Every finding on record at Alta View Post Acute

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with necessary behavioral health assessments, care, and services for the treatment of Resident 1's schizophrenia (mental disorder which leads to hallucinations, irrational thoughts, and behaviors) by failing to: 1. Identify, address, and provide Resident 1 with the necessary behavioral health care and services. 2. Develop a behavioral health care plan for Resident 1. These deficient practices denied Resident 1 behavioral health care and services needed to maintain mental well-being and resulted in Resident 1 being unnecessarily admitted to General Acute Care Hospital (GACH) 1 on 6/3/2026.Findings: During a review of Resident 1's admission record, the admission record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses the included affective-mood disorder (a mental health condition that fundamentally alters your emotional state, causing persistent and severe periods of sadness, elation, or both), psychosis (a collection of symptoms that indicate a disconnection from reality. It affects an individual's thoughts and perceptions, making it difficult to distinguish between what is real and what is not), and dementia (a progressive state of decline in mental abilities) with psychotic disturbance (a severe mental health condition that causes a disconnect from reality. It affects a person's thoughts and perceptions, making it difficult to distinguish between what is real and what is imagined). During a review of Resident 1's GACH referral to the facility dated 5/22/2026 at 10:11 am, the GACH referral indicated discharge diagnoses including mood disorder/psychosis and dementia which required supportive care. During a review of Resident 1's baseline care plan (a personalized, written guide that outlines an individual's specific health needs, daily routines, and personal goals) dated 6/2/2026, the baseline care plan indicated a goal, Improve physical and functional status, avoid complications and minimize decline. The care plan indicated Resident 1 required two-person physical assistance for bed mobility and transfers. The care plan indicated Resident 1 was cognitively impaired due to dementia with behavioral concerns of agitation and striking out. The care plan did not list any interventions for the behavioral concerns. During a review of Resident 1's physician's orders dated 6/3/2026 at 10:57 am, the physician's orders indicated May transfer to California Hospital Medical Center for further evaluation and treatment d/t uncontrolled restlessness and agitation. During a review of Resident 1's Interdisciplinary Team (IDT - consist of a variety of medical professionals and supporting personnel, including physicians, therapists, nurses, social workers, dieticians, case managers and anyone else deemed necessary to help a patient recover from an acute injury or thrive in their current condition) conference dated 6/3/2026 at 12:03 pm, the IDT indicated psychiatry consults as needed per [Responsible Party - RP] and [Resident 1] was at another nursing home. He [Resident 1] has had behaviors and is on Quetiapine Fumarate [an atypical antipsychotic primarily prescribed to treat schizophrenia - a chronic and severe mental health disorder that affects how a person thinks, feels, and acts, bipolar disorder - a mental health condition that causes extreme, uncontrollable shifts in mood, energy, and activity levels, and major depressive disorder - a serious mental health condition that causes persistent feelings of sadness, hopelessness, and a loss of interest in activities you once enjoyed] Oral Tablet 50 MG [milligrams - units of measure] (Quetiapine Fumarate) Give 2.5 tablet via PEG-Tube [Percutaneous Endoscopic Gastrostomy - a medical feeding tube surgically inserted directly through the abdomen into the stomach providing a direct route to deliver liquid nutrition, fluids, and medications to individuals who cannot safely swallow] three times a day for Psychosis m/b [manifested by] agitation Give 2.5 tab = 125 mg. Informed consent [the process of a patient voluntarily agreeing to a medical treatment or procedure after fully understanding the associated risks, benefits, and alternatives] obtained by MD [Medical Doctor - physician] from resident/responsible party. Mirtazapine [Remeron - an antidepressant] Tablet 15 MG Give 1 tablet via PEG-Tube at bedtime for Depression m/b little or no interest in doing things. Lorazepam [Ativan - a benzodiazepine that works in the brain to relieve symptoms of anxiety] Oral Tablet 1 MG (Lorazepam) *Controlled Drug-Give 1 tablet via PEG-Tube every 12 hours as needed for Anxiety m/b restlessness for 14 Days. During an interview with Certified Nursing Assistant (CNA) 1 on 6/13/2026 at 12:03 pm, CNA stated that she (CNA 1) was assigned to provide care for Resident 1 alongside another CNA (CNA 2) who was assigned to provide 1-to-1 sitter (a healthcare worker or aide who provides continuous, individualized observation to a single patient in a hospital or care facility) care to Resident 1. CNA 1 stated that Resident 1 required total assistance and was unable to get out of bed or ambulate (walk). CNA 1 stated that Resident 1 used foul language and was hitting and kicking the staff but was unable to confirm if she had been struck by Resident 1. During an interview with the Facility Marketer (FM) 1 on 6/16/2026 at 1:30 pm, FM 1 stated that one of her (FM 1) roles included marketing for the facility and connecting potential residents to the facility. FM 1 stated that residents would have to be appropriate for the facility before being admitted but was unable to state some of the reasons which would deem a resident inappropriate for the facility. FM 1 stated that when Resident 1 was initially referred to the facility, she (FM 1) had discovered that he (Resident 1) was denied admission to most facilities which deemed him (Resident 1) a hard placement. FM 1 stated that she (FM 1) had initially stated that he (Resident 1) was not appropriate when the GACH staff notified her that Resident 1 required a 1-to-1 sitter of which the staff retracted that he did not require one (1-to-1 sitter). FM 1 stated that she had gone to GACH (could not recall date) to assess Resident 1 for herself and found that there was a 1-to-1 sitter in Resident 1's room. FM 1 stated that when she asked about the 1-to-1 sitter, the GACH Social Worker (SW) stated that the 1-to-1 sitter was for a different patient in the same room. FM 1 did not ask the 1-to-1 sitter which resident they were monitoring. FM 1 stated that upon admitting Resident 1 to the facility, the staff realized that he (Resident 1) required a 1-to-1 sitter. FM 1 stated that the facility sent Resident 1 back to GACH because the facility was unable to accommodate Resident 1 because he required a 1-to-1 sitter. During an interview with the Facility Administrator on 6/16/2026 at 2:13 pm, the FA stated that the admission process included reviewing medical records which could possibly prompt a no admission depending on what it contains. The FA was unable to state if the clinicals were received before or after the FM went to see Resident 1 at GACH. The FA was unable to state if Resident 1 should have had a care plan because of the behaviors he was displaying (restlessness) stating that he would have to ask the Director of Nursing (DON). The FA was unable to respond when asked if the facility was able to provide all the necessary care a resident required once accepted to their facility. During an interview with the DON on 6/16/2026 at 3:09 pm, the DON stated that Resident 1 was in the facility less than 24 hours when the facility became aware that Resident 1 required a 1-to-1 sitter due to behaviors. The DON stated that there were concerns about safety for the staff and the residents' own but was unable to specify how Resident 1's safety was impacted. During a review of a Policy and Procedure titled, Transfer or Discharge, revised 4/2026 indicated, Once admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record. The P&P indicated under Transfer or Discharge Documentation in the Medical Record that, if the basis for the transfer or discharge is that the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, the resident's physician (or provider) documents:the specific resident needs that cannot be met. The P&P indicated a resident's refusal of treatment is not grounds for discharge unless the facility are unable to meet the needs to protect the resident. During a review of a P&P titled, Care Plans - Baseline, revised 5/2026 indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident. The P&P indicated, The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident. The P&P indicated that the baseline care plan is used to meet the needs of the resident until a person-centered care plan was developed no later than 21 days after a resident was admitted .

Based on observations, interview and record review, the facility failed to implement their policy and procedures (P&P), titled, Infection Prevention and Control Program, revised in April 2025, during an outbreak (the sudden occurrence of two or more residents (or staff) getting the same illness within a short period) of Invasive Group A Streptococcus (IGAS - refers to a surge in rare, dangerous infections caused by common bacteria [Strep A] invading blood, muscles, or lungs, rather than just the throat or skin) for two of two sampled residents, (Resident 1 and Resident 2). By failing to implement transmission-based precautions (extra, targeted safety steps taken in healthcare settings to stop the spread of specific germs from infected or suspected-infected patients to others) including posting notification signage on the front door of the facility and in all common areas on 4/16/2026 when an outbreak of IGAS was declared in the facility. This deficient practice had the potential to transmit infectious diseases and increase the risk of infection to the residents, staff, and visitors.Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Streptococcus, Group A, hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, and polyneuropathy (a condition in which a person's peripheral nerves are damaged). During a review of the Minimum Data Set (MDS - resident assessment tool) dated 3/11/2026, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required maximal to total dependent from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of facility's document titled, Infectious Disease Progress Note (IDPN - laboratory test result), dated 3/4/2026, the IDPN indicated Resident 1's laboratory test detected positive for Streptococcus pyogenes (Group A Strep or simply Strep A). During a review of Resident 1's Care Plan (CP) undated, the CP indicated Resident 1 was at risk for body rashes related to detection of Group A Streptococcus, the CP indicated interventions including to educate resident/family/caregivers of causative factors and measures to prevent skin injury. During a review of Resident 1's admission Nursing Risks Evaluation/Assessment (ANRE), dated 3/5/2026, the ANRE indicated Resident 1 arrived from a General Acute Care Hospital 1 (GACH 1) with admitting diagnosis of bacteremia cellulitis of right arm (serious bacterial skin infection that has spread from the tissue into the bloodstream) and was on cephalexin (antibiotic used to treat certain infections caused by bacteria) 500 milligram (mg - unit of measurement), and clindamycin (a strong, prescription antibiotic used to kill or stop the growth of bacteria causing infections, particularly in the skin, throat, teeth, and stomach) 300 mg. The ANRE indicated Resident 1 was not on any transmission-based precaution (extra, high-level safety rules used in healthcare settings to stop the spread of known or suspected germ infections, beyond routine, standard precautions). During a review of Resident 1's Order Summary Report, as of 4/30/2026, there was no physician's order for any transmission-based precautions. During an interview with Minimum Data Set Coordinator/Infection Preventionist Nurse 3 (MDSC/IPN3) on 4/30/2026 at 1:31 p.m., MDSC/IPN3 stated the facility was currently on outbreak for GAS with two residents who were diagnosed with Group A Streptococcus. MDSC/IPN3 stated IGAS was an invasive bacterium that could cause body rash and/or strep throat (a contagious bacterial infection of the tonsils and throat caused by Group A Streptococcus). MDSC/IPN3 stated the IGAS infection could be spread through person-to-person respiratory droplet (a tiny, wet particle of saliva or mucus released from your nose or mouth when you breathe, talk, cough, or sneeze), vomiting, etc. MDSC/IPN3 stated the spread of infection could be reduced by staff handwashing and using personal protective equipment (PPE-a barrier precaution which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) and placing residents on transmission-based precautions. MDSC/IPN3 stated that Resident 1 was readmitted from GACH 1 with antibiotic treatment for cellulitis and was receiving wound care treatment. MDSC/IPN3 stated, Resident 1 was not on any transmission-based precaution upon readmission. MDSC/IPN3 further stated, the facility was not implementing surgical mask usage for staff, family members and visitors in the facility as of the date of interview (4/30/2026). During a review of Resident 2's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Streptococcus, Group A, chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), heart failure (a condition in which the heart does not pump blood as well as it should) and cellulitis of left lower limb (leg). During a review of the MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were intact. The MDS indicated Resident 2 required moderate assistance from staff for ADLs. During a review of facility's document titled, Infectious Disease Progress Note (IDPN - laboratory test result), dated 4/11/2026, the IDPN indicated, Resident 2's laboratory test detected positive for Streptococcus pyogenes.During a review of Resident 2's CP, dated 4/30/2026, the CP indicated Resident 2 is at risk for impaired airway related to detection of Group A Streptococcus, the CP indicated interventions including to ensure adherence to prescribed regimen. During a review of Resident 2's Progress Notes (PN) dated 4/9/2026, the PN indicated Resident 2 was noted with 88 percent (% - unit of measurement), oxygen saturation, tachycardia (fast heart rate) with heart rate (HR) of 139 (normal range is 60-100 beats per minute [bpm]). During a review of Resident 2's PN on 4/14/2026, the PN indicated, Resident 2 was readmitted from AGCH 1. Resident 2 on intravenous (giving fluids or medicine directly into a vein, usually through a small tube (catheter) inserted into the hand or arm) antibiotic (medication that fight bacteria). During an interview with MDSC/IPN3 on 4/30/2026 at 1:31 p.m., MDSC/IPN3 stated, Resident 2 was hospitalized and returned to the facility with antibiotic treatment. MDSC/IPN3 stated Resident 2 was not on any transmission-based precaution upon readmission. During a review of a letter from The Los Angeles County Department of Public Health (DPH) under Acute Communicable Disease Control (ACDC) on 4/16/2026, the letter indicated that ACDC have identified invasive GAS infection in two residents who resided at the facility and were ill on 2/28/2026 and 4/9/2026. The recommendation letter indicated to conduct a retrospective review of all patients in the facility to identify patients who developed invasive IGAS infection from 1/28/2026 to present and document, submit a copy of the facility map and indicating which rooms/units the positive residents were located and post a IGAS notification letter about the increased occurrence of IGAS infections at the facility. The letter instructed the facility to print the notification letter on the facility's letterhead and to place the notification in all common areas of the facility and consider distributing to all residents and staff.During a review of ACDC's letter to the facility on 4/29/2026, the letter indicated since there were two residents with confirmed cases of invasive IGAS infection within four-month period, The ACDC would designate the two confirmed residents as an outbreak of IGAS within the facility. The letter included recommendations of exercises in mask usage, hand hygiene, PPE donning/doffing, environmental and room cleaning procedures and wound dressing practices. During an observation of the facility on 4/30/2026 at 12:46 p.m., Resident 1 and Resident 2 were observed with no cohorting (the practice of grouping together patients who have the same infection or have been exposed to the same pathogen in a designated area) and the residents were not placed in any transmission-based precaution rooms. The facility staff was observed not using surgical masks throughout the facility. There was no notification of outbreak letter observed at the entrance door and throughout the facility. During a concurrent interview and record review with the Director of Nursing (DON) on 4/30/2026 at 3:09 p.m. the DON stated the facility first received a letter from The Los Angeles County Department of Public Health (DPH), Acute Communicable Disease Control (ACDC) on 4/16/2026 indicating invasive GAS infection was identified in two residents who resided at the facility and were ill on 2/28/2026 and 4/9/2026. The DON stated she was unsure if residents who were diagnosed with IGAS infection had to be placed on a transmission-based precautions. The DON confirmed by stating there was no notification letter posted throughout the facility regarding the IGAS outbreak. The DON stated she was awaiting further instructions from ACDC on what to do during an IGAS outbreak. The DON reviewed facility's P&P titled, Infection Prevention and Control Program and stated facility staff should have been following the facility's P&P. The DON reviewed ACDC's guidance letter on 4/16/2026 and confirmed the letter indicated the facility had to post an IGAS notification letter about the increased occurrence of IGAS infections at the facility, print the notification letter on the facility's letterhead, place the notice in all common areas of the facility, and consider distributing to all residents and staff. The DON confirmed by stating the facility did not post any notification letter throughout the facility regarding the IGAS infectious disease. During a review of the facility's P&P titled, Infection Prevention and Control Program, revised 4/2025, the P&P indicated An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Outbreak management is a process that consists of:Determining the presence of an outbreak;Managing the affected residents;Preventing the spread to other residents;Documenting information about the outbreak;Reporting the information to appropriate public health authorities;Educating the staff and the public;Monitoring for recurrences;Reviewing the care after the outbreak has subsided; andRecommending new or revised policies to handle similar events in the future.The medical staff will help the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases. Prevention of infection: Important faces of infection prevention include: identifying possible infections or potential complications of existing infections;. educating staff and ensuring that they adhere to proper techniques and procedures. implementing appropriate isolation precautions when necessary; and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC - main U.S. government agency responsible for protecting public health.) During a review of facility's P&P titled, Invasive Group A Streptococcus: An Overview for Long-Term Care Facilities, dated 2/2026, with facility review date of 4/29/2026, the P&P indicated In long-term care settings, outbreaks can occur due to lapses in infection preventions and control practices, including hand hygiene, PPE use, and wound care practices. Infection Prevention and Control for IGAS: wear gloves and gown for wound care as part of Enhanced Barrier Precautions (specific, extra infection-control steps taken in nursing homes to stop the spread of dangerous, drug-resistant germs, staff wear gowns and gloves during high-contact care like bathing or dressing for residents with wounds or tubes, even if they aren't on strict isolation) and add face shield if splash is anticipated. During an outbreak, healthcare personnel (HCP) should wear facemask during all wound care activities. Maintain appropriate precautions for residents with suspected or confirmed GAS until 24 hours after starting effective antibiotics. Use Contact (safety measures used in health care facilities to prevent the spread of infections transmitted by touching a patient or their surroundings. Key actions include mandatory hand hygiene, wearing a gown and gloves when entering the room, and using dedicated equipment for that patient) and Droplet Precautions (safety steps used in health care facilities to stop the spread of germs that travel short distances (about 3-6 feet) through germ-filled droplets from coughing, sneezing, or talking. These precautions mean wearing a surgical mask when near the patient to prevent breathing in these large droplets) for wounds until drainage stops or is contained and apply Droplet Precautions for throat infections.

Based on interview and record review, the facility failed to maintain the clinical records as indicated in the facility's Charting and Documentation policy and procedure for one of three sampled residents (Resident 1) by failing to ensure to document: -A significant care event on 3/6/2026, including Resident 1's refusal of shower care, aggressive behavior, staff interventions, and outcome. -The transfer of care from Certified Nursing Assistant 1 (CNA 1) to CNA 2 during the shower refusal on 3/6/2026. These failures resulted in an incomplete medical record of Resident 1 and had potential to affect Resident 1's care.Findings: During a review of Resident 1's admission Record, the admission Recorded indicated the facility admitted Resident 1 on 2/27/2024, and readmitted the resident on 8/11/2025, with diagnoses including but not limited to schizophrenia (a chronic brain disorder that disrupts how a person thinks, feels, and acts, making it difficult to distinguish reality from imagination), bipolar disorder (a chronic mental health condition characterized by intense, extreme mood swings that interfere with daily life), and essential hypertension (high blood pressure, developing gradually over many years without a direct, identifiable, or secondary cause. During a review of Resident 1's History and Physical (H&P) dated 8/15/2025, the H&P indicated Resident 1 was competent to understand her medical condition. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 2/13/2026, the MDS indicated Resident 1 made herself understood and understood others. The MDS indicated Resident 1's cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks) was intact. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) for showers and hygiene. During a review of facility's shower schedule dated 3/6/2026, the shower schedule indicated Resident 1 was listed as scheduled for a shower. The shower schedule indicated that CNA 1 was assigned to provide care to Resident 1. During an interview on 4/8/2026 at 1:47 PM, with CNA 2, CNA 2 stated that on 3/6/2026, CNA 1 reported to her (CNA2) at the office that Resident 1 refused to take a shower from CNA 1. CNA 2 stated she (CNA2) went to approach Resident 1 in front of the shower room. CNA 2 stated she (CNA2) did not ask Resident 1 why she (Resident 1) was refusing a shower. CNA2 stated Resident 1 refused shower care before (unidentified date and time). CNA 2 stated she (CNA2) offered to provide shower to Resident 1 on 3/6/2026. CNA2 stated Resident 1 completed the shower without complaints. During an interview on 4/8/2026 at 2:31 PM with CNA 1, CNA 1 stated the alleged incident occurred on 3/6/2026 during the shower care of Resident 1. CNA 1 stated she (CNA1) was assigned to care for Resident 1 and was scheduled for a shower that day (3/6/2026). CNA 1 stated while in the shower room, Resident 1 verbalized refusal, stating she (Resident 1) did not want to shower. CNA1 stated she (CNA1) confirmed with Resident 1 if she (Resident 1) was sure, at which time Resident 1 threw a towel toward her (CNA1) and stood up from the shower chair. CNA 1 stated the Licensed Vocational Nurse (LVN unidentified) was outside the shower room. CNA 1 reported the refusal to the LVN (unidentified) and requested to monitor Resident 1 while she (CNA1) obtained assistance. CNA 1 stated she (CNA1) sought assistance from CNA 2. CNA 1 stated CNA 2 approached Resident 1, helped with the shower, and Resident 1 did not refuse care. CNA 1 stated CNA 2 assumed care of Resident 1 and completed the shower. CNA 1 stated she (CNA1) did not chart the incident. During a concurrent interview and record review on 4/8/2026 at 3:40 PM with the Medical records Director (MRD), Resident 1's medical record was reviewed. MRD stated after a thorough review of Resident1's medical record, there was no documentation of the shower refusal that occurred on 3/6/2026 or related behavioral incident were found. The MRD stated that the facility's process required that when a resident (in general) refused care, the CNA (in general) would report the refusal to the charge nurse, and the charge nurse then reported it to the supervisor. The MRD stated that Resident 1's shower refusal should have been documented as part of medical record of Resident 1's care information. During a concurrent interview and record review on 4/8/2026 at 4:49 PM with the Director of Nursing (DON), the alleged incident staff interview document of LVN1, dated 3/27/2026, was reviewed. The DON stated LVN 1 interview document indicated that LVN 1 heard someone (unidentified) inside the shower room yelling, I don't want to take a shower, and that Resident 1 verbally expressed to her she (Resident 1) did not want to take a shower. The DON stated LVN1 interview document indicated Resident 1 later agreed to take a shower with the assistance of CNA 2 and continued medication administration after CNA 2 assumed care. The DON stated that the shower refusal and behavior event on 3/6/2026 were not documented in the progress notes and were not reported to the supervisor. The DON stated there was a failure to document Resident 1's shower refusal incident. During a review of the facility's P&P titled Charting and Documentation, last reviewed on 7/2025, the P&P indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The P&P also indicated that linens should not be stored in the shower room. The P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The P&P indicated entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN [Registered Nurse] LPN [Licensed Practical Nurse]/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. The P&P indicated Certified Nursing Assistants may only make entries in the residents' medical chart as permitted by facility policy. The P&P indicated Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided. b. The name and title of the individual(s) who provided the care. c. The assessment data and/or any unusual findings obtained during the procedure/treatment. d. How the resident tolerated the procedure/treatment. e. Whether the resident refused the procedure/treatment. f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting.

Based on interview and record review, the facility failed ensure its' policy and procedures (P&P) titled Transfer or Discharge, Preparing a Resident for, were implemented for one of three sampled residents (Resident 1).This failure resulted in Resident 1 being discharged to a board and care ( without a post-discharge plan documented, and the potential to delay ordered home health services and missing the ordered follow-up doctor's appointment.During a review of Resident 1's admission Record , dated 3/6/26, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including hypertension (HTN - high blood pressure), hyperlipidemia (HLD - high cholesterol, epilepsy (chronic brain disorder characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain), and difficulty in walking.During a review of Resident 1's History and Physical (H&P), dated 1/19/26 indicated the resident had the capacity to understand and make own medical decisions.During a review of Resident 1's Order Summary Report, dated 3/6/26 indicated an order for discharge entered on 1/6/26 of: follow-up appointment with doctor on 2/23/26. Further review of the same report indicated an order entered on 1/30/26 of: may discharge on Friday 1/30/26 to board and care, home health for physical therapy (PT) and occupational therapy (OT), registered nurse (RN) for safety, and durable medical equipment (DME): wheelchair.During an interview with concurrent record review with the Director of Nursing (DON), Resident 1's order for discharge and follow-up doctor's visit orders were reviewed and the post-discharge plan was not verified as not documented in the residents' record. The DON agreed there is no way of knowing if the home health was arranged or the follow-up appointment with the resident's doctor communicated to the board and care, per the documentation.During a review of the facility's P&P titled Transfer or Discharge, Preparing a Resident for, revised November 2025, indicated, Residents will be prepared in advance for discharge. A post-discharge plan is developed for each resident prior to his or her transfer of discharge. Nursing services is responsible for: Preparing. post-discharge plan.

Based on interview and record review, the facility failed to allow one sampled resident (Resident 1) to return to the facility following a hospitalization on 12/3/2025, Resident 1 was transferred to general acute care hospital (GACH) on 11/11/2025. This deficient practice delayed Resident 1's return to the facility and had the potential to result in psychosocial harm for Resident 1, and Resident 1's responsible party. Findings:During a review of Resident 1's admission Records, the Records indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis (severe or complete loss of strength or paralysis on one side of the body and mild or partial weakness or loss of strength on one side of the body), morbid (severe) obesity (a disorder that involves having too much body fat, which increases the risk of health problems) , type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), functional quadriplegia (paralysis below the neck that affects all of a person's limbs).During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/11/2025, the MDS indicated, Resident 1 had impaired cognitive skills (mental action or process of acquiring knowledge and understanding) to make decisions on self-care activities; Resident 1 was dependent on staff for rolling left and right, sitting to lying ,sitting to standing, and transferring from chair/bed to chair. During a review of Resident 1's History and Physical (H&P) dated 7/10/2025, the H&P indicated Resident 1 had a history of cerebral infarction (a type of stroke caused by blood clot cutting off oxygen and nutrient to brain cells), encephalopathy ( permanent brain damage that causes severe confusion and forgetfulness ), urinary tract infection (UTI- an illness in any part of the urinary tract, the system of organs that makes urine).During a review of Resident 1's GACH (General Acute Care Hospital) Discharge Orders dated 11/27/2025, the order indicated, Resident 1 to be discharged from GACH to Skilled Nursing Facility (SNF) on 11/27/2025During a review of Resident 1's GACH Care Management Progress Note dated 11/28/2025, the progress note indicated, GACH discharge planner (DCP) contacted the facility on 11/28/2025. DCP note indicated, they do not have admission for today, they'll be available on Monday. DCP faxed Resident 1's clinical inquiries to the facility on [DATE].[YW1] During a review of Resident 1's GACH Care Management Progress Note dated 12/2/2025, the progress note indicated, DCP followed up with facility marketer (Mktg) and documented per facility personnel, they do not have open female bed available at this time and will let me know once open bed becomes available.During a review of Resident 1's GACH Patient Records dated 12/2/2025, the patient records indicated an order to discharge Resident 1 to SNF.During a review of the facility census, it indicated the following:11/27/2025 total census 91, two female empty beds open.11/28/2025 total census 90, three female empty beds open.11/29/2025 total census 90, two female empty beds open.11/30/2025 total census 90, two female empty beds open.12/1/2025 total census 92, one female empty bed open.12/2/2025 total census 92, one female empty bed open.12/3/2025 total census 91, one female empty bed open.12/4/2025 total census 91, one female empty bed open.12/5/2025 total census 91, one female empty bed open. During an interview on 12/5/2025 at 10:05 AM with GACH case manager, the GACH-case manager stated, Resident 1 had discharge orders as of 11/27/2025, but the facility staff have been telling us there is no bed and no mattress and bed.During an interview on 12/5/2025 at 11:58 AM with the facility admissions director (AD), the AD stated the resident with readmission request gets priority for available beds, the first time I was contacted from GACH was on 12/1/2025. AD also stated, the facility received Resident 1's inquiry from GACH on 12/1/2025. On 12/1/2025 the facility did not have a mattress. AD further stated, the facility had room and bed available but there was no mattress. AD stated, potential harm for delay and denial of readmission could result in the resident and family member being upset, it is their home and bed, the resident is entitled to come back.During an interview on 12/5/2025 at 12:23 PM with the director of social services (SS), SS stated, residents past seven-day bed hold have the right to come back to the facility post transfer to GACH. Resident 1 has been in and out of the facility to GACH and always gets readmitted . SS stated, I was informed that the hospital has been trying to send Resident 1 back to the facility as of a couple of days ago. I was informed there was no bariatric (beds specifically designed to accommodate individuals with limited mobility or health issues, providing a higher weight capacity) bed available. SS stated, I am not sure for how long the hospital (GACH) attempted to transfer Resident 1 back to the facility.During an interview on 12/5/2025 at 12:45 PM with the assistant Director of Nursing (ADON), ADON stated, Resident 1 is a long-term resident at the facility. In the last two months Resident 1 was in and out of the facility to GACH and there was no problem readmitting the resident. ADON stated, I was informed that Resident 1 was ready to come back to the facility as of yesterday. If I had prior information Resident 1 was ready to come back to the facility, I would have inquired and reviewed the readmission inquiry packet and process for readmission. ADON stated, the reason I was informed by facility staff was that the resident is not ready to come back and there is no bariatric mattress available.During an interview on 12/5/2025 at 1:32 PM with facility marketing manager (Mktg), Mktg stated, initial readmission inquiry from GACH comes directly to the Mktg or admissions department. Mktg stated, when hospital (GACH) personnel communicated with me on 12/1/2025 they were upset, they told me the facility was giving them the run around to readmit Resident 1, I informed the complainant that I was not informed before 12/1/25 the resident was ready for readmission, and I asked for Resident 1's readmission inquiries. During a review of the facility's Policy and Procedure (P&P) titled readmission to the Facility, revised on March 2025, the P&P indicated, A Medicaid resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed in a semi-private room if the resident:a. Requires the services provided by the facility;b. Meets the admission criteria as outlined in facility policy;c. Was not discharged for any reason outlined in the Transfer orDischarge Notice policy; andd. Is eligible for Medicaid nursing facility services.5. Inquiries concerning our readmission policies should be referred to theAdministrator and/or the Director of Nursing Services.

Based on observation, interview, and record review, the facility failed to ensure expired food was not stored in the kitchen for 76 of 84 residents who received food from the facility's kitchen. This deficient practice had the potential to cause food-borne illnesses to the residents related to ingestion of expired food and has a potential to lead to foodborne illnesses which can be life-threatening. During an initial kitchen tour observation on 8/18/2025 at 8:08 a.m. with the Dietary Manager (DM), it was observed to have undated and expired food items stored in the refrigerator: Undated prepared peanut butter and jellied sandwiches were stored in one of four refrigerators. Expired deli turkey slides were stored inside one of four refrigerators in a container with a label to use by 8/17/2025. During a concurrent observation and interview on 8/18/2025 at 8:08 a.m. with the Dietary Manager DM stated the label for the peanut butter and jellied sandwiches must have fallen off and that it should have a label when it was prepared and when to use by. DM stated the turkey deli should have been discarded. During an interview on 8/21/2025 at 2:02 p.m. with Registered Dietitian (RD) stated food must be labeled to avoid giving residents expired food which if given to residents, they can have gastrointestinal issues such as bacteria overgrowth. During a review of the facility's policy and procedure titled, Food Receiving and Storage, dated November 2024, states that all refrigerated or frozen foods must be labeled with a use-by date. Foods are monitored and either used by that date or discarded.

Based on observation, interview and record review, the facility failed to ensure kitchen freezer #1 and freezer #2 was maintained at 0-degree Fahrenheit (F-unit of measurement) temperature while hashbrowns, whipped topping, french fries, assorted vegetables, sweet potato fries were store. This deficient practice placed 76 of 84 residents residing in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages). During a concurrent initial kitchen tour observation on 8/18/2025 at 8:03 a.m. and interview with the Dietary Manager (DM), the following were observed. a. Freezer #1 is located outside the storeroom. The internal thermometer reads 12 degrees F. b. Freezer #2 located inside the storeroom, the internal thermometer reads 10 degrees F. During an interview with DM, stated the staff had moved items around to fit new incoming food supplies that were to be delivered. DM stated staff had been opening the freezers for breakfast preparation and that's why the temperature was not 0 degrees or less. During a subsequent observation on 8/18/2025 at 10:15 accompanied by the DSS the freezer temperature internal thermometer read 10 degrees F. The freezer located inside storeroom internal thermometer temperature reading was 0 degrees F. During an observation on 8/19/2025 at 8:10 a.m. Freezer #1 located outside the storeroom the internal thermometer read 12 degrees F. The DM stated staff had been opening the freezer for breakfast preparation and that's why the temperature was not 0 degrees. During an observation on 8/19/2025 at 4:08 p.m. the freezer internal thermometer temperature was 10 degrees F. During an interview with DM on 8/19/2025 at 8:12 a.m. stated the freezer should be at 0 degrees F or below. DM stated, if the freezer it is not with the correct temperature the food can get spoiled and if the food is fed to the residents, they can get sick depending on the severity the resident can end up in the hospital. During a telephone interview on 8/19/2025 at 10:02 p.m. The Registered Dietitian (RD) stated that the freezer should be at 0 degrees F or below and rechecked after 15 minutes if it is out of range. RD stated the refrigerator/freezer temperatures are monitored in the morning and afternoon and are logged in to prevent danger zone, bacteria overgrowth and spoil food. RD stated spoiled food is given to the residents, it can impact on the residents' health. During a review of the facility's policy and procedure titled, Refrigerators and Freezers dated and revised on November 2024, indicated acceptable ranges are less than 0 degrees F for freezers.

Based on interview and record review, the facility failed to ensure to provide a Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNF ABN, a document that the facility must provide to Medicare beneficiaries when the facility anticipates that Medicare might not pay for certain services) for two of three sampled residents (Resident 44 and Resident 95). This failure had the potential to result in Resident 44 and Resident 95 not being able to make an informed decision (a choice made after carefully gathering and assessing all relevant facts) regarding the care that may not be covered by Medicare (a federal system of health insurance for people over [AGE] years of age and for certain younger people with disabilities) program.Findings:1.During a review of Resident 44's admission Record, the admission Record indicated the facility re-admitted the resident on 2/28/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hemiparesis (mild or partial weakness or loss of strength on one side of the body), dementia (a progressive states of decline in mental abilities), hyperlipidemia (high levels of cholesterol in the blood), hypertension (high blood pressure), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Record indicated Resident 44 had a conservator (a person or entity appointed by a court to make healthcare decisions and manage personal affairs for an adult who is unable to do so themselves due to mental or physical incapacitation).During a review of Resident 44's Minimum Data Set (MDS, a resident assessment tool) dated 5/23/2025, the MDS indicated the resident had severe cognitive impairment (a significant decline in mental abilities like memory, thinking, and reasoning that interferes with a person's independence in daily life).During a review of Resident 44's SNF Beneficiary Notification Review form, the SNF Beneficiary Notification Review form indicated the resident's last covered day for Medicare Part A skilled services was on 6/6/2025. The SNF Beneficiary Notification Review Form indicated Resident 44 was not provided with a SNF ABN because the resident's Medicare Part A benefits were exhausted.2.During a review of Resident 95's admission Record, the admission Record indicated the facility re-admitted the resident on 2/28/2025 with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), stage 4 pressure ulcer (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the left buttock, unstageable pressure ulcer (full-thickness skin and tissue loss where the depth of the damage cannot be confirmed because it is covered by slough (soft, moist, yellow, tan, gray, green, or brown tissue) or eschar (hard or soft, black, brown, or tan tissue) of the sacral region (tailbone area), unstageable pressure ulcer of the right hip, colostomy (a surgical procedure that bring one end of the large intestine out through the abdominal wall to allow waste to leave the body), and muscle weakness.During a review of Resident 95's MDS dated [DATE], the MDS indicated the resident had independent cognitive skills for daily decision making (decisions consistent/reasonable).During a review of Resident 95's SNF Beneficiary Notification Review form, the SNF Beneficiary Notification Review form indicated the resident's last covered day for Medicare Part A skilled services was on 3/3/2025. The SNF Beneficiary Notification Review form indicated the facility initiated Resident 95's discharge from Medicare part A Services when benefit days were not exhausted. The SNF Beneficiary Notification Review form indicated Resident 95 was not provided with a SNF ABN because the resident was no longer skilled.During a concurrent interview and record review on 8/20/2025 at 3:06 PM with the Business Office Assistant (BOA), Resident 44 and Resident 95's SNF Beneficiary Notification Review form were reviewed. The BOA stated Resident 44 was discharged from Medicare part A services on 6/6/2025. The BOA stated Resident 44 remained in the facility after the resident's discharge from Medicare part A services. The BOA stated Resident 44 was not provided with a SNF ABN because the resident's benefits were exhausted. The BOA stated Resident 95 was discharged from Medicare part A services on 3/3/2025. The BOA stated Resident 95 remained in the facility after the resident's discharge from Medicare part A services. The BOA stated Resident 95 was not provided with a SNF ABN. The BOA stated he did not know why Resident 95 was not provided with a SNF ABN. The BOA stated a SNF ABN was supposed to be given to residents 3 days prior to when the resident's skilled services at the facility were ending.During a concurrent interview and record review on 8/21/2025 at 9:34 AM with the BOA, the facility's policy and procedure titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices dated 4/2025 was reviewed. The P&P indicated A resident (who is a Medicare beneficiary) is informed in advance and in writing when Medicare payment denial or change in coverage is likely.The facility will issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN CMS form 10055) to any Medicare (Fee for Service) resident prior to providing care that Medicare usually covers, but may not pay for under the current circumstance because the care is not medically necessary or considered custodial. The SNF ABN provides information to the resident so that he or she can decide whether to get the care that may not be paid for by Medicare and assume financial responsibility. The SNF ABN is only issued if the resident/beneficiary intends to continue services, and the facility believes the services may not be covered under Medicare. The BOA stated Resident 44 was discharged from Medicare part A services on 6/6/2025. The BOA stated Resident 44 currently resided in the facility. The BOA stated Resident 95 was discharged from Medicare part A services on 3/3/2025. The BOA stated Resident 95 continued to remain in the facility and receive services after the resident was discharged from Medicare part A services. The BOA stated that according to the facility's policy and procedure Residents 44 and 95 should have both received a SNF ABN but were not given one. The BOA stated a SNF ABN was used to notify residents that services would longer be covered by Medicare part A. The BOA stated there was a potential for Resident 44 and Resident 95 to be charged for services at the facility and not being aware they were being charged for those services because they were not provided with a SNF ABN.During a concurrent interview and record review on 8/21/2025 at 11:44 AM with the Director of Nursing (DON) the facility's policy and procedure titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices dated 4/2025 was reviewed. The P&P indicated A resident (who is a Medicare beneficiary) is informed in advance and in writing when Medicare payment denial or change in coverage is likely.The facility will issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN CMS form 10055) to any Medicare (Fee for Service) resident prior to providing care that Medicare usually covers, but may not pay for under the current circumstance because the care is not medically necessary or considered custodial. The SNF ABN provides information to the resident so that he or she can decide whether to get the care that may not be paid for by Medicare and assume financial responsibility. The SNF ABN is only issued if the resident/beneficiary intends to continue services, and the facility believes the services may not be covered under Medicare. The DON stated Resident 44 and Resident 95 should have received a SNF ABN. The DON stated Resident 44 was still residing in the facility. The DON stated Resident 95 continued to reside in the facility for two months after being discharged from Medicare part A. The DON stated a SNF ABN was supposed to be provided to Resident 44 and Resident 95 to provide notice that services may not be covered by Medicare part A. The DON stated residents have the right to be informed of changes to their plan of care, especially when it came to financial and insurance matters. The DON stated there was a potential for Resident 44 and Resident 95 to not be aware of their changes in coverage if they were not provided with a SNF ABN.

Based on interview and record review, the facility failed to provide nonpharmacological interventions (behavioral interventions that do not involve medications) prior to administering Resident 4 Lorazepam (a medication that helps reduce anxiety) PRN (as needed) for one of five residents sampled for unnecessary medications (Resident 4).This deficient practice increased the risk of Resident 4 experiencing adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication therapy (medications that affect brain activities associated with mental processes and behavior), such as drowsiness, low blood pressure, constipation, or increased risk of fall; possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted on [DATE] with diagnoses including anxiety, depression, psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), delusional disorders (having false or unrealistic beliefs), and auditory hallucinations (false perceptions of sound, such as hearing voices or noises that are not present). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 7/17/2025, the MDS indicated Resident 4 had severely impaired cognition (significant difficulty with memory, decision-making, and understanding), moderate depression, and was dependent on help for most cares such as toileting, shower/bathing self, lower body dressing, and putting on/taking off footwear. During a concurrent interview and record review on 8/20/2025 at 12:08 pm with RN Supervisor (RNS) 1, Resident 4's Order Summery Report (OSR- a monthly summary of all active physician orders) dated August 2025 and Medication Administration Record (MAR) dated July 2025 and August 2025 were reviewed. The MAR indicated Resident 4 was prescribed Lorazepam one milligram (mg- a unit of measure for mass) via gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings and medication to be administered directly to the stomach) PRN every six hours for anxiety manifested by episodes of crying on 7/14/2025. The MAR and OSR indicated staff did not provide nonpharmacological interventions prior to administering Lorazepam for 37 days. RNS 1 stated nonpharmacological interventions should be done to prevent giving residents unnecessary medications and to decrease the risk of adverse side effects of psychotropic medications like drowsiness and low blood pressure. RNS 1 further stated nonpharmacological interventions are a safer alternative for residents' health and safety.During an interview on 8/21/2025 at 1:55 pm with the Director of Nursing (DON), the DON stated, I don't know why the order (for nonpharmacological interventions) was missed. The DON further stated nonpharmacological interventions should always be provided in an effort to discontinue PRN psychotropic medications due to potential side effects such as hallucinations, loss of appetite, and agitation. During a review of the facility's policy and procedure (P&P) titled Psychotropic Medication Use dated November 2024, the P&P indicated nonpharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.

Based on observation, interview, and record review, the facility failed to ensure to accurately set the settings of the Low Air Loss mattresses (LAL - medical-grade mattress designed to prevent and treat pressure injuries [PI, injuries to the skin and underlying tissue resulting from prolonged pressure on the skin] by reducing moisture and heat buildup) for two of three sampled residents (Resident 56 and Resident 90) according with the residents' weights per the physician's orders. This failure had the potential to prevent the promotion of skin wound healing for Resident 56 and Resident 90.Findings: 1.During a review of Resident 56's admission Record, the admission Record indicated the facility admitted the resident on 3/14/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion), and PIs. During a review of Resident 56's Order Summary Report, dated 6/7/2025, the Order Summary Report indicated the LAL mattress for skin/wound management and to monitor placement, setting and function every shift and to base the setting according to the resident's weight. During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool) dated 6/11/2025 indicated the was at risk for developing pressure ulcers and the resident had one or more pressure ulcers. The MDS indicated Resident 56 had a pressure-reducing device for the bed. During a record review of Resident 56's Care Plan Report, dated 7/9/2025, the Care Plan Report indicated the LAL mattress for skin management was initiated. The Care Plan Report indicated to maintain Resident 56's skin integrity with interventions to adjust air mattress to a desired firmness according to the resident's weight. The Care Plan Report indicated interventions to check the mattress settings for accuracy. During a concurrent observation and record review on 8/18/2025 at 9:27 AM in Resident 56's room, the Weight and Vitals Summary, dated 8/6/2025, was reviewed. The resident was lying in bed sleeping, the side rails (are adjustable metal or rigid plastic bars that attach to the bed) were up on both sides of the bed, and the call light (a device used by a patient to signal his or her need for assistance) was within reach. Resident 56 was on a LAL mattress set at 160 pounds (lbs., a unit of weight). The Weight and Vitals Summary indicated Resident 56 weighed 145 lbs. During an interview on 8/18/2025 at 9:41 AM with Licensed Vocational Nurse (LVN 1), LVN 1 stated she (LVN1) did not know why Resident 56's LAL was set to 160 lbs., and that Resident 56 weighed 145 lbs. LVN 1 stated that the LAL machine had weight settings at 120 and at 160, and that the weight setting at 160 would be closest to Resident 56's weight. LVN 1 stated there was a sticker on the LAL machine to place the setting at 160. During an interview on 8/20/2025 at 9:00 AM with the Treatment Nurse (TN), the TN stated there were tubes in the mattress that distributed air and alternate to distribute pressure. The TN stated that to prevent further PIs for Resident 56, whose PIs were resolved, the LAL should be adjusted as accurately as possible. The TN stated the LAL set to 160 lbs., would not be as accurate to Resident 56's weight of 145 lbs. 2.During a review of Resident 90's admission Record, the admission Record indicated the facility admitted the resident on 6/20/2025 with diagnoses including cellulitis (a skin infection that causes swelling and redness), contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion), and pressure ulcers (a skin injury that develops when prolonged pressure is applied to the same area of the body). During a review of Resident 90's Order Summary Report dated 6/21/2025, the Order Summary indicated to monitor the settings of the LAL mattress for skin/wound management. The Order Summary indicated the LAL mattress settings should be based on Resident 90's weight. During a review of Resident 90's MDS dated [DATE], the MDS indicated the resident had functional limitations to the lower legs, needed partial to substantial assistance with showering, toileting, and dressing. The MDS indicated Resident 90 had a pressure ulcer, had a risk for developing PIs, and had a pressure reducing device for the bed. During a review of Resident 90's Care Plan Report dated 7/9/2025, the Care Plan Report indicated the use of a LAL mattress for skin management with an intervention to check and monitor the settings for accuracy and function. The Care Plan Report indicated to set the settings based on Resident 90's weight. During a concurrent observation and record review on 8/18/2025 at 10:09 AM in Resident 90's room, the Weight and Vitals Summary dated 8/5/2025, was reviewed. Resident 90 was lying in bed, the side rails were up on both sides of the bed, and the call light was within reach. Resident 90's was on a LAL mattress and the monitor was set to 160. The label on Resident 90's LAL monitor indicated LAL setting at 80-160. The Weights and Vitals Summary indicated Resident 90 weighed 117 lbs. During an interview on 8/18/2025 at 10:16 AM with the TN stated that the treatment nurses (unspecified) monitor the LAL mattress settings. The TN stated during the treatment nurses (unspecified) rounds the weights are checked and adjustments were done. The TN stated the purpose of LAL mattresses was to assist in the healing of wounds, and if not set correctly there would not be promotion of wound healing. The TN stated that residents' weights are done weekly for four weeks and then monthly as needed upon admission and readmission.During an interview on 8/20/2025 at 9:30 AM with the Director of Nursing (DON), the DON viewed a photo of Resident 56's LAL monitor setting. The photo for Resident 56's LAL monitor indicated the LAL setting to 160. The DON stated accurate settings for LAL mattress would be optimal but with the Low Air mattress that the facility had, it doesn't allow for accuracy. The DON stated we could set the LAL monitor to 120 but that would not be the solution, the solution would be to change the air mattress to one that would have a LAL monitor with a dial to set for better accuracy to Resident 56's weight of 145 lbs. The DON viewed a photo of Resident 90's LAL monitor setting which showed the dial set to 160. The DON stated the LAL monitor should be as accurate as possible, but the dial is an estimate for the weight. The DON confirmed that the dial set to 160 lbs. was inaccurate to Resident 90's weight of 117 lbs.During a review of the facility's policy and procedures (P&P) titled, Prevention of Pressure Ulcers/Injuries, dated 11/2024, indicated to select appropriate support surfaces based on the resident's mobility, continence, skin moisture and profusion, body size, and weight.During a review of the facility's policy and procedures (P&P) titled, Support Surface Guideline, dated 9/2024, indicated an individual at risk for developing pressure ulcers should be placed on a redistribution support surface such as foam, gel, static air, alternating air, or air-loss or gel when lying in bed. The P&P indicated that support surfaces are modifiable.

Based on record review and interview the facility failed to ensure that one of six sample residents (Resident 46) who was assessed at risk for weight loss, and were provided with timely nutritional intervention to prevent continuous significant weight loss, including: 1.Failure to follow Registered Dietitian (RD) interventions for Resident 46 to have dental evaluation. 2.Failure to have interdisciplinary (IDT-team-a coordinated group of experts from several different fields) meeting to strive to prevent, monitor, and intervene Resident 46's undesirable weight loss as indicated in the facility's policy and procedure on Nutrition (Impaired) Unplanned Weight Loss-Clinical Protocol revised on July 2025. 3.Failure to implement the RD interventions nutritional plan of care by not notifying the attending physician regarding Resident 46's significant weight loss and by not providing the resident with double protein with meals, and multi-vitamin as recommended by RD. 4. Failure to ensure IDT revised plan of care for Resident 46 that had a weight loss of 7.2 pounds in 14 days. 5.Failure to ensure Resident 46 was accurately reassessed by the Dietary Manager (DM). These deficient practices placed Resident 46 at risk for complications associated with weight loss. During a review of Resident 46's admission Record dated 6/25/2025, the admission record indicated the resident was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses of but not limited to, unspecified protein-calorie malnutrition (a nutritional disorder resulting from a lack of adequate protein and caloric intake). dysphagia (difficulty swallowing), pneumonitis due to inhalation of food and vomit (inflammation of the lung's air sacs caused by an inhaled substance). diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 46's Minimum Data Set (MDS-a resident assessment tool) dated 7/15/2025, the MDS indicated Resident 46's cognition (thought process) was moderately impaired. The MDS indicated Resident 46 required substantial/maximal assistance partial (helper does more than half the effort) from staff for activities of daily living (ADL's - routine tasks/activities such as bathing, dressing, toileting a person performs daily to care for themselves). During a review of Resident 46's Weight and Vitals Summary indicated Resident 46 was weighed upon admission on [DATE] listed 122.2 pounds and on 7/10/2025 Resident 46 weighed 115 pounds. Resident 45 was re- weighed on 7/14/2025 indicating 114.6 pounds. During a record review of Nutrition assessment dated [DATE], the nutrition assessment by the RD indicated a recent weight loss of 7.2 pounds that equals a 5.9 percent weight loss in 14 days. The RD Dietary interventions are to discontinue current diet and change to Consistent Carbohydrate Hydrohydrate (CCHO) diet, puree texture thin consistency, double protein with meals, multivitamins daily, and dental consultation with a desired goal weight of 125-135 pounds. During an interview on 8/20/2025 at 2:44 p.m. with the ADON, ADON stated it is her responsibility of the RD to make recommendations if there are weight changes in residents. The ADON stated the process for weight loss residents is to notify the RD, physician, and the resident or family. ADON stated once there is a change of condition the facility monitors through SBAR. The ADON stated Resident 46 was seen by RD on 7/14/2025 after readmission on [DATE] and that the RD did not provide the Resident 46's documented interventions for nursing to follow through. ADON stated that RD did not communicate to any staff. During an interview on 8/21/2025 at 2:39 p.m. with Dietary Manager(DM), DM stated Resident 46 admission weight of 122.2 on 6/26/2025 was automatically copied to his readmission assessment on 7/10/2025 and did not obtain the most current weight. DM stated he missed the significant change of weight loss of 7.2 pounds. DM stated that it is important to obtain current weight to address any issues such as weight loss or change of diet that the resident might have experienced when out of the facility. During a review of the facility's policy and procedure titled, Nutrition (Impaired) Unplanned Weight Loss-Clinical Protocol revised in July 2025, indicated, the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake.

Based on observation, interview, and record review, the facility failed to observe infection control measures by failing to wear appropriate personal protective equipment (PPE) while feeding residents on enhanced barrier precautions (EBP- infection control measures that require targeted use of gowns and gloves during high-contact resident care activities along with strict hand hygiene) for three of four sampled residents (Resident 39, Resident 44, and Resident 81)This failure had the potential to spread disease and infection among residents and staff. 1. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was initially admitted to the facility on [DATE] with diagnoses including Candidiasis (C. auris- a multidrug resistant fungus that causes life-threatening infections) and cerebral infarction (stroke- loss of blood flow to part of the brain). During a review of Resident 39's Minimum Data Set (MDS- a resident assessment tool) dated 5/22/2025, the MDS indicated Resident 39 had severely impaired cognition (significant difficulty with memory, decision-making, and understanding) and upper body impairment. During a review of Resident 39's Order Summary Report (OSR- a monthly summary of all active physician orders) dated August 2025, the OSR indicated an order to place Resident 39 on Enhanced Barrier Precautions for C. auris. During a review of Resident 39's Care Plan (CP) dated 6/27/2024, the CP indicated Resident 39 is at risk for complications related to C. auris and to: always observe EBP and maintain infection control practices daily.During an observation on 8/18/2025 at 1:17 pm, a sign that stated Enhanced Barrier Precautions was posted in front of Resident 39's room. The sign indicated to wear gloves and a gown for high-contact resident care activities such as feeding. While at Resident 39's room, certified nursing assistant (CNA) 2 was observed leaning against Resident 39's side rail and spoon feeding Resident 39 without PPE. CNA 2 was also observed touching the food on Resident 39's tray with her bare hands and wiping Resident 39's mouth with a napkin without wearing gloves.During an interview on 8/18/2025 at 1:28 pm with CNA 2, CNA 2 stated she did not need to wear PPE while feeding residents on EBP because feeding was not considered a high contact activity. CNA 2 further explained feeding only referred to gastrostomy tubes (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach).During an interview with licensed vocational nurse (LVN) 1 on 8/18/2025 at 1:25 pm, LVN 1 explained that feeding did not only refer to g-tube feedings, but for the feeders who assist the residents to eat their meals as well. LVN 1 further stated feeders should always wear PPE when feeding the residents on EBP to prevent spreading infection and hospitalization for the residents. 2. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE] with diagnoses including methicillin resistant staphylococcus aureus (MRSA- a bacteria that does not respond to antibiotics) and stroke. During a review of Resident 44's MDS dated [DATE], the MDS indicated Resident 44 had severely impaired cognition and required touching assistance and supervision with eating (helper provides touching/steadying and or contact guard assistance as resident completes activity).During a review of Resident 44's OSR dated August 2025, the OSR indicated an order to place Resident 44 on EBP for MRSA. During a review of Resident 44's CP dated 8/13/2025, the CP indicated Resident 44 is on EBP for MRSA and to maintain EBP and hand hygiene, always observe EBP.During an observation on 8/18/2025 at 1:18 pm, a sign that stated Enhanced Barrier Precautions was posted in front of Resident 44's room. While on Resident 44's room, CNA 4 was observed leaning against Resident 44's side rail and spoon feeding Resident 44 without PPE. CNA 4 was also observed handling the food on Resident 44's tray with her bare hands and wiping Resident 44's mouth with a napkin without wearing gloves.During a concurrent record review and interview on 8/18/2025 at 1:20 pm with CNA 4, the EBP sign in front of Resident 44's door was reviewed. The EBP sign indicated to wear gloves and a gown for high-contact resident care activities such as feeding. CNA 4 stated, I should have been wearing PPE when feeding [Resident 44]. 3. During a review of Resident 81's admission Record, the admission Record indicated Resident 81 was admitted to the facility on [DATE] with diagnoses including C. auris and stroke. During a review of Resident 81's MDS dated [DATE], the MDS indicated Resident 81 had severely impaired cognition and upper body impairment. During a review of Resident 81's OSR dated August 2025, the OSR indicated an order to place Resident 81 on Enhanced Barrier Precautions for C. auris. During a review of Resident 81's CP dated 1/25/2025, the CP indicated Resident 81 is on EBP related to C. auris and to maintain EBP practice and maintain good hand hygiene (before, in between, and after care).During an observation on 8/18/2025 at 1:04 pm, a sign that stated Enhanced Barrier Precautions was posted in front of Resident 81's room. The sign indicated to wear gloves and a gown for high-contact resident care activities such as feeding. While on Resident 81's room, CNA 3 was observed sitting on a chair and spoon feeding Resident 81 without wearing PPE. CNA 3 was also observed touching the food on Resident 81's tray with her bare hands and wiping Resident 81's mouth with a napkin without wearing gloves.During an interview on 8/18/2025 at 1:30 pm with CNA 3, CNA 3 stated she did not need to wear PPE when feeding residents on EBP because she is only handling the resident's food and not making physical contact with the resident. During an interview on 8/20/2025 at 8:22 am with the infection preventionist (IP), the IP stated all staff are required to wear gown and gloves when doing direct patient care with resident on EBP, including feeding the residents. Wearing the appropriate PPE helps to protect the staff and residents from transmitting infections. During a review of the facility's Policy and Procedure (P&P) titled Enhanced Barrier Precautions dated April 2025, the P&P indicated EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply: gloves and gown are applied prior to performing high contact resident care activity.

Based on interview and record review, the facility failed to offer COVID-19 vaccines for three of three residents sampled for immunizations (Resident 4, resident 62, and Resident 96). This deficient practice had the potential to result in Resident 4, Resident 62, and Resident 96 contracting, transmitting, and experiencing complications related to COVID-19 such as acute respiratory distress syndrome (ARDS- life-threatening lung injury), pneumonia (an infection/inflammation in the lungs), respiratory failure requiring oxygen, and sepsis (overwhelming infection spreading throughout the body).1. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted on [DATE] with diagnoses including anxiety, depression, psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), delusional disorders (having false or unrealistic beliefs), and auditory hallucinations (false perceptions of sound, such as hearing voices or noises that are not present). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 7/17/2025, the MDS indicated Resident 4 had severely impaired cognition (significant difficulty with memory, decision-making, and understanding). During a concurrent interview and record review on 8/20/2025 at 8:30 am with the Infection Preventionist (IP), Resident 4's immunization record dated 8/20/2025 and consent records dated 7/14/2025 were reviewed. The immunization record indicated Resident 4 received her last dose of the COVID-19 vaccine on 9/22/2022. The consent records indicated Resident 4 did not receive information on the COVID-19 vaccine and was not offered COVID-19 vaccination when admitted to the facility. The IP stated Resident 4 should have been screened and consented for the COVID-19 vaccine upon admission and was not. 2. During a review of Resident 62's admission Record, the admission Record indicated Resident 62 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing), (uncontrolled growth of abnormal skin cells), and surgery of the scalp (the skin covering the top of the skull). During a review of Resident 62's Minimum Data Set (MDS- a resident assessment tool) dated 7/31/2025, the MDS indicated Resident 62 was cognitively intact and able to make decisions for herself. During a concurrent interview and record review on 8/20/2025 at 8:30 am with the Infection Preventionist (IP), Resident 62's immunization record dated 8/20/2025 and consent records dated 8/5/2025 were reviewed. The immunization record indicated Resident 62 had no historical records of receiving the COVID-19 vaccine. The consent records indicated Resident 62 did not receive information on the COVID-19 vaccine and was not offered COVID-19 vaccination when admitted to the facility. The IP stated Resident 62 should have been screened and consented for the COVID-19 vaccine upon admission and was not. 3. During a review of Resident 96's admission Record, the admission Record indicated Resident 96 was admitted to the facility on [DATE] with diagnoses including paraplegia (loss of movement and/or sensation, to some degree, of the legs) and urinary tract infection (UTI- an infection in the bladder/urinary tract). During a review of Resident 96's hospital records dated 8/14/2025, the hospital records indicated Resident 96 was alert and oriented to person, place, and time and appropriately responsive to questions. During a concurrent interview and record review on 8/20/2025 at 8:30 am with the Infection Preventionist (IP), Resident 96's immunization record dated 8/20/2025 and consent record as of 8/20/2025 was reviewed. The medical records indicated Resident 96 received her last dose of the COVID-19 vaccine on 12/13/2023. The consent records indicated Resident 96 did not receive information on the COVID-19 vaccine and was not offered COVID-19 vaccination when admitted to the facility. The IP stated Resident 96 should have been screened and consented for the COVID-19 vaccine upon admission but was not. During an interview with the Director of Nursing (DON) on 8/21/2025 at 1:55 pm, the DON stated the IP is responsible for screening, consenting, and administering the COVID-19 vaccine to residents upon admission. The DON further stated Resident 4, Resident 62, and Resident 96 should have been consented for the COVID-19 vaccine when admitted to the facility. Ensuring the residents are up to date with the COVID-19 vaccine is important to protect them from contracting and spreading COVID-19. During a review of the facility's P&P titled Coronavirus Disease (COVID-19) - Vaccination of Residents dated April 2025, the P&P indicated each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident is fully vaccinated. The P&P further indicated the resident is provided with education regarding the benefits, risks, and potential side effects associated with the COVID-19 vaccine. COVID-19 vaccine education, documentation and reporting are overseen by the infection preventionist and coordinated by his/her designee.

Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for one of 20 sampled residents (Resident 15) by not ensuring Resident 15's call light (a device used by residents to call for assistance) was within reach. This deficient practice had the potential to cause a delay in staff meeting Resident 15's needs for assistance further resulting in falls and accidents.During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was initially admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke- loss of blood flow to a part of the brain) and needing assistance with personal care. During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool) dated 5/10/2025, the MDS indicated Resident 15 had severely impaired cognition (significant difficulty with memory, decision-making, and understanding) and was dependent for help (helper does all of the effort) with toileting hygiene, shower/bathing, lower body dressing, putting on/taking off footwear, and going from lying to sitting on side of the bed. The MDS further indicated Resident 15 required moderate (helper does less than half the effort) to maximal (helper does more than half the effort) assistance with personal hygiene, upper body dressing, and oral hygiene. During a review of Resident 15's Care Plan (CP) dated 4/6/2022, the CP indicated Resident 15 had a communication problem related to stroke and right sided weakness. The CP further indicated for staff to provide a safe environment by ensuring Resident 15's call light is within reach. During a concurrent observation and interview on 8/18/2025 at 10:05 am with Resident 15, Resident 15 was observed lifting his sheets and pillows in bed and stated, I'm looking for my call light. I use that to call the nurses for help. During a concurrent observation and interview on 8/18/2025 at 10:06 am with the Assistant Director of Staff Development (ADSD), Resident 15's call light was observed hanging against the wall and out of Resident 15's reach. The ADSD stated that the call light should always be within the resident's reach because residents use the call system for any needs that they have. If the call light is not in reach, residents could try to get up without staff assistance and fall. During an interview on 8/21/2025 at 1:55 pm with the Director of Nursing (DON), the DON stated sometimes staff forgets to place the call lights within reach after providing care for the residents. The expectation is all call lights should be within the residents' reach when they are in bed or toileting because that is how residents communicate their need for assistance. The DON further explained that not having the call light within the resident's reach could cause that resident to fall or have a medical emergency without alerting staff. During a review of the facility's policy and procedure (P&P) titled Answering the Call Light dated September 2024, the P&P stated, (staff) ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.

Based on interview, and record review, the facility failed to inform and consult with resident's physician when there was a significant change in the resident's physical status for one of six sample residents (Resident 46) regarding 7.2 pounds weight loss in 14 days. This deficient practice delayed the Medical Doctor (MD) being notified and the resident not being reassessed for the 7.2 pounds weight loss. Findings: During a review of Resident 46's admission Record dated 6/25/2025, the admission record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses of, but not limited to, Unspecified protein-calorie malnutrition (a nutritional disorder resulting from a lack of adequate protein and caloric intake). Dysphagia (difficulty swallowing), Pneumonitis due to inhalation of food and vomit (inflammation of the lung's air sacs caused by an inhaled substance). Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 46's Minimum Data Set (MDS-a resident assessment tool) dated 7/15/2025, the MDS indicated Resident 46's cognition (thought process) was moderately impaired. The MDS indicated Resident 46 required substantial/maximal assistance partial (helper does more than half the effort) from staff for activities of daily living (ADL's - routine tasks/activities such as bathing, dressing, toileting a person performs daily to care for themselves). During a record review of Resident 46's Weight and Vitals Summary indicated Resident 46 was weighed upon admission on [DATE], listed 122.2 pounds. On 7/10/2025, Resident 46 weighed 115 pounds. On 7/14/2025, Resident 46 weighed 114.6 pounds. During an interview on 8/20/2025, at 2:44 p.m. with Assistant Director of Nursing (ADON) , ADON stated she is responsible for entering the weights on the Residents medical record and is responsible for the weight variance meeting. ADON stated she cannot find any documentation where the MD was made aware of Resident 46 significant weight loss of 7.2 pounds. During an interview on 8/21/2025 at 11:54 a.m. with Director of Nurses (DON) stated, that 5% of weight loss in a month is a significant change and prompt interventions can target the comorbidities that the residents already have. DON stated the interdisciplinary team should be in alignment with weight changes because it important to early identify to prevent decline. During a review of the facility's policy and procedure titled, change in a Resident's Condition or Status, dated February 2025, indicated, a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff; requires interdisciplinary review and/or revision to the care plan.

Based on observation, interview and record review, the facility failed to maintain a clean environment for one of six sample residents (Resident 31). This deficient practice had the potential for an unsafe and unclean resident's environment with the potential for the spread of infection and to place the resident at risk for physical discomfort. During a record review of Resident 31's admission Record dated 6/27/2025, the admission record indicated the resident was admitted to the facility on [DATE], with diagnoses of, but not limited to Gastrostomy-tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), Delayed Milestone in Childhood (a situation where a child does not reach a particular developmental milestone at the expected age). During a review of Resident's 31 Minimum Data Set (MDS-a resident assessment tool) dated 7/4/2025, the MDS indicated Resident 31 is dependent (helper does all the effort) from staff for activities of daily living (ADL'S-routine tasks/activities such as bathing, dressing, toileting a person performs daily to care for themselves). During a concurrent observation and interview on 8/18/2025 at 9:55 a.m. with Certified Nursing Assistant 1 (CNA1) of Resident 31's bedroom it was observed with a thick, dried, brown-colored pasty substance was observed on the top and inner side surfaces of Resident 31's right side bed rail. CNA1 stated the side rail was dirty and was going to get cleaning wipes from housekeeping and was going to clean up the surface of Resident 31's right side rail. During an interview on 8/21/2025 at 2:02 p.m. with Director of Nursing (DON) stated it is important to keep a clean environment because it is a Residents' home, and it is important for the health of the residents. During a review of the facility's policy and procedure titled, Infection Prevention and Control dated April 2025, indicated, all personnel are trained on infection prevention and control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessment for entry and discharge from the facility were completed within the required time frame for one of three sampled residents (Resident 94).This failure had the potential to result in Resident 94 receiving a delay in care and services at the facility.Findings:During a review of Resident 94's admission Record, the admission Record indicated the facility initially admitted the resident on 6/24/2025 with diagnoses that included chronic respiratory failure (a gradual, long-term condition where the lungs can't effectively exchange oxygen and carbon dioxide, leading to symptoms like shortness of breath, fatigue, and confusion), muscle weakness, seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), encephalopathy (permanent brain damage that causes severe confusion and forgetfulness), glaucoma (a group of eye conditions that damage the optic nerve, often due to increased pressure inside the eye, leading to irreversible vision loss and potential blindness), dysphagia (difficulty swallowing), atrial fibrillation (an irregular and rapid heartbeat), quadriplegia (paralysis from the neck down, including leg and arms, usually due to a spinal cord injury), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).During a concurrent interview and record review on 8/20/2025 at 11:02 AM with the MDS Coordinator (MDS), Resident 94's Minimum Data Set Summary was reviewed. The MDS stated Resident 94 was admitted to the facility on [DATE] and discharged from the facility on 7/8/2025. The MDS stated Resident 94 was re-admitted to the facility on [DATE] and then discharged again on 7/27/2025. The MDS stated Resident 94 was then re-admitted to the facility again on 7/31/2025. The MDS stated Resident 94 had an entry MDS assessment dated [DATE] that was completed on 8/6/2025 and submitted on 8/9/2025. The MDS stated Resident 94 had a discharge MDS assessment dated [DATE] that was completed on 8/19/2025 and submitted on 8/20/2025. The MDS stated Resident 94 had another entry MDS assessment dated [DATE] that was completed on 8/19/2025 and submitted 8/20/2025.During a concurrent interview and record review on 8/20/2025 at 11:23 AM with MDS Coordinator 2 (MDS 2) Resident 94's Minimum Data Set Summary was reviewed. MDS 2 stated the entry MDS assessment should be completed within seven days and submitted 14 days after completion. MDS 2 stated the discharge MDS assessment should be completed within 14 days and submitted within 14 days of completion. MDS 2 stated Resident 94's entry MDS assessment date 7/25/2025, discharge MDS assessment dated [DATE], and entry MDS assessment dated [DATE] were not completed within the required timeframe. MDS 2 stated MDS assessments should be completed timely to ensure the resident receives an appropriate plan of care. MDS 2 stated information from the MDS assessments are used to develop the resident's plan of care.During a concurrent interview and record review on 8/20/2025 at 11:28 AM with the Director of Nursing (DON), Resident 94's Minimum Data Set Summary was reviewed. The DON verified and confirmed Resident 94's entry MDS assessment dated [DATE], discharge MDS assessment dated [DATE], and entry MDS assessment dated [DATE] were completed late. The DON stated entry MDS assessments should be completed within 7 days of entry to the facility and the discharge MDS assessment should be completed within 14 days of discharge from the facility. The DON stated there could be potential for Resident 94 to have a delay in care and services the resident received at the facility because of late MDS assessment completion.During a review of the facility's Policy and Procedure (P&P) titled MDS Completion and Submission Timeframes dated 10/2024, the P&P indicated Out facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual.During a review of the Centers for Medicare & Medicaid Services User's Manual (UM) titled Long - Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2024, the UM indicated In accordance with the requirements at 42 CFR S483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: Completion Timing: For all non-admission OBRA and PPS assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD) (A2300).For the other comprehensive MDS assessments, Significant Change in Status Assessment and Significant Correction to Prior Comprehensive Assessment, the CAA Completion Date (V0200B2) must be no later than 14 days from the ARD (A2300) and no later than 14 days from the determination date of the significant change in status or the significant error, respectively.For Entry and Death in Facility tracking records, the MDS Completion Date (Z0500B) must be no later than 7 days from the Event Date (A1600 for an entry record; A2000 for a Death in Facility tracking record).

Based on interview and record review, the facility failed to ensure the assessment entry on the Minimum Data Set (MDS- an assessment and care screening tool) related to weight loss was accurately coded to reflect the resident's weight loss of five percent in a month for one of six sampled residents (Resident 46). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and services for Resident 46. During a review of Resident 46's admission Record dated 6/25/2025, the admission record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses of, but not limited to, Unspecified protein-calorie malnutrition (a nutritional disorder resulting from a lack of adequate protein and caloric intake). Dysphagia (difficulty swallowing), Pneumonitis due to inhalation of food and vomit (inflammation of the lung's air sacs caused by an inhaled substance). During a review of Resident 46's Minimum Data Set (MDS-a resident assessment tool) dated 7/15/2025, the MDS indicated Resident 46's cognition (thought process) was moderately impaired. The MDS indicated Resident 46 required substantial/maximal assistance partial (helper does more than half the effort) from staff for activities of daily living (ADL's - routine tasks/activities such as bathing, dressing, toileting a person performs daily to care for themselves). During a record review of Resident 46's Weight and Vitals Summary indicated Resident 46 was weighed upon:admission on [DATE], listed 122.2 pounds. 2. On 7/10/2025, Resident 46 weighed 115 pounds. 3. On 7/14/2025, Resident 46 weighed 114.6 pounds. During a record review of Nutrition assessment dated [DATE], the nutrition assessment by the Registered Dietitian (RD) indicated a recent weight loss of 7.2 pounds that equals a 5.9 percent weight loss in 14 days. During a review of the care plan dated 7/14/2025, the care plan indicated Resident 46 had a weight loss of 7.2 pounds equal to 5.9 percent weight loss in the last 14 days .During a concurrent interview and record review on 8/20/2025 at 3:29 p.m. with MDS coordinator a review of Resident 46's MDS dated [DATE], Section K0300 Weight Loss indicated Resident 46 has no weight loss in the last one to six months. MDS coordinator stated that he was calculating using the formula in the Resident Assessment Instrument (RAI- manual a guidebook for nursing home staff in gathering resident information). The MDS coordinator stated misinterpreting the results after discussing it with the facility's MDS consultant. The MDS coordinator stated. Not entering residents' data correctly in the MDS assessment can alter the plan of care and would not be able to follow or revised the care plan. During an interview on 8/21/2025at 2:02 p.m. with the Director of Nursing (DON) stated the MDS was coded incorrectly and that the MDS coordinator was guided by the facility's MDS consultant. During a review of the facility's policy and procedure titled, Certifying Accuracy of the Resident Assessment, dated April 2025, indicated any health care professional completing the Minimum Data Set (MDS) is qualified to assess the medical, functional, and/or psychosocial status of the resident and must sign and certify the accuracy of the resident assessment.

Based on interview, and record review, the facility failed to develop a plan of care for one of six sample residents (Resident 46), who had lost 7.2 pounds (5.9 percent) in 14 days after admission. This deficient practice had the potential for delayed provision of necessary care and services. During a review of Resident 46's admission Record dated 6/25/2025, the admission record indicated the resident was admitted to the facility on [DATE] and was readmitted on [DATE] to the facility with diagnoses of, but not limited to, Unspecified-Calorie Malnutrition (a nutritional disorder resulting from a lack of adequate protein and caloric intake). dysphagia (difficulty swallowing), pneumonitis due to inhalation of food and vomit (inflammation of the lung's air sacs caused by an inhaled substance). During a review of Resident 46's Minimum Data Set (MDS-a resident assessment tool) dated 7/15/2025, the MDS indicated Resident 46's cognition (thought process) was moderately impaired. Please add ADL's for eating During a review of Resident 46's Weight and Vitals Summary indicated Resident 46 was weighed :A. on 6/25/2025, listed 122.2 pounds. B. On 7/10/2025, Resident 46 weighed 115 pounds. C. On 7/14/2025, Resident 46 weighed 114.6 pounds. During a record review of Nutrition assessment dated [DATE], the nutrition assessment by the Registered Dietitian (RD) indicated a recent weight loss of 7.2 pounds that equals a 5.9 percent weight loss in 14 days. During an interview on 8/21/2025 at 2:02 p.m. with the facility's Director of Nursing (DON) stated, care plans are patient centered and is how resident's problems are managed. During a review of the facility's policy and procedure titled, Weight Assessment and Intervention, dated February 2025, indicated any weight change of 5 percent or more since the last weight assessment nursing will immediately notify the dietitian in writing and the physician and multidisciplinary effort and includes the physician, nursing staff, the dietician, the consultant pharmacist, and the resident or resident's legal surrogate.

Based on observation, interview, and record review, the facility failed to explain medications that were administered to one of nine sampled residents (Resident 35) observed during medication pass, as indicated in the facility's policy and procedure (P&P), titled Medication Administration - General Guidelines, dated 10/2017 and Charge Nurse/Nurse Supervisor Competency Assessment, dated 10/2020. This deficient practice failed to provide information to Resident 35 regarding his medications before Licensed Vocational Nurse 1 (LVN1) administered the medications.Findings:During a review of Resident 35's admission Record (a document containing demographic and diagnostic information), dated 8/21/2025, the admission Record indicated the facility admitted Resident 35 on 11/27/2024 with diagnoses that included but not limited to moderate protein-calorie malnutrition, muscle weakness, pressure ulcer, rhabdomyolysis (severe muscle damage leading to kidney failure), depression (a mood disorder characterized by persistent feelings of sadness or loss of interest), schizophrenia (a mental illness that is characterized by disturbances in thought), essential hypertension (HTN - high blood pressure) and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 35's Minimum Data Set (MDS, a resident assessment tool) dated 5/26/2025, the MDS indicated Resident 35's cognition (mental action or process of acquiring knowledge and understanding through thought and senses) was intact. The MDS indicated Resident 35 needed setup or clean-up assistance from the facility staff for performing activities of daily living (ADLs - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) such as eating, needed supervision or touching assistance for oral hygiene, toileting hygiene, showering, upper and lower body dressing, putting on/taking off footwear and needed moderate assistance for personal hygiene. During a concurrent observation and interview on 8/19/2025 at 9:39 AM with LVN1 1 in Resident 35's room, LVN 1 checked Resident 35's blood pressure. LVN 1 stated Resident 35's blood pressure reading was systolic blood pressure (SBP - the pressure caused by heart while contracting) of 128 millimeters of mercury (mmHg - a measurement of pressure) and diastolic blood pressure (DBP the pressure in the arteries when the heart rests between beats) of 76 mmHg, and heart rate was 64 beats per minute. LVN 1 stated Resident 35 rated his pain level at 6 (pain scale, no pain 0, 1 to 3 mild, 4 to 6 moderate, 7 to 10 severe), on the left hip and requested acetaminophen (a medication used to treat pain and fever). LVN 1 prepared and administered the following eight medications to Resident 35 without identifying medications by their name and/or explaining their purpose and indications to Resident 35 before administering them. 1. One tablet of docusate sodium (a medication used to treat constipation) 100 milligrams ([mg] a unit of measurement for mass). 2. One tablet of ferrous sulfate (a medication used to treat low levels of iron) 325 mg (65 mg elemental iron). 3. One tablet of folic acid (a medication used to treat low levels of folic acid) 1 mg. 4. One and one-half table of metoprolol tartrate 25 mg (37.5 mg dose) with parameters to hold the dose if SBP less than 110 mmHg or HR less than 60. 5. One tablet of multivitamins with minerals. 6. One tablet of vitamin B1 (also known as thiamine) (a vitamin used to treat low levels of vitamin B1) 100 mg. 7. One tablet of vitamin C (a vitamin used to treat low levels of vitamin C) 500 mg. 8. Two tablets of acetaminophen 325 mg. During a review of Resident 35's Order Summary Report (a document containing a summary of all active physician orders), dated 8/21/2025, the order summary report indicated, but not limited to, the following physician orders: 1. Acetaminophen tablet 325 mg, give 2 tablets by mouth every 6 hours as needed for mild to moderate pain (1-6), do not exceed 3 grams of acetaminophen (APAP) from all sources in 24 hours, order date 8/3/2025, start date 8/3/2025. 2. Docusate sodium oral tablet 100 mg, give 1 tablet by mouth two times a day for constipation, hold if loose bowel movement, order date 12/8/2024, start date 12/8/2024. 3. Ferrous Sulfate tablet 325 mg (65 Fe) mg, give 1 tablet by mouth one time a day for supplement, give with food, order date 12/9/2024, start date 12/10/2024. 4. Folic Acid oral tablet 1 mg, give 1 tablet by mouth one time a day for supplement, order date 11/27/2024, start date 11/28/2024. 5. Metoprolol Tartrate oral tablet 75 mg, give 0.5 tablet by mouth every 12 hours for HTN. Hold for SBP<110 or HR<60; administer with food, (0.5 mg = 37.5 mg), order date 06/20/2025, start date 6/20/2025. 6. Multivitamin-minerals oral tablet, give 1 tablet by mouth one time a day for supplement, order date 12/10/2024, start date 12/11/2024. 7. Thiamine hydrochloride (HCl) oral tablet 100 mg, give 1 tablet by mouth one time a day for supplement, order date 11/27/2024, start date 11/28/2024. 8. Vitamin C oral tablet 500 mg (Ascorbic Acid), give 1 tablet by mouth two times a day for supplement, order date 08/9/2025, start date 8/10/2025. During an interview on 8/19/2025 at 10:25 AM with LVN 1, LVN 1 stated she (LVN1) would introduce herself to residents because I am new and in case residents do not remember me before administering medications. LVN 1 stated if the residents (in general) did not know about their medications, then she (LVN1) would inform the residents (in general) about the medications and any contraindications. LVN 1 stated Resident 35 was quite aware of all his medications and would ask if he (Resident 35) was getting his blood pressure medication after a specific blood pressure reading. LVN 1 stated Resident 35 did not prefer to engage in conversations at times or would change the conversation or dismiss it, so she (LVN1) did not feel like it was necessary to convey the name of medications and their uses to Resident 35 before administering them. During an interview on 8/21/2025 at 1:34 PM with the Director of Nursing (DON), the DON stated the facility licensed nursing staff (in general) should inform the residents (in general) about every medication, for example, I am giving your multivitamins or medication for hypertension, etc. The DON stated it was important that the nurses informed the residents (in general) about the medications and their side effects when they were being administered to prevent any surprise for the residents. The DON stated if the nurses did not explain the medications to the residents, the nursing staff would need to be retrained so that moving forward, they would inform the residents about the medications during each shift and every day. During a review of the facility's P&P titled, Medication Administration - General Guidelines, dated 10/2017, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. During a review of the facility's competency P&P titled, Charge Nurse/Nurse Supervisor Competency Assessment, dated 10/2020, the P&P indicated, Educate residents and families on the risk and benefits of a treatment or ch

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of five sampled residents (Resident 1 and 2) when on 10/22/2023, at 3:45 p.m., Resident 1 and Resident 2 punched each other. This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility and resulted in Resident 1 having facial bruises, a facial cut, and he was feeling anxious and not safe in this facility. Resident 2 had a skin tear on his forehead and a skin tear on his upper left cheek. Findings: A review of Resident 2's Admission Record indicated the facility initially admitted Resident 2 on 3/30/2023 with a readmitted [DATE]. Resident 2's diagnoses included sepsis (the body's extreme response to an infection), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). According to a review of the Initial History and Physical, dated 8/18/2023, Resident 2 had the capacity to understand and make decisions. A review of the care plan dated 8/21/2023 indicated Resident 2 had a potential for aggression related to anxiety, with episodes of screaming and yelling. The care plan goal indicated Resident 2 would verbalize understanding of need to control abusive behavior. The care plan interventions indicated to assess resident's coping skills and support system, and when resident becomes agitated to intervene before agitation. A review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 9/29/2023 indicated the resident had delusions (misconceptions or beliefs that are firmly held, contrary to reality). According to a review of the Situation, Background, Assessment, Recommendation communication form (SBAR), dated 10/23/2023 at 11:29 a.m., Resident 2 had a physical and verbal altercation with Resident 1. Resident 1 claimed that Resident 2 unplugged his TV without his permission, started a verbal altercation, then both residents started punching each other. A review of Resident 2's Skin Evaluation, dated 10/23/2023 at 11:31 a.m., indicated a skin tear of 2 cm by 0.1 cm on the left side of the forehead and a skin tear of 2.2 cm by 0.1 cm on the upper left cheek. A review of Resident 2's Order Audit Report, dated 10/23/2023 at 3:04 p.m., indicated open skin on the left upper cheek and to clean the skin with Normal Saline (NS), pat it dry, and apply an antibiotic cream daily for 14 days. A review of the Treatment Administration Record dated 10/24, 10/25, 10/26 and 10/27/2023 indicated Resident 2 received open skin treatments on the upper left cheek and left side of the forehead. A review of Resident 1's Admission Record indicated the facility initially admitted Resident 1 on 1/14/2020 with a readmitted [DATE]. Resident 1's diagnoses included sepsis (the body's extreme response to an infection), major depressive disorder (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and opioid abuse (compulsive urge to use opioid drugs [class of drugs that derive from the opium poppy plant], even when they are no longer required medically). A review of the MDS dated [DATE], indicated Resident 1's cognitive skills (ability to understand and make decisions) were intact and required supervision or touching assistance for transferring, oral and toileting hygiene, and upper body dressing. The MDS indicated Resident 1 was not walking and was used a wheelchair as a mobility device. A review of Resident 1's Skin Evaluation, dated 10/23/2023 indicated a skin tear of 0.2 centimeters (cm - unit of measurement) by 1.5 cm on the face. A review of Resident 1's Order Audit Report, dated 10/23/2023 at 6:02 p.m., indicated open skin on the left cheek and to clean the skin with Normal Saline (NS), pat it dry, and apply bacitracin (an antibiotic used to prevent bacterial infection) ointment daily for 14 days. According to a review of Resident 1's Telemedicine Visit (using telecommunications technologies to support the delivery of all kinds of medical, diagnostic and treatment) dated 10/27/2023, Resident 1 was seen for a psychiatric evaluation. The psychiatric evaluation indicated that after the physical altercation with Resident 2, Resident 1 was in physical pain from the incident, verbalized feeling anxious, and was willing to try medication for anxiety. A review of the Physician's Order dated 10/27/2023 at 8:52 p.m., indicated Resident 1 was prescribed Ativan (medication used to treat anxiety) 0.5 milligrams (mg - unit of measurement) taken every six hours as needed for anxiety for 14 days. A review of the Medication Administration Record (MAR) indicated Resident 1 received Ativan 0.5 mg every day from 11/3 through 11/10/2023. During an observation on 11/29/2023 at 12:30 p.m., Resident 1 was in his room, sitting in the wheelchair eating lunch. During a concurrent interview Resident 1 stated his old roommate (Resident 2) was moved to another room because they had an altercation. During an interview on 11/29/2023 at 4:05 p.m., Resident 1 stated that in the middle of the day on 10/22/2023 Resident 2 attacked him. Resident 1 stated that Resident 2 unplugged his TV without asking, he then told Resident 2 to not come near his stuff after which Resident 2 hit him on the cheek, and then they both started punching each other. Resident 1 stated that at the time of the altercation he was sitting in a wheelchair and Resident 2 was standing. Resident 1 stated that as a result of this altercation he received facial bruises, a facial cut, and he was feeling anxious and not safe in this facility. During an interview on 11/29/2023 at 4:20 p.m., Licensed Vocational Nurse 1 (LVN 1) stated that on 10/22/2023 around 3:45 p.m., he was in another room when he heard screaming from Resident 1's room. LVN 1 stated he went to Resident 1's room and saw that Resident 1 and Resident 2 were fighting with each other. LVN 1 stated that he separated the residents immediately and reported the incident to Director of Nursing 2 (DON 2). During an interview on 11/30/2023 at 4 p.m., the Assistant Director of Nursing (ADON) stated physical abuse happened between Resident 1 and Resident 2, and that it should not have occurred according to the abuse policy and regulations. A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation Prevention, revised April 2023, indicated residents have the right to be free from abuse, this includes physical abuse. The policy indicated the facility abuse prevention program consists of a facility wide commitment and resource allocation to support other residents and identify and investigate all possible incidents of abuse, neglect and mistreatment.

Based on observation, interview, and record review, the facility failed to provide a safe environment and supervision for one of three sampled residents (Resident 1), who was at risk for elopement (leaving facility without notice or permission, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decision to leave), at risk for wandering (occurs when a person with loss of memory, thinking or reasoning roams around and becomes lost or confused about their location), and had diagnoses of epilepsy (a brain disorder that can cause people to suddenly have a seizure), to address the resident's attempt of elopement on 11/11/2023 at 1:05 PM. The facility failed to: -Follow its policy and procedure titled, Elopements, Resident Behavior and Facility Practices, and promptly report any resident who tried to leave the premises or suspected of being missing to the Charge Nurse or Director of Nursing and the facility policy titled, Wandering, Behavior, Mood and Cognition, to develop a care plan including strategies and intervention to maintain the resident's safety. -Conduct a change of condition (COC) or Situation-Background-Assessment-Recommendation (SBAR - technique provides a framework for communication between members of the health care team and used as a tool to foster patient safety) to alert facility staff of Resident 1's attempt of elopement on 11/11/2023 at 1:05 PM. - Conduct an Interdisciplinary Team (IDT - a group of health care professionals from different fields who coordinate resident care) meeting to address Resident 1's attempt of elopement on 11/11/2023 at 1:05 PM. These deficient practices placed Resident 1 at an increased risk of decline in physical, mental and psychosocial needs, as the resident eloped from the facility on 11/11/2023 at 2:20 PM and was missing for over three days. Resident 1 was returned to the facility on [DATE], after police located him over 14 miles away from the facility, with abrasions on his right hand and leg. These negative consequences impacted Resident 1's quality of care and services received. On 11/15/2023 at 2:18 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator, regarding the facility's failure to provide a safe environment and develop a comprehensive person-centered care plan for Resident 1, who was at risk for elopement, at risk for wandering and diagnosed with epilepsy, to address the resident's attempt of elopement. The facility also failed to conduct an IDT meeting and COC or SBAR to alert facility staff of Resident 1's attempt of elopement on 11/11/2023 at 1:05 PM. On 11/17/2023 at 1 PM, while onsite at the facility, the IJ was removed in the presence of the Administrator (ADM), after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: -On 11/13/2023 and 11/14/2023 the Assistant Director of Nursing (ADON) completed an Elopement Risk Assessment on all in-house residents. Resident 1 was identified as a high risk for Elopement on 11/14/2023 by the ADON. An Elopement and Wandering Assessment for Resident 1 was completed on 11/14/2023. -On 11/14/2023, Resident 1's Elopement Care Plan was developed by ADON to include 24 hour 1:1 caregiver, to always monitor resident the entire time while at the facility. -On 11/15/2023, the IDT met, which included the Minimum Data Set (MDS) Nurse, Director of Nursing (DON), Administrator, Social Services Director, and discussed Resident's 1 plan of care with Caregiver 1. Caregiver 1 agreed and stated she understood the meeting. -On 11/15/2023, the MDS Nurse involved with assisting the resident back into the facility received a 1:1 education with the DON regarding elopement, cognitively impaired resident, no out on pass, reporting immediately to charge nurse and to redirect resident to reassure safety. The MDS Nurse was suspended pending further investigation. -Receptionist 1 and Certified Nursing Assistant 1 (CNA) was given the same 1:1 in-service by the ADON on 11/15/2023 and a disciplinary action was given to the receptionist by the Administrator. The Receptionist was suspended pending further investigation. -Three other residents (Residents 2, 3 and 4), who were at risk for elopement were identified. Their Elopement Risk Assessment were completed on 11/13 and 11/14/2023. Care plans for the identified residents were completed by the MDS nurse on 11/15/2023. The interventions added onto the care plan were placement monitoring every hour, distracting resident from wandering by offering pleasant diversions, structured activities, food, conversations, television, and books. Resident 3 interventions indicated if noted with elopement attempts and searching for exit doors provide redirection and reorientation. Resident 4 interventions added were to provide 24-hour caregiver monitoring. -The IDT met with Residents 2, 3, and 4 on 11/15/2023. The team indicated they understood the process to help support the residents. -All on duty licensed nurses, caregivers, and CNA's were in-serviced by the DON or ADON on 11/15/2023 regarding notifying the Administrator, DON/ADON, for any resident change in condition, elopement requirements of COC / SBAR, physician and responsible party notification, and appropriate care planning. -Upon admission, the admitting nurses would complete an Elopement and Wandering Assessment for all new admissions and readmissions, create care plans and update upon readmission. -MDS Nurse 2 would update the Elopement / Wandering Assessments and Care Plans for Elopement / Wandering quarterly, annually and as needed. -Medical Records staff would conduct a daily change of condition audit to ensure proper documentation and procedures for any attempts of elopement. Report findings appropriately. The audit will be indefinitely. -Medical Records Supervisor and or Medical Records Assistant will conduct a daily admission audit to ensure the care plans for elopement and wandering are completed in a timely manner. Any findings will be reported to the MDS Nurse, Director of Nursing, and Administrator. -The Maintenance Director and or Maintenance Assistant will conduct a weekly random video footage audit of facility entrance and exit areas to ensure no residents attempted to elope from the facility. The Administrator will make a binder titled, See Something, Say Something for all staff to document any incidents they witness in the building during their shift which will also include attempted elopements or actual elopements. The DON, ADON, or Customer Service Representative will review the binder daily. Any findings will be reported to the Administrator and the appropriate department. The binder will be located at Station 1 by the hydration station. -All Licensed Nurses will receive an in-service regarding accuracy of Admission Assessment, Elopement and Wandering Assessment by the DON or ADON began on 11/16/2023. Findings: A review of the General Acute Care Hospital's (GACH) Psych Emergency Department Progress Note dated 8/31/2023 indicated Resident 1 had limited responses, mostly 'yes' or 'no' or 'home / go home.' The progress note indicated Resident 1 answered yes to being sad, answered no to being happy and wished to go home. The progress note indicated Resident 1 last heard voices approximately two weeks ago and that they were trying to help him. A review of Resident 1's admission record indicated the facility admitted the resident on 9/6/2023 with diagnoses including epilepsy, unspecified psychosis (abnormal condition of the mind described as involving a loss of contact with reality) not due to substance or known physiological condition, and personal history of traumatic brain injury (TBI -brain dysfunction caused by an outside force, usually a violent blow to the head). A review of Resident 1's Elopement Risk evaluation dated 9/6/2023 indicated the resident was disoriented / confused and had moderately impaired cognitive skills (decisions poor; cues/supervision required). Under Behavior, the elopement evaluation indicated Resident 1 received medication which may cause confusion, and the resident exhibited anxiety, but had no searching behavior or looking for exits. Under Resident's Risk Potential, Resident 1 scored two out of three for 'At Risk' of Elopement. Further review indicated Resident 1 did not have a care plan with appropriate interventions for Elopement Risk. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 9/12/2023, indicated Resident 1 entered from an acute hospital and was cognitively moderately impaired. Under Behavior / Potential Indicators of Psychosis indicated none of the above (no hallucinations, no delusions), and the resident had not exhibited behaviors of wandering. The MDS indicated Resident 1 required total dependence with one person assist for transfer, locomotion off unit, and toilet use. The MDS further indicated the resident was not steady, only able to stabilize with staff assistance for walking, turning around, and moving from seated to standing position. According to a review of the Physician's Order Summary Report for 9/2023, Resident 1 received Lamictal 100 milligram (unit of measure) two times a day for seizures, Olanzapine 10 mg at bedtime for psychosis, Sertraline 100 mg at bedtime for depression, Amantadine Hydrochloride (HCl) 100 mg two times a day for personal history of traumatic brain injury. The Physician's Order Summary Report for 10/2023 indicated Resident 1 may go out on pass with caregiver. A review of the Progress Notes dated 10/14/2023 indicated Resident 1 was visited by the Psychologist on 10/7/2023. The Psychologist Notes for this visit were requested but not provided from the facility. A review of Resident 1's Wandering Risk assessment dated [DATE] indicated the resident received antipsychotic medications, antidepressants, and anti-anxiety medications. The risk assessment indicated Resident 1 had a score of four which indicated a low risk for wandering. Further review indicated Resident 1 did not have a care plan with appropriate interventions for Risk of Wandering. A review of the Progress Notes indicated there were no Nursing Notes or Progress Notes documented for Resident 1 on 11/10/2023. A review of the Progress Notes dated 11/11/2023 at 4:57 AM, indicated, Was a behavior observed? Yes. The progress notes did not indicate the specific behavior observed. During an observation and review of the facility video surveillance, dated 11/11/2023 at 1:05 PM, Resident 1 was noted attempting to elope out of the facility's front entrance. The video indicated two facility staff members were present. A review of Resident 1's medical record indicated there were no COC forms completed, no elopement risk re-evaluation, no wandering risk re-assessment, no physician notification, no IDT meeting, no care plan developed and no responsible party notification for the attempted elopement on 11/11/2023 at 1:05 PM. A review of the Progress Notes dated 11/11/2023 at 1:38 PM, and 1:39 PM indicated, Was a behavior observed? Yes. The progress notes did not indicate the specific behavior observed. A review of the Progress Notes dated 11/11/2023 at 6 PM indicated Licensed Vocational Nurse (LVN) 1 documented he was doing rounds at 3:45 PM and noticed Resident 1 was not in his room. LVN 1 then spoke with the charge nurse who indicated Resident 1 was in the patio smoking. LVN 1 documented while he was passing medications around 5:10 PM, he went to Resident 1's room and the resident was not inside. He then went to the front lobby and the smoking area but the resident was not found. LVN 1 documented the Registered Nurse (RN) supervisor was then notified. A review of the COC, dated 11/11/2023 at 8:55 PM, indicated staff could not find Resident 1 in the dining room or patio. On 11/12/2023 Resident 1 remained missing. On 11/13/2023 Resident 1 remained missing. During an interview on 11/14/2023 at 8:41 AM, Family Member 1 (FM 1) stated the police informed her that the facility's security video tape showed Resident 1 trying to leave out the front door at around 1 PM and the facility staff brought him back into the facility. FM 1 stated the police informed her the video shows Resident 1 walking out the facility around 2:30 PM and no staff stopped him from leaving. FM 1 stated the facility was aware Resident 1 wanted to go to Hollywood Boulevard on 11/11/2023 instead of waiting to go with her on 11/12/2023. She stated she spoke with a facility staff, about him wanting to go to Hollywood Blvd on 11/11/2023 and they were aware of Resident 1 wanting to go out that day instead of waiting until 11/12/2023. During an interview on 11/14/2023 at 10:28 AM, the facility Receptionist stated she brought Resident 1 back when he tried to leave the facility through the front doors around 1 PM on 11/11/2023. She stated Resident 1 tried to leave the facility multiple times on 11/11/2023 during the morning and she had to stop him from walking out the door. The Receptionist stated the resident would say he wanted to go to Hollywood Blvd. and that he did try to leave the facility before when she was working on the weekend. The Receptionist stated she could not remember exactly what date he tried to leave and that she did not inform a charge nurse when this happened. The Receptionist stated she did not think it was necessary to report since Resident 1 did not actually leave the facility. During an interview with the Maintenance Director on 11/14/2023 at 11:45 AM, in the utility room, the facility's security footage from 11/11/2023 was reviewed. The Maintenance Director stated the facility video revealed that on 11/11/2023 at 1:05 PM, Resident 1 attempted to elope from the facility by stepping out of the facility front doors and three staff, Receptionist, Minimum Data Set Nurse (MDSN), and Certified Nursing Assistant (CNA 1) were seen on the video bringing the resident back into the facility. The Maintenance Director stated the footage revealed Resident 1 did elope from the facility on 11/11/2023 at 2:22 PM. On 11/14/2023 at 1:05 PM, during an interview, the Minimum Data Set Nurse (MDSN) stated she was working on 11/11/2023, 7 AM to 3 PM shift. The MDSN stated around 1 PM she was making rounds and observed the Receptionist try to redirect Resident 1 to come back into the facility when he attempted to elope through the facility front doors. The MDSN stated Resident 1 mentioned going to see his family, mother and sister out of state. During an interview on 11/15/2023 at 8:23 AM, LVN 1 stated he arrived at the facility late around 3:40 PM on 11/11/2023 and received report from LVN 2. LVN 1 stated he asked LVN 2 where Resident 1 was because he did not see the resident in his room. LVN 1 stated LVN 2 told him Resident 1 was in the patio smoking. LVN 1 stated he did not know if 3:45 PM was the normal smoking time for residents. LVN 1 stated he did not go check if Resident 1 was in fact in the patio or dining room at 3:45 PM. LVN 1 stated around 4 PM, he started doing rounds and medications for the residents. LVN 1 stated he went back to Resident 1's room around 5:15 PM and noticed Resident 1 was still not in his room. LVN 1 stated he went to the front lobby, dining room, and patio and he did not see the resident. He stated he did a code green for elopement at that time. LVN 1 stated no staff ever informed him Resident 1 tried to leave the facility that day on 11/11/2023 at 1:05 PM. LVN 1 stated if he was informed Resident 1 tried to elope earlier that day he would have been more cautious and conducted close monitoring of Resident 1's whereabouts when he did not see the resident in his room at 3:45 PM. LVN 1 stated there was no change of condition for the attempted elopement on 11/11/2023 at 1:05 PM and there was no care plan for attempted elopement. During an interview on 11/15/2023 at 11:02 AM, LVN 2 stated she provided change of shift report to LVN 1 around 3:30 PM, LVN 1 asked where Resident 1 was, and she informed LVN 1 the resident was in the dining room. LVN 2 stated she did not actually see or confirm if Resident 1 was in the dining room or patio. LVN 2 stated she did not provide information to LVN 1 that the resident tried to elope on 11/11/2023 at 1:05 PM because she was not made aware of the attempted elopement. LVN 2 stated if she was made aware of Resident 1's attempted elopement, she would have conducted a change of condition, informed responsible party, notified physician, and started a care plan for resident attempted elopement. She stated she would have also kept closer watch and monitoring of the resident's whereabouts to ensure he did not try to elope again. During an interview on 11/15/2023 at 11:54 AM, the Minimum Data Set Nurse (MDSN) stated when Resident 1 attempted to elope on 11/11/2023 at 1:05 PM, she did not inform anyone like the charge nurse, Registered Nurse supervisor, or the Director of Nursing. The MDSN stated the protocol when a resident attempted to elope, was to conduct a search, conduct a change of condition or SBAR, notify responsible party, notify physician, conduct IDT, conduct risk for elopement assessment, create a care plan, and follow interventions to ensure resident safety. The MDSN stated the facility failed to follow protocol and the outcome of the failures was the resident eloped on 11/11/2023 at 2:22 PM and had the potential for serious injury, harm, and death. On 11/15/2023 at 1:54 PM, during an interview, the Director of Nursing (DON) stated the facility protocol when a resident attempted elopement was to conduct a change of condition or SBAR, notify physician, notify responsible party, initiate an intervention, re-evaluate and reassessment of the resident, including risk for elopement, conduct a care plan, conduct IDT review, and make recommendations. The DON stated Resident 1 had an attempted elopement on 11/11/2023 at 1:05 PM and the facility staff should have assessed the resident, conducted a change of condition, notified physician and responsible party, conducted an IDT to provide interventions, create a care plan for attempted elopement, and monitored the resident more closely to ensure resident did not elope on 11/11/2023 at 2:22 PM. The DON stated the potential outcome of the failure was the resident could suffer serious injury or even death. During an interview on 11/15/2023 at 2:07 PM, the Administrator (Admin) stated the facility protocol for when a resident attempted to elope was to stop the resident right away, notify nursing so they can do a change of condition, and conduct an assessment, interview resident to discern why they attempted to elope. The Administrator stated the facility staff failed to follow protocol when Resident 1 attempted to elope on 11/11/2023 at 1:05 PM. She stated the facility did not conduct a change of condition, notify physician and responsible party, did not conduct IDT, and no care planning to prevent elopement. She stated the potential outcome of the failures were Resident 1 eloped on 11/11/2023 at 2:22 PM and could potentially suffer serious harm, injury, or death. A review of the facility policy and procedure titled, Nursing Services, Acute Condition Changes, revised 2023, indicated nursing assistants were encouraged to use the Stop and Watch Early Warning Tool to communicate subtle changes in the resident to the nurse. The policy indicated nursing staff would contact the physician based on the urgency of the situation. A review of the facility policy and procedure titled, Care Plans, Comprehensive Person - Centered, revised 2023, indicated the IDT in conjunction with the resident and the family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan is developed within seven days of the completion of the required MDS assessment and no more than 21 days after admission. A review of the facility policy and procedure titled, Comprehensive Assessments, revised 3/2022, indicated comprehensive assessments were conducted to assist in developing a person-centered care plan, and were conducted and coordinated by a registered nurse with appropriate participation of other health professionals on the interdisciplinary team. A review of the facility policy and procedure titled, Elopements, Resident Behavior and Facility Practices, undated, indicated staff shall promptly report any resident who tried to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. If an employee observed a resident leaving the premises, they should attempt to prevent the departure in a courteous manner, get help from other staff members in the immediate vicinity, and instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. The policy indicated if an employee discovered a resident was missing from the facility they should determine if the resident was out on an authorized pass, if not, initiate a search of the building and premises. A review of the facility policy and procedure titled, Wandering, Behavior, Mood and Cognition, revised 3/2023, indicated the facility would identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and intervention to maintain the resident's safety. If an employee observes a resident leaving the premises, they should attempt to prevent the resident from leaving in a courteous manner, get help, inform the Charge Nurse or Director of Nursing Services that a resident attempted to leave or has left the premises. A review of the facility policy and procedure titled, Emergency Procedure - Missing Resident, revised 8/2023, indicated resident elopement resulting in a missing resident was considered a facility emergency. Residents at risk for wandering and or elopement would be monitored, and staff would take necessary precautions to ensure resident safety.

Based on interviews and record reviews, the facility failed to provide care and services for four out of 12 Residents (22, 27, 33, and 54) in accordance with the facility's policies and procedures (P&P) titled, Nursing Care of The Resident with Diabetes Mellitus dated 2020, Condition Changes - Clinical Protocol dated 3/2023 and Nutritional assessment dated ,d+[DATE], by failing to: 1. Notify a physician if the blood sugar (BS) consistently remained above 200 milligrams per deciliter (mg/dL - unit of measurement [normal range for a diabetic according to the American Diabetes Association: 80 -130mg/dL]) for Residents 22, 27, 33, and 54. 2. Enter physician's orders for dietary consult on the medical charts for Residents 22, 27, 33, and 54. 3. Have a system in place to ensure a Registered Dietician (RD) is aware of physician's order for dietary consultation for Residents 22, 27, 33 and 54. 4. Document and communicate with a RD regarding physician's orders for dietary consultation and consistently elevated blood sugar for Residents 22, 27, 33, and 54. 5. Implement diabetic care plan for nutritional regimen and ongoing monitoring per RD for Residents 22, 27, 33, and 54. The facility was aware Residents 22, 27, 33, and 54 had diabetes. 1. Resident 22's Hemoglobin A1C (HgA1C - is a blood test that shows the average BS level over the past two to three months) on 6/29/2023 was 13% and on 8/28/23 was 12.9%. 2. Resident 27's HgA1C level increased from 11.1% (Reference range [RR] value of 5.7 % to 6.4 %) to 12.5%. 3. Resident 33's HgA1C was 8.2 %. 4. Resident 54's was HgA1C was 9.8 %. These deficient practices placed Residents 22, 27, 33, and 54 at increased risk of complications related with prolonged and uncontrolled elevated blood sugar not limited to neuropathy (permanent nerve damage), retinopathy (damage to the nerves in the eyes), diabetic ketoacidosis (DKA: life threatening complication of diabetes), heart attack, sepsis (A life-threatening medical emergency because the body's extreme response to infection), and death. On 10/20/2023 at 2:30 PM, the facility's Administrator (ADM) and Director of Nursing (DON) were notified for an Immediate Jeopardy (IJ, a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called due to the facility's failure to provide care and services for four out of 12 Residents (22, 27, 33, and 54) in accordance with the plan of care in order to maintain acceptable blood glucose levels. The facility's ADM and DON were notified of the seriousness of the condition of these diabetic residents being endangered. An IJ Removal Plan was requested from the facility's staff. On 10/22/2023 at 11:44 AM, the IJ was removed in the presence of the ADM and DON after the facility submitted an acceptable IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) and the surveyors onsite verified and confirmed through observation, interview, and record review the facility's implementation of the IJ Removal Plan. The IJ removal plan included the following actions: 1.Residents 22, 27, 33, and 54 and/or responsible parties: a. Met with the care conference team on 10/20/2023 and the Interdisciplinary Team (IDT, a team of health care professions, who work together to establish plans of care for residents) team on 10/21/2023. The items reviewed were blood sugars, HgAlC, diet, snack order, and medications. a. The RD provided diabetic education and completed a dietary assessment on for Residents 22, 27, 33, and 54. b. On 10/2/2020, the facility's Medical Director 1 (MD1) assessed Residents 22, 27, 33, and 54. MD1 reviewed BS, HgAlC, and educated Residents 22, 27, 33 and 54 on adequate food portions and low glycemic food choices. MD1 gave orders as: i. Notify a MD for BS above 300 mg/dL and HgAlC is above 6.5 mg/dL. ii. Facility to ensure a resident(s) was compliant with medication and dietary guidelines, and education a resident(s) on diabetic diet. iii. Facility to set up endocrinologist (a physician that specializes in diabetes management) consultation. iv. Notify a MD and transfer the resident to a general acute care hospital (GACH), if BS was out of control consecutively for four finger sticks despite the above efforts. c. The Assistant Director of Nursing (ADON) began referring Residents 22,27, 33, and 54 to an endocrinologist on 10/21/2023. 2. On 10/20/2023 the Medical Records Director ran a blood sugar report for the month for all 13 diabetic residents in the facility from October 1-20, 2023. a. The blood sugar report revealed an additional resident was affected by the systemic failure (Resident 48). The Medical Director met with the resident on 10/21/2023 and reviewed the resident's blood sugars, and diabetic medications. The Medical Director provided verbal education to the resident the resident agreed to increase the glipizide (medication used to stimulate the pancreas into producing more insulin) twice a day. 3. On 10/20/2023 the DON ran a report to identify all diabetic residents in the facility. 28 residents were identified, 19 of those residents had the potential to be affected by the systemic failure. 4. On 10/20/23 and 10/21/2023, the facility's Nurse Consultant in-serviced (educated) IDT Team, licensed nurses regarding facility's P&P for resident change in condition. 5. On 10/20/2023 and 10/21/202, the facility's Nurse Consultant in-serviced all licensed nurses on fingerstick BS check, BS parameters, medical doctor notification and compliance with diabetic diet order and snacks. 6. On 10/20/2023 and 10/21/2023, the facility's Nurse Consultant in-serviced all licensed nurses on change in condition (COC- significant worsening of an employee's physical health), for HgA1C above 6.5. 7. On 10/21/2023, the ADON began utilizing the facility's Diet Communication form on when to notify the RD of a new consultation order for a resident. 8. On 10/21/2023, Admitting nurses started requesting for baseline HgA1C for all newly admitted residents with a diagnosis of diabetes. RN Supervisor and or designee, referred HgA1C equal to 6.5 or higher was referred to RD and a Physician for further evaluation. 9. Effective 10/21/2023, the DON and or designee started conducting quarterly HgAlC laboratory results review for all residents with diagnosis of Diabetes Mellitus. Any labs with an HgAlC of 6.5 or higher will be referred for a Dietary Consult and a Physician Evaluation. 10. Effective 10/21/2023 if a resident's blood sugar continued to be out of control four times consecutively the MD had to be notified by the DON and or designee. 11. Effective 10/20/2023 Medical Records and or designee began conducting a weekly Blood Sugar Audit, with directions to notify the DON and Assistant ADON with the results. Findings: a. A review of Resident 27's admission record indicated Resident 27 initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included heart failure, diabetes (An impairment in the way the body regulates and uses sugar as a fuel), kidney failure, and high blood pressure. A review of Resident 27's physician's orders dated 7/6/2022, indicated the resident was to receive regular human insulin (A natural hormone [a chemical substance produced in the body that controls and regulates the activity of certain cells or organs] in the body that helps control BS) per sliding scale (dosage dependent on BS level). A review of Resident 27's physician's orders dated 8/21/2022, indicated the resident was to have a controlled carbohydrate no added salt, mechanical soft texture (diet designed for people who have trouble chewing and swallowing), regular consistency diet. The orders indicated the resident may have peanut butter and jelly sandwiches. A review of Resident 27's physician's orders dated 3/4/2023, indicated Resident 27 to receive metformin (medication used to treat diabetes by reducing the amount of sugar the liver produces) 1000 mg with meals. A review on Resident 27's situation background assessment and recommendation (SBAR) form dated 3/21/2023 at 4:40 PM, indicated Resident 27's BS was 518 mg/dL. The SBAR indicated a physician was notified and no new orders received. A review of Resident 27's physician's orders dated 3/21/2023, progress notes dated 3/21/2023, and SBAR forms dated 3/21/2023, revealed no further action was taken for Resident 27's BS of 366 mg/dL. A review of Resident 27's care plan for Hyperglycemia (elevated BS) related to diabetes meal consumption dated 3/22/2023, indicated RD to consult for nutritional regimen and ongoing monitoring for Resident 27. A review of Resident 27's Nutritional assessment dated [DATE] at 9:15 AM, indicated Recent RD consult note addressing trend of high sugars. Nursing to inform family on risk of elevated BS when providing additional outside foods. The note indicated dietary intervention included to Recommend HS (hour of sleep) diabetic snack to support stable blood sugars. A review of Resident 27's Medication Administration Record (MAR), indicated Resident 27's BS levels consistently remained above 130 mg/dL for the following months: On 5/1/2023 to 5/31/2023, blood sugar levels ranged from 142 mg/dL to 395 mg/dL. 106 out of 126 entries were above 200 mg/dL. On 6/1/2023 to 6/30/2023, blood sugar levels ranged from 173 mg/dL to 399 mg/dL. 117 out of 123 entries were above 200 mg/dL. A review of Resident 27's situation background assessment and recommendation (SBAR - is a verbal or written communication tool used to communicate a patient's information clearly, quickly and effectively) form dated 6/29/2023 at 4:35 PM, indicated Resident 27's Hemoglobin A1C (HbA1C - is a blood test that shows the average BS [glucose] level over the past two to three months) level was 11.1% (Reference range [RR] value of 5.7 % to 6.4 %). A review of Resident 27's Medication Administration Record, indicated from 7/1/2023 to 7/31/2023, blood sugar levels ranged from 206 mg/dL to 399 mg/dL. 120 out of 121 entries were above 200mg/dL. A review of Resident 27's physician's orders dated 7/21/2023, indicated Resident 27 to receive Lantus (long-acting insulin) subcutaneous (SQ- under the skin) 12 units at bedtime. A review of Resident 27's Minimum Data Set (MDS- standardized data collection tool used to assess cognitive and functional status) dated 8/8/2023, indicated Resident 27 had severe cognitive (ability to acquire and understand knowledge) impairment. The MDS indicated the resident was dependent on facility staff for all care and needs. A review of Resident 27's care conference Interdisciplinary team (IDT, a team of health care professions, who work together to establish plans of care for residents) dated 8/09/2023 at 11:02 AM, revealed IDT team did not discuss or make recommendations for Resident 27's consistently. A review of Resident 27's SBAR form dated 8/24/2023 at 10:39 AM, indicated Elevated blood sugar reading despite DM regimen. The SBAR did not indicate what Resident 27's BS reading was. A review of Resident 27's care plan for Elevated Blood Sugar Result Despite Diabetic Management dated 8/24/2023, indicated RD to consult for nutritional regimen and ongoing monitoring for Resident 27. A review of Resident 27's physician's order dated 8/24/2023, indicated Resident 27 to receive Lantus 12 units SQ every morning. The physician's order revealed there was no documented evidence regarding the dietary consult as indicated in the Resident has Elevated Blood Sugar Results Despite Diabetic Regimen (orders put in place by physician to control blood sugar levels) per care plan dated 8/24/2023. A review of Resident 27's Medication Administration Record, indicated Resident 27's BS levels consistently remained above 130 mg/dL for the following months: On 8/1/2023 to 8/31/2023, blood sugar levels ranged from 183 mg/dL to 400 mg/dL. 114 out of 116 entries were above 200mg/dL. On 9/1/2023 to 9/20/2023, blood sugar levels ranged from 186 mg/dL to 390 mg/dL. 99 out of 116 entries were above 200mg/dL. A review of all Resident 27's nutritional notes dated from 8/24/2023 to 10/18/2023 revealed RD had not consulted or visited with Resident 27. A review of Resident 27's IDT notes dated from 8/24/2023 to 10/18/2023, revealed the IDT team had not met to discuss Resident 27's consistently elevated blood sugar. A review of Resident 27's Laboratory Results Report dated 8/26/2023, indicated Resident 27' s HbA1C level was 12.5 % mg/dL up from 11.1% on 6/29/2023. A review of Resident 27's MAR for October 2023 indicated BS level from 10/1/2023 to 10/18/2023 are all above 130 mg/dL. BS level ranged from 187 mg/dL to 400 mg/dL. 69 out of 72 entries were above 200 mg/dL. A review of Resident 27's Blood Sugar Summary for October 2023, indicated Resident 27's BS levels on: 10/9/2023 were 325mg/dL at 6:11 AM, 299 mg/dL at 12:16 PM, 303 mg/dL at 4:42 PM, and 364mg/dL at 9:43 PM. 10/10/2023 were 216mg/dL at 6:59 AM, 256 mg/dL at 12:22 PM, 325 mg/dL at 4:49 PM, and 398mg/dL at 8:29 PM. 10/11/2023 were 400 mg/dL at 6:30 AM, 306 mg/dL at 12:29 PM, 344 mg/dL at 5:26 PM, and 352 mg/dL at 8:40 PM. 10/12/2023 were 366 mg/dL at 6:34 AM, 323 mg/dL at 11:45 AM, 364 mg/dL at 5:37 PM, and 341 mg/dL at 9:22 PM. 10/13/2023 were 398 mg/dL at 6:19 AM, 234 mg/dL at 12:24 PM, 307 mg/dL at 4:08 PM, and 311 mg/dL at 8:12 PM. 10/14/2023 were 314 mg/dL at 5:37 AM, 303 mg/dL at 11:39 AM, 369 mg/dL at 5:25 PM, and 328 mg/dL at 9:23 PM. 10/15/2023 were 399 mg/dL at 5:59 AM, 261 mg/dL at 12:14 PM, 388 mg/dL at 4:11 PM, and 327 mg/dL at 8:31 PM. 10/16/2023 were 387 mg/dL at 6:14 AM, 305 mg/dL at 11:08 AM, 364 mg/dL at 4:31 PM, and 385 mg/dL at 9:10 PM. A review of Resident 27's progress notes for 10/9/2023 to 10/17/2023 did not indicate that the physician was notified for the four or more consecutive readings of BS above 130 mg/dL. During an interview on 10/19/2023 at 2:57 PM, RD stated the facility never notified RD of physician's order for dietary consultation for Resident 27. The RD stated RD had not seen/visited Resident 27 since 4/12/2023. RD further stated the facility allowed Resident 27, to eat whatever the resident [Resident 27] wanted. RD stated the facility had not changed Resident 27's diet to manage the resident's high BS levels. During an interview on 10/20/2023 at 7:08 AM, the Assistant Director of Nursing (ADON) stated if a resident has COC the ADON would assist with assessing the resident, notify the physician, and carry out physician's orders. The ADON stated she (ADON) would update the resident's care plan and notify RD if RD consult was ordered. The ADON stated the ADON would verbally notify RD if RD consultations is ordered. The ADON stated she did not document anywhere nor on residents' medical chart for notification requests and or physician's order for RD consult notifications needed for residents The ADON stated she would remember (make a mental note) which residents had dietary consultation. The ADON stated if she [ADON] was off duty, I would assume the Director of Nursing (DON) would contact RD for any dietary consults. The ADON confirmed and stated the facility did not have a specific method of communicating with the DON or anyone on pending/ordered RD consults for the residents. The ADON stated, all communications are verbal. The ADON confirmed she (ADON) never entered RD consult orders in residents' electronic health record (HER). The ADON stated it was important to maintain BS within normal limits to avoid hypoglycemia (low BS) or hyperglycemia (high BS). The ADON stated adverse effects for hyperglycemia included diabetic coma (a life-threatening complication that can result from hyperglycemia or hypoglycemia) and shock (a critical condition brought on by the sudden drop in blood flow through the body). The ADON stated prolonged elevated blood sugars could lead to arteriosclerosis (hardening of blood vessels), heart attack, stroke, neuropathy (nerve damage), retinopathy (damage to nerve in eyes), stroke, and death. During an interview and record review on 10/20/2023 at 7:08 AM, Resident 27's medical chart was reviewed. The ADON stated Resident 27's blood sugar had not been managed appropriately. The ADON reviewed the resident's blood sugar from 1/26/2023 to 10/20/2023 and stated the blood sugar had been uncontrolled since 1/26/2023. The ADON stated complications of uncontrolled high BS included, death, kidney failure, everything. The ADON stated and confirmed the facility did not notify RD of ordered dietary consults for Resident 27. The ADON reviewed physician's orders for Resident 27 and confirmed and stated physician's orders were not entered for dietary consult for Resident 27. During an interview on 10/20/2023 at 2 PM, the facility's Medical Director 1 (MD1) stated it was expected that the facility tries to control BS levels as much as possible for diabetic residents. MD1 stated it was important to identify residents who are compliant and noncompliant with diabetic regimen. MD1 stated for residents with BS difficult to manage, needed to be transferred to a general acute care hospital (GACH). MD1 stated BS levels are considered uncontrolled if the BS is above the normal range (130 mg/dL) for four or more consecutive readings. MD1 stated a physician must be notified and an endocrinologist consultation ordered for residents with uncontrolled blood sugar. MD1 stated it is expected RD consults/visits with the resident to avoid complications of prolonged high BS levels which included neuropathy, retinopathy, and DKA. MD1 stated the complications are elevated (risk increases) when a resident has other health problems. MD1 stated he was not aware that Residents 22, 27, 33, and 54 has consistently elevated blood sugar. MD1 further stated Residents 22, 27, 33, and 54 consistently elevated blood sugar was an important concern that needed to be addressed immediately to avoid life threatening complications. During an interview on 10/20/2023 at 4:12 PM, the DON defined COC as any change from a resident's baseline such as abnormal lab results, a change in mental status, and reaction to medication. The DON stated if a resident develops COC, the facility completes a head-to-toe assessment and SBAR completed. The DON stated the SBAR should paint a clear picture of what happened to the resident and the reason why. The DON stated a physician is notified of COC and the physician gives orders that are implemented. The DON stated RD is notified of dietary consult verbally. When asked how RD notification was tracked to ensure the residents are seen, the DON replied, you inform them [RD], so they have to respond. When asked about the facility's process of verifying that RD dietary consultation request was completed, the DON confirmed and stated the facility did not have a system in place to verify if RD consultations were communicated and completed. The DON then stated, this isn't just the one resident error this is something bigger. The DON stated acceptable BS levels for diabetic residents range from 100-130mg/dL. The DON defined uncontrolled diabetes as BS levels above 200mg/dL for three or more readings. The DON stated if the BS levels remain elevated for three to four consecutive readings, a physician must be informed. The DON stated continued elevated BS levels could lead to new onset or worsening of renal disease, cardiac disease, a heart attack, DKA, sepsis, and death. b. A review of Resident 22's admission record indicated the facility initially admitted the resident on 2/13/2020 and readmitted on [DATE] with diagnoses that included Diabetes, peripheral vascular disease (PVD -a slow and progressive circulation disorder) and hyperlipidemia (a high level of fats in the blood). A review of Resident 22's physician's orders dated 8/7/2021, indicated the resident was to have a controlled carbohydrate no added salt, regular texture, regular consistency diet related to blood pressure and diabetes. A review of Resident 22's Annual Nutritional assessment dated [DATE], documented by RD1 (no longer work with the facility), indicated Resident 22 had diabetes. The Nutritional Assessment did not mention the resident's BS levels nor were the resident's BS levels part of the goal of care. A review of Resident 22's Laboratory Results Report dated 6/29/2023, indicated Resident 22's HgA1C level was 13%. A review of Resident 22's SBAR form dated 6/29/2023 at 4:48 PM, indicated Resident 22's HgA1C level was 13%. The SBAR also indicated there was a new order, however, the order was not indicated on the SBAR. A review of Resident 22's MDS dated [DATE], indicated Resident 22's cognition was severely impaired (never/rarely made decisions). A review of Resident 22's IDT care conference notes dated 8/11/2023, indicated Resident 22's BS was trending high. IDT notes further indicated Resident 22 was on controlled carbohydrate diet, RD will recommend, medical doctor (MD) to review medication protocol to support tighter control of BS. A review of Resident 22's Diabetes Mellitus care plan revised on 8/15/2023 indicated Resident 22 was at risk for elevated BS readings due to non-compliant with diet regimen. Resident 22 was having soda, fruit juices, sweets, and other foods. Interventions included dietary consult for nutritional regimen and ongoing monitoring. A review of Resident 22's SBAR form dated 8/24/2023, indicated Resident 22 was noted to have elevated sugar reading despite current DM regimen, possibly due to non-compliant with diet regimen, consuming soda's, cookies, candies, chocolates, and other foods that are high in glucose (sugar), sodium (salt), and carbohydrates, despite of monitoring and explanation resident incoherent and does not fully understand education and when attempted to removed food resident gets angry due to behavioral issue . Resident [Resident 22] is under IDT. IDT in agreement. The facility did not provide any IDT care conference notes after 8/24/2023 how to address non-compliant with diet regimen for Resident 22. A review of Resident 22's care plan titled, The Resident has Elevated Blood Sugar Despite Current DM Regimen initiated 8/24/2023, indicated Resident 22 was to have a dietary consult for nutritional regimen and ongoing monitoring. A review of Resident 22's physician's orders for 8/24/2023 revealed there was no documented evidence regarding the dietary consult as indicated in the Resident has Elevated Blood Sugar Results Despite Diabetic Regimen. care plan dated 8/24/2023. A review of Resident 22's Laboratory Results Report dated 8/28/23, indicated Resident 22's HgA1C level was 12.9%. A review of Resident 22's physician's orders dated 8/28/2023, indicated Resident 22 to receive insulin glargine (helps sugar enter cells from blood stream to be used for energy) 20 units SQ every day and at bedtime. A review of Resident 22's Medication Administration Record (MAR) for September 2023, indicated Resident 22's BS check twice a day. BS level from 9/1/2023 to 9/30/2023 readings are all above 130 mg/dL. BS level ranged from 148mg/dL to 396mg/dL. 53 out of 60 entries were above 200 mg/dL. A review of Resident 22's physician's orders dated 9/3/2023, indicated Resident 22 to receive insulin glargine 20 units SQ every day and at bedtime. A review of Resident 22's physician's orders dated 9/21/2023, indicated Resident 22 to receive metformin (used to treat diabetes by reducing the amount of sugar the liver produces) 1000 milligrams (mg) twice a day. The facility did not provide any IDT care conference notes to address the uncontrolled BS for Resident 22. A review of Resident 22's MAR for October 2023 indicated BS level from 10/1/2023 to 10/18/2023 are all above 130mg/dL. BS level ranged from 173 mg/dL to 333 mg/dL. 29 out of 36 entries were above 200 mg/dL. A review of Resident 22's MAR for October 2023, indicated Resident 22's BS levels on: 10/13/2023 at 6:30 AM: 266 mg/dL, 4:30 PM: 221 mg/dL 10/14/2023 at 6:30 AM: 262 mg/dL, 4:30 PM: 236 mg/dL 10/15/2023 at 6:30 AM: 206 mg/dL, 4:30 PM: 301 mg/dL 10/16/2023 at 6:30 AM: 235 mg/dL, 4:30 PM: 222 mg/dL A review of Resident 22's medical records from 10/1/2023 to 10/17/2023 did not indicate that the physician was notified for the four or more consecutive readings of BS above 130 mg/dL. During an interview on 10/19/2023 at 2:57 PM, RD stated the facility never notified RD of physician's order for dietary consultation for Resident 22. During an interview on 10/20/2023 at 2 PM, the facility's Medical Director 1 (MD1) stated it was expected that the facility tries to control BS levels as much as possible for diabetic residents. MD1 stated it was important to identify residents who are compliant and noncompliant with diabetic regimen. MD1 stated for residents with BS difficult to manage, needed to be transferred to a general acute care hospital (GACH). MD1 stated BS levels are considered uncontrolled if the BS is above the normal range (130 mg/dL) for four or more consecutive readings. MD1 stated a physician must be notified and an endocrinologist consultation ordered for residents with uncontrolled blood sugar. c. A review of Resident 33's admission record indicated the facility admitted the resident on 11/4/2021 with diagnoses that included diabetes. A review of Resident 33's physician's orders dated 3/31/2022, indicated the resident was to receive regular human insulin per sliding scale (SS- the progressive increase in the pre-meal or nighttime insulin dose). A review of Resident 33's MAR, indicated Resident 27's BS levels indicated the following: On 5/1/2023 to 5/31/2023, blood sugar levels ranged from 131 mg/dL to 336 mg/dL. 74 out of 121 entries were above 200 mg/dL. On 6/1/2023 to 6/30/2023, blood sugar levels 131 mg/dL to 336 mg/dL. 78 out of 118 entries were above 200 mg/dL. On 7/1/2023 to 7/31/2023, blood sugar levels ranged from 179 mg/dL to 344 mg/dL. 79 out of 121 entries were above 200 mg/dL. A review of Resident 33's MDS dated [DATE], indicated Resident 33 was cognitively intact. A review of Resident 33's Medication Administration Record (MAR), indicated Resident 27's BS levels indicated from 8/1/2023 to 8/31/2023, blood sugar levels ranged from 133 mg/dL to 367 mg/dL. 79 out of 123 entries were above 200 mg/dL. A review of Resident 33's physician's orders dated 8/18/2022, indicated Resident 33 to receive Lantus 20 units every 12 hours. A review of Resident 33's physician's orders dated 8/24/2023, indicated Resident 33 to receive Metformin 1000 mg with meals. A review of Resident 33's Laboratory Results Report dated 8/25/2023, indicated Resident 33's HgA1C was 8.2 % mg/dl. A review of all Resident 33's nutritional notes dated from 8/25/2023 to 10/18/2023 indicated RD had not seen/consulted/visited with Resident 33. The nutritional notes revealed the last time Resident 33 had a nutritional evaluation was on 4/12/2023. A review of Resident 33's IDT notes dated from 8/25/2023 to 10/18/2023, revealed the IDT team had not met to discuss the residents consistently elevated blood sugar. A review of Resident 33's MAR, indicated from 9/1/2023 to 9/20/2023, blood sugar levels ranged from 146 mg/dL to 396 mg/dL. 82 out of 118 entries were above 200 mg/dL. A review of Resident 33's care plan for diabetes dated 9/14/2023, indicated RD to consult for nutritional regiment and ongoing monitoring for Resident 33. A review of Resident 33's physician's orders for 9/14/2023 revealed the dietary consult indicated in the care plan for diabetes dated 9/14/2023 was not ordered. A review of Resident 33's physician's orders dated 9/28/2023, indicated Resident 33 BS to be on a controlled carbohydrate no added salt diet. The orders indicated Resident 33 was allowed to have double portions, regular juice, and one fruit for all meals. The orders also indicated the resident may deviate from diet on special occasions and/or when the resident desires. A review of Resident 33's Medication Administration Record for October 2023 indicated BS level from 10/1/2023 to 10/15/2023 are all above 130 mg/dl. BS level ranged from 181 mg/dL to 396 mg/dL. 59 out of 64 entries were above 200 mg/dL. A review of Resident 33's Blood Sugar Summary for October 2023, indicated Resident 33's BS levels on: 10/9/2023 were 379 mg/dL at 6:41 AM, 299 mg/dL at 12:15 PM, 256 mg/dL at 5:18 PM, and 396 mg/dL at 9:29 PM. 10/10/2023 were 368 mg/dL at 6:37 AM, 332 mg/dL at 12:20 PM, 356 mg/dL at 4:99 PM, and 310 mg/dL at 9:30 PM. 10/11/2023 were 388 mg/dL at 6:10 AM, 267 mg/dL at 11:49 AM, 354 mg/dL at 4:00 PM, and 355 mg/dL at 8:16 PM. 10/12/2023 were 398 mg/dL at 6:52 AM, 301 mg/dL at 12:27 PM, 362 mg/dL at 4:38 PM, and 310 mg/dL at 9:31 PM. 10/14/2023 were 302 mg/dL at 6:26 AM, 375 mg/dL at 11:35 AM, 254 mg/dL at 5:57 PM, and 236 mg/dL at 9:43 PM. 10/15/2023 were 246 mg/dL at 6:28 AM, 369 mg/dL at 11:29 AM, 274 mg/dL at 5:03 PM, and 302 mg/dL at 8:43 PM. A review of Resident 33's progress notes from 10/9/2023 to 10/15/2023 did not indicate that the physician was notified for the four or more consecutive readings of BS above 130 mg/dl. During an interview on 10/19/2023 at 2:57 PM, the RD denied the facility notified/communicated physician's order for RD to consult with Resident 33. During an interview on 10/20/2023 at 7:08 AM, the ADON confirmed she (ADON) never entered Resident 33's dietary consult in Resident 33 EHR. During an interview on 10/20/2023 at 2 PM, the facility's Medical Director 1 (MD1) stated it was expected that the facility tries to control BS levels as much as possible for diabetic residents. MD1 stated it was important to identify residents who are compliant and noncompliant with diabetic regimen. MD1 stated for residents with BS difficult to manage, needed to be transferred to a general acute care hospital (GACH). MD1 stated BS levels are considered uncontrolled if the BS is above the normal range (130 mg/dL) for four or more consecutive readings. MD1 stated a physician must be notified and an endocrinologist consultation ordered for residents with uncontrolled blood sugar. d. A review of Resident 54's Admission Record indicated the facility initially admitted on [DATE] with diagnoses that included type 2 diabetes (a condition in which the body does not use insulin, a hormone that helps the body use sugar for energy, properly resulting in abnormally high BS levels), dysphagia (swallowing difficulties), gastroesophageal disease (when stomach acid repeatedly flows back into the tube connect the mouth and stomach), hypertension (HTN - high blood pressure), atrial fibrillation (rapid irregular heart beat), hemiplegia (paralysis to one side of the body), and encephalopathy (permanent brain injury). A review of Resident 54's MDS dated [DATE], indicated Resident 54 had severely impaired cognition and required extensive assistance and two-person physical assistance for transferring, extensive assistance and one-person physical assistance for bed mobility, dressing, eating, and personal hygiene; and total dependence and one-person physical assistance for locomotion (movement) on and off the unit, and toilet use. A review of Resident 54's MAR, indicated Resident 54's BS levels consistently remained above 130 mg/dL for the following months: 5/1/2023 to 5/31/2023, BS ranged from 180 mg/dL to 321 mg/dL. 6/1/2023 to 6/30/2023, BS ranged from 170 mg/dL to 397 mg/dL. 7/1/2023 to 7/31/2023, BS ranged from 163 mg/dL to 361 mg/dL. 8/1/2023 to 8/31/2023, BS ranged from 174 mg/dL to 345 mg/dL. A review of Resident 54's Physician Order dated 8/10/2023, indicated Resident 54 to receive 30 units of Glargine Insulin SQ in the morning for type 2 diabetes. A review of [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide an environment that was free of accident hazards for two of seven residents (Resident 24 and Resident 33) by failing to: 1. Ensure Certified Nurse Assistant 9 and 10 (CNA 9 and CNA 10) checked the integrity of the Hoyer lift (an equipment used by caregivers to safely transfer patients) sling and if the size was appropriate prior using it to transfer Resident 24 from a wheelchair (WC) to a bed on 10/5/2023 in accordance with the facility's policies and procedures (P&P) titled, Lifting Machine, Using a Mechanical, revised 9/2023, and the manufacturer's undated instruction manual on Hoyer lift sling. Resident 24 weighed 426 pounds at the facility. On 10/5/2023, the Hoyer lift sling snapped (break suddenly and completely) when CNA 9 and CNA 10 were transferring Resident 24 from WC to a bed. Resident 24 fell four feet from the Hoyer lift to the floor. These deficient practices resulted in Resident 24 was transferred to a general acute care hospital (GACH) for further evaluation and management. Resident 24 was diagnosed with right femur (thigh bone) fracture (break in a bone) and was treated for pain. Resident 24 had severe anxiety and fear secondary to the circumstances surrounding her fall incident on 10/5/2023. 2. Resident 33 was not allowed to have an extension cord wrapped around the upper siderails of the bed, and an electrical fan and phone charger connected to a power strip and placed at the foot of Resident 33's bed in accordance with the facility's P&P titled Maintenance Service dated 12/2022, and P&P titled Fire and Safety Prevention dated 12/2022, indicated. The deficient practice increased the risk for accidents related to falls, fire and safety hazards, and death for Resident 33 and all residents, staff, and guests in the facility. Findings: 1. A review of Resident 24's admission record indicated the facility originally admitted Resident 24 on 4/20/2023 with diagnoses that included but were not limited to morbid obesity (a weight that is more than 100 pounds above a person's ideal body weight), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow) and gait and mobility abnormalities (a change in walking patterns). A review of Resident 24's Care Plan, initiated 4/21/2023, indicated Resident 24 had an ADL self-care performance deficit related to impaired balance, limited mobility, limited range of motion (ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point) and a musculoskeletal impairment. The interventions indicated Resident 24 required a mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) with two person assist for transfers, the resident required assistance by one staff to turn and reposition in bed every two hours and as necessary and that Resident 24 required one staff to assist her with showering. A review of Resident 24's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 7/27/2023 indicated Resident 24 was cognitively intact. The MDS indicated Resident 24 required extensive staff assistance to total dependence with surface transfer, bed mobility, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing. The MDS further indicated Resident 24 had functional limitation (limitations due to the illness, as people with a disease may not carry out certain functions in their daily lives) impairment in ROM in both of her legs. A review of the facility's Hoyer Lift (mechanical lift) Maintenance Checklist, for the months of 8/2023, 9/2023 and 10/2023, the check lists indicated the facility's Maintenance Director (MNTD) inspected the Hoyer lift and its accessories (a finished device that is intended to support and or supplement the performance of one or more parent device[s]) for any sign of wear monthly. However, the Hoyer lift check list did not indicate the dates the Hoyer lift check was completed. A review of Resident 24's Weights and Vitals Summary, indicated that on 10/4/2023, Resident 24 weighed 426 pounds. A review of Resident 24's Progress Note dated 10/5/2023, indicated that on 10/5/2023 at around 5:50 PM, Licensed Vocational Nurse 4 (LVN 4) heard screaming sound/voices. LVN 4 went to Resident 24's room and saw Resident 24 on the floor. Resident 24 was on top of the Hoyer lift. LVN 4 interviewed CNA 9 and CNA 10 who claimed that as they were transferring Resident 24 from a WC to bed via a Hoyer lift when the Hoyer lift sling snapped. The progress note further indicated 911 (a telephone number used to reach emergency medical, fire, and police services) was contacted. The paramedics (a team of trained staff who provide emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) arrived and it took six people to transfer Resident 24 from the floor to the gurney chair (comfortable, all-purpose device that can transform from flat form to chair in seconds). A review of Resident 24's after Fall Care Plan, initiated 10/5/2023, indicated that on 10/5/2023, Resident 24 fell while being transferred from a Hoyer lift when the right and left sides of the Hoyer lift sling snapped. Resident 24 fell on to her right side and landed on top of the Hoyer lift. The goal included Resident's pain will resolve without complication by the review date of 10/25/2023. The interventions included to determine and address causative factors of Resident 24's fall. A review of Resident 24's SBAR (Situation, Background, Assessment, Recommendation - a tool used to facilitate prompt and appropriate communication between the different disciplines caring for the resident) Communication form dated 10/5/2023, indicated CNA 9 and CNA 10 used a Hoyer lift to transfer Resident 24 from WC to bed. The SBAR indicated CNA 9 and CNA 10 inspected and properly placed the Hoyer lift and Hoyer sling prior to transferring Resident 24. The SBAR indicated while transferring Resident 24, the right lower sling loop snapped and then the left lower sling loop also snapped. The SBAR indicated Resident 24 fell to the floor on her right side and landed on top of the Hoyer lift. A review of Resident 24's Physician Orders dated 10/5/2023, indicated to transfer Resident 24 to GACH via emergency services after a fall. A review of the facility's Notice of Transfer/Discharge Form, dated 10/5/2023, indicated Resident 24 was transferred to a GACH because Resident 24's needs could not be met in the facility. A review of Resident 1's GACH Emergency Department (ED) Provider Note, dated 10/5/2023, indicated Resident 24 was brought in by ambulance. Resident 24 sustained an injury to her right hip and knee after falling from mechanical lift equipment due to equipment malfunction. The ED notes indicated Resident 24 said she was being lifted back to her bed using mechanical lift and the equipment reportedly snapped and the lift [Hoyer] dropped her. The ED notes further indicated Resident 24 complained of pain in her right hip radiating down her right leg and knee. Resident 24 was having more pain during ROM of the leg right leg. A review of Resident 24's GACH computerized tomography scans (CT scans - a series of X-ray images taken by computers to create more detailed images of bones, blood vessels, and tissues inside the body) report dated 10/5/2023, indicated a transverse (straight across) and impacted (a break where the ends are driven into each other) femur (thigh) fracture was partially visualized. A review of Resident 24's GACH Medication Administration Record (MAR) for the month of 10/2023, indicated that on 10/5/2023, Resident 24 received intravenous (IV - inside a vein) Dilaudid (a strong opioid medication to treat severe pain) one milligram (mg - unit of measurement) at 7:54 PM and 0.5mg at 9:03 PM while in the emergency room . A review of Resident 24's Progress Note dated 10/6/2023 at 12:06 AM, indicated CNA 9 and CNA 10 were transferring Resident 24 from a WC to bed using a Hoyer lift. The progress note indicated while transferring Resident 24, the right lower sling loop snapped and then the left lower sling loop also snapped. The progress note indicated Resident 24 fell to the floor on her right side and landed on top of the Hoyer lift. A review of Resident 24's GACH History and Physical (H&P), dated 10/6/2023, indicated Resident 24 was admitted to the GACH on 10/5/2023 due to a mechanical fall and with a possible femur fracture. A review of the Orthopedic (a branch of medicine that treatments disorders or injuries of the bones, joints, and associated muscles) Consultation Note dated 10/6/2023, indicated Resident 24 had right femur fracture, was not a surgical candidate and to initiate a knee immobilizer (a removable device that maintains stability). It also indicated Resident 24 weighed 194.8 kilograms (437.36 pounds). A review of Resident 24's GACH Nursing Progress Note dated 10/10/2023, indicated Resident 24 said she had anxiety (nervousness/restlessness) at night regarding her pending transfer back to the facility. The progress notes further indicated Resident 24 had suicidal thoughts because she felt pushed to transfer back to the same facility she came from before hospitalization . A review of Resident 24's Psychiatric (A branch of medicine that specializes in mental health, including substance use disorders) Consultation Note dated 10/12/2023, indicated Resident 24 sustained a fall while being hoisted out of the shower and fell four feet onto the floor on 10/5/2023 and sustained a femur fracture. The psychiatric note also indicated Resident 24 was alleged to have suicidal thoughts and the consult was to assess Resident 24's safety. The psychiatric note also indicated Resident 24 had severe anxiety and fear secondary to the circumstances surrounding her fall. The psychiatric note indicated Resident 24's diagnosis was moderate major depression and psychotropic medications ( medication affecting the mind or mental processes) would be initiated. During an observation in the conference room on 10/17/2023 at 3:40 PM, the facility's blue sling used to transfer Resident 24 on 10/5/2023 was inspected. The right side loop of the Hoyer lift sling was completely separated (broken off) from the rest of the sling mesh. The left side loop of the Hoyer lift sling was broken/torn apart. The blue Hoyer lift sling was worn out with ripped in the material on all four corners around where the straps are sewn onto the sling. Also, there were two holes observed in the Hoyer lift sling mesh. During an interview on 10/17/2023 at 3:47 PM, CNA 9 stated on 10/5/2023 around 5:45 PM or 5:50 PM, he and CNA 10 were transferring Resident 24 back to bed with a Hoyer Lift. CNA 9 stated when they [CNA 9 and CNA 10] lifted Resident 24, the Hoyer lift sling loops ripped on the right side first and then the left side also ripped. CNA 9 stated Resident 24 fell landed on her heels first and then on her left hip. CNA 9 stated Resident 24 was shouting and complaining of pain on her right side from the knee to her hip. CNA 9 stated at the time of the fall, Resident 24's weight was probably over 400 pounds. CNA 9 stated when he saw the sling afterward after Resident 24's fall, he asked CNA 10 why she chose the blue Hoyer lift sling. CNA 9 stated CNA 10 replied the laundry staff gave her [CNA 10] the Hoyer lift sling because it was the only one available. CNA 9 stated the facility had a mixture of new and old Hoyer lift slings. CNA 9 stated the Hoyer lift sling used on Resident 24 was in was an older one. CNA 9 further stated he was not trained on how to differentiate which Hoyer lift sling was appropriate to use for a resident. CNA 9 further stated he did not check/inspect the integrity of Hoyer lift sling prior to using it on and transferring Resident 24 because it was already on the WC and under Resident 24. During a concurrent interview and observation with CNA 9 on 10/17/2023 at 4:37 PM, the blue Hoyer lift sling CNA 9 and CNA 10 used to transfer Resident 24 was inspected. CNA 9 stated, this was the sling that was in use when Resident 24 fell . CNA 9 stated the Hoyer lift sling did not have a tag/label to guide staff on the maximum weight capacity. CNA 9 further stated the Hoyer lift sling shows areas of wear around the straps (loops) and holes in the sling mesh and would not have used the blue Hoyer lift sling because it would probably drop Resident 24. When asked who maintains the slings, CNA 9 stated, I do not know who is responsible for ordering a new sling but probably maintenance. CNA 9 further stated the facility should check the Hoyer lift slings and change them out more often because a resident could fall which could lead to a fracture and death. During a telephone interview with MNTD on 10/18/2023, MNTD stated he monitors the Hoyer lift device and Hoyer lift slings monthly. MNTD stated most staff verbally communicate with him regarding concerns related to the Hoyer lift slings. MNTD further stated staff need to check the Hoyer lift slings tag/label to beware of weight capacity and look/inspect for any rips prior to using on a resident. MNTD stated the Hoyer lift sling should only be used if the weight capacity is indicated. MNTD stated he removes all Hoyer lift slings without tags and notifies the facility's administration. MNTD further stated laundry staff are not responsible to inspect Hoyer lift slings. MNTD further stated Hoyer lift slings should be inspected prior to use in order to prevent falls. During an interview with Laundry Attendant 1 (LNDRY1) on 10/18/2023 at 9:38 AM, LNDRY1 stated she washes the Hoyer lift slings, air dries them, and checks them to make sure no holes present in sling mesh. LNDRY1 stated Hoyer lift sling cannot be used if they look old. LNDRY1 further stated the nurses requests, visually checks for integrity and for size (small or large). LNDRY1 stated nurses are knowledgeable to determine which Hoyer lift sling is appropriate for a resident. During a telephone interview with CNA 10 on 10/18/2023 at 3:02 PM, CNA 10 stated Resident 24 needed to shower but the Hoyer lift sling that Resident 24 normally uses was not available. CNA 10 stated she went to the laundry room and the laundry attendant told CNA 10 that he only had two Hoyer lift slings. CNA 10 asked for the largest Hoyer sling the laundry attendant had. CNA 10 stated she checked the Hoyer lift sling to make sure it was not ripped. CNA 3 stated she transferred Resident 24 to a WC so Resident 24 could take a shower. CNA 10 stated she asked CNA 9 to assist her transfer Resident 24 back to bed using the Hoyer lift after Resident 24 was done taking a shower. CNA 9 stated as CNA 9 and CNA 10 lifted Resident 24 up and off the WC and forward towards the bed using the Hoyer lift, the right side of the Hoyer lift sling snapped followed by the left side and Resident 24 fell . CNA 10 further stated she checked the sling prior to transferring Resident 24 from the bed to WC but did not recheck the sling before transferring the resident from the WC and to bed. CNA 10 stated the facility trained her how to sit a resident in the Hoyer lift sling and which loops to use. CNA 10 stated, When we have heavy patients, they [patients/residents] would have their own Hoyer lift sling. CNA 10 stated the hoyer lift sling used on Resident 24 was an old sling purchased before 3/2023 by the facility's previous owner. During an interview on 10/18/23 at 4:21 PM, LVN 4 stated she heard Resident 24 and entered Resident 24's room after Resident 24 fell . LVN 4 stated Resident 24 was screaming out in pain and told LVN 4 that she fell from the Hoyer lift. LVN 4 stated the CNAs should inspect Hoyer lift slings for tears before use because tears could lead to the Hoyer lift sling ripping and the patient [resident] could fall and get hurt. During a concurrent interview and inspection with Director of Staff Development (DSD) on 10/20/23 at 9:56 AM, the Hoyer lift sling that was in use when Resident 24 fell , was inspected. The Hoyer lift sling had four straps with three loops per strap. All four straps and loops appeared discolored and frayed exposing thread like material with signs of wear and tear. The second loop on the strap to Resident 24's right leg, completely broke and separated from the sling into two separate pieces. The middle loop on the strap on Resident 24's left leg broke in one side of the strap. DSD stated Resident 24 could not bear weight on her legs and that the Hoyer lift was used for transferring Resident 24 for safety. DSD further stated, the laundry attendant must make sure there is a tag on sling so that they know if it [Hoyer lift sling] is safe. If we do not know the weight capacity of a Hoyer lift sling, then we do not know if it [Hoyer lift sling] is safe to use on the resident. The sling could break if it is not appropriate for the patient [resident]. During a concurrent interview and inspection with the Director of Nursing (DON) on 10/20/23 at 3:01 PM, the blue sling used to transfer Resident 24 when she fell was inspected. The DON stated staff LVN 4 told him that the Hoyer lift sling broke while transferring Resident 24 back to bed after shower because the Hoyer lift sling loops broke. The DON responded, I do not know when asked how old the Hoyer lift sling used on Resident 24 was. The DON also stated the sling could hold 500 to 600 pounds but did not know for sure because the Hoyer lift sling did not have a tag. The DON also stated he did not know the Maintenance Director's process for checking/inspecting the Hoyer lift sling. The DON stated CNAs should not use a Hoyer lift sling, if they do not know how much it can hold because we are dealing with the safety of the resident. During an interview with the Administrator (ADMIN) on 10/22/2023 at 10:41 AM, the ADMIN stated on 10/5/2023, she was told that Resident 24 fell . The ADMIN stated she went to Resident 24's room and saw Resident 24 on the floor and was lying across the legs of Hoyer lift. The ADMIN stated Resident 24 was screaming and saying, everything hurts. ADMIN stated the paramedics went to facility and transferred Resident 24 to a GACH. The ADMIN stated at the time of the fall, Resident 24 weighed around 420 pounds. A review of the facility's P&P titled Falls and Fall Risk, Managing, revised 3/2023, indicated, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident conditions that may contribute to the risk of falls included lower extremity weakness and functional impairments. Medical factors that contribute to the risk of falls included balance and gait disorders., as part of the initial assessment; the licensed nurse will help identify individuals with a history of falls and risk factors for subsequent falling. A review of the facility's P&P titled, Lifting Machine, Using a Mechanical, revised 9/2023, indicated, the purpose of the procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instruction. The staff should measure the resident for proper sling size and purpose, according to the manufacturer's instructions and select a sling bar that is appropriate for the resident's size and the task. A review of the facility's P&P titled, Safe Lifting and Movement of Residents, revised 7/2023, indicated, in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. A review of the facility provided Drive DeVilbiss Health Care's Levantar and Gravis Floor Lifts, instruction manual indicated, Drive DeVilbiss Healthcare recommends regular inspection and maintenance, and the sling should be examined daily for wear or fraying, if any, to not use. To only use Drive DeVilbiss branded slings, always check the sling is suitable for the particular resident and is of the correct size and capacity, never use a sling which is frayed or damage and when the resident is two inches above the lifting surface to check all sling connection points to ensure all are secure. A review of the facility's undated in-service titled, Hoyer Lift Transferring, conducted by DSD, indicated the objective was to understand the proper way of using the Hoyer lift by knowing the process, materials needed and performing with safety precautions to prevent an injury from occurring. The Inservice indicated to seek a second health care worker for assistance if needed, and how to position the resident's bed and how to place the resident into the sling. The in-service had instructions on how to attach the hooks on the strap to the holes in the sling, to ensure the resident's safety. 41511 2. A review of Resident 33's admission record indicated the facility admitted the resident with diagnoses that included stroke affecting the left side of the body and blindness in the right eye. A review of Resident 33's MDS dated [DATE], indicated Resident 33 was cognitively intact. During a concurrent observation and interview on 10/16/2023 at 9:31 AM, Resident 33 was observed in bed and an orange extension cord was extending from an outlet on the wall behind Resident 33's bed to the upper side of the bed rails. The orange extension cord was wrapped around and in between the upper bed side rails and was connected to a rectangular power strip next to Resident 33's right hip. Also observed, was a black fan that was plugged into the power strip along with a cellular phone charger at the foot of Resident 33's bed. Bed linen were observed to be on top of the power strip and fan extension. Resident 33 was asked about the extension cord wrapped around the upper side rails, power strip, and fan and stated, staff does that because I get hot. During a concurrent observation and interview Licensed Vocational Nurse 1 (LVN1) on 10/16/2023 at 9:36 AM, an orange extension cord was extending from an outlet on the wall behind Resident 33's bed to the upper side of the bed rails. The orange extension cord was wrapped around and in between the upper bed side rails and was connected to a rectangular power strip next to Resident 33's right hip. Also observed, was a black fan that was plugged into the power strip along with a cellular phone charger at the foot of Resident 33's bed. Bed linen were observed to be on top of the power strip and fan extension. LVN1 confirmed and stated, not supposed to be like that for safety reasons because of electrical fire and safety hazard . LVN1 stated the orange extension cord, and the rectangular power strip will be removed. During a follow up observation on 10/18/2023 at 10:10 AM, Resident 33's room had an orange extension cord was extending from an outlet on the wall behind Resident 33's bed to the upper side of the bed rails. The orange extension cord was wrapped around and in between the upper bed side rails and was connected to a rectangular power strip next to Resident 33's right hip, and black fan still on the bed on Resident 33's bed. Bed linen were observed to be on top of the power strip and fan extension. During a follow up observation and interview on 10/18/2023 at 10:52 AM, Resident 33's room had an orange extension cord was extending from an outlet on the wall behind Resident 33's bed to the upper side of the bed rails. The orange extension cord was wrapped around and in between the upper bed side rails and was connected to a rectangular power strip next to Resident 33's right hip, and black fan still on the bed on Resident 33's bed. Bed linen were observed to be on top of the power strip and fan extension. When asked about the orange extension cord, power strip, and fan, Certified Nursing Assistant 3 (CNA3) stated, The fan is always there, [Resident 33] wants it there to charge her phone and to plug in all her devices. CNA3 did not know if Resident 33 was allowed to have the orange extension cord, rectangular power strip, and black fan. During a follow up interview on 10/18/2023 at 12:33 PM, LVN1 stated CNA3 informed LVN3 about the interview with the surveyor and the extension cord, power strip, and fan were removed, and maintenance to mount the fan to prevent fall and fire hazards. During an interview on 10/20/2023 at 4:12 PM, the Director of Nursing (DON), stated residents are required to have a power strip that was compliant with safety regulations. The DON stated maintenance should supply residents with power strips that compliant with safety regulations. The DON stated Resident 33's fan will be placed on a table to prevent fire hazards. A review of a facility's P&P titled Maintenance Service dated 12/2022, indicated, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The policy indicated functions of the maintenance director included but were not limited to Maintaining the building in good repair and free from hazards. A review of a facility's P&P titled Fire and Safety Prevention dated 12/2022, indicated 1. Fire prevention is the responsibility of all personnel, residents, visitors, and the general public. 2. Whoever identifies a fire hazard. or other conditions that could develop into a fire hazard, must report the situation to the department director or Maintenance Director as soon as practical.

Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was diagnosed with hemiplegia (paralysis of one side of the body), and reduced mobility, received two or more-person physical assistance with transfer, per the comprehensive assessment. Resident 1 was solely transferred from wheelchair to bed by Certified Nursing Assistant 1 (CNA) on 8/18/2023. This deficient practice caused Resident 1 to complain of severe pain to the right leg on 8/18/2023, requiring transfer to the general acute care hospital (GACH) 1 where Resident 1 was diagnosed with a distal femoral fracture (break in thigh bone just above the knee joint) and treated with a soft cast. Resident 1 complained of unrelieved pain, was transferred to GACH 2 and underwent an open reduction and internal fixation (ORIF, a type of surgery used to stabilize and repair broken bones, using screws, plates, sutures, or rods to hold the bone together so it can heal) on 8/27/2023. Findings: A review of the Admission Record indicated the facility admitted Resident 1 on 6/22/2020 with diagnoses including hemiplegia and hemiparesis (paralysis of one side of the body and partial paralysis of one side of the body) following cerebral infarction (blood supply to the part of the brain was interrupted or reduced), and reduced mobility. A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 7/19/2023 indicated Resident 1 had unclear speech, difficulty communicating some words or finishing thoughts, but was able, if prompted or given time. Resident 1 comprehends most conversations and had adequate hearing and vision. The MDS indicated Resident 1 needed one-person physical assistance with bed mobility, dressing, toilet use, personal hygiene, or bathing and required two or more persons physical assistance with transfer. The MDS further indicated Resident 1 was not steady during transfer between bed and chair or between bed and wheelchair, but able to stabilize with staff assistance. According to a review of the Quarterly Nursing Risks Evaluation / Assessments dated 7/19/2023, Resident 1 needed two or more persons with bed mobility and needed two-person physical assistance during transfers. A review of the osteoporosis (a bone disease where bones become weak and brittle) Care Plan revised on 8/3/2023 indicated Resident 1 was at risk for injuries, pathological fracture (occurs to areas of weakened bone caused by an underlying disease), and pain. The care plan goal indicated Resident 1 will remain free of injuries or complications related to osteoporosis through the review date. Further review of the care plan indicated there were no interventions included to prevent injury during transfer or to prevent accidents as a facility-wide priority. A review of the activities of daily living (ADLs, skills required to independently care for oneself such as eating, bathing and mobility) care plan initiated on 9/2/2022 and revised on 8/3/2023 indicated Resident 1 had a self-care deficit related to impaired balance and right-side weakness. The care plan goal indicated Resident 1 will maintain current level of function through the review date. The care plan interventions indicated Resident 1 required total assistance by two staff to move between surfaces (transferring from chair to bed). A review of the Situation Background Assessment or Appearance and Request (SBAR) dated 8/18/2023 at 1:30 p.m., indicated the situation was Resident 1 complained of right knee pain due to transfer from wheelchair back to bed after physical therapy. The SBAR indicated Licensed Vocational Nurse (LVN) 2 heard Resident 1 yelling out in pain and upon entering the room Resident 1 pointed to her right leg. LVN 2 attempted to readjust the right leg and Resident 1 cried out in pain. The SBAR indicated Resident 1 tried to explain how she hit her knee when CNA 1 transferred the resident from wheelchair back to bed after physical therapy. During assessment of Resident 1's right knee there was no signs of redness, warmth, or tenderness, but had a bump on the knee. The primary physician was notified and gave an order for x-ray of the right knee. The SBAR indicated Resident 1 was given Tylenol Extra Strength (medication for pain) 500 milligrams (mg., unit of measurement) two tablets for pain, with relief. According to a review of the Radiology Report (provides a translation of images into words) dated 8/18/2023, Resident 1 had an impacted fracture (break in the bones that occurred when one fragment of the bone is driven into a second piece of bone) of the distal femur (thigh bone just above the knee joint). A review of the Progress Notes dated 8/18/2023 indicated Resident 1's primary physician was notified of the Xray result and gave an order to transfer Resident 1 to GACH 1 for evaluation. A review of the Progress Notes dated 8/19/2023 at 1:14 a.m., indicated Resident 1 left the facility at 12:51 a.m. by ambulance. A review of the GACH 1 Emergency (ED) Provider Notes dated 8/19/2023 at 8:15 a.m. indicated Resident 1 was admitted to the GACH with severe pain in the right leg. The ED examination indicated Resident 1's right leg was swollen and externally rotated (when the thigh and the knee rotate outward, away from the body). A review of GACH 1's x-ray of Resident 1's right femur dated 8/19/2023 indicated a distal femoral fracture. A review of the Admission Notes dated 8/20/2023 at 2:54 p.m., indicated the facility readmitted Resident 1 from GACH 1 with diagnoses including closed fracture (bones push up against the skin but do not [NAME] the skin) of the right femur. The Admission Notes indicated Resident 1 had a soft splint (material or device used to protect and immobilize a body part) on the right leg. Resident 1 did not have surgery. A review of the SBAR dated 8/22/2023 at 11:53 a.m., indicated the situation was Resident 1 had a right distal femur fracture and complained of unrelieved pain with current pain medication. The SBAR indicated the soft splint on Resident 1's right leg required re-evaluation and a more appropriate device with possible placement of hard cast. Pain management evaluated Resident 1 and gave an order for Norco (opioid medication for moderate to severe pain) every four hours. The SBAR indicated the primary physician was notified and gave order to transfer Resident 1 to GACH 2. A review of the GACH 2 Operative Note dated 8/27/2023 indicated Resident 1 had an open reduction and internal fixation (ORIF) of the supracondylar fracture (a break in the femur at the knee joint) of the right femur. A review of the Admission Notes dated 8/29/2023 indicated the facility readmitted Resident 1 from GACH 2. During an observation and concurrent interview on 8/30/2023 at 8:38 a.m., Resident 1 was lying in bed, with a cast and long brace on the right leg. Resident 1 stated she hurt herself during transfer from wheelchair to bed. Resident 1 pointed to her right knee indicating she had pain. During an interview on 8/30/2023 at 9:10 a.m., the MDS was reviewed with LVN 1, who stated and confirmed Resident 1 needed two or more persons for transfer to prevent injury to the resident. LVN 1 stated Resident 1 had a fracture after CNA 1 transferred Resident 1 by herself. During a concurrent interview and record review on 8/30/2023 at 12:52 p.m., Resident 1's ADL self-care deficit care plan revised on 8/3/2023 was reviewed with the director of nursing (DON). The DON stated Resident 1's care plan indicated the resident needed two persons for transfer. The DON stated Resident 1 may have hit her knee against the wheelchair when CNA 1 solely transferred Resident 1 from the wheelchair to the bed on 8/18/2023. The DON stated if two people were not assisting the resident, an accident may occur. The DON stated Resident 1, Had osteoporosis and a single snap or hitting of an object may trigger a fracture. During a telephone interview on 8/30/2023 at 5:30 p.m., certified nursing assistant (CNA 1) stated on 8/18/2023 at about 2 p.m., she solely transferred Resident 1 from wheelchair to bed. CNA 1 stated after transfer to bed, Resident 1 turned to her right side and complained of pain on the right leg. CNA 1 stated she could transfer Resident 1 by herself with no assistance. She is not a heavy patient. CNA 1 then stated LVN 2 provided Resident 1 with pain medication. A review of the facility policy titled, Safety and Supervision of Residents, revised on 1/2021, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents were facility-wide priorities. The same policy indicated the Interdisciplinary care team (IDT) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision and assistive device. Implementing interventions to reduce accident risks and hazards shall include ensuring that interventions were implemented.

Based on interview and record review, the facility failed to permit one of two sampled (Resident 2) to remain in the facility and not transfer or discharge him unless the transfer / discharge was necessary and appropriate. The facility failed to: 1. Ensure the reason for discharging Resident 2 was because of one of the following: the resident's welfare and the resident's needs could not be met in the facility; his care needs could not be met at the facility, his health had improved and no longer needed the services provided by the facility, for the safety of individuals in the facility due to Resident 2's clinical or behavioral status, because of Resident 2's lack of payment, or because the facility ceased operation. 2. Ensure the attending physician (Physician 1) documented in Resident 2's clinical record the basis of the transfer / discharge. 3. Ensure Resident 2 was not transferred while an appeal hearing was pending. 4. Provide and document sufficient preparation and orientation to Resident 2 for a safe and orderly transfer or discharge from the facility. On 6/5/2023, the facility found out that Board and Care #2 (B&C, a lower level of care senior living facility licensed to care for residents who need some assistance with activities of daily living [ADLs, such as eating, walking, transfer, dressing, and bathing] but do not provide medical or nursing care), was accepting Resident 2 and proceeded to transfer him the following day, on 6/6/2023. As a result, Resident 2 developed untreated severe pain requiring B&C #2 staff to transfer Resident 2 to General Acute Care Hospital 1 (GACH 1) on 6/11/2023, five days after leaving the facility. Resident 2 was admitted to GACH 1, the same day, due to right lower leg wound infection and fever requiring intravenous (IV - through the vein) antibiotic (medication to fight bacterial infections) and IV Morphine (a narcotic medication [moderate doses dull the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions]. Cross Reference: F623, F624 Findings: A review of Resident 2's Admission Record indicated the facility admitted the resident, a [AGE] year-old male, on 11/23/2022 with diagnoses including paraplegia (paralysis [inability to move] of the lower half of the body including both legs), diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]), polyneuropathy (a condition in which a person's peripheral nerves [outside the brain and spinal cord] are damaged; it affects the nerves in the skin, muscles, and organs), hypertension (abnormally elevated blood pressure), a right lower leg cellulitis (a bacterial [group of single-cell microorganisms] infection, bacteria enter the skin and tissue through a wound and the treatment includes antibiotics; without treatment it can be life-threatening), and unhealed left ischium (the lower part of the hip bone that supports a person while sitting, sometimes referred as the sit bone) pressure ulcer (a skin and soft tissue injury that forms as a result of constant or prolonged pressure exerted on the skin over bony areas) Stage IV (deep wound penetrates all three layers of skin, exposing muscles, tendons, and bones). A review of Resident 2's History and Physical exam dated 12/16/2022, indicated the resident had the capacity to understand and make decisions. A review of the Physician's Orders for Resident 2, dated 12/16/2022 and clarified on 4/11/2023, indicated to provide daily indwelling urinary catheter (a soft tubing inserted into the bladder draining urine into a bag outside the body) care; change the catheter and drainage bag if dislodge or malfunction; monitor for signs and symptoms of (urinary) infection every shift; monitor for pain; and irrigate with 30 to 60 milliliters (ml - unit of measure) as needed for heavy sediments (minerals in the urine) or blockage. A review of the Physician's Order for Resident 2, dated 12/22/2022, indicated the use of a low air loss mattress (LALM, an air mattress covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) for wound management, check placement, functioning, and settings every shift. A review of the Physician's Order for Resident 2, dated 12/27/2022, indicated to monitor the resident for pain before and after wound treatment. A review of the Physician's Order for Resident 2, dated 1/19/2023, indicated to give gabapentin (medication used for nerve pain, which can be caused by different conditions after an injury) 300 milligrams (mg) one capsule by mouth four times a day for neuropathic pain (happens when the nervous system is damaged or not working correctly). A review of the Physician's Order for Resident 2, dated 3/2/2023, indicated to give nortriptyline (medication used for nerve pain) 25 mg by mouth every night. A review of the form Notice of Transfer / Discharge to Resident 2 with notification date of 5/3/2023, indicated the resident was self-responsible and the effective date of discharge was 6/6/2023 to B&C #2 (this date and the specific B&C were not known on 5/3/2023). The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. The Notice also indicated that per the resident's request, as another reason for discharge which was handwritten on the notice. A review of the form Notice of Proposed Transfer and Discharge to Resident 2 dated and signed by a facility representative on 5/10/2023 and hand-delivered to the resident, who did not sign the form, indicated a discharge effective date of 6/9/2023 to B&C #1. The reasons for discharge were: - The discharge is necessary for your welfare and your need cannot be met in the facility. - The safety of individual in the facility is endangered by your presence. - The health of individuals in the facility is endangered by your presence. A review of the Physician's Progress Notes for Resident 2 before or on 5/3/2023 and 5/10/2023 (dates of the transfer / discharge notices) indicated no documentation justifying the need to transfer / discharge Resident 2. A review of Resident 2's Progress Notes, dated 5/24/2023, by the Interdisciplinary team (IDT, group of healthcare professionals from different disciplines who participate in the care of the resident), indicated a 30-day Notice follow-up which was initially due to violation of the facility's policy on no illicit drugs or alcohol use. The note indicated Suddenly requested a copy of the 30-day notice issued originally which he crumbled and threw away, provided with the original notice as requested. Resident 2 stated he contacted a Center to assist him with placement and was told the facility would assist him with a safe placement. A review of Resident 2's Progress Notes, dated 5/25/2023, indicated the Social Services Director (SSD) coordinated with Social Services Assistant (SSA) to assist Resident 2 looking for an Assisted Living Facility (ALF). A review of the Physician's Order for Resident 2, dated 5/25/2023, indicated to provide daily treatment to the right lower leg cellulitis, cleansing with normal saline (it is a mixture of salt and water), apply hydrogel dressing (a special dressing that absorbs wound discharge), and cover with a foam dressing. A review of Resident 2's most recent Quarterly Minimum Data Set (MDS, a standardized assessment and care-screening tool) was dated 5/28/2023. The MDS indicated the resident was able to communicate, remember, comprehend, and make decisions. Resident 2 did not have mood or behavior problems. Resident 2 was unable to walk and needed extensive assistance with one-person physical assist with bed mobility, dressing, toilet use, personal hygiene, and bathing. Resident 2 could move around using a wheelchair (locomotion) with supervision. The MDS Section for Discharge Plan indicated there was no active discharge planning for the resident to return to the community. For the MDS question Do you want to talk to someone about possibility of leaving this facility and returning to live and receive services in the community? Resident 2's response was documented as No. A review of the Physician's Progress Notes for Resident 2 dated 5/31/2023 by the resident's attending physician, indicated the resident was seen and explained the plan was to discharge him to another SNF or a lower level of care facility that accepted wound treatment. The Progress Note indicated Resident 2 should not be located near a liquor store due to alcohol abuse. Transfer the resident to a safe facility where illicit drugs transactions are not occurring or available due to the resident having illegal drugs. This is for safety of this resident and other surrounding residents. Physician 1 did not document why the needs of Resident 2 could not met at the facility. A review of Resident 2's Plan of Care for the months of 4/2023, 5/2023, and 6/2023, indicated no active plan to discharge the resident to another Skilled Nursing Facility (SNF) or to a lower level of care setting and no care plan addressing Resident 2's behavior of using drugs or alcohol. A review of Resident 2's Progress Notes dated 6/5/2023 and timed at 4:16 p.m., the SSA documented she provided the resident with another location: B&C #2, for possible discharge the same day (6/5/2023) and Resident 2 expressed he would like to be discharged as soon as possible. The SSA did not indicate checking B&C #2 was not close to a liquor store or to an area where illegal drugs were sold as Resident 2's attending physician had recommended on 5/31/2023, for Resident 2's safety. A review of the Physician's Order for Resident 2, dated 6/5/2023 and timed at 4:37 p.m., indicated to discharge the resident to B&C #2 with medications and on hospice care. The hospice agency name, a contact person and a contact number were not included. A review of the Physician's Progress Notes for Resident 2 did not include the physician had evaluated Resident 2 as eligible to receive hospice care (which include terminal illness and life expectancy less than six month) and that the physician had explained to Resident 2 the benefits of hospice care or that the resident understood and consented to receive hospice care. A review of the Physician's Order for Resident 2, dated 6/6/2023, timed at 10:04 a.m., indicated the resident would be discharged to B&C #2 on 6/6/2023 at 12:30 p.m. A review of Resident 2's undated Discharge Summary, signed by an IDT staff and not signed by Resident 2's attending physician, indicated the resident's stay in the facility was from 11/23/2022 to 6/6/2023. In the section for Recapitulation of the Resident's Stay, it was documented the resident was admitted for rehabilitation, antibiotic therapy, and pain, wound, medication management. In the section for Transfer / Discharge was Necessary Due To, it was indicated the discharge was per resident's request. A review of GACH 1's Nursing Narrative Note for Resident 2, dated 6/11/2023, indicated Resident 2 was received from B&C #2 facility due to right lower leg wound infection and fever. Resident 2 required an IV antibiotic to treat the infection and IV Morphine for pain. A review of the document from the Department of Health Care Services Office of Administrative Hearings and Appeal indicated that on 5/24/2023, the Office of Administrative Hearings and Appeal received a request for hearing from Resident 2 concerning the facility's determination to involuntarily transfer or discharge the resident. The hearing was scheduled to be conducted as a teleconference on 6/8/2023 at 1 p.m. The document indicated under Notice of Rights that the facility may not involuntarily transfer or discharge the resident while this appeal is pending unless the failure to transfer or discharge would endanger the health or safety of the resident or other individuals in the facility. On 6/12/2023, at 2:29 p.m., during a telephone interview with Resident 2, who was still at GACH 1, he stated, The facility discharged me as quick as possible from over there. Resident 2 stated he did not request to be discharged from the facility and had a pending appeal hearing. On 6/13/2023, at 11:25 a.m., during an interview, LVN 1 stated Resident 2 showed LVN 1 the Transfer / Discharge Notice (LVN did not remember the date) because Resident 2 did not understand it. LVN 1 explained the form to Resident 2 and that he (Resident 2) had 10 days to appeal. LVN 1 stated Resident 2 told him (no date specified) he had appealed but did not know the date of the hearing. On 6/13/2023, at 11:54 a.m., during an interview, the SSA stated Resident 2 received the 30-day Notice of Transfer / Discharge on 5/10/2023 and the resident refused to sign it. SSA stated she helped Resident 2 looking for places to move in all areas and she started sending out referrals (to other facilities) on 6/1/2023. On 6/14/2023 at 10:59 a.m., during an interview, the SSA stated it was the facility's duty to ensure Resident 2 was discharged somewhere safe and appropriate and she did this by relying on the word of the placement agency. On 6/14/2023 at 12:24 p.m., during an interview, Quality Assurance (QA) nurse stated Resident 2's Notice of Transfer / Discharge was dated 5/3/2023, when the resident requested to go to an ALF and the Notice was completed on 6/6/2023. This form was given Resident 2 on 6/6/2023, the day he was discharged . The original is with the patient and the copies stay with the facility. The QA stated she did not tell Resident 2 had the right to stay in the facility while the discharge was pending because I did not know about the appeal. I only know about the 30-day Notice because it was told to us in the Stand-Up meeting. On 6/14/2023 at 12:59 p.m., during an interview, the SSD stated the protocol for transfer / discharge of residents was First, we see to it that the patient is ok. We notify the doctor to get the discharge order. Then we start looking for a place for the patient. If he is accepted, we let the resident know about it and if the resident accepts that location, we get the final discharge order. The SSD also stated she was aware Resident 2 had a discharge appeal hearing but she did not know the date. On 6/14/2023 at 2:20 p.m., during an interview, the Director of Nursing (DON) stated Resident 2 was provided a 30-day notice on 5/10/2023. When asked about Resident 2's transfer / discharge appeal hearing, the DON stated the Administrator receives the appeal hearing notices. The DON stated, I know he had an appeal date, but he was discharged so the appeal did not take place. We contacted the appeals department to let them know Resident 2 was discharged and where he discharged to. The DON stated Resident 2 was discharged pending an appeal because he requested to be discharged . On 6/14/2023 at 2:58 p.m., during a telephone interview, the Administrator stated Resident 2 was discharged despite having the appeal hearing pending because he did not want to fight the discharge. Resident 2 said he appealed so that he could buy time. The Administrator said Resident 2 went to a couple of places and he finally found a place that he fell in love with and he wanted to go immediately the next day. On 6/28/2023, at 12:19 p.m., during a telephone interview, Physician 1 stated Resident 2 needed to be in a facility where the resident did not have a liquor store and drug dealing nearby and where he could receive wound care. On 6/30/2023, at 11:37 a.m., during a telephone interview, Ombudsman 1 stated the office did not get notification from the facility of a facility-initiated discharge transfer. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge with the reasons for the discharge, the effective date of the discharge and the location to which the resident was discharged . A copy of the Notice is sent to the Office of the State Long-Term Care Ombudsman. A review of the facility's P&P titled, Discharging the Resident, reviewed 1/2022, indicated the facility will educate the resident on who will be providing the resident's care after discharge. It also indicated facility-initiated discharges will include on the assessment consideration of discharge timeframes - in terms of what was safest and in the best interest of the patient - evaluating medical necessity, family and patient preference and desires, appropriateness of the discharge, resources available at the time of discharge, and ultimately the order of the physician. The policy indicated discharges can be frightening to the resident and to approach the discharge in a positive manner. A review of the facility's policy and procedure titled, Transfer or Discharge, Preparing a Resident for, revised 12/2016, indicated residents will be prepared in advance for discharge.

This is a repeat deficiency from the complaint investigation dated 6/13/23. Based on interview and record review, for one of two sampled residents (Resident 2) the facility failed to ensure: 1. Resident 2 was notified at least 30 days before the resident was transferred or discharged and the reasons for the move in writing and in a manner the resident understands. 2. The notice included the effective date of the discharge and the location to which the resident was discharged . 3. A copy of the facility-initiated notice was sent to a representative of the Office of the State Long-Term Care Ombudsman (residents' advocate group). On 5/3/2023, the facility issued a Notice of Discharge to Resident 2 without an effective date and a location since it was not until 6/5/2023 at 4:16 p.m. that the facility found out Board and Care #2 (B&C, a lower level of care senior living facility licensed to care for residents who need some assistance with activities of daily living [ADLs, such as eating, walking, transfer, dressing, and bathing] but do not provide medical or nursing care) was accepting Resident 2's admission. The facility proceeded to transfer Resident 2 the following day (6/6/2023) at noon, in less than 24 hours without ensuring B&C #2 could meet Resident 2's care needs, and without affording enough time for Resident 2 to make an informed decision to consent to the transfer and without allowing the Ombudsman Program to assist Resident 2 with his discharge / transfer rights. As a result, Resident 2 was discharged hurriedly and on 6/11/2023, five days after discharge from the facility, Resident 2's condition deteriorated and B&C #2 staff sent the Resident 2 to General Acute Care Hospital 1 (GACH 1), where he was admitted due to right lower leg wound infection and fever requiring intravenous (IV - through the vein) antibiotic (medication to fight bacterial infections) and IV Morphine (a narcotic medication [moderate doses dull the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions]. Cross Reference: F622, 624 Findings: A review of Resident 2's Admission Record indicated the facility admitted the resident, a [AGE] year-old male, on 11/23/2022 with diagnoses including paraplegia (paralysis [inability to move] of the lower half of the body including both legs), diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]), polyneuropathy (a condition in which a person's peripheral nerves [outside the brain and spinal cord] are damaged; it affects the nerves in the skin, muscles, and organs), hypertension (abnormally elevated blood pressure), a right lower leg cellulitis (a bacterial [group of single-cell microorganisms] infection, bacteria enter the skin and tissue through a wound and the treatment includes antibiotics; without treatment it can be life-threatening), and unhealed left ischium (the lower part of the hip bone that supports a person while sitting, sometimes referred as the sit bone) pressure ulcer (a skin and soft tissue injury that forms as a result of constant or prolonged pressure exerted on the skin over bony areas) Stage IV (deep wound penetrates all three layers of skin, exposing muscles, tendons, and bones). A review of Resident 2's History and Physical exam dated 12/16/2022, indicated the resident had the capacity to understand and make decisions. A review of the Physician's Order for Resident 2, dated 12/27/2022, indicated to monitor the resident for pain before and after wound treatment. A review of the form Notice of Transfer / Discharge to Resident 2, with a notification date of 5/3/2023, indicated Resident 2 was self-responsible and the effective date of discharge was 6/6/2023 to B&C #2 (the specific B&C were not known on 5/3/2023). The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. A handwritten note as another reason for discharge was per resident's request. A review of the form Notice of Proposed Transfer and Discharge to Resident 2 dated and signed by a facility representative on 5/10/2023 and hand-delivered to the resident, who did not sign the form, indicated a discharge effective date of 6/9/2023 to B&C #1. The reasons for discharge were: - The discharge is necessary for your welfare and your need cannot be met in the facility. - The safety of individual in the facility is endangered by your presence. - The health of individuals in the facility is endangered by your presence. A review of Resident 2's Progress Notes, dated 5/24/2023, by the Interdisciplinary team (IDT, group of healthcare professionals from different disciplines who participate in the care of the resident), indicated, A 30-day Notice follow-up which was initially due to violation, of the facility's policy on no illicit drugs or alcohol use. The note indicated, Suddenly requested a copy of the 30-day notice issued originally, which he crumbled and threw away, was provided with the original notice as requested. The Progress Note indicated Resident 2 stated he contacted a Center to assist him with placement and was told the facility would assist him with a safe placement. A review of Resident 2's Progress Notes, dated 5/25/2023, indicated the Social Services Director (SSD) coordinated with Social Services Assistant (SSA) to assist Resident 2 looking for an Assisted Living Facility (ALF). A review of Resident 2's most recent Quarterly Minimum Data Set (MDS, a standardized assessment and care-screening tool) was dated 5/28/2023. The MDS indicated the resident was able to communicate, remember, comprehend, and make decisions. Resident 2 did not have mood or behavior problems. Resident 2 was unable to walk and needed extensive assistance with one-person physical assist with bed mobility, dressing, toilet use, personal hygiene, and bathing. Resident 2 could move around using a wheelchair (locomotion) with supervision. The MDS Section for Discharge Plan indicated there was no active discharge planning for the resident to return to the community. For the MDS question Do you want to talk to someone about possibility of leaving this facility and returning to live and receive services in the community? Resident 2's response was documented as No. A review of the Physician's Progress Notes for Resident 2 dated 5/31/2023 by the resident's attending physician, indicated the resident was seen and discussed the plan was to discharge him to another facility or a lower level of care facility that accepted wound treatment. Resident 2 should not be located near a liquor store due to alcohol abuse. Transfer the resident to a safe facility where illicit drugs transactions are not occurring or available due to the resident having illegal drugs. This is for safety of this resident and other surrounding residents. A review of Resident 2's Plan of Care for the months of 4/2023, 5/2023, and 6/2023, indicated no active plan to discharge the resident to another Skilled Nursing Facility (SNF) or to a lower level of care setting and there was no care plan addressing Resident 2's behavior of using drugs or alcohol. A review of Resident 2's Progress Notes dated 6/1/2023, the SSA documented she had faxed transfer referrals to three SNF and one assisted living facility (ALF). According to a review of Resident 2's Progress Notes dated 6/1/2023, documented by the SSA, the SSA and Resident 2 went to ALF #1 but were told they could not accept him because of the wounds. A review of Resident 2's Progress Notes dated 6/5/2023 and timed at 4:16 p.m., the SSA documented she provided the resident with another location: B&C #2, for possible discharge the same day (6/5/2023) and Resident 2 expressed he would like to be discharged as soon as possible. The SSA did not indicate checking that B&C #2 was not close to a liquor store or to an area where illegal drugs were sold as Resident 2's attending physician had recommended on 5/31/2023, for Resident 2's safety. A review of the Physician's Order for Resident 2, dated 6/5/2023 and timed at 4:37 p.m., indicated to discharge the resident to B&C #2 with medications and on hospice care. A review of Resident 2's Progress Notes for 6/5/2023 and 6/6/2023 did not include documentation Resident 2 was explained and understood the services provided by the B&C. The documentation did not indicate B&C #2 was informed about Resident 2's alcohol and illegal drug use. A review of the Physician's Order for Resident 2, dated 6/6/2023, timed at 10:04 a.m., indicated the resident would be discharged to B&C #2 on 6/6/2023 at 12:30 p.m. with medications and on hospice care. The hospice agency name, a contact person and a contact number were not included. A review of GACH 1's Nursing Narrative Note for Resident 2, dated 6/11/2023, indicated Resident 2 was received from B&C #2 facility due to right lower leg wound infection and fever. Resident 2 was admitted to GACH 1 because he required an IV antibiotic to treat the infection and IV Morphine for pain. On 6/12/2023, at 2:29 p.m., during a telephone interview with Resident 2, who remained at GACH 1, he stated, The facility discharged me as quick as possible from over there. Resident 2 stated he did not request to be discharged from the facility. On 6/13/2023, at 11:25 a.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated Resident 2 showed LVN 1 the Transfer / Discharge Notice (LVN did not remember the date) because Resident 2 did not understand it. LVN 1 explained the form to Resident 2 and that he (Resident 2) had 10 days to appeal. LVN 1 stated Resident 2 told him (no date specified) he had appealed but did not know the date of the hearing. On 6/13/2023, at 11:54 a.m., during and interview, the SSA stated Resident 2 received the 30-day Notice of Transfer / Discharge on 5/10/2023 and the resident refused to sign it. The SSA stated she helped Resident 2 look for places to move in all areas and she started sending out referrals (to other facilities) on 6/1/2023. On 6/14/2023 at 12:24 p.m., during an interview, the Quality Assurance (QA) nurse stated Resident 2's Notice of Transfer / Discharge was dated 5/3/2023, when the resident requested to go to an ALF and the Notice was completed on 6/6/2023. This form was given to Resident 2 on 6/6/2023, the day he was discharged . The original was with the patient and the copies stay with the facility. The QA stated she did not tell Resident 2 he had the right to stay in the facility while the discharge was pending because, I did not know about the appeal. I only know about the 30-day Notice because it was told to us in the Stand-Up meeting. On 6/14/2023 at 12:59 p.m., during an interview, the SSD stated the protocol for transfer / discharge of residents was, First, we see to it that the patient is ok. We notify the doctor to get the discharge order. Then we start looking for a place for the patient. If he is accepted, we let the resident know about it and if the resident accepts that location, we get the final discharge order. The SSD also stated she was aware Resident 2 had a discharge appeal hearing but she did not know the date. On 6/14/2023 at 2:20 p.m., during an interview, the Director of Nursing (DON) stated Resident 2 was provided a 30-day notice on 5/10/2023. On 6/14/2023 at 2:58 p.m., during a telephone interview, the Administrator stated Resident 2 went to a couple of places and he finally found a place that he fell in love with and he wanted to go immediately the next day. On 6/28/2023, at 12:19 p.m., during a telephone interview, Resident 2's attending physician (Physician 1) stated Resident 2 needed to be in a facility where the resident did not have a liquor store and drug dealing nearby and where he could receive wound care. On 6/30/2023, at 11:37 a.m., during a telephone interview, Ombudsman 1 stated the office did not get notification from the facility of Resident 2's facility-initiated transfer / discharge. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge with the reasons for the discharge, the effective date of the discharge and the location to which the resident was discharged . A copy of the Notice is sent to the Office of the State Long-Term Care Ombudsman.

Based on interview and record review, the facility failed to provide sufficient preparation to ensure a safe discharge for one of two sampled residents (Resident 2), who had an unhealed left ischium (the lower part of the hip bone that supports a person while sitting, sometimes referred as the sit bone) pressure ulcer (a skin and soft tissue injury that forms as a result of constant or prolonged pressure exerted on the skin over bony areas) Stage IV (deep wound penetrates all three layers of skin, exposing muscles, tendons, and bones) and had a right lower leg cellulitis (a bacterial [group of single-cell microorganisms] infection, bacteria enter the skin and tissue through a wound and the treatment includes antibiotics; without treatment it can be life-threatening). On 6/6/2023, the facility discharged Resident 2 to a lower level of care, a Board and Care facility (B&C, a senior living facility licensed to care for residents who need some assistance with activities of daily living [ADLs, such as eating, walking, transfer, dressing, and bathing], but do not provide medical or nursing care), where Resident 2's medical and nursing needs could not be met. As a result, Resident 2 developed untreated severe pain requiring the B&C staff to transfer Resident 2 to General Acute Care Hospital 1 (GACH 1) on 6/11/2023, five days after leaving the facility. Resident 2 was admitted to GACH 1, the same day, due to right lower leg wound infection and fever requiring intravenous (IV - through the vein) antibiotic (medication to fight bacterial infections) and IV Morphine (a narcotic medication [moderate doses dull the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions]. Cross Reference: F622, F623 Findings: A review of Resident 2's Admission Record indicated the facility admitted the resident, a [AGE] year-old male, on 11/23/2022 with diagnoses including paraplegia (paralysis [inability to move] of the lower half of the body including both legs), diabetes mellitus (group of diseases that result in too much sugar in the blood [high blood glucose]), polyneuropathy (a condition in which a person's peripheral nerves [outside the brain and spinal cord] are damaged; it affects the nerves in the skin, muscles, and organs), hypertension (abnormally elevated blood pressure), right lower leg cellulitis, and Stage IV pressure ulcer to the left ischium. Resident 2 was responsible for himself. A review of Resident 2's History and Physical exam dated 12/16/2022, indicated the resident had the capacity to understand and make decisions. A review of the Physician's Orders for Resident 2, dated 12/16/2022 and clarified on 4/11/2023, indicated to provide daily indwelling urinary catheter (a soft tubing inserted into the bladder draining urine into a bag outside the body) care; change the catheter and drainage bag if dislodge or malfunction; monitor for signs and symptoms of (urinary) infection every shift; monitor for pain; and irrigate with 30 to 60 milliliters (ml - unit of measure) as needed for heavy sediments (minerals in the urine) or blockage. A review of the Physician's Order for Resident 2, dated 12/22/2022, indicated the use of a low air loss mattress (LALM, an air mattress covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) for wound management, check placement, functioning, and settings every shift. A review of the Physician's Order for Resident 2, dated 12/27/2022, indicated to monitor the resident for pain before and after wound treatment. A review of the Physician's Order for Resident 2, dated 1/19/2023, indicated to give gabapentin (medication used for nerve pain, which can be caused by different conditions after an injury) 300 milligrams (mg) one capsule by mouth four times a day for neuropathic pain (happens when the nervous system is damaged or not working correctly). A review of the Physician's Order for Resident 2, dated 3/2/2023, indicated to give nortriptyline (medication used for nerve pain) 25 mg by mouth every night. A review of the form Notice of Transfer / Discharge to Resident 2 with notification date of 5/3/2023, indicated the resident was self-responsible and the effective date of discharge was 6/6/2023 to B&C #2 (this date and the specific B&C were not known on 5/3/2023). The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. A handwritten note as another reason for discharge was per resident's request. A review of the form Notice of Proposed Transfer and Discharge to Resident 2 dated and signed by a facility representative on 5/10/2023 and hand-delivered to the resident, who did not sign the form, indicated a discharge effective date of 6/9/2023 to B&C #1. The reasons for discharge were: - The discharge is necessary for your welfare and your need cannot be met in the facility. - The safety of individual in the facility is endangered by your presence. - The health of individuals in the facility is endangered by your presence. A review of Resident 2's Progress Notes, dated 5/24/2023, by the Interdisciplinary team (IDT, group of healthcare professionals from different disciplines who participate in the care of the resident), indicated a 30-day Notice follow-up which was initially due to violation of the facility's policy on no illicit drugs or alcohol use. The note indicated Suddenly requested a copy of the 30-day notice issued originally which he crumbled and threw away, provided with the original notice as requested. Resident 2 stated he contacted a Center to assist him with placement and was told the facility would assist him with a safe placement. A review of Resident 2's Progress Notes, dated 5/25/2023, indicated the Social Services Director (SSD) coordinated with Social Services Assistant (SSA) to assist Resident 2 looking for an Assisted Living Facility (ALF). A review of the Physician's Order for Resident 2, dated 5/25/2023, indicated to provide daily treatment to the right lower leg cellulitis, cleansing with normal saline (it is a mixture of salt and water), apply hydrogel dressing (a special dressing that absorbs wound discharge), and cover with a foam dressing. A review of Resident 2's most recent Quarterly Minimum Data Set (MDS, a standardized assessment and care-screening tool) was dated 5/28/2023. The MDS indicated the resident was able to communicate, remember, comprehend, and make decisions. Resident 2 did not have mood or behavior problems. Resident 2 was unable to walk and needed extensive assistance with one-person physical assist with bed mobility, dressing, toilet use, personal hygiene, and bathing. Resident 2 could move around using a wheelchair (locomotion) with supervision. The MDS Section for Discharge Plan indicated there was no active discharge planning for the resident to return to the community. For the MDS question Do you want to talk to someone about possibility of leaving this facility and returning to live and receive services in the community? Resident 2's response was documented as No. A review of the Physician's Progress Notes for Resident 2 dated 5/31/2023 by the resident's attending physician, indicated the resident was seen and explained the plan was to discharge him to another SNF or a lower level of care facility that accepted wound treatment. Resident 2 should not be located near a liquor store due to alcohol abuse. Transfer the resident to a safe facility where illicit drugs transactions are not occurring or available due to the resident having illegal drugs. This is for safety of this resident and other surrounding residents. A review of Resident 2's Plan of Care for the months of 4/2023, 5/2023, and 6/2023, indicated no active plan to discharge the resident to another Skilled Nursing Facility (SNF) or to a lower level of care setting and no care plan addressing Resident 2's behavior of using drugs or alcohol. A review of Resident 2's Progress Notes dated 6/1/2023, the SSA documented she had faxed transfer referrals to three SNF and one assisted living facility (ALF). According to a review of Resident 2's Progress Notes dated 6/1/2023, documented by the SSA, indicated SSA and Resident 2 went to ALF #1 but were told they could not accept him because of the wounds. A review of Resident 2's Progress Notes dated 6/5/2023 and timed at 4:16 p.m., the SSA documented she provided the resident with another location: B&C #2, for possible discharge the same day (6/5/2023) and Resident 2 expressed he would like to be discharged as soon as possible. The SSA did not indicate checking B&C #2 was not close to a liquor store or to an area where illegal drugs were sold as Resident 2's attending physician had recommended on 5/31/2023, for Resident 2's safety. A review of the Physician's Order for Resident 2, dated 6/5/2023 and timed at 4:37 p.m., indicated to discharge the resident to B&C #2 with medications and on hospice care. The hospice agency name, a contact person and a contact number were not included. A review of the Physician's Progress Notes for Resident 2 did not include the physician had evaluated Resident 2 as eligible to receive hospice care (which include terminal illness and life expectancy less than six month) and that the physician had explained to Resident 2 the benefits of hospice care or that the resident understood and consented to receive hospice care. A review of Resident 2's Progress Notes for 6/5/2023 and 6/6/2023 did not include documentation by social services, nursing, or the IDT about the reason for hospice, eligibility, Resident 2's understanding of hospice care and his consent. There was no documentation the SSD or the SSA had contacted a hospice agency, provided a referral, gave information regarding Resident 2's care needs including pain management, urinary catheter care, and frequency of wound care. There was no documentation Resident 2 was explained and understood the services provided by the B&C. The documentation did not indicate B&C #2 was informed about Resident 2's alcohol and illegal drug use. A review of the Physician's Order for Resident 2, dated 6/6/2023, timed at 10:04 a.m., indicated the resident would be discharged to B&C #2 on 6/6/2023 at 12:30 p.m. with medications and on hospice care. The hospice agency name, a contact person and a contact number were not included. A review of Resident 2's undated Discharge Summary, signed by an IDT staff and not signed by Resident 2's attending physician, indicated the resident's stay in the facility was from 11/23/2022 to 6/6/2023. In the section for Recapitulation of the Resident's Stay, it was documented the resident was admitted for rehabilitation, antibiotic therapy, and pain, wound, medication management. In the section for Transfer / Discharge was Necessary Due To, it was indicated the discharge was per resident's request. A review of Resident 2's Post Discharge Plan of Care, undated, indicated the resident's discharge date was 6/6/2023. Resident 2's specific care needs, safety precautions, wound treatment instructions, including the indwelling catheter care, and the needed assistance with ADLs were not included. The name of the hospice agency, contact staff, and contact number were not included. A review of GACH 1's Nursing Narrative Note for Resident 2, dated 6/11/2023, indicated Resident 2 was received from B&C #2 facility due to right lower leg wound infection and fever. Resident 2 required an IV antibiotic to treat the infection and IV Morphine for pain. A review of GACH 1's Emergency Department (ED) Physician's Note for Resident 2, dated 6/11/2023, indicated Resident 2 complained of redness and swelling to his right lower leg with drainage coming from it over the last day. Resident 2's symptoms started four days prior, he had a fever of 100.1degrees Fahrenheit ( F, normal body temperature range 97 F - 99 F) and pain rated eight (8/10, in a pain scale from zero indicating no pain and 10 the most excruciating pain possible). Resident 2 would be admitted to the hospital for IV antibiotics. On 6/12/2023, at 2:29 p.m., during a telephone interview with Resident 2, who was still at GACH 1, he stated, The facility discharged me as quick as possible from over there. Resident 2 stated he did not receive any hospice services at B&C #2 and did not receive wound care until after four days he was at B&C #2. Resident 2 stated that in the past his wound had become infected when the dressings were not changed daily. On 6/13/2023, at 11:03 a.m., during an interview, Licensed Vocational Nurse 2 (LVN 2) stated Resident 2 was discharged to B&C #2 with Hospice Agency 1 (HA 1) and a three-week supply of medications. LVN 2 stated Resident 2 would not have been able to perform his own wound care and that the resident's hospice care should have been in place prior to his discharge. During an interview, on 6/13/2023, at 11:54 a.m., the SSA stated she used an outside placement agency to find a facility and set up hospice care, home health agency (HHA) care, or a wound care for Resident 2. The SSA stated she did not verify what agencies (Hospice or HHA) would provide care to Resident 2 or what type of services the resident qualified for. The SSA also stated she did not know if the caregivers at B&C #2 could perform wound care. On 6/13/2023, at 12:25 p.m., during a call to HA 1, staff stated Resident 2 was not a current patient and had not been their patient in the recent months. On 6/13/2023, at 12:58 p.m., during an interview, the Quality Assurance Nurse (QA 1) stated Resident 2 was discharged with HA 1 and it was the job of the social services staff to contact HA 1 and make sure wound and other care Resident 2 needed were in place to ensure a safe and appropriate discharge. QA 1 stated part of Resident 2's post discharge plan of care included ensuring wound care and other services were in place prior to Resident 2 leaving the facility. During an interview, on 6/14/2023 at 10:59 a.m., the SSA stated it was the facility's duty to ensure Resident 2 was discharged somewhere safe and appropriate and she did this by relying on the word of the placement agency. On 6/14/2023 at 11:43 a.m., during a telephone interview, Wound Care Company A (WCC A) Case Manager 1 (CM 1) stated their staff visited Resident 2 at B&C #2 to provide services (wound care) only once on 6/9/2023 (3 days after his discharge from the facility and two days prior to being hospitalized ). During an interview on 6/14/2023 at 12:59 p.m., the SSD stated Resident 2 required wound care and the facility was to make sure wound care, HHA or hospice was in place before transferring Resident 2. On 6/14/2023 at 2:20 p.m., during an interview, the Director of Nursing (DON) stated Resident 2 was provided a 30-day notice on 5/10/2023, and wound care services should have been in place prior to discharge and social services staff was to verify they were in place. The DON stated, It was our responsibility to make sure that it was done. If Resident 2 was discharged and the required services were not provided, then it was not a safe or appropriate discharge. On 6/28/2023, at 12:19 p.m., during a telephone interview, Resident 2's attending physician (Physician 1) stated Resident 2 did not qualify for hospice (did not have a terminal illness and was not near death and needing end-of-life care) but the facility's staff (did not name the staff member) told him they could only discharge Resident 2 if he needed to include hospice care. Physician 1 confirmed what he wrote in his progress notes on 5/31/2023, that Resident 2 needed to be in a facility where the resident did not have a liquor store and drug dealing nearby and where he could receive wound care. On 6/28/2023, at 4:13 p.m., during a telephone interview, Placement Agent 1 (PA 1) stated she was a marketer for different facility types and worked alone. PA 1 stated she knew the Administrator and the DON for a long time and was assisting placing Resident 2. On 6/30/2023, at 11:37 a.m., during a telephone interview, Ombudsman 1 stated the office did not get notification from the facility of a facility-initiated discharge transfer. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised 3/2021, indicated residents were notified in writing, at least thirty (30) days prior to a transfer or discharge. The policy indicated residents were permitted to stay in the facility and not be transferred or discharge unless the transfer or discharge was appropriate because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility. A review of the facility's P&P titled, Discharging the Resident, reviewed 1/2022, indicated the facility will educate the resident on who will be providing the resident's care after discharge. It also indicated facility-initiated discharges will include on the assessment consideration of discharge timeframes - in terms of what was safest and in the best interest of the patient - evaluating medical necessity, family and patient preference and desires, appropriateness of the discharge, resources available at the time of discharge, and ultimately the order of the physician. The policy indicated that discharges can be frightening to the resident and to approach the discharge in a positive manner. A review of the facility's P&P titled, Discharge Summary and Plan, revised 12/2016, indicated every resident would be evaluated for his discharge needs and will have an individualized post discharge plan. The discharge plan will include arrangements that have been made for follow-up care and services. A review of the facility's policy and procedure titled, Transfer or Discharge, Preparing a Resident for, revised 12/2016, indicated residents will be prepared in advance for discharge.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing- related problems) was provided the necessary respiratory care and services consistent with professional standards of practice. The facility failed to: 1. Ensure Resident 1 was given 100% oxygen by non- rebreather mask (face mask that delivers high concentration of oxygen) while waiting for the paramedics to arrive. Resident 1 was placed on Bilevel Positive Airway Pressure (BiPAP, machine that helps with breathing and delivers pressurized air through a face mask for those that have spontaneous breathing) mask with no oxygen supply. Resident 1's oxygen saturation continued to drop, and patient became unresponsive to painful stimuli (a technique used by medical personnel for assessing the consciousness level of a person who is not responding to normal interaction, voice commands or gentle physical stimuli such as shaking of the shoulders). 2. Implement the person-centered care plan interventions to monitor and document changes in Resident 1's orientation, increased restlessness, and air hunger, monitor and document or report breathing abnormalities. These deficient practices resulted in delay in providing necessary lifesaving intervention before the paramedics arrived. Resident 1's oxygen saturation (amount of oxygen circulating in the blood) dropped to 76% (ideal range is 95% to 100%) and patient was transferred to the general acute hospital (GACH 2) where Resident 1 was admitted to the intensive care unit (ICU, department of the hospital with patients who are dangerously ill and are kept under constant observation) and stayed for six days. Findings: A review of the Admission Record indicated the facility admitted Resident 1 on 10/2/2019 and readmitted on [DATE] with diagnoses including respiratory failure (airways cannot adequately provide oxygen to the body), chronic obstructive pulmonary disease (COPD, group of diseases that cause airflow blockage and breathing -related problems) and sleep apnea (condition in which breathing stops and restarts many times while sleeping). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 1/30/2023 indicated Resident 1 was alert to year and month only. Resident 1 needed one-person physical assistance with dressing, eating, toilet use, personal hygiene and two or more persons physical assistance with bed mobility and bathing. The MDS indicated Resident 1 had shortness of breath or trouble breathing when sitting at rest and was on oxygen therapy. A review of the Care Plan initiated on 2/1/2023 indicated Resident 1 had shortness of breath related to decreased energy and fatigue, hypoxia (low levels of oxygen in the body), COPD exacerbation (worsening of the COPD) and oxygen desaturation (decrease in oxygen level in the blood). The goal indicated Resident 1 would have no complications related to shortness of breath. The care plan interventions included to monitor and document changes in orientation, increased restlessness, anxiety, and air hunger, monitor and document or report breathing abnormalities to the physician including bradypnea (slow breathing less than 12 breaths per minute [bpm]), tachypnea (increased breathing, normal range 12 to 20 bpm) and to give 15 liters of oxygen per minute (LPM, flow rate of oxygen) by non-rebreather mask. A review of the Care Plan dated 2/10/2023 indicated Resident 1 had impaired breathing function and dependent on oxygen. The care plan goal indicated Resident 1 will recover oxygen saturation level more than 95% within five minutes and will keep oxygen level above 95% all the time. The care plan interventions indicated to give oxygen up to maximum level until oxygen saturation had recovered and set BIPAP under the care of the respiratory therapist (RT, trained health professionals who help treat and restore function for patients with airway or breathing problems). A review of the Physician's Order Summary Report dated 2/10/2023 indicated Resident 1 to receive oxygen at two liters by nasal cannula (nasal prongs) continuously for respiratory failure, monitor oxygen saturation every six hours and BiPAP at bedtime for hypoventilation (breathing too shallow or too slow). During review of the GACH 1 Physician Discharge Summary dated 2/10/23, Resident 1 was initially admitted (2/6/23) at GACH 1 as code stroke (suspected stroke) but ruled out. The Summary indicated Resident 1 had respiratory failure, obesity hypoventilation syndrome COPD and oxygen dependence. A review of the Situation, Background, Assessment and Request (SBAR) Communication and Progress Note dated 2/10/2023 indicated Resident 1 was readmitted from GACH 1 at 4:40 PM. The SBAR indicated at 6:12 PM, Resident 1's vital signs (clinical measurements specifically the heart rate, temperature, breathing rate and blood pressure (BP) that indicate the state of body functions) were BP of 148/66 (normal 120/80), heart rate of 68 bpm (normal range 60 to 100 bpm), breathing at 18 bpm (normal 12 to 20), temperature of 97.2 Fahrenheit (F, range from 97 F to 99 degrees F) and oxygen saturation of 98% on oxygen by nasal cannula at four liters of oxygen. A review of the Paramedics Patient Care Report dated 2/10/2023 at 9:59 PM indicated on arrival to facility, Resident 1 was in bed and on BiPAP machine with no supplemental oxygen. The Patient Care Report indicated Resident 1's family member came for a visit and found Resident 1 unresponsive with a low oxygen saturation and it was unknown for how long. The Paramedic Patient Care Report (Notes) indicated Resident 1 had oxygen saturation of 76%, was placed on 15 liters of oxygen by non-rebreather mask and started breathing on her own. The oxygen saturation improved to 100%. Resident 1's Glasgow Coma Scale (GCS, determines the level of consciousness) was three (indicated no response to pain). Resident 1 was taken to GACH 2. A review of the Progress Notes dated 2/10/23 at 10:24 p.m. notes indicated Resident 1 remained on oxygen at four liters by nasal cannula and was on continuous monitoring for oxygen saturation while waiting for the Respiratory Therapist (RT) to set up the BIPAP. At 9:30 PM, the notes indicated Resident 1 had decreasing saturation level and continued with oxygen treatment. The nursing documentation did not specify how much oxygen was given nor the oxygen saturation. At 9:50 p.m. Resident 1 had .abrupt decreasing . of oxygen saturation and the paramedics were called. The Notes indicated Resident 1 was transferred to the GACH 2 at 10:10 pm. The notes indicated the primary physician was notified at 10:18 p.m. A review of the GACH 2 Emergency Documentation (ED) dated 2/11/2023 at 2:55 AM, indicated Resident 1 was brought in by ambulance due to shortness of breath and altered level of consciousness (ALOC, change from a person's usual state of being alert and aware). The ED Note indicated when the paramedics arrived at the facility (SNF), Resident 1 was on BiPAP with no oxygen supply and an oxygen saturation of 55%. Resident 1 was placed on non-rebreather mask and oxygen saturation increased to 100%. Resident 1 had no response to painful stimuli, was not moving extremities or following commands. The ED Note indicated on re-assessment Resident 1's mental status improved with eyes open and interacting. Resident 1 was admitted to the ICU for close monitoring. A review of the GACH 2 Discharge Summary dated 2/16/2023 at 11:01 PM, indicated Resident 1 remained stable in the ICU, receiving oxygen via nasal cannula during the day and BiPAP at night. The Discharge Summary indicated Resident 1 was discharged on [DATE] to another facility. During a telephone interview on 2/23/2023 at 11:18 AM, Registered Nurse Supervisor (RNS 1) stated Resident 1 was readmitted to the facility on [DATE] at around 5 p.m. RNS 1 stated Resident 1 was dependent on oxygen, and he called the RT within 10 to 15 minutes of Resident 1's arrival to set up the BiPAP. RNS 1 stated he placed Resident 1 on oxygen four liters by nasal cannula and continued monitoring Resident 1's oxygen saturation. At around 9:30 pm, RNS 1 stated Resident 1's oxygen saturation dropped to 75%. RNS 1 stated he increased the oxygen and Resident 1's oxygen saturation increased to 90%. RNS 1 stated the paramedics were called. During an interview on 3/9/2023, at 12:41 p.m. the Director of Nursing (DON) stated when Resident 1's oxygen saturation decreased, LVN 1 placed Resident 1 on BiPAP thinking that it would help Resident 1 before the paramedics arrive. The DON stated Resident 1 should have the non-rebreather mask instead, which would give a high flow of oxygen. The DON further stated the nursing documentation of what happened was not clear, as it lacks information such as Resident 1's alertness or responsiveness and did not show the whole picture of what happened. A review of the facility policy titled, Oxygen Administration, reviewed on 1/26/23 indicated after completing oxygen set-up or adjustment, the following information should be recorded in the resident's medical record: -The date and time that the procedure was performed -The name and title of the individual who performed the procedure -The rate of oxygen flow, route, and rationale -The frequency and duration of the treatment -The reason for prn administration -All assessment data obtained before, during and after the procedure -How resident tolerated the procedure. A review of the facility policy titled, First Aid Treatment, reviewed on 1/26/2023, indicated basic first aid intervention included (but is not limited to) interventions for the following situations which included choking and breathing emergencies. The policy indicated the goal of emergency intervention was to stabilize the resident and the situation until further treatment was available.

Based on observation, interview, and record review, the facility failed to provide required care and services according to current standards of practice by failing to ensure multiple licensed staff, including Licensed Vocational Nurses 1, 7 and 8 (LVN) measured blood sugar levels according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice of failing to check blood sugar levels as required by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/9/2022 at 11:11 AM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) regarding the facility's failure to ensure blood sugar levels were checked prior to administering insulin as required by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/10/22 at 3:23 PM, while onsite at the facility, the IJ was removed after the facility submitted an acceptable removal plan (interventions to correct the deficient practices), which was verified and confirmed through observation, interview and record review. The IJ situation was removed in the presence of the ADM and the DON. The accepted removal plan included the following actions: 1. On 6/9/2022, the Nurse Consultant reeducated licensed staff regarding neglect, with emphasis on providing professional care and services to prevent physical harm by ensuring blood sugar levels were measured and not duplicated prior to administering insulin. 2. Facility staff identified a total of 17 residents currently in the facility with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On 6/9/2022, the Pharmacist Consultant (PC) conducted educational training with licensed staff regarding the following topics: A. Obtaining a fingerstick glucose (sugar) level B. Importance of accuracy and integrity of medical records C. Importance of measuring blood sugar level per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. On 6/10/2022, the Pharmacy Nurse Consultant began to conduct direct observations of licensed staff to ensure competency in technique and documentation for five licensed staff per day with a target date of completion for the entire nursing staff by 6/15/2022. 5. On 6/9/2022, the Medical Director (MD) reviewed the blood sugar readings of all 17 residents with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/10/22, MD personally assessed residents affected by the duplication of blood sugar readings for any adverse effect. 6. On 6/9/2022, the DON and/or the Quality Assurance Nurse will audit eight residents three times weekly to ensure licensed staff were checking blood sugar levels prior to administering sliding scale insulin. 7. The DON and ADM to be responsible for the implementation of the plan and will review and monitor the effectiveness of the plan and present findings in quarterly quality assurance meetings. Findings: During a telephone interview on 6/7/2022 at 2:33 PM, the Facility Monitor (FM) stated Residents 1, 2, and 3 had multiple identical blood sugar readings documented for insulin administration between January and March 2022. The FM stated multiple nurses documented the same blood sugar readings multiple times throughout the day, on multiple days and for multiple residents. The FM stated many of the duplicate readings were used to determine the dose of sliding scale insulin and insulin was administered as a result. A review of Resident 1's Admission Record dated 6/9/2022, indicated he was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -On 3/3/2022, insulin [MEDICATION(S)] (a fast-acting form of insulin) to inject three units (a unit of dosage for insulin) subcutaneously (under the skin) three times a day for Type II diabetes with instructions to hold if the blood sugar value was less than 120 milligrams ([ml] - a unit of measurement for mass) per deciliter ([dl] - a unit of measurement for volume). -On 3/3/22, insulin [MEDICATION(S)] to inject as per sliding scale: if blood sugar (BS) = 71-150, no coverage, 151-200 = 3 units, 201-250 = 5 units, 251-300 = 7 units, 301-350 = 9 units, 351-400 = 11 units, more than 400 = 13 units subcutaneously before meals and at bedtime for Type II diabetes. -On 4/21/22, insulin [MEDICATION(S)] (a slow-acting insulin) to inject 30 units subcutaneously in the morning for Type II diabetes. A review of Resident 1's Care Plan for diabetes, updated April 2022, indicated he was at risk for [CONDITION(S)] (low blood sugar) and [CONDITION(S)] (high blood sugar) due to diabetes with an approach plan to Accucheck (take blood sugar measurement) as ordered QID (four times daily) AC (before meals) and QHS (at bedtime). A review of Resident 1's MAR dated from January to March 2022, indicated the following examples of duplications of blood sugar readings in the record on 1/17/2022: -9 AM - 214 mg/dl - 3 units of [MEDICATION(S)] administered by Licensed Vocational Nurse (LVN 8) -1 PM - 214 mg/dl - 3 units of [MEDICATION(S)] administered by LVN 8 -5 PM - 214 mg/dl - 3 units of [MEDICATION(S)] administered by LVN 7 -11 PM - 214 mg/dl - 20 units of [MEDICATION(S)] administered by LVN 7. On 1/28/2022 at 9 AM - 254 mg/dl - 3 units [MEDICATION(S)] administered by LVN 8 -11:30 AM - 254 mg/dl - 7 units [MEDICATION(S)] administered per sliding scale by LVN 8 -1 PM - 254 mg/dl - 3 units [MEDICATION(S)] administered by LVN 8 -4:30 PM - 254 mg/dl - 7 units [MEDICATION(S)] administered per sliding scale by LVN 8 -5 PM - 254 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -6 PM - 254 mg/dl - 14 units [MEDICATION(S)] administered by LVN 7 -11 PM - 254 mg/dl - 7 units [MEDICATION(S)] administered per sliding scale by LVN 7. On 2/1/2022 at 6 AM - 371 mg/dl - 14 units [MEDICATION(S)] administered -6:30 AM - 371 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale -9 AM - 371 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -11:30 AM - 371 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7 -1 PM - 371 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -4:30 PM - 371 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7 -5 PM - 371 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -6 PM - 371 mg/dl - 14 units [MEDICATION(S)] administered by LVN 7 -11 PM - 371 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7. On 2/4/2022 at 6 AM - 397 mg/dl - 14 units [MEDICATION(S)] administered, -6:30 AM - 397 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale -9 AM - 397 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -11:30 AM - 397 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7 -1 PM - 397 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -4:30 PM - 397 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7 -5 PM - 397 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -6 PM - 397 mg/dl - 14 units [MEDICATION(S)] administered by LVN 7 -11 PM - 397 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7. Further review of Resident 1's MAR dated between January and March 2022 indicated similar findings (duplications) on the following dates: 2/5/, 2/6, 2/8, 2/18/2022, and 3/4/2022 for a total of 134 duplicate blood sugar readings. A review of Resident 2's Admission Record, dated 6/9/2022, indicated she was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -On 3/31/22, [MEDICATION(S)] R (a type of insulin) to administer per sliding scale: for blood sugar reading 70-130 = 0 units, 131-180 = 2 units, 181-240 = 4 units, 241-300 = 6 units, 301-350 = 8 units, 351-399 = 10 units, greater than 400 = 12 units and contact physician, subcutaneously before meals and at bedtime for Type II diabetes. -On 3/10/2022, insulin [MEDICATION(S)] to inject 30 units subcutaneously at bedtime related to Type II diabetes. A review of the Care Plan for diabetes, updated April 2022, indicated Resident 2 was at risk for [CONDITION(S)] and [CONDITION(S)] related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MAR dated from January to March 2022 indicated the following example of duplications of blood sugar readings in the record on 2/22/2022 at 6:30 AM - 279 mg/dl - 6 units of [MEDICATION(S)] R were administered per sliding scale, -11:30 AM - 279 mg/dl - 6 units of [MEDICATION(S)] R were administered per sliding scale by LVN 7. -4:30 PM - 279 mg/dl - 6 units of [MEDICATION(S)] R were administered per sliding scale by LVN 7. -11 PM - 279 mg/dl - 6 units of [MEDICATION(S)] R were administered per sliding scale by LVN 7. Further review of Resident 2's MAR dated between January and March 2022 indicated similar findings (duplications) on the following dates: 1/7, 1/10, 1/11, 1/17, 1/18, 1/25/2022, and 3/24/2022 for a total of 51 duplicate blood sugar readings. A review of Resident 3's Admission Record, dated 6/9/2022 indicated he was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 3 units, 251 - 300 = 4 units, 301-350 = 6 units, 351-400 = 9 units, above 400 = 12 units and report to the physician subcutaneously before meals and at bedtime for Type II diabetes. A review of Resident 3's Resident Care Plan for diabetes, updated May 2022, indicated Resident 3 was at risk for [CONDITION(S)] and [CONDITION(S)] related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MAR dated from February to March 2022, indicated the following example of duplications of blood sugar readings in the record on 3/24/2022 at 11:30 AM - 210 mg/dl - 3 units of [MEDICATION(S)] R administered by sliding scale, -4:30 PM - 210 mg/dl - 3 units of [MEDICATION(S)] R administered by sliding scale by LVN 7. -11 PM - 210 mg/dl - 3 units of [MEDICATION(S)] R administered by sliding scale by LVN 7. Further review of Resident 3's MAR dated between February and March 2022, indicated similar findings (duplications) on the following dates: 2/4, 2/5, 2/6, 2/7, 2/8, 2/9, 2/15, 2/18, 2/25/2022, and 3/7/2022 for a total of 62 duplicate blood sugar readings. A review of Resident 4, 5, 6, and 7's MARs dated between January and March 2022 indicated similar findings (duplications) between 1/20/22 and 3/31/22 for a total of 303 total duplicate blood sugar readings for Residents 1 to 7 documented by multiple licensed staff. During an interview on 6/8/2022 at 5:47 PM with the DON and the ADM, the DON stated LVN 7 and 8 have resigned and were no longer working at this facility. The DON stated LVN 7 resigned on 3/29/2022 after having previously been suspended as disciplinary action for possible duplication or false entries for vital signs and blood sugar readings. The DON stated the FM had brought her attention to LVN 7 possibly duplicating vital signs and blood sugar readings around the end of March 2022. The DON stated, when she asked LVN 7 about entering duplicate blood sugar and vital sign values in the MAR without measuring them, LVN 7 denied doing so. The ADM stated she was unsure why LVN 8 resigned. The ADM stated when the FM advised them of the trend of duplicated blood sugar readings, the facility attempted to retrain their staff regarding proper documentation procedures at that time. The DON and ADM stated they also began conducting audits of the medical records of two residents per medication cart per week to search for duplicate entries. The ADM and DON stated they did not know why so many of their residents would have so many identical blood sugar readings and could not offer any plausible alternative explanation to an intentional fabrication of the medical record. The DON stated it was possible that the resident could have as many as nine identical blood sugar readings consecutively in a 24-hour period. The DON stated the staff cannot see the previous readings when they were documenting blood sugar and do not have time to look it up. The DON stated if the blood sugar readings were inaccurate, especially if it was higher than the true value, there was a chance that the dose of insulin given to the resident could have been too high based on the sliding scale order. The DON stated that if a resident received too much insulin it could cause them to crash by dropping the residents' blood sugar too low possibly resulting in hospitalization or death. A review of the Employee Notice of Discipline form, dated 3/25/2022, for LVN 7 indicated the DON suspended LVN 7 from work due to, On 3/24/22 there was a review of documentation indicated that there is a possibility of inaccurate blood sugar readings and V/S (vital signs) documented in E-MAR (electronic MAR). During an interview on 6/9/2022 at 1:59 PM, the Pharmacist Consultant (PC) stated if residents were given large doses of insulin when their blood sugar was too low, it may cause medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . The PC stated hopefully the low blood sugar would be discovered and corrected by facility staff before it got to a life-threatening level or before hospitalization would be needed but that depends on the staff's ability to monitor residents properly or the residents' ability to communicate their change in status. The PC stated if a resident did not have the ability to communicate a change in their status, there was a higher risk that they may experience more severe effects of [CONDITION(S)] as the episode may go longer without being detected. The PC stated that in his professional opinion, documenting the same blood sugar multiple times in a row for the same resident in the same day indicated the medical record regarding those blood sugar readings was inaccurate and most likely fabricated. The PC stated, even without giving insulin, blood sugar levels will naturally rise and fall throughout the day based on food consumed and activity level so it would be highly unlikely to have two consecutive identical blood sugar readings let alone multiple times across multiple residents on multiple dates. The PC stated the onset of action (how quickly the drug starts working) for [MEDICATION(S)] insulin was 15-30 minutes, so if 11 units of [MEDICATION(S)] were given at 4:30 PM and the blood sugar was measured again at 5 PM, as per the record for Resident 1, we would expect to see a lower blood sugar reading at 5 PM due to the insulin activity. The PC stated that if multiple doses of scheduled and sliding scale insulin were given at high doses throughout the day together, there could be a risk the resident develops a life-threatening hypoglycemic episode which would require medical intervention. The PC stated that it was important for the medical record to be accurate to ensure that providers and pharmacists had the correct information on which to base their treatment decisions and recommendations regarding medication therapy. The PC stated if the medical records were inaccurate, pharmacists and physicians may recommend or prescribe inaccurate doses of insulin which could possibly result in further medical complications. During a telephone interview on 6/10/2022 at 11:29 AM, the Medical Director (MD) stated, in her professional opinion, administering large doses of fast-acting insulin to a resident pursuant to false or fabricated high blood sugar readings could result in that resident experiencing a hypoglycemic event that could end in a diabetic coma or other serious medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD stated she regularly attends monthly quality assurance meetings in person, but many times the meetings were canceled due to emergencies or scheduling conflicts. The MD stated many times she must leave the meetings early to attend to other patient's medical needs or must excuse herself from the meetings to take phone calls while they are ongoing. The MD stated she was never made aware of the issue of duplicated blood sugar readings in residents receiving insulin until the DON informed her on 6/9/2022. The MD stated she did not recall any meeting since March or afterward where this issue was discussed in a quality assurance meeting when she was present. During a telephone interview on 6/10/2022 at 1:02 PM, LVN 7 stated he used a duplicate entry function within the MAR that copied the last entry on the order when documenting blood sugars and doses of sliding scale insulin for the residents under his care between January and March 2022. LVN 7 stated he and other licensed staff were having difficulty understanding the proper way to document the blood sugar readings in the MAR and accidentally used the duplicate entry function rather than entering his own blood sugar and vital sign readings. LVN 7 denied intentionally entering any false information into the MAR. LVN 7 stated he took his own blood sugar readings, documented them in the MAR, and only administered insulin to residents when appropriate based on the parameters. LVN 7 stated he did not know why his own readings were not available anywhere in the residents' records. LVN 7 stated he also accidentally duplicated records of sliding scale insulin administrations in the MAR. During an observation and concurrent interview on 6/10/2022 at 1:19 PM, LVN 1 was observed demonstrating how to record new blood sugar readings for a resident on the MAR data input screen. LVN 1 was observed selecting the medication cart number and a resident name to input a new reading. LVN 1 was observed entering a new blood sugar reading requiring the value to be manually typed in each time. No duplicate button or similar functionality was observed on the MAR data input screen. LVN 1 stated there used to be a repeat last entry functionality on the data entry screen in the MAR but it was disabled several months ago once the facility was informed about multiple duplicate entries on vital signs and blood sugar readings on multiple residents. LVN 1 stated it was too convenient for some nurses to input false information into the record by using this duplicate functionality. LVN 1 stated, If they wanted to lie, they should have just changed the number a little bit on a new entry. LVN 1 stated that once the repeat last entry functionality was used, for a nurse to change it, they would have to manually perform an edit to strike the previous value and record a new one by entering the value manually. LVN 1 stated it would be apparent on the MAR that the new reading would be indicated as the correct one after the correction was made. LVN 1 stated the MAR was the only place blood sugar readings or medication administration records can be documented. LVN 1 stated sometimes the nurses will use the progress notes to explain anomalous (deviating from what is standard, normal or expected) readings or add clarification to an action, but will not routinely record blood sugars, vital signs, or medication administration records anyplace other than the MAR. LVN 1 stated, If it's not in the MAR, it most likely means they didn't do it. A review of the facility's policy titled, Administering Medications, reviewed January 2022 indicated medication are administered in a safe and timely manner, and as prescribed, The following information is checked/verified for each resident prior to administering medications, Vital signs, if necessary, as required or indicated for a medication, the individual administering the medication records in the resident's medical record, and the dosage. A review of the facility's policy titled, Insulin Administration, reviewed January 2022, indicated to provide guidelines for the safe administration of insulin to residents and to check blood glucose by fingerstick. A review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, reviewed January 2022, indicated the person performing this procedure should record the following information in the resident's medical record: the blood sugar results. Follow facility policies and procedure for appropriate nursing interventions regarding the blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages). A review of the facility's policy titled, Abuse and Neglect - Clinical Protocol, reviewed January 2022, indicated neglect means 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm,' and along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect, and the staff, with the physician's input as needed, will investigate alleged neglect to clarify what happened and identify possible causes and the medical director will advise facility management and staff about ways to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed properly.

Based on observation, interview, and record review, the facility failed to ensure licensed staff, including Licensed Vocational Nurse 1, 7 and 8 (LVN) measured blood sugar levels prior to administering insulin (a medication used to lower blood sugar) to seven of 11 sampled residents (Residents 1, 2, 3, 4, 5, 6 and 7) receiving sliding scale insulin (dose of insulin dependent on blood sugar readings taken immediately before administration) between 1/1/ and 3/31/2022. The deficient practice of administering insulin without first checking blood sugar levels could have caused Resident 1 -7's blood sugar levels to drop dangerously low likely leading to hospitalization or death. On 6/9/2022 at 11:11 AM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) regarding the facility's failure to ensure blood sugar levels were checked prior to administering insulin as required by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/10/2022 at 3:23 PM, while onsite at the facility, the IJ was removed after the facility submitted an acceptable removal plan (interventions to correct the deficient practices), which was verified and confirmed through observation, interview and record review. The IJ situation was removed in the presence of the ADM and the DON. The accepted removal plan included the following actions: 1. Facility staff identified a total of 17 residents currently in the facility with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. On 6/9/2022, the Pharmacist Consultant (PC) conducted educational training with licensed staff regarding the following topics: A. Obtaining a fingerstick glucose (sugar) level B. Importance of accuracy and integrity of medical records C. Importance of measuring blood sugar level per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On 6/10/2022, the Pharmacy Nurse Consultant began to conduct direct observations of licensed staff to ensure competency in technique and documentation for five licensed staff per day with a target date of completion for the entire nursing staff by 6/15/2022. 4. On 6/9/2022, the Medical Director (MD) reviewed the blood sugar readings of all 17 residents with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/10/2022, the Physician personally assessed residents affected by the duplication of blood sugar readings for any adverse effect. 5. On 6/9/2022, facility staff notified the respective primary care physicians of all residents found to be affected by duplicate blood sugar readings. 6. On 6/9/2022, the DON and/or the Quality Assurance Nurse will audit eight residents three times weekly to ensure licensed staff were checking blood sugar levels prior to administering sliding scale insulin. 7. The DON to be responsible for the implementation of the plan and will review and monitor the effectiveness of the plan and present findings in quarterly quality assurance meetings. Findings: During a telephone interview on 6/7/2022 at 2:33 PM, the Facility Monitor (FM) stated Residents 1, 2, and 3 have multiple identical blood sugar readings documented for insulin administration dated between January and March 2022. The FM stated multiple nurses documented the same blood sugar readings multiple times throughout the day, on multiple days and for multiple residents. The FM stated many of the duplicate readings were used to determine the dose of sliding scale insulin and insulin was administered as a result. A review of Resident 1's Admission Record, dated 6/9/2022, indicated he was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -On 3/3/22, Resident 1's physician prescribed insulin [MEDICATION(S)] (a fast-acting form of insulin) to inject three units (a unit of dosage for insulin) subcutaneously (under the skin) three times a day for Type II diabetes with instructions to hold if the blood sugar value is less than 120 milligrams ([ml] - a unit of measurement for mass) per deciliter ([dl] - a unit of measurement for volume). -On 3/3/2022, Resident 1's physician prescribed insulin [MEDICATION(S)] to inject as per sliding scale: if blood sugar (BS) = 71-150, no coverage, 151-200 = 3 units, 201-250 = 5 units, 251-300 = 7 units, 301-350 = 9 units, 351-400 = 11 units, more than 400 = 13 units subcutaneously before meals and at bedtime for Type II diabetes. -On 4/21/2022, Resident 1's physician prescribed insulin [MEDICATION(S)] (a slow-acting insulin) to inject 30 units subcutaneously in the morning for Type II diabetes. A review of Resident 1's Resident Care Plan for diabetes, last updated April 2022, indicated he was at risk for [CONDITION(S)] (low blood sugar) and [CONDITION(S)] (high blood sugar) due to diabetes with an approach plan to Accucheck (take blood sugar measurement) as ordered QID (four times daily) AC (before meals) and QHS (at bedtime). A review of Resident 1's MAR from January to March 2022 indicated the following examples of duplications of blood sugar readings in the record on 1/17/22 at 9 AM - 214 mg/dl - 3 units of [MEDICATION(S)] administered by Licensed Vocational Nurse (LVN 8), -1 PM - 214 mg/dl - 3 units of [MEDICATION(S)] administered by LVN 8 -5: PM - 214 mg/dl - 3 units of [MEDICATION(S)] administered by LVN 7 11 PM - 214 mg/dl - 20 units of [MEDICATION(S)] administered by LVN 7. On 1/28/2022 at 9 AM - 254 mg/dl - 3 units [MEDICATION(S)] administered by LVN 8 -11:30 AM - 254 mg/dl - 7 units [MEDICATION(S)] administered per sliding scale by LVN 8 -1 PM - 254 mg/dl - 3 units [MEDICATION(S)] administered by LVN 8 -4:30 PM - 254 mg/dl - 7 units [MEDICATION(S)] administered per sliding scale by LVN 8 -5 PM - 254 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -6 PM - 254 mg/dl - 14 units [MEDICATION(S)] administered by LVN 7 -11 PM - 254 mg/dl - 7 units [MEDICATION(S)] administered per sliding scale by LVN 7. On 2/1/2022 at 6 AM - 371 mg/dl - 14 units [MEDICATION(S)] administered, -6:30 AM - 371 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale -9 AM - 371 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -11:30 AM - 371 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7 -1 PM - 371 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -4:30 PM - 371 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7 -5 PM - 371 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -6 PM - 371 mg/dl - 14 units [MEDICATION(S)] administered by LVN 7 -11 PM - 371 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7. On 2/4/2022 at 6 AM - 397 mg/dl - 14 units [MEDICATION(S)] administered -6:30 AM - 397 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale -9 AM - 397 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -11:30 AM - 397 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7 -1 PM - 397 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -4:30 PM - 397 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7 -5 PM - 397 mg/dl - 3 units [MEDICATION(S)] administered by LVN 7 -6 PM - 397 mg/dl - 14 units [MEDICATION(S)] administered by LVN 7 -11 PM - 397 mg/dl - 11 units [MEDICATION(S)] administered per sliding scale by LVN 7. Further review of Resident 1's MAR dated between January and March 2022 indicated similar findings (duplications) on the following dates: 2/5, 2/6, 2/8, 2/18/2022, and 3/4/2022 for a total of 134 duplicate blood sugar readings. A review of Resident 2's Admission Record, dated 6/9/2022, indicated she was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Resident 2's physician prescribed [MEDICATION(S)] R (a type of insulin) to administer per sliding scale: for blood sugar reading 70-130 = 0 units, 131-180 = 2 units, 181-240 = 4 units, 241-300 = 6 units, 301-350 = 8 units, 351-399 = 10 units, greater than 400 = 12 units and contact physician, subcutaneously before meals and at bedtime for Type II diabetes. On 3/10/2022, Resident 2's physician prescribed insulin [MEDICATION(S)] to inject 30 units subcutaneously at bedtime related to Type II diabetes. A review of Resident 2's Resident Care Plan for diabetes, updated April 2022, indicated Resident 2 was at risk for [CONDITION(S)] and [CONDITION(S)] related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MAR dated from January to March 2022 indicated the following example of duplications of blood sugar readings in the record on 2/22/2022 at 6:30 AM - 279 mg/dl - 6 units of [MEDICATION(S)] R were administered per sliding scale, -11:30 AM - 279 mg/dl - 6 units of [MEDICATION(S)] R were administered per sliding scale by LVN 7 -4:30 PM - 279 mg/dl - 6 units of [MEDICATION(S)] R were administered per sliding scale by LVN 7 -11 PM - 279 mg/dl - 6 units of [MEDICATION(S)] R were administered per sliding scale by LVN 7. Further review of Resident 2's MAR dated between January and March 2022 indicated similar findings (duplications) on the following dates: 1/7, 1/10, 1/11, 1/17, 1/18, 1/25/2022, and 3/24/2022 for a total of 51 duplicate blood sugar readings. A review of Resident 3's Admission Record, dated 6/9/2022 indicated he was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 3's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 3 units, 251 - 300 = 4 units, 301-350 = 6 units, 351-400 = 9 units, above 400 = 12 units and report to the physician subcutaneously before meals and at bedtime for Type II diabetes. A review of Resident 3's Resident Care Plan for diabetes, last updated May 2022, indicated Resident 3 was at risk for [CONDITION(S)] and [CONDITION(S)] related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's MAR dated from February to March 2022 indicated the following example of duplications of blood sugar readings in the record on 3/24/2022 at 11:30 AM - 210 mg/dl - 3 units of [MEDICATION(S)] R administered by sliding scale, -4:30 PM - 210 mg/dl - 3 units of [MEDICATION(S)] R administered by sliding scale by LVN 7 -11 PM - 210 mg/dl - 3 units of [MEDICATION(S)] R administered by sliding scale by LVN 7. Further review of Resident 3's MAR dated between February and March 2022 indicated similar findings (duplications) on the following dates: 2/4, 2/5, 2/6, 2/7, 2/8, 2/9, 2/15, 2/18, 2/25/2022 and 3/7/2022 for a total of 62 duplicate blood sugar readings. A review of Resident 4, 5, 6, and 7's MARs dated between January and March 2022 indicated similar findings (duplications) between 1/20/22 and 3/31/22 for a total of 303 total duplicate blood sugar readings for Residents 1 to 7 documented by multiple licensed staff, including LVN 1, 7 and 8. During an interview on 6/8/2022 at 5:47 PM with the DON and the ADM, the DON stated LVN 7 and 8 have resigned and were no longer working at this facility. The DON stated LVN 7 resigned on 3/29/2022 after having previously been suspended as disciplinary action for possible duplication or false entries for vital signs and blood sugar readings. The DON stated a FM had brought her attention to LVN 7 possibly duplicating vital signs and blood sugar readings around the end of March 2022. The DON stated, when she asked LVN 7 about entering duplicate blood sugar and vital sign values in the MAR without measuring them, LVN 7 denied doing so. The ADM stated she was unsure why LVN 8 resigned. The ADM stated when a FM advised them of the trend of duplicated blood sugar readings, the facility attempted to retrain their staff regarding proper documentation procedures at that time. The DON and ADM stated they also began conducting audits of the medical records of two residents per medication cart per week to search for duplicate entries. The ADM and DON stated they did not know why so many of their residents would have so many identical blood sugar readings and could not offer any plausible alternative explanation to an intentional fabrication of the medical record. The DON stated it was possible that the resident could have as many as nine identical blood sugar readings consecutively in a 24-hour period. The DON stated the staff cannot see the previous readings when they were documenting blood sugar and do not have time to look it up. The DON stated if the blood sugar readings were inaccurate, especially if it was higher than the true value, there was a chance that the dose of insulin given to the resident could have been too high based on the sliding scale order. The DON stated that if a resident received too much insulin it could cause them to crash by dropping the residents' blood sugar too low possibly resulting in hospitalization or death. A review of the Employee Notice of Discipline form, dated 3/25/2022, for LVN 7 indicated the DON suspended LVN 7 from work due to, On 3/24/2022 there was a review of documentation indicated that there was a possibility of inaccurate blood sugar readings and V/S (vital signs) documented in E-MAR (electronic MAR). During an interview on 6/9/2022 at 1:59 PM, the Pharmacist Consultant (PC) stated if residents were given large doses of insulin when their blood sugar was too low, it may cause medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . The PC stated hopefully the low blood sugar would be discovered and corrected by facility staff before it got to a life-threatening level or before hospitalization would be needed but that depends on the staff's ability to monitor residents properly or the residents' ability to communicate their change in status. The PC stated if a resident did not have the ability to communicate a change in their status, there was a higher risk that they may experience more severe effects of [CONDITION(S)] as the episode may go longer without being detected. The PC stated that in his professional opinion, documenting the same blood sugar multiple times in a row for the same resident in the same day indicated that the medical record regarding those blood sugar readings was inaccurate and most likely fabricated. The PC stated, even without giving insulin, blood sugar levels will naturally rise and fall throughout the day based on food consumed and activity level so it would be highly unlikely to have two consecutive identical blood sugar readings let alone multiple times across multiple residents on multiple dates. The PC stated the onset of action (how quickly the drug starts working) for [MEDICATION(S)] insulin was 15-30 minutes, so if 11 units of [MEDICATION(S)] were given at 4:30 PM and the blood sugar was measured again at 5 PM, as per the record for Resident 1, we would expect to see a lower blood sugar reading due to the insulin activity. The PC stated that if multiple doses of scheduled and sliding scale insulin are given at high doses throughout the day together, there could be a risk the resident develops a life-threatening hypoglycemic episode which would require medical intervention. PC stated that it is important for the medical record to be accurate to ensure that providers and pharmacists have the correct information on which to base their treatment decisions and recommendations regarding medication therapy. PC stated if the medical records are inaccurate, pharmacists and physicians may recommend or prescribe inaccurate doses of insulin which could possibly result in further medical complications. During a telephone interview on 6/10/2022 at 11:29 AM, the Medical Director (MD) stated in her professional opinion, administering large doses of fast-acting insulin to a resident pursuant to false or fabricated high blood sugar readings could result in that resident experiencing a hypoglycemic event that could end in a diabetic coma or other serious medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . During a telephone interview on 6/10/2022 at 1:02 PM, LVN 7 stated he used a duplicate entry function within the MAR that copied the last entry on the order when documenting blood sugars and doses of sliding scale insulin for the residents under his care between January and March 2022. LVN 7 stated he and other licensed staff were having difficulty understanding the proper way to document the blood sugar readings in the MAR and accidentally used the duplicate entry function rather than entering his own blood sugar and vital sign readings. LVN 7 denied intentionally entering any false information into the MAR. LVN 7 stated he took his own blood sugar readings, documented them in the MAR, and only administered insulin to residents when appropriate based on the parameters. LVN 7 stated he did not know why his own readings were not available anywhere in the residents' records. LVN 7 stated he also accidentally duplicated records of sliding scale insulin administrations in the MAR. During an observation and concurrent interview on 6/10/2022 at 1:19 PM, LVN 1 was observed demonstrating how to record new blood sugar readings for a resident on the MAR data input screen. LVN 1 was observed selecting the medication cart number and a resident name to input a new reading. LVN 1 was observed entering a new blood sugar reading requiring the value to be manually typed in each time. No duplicate button or similar functionality was observed on the MAR data input screen. LVN 1 stated there used to be a repeat last entry functionality on the data entry screen in the MAR but it was disabled several months ago once the facility was informed about multiple duplicate entries on vital signs and blood sugar readings on multiple residents. LVN 1 stated it was too convenient for some nurses to input false information into the record by using this duplicate functionality. LVN 1 stated, If they wanted to lie, they should have just changed the number a little bit on a new entry. LVN 1 stated that once the repeat last entry functionality was used, for a nurse to change it, they would have to manually perform an edit to strike the previous value and record a new one by entering the value manually. LVN 1 stated it would be apparent on the MAR that the new reading would be indicated as the correct one after the correction was made. LVN 1 stated the MAR was the only place blood sugar readings or medication administration records can be documented. LVN 1 stated sometimes the nurses will use the progress notes to explain anomalous (not standard or expected) readings or add clarification to an action, but will not routinely record blood sugars, vital signs, or medication administration records anyplace other than the MAR. LVN 1 stated, If it's not in the MAR, it most likely means they didn't do it. A review of the facility's policy titled, Administering Medications, reviewed January 2022 indicated medications were administered in a safe and timely manner, and as prescribed. The following information was checked/verified for each resident prior to administering medications, vital signs, if necessary. As required or indicated for a medication, the individual administering the medication records in the resident's medical record, the dosage. A review of the facility's policy titled, Insulin Administration, reviewed January 2022, indicated to provide guidelines for the safe administration of insulin to residents, and check blood glucose by fingerstick. A review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, reviewed January 2022, indicated the person performing this procedure should record the following information in the resident's medical record, the blood sugar results. Follow facility policies and procedure for appropriate nursing interventions regarding the blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral medication dosages).

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a history of falls, was a high fall risk, was on fall precautions, and a history of right [CONDITION(S)] (broken bone), was observed by staff frequently, maintaining a visual check, per Resident 1's care plan on falls / potential for injury and failed to specify the type of assistance Resident 1 required. Certified Nursing Assistant 1 was the assigned sitter for Resident 1 but assisted another resident. As a result, on 11/13/2021, at 1 PM, Resident 1 suffered a second injury to the right leg in four months. Resident 1 fell from the wheelchair and Family Member 1 assisted the resident back to bed. Resident 1 was transferred to the general acute care hospital (GACH) where Resident 1 was diagnosed with right femur (thigh bone) comminuted fracture (bone broken in at least two places caused by severe traumas) distal to the tip (away from) of the right hip prosthesis (artificial device implanted into the body). Resident 1 had a right femur periprosthetic fracture (a broken bone that occurs around surgical implants), and an open reduction and internal fixation (ORIF - a type of surgery used to stabilize and repair broken bones, some form of hardware is used to hold the bone together so it can heal) surgery was performed. Resident 1 required [MEDICATION(S)] (a controlled substance) to treat the severe pain. Findings: A review of Resident 1's Face sheet indicated Resident 1 was an [AGE] year old female, originally admitted to the facility on [DATE] with diagnoses including abnormalities of gait (manner of walking) and mobility, unspecified [CONDITION(S)] (disease caused by wearing down of protective tissue at the ends of bones), muscle weakness, history of falling, lack of coordination, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and [CONDITION(S)] (a mental disorder that affects a person's ability to think, feel, and behave clearly). A review of Resident 1's Care Plan, dated 9/3/2021, indicated Resident 1 was a high risk to experience complications related to the use of [CONDITION(S)] medication (changes the nervous system function and results in alterations in perception, mood, consciousness, cognition, or behavior), anti-[CONDITION(S)]: [CONDITION(S)] manifesting behavior cursing at staff. The care plan indicated the approach or plan included but was not limited to monitoring interaction of resident with others for appropriateness. A review of Resident 1's Admission Orders, dated 11/10/2021, indicated Resident 1's admission diagnoses included status post right hip hemiarthroplasty (hip joint replacement surgery 7/6/2021), [CONDITION(S)] disorder (a mental condition marked by alternating periods of elation and depression), depression, and aggressive behavior. The admission orders further indicated fall precautions were ordered for Resident 1. According to a review of Resident 1's Fall Risk assessment dated [DATE], Resident 1 was disoriented times three (person, place and time) at all times, and was chair bound. The fall risk assessment indicated Resident 1 had a score of 14 and that a score of 10 or greater indicated Resident 1 was a high risk for falls. A review of Resident 1's Fall Risk Care Plan, dated 11/10/2021, indicated Resident 1 had a potential and risk for falls or injury related to cognition deficits, poor decision making, use of psychoactive medications, noncompliance with asking for assistance, declining in functional status, lack of safety awareness and judgement, and history of falls. The care plan goals indicated Resident 1 would remain free from fall and self-injury, and to minimize injury related to fall. The care plan approach for Resident 1 included, but was not limited to, assessing and observing the level of safety awareness and judgement, provide verbal cueing, maintain a visual check when up in a wheelchair and when in bed, and assist the resident with transfer. The care plan did not indicate safety education to responsible party or family. According to a review of Resident 1's H&P, dated 11/11/2021, Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Physical Therapy (PT) Evaluation & Plan of Treatment, dated 11/11/2021, indicated Resident 1 was referred to PT due to new onset of decrease in functional mobility as to bed mobility, transfers, and gait, decreased neuromotor (relating to the effects of nerve impulses on muscles) control, decreased postural alignment and reduced sitting/standing balance placing resident at risk for decreased participation with functional tasks, falls, and decrease of mobility. The PT evaluation indicated Resident 1 was a fall risk and the plan of treatment indicated fall predictors included decreased knee strength, delayed anticipatory reactions, discontinuity of steps, inadequate postural control within transitional movements, poor negotiation of obstacles, and reduced strength in lower calf muscle. A review of Resident 1's Occupational Therapy (OT) Evaluation & Plan of Treatment, dated 11/11/2021, indicated Resident 1 was referred to OT due to exacerbation of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced balance, and increased need for assistance from others. The OT evaluation & plan of treatment further indicated Resident 1 presented with balance deficits, poor safety awareness, impaired reality and abstract thinking, reduced functional activity tolerance, and decline with functional mobility. A review of the Medication Administration Record (MAR), dated 11/11, 11/12 and 11/13/2021, indicated Resident 1 was administered [MEDICATION(S)] 0.25 mg (an antipsychotic medication that works on the brain to treat [CONDITION(S)]) by mouth at 9 AM for [CONDITION(S)] disorder. A review of Resident 1's Minimum Data Set (MDS - a comprehensive, standardized assessment and care screening tool), dated 11/13/2021, indicated Resident 1 was unable to make decisions, had history of falls, and required extensive assistance with one-person physical assist for activities of daily living (ADL - surface transfer, bed mobility, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene). The MDS indicated Resident 1 was not steady and only able to stabilize with staff assistance including transitioning from seated to standing position, walking, turning around, and surface to surface transfer. A review of the facility document titled, COVID-19 (a contagious respiratory disease caused by [CONDITION(S)]-CoV-2): Screening Checklist for Visitors, dated 11/13/2021, indicated Family Member 1 (FM 1) visited Resident 1 at the facility. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR) Communication Form, dated 11/13/2021, timed at 1 PM, indicated a change in condition, status post fall, right leg pain and swelling on right anterior (front) leg or femur. The SBAR communication form indicated FM 1 called the attention of the nursing staff and stated Resident 1 slid from her wheelchair to the floor. FM 1 assisted Resident 1 from the floor to the bed and called the nursing staff. The SBAR form indicated Resident 1 had complaints of discomfort on the right anterior leg with noted redness and swelling. The physician was notified, ordered for X-ray (diagnostic test that can be used to check for fractures), and transfer Resident 1 to the GACH. A review of Resident 1's Care Plan, dated 11/13/2021, indicated Resident 1 was status post fall and was at risk for additional fall/injurious fall. The approach / plan included visual check resident when up in the wheelchair. The care plan did not indicate any new interventions to prevent falls for Resident 1. A review of Resident 1's Resident Transfer Record, dated 11/13/2021, indicated Resident 1's reason for transfer included further evaluation due to swelling and pain at the right leg and femur fracture. According to a review of Resident 1's Physician's Telephone Order, dated 11/13/2021, Resident 1 was discharged to the GACH for further evaluation due to status post fall. A review of the GACH H&P indicated Resident 1 was admitted on [DATE] with a chief complaint of severe pain of the right leg with ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising). The H&P indicated the X-ray revealed a comminuted fracture (bone broken in at least two places caused by severe traumas like a car accident) distal to the tip (away from) of the right hip prosthesis. The H&P indicated Resident 1 returned to the GACH from the facility one week prior and had a past surgical history of a right hip arthroplasty within a year. A review of Resident 1's GACH Operative Report, dated 11/19/2021, indicated Resident 1 had a right femur periprosthetic fracture (a broken bone that occurs around surgical implants), and an open reduction and internal fixation (ORIF - a type of surgery used to stabilize and repair broken bones, some form of hardware is used to hold the bone together so it can heal) surgery was performed. A review of the GACH Medical Progress Noted dated 11/21/2021 indicated Resident 1 was sometimes agitated and complained of severe pain. The assessment and plan indicated Resident 1 was status post-surgical repair of the right femoral shaft fracture at the tip of the right hip prosthesis, with anxiety due to pain, chronic pain exacerbation, and to increase [MEDICATION(S)] (a controlled substance to treat severe pain) to 3-4 mg every three hours as needed. During an observation on 11/30/2021 at 2:55 PM, there were three residents noted in the facility Observation Room and one facility staff. During an interview with Licensed Vocation Nurse (LVN) 1, on 12/22/2021, at 1:30 PM, LVN 1 stated Certified Nursing Assistant (CNA) 1 called LVN 1 to come to the room to assess Resident 1. LVN 1 stated she assessed Resident 1 and observed redness and pain on Resident 1's right leg. LVN 1 further stated sitters (staff assigned to provide supervision for resident safety) were supposed to be with residents at all times. During an interview with CNA 1, on 12/22/2021, at 1:56 PM, CNA 1 stated she was assigned as the sitter for Resident 1 in the facility Observation Room. CNA 1 stated while she assisted another resident who asked for water, Resident 1 got up from the wheelchair and fell . CNA 1 stated, I had my back to Resident 1 while getting the water. It happened fast and it was my fault that Resident 1 fell . CNA 1 stated Resident 1 needed a sitter because Resident 1 always wanted to get up and had periods of aggressiveness. During an interview on 1/27/2022, at 3:11 PM, LVN 2 stated Resident 1 had poor safety awareness and family cannot be used as 1:1 supervision for residents. LVN 2 stated FM 1 reported to her that Resident 1 fell and that he brought her back into bed. LVN 2 stated the sitter was in the room when Resident 1 fell and was unsure why the sitter did not tell FM 1 not to move Resident 1 after falling. LVN 2 stated the sitter should have let the facility staff know about the fall so that a thorough assessment can be performed and to not cause further injury. LVN 2 stated the Observation Room was not a 1:1 room. On 1/27/2022, at 4:13 PM, during an interview, RN 2 stated Resident 1 had a history of falls and was placed in a room used for monitoring residents with a staff member supervising the resident. RN 2 stated the staff member in the room could not leave the room unless there was another staff member present to cover. RN 2 stated family members could not be used as sitters. RN 2 stated the sitter needed to be able to visualize the resident for their safety. RN 2 stated Resident 1 was ambulatory in the past and had unsteady gait. RN 2 further stated Resident 1 had right leg surgery recently (7/2021, four months prior) from a previous fall at the facility. During an interview on 1/27/2022, at 4:27 PM, the Director of Nurses (DON) stated Resident 1 was placed in the observation room where the facility provided staff members to constantly monitor residents in the room for safety and comfort. The DON stated the staff member in the observation room should be able to visualize the resident in the room. During an interview on 3/23/2022 at 11:57 AM, the DON stated Resident 1's sitter was not in proximity (nearby) to help the resident before she fell . The DON stated the importance of implementing new care plan interventions was to prevent further incidents and falls from occurring. A review of the facility's policy and procedure (P&P) titled, Falls - Clinical Protocol, dated 1/2021, indicated the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals were often at greater risk for serious adverse consequences of falls. A review of the facility's P&P titled, Safety and Supervision of Residents, dated 1/2021, indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated the facility-oriented and resident-oriented approaches to safety were used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual risk factors, and then adjusts interventions accordingly. The P&P further indicated resident supervision was a core component of the systems approach to safety. The type and frequency of resident supervision was determined by the individual resident's assessed needs and identified hazards in the environment. A review of the facility's undated policy and procedure titled, Care Plans-Preliminary, indicated the interdisciplinary team will review the Attending Physician's order and implement a nursing care plan to meet the resident's immediate care needs to assure that the residents immediate care needs are met and maintained. A review of the facility document titled, Care of Residents Requiring Continuous Supervision or One on One Supervision, undated, indicated the professional responsibilities/expectations when assigned in the observation room or as sitter include staff/sitters may not ask a family member or visitor to relieve them for a short break, sitters/staff may not leave the room nor leave the resident unattended in the room, and ensure resident's safety and comfort.

Based on observation, interview and record review, the facility failed to identify and ensure one of four sampled residents (Resident 2), who was at risk for pain and distress related to amputations on both lower legs (surgical removal) and had hypertension (high blood pressure, a condition when the force of the blood against the artery wall is too high), received care and services in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to: -Implement Resident 2's Physician's Order to administer pain medication [MEDICATION(S)]/acetaminophen 10/325 mg ([MEDICATION(S)] - a controlled substance used to relieve moderate to severe pain), as needed every six hours for severe pain. -Recognize and assess Resident 2's pain every shift, related to the resident's amputations. -Implement Resident 2's care plan for limitations in joint mobility and monitor for pain every shift. This deficient practice caused Resident 2 to experience severe untreated pain (rated 8 or 9 out of 10 on a pain scale from 0-10 where 10 is the worst possible pain) between 12/2 - 12/5/2021 when the pain medication was not administered as ordered. Findings: A review of Resident 2's Admission Record (face sheet) indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's Order Summary Report (a document summarizing a resident's current physician's orders), dated 9/27/2021, indicated Resident 2 was to receive [MEDICATION(S)]/acetaminophen 10/325 mg ([MEDICATION(S)]), one tablet by mouth every six hours as needed for severe pain (pain score 7-10.). On 9/29/2021, the Order Summary Report indicated the attending physician ordered Resident 2 to be assessed for pain every shift and indicated a score of 0 was no pain, 1-3 mild pain, 4-6 moderate pain, and 7-10 severe pain. A review of the care plan updated 9/2021 indicated Resident 2 had impaired physical mobility related to limited movement, with complications of unrelieved phantom pain (pain that feels like it is coming from a body part that is no longer there). The care plan indicated the contributing factor was Resident 2's left below the knee amputation and the right above the knee amputation. The care plan approach indicated to monitor for pain and notify the physician of any pain. There was no pain medication noted on the care plan. According to a review of the care plan updated 9/2021, Resident 2 had limitations in joint mobility with the approach to monitor for pain every shift. There was no pain medication noted on the care plan. A review of the care plan updated 9/2021 indicated Resident 2 was at risk for pain related to chronic pain syndrome with the goal to have pain under control with medication. The care plan approach indicated to administer analgesics as ordered, [MEDICATION(S)] 10-325 mg every six hours as need for severe pain, and to observe effectiveness of medications. A review of the annual Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) dated 10/16/2021 indicated Resident 2 was able to make decisions and did not have a memory problem. The MDS indicated Resident 2 received as needed (PRN) pain medication and had pain within the last five days. A review of Resident 2's MAR for November 2021 indicated Resident 2 typically received one to three doses of the pain medication [MEDICATION(S)]/acetaminophen 10/325 mg ([MEDICATION(S)]) per day for pain scores ranging from 7-9. A review of Resident 2's Controlled Drug Record for [MEDICATION(S)] /acetaminophen 10/325 mg ([MEDICATION(S)]) was unavailable from 11/4 to 11/17/2021. According to a review of Resident 2's progress notes, dated 11/1/2021 to 12/6/2021, there was no record that licensed nursing staff assessed or monitored Resident 2 for pain during the administration of [MEDICATION(S)] /acetaminophen 10/325 mg ([MEDICATION(S)]). A review of the Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) for Resident 2's [MEDICATION(S)] /acetaminophen 10/325 mg, indicated Resident 2 did not receive any [MEDICATION(S)]/ acetaminophen 10/325 mg between 12/1/2021 at 9:30 PM - 12/5/2021 at 10:13 PM (four days). During an observation of Medication Cart 2 on 12/4/2021 at 1:10 PM, with the Licensed Vocational Nurse (LVN 1), and a concurrent interview, LVN 1 stated Resident 2's [MEDICATION(S)]/acetaminophen 10/325 mg was reordered from the pharmacy but had not yet arrived. LVN 1 stated there was currently no other [MEDICATION(S)]/acetaminophen 10/325 mg available for Resident 2 in the facility. A review of Resident 2's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's progress notes dated 12/1 - 12/6/2021, indicated no record that licensed nursing staff assessed Resident 2 for pain between 12/1/2021 at 9:30 PM - 12/5/2021 at 10:13 PM. During an interview on 12/6/2021 at 4:10 PM Resident 2 stated he takes [MEDICATION(S)] for pain in his stumps since he had his legs amputated. Resident 2 stated he experienced 8 or 9 out of 10 pain throughout the time his pain medication was unavailable from 12/2/21 to 12/5/21. Resident 2 stated he did his best to take his mind off the pain and tried follow up with staff regarding his refill. Resident 2 stated he asked three charge nurses: LVN 2, LVN 3, and LVN 4 why his refill was late and got three different explanations. Resident 2 stated he did not receive the [MEDICATION(S)] or any other pain medication from the facility's emergency medication kit or any other source during that time. Resident 2 stated staff denied him medication from the emergency kit because they said it was not an emergency. Resident 2 stated he has been living at the facility for about fourteen months and this was the second time the facility failed to refill his [MEDICATION(S)]/acetaminophen 10/325 mg on time. During an interview on 12/6/2021 at 4:55 PM, LVN 4 stated Resident 2 asked him about his pain medication on Sunday 12/5/2021. LVN 4 stated he called the pharmacy around 5 PM to follow up. LVN 4 stated the medication was delivered later that night and he administered a dose to Resident 2 around 10 PM. During an interview on 12/8/2021 at 11:38 AM, the Director of Nursing (DON) stated she was unable to find the missing Controlled Drug Records for Resident 2's [MEDICATION(S)] /acetaminophen 10/325 mg between 11/1/2021 and 11/19/2021. The DON stated and confirmed Resident 2 was not offered any pain medication from the facility's emergency kit between 12/2/2011 and 12/5/2021 when his own supply of pain medication [MEDICATION(S)] /acetaminophen 10/325 mg was unavailable, and that licensed staff failed to assess his pain during that time. The DON acknowledged the facility failed to refill Resident 2's [MEDICATION(S)]/ acetaminophen 10/325 mg on time to ensure he did not go without treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility policy titled, Administering Medications, and dated April 2019, indicated medications are administered in accordance with prescriber orders, including any required time frame. A review of the facility's policy titled, Pain Assessment and Management, undated, indicated the purpose was to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs. The policy indicated the pain management program was based on a facility-wide commitment for appropriate assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy indicated the steps in procedure was to review the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's policy titled Medication Ordering and Receiving from Pharmacy, dated April 2008, indicated medications and related products were received from the dispensing pharmacy on a timely basis. A review of the facility policy and procedure dated April 2017, titled, Documentation of Medication Administration, indicated the facility shall maintain a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Signature and title of the person administering the medication.

This is a repeat deficiency from 10/2021, intake 6. Based on observation, interview, and record review, the facility failed to ensure [MEDICATION(S)]/acetaminophen ([MEDICATION(S)] - a controlled substance, medication used to treat moderate to severe pain) 10/325 milligrams (mg - a unit of measure for mass) was reordered from the pharmacy in a timely manner for one of four sampled residents (Resident 2) receiving medications for severe pain between 12/2/21 and 12/5/21. This deficient practice caused Resident 2 to experience severe untreated pain (rated 8 or 9 out of 10 on a pain scale from 0-10 where 10 is the worst possible pain) between 12/2 - 12/5/2021 when the medication was unavailable. Findings: A review of Resident 2's Admission Record (face sheet) indicated Resident 2 was originally admitted to the facility on [DATE] with diagnoses including acquired absence of left leg below knee (left leg amputation below the knee) and acquired absence of right leg above the knee (right leg amputation above the knee). A review of Resident 2's Order Summary Report (a document summarizing a resident's current physician's orders), dated 12/6/2021, indicated on 9/27/2021 the attending physician ordered [MEDICATION(S)]/acetaminophen 10/325 mg ([MEDICATION(S)]), one tablet by mouth every six hours as needed for severe pain (pain score 7-10.). On 9/29/2021, the Order Summary Report indicated the attending physician ordered Resident 2 to be assessed for pain every shift and indicated a score of 0 was no pain, 1-3 mild pain, 4-6 moderate pain, and 7-10 severe pain. A review of Resident 2's Medication Administration Record (MAR - a record of all doses of medications administered to the resident) for November 2021 indicated Resident 2 typically received one to three doses of the pain medication [MEDICATION(S)]/acetaminophen 10/325 mg ([MEDICATION(S)]) per day for pain scores ranging from 7-9. During an observation of Medication Cart 2 on 12/4/2021 at 1:10 PM, with the Licensed Vocational Nurse (LVN 1), an empty medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) for Resident 2's [MEDICATION(S)]/acetaminophen 10/325 mg was observed in the cart. During a concurrent interview, LVN 1 stated Resident 2's [MEDICATION(S)]/acetaminophen 10/325 mg was reordered from the pharmacy but had not yet arrived. LVN 1 stated there was currently no other [MEDICATION(S)]/acetaminophen 10/325 mg available for Resident 2 in the facility. A review of the Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) for Resident 2's [MEDICATION(S)]/acetaminophen 10/325 mg, indicated Resident 2 did not receive any [MEDICATION(S)]/acetaminophen 10/325 mg between 12/1/2021 at 9:30 PM - 12/5/2021 at 10:13 PM (four days). A review of Resident 2's MAR for December 2021 indicated Resident 2 received a dose of [MEDICATION(S)]/acetaminophen 10/325 mg around 9:30 PM on 12/1/2021 and did not receive another dose until 12/5/2021 around 10:13 PM. A review of Resident 2's progress notes dated 12/1 - 12/6/2021, indicated no record that licensed nursing staff assessed Resident 2 for pain between 12/1/2021 at 9:30 PM - 12/5/2021 at 10:13 PM. During an interview on 12/6/2021 at 4:10 PM Resident 2 stated he takes the [MEDICATION(S)] medication for pain in his stumps since he had his legs amputated. Resident 2 stated he experienced 8 or 9 out of 10 pain throughout the time his [MEDICATION(S)]/acetaminophen 10/325 mg was unavailable from 12/2/21 to 12/5/21. Resident 2 stated he did his best to take his mind off the pain and tried follow up with staff regarding his refill. Resident 2 stated he asked three charge nurses: LVN 2, LVN 3, and LVN 4 why his refill was late and got three different explanations. Resident 2 stated he did not receive the [MEDICATION(S)] or any other pain medication from the facility's emergency medication kit or any other source during that time. Resident 2 stated staff denied him medication from the emergency kit because they said it was not an emergency. Resident 2 stated he has been living at the facility for about fourteen months and this was the second time the facility failed to refill his [MEDICATION(S)] on time. During an interview on 12/6/2021 at 4:50 PM, LVN 5 stated he was unable find a record of the refill request sent for Resident 2's [MEDICATION(S)]/acetaminophen 10/325 mg via fax. LVN 5 stated sometimes refill requests were sent to the pharmacy directly through the computer system but he did not know how to access a record of that. During an interview on 12/6/2021 at 4:55 PM, LVN 4 stated Resident 2 asked him about his pain medication on Sunday 12/5/2021. LVN 4 stated he called the pharmacy around 5 PM to follow up and was told it would be delivered that night. LVN 4 stated he did not understand why the pharmacy delayed medication refills. LVN 4 stated the medication was delivered later that night and he administered a dose to Resident 2 around 10 PM. During a telephone interview on 12/7/2021 at 2:10 PM, the Registered Pharmacist (RPH) at Pharmacy 1 stated the facility first requested a refill for Resident 2's [MEDICATION(S)] /acetaminophen 10/325 on 12/3/2021 at 11:24 AM via a phone call from LVN 6. The RPH stated Pharmacy 1 processed the refill on 12/4/2021 and delivered it to the facility on [DATE]. The RPH stated there was no other issues with filling the prescription on time that were apparent from the pharmacy's documentation. The RPH stated the pharmacy always requests at least two to three days of advanced notice to process refills and that if the facility was out of Resident 2's [MEDICATION(S)]/acetaminophen 10/325 mg, they could have called the pharmacy to request access to the [MEDICATION(S)]/acetaminophen 10/325 mg available in the facility's emergency medication kit. The RPH stated there was no record of any request from the facility to access the facility's emergency kit between 12/3/2021 and 12/5/2021. During an interview on 12/8/2021 at 11:38 AM, the Director of Nursing (DON) stated the facility's policy was to reorder any medication that was active when a five-day supply or less of the medication remained. The DON confirmed the first time the facility requested a refill for Resident 2's [MEDICATION(S)]/acetaminophen 10/325 mg was when LVN 6 called Pharmacy 1 for a refill on 12/3/2021, two days after the last dose was administered. The DON stated and confirmed Resident 2 was not offered any pain medication from the facility's emergency kit between 12/2/21 and 12/5/21 when his own supply of pain medication [MEDICATION(S)] /acetaminophen 10/325 mg was unavailable, and that licensed staff failed to assess his pain during that time. The DON acknowledged the facility failed to refill Resident 2's [MEDICATION(S)]/acetaminophen 10/325 mg on time to ensure he did not go without treatment for severe pain. A review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, dated April 2008, indicated medications and related products were received from the dispensing pharmacy on a timely basis. The policy indicated to reorder medication five days in advance of need to assure an adequate supply was on hand. A review of the facility's policy and procedure revised in April 2019, titled, Controlled Substances, indicated controlled substances are reconciled upon receipt, administration, disposition. The nurse administering the medication was responsible for recording time, quantity of the medication remaining. A review of the facility's policy and procedure titled, Medication Orders and Receipt Record, dated 1/2021 indicated the facility shall document all medications that it orders and receives. The Charge Nurse will maintain medication order and receipt records. The medication order/receipt record shall contain: Order date; Name and title of person placing the order. The date and quantity received; and Name and title of the person receiving the order. The Director of Nursing Services will designate individuals to be responsible for completing medication order/receipt forms. Medications should be ordered in advance, based on the dispensing pharmacy's required lead time.

Based on interview and record review the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) provided the necessary assistance and supervision to prevent accident with injury for one of two sampled residents (Resident 1). Resident 1, who was quadriplegic (partial or complete paralysis [inability to move] from the neck down including both arms and legs, caused by injury or disease to the spinal cord [long, tube like structure that begins at the end of the [CONDITION(S)] to the bottom of the spine that allows movement, feeling sensation and control of body functions], and was assessed as needing one-person assistance with eating and drinking, the facility failed to: 1. Provide supervision and assistance when Resident 1 was drinking hot chocolate as per plan of care assessment and per policies. 2. Provide protective covering or clothing to protect Resident 1 from accidental spills. As a result, on 2/17/2021, at about 5 p.m., Resident 1 sustained a second-degree burn (this type of burn affects both the first layer of the skin [epidermis] and the second layer of skin [dermis]. It may cause swelling and red, white, or blotchy [uneven color] skin. Blisters may develop, and pain can be severe. Deep second-degree [CONDITION(S)] can cause scarring) from hot chocolate that spilled on the resident ' s chest. The wound did not heal for four months and got infected requiring transfer to General Acute Care Hospital 1 (GACH 1) on 6/28/2021. Findings: A review of Resident 1 ' s Admission Record (Face Sheet) indicated the facility readmitted the resident on 1/25/2021 with diagnoses including [CONDITION(S)], [CONDITION(S)] (bacterial infection involving the inner layers of the skin), and [CONDITION(S)] (sudden, uncontrolled electrical activity in the brain that causes temporary abnormalities in muscle tone or movements [stiffness, twitching or limpness], behaviors, sensations or states of awareness). A review of Resident 1 ' s Minimum Data Set (MDS, standardized assessment and care-screening tool), dated 12/10/2020, indicated the resident was alert and oriented (able to understand and make decisions). Resident 1 was totally dependent on staff with bed mobility, transfers, eating, personal hygiene, and bathing. Resident 1 needed one-person physical assist with eating and bed mobility and needed two or more-person physical assistance with transfers. A review of Resident 1 ' s Occupational Therapy (OT, treatment to improve motor skills, balance and coordination) Evaluation and Plan of Treatment form, dated 1/27/2021, indicated Resident 1 had been a quadriplegic for five years and was totally dependent with all self-care including feeding, hygiene, and grooming. Resident 1 had impaired fine motor (ability to make movements using the small muscles in the hands and wrists) and impaired gross motor (involve large muscle of the arms legs and trunk such as sitting, walking, and running) coordination. Resident 1 could only move his neck and use it for call lights and to control the stylus (object shaped like a pen used to draw, point, sign, and swipe on touchscreen electronic devices) for his computer tablet. A review of Resident 1 ' s Care Plan developed on 1/25/2021 indicated Resident 1 had self-care deficits related to joint limitation, [CONDITION(S)], at risk for unavoidable decline and infection. Interventions included assisting the resident with all activities of daily living (ADLs - such as eating, transferring, personal hygiene and bathing) as needed and provide a safe environment.) A review of Resident 1 ' s Care Plan developed on 1/25/2021 for the resident ' s high risk for trauma/injuries related to [CONDITION(S)], had a goal for the resident not to have traumatic injuries within the next three months. The interventions included always maintaining supervision and vigilance, reducing unsafe activities, and modifying them as needed, and keeping an environment free of safety hazard such as toxic and very hot liquids. A review of Resident 1 ' s Nutritional assessment dated [DATE] indicated Resident 1 was a feeder (action of a person feeding another person who cannot otherwise feed themselves). A review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR, is a form for the health care professionals to communicate effectively with one another and allows for important information to be transferred accurately) Communication Form dated 2/17/2021 timed at 9 p.m. Indicated Resident 1 complained of burning sensation of the skin (on his chest) after drinking hot chocolate with a straw and the hot chocolate dripped on his chest. Resident 1 had slight redness on the chest and cold compress was applied for 20 minutes. Tylenol (acetaminophen, medication that treat minor aches and pains, and reduces fever) 650 milligrams (mg, unit of measurement) was given anticipating any pain or discomfort. Resident 1's attending physician was notified and ordered to monitor for pain and skin. A review of Resident 1 ' s Non-Pressure Sore Skin Problem Report dated 2/18/2021 indicated the burn site on the upper chest was pink in color and unable to determine the size and the extent. A review of Resident 1 ' s Skilled Nursing Facility (SNF) Wound Care (form) dated 2/18/2021, indicated the resident (Resident 1) had an upper chest burn. The peri-wound (tissue surrounding the wound) was fragile, erythematous (redness of the skin caused by injury) and discolored. The treatment plan included a physician ' s order to cleanse the burn area with normal saline (N/S - a salt and water solution like the blood plasma [yellowish liquid component of blood] and apply [MEDICATION(S)] cream (used to prevent and treat wound infections in patients with second- and third-degree [CONDITION(S)] and cover with dressing for 30 days. A review of the Treatment Administration Record (TAR) dated 3/19/2021 indicated to cleanse the upper chest burn with NS pat dry and apply xeroform gauze (a yellow gauze dressing used to keep wounds moist) followed by non- adherent pad and cover with dry dressing daily for 30 days. A review of Resident 1 ' s SNF Wound Care dated 4/1/2021 indicated Resident 1 ' s upper chest burn was not healing, and debridement (removal of dead tissue to promote healing) was done by the wound care specialist. The treatment plan included to clean with N/S and apply Xeroform daily. A review of Resident 1 ' s SNF Wound Care dated 4/22/2021 indicated the upper chest burn periwound was fragile, erythematous, scar and discolored. The treatment plan included to clean with N/S and apply [MEDICATION(S)] (an antibiotic that prevents bacteria from growing in the skin) daily. A review of the Physician Order dated 5/8/2021 indicated to cleanse the upper chest burn with NS, pat dry and apply triple antibiotic (antibiotic that contains [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] used to prevent infection) ointment, cover with non-adherent pad daily for 14 days. A review of the SNF Wound Care dated 5/20/2021 indicated Resident 1 ' s upper chest burn had multiple scabs and multiple superficial openings. Treatment plan included to clean with normal saline and apply [MEDICATION(S)] cream daily and to start on [MEDICATION(S)] D (sulfamethoxazole and [MEDICATION(S)], combination antibiotic to treat infections) 1 tablet orally one time a day for seven days. A review of the SNF Wound Care dated 6/3/2021 indicated the upper chest burn had multiple superficial openings and with moderate serosanguineous (wound discharge contains blood and clear yellow liquid) drainage. The treatment included to cleanse the wound with normal saline and apply alginate (highly absorptive dressing used to manage moderate to large amounts of exudate) daily. A review of the SNF Wound Care dated 6/17/2021 indicated Resident 1 ' s upper chest burn size was 13.5 cm by 10.5 cm x 0.1 cm. There was moderate serosanguineous drainage. Treatment plan included to cleanse with NS and apply xeroform every other day for 30 days. A review of the SNF Wound Care dated 6/24/2021 indicated Resident 1 ' s upper chest wound measure 13 cm. by 10 cm by 0.1 cm. There was light serosanguineous drainage. The treatment plan included to cleanse with NS and apply Santyl (applied to severe [CONDITION(S)] or skin ulcers to help remove dead skin tissue and aid in wound healing) and collagen powder (when sprinkled in the wound, dissolves to form a protective gel and stimulate wound healing) daily. A review of the SBAR dated 6/28/2021 at 9 p.m., indicated Resident 1 had non healing wounds. The primary physician was notified and gave an order to transfer Resident 1 to GACH 1 for further evaluation. A review of the GACH 1 History and Physical (H and P) dated 6/29/2021 at 11:49 a.m., indicated Resident 1 had a right chest open wound with pus draining. Resident 1 was started on [MEDICATION(S)] (antibiotic) 3.375 grams (Unit of measurement) intravenous (IV, given into the veins) every six hours and [MEDICATION(S)] (antibiotic) for pharmacy to dose. Resident 1 had a wound culture (a test that detects and identify bacteria that causes the infections in a wound) of the burn site. A review of the GACH 1 Infectious Disease Consultation dated 7/5/2021 at 1:00 p.m., indicated Resident 1 had pain at the site of the burn in the right side of the chest. The Consultation Report indicated Resident 1 had [CONDITION(S)] (deep infection of the skin) of the chest wall with Methillin-resistant Staphylococcus aureus (MRSA, a type of bacteria that is resistant to several antibiotics). A review of Resident 1 ' s Nurses ' Admission and Assessment record dated 7/7/2021 indicated Resident 1 was readmitted to the facility on [DATE]. Resident 1 had upper chest burn site measuring 8.5 cm by 9.0 cm. A review of the Admission Orders Record Continuation dated 7/7/2021 indicated an order for [MEDICATION(S)] DS one tablet orally every 12 hours for seven days for right chest wound MRSA. During an interview and a concurrent record review with the Licensed Vocational Nurse 1 (LVN 1), on 7/6/2021 at 2:45 p.m., Resident 1's MDS dated [DATE] was reviewed. LVN 1 stated based on the MDS assessment, Resident 1 was dependent on one person when eating and drinking. LVN 1 further stated, a staff should stay with the resident while he was eating and drinking. LVN 1 stated Resident 1 was alone when drinking the hot chocolate. Resident 1 spilled his hot chocolate on his chest that caused a second-degree burn. On 7/1/2021, at 3:25 p.m., during an interview, Director of Nursing (DON) stated when Resident 1 was drinking the hot chocolate, his chest was bare. DON stated the chest burn was not healing despite treatment, became crusty and had scabs. Resident 1 was sent to GACH 1 on 6/28/2021 for treatment to the non-healing chest burn. On 7/1/2021 at 3:50 p.m., during an interview, CNA 1 stated Resident 1 requested hot chocolate drink before dinner on 2/17/2021 and she gave him the hot chocolate drink as requested. CNA 1 stated she placed the straw in the hot chocolate, set-up the table for Resident 1 to drink it and left. CNA 1 stated after approximately five minutes she saw the call light and heard Resident 1 calling her name. CNA 1 went to check on the resident and saw the hot chocolate spilled on Resident 1's chest. CNA 1 dried Resident 1's chest with a towel and informed LVN 2. CNA 1 stated she should not have left Resident 1 while he was drinking the hot chocolate. On 7/8/2021, at 12:25 p.m., during an interview, Occupational Therapist 1 (OT 1) stated Resident 1 needed assistance when eating and drinking. On 7/8/2021, at 12:35 p.m., during an interview, Resident 1 stated on 2/17/2021 CNA 1 gave him the hot chocolate drink as he requested, set up the hot chocolate for him to drink with the straw and left. Resident 1 stated he started to take a sip and found the chocolate drink too hot. He let go of the straw and the hot drink kept dripping on his chest. Resident 1 stated he suffered a burn on his chest which did not heal well, and he had to go to the hospital. Resident 1 stated the hospital informed him that his wound was infected. Resident 1 further stated he was given intravenous (given through the vein) antibiotics. On 7/8/2021 at 1:20 p.m., during an interview, the DON stated the burn from the hot chocolate could have been prevented if Resident 1 had supervision when he was drinking the hot chocolate and having protective clothing on his chest and not a bare chest. On 7/9/2021 at 4:57 p.m., during a telephone interview, LVN 2 stated on 2/17/2021, she checked Resident 1 after the hot chocolate spilled on his chest. Resident 1 complained of burning sensation on his chest. LVN 2 stated Resident 1 was dependent on staff for ADLs and LVN 2 stated CNA 1 should have stayed with Resident 1 while he was drinking his hot chocolate. A review of the facility ' s policy and procedures, titled, Activities of Daily Living (ADLs), Supporting, revised on 3/2018, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care) b. Mobility (transfer and ambulation, including walking) c. Elimination (toileting) d. Dining (meals and snacks) and e. Communication (speech, language, and any functional communication systems). A review of the facility ' s policy and procedures titled, Serving Hot Beverages and Soups to Residents, with a revised date of 1/1/2018, indicated to use caution prior to serving hot beverages/soup to residents who may be unable to determine the safety of the item in question or are at risk for a burn. The Policy indicated to follow the safety precautions which included residents should be supervised while drinking hot beverages. When serving hot liquids to residents with behavioral or medical conditions that put them at risk for spills, consider the following: It is important to evaluate a resident's ability to independently manage hot beverages and provide appropriate assistance .Allow hot liquids to cool before serving. A review of the facility ' s policy and procedures titled Safety of Hot Liquids, with a revised date of 10/2014 indicated residents who prefer hot beverages (such as coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular Hot Liquids Safety Evaluations as indicated and document the risk factors for scalding and [CONDITION(S)] in the care plan. Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from [CONDITION(S)]. Such interventions may include: Maintaining a hot liquid serving temperature of not more than 180 degrees Fahrenheit, serving hot beverages in a cup with a lid .Providing protective lap covering or clothing to protect skin from accidental spills and Staff supervision or assistance with hot beverages.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) identified as high risk for falls and with prior history of fall, was free from fall. Certified Nursing Assistant 4 (CNA 4) was assigned to one to one (1:1, not leave a resident unattended, be watchful, and call for help if Resident 2 had a change in behavior) to supervise Resident 2. CNA 4 was not trained prior to being assigned the 1:1 supervision for Resident 2. This deficient practice resulted in Resident 2 falling on 3/13/2021 in the facility and transferred to general acute care hospital (GACH) for fall and desaturation (abnormal oxygen level in the blood) via 911 (emergency assistance from police, fire, and ambulance services). In GACH, the resident was diagnosed with right [CONDITION(S)] (break in a bone), two right posterior (behind) fractured ribs, right-sided hemothorax (a collection of blood in the space between the chest wall and the lung), and a left frontal scalp contusion (a bruise from a direct blow or an impact, such as a fall). Resident 2 had surgical repair of the right [CONDITION(S)]. Findings: A review of Resident 2's Facesheet dated 3/22/2021, indicated the facility originally admitted Resident 2 on 10/16/2020 with a diagnoses including abnormalities of gait (a person's manner of walking) and mobility, unspecified dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbance, lack of coordination, unspecified [CONDITION(S)] (a disease that damages the eye's optic nerve and can lead to [CONDITION(S)], often caused by high pressure in the eye), and history of [CONDITION(S)] (TIA - a brief episode of neurological dysfunction resulting from an interruption in the blood supply to the brain or the eye, sometimes a warning of stroke) and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) without residual deficits. A review of Resident 2's Fall Risk assessment dated [DATE], indicated Resident 2 scored a six (total score is 10 or greater, a resident is considered at HIGH RISK for falls). Interventions including initiate prevention protocol immediately and document on the care plan. A review of Resident 2's Resident fall risk Care Plan dated 10/16/2020, indicated Resident 2 had a potential and at risk for falls or injury related to cognition deficits, poor decision making, unsteady gait, poor body balance and control, declining in functional status, lack of safety awareness and judgement, and limitations in joint mobility on lower extremities. The care plan goals indicated Resident 2 would remain free from fall and self-injury, and to minimize injury related to fall. The care plan further indicated approach plan for the resident included, but was not limited to, assessing and observing level of safety awareness and judgement, provide verbal cueing, maintain a visual check when up in a wheelchair and when in bed, and assist the resident with transfer. A review of Resident 2's Physical Therapy (PT) & Plan of Treatment dated 10/17/2020, indicated Resident 2 was referred to PT for .exhibiting new onset of decrease in strength, decrease in functional mobility, reduced ability to safely ambulate and cognitive deficits indicating the need for PT to increase independence with gait and facilitate with all functional mobility. The PT & Plan of Treatment further indicated Resident 2's bilateral (both) lower extremity strength was three of of five (3/5, Part moves through full range against gravity without added resistance; muscle holds test position - no added pressure). The PT & Plan of Treatment further indicated Resident 2 was able to maintain balance without support against minimum resistance while sitting and standing. A review of Resident 2's Minimum Data Set (MDS - a comprehensive, standardized assessment and care screening tool) dated 10/23/2020, indicated Resident 2 had moderate cognitive impairment, required limited to extensive assistance with one to two person physical assist for activities of daily living (ADL, surface transfer, bed mobility, locomotion on and of the unit, dressing, eating, toilet use, and personal hygiene). The same MDS indicated Resident 2 was not steady and only able to stabilize with staff assistance including transition from seated to standing position, walking, turning around, and surface to surface transfer. The MDS further indicated Resident 2 had no prior history of falls. A review of Resident 2's Care Plan dated 10/26/2020, indicated Resident 2 was at risk for falls related to muscle weakness, use of psych (psychiatry, mental illness), meds (medication), impaired vision due to [CONDITION(S)], impaired safety judgement related to dementia. The goals included to minimize the risk for falls the next three months and decrease significant injury as a result from falls in the next three months. The care plan approach plan included, and not limited to, completing a fall risk assessment on admission and every three months, and as needed, and to monitor/anticipate for factors that caused prior falls. A review of Resident 2's Occupation Therapy (OT) & Plan of Treatment, dated 10/29/2020, indicated Resident 2 was referred to OT for continuation of treatment due to new onset of decrease in strength, decrease in functional mobility, reduced balance, reduced functional activity tolerance, decreased coordination, reduced ADL participation and decreased judgement. The OT & Plan of Treatment further indicated; Resident 2 was able to maintain balance without support against minimum resistance. The OT & Plan of Treatment further indicated, Resident 2 was .noted to have strength deficits, impaired cognition, balance deficits, reduced functional activity tolerance, impaired coordination resulting in overall decline with self-care and mobility. A review of Resident 2's SBAR (Situation-Background-Assessment-Recommendation) Communication Form dated 11/7/2020, indicated The change in condition, symptoms, or signs observed and evaluated is/are unwitnessed fall. The SBAR communication form further indicated Resident found lying on the floor. A review of Resident 2's Fall Risk Assessment, dated 11/7/2020, the fall risk assessment indicated, Resident 2 scored a 10. The fall risk assessment further indicated, If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. During a review of Resident 2's Resident Care Plan, dated 11/7/2020, the resident care plan indicated, Resident 2's concerns and problems included status post fall and risk for additional fall/injurious fall. The resident goals included minimize the risk for falls in the next one month, decrease significant injury as a result from falls in the next one month, and will be free from injury for 72 hours. The resident care plan further indicated, the approach plan included assessing Resident 2 for injury and discomfort, reminding the resident to always ask for help/assistance, assist the resident to bathroom for toileting needs, visual check when resident is up in the wheelchair, and placing Resident 2 in front of the nurses' station or recreational areas where staff is present for visual check, and physical therapy (PT) screening status post fall. A review of Resident 2's Resident Care Conference Review dated 11/9/2020, indicated an interdisciplinary team (IDT, health professionals from different disciplines, along with the patient, who work collaboratively as a team) meeting was conducted to address Resident 2's unwitnessed fall. The resident care conference review further indicated Resident 2 was found lying on the floor on the right side of the bed. A review of Resident 2's Fall Risk assessment dated [DATE], indicated Resident 2 scored a 10 (total score is 10 or greater, the resident is considered at HIGH RISK for falls), for fall risk, and prevention protocol initiated immediately and documented on the care plan. A review of Resident 2's Fall Risk assessment dated [DATE], indicated Resident 2 scored a 13 for fall risk, and prevention protocol initiated immediately and documented on the care plan. A review of Resident 2's Resident Care Plan, dated 2/11/2021, indicated Resident 2 was at risk of falls related to history of falls, impaired cognition, impaired vision, impaired mobility & transfer, fall risk assessment score, elimination status, ambulation status. The care plan goals indicated was to minimize risk for falls in the next three months and to decrease significant injury as a result from falls in the next three months for the resident. The care plan further indicated to update the resident's fall assessment, monitor anticipate/intervene for factors causing prior falls, monitor environment for wet spots or items below field of vision, assure lighting is adequate, maintain call light within reach and answer promptly, visual checks, and observe resident's activities when out of bed. A review of Resident 2's SBAR Communication Form dated 2/12/2021, indicated The change in condition, symptoms, or signs observed and evaluated is/are swelling left eye due to found sitting on the floor mat at the foot of the bed. A review of Resident 2's Fall Risk assessment dated [DATE], indicated Resident 2 scored 15 for fall risk, and prevention protocol initiated immediately and documented on the care plan. A review of the facility's Inservice Attendance dated 2/15/2021, and topic titled Education/Training about care of residents requiring continuous supervision or 1:1 supervision, indicated that Professional responsibilities/expectations when assigned in the observation room or as sitter . Ensures resident's safety and comfort. The inservice attendance further indicated CNA 4 did not attend the inservice. A review of Resident 2's MDS dated [DATE], indicated Resident 2 had severe cognition impairment, and required extensive assistance or was totally dependent on staff for ADLs, and was only able to stabilize with staff assistance when transferring between bed and chair or wheelchair. The MDS further indicated, Resident 2 did not have a fall in the last two to six months prior to admission/entry or reentry. A review of Resident 2's Resident Care Plan, dated 3/6/2021, indicated Resident 2 was a potential/risk for fall/injury related to cognition deficit, unsteady gait, poor body balance and control, declining in functional status, and dementia. The care plan goals indicated the resident goals will remain free from fall and self-injury as possible as condition permits and minimize injury related to fall. The care plan further indicated Resident 2 be assessed and observed level of safety awareness and judgement, provide verbal cueing related to safety issues and concerns, maintain visual check when up in wheelchair and when in bed, maintain a clutter free environment, call light within reach, keep bed in lowest setting, and assist resident with transfer. A review of Resident 2's Fall Risk assessment dated [DATE], indicated Resident 2 scored a 16 for fall risk, and prevention protocol initiated immediately and documented on the care plan. A review of Resident 2's PT & Plan of Treatment dated 3/8/2021, indicated, Resident 2 was referred to PT for exhibiting new onset of decrease in strength, decrease in functional mobility, reduced ability to safely ambulate and reduced sensation indicating the need for PT to assess functional abilities, facilitate with all functional mobility, increase functional activity tolerance and facilitate discharge planning. The PT & Plan of Treatment indicated, Resident 2's bilateral lower extremity strength was two over five (2/5, part moves through full range on a gravity-eliminated plan, takes minimal resistance then breaks) and he had poor sitting and standing balance. The PT & Plan of Treatment further indicated, Resident 2 was totally dependent with bed mobility (rolling, bridging, scooting, lying down to sitting up, sitting up to lying down) and transfers (Sitting to standing). A review of Resident 2's OT Evaluation & Plan of Treatment, dated 3/8/2021, indicated Resident 2 was referred to OT for .new onset of decrease strength in functional mobility, reduced balance, reduced functional activity tolerance, decreased coordination, reduced ADL participation and decreased judgement. The OT Evaluation & Plan of Treatment indicated, Resident 2 had poor sitting balance during ADLs and was unable to stand during ADLs. The OT Evaluation & Plan of Treatment further indicated, Resident 2 was .noted to have strength deficits, impaired cognition, balance deficits, reduced functional activity tolerance, impaired coordination resulting in overall decline with self-care and mobility, and dependent and requires extensive assist with self-care. A review of Resident 2's Standard Psychotherapeutic Drug (medications used to treat mental disorders) Order dated 3/10/2021, indicated Resident 2 was prescribed [MEDICATION(S)] (a medication used to treat [CONDITION(S)] [serious mental illness, a disorder that affects a person's ability to think, feel, and behave clearly] 100 milligrams (mg, unit dose measurement) by mouth every day for [CONDITION(S)]. The same standard psychotherapeutic drug order further indicated, the side effects of [MEDICATION(S)] included tardive dyskinesia (facial and tongue movements), cognitive impairment, decreased mental status, akathisia (a state of agitation, distress, and restlessness), and Parkinsonism (tremors, drooling, and rigidity). A review of Resident 2's Physician and Telephone Orders dated 3/10/2021, indicated bilateral (both) padded quarter (¼ )side rails to reduce risk of injury in a fall, fall precaution, floor mats, low bed for preventative reasons, and provide 1:1 supervision. A review of Resident 2's [CONDITION(S)] (medication that affects behavior, mood, thoughts, or perception) Medication Record, dated 3/2021, indicated Resident 2 received [MEDICATION(S)] 100mg at 9:00 AM on 3/11/2021 and 3/12/2021, and also received [MEDICATION(S)] 30mg by mouth at 9:00 PM on 3/10/2021, 3/11/2021, and 3/12/2021.(not sure relevance, was the resident not to receive these medication). A review of Resident 2's Progress Note, dated 3/13/2021, indicated Resident 2 was found near his bed lying on his left side, unable to move his right lower extremities, and noted with slight swelling on the left side of his face. A review of Resident 2's Physician and Telephone Orders, dated 3/13/2021, indicated to transfer Resident 2 to hospital via 911 due to fall and desaturation. A review of Resident 2's GACH Emergency Department (ED) Documentation dated 3/13/2021, indicated Resident 2 was brought from the facility after a fall from bed. The ED documentation further indicated Resident 2 had a right [CONDITION(S)], fractures involving the right posterior 6th and 7th ribs with associated small right-sided hemothorax. The ED documentation further indicated medical decisions including to admit Resident 2 to SICU (surgical Intensive Care Unit), trauma (physical injuries of sudden onset and severity which require immediate medical attention), and orthopedic (branch of medicine dealing with correction of deformities of bones or muscles) consult. The ED documentation further indicated Resident 2 had intravenous (into a vein) line inserted (placed) and administered oxygen two (2) liters per min (L/Min). The ED documentation indicated Resident was initially just moaning, no responding to questions but late with pain controlled, states pain in right (R) leg/hip. A review of Resident 2's GACH Pelvis XR (X-Ray) dated 3/13/2021, indicated Resident 2 had right intertrochanteric (hip) fracture. A review of Resident 2's GACH CT (Computed Tomography - computerized X-ray imaging procedure) of the abdomen, pelvis, and Thorax (part of the body between the abdomen and neck) dated 3/13/2021, indicated Resident 2 sustained intertrochanteric fracture involving the right hip, and fractures involving the right posterior 6th and 7th ribs with associated small right-sided hemothorax. A review of Resident 2's GACH CT Head/Brain dated 3/13/2021, indicated Resident 2 sustained a small left frontal scalp contusion. A review of Resident 2's GACH History and Physical (H&P) dated 3/13/2021, indicated Resident 2 was diagnosed with a small frontal scalp contusion, a right hip intertrochanteric fracture, and fracture of right posterior 6th and 7th ribs with small hemothorax. A review of Resident 2's GACH Orthopedic Consultation from the GACH, dated 3/13/2021, indicated Resident 2 was brought in to the GACH with a right intertrochanteric fracture. The orthopedic consultation further indicated, Resident 2 was consented for a right hip open reduction and internal fixation (a type of hip surgery) versus possible hemiarthroplasty (a type of hip surgery). The orthopedic consultation indicated, The risks include but are not limited to infection, bleeding, damage to surrounding structures including nerves, vessels, tendons, muscles, and bone, recurrence of patient problem and need for further surgery. The risks associated with anesthesia include cardiopulmonary (relating to the heart and lungs), [CONDITION(S)] (relating to the brain) events, and even death. A review of Resident 2's Operative Report from the GACH, dated 3/14/2021, indicated Resident 2 underwent a Right femur (thigh bone) closed reduction and medullary fixation (a type of hip surgery) under General endotracheal anesthesia (inhalation anesthesia technique in which anesthetic and respiratory gases pass through a tube placed in the trachea, or wind pipe, through the mouth or nose). The operative report further indicated, during the procedure, Resident 2 had a left femoral line (an intravenous line inserted through the groin) inserted and was transfused with four units of packed red blood cells (PRBC, blood). A review of Resident 2's GACH SICU H&P dated 3/16/21 and timed 9:17 AM, indicated Resident 2 was groaning and complaining of pain of the right leg. During an interview on 4/26/2021, at 9:15 AM, Licensed Vocational Nurse1 (LVN) 1 stated, Resident 2 had a history of restlessness, unable to follow instructions, and had problems with his sight. LVN 1 further stated Resident 2's fall interventions implemented included 1:1 supervision, fall mats, bedside rails, call lights in place, but the resident does not use the call light. LVN 1 further stated he did not have a full history if the resident has a history of falls in the past. During an interview on 4/27/2021, at 8:55 AM, LVN 2 stated, that on 3/13/2021, he was performing rounds in the morning and observed CNA 4 seated between Resident 2 and Resident 7's bed and observed Resident 2 sleeping at that time. LVN 2 continued to state that at around 9:15 AM, CNA 4 reported that Resident 2 fell . LVN 2 found Resident 2 on the floor, at the bed side, laying on the right side. LVN 2 stated Resident 2 left side of face was swollen. LVN 2 further stated, Resident 2 had a 1:1 sitter because of the resident had poor safety awareness, was confused, and had unsteady gait. LVN 2 stated, the interventions implemented to prevent falls for Resident 2 included 1:1 sitter, bed in the lowest position, floor mats, and the call light was within reach. During record review with MDS Coordinator 1 (MDS 1), on 4/27/2021 at 10:55 AM, indicated Resident 2's MDS dated [DATE], did not indicate the resident fell in the last two to six months prior to admission/entry or reentry. In a concurrent interview, the MDS 1 stated Resident 2's same MDS should have indicated the resident fell on [DATE]. During an interview on 4/27/2021 at 12:22 PM, Registered Nurse 1 (RN) stated that on 3/13/2021 at around 9:00 AM, she was informed that Resident 2 fell . RN 1 stated she found Resident 2 on the floor with left face swelling. RN 1 stated Resident 2's oxygen saturation (measure of the amount of oxygen in the blood) was dropping low to the 80's (oxygen saturation reference: 95 percent [%] to 100%), called 911, and the resident transferred to GACH. RN 1 further stated Resident 2 was a high risk for fall because the resident had dementia, unsteady gait, weakness, and history of falls in the facility. RN 1 further stated the fall interventions implemented for Resident 2 included 1:1 sitter supervision, floor mats, and ensure the call light was within reach. During an interview on 4/27/2021 at 3:34 PM, CNA 4 stated she was assigned to supervise Resident 2 as a 1:1 sitter the day the resident fell . CNA 4 stated Resident 2 got up really quickly and he fell . CNA 4 stated Resident 2 was confused, had poor vision, and was not aware Resident 2 could get up out of bed. CNA 4 stated, she sat close to the bed of the resident and had eye contact with the resident. CNA 4 stated, If I knew he was going to fall, I would have sat on his bed. CNA 4 stated, the interventions in place before the accident occurred were a 1:1 sitter, floor mats on the ground, and bed in lowest position. CNA 4 further stated, They (facility) should have put a bed alarm, and did not recall if the resident had a bed alarm. CNA 4 stated she was not trained nor in-serviced on 1:1 sitter responsibility. During an interview on 4/28/2021 at 11:33 AM, the Director of Nursing (DON) stated, Resident 2 had diagnoses of chronic renal disease (long term kidney disease) with [CONDITION(S)] (the process of removing waste products and excess fluids from the body when the kidneys are not functioning adequately), hypertension (abnormal blood pressure), and dementia. The DON stated Resident 2 had a history of falls and was always considered a fall risk. The DON further stated that on 3/13/2021, a facility staff was assigned 1:1 to supervise the resident. The DON further stated Resident 2 got up, took some steps, lost his balance, and fell . The DON stated CNA 4 was at Resident 2's bedside the entire time, witnessed the resident fall but was unable to catch the resident. The DON further stated Resident 2 was unpredictable, able to stand up and walk, and had cognitive impairment. The DON stated fall interventions implemented for Resident 2 included floor mats, low bed, and 1:1 supervision. During an interview on 4/29/2021 at 11:22 AM, the Director of Staff Development (DSD) stated, Resident 2 should not fall nor sustain injury when assigned 1:1 sitter. The IP further stated Supervision/Sitter were trained on fall prevention, 1:1 supervision with emphasis to not leave a resident unattended. The IP further stated a sitter must be watchful and call for help if a resident has a change in behavior. During an interview on 5/13/2021, at 11:42 AM, the DSD stated, she was not sure if CNA 4 attended the in-service for Education/Training about care of residents requiring continuous supervision or 1:1 supervision. DSD further stated, CNA 4 should have attended the in-service prior to being assigned as a 1:1 because she would not know what to do and CNA 4 should know what the roles and responsibilities of a sitter are. A review of the facility's undated policy and procedure titled Safety and Supervision of Resident, indicate Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and the MDS. The policy and procedure further indicated, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment and The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when . there is a change in the resident's condition. During a review of the facility's undated policy and procedure titled, Falls - Clinical Protocol, indicated The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. Risks of serious consequences can sometimes be minimized even if falls cannot be prevented.

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to maintain skin integrity for four of seven sampled residents (Resident 1, Resident 2, Resident 3, and Resident 7) by failing to: 1. Implement pressure injury interventions for Resident 1 admitted with stage 1 (redness, maybe painful intact skin injury) to the sacrococcyx (lower back and tail bone) area, and prevent the progression from stage 1 on 11/22/2020 to stage 4 (injury extending beyond the fatty tissue and into muscles, tendons and ligaments) on 12/3/2020, a progression of pressure injury in 11 days. This deficient practice resulted in the progression of pressure injury for Resident 1. 2. Ensure two Certified Nursing Assistants (CNA 2 and CNA 3) and two Licensed Vocational Nurses (LVN 1 and LVN 2) performed daily skin assessments, identified and reported any skin concerns, and turned and repositioned Resident 2 every two hours on 4/1/2021, 4/2/2021, 4/3/2021, 4/4/2021, 4/5/2021, 4/6/2021, 4/7/2021, 4/9/2021, 4/12/2021, 4/13/2021, 4/14/2021, 4/15/2021, 4/19/2021, and 4/20/2021. Resident 2 was admitted with no pressure injury or any skin concerns, however, was at risk for pressure injury. This deficient practice had the potential to develop pressure injury for Resident 2. 3. Ensure LVNs and CNAs monitored and checked the low air loss mattress (LALM, a mattress used to prevent and treat pressure injuries) was at correct settings and turned on every shift per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility further failed to ensure Resident 3 did not lay on a deflated LALM, and on an unpadded metal bed frame from 3/18/2021. This deficient practice had the potential to develop pressure injury for Resident 3 4. Implement pressure injuries physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficient practices had the potential for progression of pressure injury for Resident 7. On 4/23/2021 at 6:38 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM) and Director of Nursing (DON) regarding facility's staff failure to provide skin assessment and skin interventions to prevent the development of new pressure injuries and worsening of skin condition for Residents 1, 2, 3, and 7. On 4/26/2021 at 3:50 PM, the IJ was lifted after the ADM and DON submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The surveyors verified and confirmed the implementations of the POA while onsite by observation, interview, and record review. The IJ was removed in the presence of the ADM and DON. The acceptable POA as follows: 1. On 4/23/2021, the facility's licensed nurses (LNs) and certified nursing assistants (CNAs) completed a skin assessment for all 96 residents. For Residents 2, skin assessment was completed by the Wound Care Specialist (WCS, physician) with new wound orders and the care plan was updated to reflect the new plan of care. For Residents 3 and 7, care plans were updated to reflect new plan of care. 2. From 4/23/2021 to 4/26/2021, facility staff were in services for pressure injuries assessment, wound care, interventions (LALM) and prevention. Findings: 1. A review of the Facesheet (Admission Record) indicated the facility first admitted Resident 1 on 11/11/2020, and was readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Initial History and Physical (H&P) dated 11/12/2020, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment used as a care-planning tool) dated 12/11/2020, indicated Resident 1 had no cognition (ability to learn, remember, understand, and make decisions) impairment. The same MDS indicated Resident 1 required total assistance with one-person physical assist for bed mobility. A review of Resident 1's Braden Scale (pressure ulcer risk predictor tool) assessment tool dated 11/11/2020, indicated the resident was moderately at risk to develop pressure ulcer. A review of Resident 1's Nurses' Admission and Assessment Record dated 11/12/2020, indicated the resident had redness to the sacrococcyx (lower back and tail bone) area on admission. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same order indicated to apply [MEDICATION(S)] (medication for wound management) and continue dry dressing daily for 30 days. The order further indicated the pressure injury changed from redness (stage I) to stage II, two days after 11/20/2020 readmitted . A review of Resident 1's Physician Orders, dated 11/25/2020, indicated to change the resident's sacrococcyx pressure injury from stage II to stage III (pressure ulcer beyond the dermis and involves the fat tissue, may resemble a crater) pressure injury. The same order indicated, apply [MEDICATION(S)] (medication for wound management) and continue dry dressing daily for 30 days. The order indicated the pressure injury changed from stage II to stage III in three days. A review of Resident 1's Physician Orders, dated 12/3/2020, indicated to change the resident's sacrococcyx pressure injury from stage III to stage IV (injury extending beyond the fatty tissue and into muscles, tendons and ligaments) pressure injury. The same order indicated, apply Santyl ointment (medication for wound management) and continue dry dressing daily for 30 days. The same order indicated the pressure injury changed from stage III to stage IV in eight days. During an interview and concurrent record review with the Director of Nursing (DON) on 4/26/2021, at 9:05 AM, Resident 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON acknowledged and stated Resident 1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON further acknowledged and stated there was no change in medication and or treatment plan for pressure ulcer progression from stage II to stage III after 11/25/2020 for Resident 1. During record review with the DON on 4/26/2021, at 9:15 AM, Resident 1's care plan on alteration in skin integrity and actual presence of pressure ulcer/injury in sacral area dated 11/21/2020 and updated on 12/1/2020, indicated concern for alteration in skin integrity and actual presence of pressure ulcer/ injury in sacral area. However, in a concurrent interview, the DON acknowledged and stated the care plan did not reflect revised and or additional interventions to address Resident 1's stage II and stage III pressure injury. The DON stated there should have been additional interventions to prevent progression of Resident 1's pressure injury. During record review with the DON on 4/26/2021, at 9:20 AM, Resident 1's SNF (Skilled Nursing Facility) Wound Care document, dated 12/3/2020, indicated a Wound Care Specialist (WCS, physician) was asked for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The same document indicated the resident's pressure injury required subcutaneous tissue debridement (medical removal of dead, damaged, or infected tissue to improve healing). However, in a concurrent interview, the DON acknowledged and stated the WCS evaluated Resident 1's pressure injury on 12/3/2020, after the pressure injury progressed to stage 4. The DON further stated, she remembered a discussion about the resident's pressure injury progressing, however, the DON did not provide any documentation for additional interventions implemented for Resident 1. 2. A review of the Facesheet indicated the facility admitted Resident 2 on 3/11/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 2's Initial H&P dated 3/13/2021, indicated Resident 2 had fluctuating capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE], indicated Resident 2 was unable to complete an interview, and had short-term and long-term memory problems. The MDS further indicated Resident 2 required total assistance with two-person physical assist for bed mobility. A review of Resident 2's Braden Scale assessment tool dated 3/11/2021, indicated Resident 2 was a high risk for pressure injury. A review of Resident 2's Nurses' Admission and Assessment Record dated 3/11/2021, indicated the resident had gastrostomy tube (a tube for nutrition, medication and hydration), and [CONDITION(S)] (surgically created opening in the skin to collect and pass feces). The same admission assessment record indicated Resident 2 did not have pressure injury or any other skin concerns. A review of Resident 2's CNA (certified nurse assistant) Daily Charting Form dated 4/2021, indicated Resident 2 was not repositioned and or turned every two hours or as needed. The same form documentation indicated n for no to indicate Resident 2 was not turned and or repositioned every two hours for 13 days on: 4/1/2021 4/2/2021 4/3/2021 4/4/2021 4/5/2021 4/6/2021 4/7/2021 4/9/2021 4/12/2021 4/13/2021 4/14/2021 4/15/2021 4/19/2021 4/20/2021 During an interview on 4/23/2021, at 12:10 PM, the DON stated the previous shift nurses did not report Resident 2 had skin concerns. During Resident 2's skin assessment with Licensed Vocational Nurses (LVN 1 and LVN 2) on 4/23/2021, at 11:58 AM, Resident 2 was observed in Resident 2's room, on his bed, with skin discoloration on right plantar (sole) foot. Concurrently, during an interview on 4/23/2021, at 11:58 AM with LVN 1, LVN 1 stated it appears to be deep tissue injury (DTI, pressure related injury under intact skin, initially have the appearance of a deep bruise). LVN 1 further stated the previous shift staff did not report Resident 2 had any skin concerns. LVN 1 then stated, will re-evaluate with DON for accurate staging. During an interview on 4/23/2021, at 1:00 PM, LVN 2 stated Resident 2's skin was intact per the resident's progress note. LVN 2 further stated, Resident 2 appeared to have DTI which typically takes between seven to 14 days to occur and was not able to determine the extent of the pressure injury. LVN 2 further stated Resident 2's pressure injury is pending re-evaluation to determine staging. During an interview on 4/23/2021 at 1:10 PM, CNA 2 stated she was assigned Resident 2 on 4/23/2021, on the 7:00 AM to 3:00 PM shift. CNA 2 stated she performed and completed Resident 2's morning care (shaved the face, cleaned body and gave a bath, changed adult pads, and changed clothes, gown and socks). CNA 2 stated she did not see any concerns including skin on the resident to notify the licensed nurse and did not document. During an interview on 4/23/2021, at 1:13 PM, LVN 1 stated staff should have noticed the skin concern on Resident 2's foot and notify the licensed nurses to evaluate the skin. LVN 1 stated Resident 2's pressure injury could progress to an open wound if not evaluated and treated. During an interview on 4/23/2021, at 1:40 PM, CNA 3 confirmed and stated she was assigned Resident 2 on 4/22/2021 the 7:00 AM to 3:00 PM shift. CNA 3 stated she performed and completed the resident's bath and perineum (area between the rectum and, the male and female private body parts) and care. CNA 3 stated she did not see any concerns on Resident 2 to notify licensed nurses. CNA 3 further stated Resident 2 did not have any skin concern and was aware to notify licensed nurses if any identified skin concerns. During a concurrent observation on 4/23/2021 at 1:20 PM, in Resident 2's room, on his bed, LVN 1 and the DON performed a skin assessment on Resident 2. Concurrently, during an interview on 4/23/2021 at 1:20 PM, the DON stated, skin does not meet DTI criteria, and further stated will discuss observation with WCS for possible Vitamin A and D order for the resident's foot. During an interview on 4/23/2021, at 4:20 PM, the WCS stated the facility's DON requested to evaluate Resident 2 on 4/23/2021, and that the resident had right foot hyperpigmentation (areas of skin become darker in color than the normal surrounding skin). The WCS further stated that if the hyperpigmentation peels off it's not a DTI, its superficial. The WCS stated, the cause for the resident's hyperpigmentation was unknown, however, it could have been pressure; resident is bed bound and it is on a pressure point surface on the body. DTI goes all the way deep into the skin this is superficial. During Resident 2's record review with the WCS on 4/23/2021 at 4:25 PM, the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Concurrently, during an interview with the WCS on 4/23/2021 at 4:25 PM, the WCS stated this does not look like [CONDITION(S)] now. If [MEDICATION(S)] (medication to treat infection) did not work, you could also do [MEDICATION(S)] (medication to treat infection), but [MEDICATION(S)] was a good call looks like it worked. The WCS stated, he did not know what caused Resident 2's [CONDITION(S)]. The WCS further stated [CONDITION(S)] could come from cracked skin that allowed bacteria to enter. During record review with the DON on 4/26/2021 at 1:25 PM, Resident 2's [CONDITION(S)] care plan dated 3/12/2021, indicated Resident 2 had undetermined side [CONDITION(S)]. The DON stated the resident's care plan was missed and was not resident specific. A review of Resident 2's SBAR (Situation, Background, Appearance, and Review and Notify) Communication Form dated 4/23/2021, indicated a change of condition observed on the resident's right lateral plantar foot discoloration. The SBAR further indicated, a physician was notified, and new orders received to apply Vitamin A and D daily for 14 days. A review of Resident 2's Physician Orders, dated 4/23/2021 timed 3:30 PM, indicated to monitor Resident's right foot every shift for skin breakdown. 3. A review of Resident 3's Facesheet indicated the facility admitted Resident 3 on 3/8/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's History and Physical dated 3/20/2021, indicated Resident 3 had the capacity to understand and make decisions. A review of Resident 3's MDS dated [DATE], indicated the resident had intact cognition, and was at risk to develop pressure ulcers and injuries. A review of Resident 3's Nurses' Admission and Assessment Record dated 3/9/2021, indicated Resident 3 had scar tissue of the sacrum (lower back) area. A review of Resident 3's Braden Scale dated 3/9/2021, indicated the resident scored 14, and had moderate risk to develop pressure injury. A review of Resident 3's skin care plan dated 3/9/2021, indicated Resident 3 was at risk for skin breakdown and ulcer formation. The care plan further indicated approach included to address Resident 3's risk for skin breakdown and, administer medication and treatment as ordered. A review of Resident 3's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The same order further indicated to check LALM for placement and functioning every shift. During an observation with LVN 7 on 4/23/2021 at 4:43 PM, in Resident 3's room, Resident 3's LALM was observed turned off and not plugged to electric power. The mattress was observed deflated and resident was lying on metal frame. Concurrently, interview on 4/23/2021 at 4:43 PM with LVN 7, LVN 7 did not know how long Resident 3 was on the metal frame. LVN 7 confirmed and stated Resident 3's LALM was turned off. Observed LVN 7 attempt to plug in LALM to power and was not able. LVN 7 then stated, I cannot plug it in, I have to get an extension cord. During an observation with LVN 1 and LVN 7 on 4/23/2021 at 5:22 PM, in Resident 3's room, LVN 7 used an extension cord to plug in Resident 3's LALM. LVN 1 was observed turn on the LALM. LVN 1 stated there was a doctor order since 3/18/2021 for the LALM, and therefore should be turned on. LVN 1 stated Resident 3 was at risk for skin breakdown if the LALM was turned off. During a telephone interview with LVN 1 on 5/12/2021 at 4:08 PM, LVN 1 stated treatment nurse responsibilities include looking at the resident's LALM during treatments. LVN 1 stated the treatment nurse should be making sure the LALM is on the correct settings and the LALM is plugged in and on. During a telephone interview with LVN 7 on 5/12/21 at 4:15 PM, LVN 7 stated charge nurse responsibilities include making rounds at the start of the shift. LVN 7 stated during rounds the charge nurse should be checking on patients and checking all the patient's assistive devices. LVN 7 stated I should check all assistive devices during rounds, this includes checking the LALM. I have to check if the LALM is functioning and make sure it is turned on. LVN 7 stated if the LALM is off, this puts the resident at risk for getting a pressure ulcer. On 5/12/2021 at 10:56 AM, a request was made with the DON for copies of the facility's rounding policy, treatment nurse responsibilities policy, charge nurse responsibilities policy, and assistive device management policy. The DON acknowledged document request and stated the documents would be sent to the department by email. On 5/12/2021 at 1:18 PM, a second request was made with the DON for copies of the facility's round policy, treatment nurse responsibilities policy, charge nurse responsibilities policy, and assistive device management policy. The DON stated medical records were putting the policies together and would send copies to the department by email. Policies were not received timely. 4. A review of the Facesheet indicated the facility admitted Resident 7 on 3/3/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 7's H&P dated 3/5/2021, indicated Resident 7 did not have the capacity to understand and make decisions. A review of Resident 7's MDS dated [DATE], indicated Resident 7 had severe cognition impairment. The MDS indicated Resident 7 required total assistance with one-person physical assist for bed mobility. A review of Resident 7's Nurses' Admission and Assessment Record dated 3/4/2021, indicated Resident 7 had left trochanter stage III pressure injury, right lateral ankle stage 4 pressure injury, right medial shin stage 4 pressure injury, left medial shin unstageable ulcer, right inner knee unstageable ulcer and right lateral plantar foot unstageable ulcer. A review of Resident 7's Braden Scale dated 3/3/2021, indicated Resident 7 was a high risk for pressure injury. A review of Resident 7's care plan dated 3/28/2021, indicated Resident 7 required a LALM. The approach plan indicated to apply LALM as ordered and ensure proper functioning, and settings based on resident's weight per manufacturer. A review of Resident 7's Treatment Administration Record (TAR), dated 4/2021, indicated 21 missing signatures of completion for LALM monitoring on: 4/14/2021 day shift 4/15/2021 day, evening, and night shifts 4/16/2021 day, evening, and night shifts 4/17/2021 evening shift 4/18/2021 evening shift 4/19/2021 evening, and night shift 4/20/2021 night shift 4/21/2021 day, and night shift 4/22/2021 day, evening, and night shift 4/23/2021 day, evening, and night shift 4/24/2021 evening shift. A review of Resident 7's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 7's TAR dated 4/2021, indicated missing signatures of completion for left media, shin unstageable ulcer treatment on: 4/14/2021 4/15/2021 4/16/2021 4/21/2021 4/22/2021 4/23/2021 A review of Resident 7's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 7's TAR, dated 4/2021, indicated missing signatures of completion for left trochanter stage III pressure injury treatment on: 4/14/2021 4/15/2021 4/16/2021 4/21/2021 4/22/2021 4/23/2021 A review of Resident 7's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 7's TAR dated 4/2021, indicated missing signatures of completion for right lateral (on the side) ankle stage IV treatment on: 4/14/2021 4/15/2021 4/16/2021 4/21/2021 4/22/2021 4/23/2021 A review of Resident 7's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] day shift for 30 days. A review of Resident 7's TAR dated 4/2021, indicated missing signatures of completion for right lateral foot unstageable ulcer treatment on: 4/14/2021 4/15/2021 4/16/2021 4/21/2021 4/22/2021 4/23/2021 A review of Resident 7's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 7's TAR dated 4/2021, indicated missing signatures of completion for right inner knee unstageable ulcer treatment on: 4/14/2021 4/15/2021 4/16/2021 4/21/2021 4/22/2021 4/23/2021 A review of Resident 7's physician order, dated 4/3/2021, indicated right medial shin stage 4 pressure injury, to cleanse with NS, pat dry, apply Medi-honey and cover with dry dressing, one time a day, and every day shift for 30 days. A review of Resident 7's TAR dated 4/2021, indicated missing signatures of completion for right medial shin stage 4 pressure injury treatment on: 4/14/2021 4/15/2021 4/16/2021 4/21/2021 4/22/2021 4/23/2021 During interview on 4/25/2021 at 9:40 AM, the DON acknowledged and stated the assigned treatment nurse did not document skin treatments performed and completed on Resident 7's TAR. The DON stated the facility did not have any other documentation to confirm skin treatments were completed for the resident. During an observation with LVN 2 on 4/25/2021 at 10:05 AM, in Resident 7's room, Resident 7 was observed lying on a LALM. Concurrently, during an interview on 4/25/ at 10:05 AM, LVN 2 confirmed and stated the LALM was set at level nine. LVN 2 the LALM should be set at level three. LVN 2 stated level nine setting is for residents who weigh 205 kilograms (kg, unit of weight measurement) or 450 pounds (lbs, unit of weight measurement), and level three setting was for residents who weigh 65 kg or 140 lbs. LVN 2 stated pressure injury could get worse if LALM was not on the correct setting. During interview on 4/25/2021 at 11:45 AM, LVN 4 acknowledged and stated, skin treatment documentations on Resident 7's TAR were missing. LVN 4 further stated she performed and completed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN 4 stated it is important to perform and complete skin treatment as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's policy titled Pressure Ulcer Risk Assessment revised 9/2013, indicated if pressure ulcers are not treated when discovered, they have the potential to become larger, painful, and infected. The policy further indicates staff will perform routine skin inspections with daily care, nurses are notified to inspect the skin for changes identified, and nurses will conduct skin assessment at least weekly to identify changes. A review of facility undated policy titled Admission Assessment and Follow Up: Role of the Nurse, indicated the date and time the assessment was performed . all relevant assessment data obtained during the procedure, should be recorded in the resident's medical record. A review of the facility's undated policy titled Prevention of Pressure Ulcers, indicated interventions and prevention measures for a person in bed includes change position at least every two hours or more frequently if needed, determine if resident needs a special mattress per bed selection algorithm . the care process should include efforts to stabilize, reduce or remove underlying risk factors, to monitor the impact of the interventions, and to modify the interventions as appropriate.

Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who was diagnosed with dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), history of falls, and cognition was severely impaired, received one on one (1:1, sitter/one person monitoring the resident safety and fall prevention at all times) monitoring per the physician's orders. As a result, Resident 1 was left unattended, fell to the floor, sustained a laceration (cut/tear) on the right forehead with nose bridge injury on 11/30/2020, at 11:30 PM. Findings: Cross Reference F 839 A review of the Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), and other abnormalities of gait and mobility. A review of Resident 1's Nursing Notes dated 8/8/2020, indicated Resident 1 was found on the floor with a big bump on the left forehead, and ice pack was applied for 15-20 minutes. The Nursing Notes indicated Resident 1 was taken to the General Acute Care Hospital (GACH 1) for further evaluation. A review of Resident 1's Care Plan for Actual Fall related to resident getting out of bed unassisted, dated 8/8/2020, indicated the goal was to prevent further fall and injury. The interventions included Resident 1 required verbal cue, safety education, and floor mat on the floor as needed. The care plan interventions did not include the specific assistance required. A review of Physician's Admission Orders dated 8/10/2020, indicated to apply floormat when Resident 1 is in bed to reduce risk of injury during a fall, monitor placement of floor mat every shift and, place bed in low position and monitor placement of bed position every shift. According to a review of Resident 1's Interdisciplinary Team Notes (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient), dated 8/11/2020, Resident 1 was placed on a 24-hours per day observation for safety, and placed on 1:1 precaution due to a fall on 8/8/2020. A review GACH 1 History and Physical (H&P) dated 9/5/2020, indicated GACH 1 admitted Resident 1 on 9/5/2020 for generalized weakness, failure to thrive, and status post fall. The H&P indicated Resident 1 had a large forehead bump and ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) to the right eye. A review of the facility's Nursing Notes, dated 9/10/2020, indicated the facility readmitted Resident 1 on 9/10/2020 from GACH 1 with diagnoses including right forehead hematoma (collection of blood outside of a blood vessel), right side of face discoloration, bilateral arm bruising (a skin injury that results in a discoloration of the skin. Blood from damaged blood cells deep beneath the skin) and left forearm and wrist pain after having another fall (this time at GACH 1). A review of the facility Physician's Admission orders, dated 9/10/2020, indicated Resident 1 returned to the facility and was on 1:1 monitoring every shift, to reduce risk of falls and apply floormat when in bed to reduce risk of injury. A review of the Resident 1's Care Plan on Risk for Fall / Injury, dated 9/13/2020, indicated Resident 1's contributing factors included cognition deficit (impairment in one's mental processes), unsteady gait, attempts to function beyond ability, and lacks safety awareness. The goal indicated to minimize the risk for falls and decrease significant injury as a result from falls in the next three months for the resident. The care plan interventions included Resident 1 on 1:1 monitoring, remind resident to ask for assistance, teach the resident the importance of fall prevention, and apply floor mat as ordered. According to a review of Resident 1's Care Plan on Risk for Fall / Propensity for fall (tendency to behave in a particular way), dated 9/13/2020, related to history of falls and use of [CONDITION(S)] medications (affect your mind-your emotions and your behavior-typically by altering the balance of the chemicals in your brain). The goal was to minimize the risk for falls and decrease significant injury from falls for the next three months. The care plan interventions included 1:1 monitoring, teach the resident the importance of fall prevention, remind the resident to ask for assistance, and medication review for side effects. A review of a Fall Risk Assessment, dated 9/16/2020, indicated Resident 1 had one to two falls the past three months 8/8/2020, 9/10/2020, Resident 1 was disoriented to person, place and thing, at all times. The fall risk assessment indicated Resident 1 scored 16 (10 or higher was considered high risk for potential falls) for fall risk. A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool) for significant change after fall, dated 9/19/2020, indicated Resident 1 had severe mental impairment, and sometimes had the ability to understand others. The MDS indicated Resident 1 required extensive assistance with two people assist with bed mobility, transferring, and walking. One person assists with dressing, eating, and total dependence with toilet use. The MDS further indicated Resident 1 was not steady for surface-to-surface transfer, between bed and chair or wheelchair. A review of the Nursing Progress Notes, dated 11/30/2020, at 11:30 PM, indicated Resident 1 was in bed, fell to the floor on the right side from bed, had a small laceration to right forehead and over bridge of nose, ice packs applied, cleaned with normal saline and dressing applied. According to a review of the Situation Background Assessment and Request form (SBAR), dated 11/30/2020, not timed, Resident 1 fell from bed, causing a small laceration to right forehead and nose bridge injury. The SBAR form indicated under patient history there was no history. Under the Assessment /Appearance section, the documentation indicated no change and remained blank. The Request section remained blank, regarding new orders or change in current orders. A review of the Physician's orders, dated 12/1/2020, indicated Resident 1 received an X-ray of facial bones, neurological checks (assess an individual's neurological functions and level of consciousness to determine whether the individual was functioning properly) for 72 hours, and to cleanse right forehead laceration with normal saline, pat dry, leave open to air for five days then reevaluate. During an interview, on 1/11/2021 at 3:20 PM, Licensed Vocational Nurse 1 (LVN 1) stated she entered the room to attend to Resident 1's roommate and Security Guard 2 (SG 2) was assigned 1:1 to monitor Resident 1. LVN 1 stated while attending to Resident 1's roommate, SG 2 left Resident 1's room and went to the front desk, located seven rooms away from Resident 1's room. LVN 1 stated Resident 1 got out of bed, took two steps, and then fell to the ground moments after the security guard left Resident 1's room. LVN 1 stated she assisted Resident 1 back to bed, observed Resident 1 sustained a bump to the forehead. LVN 1 applied ice pack on Resident 1's forehead. LVN 1 stated the bed was in a low position with a floor mat in place. During an interview, on 2/9/2021 at 3:04 PM, the SG 2 stated he has worked at the facility for four to five years and was not a certified nursing assistant (CNA). SG 2 stated, that on 11/30/2020 on the 3 PM to 11PM shift, he informed LVN 1 he was going to check if his relief had reported to work. SG 2 stated he spoke with the charge nurse who stated the relief was in the building and SG 2 then clocked out and exited the building. A review of the facility's Aggressive and Violent Behavior Intervention Guidelines, created on 11/15/2016, indicated that SG 2 attended the orientation of Constant Observation, one to one monitoring of residents. The same document further indicated to keep the resident in clear view at all times, never leave the resident alone and continuously monitor resident until such time that the treatment team assess the resident to longer be a danger to self or others. A review of Inservice/Meeting for Fall Risk dated 9/16/2020, indicated SG 2 attended the training. The lesson plan included fall prevention, implementation and prevent falls. During an interview, on 2/10/2021 at 10:30 AM, the Director of Nursing (DON) stated Resident 1 attempted to get out of bed and was therefore placed 1:1 sitter monitoring after a previous fall on August 2020. The DON stated Resident 1 was on 1:1 monitoring and that, SG 2 should not leave the resident unattended until SG 2 replacement arrived. The DON further stated Resident 1's fall was preventable if the SG 2 remained with the resident. During an interview, on 2/10/2021 at 10:30 AM, the DON stated the facility did not have a policy for the one on one monitoring. A review of the facility's undated policy and procedure titled, Abuse and Neglect, indicated Neglect referred to refusal or failure to fulfill any part of one's obligations or duties to an individual. The facility management and staff will institute measures to address the needs of resident/patients and minimize the possibility of abuse and neglect. A review of the facility's undated policy and procedure titled, Falls, indicated based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risk of serious consequences of fall. A review of the facility's undated policy and procedure titled, Care Plans-Preliminary, indicated the interdisciplinary team will review the Attending Physician's order and implement a nursing care plan to meet the resident's immediate care needs to assure that the residents immediate care needs are met and maintained.

Based on interview and record review, the facility failed to maintain an infection prevention and control program for one of two sampled residents (Resident 1). For Resident 1, who was diagnosed with dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), the facility did not prevent / control the spread of Coronavirus 2019, (COVID-19, a virus that causes respiratory illness that can spread from person to person), and allowed many staff to interact together in a crowded space, not providing a safe / sanitary environment for Resident 1. As a result, on [DATE], the facility had a Christmas / Recognition Party which had the potential for harm to residents due to the non-compliance. From [DATE] to [DATE], 27 staff members and 37 residents tested positive for COVID-19. In addition, Resident 1 tested positive for COVID-19 disease on [DATE], was transferred to the General Acute Care Hospital (GACH 1) and later died on [DATE] of pneumonia and COVID-19. Findings: A review of the Admission Record indicated the facility admitted Resident 1 on [DATE] and readmitted him on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the History and Physical from GACH 1, dated [DATE], indicated Resident 1 was admitted to GACH 1 for generalized weakness, failure to thrive, and status post [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool) for significant change after fall, dated [DATE], indicated Resident 1 had severe mental impairment (significant problems), and sometimes had the ability to understand others. The MDS indicated Resident 1 required extensive assistance with transferring, dressing, eating, and total dependence with toilet use. A review of the COVID-19 report indicated that Resident 1 tested negative for COVID-19 on [DATE], [DATE], [DATE], and [DATE]. Resident 1 tested COVID-19 positive [DATE]. According to a review of the nursing assignment sheet, dated [DATE], Certified Nursing Assistant 4 (CNA 4) was assigned to Resident 1 during the 3 p.m. to 11 p.m. shift. A review of the emergency room Physician's Note from GACH 2, dated [DATE], indicated Resident 1 was admitted to the emergency room with altered mental status, poor oral intake for three days and a positive test for COVID-19. The chest x-ray completed on [DATE] indicated patchy bilateral pulmonary infiltrates (the filling of airspaces with fluid) in the right, greater than left lungs. Resident 1 was transferred to GACH 1. A review of the final Progress Note from GACH 1, dated [DATE], indicated Resident 1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was treated with Aspirin (a medication used to reduce pain, fever, or inflammation) and [MEDICATION(S)] (blood thinner that prevents the formation of blood clots), and was placed into Hospice Care (prioritizes comfort and quality of life by reducing pain and suffering). Resident 1 was discharged back to the skilled facility on [DATE] on hospice care. During an interview on [DATE] at 12:36 PM., Resident 3, mentally intact, stated and confirmed the facility held a Christmas Party in the facility's rehabilitation room and patio. Resident 3 stated the facility put up a tent on the patio. Resident 3 stated he witnessed the party from the other half of the patio but did not attend the party. Resident 3 stated there were at least 20 staff members inside the rehabilitation room during the party States some staff were wearing a mask while other staff were not. Resident 3 also stated he believed the party resulted in several staff members getting infected with COVID-19. During an interview on [DATE] at 1:30 PM., the facility Administrator, stated and confirmed the facility held a Recognition Ceremony on [DATE] in the facility's rehabilitation room and patio. During an interview on [DATE] at 1:52 PM., CNA 3 stated and confirmed she attended the Christmas Party held by the facility on [DATE] at the facility's patio and rehabilitation room. CNA 3 stated and confirmed she tested positive for COVID-19 on [DATE]. A review of CNA 3's COVID-19 Test Result Summary indicated CNA 3 tested positive for COVID-19 on [DATE]. During an interview on [DATE] at 2:30 PM, Kitchen Staff 1(KS 1) agreed to be interviewed and stated he was the kitchen helper / dishwasher. KS 1 stated he's been working in the facility for two years and he was present during the Christmas party on [DATE] but did not get food. KS 1 stated there were more than 20 people present with some staff wearing masks, while others did not. KS 1 stated staff were not social distancing, and clarified staff were not six feet apart. KS 1 stated it was not ok for the facility to hold a party due to the possibility it could have resulted to a COVID-19 spread and potentially infect employees. During an interview on [DATE] at 3:31 PM., CNA 4 stated and confirmed she attended the gathering in the facility's rehabilitation room on [DATE]. CNA 4 stated and confirmed she tested positive for COVID-19 on [DATE]. A review of CNA 4's COVID-19 Test Result Summary indicated CNA 4 tested positive for COVID-19 on [DATE]. A review of the Certificate of Death, dated [DATE], indicated Resident 1 cause of death was Pneumonia and COVID-19. During a phone interview and concurrent record review, on [DATE] at 10:36 AM, the Infection Preventionist (IP, responsible for the facility's activities aimed at preventing healthcare-associated infections) stated and confirmed after review of the facility's Line Listing (a list of COVID-19 positive resident and staff), 27 staff members and 37 residents tested positive for COVID-19 from [DATE] to [DATE]. A review of the facility's Mitigation Plan (MP) faxed to the Department on [DATE], indicated the facility implemented a staffing plan to limit transmission, including dedicated, consistent staffing teams who directly interact with residents that are COVlD-19 positive. Limiting clinical and other staff who have direct resident contact to specific floors or wings. There should be no rotation of staff between floors or wings during the period they are working each day, and established policy to minimize the number of staff interacting with each resident. Under Designation of Space, the MP indicated all congregate spaces have been closed and all group events involving proximity ceased. There was no communal dining, or, in accordance with CMS guidance, eating in dining areas with appropriate social distancing was only used as a last resort, i.e., only allowed for residents without signs or symptoms of a respiratory infection, without a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] such accommodation. The facility must perform terminal cleaning at the end of each meal.

Based on interview and record review the facility failed to develop a safe and appropriate discharge plan for one of three sampled residents (Resident 1). Resident 1, who was discharged from the facility and had delusional disorders (serious mental illness in which a person cannot tell what is real from what is imagined), the facility failed to ensure the involvement and supervision of the resident's physician; provide effective transition to the lower level of care facility; and failed to ensure the physician evaluated, identified and documented the medical and discharge needs of Resident 1. As a result, Resident 1 was admitted to the General Acute Care Hospital (GACH) after being off his antipsychotic medication for approximately two weeks and eating his own feces. Resident 1 [MEDICAL CONDITION] (a severe infection of the blood) and died less than one month after discharge from the skilled facility. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the facility admitted Resident 1 on [DATE] with [DIAGNOSES REDACTED]. disorder (disconnection with reality) the person cannot tell what is real from what is imagined), and [MEDICAL CONDITION]. A review of the physician's orders [REDACTED]. A review of Resident 1's physician's orders [REDACTED]. According to a review of the manufacturer's recommendation, [MEDICATION NAME] requires blood laboratory testing, every two to four weeks, to ensure monitor renal and liver functioning and ability to fight off infection. Discontinuation of [MEDICATION NAME] need to be done by lowering the dosage slowly over a two-week period and monitor the individual for increased [MEDICAL CONDITION] and attempts at self-harm. According to the Black Box Warning, [MEDICATION NAME] treatment has caused severe [DIAGNOSES REDACTED] (low white blood count. [DIAGNOSES REDACTED]s help to fight infections). Severe [DIAGNOSES REDACTED] can lead to serious infection and death. A review of Resident 1's Minimum Data Set (MDS- standardized assessment and care planning tool) dated [DATE], indicated Resident 1 was cognitively intact, could speak clearly, was able to make himself understood and could understand others. The MDS indicated Resident 1 denied feeling down or having difficulty with sleep or lack of appetite. Resident 1's MDS indicated that he needed at least one other person to help him with walking, dressing himself, toileting and bathing himself. A review of Resident 1's Physician's Assistant (PA) Consultation Note dated [DATE], indicated Resident 1 was compliant with the medications, was withdrawn, had [MEDICAL CONDITION], and no suicidal ideation. The treatment plan indicated to continue current medications, observe for compliance, observe for deterioration in function, provide emotional support for compliance with treatment, and to start [MEDICATION NAME] ([MEDICATION NAME] - antidepressant) 25mg daily for depression manifested by episodes of crying. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 was cognitively intact, did not have memory problems, denied feeling depressed or down, denied hearing and seeing things that were not real, did not have thoughts of hurting himself, and did not have indicators of [MEDICAL CONDITION]. The MDS also indicated Resident 1 did not require assistance with walking, dressing himself, and toileting but did require physical help with transferring in and out of a bathtub. A review of the Physician's Telephone Order dated [DATE], indicated MD 1 ordered to discharge Resident 1, on the same day ([DATE]), to a lower level of care facility, a boarding care home. MD 1 did not order follow up laboratory blood testing, physician appointments, or a certified pharmacy authorized to fill [MEDICATION NAME], as not all pharmacies can prescribe this medication. According to a review of Resident 1's Discharge Summary dated [DATE], by MD 1, the facility discharged Resident 1 because his health had improved sufficiently. Further review of the medical record indicated there was no documentation explaining how/why Resident 1's status had improved such that he could be discharged to a lower level of care. A review of the medical record indicated Resident 1 was not prescribed any other medications and there was no documentation to indicate Resident 1 received medications upon discharge or that home health services was ordered. A review of Resident 1's Discharge Summary and Post Discharge Plan of Care form dated [DATE], indicated there was no information regarding instruction to Resident 1 about the medication regimen, follow up laboratory tests, or medical and psychiatrist follow up. A review of Resident 1's Social Work Progress Notes dated [DATE], indicated there was no information regarding instructions to Resident 1 and the receiving boarding care home about Resident 1's medication regimen, behaviors to monitor, laboratory tests or medical and psychiatrist follow up. A review of Resident 1's GACH Emergency Treatment Report completed by MD 2 and dated [DATE] (27 days after discharge from the Skilled Nursing Facility (SNF) ), indicated the owner of the boarding care home brought Resident 1 to the GACH Emergency Department (ED) because Resident 1 was confused, was eating his own feces (bowel movement), would not talk, and hit another person. According to a review of the GACH ED Departure Report dated [DATE], MD 2 indicated the Resident 1 was evaluated by the attending psychiatrist at the Behavioral Health Unit who indicated the resident had altered-mentation as he was displaying coprophagia (consumption of feces), rapid decline in ability to perform Activities of Daily Living, and had not taken any medications in two weeks. The report indicated upon evaluation Resident 1 was nonverbal and muttering which was indiscernible. A review of the GACH's Death Summary Report completed by MD 2, indicated Resident 1 was admitted to the hospital on [DATE] due to confusion so severe that he hit another person, stopped talking and began eating his own feces. On the day of admission ([DATE]) Resident 1 had been off his antipsychotic medications for two to three weeks as the caregiver could not to refill them. Resident 1 was sent to the Intensive Care Unit, and was intubated (a tube is inserted into the windpipe to open the airway. The tube is connected to a ventilator, a machine to assist with breathing). Resident 1 [MEDICAL CONDITION] (severe infection of the blood). Physicians informed Resident 1's family of his poor condition, and they requested comfort care. Resident 1 died on [DATE], at 8:15 p.m., due [MEDICAL CONDITION] and [MEDICAL CONDITION]. During an interview, on [DATE] at 3:31 p.m., the boarding care home Caregiver 1 and owner stated Resident 1 was alert and oriented when he arrived at the home, but around the beginning of December Resident 1 started acting strange and then stopped talking. Resident 1 tried to hit another person, started to eat his own feces. Caregiver 1 took Resident 1 to the GACH on [DATE]. Caregiver 1 stated she tried to find a pharmacy that would fill Resident 1's prescription for [MEDICATION NAME] but could not find one. Caregiver 1 stated that the facility did not tell her anything about a special pharmacy or what would happen if Resident 1 would not take the [MEDICATION NAME]. Caregiver 1 stated her home was not a licensed facility. During an interview, on [DATE] at 1:21 p.m., the SNF Pharmacist 1 stated, The medication ([MEDICATION NAME]) can be very dangerous. It requires blood tests to monitor for signs of damage to the immune system, and that not every pharmacy can dispense [MEDICATION NAME] and not any doctor can prescribe it. On [DATE], at 3 p.m., during an interview, the SNF Administrator stated he did not know what care a resident on [MEDICATION NAME] required. The Administrator stated he did not know that pharmacies and physicians were required to be certified through a special safety program to have permission to prescribe and fill prescriptions for [MEDICATION NAME]. The Administrator after reviewing Resident 1's clinical record stated there was no documentation of a physician's evaluation of Resident 1's needs before his discharge and did not include evidence MD 1 participated in the discharge planning. During an interview on [DATE] at 3:10 p.m., the Director of Nursing (DON) stated she did not know that pharmacies and physicians were required to be certified through a special safety program in order to have permission to prescribe and fill prescriptions for [MEDICATION NAME]. The DON stated she did not know that laboratory blood testing was required to ensure the safe use [MEDICATION NAME] or that MD 1 should have ordered it. On [DATE] at 2:02 p.m., during an interview, Staff 3 (social worker aide) stated MD 1 did not order for the facility to arrange Resident 1 to receive laboratory blood testing services, or services from a certified pharmacy or physician services related to [MEDICATION NAME]. During an interview with MD 1 on [DATE] at 2:15 p.m., MD 1 stated, It's not my fault, it's the nursing home's fault. I'm very busy seeing patients at the hospital. I don't know if I wrote progress notes. I don't participate in discharge meetings. During an interview with Physician's Assistant 1 (PA 1) on [DATE] at 3:54 p.m., he stated that he and his medical group were certified to prescribe the medication [MEDICATION NAME] and did prescribe [MEDICATION NAME] for Resident 1 but did not continue to provide services for Resident 1 after the facility discharged him. PA 1 stated the facility did not inform him or his medical group that MD 1 had ordered the facility to discharge Resident 1. On [DATE] at 10:15 a.m., during an interview, the skilled facility's medical director stated MD1 did not order the facility to include Resident 1's psychiatric provider in the discharge planning of Resident 1. During an interview on [DATE] at 10:20 am, the Administrator stated neither the attending physician of Resident 1 or the facility's Medical Director determined that Resident 1 needed to be placed in a psychiatric facility. During an interview on [DATE] at 10:25 am, the Administrator stated the attending physician who orders the facility to discharge a resident was responsible for identifying the needs of a resident upon their discharge from the facility, and for ordering the services the facility was to arrange, based on the physician's identification of the resident's needs. During an interview on [DATE] at 1:32 pm, PA 1 stated he was certified through the Risk Evaluation and Mitigation Strategies (REMS program - a safety program through which a medical provider is certified to be able to prescribe certain medications), to prescribe the medication [MEDICATION NAME]. PA 1 stated that the facility did not inform the provider group that MD 1 ordered the facility to discharge Resident 1. PA 1 stated his provider group only provides care for residents while they reside at the facility, and will participate in the resident's discharge planning if the facility invites the provider group to do so. A review of the facility's policy and procedures titled, Transfer or Discharge Documentation, revised [DATE], indicated should the resident be transferred or discharged for the following reasons, the basis for the transfer or discharge must be documented in the resident's clinical record by the resident's Attending Physician: a. The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility; or b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility.

Based on interview and record review the facility failed to implement facility policy titled, Transfer or Discharge Documentation, and develop safe and appropriate discharge plans, with the involvement of the Interdisciplinary Team (IDT - a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient), the resident and the resident's responsible party; inform the resident/resident responsible party of the final discharge plan; provide effective transition to the lower level of care facility; document referrals to a hospice agency; and failed to ensure the physician evaluated, identified and documented the medical and residents discharge needs for five of eight sampled residents (Residents 1, 2, 6, 7, and 8). These deficient practices resulted in the following: Resident 1 wandering away from the independent living facility and living without shelter for a week before medical responders found him wandering in a street and took him to a hospital. Resident 2 living in a friend's backyard trailer, without air conditioning, having periods of forgetfulness, which affected his taking his medications, and enrolling himself in a hospice program. Resident 6 being sent to another skilled nursing facility (Skilled Care 1), which did not have record of Resident 6 arriving or being a resident there. There was no follow up for Resident 6. Resident 7 being sent immediately from the independent living facility to another skilled care facility, due to R7's need for extensive care. Resident 8 was sent to a lower level of care facility but the Skilled Nursing Facility (SNF) did not tell the lower level of care facility about the resident's need for [MEDICAL TREATMENT] treatments (a machine is used to perform some of the functions normally managed by a healthy kidney, by cleansing the blood). This resulted in R8's hospitalization and need for emergency [MEDICAL TREATMENT] and other treatment at the hospital. A pattern of the facility's system failure to implement its policy regarding Transfer or Discharge, and to ensure residents who were unable to care for themselves and required supervision and/or assistance with care was discharged appropriately with safe placement identified. The facility discharged Residents 1, 2, 6, 7, and 8 without an IDT assessment to ensure that the discharge and the placement was appropriate and safe to meet the resident's needs. The facility's non-compliance put Residents 1, 2, 6, 7, and 8 at risk for a decline and potential for injury and harm. On [DATE], at 2:18 p.m., The Department of Public Health (Department) called an Immediate Jeopardy (IJ - a noncompliant situation which would likely cause serious harm to the health and safety of residents) in the presence of the Administrator (ADM) and the Director of Nursing (DON). The Department verbally notified the Administrator and the Director of Nursing of the failure to have systems in place to discuss and develop safe and appropriate discharge plans, with the involvement of the Interdisciplinary Team, the resident and the resident's responsible party; inform the resident/resident responsible party of the final discharge plan; provide effective transition to the lower level of care facility for Residents 1, 2, 6, 7, and 8. This failure resulted or could have resulted in the residents not receiving the medical services they needed and could have resulted in death. On [DATE] at 9 a.m., the ADM and DON provided an acceptable plan of action (POA) for correction of the IJ. The POA included the following: 1. The policy titled, Discharging the Resident was revised to address the requirements of discharge detailed in the State Operations Manual Appendix PP 2019. 2. The Director of Staff Development (DSD) developed an in-service lesson plan regarding the federal requirements for discharging and transferring residents. 3. The Licensed Social Worker, contracted with the facility, gave a directed-in-service to the Directors of Staff Development, the Administrator, the social worker assistants, and the discharge nurses regarding the federal requirements for discharging and transferring residents. 4. The Administrator posted the federal regulations in the nursing stations and in the social service office for staff reference when planning the discharges and transfers of residents. On [DATE], at 12 p.m., while onsite at the facility, the Department confirmed the implementation of the facility's corrective plan of action through interviews and record reviews. The Immediate Jeopardy was removed in the presence of the Administrator and the Director of Nursing. Findings: a.A review of R1's medical record titled Progress Notes, written by Nurse Practitioner 1 (NP1), dated [DATE], indicated R1 had a history of [REDACTED]. A review of Resident 1's (R1) medical record indicated an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of R1's medical record titled Initial History and Physical, written by MD1, dated [DATE], indicated R1 has fluctuating capacity to understand and make decisions. A review of the Physician and Telephone Orders, dated [DATE], indicated Medical Doctor 1 (MD 1) gave a telephone order for the facility to discharge R 1 but did not indicate MD 1's signature. During an interview with Family Member 1 on [DATE] at 2:35 p.m., Family Member 1 stated that R1 had dementia and had been hit by a car while wandering in a street in the past and that the facility did not involve Family Member 1 in the planning of or notify him verbally or in writing of R1's discharge. Family Member 1 stated he wished the facility had informed him of R 1's discharge because R 1 needs a place that has locks on the doors. Family Member 1 stated R1 needed a place where he cannot wander off and keep getting hurt and picked up by ambulances again and again. During an interview the proprietor (owner) of the independent living facility (P1) that received R1 on [DATE] at 10:02 a.m., stated that her facility did not provide nursing care and did not have nurses on staff. P1 stated her facility only offered light cooking and cleaning only and provided for residents who were walking and independent. P1 stated R1 stayed at her facility less than 12 hours before he began to yell and left her facility, after which she reported R1 to the police as missing. P1 stated the skilled nursing facility did not inform her that R1 had dementia and a history of wandering from facilities or that R1 needed assistance with bathing, grooming, dressing himself and taking his medications. P1 stated her facility was not appropriate for R1. During a review of the medical record for R1, the document titled Emergency Department (ED) Provider Notes, written by MD2, dated [DATE], indicated R1 was brought to an emergency department by emergency medical responders on [DATE] after he had likely been on the streets for a week. A review of R1's medical record and a concurrent interview with the Minimum Data Set coordinator (MDS) 1 on [DATE] at 11 a.m., regarding the Section G on the Minimum Data Set (a care planning and screening tool) dated [DATE], indicated R1 needed assistance with getting in and out of bed, dressing, toileting, hygiene and bathing (resident was rated a 2 for assistance, 3 indicated extensive assistance). MDS1 stated at the time of his discharge R1 needed assistance with getting in and out of bed, dressing, toileting, hygiene and bathing. A review of R1's medical record and a concurrent interview with Social Worker Assistant (SWA)1, on [DATE] at 4:01 p.m., SWA1 stated there was no documentation of the facility informing P1 of R1's history of dementia and wandering from facilities or documentation of R1's needs for assistance and safety. A review of R1's medical record and a concurrent interview with Registered Nurse (RN)1 on [DATE] at 4:56 p.m., the document titled, Post Discharge Plan of Care, dated [DATE], did not indicate that R1 or his responsible party participated in or received documentation about R1's discharge plan of care. RN1 stated neither R1 or his responsible party participated in or received documentation about R1's discharge. Regarding the physician order [REDACTED]. During an interview with MD 1 on [DATE] at 9 a.m., MD 1 stated he did not remember giving a telephone order for the facility to discharge R 1. During an interview with RN1, on [DATE] at 5:05 p.m., RN1 stated R1 was not appropriate for an independent living facility because he needed a lot of assistance that an independent living facility did not provide. RN 1 stated R1's medical record did not include documentation informing the assisted living facility staff of R1's needs, history of dementia, or wandering in streets. b. A review of Resident 2's (R2) medical record indicated an admission to the skilled nursing facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE], indicated R2 needed assistance of one person to transfer in and out of bed, walk using a cane, dress, toilet, and bath. A Review of the POS [REDACTED]. A review of the Physician and Telephone Orders, dated [DATE], indicated MedDir 1 gave a telephone order for the facility to discharge R 2 but did not indicate MedDir 1's signature. A review of another Physician and Telephone Orders, dated [DATE], indicated that MedDiR 1 ordered the facility to arrange for R 2 to receive hospice services after his discharge. According to a review of the Notice of Transfer/Discharge, dated [DATE], the facility notified R 2 of his discharge and discharged him on the same date of [DATE], but the form did not indicate the signature of R 2. During an interview, on [DATE] at 11 a.m., MDS1 stated and confirmed, based on the MDS, that R2 needed assistance from staff with transferring in and out of bed, walking with a cane, dressing, toileting, and bathing. During an interview on [DATE] at 4:56 p.m., Licensed vocational nurse 1 (LVN 1) stated and confirmed that R2 needed at least 20 medications a day at the time of his discharge. LVN 1 also stated R2 needed one-person-assist with most things, such as taking his medications, walking, showering, getting dressed, and getting in and out of bed, as indicated in the MDS. LVN 1 stated she filled out the Notice of transfer/Discharge instead of a physician; the facility should have given R2 30 days written notice of his discharge but did not; and R2 did not sign the notice of discharge even though he was alert and oriented and capable of signing a document. During an interview with R2 on [DATE] at 1:30 p.m., R2 stated, I am legally disabled [MEDICAL CONDITION]. R2 stated the facility discharged him to a few blocks from a friend's house who had a trailer in his backyard. R2 stayed there to stay safe from COVID (Covid-19, a respiratory disease that has caused a worldwide pandemic that has killed many people). R2 stated the trailer had no air conditioning and was very hot during the day. R2 stated he walked with a cane, because he had difficulty walking and was unsteady on his feet and gets tired easily. R2 stated he must use a ridesharing program for transportation to the grocery, and when he goes to the grocery, he cannot buy much food because he cannot carry much food back to the trailer. R2 also stated he gets confused every few days and loses track of time, which he stated was, scary, because I know I can't figure out how to do something that I know I know how to do. R2 stated he had difficulty dressing because he could not bend over well. R2 stated he loses track of time and therefore had difficulty knowing whether he took his medications and loses count when he was preparing the medications. R2 stated he must take [MEDICAL CONDITION] daily for them to be effective. R2 stated he was so depressed when the facility dropped him off that he could not think enough to take his medications because he was so overwhelmed. R2 began to cry and stated he enrolled himself in a hospice program (a service for those with terminal medical conditions that helps someone to die in a comfortable state of being). During an interview with Med Dir 1 on [DATE] at 1:45 p.m., MedDir 1 stated she did not remember giving a telephone order to discharge R2. c. A review of Resident 6's (R6) medical record indicated an admission to the skilled nursing facility on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS (undated) indicated R6 needed assistance with transferring in and out of bed, walking, dressing, toileting, and bathing. A review of the Notice of Transfer/Discharge, dated [DATE], indicated the facility gave R6 his written notice of discharge on [DATE] but discharged R 6 the same day to another care facility. The Notice of Transfer / Discharge did not indicate the signature of R 6; did not indicate a reason for R 6's discharge; or the complete name, address, and phone number of R 6's receiving facility. A review of R6's Discharge/Transfer Transportation Safety Assessment, dated [DATE], indicated R6 was Unable to meet self-care needs and had several blank areas where information should have been documented. A review of the Physician and Telephone Orders, dated [DATE], indicated MD 1 gave a telephone order for the facility to discharge R6 but did not indicate MD 1's signature. A review of the Social Work Progress Notes, dated [DATE], indicated Skilled Care 1 (a skilled nursing facility for resident who cannot care for themselves) accepted R6 for admission. During an interview, on [DATE] at 11 a.m., MDS1 stated and confirmed that R6 needed assistance with transferring in and out of bed, walking, dressing, toileting, and bathing. The medical record did not indicate R6 was alert and able to make decisions. During an interview on [DATE] at 4:56 p.m., LVN 1 stated she should have completed the document but did not. LVN 1 also stated, R6 was unable to meet his self-care needs. LVN 1 stated MD 1 gave the telephone order to discharge R 6 and should have signed the telephone order but did not. A review of R6's medical record and concurrent interview with Social Worker (SW)1 on [DATE] at 4:01 p.m. During an interview on [DATE] at 4 p.m., the Admission Coordinator (AC) for Skilled Care 1 (AC) stated, We never accepted R6. He never arrived here. During another interview, on [DATE] at 12:01 p.m., the Director of Nursing (DON)2 for Skilled Care 1 stated, We have no record of admitting R6. During an interview on [DATE] at 12:21 p.m., with the Infection Preventionist (IP) for Skilled Care 1 stated, We have no record of ever admitting or accepting R6 in February of 2020, or ever. During an interview, on [DATE] at 12:45 p.m., SWA1 stated she did not know why the discharge paperwork for R6 was so incomplete. SWA1 also stated she did not know why the staff at Skilled Care 1 said R6, never arrived. A review of the medical record for R 6, and interview with LVN 1 on [DATE] at 4:56 p.m., the document titled Discharge Summary, dated [DATE], did not indicate a reason for R 6's discharge, a list of R 6's [DIAGNOSES REDACTED]. LVN 1 stated R 6's Discharge Summary should have a reason for R 6's discharge, a list of R 6's [DIAGNOSES REDACTED]. d. A review of Resident 7's medical record indicated an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical record indicated R7 was self-responsible and had the capacity to understand and make decisions. Notice of Transfer/Discharge, dated [DATE], indicated, the facility gave R 7 her written notice of discharge on [DATE] but discharged R 7 the same day to an independent home, and does not indicate the signature of R 7. A review and concurrent interview of R7's medical record, on [DATE] at 11 a.m., Section G of the MDS dated [DATE], indicated R7 needed assistance with transferring in and out of bed, dressing and personal hygiene; and needed extensive assistance with toileting, and bathing. MDS1 confirmed that R7 needed assistance transferring in and out of bed, dressing and personal hygiene; and needed extensive assistance with toileting, and bathing. During an interview on [DATE] at 4:56 p.m., LVN 1 stated R 7 did not sign the Notice of Transfer/Discharge but was capable of doing so, and the facility should have given R7 30 days written notice of discharge but did not. LVN1 stated R7 needs assistance with Grooming/Dressing, Bathing, Housekeeping, Shopping, Transportation to MD/Other, Therapy, Financial Management, R7 was not independent and used a wheelchair. During an interview on [DATE] at 10:15 a.m., P1 stated R7 didn't arrive at my assisted living facility. She needed too much assistance. P1 stated, R7 went to another place, a facility. During an interview on [DATE], at 3 p.m., SWA1 stated she did not know R7 did not arrive at the independent living facility as planned. SWA1 stated she did not know that the independent living facility did not provide the services that R7 needed. SWA1 stated the skilled nursing facility should not have discharged R7 to an independent living facility that could not give R7 the assistance she needed. SWA1 stated the skilled nursing facility (SNF) did not discharge R7 correctly. SWA1 stated the SNF's discharge of R7 to an independent care facility could have resulted in a delay in the medical services that R7 needed such as medication administration and extensive assistance with care needs. e. A review of Resident 8's Face Sheet indicated an admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of R8's medical record and a concurrent interview with MDS1 on [DATE] at 11 a.m., Section C of the MDS, dated [DATE], indicated R8's cognition was Moderately impaired. MDS1 stated and confirmed R8 had moderately impaired cognition (characterized by ongoing memory problems such as confusion, attention problems, or language difficulties). A review of R8's Minimum Data Set Section G dated [DATE], indicated R8 needed assistance with transferring in and out of bed, walking and personal hygiene and that R8 needed extensive assistance with toileting and bathing. A review of R8's Discharge/Transfer Transportation Safety Assessment, dated [DATE], indicated R8 was Unable to meet self-care needs. During an interview, on [DATE] at 4:56 p.m., LVN1 stated R8 was unable to care for herself and was receiving [MEDICAL TREATMENT] services during her stay at the SNF. LVN1 stated R8 cannot take care of herself and the physician should have ordered for the facility to arrange for R8 to receive [MEDICAL TREATMENT] services at a lower level of care facility. LVN1 stated the facility should have conveyed to the independent care facility that R8 required [MEDICAL TREATMENT] but did not. LVN 1 stated the medical record for R 8 does not include a Discharge Summary and that a physician did not write a Discharge Summary for R 8. During an interview, on [DATE] at 5:15 pm, the ADM stated the physicians for R 1, R 2, R 6, and R 8 should have signed their telephone orders to discharge the residents but did not. During an interview on [DATE] at 3:15 p.m., SWA1 stated she knew R8 was receiving [MEDICAL TREATMENT] services but did not arrange for such services to continue at the independent living facility or tell the independent living facility to do so. SWA1 stated R8's medical record did not indicate the SNF involved R8's family in the discharge planning or informed the family of R8's discharge to a lower level of care. A review of R8's Physician and Telephone Orders, dated [DATE], indicated a physician ordered the facility to discharge R8 to a lower level of care and arrange for R8 to receive home health services (a service involving a medical or nursing provider coming to a patient's residence and performing medical or nursing care as ordered by a physician). A review of the document titled Physician and Telephone Orders, dated [DATE], indicated MD 2 gave a telephone order for the facility to discharge R 8 but did not indicate MD 2's signature. A review R8's medical record included a document titled Emergency Department Encounter Note, written by MD6, on [DATE], three days after R8's discharge from the SNF. The ED note indicated R8 did not have [MEDICAL TREATMENT] for five days after the SNF discharged her to a lower level of care, for which she suffered very high blood pressure, difficulty breathing, and required emergency [MEDICAL TREATMENT] and other treatment at the hospital. The ED Note indicated MD6 stated, R8 conditions had not been treated and R8 could have died as a result. During interviews on [DATE] at 5:05 p.m. and 5:10 p.m. respectively, RN1 and LVN1 stated the facility did not discharge Residents 1, 2, 6, 7, and 8 correctly. RN1 stated, Not following the state and federal regulations for discharging a resident can lead to dangerous situations. During an interview with ADM on [DATE] at 5:15 p.m., The Administrator stated the facility's policy and procedure for transfers and discharges did not address all the state and federal requirements for transfers and discharges. The Administrator stated the physicians of Residents 1, 2, 6, 7, and 8 should have documented the reasons for their discharges but did not. A review of the facility's policy and procedures titled, Transfer or Discharge Documentation, revised [DATE], indicated should the resident be transferred or discharged for the following reasons, the basis for the transfer or discharge must be documented in the resident's clinical record by the resident's Attending Physician: a. The transfer or discharge is necessary forth resident's welfare, and the resident's needs cannot be met in the facility; or b. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. A review of the facility's policy and procedures titled, Telephone Orders, revised ,[DATE], indicated, Telephone orders must be countersigned by the physician during his or her next visit.

Based on observation, interview, and record review, the facility failed to: A. Notify the physician when one out of eight residents (Resident 51) investigated for quality of care had a blood glucose result greater than 350 milligram per deciliter (mg/dl-unit of measure). B. Assess the external catheter (thin tube) length of a peripherally inserted central catheter (PICC-a long, thin tube is inserted through a vein in the arm and passed through to the larger veins near the heart) upon admission, during dressing changes and obtain an okay to use (an order given by the medical doctor indicating that the medical equipment is cleared for usage by medical staff) order by the physician prior to use for one of three sampled residents (Resident 26). C. Ensure the license nurse who received a physician's telephone order for a warm compress for one of three sampled residents (Resident 83), transcribed the order into the resident's treatment records so that the nursing staff could implement the order. D. Ensure that licensed nurses did not sign the Medication Administration Record ((MAR) - a record of mediations administered to residents) that 414 doses of [MEDICATION NAME] (a medication used to treat Human Immunodeficiency Virus (HIV - [MEDICAL CONDITION] that causes a weakened immune system)) 100 milligrams ((mg) - a unit of measure for mass) were given when unavailable in the facility between 4/6/19 and 3/2/20 for one of 20 observed residents (Resident 61). E. Ensure that licensed nurses did not sign the MAR that 176 doses of Atrovent (an inhaled medication used to treat breathing problems) medications were given when unavailable in the facility between 1/18/20 and 3/3/20 for one of 20 observed residents (Resident 45.) F. Ensure that licensed nurses did not sign the MAR that 60 doses of [MEDICATION NAME] (a medication used to treat high blood sugar) were given when unavailable between 12/5/19 and 3/4/20 for one of 20 observed residents (Resident 7.) G. Ensure that licensed nurses did not sign the MAR that five doses of Potassium Chloride ER (a medication used to supplement low potassium levels) eight milliequivalents ((mEq) - a measure of strength for medications like potassium) were given when unavailable between 2/27/20 and 3/2/20 for one of 20 observed residents (Resident 51). The deficient practice had the potential to place Resident 26,51 and 83 at increased risk of ineffective care management. The deficient practice of signing the MAR that medications were given when they were unavailable in the facility caused the MAR to falsely reflect care provided to Residents 7, 45, 51, and 61. This increased the risk that Residents 7, 45, 51, and 61 could have experienced serious health complications such as respiratory arrest (the inability to breathe), abnormal heart rhythms, coma (a prolonged period of unconsciousness brought on by illness or injury), or life-threatening infections (invasion of the body by disease causing organisms) likely resulting in hospitalization or death. On 3/3/20 at 3:30 p.m., the Department of Public Health (Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the administrator (ADM) and director of nursing (DON). On 3/3/20 at 5:48 p.m., the ADM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. Licensed staff reassessed Resident 61 and found her condition to be stable with no adverse reactions. Licensed staff notified the resident's attending physician regarding a change in status due to missing or delayed treatment. All medications found to be missing from the medication cart, including [MEDICATION NAME], were reordered from the pharmacy on 3/4/20. Resident 61's attending physician (MD 1) ordered lab tests to further assess her condition. 2. Licensed staff reassessed Resident 45 and found her condition to be stable with no adverse reactions. Licensed staff notified the resident's attending physician regarding a change in status due to missing or delayed treatment. All medications found to be missing from the medication cart, including Atrovent, were reordered from the pharmacy on 3/3/20. Resident 45's attending physician (MD 1) ordered a chest x-ray to further assess her condition. 3. MD 1 indicated that she would reassess Residents 45 and 61 in person on 3/6/20. 4. Licensed staff performed a facility-wide three-way medication cart audit (a check to ensure that the residents' current physician's orders match what is written on their MAR and that the medication cart contains all of the medications necessary for the residents' current physician's orders.) 5. Upon completion of the three-way medication cart audit, licensed staff discovered medications missing for five additional residents. Licensed staff reassessed those additionally affected residents' conditions and found them to be stable with no adverse reactions. Licensed staff notified the affected residents' respective physicians of a change in status due to missing or delayed treatment. Licensed staff reported the resident's respective physicians issued no new orders as a result of the change in status reports. 6. The DON conducted an in-service (training) for all licensed staff on 3/3/30 at 3:00 p.m. to discuss findings and review regulations, policies, and procedures regarding availability of medications, documentation, and reordering medication from the pharmacy. 7. The director of staff development (DSD), DON, and ADM provided disciplinary action to all licensed staff found to be signing the MAR that medications were given to residents when the medications were unavailable in the facility. On 3/5/20 at 9:56 a.m., the Department did a facility-wide random check of medication availability. Resident 7's [MEDICATION NAME] was missing from Nursing Station 2 Medication Cart 2. On 3/5/20 at 12:06 p.m., in a conference meeting with the ADM and DON, the Department informed the facility that the POA was not accepted and Immediate Jeopardy was still in effect due to additional findings. On 3/6/20 at 11:53 a.m., the ADM provided the Department with an amended POA which included the following additional summarized actions: 1. Licensed staff reassessed Resident 7 and found her condition to be stable with no adverse reactions. Licensed staff notified the resident's attending physician regarding a change in status due to missing or delayed treatment. All medications found to be missing from the medication cart, including [MEDICATION NAME], were reordered from the pharmacy on 3/6/20. Resident 7's attending physician (MD 2) ordered lab tests to further assess her condition. 2. Licensed staff performed another facility-wide three-way medication cart audit and found four additional residents were missing medications. Licensed staff reassessed those additionally affected residents' conditions and found them to be stable with no adverse reactions. Licensed staff notified the affected residents' respective physicians of a change in status due to missing or delayed treatment. Licensed staff reported the resident's respective physicians issued no new orders as a result of the change in status reports. 3. The DON and ADM conducted an additional in-service with all licensed staff to reiterate policies, procedures, and protocols regarding medication administration. 4. Pharmacy consultants (professionals hired to help ensure compliance with pharmacy services regulations) performed an additional three-way medication cart audit on 3/6/20. On 3/9/20 at 10:42 a.m., the Department did a facility-wide random check of medication availability. Resident 51's Potassium Chloride ER 8 mEq was missing from Nursing Station 2 Medication Cart 2. On 3/9/20 at 1:48 p.m., in a conference meeting with the ADM and DON, the Department informed the facility that the POA was not accepted and Immediate Jeopardy was still in effect due to additional findings. On 3/10/20 at 7:39 a.m., the ADM provided the Department with an amended POA which included the following additional summarized actions: 1. Licensed staff reassessed Resident 51 and found his condition to be stable with no adverse reactions. Licensed staff notified the resident's attending physician regarding a change in status due to missing or delayed treatment. All medications found to be missing from the medication cart, including Potassium Chloride, were reordered from the pharmacy on 3/9/20. Resident 51's attending physician ordered lab tests to further assess his condition. 2. Licensed staff performed another facility-wide three-way medication cart audit and found no additional residents were missing medications. 3. The DON and ADM conducted an additional in-service with all licensed staff to reiterate policies, procedures, and protocols regarding medication administration. On 3/10/20 at 11:41 a.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy, in the presence of the ADM and the DON. Findings: A. A review of Resident 51's admission record indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. waste from the blood). A review of Resident 51's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/10/20, indicated the resident was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact and required extensive one-person assistance from staff for bed mobility, transfers, ambulation in the corridor, locomotion on and off the unit, dressing, and toilet use. A review of Resident 51's physician's orders, dated 1/10/20, indicated an order for [REDACTED]. The order indicated to give 10 units (unit of measurement) of [MEDICATION NAME]and to call the medical doctor (MD) for blood sugar greater than 350 mg/dl. On 3/6/20 at 7:47 a.m., during a concurrent interview and record review, Licensed Vocational Nurse 1 (LVN 1) verified that, according to the 2/2020 Medication Administration Record (MAR), Resident 10 had a blood glucose level of 369 mg/dl and was given 10 units of [MEDICATION NAME]by the nurse. When asked if the nurse notified the physician, as indicated by the physician's order, LVN 1 stated she could not find documentation anywhere in the resident's medical record that the physician was notified of the resident's blood glucose being greater than 350 mg/dl. On 3/10/20 at 2:03 p.m., during an interview, Registered Nurse 1 (RN 1) stated it was important to notify the physician if a resident is hyperglycemic (high blood sugar) because the resident can develop complications such as diabetic ketoacidosis (a serious diabetes complication where the body produces excess blood acids ([MEDICATION NAME])), which can very dangerous for the resident. A review of the facility's policy and procedure titled, Diabetes - Clinical Protocol revised in 4/2015, indicated that the physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into the Medication Administration Record and care plan. B. A review of Resident 26's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. to an infection). A review of Resident 26's history and physical examination [REDACTED]. A review of Resident 26's general acute care hospital (GACH 2) diagnostic radiology consultation report dated 2/11/20 indicated, Right-sided PICC line is present with its tip at the level of the right brachiocephalic junction (vein in the neck). There was no physician's order indicating the PICC was okay to use (MD order and radiographic confirmation of tip placement is required prior to use of the PICC) in the record. A review of Resident 26's physician order for [REDACTED]. The order indicated to measure the external catheter length of PICC upon admission and with each dressing change. A review of Resident 26's intravenous therapy care plan dated 2/19/20 indicated to measure the external catheter length for PICC upon admission and with each dressing change. A review of Resident 26's intravenous therapy medication record dated 2/19/20 through 3/4/20 indicated registered nurses did not fill out the portion of the record asking to measure the external catheter length in centimeters. A review of Resident 26's intravenous therapy medication record dated 2/25/20 through 3/10/20 indicated a registered nurse (RN) changed the resident's dressing on 2/27/20 at 10:20 a.m. but did not measure the external catheter length of the PICC as indicated by the physician's order and care plan. During an interview with RN 1 on 3/10/20 at 1:34 p.m., RN 1 stated registered nurses were responsible for managing, assessing, and administering intravenous therapy through Resident 26's PICC. RN 1 confirmed registered nurses, including herself, did not measure the external catheter length of the PICC per physician's orders and the care plan. RN 1 stated it was important to measure the external catheter length of the PICC upon admission and during every dressing change to make sure that the PICC is in the right place (i.e., in the superior vena cava-a large vein located in the upper chest which collects blood from the head and arms and delivers it back to the right atrium of the heart). RN 1 stated only by measuring the external length upon admission and every dressing change thereafter could RNs properly assess if the catheter had moved and was in the appropriate place. RN 1 confirmed if the tip of the PICC was in the wrong place, it could lead to complications and potentially decrease the effectiveness of medications. RN 1 also stated that Resident 26's PICC was placed in the hospital. When PICCs are placed in the hospital, RN 1 stated the registered nurses do not require an okay to use order by the physician. RN 1 stated usually the hospital records indicated whether a PICC was okay to use. RN 1 confirmed however that she could not locate an okay to use order in Resident 26's hospital records. When asked how RNs would then assess whether the PICC was in the right place if they were not obtaining an okay to use order from the facility's physician or clarifying the information with the hospital, RN 1 confirmed they were only assuming the PICC was in the right place. RN 1 confirmed incorrect placement of a PICC could cause complications in medication delivery and increase. A review of the facility's policy titled General Policies for IV Therapy dated June 2018 indicated confirmation of PICC placement is to be on the resident's chart. A review of the facility's policy titled PICC Dressing Change dated June 2018 indicated length of the external catheter is obtained upon admission and during dressing changes. C. A review of Resident 83's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. to an infection), and heart failure (when the heart is unable to pump blood as well as it should) A review of Resident 83's history and physical examination [REDACTED]. A review of Resident 83's optometry examination dated 3/3/20 indicated the resident had upper eyelid [MEDICAL CONDITION] with no discharge and recommended infection treatment and hot compresses. A review of Resident 83's optometrist's telephone order dated 3/3/20 indicated to apply warm cloth compress to left eyelid morning and night for 7 days due to eyelid chalazion (a bacterial infection of an oil gland in the eyelid). A review of Resident 83's MAR for the month of March 2020 indicated no order to apply a warm cloth compress to the left eyelid morning and night for 7 days per optometrist's order. During a concurrent interview and record review with licensed vocational nurse 3 (LVN 3) on 3/5/20 at 8:24 a.m., LVN 3 confirmed that there was no warm cloth compress transcribed in Resident 83's MAR. During an interview with Resident 83 on 3/5/20 at 8:36 a.m., Resident 83 stated she never received a warm compress to place on her eye. During a concurrent interview and record review with LVN 5 on 3/5/20 at 2:02 p.m., LVN 5 stated he was the one who transcribed the optometrist's telephone orders into the MAR. LVN 5 confirmed he did not transcribe the order for the warm compress. During an interview with the Director of Nursing (DON) on 3/10/20 at 7:30 p.m., the DON stated only the nurse taking the telephone order from the physician should be the one who directly writes or transcribes the order into the resident's MAR. The DON confirmed nurses were not following the facility's procedure and as a result the order for warm compress was not provided to the resident. A review of the facility's policy titled Telephone Orders revised February 2014 indicated, Verbal telephone orders may only be received by licensed personnel. Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. D. A review of Resident 61's admission record, dated 3/1/20, indicated that she was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 61's physician's order, dated 4/5/19, indicated that she was prescribed [MEDICATION NAME] 100 mg to be taken by mouth twice daily at 9:00 a.m. and 5:00 p.m. [MEDICAL CONDITION]. A review of Resident 61's MAR between 4/6/19 and 3/2/20 indicated that a total of 654 doses of [MEDICATION NAME] 100 mg were signed as administered to Resident 61 and a total of 10 doses were documented as refused or omitted. On 3/3/20 at 10:05 a.m., during an interview, the medical records director (MRD) stated that he could not find any record of pharmacy delivery history for Resident 61's [MEDICATION NAME] but knows that the resident uses two different pharmacies to deliver [MEDICAL CONDITION] (Pharmacy 1 and Pharmacy 2.) On 3/3/20 at 10:51 a.m., during a telephone interview, the pharmacy technician (PTC 3) stated that Pharmacy 1 only had records of delivering a 15-day supply of [MEDICATION NAME] (the generic name for [MEDICATION NAME]) 100 mg for Resident 61 on 4/6/19. PTC 3 stated that another order was placed on 2/11/20 but was not delivered due to insurance reasons. PTC 3 stated that the most recent delivery from Pharmacy 1 was made on 3/3/20 after the facility provided a billing authorization. PTC 3 stated that Pharmacy 1 made no other deliveries for [MEDICATION NAME] between 4/6/19 and 3/3/20. On 3/3/20 at 12:33 p.m., during an observation of Nursing Station 1 Medication Cart 1, Resident 61's [MEDICATION NAME] could not be found in the medication cart. During a concurrent interview, the licensed vocational nurse (LVN 4) stated that he noticed that the [MEDICATION NAME] was unavailable in the facility yesterday and informed the resident's physician and placed a refill order with the pharmacy. LVN 4 stated that the doses scheduled for 9 a.m. were marked as unavailable in the March 2020 MAR on 3/2 and 3/3/20. On 3/3/20 at 2:34 p.m., during a telephone interview, the pharmacist (RPH 2) stated that Pharmacy 2 does deliver two of Resident 61'[MEDICAL CONDITION] but has no record of making any deliveries for either her brand [MEDICATION NAME] or generic [MEDICATION NAME] tablets. A review of Resident 61's February and March 2020 MAR indicated that between 2/11 and 3/1/20, all but two doses (on 2/12 and 2/26/20) of [MEDICATION NAME] 100 mg were signed as given. On 3/4/20 at 1:48 p.m., during an interview, LVN 2 stated that he has worked for this facility for approximately a month and was responsible for administering medications to Resident 61, including the 9 a.m. dose of [MEDICATION NAME] 100 mg, when she was on Nursing Station 2, however, her room was recently changed and she is now currently on Nursing Station 1. LVN 2 stated that he signed the MAR that several of the 9 a.m. doses of [MEDICATION NAME] were given in February 2020 and that his initials on the MAR indicate that the medication was actually administered to the resident. LVN 2 stated that if medications were not given for any reason, he would circle his initials and document the reason on the back of the MAR. LVN 2 denied ever signing Resident 61's MAR that [MEDICATION NAME] was administered without actually giving it to her but could not offer an explanation as to how he was giving the medication when it was unavailable in the facility. LVN 2 stated that he was unable to describe the appearance of a [MEDICATION NAME] 100 mg tablet. LVN 2 stated that if medications were unavailable, he would first check the facility's other medication carts, as residents' rooms are changed frequently, and some medications may not be transferred appropriately. LVN 2 stated that if he could not find a missing medication that way, he would notify the physician and call the pharmacy for a replacement. LVN 2 stated that sometimes he feels that it is impossible to pass medications to all of his residents in the morning within two hours and has to rely on the help of others from time to time to complete his morning medication pass. On 3/4/20 at 2:35 p.m., Resident 61 was observed in her room lying in her bed with her head elevated. During a concurrent interview, Resident 61 stated that she is familiar with [MEDICATION NAME] and knows it as one of [MEDICAL CONDITION]. Resident 61 stated that sometimes her medications get lost when they move her from room to room. Resident 61 stated that they have made her change rooms five times since her initial admission in April 2019. Resident 61 stated that she was not sure if they give her the [MEDICATION NAME] 100 mg tablet or not. When shown a picture of what a [MEDICATION NAME] 100 mg tablet looks like, Resident 61 stated that she does not remember receiving any medication that looks like that. On 3/6/20 at 10:17 a.m., during an interview, the DON stated that Resident 61 receives her medications from two different pharmacies so it is possible that she may have received [MEDICATION NAME] 100 mg from another pharmacy, but stated that she can produce no record of delivery for [MEDICATION NAME] 100 mg from any pharmacy. DON stated that, despite the MAR is being signed between 5/5/2019 and 3/3/20, if it cannot be proven that any [MEDICATION NAME] 100 mg was delivered here, then the most likely explanation is that the [MEDICATION NAME] was not given to Resident 61. The DON stated that it is imperative that residents receive their medications as ordered and that Resident 61 may suffer complications from not receiving [MEDICATION NAME] which could lead to life-threatening infections likely resulting in hospitalization or death. On 3/6/20 at 10:34 a.m., during a telephone interview, [MEDICAL CONDITION] physician (MD 3) stated that she has been treating Resident 61'[MEDICAL CONDITION] she was an adolescent. MD 3 stated that if Resident 61 does not receive [MEDICAL CONDITION] as prescribed, there is big risk for [MEDICAL CONDITION] to develop resistance to her medications which would cause them not to work anymore. MD 3 stated that [MEDICATION NAME] 100 mg is especially important because it keeps another medication Resident 61 takes [MEDICAL CONDITION].[MEDICATION NAME] (a medication used to treat HIV), at an effective level in her blood. MD 3 stated that Resident 61 has developed resistance to [MEDICAL CONDITION] over her years of treatment and that [MEDICATION NAME] is one of the only fully effective medications left that she can use. MD 3 stated that if Resident 61'[MEDICAL CONDITION] develops resistance to [MEDICATION NAME], it may not be possible to fully treat [MEDICAL CONDITION] the future. MD 3 stated that if Resident 61'[MEDICAL CONDITION] not fully treated, there is a risk that she may develop life-threatening opportunistic infections (infections that occur in people with weak immune systems) which could lead to hospitalization or death. MD 3 stated that if Resident 61'[MEDICAL CONDITION] not fully treated, she may also become more likely to spread [MEDICAL CONDITION] to others. MD 3 stated that she is concerned that Resident 61 has not been receiving her [MEDICATION NAME] as documented in her MAR and thought that being in a skilled nursing facility would help to increase her compliance with her medications to ensure that the medications work in the future. MD 3 stated that she relies heavily on the information in the MAR to inform her treatment decisions and even has her patients bring their MAR with them to their appointments for review. MD 3 stated that she trusts that the medications are being given as they are documented and if the medications were not actually given it may cause her to make incorrect treatment decisions that could put the resident at further risk of harm due to adverse effects (unwanted side effects of medications) of higher doses or other medications. On 3/9/20 at 7:50 a.m., during an interview, the ADM stated that he was able to find many other delivery records for [MEDICATION NAME] for Resident 61 and provided additional pharmacy delivery receipts from Pharmacy 1. A review of Pharmacy 1's delivery receipts indicated that a 15-day supply (30 tablets) of [MEDICATION NAME] 100 mg was delivered to the facility for Resident 61 on the following dates: 4/25/19, 5/24/19, 6/28/19, 8/29/19, 11/28/19, 12/19/19, 1/1/20. On 3/9/20 at 8:27 a.m., during a telephone interview, PTC 4 stated that Pharmacy 1 delivered a 15-day supply of the generic [MEDICATION NAME] 100 mg tablets on 4/6/19 and confirmed that a 15-day supply of the brand [MEDICATION NAME] 100 mg tablets was delivered on 4/25, 5/24, 6/28, 8/29, 11/28, 12/19/19, and 1/1/20 for Resident 61. PTC 4 stated that the delivery history given earlier by PTC 3 was for the generic [MEDICATION NAME] only and was under a different prescription number than the brand [MEDICATION NAME]. PTC 4 stated that the eight deliveries Pharmacy 1 made on the dates listed above constitute the entirety of the generic [MEDICATION NAME] or brand [MEDICATION NAME] that was delivered to the facility for Resident 61 and was equal to 120 days of supply or 240 tablets. PTC 4 stated that, initially, Resident 61 was prescribed the generic [MEDICATION NAME] 100 mg tablets, but her insurance only covered the brand [MEDICATION NAME] and thus was later changed. A review of Resident 61's Resident Census List, dated 3/4/20, indicated that between 4/5/19 and 3/2/20, she was out of the facility for one day (2/12/20) due to a hospital visit. A review of Resident 61's MAR indicated that the facility signed a total of 654 total doses of [MEDICATION NAME] or [MEDICATION NAME] 100 mg tablets as administered between 4/6/19 and 3/2/20, however, only 240 totals doses were delivered, leaving a total deficit of 414 doses that were signed as given, but unavailable in the facility. On 3/9/20 at 10:07 a.m., during an interview, the registered nurse supervisor (RN 1) stated that the facility does not keep [MEDICATION NAME] or [MEDICATION NAME] 100 mg tablets in any of the facility's emergency kits (kits containing medications for emergency use) or in facility medication supply. RN 1 stated that any medications like that would only be ordered pursuant to a physician's order and would be specific to that resident for whom it was prescribed. On 3/10/20 at 1:13 p.m., during an interview, the DON stated that she agrees that the Resident 61's MAR does not reflect the care actually provided to her and that the most reasonable explanation is that the facility's licensed nursing staff signed the MAR that several doses of [MEDICATION NAME] were given when they could not have been. The DON stated that she has been unable to establish that enough [MEDICATION NAME] was ordered to cover the doses signed for. The DON stated that she understands the seriousness of this situation and stated that she wishes the other nurses realized that they are dealing with a human life and that not giving the residents their medications as ordered can kill them. On 3/10/20 at 3:34 p.m., during an interview, the DON stated that, after searching thoroughly and contacting each pharmacy individually, she was unable to obtain any additional records of delivery for Resident 61's [MEDICATION NAME] or [MEDICATION NAME] 100 mg tablets. E. A review of Resident 45's admission record, dated 3/1/20, indicated that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) A review of Resident 45's physician order, dated 12/23/19, indicated that she was prescribed Atrovent HFA to use two puffs by mouth four times daily at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. On 3/2/20 at 10:40 a.m., during an observation of Nursing Station 2 Medication Cart 3, Resident 45's Atrovent could not be found in the medication cart. A review of Resident 45's March 2020 MAR, indicated Atrovent was last administered to Resident 45 on 3/2/20 at 9:00 a.m. During a concurrent interview, LVN 11 stated that she was unable to find the Atrovent in the medication cart or anywhere else in the facility. LVN 11 stated that she signed the MAR that she gave Resident 45 her dose of Atrovent this morning at 9 a.m. even though it was not in available in the medication cart. LVN 11 stated that she should have circled the dose to indicate that it was unavailable, but forgot to do so. A review of Resident 45's MAR indicated that a total of 276 doses of Atrovent were signed as given between 12/23/19 and 9 a.m. on 3/2/20. On 3/3/20 at 9:20 a.m., during an interview, the DON stated that Pharmacy 1 was the only pharmacy the facility used to supply Resident 45's medications. On 3/3/20 at 9:24 a.m., during an interview, PTC 1 stated that Pharmacy 1 delivered a 25-day supply of Atrovent (one inhaler containing 200 puffs) for Resident 45 on 12/23/19. PTC 1 stated that Pharmacy 1 made no other deliveries of this medication for Resident 45. A review of Resident 45's MAR between 12/23/19 and 9 a.m. on 3/2/20 indicated that as the pharmacy only supplied a 25-day supply, the facility would have only had enough medication to administer Atrovent as documented through 1/17/20. From 1/18/20 through 9 a.m. on 3/2/20 a total of 176 additional doses were signed as given (1 omitted) even though the medication was unavailable in the facility. On 3/3/20 at 10:25 a.m., during an interview, Resident 45 stated that her licensed nurse offered her the Atrovent inhaler this morning, but she refused it because she was not familiar with it. Resident 45 stated that she doesn't remember receiving any of that medication since she last came back from the hospital in late December 2019. On 3/3/20 at 10:39 a.m., the DON stated that she could not explain how 176 doses of Atrovent were signed for when the medica (TRUNCATED)

Based on observation, interview, and record review, the facility failed to: 1. Administer 414 doses of [MEDICATION NAME] (a medication used to treat Human Immunodeficiency Virus (HIV - [MEDICAL CONDITION] that causes a weakened immune system)) 100 milligrams ((mg) - a unit of measure for mass) to one of 20 observed residents (Resident 61) between [DATE] and [DATE]. 2. Administer 176 doses of Atrovent (an inhaled medication used to treat breathing problems) to one of 20 observed residents (Resident 45) between [DATE] and [DATE]. 3. Administer 60 doses of [MEDICATION NAME] (a medication used to treat high blood sugar) to one of 20 observed residents (Resident 7) between [DATE] and [DATE]. 4. Administer five doses of Potassium Chloride ER (a medication used to supplement low potassium levels) eight milliequivalents ((mEq) - a measure of strength for medications like potassium) to one of 20 observed residents (Resident 51) between [DATE] and [DATE]. The deficient practice of failing to administer medications in accordance with physician's orders [REDACTED]. On [DATE] at 3:30 p.m., the Department of Public Health (Department) called an Immediate Jeopardy situation (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the administrator (ADM) and director of nursing (DON). On [DATE] at 5:48 p.m., the ADM provided the Department with a Plan of Action (POA) which included the following summarized actions: 1. Licensed staff reassessed Resident 61 and found her condition to be stable with no adverse reactions. Licensed staff notified the resident's attending physician regarding a change in status due to missing or delayed treatment. All medications found to be missing from the medication cart, including [MEDICATION NAME], were reordered from the pharmacy on [DATE]. Resident 61's attending physician (MD 1) ordered lab tests to further assess her condition. 2. Licensed staff reassessed Resident 45 and found her condition to be stable with no adverse reactions. Licensed staff notified the resident's attending physician regarding a change in status due to missing or delayed treatment. All medications found to be missing from the medication cart, including Atrovent, were reordered from the pharmacy on [DATE]. Resident 45's attending physician (MD 1) ordered a chest radiograph (chest x-ray- imaging test that uses small amounts of [MEDICAL CONDITION] to produce pictures of the organs, tissues, and bones of the body) to further assess her condition. 3. MD 1 indicated that she would reassess Residents 45 and 61 in person on [DATE]. 4. Licensed staff performed a facility-wide, three-way medication cart audit (a check to ensure that the residents' current physician's orders [REDACTED].'s orders [REDACTED]. 5. Upon completion of the three-way medication cart audit, licensed staff discovered medications missing for five additional residents. Licensed staff reassessed those additionally affected residents' conditions and found them to be stable with no adverse reactions. Licensed staff notified the affected residents' respective physicians of a change in status due to missing or delayed treatment. Licensed staff reported the resident's respective physicians issued no new orders as a result of the change in status reports. 6. The DON conducted an in-service (training) for all licensed staff on [DATE] at 3:00 p.m. to discuss findings and review regulations, policies, and procedures regarding availability of medications, documentation, and reordering medication from the pharmacy. 7. The director of staff development (DSD), DON, and ADM provided disciplinary action to all licensed staff found to be signing the MAR that medications were given to residents when the medications were unavailable in the facility. On [DATE] at 9:56 a.m., the Department did a facility-wide random check of medication availability. Resident 7's [MEDICATION NAME] was missing from Nursing Station 2 Medication Cart 2. On [DATE] at 12:06 p.m., in a conference meeting with the ADM and DON, the Department informed the facility that the POA was not accepted and Immediate Jeopardy was still in effect due to additional findings. On [DATE] at 11:53 a.m., the ADM provided the Department with an amended POA which included the following additional summarized actions: 1. Licensed staff reassessed Resident 7 and found her condition to be stable with no adverse reactions. Licensed staff notified the resident's attending physician regarding a change in status due to missing or delayed treatment. All medications found to be missing from the medication cart, including [MEDICATION NAME], were reordered from the pharmacy on [DATE]. Resident 7's attending physician (MD 2) ordered lab tests to further assess her condition. 2. Licensed staff performed another facility-wide, three-way medication cart audit and found four additional residents were missing medications. Licensed staff reassessed those additionally affected residents' conditions and found them to be stable with no adverse reactions. Licensed staff notified the affected residents' respective physicians of a change in status due to missing or delayed treatment. Licensed staff reported the resident's respective physicians issued no new orders as a result of the change in status reports. 3. The DON and ADM conducted an additional in-service with all licensed staff to reiterate policies, procedures, and protocols regarding medication administration. 4. Pharmacy consultants (professionals hired to help ensure compliance with pharmacy services regulations) performed an additional three-way medication cart audit on [DATE]. On [DATE] at 10:42 a.m., the Department did a facility-wide random check of medication availability. Resident 51's potassium chloride ER 8 mEq was missing from Nursing Station 2 Medication Cart 2. On [DATE] at 1:48 p.m., in a conference meeting with the ADM and DON, the Department informed the facility that the POA was not accepted and Immediate Jeopardy was still in effect due to additional findings. On [DATE] at 7:39 a.m., the ADM provided the Department with an amended POA which included the following additional summarized actions: 1. Licensed staff reassessed Resident 51 and found his condition to be stable with no adverse reactions. Licensed staff notified the resident's attending physician regarding a change in status due to missing or delayed treatment. All medications found to be missing from the medication cart, including Potassium Chloride, were reordered from the pharmacy on [DATE]. Resident 51's attending physician ordered lab tests to further assess his condition. 2. Licensed staff performed another facility-wide three-way medication cart audit and found no additional residents were missing medications. 3. The DON and ADM conducted an additional in-service with all licensed staff to reiterate policies, procedures, and protocols regarding medication administration. On [DATE] at 11:41 a.m., while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department accepted the POA and removed the Immediate Jeopardy, in the presence of the ADM and the DON. Findings: A. A review of Resident 61's admission record, dated [DATE], indicated that she was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 61's physician's orders [REDACTED]. . A review of Resident 61's MAR between [DATE] and [DATE] indicated that a total of 654 doses of [MEDICATION NAME] 100 mg were signed as administered to Resident 61 and a total of 10 doses were documented as refused or omitted. On [DATE] at 10:05 a.m., during an interview, the medical records director (MRD) stated that he could not find any record of pharmacy delivery history for Resident 61's [MEDICATION NAME] but knows that the resident uses two different pharmacies to deliver [MEDICAL CONDITION] (Pharmacy 1 and Pharmacy 2.) On [DATE] at 10:51 a.m., during a telephone interview, the pharmacy technician (PTC 3) stated that Pharmacy 1 only had records of delivering a 15-day supply of [MEDICATION NAME] (the generic name for [MEDICATION NAME]) 100 mg for Resident 61 on [DATE]. PTC 3 stated that another order was placed on [DATE] but was not delivered due to insurance reasons. PTC 3 stated that the most recent delivery from Pharmacy 1 was made on [DATE] after the facility provided a billing authorization. PTC 3 stated that Pharmacy 1 made no other deliveries for [MEDICATION NAME] between [DATE] and [DATE]. On [DATE] at 12:33 p.m., during an observation of Nursing Station 1 Medication Cart 1, Resident 61's [MEDICATION NAME] could not be found in the medication cart. During a concurrent interview, the licensed vocational nurse (LVN 4) stated that he noticed that the [MEDICATION NAME] was unavailable in the facility yesterday and informed the resident's physician and placed a refill order with the pharmacy. LVN 4 stated that the doses scheduled for 9:00 a.m. were marked as unavailable in the [DATE] MAR on ,[DATE] and [DATE]. On [DATE] at 2:34 p.m., during a telephone interview, the registered pharmacist (RPH 2) stated that Pharmacy 2 does deliver two of Resident 61'[MEDICAL CONDITION], but has no record of making any deliveries for either her brand [MEDICATION NAME] or generic [MEDICATION NAME] tablets. A review of Resident 61's February and [DATE] MAR indicated that between ,[DATE] and [DATE], all but two doses (on ,[DATE] and [DATE]) of [MEDICATION NAME] 100 mg were signed as given. On [DATE] at 1:48 p.m., during an interview, LVN 2 stated that he has worked for this facility for approximately a month and was responsible for administering medications to Resident 61, including the 9:00 a.m. dose of [MEDICATION NAME] 100 mg, when she was on Nursing Station 2, however, her room was recently changed and she is now currently on Nursing Station 1. LVN 2 stated that he signed the MAR that several of the 9:00 a.m. doses of [MEDICATION NAME] were given in February 2020 and that his initials on the MAR indicate that the medication was actually administered to the resident. LVN 2 stated that if medications were not given for any reason, he would circle his initials and document the reason on the back of the MAR. LVN 2 denied ever signing Resident 61's MAR that [MEDICATION NAME] was administered without actually giving it to her but could not offer an explanation as to how he was giving the medication when it was unavailable in the facility. LVN 2 stated that he was unable to describe the appearance of a [MEDICATION NAME] 100 mg tablet. LVN 2 stated that if medications were unavailable, he would first check the facility's other medication carts, as residents' rooms are changed frequently, and some medications may not be transferred appropriately. LVN 2 stated that if he could not find a missing medication that way, he would notify the physician and call the pharmacy for a replacement. LVN 2 stated that sometimes he feels that it is impossible to pass medications to all of his residents in the morning within two hours and has to rely on the help of others from time to time to complete his morning medication pass. On [DATE] at 2:35 p.m., Resident 61 was observed in her room lying in her bed with her head elevated. During a concurrent interview, Resident 61 stated that she is familiar with [MEDICATION NAME] and knows it as one of [MEDICAL CONDITION]. Resident 61 stated that sometimes her medications get lost when they move her from room to room. Resident 61 stated that they have made her change rooms five times since her initial admission in [DATE]. Resident 61 stated that she was not sure if they give her the [MEDICATION NAME] 100 mg tablet or not. When shown a picture of what a [MEDICATION NAME] 100 mg tablet looks like, Resident 61 stated that she does not remember receiving any medication that looks like that. On [DATE] at 10:17 a.m., during an interview, the DON stated that Resident 61 receives her medications from two different pharmacies so it is possible that she may have received [MEDICATION NAME] 100 mg from another pharmacy, but stated that she can produce no record of delivery for [MEDICATION NAME] 100 mg from any pharmacy. DON stated that, despite the MAR being signed between [DATE] and [DATE], if it cannot be proven that any [MEDICATION NAME] 100 mg was delivered here, then the most likely explanation is that the [MEDICATION NAME] was not given to Resident 61. The DON stated that it is imperative that residents receive their medications as ordered and that Resident 61 may suffer complications from not receiving [MEDICATION NAME] which could lead to life-threatening infections likely resulting in hospitalization or death. On [DATE] at 10:34 a.m., during a telephone interview, [MEDICAL CONDITION] physician (MD 3) stated that she has been treating Resident 61'[MEDICAL CONDITION] she was an adolescent. MD 3 stated that if Resident 61 does not receive [MEDICAL CONDITION] as prescribed, there is big risk for [MEDICAL CONDITION] to develop resistance to her medications which would cause them not to work anymore. MD 3 stated that [MEDICATION NAME] 100 mg is especially important because it keeps another medication Resident 61 takes [MEDICAL CONDITION].[MEDICATION NAME] (a medication used to treat HIV), at an effective level in her blood. MD 3 stated that Resident 61 has developed resistance to [MEDICAL CONDITION] over her years of treatment and that [MEDICATION NAME] is one of the only fully effective medications left that she can use. MD 3 stated that if Resident 61'[MEDICAL CONDITION] develops resistance to [MEDICATION NAME], it may not be possible to fully treat [MEDICAL CONDITION] the future. MD 3 stated that if Resident 61'[MEDICAL CONDITION] not fully treated, there is a risk that she may develop life-threatening opportunistic infections (infections that occur in people with weak immune systems) which could lead to hospitalization or death. MD 3 stated that if Resident 61'[MEDICAL CONDITION] not fully treated, she may also become more likely to spread [MEDICAL CONDITION] to others. MD 3 stated that she is concerned that Resident 61 has not been receiving her [MEDICATION NAME] as documented in her MAR and thought that the resident living in a skilled nursing facility would help to increase her compliance with her medications to ensure that the medications work in the future. MD 3 stated that she relies heavily on the information in the MAR to inform her treatment decisions and even has her patients bring their MAR with them to their appointments for review. MD 3 stated that she trusts that the medications are being given as they are documented and if the medications were not actually given it may cause her to make incorrect treatment decisions that could put the resident at further risk of harm due to adverse effects (unwanted side effects of medications) of medication doses that are higher than necessary or other unnecessary medications. On [DATE] at 7:50 a.m., during an interview, the ADM stated that he was able to find many other delivery records for [MEDICATION NAME] for Resident 61 and provided additional pharmacy delivery receipts from Pharmacy 1. A review of Pharmacy 1's delivery receipts indicated that a 15-day supply (30 tablets) of [MEDICATION NAME] 100 mg was delivered to the facility for Resident 61 on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. On [DATE] at 8:27 a.m., during a telephone interview, PTC 4 stated that Pharmacy 1 delivered a 15-day supply of the generic [MEDICATION NAME] 100 mg tablets on [DATE] and confirmed that a 15-day supply of the brand [MEDICATION NAME] 100 mg tablets was delivered on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], [DATE], and [DATE] for Resident 61. PTC 4 stated that the delivery history given earlier by PTC 3 was for the generic [MEDICATION NAME] only and was under a different prescription number than the brand [MEDICATION NAME]. PTC 4 stated that the eight deliveries Pharmacy 1 made on the dates listed above constitute the entirety of the generic [MEDICATION NAME] or brand [MEDICATION NAME] that was delivered to the facility for Resident 61 and was equal to 120 total days of supply or 240 tablets. PTC 4 stated that, initially, Resident 61 was prescribed the generic [MEDICATION NAME] 100 mg tablets, but her insurance only covered the brand [MEDICATION NAME] and thus was later changed. A review of Resident 61's Resident Census List, dated [DATE], indicated that between [DATE] and [DATE], she was out of the facility for one day ([DATE]) due to a hospital visit. A review of Resident 61's MAR indicated that the facility signed a total of 654 total doses of [MEDICATION NAME] or [MEDICATION NAME] 100 mg tablets as administered between [DATE] and [DATE], however, only 240 totals doses were delivered, leaving a total deficit of 414 doses that were signed as given, but unavailable in the facility. On [DATE] at 10:07 a.m., during an interview, the registered nurse supervisor (RN 1) stated that the facility does not keep [MEDICATION NAME] or [MEDICATION NAME] 100 mg tablets in any of the facility's emergency kits (kits containing medications for emergency use) or in facility medication supply. RN 1 stated that any medications like that would only be ordered pursuant to a physician's orders [REDACTED]. On [DATE] at 1:13 p.m., during an interview, the DON stated that she agrees that the Resident 61's MAR does not reflect the care actually provided to her and that the most reasonable explanation is that the facility's licensed nursing staff signed the MAR that several doses of [MEDICATION NAME] were given when they could not have been. The DON stated that she has been unable to establish that enough [MEDICATION NAME] was ordered to cover the doses signed for. The DON stated that she understands the seriousness of this situation and stated that she wishes the other nurses realized that they are dealing with a human life and that not giving the residents their medications as ordered can kill them. On [DATE] at 3:34 p.m., during an interview, the DON stated that, after searching thoroughly and contacting each pharmacy individually, she was unable to obtain any additional records of delivery for Resident 61's [MEDICATION NAME] or [MEDICATION NAME] 100 mg tablets. B. A review of Resident 45's admission record, dated [DATE], indicated that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 45's physician order, dated [DATE], indicated that she was prescribed Atrovent HFA to use two puffs by mouth four times daily at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. On [DATE] at 10:40 a.m., during an observation of Nursing Station 2 Medication Cart 3, Resident 45's Atrovent could not be found in the medication cart. A review of Resident 45's [DATE] MAR, indicated Atrovent was last administered to Resident 45 on [DATE] at 9:00 a.m. During a concurrent interview, LVN 11 stated that she was unable to find the Atrovent in the medication cart or anywhere else in the facility. LVN 11 stated that she signed the MAR that she gave Resident 45 her dose of Atrovent this morning at 9:00 a.m. even though it was not in available in the medication cart. LVN 11 stated that she should have circled the dose to indicate that it was unavailable but forgot to do so. A review of Resident 45's MAR indicated that a total of 276 doses of Atrovent were signed as given between [DATE] and 9:00 a.m. on [DATE]. On [DATE] at 9:20 a.m., during an interview, the DON stated that Pharmacy 1 was the only pharmacy the facility used to supply Resident 45's medications. On [DATE] at 9:24 a.m., during an interview, PTC 1 stated that Pharmacy 1 delivered a 25-day supply of Atrovent (one inhaler containing 200 puffs) for Resident 45 on [DATE]. PTC 1 stated that Pharmacy 1 made no other deliveries of this medication for Resident 45. A review of Resident 45's MAR between [DATE] and 9:00 a.m. on [DATE] indicated that as the pharmacy only supplied a 25-day supply, the facility would have only had enough medication to administer Atrovent as documented through [DATE]. From [DATE] through 9:00 a.m. on [DATE] a total of 176 additional doses were signed as given (1 omitted) even though the medication was unavailable in the facility. On [DATE] at 10:25 a.m., during an interview, Resident 45 stated that her licensed nurse offered her the Atrovent inhaler this morning, but she refused it because she was not familiar with it. Resident 45 stated that she doesn't remember receiving any of that medication since she last came back from the hospital in late [DATE]. On [DATE] at 10:39 a.m., the DON stated that she could not explain how 176 doses of Atrovent were signed for when the medication was unavailable in the facility. The DON stated that she would have to ask the nurses what happened. The DON stated that the inhaler could have been saved from before Resident 45's last hospital admission even though she knows that they are not supposed to do that. On [DATE] at 11:11 a.m., during a telephone interview, PTC 2 stated that Pharmacy 1 has never delivered any Atrovent for Resident 45 prior to [DATE]. On [DATE] at 11:13 a.m., during an interview, MD 1 stated that although the omission of Atrovent for Resident 45 may not itself have a life-threatening clinical impact, if the medication was omitted for other residents with certain breathing problems it could be life-threatening. MD 1 stated that she is concerned that medications are not being given in the facility as recorded in the MAR and that she relies on the accurate reporting in the MAR to make informed treatment decisions. MD 1 stated that without and accurate record of what medications were given at their current doses, that she may make incorrect treatment decisions to start or stop medications or to increase or decrease their doses which could cause health complications due to adverse effects of medications. On [DATE] at 1:21 p.m., during an interview, LVN 9 stated that she is responsible for administering medications to Resident 45 in the morning. LVN 9 stated she is familiar with Atrovent and confirmed that her initials were on many 9:00 a.m. and 1:00 p.m. doses of Atrovent for Resident 45 in the February 2020 MAR. LVN 9 stated that her initials on the MAR indicate that the medication was given. LVN 9 stated that if not given for any reason, she would circle the dose and provide a written explanation on the back. When informed that there was not enough Atrovent ordered for Resident 45 to last beyond [DATE], LVN 9 stated that she may have signed doses of Atrovent on the MAR without giving them. LVN stated that sometimes she is in a hurry and may have skipped the medications that take a longer time to administer, like breathing treatments. LVN 9 stated that it is possible that she forgot to go back to indicate that the doses were not given, but that it is unlikely since there are so many doses signed for. LVN 9 stated that she has a total of 34 residents to administer medication to and feels like it is difficult to complete in a two-hour period. LVN 9 stated that she tries her best, but sometimes it takes longer because some residents are more difficult than others and require more time. On [DATE] at 10:07 a.m., during an interview, the registered nurse supervisor (RN 1) stated that the facility does not keep Atrovent in any of the facility's emergency kits (kits containing medications for emergency use) or in facility medication supply. RN 1 stated that any medication like that would only be ordered pursuant to a physician's orders [REDACTED]. On [DATE] at 2:48 p.m., during an interview, LVN 11 stated that she failed to indicate on the MAR that the 9:00 a.m. dose of Atrovent on [DATE] was not given because she was distracted by the immediate needs of another resident. LVN 11 stated that she should have gone back and circled her initials on that date because the Atrovent was not available. LVN 11 states that she understands that her initials on the MAR for a dose indicates that the medication was given. LVN 11 acknowledges that her initials are on many other doses in the February 2020 MAR and stated that I do remember giving her the inhaler. LVN 11 denied signing the MAR that the medication was given without actually giving it, but was unable to offer an explanation as to how she administered the inhaler when the resident's supply would have been exhausted by [DATE] or why the resident did not remember receiving it. LVN 11 stated this facility is so disorganized, sometimes medications are missing from the cart due to room changes, and you have to go to the other carts to try to find them. On [DATE] at 1:13 p.m., during an interview, the DON stated that there are no other pharmacy delivery records available for Resident 45's Atrovent and confirmed that Pharmacy 1 is the only pharmacy used to supply her medications. The DON agrees that the Resident 45's MAR does not reflect the care actually provided to her and that the most reasonable explanation is that the facility's licensed nursing staff signed the MAR that several doses of Atrovent were given when they could not have been. The DON stated that she understands the seriousness of this situation and stated that she wishes the other nurses realized that they are dealing with a human life and that not giving the residents their medications as ordered can kill them. C. A review of Resident 7's admission record, dated [DATE], indicated that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) A review of Resident 7's physician's orders [REDACTED].) to inject 20 units subcutaneously (under the skin) every night at bedtime (scheduled for 9:00 p.m.) A review of Resident 7's MAR from [DATE] to [DATE] indicated that 56 doses of [MEDICATION NAME] were signed as administered. A review of Resident 7's MAR from [DATE] indicated that pages 2 and 3 (containing information regarding [MEDICATION NAME] administration in [DATE]) were missing. A review of Resident 7's MAR from [DATE] to [DATE] indicated that 33 doses of [MEDICATION NAME] were signed as administered. On [DATE] at 9:56 a.m., during an observation of Nursing Station 2 Medication Cart 2, Resident 7's [MEDICATION NAME] could not be found in the medication cart. On [DATE] at 10:33 a.m., during an interview, LVN 2 stated that he could not find Resident 7's [MEDICATION NAME] in the medication cart, the medication storage room, or anywhere else in the facility. A review of Resident 7's pharmacy delivery records indicated Pharmacy 1 delivered one 10 ml vial of [MEDICATION NAME] on [DATE]. On [DATE] at 8:23 a.m., during a telephone interview, the registered pharmacist (RPH 1) confirmed that Pharmacy 1 only delivered one vial of [MEDICATION NAME] for Resident 7 on [DATE]. RPH 1 stated that Pharmacy 1 did not deliver [MEDICATION NAME] for Resident 7 on any other dates. RPH 1 stated that one 10 ml vial of [MEDICATION NAME] is considered a 28-day supply since, per the manufacturer's instructions, it must be used or discarded within 28 days of its first use. A review of Resident 7's MAR indicated that, after [DATE], the [MEDICATION NAME] that Pharmacy 1 had initially supplied would have been expired, however, excluding [DATE] (for which the MAR is unavailable for [MEDICATION NAME]), 60 doses of [MEDICATION NAME] were signed as given between [DATE] and [DATE]. On [DATE] at 9:36 a.m., during a telephone interview, MD 2 stated that he is the attending physician for Resident 7. MD 2 stated that it is imperative that Resident 7 receive her [MEDICATION NAME] as ordered to avoid complication of diabetes. When informed that Resident 7 may have missed several doses of [MEDICATION NAME] even though the MAR was signed indicating those doses were given, MD 2 stated That's wrong. That's so wrong. MD 2 stated that without the [MEDICATION NAME], the resident may experience uncontrolled diabetes which could cause serious health complications resulting in hospitalization or death. MD 2 stated that he would order additional lab tests to assess Resident 7's condition and come by this weekend to reassess her condition personally as her blood sugars have been elevated for several weeks. MD 2 stated that he relies on accurate information from the nursing staff as to what medications were given at the currently prescribed doses in order to guide his treatment decisions. If the medication was not actually given, he would possibly order a higher dose of insulin than the resident needed leading to complications such as [DIAGNOSES REDACTED] (low blood sugar) that may result in coma or death. On [DATE] at 10:17 a.m., during an interview, the DON agreed that it would have been impossible for Resident 7 to have received her [MEDICATION NAME] after [DATE] since it would have expired 28 days after the initial delivery from Pharmacy 1 on [DATE]. The DON stated that there is no record of any other deliveries for it and Pharmacy 1 is the only pharmacy that supplies medications for Resident 7. The DON stated that it is imperative that residents receive their medications as ordered and that Resident 7 may suffer complications from not receiving her medications as ordered possibly leading to life threatening complications that could result in hospitalization or death. On [DATE] at 10:07 a.m., during an interview, the registered nurse supervisor (RN 1) stated that the facility does not keep [MEDICATION NAME] in any of the facility's emergency kits or in facility medication supply. RN 1 stated that any medication like that would only be ordered pursuant to a physician's orders [REDACTED]. On [DATE] at 1:13 p.m., during an interview, the DON agreed that the Resident 7's MAR does not reflect the care actually provided to her and that the most reasonable explanation is that the facility's licensed nursing staff signed the MAR that several doses of [MEDICATION NAME] were given when they could not have been. On [DATE] at 3:13 p.m., during an interview, LVN 10 stated that she administers insulin to Resident 7 and is familiar with [MEDICATION NAME]. LVN 10 acknowledged that she signed for multiple doses of [MEDICATION NAME] for Resident 7 on the February 2020 MAR. LVN 10 stated that her initials on the MAR indicated that the medication was given. LVN 10 stated that if for any reason the medication was not given, the initials would be circled and an explanation written on the back of the MAR. LVN 10 stated that Resident 7 has three different types of insulin and most likely what happened is that she only administered two of them, but signed for all three on the MAR. LVN 10 stated that it was possible that she signed Resident 7's MAR that the [MEDICATION NAME] was given without actually having given it to her. On [DATE] at 3:29 p.m., during an interview, the medical records director (MRD) stated that, after a thorough search, pages 2 and 3 of Resident 7's [DATE] MAR could not be found anywhere in the facility. D. A review of Resident 51's admission record, dated [DATE], indicated that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 51's physician's orders [REDACTED]. A review of Resident 51's MAR indicated that, between [DATE] and 3 (TRUNCATED)

Based on interview and record review, the facility failed to ensure safe transfer and discharge when the facility used inappropriate mode of transport and personnel accompanying the resident for one (1) of three (3) sampled residents (Resident 2) who had history of combative behavior and potential use for oxygen (an element in the air which sustains life). This failure had placed the health and safety of Resident 2 in jeopardy. On (MONTH) 14, 2019 at 5:14 PM, an Immediate Jeopardy (IJ - a noncompliant situation which would likely to cause serious harm to the health and safety of the resident) was called in the presence of the Administrator and the Director of Nurses (DON). The Administrator and the DON were verbally notified of the failure to safely transfer Resident 2 to a hospital that was 65 miles away from the facility, using the facility's wheelchair van accompanied by the facility's driver and a Certified Nursing Assistant (CNA). Resident had documented history of increased agitation, confusion, anxiety, combative behavior and had a doctor's order for oxygen (a component of the air to sustain life) use when difficulty breathing occurred. Both the CNA and driver did not have training on proper administration of oxygen to a resident. According to the DON, this kind of transfer should be via a Basic Life Support (BLS) Ambulance (a transport vehicle and service for residents who require medical transportation and continuous medical supervision/monitoring). There was no written policy on the proper determination of the appropriate type of transport to use for this situation. On (MONTH) 15, 2019 at 5:31 PM, the Immediate Jeopardy was removed in the presence of the Administrator and the DON. The facility Corrective Action Plan was approved through interview and record review. The Corrective Action Plan included the following components: 1. List of residents with mental health [DIAGNOSES REDACTED]. 2. Residents with mental issues and other residents with potential or upcoming transportation needs were reassessed for appropriate transportation. 3. Facility Policy and Procedure updated to include transfer/discharge criteria and qualification with the use of the Discharge/Transfer Transportation Assessment form. 4. RN to use the Discharge/Transfer Transportation Assessment form to determine appropriateness of the transportation. Assessment results will be relayed to the physician to finalize the order the mode of transportation. 5. When a BLS transportation is ordered by the physician, BLS must be utilized even if the facility needs to cover for the transportation expenses. Findings: An unannounced visit was conducted to investigate a complaint. A review of Resident 2's face sheet (a facility document which indicates the demographic information of the resident), indicated the resident was admitted to the facility on (MONTH) 19, 2019. There were no diagnoses or family or resident representative information available on the face sheet. A review of Resident 2's Initial History and Physical indicated diagnoses which included diabetes (increased blood sugar), failure to thrive (refers to the physical and emotional deprivation that signifies a deficiency in growth and healthy functioning), [MEDICAL CONDITION] (low red blood cell count (component of the blood which carries oxygen and nutrients to the different parts of the body), [MEDICAL CONDITION] (brain disease, damage, or malfunction), developmental delay (less developed mentally or physically than is normal for its age), and dementia with behavioral disturbance (often globally described as agitation including verbal and physical aggression, wandering, and hoarding). A review of Resident 2's physician order sheet from (MONTH) 2019 to (MONTH) 2019 indicated the following transfer and discharged orders and reason for the transfer: February 22, 2019 at 1:30 PM - (MONTH) transfer resident to (name of Hospital #1) due to anxiety (restlessness), agitation (an action of disturbing something), combative behavior with bed hold x (for) 7 days. March 2, 2019 at 11:30 PM - Resident readmitted back to (name of the facility) from (name of Hospital #1). Will resume all previous orders. March 12, 2019 - Transfer to (name of Hospital #1) for further eval (evaluation). Cloudy urine, anxiety, gen (generalized) weakness. March 13, 2019 at 8:20 AM - (MONTH) accept from (name of Hospital #1). Resume all previous orders . March 25, 2019 - Transfer to (name of Hospital #2) for further evaluation. Anxiety, agitation. March 26, 2019 at 4:30 PM - Readmit to (name of the facility) from (name of Hospital #2). Continue acute hospital orders and resume all previous orders. SNF orders. A review of Resident 2' re-admission orders [REDACTED]. A review of Resident 2's physician order dated (MONTH) 8, 2019, indicated Transfer to (name of Hospital #3, 65 miles away from the facility) for further evaluation. Increased confusion, anxiety, agitation. The MD order did not mention that the transfer was per family representative's request. On (MONTH) 29, 2019 at 1:53 PM during an interview with the Director of Nurses (DON), the DON described that on (MONTH) 28, 2019 a lady came to the facility, and had identified herself as the conservator (public guardian or protector) for Resident 2. The conservator mentioned to the facility that Resident 2 was missing form another facility for 3 months, and had informed of the real name of the Resident 2. The DON stated prior to this, there was a staff from another facility who had seen Resident 2 and had identified Resident 2 as their former resident who eloped (left the facility without facility permission and knowledge). On (MONTH) 29, 2019 at 4:07 PM, during an interview with the Administrator, the Administrator stated the staff from (name of the retirement home) identified Resident 2 with her real name. The Administrator stated the retirement home had informed the family of Resident 2, conservator and the police of the current whereabouts of Resident 2. A review of Resident 2's Authorization for Use and Disclosure of Protected Health Information executed and signed (MONTH) 28, 2019, the document was signed by the conservator as the Personal Representative's authority to act on resident's behalf. On (MONTH) 10, 2019 at 1:55 PM, during an interview with the DON, the DON stated Resident 2 was transported via the private vehicle of the facility on (MONTH) 8, 2019. The DON stated the Discharge Licensed Vocational Nurse (DLVN) spoke with the Hospital #3 ER nurse and ER Supervisor for Resident 2's transfer, but did not document the details of what transpired during the conversation. There were no hospital personnel identified to take responsibility for the transfer of Resident 2 to the hospital On (MONTH) 10, 2019 at 3:59 PM to 4:22 PM, during an interview with the DLVN the DLVN stated that she was responsible in transferring Resident 2 to Hospital #3, which was more than 30 miles away from the facility. She mentioned talking to the ambulance company and was refused due to the more than 30 mile-limit for transport for insurance coverage. She stated that she was instructed by the Administrator to transfer Resident 2 as soon as possible and to get a doctor's order for transfer. DLVN stated that the transfer could have been done on a later time. The DLVN described Resident 2 having anxiety, agitation and confusion. She added that Resident 2 could act up with episodes of uncontrolled behavior. On (MONTH) 14, 2019 at 1:10 PM, during an interview with the facility driver (FD), the FD stated that he was responsible for transporting Resident 2 to Hospital #3 for one and a half hour-travel with a Certified Nurse Assistant (CNA 1). FD stated that he did not know Resident 2 would need oxygen and had episodes of combative behavior. The FD stated that during the transfer, he did grabbed CNA 1 to watch over Resident 2 during travel and he dropped Resident 2 to the ER not CNA 1. On (MONTH) 14, 2019 at 1:20 PM, during an interview with CNA 1, CNA 1 stated that she accompanied FD in transporting Resident 2 to Hospital #3. On (MONTH) 14, 2019 at 1:53 PM, during an interview with the DON, the DON stated that the transfer based on the physician order was not an immediate emergency. The DON stated that usually for resident who were for evaluation of agitation, anxiety and confusion to the hospital, the transport vehicle should have been a BLS Ambulance not a regular facility transport vehicle. On (MONTH) 14, 2019 at 4:29 PM, during an interview with the Administrator, the Administrator stated that he gave the information to the DLVN for the transfer per family's request and to get a physician's order for transfer and to follow the doctor's order. There was no documentation about the conversation with the family or the conservator about the transfer for Resident 2 to where, when and how. A review of the facility policy and procedure titled Discharging the Resident, revised (MONTH) 2012, did not indicate the process for transferring residents more than 30 miles away from the facility, what criteria to use to determine the mode of transportation to safety transfer the resident.

Based on observation, interview and record review, the facility failed to ensure four of four sampled residents (Residents 1, 2, 3, and 4) were free from neglect, which included, but were not limited to: a. Failure to administered Resident 1's intravenous (IV, administered into, a vein) antibiotics ordered on [DATE], at 5 p.m., and 1/9/19 at 8 a.m. b. Failure to administered Residents' 2 and 3 IV antibiotics on time. These deficient practices had the potential for worsening of infections, adverse effects from infusing the IV antibiotic rate faster than prescribed and for delayed antibiotics administration. Cross-reference F725 and F755. During a complaint investigation on 1/9/18, at 8:25 a.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identify and called on 1/9/19 at 4 p.m. under F600. The facility administrator and director of nursing were notified of the IJ situation. The facility failed to ensure residents who had infections were free of neglect by administering the scheduled intravenous (IV, administered into, a vein) antibiotic (used to treat growth of or destroys microorganisms) medications as ordered by the physician. The IJ was removed on 1/15/19 at 2 p.m., after verification that the plan of action were implemented to ensure residents received their prescribed medication. The administrator and DON was notified of IJ removal. Findings: 1. A review of Resident 1's Admission Record, dated 1/9/19, indicated Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1 [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, an assessment and care-screening tool), dated 11/8/18, indicated Resident 1 was rarely or never understood. Resident 1 required extensive assistance from staff with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's IV Therapy Care Plan, dated 1/9/19, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 9:53 a.m., Resident 1's Intravenous Therapy Medication Record was reviewed with the Director of Nursing (DON). The DON confirmed the IV antibiotic [MEDICATION NAME] was not administered as ordered 1/8/19 at 5:00 p.m. (17 hours after the order was obtained). The DON stated the initial IV antibiotic medication should be given within 4 (four) hours from the time the physician's orders [REDACTED]. Also, on 1/9/19, at 9:53 a.m., during concurrent interview and record with the DON, the IV [MEDICATION NAME] 1 g due on 1/9/19 at 8:00 a.m. was not administered. The DON stated the facility had one hour before and one after the scheduled times to administer the medications. The DON stated there were no registered nurses to administer the [MEDICATION NAME] on time. The DON stated she would call the physician to have the [MEDICATION NAME] start time changed. On 1/9/19, at 11:23 a.m., Resident 1 was observed in his bed with the DON. Resident 1 had an intravenous catheter (IVC, a small tube placed into the vein) to the right upper extremity (RUE) completely wrapped and taped. The DON removed the gauze and tape and found Resident 1's IVC to the RUE was pulled-out. The DON stated on 1/9/19 at 10:00 a.m., she assessed Resident 1's IVC site and found it to be out, prompting her to call the physician to have the order changed to [MEDICATION NAME] administration time to 11:00 a.m. The DON stated she did not document her findings. On 1/9/19, at 12:29 p.m., the DON was observed initiating Resident 1's [MEDICATION NAME] that was due at 8:00 a.m. The [MEDICATION NAME] bag indicated the medication was started at 11:55 a.m. The DON stated the medication was not started until 12:05 p.m., (four hours late from the original order) because Resident 1 was a hard-stick. The DON stated she made two attempts at inserting the IVC, which was successfully inserted to the left antecubital (AC) fossa, where the arm bends. On 1/9/19, at 1:09 p.m., Resident 1's [MEDICATION NAME] bag was observed with the DON. The DON stated the IV [MEDICATION NAME] bag was 100 milliliters (mL), which was the full amount of the [MEDICATION NAME] bag. The IV was not infused (allow (a liquid) to flow into a resident vein) after it was hung at 12:05 p.m. The DON stated the [MEDICATION NAME] duration exceed the prescribed duration of 1 hour. The DON stated the AC IV site is not the ideal location for an IVC because Resident 1 bends his arm a lot. The DON stated a pillow or arm board could have prevented the resident from bending her arm. On 1/9/19, at 1:34 p.m., the emergency-kit (E-kit, prescribed medication available in the facility to be used as an initial dosage until the pharmacy delivered the resident medication) was observed in the medication room with the DON. The E-kit inventory taped to the top of the kit indicated it was stocked with two (2) vials of [MEDICATION NAME]. When the E-kit was opened, the DON confirmed the presence of two vials [MEDICATION NAME], that could be used to administer the IV [MEDICATION NAME] to Resident 1 on 1/8/19 at 5 p.m. On 1/9/19, at 2:12 p.m., the pharmacy Delivery Manifest, dated 1/9/19, was reviewed with the DON. Concurrent interview and record review with DON indicated Resident 1's supply of [MEDICATION NAME] was delivered on 1/9/19 at 1:24 a.m. On 1/9/19, at 3:06 p.m., the Administrator was interviewed. The Administrator stated, We are not a 24-hour RN facility. The Administrator confirmed there was no RN on duty from 1/9/19 at 12:35 a.m. until DON clocked-in at 9:30 a.m. An RN has scope of practice to administered the IV medication. On 1/9/19, at 3:20 p.m., findings of neglect were discussed with the Administrator and the DON. The DON confirmed Resident 1's IV antibiotic [MEDICATION NAME] was not administered for 17 hours after it was order. The DON confirmed the [MEDICATION NAME] was available in the E-kit for administration, but was not utilized. The DON had no explanation for the reason the [MEDICATION NAME] was not administered. The DON stated medications require specific frequency and duration (if IV infused). 2. A review of Resident 2's GACH 2's Hospitalist History & Physical, dated 12/31/18, indicated Resident 2 was admitted to the intensive care unit for close vital sign monitoring. Resident 2 diagnoses, included, but were not limited to, health-care associated pneumonia (lung infection) and [MEDICAL CONDITION] (is the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), end-organ damage including toxic metabolic [MEDICAL CONDITION] from the healthcare-associated pneumonia, toxic metabolic [MEDICAL CONDITION] secondary to acute [MEDICAL CONDITION]. Resident 2 had a recent UTI, required broad-spectrum antibiotics, IV fluids, lumbar puncture (the collection of spinal fluid for testing), and sputum and blood cultures (tests for infection). A review of Resident 2's Skilled Nursing Facility Admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses, which included, but were not limited to, [MEDICAL CONDITION] ([MEDICAL CONDITION], lung disease making it difficult to breath), healthcare associated pneumonia, [MEDICAL CONDITION] acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (oxygen deficiency), and toxic metabolic [MEDICAL CONDITION]. A review of Resident 2's Minimum Data Set (MDS, an assessment and care-screening tool), dated 12/31/18, indicated Resident 2 had a Brief Interview for Mental Status score (BIMS) of three (3), indicating severely impaired cognition (the mental action of acquiring knowledge and understanding through thought, experience, and the senses). Resident 2 required extensive assistance from staff with bed mobility, transfer, locomotion, dressing, eating, toilet use, and personal hygiene. A review of Resident 2's Physician order [REDACTED]. A review of Resident 2's IV Therapy Care Plan, dated 1/4/19, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 9:53 a.m., Resident 2's Intravenous Therapy Medication Record was reviewed with the Director of Nursing (DON). The DON confirmed Resident 1 had received [MEDICATION NAME] 1g every 12 hours from 1/5/19 to 1/8/19 at 8:00 a.m. and 8:00 p.m. The DON confirmed Resident 2 did not receive the medication on 1/9/19 at 8:00 a.m. The DON stated there were no registered nurses to administer the Cefepmine on time, today 1/9/19 at 8 a.m. The DON stated she would call the physician to have the [MEDICATION NAME] start time changed. A review of Resident 2's Physician and Telephone Orders, dated 1/9/19 at 10:15 a.m., indicated, schedule antibiotics (ATB) time changed to 10:00 a.m. and 10:00 p.m. for [MEDICATION NAME] 1g every 12 hours until end of IV ATB therapy. A review of the Intravenous Therapy Medication Recorded, indicated Resident 2 received [MEDICATION NAME] 1g IV at 10:55 a.m. On 1/9/19, at 11:35 a.m., Resident 2's [MEDICATION NAME] bag, which was connected to the peripheral (through the vein) IVC via IV tubing, was observed with Licensed Vocational Nurse 1 (LVN) 1. During concurrent interview, LVN 1 confirmed Resident 2's [MEDICATION NAME] start time was 1/9/19 at 10:55 a.m. as indicated by documentation on the bag. LVN 1 confirmed the [MEDICATION NAME] bag was empty, indicating the [MEDICATION NAME] IV rate was infused faster than prescribed. On 1/9/19, at 3:06 p.m., the Administrator was interviewed, the Administrator confirmed there was no RN on duty from 1/9/19 at 12:35 a.m. to administer the IV antibiotic medication to the Resident 2, until DON clocked-in at 9:30 a.m. On 1/9/19, at 3:20 p.m., the findings were discussed with the Administrator and the DON. The DON stated the physician orders [REDACTED]. The DON confirmed the physician did not order an administration schedule for Resident 2's [MEDICATION NAME] order during a concurrent review of the physician order. The DON stated antibiotics must be administered as soon as possible because infections can get worse. The DON stated medications require specific frequency and duration (if IV infused), so that blood concentrations can be maintained for the efficacy of the medication. The DON stated infusing IV medication rate faster than prescribed could increase the chances of a resident developing adverse reactions. The DON stated the facility utilized the drip method, where gravity and a mechanical controller dictates the flow, of infusing IV medications. On 1/10/19, at 11:25 a.m., the setup and administration of Resident 2's [MEDICATION NAME] was observed. The Registered Nurse Supervisor (RNS) was observed to start Resident 2's [MEDICATION NAME] at 11:35 a.m. On 1/10/19, at 12:22 p.m., the RNS was interviewed. The RNS confirmed medications could be administered 1 hour before and 1 hour after the scheduled administration time. The RNS confirmed Resident 2's [MEDICATION NAME] was due at 10:00 a.m., but was not administered until 11:35 a.m. In regards to the late administration of [MEDICATION NAME], the RNS stated, I do not know what to attribute it to. On 1/10/19, at 3:03 p.m., the findings were discussed with the Administrator and the DON. The DON admitted the RNS should have prioritized the administration of Resident 2's [MEDICATION NAME] so that it was administered within the time allowed (1 hour before and 1 hour after 10:00 a.m.). A review of Resident 2's GACH laboratory result dated 1/4/19 indicated White Blood Cell (WBC, cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders) count was 9.3 per microliter of blood (mcL) (Normal range is between 3,500 and 10,500 white blood cells per microliter of blood (mcL). A review of Resident 2's laboratory results, dated 1/9/19, at 10:20 p.m., indicated a high WBC count of 13.38 mcL. (A high WBC indicates an increase in disease-fighting cells in your blood) and a high absolute [DIAGNOSES REDACTED] count of 10.43 (normal 1.56-6.13 x103/uL). An increased WBC and [DIAGNOSES REDACTED] (the most common type of white blood cell) could indicate infection. 3. A review of Resident 3's Admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses, which included, but were not limited to, acute [MEDICAL CONDITION] ulcer (sore that develops on the lining of the esophagus, stomach, or small intestine), non-infective gastroenteritis (intestinal infection) and [MEDICAL CONDITION] (chronic inflammation of the digestive system), and abdominal pain. A review of Resident 3's Minimum Data Set (MDS, dated [DATE], indicated the resident cognitive skills for daily decision-making were intact and required limited assistance from staff with personal hygiene and extensive assistance with bed mobility, transfer, dressing, and toilet use. A review of Resident 3's Order Summary Report, dated 12/28/18, indicated the physician ordered, [MEDICATION NAME] (antibiotic) 500 (milligrams (mg) IV every 6 (six) hours for [MEDICAL CONDITION] for 57 days on 12/10/18. A review of Resident 3's IV Therapy Care Plan, dated 12/11/18, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 2:20 p.m., Resident 3's Intravenous Therapy Medication Record was reviewed with the DON. During concurrent interview with the DON, DON stated Resident 3 had received [MEDICATION NAME] 500 mg every 6 hours from 12/26/18 to 1/8/19 at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. On 1/9/19, the [MEDICATION NAME] was not administered at 6:00 a.m. The DONS stated there were no RN's on duty to administer the medication. The DON confirmed the [MEDICATION NAME] was administered at 10:25 a.m. on 1/9/19. On 1/9/19, at 3:06 p.m., the Administrator was interviewed. The Administrator stated, We are not a 24-hour RN facility. The Administrator confirmed there was no RN on duty from 1/9/19 at 12:35 a.m. until DON clocked-in at 9:30 a.m. On 1/9/19, at 3:20 p.m., the findings of neglect were discussed with the Administrator and the DON. The DON stated antibiotics must be administered as soon as possible because infections can get worse. 4. A review of Resident 4's Admission Record indicated Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Resident 4 [DIAGNOSES REDACTED]. A review of Resident 4's Minimum Data Set (MDS, assessment and care-screening tool), dated 11/7/18, indicated Resident 4 had a BIMS of two (2), indicating severely impaired cognition. Resident 4 required extensive assistance from staff with bed mobility, transfer, and dressing, and total dependence on toilet use and personal hygiene. A review of Resident 4's Physician order [REDACTED]. A review of Resident 4's IV Therapy Care Plan, dated 1/9/19, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 10:50 a.m., Resident 4's [MEDICATION NAME] bag was observed with the DON. The DON confirmed Resident 4's [MEDICATION NAME] was initiated on 1/9/19 at 10:50 a.m. instead of 9 a.m. A review facility's policy on Abuse and Neglect - Clinical Protocol, revised (MONTH) 2007, indicated, neglect refers to refusal or failure to fulfill any part of one's obligations or duties to an individual. A review of the facility's policy, General Policies for IV Therapy, dated (MONTH) (YEAR), indicated, IV medications may be administered by registered nurses (RN). Initial antibiotic dose is to be given within 4 (four) hours from the time the physician's orders [REDACTED]. Subsequent doses are to be administered within 1 hour before or 1 hour after the scheduled time.

Based on observation, interview, and record review, the facility failed to have a sufficient nursing staff with the appropriate competencies and skills sets to administer intravenous (IV, administered into, a vein) medications for four of four sampled residents (Residents 1, 2, 3 and 4), which included, but were not limited to, a. Ensure the facility had a scheduled registered nurse to administer scheduled intravenous (IV) medication on time for Residents 1, 2, and 3; b. Ensure the registered nurse had knowledge to infuse IV medications for the prescribed duration (Residents 1, 2, and 4); and, c. Ensure the registered nurse had the competency to check the IV site of Resident 1 for proper placement. These deficient practices had the potential for the development or worsening or infections, increased adverse effects from infusing the antibiotic faster than prescribed, and decreased efficacy for antibiotics administered late and/or infused slower than prescribed. Cross-reference F600 and F755. During a complaint investigation on 1/9/18, at 8:25 a.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identify and called on 1/9/19 at 4 p.m. The facility administrator and director of nursing were notified of the IJ situation. The facility failed to have an available registered nurse with skills sets to provide nursing and related services to ensure residents received scheduled IV antibiotics medication on time as prescribed by the physician. The IJ was removed on 1/15/19 at 2 p.m., after verification that the plan of action were implemented to ensure residents received their prescribed medication. The administrator and DON was notified of IJ removal. Findings: 1. A review of Resident 1's Admission Record, dated 1/9/19, indicated Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1 [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, an assessment and care-screening tool), dated 11/8/18, indicated Resident 1 was rarely or never understood. Resident 1 required extensive assistance from staff with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's IV Therapy Care Plan, dated 1/9/19, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 9:53 a.m., Resident 1's Intravenous Therapy Medication Record was reviewed with the Director of Nursing (DON). The DON confirmed the IV antibiotic [MEDICATION NAME] was not administered as ordered 1/8/19 at 5:00 p.m. (17 hours after the order was obtained). The IV [MEDICATION NAME] 1 g due on 1/9/19 at 8:00 a.m. was not administered at the time of interview with the DON. The DON stated the facility had one hour before and one after the scheduled times to administer the medications. The DON stated there were no registered nurses to administer the [MEDICATION NAME] on time. The DON stated she would call the physician to have the [MEDICATION NAME] start time changed. On 1/9/19, at 11:23 a.m., Resident 1 was observed in his bed with the DON. Resident 1 had an intravenous catheter (IVC, a small tube placed into the vein) to the right upper extremity (RUE) completely wrapped and taped. The DON removed the gauze and tape and found Resident 1's IVC to the RUE was pulled-out. The DON claimed at 10:00 a.m., she assessed Resident 1's IVC site and found it to be out, prompting her to call the physician to have the order changed to [MEDICATION NAME] administration time to 11:00 a.m. The DON stated she did not document her findings. On 1/9/19, at 12:29 a.m., the DON was observed initiating Resident 1's [MEDICATION NAME] that was due at 8:00 a.m. The [MEDICATION NAME] bag indicated the medication was started at 11:55 a.m. The DON admitted the medication was not started until 12:05 p.m., (four hours late from the original order) because Resident 1 was a hard-stick. The DON stated she made two attempts at inserting the IVC, which was successfully inserted to the left antecubital (AC) fossa, where the arm bends. On 1/9/19, at 1:09 a.m., Resident 1's [MEDICATION NAME] bag was observed with the DON. The DON confirmed the IV [MEDICATION NAME] bag was 100 milliliters (mL), which was the full amount of the [MEDICATION NAME] bag. The IV was not infused (allow (a liquid) to flow into a resident vein) after it was hanged at 12:05 p.m. The DON confirmed the [MEDICATION NAME] duration exceeded the prescribed duration of 1 hour. The DON stated the AC IV site is not the ideal location for an IVC because Resident 1 bends his arm a lot. The DON stated a pillow or arm board could have prevented the [MEDICATION NAME] from exceeding the prescribed infusion duration. On 1/9/19, at 1:34 p.m., the emergency-kit (E-kit) was observed in the medication room with the DON. The E-kit inventory taped to the top of the kit indicated it was stocked with two (2) vials of [MEDICATION NAME]. When the E-kit was opened, the DON confirmed the presence of two vials [MEDICATION NAME], that could be used to administer the IV [MEDICATION NAME] to Resident 1 on 1/8/19 at 5 p.m. On 1/9/19, at 2:12 p.m., the pharmacy Delivery Manifest, dated 1/9/19, was reviewed with the DON. The DON confirmed Resident 1's supply of [MEDICATION NAME] was delivered on 1/9/19 at 1:24 a.m. On 1/9/19, at 3:06 p.m., the Administrator was interviewed. The Administrator stated, We are not a 24-hour RN facility. The Administrator confirmed there was no RN on duty from 1/9/19 at 12:35 a.m. until DON clocked-in at 9:30 a.m. On 1/9/19, at 3:20 p.m., the findings were discussed with the Administrator and the DON. The DON confirmed Resident 1's IV antibiotic [MEDICATION NAME] was not administered for 17 hours after it was order. The DON confirmed the [MEDICATION NAME] was available in the E-kit for administration, but was not utilized. The DON had no explanation for the reason the [MEDICATION NAME] was not administered. The DON stated medications require specific frequency and duration (if IV infused). 2. A review of Resident 2's GACH 2's Hospitalist History & Physical, dated 12/31/18, indicated Resident 2 was admitted to the intensive care unit for close vital sign monitoring. Resident 2 diagnoses, included, but were not limited to, health-care associated pneumonia (lung infection) and [MEDICAL CONDITION] (is the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), end-organ damage including toxic metabolic [MEDICAL CONDITION] from the healthcare-associated pneumonia, toxic metabolic [MEDICAL CONDITION] secondary to acute [MEDICAL CONDITION]. Resident 2 had a recent UTI, required broad-spectrum antibiotics, IV fluids, lumbar puncture (the collection of spinal fluid for testing), and sputum and blood cultures (tests for infection). A review of Resident 2's Skilled Nursing Facility Admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses, which included, but were not limited to, [MEDICAL CONDITION] ([MEDICAL CONDITION], lung disease making it difficult to breath), healthcare associated pneumonia, [MEDICAL CONDITION] acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (oxygen deficiency), and toxic metabolic [MEDICAL CONDITION]. A review of Resident 2's Minimum Data Set (MDS, an assessment and care-screening tool), dated 12/31/18, indicated Resident 2 had a Brief Interview for Mental Status score (BIMS) of three (3), indicating severely impaired cognition (the mental action of acquiring knowledge and understanding through thought, experience, and the senses). Resident 2 required extensive assistance from staff with bed mobility, transfer, locomotion, dressing, eating, toilet use, and personal hygiene. A review of Resident 2's Physician order [REDACTED]. A review of Resident 2's IV Therapy Care Plan, dated 1/4/19, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 9:53 a.m., Resident 2's Intravenous Therapy Medication Record was reviewed with the Director of Nursing (DON). The DON confirmed Resident 1 had received [MEDICATION NAME] 1g every 12 hours from 1/5/19 to 1/8/19 at 8:00 a.m. and 8:00 p.m. The DON confirmed Resident 2 did not receive the medication on 1/9/19 at 8:00 a.m. The DON stated there were no registered nurses to administer the Cefepmine on-time, today 1/9/19 at 8 a.m. The DON stated she would call the physician to have the [MEDICATION NAME] start time changed. A review of Resident 2's Physician and Telephone Orders, dated 1/9/19 at 10:15 a.m., indicated, schedule antibiotics (ATB) time changed to 10:00 a.m. and 10:00 p.m. for [MEDICATION NAME] 1g every 12 hours until end of IV ATB therapy. A review of the Intravenous Therapy Medication Recorded, indicated Resident 2 received [MEDICATION NAME] 1g IV at 10:55 a.m. On 1/9/19, at 11:35 a.m., Resident 2's [MEDICATION NAME] bag, which was connected to the peripheral IVC via IV tubing, was observed with Licensed Vocational Nurse 1 (LVN) 1. LVN 1 confirmed the [MEDICATION NAME] infusion duration was prescribed at 1 hour. LVN 1 confirmed Resident 2's [MEDICATION NAME] start time was 1/9/19 at 10:55 a.m. as indicated by documentation on the bag. LVN 1 confirmed the [MEDICATION NAME] bag was empty, indicating the [MEDICATION NAME] IV rate was infused faster than prescribed. On 1/9/19, at 3:06 p.m., the Administrator was interviewed, the Administrator confirmed there was no RN on duty from 1/9/19 at 12:35 a.m. until DON clocked-in at 9:30 a.m. On 1/9/19, at 3:20 p.m., the findings were discussed with the Administrator and the DON. The DON stated the physician orders [REDACTED]. The DON confirmed the physician did not order an administration schedule for Resident 2's [MEDICATION NAME] order during a concurrent review of the physician order. The DON stated antibiotics must be administered as soon as possible because infections can get worse. The DON stated medications require specific frequency and duration (if IV infused), so that blood concentrations can be maintained for the efficacy of the medication. The DON stated infusing IV medication rate faster than prescribed could increase the chances of a resident developing adverse reactions. The DON stated the facility utilized the drip method, where gravity and a mechanical controller dictates the flow, of infusing IV medications. On 1/10/19, at 11:25 a.m., the setup and administration of Resident 2's [MEDICATION NAME] was observed. The Registered Nurse Supervisor (RNS) was observed to start Resident 2's [MEDICATION NAME] at 11:35 a.m. On 1/10/19, at 12:22 p.m., the RNS was interviewed. The RNS confirmed medications could be administered 1 hour before and 1 hour after the scheduled administration time. The RNS confirmed Resident 1's [MEDICATION NAME] was due at 10:00 a.m., but was not administered until 11:35 a.m. In regards to the late administration of [MEDICATION NAME], the RNS stated, I do not know what to attribute it to. On 1/10/19, at 3:03 p.m., the findings were discussed with the Administrator and the DON. The DON admitted the RNS should have prioritized the administration of Resident 2's [MEDICATION NAME] so that it was administered within the time allowed (1 hour before and 1 hour after 10:00 a.m.). A review of Resident 2's GACH laboratory result dated 1/4/19 indicated White Blood Cell (WBC, cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders) count was 9.3 per microliter of blood (mcL) (Normal range is between 3,500 and 10,500 white blood cells per microliter of blood (mcL). A review of Resident 2's laboratory results, dated 1/9/19, at 10:20 p.m., indicated a high WBC count of 13.38 mcL. (A high WBC indicates an increase in disease-fighting cells in your blood) and a high absolute [DIAGNOSES REDACTED] count of 10.43 (normal 1.56-6.13 x103/uL). An increased WBC and [DIAGNOSES REDACTED] could indicate infection. 3. A review of Resident 3's Admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses, which included, but were not limited to, acute [MEDICAL CONDITION] ulcer (sore that develops on the lining of the esophagus, stomach, or small intestine), non-infective gastroenteritis (intestinal infection) and [MEDICAL CONDITION] (chronic inflammation of the digestive system), and abdominal pain. A review of Resident 3's Minimum Data Set (MDS, dated [DATE], indicated the resident cognitive skills for daily decision-making were intact and required limited assistance from staff with personal hygiene and extensive assistance with bed mobility, transfer, dressing, and toilet use. A review of Resident 3's Order Summary Report, dated 12/28/18, indicated the physician ordered, [MEDICATION NAME] (antibiotic) 500mg IV every 6 (six) hours for [MEDICAL CONDITION] for 57 days on 12/10/18. A review of Resident 3's IV Therapy Care Plan, dated 12/11/18, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 2:20 p.m., Resident 3's Intravenous Therapy Medication Record was reviewed with the DON. The DON confirmed Resident 3 had received [MEDICATION NAME] 500 mg every 6 hours from 12/26/18 to 1/8/19 at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. On 1/9/19 the [MEDICATION NAME] was not administered at 6:00 a.m., there were no RN's on duty to administer the medication. The DON confirmed the [MEDICATION NAME] was administered at 10:25 a.m. on 1/9/19. On 1/9/19, at 3:06 p.m., the Administrator was interviewed. The Administrator stated, We are not a 24-hour RN facility. The Administrator confirmed there was no RN on duty from 1/9/19 at 12:35 a.m. until DON clocked-in at 9:30 a.m. On 1/9/19, at 3:20 p.m., the findings were discussed with the Administrator and the DON. The DON stated the physician orders [REDACTED]. The DON confirmed the physician did not order an administration schedule for Resident 3's [MEDICATION NAME] order during a concurrent review of the physician order. The DON stated antibiotics must be administered as soon as possible because infections can get worse. The DON stated medications require specific frequency and duration (if IV infused), so that blood concentrations can be maintained for the efficacy of the medication. 4. A review of Resident 4's Admission Record, indicated Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's Minimum Data Set (MDS, assessment and care screening tool) dated 11/7/18, indicated Resident 4 had a BIMS of two (2), indicating severely impaired cognition. Resident 4 required extensive assistance with bed mobility, transfer, and dressing, and total dependence on toilet use and personal hygiene. A review of Resident 4's Physician order [REDACTED]. A review of Resident 4's IV Therapy Care Plan, dated 1/9/19, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 10:50 a.m., Resident 4's [MEDICATION NAME] bag was observed with the DON. The DON confirmed Resident 4's [MEDICATION NAME] was initiated on 1/9/19 at 10:50 a.m. (50 minutes late). The DON confirmed the bag was empty however; the prescribed infusion duration was 1 hour. The DON also claimed the IV tubing was just changed, however, the IV tubing was not labeled to support this claim. A review of the policy, Staffing, revised (MONTH) 2007, indicated our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services.

Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Residents 1, 2, 3, and 4) received medication as ordered, utilize emergency Kit to meet residents needs, included, but are not limited to: a. Failure to administer Resident 1 intravenous (IV) antibiotics (a medicine that inhibits the growth of or destroys microorganisms) within four hours after the physician ordered; b. Ensuring there was a system in place to monitor residents for adverse effects for not receiving the prescribed IV antibiotics within four hours of the physician order [REDACTED].>c. Ensuring the IV antibiotic was administered on-time (Resident 1, 2, and 3); d. Ensuring the IV antibiotic administration was administered at the appropriate frequency consistent with the previous administration times (Resident 2 and 3); e. Ensuring the IV antibiotic was infused as prescribed in regards to the duration (Resident 1, 2, and 4); f. Ensuring the IV tubing was labeled with the date and time at which it was changed (Resident 4); and, These deficient practices had the potential for the development or worsening or infections, increased adverse effects from infusing the antibiotic faster than prescribed, and decreased efficacy for antibiotics administered late and/or infused slower than prescribed. Cross-reference F600 and F725. During a complaint investigation on 1/9/18, at 8:25 a.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identify and called 1/9/19 at 4 p.m. The facility administrator and director of nursing (DON) were notified of the IJ situation. The facility failed to provide pharmaceutical services including utilizing the IV emergency kit to obtained the first dose of IV antibiotics medication for Resident 1 and to ensure four of four sampled residents (Residents 1, 2, 3, and 4) received timely their prescribed medications. The IJ was removed on 1/15/19 at 2 p.m., after verification that the plan of action was implemented to ensure residents received their prescribed medication. The administrator and DON was notified of IJ removal. Findings: 1. A review of Resident 1's Admission Record, dated 1/9/19, indicated Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1 [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (MDS, an assessment and care-screening tool), dated 11/8/18, indicated Resident 1 was rarely or never understood. Resident 1 required extensive assistance from staff with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 1's Physician order [REDACTED]. A review of Resident 1's IV Therapy Care Plan, dated 1/9/19, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 9:53 a.m., Resident 1's Intravenous Therapy Medication Record was reviewed with the Director of Nursing (DON). The DON confirmed the IV antibiotic [MEDICATION NAME] was not administered as ordered 1/8/19 at 5:00 p.m. (17 hours after the order was obtained). The IV [MEDICATION NAME] 1 g due on 1/9/19 at 8:00 a.m. was not administered at the time of interview with the DON. The DON stated the facility had one hour before and one after the scheduled times to administer the medications. The DON stated there were no registered nurses to administer the [MEDICATION NAME] on time. The DON stated she would call the physician to have the [MEDICATION NAME] start time changed. On 1/9/19, at 11:23 a.m., Resident 1 was observed in his bed with the DON. Resident 1 had an intravenous catheter (IVC, a small tube placed into the vein) to the right upper extremity (RUE) completely wrapped and taped. The DON removed the gauze and tape and found Resident 1's IVC to the RUE was pulled-out. The DON stated at 10:00 a.m., she assessed Resident 1's IVC site and found it to be out, prompting her to call the physician to have the order changed to [MEDICATION NAME] administration time to 11:00 a.m. The DON stated she did not document her findings. On 1/9/19, at 12:29 p.m., the DON was observed initiating Resident 1's [MEDICATION NAME] that was due at 8:00 a.m. The [MEDICATION NAME] bag indicated the medication was started at 11:55 a.m. The DON admitted the medication was not started until 12:05 p.m., (four hours late from the original order) because Resident 1 was a hard-stick. The DON stated she made two attempts at inserting the IVC, which was successfully inserted to the left antecubital (AC) fossa, where the arm bends. On 1/9/19, at 1:09 p.m., Resident 1's [MEDICATION NAME] bag was observed with the DON. The DON confirmed the IV [MEDICATION NAME] bag was 100 milliliters (mL), which was the full amount of the [MEDICATION NAME] bag. The IV was not infused (allow (a liquid) to flow into a resident vein) after it was hanged at 12:05 p.m. The DON confirmed the [MEDICATION NAME] duration exceeded the prescribed duration of 1 hour. The DON stated the AC IV site is not the ideal location for an IVC because Resident 1 bends his arm a lot. The DON stated a pillow or arm board could have prevented the [MEDICATION NAME] from exceeding the prescribed infusion duration. On 1/9/19, at 1:34 p.m., the emergency-kit (E-kit) was observed in the medication room with the DON. The E-kit inventory taped to the top of the kit indicated it was stocked with two (2) vials of [MEDICATION NAME]. When the E-kit was opened, the DON confirmed the presence of two vials [MEDICATION NAME], that could have been used to administer the IV [MEDICATION NAME] to Resident 1 on 1/8/19 at 5 p.m. On 1/9/19, at 2:12 p.m., the pharmacy Delivery Manifest, dated 1/9/19, was reviewed with the DON. The DON confirmed Resident 1's supply of [MEDICATION NAME] was delivered on 1/9/19 at 1:24 a.m. On 1/9/19, at 3:06 p.m., the Administrator was interviewed. The Administrator stated, We are not a 24-hour RN facility. The Administrator confirmed there was no RN on duty from 1/9/19 at 12:35 a.m. until DON clocked-in at 9:30 a.m. On 1/9/19, at 3:20 p.m., the findings were discussed with the Administrator and the DON. The DON confirmed Resident 1's IV antibiotic [MEDICATION NAME] was not administered for 17 hours after it was order. The DON confirmed the [MEDICATION NAME] was available in the E-kit for administration, but was not utilized. The DON had no explanation for the reason the [MEDICATION NAME] was not administered. The DON stated medications require specific frequency and duration (if IV infused). 2. A review of Resident 2's GACH 2's Hospitalist History & Physical, dated 12/31/18, indicated Resident 2 was admitted to the intensive care unit for close vital sign monitoring. Resident 2 diagnoses, included, but were not limited to, health-care associated pneumonia (lung infection) and [MEDICAL CONDITION] (is the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), end-organ damage including toxic metabolic [MEDICAL CONDITION] (a result of infections) from the healthcare-associated pneumonia, toxic metabolic [MEDICAL CONDITION] secondary to acute [MEDICAL CONDITION]. Resident 2 had a recent UTI, required broad-spectrum antibiotics, IV fluids, lumbar puncture (the collection of spinal fluid for testing), and sputum (a mixture of saliva and mucus coughed up from the respiratory tract) and blood cultures (tests for infection). A review of Resident 2's Skilled Nursing Facility Admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses, which included, but were not limited to, [MEDICAL CONDITION] ([MEDICAL CONDITION], lung disease making it difficult to breath), healthcare associated pneumonia, [MEDICAL CONDITION] acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (oxygen deficiency), and toxic metabolic [MEDICAL CONDITION]. A review of Resident 2's Minimum Data Set (MDS, an assessment and care-screening tool), dated 12/31/18, indicated Resident 2 had a Brief Interview for Mental Status score (BIMS) of three (3), indicating severely impaired cognition (the mental action of acquiring knowledge and understanding through thought, experience, and the senses). Resident 2 required extensive assistance from staff with bed mobility, transfer, locomotion, dressing, eating, toilet use, and personal hygiene. A review of Resident 2's Physician order [REDACTED]. A review of Resident 2's IV Therapy Care Plan, dated 1/4/19, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 9:53 a.m., Resident 2's Intravenous Therapy Medication Record was reviewed with the Director of Nursing (DON). The DON confirmed Resident 1 had received [MEDICATION NAME] 1g every 12 hours from 1/5/19 to 1/8/19 at 8:00 a.m. and 8:00 p.m. The DON confirmed Resident 2 did not receive the medication on 1/9/19 at 8:00 a.m. The DON stated there were no registered nurses to administer the Cefepmine on-time, today 1/9/19 at 8 a.m. The DON stated she would call the physician to have the [MEDICATION NAME] start time changed. A review of Resident 2's Physician and Telephone Orders, dated 1/9/19 at 10:15 a.m., indicated, schedule antibiotics (ATB) time changed to 10:00 a.m. and 10:00 p.m. for [MEDICATION NAME] 1g every 12 hours until end of IV ATB therapy. A review of the Intravenous Therapy Medication Recorded, indicated Resident 2 received [MEDICATION NAME] 1g IV at 10:55 a.m. Though the time of IV antibiotic was changed from 8 a.m. to 10 a.m., the IV antibiotic was not given at 10 a.m. On 1/9/19, at 11:35 a.m., Resident 2's [MEDICATION NAME] bag, which was connected to the peripheral IVC via IV tubing, was observed with Licensed Vocational Nurse 1 (LVN) 1. LVN 1 confirmed the [MEDICATION NAME] infusion duration was prescribed at 1 hour. LVN 1 confirmed Resident 2's [MEDICATION NAME] start time was 1/9/19 at 10:55 a.m. as indicated by documentation on the bag. LVN 1 confirmed the [MEDICATION NAME] bag was empty, indicating the [MEDICATION NAME] IV rate was infused faster than prescribed. On 1/9/19, at 3:06 p.m., the Administrator was interviewed, the Administrator confirmed there was no RN on duty from 1/9/19 at 12:35 a.m. until DON clocked-in at 9:30 a.m. On 1/9/19, at 3:20 p.m., the pharmacy services findings were discussed with the Administrator and the DON. The DON stated the physician orders [REDACTED]. The DON stated antibiotics must be administered as soon as possible because infections can get worse. The DON stated medications require specific frequency and duration (if IV infused), so that blood concentrations can be maintained for the efficacy (effectiveness) of the medication. On 1/10/19, at 11:25 a.m., the setup and administration of Resident 2's [MEDICATION NAME] was observed. The Registered Nurse Supervisor (RNS) was observed to start Resident 2's [MEDICATION NAME] at 11:35 a.m. On 1/10/19, at 12:22 p.m., the RNS was interviewed. The RNS confirmed medications could be administered 1 hour before and 1 hour after the scheduled administration time. The RNS confirmed Resident 1's [MEDICATION NAME] was due at 10:00 a.m., but was not administered until 11:35 a.m. In regards to the late administration of [MEDICATION NAME], the RNS stated, I do not know what to attribute it to. On 1/10/19, at 3:03 p.m., the findings were discussed with the Administrator and the DON. The DON stated the RNS should have prioritized the administration of Resident 2's [MEDICATION NAME] so that it was administered within the time allowed (1 hour before and 1 hour after 10:00 a.m.). A review of Resident 2's GACH laboratory result dated 1/4/19 indicated White Blood Cell (WBC, cells of the immune system that are involved in protecting the body against both infectious disease and foreign invaders) count was 9.3 per microliter of blood (mcL) (Normal range is between 3,500 and 10,500 white blood cells per microliter of blood (mcL). A review of Resident 2's laboratory results, dated 1/9/19, at 10:20 p.m., indicated a high WBC count of 13.38 mcL. (A high WBC indicates an increase in disease-fighting cells in your blood) and a high absolute [DIAGNOSES REDACTED] count of 10.43 (normal 1.56-6.13 x103/uL). An increased WBC and [DIAGNOSES REDACTED] (most common type of WBC) could indicate infection. 3. A review of Resident 3's Admission Record indicated the resident was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses, which included, but were not limited to, acute [MEDICAL CONDITION] ulcer (sore that develops on the lining of the esophagus, stomach, or small intestine), non-infective gastroenteritis (intestinal infection) and [MEDICAL CONDITION] (chronic inflammation of the digestive system), and abdominal pain. A review of Resident 3's Minimum Data Set (MDS, dated [DATE], indicated the resident cognitive skills for daily decision-making were intact and required limited assistance from staff with personal hygiene and extensive assistance with bed mobility, transfer, dressing, and toilet use. A review of Resident 3's Order Summary Report, dated 12/28/18, indicated the physician ordered, [MEDICATION NAME] (antibiotic) 500mg IV every 6 (six) hours for [MEDICAL CONDITION] for 57 days on 12/10/18. A review of Resident 3's IV Therapy Care Plan, dated 12/11/18, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 2:20 p.m., Resident 3's Intravenous Therapy Medication Record was reviewed with the DON. The DON confirmed Resident 3 had received [MEDICATION NAME] 500 mg every 6 hours from 12/26/18 to 1/8/19 at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. On 1/9/19 the [MEDICATION NAME] was not administered at 6:00 a.m. The DON stated there were no RN's on duty to administer the medication. The DON confirmed the [MEDICATION NAME] was administered at 10:25 a.m. on 1/9/19. On 1/9/19, at 3:06 p.m., the Administrator was interviewed. The Administrator stated, We are not a 24-hour RN facility. The Administrator confirmed there was no RN on duty from 1/8/19 at 12:35 a.m. until DON clocked-in at 9:30 a.m. On 1/9/19, at 3:20 p.m., the phramacy findings were discussed with the Administrator and the DON. The DON stated antibiotics must be administered as soon as possible because infections can get worse. The DON stated medications require specific frequency and duration (if IV infused), so that blood concentrations can be maintained for the efficacy of the medication. 4. A review of Resident 4's Admission Record, indicated Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 4's Minimum Data Set (MDS, assessment and care screening tool) dated 11/7/18, indicated Resident 4 had a BIMS of two (2), indicating severely impaired cognition. Resident 4 required extensive assistance with bed mobility, transfer, and dressing, and total dependence on toilet use and personal hygiene. A review of Resident 4's Physician order [REDACTED]. A review of Resident 4's IV Therapy Care Plan, dated 1/9/19, indicated an intervention developed and implemented was, infuse the fluids and/or medications as ordered. On 1/9/19, at 10:50 a.m., Resident 4's [MEDICATION NAME] bag was observed with the DON. The DON confirmed Resident 4's [MEDICATION NAME] was initiated on 1/9/19 at 10:50 a.m. (50 minutes late). The DON confirmed the bag was empty however; the prescribed infusion duration was 1 hour. The DON also claimed the IV tubing was just changed, however, the IV tubing was not labeled to support this claim. A review of the policy, Medication Administration Schedule, revised (MONTH) 2012, indicated medications are administered according to the following routine schedule. A review of the facility's policy, General Policies for IV Therapy, dated (MONTH) (YEAR), indicated, IV medications may be administered by registered nurses (RN). Initial antibiotic dose is to be given within 4 (four) hours from the time the physician's orders [REDACTED]. Subsequent doses are to be administered within 1 hour before or 1 hour after the scheduled time. A review of the policy, Method of Administration Guidelines, dated (MONTH) (YEAR), indicated, a pump should also be considered in the following situations: a positional IV site. A review of the policy, Continuous Infusion of Medications and Solutions, dated (MONTH) (YEAR), indicated, label medication/solution container and administration set with: date and time; nurse's initials.

Based on interview and record review, the facility's nursing staff failed to ensure they effectively monitored one of two sampled residents (Resident A) who had a history of [REDACTED]. Resident B retaliated by punching Resident A in his face. Resident A sustained bleeding and swelling to his nose. He was transferred to a general acute care hospital (GACH) where he was assessed and diagnosed with [REDACTED]. Findings: A review of Resident A's Admission Records indicated he was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident A's Minimum Data Set (MDS) Assessment, dated May 3, 2017, indicated Resident A's speech was clear, he was able to understand others and to make himself understood. The MDS indicated Resident A had severe cognitive (mental ability) impairment. A review of Resident A's clinical records indicated the following incidents: 1. A Situation Background Assessment Recommendation (SBAR, a form of communication between members of a health care team), dated March 13, 2017, indicated an allegation of Resident A punching a resident. The Social Work Progress Notes, dated March 17, 2017, indicated at 2:30 p.m., Resident A was having a verbal altercation with his roommate (Resident C). Resident D rolled his wheelchair between Resident A and Resident C and yelled, Shut up to both residents. Resident A then hit Resident D on his chin. Resident A's Care Plan, dated March 17, 2017, indicated Resident A with an allegation of pushing another resident. Goals for Resident A indicated he will have no further episodes of allegation of pushing another resident. Approaches used included monitoring Resident A hourly. 2. An SBAR, dated June 16, 2017, indicated an allegation of Resident A pulling another resident by the legs. A review of the assessment under Progress Notes indicated at 9:15 p.m., a security guard was standing outside in the smoking patio, supervising residents. Resident A was sitting in his wheelchair talking to Resident E who was sitting on a bench. Resident A suddenly hit/slapped Resident E on his left shoulder with his fist. The security guard tried to separate the residents by pulling Resident A's wheelchair away from Resident E. While pulling Resident A away, Resident A bended over, grabbed Resident E by his legs and tried to pull him off the bench. Resident E fell on his knees. As the security guard was trying to help Resident E up from the ground, Resident A tried to hit/slap the security guard with his fist. Resident A's Care Plan, dated June 19, 2017, indicated Resident A with an allegation of slapping the left shoulder of a resident and pulling his leg. Goals set for Resident A included he will have no further incidents daily. Approaches used included monitoring for any episodes of slapping another resident and pulling his leg, the activity staff will monitor/supervise Resident A in the patio/smoking area and monitor hourly. 3. An SBAR, dated June 26, 2017, at 6 p.m., indicated an allegation of Resident A with bleeding and swelling to his nose. A review of the assessment under Progress Notes, indicated a Licensed Vocational Nurse (LVN) was passing Station I and heard someone calling for help from the patio. When she got to the patio, she found Resident A with swelling, skin discoloration, and bleeding to his nasal bridge. Resident A reported Resident B hit him. An Investigation Report, dated June 26, 2017, indicated Resident B reported he was talking to other residents when Resident A approached him, told him to shut up and hit him in the back of his head. Resident B then stood up and hit him back. The Hourly Monitoring, dated March 17 thru June 26, 2017, indicated Resident A was observed at the top of each hour at one of eight different locations. Documentation did not indicate where Resident A was the remainder of the hours. On June 26, 2017, the Hourly Monitoring indicated Resident A was observed in the front patio/smoking area at 6 p.m., but assaulted Resident B at 6:35 p.m. Resident A's physician's orders [REDACTED]. Resident A's Radiology Report at the GACH, dated June 26, 2017, indicated a CT scan (Computerized Tomography, a special x-ray that produce cross-sectional images of the body using x-rays and a computer) of the brain that showed evidence of an acute (occurred quickly) nasal bone fracture. On June 28, 2017, at 3:44 p.m., during an interview, the Director of Nursing (DON) stated Licensed Vocational Nurse 1 (LVN 1) heard someone calling for help from the patio. When LVN 1 got to the patio, she saw Resident A with a nose bleed and Resident A stated Resident B hit him. The DON stated Resident A was confused and he was the one who hit Resident B on the back of his head. Resident B retaliated and hit Resident A in his face. The DON stated Resident A was monitored and transferred to the GACH for evaluation. A review of Resident B's Admission Records indicated he was admitted to the facility on [DATE]. On September 18, 2017, at 3:15 p.m., Resident B was observed in his room, lying in bed. He was alert and oriented to name, date, time, and place. During an interview, Resident B stated he was sitting in the patio talking to a few residents, not Resident A. Resident B stated Resident A came up to him, told him to shut up then hit him in the back of his head, he then hit Resident A in his face. Resident B stated he did not know why Resident A hit him, he had not had any problems with him before then. On September 21, 2017, at 3:50 p.m., during a telephone interview, the Activity Director (AD) stated security guards were scheduled to monitor residents in the patio area and the activity room after hours and they were there until 11 p.m. The AD stated during a stand-up meeting with staff, there was a general statement made about the incident between Resident A and Resident B but nothing specifically directed at her except to be sure to monitor the two residents when they are in the patio together. On September 21, 2017, at 4:40 p.m., during a telephone interview, the DON stated the purpose of monitoring Resident A hourly was to know his whereabouts and what he was doing. The DON stated she could not answer how knowing where the resident was and what he was doing at 6 p.m., would prevent him from random assaultive behavior the remainder of the hours. On September 21, 2017, at 5:03 p.m., during a telephone interview, LVN 1 stated she was pushing another resident in the lobby on June 26, 2017, at 6 p.m. when she heard someone in the patio yelling for help. LVN 1 stated she, a Certified Nursing Assistant (CNA), a Registered Nurse (RN) and the DON went to the patio area and saw Resident A with a bloody nose. LVN 1 stated there was no staff in the patio area watching the residents.