Every finding on record at Adams Farm Living & Rehabilitation

Based on observations, record reviews and staff interviews, the facility failed to implement their policy for Enhanced Barrier Precautions (EBP) when Nurse Aide (NA) #3 failed to don a gown and gloves before providing oral care for Resident #2 who was under EBP for wounds and an indwelling catheter. The deficient practice occurred for 1 of 5 staff members observed for EBP (Nurse Aide #3).Findings included:The facility's Enhanced Barrier Precautions (EBP) policy dated 5/13/2023 revealed it was the policy of the facility to utilize Enhanced Barrier Precautions (EBP), an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gown and gloves used during high contact resident care activities. Enhanced Barrier Precautions were indicated for high contact care activities for residents with wounds or indwelling medical devices including central lines and gastrostomy feeding tubes and required hand hygiene before and after leaving the room and the use of gloves and a gown. Observation of Resident #2's room on 12/2/25 at 2:58 PM revealed there was signage outside the room indicating Enhanced Barrier Precautions (EBP) were to be used. The room was a semi-private room and both residents in the room were on EBP. A blue Enhanced Barrier Precautions (EBP) sign was noted outside Resident #2's door on 12/2/25 at 2:58 PM. The sign read in part, STOP Enhanced Barriers. Everyone must clean hands before entering and after leaving the room .All healthcare personnel must wear gown and gloves for the following High Contact Resident Care Activities which include: dressing, bathing/showering, transferring, changing linens, provide hygiene, changing briefs or assisting with toileting, and device care or use; central lines, urinary catheter, feeding tubes, tracheostomy, wound care: any skin opening requiring a dressing. An observation was conducted with Nurse Aide #3 on 12/4/2025 at 9:20 AM in Resident #2's room. NA #3 entered Resident #2's room with a blanket and items to provide oral care. NA #3 draped a blanket over Resident #2 without gloves or a gown. NA #3 began providing oral care on Resident #2 and had a mask and gloves on without a gown. The NA was stopped by the surveyor and asked to place a gown on. Interview conducted with NA #3 on 12/4/2025 at 9:22 AM revealed she was assigned to Resident #2 for the morning shift. Interview included questions about the EBP for Resident #2 and NA #3 stated, I was rushing and I know better. NA #3 further revealed I got two out of three correct with my mask and gloves on. NA #3 stated she received training on the computer and by the Infection Preventionist regarding Enhanced Barrier Precautions. An interview was conducted with the Director of Nursing (DON) on 12/2/2025 at 4:00 PM. The DON stated EBP was only needed when there was a high contact care activity being performed on residents. The DON defined high activity care for residents as being wound care, activities of daily living care, ambulation, and gastrostomy care. She stated if staff were just answering a call light or changing the tube feeding you would not need full personal protective equipment (PPE) for EBP. The DON stated she expected all staff to follow infection control policy for EBP and to identify the posting of the EBP signs on the residents' doors. An interview with the Administrator on 12/3/2025 at 1:44 PM revealed she was aware Resident #2 was on EBP. The Administrator stated residents who require EBP are those who have wounds, have a urinary catheter, tracheostomy, and gastrostomy tube. She said the staff do not need to have PPE on when entering a resident room on EBP to answer their call light. The Administrator stated any residents on EBP would have a sign posted on their door and any staff member physically providing hands on care for the resident was expected to have a gown and gloves on. The Administrator stated the nursing staff were educated regarding Enhanced Barrier Precautions through in-person and on-line in-services. The Administrator stated the NA should have worn a protective gown and gloves while performing oral care to Resident #2.

Based on record review and interviews with RP (Responsible Party), staff, Nurse Practitioner (NP), and Physician the facility failed to notify the RP when Resident # 1's seizure medication was discontinued. Interview with the RP revealed if she had been notified, she would have been an advocate for Resident # 1 and informed the facility that the resident's seizure medication was not to be discontinued prior to a neurologist evaluating the resident and making the decision. Resident # 1 seized following the seizure medication discontinuation and was hospitalized in the Intensive Care Unit. This was for one (Resident #1) of three sampled residents whose medications were reviewed. The findings included: Record review revealed Resident # 1 was admitted to the facility on [DATE]. The resident had the following diagnoses: chronic obstructive pulmonary disease, chronic respiratory failure, ischemic heart disease, history of hip fracture, depressive disorder, history of cerebellar infarcts (stroke), dysphagia (difficulty swallowing), cognitive communication deficit, hypertension, and hyperlipidemia. A nursing entry on 11/4/24 at 8:20 PM included the following information. Resident # 1 had a change in condition. She was witnessed to have twitching of both sides of her face and abnormal vital signs. The provider and EMS (Emergency Medical Services) were called and the resident was transferred to the hospital. Review of a hospital discharge summary, dated 11/15/24, revealed Resident # 1 was hospitalized from 11/4/24 until 11/15/24 for the acute principle problem of metabolic encephalopathy. Further review of this hospital discharge summary noted the following information was documented by the physician. Resident # 1 had presented to the hospital with altered mentation in addition to seizure active (as written) with mouth foaming. The resident's MRI (Magnetic Resonance Imaging) showed areas of her brain which could act as seizure focus. The resident was placed on Keppra (a seizure medication) while hospitalized . The hospital physician noted the resident should follow up with neurology regarding the long term plan for Keppra. According to Resident # 1's facility record she was admitted to the facility and orders were initiated on 11/15/24 for the Levetiracetam (Keppra) 500 mg (milligrams) two times per day. Review of the record revealed no neurology consult was ordered or initiated after 11/15/24. On 2/12/25 a verbal order was entered by Nurse #1 into the resident's electronic medical record to discontinue Levetiracetam. There was no documentation of who gave the verbal order. There was no documentation Resident # 1's Responsible Party was notified of the Keppra discontinuation. An interview with Nurse # 1 on 4/21/25 at 1:50 PM revealed she made rounds with NP # 1 on 2/12/25 and NP # 1 had noted the resident had no definite diagnosis of epilepsy, her Keppra level was in range, and NP # 1 had given the verbal order to discontinue the resident's Keppra. An interview with NP # 1 on 4/22/25 at 1:27 PM revealed she did not recall giving an order for the Keppra discontinuation and she had not discussed any Keppra discontinuation with Resident # 1's RP. Review of Resident # 1's nursing notes revealed the following entry at 8:56 PM on 4/9/25 by Nurse # 2. Resident noted with facial twitching, nonverbal when called but respond to tactile stimuli [touch]. Before this resident noted wheeling self down in hallway and verbal. V/S [vital signs] noted T [Temperature]-98.1, RR [Respirations] 16, BP [Blood Pressure] 200/91 and SPO2 [Peripheral Oxygen Saturation]-100% with O2 3 lit/min via NC [oxygen at 3 liters/minute via nasal cannula]. On call [Name of on call NP] NP called and updated. New order received to send resident out for acute change in condition. RP [name of RP] notified. EMS [Emergency Medical Services] called and resident sent out of facility at 7:40 PM to [name of hospital] with even rise and fall of chest. Review of 4/9/25 ED (emergency department) physician notes revealed Resident # 1 was received by them already intubated (a procedure where a breathing tube is inserted into the windpipe) by EMS. The ED physician noted the nursing home medication list showed the resident had not been receiving Keppra. The physician further noted, Plan after confirming patient's airway, ordered labs, expedited CT [computed tomography] imaging of patient's head to assess for intracranial hemorrhage. My dependent review of the patient's head CT shows no intracranial hemorrhage. I think we have a good story for why the patient seized. Likely not receiving Keppra. According to the 4/9/25 hospital records, Resident # 1 was admitted to the Intensive Care Unit. Resident # 1's RP was interviewed on 4/22/25 at 10:10 AM and reported the following information. No one had called to inform her that Resident # 1's Keppra had been discontinued on 2/12/25. She learned about it when Resident # 1 was hospitalized at the hospital with another seizure on 4/9/25. She was an advocate for Resident # 1. When Resident # 1 was hospitalized in November 2024 the hospital physician had told her (the RP) that the resident would have to see a neurologist before a determination could be made that she could stop taking the Keppra. If the facility had called her, she would have told them this. Interview with Resident # 1's physician on 4/23/25 at 9:46 AM revealed he did not know anything about the Keppra discontinuation until 4/21/25, which was after the resident was hospitalized and the RP had been informed by the hospital staff of the Keppra discontinuation. The facility presented the following corrective action plan. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 4/10/2025, Resident's RP notified the Director of Nursing (DON) that she had not been notified regarding the discontinuation of Keppra in February 2025. The DON completed a review of Resident's chart on 4/10/25 and noted that a verbal order had been given to discontinue Keppra on 2/12/25. The Nurse Practitioner (NP) visited the resident on 2/10/25, and ordered labs, to include Keppra level. On 2/11/25, labs were obtained and communicated to the NP. On 2/12/25, the NP visited the facility and gave a verbal order to the Registered Nurse to discontinue Keppra. The RN input the discontinuation order into the EMR for the resident. The nurse did not document in Resident's chart that she notified the RP regarding discontinuation of the medication. Completion Date 4/10/2025 Nurse #1 was in-serviced by the Clinical Nurse Liaison on 4/10/25, on the proper procedure for obtaining orders which include the following: read back to the provider to ensure accuracy of the order, entry of the verbal order to include name of resident, order change with date, time, and duration; name of person receiving the order, date and time of order receipt, and provider who gave the order. After the order is entered in the electronic medication administration record, the nurse will complete a progress note to indicate the full order change as listed above with the name of the provider who gave the order, with reason for order change. The nurse will also notify the responsible party and document the name of the person notified. Completion Date 4/10/2025 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. The clinical managers completed an audit on 4/10/25, of anticonvulsant orders written to change, add or discontinue for dates of 4/01/25-4/10/25, to validate that residents/RP were notified regarding new or change in orders. No new concerns were identified. Completion date: 4/10/25 100% of all nurses were inserviced by the Director of Nursing/designee on the above process for receiving verbal, in-person or telephone orders, and in-serviced on notification of responsible party and documentation requirements. Nurses who are on medical leave or PRN (as needed) status will be in-serviced prior to the next scheduled shift. Completion date: 4/10/25 Any new hires after 4/10/25 will receive training by the Staff Development Coordinator (SDC) of the above during facility orientation. The DON notified the SDC of this responsibility on 4/10/2025. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Completion Date: 4/11/25 and on-going New medication orders will be reviewed during the morning clinical meeting by the Clinical Interdisciplinary Team (IDT) team and/or notes will be reviewed for notification and the order reviewed for completeness. The IDT team will complete any outstanding RP notifications at that time. The IDT team was in-serviced on this process on 4/10/25 by the Clinical Nurse Liaison. Completion date: 4/11/25 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Notification of Change audits implemented to review any new medication changes for documentation and notification to the responsible party 5x a week for 4 weeks and then 3x a week for 8 weeks. Completion date: Audits began 4/11/25 and on-going Compliance will be discussed weekly by the DON/designee X 4 weeks and then monthly for 6 months during the morning administrative meeting. Any non-compliance will be noted and corrective actions taken. Completion date: weekly audits began 4/11/25 and on-going Members of the Quality Assurance (QA) team met and made the decision to implement this said plan on 4/10/25. The QA committee will revisit the plan with each quarterly meeting x 6 months. Audits will be presented to the quarterly QA committee for x 6 months whereby an IDT approach is held with the Medical Director to discuss effectiveness of the plan. All discussions, revisions to plan, and additional in-servicing will be noted in the QA Committee Meeting Minutes. Completion date: 4/10/25 and on-going The facility alleges compliance 4/12/2025 On 5/1/25 the following was done to validate the facility's corrective action plan. Multiple nurses were interviewed and reported the process as outlined in the facility's corrective action plan of receiving new orders and notifying Responsible Parties. The facility presented documentation verifying Nurse # 1 had been inserviced on proper procedure of new orders (which included notifying the responsible party). The facility presented evidence of inservices and audits per their corrective action plan. On 5/1/25 the facility's corrective action plan of 4/12/25 was validated.

Based on record review and interviews with staff, Physicians, Nurse Practitioners (NPs), and Responsible Party (RP) the facility failed to ensure a resident (Resident #1) received follow-up for a newly diagnosed disorder per a plan of care set forth upon discharge from the hospital and received seizure medication. Resident # 1 was hospitalized from 11/4/24 to 11/15/24 with diffuse encephalopathy (disease of the brain that alters brain function and structure) and seizure like activity. Hospital discharge plans on 11/15/24 included orders for a seizure medication (Keppra) and directions that Resident # 1 should follow up with neurology. The facility never arranged a neurology follow-up visit as directed. On 2/12/25 Resident # 1's Keppra was discontinued per a verbal order taken by a nurse with no explanation for the discontinuation and no indication in the record which provider had given the order. Per interviews with Resident # 1's Nurse Practitioner and Physician, they did not recall discontinuing the Keppra. On 4/9/25 Resident # 1 experienced a seizure, required intubation (a procedure where a breathing tube is inserted into the windpipe) by Emergency Medical Services (EMS), and was hospitalized in the intensive care unit. This was for one of three sampled residents whose medications were reviewed. The findings included: Record review revealed Resident # 1 was admitted to the facility on [DATE]. The resident had the following diagnoses: chronic obstructive pulmonary disease, chronic respiratory failure, ischemic heart disease, history of hip fracture, depressive disorder, history of cerebellar infarcts (stroke), dysphagia (swallowing difficulties), cognitive communication deficit, hypertension, and hyperlipidemia. A nursing entry on 11/4/24 at 8:20 PM included the following information. Resident # 1 had a change in condition. She was witnessed to have twitching of both sides of her face and abnormal vital signs. The provider and EMS were called and the resident was transferred to the hospital. Review of a hospital discharge summary, dated 11/15/24, revealed Resident # 1 was hospitalized from 11/4/24 until 11/15/24 for the acute principle problem of metabolic encephalopathy. Further review of this hospital discharge summary noted the following information was documented by the physician. Resident # 1 had presented to the hospital with altered mentation in addition to seizure active (as written) with mouth foaming. She was also in a hypertensive emergency. Under the heading Seizure Like Activity, the physician further noted, MRI [Magnetic Resonance Imaging] without acute abnormality, EEG [Electroencephalogram-test used to diagnose brain conditions] suggestive of severe diffuse encephalopathy-no seizures or definite epileptiform discharges [abnormal patterns on an EEG that resemble seizure activty]. She was started on Keppra on 11/5, transitioned to PO [oral] 11/8. Discussed case with neurology informally 11/14-14 (as written). Given MRI finding with chronic foci of hemosiderin staining involving the bilateral cerebral hemispheres (could potentially act as seizure focus), will continue Keppra (had briefly held on 11/14 with concern for AMS [altered mental status]-though she's improved today, and [RP] noted she was better a few days ago as well-when she was on the same Keppra dose. Follow with neurology outpatient regarding long term plan with Keppra. The hospital discharge summary also included the neurologist's impression of the EEG study which included the notation that the lack of epileptiform activity during interictal EEG does not exclude the diagnosis of epilepsy. Under the hospital physician's recommendations for outpatient follow up, the physician noted the resident should follow up with neurology as an outpatient for a concern for her cognitive deficits as well as determining whether to continue the Keppra long term. Under discharge instructions there was a notation which read, ambulatory referral to Neurology- appointment is requested in approximately: 4 weeks. Discharge medications listed on the hospital discharge summary included Levetiracetam [Keppra] 500 mg [milligrams] by mouth two times per day. According to Resident # 1's facility record she was readmitted to the facility and orders were initiated on 11/15/24 for the Levetiracetam 500 mg two times per day. Review of the record revealed no neurology consult was ordered or initiated following 11/15/24. Nurse # 1, who worked with admitting residents to the facility, was interviewed on 4/21/25 at 1:50 PM and reported the following information. When a newly admitted resident had orders for a specific follow- up that was already arranged by the hospital then the facility would automatically follow through and arrange for the resident to attend the follow-up. If there were recommendations for a follow-up but there were no definitive plans or appointments made at time of hospital discharge, then the physician/provider reviewed the discharge summary and would inform staff if they wished for the facility to arrange for any follow-up to be done. At the time of Resident # 1's readmission to the facility on [DATE] there had been a different physician who had been the provider. Resident # 1's provider changed in December 2024 to another physician, who now also served as the facility's medical director. Facility providers, who had been responsible for Resident # 1's care in November 2024 were no longer involved with the resident. Record review revealed Resident # 1 was seen by Nurse Practitioner # 3 on 11/18/24. NP # 3 documented the following information in her 11/18/24 progress note. Resident # 1 had a MRI in the hospital that was unremarkable and her EEG was suggestive of diffuse encephalopathy. Her Keppra would be continued. NP # 3 made no notation about a referral to the neurologist. Review of Resident # 1's significant change Minimum Data Set assessment, dated 11/24/24, revealed Resident # 1 was severely cognitively impaired. She had a diagnosis of seizures and was receiving an anticonvulsant. According to the record, NP # 3 again saw Resident # 3 on 11/25/24 and documented the resident was alert, ambulatory with a walker, and the resident and staff did not express any concerns on that date. NP # 3 also noted the resident's Keppra would be continued. There was no mention of a referral to Neurology. NP # 3 was interviewed on 4/23/25 at 3:10 PM and reported the following information. She had worked only part time at the facility one day per week. She no longer worked at the facility and her last day was around 11/25/24. She could no longer recall Resident # 1 or access her records. While working at the facility, she worked full time at a hospital and helped to discharge residents. At the hospital where she worked, follow-up appointments were arranged at hospital discharge. On her visits with Resident # 1 in November she may have assumed the appoinment was set up and the resident would go since this was the practice to which she was accustomed. If she had continued to work at the facility and see Resident # 1, she would have questioned the facility staff why they had not sent Resident # 1 to a neurology appointment. The facility staff should also have seen that the resident needed the neurology appointment and made sure that it had occurred. Although she could not recall specific orders she had given for Resident # 1, while working at the facility she had encountered problems in general with her orders being entered into the electronic system correctly. She was accustomed to placing her own orders in the electronic record. At the facility she was required to write her orders on paper and then rely on the nurses to enter the orders timely and correctly. Although she did not recall specific residents, there had been times when orders were not placed in the computer right away or errors made when the nurse entered orders, but she could not say what had happened specifically with Resident # 1. According to NP # 3, if it had been in the discharge summary that the resident needed to go to the neurologist, then the plan was there, and it should have been carried out. An interview with the Administrator on 4/21/25 at 12:30 PM revealed that in February 2025 Resident # 1 began part of a collaborative health care program in which NP # 1 also routinely saw and coordinated her care. The primary physician remained involved also in the care of Resident # 1. She was first seen by the collaborative NP (NP #1) in February 2025 through the collaborative program. On 2/4/25 NP # 2 (who was part of the physician's practice and not part of the collaborative program) saw Resident # 1 and made a progress note. NP # 2 documented the following information on 2/4/25. There had been no reports of seizure activity at the time and the resident's epilepsy appeared stable. The resident's Keppra would be continued. NP # 2 was interviewed on 4/23/25 at 12:06 PM and reported the following information. She (NP # 2) first began seeing facility residents in January 2025. On 2/1/25 Resident # 1 had started in the collaborative program of which NP # 1 was a part. She (NP # 2) was trying to make sure all the regulatory visits were done when she first started at the facility. She (NP # 2) did see Resident # 1 on 2/4/25 while not realizing Resident # 1 had become part of the collaborative program and was to be seen primarily by NP # 1 for routine visits. When she (NP # 2) initially saw residents she would ask the nurses about any concerns, review vitals, and look at some of the progress notes. She would have done this for Resident # 1. No concerns had been mentioned to her when she saw Resident # 1. No one had mentioned the resident needed a neurology appointment and she had not been aware of the need. Following 2/4/25, she did not see Resident # 1 again. NP # 1 would have covered Resident # 1. Review of the record revealed NP # 1, who was part of the collaborative program, saw Resident # 1 on 2/11/25. Review of NP # 1's 2/11/25 progress note revealed the following information. NP # 1 noted Resident # 1 was confused, chronically ill appearing, frail, and dependent on oxygen for chronic hypoxia (low oxygen levels). The resident was not able to provide reliable information. The NP further noted she had discussed with Resident # 1's RP (responsible party) the goals of care and the RP wished for Resident # 1 to be a full code. There was no documentation that any discussion was held regarding a neurology follow up or that there was a plan to discontinue Resident # 1's Keppra. NP # 1 did note that the resident had chronic kidney disease, stage 3b (stage of kidney disease prior to kidney failure) and her BUN (blood urea nitrogen) on 11/15/24 had been 17 (normal 6-20), and creatinine .64 (normal .50 to 1.20). NP # 1 noted that she would obtain a CMP (complete metabolic panel) the next day and nephrotoxin drugs (drugs that damage the kidneys) would be avoided. On 2/10/25 an order for labs was entered into the computer by Nurse # 1 for a CBC (Complete Blood Count) Basic Metabolic Panel, and a Keppra level. It was noted to be ordered by Resident # 1's physician. Review of lab results revealed the resident's 2/11/25 Keppra level was 26.4 which was within the reference range. Resident # 1's 2/10/25 BUN (blood urea nitrogen) was 20.1, Creatinine was .26 and the BUN/Creatinine ratio was 56.2 (normal 6-25). (These labs can reflect kidney function.) On 2/12/25 a verbal order was entered into the resident's electronic record to discontinue Levetiracetam (Keppra) by Nurse # 1. There was no documentation who gave the verbal order or why the Keppra was discontinued. On 4/21/25 the Administrator printed the verbal order from the Resident's electronic record. The order was on a page with other orders entered into the electronic record for the date of 2/12/25. At the bottom of the page was the physician's electronic signature for the date of 2/12/25 at 4:42 PM. An interview with Nurse # 1 on 4/21/25 at 1:50 PM revealed she made rounds with NP # 1 on 2/12/25 and NP # 1 had noted the resident had no definite diagnosis of epilepsy, her Keppra level was in range, and NP # 1 had given the verbal order to discontinue the resident's Keppra. Review of Resident # 1's February 2025 Medication Administration Record revealed Resident # 1 received her last dose of Keppra on the morning of 2/12/25. NP # 1 was initially interviewed on 4/22/25 at 1:27 PM and reported the following information. The facility did not allow for the providers to enter orders into the electronic medical record themselves. She did not recall giving a verbal order to discontinue the Keppra. She could not speak to something she did not recall doing. While working at the facility she had communicated with the DON (Director of Nursing) that she had a concern about not being able to enter her orders into the electronic record. She recalled talking to Resident # 1's RP once and the conversation was focused on advanced directives. She recalled she did not discuss any discontinuation of Keppra with the RP. On 4/22/25 at 4:15 PM, NP # 1 initiated a call to the surveyor to inform the surveyor that she could access her call records if needed to validate she had talked to the RP. NP # 1 then stated the following information. The facility had called her the previous week and asked her why she had discontinued Resident # 1's Keppra. She could not recall doing it. She (NP # 1) wanted the surveyor to know that it did not make sense to her. She had been a NP for many years and it would not have been her practice to have discontinued Keppra without consulting with a neurologist. NP # 1 reported it did not make medical sense to have done so, and she was concerned that the facility was saying she did something she could not recall doing. She knew she had not signed any order. On 2/24/25 Resident # 1's physician noted he saw the resident for a required visit. Under medications within the physician's note, it was noted that the resident's Keppra was still an active medication. The physician's progress note also included under diagnoses, Other epilepsy, not intractable, with status epilepticus. Stable no recurrent seizures. Review of Resident # 1's nursing notes revealed the following entry at 8:56 PM on 4/9/25 by Nurse # 2. Resident noted with facial twitching, nonverbal when called but respond to tactile stimuli [touch]. Before this resident noted wheeling self down in hallway and verbal. V/S [vital signs] noted T [Temperature]-98.1, RR [Respirations] 16, BP [Blood Pressure] 200/91 and SPO2 [Peripheral Oxygen Saturation]-100% with O2 3 lit/min via NC [oxygen at 3 liters/minute via nasal cannula]. On call [Name of on call NP] NP called and updated. New order received to send resident out for acute change in condition. RP [name of RP] notified. EMS [Emergency Medical Services] called and resident sent out of facility at 7:40 PM to [name of hospital] with even rise and fall of chest. Medication Aide (MA) # 1 was interviewed on 4/21/25 at 1:40 PM and reported the following information. She had been assigned to care for Resident # 1 on 4/9/25. That evening Resident # 1 seemed herself before dinner. She had been rolling up and down the halls in her wheelchair. Around dinner time, she (MA # 1) had entered the room and saw the resident was not talking and that her face was twitching. She immediately got Nurse # 2. Nurse # 2 did an assessment and sent the resident to the hospital. Nurse # 2 was interviewed on 4/21/25 at 1:09 PM and reported the following information. Earlier in the evening on 4/9/25 she had seen Resident # 1 in the hallway and she was talking. There was nothing abnormal about the resident. Around dinner time, the Medication Aide had called her because she had seen that the resident had twitching in her face. She went to check the resident and saw that her face was twitching and that she was not talking. She called the provider and then 911 to have the resident sent to the hospital. Review of EMS records revealed on 4/9/25 EMS was called at 7:18 PM and arrived at 7:32 PM. The Paramedic noted the following information. At arrival the resident was unresponsive and actively seizing. Her eyes were deviated to the right and she had rhythmic jerking/twitching of her jaw. At baseline the resident was oxygen dependent. Her oxygen level was 67% at 7:36 PM. She was placed on a non-rebreather mask and her oxygen level improved. At 7:45 PM her oxygen level was 100%. She began to have increased salivary secretion and was suctioned. The resident was transferred to the stretcher, secured and loaded into the EMS unit (ambulance). Once in the ambulance the resident was given Versed but her seizure activity persisted. Her respirations dropped to 2 per minute and were shallow. A nasopharyngeal airway was placed and bag-valve-mask ventilations were begun. Additional Versed was administered which stopped the seizure. At that time the resident did not have any respiratory effort on her own and continued to have profuse salivary secretions. Therefore, she was intubated to protect her airway. EMS departed the facility at 8:00 PM and transferred Resident # 1 to the care of the hospital at 8:30 PM. Review of 4/9/25 ED physician notes revealed Resident # 1 was received by them already intubated by EMS. The ED physician noted the nursing home medication list showed the resident had not been receiving Keppra. The physician further noted, Plan after confirming patient's airway, ordered labs, expedited CT (computed tomography) imaging of patient's head to assess for intracranial hemorrhage. My dependent review of the patient's head CT shows no intracranial hemorrhage. I think we have a good story for why the patient seized. Likely not receiving Keppra. The admitting hospitalist on 4/9/25 wrote, She has a diagnosis of epilepsy and was supposed to be on Keppra 500 mg BID [twice daily] (listed on discharge summary from 11/4/24); however, she was apparently not on this at nursing facility for unclear reasons. She was seen normal at 6PM on evening of 4/9/25. When staff checked on her later, she was less responsive and was twitching with a right sided gaze. EMS was called and administered IM [intramuscular] Versed [a medication used for seizures] without improvement before establishing IV [intravenous] access and administering an additional Versed dose IV. There was roughly 45 minutes reported before seizures resolved. Hospital records for the date of 4/9/25 also included a hospital neurology consult report. The hospital neurologist documented on 4/9/25 that the etiology of her prolonged seizure is probably secondary to not being on AEDs [Antiepileptic drugs]. Resident # 1's RP was interviewed on 4/22/25 at 10:10 AM and reported the following information. Resident # 1 remained in the hospital. Her speech was now like mush. When Resident # 1 had been discharged from the hospital in November 2024, the hospital had told her that Resident # 1 would need to see a neurologist before her Keppra could ever been discontinued. The facility had never arranged a neurologist visit and the resident's Keppra had been discontinued without her (the RP) being notified. Resident # 1's facility physician, who serves as the facility's medical director, was interviewed on 4/21/25 at 1:17 PM and reported the following information. The Keppra had been discontinued by the NP and he had not been consulted about it. The resident's EEG in the hospital had not shown definitive epilepsy. The resident had diffuse encephalopathy. The encephalopathy or other conditions could have led to the frothing of her mouth and seizure like activity that had been witnessed when she was hospitalized in November 2024. The Keppra was being administered prophylactically (preventative). Individuals are not kept on seizure medication for a lifetime if there is not a definitive diagnosis of epilepsy. He did not know about the neurology consult recommendation. Often hospitalists make lots of recommendations upon discharge. For a resident with a definitive diagnosis of seizures, the neurology consult would have been warranted. For those with no definitive diagnosis and no further seizures, then sometimes it was not indicated. It was his understanding that was why the NP had discontinued the Keppra. Although he had not been involved in the decision to discontinue the Keppra, he agreed that the decision to discontinue it was an acceptable thing to do. The physician reported that they tried to reduce the number of medications residents received when possible. A follow up interview was conducted with the facility Physician on 4/23/25 at 9:46 AM and the physician reported the following information. The first he knew about the discontinuation of the Keppra was on 4/21/25. Facility staff told him the Keppra had been discontinued by NP # 1. He (the Physician) often received batches of orders electronically at one time to sign from the facility. He did not recall signing the Keppa discontinuation order. There should have been some documentation by Nurse # 1 who received the discontinuation order or by NP # 1, who he was told gave the order, for the reasoning behind the order in the record. The Administrator and the Corporate Director of Operations were interviewed on 4/21/25 at 4:00 PM. The Corporate Director of Operations reported Resident # 1's RP had come to them after Resident # 1 was hospitalized with the concern that Resident # 1's Keppra had been discontinued. They started looking into the issue. The Administrator reported that they had initiated an investigation and found that NP # 1 had given the verbal order to discontinue the Keppra and they had followed physician orders to do so. On 4/22/25 at 4:26 PM and 4/23/25 at 10:32 AM interviews were conducted with the Administrator and the Regional Clinical Director via phone. They reported the following information. In their facility investigation, they had talked to NP # 1 on 4/16/25 and she recalled giving other orders and being with Nurse # 1 who took the verbal order for Keppra along with other verbal orders on 4/12/25. It is corporate policy that the providers do not enter their own orders. This is to ensure that there are no errors made in entering orders into the electronic medical record system. Every resident is assigned providers who can go in and view a resident's record. Orders go to the attending physician to review and sign when written by the Nurse Practitioner. There was a way that orders given by the Nurse Practitioner could go to the NP to electronically sign but that would have to be entered manually in order for the order to go to the NP instead of the physician. During the interview on 4/23/25 at 10:32 AM the Regional Clinical Director looked in the electronic system and did not see a notation with the verbal order who had given the verbal order. The Regional Clinical Director reported that the electronic medical record system is set up so that only one provider can sign an order, and that Resident # 1's physician signed the order that NP # 1 gave to discontinue the Keppra on 4/12/25. The hospital neurologist who saw Resident # 1 on 4/9/25 at the hospital, was interviewed on 4/25/25 at 8:31 AM and reported the following information. Providers have to be careful in stopping medications such as seizure medications. It was his opinion that it would have been good for Resident # 1 to have gone to the neurologist as recommended. He did not work in outpatient neurology, but he would think an outpatient neurologist would have done more history and possibly more work up at a neurology visit. Resident # 1's Keppra dose was the lowest dose so there was nothing to wean. There was a suspicion of seizure activity in November 2024, but he did not think it was dangerous care for the resident to be taken off Keppra if she had not had seizure activity after some months. It would have been his preference that she would have seen a neurologist before that decision was made. He saw Resident # 1 when she came into the hospital on 4/9/25 but had not continued to follow her. During the interview, the hospital neurologist reviewed Resident # 1's progress notes from 4/17/25 and reported Resident # 1 didn't seem to be doing as well as before her seizure, but he commented the resident was [AGE] years old and it took time for older individuals to bounce back . The facility presented the following corrective action plan: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident # 1 was hospitalized from 11/4/24 to 11/15/24 with diffuse encephalopathy and had been observed with seizure like activity which included facial twitching and foaming at the mouth. The hospital physician noted in the 11/15/24 hospital discharge summary the resident's MRI showed there were areas in the resident's brain that could potentially act as a seizure focus although the resident's EEG had shown no definite epileptiform discharges. The hospital physician noted in the discharge summary that the resident had been placed on Keppra (an antiseizure medication) while hospitalized and the medication should be continued at the facility and there should be follow- up with a neurologist to determine the long-term use of Keppra. Neurology consultation was not obtained per hospital's recommendation. On 2/12/25 Resident # 1's Keppra was discontinued per a verbal order entered by Nurse # 1 with no documentation in the record why Keppra was discontinued and no documentation in the verbal order which provider gave the order. Resident #1 was discharged to the hospital on 4/9/25 and remains in the hospital. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 4/10/25, a 100% audit was conducted by the Clinical Nurse Liaison to identify all current residents receiving anticonvulsant therapy and all residents with diagnosis of seizure disorder, epilepsy, and convulsions. The audits revealed no negative findings. All identified residents also had a chart review completed by the Clinical Nurse Liaison to determine consult needs from 11/1/24 to 4/10/25; there were no negative findings identified. Completion date: 4/10/25 Nurse #1 was in-serviced by the Clinical Nurse Liaison on 4/10/25, on the proper procedure for obtaining orders which include the following: read back to the provider to ensure accuracy of the order, entry of the verbal order to include name of resident, order change with date, time, and duration; name of person receiving the order, date and time of order receipt, and provider who gave the order. After the order is entered in the electronic medication administration record, the nurse will complete a progress note to indicate the full order change as listed above with the name of the provider who gave the order, with reason for order change. The nurse will also notify the family and document the name of the person notified. Completion date: 4/10/25 100% of all nurses were in-serviced by the Director of Nursing Services and the Nurse Manager on the above process for receiving verbal (in-person or telephone) orders and in-serviced on notification of families and documentation requirements. The facility does not utilize agency nurses. Nurses who are on medical leave or PRN status will be in-serviced prior to next scheduled shift. Completion date: 4/10/25 Any new hires after 4/10/25 will receive training of the above by the Staff Development Coordinator during facility orientation. The SDC nurse was trained on 4/10/25 with all other administrative nurses. Completion date: 4/10/25 and thereafter 100% of Administrative Nurses in-serviced on the process of consultation recommendation and MD follow-up by the Clinical Nurse Liaison. Consult sheets and recommended consultations on the discharge summaries will be highlighted and placed in the NP/MD box for MD to review at next scheduled facility visit. MD then returns reviewed items to the box. Administrative nurses gather MD reviews from the box daily Monday through Friday. Each consult recommendation is discussed during morning IDT meeting, approved consult recommendation are communicated to Medical Records director to schedule the appointment. MD will be contacted by administrative nurse to discuss reasoning for any consults that were declined. Discussion will be documented in nurse's notes for review during daily morning meeting. Consults will be scheduled as ordered by the medical provider. If the MD declines a recommended consult, the nurse will document her discussion with the MD regarding the reason for the declination of the recommended service. Negative findings will be documented on the Consultation Audit Tool to ensure a complete IDT approach with the medical providers. Completion: Only Administrative nurses process the discharge summaries, and they are available weekends and after hours to accommodate each admission. 4/10/25 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Upon receiving consult sheets and discharge summaries receiving nurse contacts resident's provider and reviews recommended medication. Medication orders are entered into the EMR when approval received. Discharge summaries will be placed in provider's box for review upon next scheduled facility visit, review will include non-medication items such as consultation. Consult sheets from appointments and discharge summaries will be reviewed during the morning clinical meeting by the Clinical IDT team. Clinical IDT will ensure all medication is entered into the EMR. Any new medication and approved consult orders will be transcribed to the MAR. Any recommendations from consult sheets will be communicated to the MD and if the MD agrees, orders will be written and transcribed to MAR. If the MD disagrees with any recommendations, including consultations, the nurse will document their discussion with the MD regarding the reason for the decline of the recommended service, and the name of the doctor giving the declination in the nurses' notes. Negative findings will be documented on the Consultation Audit Tool. Completion Date: 4/11/25 and on-going New medication orders will be reviewed during the morning clinical meeting by the Clinical IDT team and/or notes will be reviewed for notification and the order reviewed for completeness. Any findings will be corrected during the IDT clinical meeting. The IDT team was in-serviced on this process on 4/10/25 by the Clinical Nurse Liaison. Completion date: 4/11/25 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. New admissions/readmissions and appointment consult sheets will be audited by the DNS/designee weekly x4 and then monthly thereafter for 6 months to ensure compliance with the new appointment protocol. Completion date: weekly audits began 4/11/25 and on-going Notification of Change audits implemented to review any new medication changes and review of the nurse note to ensure family notification is documented. Audits will be conducted 5x a week for 4 weeks and then 3x a week for 8 weeks by the DNS/Designee. Completion date: Audits began 4/11/25 and on-going Compliance will be discussed weekly by the DNS/designee X 4 weeks and then monthly for 6 months during the morning administrative meeting. Any non-compliance will be noted and corrective actions taken. Completion date: weekly audits began 4/11/25 and on-going Members of the QA team met and made the decision to implement this said plan on 4/10/25. The QA committee will revisit the plan with each quarterly meeting x 6 months. Audits will be presented to the quarterly QA committee for x 6 months whereby an IDT approach is held with the Medical Director to discuss effectiveness of the plan. All discussions, revisions to plan, and additional in-servicing will be noted in the QA Committee Meeting Minutes. Completion date: 4/10/25 and on-going The facility alleges compliance 4/12/2025 On 5/1/25 the facility's corrective action pl [TRUNCATED]

Based on record review, and staff, Physician, and Nurse Practitioner (NP) interview the facility failed to ensure during visits the providers reviewed the total plan of care for Resident # 1's newly diagnosed neurological disorder when there was a change in primary providers and collaborative health care providers added to health care decision making for the resident. Multiple providers saw Resident # 1 and failed to recognize the hospital discharge plan was to have the neurologist see the resident and no appointment had been set up for her and completed prior to discontinuation of her seizure medication. On 2/12/25 Resident # 1's seizure medication was discontinued. Interviews with Resident # 1's NP and Physician revealed neither recalled giving the order. Following the failure of multiple providers to recognize Resident # 1 needed neurology follow up and following the failure of the providers to recognize the discontinuation of the seizure medication when reviewing the plan of care, the resident seized and was hospitalized in the Intensive Care Unit. This was for one (Resident # 1) of three residents whose medications were reviewed. The findings included: Record review revealed Resident # 1 was admitted to the facility on [DATE]. The resident had the following diagnoses: chronic obstructive pulmonary disease, chronic respiratory failure, ischemic heart disease, history of hip fracture, depressive disorder, history of cerebellar infarcts (stroke), dysphagia, cognitive communication deficit, hypertension, and hyperlipidemia. A nursing entry on 11/4/24 at 8:20 PM included the following information. Resident # 1 had a change in condition. She was witnessed to have twitching of both sides of her face and abnormal vital signs. The provider and EMS (Emergency Medical Services) were called and the resident was transferred to the hospital. Review of a hospital discharge summary, dated 11/15/24, revealed Resident # 1 was hospitalized from 11/4/24 until 11/15/24 for the acute principle problem of metabolic encephalopathy. Further review of this hospital discharge summary noted the following information was documented by the physician. Resident # 1 had presented to the hospital with altered mentation in addition to seizure active (as written) with mouth foaming. She was also in a hypertensive emergency. Under the heading Seizure Like Activity, the physician further noted, MRI [Magnetic Resonance Imaging] without acute abnormality, EEG [Electroencephalogram-test used to diagnose brain conditions] suggestive of severe diffuse encephalopathy-no seizures or definite epileptiform discharges [abnormal patterns on an EEG that resemble seizure activty]. She was started on Keppra on 11/5, transitioned to PO [oral] 11/8. Discussed case with neurology informally 11/14-14 (as written). Given MRI finding with chronic foci of hemosiderin staining involving the bilateral cerebral hemispheres (could potentially act as seizure focus), will continue Keppra (had briefly held on 11/14 with concern for AMS [altered mental status]-though she's improved today, and [RP] noted she was better a few days ago as well-when she was on the same Keppra dose. Follow with neurology outpatient regarding long term plan with Keppra. The hospital discharge summary also included the neurologist's impression of the EEG study which included the notation that the lack of epileptiform activity during interictal EEG does not exclude the diagnosis of epilepsy. Under the hospital physician's recommendations for outpatient follow up, the physician noted the resident should follow up with neurology as an outpatient for a concern for her cognitive deficits as well as determining whether to continue the Keppra long term. Under discharge instructions there was a notation which read, ambulatory referral to Neurology- appointment is requested in approximately: 4 weeks. Discharge medications listed on the hospital discharge summary included Levetiracetam [Keppra] 500 mg [milligrams] by mouth two times per day. According to Resident # 1's facility record she was admitted to the facility and orders were initiated on 11/15/24 for the Levetiracetam (Keppra) 500 mg two times per day. Review of the record revealed no neurology consult was ordered or initiated following 11/15/24. Nurse # 1, who worked with admitting residents to the facility, was interviewed on 4/21/25 at 1:50 PM and reported the provider reviewed the hospital discharge instructions upon admission and instructed the facility if they needed to arrange follow up appointments. Resident # 1's provider changed in December 2024 to another physician, who now also served as the facility's medical director. Facility providers, who had been responsible for Resident # 1's care in November 2024, were no longer involved with the resident. Record review revealed Resident # 1 was seen by Nurse Practitioner # 3 on 11/18/24 and on 11/25/24. NP # 3 made no notation about a referral to the neurologist. NP # 3 was interviewed on 4/23/25 at 3:10 PM and reported the following information. She had worked only part time at the facility one day per week. She was accustomed to the follow-up appointments being arranged by the hospital prior to discharge. She left work at the facility around 11/25/24, but If she had continued to work she would have questioned why the resident was not sent to neurology. According to information provided by the Administrator on 4/24/25 at 11:00 AM the date of 12/3/24 was the last date of service by the prior Medical Director and his team. A new Medical Director and new Nurse Practitioners then began seeing residents. Also interview with the Administrator on 4/21/25 at 12:30 PM revealed that in February 2025 Resident # 1 began part of a collaborative health care program in which NP # 1 also routinely saw and coordinated her care. The primary physician remained involved also in the care of Resident # 1. Resident # 1 was first seen by the collaborative NP (NP #1) in February 2025 through the collaborative program. Record review revealed on 2/4/25 NP # 2 (who was part of the physician's practice and not part of the collaborative program) saw Resident # 1 and made a progress note. NP # 2 documented the following information on 2/4/25. There had been no reports of seizure activity at the time and the resident's epilepsy appeared stable. The resident's Keppra would be continued. There was no notation about a missed neurology consult. NP # 2 was interviewed on 4/23/25 at 12:06 PM and reported the following information. She (NP # 2) had first begun seeing facility residents in January 2025. On 2/1/25 Resident # 1 had started in the collaborative program of which NP # 1 was a part. She (NP # 2) was trying to make sure all the regulatory visits were done when she first started at the facility. She (NP # 2) did see Resident # 1 on 2/4/25 while not realizing Resident # 1 had become part of the collaborative program and was to be seen primarily by NP # 1 for routine visits. When she (NP # 2) initially saw residents she would ask the nurses about any concerns, review vitals, and look at some of the progress notes. She would have done this for Resident # 1. No concerns had been mentioned to her when she saw Resident # 1. No one had mentioned the resident needed a neurology appointment and she had not been aware of the need by reviewing the record. Following 2/4/25, she did not see Resident # 1 again. NP # 1 would have covered Resident # 1. Review of the record revealed NP # 1, who was part of the collaborative program, saw Resident # 1 on 2/11/25. Review of NP # 1's 2/11/25 progress note revealed no mention of a missed neurological appointment. On 2/12/25 a verbal order was entered into the resident's electronic record to discontinue Levetiracetam (Keppra) by Nurse # 1. There was no documentation who gave the verbal order. On 4/21/25 the Administrator printed the verbal order from the Resident's electronic record. The order was on a page with other orders entered into the electronic record for the date of 2/12/25. At the bottom of the page was the physician's electronic signature for the date of 2/12/25 at 4:42 PM. Interview with Nurse # 1 on 4/21/25 at 1:50 PM revealed she had made rounds with NP # 1 on 2/12/25 and NP # 1 had noted the resident had no definite diagnosis of epilepsy, her Keppra level was in range, and NP # 1 had given the verbal order to discontinue the resident's Keppra. Review of Resident # 1's February 2025 Medication Administration Record revealed Resident # 1 received her last dose of Keppra on the morning of 2/12/25. NP # 1 was interviewed on 4/22/25 at 1:27 PM and reported the following information. She did not recall giving a verbal order to discontinue the Keppra. On 2/24/25 Resident # 1's physician noted he saw the resident for a required visit. Under medications within the physician's note, it was noted that the resident's Keppra was still an active medication although the Keppra had been discontinued on 2/12/25. The physician's progress note also included under diagnoses, Other epilepsy, not intractable, with status epilepticus. Stable no recurrent seizures. Review of Resident # 1's nursing notes revealed on 4/9/25 the resident was sent to the hospital for seizure activity and admitted . The admitting hospitalist on 4/9/25 wrote, She has a diagnosis of epilepsy and was supposed to be on Keppra 500 mg BID [twice daily] (listed on discharge summary from 11/4/24); however, she was apparently not on this at nursing facility for unclear reasons. She was seen normal at 6PM on evening of 4/9/25. When staff checked on her later, she was less responsive and was twitching with a right sided gaze. EMS [Emergency Medical Services] was called and administered IM [intramuscular] Versed [a medication used for seizures] without improvement before establishing IV [intravenous] access and administering an additional Versed dose IV. There was roughly 45 minutes reported before seizures resolved. According to the 4/9/25 hospital records, Resident # 1 was admitted to the Intensive Care Unit. Resident # 1's facility physician, who serves as the facility's medical director was interviewed on 4/21/25 at 1:17 PM and again on 4/23/25 at 9:46 AM and the physician reported the following information. The first he knew about the discontinuation of the Keppra was on 4/21/25. Facility staff had told him the Keppra had been discontinued by NP # 1. He (the Physician) often received batches of orders electronically at one time to sign from the facility. He did not recall signing the Keppa discontinuation order. There should have been some documentation by Nurse # 1 who received the discontinuation order or by NP # 1, who he was told gave the order, for the reasoning behind the order in the record. He was also not aware of the recommendation from the hospital in November 2024 that the resident needed to see a neurologist. During an interview with the Administrator on 4/22/25 at 4:26 PM, the Administrator reviewed the physician's progress note of 2/24/25 which noted Keppra was an active medication although it had been discontinued per his signature on an order. The Administrator reported that at times she thought the providers cut and pasted information from past visits, but they were not supposed to do so when seeing and reviewing residents' care.

Based on record review and interviews with staff, Nurse Practitioner, Physician, Consultant Pharmacist, and Pharmacy Director of Clinical Services, the Consultant Pharmacist failed to report to the attending physician when Resident # 1's record showed the following: 1)a neurological consult never was obtained although recommended when Resident # 1 experienced a newly diagnosed neurological disorder while hospitalized in November 2024 and was placed on Keppra (a seizure medication) with instructions that neurology should be involved in the continued plan for the Keppra; 2) the Keppra was discontinued on 2/12/25 with no documented reason for the discontinuation and the neurological consult still had not been completed at its discontinuation; and 3) following the discontinuation which was signed by the physician, the physician noted in his 2/24/25 progress note that the Keppra was an active drug although his signature appeared by the discontinuation order. This was for one (Resident #1) of three sampled residents whose medications were reviewed. The findings included: Record review revealed Resident # 1 was admitted to the facility on [DATE]. The resident had the following diagnoses: chronic obstructive pulmonary disease, chronic respiratory failure, ischemic heart disease, history of hip fracture, depressive disorder, history of cerebellar infarcts (stroke), dysphagia (swallowing difficulties), cognitive communication deficit, hypertension, and hyperlipidemia. A nursing entry on 11/4/24 at 8:20 PM included the following information. Resident # 1 had a change in condition. She was witnessed to have twitching of both sides of her face and abnormal vital signs. The provider and EMS (Emergency Medical Services) were called, and the resident was transferred to the hospital. Review of a hospital discharge summary, dated 11/15/24 and located in the facility record, revealed Resident # 1 was hospitalized from 11/4/24 until 11/15/24 for the acute principle problem of metabolic encephalopathy. Further review of this hospital discharge summary noted the following information was documented by the physician. Resident # 1 had presented to the hospital with altered mentation in addition to seizure active (as written) with mouth foaming. The resident's MRI (Magnetic Resonance Imaging) showed areas of her brain which could act as seizure focus. The resident was placed on Keppra (a seizure medication) while hospitalized . The hospital physician noted the resident should follow up with neurology regarding the long term plan for Keppra. The physician included in the discharge summary that the appointment was requested to be done in approximately four weeks. According to Resident # 1's facility record the resident was admitted to the facility and orders were initiated on 11/15/24 for the Levetiracetam (Keppra) 500 mg (milligrams) two times per day. Review of the record revealed no neurology consultation was ordered or initiated after 11/15/24. On 12/18/24 the Consultant Pharmacist completed a pharmacy review and noted Resident # 1 had been readmitted to the facility on [DATE] with metabolic encephalopathy and seizure like activity. Keppra had been added to Resident # 1's drug regimen and the pharmacist made a notation follow for neuro. On 1/14/25 the Consultant Pharmacist noted Keppra had been added in November 2024 for seizures and she again put follow for neuro. There was no notation about the missed neurological follow up. On 2/12/25 a verbal order was entered into the resident's electronic medical record to discontinue Levetiracetam (Keppra) by Nurse # 1. On 2/19/25 the Consultant Pharmacist again did a review and noted Keppra had been added in November 2024 and discontinued in February 2025. The Consultant Pharmacist did not note she was reporting to the physician that the neurological consult had never been completed. Review of Resident # 1's February 2025 Medication Administration Record revealed Resident # 1 received her last dose of Keppra on the morning of 2/12/25. On 2/24/25 Resident # 1's physician noted he saw the resident for a required visit. Under medications within the physician's note, the physician noted that the resident's Keppra was still an active medication although his signature was by the discontinuation order of 2/12/25. The physician's progress note also included under diagnoses, Other epilepsy, not intractable, with status epilepticus. Stable no recurrent seizures. On 3/17/25 the Consultant Pharmacist noted again Keppra had been added in November 2024 and discontinued in February 2025. The Consultant Pharmacist did not ask for clarification from the physician regarding why he indicated Keppra was active on 2/24/25 although it was discontinued on 2/12/25 per his signature. The facility's Consultant Pharmacist was interviewed on 4/21/25 at 2:42 PM and reported she could not comment on the provider's choice to discontinue the Keppra and not complete a neurology consult. The Pharmacist who serves as Director of Clinical Services for the Pharmacy Consulting Practice was interviewed on 4/23/25 at 10:19 AM and reported the following information. The consultant pharmacists noted newly written orders and orders for discontinuation when doing their reviews. In doing pharmacy reviews, the consultant pharmacist would not question if the provider had not included a rationale in the record for the decision to discontinue the Keppra and they would not have questioned the physician about the resident not going to a neurologist prior to the discontinuation of the Keppra.

Based on record review and interviews with staff and physician, the facility failed to ensure a record was complete regarding the rationale to discontinue a seizure medication and that a physician's progress note was accurate regarding a seizure medication being discontinued. This was for one (Resident # 1) of three sampled residents whose medications were reviewed. The findings included: 1a. Record review revealed on 2/12/25 there was a verbal order entered into Resident # 1's record by Nurse # 1 to discontinue Keppra (a seizure medication). There was no documentation to show which provider gave the verbal order. An interview with Nurse # 1 on 4/21/25 at 1:50 PM revealed she had made rounds with Nurse Practitioner (NP) # 1 on 2/12/25 and NP # 1 had noted the resident had no definite diagnosis of epilepsy, her Keppra level was in range, and NP # 1 had given the verbal order to discontinue the resident's Keppra. The reason for the discontinuation of the Keppra was not entered into the record. Resident # 1's physician, who serves as the facility's medical director, was interviewed on 4/23/25 at 9:46 AM and reported the reasoning for the Keppra discontinuation should have been documented in Resident # 1's record by the provider who gave the order or by the nurse who took the order. 1b. Review of physician progress notes revealed Resident # 1's physician noted he saw the resident for a required visit on 2/24/25. Under medications within the physician's note, it was noted that the resident's Keppra was still an active medication. Review of physician orders revealed Resident # 1's Keppra had been discontinued on 2/12/25, which was prior to the 2/24/25 note and which therefore indicated the 2/24/25 progress note was not accurate.

Based on record review, observation and staff interviews the facility failed to label medications which were not stored in the pharmacy or manufacturer packaging (500 hall medication cart for medication storage review for 2 of 3 medication carts reviewed) . 1.An observation of the 400-hall medication cart was conducted on 08/21/24 at 10:49 AM in the presence of Nurse #3 and Nurse #4. The medication cart contained 4 loose pills of various shapes, colors, and sizes on the bottom of cart drawers. Nurse #4 indicated each nurse assigned to the medication cart was responsible for cleaning the medication cart they were assigned to, ensuring it was organized, and well stocked. An interview was conducted with the Director of Nursing on 08/21/24 at 11:15 AM. The DON indicated the medication carts were to be cleaned by the nurses on duty. The DON indicated each nurse should clean, organize the medication carts, and discard any loose pills. 2. An observation of the 500-hall medication cart was conducted on 08/21/24 at 11:02 AM in the presence of Nurse #3, Nurse #5, and Medication Aide (MA) #3. The medication cart contained three white pills that were placed in a white clear bag which was not labelled. There was no medication name, resident name, and/or dosage instructions on the bag. MA #3 was interviewed on 08/21/24 at 11:11 AM indicated that she placed the three white caplets in the clear white bag. Nurse #5 was interviewed on 08/21/24 at 11:08 AM and indicated each nurse assigned to the medication cart was responsible for ensuring each medication was labelled. An interview was conducted with the Director of Nursing on 08/21/24 at 11:15 AM. The DON indicated the nurses oversee the medication aides. The DON further indicated each nurse and medication aide must use medication from a labeled container and after removing the medication from the original container, must administer the medication to residents immediately per physician orders.

Based on observations, record review, and interviews of staff, the facility failed to clean the top and bottom ovens as evidenced by brown and black soiling for 2 of 2 ovens, and the facility failed to label and date perishable food items when opened or date when to discard in the walk-in refrigerator. These practices had the potential to affect food served to residents. Findings included: 1. On [DATE] at 9:55 am an interview and observation of the kitchen was done with the Dietary Manager in training. Observation of the 2 ovens' tops and bottoms had burnt on food stains and burnt food debris on the bottom pan and brown and black soiling on the interior walls and racks. The Dietary Manager stated the oven was supposed to be cleaned weekly and had not been cleaned and he added that the oven it was very dirty. On [DATE] at 10:05 am an interview and observation of the kitchen ovens were done with the Cook. The [NAME] stated he was not sure when the ovens were last cleaned and there was no log of when the ovens were being cleaned or last cleaned. The [NAME] stated he usually cleaned the ovens each week and could not remember the last time he cleaned the oven. On [DATE] at 10:45 am an interview and observation of the kitchen ovens were completed with the Administrator. The Administrator observed the ovens and made no comment. The [NAME] was present and commented he could not remember when the ovens were last cleaned and there was no logbook. On [DATE] at 2:16 pm the Corporate Regional Manager for Dietary was interviewed. She stated the facility was aware of kitchen cleanliness issues back in ,d+[DATE] and the first week of ,d+[DATE]. The kitchen staff were educated about cleaning the kitchen, including the appliances, in [DATE]. The Dietary Manager was required to complete rounds to check the kitchen for cleanliness. The Dietary Manager and District Manager resigned (date unknown), and the staff had not kept up with cleaning the kitchen. The first week in ,d+[DATE] corporate staff had identified the need to address the cleanliness of the kitchen again. Corporate staff and the kitchen vendor had created an audit tool to address the prior failure ,d+[DATE]. The Management decided that on Mondays a walk-through of the kitchen would be implemented to address the issues using the audit. The issues were not addressed on this Sunday [DATE] because there was not a manager to oversee the staff. The Corporate Regional Manager stated that the 2 ovens were soiled and appeared more than a week since it was last cleaned. She stated the ovens were wiped down on Mondays after each use. The prior Dietary Manager was cleaning and had resigned so the oven was not getting cleaned. There was currently a new experienced Dietary and District Manager that just started. 2. On [DATE] at 9:55 am an interview and observation of the kitchen was done with the Dietary Manager in training. Observations of food stored inside the walk-in refrigerator revealed the following items were stored without a label and/or date: - cheese slices in a plastic container - chopped garlic in a jar - beef flavored base in a container - sour cream in a container - 6 plates of lettuce and tomatoes covered in plastic - cherries in a container - raw eggs out of the shell in a container. During the observations, the Dietary Manager in training stated there was not a kitchen staff member assigned to check perishable foods for labeling and discard date. Any staff could check and staff that received food items from the vendor dated the box for date received. Staff were expected to label all food items upon opening. The cook usually checked the perishables for expiration. On [DATE] at 11:10 an interview and observation was conducted with the Administrator. She was informed of the kitchen findings. The Administrator stated there was a new experienced Dietary Manager, and he was called in today [DATE]. The Dietary Manager in training had been working about a week and was working today. The Administrator observed the unlabeled food items in the walk-in refrigerator and made no comment. She then stated that there was a person assigned to check for labels and discard food items when expired but had not stated who and directed me to the new Dietary Manager. On [DATE] at 12:00 pm the new Dietary Manager was interviewed. When asked about the labeling and discarding of food items, he stated he would manage the dating and labeling of food items when they are opened and for discard date. On [DATE] at 2:16 pm the Corporate Regional Manager for dietary was interviewed. The labeling of food items were not addressed on Sunday [DATE] because there was no manager to oversee. Dietary staff were aware to complete food labeling including the cook when food was first opened and to check food items daily for expiration.

Based on record review, observations and staff interviews the facility failed to prevent a urinary catheter bag from encountering the floor to reduce the risk of infection or injury for 1 of 1 resident (Resident #42) reviewed for urinary catheter care. The findings included: A review of the facility administrative daily rounding tool, titled, Resident and Room Audit sheets, revealed a section that read, if applicable is the catheter positioned properly? Is the Catheter bag off of the floor? Resident # 42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of admission Minimum Data Set, dated dated [DATE], revealed Resident #42 had moderate cognitive impairment, required extensive assistance of two staff members with toilet use and personal hygiene and had a urinary catheter. A review of the Resident specific care plan revealed a focused area for Urinary Catheter care with interventions to provide catheter care each shift and as needed that included to follow the facility procedure for catheter care. A review of the facility policy, titled: Catheter care, stated staff are to ensure proper care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] An observation of Resident # 42 was conducted on 4/11/2022 at 3:29 p.m. and the urinary catheter bag was observed lying on the floor, with no barrier between the bag and floor, and half of the bag touching the floor surface. An interview was conducted with a family member for Resident # 42, on 4/11/2022 at 3:29 p.m. and she revealed the urine catheter bag always had to rest on the floor because her mother had a recent fall and the bed most be kept in a low position. She indicated this was a regular occurrence as a result of the need for a low bed position. An observation was conducted on 4/13/2022 at 9:48 a.m. of Resident #42 lying in bed with the urine catheter bag lying on the facility floor, with no barrier between the bag and the floor, and the bed in the lowest position. An interview was conducted with the Director of Nursing (DON) on 4/13/2022 at 10:01 a.m. and she stated she observed the urine catheter bag for Resident # 42 lying in the floor and immediately picked the bag up off of the floor and stated it should not be on the floor. She stated she would immediately find an alternative method to hang the urine catheter bag. She revealed it was her expectation that all urine catheter bags not be touching the floor and this had occurred because of the low bed intervention put into place on 4/11/2022 due to a fall. An interview was conducted with the Treatment nurse, on 4/13/2022 at 10:04 a.m. and she revealed she had observed the urine collection bag for Resident # 42 hanging on the bed with the bed in the lowest position. She added that the urine catheter collection bag was touching the floor and a catheter bag should not touch the floor. She entered a conversation with the DON on how to resolve the situation to maintain proper care of the urine catheter bag for the Resident.

Based on resident and staff interviews and record review, the facility failed to refer a resident, who exhibited new behaviors which resulted in additional psychiatric diagnoses, for a level II Preadmission Screening and Resident Review (PASARR) for 1 of 1 resident (Resident #109) reviewed for PASARR. Findings included: Resident #109 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. He had a level I PASARR number upon initial admission. The medical record indicated Resident #109 exhibited visual hallucinations in August 2019, was seen by psychiatry in the facility and subsequently diagnosed with [REDACTED]. The medical record revealed a level II PASARR referral (the purpose of the Level II screening is to assure that individuals with serious mental illness entering or residing in Medicaid certified nursing facilities receive appropriate placement and services) was not completed by the facility when the [DIAGNOSES REDACTED]. The facility completed a psychiatric evaluation on 8/29/19 which explained Resident #109 had endorsed visual hallucinations of bugs and spiders crawling on his skin .and crawling in his hair. The psychiatric nurse practitioner started the resident on [MEDICATION NAME] (an anti-psychotic medication), 25 milligrams, daily, for visual hallucinations and [MEDICAL CONDITION]. The comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #109 had moderately impaired cognition. He reported mood symptoms that included feeling down and feeling tired/little energy. Resident #109 received antipsychotic and antidepressant medications for 7 of 7 days during the MDS look back period. A care plan for the use of an anti-psychotic medication and hallucinations was updated [DATE] and interventions included, Encourage resident to vent/express feelings in a therapeutic manner and identify any changes to mood/behavior, if noted, document and inform physician. On 2/25/20 at 2:15 PM Resident #109's current PASARR number was provided by the Director of Transitional Services and indicated a level I PASARR number. The Diagnosis/History report provided by the medical records department on 2/26/20 at 2:25 PM revealed [DIAGNOSES REDACTED]. On 2/27/20 at 9:47 AM an interview was completed with Social Worker (SW) #1. She reported the facility verified PASARR numbers prior to a resident's admission to the facility. She stated she did not know that a level II PASARR needed to be completed when a resident was identified with a mental illness diagnosis. SW #1 was unaware Resident #109 had told staff he had seen bugs or acknowledged visual hallucinations. The Director of Transitional Services was interviewed on 2/27/20 at 10:09 AM. She confirmed Resident #109 had a level one PASARR when he was initially admitted to the facility. She said nobody at the facility completed level II PASARR applications when a resident was newly diagnosed with [REDACTED]. During an interview with Unit Manager #1 on 2/27/20 at 11:08 AM, she recalled around August 2019 Resident #109 had stated he had seen bugs and spots. She stated the psychiatric nurse practitioner visited the resident and started him on [MEDICATION NAME]. Since then, Unit Manager #1 reported Resident #109's hallucinations had reduced to less than once a week. On 2/27/20 at 1:23 PM an interview was completed with Resident #109. He acknowledged that he still saw bugs at times, crawling on me and said, I keep my head washed so the bugs don't crawl on him. He added he told staff when he saw bugs and they looked for the bugs on him but they don't see nothing. The Administrator was interviewed on 2/27/20 at 2:34 PM. She said level II PASARR applications were completed when there was a MDS significant change assessment. She explained the facility had recently become aware that level II PASARR's needed to be completed when there was a new mental illness diagnosis. She reported the Director of Transitional Services was responsible for completing level 2 PASARR referrals.

Based on record review and staff interviews the facility failed to accurately transcribe, order, and follow a physician order [REDACTED]. Findings include: Resident #216 was readmitted to the facility after a hospital admission for aspiration pneumonia on 7/24/19. Resident #216's [DIAGNOSES REDACTED]. Nursing Notes revealed that Resident #216 arrived at the facility on 7/24/19 at approximately 2:30 PM. Resident #216's discharge summary from the hospital on [DATE] revealed an order for [REDACTED]. A Physician order [REDACTED]. Resident #216's July 2019 Medication Administration Record [REDACTED]. The first dose of [MEDICATION NAME] received by Resident #216 after his admission on 7/24/19 at approximately 2:30 PM was not documented as given until [DATE] at 8:00 PM. Resident #216 missed a dose at 8:00 PM on 7/24/19 and at 8:00 AM and 2:00 PM on [DATE]. Resident #216's pain assessments from 7/24/19 through [DATE] revealed that his pain was assessed each shift, as needed pain medication was administered when needed, and nursing staff re-evaluations revealed it was effective, with no more pain reported. A Medication Incident Report from [DATE] at 5:00 PM revealed that an error was made by the Assistant Director of Nursing (ADON) on 7/24/19. The report documented that the order for [MEDICATION NAME] was not transcribed into the facility's electronic medical record until [DATE] after it was checked by a second nurse. The Director of Nursing (DON) and the physician were both notified of the error on [DATE]. During an interview with the ADON and DON on 2/27/20 at 11:08 AM she stated that when a resident is admitted to the facility from the hospital, their discharge summary is reviewed, and medication orders are verified by the doctor or on-call provider. The ADON stated that orders are placed into the facility ' s EMR by herself or the DON and were usually double-checked and verified the following day by both nurses during the morning meeting based on the company ' s policy. It was stated that due to multiple new admissions the next morning ([DATE]), they did not catch the error until later in the day. The DON stated that after the error was made, it was their new policy to have the orders double-checked by two nurses the day of the admission and not the next day. During an interview with the Physician on 2/27/20 at 11:23 AM she stated that the resident received [MEDICATION NAME] for [MEDICAL CONDITION] pain. She was made aware of the medication transcription error by the DON, the day after Resident #216's admission. She stated that she would always prefer that medications are given as soon as possible and as ordered, but that she felt as though the nurses had managed the resident's pain effectively, and that the three missed doses of [MEDICATION NAME] had not caused a harmful outcome to the resident.

Based on observations and staff interviews the facility failed to ensure dietary staff members fully restrained their hair while working in the kitchen. This was evident in 2 of 2 kitchen observations. Findings Included: An observation on 2/25/19 at 6:54 am of the kitchen revealed Dietary Aide #1 was preparing beverages and did not have a hair restraint covering his beard. An interview on 2/25/19 at 6:58 am with Dietary Aide #1 revealed he had worked at the facility for about 3 months and he had not been told he needed to cover his beard. He added he wasn ' t sure if the facility had beard guards. An observation on 2/27/19 at 11:30 am with the Dietary Manager (DM) revealed Dietary Aide #2 was working on the serving line preparing for the lunch meal service. Her hair from the middle section of her head to her bangs was not in a hair restraint. An interview on 2/27/19 at 11:40 am with the DM revealed Dietary Aide #2 should use 2 hairnets to make sure all her hair was covered. He stated employees with facial hair should wear beard guards while working in the kitchen. The DM added beard guards were available for the employees to wear. An interview on 2/27/19 at 12:00 pm with the Administrator revealed she expected all staff working in the kitchen to have their hair covered.

Based on observations and staff interviews, the facility failed to properly dispose of expired medications in 1 of 1 medication storage rooms (300/400 hall) and 2 of 2 medication carts (100/500 and 300/400 carts) reviewed for proper medication storage. Findings include: An observation was made of the 300/400 hall medication storage room on 2/24/19 at 5:15am with Nurse #13. It was observed that there were 4 cans of 240 ml (milliliters) Suplene Therapy Nutrition that had an expiration date of 1/2019. An observation was made of the 300/400 hall medication cart on 2/24/19 at 5:30am with Nurse #13. It was observed that there were 2 syringes of [MEDICATION NAME] lock flush 500 units/5 ml that had an expiration date of 1/2019. An observation was made of the 100/500 hall medication cart on 2/24/19 at 6:45am with the ADON (Assistant Director of Nursing). It was observed that there was a pint size bottle of Pink [MEDICATION NAME] that had an expiration date of 1/2019. An interview was conducted on 2/24/19 at 5:30am with Nurse #13. Nurse #13 reported any medications that had expired should have been removed from the medication room and medication cart. An interview was conducted on 2/24/19 at 7:00am with the ADON. She reported it was her expectation that no medications on the medication cart be expired. An interview was conducted with the Administrator on 2/27/19 at 10:00am. She reported it was the responsibility of the nurses and the pharmacy to check for expired medications. She reported it was her expectation that all expired medications be removed from the medication storage rooms and carts.

Based on record review, staff interviews and resident interview, the facility staff failed to treat a resident with dignity and respect when a resident asked the cook for an alternative dinner meal. This was evident in 1 of 3 sampled residents (Resident #1) that had a verbal altercation with an employee which resulted in the resident feeling intimidated and anxious. Findings included: Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed that Resident #1 was cognitively intact and did not have any mood or behaviors issues. He was coded as being independent with set up help for eating, toileting and personal hygiene and supervision with set up help for transfers. A review of Resident #1's care plan dated 8-6-18 revealed a goal that the resident would show no significant weight changes and maintain hydration. The interventions for the that goal were as followed; dietician to evaluate and follow up per facility protocol, determine food preferences, offer between meal supplements as ordered and promptly offer resident food alternatives when appropriate for any meal served. A review of the initial allegation report dated 9-17-18 revealed the following information; On 9-16-18, nursing assistant (NA) #1 reported Resident #1 had gone to the kitchen requesting an alternate dinner meal and the dietary cook told the resident he would make him a burger. NA #1 also reported that Resident #1 and the dietary cook started exchanging words and became very loud. The report revealed the dietary cook was counseled by his immediate supervisor and that the dietary cook apologized to Resident #1. The dietary cook was suspended on 9-16-18 pending further investigation. The investigation report dated 9-19-18 revealed the dietary cook was employed by the facility's contract dietary service and was suspended on 9-16-18 and terminated on 9-20-18. The report also revealed an interview with Resident #1 who confirmed he felt intimidated by the actions of the dietary cook. An interview with Resident #1 conducted by the facility's Social Worker during the facility's investigation on 9-17-18 revealed in part the following; Resident #1 took his tray back to the kitchen thinking that the cook was just trying to be funny because this error has happened before. The cook came out and said here you go again with that s I placed the tray on the counter and he told me you don't have to throw the m .f I said to him I did not throw it. The resident felt the cook was aggressive with him. The interview continued The cook started tapping his chest and invading my space as if he was trying to intimidate me and saying he was from D.C. On 11-19-18 at 4:53pm an interview was conducted with NA #1. She stated she saw Resident #1 coming down the hall in his wheel chair with his tray on his lap and when she asked him what was wrong she stated the resident told her he was upset because he had pork on his tray again. NA #1 stated she took the tray to the kitchen and asked if the cook could give Resident #1 something else to eat and walked away. She stated she saw the resident and the cook exchange words and then the cook gave the resident a plain hamburger. NA #1 stated she heard the resident ask for something to be put on the hamburger and then more words were exchanged between the cook and the resident. NA #1 denied remembering what was said during the exchange between the cook and the resident. During an interview with Resident #1 on 11-19-18 at 5:34pm he stated he had told the kitchen that he did not eat pork and that it was on his dietary card but that he was given pork on his tray that day. He stated when he asked for something else, the cook came out into the dining room and began pacing telling the resident he was not going to keep making different food for him every meal. The resident stated the cook did get him a hamburger, but it was plain and when he asked for something to be put on the hamburger the cook became upset. Resident #1 stated the cook hovered over him while beating on his chest telling the resident he was from D.C. He also stated he felt the cook was aggressive with him and that he felt intimidated by the cook because he was suffering from Post-Traumatic Stress Disorder from recently being shot 5 times, so he felt anxious and intimidated when the cook invaded his space. The resident was not diagnosed by a physician with [MEDICAL CONDITION]. An interview occurred on 11-20-18 at 8:15am with the Regional Dietary Manager who stated he was informed of the altercation by the facility's Administrator on 9-16-18, the day of the altercation. He stated he immediately came to the building and suspended the cook and the cook was escorted out of the building till an investigation could be completed. The Administrator was interviewed on 11-20-18 at 10:26am. She stated she did not come to the facility the evening of the altercation. She stated she was informed by NA #1 of the altercation by phone right after the altercation and she in return called the Regional Dietary Manager to have the employee suspended and removed from the building. The Administrator stated that Resident #1 was not assessed till the next day by the social worker because there was no physical contact. During an interview with the Social Worker on 11-20-18 at 11:56am she stated she interviewed Resident #1 the next day (9-17-18) and that the resident appeared calm and initially did not want to discuss the altercation. The Social Worker stated she did not assess Resident #1's mental state during the interview but that the resident did tell her he was upset and felt that the cook was trying to intimidate him. Two attempts were made to contact nursing assistant (NA) #2; 11-19-18 at 2:45pm and 11-20-18 at 2:47pm. Messages were left for a return call. An attempt was made on 11-20-18 at 11:28am to contact the dietary cook involved in the altercation and received a call back at 2:30pm on 11-20-18 from another person stating the phone no longer belonged to the dietary cook. An interview with the Dietary Supervisor occurred on 11-21-18 at 12:14pm. The Dietary supervisor stated she no longer worked at the facility but was working there at the time of the altercation. She stated she was not present when the altercation between the dietary cook and Resident #1 occurred. The supervisor stated she was called by the facility's Administrator about the altercation and that she arrived at the facility a short time later. She stated she spoke with the cook about the altercation and that he told her the resident came to the door of the kitchen and words were exchanged. She stated the dietary cook finished out the evening in the kitchen cleaning and was suspended the next day (9-17-18). The supervisor denied that the cook had any further contact with residents that evening.

Based on record review, family interview and staff interview the facility failed to provide treatment to an open area on a resident's sacrum for 4 days for 1 of 3 residents (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of Resident #3's discharge record dated 9-14-18 from the hospital revealed no documentation or orders related to a sacral wound. Resident #3's admission notes to the facility dated 9-14-18 was reviewed and revealed that nurse #1 documented the resident had a reddened and open area on sacrum area. The nurse also documented that the resident did not have any complaints of pain or discomfort. A review of Resident #3's physician orders [REDACTED]. A review of the care plan for Resident #3 dated 9-15-18 revealed a goal that the resident would not have any skin breakdown, surgical wound would heal, and his sacral wound would show positive signs and symptoms of healing. The interventions for those goals were as followed; weekly skin assessment, administer treatments as ordered by the physician, administer pain medication as ordered, encourage and assist with frequent positioning. A review of Resident #3's medical record revealed no documentation regarding Resident 3's sacral pressure ulcer on 9-15-18 and 9-16-18. A review of Resident #3's (MONTH) (YEAR) Treatment Administration Records (TAR) revealed there was no treatment of [REDACTED]. A review of the physician progress notes [REDACTED]. The physician documented the resident had an area of yellow slough on his sacrum per nursing and it caused the resident pain. The assessment and plan documented by the physician for the resident's sacrum revealed a [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED].#3's sacral pressure ulcer. The order specified for the sacral pressure ulcer to be cleaned with normal saline, apply Santyl and cover with foam dressing daily. The documentation by the wound care nurse dated 9-18-18 revealed her first assessment of Resident #3's pressure ulcer to his sacrum with slough tissue and a small amount of serous drainage. She measured the wound as being 4 centimeters wide and 2 centimeters long. The note also revealed there was no signs or symptoms of infection. The admission Minimum Data Set ((MDS) dated [DATE] revealed that Resident #3 was cognitively intact but coded as having a poor appetite for 2-6 days and trouble sleeping for 7-11 days. Resident #3 was also coded as needing extensive assistance with 2 people for bed mobility and transfers and extensive assistance with one person for dressing, toileting and personal hygiene. Resident was coded for a pressure ulcer. A review of the treatment record dated 9-18-18 to 9-24-18 reflected the wound care nurse provided wound care to Resident #3's sacral area beginning on 9-18-18 and continued until his discharge on 9-24-18. The nurse's notes dated 9-24-18 at 2:57pm revealed Resident #3 went to an Orthopedic doctor's appointment at 9:00am and was prescribed [MEDICATION NAME] (antibiotic) 100mg twice a day for 14 days for an infection of the residents sacral wound and at 8:00pm the resident was sent to the hospital with a fever. A review of the wound measurements, documented by the wound care nurse on 9-24-18 were 6 centimeters wide and 5 centimeters long and 4 centimeters deep. A review of Resident #3's hospital record dated 9-24-18 revealed that the resident was admitted to the hospital with [REDACTED]. The hospital record indicated the resident had to receive surgery to have the wound debrided with final wound measurements as followed; 10 centimeters long x 10 centimeters wide x 4 centimeters deep with 5 centimeters tunneling bilaterally exposing bone in the base of the wound. The record also revealed Resident #3 was to continue to receive intravenous antibiotic therapy for the infection upon discharge. During an interview with Resident #3's family member on 11-20-18 at 12:21pm she stated she had informed the facility when the resident was admitted on [DATE] that the resident had a pressure ulcer starting that was red and opened and needed treatment. The wound care nurse was interviewed on 11-20-18 at 1:27pm. She stated she would typically complete a skin assessment on every new resident within 24 hours unless it was a weekend and then she would follow up on the following Monday. The wound care nurse stated she was off on 9-17-18 so she was not able to assess or obtain orders for the residents wound till 9-18-18 when she returned to work. She also stated she was not able to state what the wound looked like prior to 9-18-18. The wound care nurse stated Resident #3 did not receive any treatment for [REDACTED]. She denied that there were any signs or symptoms of infection and stated when she was not working, that it was the responsibility of the hall nurse to provide wound care. The wound care Physician Assistant was interviewed on 11-20-18 at 1:27pm. The Physician Assistant stated she believed when the treatment that was provided to the resident from 9-18-18 to 9-23-18 removed the slough an underlining infection became relevant. She was unable to state if not having treatment for 4 days caused the infection or not since she did not see the wound prior to 9-18-18. An interview was conducted with the Director of Nurses (DON) on 11-20-18 at 2:07pm. The DON stated the admission nurse does not measure or stage a wound upon a resident's admission but does identify if there was a wound and what it looked like. The DON also stated the admission nurse would then leave a message for the wound care nurse to follow up, but the admission nurse would not call the doctor for orders to treat the wound. She stated she expected the admission nurse would follow the orders from the hospital or the standing orders on the facilities wound care protocol. The DON stated she was not aware that the wound care for Resident #3 was not completed for 4 days or that the wound was getting progressively worse. During an interview with nurse #1 on 11-20-18 at 3:36pm she stated she was the nurse who admitted Resident #3 but did not remember specific details. The nurse stated if a resident came to the facility with no wound care orders but had a wound on his sacral area that was reddened and opened. The nurse denied measuring the area but put a foam dressing on and let the wound care nurse know. The nurse denied calling the doctor for orders I believe this is the wound care nurses job. She stated she did not know how orders were received if the wound care nurse was not working for several days I guess who ever was working that cart would have to call the doctor. Nurse #1 could not remember providing any treatment to Resident #3's sacral wound. There were several attempts made over a 3-day period to reach the emergency room physician and the attending physician who cared for Resident #3. During the exit interview on 11-20-18 at 4:15pm the Administrator and DON stated they were aware after speaking with the surveyor that there is a breakdown in the system. The Administrator stated the employees had received training on the facility's computer system and believed the documentation would improve. The Administrator and the DON stated they were unaware that treatment was not provided to the resident and expected with the new computer system prompting the employee in the proper procedure the breakdown in wound care would improve.

Based on record review, staff, pharmacist and physician interviews the facility failed to obtain documentation for the rationale and duration to extend an as needed (PRN) order for a [MEDICAL CONDITION] medication beyond 14 days for 1 of 3 residents reviewed for unnecessary medications (Resident #1). Findings Included: Resident #1 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) physician orders [REDACTED].½ tablet twice daily PRN for anxiety. The order had a start date of 3/21/18. The order did not include a stop date. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]½ tablet (0.25 mg) by mouth two times daily PRN. The MAR indicated [REDACTED]. Review of the (MONTH) (YEAR) MAR for Resident #1 identified an order for [REDACTED].½ tablet (0.25 mg) by mouth two times daily PRN. The MAR indicated [REDACTED]. Review of the consultant Pharmacist note for Resident #1 dated 4/30/18 revealed no recommendations for the physician. Review of the physician progress notes [REDACTED]. Review of the consultant Pharmacist note for Resident #1 dated 5/31/18 revealed a recommendation to the physician regarding the [MEDICATION NAME] 0.25 mg twice daily PRN for anxiety. The note stated per new CMS guidance, prn [MEDICAL CONDITION] medications are limited to 14 days. To extend a prn order past 14 days please document rationale in chart and indicate a duration of prn order (excluding antipsychotic prns which are 12 days only). If you would like to extend the use of the [MEDICATION NAME] past 14 days, please document a rationale and indicate a duration for its use (i.e.: 3 months). There was a check mark that the physician agreed with the recommendation. The note was signed, but not dated. A telephone order dated 6/26/18 for Resident #1 stated to discontinue the [MEDICATION NAME]. A quarterly minimum data set (MDS) for Resident #1 dated 8/26/18 revealed her cognition was moderately impaired did not identify any mood or behavior concerns. An interview with the MD (Doctor of Medicine) for Resident #1 on 9/18/18 at 1:30 pm revealed she didn ' t recall the resident having an order for [REDACTED]. The MD added she was still working on how to manage residents on prn [MEDICAL CONDITION] within the regulation guidelines. A phone interview on 9/19/18 at 10:55 am with the Pharmacist revealed she had been the Consultant Pharmacist for the facility since (MONTH) (YEAR). She stated her first review for Resident #1 was on 4/30/18 and her records didn ' t indicate the resident had been on a prn anti-anxiety medication. She added she wasn ' t sure if there was an order for [REDACTED].#1 ' s physician. An interview was conducted on 9/19/18 at 11:49 with the Director of Nursing (DON), Administrator and MD. The DON stated the Pharmacist had identified the prn anti-anxiety order for Resident #1 on 5/31/18 and the order was discontinued by the MD on 6/26/18. She added the facility had a process for identification of prn anti-anxiety medications, but in this case the process wasn ' t handled timely. The DON stated the facility had discussed looking at their systems for the management of prn [MEDICAL CONDITION], but she didn ' t believe they had a quality assurance plan to address the process. An interview with the Administrator on 9/19/18 at 12:40 pm confirmed that the facility did not have a quality assurance plan that included evaluation of all residents on prn [MEDICAL CONDITION], staff in-services and monitoring tools. She added it was her expectation that prn orders for [MEDICAL CONDITION] medications were written per the guidelines.

Based on record reviews and staff interviews the facility failed to notify a resident's responsible party after the resident got her left foot caught under a wheelchair while being transported in the hallway which later revealed a non-displaced distal [MEDICAL CONDITION] and fibula for 1 of 4 residents sampled for supervision to prevent accidents (Resident #3). Findings included: Resident #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a care plan with onset date of 02/01/18 revealed Resident #3 had a [DIAGNOSES REDACTED]. The goals indicated in part staff would implement interventions to maintain a safe environment daily to reduce risk for injury. A review of an annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 had short term and long term memory problems and was severely impaired in cognition for daily decision making. The MDS also indicated Resident #3 was totally dependent on staff for bed mobility, transfers and locomotion on and off the unit. A review of a facility document titled Occurrence Report completed by the Director of Nursing (DON) indicated on 05/19/18 at 5:00 PM an incident had occurred when Resident #3 was being transported in a wheelchair and her left foot was caught under the chair. A review of nurse's progress notes dated 05/19/18 revealed there was no documentation of notification to Resident #3's responsible party (RP) after Resident #3's left foot was caught under the wheelchair. A review of a facility document titled Investigation Summary dated 05/20/18 indicated on 05/19/18 at approximately 5:00 PM, NA #1 was transporting Resident #3 to the dining room in her wheelchair when Resident #3 suddenly dropped her foot while NA#1 was pushing the wheelchair and Resident #3's foot was caught under the chair. The document further indicated Resident #3 called out and NA #1 immediately stopped the chair and told Nurse #1 what had happened. The document revealed Nurse #1 assessed Resident #3's leg and did not observe swelling at that time and Resident #3 did not complain of pain when she attempted range of motion. The document also revealed Nurse #1 stated she had gotten busy during the shift and had forgotten to call Resident #3's representative (RP). The document indicated Resident #3's RP had stated she was not notified on 05/19/18 after the incident had occurred. The document further indicated the RP had stated she was not notified until x-rays were done on Resident #3's left leg because there was some swelling present and when she inquired about the swelling she was told Resident #3's foot had been caught under her wheelchair the day before on 05/19/18. A review of a nurse's progress note dated 05/20/18 at 6:27 PM revealed in part Nurse #1 had been notified that Resident #3's left leg got caught in a wheelchair while on her way to the main dining room. The notes further revealed on this date of 05/20/18 Resident #3's leg was swollen and she complained of pain when touched and the physician on call was notified and orders were received to obtain an x-ray of left tibia and fibula including the left ankle and foot. A review of an x-ray report dated 05/20/18 indicated acute fracture of distal left tibia-fibula but no other boney pathology. The report further indicated left ankle x-ray revealed an acute non-displaced distal tibia and fibula fracture. A review of a facility document titled Resident Grievance Form dated 05/21/18 indicated Resident #3's family was not called when Resident #3's foot was caught under her wheelchair. During an interview on 07/06/18 at 8:56 AM, Nurse #2 stated she worked at the facility on the 7:00 PM to 7:00 AM shift on 05/19/18. She explained Nurse #1, who was also the weekend nursing supervisor had been assigned to a medication cart during the 7:00 AM to 7:00 PM shift on 05/19/18. She further explained during shift report on 05/19/18 Nurse #1 asked her to check Resident #3's legs because she had some swelling but did not report that Resident #3 had caught her foot under her wheelchair. Nurse #2 stated she checked Resident #3's legs and saw slight swelling in her left leg above the ankle and monitored Resident #3 during the night but the swelling did not increase. She further stated at that time she did not know an event had occurred with Resident #3 because there were no nurse's progress notes regarding the incident. She explained when she came back to work on 05/20/18 at 7:00 PM she asked Nurse #1 during shift report what had happened with Resident #3 and she said when NA #1 was pushing her in a wheelchair to the dining room on 05/19/18 Resident #3 got her foot caught under the wheelchair. Nurse #2 stated she called Resident #3's RP after they received x-ray results and Resident #3's RP asked why no one had called her about the wheelchair incident. Nurse #2 explained when an incident happened it was her usual practice to notify the resident's RP after the incident occurred. During a phone interview on 07/06/18 at 9:37 AM, Nurse #1 stated she no longer worked at the facility but recalled the incident when Resident #3 got her foot caught under the wheelchair. She further stated she had gotten busy during her shift on 05/19/18 and had forgotten to call Resident #3's RP. During an interview on 07/06/18 at 10:49 AM the DON stated she recalled Nurse #2 had called her on Sunday night on 05/20/18 and reported Resident #3 had a fracture. She explained during an investigation Nurse #1 reported she had not called Resident #3's RP after the incident because she got busy and forgot to call her. She further stated it was her expectation for the resident's RP to be notified after an incident occurred. During an interview on 07/06/18 at 11:29 AM, the Staff Development Coordinator explained when an incident occured the nurse would be expected to notify the resident's RP and document it in the resident's medical record.

Based on record reviews and staff interviews the facility failed to document a nursing assessment after a resident's left foot was caught under a wheelchair which later revealed a non-displaced distal [MEDICAL CONDITION] and fibula for 1 of 4 sampled resident for supervision to prevent accidents (Resident #3). Findings included: Resident #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a care plan with onset date of 02/01/18 revealed Resident #3 had a [DIAGNOSES REDACTED]. The goals indicated in part staff would implement interventions to maintain a safe environment daily to reduce risk for injury and interventions were listed in part Resident #3 was non-verbal and staff were to identify non-verbal indicators of pain or discomfort. A review of an annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 had short term and long term memory problems and was severely impaired in cognition for daily decision making. The MDS also indicated Resident #3 was totally dependent on staff for bed mobility, transfers and locomotion on and off the unit. A review of a facility document titled Occurrence Report completed by the Director of Nursing (DON) indicated on 05/19/18 at 5:00 PM an incident had occurred when Resident #3 was being transported in a wheelchair and her left foot was caught under the chair. A review of nurse's progress notes dated 05/19/18 revealed there was no documentation of a nursing assessment of Resident #3 after her left foot was caught under the wheelchair A review of a facility document titled Investigation Summary dated 05/20/18 indicated on 05/19/18 at approximately 5:00 PM, NA #1 was transporting Resident #3 to the dining room in her wheelchair when Resident #3 suddenly dropped her foot while NA#1 was pushing the wheelchair and Resident #3's foot was caught under the chair. The document further indicated Resident #3 called out and NA #1 immediately stopped the chair and told Nurse #1 what had happened. The document revealed Nurse #1 assessed Resident #3's leg and did not observe swelling at that time and Resident #3 did not complain of pain when she attempted range of motion. The document also revealed Nurse #1 stated she had gotten busy during the shift and had forgotten to document the incident. A review of a nurse's progress note dated 05/20/18 at 6:27 PM revealed in part Nurse #1 had been notified that Resident #3's left leg got caught in a wheelchair while on her way to the main dining room. The notes further revealed on this date of 05/20/18 Resident #3's leg was swollen and she complained of pain when touched and the physician on call was notified and orders were received to obtain an x-ray of left tibia and fibula including the left ankle and foot. A review of an x-ray report dated 05/20/18 indicated an acute fracture of distal left tibia-fibula but no other boney pathology. The report further indicated left ankle x-ray revealed an acute non-displaced distal tibia and fibula fracture. During an interview on 07/06/18 at 8:56 AM, Nurse #2 stated she worked at the facility on 05/19/18 during the 7:00 PM to 7:00 AM shift. She explained Nurse #1, who was also the weekend nursing supervisor had been assigned to a medication cart during the 7:00 AM to 7:00 PM shift on 05/19/18. She further explained during shift report on 05/19/18 Nurse #1 asked her to check Resident #3's legs because she had some swelling but did not report that Resident #3 had caught her foot under her wheelchair. Nurse #2 stated she checked Resident #3's legs and saw slight swelling in her left leg above the ankle and monitored Resident #3 during the night but the swelling did not increase. She further stated she did not know an event had occurred with Resident #3 because there were no nurse's progress notes regarding the incident or assessment of Resident #3's left leg by Nurse #1. Nurse #2 explained when an incident happened it was her usual practice to document assessments in the nurse's progress notes. During a phone interview on 07/06/18 at 9:37 AM, Nurse #1 stated she no longer worked at the facility but recalled the incident when Resident #3 got her foot caught under the wheelchair. She further stated she had gotten busy during her shift on 05/19/18 and had forgotten to write a nurse's progress note of her assessment of Resident #3's left leg. During an interview on 07/06/18 at 10:49 AM the DON stated she recalled Nurse #2 had called her on Sunday night on 05/20/18 and reported Nurse #1 had reported NA#1 was transporting Resident #3 in a wheelchair but Resident #3 dropped her feet onto the floor and her left foot went under the wheelchair. She explained Nurse #1 did not document the incident at the time it occurred and did not document her assessment of Resident #3's leg because she stated she got busy and forgot to write it. She stated it was her expectation for nurses to document assessments of residents in the nurse's progress notes. During an interview on 07/06/18 at 11:29 AM, the Staff Development Coordinator explained when an incident occured the nurse would be expected to document assessments in a nurse's progress note.

Based on record review and staff interviews, the facility failed to submit a 24 hour and 5 day report to the state of North Carolina for an allegation that the facility received for 1 of 1 cases reviewed for misappropriation of property (Nurse #2). Findings included: On 4/11/18, the Administrator provided a file on complaints she had received against nurse #2. In the file provided revealed an allegation that was sent to the facility via email dated 2/7/18 that stated 2 employees had been taking medications from the facility for personal use. The first allegation came via email to the facility and stated .your employee nurse #2 takes [MEDICATION NAME] and other over the counter pills on a regular for her and herself and kids, and she named another employee . On 4/11/18, the Administrator provided a file on complaints she had received against nurse #2. The file provided by the facility on 4/11/18 revealed the facility had conducted and completed a thorough investigation of the allegation, which was completed on 2/9/18. The facility contacted the police department to report the incident, accounted for all the medications that were alleged to be taken, interviewed staff involved and the board of nursing was notified regarding the incident. The alleged staff members also underwent in-service training regarding medications diversion. The facility found the incident to be unsubstantiated. The administrator was interviewed on 4/1/18 at 2:23 PM. She stated that she did not report the incident to the state because she looking into the concern immediately and determined that it was domestic dispute between an employee and an ex- boyfriend. She stated based on the research that she did, she concluded it was a domestic connection. The administrator was interviewed on 4/13/18 at 4:59 PM. She stated that her report/investigation was completed correctly.

Based on record review and staff interviews the facility failed to complete the comprehensive admission minimum data set (MDS) assessment by the 14th day of admission for 1 of 22 sampled residents reviewed for MDS assessment (Resident #175.) Findings Included: Resident #175 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 4/2/18 was not completed until 4/11/18. An interview with the MDS Nurse on 4/12/18 at 4:00 pm revealed the 14 day comprehensive MDS for Resident #175 was not completed until 4/11/8. He stated the Social Worker (SW) who was responsible for sections, C, D, E and Q had not completed them until 4/11/18. The MDS Nurse added the care area assessments (CAA ' s) were also not completed until 4/11/18. He stated the 14 day comprehensive assessment was late and should have been completed by 4/8/18. An interview with the SW on 4/12/18 at 4:36 pm revealed she was responsible for completing sections C, D, E and Q of the 4/2/18 MDS for Resident #175. The SW stated she had not completed those sections of the MDS on time because she was new and had been very busy. An interview with the Administrator on 4/13/18 at 5:12 pm revealed it was her expectation that residents receive quality care and that included completion of the comprehensive admission MDS by the 14th day of admission.