Every finding on record at Aicota Health Care Center

Based on observation, interview, and document review the facility failed to ensure milk products were served to residents at safe temperatures for consumption. This deficient practice had the potential to affect 5 residents (R8, R11, R17, R20, R38) who were served milk at unsafe temperatures. In addition, the facility failed to ensure staff preparing food had proper hair restraints in place. This deficient practice had the potential to affect any person consuming food prepared by the facility.R8's admission Record dated 1/9/26, identified an admission date of 10/30/25 and diagnoses of malignant neoplasm of part of the left bronchus or lung, and chronic kidney disease.R11's admission Record dated 1/9/26, identified an admission date of 3/21/22 and diagnoses of chronic atrial fibrillation, vascular dementia, hypertension and diabetes.R17's admission Record dated 1/9/26, identified an admission date of 5/5/25 and diagnoses of hypertensive heart disease, and rheumatoid arthritis.R20's admission Record dated 1/9/26, identified an admission date of 12/18/25 and diagnoses of chronic obstructive pulmonary disease (COPD), and anemia.R38's admission Record dated 1/9/26, identified an admission date of 4/18/23 and diagnoses of late onset Alzheimer's disease, atrial fibrillation and chronic kidney disease.During an observation and interview on 1/7/26 at 8:49 a.m., dietary aid (DA)-A was standing at a serving table in the dining room with breakfast items including a partially full gallon of milk and a quart of half and half which were not on ice. There were five residents still eating, and two unidentified nursing assistants (NA)s. At 9:04 a.m., one NA poured a glass of milk from the jug sitting on the table as DA-A was standing by watching. The NA didn't serve the glass of milk, and DA-A got a thermometer and checked the temperature of the milk at 42 degrees Fahrenheit (F). DA-A then poured what was left in the half and half container into a glass and checked the temperature at 64 degrees F. DA-A stated the milk and half and half should be at 41 degrees F or lower and the risk to someone drinking this would be food poisoning or something. DA-A stated his normal practice would be to put the milk and creamer in the fridge, which was right by the serving table, between uses.During an observation on 1/7/26 at 11:18 a.m., cook (CK)-A had placed the hot food in the steam table, then proceeded to dish up plates. CK-A was not wearing a hair net. At 11:23 a.m., there was noted to be a half-full, clear gallon container of milk on the serving table and not on ice. At 11:34 a.m., the milk was still on serving table. At 11:45 a.m., culinary supervisor (CS)-E was behind the steamtable dishing up plates. CS-E has a full beard of about one inch in length and was not wearing a beard net. The milk was still on the serving table with unidentified staff pouring beverages. An unidentified dietary aid (DA) made chocolate milk with the milk from the gallon jug on the serving table and brought it to R20. At 11:53 a.m., CS-E poured milk from the jug on the serving table into a glass and used a thermometer to get a temperature of 55 degrees F. CS-E stated it was too warm so it should be thrown out, he stated the risk to residents would be listeria. CS-E got the help of other staff to collect the glasses of milk served from this gallon to R8, R11, R17, R20, and R38.During an interview on 1/7/26 at 12:06 p.m., CD-B stated he would expect the milk to be on ice or only pulled out briefly for use. CD-B stated Listeria would be the risk of serving milk out of safe temperatures. CD-B observed CK-A behind the steam table working with food without a hair net and stated he would expect CK-A to have a hair net on then went and grabbed her one.During an interview on 1/7/26 at 12:20 p.m., CS-E stated he thought he would need a beard net if the beard was an inch or longer, which he stated he thought his was close to and he would wear a beard net if it was needed.During an interview on 1/8/26 at 10:18 a.m., the administrator stated her expectation would be that they follow regulation and have protective gear on which included hair and beard nets. The administrator also stated she would expect milk products to be served in range for safe consumption.During an interview on 1/9/26 at 10:52 a.m., CD-B stated he would expect a beard net to be worn if the beard was one-eight inch or longer.

Based on interview and document review, the facility failed to accurately submit the payroll-based journal system (PB&J) staffing data to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 53 residents residing in the facility.Findings include:The facility's PB&J data submitted to CMS for 7/1/25, through 9/30/25, identified the facility was triggered for no registered nurse hours on the following days: 7/1/25, 7/2/25, 7/8/25, 7/9/25, 7/14/25, 7/15/25, 7/16/25, 7/23/25, 7/24/25, 7/26/25, 7/27/25, 8/10/25, 8/14/25, 8/21/25, 8/22/25, 8/23/25, 8/25/25, 8/28/25, 9/1/25, 9/4/25, 9/5/25, 9/6/25, 9/7/25, 9/8/25, 9/11/25, 9/12/25, 9/15/25, 9/19/25, 9/25/25, 9/26/25, 9/27/25, 9/28/25, 9/30/25.In addition, the facility's PB&J data submitted to CMS for 7/1/25, through 9/30/25, identified the facility was triggered for failure to have licensed nursing coverage 24-hours a day on the following days: 7/1/25, 7/2/25, 7/3/25, 7/8/25, 7/9/25, 7/10/25, 7/11/25, 7/12/25, 7/13/25, 7/15/25, 7/16/25, 7/17/25, 7/24/25, 7/26/25, 7/27/25, 7/28/25, 7/29/25, 7/30/25, 7/31/25, 8/3/25, 8/6/25, 8/9/25, 8/10/25, 8/13/25, 8/16/25, 8/23/25, 8/28/25, 9/4/25, 9/5/25, 9/6/25, 9/7/25, 9/9/25, 9/10/25, 9/11/25, 9/17/25, 9/18/25, 9/19/25, 9/20/25, 9/21/25, 9/23/25, 9/24/25, 9/25/25.The facility was able to provide payroll documentation identifying there was a registered nurse on the above listed days and licensed nursing coverage 24-hours a day on the above listed days.During an interview on 1/9/26 at 11:23 a.m., the director of nursing (DON) stated they were not able to get into the program, they finally received a username, but when they submitted the file, it was formatted incorrectly. The DON stated they worked on trying to submit data up until the deadline but missed the deadline because of the time difference (the program was based on the Eastern time zone).Compliance with CMS Payroll Based Journal Reporting dated 7/1/19, identified the facility would comply with the CMS PBJ policy by reporting to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data. The quarters were listed as well as the dates the information was due.

Based on interview and document review, the facility failed to ensure agency nursing staff received appropriate orientation, training and supervision. This had the potential to affect all 53 residents who resided in the facility. Findings include:A review of agency orientation paper work identified the following sections: HR (human resources) and HR paper work, orientation tour, safety, other (care plans in closet, bath schedule, point click care log in and documentation, dining room cards, walking expectations, linen rooms/hopper, barrel empty, lift training total lift, daily routines, lift training sit to stand), changes in physical and mental condition changes, breaks, daily routines am (day), daily routines pm (evening), daily routines noc (night). The orientation paperwork included employee name, date task completed, and completed by initials. A spot for agency staff printed name, signature and date, and orientation leader signature.A review of agency staff members orientation paperwork identified the following:Anonymous staff member (ASM)-P, nothing filled out except agency staff signature and date.ASM- N, nothing filled out except agency staff printed name, signature and date.ASM-M, completed by column completed thru XXXX, printed name, signature and no date.ASM-I, date task completed line drawn through, completed by no initials but line drawn through no dates. Printed name, signature and date.ASM-K, completed by initials of agency staff, printed name, signature and date.ASM-G, completed by initials of agency staff, printed name, signature and date.ASM-O, date task completed line drawn through, completed by no initials but line drawn through no dates. Printed name, signature and date.ASM-J, date task completed line drawn through, completed by no initials but line drawn through no dates. Printed name, signature and date.ASM-Q, date task completed filled out with line drawn through, completed by initials of agency staff member. Printed name, signature and date.ASM-H, date task completed had agency staff member initials, nothing in completed by column. Printed name, signature and date.ASM-C, date task completed date filled in, completed by agency staff initials. Printed name, signature and date.ASM-L, completed by agency staff initials. Printed name, signature and date.Did not receive orientation paperwork for five staff hired between October and December of 2025. None of the orientation paperwork had the signature of the orientation leader.During an interview during the course of the survey 1/5/26-1/9/26, anonymous staff member (ASM)-C stated there was no training or orientation to the facility. Just given an assignment and told to go. ASM-C feared there would be retaliation for talking with surveyors.During an interview during the course of the survey ASM-F stated agency staff had no training when they started at the facility but were currently being told they must sign and back date their orientation sheets. ASM-F stated agency staff were told if they did not do this, they would have their contracts cancelled.During an interview during the course of the survey 1/5/26-1/9/26, ASM-G stated they did not receive an orientation to the facility. ASM-G stated they were concerned about retaliation from the facility by being interviewed. ASM-G stated they were made to sign orientation papers with a fake dated. ASM-G stated other agency staff were asked to do the same.During an interview during the course of the survey 1/5/26-1/9/26, ASM-J stated they signed their orientation paperwork on 1/7/26, they were told they couldn't find the original paperwork.During an interview during the course of the survey 1/5/26-1/9/26, ASM-N reviewed their orientation paperwork and verified it had not been filled out, only signed. During an interview during the course of the survey 1/5/26-1/9/26, ASM-P reviewed their orientation paperwork and verified it had not been filled out, only signed. During an interview on 1/9/26 at 10:37 a.m., scheduling coordinator (SC)-R stated she was in charge of orientation for agency staff. SC-R stated when agency staff started on an off shift or a weekend, she would leave a note for a staff person to sign the agency orientation paperwork. SC-R stated agency staff were expected to be competent and ready to start work. SC-R stated for Grapetree staff they were supposed to receive an hour of orientation and for Shift key no orientation they would receive a tour of the building. SC-R stated human resources had no involvement at the facility, she was in charge of ensuring the check list was completed. SC-R was not sure who the orientation leader was for signature on the paperwork. SC-R expected the columns to be completed and signed off. SC-R stated she was unable to find all of the agency staff paperwork.During an interview on 1/9/26 at 9:08 a.m., registered nurse (RN)-A stated they had no official role in the process. RN-A stated they expected agency staff to come prepared to take care of residents.During an interview on 1/9/26 at 11:09 a.m., the director of nursing (DON) stated agency staff were expected to complete the paperwork. The DON stated ideally, she would expect the paperwork to be completed. The DON identified the orientation leader as a nursing assistant, a nurse, or SC-R. The DON verified she was ultimately responsible for agency staff orientation.A policy on agency staff orientation was requested but not provided.

Based on observation, interview, and document review the facility failed to facilitate resident preferences for meals for 1 of 1 resident (R27) reviewed for choices.Findings include:R27'S annual Minimum Data Set (MDS) dated [DATE], identified R27 had diagnoses which included atrial fibrillation (an irregular and often very rapid heart rhythm), heart failure (when the heart muscle doesn't pump blood as well as it should), gastroesophageal disease (when stomach acid flows back up into the esophagus and causes heartburn), depression, and chronic obstructive pulmonary disease (lung and airway diseases that restrict breathing). In addition, R27's MDS identified R27 was cognitively intact and was able to understand and be understood. R27's care plan was requested but not provided. R27's care plan, unable to provide a date, identified nutrition as care plan concern. Staff were directed to provide her diet as ordered, her dislikes were listed, staff were to encourage R27 to make food choices at all meals and to provide snacks and supplements.R27's nursing assistant Kardex dated 8/28/25, had a section titled Eating, the information provided was R27 was independent for eating. It did not include likes or dislikes.R27's meal ticket identified texture was regular and regular house diet. The section Dislikes was blank.The kitchen's Meal Distribution Report, no date, listed the resident's name, whether they ate in their room, allergies, texture/special diets, dislikes, notes, standing orders. Information in the book identified R27 ate in her room, had a regular diet and regular texture. The section for dislikes was left blank.During an observation on 1/7/26 at 11:31 a.m., the menu was posted outside of the dining room. For week three, lunch was listed as a hot turkey sandwich on white, garlic mashed potatoes, brussel sprouts and pineapple angel cake. Dinner was listed. No alternatives were listed.During an observation on 1/7/26 at 11:48 a.m., a staff entered R27's room with her lunch tray.During an observation on 1/7/26 at 11:51 a.m., R27 verified her meal ticket was titled breakfast and had no dislikes listed. R27 verified she received brussel sprouts and didn't like them, she also stated she did not have an opportunity to order her lunch (she wasn't told what was for lunch and/or offered the alternative). There was not a ticket on the tray for the evening meal.During an interview on 1/5/26 at 4:38 p.m., R37 stated she didn't get to make choices about the food she was served, she said it would just arrive. R37 stated she would periodically receive a questionnaire about food, and she would tell them she didn't like vegetables like broccoli and cauliflower but would still get them.During an interview on 1/7/26 at 12:39 p.m., cook (C)-A stated there was an always available menu and the kitchen needed to know by 10:00 a.m., to get the alternative. C-A stated the menu was posted in the hallway by the dining room. C-A stated residents needed to tell the nursing staff about preferences and dislikes, she said they did not go out and meet the residents. C-A brought out the book (meal distribution) she verified there were not dislikes noted for R27 in the book.During an interview on 1/7/26 at 1:00 p.m., nursing assistant (NA)-A stated the care plan for a resident would be found in the closet. NA-A provided the care plan for R27, there was nothing to identify likes or dislikes on the care plan. NA-A stated the process was to go around and ask residents if they wanted what was on the menu or the alternative. NA-A verified the menu was posted outside of the dining room and a resident would need to go and look at it to know what would be served for lunch and dinner. After looking about the room, NA-A was able to find the laminated always offered menu. NA-A verified she had not had time to ask R27 if she wanted what was on the menu for lunch or the alternative.During an interview on 1/7/26 at 1:17 p.m., the director of nursing (DON) stated the unit nurse manager would be the person to ensure the care plan was updated and current and that the likes and dislikes were noted. The DON verified it would be important to know a resident's food preferences to provide individualized care. The DON also verified the residents were not provided with a copy of the menu daily, weekly, or monthly. The DON stated they would need to go and look at the posted menu outside of the dining room.During an interview on 1/8/26 at 10:47 a.m., anonymous staff member (ASM)-D stated they needed to collect lunch tickets, when asked if they needed to be collected by 10:00 a.m., ASM-D stated that was correct, but it has been too busy to collect them timely. During an interview on 1/8/26 at 2:55 p.m., registered nurse (RN)-A verified resident autonomy was important. RN-A verified the menu was posted in the hallway by the dining room and not delivered to residents. RN-A stated it was the expectation that the staff would tell residents what was for lunch and dinner and ask if they wanted an alternative meal. RN-A stated they were not sure how the kitchen was notified of preferences and dislikes.During an interview on 1/9/26 at 10:18 a.m., the culinary director (CD)-B verified the menu was posted outside the dining room. CD-B stated the nursing staff were supposed to be asking residents what they wanted for lunch and dinner. CD-B stated the kitchen needed the meal tickets around 11:30 a.m., to receive the alternative. CD-B stated they would get the preferences and the dislikes from nursing staff. CD-B reviewed the meal distribution book and verified R27 did not have anything listed for dislikes. CD-B verified it was important for residents to receive what they wanted for meals as their needs should come first.During an interview on 1/9/25 at 10:59 a.m., the DON verified resident should have choices about everything from getting up to going to bed, what they eat and how often they want to eat.The Combined Federal and State [NAME] of Rights dated 12/22/25, identified the resident had the right to be informed of, and participate in, his or her treatment.The policy Resident Rights dated 10/15/24, identified Residents shall have the right to appropriate medical and personal care based on individual needs. Appropriate care for residents means care designed to enable residents to achieve their highest level of physical and mental functioning.

Based on interview and document review, the facility failed to develop a person-centered care plan to include necessary post-treatment assessments and documentation needs for 1 of 2 residents (R42) reviewed for care planning. R42's admission minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of acute and chronic respiratory failure with hypoxia, kidney transplant rejection, end-stage-renal-disease (ESRD), and dependence on renal dialysis. R42's care plan dated 1/6/26, identified a focus statement for a high risk of complications related to on-going dialysis treatments. Interventions didn't include instructions to assess R42 upon return from a dialysis treatment for his overall condition and status, vital signs, presence of thrill or bruit in fistula, or status of dressings on the fistula. R42's provider orders dated 12/23/25, identified an order to check AVS fistula every shift, every day, and an order for dialysis treatments on Mondays, Wednesdays, and Fridays and R42 was to be ready at 7 a.m. R42 also had an order for weight to be taken on bath day. R42's electronic medical record (EMR) lacked documentation of R42's return from and assessment after returning from dialysis treatments. During an interview on 1/8/26 at 1:11 p.m., registered nurse (RN)-A, who identified as being a nurse manager for R42, stated she would want the care plan to include post-dialysis assessments because it could help with early intervention for potential blood pressure issues. RN-A confirmed the current care plan didn't include this.

Based on interview and document review, the facility failed to follow bowel protocols for 1 of 3 residents (R3) reviewed for quality of care.R3's significant change in status assessment (SCSA) minimum data set (MDS), dated [DATE], identified severely impaired cognition and diagnoses of Alzheimer's dementia, anxiety disorder, major depressive disorder, uterovaginal prolapse and constipation. R3's MDS also indicated moderate assistance needed for bed mobility, transfers, and toilet hygiene. The MDS also identified R3 was occasionally incontinent of bowel and bladder and was on a toileting program, R3 needed moderate assist for transferring and toilet hygiene. R3's care plan, dated 8/18/21, identified R3 was incontinent of bowel and bladder and needed an assist of one to bring her to the toilet and provide incontinent care as needed. The care plan didn't address constipation. R3's provider orders, dated 11/17/24, for bowel movement (BM) protocol: -Give four ounces (oz) of prune juice after five shifts of no BM as needed (PRN) for constipation.-Senna 8.6 milligrams (mg) PRN for constipation, if no BM after 24 hours give senna and prune juice together (if milk of magnesia contraindicated).-Milk of magnesia (MOM) give 30 milliliters (mL) PRN for constipation mix with four ounces of prune juice. Give after 24 hours of no results of plain prune juice.-Dulcolax rectal suppository, give one suppository rectally PRN for constipation.-Fleet enema rectally as needed for constipation if no BM 24 hours after Dulcolax suppository.-1/9/24, give MiraLAX 17 grams every other day. R3's electronic medical record (EMR) identified the following: -a bowel report, dated 1/3 to 1/9/26, with no bowel movement documented from 1/4 through 1/7/26.-progress notes for the dates of 1/4 to 1/7/26 do not have notes regarding bowels.-medication administration record (MAR) for January 2026 didn't identify an as needed (PRN) bowel medication given until after the interview below with RN-B and was given on 1/7/26 at 3:38 p.m., when Senna was given and recorded as ineffective. And on 1/8/26 at 1:49 p.m., MOM 30 mL was given and recorded as effective. An untitled facility-submitted worksheet, dated 1/5/26, had a list of residents including R3. Next to R3 was a hand-written time of 9:52 a.m. and the letter m circled. During an interview on 1/7/26 at 2:30 p.m., nursing assistant (NA)-B stated she would be responsible for documenting BMs. She will also let the nurses know if they haven't had one for a while.During an interview on 1/7/26 at 2:53 p.m., registered nurse (RN)-B stated they ran a bowel report every day on the afternoon shift, and that shift would then give the PRN medication. RN-B checked R3's EMR and stated there wasn't a BM documented since 1/3/25. RN-B stated she usually started with giving R3 Senna, or any of them if that one had already been used.During an interview on 1/8/26 at 9:19 a.m., RN-C stated BMs were documented by the nursing assistants. On afternoon shift they look for when the last BM was, if it was so many shifts then they use a PRN. Can try whatever they have under the orders. During an interview on 1/8/26 at 11:08 a.m., the director of nursing (DON) stated alerts would show up in the EMR if a resident hadn't had a BM in more than 48 or 72 hours. The PM shift runs a bowel report every day. The DON stated she would expect an assessment be completed if the resident had gone without for a few days. They follow MAGIC standing orders. The risk could be an obstruction, and before that them just being ill. An undated document, Aicota Bowel Protocol, identified bowel lists should be run on the PM shift and provided directions for how to run this list. An example bowel report is provided, with five consecutive shifts of no BM documented and highlighted with a line drawn after the fifth shift indicating when an intervention would be started.

Based on observation, interview and document review the facility failed to ensure a resident was toileted timely to prevent an incontinence accident for 1 of 1 resident (R27) reviewed for bowel and bladder.Findings include:R27'S annual Minimum Data Set (MDS) dated [DATE], identified R27 had diagnoses which included atrial fibrillation (an irregular and often very rapid heart rhythm), heart failure (when the heart muscle doesn't pump blood as well as it should), gastroesophageal disease (when stomach acid flows back up into the esophagus and causes heartburn), depression, and chronic obstructive pulmonary disease (lung and airway diseases that restrict breathing). In addition, R27's MDS identified R27 was cognitively intact and was able to understand and be understood. R27's MDS identified she was frequently incontinent of bladder and occasionally incontinent of bowel. In addition, R27's MDS identified she was dependent on staff for toileting hygiene.R27's care plan, undated, identified R27 was continent of bladder with episodes of incontinence and required an assist of two for toilet use.R27's nursing assistant Kardex dated 8/28/25, had a section titled Toileting, the information provided included Resident is continent with episodes of incontinence. The information also identified R27 was an assist of two for transfers/adjust clothing/change incontinent product. R27's Kardex identified R27 was a two-assist with Hoyer lift and medium sling transfer.During an observation and interview on 1/5/26 at 4:36 p.m., R27 stated she was currently wet, she stated she had told a male staff member, and he said he would get help. R27 stated she would often sit wet several times a day. R27 stated staff did not come in every few hours and offer to take her to the bathroom. R27 stated it could take up to 30 minutes to get her call light answered and it had been on since 4:30 p.m., R27 turned her call light back on during the interview.On 1/5/26 at 4:53 p.m., a male staff member answered her call light. R27 asked him to get the girls because she was wet and still waiting for help.On 1/5/26 at 4:57 p.m., two unidentified female staff entered R27's room to assist her to the commode. One of the staff remarked it was often difficult to find two female staff for assistance with toileting.On 1/6/26 at 1:53 p.m., R27 was brought back to her room by an unidentified staff, she had been in the activity. The staff member was heard to say, I'll be right back.On 1/6/25 at 2:16 p.m., staff entered R27's room and asked her what she needed, at that time a second staff entered the room with the mechanical lift.On 1/8/26 at 12:54 p.m., R27 stated she had just been gotten up for the day. She stated they were late getting her up and that she preferred to be up between 10:00 a.m. and 10:30 a.m.During an interview during the course of the survey between 1/5/26-1/9/26, an anonymous staff member (ASM)-C stated they took care of about 27 residents with a partner, sometimes the partner was a nurse. ASM-C stated they were able to complete tasks, just not always timely.During an interview during the course of the survey between 1/5/26-1/9/25, ASM-G stated they were concerned about retaliation from the facility by being interviewed. ASM-G stated they took care of 25-27 residents alone. ASM-G stated they were unable to perform tasks timely (toileting, getting residents up timely [sometimes after 10:30 a.m.]).During an interview on 1/9/26 at 10:59 a.m., the director of nursing (DON) stated she would expect a resident who was identified as wet should receive toileting assistance in about 10 minutes. The DON identified the concerns as dignity and skin breakdown and irritation. The DON identified two nursing assistants for 27 residents would be bare staffing and it would be better to have three.The policy Call light dated 11/12/12, identified the expectation was to respond promptly to resident's calls for assistance.The policy Resident Rights dated 10/15/24, identified Residents shall have the right to appropriate medical and personal care based on individual needs. Appropriate care for residents means care designed to enable residents to achieve their highest level of physical and mental functioning.

Based on interview and document review, the facility failed to perform vital sign monitoring, assessment, and documentation of resident's condition and fistula status (also called a shunt, a connection made between a vein and an artery for the necessary blood flow to facilitate a machine to remove the excess waste and water from the person's blood which the kidneys are not able to) after returning from a renal dialysis treatment at an offsite dialysis facility for 1 of 1 (R42) resident reviewed for dialysis care. R42's admission minimum data set (MDS), dated [DATE], identified intact cognition and diagnoses of acute and chronic respiratory failure with hypoxia, kidney transplant rejection, end-stage-renal-disease (ESRD), and dependence on renal dialysis. R42's care plan, dated 1/6/26, identified a problem statement for a high risk of complications related to on-going dialysis with a goal for R42 to attend dialysis appointments as scheduled. Interventions included avoiding lotion on dialysis site, check for bruit and thrill every shift and to notify provider and dialysis of any concerns, to coordinate services with dialysis center, and for a dialysis binder to go to/from appointments for coordination of care. R42's provider orders, dated 12/23/25, identified an order to check AVS fistula every shift, every day, and an order for dialysis treatments on Mondays, Wednesdays, and Fridays and R42 was to be ready at 7 a.m. R42 also had an order for weight to be taken on bath day. R42's electronic medical record (EMR), for the dialysis treatment dates of 1/5 and 1/7/26, didn't identify vital sign values, progress note, or assessment for R42's return from a dialysis treatment. During an interview on 1/5/26 at 6:16 p.m., R42 stated the facility didn't do anything for him after dialysis. R42 explained the dialysis center took his vital signs and bandaged his fistula prior to him leaving the center, and he brought that binder back to the facility. At this time, R42's fistula is covered with gauze dressings and tape, he stated he had dialysis this morning and will take it off tomorrow. During an interview on 1/7/26 at 3:03 p.m., licensed practical nurse (LPN)-A stated they made sure to provide R42 with a meal and ask how it went. LPN-A demonstrated the dialysis communication book they used to communicate with the dialysis center. Prior to dialysis they took R42's weight and vitals and checked for a thrill on the fistula, and when R42 came back they checked the book to see how it went for him and the vitals dialysis recorded before he left there. During an interview on 1/8/26 at 9:54 a.m., LPN-B stated for R42 there wasn't a whole lot to do unless he was feeling dizzy or something. They have a communication book that goes back and forth with dialysis. LPN-B added R42 was cognitively intact and would tell them if something was wrong. During an interview on 1/8/26 at 11:00 a.m., the director of nursing (DON) stated vitals and site check were done on return, the dialysis center did the pre- and post-weight and share information with a binder that went back and forth with R42. The DON stated her expectation would be for these things to be charted. The DON also stated the risks for a person after dialysis could be bleeding or blood pressure issues. The DON stated the nurses got some dialysis education upon hire but thought they should be reeducating when they got a new dialysis resident as they didn't take dialysis residents very often. During an interview on 1/8/26 at 1:11 p.m., registered nurse (RN)-A and nurse manager for R42 stated she would want the care plan to include the post-dialysis assessments, which it didn't right now. A dialysis policy was requested on 1/8/26 at 10:04 a.m. but was not received.

Based on record review and interviews, the facility failed to ensure the information on the daily nurse staffing was in a format that was clear to residents and visitors. This had the potential to affect all 53 residents who resided in the facility and their families and visitors. Findings include: On 1/8/26, the Daily Staffing Posting was reviewed. The posting included the following: Date, facility name, census. Shift category identified registered nurse (RN), nursing assistant (NAR), licensed practical nurse (LPN), and nursing assistant in training (NAIT). The first column was titled Shift Category second column titled Shift Time was listed as follows: RN - Skilled 2:00 PM-10:30 PMNAR 6:00 AM-6:30 PMNAR 10:00 PM-6:30 AMNAR 6:00 AM-2:30 PMLPN - Skilled 6:00 AM-2:30 PMNAR 2:00 PM-10:30 PMLPN - Skilled 10:00 PM-6:30 AMLPN - Skilled 6:00 PM-6:30 AMNAR 6:00PM-6:30 AMNAR 11:30 PM-8:00 AMRN - Skilled 6:00 AM-2:30 PMNAIT 6:00 AM-2:30 PMLPN - Skilled 6:00 AM-6:30 PM The totals for each skill category were not totaled per shift but rather for the 24-hour period. Residents, visitors and families were not able to see who was working by shift. The nursing assistants in training were included in the totals for staff working. During an interview on 1/8/26 at 11:01 a.m., visitor (V)-S and R49 reviewed the staff posting, V-S read it to R49 and they discussed it. V-S said they didn't understand what NAR or NAIT meant, they thought maybe a nurse assistant. V-S stated they could see there were different shifts all mixed together but said would not be able to tell how many or what staff were working on each shift without getting another piece of paper to figure it out. During an interview on 1/9/26 at 11:23 a.m., the director of nursing (DON) stated the posting for nursing staff had all of the required elements. A policy on staffing was requested but not provided.

Based on interview and document review, the facility failed to timely submit staffing data for 2 of 4 quarters reviewed (quarter 1 and 2) to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. The provider had implemented corrective action prior to the investigation, therefore, the deficiency was issued as past non-compliance. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D for fiscal year 2024 quarter 1 (October 1- December 31) and fiscal year 2024 quarter 2 (January 1- March 31), identified no data had been submitted. During interview on 1/17/25 at 4:35 p.m., director of nursing (DON) stated it was their responsibility to send staffing data to CMS. DON further stated not being aware of submission failure until after an internal audit revealed the problem. DON identified an incorrect data file had been used for the submission of staffing data. DON reported the problem was addressed already and the correct file type was now used for submitting staffing data to CMS. The expectation was for staffing data to be submitted correctly each quarter before the deadline. It was important to ensure staffing data was submitted before the deadline because it could interfere with the facility's overall star rating and impact the accuracy staffing information being presented to CMS.

Based on interview and document review the facility failed to ensure submitted Minimum Data Set (MDS) assessments were accurate and/or comprehensive for 35 out of 54 residents (R2, R3, R4, R5, R6, R7, R9, R11, R13, R14, R17, R20, R21, R24, R25, R26, R28, R29, R31, R32, R33, R34, R35, R36, R38, R39, R42, R43, R44, R47, R48, R49, R50, R152. R204) reviewed for MDS accuracy. Findings include: The following resident's MDS assessments indicated restraints were being utilized in MDS section P- Restraints: -R3's admission MDS assessment dated [DATE], Section P indicated restraint use. -R5's admission MDS assessment dated [DATE], Section P indicated restraint use. -R6's annual MDS assessment dated [DATE], Section P indicated restraint use. -R7's quarterly MDS assessment dated [DATE], Section P indicated restraint use. -R9's significant change MDS assessment dated [DATE], Section P indicated restraint use. -R11's annual MDS assessment dated [DATE], Section P indicated restraint use. -R13's significant change MDS assessment dated [DATE], Section P indicated restraint use. -R14's significant change MDS assessment dated [DATE], Section P indicated restraint use. -R17's quarterly MDS assessment dated [DATE], Section P indicated restraint use. -R20's admission MDS assessment dated [DATE], Section P indicated restraint use. -R21's quarterly MDS assessment dated [DATE], Section P indicated restraint use. -R24's quarterly MDS assessment dated [DATE], Section P indicated restraint use. -R25's annual MDS assessment dated [DATE], Section P indicated restraint use. -R26's admission MDS assessment dated [DATE], Section P indicated restraint use. -R28's quarterly MDS assessment dated [DATE], Section P indicated restraint use. -R29's quarterly MDS assessment dated [DATE], Section P indicated restraint use. -R31's quarterly MDS assessment dated [DATE], Section P indicated restraint use. -R32's quarterly MDS assessment dated [DATE], Section P indicated restraint use. -R33's annual MDS assessment dated [DATE], Section P indicated restraint use. -R34's quarterly MDS assessment dated [DATE], Section P indicated restraint use. -R36's significant change MDS assessment dated [DATE], Section P indicated restraint use. -R38's annual MDS assessment dated [DATE], Section P indicated restraint use. -R39's annual MDS assessment dated [DATE], Section P indicated restraint use. -R42's admission MDS assessment dated [DATE], Section P indicated restraint use. -R43's quarterly MDS assessment dated [DATE], Section P indicated restraint use. -R44's quarterly MDS assessment dated [DATE], Section P indicated restraint use. -R47's admission MDS assessment dated [DATE], Section P indicated restraint use. -R48's admission MDS assessment dated [DATE], Section P indicated restraint use. -R49's admission MDS assessment dated [DATE], Section P indicated restraint use. -R50's admission MDS assessment dated [DATE], Section P indicated restraint use. -R204's admission MDS assessment dated [DATE], Section P indicated restraint use. The following resident's MDS assessments lacked BIMS scores in section C - Cognition: -R4's quarterly MDS assessment dated [DATE], did not include a BIMS score. -R8's quarterly MDS assessment dated [DATE], did not include a BIMS score. -R13's significant change MDS assessment dated [DATE], did not include a BIMS score. -R14's significant change MDS assessment dated [DATE], did not include a BIMS score. -R24's quarterly MDS assessment dated [DATE], did not include a BIMS score. -R33's annual MDS assessment dated [DATE], did not include a BIMS score. -R34's quarterly MDS assessment dated [DATE], did not include a BIMS score. -R35's quarterly MDS assessment dated [DATE], did not include a BIMS score. -R36's significant change MDS assessment dated [DATE], did not include a BIMS score. -R38's annual MDS assessment dated [DATE], did not include a BIMS score. -R43's quarterly MDS assessment dated [DATE], did not include a BIMS score. -R152's admission MDS assessment dated [DATE], did not include a BIMS score. -R204's admission MDS assessment dated [DATE], did not include a BIMS score. On 1/17/25, the MDS coordinator was not available for interview. During an interview on 1/17/25 at 12:46 p.m., the director of nursing (DON) stated the facility was a restraint free facility and indicated restraints were not being utilized with any of their residents. There should not be any residents with a current MDS assessment coded with restraint use. The Cogntive section should be completed everytime a MDS assessment is due. All resident's should have a BIMS score each time their MDS data is due and submitted.

Based on interview and document review, the facility failed to consistently provide a surety bond (a written agreement to guarantee payment of another company's obligation under a separate contract) to protect the account balance of the resident trust fund. This had the potential to affect 26 of 26 residents at the facility who have a trust account. Findings include: Review of the facility Trust-Current Account Balance report dated 1/17/25, identified 26 current resident trust accounts were managed by the facility. The sum of all 26 resident trust accounts on 1/17/25 totaled $3,142.09. During interview on 1/16/25 at 3:03 p.m., revenue cycle manager (RCM) confirmed having partial responsibility for managing the resident trust fund account and was unaware of a surety bond. During interview on 1/17/24 at 12:40., business office manager (BOM) confirmed having the primary responsibility of managing the resident trust fund account. BOM was unsure of the amount of the surety bond or how to locate the surety bond. BOM stated the administrator would provide the surety bond shortly. A Merchants Bonding Company Resident Trust Fund Surety Bond notarized on 1/17/25 and effective from 1/1/25 to 1/1/26 was provided on 1/17/25. A request for the surety bond effective prior to 1/1/25 was requested but not received. A policy Trust Fund dated 5/10/24, identified a primary purpose was to comply with applicable regulatory agency rules. The policy did not address surety bonds.

Based on interview and record review the facility failed to ensure provider required regulatory visits occurred face to face for 33 out of 54 residents (R1, R3, R4, R6, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R21, R23, R24, R25, R27, R28, R30, R31, R32, R33, R34, R35, R39, R43, R44, R45, R49) reviewed for regulatory visit compliance. Findings include: On 1/21/25, the facility provided documentation which identified the following residents as having received regulatory visits via telemedicine [a visit conducted via audio and sound by a provider located in a different location] instead of required in person visits on the following dates: R1's quarterly MDS assessment dated [DATE], indicated R1 was cognitively intact with diagnoses of coronary artery disease, and heart failure. R1 had regulatory visits via telehealth on 8/2/24, and 12/22/24. R3's admission MDS assessment dated [DATE], indicated R3 was cognitively intact with diagnoses of wedge compression fracture of fourth lumbar vertebra and atrial fibrillation. R3 had a regulatory visit via telehealth on 12/18/24. R4's quarterly MDS assessment dated [DATE], indicated R4 did not have a cognitive assessment completed. R4's diagnoses included atrial fibrillation, coronary artery disease, hypertension, and renal insufficiency. R4 had regulatory visits via telehealth on 8/2/24 and 12/18/24. R6's annual MDS assessment dated [DATE], indicated R6 had moderate cognitive impairment with diagnoses of post-traumatic osteoarthritis, right ankle and foot and heart failure. R6 had regulatory visits via telehealth on 8/2/24, and 12/18/24. R7's quarterly MDS assessment dated [DATE], indicated R7 had moderate cognitive impairment with the diagnoses of atrial fibrillation, hypertension, and depression. R7 had regulatory visits via telehealth on 11/22/24, and 12/18/24. R9's significant change MDS assessment dated [DATE], indicated R9 had mild cognitive impairment with diagnoses of left femur fracture and hypertension. R9 had a regulatory visit via telehealth on 12/18/24. R10's quarterly MDS assessment dated [DATE], indicated R10 had moderate cognitive impairment with diagnoses of hypertension, CVA, aphasia, and dementia. R10 had regulatory visits via telehealth on 8/2/24, and 12/18/24. R11's annual MDS assessment dated [DATE], indicated R11 had moderate cognitive impairment with diagnoses of stroke, cancer, and hypertension. R11 had a regulatory visit via telehealth on 12/18/24. R12's quarterly MDS assessment dated [DATE], indicated R12 had severe cognitive impairment with diagnoses of atrial fibrillation and hypertension. R12 had a regulatory visit via telehealth on 11/18/24. R13's significant change MDS assessment dated [DATE], indicated R13 was cognitively intact with diagnoses of cerebrovascular accident, aphasia, and depression. R13 had regulatory visits via telehealth on: 8/2/24, and 11/22/24. R14's significant change MDS assessment dated [DATE], indicated R14 had severe cognitive impairment with diagnoses of dementia and cancer. R14 had a regulatory visit via telehealth on 12/18/24. R15 significant change MDS dated [DATE], indicated R15 had severe cognitive impairment with diagnoses of dementia and cancer. R15 had a regulatory visit via telehealth on 12/18/24. R16's quarterly MDS assessment dated [DATE], indicated R16 had severe cognitive impairment with diagnoses of Alzheimer's disease and atrial fibrillation. R16 had regulatory visit via telehealth on 12/18/24. R17's quarterly MDS assessment dated [DATE], indicated R17 had mild cognitive impairment with diagnoses of dementia and hypertension. R17 had a regulatory visit via telehealth on 11/22/24. R18's quarterly MDS assessment 11/4/24, indicated R18 had moderate cognitive impairment with diagnoses of CVA, hypertension, aphasia, hemiplegia, and seizure disorder. R18 had a regulatory visit via telehealth on 12/18/24. R19's quarterly MDS assessment dated [DATE], indicated a cognitive assessment was not completed. R19 had the diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R19 had a regulatory visit via telehealth on 12/18/24. R21's quarterly MDS assessment dated [DATE], indicated R21 was cognitively intact with diagnoses of cancer, hypertension, congestive heart failure, diabetes, and Parkinson's disease. R21 had a regulatory visit via telehealth on 12/18/24. R23's quarterly MDS assessment dated [DATE], indicated R23 had severe cognitive impairment with diagnoses of Alzheimer's disease, hypertension, anxiety, and depression. R23 had a regulatory visit via telehealth on 12/18/24. R24's quarterly MDS assessment dated [DATE], indicated a cognitive assessment was not completed. R24's diagnoses included cerebrovascular accident, traumatic brain injury, seizure disorder, hypertension, aphasia, and dementia. R24 had a regulatory visit via telehealth on 11/22/24. R25's annual MDS assessment dated [DATE], indicated R25 had moderate cognitive impairment with diagnoses of coronary artery disease, hypertension, and dementia. R25 had a regulatory visit via telehealth on 12/18/25. R27's quarterly MDS assessment dated [DATE], indicated R27 was cognitively intact with the diagnoses of cerebrovascular accident, hemiplegia, dementia, asthma, and depression. R27 had a regulatory visit via telehealth on 12/18/24. R28's quarterly MDS assessment dated [DATE], indicated R28 was cognitively intact with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R28 had a regulatory visit via telehealth on 11/22/24. R30's quarterly assessment dated [DATE], indicated R30 had severe cognitive impairment with diagnoses of hypertension, benign prostatic hyperplasia, dementia, and Parkinson's disease. R30 had a regulatory visit via telehealth on 12/18/24. R31's quarterly MDS assessment dated [DATE], indicated R31 was cognitively intact with diagnoses of atrial fibrillation, heart failure, hypertension, and peripheral vascular disease. R31 had a regulatory visit via telehealth on 11/22/24. R32's quarterly MDS assessment dated [DATE], indicated R32 had moderate cognitive impairment with diagnoses of hypertension, CVA, aphasia, and dementia. R32 had a regulatory visit via telehealth on 8/2/24. R33's annual MDS assessment dated [DATE], indicated a cognitive assessment was not completed. R33 had diagnoses of renal insufficiency, diabetes, Alzheimer's disease, and depression. R33 had a regulatory visit via telehealth on 12/18/24. R34's quarterly MDS assessment dated [DATE], indicated a cognitive assessment was not completed. R34's diagnoses included hypertension, diabetes, and Parkinson's disease. R34 had a regulatory visit via telehealth on 12/18/24. R35's quarterly MDS assessment dated [DATE], indicated a cognitive assessment was not completed. R35's diagnoses included end stage renal disease, Alzheimer's disease, and anxiety disorder. R35 had a regulatory visit via telehealth on 12/18/24. R39's annual MDS assessment dated [DATE], indicated R39 had severe cognitive impairment with diagnoses of congestive heart failure, dementia, and atrial fibrillation. R39 had a regulatory visit via telehealth on 12/18/24. R43's quarterly MDS assessment dated [DATE], indicated a cognitive assessment was not completed. R43 had the diagnoses of neurocognitive disorder with Lewy bodies and coronary artery disease. R43 had a regulatory visit via telehealth on 12/18/24. R44's quarterly MDS assessment dated [DATE], indicated R44 had severe cognitive impairment with diagnoses of osteoarthritis and chronic pain. R44 had a regulatory visit via telehealth on 12/18/24. R45's quarterly MDS assessment dated [DATE], indicated R45 had moderate cognitive impairment with diagnoses of atrial fibrillation, multiple rib fractures, and a seizure disorder. R45 had a regulatory visit via telehealth on 12/18/24. R49's admission MDS assessment dated [DATE], indicated R49 was cognitively intact with diagnoses of Staphylococcal arthritis, left knee and seizure disorder. R49 had a regulatory visit via telehealth on 12/18/24. During an interview on 1/17/25 at 12:46 p.m., the director of nursing (DON) stated the facility had started to do Telehealth visits back in August of 2024, when they switched to the Twin Cities Physician Group. The DON confirmed telehealth was being utilized at the facility to complete required provider regulatory visits. During an interview on 1/17/25 at 4:30 p.m., the Twin Cities Physician group vice president of operations confirmed their group provided telehealth services at the facility and stated they primarily used telehealth for regulatory visits. During an interview on 1/21/25 at 10:30 a.m., the medical director confirmed they were utilizing telehealth visits to perform provider regulatory visits. The MD explained they sent a registered nurse to the facility who was trained to operate telehealth equipment and perform assessments like auscultation of heart and lung when needed. The MD indicated they believed the telehealth visits were complaint with federal regulations. The facility policy Telehealth dated 5/1/2020, indicated the Twin Cities Physicians provided HIPPA compliant interactive audio/video telehealth visits at their facility. The policy did not address federal regulation requirements for in-person provider regulatory visits at long term care facilities. The Centers for Medicare & Medicare Services (CMS) memo Ref: QSO-22-15-NH & NLTC & LSC issued 4/7/22, identified long term care regulatory visits could no longer be conducted via telehealth as of 30 days from the issuance of the memo.

Based on observation, interview, and document review, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of psychotropic medications [mood altering medications] for 1 of 6 residents (R252) reviewed for psychotropic medications. Findings include: R252's admission Minimum Data Set (MDS) dated [DATE], did not include a cognitive assessment. R252's Section I Active Diagnoses included: cerebrovascular accident (CVA), hemiplegia, anxiety, hallucinations, attention deficit disorder, and depression. Section E -Behaviors indicated R252 experienced hallucinations and delusional thinking and exhibited behaviors which included: physical and verbal symptoms directed towards others one to three times during the assessment period. Part E0500 indicated the behaviors put the resident at significant risk for physical illness/harm, significantly interfered with resident's care, and significantly impacted the resident's participation in activities and social interaction. R252's Care plan last reviewed on 1/14/25, included the following focus, goal, and interventions: -Focus: the resident uses anti-anxiety medications related to anxiety disorder. Goal: R252 will be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions: give antianxiety medications as ordered by physician. Monitor for side effects and effectiveness. -Focus: R252 is on sedative/hypnotic therapy d/t hallucinations/delusions: diphenhydramine use. Goal: resident will be free of any discomfort or adverse side effect. Intervention: administer -Focus: Behavior management r/t anxiety dx evidenced by anger, decreased mood, irritability, paranoia, hallucinations, delusional thoughts, physical aggression, verbal aggression. Goal: R252 will respond well to pscyh med use with no increase in behaviors/symptoms through next review. Interventions: included non-pharmacological interventions and instructed staff to document effectiveness of interventions. R252's care plan lacked evidence that R252's use of antipsychotic medications had been incorporated into R252's plan of care. The care plan also lacked evidence of direction for non-pharmacological interventions to be attempted prior to the administration of as needed (PRN) psychotropic medications. R252's Orders Summary Report Dated 1/17/25, and Medication Administration Record for the Month of January 2025, (documented dates 1/1 - 1/17/25) included the following orders for psychotropic medications: -diphenhydramine HCl Injection Solution (Diphenhydramine HCl) Inject 50 mg intramuscularly every 8 hours as needed for Hallucinations related to other hallucinations (R44.2) Mix Benadryl and Haldol together- give injection along with Ativan Injection (B52 Shot). Ordered: 1/11/25 no stop date. -If B52 injection (Benadryl, Haldol, Ativan) is given, vitals should be monitored every 2 hours for 6 hours. -Haldol injection Solution 5 MG/ML Inject 5 mg intramuscularly every 8 hours as needed for hallucinations related to other hallucinations (R44.2). Mix Benadryl and Haldol together- give injection along with Ativan Injection (B52 Shot). Order renewed 1/11/25 no stop date. -Ativan injection solution 2 MG/ML (lorazepam) Inject 2 mg intramuscularly one time only for hallucinations until 1/7/25. To be given as part of B52 shot. Reordered: 1/11/25 no stop date. -haloperidol Oral Tablet 5 MG (Haloperidol) Give 5 mg by mouth every 4 hours as needed for restlessness, agitation related to restlessness and agitation (R45.1) for 3 Days Ordered 1/15/25. -Haldol Oral Tablet 2 MG (Haloperidol) Give 2 mg by mouth every 6 hours as needed for hallucinations. Start date: 1/10/25 discontinued: 1/15/25. -Haldol Oral Tablet 2 MG (Haloperidol) Give 2 mg by mouth every 6 hours as needed for hallucinations. Start date: 1/3/25 discontinued: 1/10/25. -Lorazepam SoluTab Give 0.5 mg by mouth every 4 hours as needed for anxiety and shortness of breath. Start date: 1/16/25. -clonazepam oral tablet 1 mg (Klonopin) give 1 mg by mouth every 12 hours as needed for anxiety/behaviors related to anxiety disorder unspecified (F41.9). ensure 4 hours between schedule dose and prn dose. Start Date; 1/11/25 -D/C Date- 1/15/25. -clonazepam oral tablet 1 mg (Klonopin) give 1 mg by mouth every 4 hours as needed for anxiety/behaviors related to anxiety disorder unspecified (F41.9). for 3 days. Start date: 1/15/24. R252's Medication Administration Record indicated the following PRN medications were administered to R252 between 1/2/25 and 1/17/25: -haloperidol Oral Tablet 5 MG (Haloperidol). Two doses on 1/16/25. -Haldol 2mg every 6 hours PRN. Doses were administered on: 1/3/25, 1/4/25, 1/6/25, 1/7/25, 2 doses 1/8/25, 2 doses 1/9/25, 2 doses 1/10/25, 1/12/25, 2 doses 1/14,25, and 1/15/25. -Ativan Injection Solution 2 MG/ML (Lorazepam) Inject 2 mg intramuscularly: one dose was administered on 1/7/25. -lorazepam soluble tab 0.5 mg as needed at bedtime PRN. Doses were administered on: 1/16/25 and two doses 1/17/25. -clonazepam oral tablet 1 mg give 1 mg by mouth every 12 hours as needed for anxiety/behaviors. Doses were administered on: 1/3/25, 1/4/25, 1/5/25, 1/7/25, two doses 1/8/25, 1/9/25, two doses 1/10/25, two doses 1/11/25, 1/13/25, and two doses 1/14/25. -clonazepam oral tablet 1 mg (Klonopin) give 1 mg by mouth every 4 hours as needed for anxiety/behaviors. Doses were administered on: 1/15/25, and two doses 1/16/25. R252's medical record lacked evidence to support staff had attempted non-pharmacological interventions prior to the administration of the psychotropic medications: Haldol, lorazepam, clonazepam, and Benadryl. . During an intermittent observation on 01/14/25 between 3:28 and 7:02 p.m., R252 was in bed intermittently making low volume non-distinguishable sounds. During an interview on 1/16/25 at 2:01 p.m., licensed practical nurse (LPN-B) stated when a resident had a medication like Ativan or Haldol, they would do an assessment on the resident to see what was going on before they gave the medication. If the resident could not speak, then they would base thier assessment to give on non-verbal cues. During an interview on 1/16/25 at 2:27 p.m., registered nurse (RN-B) stated for PRNs, if a resident had PRN medication like Haldol or Ativan ordered, they would give the PRN to the resident if they requested it. Likewise, if they assessed a resident and found they had symptoms of anxiety or behaviors that were uncomfortable or could become worse they would also give the PRN in that instance. During an interview on 1/17/25 at 8:06 a.m., (LPN-A) stated they did not have a specific place where they charted non-pharmacological interventions prior to administration of medications like Haldol or Ativan. LPN-A stated their practice was to make sure order parameters were met prior to administering PRN medications and they did try to do non-pharmacological interventions like essential oils when they could. During an interview on 1/17/25 at 12:23 p.m., (RN-A) stated R252's care plan did have non-pharmacological interventions however they would have to review to R252's chart to determine if interventions were being attempted prior to administration of psychotropics. During an interview on 1/17/25 at 1:29 p.m. the director of nursing (DON) stated they had reviewed R252's documentation and they had not found documentation of non-pharmacological interventions being attempted prior to administered doses of Haldol and lorazepam. The DON stated they had the expectation that staff would attempt non-pharmacologic interventions prior to administration of lorazepam or Haldol. The DON indicated they had discussed with staff that non-pharmacologic interventions prior to psychotropic drug administation should be included in the orders so it can be documented on. The facility policy Medications: Psychotropic Medications dated 12/23/24, indicated the facility would comply with state and federal regulations related to psychotropic medications and line item 19 indicated non-pharmacologic interventions should be attempted prior to the administration of PRN psychotropic medications.

Based on interview and document review the facility failed to ensure orders for PRN (as needed) psychotropic medication (mood altering medications) were time limited to 14 days for 2 of 6 residents (R29, R42). In addition, the facility failed to ensure provider assessment and documentation of rationale and duration of continuation of a psychotropic PRN medication beyond 14 days occurred for one of six residents (R29) reviewed for PRN psychotropic medication use. R29 R29's Minimum Data Set (MDS) dated [DATE], identified R29 was cognitively intact. R29's diagnoses included wedge compression fracture of second lumbar vertebra, congestive heart failure, major depression, anxiety disorder, intermittent explosive disorder. R29's Order Summary Report listed orders as of 1/2025, identified lorazepam solu tab give 0.5 mg by mouth every 4 hours as needed for anxiety ordered. Order date was 8/16/24, with no stop date. A document titled Order Number 280894 from the hospice agency documented the following hospice order dated 11/15/24: Pt appropriate to continue lorazepam 0.5 mg q 4 hours prn for anxiety/SOB. RNCM/hospice md to review in 60 days 1/14/25. An unrequested facility provided document titled PRN Medication Audit Report 12/1/24 to 1/17/25, indicated R29 had received Morphine PRN twice and had not received PRN Ativan during the reported time interval. R29's medical record and provided documentation lacked evidence to show R29's PRN Ativan had been reviewed between 8/16/24 and 11/15/24, nor was there documented rationale for a greater than 14 day order duration for PRN Ativan. During an interview on 1/17/25 at 12:15 p.m., the director of nursing (DON) stated PRN psychotropic medication should be reviewed every 14 days and indicated they were checking with hospice to determine if the hospice agency had a process in place to review R29's prn Ativan order every 14 days. During a follow-up interview on 1/17/25 at 4:29 p.m., the DON stated they had not been able to find evidence that PRN psychotropics were being reviewed every 14 days for order continuation or at an alternative interval determined by the provider. The facility policy Medications: Psychotropic Medications dated 12/23/24, indicated the facility would comply with state and federal regulations related to psychotropic medications and line item 18 indicated PRN psychotropic medications will be ordered for 2 weeks and only for specific clearly documented circumstances and will be re-evaluated if extension past 2 weeks is needed and documented rationale written by provider. 49878 R42 R42's admission minimum data set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of traumatic subarachnoid hemorrhage with loss of consciousness, hypertension, post-traumatic stress disorder, bipolar disorder, dementia, depression, and type 2 diabetes. R42's orders dated 1/10/25 with no end date, identified lorazepam (anti-anxiety medication) oral tablet 1 milligram (mg) give 0.5 mg by mouth every 4 hours as needed (PRN) for anxiety. R42's care plan last revised on 11/27/24, identified resident as taking psychoactive medication related to dementia, and taking antidepressant medication related to dementia and bipolar disorder. Psychoactive medication informed consent form dated 11/1/24, identified R42's spouse consented to R42 receiving melatonin (sleep aid), Abilify (antipsychotic medication), memantine (dementia medication), and sertraline (antidepressant). During interview on 1/17/25 at 4:29 p.m., the director of nursing (DON) stated they had not been able to find evidence that PRN psychotropics were being reviewed every 14 days for order continuation or at an alternative interval determined by the provider. Facility policy Psychotropic Medications dated 5/23/24, stated PRN psychotropic medications will be ordered for 2 weeks and only for specific clearly documented circumstances and will be re-evaluated if extension past 2 weeks is needed and documented rationale written by provider.

Based on interview and document review, the facility failed to offer pneumococcal conjugate vaccine 20 variant (PVC20) as directed by the Centers for Disease Control (CDC) for 4 of 5 residents (R11, R16, R37, R44) reviewed for immunizations. Findings include: R11's quarterly Minimum Data Set (MDS) dated [DATE], identified diagnoses of Alzheimer's disease, diabetes and kidney disease. R11's undated immunization record, identified R11 received pneumococcal polysaccharide vaccine (PPSV23) on 2/21/11, and the pneumococcal conjugate vaccine (PCV13) on 11/4/14. R11's medical record failed to provide evidence the PCV20 (pneumonia immunization) was offered and/or education was provided in conjunction with the provider to R11/R11's representative. R16's annual MDS dated [DATE], identified diagnoses of heart and kidney disease. R16's undated immunization record, identified R16 received PPSV23 on 5/30/02, and the PCV13 on 10/27/15. R16's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R16/R16's representative. R37's annual MDS dated [DATE], identified a diagnosis of dementia and Parkinson's disease. R37's undated immunization record, identified R37 received the pneumococcal 23 (PPSV23) on 10/23/03 and the pneumococcal conjugate vaccine 13 variant (PCV13) on 1/26/18. R37's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R37/R37's representative. R44's quarterly MDS dated [DATE], identified a diagnosis of Alzheimer's, heart and kidney disease. R44's undated immunization record, identified R44 received the pneumococcal poly on 8/29/14 and the pneumococcal conjugate vaccine 13 variant (PCV13) on 8/31/15. R44's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R44/R44's representative. During an joint interview on 11/1/23, at 9:45 a.m. with the director of nursing (DON) and registered nurse (RN)-A, the DON indicated the facility was not currently offering the PCV20 to their residents. They had just completed resident's yearly influenza vaccination and had not began to update their resident's with their PCV20 vaccinations, but was on their radar. The facility's undated Influenza/Pneumococcal Vaccine policy, indicated pneumococcal vaccines would be offered to each resident according to the current recommendations from the CDC unless contraindicated.

Based on interview and document review, the facility failed to ensure a written notice of bed hold was provided at the time of transfer along with ongoing attempts at getting the beg hold signed following an emergent transfer for 1 of 1 resident (R204) reviewed for hospitalization . Findings include: R204's significant change Minimum Data Set (MDS) dated [DATE], identified R204 had moderate cognitive impairment. Diagnoses included infection to right hip prosthesis, vascular dementia, heart failure and metabolic encephalopathy. R204's progress notes identified the following: - 10/6/23, R204 experienced a hypoglycemic episode (low blood sugar) and low oxygen saturation of 85% with shortness of breath. An order was received to transport R204 to the emergency department to be evaluated. R204 was transported to the hospital via ambulance at 1:10 p.m. - 10/7/23, R204 was admitted to the hospital. The medical record lacked evidence R204 or her family representative was provided a written notice of bed hold upon transfer, or within a 24 hour period following, to ensure potential costs and bed reservation were explained while R204 was hospitalized . Further, the medical record lacked evidence the bed hold was provided at the time of transfer as well as ongoing attempts by the facility to obtain a signed bedhold. The form Transfer, Discharge or Therapeutic Leave Notice dated 10/6/23, identified the facility's intent to transfer or discharge R204 because it was necessary to meet the resident's well-being and the resident's well-being could not be met in the facility. The form indicated the facility's bed hold policy applied to all residents regardless of source of payment and any resident could choose to have bed held while hospitalized at 30% of the current per diem rate. The form was signed by registered nurse (RN)-A dated 10/6/23, with notation that a verbal consent was received by R204. The form was not physically signed by the resident or their representative. When interviewed on 11/1/23, at 1:30 p.m. RN-A stated she did not complete a written notice of transfer and bed hold, nor sent the form with when the resident was transferred to the hospital. RN-A obtained a verbal consent for transfer and bed hold from R204 when RN-A arranged the transfer. During interview on 11/1/23, at 1:20 p.m. the administrator stated the facility did obtain a verbal bed hold from R204 at the time of transfer on 10/6/23. It was filed incorrectly in a billing folder in the billing office and had not been scanned into the patients chart. The bed hold form identified a verbal bed hold was obtained from R204 by RN-A; however, lacked a signature from R204 or a representative. The administrator was unable to find documentation the written bed hold had been sent to R204 or her representative, or evidence of ongoing attempts to obtain a signature. The facility policy Bed Hold Policy dated 11/27/17, identified nursing staff would get a signed or verbal consent for bed hold and document on Transfer, Discharge or Therapeutic Leave Notice. A copy would be provided to the resident and/or family member/legal representative as proof of their Bed Hold Policy once signed.

Based on interview and document review, the facility failed to ensure residents were allowed to transfer back to the facility following transfer to the hospital for 1 of 2 residents (R204) reviewed for hospitalization . Findings include: R204's significant change Minimum Data Set (MDS) dated [DATE], identified R204 had moderate cognitive impairment. Diagnoses included infection to the right hip prosthesis, vascular dementia, heart failure and metabolic encephalopathy. R204's discharge MDS dated [DATE], identified R204 was discharged from the facility on 10/6/23, to a short term general hospital with return anticipated. R204's progress notes identified the following: - 10/6/23, R204 experienced a hypoglycemic episode (low blood sugar) and low oxygen saturation of 85% with shortness of breath. An order was received to transport R204 to the emergency department to be evaluated. R204 was transported to the hospital via ambulance at 1:10 p.m. - 10/7/23, R204 was admitted to the hospital. The form Transfer, Discharge or Therapeutic Leave Notice with date 10/6/23, identified the facility's intent to transfer or discharge R204 because it was necessary to meet the resident's well-being and the resident's well-being could not be met in the facility. The facility's bed hold policy applied to all residents regardless of source of payment and any resident could choose to have bed held while hospitalized at 30% of the current per diem rate. The form was signed by registered nurse (RN)-A dated 10/6/23 with notation that a verbal consent had been received from R204. The form lacked a signature and the medical record lacked evidence of attempts made to obtain the signature. A letter addressed to R204 dated 10/16/23, identified the purpose was to notify R204 the facility was serving her a 30 day discharge notice due to her inability to pay for her care and stay at the facility. The facility received notification from the county R204's application for medical assistance was denied a second time for non compliance of paperwork requested. The letter notified R204 of her right to appeal and was signed by the facility's administrator. During interview on 10/30/23, at 1:09 p.m. with the director of nursing (DON) and administrator, the DON stated the facility's current census was 50 with no residents in the hospital. A Resident List Report dated 10/30/23, lacked R204's name on the current census. During interview on 11/1/23, at 1:35 a.m. registered nurse (RN)-A stated she obtained a verbal bed hold consent from R204 when she transferred to the emergency roiagnom on [DATE]. RN-A received an update from the hospital on 10/10/23, and there was no immediate plans for discharge. During interview on 11/1/23, at 1:45 p.m. the long term care ombudsman stated she never received a discharge notice from the facility identifying a 30 day notice of discharge for non payment. The ombudsman received the discharge notice information from the hospital staff. The facility sent the hospital the 30 day notice of discharge and were refusing to allow R204 to return to the facility. The ombudsman tried to reach out to the facility but no one had responded. The hospital was attempting to get R204 out of the hospital and the facility kept telling the hospital they did not have a bed hold for R204. R204 was in the hospital over 25 days because R204 wanted to return to that facility and the facility was not allowing her back. R204's medical assistance had not been completed correctly and was denied, but the hospital was assisting her with the application and it was getting sorted out The ombudsman had spoken with R204 and R204 had stated she wanted to return to the facility so she had reached out to the Senior Linkage Line and they assisted her to secure an attorney as well as assisting R204 to find nursing home placement. During joint interview on 11/1/23, at 2:55 p.m. with administrator and the director of nursing (DON), the administrator stated it was not the facility's responsibility to assist residents to fill out their medical assistance paperwork; however, they had documented attempts of assisting R204 to complete her application. The facility never stated they would not accept R204 back when she was discharged from the hospital. It had been relayed to the administrator, R204 had called after receiving the 30 day notice of discharge from the facility and stated R204 did not want to come back. The administrator understood R204 was still in the hospital and was not stable for discharge due to illness and could not return yet. During telephone interview on 11/1/23, at 3:15 p.m. the hospital licensed social worker (LSW)-A stated the hospital phoned the facility on 10/12/23 and 10/13/23, and spoke with RN-A. Their notes indicated discharge planning was discussed. On 10/13/23, the hospital documentation identified the hospital received a call from the facility from RN-B, in which RN-B informed the hospital after review of R204's records, a bed hold was not on file and so the facility would not take her back on her discharge from the hospital. During joint interview on 11/1/23, at 3:25 p.m. with the administrator and RN-B, RN-B stated she received a call from the hospital to discuss R204's discharge and return to the facility. For all admissions and readmissions, RN-B always discussed the situation with the administrator. RN-B discussed R204's case with the administrator and was told to notify the hospital the facility did not have a bed hold for R204 and therefore would not be taking her back, which she did. During telephone interview on 11/2/23 at 11:50 p.m. LSW-B stated R204 was stable to return to the skilled nursing facility as of 10/16/23, then the facility called and informed them they would not accept R204 back. R204 has remained in the hospital since and even though she was getting some therapy while at the hospital, R204 would have benefited to return to the skilled nursing facility where she would receive more intensive rehabilitation, as R204's goal was to return to her own home. LSW-B knew R204 wanted to return to the facility and had legal representation involved. R204's hospital records/notes identified the following: - Hospital Discharge Planning assessment dated [DATE], R204 was admitted to the hospital from a skilled nursing facility and her preference and plan was to return to the facility. RN-B at the facility was notified of the discharge plan. - Case management note dated 10/12/23, the facility was contacted to discuss equipment and supplies R204 would need on her transfer back to the facility. - Case management note dated 10/13/23, the facility was contacted regarding discharge plans and dressing supplies needed. - Progress note dated 10/17/23, the orthopedic surgeon stated R204 was medically stable for discharge. - Orthopedic note dated 11/2/23, R204 was cleared for discharge since 10/16/23. R204 had ongoing hospitalization as the hospital waited for rehabilitation placement and discharge plan for R204. An email communication from LSW-B dated 11/2/23, identified the hospital stopped communicating with the facility when the ombudsman became involved with R204's case. During interview on 11/1/23, at 3:30 p.m. the administrator stated he notified his staff to keep R204's room with her belongings as her room needed to be available for her. The facility did not have a bed hold on file for R204, and so they did not legally have to hold a bed for her. The hospital was indicating the facility had to take R204 back and that was not correct. The administrator felt the hospital was trying to force the issue because no other facility would admit R204 due to her complexity and multiple infections. The facility's policy Discharge of Resident from Aicota dated 7/1/23, identified a purpose to insure the resident a safe and courteous departure from the facility and to provide and organize a discharge that would promote the highest quality of well being for the resident in their new surrounding.

Based on observation, interview and document review, the facility failed to ensure the actual hours and amount of staff were posted per each shift. This had the potential to affect all residents residing in the facility. Findings include: On 10/31/23, at 11:15 a.m. the nurse staff posting was observed posted in the hallway near the business office. The posting Today's Staffing contained the following information: census, date, start of day shift, start of evening shift, start of night shift, number of registered nurses (RN) with a total hours and full time equivalent (FTE) for each shift, number of licensed practical nurses (LPN) with a total hours, FTE's for each shift, and number of assistants with a total hours and FTE's for each shift, and then an accumulated total. The schedule and nurse posting were compared and identified the following: - The Today's Staffing dated 10/29/23, identified a census of 50. Start time day shift of 6:00 a.m., start time of evening shift at 2:15 p.m. and start time of night shift of 10:45 p.m. The number of RN's identified for the day shift were 15.75 hours with 1.97 FTE's, evening shift 17 hours and 2.13 FTE's and night shift of 39.50 hours with 4.94 FTE's. The number of LPN's identified for the day shift were 8.25 hours with 1.03 FTE, evening shift 9 hours with 1.13 FTE's and night shift with 24 hours and 3 FTE's. The numbers of assistants identified for the day shift were 32.50 hours with 5.03 FTE's , evening shift 34.25 hours and 4.31 FTE's and night shift 20.25 hours and 2.53 FTE's. The posting lacked the actual number and actual hours worked by each discipline on each shift. The corresponding working schedule Daily Attendance Report dated 10/29/23, identified the following for day shift: one RN 6:00 a.m. to 2:30 p.m., one RN 6:00 a.m. to 6:30 p.m., one LPN 6:00 a.m. to 6:30 p.m.; one nursing assistant (NA) 6:00 a.m. to 9:00 a.m., one NA 9:00 a.m. to 2:30 p.m., two NA's 6:00 a.m. to 2:30 p.m., and two NA's 6:00 a.m. to 6:30 p.m. The evening shift identified the following staff: two RN's 2:00 p.m. to 10:30 p.m. , one LPN 2:00 p.m. to 10:30 p.m. and four NA's 2:00 p.m. to 10:30 p.m The following were identified to work the night shift: one RN 6:00 p.m. to 6:30 a.m., one LPN 6:00 p.m. to 6:30 a.m., and three NA's 6:00 p.m. to 6:30 a.m - The Today's Staffing dated 10/30/23, identified a census of 50. Start time day shift of 6:00 a.m., start time of evening shift at 2:15 p.m. and start time of night shift of 10:45 p.m. The number of RN identified for the day shift were 12.5 hours with 1.56 FTE's, evening shift 25.5 hours and 3.19 FTE's and night shift of 13.5 hours with 1.69 FTE's. The number of LPN's identified for the day shift were 31.5 hours with 3.94 FTE, evening shift 5 hours with .63 FTE's and night shift with 0 hours and 0 FTE's. The numbers of assistants identified for the day shift were 38.25 hours with 5.75 FTE's , evening shift 35.25 hours and 4.44 FTE's and night shift 13.5 hours and 1.69 FTE's. The posting lacked the actual number and actual hours worked by each discipline on each shift. The corresponding Daily Attendance Report dated 10/30/23, identified the following for day shift: two management RN's 8:00 a.m. to 4:30 p.m., three LPN 6:00 a.m. to 2:30 p.m.; one LPN 6:00 a.m. to 6:30 p.m. one NA 6:00 a.m. to 9:00 a.m., one NA 9:00 a.m. to 2:30 p.m., three NA's 6:00 a.m. to 2:30 p.m., and one NA 6:00 a.m. to 6:30 p.m. The evening shift identified the following staff: two RN's 2:00 p.m. to 10:30 p.m. , one NA 2:00 p.m. to 10:30 p.m., one NA 2:00 p.m. to 10 : 00 p.m., and one NA 2:30 p.m. to 10:30 p.m. The following were identified to work the night shift: one RN 6:00 p.m. to 6:30 a.m., one RN 10:00 p.m. to 6:30 p.m. LPN 6:00 p.m. to 6:30 a.m., one NA's 6:00 p.m. to 6:30 a.m. and one NA 10: p.m. to 6:30 a.m. - The Today's Staffing dated 10/31/23, identified a census of 52. Start time day shift of 6:00 a.m., start time of evening shift at 2:15 p.m. and start time of night shift of 10:45 p.m. The number of RN's identified for the day shift were 26.25 hours with 3.28 FTE's, evening shift 20 hours and 2.5 FTE's and night shift of 6.75 hours with .84 FTE's. The number of LPN's identified for the day shift were 15.5 hours with 1.94 FTE, evening shift 12.75 hours with 1.59 FTE's and night shift with 6.75 hours and 0.84 FTE's. The numbers of assistants identified for the day shift were 46 hours with 5.75 FTE's , evening shift 40 hours and 5 FTE's and night shift 13.5 hours and 1.69 FTE's. The posting lacked the actual number and actual hours worked by each discipline on each shift. The corresponding Daily Attendance Report dated 10/31/23, identified the following for day shift: three management RN's 8:00 a.m. to 4:30 p.m., one RN 6:00 a.m. to 2:30 p.m. one LPN 6:00 a.m. to 6:30 p.m.; one LPN 6:00 a.m. to 2:30 p.m. one NA 6:00 a.m. to 9:00 a.m., one NA 9:00 a.m. to 2:30 p.m., three NA's 6:00 a.m. to 2:30 p.m., and two NA 6:00 a.m. to 6:30 p.m. The evening shift identified the following staff: one RN 2:00 p.m. to 10:30 p.m. , one RN 6:00 p.m. to 10:30 p.m., one LPN 2:30 p.m. to 10:30 p.m., one trained medication assistant (TMA) 2:00 p.m. to 6:00 p.m., three NA's 2:00 p.m. to 10 : 00 p.m., and four NA's names written in without identifying the hours they worked. The following were identified to work the night shift: one RN 10:00 p.m. to 6:30 a.m., one LPN 6:00 p.m. to 6:30 a.m., one NA's 6:00 p.m. to 6:30 a.m. and one NA 10:00 p.m. to 6:30 a.m. During interview on 10/31/23, at 2:37 p.m. the director of nursing stated the facility used Smartlinks staffing system for scheduling and it pulled the information from the schedule in to the form the facility used for the nurse staff posting requirement. The DON didn't realize the actual numbers and total numbers of staff were not pulled per actual shift, as the facility used multiple shifts in their schedule to cover the resident needs. For instance the day shift had people that worked 6:00 a.m. to 2:30 p.m. and 6:00 a.m. to 6:00 p.m. and all the staff scheduled to start at 6:00 a.m. were listed under the day shift of the nurse staff posting. A policy on nurse staff posting was requested and not received.

Based on interview and document review, the facility failed to identify use of continuous positive air way pressure ([CONDITION(S)]) therapy on the Minimum Data Set (MDS) for 1 of 1 resident (R51) reviewed for accurate MDS. Findings include: R51's Admission Record printed on 9/29/22, identified a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R51's five day admission MDS, dated [DATE], did not identify R51's [CONDITION(S)] use. R51's Nursing-Admission/Readmission Evaluation dated 9/12/22, and completed by registered nurse (RN)-B indicated R51 used [CONDITION(S)] therapy. On 9/27/22, at 10:06 a.m. R51 stated the staff donned personal protective equipment at night when she was wearing her [CONDITION(S)]. On 9/27/22, at 4:10 p.m. outside of R51's door was a three drawer bin with PPE supplies. The sign on the door indicated she was in contact and droplet precautions at night. On 9/28/22, at 8:35 a.m. R51 stated she takes her [CONDITION(S)] off herself in the morning when she woke up. R51 stated staff wore PPE when she had her [CONDITION(S)] running at night. During an interview on 9/29/22, 12:31 p.m. RN-B stated R51 was in isolation for [CONDITION(S)] use. RN-B stated she completed R51's admission MDS but stated during the completion window R51 was not wearing her [CONDITION(S)]. During an interview on 9/29/22, at 3:46 p.m. the director of nursing (DON) stated [CONDITION(S)] therapy should have been noted on the admission MDS. The DON stated if [CONDITION(S)] therapy was indicated on the admission assessment it should have been on the admission MDS. The DON stated accuracy of the MDS was important for care of the resident and for payment. The facility policy titled Policy and Procedure for Completion of the Minimum Data Set and Quarterly Reviews dated 7/20/22, indicated all persons completing a portion of the MDS were responsible for the accuracy of that information and would verify by signing/dating in the appropriate section of the MDS.

Based on interview and document review, the facility failed to ensure 2 of 2 residents (R40 and R46) reviewed for diabetic management were provided adequate care in accordance with current standards of practice and facility standing orders. This practice included lack of monitoring of low diabetic blood glucose (sugar) readings and lack of physician notification, which resulted in an immediate jeopardy (IJ) for R40 and R46. The Immediate Jeopardy (IJ) began on 6/2/21, when R40 had a blood glucose reading of 40 milligrams per decilitre (mg/dl) without physician notification for further evaluation of diabetic management, and further lack of continued monitoring of R40's blood glucose (BG) until R40's BG was 70 mg/dl , or higher. The administrator and director of nursing (DON), were notified of the IJ on 8/26/21, at 6:03 p.m. The IJ was removed on 8/27/21, at 2:40 p.m. but noncompliance remained at the lower scope and severity level of D, no actual harm with the potential for more than minimal harm that is not IJ. Findings include: R40's Admission Record printed 8/27/21, indicated R40's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R40's quarterly Minimum Data Set (MDS) dated [DATE], identified R40 had intact cognition, exhibited no behaviors or rejection of care, and received insulin injections. R40's care plan revised 8/5/21, indicated R40 had the potential for adverse side effects from insulin use and directed staff to observe for any signs and symptoms of [CONDITION(S)] (elevated blood sugars) or [CONDITION(S)] (low blood sugars) of slurred speech, loss of consciousness, confusion, increased lethargy, sweating, increased thirst and urination. R40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .d.) before meals and at bedtime. Facility standing orders dated 6/2020, indicated if a resident is able to consume liquids safely and blood sugar is less than 70[milligrams] [per deciliter] mg/dl, give four ounces juice or 15 gm [grams] glucose gel. If blood sugar is less than 50 mg/dl give 8 oz. juice or 30 gm glucose gel and update physician/nurse practitioner (NP). If resident is unwilling or unable to consume liquids give [MEDICATION(S)] 1 mg IM [intramuscular] injection from [emergency kit] E-Kit [contains medications that are used to control sudden symptoms] and call physician/NP-C. Repeat accu-checks [blood sugar] in 15 minutes following treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R40's medical record revealed the following: R40's blood glucose readings less than 50 mg/dl for the months of June, July and August 2021 were as follows: 6/2/21, at 8:00 p.m.: 40 mg/dl 6/11/21, at 4:24 p.m.: 41 mg/dl 7/27/21, at 4:04 p.m.: 36 mg/dl 8/4/21, at 4:29 p.m.: 41 mg/dl 8/16/21, 4:38 p.m.: 49 mg/dl 8/19/21, at 4:10 p.m.: 44 mg/dl R40's progress notes from 6/2/21 to 8/19/21 revealed the following: - 6/2/21, BG of 40 at bedtime (8:54 p.m.), was confused and unable to fully communicate. R40's progress note lacked documentation R40's physician or NP were notified of R40's BG below 50 as directed in the facilities standing orders. In addition, R40's progress note indicated R40's BG was not checked again until 9:24 p.m. with a BG of 60 and then not again until 7:33 a.m. the next day. - 6/11/21, BG was 41 at 4:24 p.m., lacked documentation R40's physician or NP were notified and R40's BG was not checked again until 9:35 p.m. -7/27/21, BG was 36 at 4:02 a.m. R40's extremities were shaking and flailing, and diaphoretic. R40 was administered a tube of oral glucose gel (medicine to treat low blood sugar) and a glass of orange juice. R40's BG rechecked at 4:20 p.m. was 51, at 4:51 p.m. was 59. R40's BG was not checked again until 6:01 p.m. R40's progress lacked documentation R40's physician or NP were notified of R40's BG below 50. -8/4/21, BG was 41 at 4:29 p.m., lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's progress note further lacked documentation R40's physician or NP were notified of R40's BG of 41. -8/16/21, BG of 49, at 4:38 p.m. and showed no signs or symptoms of [CONDITION(S)]. R40's BG was not checked again until 8:39 p.m. R40's progress note lacked documentation R40's physician or NP was notified of R40's BG below 50. -8/19/21, BG of 44 at 4:10 p.m. and was given a [MEDICATION(S)] orally. A R40's BG was 59 at 5:15 p.m. and not rechecked again until 6:55 p.m. Although R40's NP was notified, the facility failed to continue to monitor R40's BG according the facility standing orders. For the months of 6/21, 7/21 and 8/21, R40 had the following blood glucose levels below 70 mg/dl: -6/4/21, at 8:29 p.m. BG 68. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 10:01 p.m. -6/6/21, at 4:43 p.m. BG 61. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 8:57 p.m. -6/7/21, at 8:27 p.m. BG 66. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 6/8/21 at 8:05 a.m. -6/13/21, 11:37 a.m. BG 63. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 6/13/21, at 4:38 p.m. -6/17/21, at 9:15 p.m. BG was 53 and 65. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 8/18/21, at 1:15 a.m. - 6/30/21, at 4:41 p.m. BG was 67. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 6/30/21, at 9:10 p.m. -7/5/21, at 4:30 p.m. BG was 55, at 5:05 p.m. R40 had a fall and R40's progress notes lacked recheck of R40's BG at the time of fall was was not rechecked until 9:15 p.m. -7/9/21, at 4:49 p.m. BG was 64. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 9:47 p.m. -7/21/21, at 4:38 p.m. BG was 55. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 8:29 p.m. -7/24/21, at 4:47 p.m. BG was 67. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 9:01 p.m. -7/25/21, at 4:41 p.m. BG was 58. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 9:03 p.m. -7/30/21, at 8:01 p.m. BG was 64. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 11:54 a.m. -8/3/21, at 8:45 p.m. BG was 63. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 8/4/21, at 8:48 a.m. -8/5/21, at 4:57 p.m. BG was 53. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 9:57 p.m. - 8/7/21, at 8:26 a.m. BG was 65. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 11:40 a.m. - 8/10/21, at 9:51 p.m. BG was 64. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 8/11/21, at 8:36 a.m. - 8/11/21, at 4:44 p.m. BG was 65. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 8:16 p.m. -8/14/2021, at 4:36 p.m. BG was 63. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented . R40's BG was not rechecked until 9:16 p.m. - 8/15/2021, at 4:36 p.m. BG was 52. R40's medical record lacked documentation of monitoring R40's medical status for signs or symptoms of [CONDITION(S)], and if interventions to treat [CONDITION(S)] were implemented. R40's BG was not rechecked until 9:11 p.m. Review of R40's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R40's physician note further indicated R40 had [CONDITION(S)] unawareness (is a condition in which a person with diabetes does not experience the usual early warning symptoms of [CONDITION(S)]) and staff needed to monitor R40 closely. On 8/25/21, at 12:58 p.m. registered nurse (RN)-E stated R40's BG levels had been all over and lately had been running extremely low which required R40 to be administered [MEDICATION(S)] IM. RN-E stated the night shift nurse reported R40 had questionable behavior and was showing signs of confusion. RN-E stated R40's BG on 8/25/21, at approximately 7:00 a.m. was 68 and R40 was given a glass of orange juice. RN-E stated she did not recheck R40's BG after 15 minutes because R40 was going to eat breakfast. On 8/26/21, at 12:52 p.m. the director of nursing (DON) verified R40's blood glucose on 8/24/21, at 4:20 p.m. was 58 and R40's BG had not been checked again until 8:50 p.m. The DON stated R40 was not symptomatic, was able to take in juice, and ate 76-100% of her meal, so it was not necessary to recheck R40's BG. The DON further stated the nurses used nursing judgement on when to recheck a BG and she would expect R40's BG to have increased after given juice and eating supper. The DON stated the facility standing orders for low BG were in place for when a resident was given a rescue medication or if a resident was unable to consume liquids then rechecking the BG in 15 minutes would be necessary. On 8/27/21, at 2:50 p.m. NP-C stated R40 had [CONDITION(S)] unawareness and was unable to recognize when her BG levels were low, so monitoring R40's BG closely was important. The NP-C stated R40's BG had no pattern and could go from BG levels of 40 to 600, and the low BG levels were more detrimental than the highs. The NP-C stated she would expect staff to follow the facility standing orders and monitor a residents BG level below 70 every 15 minutes until the BG was 70 or higher. NP-C further stated, residents could drop even after a treatment was given so it was important to recheck BG every 15 minutes regardless if it was around meal time or a meal was consumed. NP-C stated she would expect to be notified with any BG levels below 50 or when the resident was not responding to the interventions. NP-C stated she relied on staff's documentation in the resident's chart to see the history of the resident's BG levels, interventions used and the residents response to determine further treatment. R46's Admission Record printed 8/26/21, indicated R46's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's quarterly Minimum Data Set (MDS) dated [DATE], identified R46 had a mild cognitive impairment and required extensive assistance for transfers, bed mobility, dressing, toileting and personal hygiene. R46's care plan dated 8/23/21, indicated R46 was to have blood sugar checks as ordered, and directed staff to observe and report any signs and symptoms of [CONDITION(S)] (elevated blood sugars) or [CONDITION(S)] (low blood sugars). Facility Standing Orders for [CONDITION(S)] for R46 dated 6/2020, indicated that if a resident was able to consume liquids safely and BG was less than 70 mg/ml, give four ounces of juice or 15 grams glucose gel. If BG was less than fifty mg/dl. give eight ounces of juice or thirty grams glucose gel and update MD/NP. If resident was unwilling or unable to consume liquids give [MEDICATION(S)] 1 mg intramuscular (IM) injection from e-kit and call MD/NP. Repeat accu-checks in 15 minutes following treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Will continue [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] as ordered. R46 receives his [MEDICATION(S)] in the morning. Would like an update again in a week. R46's medical record revealed blood sugars less than 70 mg/dl were as follows: On 6/9/21, at 1:58 a.m.: 67 mg/dl. Although this BG was under 70, there was no documentation of an assessment, a BG recheck or that any interventions were implemented regarding R46's medical status or symptoms of [CONDITION(S)]. There was also no indication if the MD/NP was notified. 7/4/21, at 7:12 p.m.: 61 mg/dl. Although this BG was under 70, there was no documentation of an assessment, a BG recheck done in a timely manner or that any interventions were implemented regarding R46's medical status or symptoms of [CONDITION(S)]. There was also no indication if the MD/NP was notified. 7/4/21, at 9:28 p.m.: 56 mg/dl. Although this BG was under 70, there was no documentation of an assessment, or a BG recheck. R46 refused a snack at 9:54 p.m. There was also no indication if the MD/NP was notified. 7/5/21, at 3:45 a.m.: 69 mg/dl. Although this BG was under 70, there was no documentation of an assessment or that any interventions were implemented regarding R46's medical status or symptoms of [CONDITION(S)]. There was also no indication if the MD/NP was notified. 7/5/21, at 8:11 p.m.: 68 mg/dl. Although this BG was under 70, there was no documentation of an assessment, a BG recheck or that any interventions were implemented regarding R46's medical status or symptoms of [CONDITION(S)]. There was also no indication if the MD/NP was notified. 7/12/21, at 9:03 p.m.: 68 mg/dl. Although this BG was under 70, there was no documentation of an assessment, or a BG recheck. R46 refused a snack 9:54 p.m. There was also no indication if the MD/NP was notified. 7/13/21, at 5:38 a.m.: 68 mg/dl. Although this BG was under 70, there was no documentation of an assessment, a BG recheck or that any interventions were implemented regarding R46's medical status or symptoms of [CONDITION(S)]. There was also no indication if the MD/NP was notified. 7/15/21, at 2:25 a.m.: 66 mg/dl. Although this BG was under 70, there was no documentation of an assessment or a BG recheck. R46 ate seventy six to one hundred percent of his snack. There was also no indication if the MD/NP was notified. 7/24/21, at 7:31 p.m.: 60 mg/dl. Although this BG was under 70, there was no documentation of an assessment, a BG recheck or that any interventions were implemented regarding R46's medical status or symptoms of [CONDITION(S)]. There was also no indication if the MD/NP was notified. 8/12/21, at 1:52 a.m.: 66 mg/dl. Although this BG was under 70, there was no documentation of an assessment or that any interventions were implemented regarding R46's medical status or symptoms of [CONDITION(S)]. There was also no indication if the MD/NP was notified. 8/21/21, at 8:08 p.m.: 69 mg/dl. Although this BG was under 70, there was no documentation of an assessment or a BG recheck. R46 ate seventy six to one hundred percent of his snack. There was also no indication if the MD/NP was notified. 8/25/21, at 8:19 p.m.: 69 mg/dl. Although this BG was under 70, there was no documentation of an assessment or a BG recheck. R46 ate seventy six to one hundred percent of his snack. There was also no indication if the MD/NP was notified. R46's progress note dated 7/4/21, at 9:28 p.m. indicated that R46 refused a snack, BG dropped to 56. R46 then agreed to a glass of regular Coke and two graham crackers after all other options were refused. There was also no indication if the MD/NP was notified. R46's progress note dated 8/12/21, at 2:36 a.m. indicated staff was to obtain a 2:00 a.m. BG. Reading at 2:00 a.m. was 66. RN-D asked resident if he would like a snack. R46 declined and stated he felt fine. There was also no indication if the MD/NP was notified. On 08/26/21, at 10:33 a.m. licensed practical nurse (LPN)-A stated if the BG was under 100, she would look to see what R46 had eaten, if R46 had not eaten LPN-A would call the provider and still give the [MEDICATION(S)], LPN-A would consult with a registered nurse (RN) on duty or with RN-B if a good meal was eaten, to see what was recommended. On 08/26/21, at 11:10 a.m. RN-B stated depending on what the BG reading was, she would offer a snack, hold the insulin, call the provider and document in the progress note or Treatment Administration Record (TAR). RN-B stated she would have expected staff to follow the standing orders and hold the insulin. On 8/26/21, at 4:27 p.m. the director of nursing (DON) was interviewed. The DON stated if a resident's blood sugar was low and if the resident was alert and able to consume food she would have expected staff to use food instead of a rescue medication. The DON further stated if the resident had eaten, she would expect the BG to go up and she would not expect staff to recheck a blood sugar. The DON stated the standing orders were to be followed when a rescue medication such as [MEDICATION(S)] and/or orange juice needed to be used. The DON stated her expectation was if a rescue medication were used, then the BG would be rechecked after 15 minutes. The DON acknowledged that the instructions on the standing order should have been clearer. On 8/27/21, at 2:41 p.m. nurse practitioner (NP)-C stated during a telephone interview, that R46 was on multiple diabetic medications due to his erratic BG levels. [MEDICATION(S)] was added and R46 responded well initially, and the [MEDICATION(S)] does was decreased. R46's [MEDICATION(S)] had since been increased to the maximum dose of 4.5 milligrams weekly. The NP stated she would expect staff to follow the facility standing orders for diabetics. The NP further stated she would expect treatment and monitoring every 15 minutes if a resident was symptomatic or at least until their BG was above 70. In addition, the NP stated it was her expectation staff would notify her anytime a resident was not responding to interventions. The facility's Blood Glucose Monitoring Policy recognizing symptoms of altered BG dated 1/15/21, indicated [CONDITION(S)] was a condition resulting when the blood glucose levels drop below the specified limits less than 72 milligrams per deciliter (mg/dl). The policy directed staff, when confirmed [CONDITION(S)], to implement the facility Standing Orders (SO). SO for [CONDITION(S)] was glucose 15 gel 40%, or [CONDITION(S)] [MEDICATION(S)] 1 mg, located in the emergency kit, then update MD/NP. The deficient practice was corrected on 8/27/21, at 2:40 p.m. after the facility developed and implemented corrective action to include updating the facility standing orders to include glucose checks every 15 minutes after treatment and again until appropriate glucose levels of 70 mg/dl or above. All nursing staff with the potential to administer or check blood glucose would be educated on medication administration; avoiding common errors, diabetes; the basics and managing blood glucose levels, and the updated facility standing orders prior to their next working shift. To ensure staff were educated prior to the shift, their building access would be deactivated and would need to speak to the department manager and complete education to return to the floor. On 8/27/21, all TMA's and licensed staff working were interviewed and verified the changes to the updated facility standing orders.

Based on interview and document review, the facility failed to ensure medications were administered per physician orders [REDACTED]. This failure resulted in an immediate jeopardy situation for R1. However, at the time of the investigation, it was determined the medication errors had been immediately identified and the facility developed and implemented corrective actions on [DATE], therefore the deficient practice was issued as past non-compliance. The past noncompliance immediate jeopardy began on [DATE], when R1 was administered another resident's medications in error. The Administrator and Director of Nursing (DON) were notified of the past non-compliance immediate jeopardy at 1:25 p.m. on [DATE]. Findings include: R1's [DIAGNOSES REDACTED]. R1's re-entry from the hospital Minimum Data Set (MDS) assessment dated [DATE], indicated R1's cognition was intact. R1's Medication Error Report dated [DATE], indicated at 4:30 p.m. R1 received the following medications in error: -[MEDICATION NAME] 10 milligrams (mg) - [MEDICATION NAME] used to prevent chest pain -[MEDICATION NAME] concentrate 0.5 mg - benzodiazepine used to treat anxiety -[MEDICATION NAME] 8 mg - antiemetic used to treat nausea and vomiting -[MEDICATION NAME] HCL 0.1 mg - used to lower blood pressure -[MEDICATION NAME] HCL 50 mg - antihypertensive drug for treatment of [REDACTED].>-potassium 10 mg - replaces potassium loss -sennosides 8.6 mg - used for constipation R1's provider Progress Note written by the nurse practioner (NP) [DATE], indicated R1 had acute/chronic systolic [MEDICAL CONDITION] and [MEDICAL CONDITION] and had a recent hospitalization . A care conference was held [DATE], which included R1's son, daughter, and R1. Family signed a new POLST (Physicians Orders for Life Sustaining Treatment) which directed DNR/DNI (do not resuscitate/intubate), provide comfort cares and no further hospitalization s were desired. A Nursing Home Incident Report (NHIR) dated [DATE], indicated a medication error occurred when R1 was administered another resident's medications at 4:30 p.m. on [DATE] by mistake. R1's Progress Notes (PN) revealed the following: [DATE], at 5:30 p.m. resident given wrong medications. Licensed practical nurse (LPN)-A notified registered nurse (RN)-A of the error, and she directed LPN-A to call the NP. LPN-A called the NP who gave new orders. R1's blood pressure was checked which was stable. Staff were aware of comfort care and no hospitalization s. R1 was alert at this time. LPN-A also called the DON and updated her on the situation. [DATE], at 8:25 p.m. LPN-A, medication nurse for the p.m. (evening) shift, called this writer (DON) and reported at 4:30 p.m. R1 was given another resident's 4:00 p.m. medications. NP and myself were updated. NP instructed LPN-A to take resident's blood pressure every hour and update the NP with any out of baseline parameter readings. [DATE], at 10 p.m. R1's blood pressure stable since p.m. 90's over 50's. [DATE], at 12:52 a.m. R1's condition at 11:30 p.m.: skin color gray/blue. Respirations 20, Pulse 88. Oxygen saturation 75% via nasal cannula. Crackles noted in all lung fields. R1 is resting with eyes closed, but softly moaning. [DATE], at 4:57 a.m. writer was called to R1's room by a nursing assistant (NA). R1 had no spontaneous respirations, no apical heart beat, and no blood pressure. Time of death 4:57 a.m. On [DATE], at 11:17 a.m. the NP stated she had met with R1's family later in the afternoon on [DATE], at which time a new POLST was written. The NP stated she'd left the facility at approximately 3:00 p.m. and received a phone call between 5 - 5:30 p.m. from an LPN at the facility reporting she had given R1 the wrong medications. The NP stated she was concerned because of the cardiac medications that were administered in error therefore, gave orders to the LPN-A to check R1's blood pressure every hour and call the NP if R1's systolic (upper blood pressure number) was under 100. She also directed LPN-A, to hold R1's scheduled blood pressure medication, to push fluids, and to notify the family. The NP stated she had told the LPN-A to keep her updated if the family wanted R1 to be seen at the hospital. The NP stated she had also offered to contact the family regarding the error in case they desired R1 to be evaluated at the hospital however, LPN-A reported to the NP the family was currently at the facility so she would inform them in person of the medication error. The NP stated at around 7:00 p.m., the LPN-A called her back and reported R1's lowest systolic blood pressure was 80. She also reported R1 was alert, oriented, and talking. The NP reminded the LPN-A to report to the night shift staff of the need to continue hourly monitoring of R1. The NP also stated the LPN-A had verbalized she had spoken to R1's family who indicated they did not want R1 hospitalized . The NP stated she did not receive any further communication from the facility until the following morning when the DON informed her of R1's passing. The NP stated she was unable to verify if the medication error could have potentiated R1's passing. The NP stated on [DATE], she had arrived at the facility around 10:00 a.m. and had spoken with R1's family member (FM)-B and informed her about the medication error that occurred the previous day. FM-B stated she had not been informed of the error occurring. The NP reviewed R1's medical record and noted none of the orders she had given to the LPN-A on [DATE], had been transcribed in R1's medical record. Review of the facility Recap of Events form documented by the NP on [DATE], indicated due to multiple medications involved in the error. These could have affect R1's blood pressure, and because R1 had multiple comorbidities, the medication errors could have caused adverse side effects for R1. The NP documentation also indicated she had explained to the LPN-A that although the family's decision earlier in the day, was for R1 to no longer be hospitalized , the medication error which occurred could have certainly changed their decision and the family may have wanted R1 be sent to the emergency department for an evaluation and/or treatment. The family conference note written by the Medical Director [DATE], indicated the medication error involved R1 receiving medications which she had not been prescribed. R1's vital signs, as reported by nursing, revealed R1's blood pressure had dropped as low as 89 systolically (upper number) with documented [MEDICAL CONDITION](increased pulse) as high as 124 (normal pulse ,[DATE]) shortly after the medications were given. R1's vital signs were noted to be stable at approximately 9:00 p.m. with her blood pressure in the upper 90's systolically and pulse in the upper 80's. The documentation indicated candid discussion had occurred with FM-A and FM-B regarding the medications and potential effects. Family was also informed of side effects. Review of Medication Error Reports involving LPN-A from [DATE] - [DATE], revealed LPN-A had been responsible for 16 medication errors during that timeframe. The errors included medications administered outside of the prescribing parameters, wrong doses administered, extra doses administered, dose omissions and administration of the wrong drug. The medication errors involved antihypertensive, diabetic medication, and anticoagulant (blood thinners) medications. On [DATE], at 6:25 p.m. a telephone interview was conducted with family member (FM)-[NAME] FM-A stated he had received a call from the facility at about 5:10 a.m. on [DATE], to tell him his mother had died . FM-A stated when his sister had gone to the facility to pick up R1's things, the NP had informed her about the medication error. FM-A stated the NP was upset since she had instructed staff to notify the family when the error had occurred. FM-A stated the family had previously decided on comfort care measures because R1 had expressed she did not want to go to the hospital anymore. On [DATE], at 2:24 p.m. the DON verified LPN-A had been responsible for 16 medication errors from [DATE] - [DATE] documented. The DON stated she reviewed the facility medication errors with LPN-A, but had not always retained good documentation of those conversations. The DON also verified LPN-A had not had any disciplinary action, or a performance improvement plan, initiated to decrease LPN-A the medication error occurrences. The DON confirmed LPN-A's personnel file did not include any performance evaluations or medication adminsitration competency checks. In addition, the DON stated the facility medication errors were tracked and discussed quarterly at the quality assurance meetings, but were not tracked/trended according to the individual resident or staff member who made the errors. On [DATE] at 3:09 p.m., a telephone interview was conducted with RN-B. RN-B stated she had worked the night shift following R1's [DATE], medication error and when she started her shift, LPN-A appeared upset. LPN-A pulled RN-B aside and informed her she had made a medication error. RN-B stated RN-A had then reported to her the medication error involving R1. RN-B stated she was not told what medications were involved, and she did not ask. RN-B stated she was only informed that the error had happened earlier in the shift, the DON and NP had been notified, and hourly blood pressure checks had been performed. RN-B stated she had not been informed or directed to continue hourly monitoring of R1 throughout the night shift. On [DATE], at 8:36 a.m. a telephone interview was conducted with LPN-[NAME] LPN-A described administering the wrong medications to R1. She identified the error as she went to administer medications for the next resident. LPN-A stated she immediately reported the error to RN-A and had called the NP on-call. LPN-A stated the NP had directed her to to check R1's blood pressures hourly, and to push fluids. LPN-A stated after she had checked R1's blood pressures and had notified the DON who asked if R1's family were present and directed her to inform R1's family of the error so they could help encourage fluids for R1. LPN-A stated she had seen the family leaving the facility but was so upset, she panicked and did not call the family to inform them. When asked, LPN-A verfied she did not inform the NP, DON, or RN-A that she had not informed the family as directed. LPN-A verified the error and confirmed she had not transcribed the NP's new orders, had not provided a full report to the on-coming shift, and had not documented the monitoring of R1's blood pressure and pulse readings in the medical record or progress notes. In addition, LPN-A acknowledged she had not filled out the medication error report until the day after the error had occurred. The facility's [DATE] Medication Errors (Reporting) policy, directed staff to report the error immediately to the Nurse in Charge who would assess the situation, and if emergency or life threatening, would notify a physician immediately. Further the policy indicated a medication error report would be filled out completely by the person who made the error, or the person who discovered the error. The DON was then to assess the error and decide if the error was significant enough to contact the resident and/or responsible party. If a significant medication error occurred, the DON was to contact the resident and/or responsible party. The policy was updated [DATE], to include contacting the DON and the resident's family immediately if the error was significant in nature, an emergency or life threatening. The definition of a significant medication indicated it was an error that caused discomfort or jeopardizes health. It is determined by using professional judgement based on resident condition, drug category, and frequency. The Charge Nurse should reach out to the pharmacy, MD/NP, DON and/or resident care coordinator to assist with determining if it is a significant medication error. High risk medications include, but are not limited to: [MEDICATION NAME], insulin, [MEDICATION NAME] and narcotics. The deficient practice was corrected on [DATE], after the facility had developed and implemented the following corrective actions: Investigated the incident, reviewed/revised policies and procedures related to medication errors and shift reporting. Reviewed and revised medication error forms. Updated facility medication error tracking to include tracking staff member involved with the error in order to identify trends. Performed medication pass competencies with all nurses and trained medication aides. All nursing staff were educated regarding medication errors and shift reporting policies and procedures. Enhanced current QAPI (quality assurance performance improvement) project for decreasing medication errors.

Based on observation, interview and document review, the facility failed to reassess the ability to safely use a power lift recliner for 1 of 1 resident (R53) reviewed for falls. This resulted in actual harm to R53 who climbed out of the recliner in a reclined position, fell , and sustained a left [MEDICAL CONDITION]. The immediate jeopardy (IJ) began on 6/24/19, at 8:30 p.m. when R53 was found on the floor in front of her power lift recliner that was unplugged, but remained in the reclined position. The facility had failed to assess R53 for use of a power lift recliner, and had failed to reassess after staff knew she had previously self transferred from the recliner in the reclined position. This resulted in an immediate jeopardy (IJ) situation for R53. The administrator and director of nursing (DON) were informed of the IJ on 6/26/19, at 1:29 p.m. The IJ was removed on 6/27/19, at 4:11 p.m. however, noncompliance remained at a lower severity level, actual harm, that is not immediate jeopardy (Level G). Findings include: R53's Admission Record printed 6/25/19, indicated R53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. dementia, and [MEDICATION NAME] degeneration. R53's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R53 was severely cognitively impaired. The MDS indicated R53 required extensive assistance with transfers, her balance during transitions and walking was unsteady, and she was only able to stabilize with human assistance. R53's Care Area Assessment (CAA) for falls dated 6/10/19, indicated R53 made no attempt to move on her own, and transferred with extensive assistance. The CAA indicated care plan considerations included R53 was a risk for falls related to impaired balance, diuretic use, bowel and bladder incontinence, vision and hearing impairment, [MEDICAL CONDITION], impaired cognition, dementia and [MEDICAL CONDITION]. Further, the CAA indicated staff were to assist with all transfers, give medications per orders, place the bed against the wall, place a fall mat next to the bed, unplug recliner when resident is in it, bed alarm per family request, and keep wheelchair out of room. R53's care plan dated 5/31/19, indicated R53 was at risk for falling related to unsteady gait, history of falls from prior nursing home, including a fall in (MONTH) (YEAR), that resulted in a right femur fracture. R53's goal was to have no injuries from falls. Interventions were identified to include: assess for unsteady gait and balance, fall mat on left side of bed, call light in reach and encourage use, clear pathways to bathroom, and wheelchair kept out of room when not in use. R53's care plan further indicated she had altered and impaired physical mobility related to confusion, [MEDICAL CONDITION], dementia, [MEDICAL CONDITION], poor judgement skills, unsteady gait, vision deficit, and weakness. R53's goal was to minimize decline. Interventions included: staff to unplug power lift recliner when R53 is in recliner, assist of one for bed mobility, transfers, and wheelchair, foot pedals on wheelchair for locomotion use only, left side rail to improve bed mobility, and to observe for changes in ability, gait, and balance. R53's closet care plan (a nursing assistant care plan located in the resident's closet) printed 6/25/19, indicated R53 required assistance of one for dressing, bathing, transferring, personal hygiene, and mobility. The closet care plan also indicated R53's power lift recliner was to be unplugged when R53 was in the recliner, and included instruction that nursing assistants were to communicate any changes with R53 to the nurse. R53's Morse Fall Scale assessment completed 5/31/19, indicated R53 was at low risk for falls. A subsequent Morse Fall Scale completed on 6/24/19, indicated R53 was at high risk for falls. R53's Assessment of Ability to Operate a Lift Chair (power lift recliner) dated 6/3/19, indicated R53 could not demonstrate physical ability to safely operate the power lift recliner. The assessment indicated R53 did not have the cognitive capacity to safely operate the chair, and did not understand the power recliner controls. The assessment further indicated R53's family had reported that when R53 was at a previous facility, staff would operate the recliner chair for her. Family agreed as a safety course of action to unplug the recliner chair so that if the controls were to get stuck it, R53 could not lift the chair. R53's Physical Therapy (PT) assessment completed 6/4/19, indicated R53's balance during transitions and walking was not steady, and R53 was only able to stabilize with staff assistance. R53's behavior charting indicated on 6/21/19, at 6:02 p.m. R53 was wandering without using her wheelchair or walker, and had self-transferred. The behavior charting further indicated it was a new behavior for R53, and indicated R53's behavior was disruptive with the potential to harm self or others. On 6/24/19, at 7:20 p.m. R53 was observed sitting in a stationary chair about two to three feet away from her power lift recliner. The power lift recliner was in the reclined position with the feet elevated. When speaking with R53, she appeared to be confused, and was asking if school was out. A few minutes later trained medication aide (TMA)-A entered R53's room and stated, Did you crawl out of the recliner? TMA-A turned to the surveyor and stated he had put R53's feet up in the power lift recliner so she would stay in there. TMA-A then asked R53 if she needed to use the bathroom, before assisting R53 back into the power lift recliner. A progress note from 11:37 p.m. on 6/24/19, indicated staff had been helping a resident in a close by room, and heard R53 yelling for help. The progress note indicated R53 was found on the floor in front of her recliner on her left side. Recliner was unplugged, and the foot rest remained in an upright position. According to the notes, R53 denied hitting her head, and complained her left cheek was sore, her left hip hurt along with her back and right hip. No discoloration or displacement noted. Res (resident) was noted to have transferred herself to the bathroom at the beginning of the shift, transferred herself to the ohter chair next to the recliner. res was given a suppository yesterday and also had an incontinent BM (bowel movement) before dinner. Res also c/o (complained) her hemorrhoids being painful and making it difficult to go. Res usual bedtime is around 9:30 p.m., res. toileted 3:20 (p.m.), 4:38 (p.m.), 6:30 (p.m.), 7:25 (p.m.) and 8:40 (p.m.) this evening. This behavior is out of the ordinary for this res. When asked what she was trying to do and res. stated, what do you do when you get up. Res VS (vital signs) obtained and pelvis rocked and res. states pain 'everywhere', in both hips, back, left cheek. Adminsitrator and MD updated. Daughter (name) updated and does not want res to be seen at this time in ER. Will wait for MD to evaluate her in a.m. and to keep her comfortable through the night. Res after HS (bedtime) cares is resting comfortably with her eyes closed, breathing normally and in no sign/symptom of pain noted and bed in lowest position. On 6/25/19, at 6:25 a.m. a progress note indicated, R53 Still has discomfort with weight bearing on left leg-she indicates the groin/hip hurts. The note indicated R53 was more comfortable when lying down in bed, and reiterated the family had requested R53 be seen by a medicine doctor (MD) that morning. On 6/25/19, at 9:26 a.m. a telephone interview was conducted with family member (FM)-C. FM-C stated the facility had called about 10:30 p.m. on 6/24/19, reporting R53 got out of her recliner power chair, thinking she could walk, and had a fall. FM-C stated the facility reported R53 had made two to three other attempts that same day of getting up on her own, and R53's behavior was unusual. FM-C stated the facility reported R53 slept well, and appeared comfortable through the night, but that R53 did complain the left side of her neck and left hip hurt. FM-C stated she did not request to have R53 sent to the ER because the facility had reported R53 was able to walk to the bathroom after the fall, and was resting comfortably when in bed. FM-C verified she had requested R53 be evaluated in the morning by the MD. FM-C stated the NP had evaluated R53 that morning, and R53 was sent to the ER (emergency room ) for further evaluation. On 6/25/19, at 11:24 a.m. nursing assistant (NA)-B stated she had worked with R53 a little. NA-B stated R53 required assist of one for everything. NA-B stated she was unaware of R53 attempting to transfer herself. NA-B stated R53 had fall precautions in place that included a fall mat on the floor next to her bed, and staff was to unplug the power lift recliner power when R53 was in it so she would not use the remote to sit herself up. On 6/25/19, at 11:28 a.m. licensed practical nurse (LPN)-A stated R53's family did not want R53 to be sent to the ER the night she fell , and had requested the NP to evaluate R53 in the morning. LPN-A stated R53 was evaluated that morning by the NP, and R53 was sent to the ER to be further evaluated. On 6/25/19, at 2:01 p.m. LPN-A reported R53 had been admitted to the hospital with [REDACTED]. On 6/25/19, at 2:29 p.m. an interview was conducted with the DON. The DON stated a full fall investigation was completed at the time of R53's fall. The DON stated R53 was within her toileting times. The DON stated she was aware R53 self-transferred from the power lift recliner earlier in the day. The DON stated staff had been in R53's room multiple times on 6/24/19, because R53 had an incontinent bowel movement prior to her fall. The DON stated staff were very aware of R53's needs on 6/24/19, and staff had picked up R53's behaviors were out of her norm. The DON stated R53 had not attempted to ambulate on her own prior to 6/24/19, even though behavior charting indicated R53 had ambulated on own on 6/21/19. The DON stated the facility had started unplugging the power lift recliners as a blanket policy because they'd previously had a resident who was ejected out of the chair due to the handheld control getting stuck between the resident and the chair. The DON stated occupational therapy (OT) would assess a resident to see if they were safe to operate a power lift recliner. The DON further stated a safety assessment of the power lift recliner had been completed when R53 was admitted . The DON stated R53's activities were out of her scope the day she had fallen. The DON stated she believed R53's ability to ask for assistance had not changed, but stated R53 was more verbal than normal on the day she fell . The DON verified no reassessment had been completed for R53 when she started to self-transfer out of the power lift recliner. The DON stated she did not feel R53's recliner being unplugged and in the reclined position with the feet elevated, and her previous attempts of getting out of the recliner on her own contributed to her fall on 6/24/19 in the evening. The DON confirmed R53 was admitted to the hospital 6/25/19, for a left [MEDICAL CONDITION] and was awaiting surgical consult. On 6/25/19, at 3:52 p.m. the DON stated, Residents have good days and bad days, and it doesn't mean (R53) would get up on her own again. The DON further stated, The staff know the residents well, and 'flukey' things happen. Unfortunately people fall down. During a follow up interview on 6/25/19, at 4:47 p.m. the DON verified she was R53 had made two prior attempts to get out of her recliner chair on her own, that same day prior to her fall, on 6/24/19. On 6/26/19, at 1:29 p.m. an interview was conducted with the administrator. The administer stated she did not understand how the facility could have done anything differently to prevent R53 from falling. The administrator stated interventions were put in place. The administrator further stated the NA's increased checks on R53, and R53's power lift recliner was unplugged because it was not safe for R53 to operate. The immediate jeopardy that began on 6/24/19, at 8:30 p.m. and was removed on 6/27/19, at 4:11 p.m. when it could be confirmed the facility had taken actions to remove the immediacy. However, the non-compliance remained at the lower scope and severity level of a G. Interventions verified as implemented included: -All power recliners were removed from the day rooms. -The assessment for the use of power recliners was revised. -All residents with power recliners in their rooms were reassessed by PTA (physical therapy assistant), OT, and the RN using the revised assessment, and care plan changes were made as required. -A Power Recliner use policy was created. -Staff on duty were educated about the use of power recliners, and education for all other staff was initiated by the DON, as employees reported to work. The education was to continue until all staff had received the education. The facility's Falls Prevention policy dated 12/1/10, directed to complete a fall risk assessment on admission and periodically thereafter to determine risk of falls. The environment will be evaluated for possible correction of hazards. Alarms are not designed to prevent the resident from getting up nor are they designed to prevent falls. Alarms are utilized to assist in identifying a mobility pattern for the resident. Alarms do let staff know that a potential for a fall is occurring Staff's speedy response to an alarm may prevent the fall. The facility's Power Recliner policy dated 6/26/19, indicated an assessment will be completed by an RN, PT or OT to determine resident's ability to safely use the power recliner chair. If a resident is deemed appropriate, the power recliner will be placed in the resident room. If the power recliner if deemed inappropriate, it will either be removed from the resident room or it will not be placed. The Power Recliner Assessment will be reviewed at admission, re-admission, and significant change in condition or at a minimum at each quarterly care conference. Acute changes in resident mobility, cognition or behaviors will be brought to the Charge Nurse on duty to a have immediate issues/concerns addressed with positional interventions discussed and care plan will continue to be updated accordingly.