Every finding on record at Alden Courts of Waterford

Based on interview and record review, the facility failed to ensure a resident with a neck fracture had his cervical neck collar (C-collar) in place.This applies to 1 resident (R1) reviewed for quality of care.The findings include:R1's Face Sheet showed his diagnoses include a nondisplaced fracture of his first cervical vertebra, unspecified dementia, and history of falls.R1's March 3, 2026 nursing progress notes showed R1 was admitted to the facility .around 6:30 PM. Resident has a cervical collar due to traumatic closed fracture of C1 vertebra. R1's March 2026 Physician Orders showed a March 4, 2026 order of C-collar on at all times [related to] C1-C2 fracture. On March 12, 2026 a 2:30 PM, V4 CNA (Certified Nursing Assistant) stated he cared for R1 on March 4, 2026. V4 stated R1 had been in bed with the C-collar on, and then later he heard a noise coming from R1's room. V4 stated when he entered R1's room, R1 was on the floor, and his C-collar was on the opposite side of R1's bed near the dresser. V4 stated R1 was supposed to have the cervical collar on at all times, and R1 was a high fall risk.On March 12, 2026, at 2:58 PM, V6 RN (Registered Nurse) said she was the nurse who sent R1 to the emergency room on March 4, 2026 after he fell. V6 said R1 did not have the cervical collar on when she assessed R1, even though the collar was to be on at all times due to his previous fractures. R1's March 4, 2026 nursing progress notes showed R1 fell and was transported via 911 to the Emergency Department (ED). R1's Emergency Medical Services (EMS) March 04, 2026 patient care record showed nursing home staff stated that they last checked on R1 around 9:00 PM. Staff stated that they checked in on R1 again about fifty minutes later when they found R1 on the floor. The report showed the assessment performed by the paramedics revealed a deformity on R1's right hip joint. Paramedics placed a blanket around R1's hip and tied it tight for stabilization of the injury before R1 was brought to the ambulance on the stretcher and taken to the nearest hospital. The report did not show R1's cervical collar was put back in place or was provided to EMS to stabilize R1's head, or that EMS personnel were notified of the existing neck fracture prior to any transport. On March 12, 2026, at 1:20 PM V8 (Physical Therapist) said it is the nursing department's responsibility to ensure devices are placed and removed as ordered. V8 said that the facility consists of cognitively impaired residents who may often take off devices so the staff should monitor and ensure that devices are in place as ordered.R1's Care Plan Report for his C-collar (initiated March 4, 2026) showed Requires a brace secondary to limitation in [range of motion]/fracture C1 vertebra. An intervention showed Apply splint/brace per MD order to affected area.R1's March 4, 2026 ED Note showed spoke with [V6 RN] at [facility], per [facility] closed fracture of the neck C1-C2 known for patient. Patient did not arrive in C-collar. [MD] notified, aspen collar applied.

Based on interview and record review, the facility failed to prevent a cognitively impaired resident (R1) from eloping through an unalarmed door. The facility also failed to secure an exit door with nonfunctioning alarm in accordance with the facility policy. This failure resulted in R1 exiting the facility unnoticed by staff and discovered outside the facility in cold weather on January 31, 2026, putting R1 at risk for injury due to falls and cold weather, and becoming lost due to cognitive impairment. This applies to 1 of 3 residents (R1) reviewed for risk of elopement in the sample of 13. V1 (Administrator) was notified of the Immediate Jeopardy on March 4, 2026, at 10:55 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, as of February 4, 2026, prior to the start of the survey on March 2, 2026, and was therefore Past Noncompliance. This past non-compliance occurred from January 30, 2026 -February 4, 2026. The findings include:On March 2, 2026, at 10:04 AM, V1 (Administrator) identified R1 as having left the facility through an unalarmed door undetected by staff and stated that happened a couple weeks ago. V1 stated there was not an incident report, investigation, or progress note in R1's medical record documented at the time of the occurrence. R1's EMR (Electronic Medical Record) showed R1 was [AGE] years old, readmitted to the facility on [DATE], with multiple diagnoses including unspecified dementia, history of acute respiratory failure with hypoxia, history of fractures of the right humerus and left orbital bones and history of non-displaced fracture of the 6th cervical vertebrae, chronic obstructive pulmonary disease, and chronic diastolic and systolic congestive heart failure. R1's MDS (Minimum Data Set) dated January 9, 2026, showed R1 was severely cognitively impaired and required assistance with ADLs (Activities of Daily Living) including set up assistance with eating, supervision with oral and personal hygiene, bed mobility, sit to stand transfer and ambulation with walker up to 50 feet, partial assistance with bathing, substantial assistance with upper body dressing, and dependent with lower body dressing. Walking greater than 150 feet was not attempted due to medical conditions or safety concerns. On March 3, 2026, at 10:42 AM, V1 (Administrator) stated she was informed the Unit B exit door, to outside of the building, did not have a working audible alarm at the exit, on January 30, 2026. R1 resided on the B unit, but not on the hallway where the unalarmed exit door was located. On March 2, 2026, at 3:45 PM, R1 was alert but confused about date and time. R1 stated she did recall going out a door into the cold and did not know how to get back into the facility. R1 stated she kept walking until she saw a door with a window and started to knock on the window in order for someone to open the door. R1 stated she remembered feeling cold and felt like she was outside for a long time before someone came. R1 stated she began to say her prayers hoping someone would come and bring her inside out of the cold. On March 2, 2026, at 2:15 PM, V5 (CNA, Certified Nursing Assistant) stated on January 31, 2026, she was working on Unit A on the second shift and was passing dinner trays when V5 saw R1 standing outside the Unit A exit door by herself. V5 stated she alerted V4 (RN, Registered Nurse on Unit B), V6 (CNA on Unit B) and V7 (CNA on Unit B) by walking to Unit B and telling the staff R1 was outside of the facility. V5 explained V7, V6, and V5 went outside the Unit B exit door to R1's location outside (by Unit A exit door). V5 also stated V13 (RN on Unit A) opened the door and let R1, V5, V6, and V7 inside. On March 2, 2026, at 2:34 PM, V6 (CNA) stated he was R1's assigned CNA for the second shift (2 PM - 10 PM) on January 31, 2026. V6 stated at the beginning of the shift staff were made aware that the Unit B exterior door alarm was not working. V6 stated earlier in the week, staff were also made aware of the Unit B exit door alarm was not working. V6 stated dinner had just been completed around 6:00 PM, and while V6 was escorting a resident out of the dining room, V5 came from Unit A to tell staff R1 was outside. V6 stated V7 (CNA) also heard that R1 was outside and went down the hall toward the Unit B exit door to find R1. V6 stated he followed V7 out the exit door. V6 stated no alarm was heard when Unit B exit door was opened. V6 stated he saw R1 standing outside the Unit A exit door. V6 stated R1 had to sit in a wheelchair to come inside. V6 described R1 as being too weak to keep walking and noted R1 was breathing heavy with her shoulders going up and down with each breath. V6 stated R1 kept repeating I'm cold and R1's skin was cold to touch. On March 2, 2026, at 2:47 PM, V7 stated she was in the dining room, which was across from the nurses' station and overheard V5 tell V4 that R1 was outside the exit door of Unit A. V7 stated she just started to run down the hall toward the exit to find R1 outside. V7 stated she found R1 outside the Unit A exit door and stated R1 appeared weak and R1 kept saying I'm cold and R1's skin was cold to touch. V7 stated R1 was so weak she was placed in a wheelchair because she could not walk anymore. V7 stated she remembers being told in report both that day and during the previous week that the B wing exit door, near room [ROOM NUMBER], door alarm was not functioning. On March 2, 2026, at 1:12 PM, V4 stated it was almost the end of her shift (6AM - 6PM) on January 31, 2026, when V5 came to the nurses' station to report R1 was outside of the facility. V4 stated she had talked to R1 about 5 minutes earlier when R1 was walking out of the dining room with her walker and stopped at the nurses' station to talk to V4. V4 stated R1 continued to walk down the hall toward the B wing exit door near room [ROOM NUMBER]. R1's room was located in the other hallway on Unit B. R1 was not redirected to her room away from the unalarmed exit door. V4 stated she did not hear an alarm sound when R1 exited the facility and stated the door panel at the nurse's station only lights up with a red flashing light when an exit door is opened. V4 stated the panel was behind her and when she did not hear an alarm, she had no reason to look at the panel. V4 stated staff were aware and had gotten in report that the exit door alarm was not functioning. V4 stated there were only 3 staff on the 2 PM -10 PM evening shift that day and no one was assigned to just monitor the exit door. V4 stated the CNA staff were in the dining room and finishing the dinner meal when R1 walked out of the unalarmed exit door. V4 stated R1 was wearing only a sweat shirt and sweat pants when she went out the exit door. V4 stated she did not write a progress note in R1's medical record nor did V4 notify the physician or resident representative. V4 stated the only one she notified was V1. According to AccuWeather historical data, the outside temperature for the facility's location showed the temperature on January 31, 2026, was a high of 19F (degree Fahrenheit) and a low of 6F. On March 2, 2026, at 2:18 PM, V5 walked with surveyor the path R1 took from the Unit B nurses station, where R1 was last observed, to where V5 found R1 outside and measured the distance using a pedometer. R1 walked 195 feet before being observed or redirected by staff . On March 2, 2026, at 4:28 PM, V8 (R1's physician) stated V8 was not informed R1 had exited the facility unnoticed on January 31, 2026. V8 stated R1 leaving the facility unsupervised had potential for harm to R1 due to the risk of injury related to falls or R1 becoming disoriented and lost. The Facility's policy titled Door Alarm Function Test, undated, showed Procedure.6. Nonfunctioning alarms .Until repair is made the door must be made secure by placement of an additional temporary alarm or added supervision. The Facility's policy titled Elopement and Management of Missing Resident dated March 28, 2023, showed Definition: Elopement is defined as a dependent (cognitively impaired, non-decisional) resident leaving the facility without staff awareness and under circumstances that place the resident's health, safety or welfare at risk.2. Responding to a Resident Leaving or Attempting to Leave the facility or Designated Unit.g. Notify attending physician or NP.h. Document occurrence .p. Upon return of the resident to the facility the Director of Nursing/designee should. j. Conduct a full body assessment and examine for injuries and obtain vitals.vii. Document accordingly in the resident medical record. Prior to March 2, 2026, survey, the facility took the following actions to correct the deficient practice: 1. On January 31, 2026, at 7:00 PM, a head count on all units was completed to make sure no other residents were affected. Every resident was accounted for.2. On January 31, 2026, at 7:00 PM, all other facility door alarms were checked for proper functionality and in good working order. The door alarm verification checks will be done once per day by Maintenance Director/Building Manager, or Manager on duty, and documented on the form.3. On February 3, 2026, at 7:00AM, the temporary exit audible door alarm was installed on Unit B exit door.4. R1's elopement assessment was completed and care plan updated on February 4, 2026.5. All residents were assessed for exit seeking behaviors. Completed on February 3, 2026.6. Residents identified at risk for elopement had their care plans updated on February 4, 2026.7. The Administrator, Nurse Consultant, and Medical Director reviewed the facility policies related to the occurrence: Door alarms, Routine Resident Checks, and Elopement. Completed on February 3, 2026.8. The DON/ADON (Director of Nursing/Assistant Director of Nursing) and Social Service/Designee have reviewed and updated all residents safety care plans as needed. Completed on February 4, 2026.9. The elopement binder was reviewed and updated with current identification picture, face sheet, and elopement care plan on February 3,2026, and the binders are available at each nurses station.10. All staff were in-serviced beginning on February 3, 2026 and ending on February 4, 2026,by the Administrator on the following topics: How to redirect wandering residents away from exits, how to promote safer outcomes for residents through supervision, answering door alarms promptly and reporting any changes in cognition or exit seeking behaviors to the nurse, on routine resident check policy, and where to locate the at risk of elopement binders. Everyone that has worked has been serviced. In-servicing will continue until all employees have been educated. Anyone not educated will be educated prior to returning to work. New staff will be educated on procedure upon hire at general orientation.11. An audit tool to review compliance was developed and an update to the QA Door Alarm Check Verification form was initiated on February 3, 2026. The Audits will be done two times a week for 1 month or until compliance is maintained.12. An emergency QA (Quality Assurance) meeting was held at 1:00 PM on February 3, 2026, by the Administrator with the Director of Nursing and Medical Director regarding the incident and to discuss the plan. The QA committee agreed with the plan as outlined above.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices during provisions of care with regards to hand hygiene and changing gloves. The facility also failed to use the required PPE (Personal Protective Equipment) for residents who were placed on EBP (Enhance Barrier Precaution) and Isolation Precaution. This applies to 4 of 16 residents (R3, R24, R29, R36) reviewed for infection control in the sample of 16. The findings include: 1. Face sheet shows that R24 is 81 years-old who has multiple medical diagnoses including neuromuscular dysfunction of the bladder. On August 25, at 10:50 AM, R24 was resting in bed, she had an indwelling urinary catheter. There was an EBP signage posting on her door. V20 (Nurse) stated that R24 has an indwelling urinary catheter due to urinary retention. On August 26, 2025, around 3:00 PM, R24 was sitting in her wheelchair, when V8 (CNA) put the shoes on to R24. V8 then assisted R24 to get on to the sit-to-stand lift machine where V8 started providing peri-care. R24's leg buckled during provision of peri-care, so V8 assisted R24 back to the wheelchair and from the wheelchair R24 was transferred to bed. V8 continued to provide peri-care and urinary catheter care while wearing the same soiled gloves. After she cleaned R24's perineum, V8 changed her gloves and performing without hand hygiene she donned another pair of gloves and applied barrier cream to R24's buttocks. V8 then changed her gloves again without performing hand hygiene she donned another pair of gloves and applied the incontinence brief. V8 provided care wearing only gloves she did not wear any gown. R24's POS (Physician Order Summary) dated June 2, 2025, shows R24 was placed on EBP for device care or use of urinary catheter. 2. R3 was on enhance barrier precaution (EBP) due to wound care. There was a EBP signage posted on R3's bedroom door. On August 26, 2025, at 9:31 AM, V10 (Nurse) with the help of V11 (Certified Nursing Assistant/CNA) provided wound care to R3's left toe. V11 wore a pair of gloves but did not wear a gown. V11 held R3's left foot and right foot one at a time during skin assessment. After the wound care was completed, and while wearing the same gloves, V11 opened R3's closet to get new socks, he changed R3's socks, he put the shoes onto R3's feet while R3 was still in bed, and assisted R3 to transfer from bed to wheelchair. V11 removed his soiled gloves and without performing hand hygiene combed R3's hair. R3's physician order summary dated July 14, 2025, shows R3 was placed on EBP for chronic wound. On August 27, 2025, at 1:08 PM, V15 (Assistant Director of Nursing/ADON) stated when staff is providing care to a resident, the staff must change gloves and perform hand hygiene from dirty to clean task or in between tasks, and prior to exiting the resident's room to prevent spread of infection. In addition, the staff must wear complete personal protective equipment (PPE) such as gloves, gown, and mask, during provisions of care to resident who is placed on EBP due to either IV (Intravenous) line, indwelling urinary catheter, gastric-tube, or wound care, to protect the resident from potential infection. The Enhance Barrier Precaution (EBP) posting shows: Providers and staff must wear gloves and gown for the following high-contact resident care activities: Dressing Transferring Providing hygiene Changing briefs and assisting with toileting Device care or use: central catheter, urinary catheter, feeding tube, tracheostomy. Wound care: any skin opening requiring a dressing. 3. R36's face sheet showed R36 was admitted to the facility on [DATE], with diagnoses that include Alzheimer's disease, dementia, asthma and obstructive sleep apnea. R36 had a diagnosis of Covid-19 dated August 23, 2025. R36 had the following care plan dated August 23, 2025, that showed: R36 noted with a positive Covid 19 test result. Requiring single room contact/droplet isolation. R36 has a physician order dated August 23, 2025, that showed the following: Isolation contact and droplet precautions due to positive covid test result. On August 25, 2025, at 11:13 AM, V19 (Housekeeping) was cleaning R36's room with the door open. There were droplet and contact isolation signs on the outside of the door. The sign showed the following: stop. Everyone must make sure their eyes, nose and mouth are fully covered before room entry. While cleaning R36's room, V19 was wearing a surgical mask, gown and gloves only. V19 was not wearing an N95 mask nor was he wearing googles, face shield or any eye protection. Once V19 left R36's room, V19 stated he should have had on an N95 mask while cleaning R36's room. On August 27, 2025, at 2:00 PM, V15 (Assistant Director of Nursing/Infection Preventionist) stated that staff are required to don a face shield, N95, gown, and gloves before entering a resident's room that is on contact and droplet isolation for Covid-19 to prevent the spread of infection. The facility's Acute Respiratory Illness testing plan and response strategy policy dated February 2025 showed the following: initiate contact and droplet precautions, including gowns, gloves, fit-tested N95 respirator, and eye protection, such as googles or a face shield, for residents with signs of acute respiratory illness. 4. On August 25, 2025, at 10:37 AM, no EBP (Enhanced [NAME] Precaution) sign was posted on R29's door or door frame. While wearing mask and gloves, V3 (RN/Registered Nurse) assisted R29 to stand, pivot and transfer to the bed. V3 unfastened R29's disposable brief. R29 had an indwelling urinary catheter. R29's sacral/coccyx and the surrounding buttock areas were denuded (outer layer of the skin was lost) and the exposed skin was pinkish in color. R29 had no dressing in place. V3 went to the bathroom, removed her gloves, washed her hands and put on two pairs of gloves (double gloved). V3 then started cleaning R29's anal area, sacral/coccyx and buttocks area using disposable cloths to remove the pasty stool. After cleaning the above mentioned areas, V3 removed the top glove (one of the double glove) on her right hand, then applied the Zinc Oxide ointment on R29's sacral/coccyx and buttocks areas, using her right gloved hand. V3 then removed her bilateral gloves, put on a new pair of gloves and applied the new disposable brief on R29. There was no hand hygiene performed (hand washing or use of alcohol hand rub) in between the dirty to clean task after removing the gloves. During the above observations and provision of care to R29, V3 was not wearing a gown. On August 27, 2025, at 1:03 PM, V2 (Director of Nursing) stated that R29 is on EBP due to indwelling urinary catheter and pressure injury. V2 stated that an EBP sign should have been posted on R29's door to alert the staff to put on appropriate PPE (Personal Protective Equipment) during high-contact resident care. According to V2, V3 (RN) should have worn a gown when she (V3) provided incontinence care to R29 because the care being provided is considered high-contact care and additionally, the resident had an indwelling urinary catheter and pressure injury on the buttocks. V2 stated that if a staff chooses to use double gloves, those double gloves showed be removed after the dirty task, hand hygiene either hand washing, or use of the alcohol rub should be performed before applying a new pair of gloves to continue with the clean task. According to V2, hand hygiene and using a clean gloves between dirty to clean task is important to prevent cross contamination and infection. The facility's policy regarding EBP dated December 2024 showed, Enhanced Barrier Precautions (EBP) are an infection control prevention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. As well as to prevent multi-drug-resistant organism acquisition of those with an increased risk of acquiring MDROs including residents with chronic wound or an indwelling medical device. Under the guidelines of the same policy showed, 1. EBP involves gown and gloves use during high-contact resident care activities for residents known to be infected or colonized with MDROs when contact precautions do not otherwise apply. As well as residents with a chronic wound and/or indwelling medical device. Under the procedure of the same policy showed that high-contact resident activities included the following: changing briefs or assisting with toileting, device care or use, including urinary catheter and wound care. Under the procedure it showed, 4. Post CDC EBP sign outside of the resident's door. a. Gown and gloves use prior to the high-contact care. The facility's policy regarding hand hygiene dated October 2024 showed, It is the policy of the facility that hand hygiene (HH) (hand washing and/or Alcohol-based hand rub (ABHR), also known as Alcohol-based hand sanitizer (ABHS) is to be performed to reduce the potential spread of pathogens. The same policy showed that use of the ABHS is the preferred method of use in most clinical situations. It is the most effective product for reducing the number of germs on the hands of health care providers. ABHS should be used: . e. Immediately upon removal of gloves and PPE.

Based observation, interview, and record review, the facility failed to ensure safe transfer for a resident who requires extensive assistance. This applies to 1 of 1 resident (R24) reviewed for transfer in the sample of 16. The findings include: The Face sheet shows that R24 is 81 years-old who has multiple medical diagnoses including Alzheimer's disease, generalized muscle weakness, abnormalities of gait and mobility, other specified injury of muscle and tendon head, subsequent encounter, and needs for assistance with personal care. R24's Minimum Data Sheet dated July 12, 2025, shows that R24 is cognitively impaired and requires extensive assistance for toileting and transfer. On August 26, 2025, around 3:00 PM, V8 (Certified Nursing Assistant, CNA) assisted R24 to get onto the sit-to-stand lift. When R24 was standing on the sit-to-stand lift, V8 started providing peri-care. R24's legs and knees started buckling, the sling slipped up underneath her breast, and her knees bent to 90 degrees, leaving R24 hanging on a sling from the sit-to-stand lift. R24 looked anxious and was asked twice if she was okay to which she responded No. V8 stopped what she was doing, and assisted R24 back to the wheelchair. While R24 was sitting in her wheelchair, V8 placed a gait belt around R24's trunk. V8 struggled to transfer R24 to the bed. V8 did it by holding/pulling R24's pants, for R24 to stand and pivot. R24 was unsteady and looked weak. V8 transferred R24 to bed, R24's lower extremities were dangling at the edge of the bed. V8 lifted R24's legs to reposition it. On August 27, 2025, at 1:32 PM, V15 (Assistant Director of Nursing/ADON) stated that V8 approached her and informed her that R24 needed to be re-evaluated for transfer because she was not bearing weight. V15 also said that when staff transfers a resident with the use of gait belt, the staff must hold the resident through the gait belt for safety. If the resident has a change of condition and is unable to bear weight, but the resident uses a sit-to-stand machine or transfer through stand and pivot the staff must call another person to help with transfer as a safety measure. V15 further stated V8 should have called another staff to assist with transfer if R24 was not bearing weight.

Based on observation, interview and record review, the facility failed to administered oxygen as ordered by the facility and failed to ensure that the facility's policy regarding oxygen administration was followed.This applies to 1 of 2 residents (R29) reviewed for oxygen therapy in the sample of 16. The findings include:R29 had multiple diagnoses including COPD (chronic obstructive pulmonary disease) and chronic respiratory failure with hypoxia, based on the face sheet.On August 25, 2025 at 10:29 AM, R29 was sitting inside the television room. R29 had an ongoing oxygen via nasal cannula at two liters per minute, using an oxygen concentrator. On August 25, 2025 at 10:35 AM, V3 (RN/Registered Nurse) assisted R29 to stand, pivot and transfer to the wheelchair, because the resident will be taken to the room. After R29's transfer to the wheelchair, V3 removed the nasal cannula from R29, turned off the oxygen concentrator and wheeled the resident inside the room. R29's oxygen nasal cannula and oxygen concentrator was left in the television room.On August 25, 2025 at 10:37 AM, upon arrival in the resident's room, R29 stated I need my oxygen. V3 went out of the room and retrieve the oxygen concentrator from the television room, then placed the oxygen nasal cannula on the resident and started the oxygen concentrator at two liters per minute. At 11:00 AM, after wheeling R29 back to the television room, R29's oxygen concentrator came with the resident. R29's oxygen was ongoing at two liters per minute via nasal cannula.On August 25, 2025 at 12:06 PM, R29 was eating her lunch meal inside the unit dining room. R29 had ongoing oxygen via nasal cannula at two liters per minute using the portable oxygen that was at the back of the resident's wheelchair. V3 was asked to check the oxygen portable tank and confirmed that R29 was receiving two liters per minute of oxygen.On August 26, 2025 at 9:25 AM, R29 was inside the television room. R29 had an ongoing oxygen via nasal cannula at two liters per minute using the oxygen concentrator. V3 was present during this observation. R29 then asked to use the bathroom. V3 turned off the oxygen concentrator and removed the oxygen nasal cannula. V3 assisted R29 to stand, pivot and transfer to her wheelchair. R29 was wheeled to the unit tub room (close to the unit nursing station). During the entire time that the resident was inside the bathroom, R29's had no oxygen ongoing. After using the bathroom, R29 was brought back at the television room, then V3 applied the oxygen nasal cannula and started to administer the oxygen at two liters per minute, using the oxygen concentrator. R29's active order summary showed an order dated July 14, 2025 to administer oxygen continuously via nasal cannula at four liters per minute related to chronic respiratory failure with hypoxia.R29's active care plan initiated on July 5, 2025 showed that the resident had COPD and required oxygen therapy. The same care plan had several interventions including, Administer oxygen per [Physician] orders.On August 26, 2025 at 10:30 AM, V3 was asked to confirm the oxygen order for R29. It was only this time that V3 recognized that the resident should receive four liters per minute of oxygen continuously and changed the oxygen setting to the ordered 4 liters per minute instead of two liters per minute.On August 26, 2025 at 11:52 AM, V4 (Certified Nursing Assistant) assisted R29 to transfer from the chair to the wheelchair. After transferring R29 to her wheelchair, V4 turned off the oxygen concentrator and disconnected the nasal cannula from the concentrator, then proceeded to connect the same nasal cannula tubing to the portable oxygen that was behind the resident's wheelchair, then turned on the portable oxygen, which was set at four liters per minute. V4 then took R29 inside the unit dining room. V4 was asked if the CNAs are allowed to stop and disconnect a resident from the oxygen concentrator and if the CNAs are allowed to connect and start the portable oxygen. V4 stated that she was not sure. At 12:20 PM, V3 (RN) stated that she was not sure if CNAs are allowed to stop and disconnect a resident from the oxygen concentrator and if the CNAs are allowed to connect and start the portable oxygen.On August 27, 2025 at 1:16 PM, V2 (Director of Nursing) stated that R29's oxygen should be administered as ordered by the physician to ensure that the resident receives sufficient oxygen, especially for R29 who has a diagnoses of COPD and chronic respiratory failure with hypoxia. According to V2, it is outside of the CNA's scope of practice to disconnect the oxygen tubing and turn off the oxygen and reconnect the oxygen tubing and start the oxygen. V2 stated that the CNAs can only handle/adjust the nasal cannula or mask to make sure that it is in place. The facility's policy regarding oxygen concentrator dated September 2020 showed, Residents will be administered oxygen via oxygen concentrator upon Physician's order by an RN (Registered Nurse), LPN (Licensed Practical Nurse) or RT (Respiratory Therapist). Certified Nurse Assistants may adjust or reapply nasal cannula or mask only. Under the procedure of the same policy showed, 1. To operate concentrator: .e. Set liter flow dial to LPM (Liter per Minute) prescribed by physician.

Based on observation, interview and record review the facility failed to provide urinary catheter care, failed to ensure that the urinary catheter tubing was not dragging on the floor during transport and failed to secure the urinary catheter to prevent movement based on the facility's policy.This applies to 1 of 3 residents (R29) reviewed for urinary catheter in the sample of 16. The findings include: R29 had multiple diagnoses including neuromuscular dysfunction of the bladder, based on the face sheet.On August 25, 2025 at 10:35 AM, V3 (Registered Nurse) assisted R29 to stand, pivot and transfer to the wheelchair. V3 took R29 to the room. While transporting R29 to the room, the resident's urinary catheter tubing was observed dragging on the floor.On August 25, 2025 at 10:37 AM, V3 assisted R29 to stand, pivot and transfer to the bed. V3 unfastened R29's disposable brief. R29 had a catheter stabilization/securement adhesive (only) on her right leg, but the actual device to secure the catheter was not present. The urinary catheter was not secure to prevent movement. R29 had a moderate amount of pasty stool. V3 provided bowel incontinence care to R29 while the resident was turned on the right side, but did not reposition R29 to clean the front perineal area. V3 did not provide perineal care to the front area of R29, including the urinary catheter and insertion site. After the provision of care, R29 was assisted back to the wheelchair. V3 did not apply a new urinary catheter stabilization/securement device to secure R29's catheter. At 10:55 AM, V3 started pushing R29's wheelchair towards the unit television room. While V3 was transporting R29, the resident's urinary catheter tubing was observed dragging on the floor and was getting caught on the resident's wheel and feet. V3 was informed of the said observation.On August 27, 2025 at 1:10 PM, V2 (Director of Nursing) stated that for all urinary catheter, a device to secure the urinary catheter should be used to prevent pulling of the urinary catheter and to prevent trauma to the insertion site. V2 stated that the urinary catheter tubing should not be allowed to drag on the floor to prevent pulling and infection. According to V2, the nurse should have provide front perineal care, including urinary catheter and insertion site care to R29, especially because the resident had an episode of bowel incontinence, to ensure good hygiene, cleanliness and to prevent urinary infection.The facility's policy and procedure regarding indwelling urinary catheter dated September 2020 showed, Indwelling catheters will be utilized to facilitate urinary drainage when medically necessary. The same policy under the procedure showed, 4. Secure catheter tubing as appropriate to minimize movement of catheter. 7. Complete indwelling catheter cares by cleansing catheter insertion site daily and as needed.

Based on observation, interview and record review, the facility failed to provide pressure injury treatment to a resident as ordered by the physician.This applies to 1 of 3 residents (R29) reviewed for pressure injury in the sample of 16. The findings include:R29 had multiple diagnoses including COPD (chronic obstructive pulmonary disease), chronic respiratory failure with hypoxia, Alzheimer's disease and generalized muscle weakness, based on the face sheet. On August 25, 2025 at 10:37 AM, R29 was taken to her room by V3 (RN/Registered Nurse). R29 was assisted to bed by V3 and while in bed, the resident's disposable brief was removed. The skin on R29's sacral/coccyx and the surrounding buttock areas were denuded (outer layer of the skin was lost) and the exposed skin was pinkish in color. R29 had no dressing in place on the buttocks/sacral/coccyx areas. After providing bowel incontinence care to R29, V3 applied Zinc Oxide ointment on R29's sacral/coccyx and buttocks areas. According to V3, zinc oxide was the only skin treatment that is being applied on R29's sacral/coccyx and buttocks areas. No other skin treatment or dressing was applied by V3.The wound physician assessment dated [DATE] showed that R29 has a stage 2 pressure injury on the coccyx extending to the buttocks measuring 7 cm (centimeters) in length x 5 cm in width x 0 cm in depth. It had 100% open dermis and the peri-wound was denuded. The wound physician documented that the pressure injury had light serous exudate. The same assessment showed recommended daily and as needed treatment, by cleaning the pressure injury with normal saline, zinc oxide to be applied topically and to cover with foam dressing.R29's order summary report showed an active order dated August 8, 2025 for zinc oxide ointment to the buttock topically every day shift and as needed for skin condition related to stage 2 pressure injury. The same order report showed an active order dated August 7, 2025 for, Optifoam Gentle EX (extra or enhanced) (a silicone faced foam with border) Sacrum 7 x 7, apply to buttocks topically every night shift and as needed post cleansing the area with normal saline.On August 26, 2025 at 4:18 PM, V3 stated on August 25, 2025 after seeing R29 without the dressing on the buttocks, she asked V12 (CNA/Certified Nursing Assistant) if there was a dressing on R29's buttocks on the morning of August 25, 2025 before the resident was given a shower at around 7:00 AM. V3 stated that she was informed by V12 that there was no dressing on R29's buttocks on the morning of August 25, 2025 before the resident's shower. V3 confirmed that she was not notified by V12 about the missing foam dressing. According to V3 she did not apply the foam dressing on R29's buttocks during her shift on August 25, 2025 (6:00 AM - 6:00 PM) because the order to apply the foam dressing should be done during the night shift. V3, admitted that she was not aware that there was an order to apply the foam dressing on the buttocks as needed.On August 27, 2025 at 9:18 AM, V12 (CNA) stated that on August 25, 2025 when she assisted R29 to get up and provided shower to the resident at around 7:00 AM, the resident had no foam dressing on her sacral/coccyx and/or buttocks. V12 admitted that she did not inform the nurse on duty (V3) about R29 not having the foam dressing.On August 27, 2025 at 9:23AM, V16 (RN) stated that he applied the foam dressing on R29's buttocks at around 12:00 AM on August 25, 2025 during his shift (6:00 PM-6:00 AM) on August 24, 2025. According to V16, he did not receive a report from the CNA assigned to the R29 that the foam dressing got removed or got soiled after the application at 12:00 AM on August 25, 2025. V16 stated that, if he was informed, he will reapply the foam dressing because there is an order to apply the foam dressing as needed.On August 27, 2025 at 12:55 PM, V2 (Director of Nursing) stated that all pressure injury treatments should be administered as ordered by the physician because it assist with wound healing. According to V2, if the foam dressing was missing for whatever reason, the foam dressing should be reapplied to R29, since there was an order to apply as needed. V2 added that for R29, it is important for the resident to have the foam dressing because it also serves as a protection for the buttocks area since R29 likes to sit in the chair and refuses to use the gel cushion.

Based on interview and record review, the facility failed to ensure medication orders were transcribed accurately on admission. This applies to 2 of 3 residents (R1 and R2) reviewed for medications in a sample of 3. Findings include: 1. R2's Face Sheet showed R2 was initially admitted to the facility on [DATE], went to the hospital on 12/20/24 for a fall, and was readmitted to the facility on [DATE]. R2's 12/21/24 hospital discharge orders showed to orally administer the scheduled medications 81 mg of aspirin twice daily, carbidopa-levodopa 10-100 four times daily, dicyclomine 20 mg before meals and at bedtime, vitamin D 100 mcg daily, and to apply hydrocortisone topically twice daily. R2's discharge orders also included to administer the as-needed medications of hydrocodone-acetaminophen 5-325 every four hours as needed, simethicone every six hours as needed, and to apply zinc oxide topically as needed. R2's December 2024 POS (Physician Order Sheet) and MAR did not include any of the above medications. On 1/30/25 at 11:05 AM, V3 ADON (Assistant Director of Nursing) verified that these medications were missed on R2's December 2024 MAR, adding the medications were not made available to R2 and this was a transcription error. R2's 12/21/24 care plan showed to administer medications per Physician orders. 2. R1's Face Sheet showed R1 was initially admitted to the facility on [DATE], went to the hospital on 12/28/24, and was readmitted to the facility on [DATE]. R1's 1/3/25 hospital discharge orders showed to administer levothyroxine 88 mcg (micrograms) by mouth every morning, alprazolam 0.125 mg (milligrams) every twelve hours as needed, and to use an albuterol inhaler every four hours as needed. R1's January 2025 MAR (Medication Administration Record) showed R1 did not start receiving levothyroxine until 1/7/25, missing the scheduled doses on 1/4, 1/5, and 1/6/25. R1's MAR also showed the order for the albuterol inhaler was not entered until 1/6/25. The MAR also showed R1's 1/3/25 alprazolam order incorrectly transcribed as 0.25 mg every twelve hours (instead of 0.125 mg). On 1/29/25 at 3:07 PM, V2 DON (Director of Nursing) stated that during order transcription for R1, the levothyroxine and albuterol orders were missed and then entered on 1/6/25. V2 stated R1 did not receive any of the incorrectly transcribed doses of alprazolam. R1's 1/3/25 Care Plan showed to administer medications per Physician orders. The facility's 6/2022 Re-Admissions policy showed, .C . 2. The facility nurse will clarify and confirm all admission orders (or any changes, additions, or deletions from previous POS) with the attending physician (see P&P P-7037: New Admission Orders) .

Based on observation, interview, and record review the facility failed to assess a new pressure injury area, failed to implement pressure injury treatment orders, and failed to ensure pressure reducing interventions were in place for four of six residents (R16, R31, R6, R46) reviewed for pressure injuries in the sample of 15. The findings include: 1. R16's Order Summary Report shows she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, bipolar disorder, dementia with agitation, and pressure injury of sacral region stage II. R16's Wound Care Physician Notes dated August 7, 2024 shows, Plan of Care: Continue with skin ulcer prevention protocol of the facility including daily skin check, provide stage appropriate mattress, offload heels with heel protectors or pillow. On August 26, 2024 at 10:35 AM, V5 and V6 CNAs (Certified Nursing Assistants) provided incontinence care for R16. R16's heels were directly on the bed and were not offloaded. R16 was laying on her back. V5 wiped R16's buttocks. There was an open area a little bigger that pea size noted to R16's coccyx. V5 applied A and D ointment to R16's buttocks, but did not place any ointment on the open area. R16 was transferred into her high back wheeled recliner via mechanical lift and brought out to the TV area. There was no cushion on R16's high back wheeled recliner chair. On August 27, 2024 at 11:00 AM, this surveyor requested V2 DON (Director of Nursing) to assess R16's buttocks. At 1:59 PM, V2 said that R16 has an open area on her coccyx. V2 said R16 had a pressure injury there in the past. V2 said the area is opened again and is a stage II pressure injury. V2 said she did not know R16 had an open area to her buttocks. R16's Treatment Administration Record shows a foam dressing was ordered from July 19, 2024-August 5, 2024. Zinc oxide cream was ordered on August 5, 2024. R16's Order Summary Report dated August 27, 2024 shows a new order was entered on August 27, 2024 for medihoney wound/burn dressing paste to coccyx every night shift and cover with foam bordered dressing. R16's Wound Care Physician Note dated August 28, 2024 shows R16 has a stage III pressure area to her coccyx that measure 1 cm X 0.8 cm X 0.1 CM. R16's Shower Day Worksheet shows she did not have any open areas on August 21, 2024 or August 24, 2024. It showed an open area noted on August 28, 2024. On August 27, 2024 at 1:59 PM, V2 said that R16 should have heel protectors in her room for when she is in bed. V2 said the heel protectors are provided by the hospice company. V2 said if the wound care doctor recommends interventions, then staff should follow them. 2. R31's Admission Record dated August 27, 2024 shows she was admitted to the facility on [DATE] with diagnoses including right femur fracture, osteoporosis, difficulty walking, muscle weakness, pressure injury of right and left heel, history of falling and dementia. R31's Braden Scale dated August 17, 2024, shows she has a mild risk of developing a pressure injury. R31's Wound Physician Progress Notes dated August 21, 2024 shows Assessment and Plan: Low air loss mattress, reposition every two hours and as needed, pressure relieving seat cushion, offload heels, and heel protectors to both feet. R31's Wound Physician Progress Notes dated August 28, 2024 shows R31 has an unstageable pressure injury to her coccyx. On August 27, 2024 at 9:33 AM, V8 took R31 to the bathroom to toilet her. There was a foam dressing to R31's coccyx that was partially intact. V8 removed the foam dressing as it was coming off. V8 finished toileting R31 and transferred her back into her wheel chair to put her in the TV room. V8 notified V15 LPN (Licensed Practical Nurse) about R31's dressing at 10:04 AM. At 10:41 AM, V2 DON (Director of Nursing) and V15 went into R31's room to apply a new dressing. There was a nickel sized open area noted to R31's coccyx. The wound bed was covered with yellow tissue. R31 did not have a low air low mattress in place. On August 27, 2024 at 1:59 PM, V2 said she does not believe R31 has ever had a low air loss mattress. V2 said if the wound doctor recommends interventions, then staff should follow them. V2 said she usually enters the order when the wound care doctor emails her their notes. On August 28, 2024 at 10:16 AM, V3 CNA said if an open area is found on a resident, she tells her nurse right away, because she wants to make sure the nurse can assess the wound and get a dressing placed. 40085 3.) R6's face sheet shows she has diagnoses including dementia and a pressure injury to her right heel. R6's active care plan shows she requires staff assistance to turn and reposition and is at risk to develop pressure a injury. A Braden Scale (pressure ulcer risk assessment) completed on 8/26/24 shows she is at risk to develop pressure. A wound assessment completed on 7/31/24 by V13 (wound care physician) shows R6 has a Deep Tissue Pressure Injury (DTI) to her right heel measuring 2 centimeters (cm.) long x 3 cm. wide x 0 cm. deep. The assessment identifies treatment orders to include off load heels and heel protectors to both feet, and for Betadine solution skin prep and an Optifoam dressing to be applied every 2 days and PRN (as needed). A wound assessment completed on 8/14/24 by V13 shows R6's right heel pressure injury remained the same size and the same treatments and interventions were ordered. (There is no documented wound assessment in the Electronic Medical Record in between 7/31/24 and 8/14/24). R6's active Physician Order Summary shows the order for Betadine was not entered until 8/14/24, and the Optifoam dressing order was not entered until 8/15/24. R6's Treatment Administration Record (TAR) shows no treatment for the DTI to her right heel were administered until 8/14/24 (Betadine solution) and Optifoam (8/15/24). (15 and 16 days later) On 8/28/24 at 7:17 AM, V13 said R6's DTI was identified on 7/31/24 and he saw her that same day. V13 said he gave treatment orders that day to include offloading off heels with heel protectors or pillows and Betadine with a Optifoam dressing. V13 said DTI's can develop very quickly and off loading is one piece that is important to prevent pressure injuries from developing or worsening. On 8/28/24 at 7:32 AM, V2 (Director of Nursing) V13 and this surveyor entered R6's room. Her bed was in the low position and she was still asleep. V2 raised R6's bed and when the covered were pulled back to assess the pressure injury, R6's heels were flat against the mattress with no offloading of her heels. V13 completed the assessment and said it measured 2 cm x 2 cm and was improving. R6's right heel had a purplish discoloration to it. After the assessment was completed V2 verified that R6's heels should have been offloaded. On 8/28/24 at 10:20 AM, V2 said she was not aware of the treatment orders for R6's pressure injury until 8/14/24. V2 looked for any prior orders on the TAR and was unable to find that it was being administered prior to 8/14/24. V2 said the wound care doctor had not sent his 7/31/24 assessment to her and she was not sure who V13 rounded with on 7/31/24 when he gave the treatment orders. V2 verified V13's 7/31/24 assessment showed treatment orders to begin that day and every continue every 2 days and as needed. The facility policy provided Prevention and Treatment of Pressure Injury and Other Skin Alteration policy dated 03/02/21 shows treatment modalities and interventions should be identified and implemented. Pressure injury skin assessments should be documented weekly. 4.) R46's active alteration in skin care plan initiated on 7/18/24 shows she has a pressure injury to her right coccyx. Interventions include turning and repositioning and off loading heels. R46's Braden Scale completed 8/20/24 shows she is at risk to develop pressure injuries. A wound assessment completed on 8/21/24 by V13 shows R46 has a 0.4 x 0.4 x 0.1 stage 3 pressure injury to her coccyx. Treatment recommendations include offloading heels with pillows or heel protectors. On 8/26/24 at 9:50 AM, this surveyor entered R46's room with V9 (CNA) to observe care being provided. When V9 pulled back the covers from R46, her heels were flat against the bed and not off loaded. On 8/27/24 at 8:51 AM, V5 CNA said when residents are at risk for pressure and in bed they should have their heels off loaded with pillows or heel protectors. On 8/27/24 at 1:59 PM, V2 said interventions for residents with pressure injuries include off loading heels with either a pillow or heel protectors and the staff should follow the physician recommendations.

Based on observation, interview, and record review the facility failed to secure controlled substances and the facility failed to label insulin pens with the date opened for 5 of 15 residents (R47, R33, R6, R24, R8) reviewed for medications in the sample of 15. The findings include: On 8/28/24 at 9:30 AM, V15 Licensed Practical Nurse unlocked the medication room door and entered the medication room with this surveyor. This surveyor saw the fridge was unlocked and V15 said oh that should be locked. The medication room contained house stock (over the counter) medications in cabinets, medical supplies and a fridge. Inside the fridge contained: an opened bottles of R47's hyrdromorphone (schedule II narcotic) a bottle of liquid lorazepam, and an unopened bottle of liquid lorazepam and opened bottles of liquid lorazepam for R6, R33, and R24. On 08/28/24 at 9:52 AM, V2 Director of Nursing said the fridge needs to be locked because it has controlled substances which need to be double locked. V2 said the nurses need to lock the fridge at all times. The facility's Storage/Labeling/Packaging of Medications dated 1/2022 shows Schedule II controlled medications are stored under a double-lock system accessible to only licensed staff. 40085 2.) On 8/27/24 at 8:25 AM, during morning medication pass inside the medication on the B wing there were two open and not dated insulin pens inside of it belonging to R8. One insulin pen was identified as containing Lispro and the second was identified as Aspart. V12 (Registered Nurse) said all insulin pens should be labeled and dated with an open date and expiration date. R8's active order summary shows an order for Lispro insulin to be given on a sliding scale basis with a start date of 8/19/24, and an order for Lantus Solostar 17 units to be given one time a day, expires after 28 days. No active order was found for Aspart. On 8/28/24 at 11:14 AM, V2 (Director of Nursing) said insulin pens should be labeled when open and have an expiration date of 28 days after opening. The facility provided Prefilled Insulin Multi-Dose Pens, Use of policy dated 01/2022 shows Insulin pens should be initialed and noted with the open date and the expiration date and initials of the nurse at the time the pen is first used.

Based on interview and record review the facility failed to ensure PRN (as needed) psychotropic medications had a stop date for 2 of 5 residents (R16, R33) reviewed for psychotropic medications in the sample of 15. The findings inlcude: R16's Physician Orders (POS) dated 08/08/24 shows an order for lorazepam intensol oral concentrate 2 mg/ml Give 0.25 ml sublingually every 1 hour as needed for anxiety/agitation related to unspecified dementia, unspecified severity, with agitation, bipolar disorder. There are no stop dated included in this order. R33's POS dated 5/28/24 shows an order lorazepam intensol oral concentrate 2 mg/ml Give 0.25 ml by mouth every 2 hours as needed for anxiety, restlessness and another order for lorazepam intensol oral concentrate 2 mg/ml Give 0.5 ml by mouth every 2 hours as needed for anxiety, restlessness. There are no stop dates included in this order. On 08/28/24 at 11:14 AM, V2 Director of Nursing said PRN medications need to have a stop date of 14 days after the start of the order and be reordered by the doctor if still needed. The facility's As-needed Psychotropic and Antipsychotic Medication Orders dated 1/2022 shows PRN orders for psychotropic medications (excluding antipsychotics) are limited to 14 days.

Based on observation, interview and record review the facility failed to ensure dietary supplements were provided for 2 of 15 residents (R46, R14) reviewed for weight loss in the sample of 15. The findings include: 1.) R46's face sheet shows she was admitted to the facility on [DATE] and has diagnosis including dementia and severe protein-calorie malnutrition. R46's active nutrition care plan initiated 7/29/24 and active Physician Order Summary (POS) both show she should receive the following supplements: Mighty Shakes with meals, fortified cereal at breakfast, Magic Cup with lunch and Pro T gold (nutritional supplement) 2 times a day. R46's July admission weight is documented at 90.8 pounds (lbs.) and on 8/8/24 her weight was 86.2 (lbs.) A comprehensive nutrition assessment completed by V10 (Dietician) on 8/21/24 shows R46 had a significant weight loss of 5.1% in one month. On 8/27/24 the breakfast service on the B wing was observed between 8:20 AM until 8:51 AM when R46 was finished with breakfast. R46 was not served a Mighty Shake. Next to R46's meal tray was her diet order card which clearly indicated she should receive a 4 ounce carton of Mighty Shake at Breakfast. No Mighty Shakes were seen being handed out with meals during the breakfast service to any residents on the B wing. On 8/27/24 at 8:40 AM, V12 (Registered Nurse/RN) said she doesn't believe anyone on the unit is on Mighty Shakes, but some residents receive Med Pass (another supplement) and those can sometimes be interchanged. V12 said there is no tracking of Mighty Shakes in the nursing documentation (Medication Administration Record) to show if someone received one. 2.) R14's face sheet shows she was admitted to the facility 9/30/2023 with diagnoses including dementia, and vitamin B12 deficiency anemia. R14's active care plan does not address weight loss. R14's last Comprehensive Nutritional Summary was completed 6/14/24 by V10 and shows she should be on Mighty Shakes and fortified cereal at breakfast. R14's active POS shows Mighty Shakes were changed on 8/7/24 to be given 2 times a day with lunch and dinner. R14's weight summary report shows a July weight (no specific day was specified on the monthly report) of 118.6 lbs. and an August weight of 110.8 lbs. a 6.58% (7.8 lbs.) weight loss in one month. On 8/27/24 at 10:10 AM, V10 said dietary supplements are given to residents with weight loss, or at risk for weight loss, including hospice residents. V10 said the documentation for med pass and liquid protein is in the MAR and nurses document that, but Magic Cup and Mighty Shakes is identified on the residents diet cards and the Certified Nursing Assistants (CNA's) are responsible to obtain those from the nourishment/serving area refrigerators on the units. V10 said the CNA's then document them in the tasks charting of the Electronic Medical Record/EMR. On 8/27/24 at 12:24 PM, R14 was observed in the dining area on the B wing there was no Mighty Shake or Magic Cup served with her noon meal. On 8/28/24 at 10:31 AM, V9 (CNA) said there is no list on the unit or any other way of identifying who should receive Magic Cups or Mighty Shakes and they do not know who gets them until they complete their task charting in the EMR at the end of the day. The facility provided Dietary Supplement policy revised 5/24 shows food and dietary supplements should be provided as ordered to enhance a resident's nutritional status.

Based on observation, interview, and record review, the facility failed to maintain a resident urinary drainage bag below the level of her bladder in order to prevent urinary tract infections for one of five residents (R16) reviewed for urinary catheter or urinary tract infections in the sample of 15. The findings include: R16's Order Summary report dated August 27, 2024 shows she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, encounter for fitting and adjustment of urinary device, mental disorder, bipolar disorder, and dementia. On August 26, 2024 at 10:35 AM, V5 and V6 CNAs (Certified Nursing Assistants) transferred R16 from her bed to her high back wheeled recliner via mechanical lift. While R16 was on her sling, in the air, V6 lifted R16 urinary drainage bag above the level of her bladder and set the bag on top of R16's lap. V5 and V6 transferred R16 into her recliner. V6 then lifted R16's urinary drainage bag above the level of her bladder again, in order to hang it on the side of her recliner. There was amber urine in the tubing and in the urinary drainage bag. On August 28, 2024 at 10:16 AM, V3 CNA said urinary drainage bag should be kept below the level of the bladder because if it's not, then the urine could go back and create infection. The facility's Catheter Care Policy dated September 2020 shows daily and as needed catheter care will be done to promote comfort and cleanliness. It does not include information regarding where to keep the urinary drainage bag.

Based on observation, interview, and record review, the facility failed to follow enhanced barrier precautions (EBP) and failed to change their gloves and perform hand hygiene in a manner to prevent cross contamination for two of 15 residents (R16, R44) reviewed for infection control in the sample of 15. The findings include: 1. R16's Order Summary report dated August 27, 2024 shows she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, encounter for fitting and adjustment of urinary device, encounter for attention to gastrostomy, mental disorder, bipolar disorder, and dementia. An order for EBP for device care or use of feeding tube and urinary catheter dated August 5, 2024. On August 26, 2024 at 10:33 AM, there was a sign on R16's door that showed Enhanced Barrier Precautions. V7 (RN) Registered Nurse and V6 CNA (Certified Nursing Assistant) were in R16's room to disconnect R16's percutaneous endoscopic gastrostomy tube. Neither V7 or V6 had gowns on. On August 26, 2024 at 10:35 AM, V5 and V6 CNAs provided incontinence care to R16. V6 wiped R16's front peri area, helped R16 turn onto her side. There was stool in R16's buttocks. V6 did not change her gloves or perform hand hygiene. 2. R44's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, diabetes, palliative care, and chronic cough. On August 26, 2024 at 10:17 AM, V5 CNA took R44 to the bathroom. There was urine in R44's incontinence brief. V5 removed R44's incontinence brief, touched R44 handles of her wheel chair, retrieved wet wipes then proceeded to wipe R44 front peri area and buttocks. V5 applied cream, touched the transfer belt, placed a new brief onto R44, and then pulled up R44 pants. V5 did not change her gloves or perform hand hygiene before touching multiple clean items. R44's Care Plan initiated July 31, 2024 shows, R44 requires bowel and bladder support secondary to bladder incontinence and bowel incontinence. On August 28, 2024 at 10:16 AM, V3 CNA said gloves and gown should be worn when residents have a peg tub, urine catheter and wounds. V3 said gloves should be changed before placing a new incontinence brief because you could contaminate clean items. The facility's Enhanced Barrier Precautions policy dated December 14, 2023 shows, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. As well as to prevent multi drug resistant organism acquisition of those with an increased risk of acquiring MDROs including residents with a chronic wound or an indwelling medical device. Gown and gloves use prior tot he high contact care activity. The facility's Hand Washing and Hand Hygiene policy dated June 4, 2024 shows, Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items.

Based on observation, interview and record review, the facility failed to serve roasted potatoes suitable for mechanical soft diets and failed follow menu spread sheet for serving vegetables and pulled pork. This applies to 7 of 7 residents (R8, R23, R27, R35, R36, R39, R245) reviewed for dining in the sample of 15. The findings include: Physician Order Sheet and facility Diet Order listing showed that R8, R23, R27, R27, R35, R36 and R245 are on mechanical soft diets. On October 2, 2023, at 12:39 PM, V8 (Cook) was at the steam table plating the lunch meal. V8 stated that the residents receive the same item of roasted potatoes for regular and mechanical soft diets. R8, R23, R27, R35, R36, R39, R245 who were on mechanical soft diets received roasted potatoes with skin on them. R35 only had 2 teeth in front and did not touch her potatoes. R8 also received coleslaw instead of cooked vegetables. On inquiry, whether the residents can have skin of potatoes for mechanical soft diet, V7 (Dietary Manger) stated that they followed the recipe for roasted potatoes. V7 was asked to provide policy and procedure for the same. V7 came back at a later time and agreed that potato skin and coleslaw should have been avoided for mechanical soft diets. Facility Spring/Summer menu spreadsheet for October 2, 2023 (Cycle Day 9) showed to serve braised cabbage instead of confetti coleslaw for mechanical soft diets. Facility Standards of Professional practice for Regular ground/mechanical soft diets included as follows: Breads and starches to avoid: Potato skins, potato chips, tortilla chips, pretzels, French bread, hard taco shells. Vegetables: Avoid: Hard raw vegetables. On October 4, 2023, at 12:29 PM, at lunch meal service R8, R23, R27, R35, R36, R39, R245 received pulled pork served in a bun. The pulled pork was noted to have strands of pork in varying sizes and length. V7, who was in the area stated that the regular and mechanical soft diets received the same pulled pork. Facility Spring/Summer menu spreadsheet for October 4, 2023 (Cycle Day 11) showed pureed pulled pork for mechanical soft diets. V7 stated that it must have been a typo and she will check with the menu specialist. On October 4, 2023 at 1:38 PM, V7 stated that the menu specialist stated that the mechanical soft diets were supposed to receive ground pulled pork instead of regular consistency of the same and that the typo of serving pureed pork will be corrected. V7 added that the menu specialist also confirmed that the mechanical soft diets should not receive potato skin. Policy and Procedure titled Mechanical Soft Prep (last revised August 18) included as follows: Policy: Mechanical soft food will be served as ordered. Mechanical soft food will be palatable, attractive, and prepared in a safe manner. Purpose: To provide residents with the consistency needed to tolerate food. Procedure: 1. The food used for the general diet will be used for the mechanical soft diet. Foods that are difficult to chew are replaced with foods that have been altered into a form that can be easily chewed.

Based on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene and gloving during incontinence care, wound care, and medication administration. In addition, the facility failed to provide clean barrier during blood glucose monitoring. This applies to 6 of 15 residents (R1, R4, R7, R14, R29, R33) reviewed for infection control in the sample of 15. The findings include: 1. On October 3, 2023, at 10:13 AM, V17 (Certified Nursing Assistant/CNA) assisted R7 to the bathroom. V17 assisted R7 to transfer from wheelchair to the toilet. When R7 finished using the toilet, V17 put the shoes on R7, assisted R7 to stand up and proceeded to provide peri-care, then she pulled the incontinence brief and pants back up to R7, while wearing the same soiled gloves all throughout the care. 2. On October 3, 2023, at 10:29 AM, V17 (CNA) and V22 (Resident Assistant/RA) rendered incontinence care to R33. V17 cleaned R33's perineum from front to back, she (V17) applied clean incontinence brief, and barrier cream, and repositioned R33. V17 changed her gloves without hand hygiene all throughout the care. 3. On October 4, 2023, at 11:48 AM, V18 (Nurse) provided wound care to R29 who had a pressure ulcer on the left heel. V18 removed R29's socks, touched R29's bare foot to check the wound, then proceeded to remove soiled dressing, then she cleaned the wound while wearing same gloves. After cleaning the wound, V18 changed her gloves without hand hygiene, she applied (Brand name of topical ointment) on the wound and covered it with bordered gauze. V18 assisted R29 back to the wheelchair, she picked up the garbage, removed her gloves and left the room without hand hygiene. On October 4, 2023, at 4:55 PM, V2 (Director of Nursing/DON) stated that during wound care when staff remove the soiled dressing, they should change their gloves and do hand hygiene. During peri-care, the staff must perform hand hygiene and change gloves in between task to prevent contamination and potential infection. Facility's Non-Sterile Dressing Change Policy and Procedure dated 3/2021 indicates: Guidelines: 1. non-sterile dressings protect open wounds and absorb drainage. 2. Designated staff member will use non-sterile dressing technique for all dressing changed unless otherwise indicated by the physician or nurse practitioner/NP or manufacturer guidelines. Clean aseptic technique should be used. Procedure: 10. Remove soiled dressing and place in a trash bag after observing soiled dressing and peri-wound for any drainage, checking for amount, color, consistency, and odor. 11. Remove gloves, perform hand hygiene, and apply new gloves. 13. Clean wound with normal saline or prescribe cleanser. 15. Upon completion, removes gloves, perform hand hygiene, and apply new gloves. 17. Apply prescribed topical agent to the wound bed. 18. Apply wound dressing. 21. Discard gloves and all supplies in trash bag and remove equipment. 22. Perform hand hygiene. Facility's Hand Washing and Hand Hygiene dated June 4, 2020, shows, Purpose: Appropriate hand hygiene is essential in preventing the spread of infectious organisms in healthcare settings. Guidelines: 1. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items. Specific examples include but are not limited to: f. After removing gloves. g. After touching any item or surface that may have been contaminated with blood and body fluids, excretions, and secretions. 48308 4. R4's Admission Record showed R4 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, type 2 diabetes, hypertension, and muscle weakness. R4's MDS (Minimum Data Set) dated June 29, 2023, showed R4 was severely cognitively impaired and required extensive assistance with bed mobility, toilet use, personal hygiene, and eating and is dependent on staff for transfer. On October 3, 2023, at 11:04 AM, V9 and V10 (both CNAs) provided incontinence care to R4. R4 was lying in bed and V10 cleansed the front of R4. V9 assisted to turn R4 to her right side and V10 cleansed the perineal area from the back. V9 commented there was brown smear on the wipe after cleaning. R4 urinated again while on her right side and V9 turned R4 to her back. V10 cleansed R4 front of the perineum again without changing gloves. On October 3, 2023, at 2:36 PM, V4 (Infection Preventionist/IP Nurse) stated the expectation for staff while providing incontinence care would be to change gloves between wiping stool and cleansing the front of the perineum. 5. R1's Admission Record showed R1 was admitted to the facility on [DATE]. R1's MDS (Minimum Data Set) showed R1 had multiple diagnoses including type 2 diabetes, dementia, anemia, hypothyroidism, polyosteoarthritis, and asthma. R1's MDS (Minimum Data Set) dated August 4, 2023, showed R1 had severe cognitive impairment and required extensive assistance with bed mobility, dressing, personal hygiene, and toilet use and dependent on staff for transfer and uses a wheelchair for mobility. On October 2, 2023, at 12:02 PM, R1 was seated in her wheelchair at a dining table with 3 other residents. The table was set with clean linen tablecloth and napkins, plates, and utensils. V3 (Registered Nurse/RN) performed blood glucose test on R1 while she was at the dining table, held R1's finger over the clean utensils, pricked the finger with lancet, drawing blood and placing the blood on the glucose monitor strip without a barrier. V4 (IP Nurse) also witnessed V3 perform the blood glucose test at the dining table. V4 told V3 you are not allowed to do that. 16746 6. On October 3, 2023 at 4:04 PM, after preparing and administering a medication to R29, V6 (Licensed Practical Nurse) wheeled R29's wheelchair to the unit TV (television) lounge and then wheeled R14's reclining wheelchair out of the unit TV lounge to the unit nursing station. After wheeling and positioning R14's reclining wheelchair close to the medication cart (by the unit nursing station), V6 started preparing R14's medications. V6 took a bottle of Vitamin D3 tablets, opened the bottle cap and poured several tablets of the said medication inside the bottle cap. Since V6 needed only one tablet of the Vitamin D3, V6 used her finger to hold on to the one tablet (while still inside the bottle cap) and returned the rest of the tablets back inside the bottle. V6 then crushed the medication, mixed it with apple sauce and administered the Vitamin D3 with other medications to R14. During the above-mentioned procedure, V6 did not perform hand hygiene (hand washing and/or gloving) after handling the wheelchairs of R29 and R14, and before preparing R14's medication. On October 4, 2023 at 12:07 PM, V2 (Director of Nursing) stated that it is not the standard of practice at the facility to touch medications with bare hands/fingers. V2 also stated that it was not the standard of practice at the facility to return the medications back inside the bottle especially if the medications were potentially contaminated to ensure infection control. On October 4, 2023 at 12:15 PM, V6 acknowledged that she held R14's medication with her bare hand/finger without performing hand hygiene and/or putting on gloves, after handling the wheelchairs of the two residents. Review of the facility's pharmacy medication pass guidelines dated 2005-2019 showed to practice hand hygiene (hand wash with soap and water or use of commercially prepared alcohol gel) under multiple circumstances including, before starting the medication pass and after physical contact with resident during medication pass. The same medication pass guidelines showed in-part under infection control, Follow all facility infection control policies and procedures, including proper hand hygiene and Do not touch medications directly; if this happens, discard medication and administer new.

Based on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 5 of 5 residents (R14, R26, R36, R245 and R249) reviewed for ADLs (activities of daily living) in the sample of 15. The findings include: 1. R14 had multiple diagnoses including dementia without behavioral disturbance, late onset of Alzheimer's disease and bullous disorder (rare skin condition causing large, fluid filled blisters) based on the face sheet. R14's quarterly MDS (minimum data set) dated July 25, 2023 showed that the resident was severely impaired with cognition and required extensive assistance from the staff with personal hygiene. On October 2, 2023 at 2:05 PM, R14 was sitting in her wheelchair inside her room. R14 was alert but non-verbal. R14's fingernails were long with black and thick yellow substances underneath. V2 (Director of Nursing) stated that R14's family does not want the resident's fingernails shorten, however V2 acknowledged that R14's fingernails should be cleaned by the staff. On October 3, 2023 at 10:28 PM, R14 was sitting in her high back reclining chair. R14 was alert but non-verbal. In the presence of V6 (Licensed Practical Nurse/LPN) and V5 (family/POA [Power of Attorney]), multiple of R14's fingernails were observed with black substances underneath. V5 stated that she told the facility staff about the long and dirty fingernails of R14, but the staff does not trim and/or clean the resident's fingernails. V5 stated that the last time she trimmed and cleaned R14's fingernails was on the first of September 2023. According to V5, R14 had a history of resisting care but because of the progression of dementia, R14 had been calmer and compliant with care. V6 was present during the entire interview of V5. R14's active care plan initiated on April 14, 2017 showed that the resident had ADL self-care performance deficit related to dementia. The same care plan showed multiple interventions including, Assist with ADL tasks as needed, Assist with personal hygiene as needed and Provide needed level of assistance and support to complete Activities of Daily Living. 2. R26 had multiple diagnoses which included dementia without behavioral disturbance and Alzheimer's disease, based on the face sheet. R26's annual MDS dated [DATE] showed that the resident was moderately impaired with cognition and required extensive assistance from the staff with personal hygiene. On October 2, 2023 at 11:12 AM, R26 was in bed, alert and verbally responsive. R26 had accumulation of long chin hair and her fingernails had black substances underneath. R26 was asked if she wanted the staff to remove her facial hair and clean her fingernails. R26 replied, okay. V3 (Registered Nurse) was present during the observation and interview of R26. On October 3, 2023 at 11:40 AM, R26 was in bed, alert and verbally responsive. R26 had accumulation of long chin hair and her fingernails had black substances underneath. In the presence of V6 (LPN), R26 was again asked if she wanted the staff to remove her facial hair and clean her fingernails. R26 replied, yes. R26's active care plan initiated on November 20, 2021 showed that the resident had ADL self-care deficit. The same care plan showed multiple interventions including, Assist with ADL task as needed and Provide needed level of assistance and support to complete Activities of Daily Living. On October 4, 2023 at 12:09 PM, V2 (Director of Nursing) stated that it is part of the nursing care and service to provide assistance to all residents needing assistance with shaving/removal of unwanted facial hair and cleaning and trimming of fingernails to ensure and maintain good hygiene and grooming. 36567 3. R36's face sheet showed multiple diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified abnormalities of gait and mobility, weakness, history of falling. R36's Annual MDS dated [DATE] showed that R36 was severely impaired in cognition and required extensive one person assistance with personal hygiene. On October 2, 2023 at 11:30 AM, R36 was seated in the television room and noted to have long nails with some of them jagged with chipped nail polish. R36 was able to respond clearly to queries. R36 remarked I need my nails done and cut. I need them to cut it. R36 also had several long facial hairs on her chin. R36 stated I have to have them remove it. On October 3, 2023 at 1:55 PM, R36's nails were still long and jagged and R36 stated that her facial hair was removed but they did not have time to do my nails. R36's request about her nails was relayed to V12 (Certified Nursing Assistant). R36's restorative care plan dated July 24, 2023 included that R36 has an ADL (activities of daily living) Self Care Performance Deficit related to Syncope, Dementia, Chronic Obstructive Pulmonary Disease, Depression, weakness. Intervention included to assist with ADL tasks as needed. 4. R245's face sheet showed multiple diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anxiety disorder, urinary tract infection, history of falling. R245's 5-day MDS dated [DATE] showed that R245 was severely impaired in cognition and required limited one person assistance in personal hygiene. On October 2, 2023 at 10:37 AM, R245 was seated at the nurses station and noted to have blackish substance underneath his finger nails. R245 did not respond clearly with queries. On October 3, 2023 at 11:37 AM, R245 was again seated at the nurses station and his finger nail showed blackish substance underneath. This was relayed to V11 (Resident Assistant). R245's restorative care plan revised October 26, 2022 included that R245 has an ADL Self Care Performance Deficit related to elbow infective bursitis, right elbow cellulitis, Dementia, weakness. Intervention included to assist with ADL tasks as needed. 5. R249's face sheet showed multiple diagnoses including hemiplegia, unspecified affecting left nondominant side, transient cerebral ischemic attack, Alzheimer's disease, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit. R249's Admission MDS dated [DATE] included that R249 was severely impaired in cognition and required extensive one person assistance with personal hygiene. On October 2, 2023 at 11:45 AM, R249 was in the lounge area watching television. R249 had multiple long facial hairs on her chin area. R249 stated that she needs help with grooming. R249 was able to respond clearly to queries. R249's restorative care plan revised August 18, 2023 included that R249 has potential for ADL fluctuations secondary to hemiplegia/hemiparesis. Intervention for the same included to assist resident with ADLs as needed.

Based on interview and record review, the facility failed to ensure a resident's medications were administered timely in accordance with the prescriber's order and the facility's Medication Pass Guidelines. This applies to 1 of 1 resident (R21) reviewed for medication administration in a sample of 15. The findings include: R21's admission record showed that R21 was admitted to the facility on [DATE], with multiple diagnoses including Chronic obstructive pulmonary disease, vascular dementia, anxiety disorder, essential hypertension, chronic kidney disease and overactive bladder. R21's MDS (Minimum Data Service) dated June 30, 2023, showed R21 is cognitively intact and requires supervision with most of her ADL's (Activities of Daily Living). On October 4, 2023, at 11:30 AM, V21 (R21's Power of Attorney) stated that she had concerns regarding facility staffing. V21 stated that on September 23, 2023, and September 24, 2023, R21 received her medication scheduled for 8:00 AM after 11:00 AM. R21's Medication administration audit report for September 23, 2023, showed scheduled 8:00 AM medications were not administered until 11:14 AM on September 23, 2023. The medications administered late included Gabapentin 600 mg (milligrams) and diphenhydramine 25 mg. 2 capsules, ordered to be given three times per day (08:00AM, 2:00PM and 8:00PM). Also administered late were (Brand Name) moisturizing mouth solution, probiotic capsule, triamcinolone cream and alprazolam 0.25 mg. were ordered to be given twice a day (08:00 AM, 8:00PM) were given at 11:15 AM. Fluticasone-Umecliden-Vilant aerosol powder inhaler and Seroquel 12.5mg scheduled to be given at 2:00 PM were administered late at 5:59 PM on September 23, 2023. On September 24, 2023, the medications were administered late, at 10:44 AM included Gabapentin 600 mg (milligrams) and diphenhydramine 25 mg. 2 capsules, ordered to be given three times per day (08:00 AM, 2:00 PM and 8:00 PM). R21's order summary report showed Gabapentin 600 mg was ordered to be given three times a day for low back pain on August 15, 2023. Diphenhydramine 50 mg was ordered to be given three times a day for allergy symptoms on August 15, 2023. Fluticasone -Umecliden-Vilant aerosol powder breath activated (inhaler) 1 puff orally every afternoon for respiratory symptoms was ordered on June 9, 2022. RisaQuad (probiotic product) was ordered to be given two times a day for bowel management on April 29, 2022. Seroquel 12.5 mg. was ordered to be given in the afternoon for vascular dementia with behavioral disturbance on July 28, 2023. On October 4, 2023, at 1:18 PM, V4 (Infection Preventionist Nurse) stated V19 (Licensed Practical Nurse) was the nurse who worked the A wing and half of the B wing on September 23 and 24, 2023 during the 6 AM to 6 PM shift. On October 4, 2023, at 1:30 PM, V19 stated she has been a nurse since 2003 and she worked on first shift on September 23 and 24, 2023 and was assigned to A wing and half of B wing. V19 further stated she had a discharge on A wing on Saturday September 23, 2023, that delayed her medication pass on the B wing and she administered R21 medications late for both Saturday and Sunday. V19 stated it is safer to have a nurse on each wing as A wing residents take a lot of time and families have many requests that take staff time to address. This causes a delay in being able to give care and medications timely to the residents on the B wing assignment. The facility's Medication Pass Guidelines dated April of 2019, showed 5. Medication Timing .All medications should be given in the correct time window or a reason for late/early administration should be documented on the MAR/eMAR.

Based on observation, interview and record review, the facility failed to maintain dumpster area free from debris. This has potential to affect 54 residents that reside in the facility. The findings include: The Facility Data Sheet dated October 2, 2023, showed that the facility census was 54. On 10/04/23 at 11:37 AM, the facility dumpster area was toured in the presence of V7 (Dietary Manager). The gates leading to the dumpster were open. The dumper was situated in an area close to a wooded area easily accessible by rodents and other critters. The dumpster lid covers were open and was full of bagged garbage. There was also an open barrel near the dumpster filled with miscellaneous waste that was open to air and covered with flies. At the back of the dumpster there were several bagged garbage (with clear plastic covers) on the floor. The contents of the bags were visible through the plastic and showed incontinent briefs and other garbage. V7 stated that they may be trash collected by housekeeping from the residents' rooms. There were also other used paper products and debris on the floor. V7 stated that the dumpster holds garbage collected from the kitchen and resident areas by dietary and housekeeping staff. On 10/04/23 at 12:05 PM, V15 (Building Manager) stated that the dumpster maintenance is spilt between him and V16 (House Keeping Manager). V15 stated The waste management has skipped us a couple of times. They did not pick up [trash] on the last two weekends. They are supposed to come in at 8:00 AM every day from Monday through Friday. V15 stated that the dumpster lids have been torn and the hinges on the gate to the dumpster is not working properly and therefore are unable to be closed properly. V15 stated that he has contacted the contracted provider several times but has not received an adequate response. V15 stated that the contacts were made via personal email. V15 did not provide records of the same. Facility policy and procedure titled Grounds and Exterior Inspection (revised August 15) included as follows: Policy: Building Manager will inspect the exterior of the building and grounds daily. Procedure: Weather permitting, the Building Manager will walk the outside perimeter of the building(s) during every schedule workday to check for concerns including, but not limited to: 4) garbage collection issues 7) trash and debris The Building Manager and Housekeeping Supervisor will work together to maintain the exterior free of trash and debris and maintain exits and sidewalks free of snow and ice accumulation.

Based on interview and record review, the facility failed to follow its policy when they did not provide a notice of discharge to the resident's representative, before the discharge, which included explanation and rights to appeal, when the facility did not allow a resident to return after the ten-day bed hold lapsed, which constituted a facility discharge. This applies to 1 of 3 residents (R1) reviewed for bed holds. The findings include: R1's Electronic Health Record (EHR) showed R1 was originally admitted on [DATE], and was recently sent to the hospital on [DATE], where she is. The EHR showed R1 had multiple diagnoses including cerebral infarction, Alzheimer's disease, hypertension, type 2 diabetes, dysphagia, hemiplegia left dominant side, dementia, and vascular dementia. R1's Minimum Data Set (MDS), discharge - return anticipated, dated [DATE] showed R1 could not complete the mental assessment, but was considered severely impaired for daily decision making. R1's Care Plan dated [DATE] showed: R1 will not be discharging from the facility, as determined by the inter-disciplinary team, physician, resident and/or legal representative. R1 has impaired cognitive functioning related to diagnosis of dementia. Assist with decision making including family or responsible party as needed. On [DATE], V2 (Director of Nursing/DON) stated, on [DATE], V2 informed V12 (R1's Guardian) that R1's 10-day bed hold lapsed, and another resident was going to be admitted to R1's room. V2 stated, she informed V12 that R1 is considered long term and there are no other beds available, and R1 would need to go on the waiting list if she wanted to return to the facility. V2 stated, R1 was discharged on the 11th day, [DATE]st, per policy. During interviews, V1 (Administrator) stated, R1's room was held for 10 days, from [DATE]-[DATE], and on [DATE], V1 made V12 aware that the bed hold period expired. V1 stated, she made V12 aware that R1 would not be able to return to the facility, because R1's room was going to a new admission, and since R1 is considered long term, and there were no more long-term beds available, she would have to go on the waiting list. V1 stated, there was no semi-private long-term beds available, and the last semi-private female bed was considered a short-term bed, but a new admit was taking that bed on [DATE]th. V1 stated, R1 had electronic monitoring and a resident in a semi-private room would have to consent to the use of the camera. V1 stated, she did not ask V12 if she would forgo the electronic monitoring to be put in a semi-private room, because the only bed available could not accommodate a long-term care resident. When asked if V1 was advised to or if there was any reason to give V12 a notice of discharge, she said no. R1's Electronic Health Records (EHR) showed no documentation of Involuntary Discharge Notice provided to V12. The facility policy titled Discharge or Transfer, Involuntary ([DATE]) reviewed showed: Policy: The facility will provide proper procedure and notification of an involuntary transfer or discharge pursuant to the regulations of long term care facilities .; and state rules and regulations . Notification and Documentation . 2) Residents and their representative(s) must be notified of the transfer and the reasons for the transfer. This notice must be provided in writing thirty (30) days prior to transfer or, as soon as practical . d) The state public health form Notice of Involuntary transfer or Discharge and Opportunity for a Hearing must be completed and given to the resident with a copy placed in the resident record. Additional copies must be sent by registered or certified mail to the resident's representative This information must be documented in the record with corresponding notation of the information having been provided to the resident and appropriate individuals

Based on observation, interview and record review, the facility failed to identify the root cause of a resident elopement and identify interventions to prevent further resident elopements. The facility failed to provide adequate staffing and supervision for residents at risk for elopement. The facility also failed to assess newly admitted residents ' risk for elopement and provide for accurate and ongoing elopement risk assessments by a trained and qualified individual. The facility also failed to provide staff training on resident elopement and missing resident procedures. These failures resulted in immediate jeopardy and have the potential to affect all residents residing at the facility identified to be at risk for elopement (R1-R8). As a result of the failure, R1 eloped undetected on 9/5/21 through an unlocked/unalarmed door near R1's room. R1 remained unsupervised in the outdoor environment, crossed streets, walked through parking lots, and had physical access to an ungated and unsupervised pond and open buildings. R1 was found approximately two blocks from the facility approximately two hours after she was identified as missing. The IJ (Immediate Jeopardy) began on 9/5/21 at 5:30 AM when R1 was identified as missing at the facility and ended on 9/23/21 at 4:29 PM when the removal plan was accepted. V1 (Administrator) and V3 (Consulting Administrator) were notified of the IJ on 9/23/21 at 8:50 AM. V1 and V2 (Consultant) were provided with the IJ Template outlining the failures. Although the immediacy was removed on 9/23/21, the facility remains out of compliance at Severity Level II due to the need to evaluate and implement new policies and procedures and Quality Assurance monitoring. This applies to 8 of 8 residents (R1-R8) identified by the facility as at risk for elopement in a sample of 8. The findings include: 1. Face sheet, dated 9/20/21, showed R1 was admitted to the facility on [DATE] and had diagnoses which included dementia without behavioral disturbance, abnormalities of gait and mobility, weakness, anxiety disorder, and history of falling. Initial Elopement Risk Assessment, dated 9/27/20, shows the assessment questions were left blank resulting in R1 not being assessed for elopement risk. As of 9/5/21 at the time of R1's elopement from the facility, the clinical record showed no Elopement Risk Assessment was performed on R1 since her admission to the facility on [DATE]. Review of R1's care plan as of 9/5/21 at the time of her elopement from the facility showed the care plan failed to include any elopement focus or interventions to prevent R1 from eloping from the facility. Resident Service Plan, reviewed 3/24/20, shows, Encourage R1 to walk indoors; she should be accompanied by staff or family if wanting to walk outdoors. On 9/20/21 at 2:30 PM, V4 (CNA- Certified Nursing Assistant) stated on 9/5/21 she saw R1 at approximately 4:30 AM when she took R1's vitals. At approximately 5:30 AM, V4 looked for R1 to dress R1 but was unable to locate her. V4 stated no exit alarms were sounding on the C-Wing and she had not heard any alarms during her shift. When V4 was unable to locate R1 after searching, V4 told V5 (RN-Registered Nurse) and the two staff began searching the XXX-Wing for R1 but were unable to locate her. V4 stated she saw V5 go outside the exit door by R1's room to search for R1 but no alarms sounded when V5 exited. V4 stated she and V5 continued to search and informed other facility staff to assist in the search. V4 stated she exited the building and checked a nearby ungated pond for R1 as well as a nearby building but was unable to locate R1. V4 stated she did not hear any exit alarms during her shift or when the staff exited to search for R1. V4 stated R1, as well as R3 and R4, had a history of wandering and exit seeking while residing on the wing. On 9/22/21 at 7:41 AM, V5 (RN) stated the last time he saw R1 on 9/5/21 was approximately 4:30 AM before he began passing medications. V5 stated at approximately 5:30 AM, V4 asked him to assist searching for R1 because V4 was unable to locate her and that a door at the end of R1's hall was left unlocked. V5 stated they both searched the entire wing, were unable to locate R1, and V5 then checked the wing exits. V5 stated the door near R1's room was closed however was not locked and the alarm was disarmed. V5 stated he was able to exit the door without unlocking it and without an audible alarm sounding on the wing. V5 stated he immediately ran to the nearby ungated water to make sure R1 was not there and was relieved not to find her because it was not protected from wandering residents. V5 stated at approximately 6:05 AM he checked the nearby outdoor area and returned to the XXX-Wing to call V3 (Director of Nursing) and told V3 he was calling 911 immediately. V5 stated he alerted the nurses on the other resident wings in the building as well as staff arriving for the next nursing shift. V5 stated when 911 arrived, he printed pictures of R1 and gather information for the police to search for R1. V5 stated it was only after R1 was identified as missing and staff, V3, and 911 were informed, that he noticed a red blinking light on the exit door alarm panel at the nursing station. V5 stated he had not heard any exit alarms during his shift on the wing and was not aware an exit door alarm could be silenced at the nurses' station. V5 stated he left the wing for approximately 10-20-minute intervals during his shift, but that V4 took alarms very seriously and would not have disarmed alarms if they sounded without attending to the exit door. V5 stated he strongly believed someone without an exit door key previously silenced the audible alarm at the nursing station and forgot to tell a staff with a key to go back and arm the door lock/alarm at the exit. On 9/21/21 at 11:00 AM, V7 (CNA) stated she arrived at work on 9/5/21 and noticed staff outside the facility and was told a resident was missing. V7 stated she and another staff got in her car and searched the facility campus, the nearby hospital parking lot, a gas station, a convenience store, and returned to the facility searched around the facility when she got a call from V8 (Housekeeping) who told V7 she found R1 approximately 1-2 blocks away from the facility. V7 ran to V8 and R1 and R1 was standing outside in a gown, an incontinence brief, slip-on shoes with no socks, no glasses, and V7 described R1 as looking tired. V7 stated the outdoor temperature was in the 60's degrees Fahrenheit and R1 told V7 she was cold. Facility document Interviews, undated, shows V8 stated After driving around, I saw the patient in the parking lot of (name of business) standing between two parked cars. Progress note, dated 9/5/21, shows R1 was last seen at approximately 4:30 AM. At 5:30 AM, V5 was told by V4 that V4 was unable to locate R1 in the facility. At 5:45, V5 found the exit door at the back of the hall noted to be opened. At 6:05 AM 911 was called, at 7:30 AM R1 was located outside the facility and returned to the facility, and at 7:45 AM R1 was transported to the hospital for evaluation. Incident/Accident Notification, dated 9/10/21 provided to Illinois Department of Public Health, fails to show R1 eloped from the facility through an unlocked/unalarmed facility exit door. Review of the investigation documentation shows the facility failed to identify the root cause of R1's elopement and failed to implement interventions to prevent facility staff from silencing exit door alarms without relocking/re-alarming an exit door. On 9/20/21 and 9/22/21, the exit doors on the resident wings were able to be unlocked and opened after the door bars was pushed for 15 seconds. Once unlocked and unopened, the alarms at the door automatically silenced but the alarms at the nurses' station continued to sound. The alarms at the nurses' stations were able to be silenced manually by staff without staff having to investigate the exit door, re-lock the exit door, or re-alarm the exit door alarm. Review of the outdoor environment of the facility on 9/22/21 showed R1 had walking access to several parking lots, streets, open buildings, and an ungated/unsupervised pond that was accessible by walking on the sidewalk near the door she exited. The pathway to the location in which R1 was located included walking across parking lots and crossing a street that supported local traffic. On 9/20/21 at 2:00 PM, V25 (CNA) stated R1 had a history of pushing the outdoor exit doors open and causing the door alarms to sound since she was admitted to the facility. V25 stated R1 always wanted to go outside especially if the weather was nice. On 9/20/21 at 2:08 PM, V9 (CNA) stated R1 was one we have to keep an eye on. V9 stated staff will catch R1 at the outdoor exit door or in the enclosed patio exit door. Progress notes dated 11/21/20 and 11/21/20, 12/6/20, 1/21/21, 2/18/21, 3/4/21, 3/14/21, show R1 walking throughout the night on the wing. Progress notes, dated 9/2/21,9/3/21, 9/4/21, and 9/5/21 show R1 was non-compliant with COVID-19 isolation requirements and was unable to stay in her room due to dementia and forgetfulness. Behavior monitoring CNA Task, effective 1/9/2015, shows R1 was monitored for feeling restless/anxious/wandering. The documentation shows R1 experienced the behaviors on September 2, 3, 6, 9, 16, 2021. Facility Policy/Procedure, dated 11/2017, shows, A Social Service/Behavioral Health staff member or designee will conduct the Elopement Risk Assessment at admission (within 14 days of admission), quarterly, annually and episodically, and it will be filed in the medical record or electronically : Any necessary changes will be noted in a progress note, or by additional assessment. If no changes are documented, this assessment will be considered representative of the resident's current status and will be considered as supporting documentation for the initial MDS (Minimum Data Set) If a resident is evaluated at being At-Risk for elopement, the following procedures will be implemented: 1. The resident's picture will be taken and provided to the nursing station of the unit the resident resides on and to the front office for monitoring of the front door to the facility. 2. Increased monitoring will be initiated if there is a change in condition for an elevated concern of elopement. 3. The resident will be re-assessed quarterly and/or as needed to continue monitoring the resident's behavior as it relates to elopement risk. IF a resident does elope from the facility, the following procedures will be implemented: A 'Code Green' will be paged overhead A head count and search will be conducted to assist in locating the resident 2. Facility document Correction Plan, undated, shows in response to R1's elopement on 9/5/21, 5. On 9/5/21 V1, V3, and V4 immediately implemented an audit of all residents to assess for elopement risk. Individualized plans of care have been updated based on the assessment. This was completed by 9/7/21. On 9/20/21 at 10:00 AM V3 (DON) provided the document At Risk for Elopement which showed only two residents (R1 and R2) were identified as at risk for elopement. The document failed to include R3-R8 as identified as at risk for elopement. On 9/20/21 at 3:34 PM, V19 (Receptionist) stated R1 and R2 were the only residents identified as elopement risks according to the Elopement Risk Binder of at-risk residents kept at the front door. The binder failed to include information regarding R3-R8 as being at risk for elopement. Face sheet, dated 9/20/21, shows R2 was admitted to the facility on [DATE] and R2's diagnoses include Alzheimer's disease, conduction disorders, and dementia. Care Plan initiated 05/14/2021 shows R2 was receiving antidepressant [CONDITION(S)] medication for a diagnosis of Alzheimer's Disease and antipsychotic [CONDITION(S)] medication for Dementia without Behavioral disturbances. The care plan shows R2's symptoms may include sleep disturbances, low mood, wandering and anxiousness. Review of R2's clinical record shows no Elopement Risk assessment was performed on R2 since admission until 09/07/2021 after R1's elopement. The assessment determined R2 to be at high risk for elopement. On 9/22/21 at 7:41 AM, V5 stated R2 was capable of eloping from the facility because R2 was young, did not look like a typical resident, and visitors often held the door for R2 when they left the wing thinking R2 was another outside visitor and not a resident. Progress notes, dated 5/14/21, shows R2 was ambulating around the wing and entering other residents' rooms. Progress notes, dated 6/2/21 showed R2 was having difficulty with self-control and aggression, throwing items, pushing wheelchairs, becoming angry, and yelled, I'm just going to leave this place because this is bullshit. The progress note showed R2 was very difficult to redirect and calm down. Progress notes, dated 9/11/21, show R2 was refusing medications, calling staff names, slamming doors, and staff were able to redirect R2. Progress notes, dated 9/20/21, show R2 was sent to the hospital related to behavioral disturbances including throwing chairs, attacking staff, and becoming very physically aggressive Face sheet, dated 9/21/21, shows R3 was admitted to the facility on [DATE] and R3's diagnoses include vascular dementia. On 9/20/21 at 2:52 PM, R3 walked toward the outdoor exit door and pushed on the door bar. The door alarm sounded and then silenced when she stopped pushing on the door bar. V4 (CNA) walked to R3 and escorted R3 away from the exit. Elopement risk assessments for R3 showed the following: 5/14/21 - at risk for elopement 9/21/21- low/no risk for elopement and no history of exit seeking behavior Progress notes, dated 5/15/21 and 5/16/21, show R3 was seeking exits several times and required as needed [MEDICATION(S)] was administered. On 9/21/21 at 1:14 PM, V22 (LPN-Licensed Practical Nurse) stated she initially performed R3's new admission elopement risk assessment and erroneously identified R3 at high risk because she did not observe R3 exit seeking the day she completed the assessment. V22 stated after she completed the assessment, R3 was exit seeking and she reported the exit seeking to a supervisor. V22 stated she would consider R3 an elopement risk because of R3's subsequent exit seeking behavior. On 9/20/21 at 2:30 PM, V4 (CNA) stated R3 had a history of pushing the exit doors and attempting to elope from the facility. V4 stated R4 also pushes the exit door to get outside and sets off the exit door alarms. Care plan, dated 7/11/21, shows, R4 expresses the want to 'leave' unit and get cash and cigarettes. Although redirectable, he is exit seeking. Elopement risk assessment, dated 9/7/21, shows R4 was assessed as having no history of elopement or exit seeking attempts, and yet having reported episodes/attempts to leave the facility without notification to staff. The document shows, If the answer to either of the above is YES, place the resident 'AT RISK' and on the Elopement At-Risk Program The assessment concludes R4 was at low risk for elopement. Elopement Risk Assessment, dated 8/23/21, shows R5 was at low/no risk for elopement. Elopement Risk Assessment, dated 3/30/21, shows R6 was at low/no risk for elopement. On 9/20/21 at 2:18 PM, V12 (Activity Aide) stated the staff must monitor R5 because she wanders and likes to lay in other residents' beds. On 9/20/21 at 2:18 PM, V11 (CNA) stated R5 had a history of attempting to elope by hitting the exit door bar and sounding the alarm to go outside. On 9/22/21 at 7:41 AM, V5 (RN) stated R5 and R6 were typically exit seeking and elopement risks. On 9/20/21 at 3:25 PM, V11 (CNA) stated R6 seeks exits and was at risk for elopement at the facility. On 9/21/21 at 2:39 PM, V6 (Social Services Designee) V6 stated after speaking with direct care staff she reassessed R3-R6 again and revised their risk status to indicate they were all at risk of elopement. V6 stated she began to work at the facility as the Social Services designee approximately two months ago. V6 stated she previously had no experience as a social services designee, was provided four days training at another facility, and had four hours of consultation from the Social Worker Consultant since her hire. V6 stated she was provided an admission packet of assessments during training and told to complete them for new residents. V6 stated she was never instructed how to complete the facility elopement risk assessment. On 9/22/21 at 10:00 AM, V1 provided the document At Risk for Elopement which showed R1-R6 were identified as being at risk for elopement with R3-R6 newly identified as elopement risks. On 9/23/21 at 8:50 AM, V1 and V2 stated all facility residents were reassessed again for elopement risk by V24 (Social Services Consultant) and V6 (Social Services Designee) and two more residents, R7 and R8, were added to the list of residents at risk for elopement at the facility. Elopement Risk Assessment, dated 9/22/21, shows R7's admitted was 7/1/21 and R7 was assessed to be at risk for elopement based on R7's diagnosis of dementia, staff reported episodes of R7 seeking exits or attempts to leave the facility without notifying staff. Elopement Risk Assessment, dated 9/7/21, shows R8 was assessed as low/no risk for elopement. However, Elopement Risk Assessment, dated 9/22/21, shows R8 was re-assessed to be at risk for elopement related to her diagnosis of dementia and staff reports of R8's exit seeing behavior. 3. On 9/21/21 at 9:36 AM, V1 (Administrator) stated the manager on duty was responsible for checking all door locks/alarms in the facility on weekends since 9/5/21. V1 stated the maintenance department was responsible for checking all door alarms/locks at the facility during the week. On 9/20/21 at 2:30 PM on the YYY Wing, the door alarm light at the patio door exit was not lit. On 9/20/21 at 2:45 PM with V13 (RN), the patio door exit alarm light continued to be unlit. V13 unlocked the door, pushed the door open, and the alarm did not sound. The door alarm key lock was positioned to the DISABLED position. V13 utilized her alarm key and turned the lock to the ENABLE position and a red light turned on. V13 pushed open patio exit door again but no alarm sounded. On 9/20/21 at 3:40 PM, V18 (Activity Aide) stated the patio was the designated staff smoking area and she has used the area for some time to smoke when she is working at the facility. V18 she walked through the patio door to smoke earlier in the day and used her key to unlock the exit door to the patio. V18 stated she has never had to disable an alarm to exit through the patio door to smoke and did not think she had a key for any of the door alarms. V18 stated she had never heard a door alarm sound when she unlocked the patio door and opened the door to exit to the patio. On 9/21/21 at 9:36 AM, V20 (Building Manager) stated all door alarms, including patio doors, should be functioning in spite of doors being locked. V20 stated he was not aware that V18 had not needed to disarm the patio door alarm before going out to smoke for some time. On 9/20/21 at 2:45 PM, V13 (RN) stated she checks the exit door alarms and locks at the beginning of each shift and the patio door alarm and lock were functioning at the beginning of her shift that day. On 9/20/21 at 3:07 PM with V1 and V3, V17 (Maintenance) stated that Maintenance checks all door locks and alarms twice a day in the facility. V17 stated the alarm was malfunctioning and required the alarm company to service the device. 4. On 9/22/21 at 11:10 AM with V1 (Administrator), V2 (Consulting Administrator) and V3 (Director of Nursing), V2 stated on 9/5/21 the facility provided all staff training that instructed any facility staff who identifies a missing resident to announce an overhead page alert of Code Green. On 9/22/21 at 7:41 AM, V5 (RN) stated he was not aware of the term Code Green at the facility. On 9/21/21 at 11:00 AM, V7 (CNA) did not state she would call an overhead Code Green when asked what procedures she would follow if she identified a missing resident. On 9/20/21 at 2:08 PM, V9 (CNA) failed to state she would call an overhead Code Green if she identified a missing resident at the facility On 9/20/21 at 2:17 PM, V10 (CNA) failed to identify she would call a Code Green if she identified a missing resident at the facility. On 9/21/21 at 1:21 PM, V23 (CNA) stated he was not aware of a Code Green and was not sure what it meant. On 9/20/21 at 2:18 PM, V11 (CNA) failed to identify she would perform a head count of residents if she identified a missing resident at the facility. A review of the elopement/missing resident policies utilized to in-service facility staff after R1 eloped showed inconsistent procedures for elopement risk/missing residents. The following policies were utilized to train various staff: Missing Resident - dated 2/2011 - no mention of Code Green Wandering (Elopement) - dated 6/1997 - no mention of Code Green Code Green - undated Exit Seeking/Elopement vs. An Unplanned Discharge Policy and Procedure - Rev 11/2017 On 9/22/21 at 11:10 AM, V1, V2 and V3 stated the following multiple policies were utilized to train various facility staff after R1's elopement - some of which did not include instructions to overhead page a Code Green when a missing resident was identified. V2 also stated some of the policies were outdated and no longer in effect: Missing Resident - dated 2/2011, outdated per V2, and no mention of Code Green Wandering (Elopement) - dated 6/1997, outdated per V2, and no mention of Code Green 5. Facility at Risk for Elopement document, provided 9/24/21, shows R1-R8 were identified as elopement risks. Facility roster, updated 9/20/21, showed five residents (R2-R4, R7 and R8) identified to be at risk for elopement resided on the YYY-Wing and three residents (R1, R5, and R6) were identified to be at risk for elopement resided on the XXX-Wing On 9/22/21 at 7:41 AM, V5 stated on 9/5/21 he began his night shift supervising the YYY-Wing and V22 stayed from her previous shift until 8:30 AM to supervise the XXX Wing. V5 stated at 8:30 PM, V22 left her shift, and he took over responsibility for supervising the XXX Wing and half of the YYY Wing. V5 stated after 8:30 PM, V26 (Nurse) was responsible for supervising the LLL Wing and the other half of the YYY Wing. V5 stated he was required to leave the XXX Wing for 10-20 minutes at a time throughout his shift to check on residents in the YYY Wing which left V4 the only staff on the XXX-Wing to supervise both halls. V5 stated each wing had their own call light systems that could not be heard from the other wings. On 9/20/21, tour of the facility showed the facility had three resident wings, LLL-Wing, YYY-Wing, and XXX-Wing. The facility wings were completely independent of one another and were accessible to each other only by walking out the closed doors of one wing, through a foyer, and entering through the closed doors of the next wing. Each wing had two halls - one hall could not be visualized when working in the other hall. Facility Daily Schedule, dated 9/4/21, shows the 10 PM to 6 AM shift had only two nurses (V5 and V26) responsible for the three resident wings from 8:30 AM to 6 AM. The schedule shows only one CNA was assigned to each wing from 10 PM to 6 PM - V4 to XXX-Wing, V27 (CNA) to YYY-Wing, and V28 (CNA) to LLL-Wing. The facility submitted the following plan on 3/1/21 to remove the immediacy: - The facility door alarm company arrived at the facility at 2:30 PM on 9.22.21 and the ability to silence the alarms at the nursing station was dismantled at 3:40 PM on 9.22.21 - Interviews were conducted with all employees identifying elopement risk/wandering residents- Completed 9.23.21 but awaiting response from 9 employees. The information was cross referenced with resident assessment and care plans- Completed 9.22.21. Resident assessments and care plans were updated with new information - Completed 9.22.21 - On 9.22.21, all staff were in-serviced by V1, V3, V6 and V29 (Business Officer Manager) on staff response to alarms and the Code Green process - Code Green process cards were created and distributed to all working staff in facility and will continue to be distributed to staff reporting to work- Completed 9.22.21 - Code Green process signage was created and posted at each nursing station - Completed 9.22.21 - V6 (Memory Care Director) was provided additional training on elopement, assessments, wandering, tasks, care plans, as well as personalization of care plans - Completed 9.21.21 - The Memory Care Director will have continued training and monitoring which will continue three times a week for 30 days and then two times a week for 60 days - The Memory Care Director will have every elopement assessment and elopement care plan reviewed a frequency of three times a week for 30 days and then two times a week for 60 days. These elopement risk assessments include initial, quarterly, change in condition, and annual elopement risk assessments and care plans. - The staffing schedule was revised on 9.22.21 to ensure a minimum of 2 staff per unit per each shift. - Elopement Drills will be performed by V6 on each shift, on each unit, weekly for 2 weeks and then evaluated to determine further frequency. Elopement Drills will be audited weekly by the Administrator - Code Green Pop Quizzes will be given to staff daily on all shifts for 2 weeks and then evaluated to determine further frequency. Individuals who answer incorrect will receive immediate education. the administrator will review the pop quizzes on a weekly basis - The facility clarified the Missing Resident Policy. - Daily Alarm Checks will continue to be conducted on an ongoing basis. Daily Door Alarm Checks will continue to be conducted by the Building Manager and/or Building Manager Assistant every AM and PM each weekday. Daily Door Alarm Checks will continue to be conducted by facility Manager on Duty every AM and PM each day. Daily Door Alarm Checks will be conducted by the night shift each night - QA (Quality Assurance) audits were initiated to ensure completed and accurate elopement risk assessments and care plans are being performed by the Memory Care Director. These will be performed by Administration, Clinical Leadership, and/or facility designee and will continue daily for two weeks and then weekly for 2 months. - QA audits were initiated to ensure completion of employee interviews in regards to residents at risk for elopement. These will be performed by Administration, Clinical Leadership, and/or facility designee and will continue daily for two weeks and then weekly for 2 months. - QA audits were initiated to ensure staff retention and demonstration of the code green process. These will be performed by Administration, Clinical Leadership, and/or facility designee and will continue daily for two weeks and then weekly for 2 months.

Based on interview and record review, the facility failed to follow their policy for administering medications, including correct dose and medication administration documentation. This failure resulted in R1 receiving a narcotic overdose on (MONTH) 15, 2019, requiring narcotic reversal treatment at the local hospital. R1 expired on (MONTH) 17, 2019 at the facility. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for medication administration in the sample of 5. The findings include: 1. On (MONTH) 23, 2019 at 2:12 PM, V6 (RN-Registered Nurse) said, I came to work on the evening of (MONTH) 15, 2019. I had worked the previous night and (V7) (RN) told me she reordered the [MEDICATION NAME] for (R1) from the pharmacy, because she ran out of the medication. I knew there was enough medication in the bottle when I left on my previous shift, and asked her to show me how that was possible. She showed me that she used the plastic medication cup to measure the medication. I told her that she gave too much medication to the resident. I always used a syringe to measure the medication. I know it's impossible to measure that small amount of medication with a medication cup. When I first arrived at the facility for my shift on (MONTH) 15, (R1) was breathing at a rate of five breaths per minute, which was very low. We notified the physician and he wanted the resident to receive [MEDICATION NAME] (opioid overdose medication treatment). We don't keep [MEDICATION NAME] at the facility, so we had to call 911 and send her to the hospital. She returned to the facility several hours later. The EMT (Emergency Medical Technician) reported to me that (R1) got six double doses of [MEDICATION NAME] at the hospital and was receiving oxygen at a rate of 10 liters per minute. Normally she is on 2 liters per minute. On (MONTH) 26, 2019 at 10:17 AM, V7 (RN) said, On (MONTH) 15, 2019, I ran out of (R1's) [MEDICATION NAME] (narcotic pain medication) during my shift, and when I reported this to the oncoming nurse (V6-RN) at shift change, he said how could that be? How much did you give? The medication order shows to give 0.25 ml (milliliters) to 0.50 ml. The medication didn't come with a syringe for dispensing the medication, so I used a medication cup when I gave the medication. I had been administering the medication with a medication cup, and actually gave 2.5 ml or 5 ml, which was ten times the ordered dosage. I had been doing this since (MONTH) 2019 because there was never a syringe available with that medication. So every time I gave the medication to (R1), I was giving her too much medication. It was more than she was supposed to receive, but I didn't realize I was making the mistake until I ran out of the medication. That's when I realized I had a problem. I couldn't understand how the medication level was going down so fast. I then thought to myself, I think I know why she is struggling to breath so much, because I gave her too much medication. Every time I gave her the [MEDICATION NAME] medication in (MONTH) 2019 and (MONTH) 2019, I used a medication cup instead of a syringe, and gave either 2.5 ml or 5 ml instead of the ordered dose, even though I documented on the controlled drug form that I gave 0.25 ml or 0.5 ml, which was incorrect documentation. Sometimes I get really busy and I forget to document on the MAR (Medication Administration Record) or the narcotic sheet that I gave the medication to the resident. But if I signed it out in one place but forgot to record it in another place, I did still give it. I was just too busy and forgot to sign it. The facility's Controlled Drug Receipt/Record/Disposition Form and Medication Administration Audit Report dated (MONTH) 26, 2019, show V7 administered [MEDICATION NAME] 4 mg/ml oral solution to R1 on: [DATE] at 12:00 PM (0.5 ml) [DATE] at 11:00 AM (0.5 ml) and also at 5:30 PM (0.5 ml) [DATE] at 11:00 AM (0.5 ml) [DATE] at 6:00 PM (0.5 ml) [DATE] at 10:00 AM (0.5 ml) and 4:00 PM (0.5 ml) [DATE] at 10:00 AM (0.5 ml) [DATE] at 10:12 AM (0.25 ml) (Documented on MAR (Medication Administration Form) not documented on Controlled Drug Form) [DATE] at 11:00 AM (0.25 ml) and 6:00 PM (0.5 ml) [DATE] at 11:50 AM (0.5 ml) and 4:30 PM (0.25 ml) R1's MAR dated (MONTH) 2019 shows V7 did not document the administration of the above medications on the MAR on (MONTH) 5, (MONTH) 6 (10:00 AM and 4:00 PM doses), (MONTH) 7, (MONTH) 14 (11:00 AM and 6:00 PM doses), and (MONTH) 15, 2019 at 4:30 PM. The facility's Medication Incident Report dated (MONTH) 15, 2019 at 9:51 PM shows V7 (RN) administered [MEDICATION NAME] multiple times at the incorrect dose. Not having a syringe to measure the medication contributed the most to giving the wrong medication per the report. Given by med cup 2.5 ml mistaken for 0.25 ml. Given by med cup 5.0 ml mistaken for 0.5 ml On (MONTH) 26, 2019 at 11:15 AM, V9 (Pharmacist) said R1 received ten times the prescribed dosage of [MEDICATION NAME]. An overdose can cause a depressed central nervous system, including low blood pressure, sedation, drowsiness, confusion, and respiratory depression. The symptoms documented by the facility indicate this resident had respiratory depression. I was in the facility on (MONTH) 9, 2019 to do medication record review and review the medication rooms. We spot check medications, but I don't believe the liquid narcotics ever got looked at. I look at the records and match them up with stock left in the bottle. I don't recall checking the bottles of liquid medications. On (MONTH) 26, 2019 at 1:49 PM, V10 (Physician) said, On (MONTH) 15, I received a call from our hospice nurse that (R1) received substandard medication orders and the nurse at the facility gave too much medication. I was told by our nurse that the resident was heavily sedated and obtunded and had respiratory depression. I ordered [MEDICATION NAME] to be administered to the resident or to send the resident to the hospital via 911. For a women of her weight, I would order 0.5 mg to 1 milligram with a maximum dose of 2 milligrams at any given time. I would never order 5 milligrams of the medication to be given at one time, and I would order it to be given every four hours as needed. I would not want the resident to receive more than 6 milligrams of [MEDICATION NAME] in a day. For a resident to receive 40 mg, within the time period (R1) received the [MEDICATION NAME], they would definitely become obtunded and have respiratory depression. That is too high of a dose, and I would never prescribe that amount of medication for a woman of her size. The Controlled Drug Receipt/Record/Disposition Form shows on (MONTH) 15, 2019, V6 (RN) administered 1 mg of [MEDICATION NAME] at 2:47 AM, and V7 administered 20 mg of [MEDICATION NAME] at 11:50 AM, and 10 mg. at 4:30 PM, for a total dosage of 31 mg in 14.5 hours. On (MONTH) 30, 2019 at 11:49 AM, V13 (Physician) said, I am aware the resident received an overdose of the [MEDICATION NAME] on (MONTH) 15. I consider this a significant medication error. Receiving ten times the dosage could cause respiratory depression, and could lead to aspiration pneumonia as well. I would expect the nursing staff to give the medication as ordered. I do know that she was stable with her dementia and [MEDICAL CONDITIONS] prior to the overdose and receiving [MEDICATION NAME] at the hospital. Records from the local hospital dated (MONTH) 15, 2019 at 9:15 PM show R1 was admitted with a [DIAGNOSES REDACTED]. R1's vital signs at 9:24 PM showed blood pressure of ,[DATE], pulse of 106, and respirations of 10 per minute. A reassessment at 9:30 PM showed R1's vital signs with a respiratory rate of 6 breaths per minute, and R1 was receiving oxygen at a rate of 15 liters per minute via non-rebreather mask. R1 arrived at the emergency department very drowsy, alert to oral suctioning and sternal rub, moaning and barely opening her eyes. Course crackles and gurgling was noted. Hospital documentation shows R1 received three doses of [MEDICATION NAME] in the emergency room , and was discharged back to the care of the nursing home on (MONTH) 16, 2019 at 12:21 AM. On (MONTH) 15, 2019 V14 (emergency room Physician) documented, Patient (R1) appears to be in rapid [MEDICAL CONDITION]. Patient also with rales on her [MEDICAL CONDITION] exam and with her being oversedated due to the air and [MEDICATION NAME] ([MEDICATION NAME]) administration, I suspect she could have aspiration pneumonia. Going forward I will recommend chest x-ray, supplemental oxygen, continued [MEDICATION NAME] use via nebulizers as well as antiarrhythmic for rate control, possible anticoagulation. She would also need laboratories as well. POA (Power of Attorney), daughter and granddaughter state they do not want anything done at this time per their mother and grandmother. They wish for no increased supplemental oxygen, antiarrhythmic IV fluids, laboratories, chest x-ray, etc. I did inform them that her present condition may continue to deteriorate and may lead to her death in the very near future which they verbalized understanding of. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated (MONTH) 11, 2019 shows R1 had severe cognitive impairment, was able to eat with supervision, and required limited to extensive assistance with all other ADLs (Activities of Daily Living). R1 was incontinent of bowel and bladder. R1 had adequate hearing, clear speech, was able to make herself understood, and was able to understand others. R1 did not exhibit any behaviors. R1 received pain medication as needed, and had shortness of breath or trouble breathing with exertion, and when lying flat. R1 had a condition or chronic disease that may have resulted in a life expectancy of less than six months. R1's Order Summary Report dated (MONTH) 23, 2019 shows the following orders for [MEDICATION NAME]: [MEDICATION NAME] HCl Tablet 2 mg, give 1 tablet by mouth every 6 hours as needed for pain management, dated (MONTH) 14, (YEAR). [MEDICATION NAME] HCl Solution 4 mg/ml, give 0.25 ml by mouth every 1 hour as needed for moderate shortness of breath (0.25 ml = 1 mg). (MONTH) give oral or sublingual. Order dated (MONTH) 21, 2019. [MEDICATION NAME] HCl Solution 4 mg/ml, give 0.25 ml by mouth every 2 hours as needed for moderate pain (0.25 ml = 1 mg). (MONTH) give oral or sublingual. Order dated (MONTH) 21, 2019. [MEDICATION NAME] HCl Solution 4 mg/ml, Give 0.5 ml by mouth every 1 hours as needed for severe shortness of breath (0.25 ml = 1 mg). (MONTH) give oral or sublingual. Order dated (MONTH) 21, 2019. [MEDICATION NAME] HCl Solution 4 mg/ml, Give 0.5 ml by mouth every 2 hours as needed for severe pain (0.25 ml = 1 mg). (MONTH) give oral or sublingual. Order dated (MONTH) 21, 2019. [MEDICATION NAME] HCl Solution 4 mg/ml Give 0.5 ml by mouth every 2 hours as needed for severe pain (0.5 ml = 2 mg). (MONTH) give oral or sublingual. Order dated (MONTH) 21, 2019. 2. On (MONTH) 30, 2019 at 12:23 PM, R2 was sitting in dining room eating lunch with assistance from facility staff. R2 is confused and not able to be interviewed due to her cognitive status. R2 appears calm and cooperative and awake. Does not exhibit any pain symptoms and does not appear lethargic or having difficulty breathing. The EMR shows R2 was admitted to the facility in (MONTH) 2019 with multiple [DIAGNOSES REDACTED]. R2's MDS dated (MONTH) 17, 2019 shows R2 has severe cognitive impairment, requires supervision with one-person physical assistance for eating, requires total assistance for bathing, and extensive assistance for all other ADLs. R2 is frequently incontinent of bowel and bladder. R2's MAR dated (MONTH) 2019 shows R2 had an order dated (MONTH) 10, 2019 for [MEDICATION NAME]-[MEDICATION NAME] Tablet (narcotic pain medication) ,[DATE] mg. Give 1 tablet by mouth every 4 hours as needed for pain management for moderate pain ,[DATE] pain scale. R2's Controlled Drug Receipt/Record/Disposition Form dated (MONTH) 15, 2019 shows R2 was administered [MEDICATION NAME] ,[DATE] mg. on (MONTH) 16, 2019 at 3:00 PM by V7 (RN), [MEDICATION NAME] ,[DATE] mg. on (MONTH) 19, 2019 at 7:00 AM by V12 (RN), and [MEDICATION NAME] ,[DATE] mg. on (MONTH) 19, 2019 at 4:00 PM by V7. V7 and V12 did not document on R2's MAR that the medication was administered to R2. On (MONTH) 30, 2019 at 1:17 PM, V2 (DON-Director of Nursing) said, nursing staff should document on the narcotic count sheet that they are pulling the medication from the medication cart, and then document on the MAR when they give the medication. V2 said, The two times should match. 3. On (MONTH) 30, 2019 at 12:26 PM, R3 was sitting in the dining room eating lunch under supervision of staff. R3 was unable to be interviewed due to her cognitive status. She appeared alert, did not appear lethargic or to be in respiratory distress. R3's EMR shows she was admitted to the facility on (MONTH) 12, 2019 with multiple [DIAGNOSES REDACTED]. R3's MDS dated (MONTH) 19, 2019 shows R3's cognition is moderately impaired. R3 requires setup and supervision with meals and requires extensive two person assist for all other ADLs. R3's POS (Physician order [REDACTED]. Give 0.5 tablet by mouth every 4 hours as needed for pain management. R3's MAR dated (MONTH) 1, 2019 to (MONTH) 31, 2019 shows that R3 was administered [MEDICATION NAME] from (MONTH) 12, 2019 until (MONTH) 17, 2019. Review of the (MONTH) medication audit sheet and the controlled drug receipt/record/disposition sheet shows discrepancies on (MONTH) 13, 14, and 15. During this time period, V6, V7, and V12 (nurses) signed out the [MEDICATION NAME] to be given but did not document on the MAR in the computer that the medication had been given. On (MONTH) 13, 2019 this occurred two times. On (MONTH) 14, 2019 this occurred two times and on (MONTH) 15, 2019 it occurred one time. Record review showed that on two other occasions, once on (MONTH) 15 and again on (MONTH) 17, the time between when the medications was signed out on the controlled drug/receipt/record/disposition sheet showed that a time lapse from one area of documentation to the other area was 45 minutes to 1 hour and 30 minutes. On (MONTH) 30, 2019 at 2:11 PM, V7 (RN), V7 stated that she worked on [DATE] day shift. She described the procedure for administering a control substance after a resident requests something for pain. V7 said, First you look in the computer at the medication administration record (MAR) to see what medication they can have based on resident's pain scale rating. If it's minor pain, Tylenol or [MEDICATION NAME] would be given. If the pain is moderate to severe they might have a controlled substance ordered. If it is a controlled substance, you have to look in the book and the medication is kept in a locked drawer. You are supposed to check the box on the MAR next to what medication you are giving, the time administered will appear, you will get a reminder to reassess and document a response to the medication given. The controlled substance has to be signed out in the book so that the counts are correct. If the medication is signed out on the controlled drug record but is not on the MAR, that means I was busy and forgot to document on the computer. On (MONTH) 30, 2019 at 3:11 PM, V12 (RN) stated she worked on [DATE] from 6:00 AM to either 2:00 or 3:00 PM. When a resident either asks for pain medication or appears to be in pain, I first check the computer to see what medications are ordered and determine based on the resident's report of pain or my assessment if they should get something like Tylenol or something stronger. I double check the computer to see of they have received anything recently. I also double check that I have the right resident, right medication, right dose, right route and right time. If giving a controlled substance I pull medication and make sure that the controlled medication sheet matches the order in the computer. I usually have the computer and narcotic book open when I administer narcotics and document. When I look at the narcotic count sheet if the pill count is off then I will look more into when last dose was given. I was not in the habit of checking the liquid amount prior to administering. I was written up for not doing that and now with the new procedure in place, I will check the liquid medication volume before administering the medication to make sure there wasn't a dose given and was not documented on the MAR. The facility's Medication Administration: General Guidelines Policy dated (MONTH) (YEAR) shows: [NAME] Policy: To ensure that medications are administered safely as prescribed. B. Prerequisites: 1. physician's orders [REDACTED]. Medication Administration Records (MARs) or Electronic Medication Administration Records (eMAR). 4. Associated supplies. D. Procedure: 3. Medications are prepared and administered by the same nurse. Administration should occur at the time of preparation. 4. Prior to administration, the nurse must verify medications and orders by comparing the medication label with the physician's orders [REDACTED]. Any discrepancies must be followed up by checking the original physician's orders [REDACTED]. On paper records, initials are verified by signature each month in the section provided on the back of the MAR/TAR. 11. All necessary items/supplies should be readily available for the proper administration of medication. On (MONTH) 30, 2019 at approximately 2:00 PM, V2 (DON-Director of Nursing) provided the facility's Medication Pass (Guidelines/Tips) Competency form, dated (MONTH) 2019. V2 said all facility nursing staff are expected to follow the medication pass tasks. The competency shows: Task 9. All medications must be given in the correct strength, route, dosage form, time and to the correct resident.

Based on interview and record review, the facility failed to follow their policy for administering medications. This failure resulted in R1 receiving a narcotic overdose on (MONTH) 15, 2019, requiring narcotic reversal treatment at the local hospital. R1 expired on (MONTH) 17, 2019 at the facility. This applies to 1 of 3 residents (R1) reviewed for medication administration in the sample of 5. The findings include: 1. On (MONTH) 23, 2019 at 2:12 PM, V6 (RN-Registered Nurse) said, I came to work on the evening of (MONTH) 15, 2019. I had worked the previous night and (V7) (RN) told me she reordered the [MEDICATION NAME] for (R1) from the pharmacy, because she ran out of the medication. I knew there was enough medication in the bottle when I left on my previous shift, and asked her to show me how that was possible. She showed me that she used the plastic medication cup to measure the medication. I told her that she gave too much medication to the resident. I always used a syringe to measure the medication. I know it's impossible to measure that small amount of medication with a medication cup. When I first arrived at the facility for my shift on (MONTH) 15, (R1) was breathing at a rate of five breaths per minute, which was very low. We notified the physician and he wanted the resident to receive [MEDICATION NAME] (opioid overdose medication treatment). We don't keep [MEDICATION NAME] at the facility, so we had to call 911 and send her to the hospital. She returned to the facility several hours later. The EMT (Emergency Medical Technician) reported to me that (R1) got six double doses of [MEDICATION NAME] at the hospital and was receiving oxygen at a rate of 10 liters per minute. Normally she is on 2 liters per minute. On (MONTH) 26, 2019 at 10:17 AM, V7 (RN) said, On (MONTH) 15, 2019, I ran out of (R1's) [MEDICATION NAME] (narcotic pain medication) during my shift, and when I reported this to the oncoming nurse (V6-RN) at shift change, he said how could that be? How much did you give? The medication order shows to give 0.25 ml (milliliters) to 0.50 ml. The medication didn't come with a syringe for dispensing the medication, so I used a medication cup when I gave the medication. I had been administering the medication with a medication cup, and actually gave 2.5 ml or 5 ml, which was ten times the ordered dosage. I had been doing this since (MONTH) 2019 because there was never a syringe available with that medication. So every time I gave the medication to (R1), I was giving her too much medication. It was more than she was supposed to receive, but I didn't realize I was making the mistake until I ran out of the medication. That's when I realized I had a problem. I couldn't understand how the medication level was going down so fast. I then thought to myself, I think I know why she is struggling to breath so much, because I gave her too much medication. Every time I gave her the [MEDICATION NAME] medication in (MONTH) 2019 and (MONTH) 2019, I used a medication cup instead of a syringe, and gave either 2.5 ml or 5 ml instead of the ordered dose, even though I documented on the controlled drug form that I gave 0.25 ml or 0.5 ml, which was incorrect documentation. The facility's Controlled Drug Receipt/Record/Disposition Forms show V7 administered [MEDICATION NAME] 4 mg/ml oral solution to R1 on: [DATE] at 12:00 PM (0.5 ml) [DATE] at 11:00 AM (0.5 ml) and also at 5:30 PM (0.5 ml) [DATE] at 11:00 AM (0.5 ml) [DATE] at 6:00 PM (0.5 ml) [DATE] at 10:00 AM (0.5 ml) and 4:00 PM (0.5 ml) [DATE] at 10:00 AM (0.5 ml) [DATE] at 10:12 AM (0.25 ml) (Documented on MAR (Medication Administration Form) not documented on Controlled Drug Form) [DATE] at 11:00 AM (0.25 ml) and 6:00 PM (0.5 ml) [DATE] at 11:50 AM (0.5 ml) and 4:30 PM (0.25 ml) The facility's Medication Incident Report dated (MONTH) 15, 2019 at 9:51 PM shows V7 (RN) administered [MEDICATION NAME] multiple times at the incorrect dose. Not having a syringe to measure the medication contributed to the most to giving the wrong medication per the report. Given by med cup 2.5 ml mistaken for 0.25 ml. Given by med cup 5.0 ml mistaken for 0.5 ml On (MONTH) 26, 2019 at 1:49 PM, V10 (Physician) said, I received a call from our hospice nurse that (R1) received substandard medication orders and the nurse at the facility gave too much medication. I was told by our nurse that the resident was heavily sedated and obtunded and had respiratory depression. I ordered [MEDICATION NAME] to be administered to the resident or to send the resident to the hospital via 911. For a women of her weight, I would order 0.5 mg to 1 milligram with a maximum dose of 2 milligrams at any given time. I would never order 5 milligrams of the medication to be given at one time, and I would order it to be given every four hours as needed. I would not want the resident to receive more than 6 milligrams of [MEDICATION NAME] in a day. For a resident to receive 40 mg, within the time period (R1) received the [MEDICATION NAME], they would definitely become obtunded and have respiratory depression. That is too high of a dose, and I would never prescribe that amount of medication for a woman of her size. The Controlled Drug Receipt/Record/Disposition Form shows on (MONTH) 15, 2019, V6 (RN) administered 1 mg of [MEDICATION NAME] at 2:47 AM, and V7 administered 20 mg of [MEDICATION NAME] at 11:50 AM, and 10 mg. at 4:30 PM, for a total dosage of 31 mg in 14.5 hours. On (MONTH) 30, 2019 at 11:49 AM, V13 (Physician) said, I am aware the resident received an overdose of the [MEDICATION NAME] on (MONTH) 15. I consider this a significant medication error. Receiving ten times the dosage could cause respiratory depression, and could lead to aspiration pneumonia as well. I would expect the nursing staff to give the medication as ordered. I do know that she was stable with her dementia and [MEDICAL CONDITIONS] prior to the overdose and receiving [MEDICATION NAME] at the hospital. Records from the local hospital dated (MONTH) 15, 2019 at 9:15 PM show R1 was admitted with a [DIAGNOSES REDACTED]. R1's vital signs at 9:24 PM showed blood pressure of ,[DATE], pulse of 106, and respirations of 10 per minute. A reassessment at 9:30 PM showed R1's vital signs with a respiratory rate of 6 breaths per minute, and R1 was receiving oxygen at a rate of 15 liters per minute via non-rebreather mask. R1 arrived at the emergency department very drowsy, alert to oral suctioning and sternal rub, moaning and barely opening her eyes. Course crackles and gurgling was noted. Hospital documentation shows R1 received three doses of [MEDICATION NAME] in the emergency room , and was discharged back to the care of the nursing home on (MONTH) 16, 2019 at 12:21 AM. On (MONTH) 15, 2019 V14 (emergency room Physician) documented, Patient (R1) appears to be in rapid [MEDICAL CONDITION]. Patient also with rales on her [MEDICAL CONDITION] exam and with her being oversedated due to the air and [MEDICATION NAME] ([MEDICATION NAME]) administration, I suspect she could have aspiration pneumonia. Going forward I will recommend chest x-ray, supplemental oxygen, continued [MEDICATION NAME] use via nebulizers as well as antiarrhythmic for rate control, possible anticoagulation. She would also need laboratories as well. POA (Power of Attorney), daughter and granddaughter state they do not want anything done at this time per their mother and grandmother. They wish for no increased supplemental oxygen, antiarrhythmic IV fluids, laboratories, chest x-ray, etc. I did inform them that her present condition may continue to deteriorate and may lead to her death in the very near future which they verbalized understanding of. The EMR (Electronic Medical Record) shows R1 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Data Set) dated (MONTH) 11, 2019 shows R1 had severe cognitive impairment, was able to eat with supervision, and required limited to extensive assistance with all other ADLs (Activities of Daily Living). R1 was incontinent of bowel and bladder. R1 had adequate hearing, clear speech, was able to make herself understood, and was able to understand others. R1 did not exhibit any behaviors. R1 received pain medication as needed, and had shortness of breath or trouble breathing with exertion, and when lying flat. R1 had a condition or chronic disease that may have resulted in a life expectancy of less than six months. R1's Order Summary Report dated (MONTH) 23, 2019 shows the following orders for [MEDICATION NAME]: [MEDICATION NAME] HCl Tablet 2 mg, give 1 tablet by mouth every 6 hours as needed for pain management, dated (MONTH) 14, (YEAR). [MEDICATION NAME] HCl Solution 4 mg/ml, give 0.25 ml by mouth every 1 hour as needed for moderate shortness of breath (0.25 ml = 1 mg). (MONTH) give oral or sublingual. Order dated (MONTH) 21, 2019. [MEDICATION NAME] HCl Solution 4 mg/ml, give 0.25 ml by mouth every 2 hours as needed for moderate pain (0.25 ml = 1 mg). (MONTH) give oral or sublingual. Order dated (MONTH) 21, 2019. [MEDICATION NAME] HCl Solution 4 mg/ml, Give 0.5 ml by mouth every 1 hours as needed for severe shortness of breath (0.25 ml = 1 mg). (MONTH) give oral or sublingual. Order dated (MONTH) 21, 2019. [MEDICATION NAME] HCl Solution 4 mg/ml, Give 0.5 ml by mouth every 2 hours as needed for severe pain (0.25 ml = 1 mg). (MONTH) give oral or sublingual. Order dated (MONTH) 21, 2019. [MEDICATION NAME] HCl Solution 4 mg/ml Give 0.5 ml by mouth every 2 hours as needed for severe pain (0.5 ml = 2 mg). (MONTH) give oral or sublingual. Order dated (MONTH) 21, 2019. The facility's Medication Administration: General Guidelines Policy dated (MONTH) (YEAR) shows: [NAME] Policy: To ensure that medications are administered safely as prescribed. B. Prerequisites: 1. physician's orders [REDACTED]. Medication Administration Records (MARs) or Electronic Medication Administration Records (eMAR). 4. Associated supplies. D. Procedure: 3. Medications are prepared and administered by the same nurse. Administration should occur at the time of preparation. 4. Prior to administration, the nurse must verify medications and orders by comparing the medication label with the physician's orders [REDACTED]. Any discrepancies must be followed up by checking the original physician's orders [REDACTED]. On paper records, initials are verified by signature each month in the section provided on the back of the MAR/TAR. 11. All necessary items/supplies should be readily available for the proper administration of medication. On (MONTH) 30, 2019 at approximately 2:00 PM, V2 (DON-Director of Nursing) provided the facility's Medication Pass (Guidelines/Tips) Competency form, dated (MONTH) 2019. V2 said all facility nursing staff should be following the competency tasks. The competency shows: Task 9. All medications must be given in the correct strength, route, dosage form, time and to the correct resident.