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident 16's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and irrational worry or fear that interferes with daily life), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty of breathing) and dementia (a progressive state of decline in mental abilities).

During a review of Resident 16's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/10/2025,

the MDS indicated, Resident 16's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 16 was dependent (helper does all of the effort) from staff with oral hygiene, upper body dressing, and personal hygiene.

During a review of Resident 16's Order Summary Report (a document containing active orders), dated 3/20/2025, the Order Summary Report indicated, the physician placed a telephone order on 2/1/2025 for Resident 16 to start on lorazepam (medication used to relieve anxiety) to give 0.5 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth every 12 hours as needed for anxiety manifested by restlessness (unable to stay still in bed).

2. During a review of Resident 41's Admission Record, the Admission Record indicated 41 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident 41's diagnoses included anxiety disorder, anemia (a condition where the body does not have enough healthy red blood cells), and protein calorie malnutrition (a condition caused by a severe lack of protein and calories).

During a review of Resident 41's MDS, dated [DATE REDACTED], the MDS indicated, Resident 41's cognitive skills for daily decision making was severely impaired. The MDS indicated, Resident 41 required maximal assistance (helper does more than half the effort) from staff with eating, upper body dressing, and personal hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 26 055525 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055525 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 During a review of Resident 41's Order Summary Report, dated 3/20/2025, the Order Summary Report indicated, the physician placed a telephone order on 2/25/2025 for Resident 41 to start on lorazepam to give Level of Harm - Minimal harm or 0.25 milliliter ([ml] - unit of fluid volume) by mouth every 4 hours as needed for anxiety manifested by potential for actual harm restlessness causing shortness of breath.

Residents Affected - Few During a concurrent interview and record review on 3/19/2025 at 3:00 p.m., with the Director of Nursing (DON), Residents 16 and 41 clinical records, were reviewed. The DON stated Residents 16 and 41 were both on lorazepam PRN for anxiety with no duration (extent) of therapy. The DON stated all PRN psychotropic medication should have a stop date. The DON stated the physician should assess and reevaluate the continued use of the lorazepam to comply with the regulation. The DON stated the provider should have documentation indicating the justification for extending the use of lorazepam after 14 days. The DON stated the risk of not putting a stop date for a PRN psychotropic medication could result in a resident receiving unnecessary medication.

During a review of the facility's policy and procedure (P&P), titled, Psychotropic Medication Use, dated 7/2022, the P&P indicated, for psychotropic medications that are not antipsychotic, if the prescriber or attending physician believed it was appropriate to extend the PRN order beyond 14 days, the physician should document the rationale for extending the use and include the duration for the PRN order.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 26 055525 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055525 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 46832 Residents Affected - Some Based on observation and interview, the facility failed to ensure the medication room storage refrigerator was maintained below 46 degrees as indicated in the facility's policy and procedure (P&P) titled, Medication Storage in the Facility.

This deficient practice had the potential for medications be stored in improper temperature, or humidity and can alter the effectiveness of the medication.

Findings:

During an observation, on 3/19/2025, at 12:20 p.m., at the medication room storage refrigerator, the refrigerator had unopened insulin (a hormone that lowers the level of blood sugar in the blood) vials, insulin pens, and unopened multidose tuberculin (a substance used in a skin test to help diagnose tuberculosis [TB] infection) injection vials. The medication storage refrigerator temperature was observed at 48 degrees Fahrenheit.

During a concurrent observation and interview, on 3/19/2025, at 12:22 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated per policy, the temperature for the refrigerator should be maintained between 36-46 degrees. LVN 1 stated the refrigerator temperature was 48 degrees. LVN 1 stated the risk of having an out of range temperature of the medication refrigerator could result in medications expiring.

During a review of the facility's P&P titled, Medication Storage in the Facility, dated 4/2008, the P&P indicated, medications requiring refrigeration or 'temperatures between 2 degrees Celsius (36 degrees Fahrenheit) and 8 degrees Celsius (46 degrees Fahrenheit), should be kept in a refrigerator with a thermometer to allow temperature monitoring.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 26 055525 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055525 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46832

Residents Affected - Few Based on observation, interview and record review, the facility failed to ensure:

1. Kitchen refrigerator 1 had an external thermometer (an appliance to monitor the temperature of a refrigerator) in working condition.

2. The large clear egg noodle pasta bin in the dry storage area was labeled with name and date.

3. Kitchen refrigerator 2 had proper internal temperature (40 degrees Fahrenheit or lower) maintained for the refrigerated food items.

This deficient practice had the potential to cause rapid growth of bacteria that can cause foodborne illness (food poisoning).

Findings:

1). During the initial kitchen tour observation, on [DATE REDACTED], at 8:27 a.m., the external thermometer of refrigerator 1 was observed counting upwards in seconds and minutes starting from zero and the internal thermometer of refrigerator 2 was observed at 42 degrees Fahrenheit.

During a concurrent observation and interview, on [DATE REDACTED], at 8:30 a.m., with the Dietary Aide 1 (DA 1), DA 1 stated he did not know why the external thermometer of refrigerator 1 was counting upwards or if it had malfunctioned. DA 1 stated the risk of having a malfunctioned external thermometer on a refrigerator could result in spoiled food.

2). During a concurrent observation and interview, on [DATE REDACTED], at 8:55 a.m., with the Dietary [NAME] (DC),

the DC stated the large, clear container contained uncooked egg noodle pasta and was not labeled with name and date. The DC stated the risk of not labeling food in the dry storage container could result in not knowing what food contents are in the bin and until when it was good for.

During a concurrent observation and interview, on [DATE REDACTED], at 9:48 a.m., with the Dietary Supervisor (DS), the DS stated the refrigerator 2's internal temperature was 42 degrees Fahrenheit. The DS stated the internal temperatures for refrigerators should be 40 degrees Fahrenheit or below. The DS stated the risk of a refrigerator with internal temperature of 42 degrees could result in expired food.

During a review of the facility's undated policy and procedure (P&P), titled Refrigerator/Freezer Storage, the P&P indicated, if temperatures are not within appropriate range, the dietary staff should notify the dietary supervisor and/or Maintenance Supervisor and Administrator. The P&P indicated the refrigerator temperature should be 40 degrees Fahrenheit or lower.

During a review of the facility's undated P&P titled, Storage of canned and Dry Goods, the P&P indicated, food items should be dated and labeled when placed in containers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 26 055525 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055525 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46144 potential for actual harm Based on observation, interview and record review, the facility failed to ensure the humidifier (a product that Residents Affected - Few adds moisture to the air to help with breathing) for one of six sampled residents (Resident 105), was changed and labeled with date.

This deficient practice placed Resident 105 at risk for respiratory infection (an infection affecting the nose, throat, sinuses, airways, and lungs).

Findings:

During a review of Resident 105's Admission Record, the Admission Record indicated Resident 105 was initially admitted to the facility on [DATE REDACTED] and was readmitted on [DATE REDACTED]. Resident 105's diagnoses included end stage renal disease ([ESRD] - irreversible kidney failure, diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities).

During a review of Resident 105's Minimum Data Set ([MDS] a resident assessment tool), dated 3/18/2025,

the MDS indicated Resident 105's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired. The MDS indicated Resident 105 was dependent on staff for showering, dressing, and from lying to sitting in chair. The MDS indicated Resident 105 required respiratory treatment with oxygen therapy (providing a patient with supplemental oxygen, which is extra oxygen beyond what they can breathe from the air).

During an observation on 3/18/2025 at 10:34 a.m. in Resident 1's room, there was a humidifier attached to

the oxygen concentrator (a medical device that extracts and concentrates oxygen from air, delivering a higher concentration of oxygen to the patient) that was not dated or labeled.

During an interview on 3/19/2025 at 12:07 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the humidifier with no date labeled, could not be identified if the humidifier was changed. LVN 2 stated the humidifier should have been changed weekly. LVN 2 stated if the humidifier was not changed weekly, it placed the resident at risk for developing a respiratory infection.

During a review of facility's undated policy and procedure (P&P) titled, Oxygen Administration, the P&P indicated the oxygen humidifier should be changed weekly and as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 055525 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055525 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46832

Residents Affected - Some Based on observation, interview and record review, the facility failed to meet the required 80 square feet for each resident in House Station Rooms 1, 2, 3, 4, 6, 8, 9 and 10, and Annex Station room [ROOM NUMBER].

This deficient practice had the potential to result in unsafe condition when providing nursing care and treatment to the residents living in the affected rooms.

Findings:

During a review of the facility's document titled, Request for Waiver Variation Letter, dated 3/18/2025, the waiver indicated the House Station rooms 1, 3, 4, 6, 7, 8, 10 and Annex Station rooms 3, 4, 5, 6, 7, 8, and 10, did not meet the requirement of 80 square feet (sq ft) per resident.

During a review of the facility's Client Analysis form, on 3/21/2025, at 9:45 a.m., the facility's Client Analysis form indicated:

House Station Rooms

a. room [ROOM NUMBER] had three resident beds, which measured 216 square feet.

b. room [ROOM NUMBER] had two resident beds, which measured 144 square feet.

c. room [ROOM NUMBER] had four resident beds, which measured 252 square feet.

d. room [ROOM NUMBER] had three resident beds, which measured 198 square feet.

e. room [ROOM NUMBER] had three resident beds, which measured 208 square feet.

f. room [ROOM NUMBER] had four resident beds, which measured 260 square feet.

g. room [ROOM NUMBER] had one resident bed, which measured at 99 square feet.

h. room [ROOM NUMBER] had one resident bed, which measured at 99 square feet.

Annex Station Room

a. room [ROOM NUMBER] had four resident beds, which measured at 312 square feet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 055525 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055525 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 During an interview on 3/20/2025, at 9:47 a.m., with the Director of Nursing (DON), the DON stated the Administrator submitted a room waiver form on 3/18/2025. The DON stated some of the facility's rooms were Level of Harm - Potential for smaller than the required square footage of 80 square feet per resident. The DON stated the risk for not minimal harm meeting the required square footage for each resident could result in residents' not being able to move around freely. The DON stated there were no harm caused to the residents in the affected rooms. Residents Affected - Some

During observations made to the multiple affected rooms in the House Station Rooms (Rooms 1, 2, 3, 4, 6, 8, 9, 10) and Annex Station Room (room [ROOM NUMBER]) on 3/18/2025 to 3/21/2025, the room sizes of

the above rooms did not adversely affect the residents' health and or safety.

The Department is recommending a waiver.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 055525

F-F758.

This deficient practice placed Residents 16 and 41 at risk for unnecessary medication administration.

Findings:

1.During a review of Resident 16's Admission Record, the Admission Record indicated, Resident 16 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident 16's diagnoses included anxiety disorder (a mental health condition characterized by excessive, persistent, and irrational worry or fear that interferes with daily life), chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty of breathing) and dementia (a progressive state of decline in mental abilities).

During a review of Resident 16's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/10/2025,

the MDS indicated, Resident 16's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 16 was dependent (helper does all of the effort) from staff with oral hygiene, upper body dressing, and personal hygiene.

During a review of Resident 16's Order Summary Report, dated 3/20/2025, the Order Summary Report indicated physician's telephone order, dated 2/1/2025, for Resident 16 to start lorazepam (medication used to relieve anxiety) 0.5 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) by mouth every 12 hours as needed for anxiety manifested by restlessness (unable to stay still in bed).

During a review of the Pharmacist Consultant Medication Regimen Review (MRR), dated 2/15/2025, the MRR indicated the recommended maximum daily dose for lorazepam when used for the elderly is 2mg/day, indicating Resident 16's order of lorazepam 0.5mg/ml every 12 hours as needed, had the potential to exceed 2mg/day. The MRR indicated pharmacy consultant's recommendation for Resident 16's physician to re-evaluate the order of lorazepam or to document the risk and benefit if the current order was indicated.

2.During a review of Resident 41's Admission Record, the Admission Record indicated 41 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident 41's diagnoses included anxiety disorder, anemia (a condition where the body does not have enough healthy red blood cells), and protein calorie malnutrition (a condition caused by a severe lack of protein and calories).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 26 055525 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055525 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 During a review of Resident 41's MDS, dated [DATE REDACTED], the MDS indicated, Resident 41's cognitive skills for daily decision making was severely impaired. The MDS indicated, Resident 41 required maximal assistance Level of Harm - Minimal harm or (helper does more than half the effort) from staff with eating, upper body dressing, and personal hygiene. potential for actual harm

During a review of Resident 41's Order Summary Report, dated 3/20/2025, the Order Summary Report Residents Affected - Few indicated physician's telephone order dated 2/25/2025, for Resident 41 to start on lorazepam to give 0.25 milliliter ([ml] - unit of fluid volume) by mouth every 4 hours as needed for anxiety manifested by restlessness causing shortness of breath.

During a review of the Pharmacist Consultant MRR, dated 2/15/2025, the MRR indicated, Resident 41's order for lorazepam 0.5mg every 4 hours as needed for anxiety, had no stop date. The MRR indicated, per Center for Medicare and Medicaid Services (CMS) Mega Rules, effective 11/28/2017, the prescriber must document the rationale and duration of use for all as needed psychotropic drug orders beyond 14 days.

During a concurrent interview and record review on 3/20/2025 at 2:41 p.m., with the Director of Nursing (DON), Residents 16 and 41, clinical records were reviewed. The DON stated Residents 16 and 41's clinical records did not indicate documentations the licensed nursing staff followed-up with the residents' physicians to address the pharmacist consultant's recommendation regarding the use of lorazepam. The DON stated

the timeline to follow-up pharmacy consultant recommendation was 1 month or before the next scheduled visit of the pharmacy consultant. The DON stated it was important for the licensed staff to address and discuss pharmacist consultant's recommendations with the resident's physician for residents' safety and to avoid the residents receive unnecessary medication.

During a review of the facility's policy and procedure (P&P), titled, Consultant Pharmacist Reports, dated 8/2014, the P&P indicated, the recommendations should be acted upon and documented by the facility staff and or the prescriber. The P&P indicated if the physician accepts and acts upon suggestion, or rejects, the physician must provide an explanation for disagreeing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 26 055525 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055525 B. Wing 03/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crenshaw Nursing Home 1900 S Longwood Ave Los Angeles, CA 90016

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic Level of Harm - Minimal harm or medications are only used when the medication is necessary and PRN use is limited. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47923 Residents Affected - Few Based on interview and record review, the facility failed to ensure two of four sampled residents (Resident 16 and 41), who received as needed (PRN) psychotropic medication (any drug that affects brain activities associated with mental process and behavior), were reevaluated after 14 days. Cross Refer to