Every finding on record at Aspire at Ridge Haven

Based on record reviews and interviews, the facility failed to ensure accurate documentation related to medication administration for two Residents (#28, #96) out of eight residents sampled. Findings include: 1Review of an admission record dated 06/03/2026 showed Resident # 28 was admitted originally on 08/20/2020 and readmitted [DATE] with diagnoses to include but not limited to metabolic encephalopathy, unspecified asthma, uncomplicated, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, unspecified Review of an Electronic Medication Administration Record showed Ipratropium- Albuterol Solution 0.5-2.5 (3) milligrams/3 milliliters [MG/ ML], 3 inhales orally via nebulizer three times a day for Chronic Obstructive Pulmonary Disease [COPD] 05/12/2026, revealed medication was marked administered at 1500 on 06/01/2026. On 06/02/2026 at 4:47 PM an interview was conducted with Staff E, Licensed Practical Nurse [LPN]. Staff E stated she works 7 am to 7 pm. She stated she did not give Resident # 28 her nebulizer treatment on 6/1 because the resident was in activities. 2Review of a Resident Information Record dated 06/03/2026 showed Resident # 96 was admitted to the facility on [DATE], with diagnoses to include but not limited to Parkinson's Disease without dyskinesia, without mention of fluctuations, Type 2 Diabetes Mellitus with hyperglycemia, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance mood disturbance, and anxiety. Review of an Electronic Medication Administration Record [EMAR] showed Bacitracin Ophthalmic Ointment 500 Unit Gram (Bacitracin Ophthalmic) instill 1 application in left eye two times a day for twice daily for 7 days until 05/25/2026. Order start date 05/18/2026. [EMAR] showed medication was administered on 05/18/2026 at 1700 and on 05/20/2026 to 05/22/2026 at 0900. Review of an Administration note dated 05/19/2026 and 5/22/2026 Bacitracin Ophthalmic Ointment 500 Unit Gram instill 1 application in left eye two times a day for twice daily for 7 days until 05/25/2026, showed medication was on order. Review of an Administration note dated 05/20/2026 Bacitracin Ophthalmic Ointment 500 Unit Gram instill 1 application in left eye two times a day for twice daily for 7 days until 05/25/2026, showed awaiting for pharmacy to send. On 06/02/2026 at 5:28 PM an interview was conducted with Staff G, License Practical Nurse [LPN]. Staff G stated Resident # 96 was ordered Bacitracin for 7 days for a Sty on his left eye. The medication was ordered on May 18th, but it never arrived at the facility. Someone documented that they gave Resident # 96 the Bacitracin, but she knows that it was not administered because she informed the nurse practitioner and reached out to pharmacy that the medication never arrived to the facility. They ended up having to order a different medication for him. On 06/03/2026 1:31 PM an interview was conducted with the Director of Nurses [DON]. The DON stated her expectation is that her nurses document according to policy and not falsely document in the medical record. The facility said the did not have a documentation policy for this citation.

Based on observations and interviews, the facility failed to provide reasonable access for phone communication for one (Resident # 28) out of eight residents sampled. Findings include:On 06/01/2026 at 10:00 AM Resident # 28 was observed at the nursing station on the phone discussing personal business around staff and other residents. She stated she doesn't like to make phone calls at the nurse's station because everyone hears her conversation and she doesn't have any privacy. On 06/02/2026 at 1:00 PM and at 4: 45 PM, Resident # 28 was observed lying down in bed. She stated she had told staff a few months ago that she wanted a phone in her room so she could receive and make phone calls. Review of an admission record dated 06/03/2026 showed Resident # 28 was readmitted [DATE] with diagnoses to include but not limited to metabolic encephalopathy, unspecified asthma, uncomplicated, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. On 06/02/2026 at 2:00 PM an interview was conducted with Staff E, License Practical Nurse [LPN]. Staff E stated she was aware Resident # 28's request for a phone, a while ago. Someone [facility staff], I don't remember who, told Resident #28 they were going to bring a phone, and they did. Although, the one they put in her room doesn't work. On 06/02/ 2026 at 2:30 PM an interview was conducted with the Maintenance Director. The Maintenance Director stated every resident should have a phone in their room. The only reason a phone would not be in a resident room is when there had been a request by the resident to remove the phone. Resident #28 was provided with a phone yesterday but the line in her room doesn't work. We have to call a professional phone company to install a phone line in her room. He stated prior to them putting a phone in her room yesterday he did not know how she received or made phone calls because the line in her room doesn't work. On 06/02/2026 at 3: 00 PM an interview was conducted with the Nursing Home Administrator[NHA]. The NHA stated all residents should have phone access in their rooms so they can call their family or friends. The facility can't restrict a resident's right to communicate with whoever they want in a private area. The Nursing Home Administrator stated the facility did not have a policy for this citation.

Based on interview and record review, the facility did not ensure Level 2 Preadmission Screening and Resident Review (PASRR) evaluation was submitted for one (Resident 88) out of five residents reviewed. Findings include: Review of an information record dated 06/03/2026 showed Resident # 88 was admitted to the facility originally on 04/22/2022 and readmitted on [DATE] with diagnoses to include but not limited to unspecified dementia without behavioral disturbance, recurrent moderate major depressive disorder, brief psychotic disorder, generalized anxiety disorder, and bipolar type schizoaffective disorder. Review of a PASRR dated 2/21/2024 revealed Resident # 88 had Anxiety Disorder, Depression Disorder, Psychotic Disorder, Schizoaffective Disorder and other schizoaffective disorder, bipolar type listed as qualifying mental health diagnoses. Review of the medical record revealed the resident was not assessed for PASRR Level II. On 06/03/2026 at 3:12 PM an interview was conducted with the Social Service Director [SSD]. The SSD stated that when a resident is admitted to the facility, she reviews their PASRR. If the PASRR is incorrect, they are updated, then signed by a Registered Nurse. During the review of the PASRR if they become aware of any conditions put on the third page. For instance, if a resident had a [NAME] Act, or an altercation involving law enforcement or life limitation, then she would submit for level II PASRR. The SSD stated when Resident # 88 arrived at the facility she did not have most of the diagnoses that were added to her chart. Resident #88 had a fall with fracture, and she was having nightmares that her husband was sleeping around with residents at the facility. At that time Resident #88 was reassessed and her level I PASRR was updated with new diagnoses. The SSD stated they did not submit for level II because Resident #88 had a short-term mental episode, but she returned back to her baseline. Review of the facility policy titled Policies and Procedures Revision date 11/08/2021 showed Subject: Preadmission Screening and Resident Review (PASRR). Policy: The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disable (ID) residents receive appropriate pre-admission screening according to Federal/ State guidelines. The purpose is to ensure that the residents with SMI or ID receive the care and services they need in the most appropriate setting. Procedure: 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results.

Based on interview, observation, and record review, the facility did not review and revise the comprehensive care plan related to communication for one (Resident #49) of five residents reviewed for care plans.Findings include: Review of Resident #49's admission record revealed an admission date of [DATE], with an initial admission date of [DATE]. Diagnosis to include but not limited to malignant neoplasm of head, face, and neck (onset [DATE]), and other specified types of non-[NAME] Lympohma, lymph nodes of head, face, and neck (onset [DATE]). Review of Resident #49's Minimum Data Set Resident Assessment (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 14, indicating intact cognitive function. Hearing aid or other hearing appliances used is marked no. Review of Resident #49's care plan revealed a focus to include a potential communication problem due to: hard of hearing. Review of Resident #49's Audiology Treatment Note dated [DATE] revealed Resident #49, a long-standing hearing aid user, was fitted for hearing aids. Treatment note dated [DATE] revealed the resident is doing very well with the hearing aids but would like an increase in volume for voices. On [DATE] at 3:25 p.m., Resident #49 stated he wears hearing aids, but his hearing aids were not working. He stated the batteries died and he has been unable to charge them. He stated he has let staff know about his hearing aids, but they have not been fixed. On [DATE] at 1:13 p.m., during an interview with Staff H, Certified Nursing Assistant (CNA), stated Resident #49 wears hearing aids. She stated she was unaware of Resident #49 having issues with his hearing aids. She stated she would look at a kardex to determine if they wear hearing aids. On [DATE] at 1:22 p.m., during an interview with Staff G, Registered Nurse (RN), stated Resident #49 wears hearing aids, and was unaware he had issues with them. She stated she looks at the resident's care plan to determine if they wear hearing aids. On [DATE] at 10:33 a.m., an interview was conducted with the MDS coordinator. She stated care plans are updated when there are new physician orders, new diagnosis, or if there are updates to the resident's health record. She stated Resident #49 has a communication problem but is not care planned for hearing aids. She stated if Resident #49 wears hearing aids, there should be a care plan for hearing aids. On [DATE] at 10:45 a.m., an interview was conducted with the Social Services Director (SSD). She stated Resident #49 has hearing aids but does not always wear them. She stated she was aware Resident #49 was having issues with his hearing aids and has placed him on a list to be seen by the Audiologist. She stated if a resident has hearing aids, it should be on their care plan. On [DATE] at 1:46 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated since she does not care for the resident personally, she is unaware if he has hearing aids. She stated if the resident has hearing aids, it should be on their care plan. Review of the facility's policy titled Plan of Care, with an effective date of [DATE], revealed: Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident/and or resident representative (s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Procedure: Review, update, and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of OBRA MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being.

Based on observations, interviews and record review, the facility failed to provide bedfast and residents who prefer to be in their room receive activities to meet the interests and support the physical, mental and psychosocial well-being for one (Resident #82) of two resident reviewed.Findings included:On 5/31/26 at 3:35 p.m., an observation and interview occurred with Resident #82 and three of their family members. Resident #82's family members stated they have not seen staff engaging the Resident #82 in 1:1 activities during their stay at the facility. The family members stated they would prefer the facility to do more activities of Resident #82's preference and 1:1. The family members stated they did not mind if activities occurred while they are visiting as they prefer Resident #82 receive interaction that could stimulate, engage and potentially distract from certain behaviors. The family members stated Resident #82 loves to listen and sing to their favorite musician. The family stated they have only seen staff provide the activity one time during Resident #82's stay.On 6/1/26 at 9:32 a.m., 2:52 p.m., and 4:27 p.m.; Resident #82 was observed sleeping in bed. On 6/1/26 at 12:15 p.m., an interview was conducted with Staff J, Licensed Practical Nurse (LPN). Staff J, LPN stated they are unsure of what 1:1 activities are provided for residents who prefer to stay in their room or are bed bound.On 6/1/26 at 4:48 p.m., an interview was conducted with Staff F, Registered Nurse (RN). Staff F, RN stated they never see Resident #82 participate in activities, but Resident #82 used to often. Staff F, RN stated due to Resident #82's decline in health and worsening dementia it has been more difficult getting Resident #82 out of their room or bed to participate in group activities, and Resident #82 just doesn't want to get up anymore.On 6/2/26 at 3:26 p.m., an interview was conducted with Staff K, Certified Nursing Assistant (CNA)/Activities Assistant (AA). Staff K, CNA/AA stated the activity department records 1:1 activities and attendance in an activity binder. The department provides activities such as social talk or assisting the residents with whatever they may need help with. Staff K, CNA/AA stated Resident #82 loves participating in coffee social, and the resident is usually sitting at the nurses' station. Staff K, CNA/AA stated all activities are provided to all residents who attend. Attendance is documented, this includes 1:1s. Staff K, CNA/AA stated the Activity Director (AD) is the one who documents the residents' activities in the resident portal under the activity task.On 6/2/26 at 3:33 p.m., an interview was conducted with the AD. The AD stated 1:1 activities for bed bound or residents who prefer to remain in their room include social visits. The AD stated they document attendance and refusals in the activity attendance book. The AD stated they encourage residents to participate in activities as much as possible, but most times residents do not want to participate. The AD stated the CNA staff does not get the residents up and ready or bring them to activities as they have been requested to various times by the AD. The AD stated Resident #82 usually comes to the coffee social and will usually sit and sing to herself or make fun noises. The AD stated Resident #82's attendance in activities is documented daily in the participation record.On 6/2/26 at 4:37 p.m., the AD provided Resident #82's attendance record for the day 6/1/26. The residents' attendance was recorded for 9:45 a.m., coffee social; 10:30 a.m., Trivia; 1:30 p.m., Pretty Nails; and 3:00 p.m., TV Classics.On 6/3/26 at 9:45 a.m., an observation and interview was made with Resident #82. When asked to see Resident #82's nails, the resident presented their hands. The resident's nails were observed unpainted, a brown/black matter under the resident's nails, and untrimmed. Resident #82 stated they did not go to get their nails done on 6/1/26. Resident #82 stated they love having their nails painted and done and would like them to be done.On 6/3/26 at 10:13 a.m., an interview and observation was conducted with the Regional Nurse Consultant (RNC) with Resident #82 in the resident's room. The RNC stated Resident #82 is confused and might not know what day it is to determine if they went to activities on 6/1/26. Resident #82 told the RNC they did not get their nails done on 6/1/26 and the RNC confirmed the resident's nails were not done. Resident #82 told the RNC they love having their nails done and painted.On 6/3/26 at 1:55 p.m., an interview was conducted with the AD. The AD stated Resident #82 did not stay in the Pretty Nails activity due to being sent back to their room for being moody and disruptive. The AD stated Resident #82 typically does not refuse to participate in activities. The AD is unsure as to why there is a lack of Resident #82's attendance record for activities. The AD stated the activities department is responsible for ensuring activity attendance is documented, but they were gone for 3-weeks and just got back. The AD stated they do not track or document resident activity refusals. The AD stated most days Resident #82 is sleeping in bed and not at activities during the scheduled times. The AD stated they make adjustments to residents' care plans when interests change.On 6/3/26 at 3:43 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated residents should be offered and provided activities that meet their preferences. The DON stated there should be a wide range of activities for all residents, and activities to meet residents' cognitive levels. The DON stated activities have gotten better in variety but still are not very popular at the facility amongst the residents. The DON stated both care and activity staff should be encouraging residents to participate and providing residents with activity reminders. The DON stated the AD should be documenting and keeping track of attendance, and that all resident attendance and refusals should be tracked and documented in the resident's electronic health record (EHR). The DON stated for residents who cannot get out of bed or prefer to remain in their room should be offered 1:1 activities, and socializing is the bare minimum as a provided activity for this demographic of residents. The DON stated these residents should be offered stimulating 1:1 activities such as puzzles, games, coloring, and word searches. The DON stated Resident #82's attendance for activities should not be marked as attended if the resident had to leave the activity due to their behaviors, and it is not appropriate documentation if the resident is marked as attended if they did not get to participate in the activity. The DON stated Resident #82 tends to get bullied by other residents for making noises and singing, causing the resident to typically be removed from the activity. The DON stated based off the documentation, Resident #82 is not getting their preferred activities. The DON stated despite the resident's care plan being updated on 5/7/26, BINGO is still on their care plan for preferences of activity and should have been updated with the AD knowing the resident no longer likes the activity.A review of Resident #82's admission record revealed an initial admission date of 1/27/26 and a readmission date of 5/21/26, with diagnoses to include unspecified dementia, generalized anxiety disorder, mood disorder, major depressive disorder, altered mental status, and chronic kidney disease.A review of Resident #82's Quarterly Minimum Data Set (MDS) assessment, dated 2/3/26, revealed Resident #82 is cognitively intact. Further review of Resident #82's cognitive patterns revealed the resident scored a 2- no cue required for recall, and did not present any behaviors of inattention, disorganized thinking, and altered level of consciousness. Review of Resident #82's assessment of hearing, speech, and vision revealed the resident had adequate hearing and vision and is able to be verbally understood and understands others. For Resident #82's activity and routine preferences, the resident indicated the following: having books or magazines to read, listen to music they like, and participate in their favorite activities. Review of Resident #82's functional abilities revealed the resident has no impairments.A review of Resident #82's current Care Plan revealed staff is to invite, encourage and escort the resident to preferred activities consistent with the resident's interests as a diversion from pain related to general age discomfort. Further review revealed Resident #82's preferred recreational interests, as of 1/29/26, are listening to classical music, playing bingo, crocheting and reading mystery novelsA review of Resident #82's progress notes revealed there was no documentation regarding activities participation of any type being provided to the Resident #82.A review of Resident #82's activities attendance records from 1/1/26-6/3/26 revealed the resident has attendance and activities documented for the following dates:1/28/26: BINGO2/3/26: Indoor visits and fudge (activities goes room to room)2/8/26: Ice cream social3/3/26: Ice cream social3/25/26: Mini Luncheon4/2/26: Coffee Social4/8/26: Coffee Social4/9/26: Church Service4/28/26: The Price is Right5/2/26: Coffee Social5/27/26: Coffee Social, Mass with Father Joseph6/1/26: Coffee Social, Trivia, Pretty Nails, TV ClassicsResident #82 did not have any documented attendance for 1:1 activities.A review of Resident #82's Activities Task revealed the resident had no attendance or activities documented for at least the last 30 days for all 3 sections: Activity Location, Participated (Yes/No), Describe Activity.A review of the facility's Social Activities Policy, dated 11/30/14 and revised 3/13/19, revealed the following: The social activities are modified to meet the basic needs of love and belonging in residents who experience deficits in judgement, reasoning and perception. The activities focus on acceptance of the individual and the stimulation of learned social responses. To provide opportunities for socialization regardless of one's cognitive limitations. To provide an atmosphere of acceptance through strategic groupings of residents. To encourage the development of friendships.

Based on interviews, observations, and record review the facility failed to ensure timely care and physician notification related to a skin condition change for one (Resident #82) out of one resident sampled; and failed to provide medications as ordered for one (Resident #96) out of eight residents sampled. Findings included: On 5/31/26 at 2:15 p.m., an observation was made of Resident #82 lying in their bed aggressively itching their body. On 5/31/26 at 3:35 p.m., an observation and interview occurred with Resident #82 and three of their family members. Resident #82 was observed with random spots of a brownish color, on the resident's clothing, bed sheets, and pillow. Resident #82 was observed itching arms and legs continuously. Resident #82's family member stated the resident has been dealing with a severe rash for about three weeks and is unable to stop itching. The family members stated they have been asking for help for Resident #82. The family members stated they would like to find a cause or reason for the rash, rather than just treating its symptoms. Resident #82 was observed with severe redness of the skin and scattered bumps and open scarring from itching on the resident's back, stomach, and both full upper and lower extremities. On 5/31/26 at 3:47 p.m., Staff F, Registered Nurse (RN) changed Resident #82's shirt per the family members request. Staff F, RN stated they will put in a higher dosage of the resident's medication to subdue the itching and irritation of the skin. Staff F, RN stated they advised the Unit Manager (UM) of Resident #82 needing a dermatology consult. On 5/31/26 at 3:55 p.m., Staff J, Licensed Practical Nurse (LPN) came and provided Resident #82 with prescribed itching cream on all irritated areas. On 5/31/26 at 4:52 p.m., an interview was conducted with Staff J, LPN. Staff stated the resident has been dealing with this skin rash for at least a few days now. On 6/1/26 at 10:19 a.m., an interview was conducted with Staff L, Wound Care (WC)/LPN. Staff L, WC/LPN stated being unaware of Resident #82's skin condition but will check it out. On 6/1/26 at 4:27 p.m., an observation was made of Resident #82 sleeping in bed. Resident #82 was observed with the same shirt that was put on the resident on 5/31/26 with scattered brownish colored spotting present on the shirt and bed sheets. On 6/2/26 at 12:15 p.m., an interview was conducted with Staff J, LPN. Staff J, LPN stated they are unaware of Resident #82's shirt not being changed since 5/31/26. On 6/2/26 at 12:19 p.m., an interview was conducted with Staff L, WC/LPN. Staff L, WC/LPN stated they were informed of Resident #82's current skin condition and told the staff to seek a dermatology consult and advise the Medical Director (MD) about the situation. Staff L, WC/LPN stated they would expect residents' who have skin openings to have their wounds cleaned per the provider's order and to be in clean clothes each day. Staff L, WC/LPN stated it is not proper to leave a resident in the same blood stained clothing from the day before if the skin is open and bleeding. On 6/2/26 at 4:48 p.m., an interview was conducted with Staff F, RN. Staff F, RN stated Resident #82 started having these skin issues around 5/25-26/26. Staff F, RN stated they informed the UM of Resident #82 needing a dermatology consult on 5/31 around 4:00 p.m., Staff F, RN did not follow up with the UM on 6/1/26 due to being on the medication cart all day. During the interview an observation was made when Staff F, RN got up to ask Staff M, LPN/UM if they put in the consultation for dermatology for Resident #82. Staff M, LPN/UM was heard stating they did not put in the consultation for Resident #82. Staff F, RN returned and stated Resident #82 did not have the dermatology consultation entered. On 6/3/26 at 9:37 a.m., an interview was conducted with the Administrator of the Dermatology provider (ADP) for the facility. The ADP stated when they receive a consult, they will determine if the matter is urgent or not. If the skin issue present is an urgent matter, then one of the three dermatology providers will get to the facility within 24 hours. The ADP described a highly urgent skin issue as a rash causing the resident to suffer or causing the resident to be uncomfortable. The ADP stated consults can be received over the phone or through fax. The ADP stated they have not received a dermatology referral from the facility for Resident #82 but are always willing to help if they were to receive. The ADP stated due to Resident #82's situation, it is expected for a dermatology consult be put in for the resident as it is an urgent matter and the resident's skin should have a scraping done to rule out what is going on with the resident. On 6/3/26 at 9:50 a.m., an observation and interview were conducted with Resident #82. Resident #82 was observed scratching uncontrollably and explaining they are just so itchy, and would like for something to be done to help the itching as they feel they are suffering. On 6/3/26 at 10:00 a.m., an interview and observation were conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The DON stated Resident #82's rash is present all over their body and advised the resident they should not keep itching and digging at their skin. Resident #82 stated they are unable to help the itching as it is awful and does not stop. Resident #82 told the DON and NHA they would love something to be done. The DON stated at least the MD should have been notified as this being an urgent issue a dermatology consult should have been put in right away for Resident #82. The DON stated the care staff did not follow proper protocol when a resident has a change in condition (CIC) and should have advised the proper parties to start a treatment plan. A review of Resident #82's admission record revealed an initial admission date of 1/27/26 and a readmission date of 5/21/26, with diagnoses to include dementia, anxiety disorder, mood disorder, major depressive disorder, altered mental status, and chronic kidney disease. A review of Resident #82's Quarterly Minimum Data Set (MDS) assessment, dated 2/3/26, revealed Resident #82 is cognitively intact. Resident #82's cognitive patterns revealed the resident did not need a cue required for recall, and did not present any behaviors of inattention, disorganized thinking, and altered level of consciousness. Review of Resident #82's assessment of hearing, speech, and vision revealed the resident had adequate hearing and vision and can be verbally understood and understand others. Review of Resident #82's functional abilities revealed the resident has no impairments. Review of Resident #82's skin conditions revealed the resident is at risk of further or worsening skin issues but no current skin issues. A review of Resident #82's current Care Plan revealed the resident is at risk for skin breakdown and should have daily skin observations for any signs and symptoms of skin breakdown. Review of Resident #82's chart did not reveal any CIC completed related to skin rashes. A review of Resident #82's progress notes dated 5/4/26-6/4/26 revealed a physician note from 5/31/26 and 6/2/26 stating staff had not reported any significant physical changes in Resident #82's condition. A review of Resident #82's Weekly Skin Evaluations from 5/10/26-6/3/26 revealed the following: 5/11/26: No new areas of concern. 5/17/26: No new skin issues noted at this time. 5/27/26: No new skin issues noted at this time. 6/3/26: No other skin issues noted staples removed from head on 5/31 A review of Resident #82's Skin Observation Task from 5/5/26-6/4/26 the resident was observed with a red area of skin on the following dates: 5/5/26, 5/8/26, 5/9/26, 5/10/26, 5/12/26, 5/15/26, 5/16/26, 5/22/26, 5/23/26, 5/26/26, 5/27/26, 5/30/26, 5/31/26, 6/1/26, 6/3/26. The red area was reported to be a new skin condition on the following dates: 5/23/26, 5/26/26, and 6/1/26. A review of the facility's Notification of CIC Policy, dated 11/30/14 and revised 12/16/20, revealed the following: The center is to promptly notify the Patient/Resident, the attending physician, and the Resident Representative when there is a change in the status or condition. Procedure: The nurse to notify the attending physician and Resident Representative when there is a(n): Significant change in the patient/resident's physical, mental, or psychosocial status Need to alter treatment significantly New treatment Discontinuation of a current treatment due to but not limited to: Adverse consequences Acute condition Exacerbation of a chronic condition . The nurse to complete an evaluation of the Patient/Resident. Document evaluation in the medical record. Notify the patient/resident and the resident representative of the CIC. Document notification in the medical record. Document resident/patient CIC on 24 hour report. Photographic evidence obtained. 2. On 6/2/26 at 4:00 p.m., Resident #96 was observed sitting up in his wheelchair visiting with his resident representative (RR). Resident #96 was observed well-groomed with no signs of distress. The RR stated having some concerns. The RR stated Resident #96 had orders for medication related to an eye infection and did not receive it until seven days after the doctor ordered the medication. The RR stated Resident #96 was supposed to receive the medication on May 18th and did not receive any medication for his eye until the 25th of May. Review of a Resident Information Record dated 6/3/26 showed Resident #96 was admitted to the facility on [DATE], with diagnoses to include but not limited to Parkinson's Disease without dyskinesia, without mention of fluctuations, Type 2 Diabetes Mellitus with hyperglycemia, vascular dementia. Review of an Electronic Medication Administration Record [EMAR] showed Bacitracin Ophthalmic Ointment 500 Unit Gram (Bacitracin Ophthalmic) instill 1 application in left eye two times a day for 7 days until 5/25/26. Order start date 5/18/26. Review of an Administration note dated 5/19/26 Bacitracin Ophthalmic Ointment 500 Unit Gram instill 1 application in left eye two times a day for 7 days until 5/25/26, showed, on order. Review of an Administration note dated 5/20/26 Bacitracin Ophthalmic Ointment 500 Unit Gram instill 1 application in left eye two times a day for 7 days until 5/25/26, showed, waiting for pharmacy to send. Review of an Administration note dated 5/22/26 Bacitracin Ophthalmic Ointment 500 Unit Gram instill 1 application in left eye two times a day for 7 days until 5/25/26, showed on order. Review of an Administration note dated 5/25/26 Bacitracin Ophthalmic Ointment 500 Unit Gram instill 1 application in left eye two times a day for 7 days until 5/25/26, showed, call placed to hospice to change medication per pharmacy requires an alternative. Review of an Administration note dated 5/25/26 Erythromycin Ophthalmic Ointment 5 Milligram/ Gram instill 1 application in left eye two times a day to apply to left eye for hordeolum twice daily for 7 days. Until 6/2/26. Ordered. On 6/2/26 at 5:28 p.m. an interview was conducted with Staff G, LPN. Staff G stated Resident #96 was ordered Bacitracin for 7 days for a Sty on the left eye. The medication was ordered on May 18th, but the facility never received the medication. Someone documented that they gave Resident #96 the Bacitracin, but she knows that it was not administered because reached out to the pharmacy and the medication never arrived, as the pharmacy did not have the medication. Staff G, LPN stated informing the nurse practitioner and the medication was changed to Erythromycin and provided to Resident #96 on May 26th. On 6/2/26 at 5:49 p.m. an interview was conducted with a [Pharmacy Provider (PP)] Pharmacy Tech/Customer service representative. The pharmacy tech stated the pharmacy received an order from the facility on May 18th for Bacitracin 500 grams. The medication was identified as an over-the-counter drug. They received a new order for Erythromycin that was delivered to the facility on the 26th. The pharmacy tech stated she have to transfer the call to her supervisor to provide more information as to why the Bacitracin medication was not delivered to the facility when the pharmacy received the order. On 6/2/26 at 6:00 p.m. an interview was conducted with the [PP] Customer Service Lead. The Customer service lead stated they received an order for Bacitracin 500 grams for 7 days from the facility. They faxed an authorization form to the facility on 5/20 for coverage because the medication was identified as an over-counter drug. Based on review, the facility did not send the authorization back to the pharmacy to cover the cost of the drug. On 6/3/26 1:31 p.m. an interview was conducted with the Director of Nurses [DON]. The DON stated she was informed about Resident #96 Bacitracin this morning or yesterday afternoon. She stated she should have been informed about the situation when it happened. When the nurses were informed that the medication was not available, they should have reached out to the physician to obtain another script so that the resident could have received his medication. Review of the facility policy titled, Administering Medication Revised dated April 2019. Showed Policy Statement, Medication are administered in a safe and timely manner, and as prescribed.

Based on observations, record reviews, and interviews, the facility failed to ensure that nebulizer supplies was stored according to professional standards for one (Resident #28) out of eight residents sampled. Finding include: On 06/01/2026 at 10:00 AM, and on 06/02/2026 at 4:47 PM Resident #28's nebulizer mask was observed lying down exposed, unbagged on top of the nightstand. Review of an admission record dated 06/03/2026 showed Resident #28 was admitted originally on 08/20/2020 and readmitted [DATE] with diagnoses to include but not limited to metabolic encephalopathy, asthma, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease. On 06/02/2026 at 4:47 PM an interview was conducted with Staff E, License Practical Nurse, [LPN]. Staff E stated the nebulizer mask was supposed to be stored in a bag and not left out on the nightstand. She stated she will throw the mask away because she doesn't know how long the mask has been sitting on the nightstand. She stated she knows she did not put the mask on the nightstand because she has not given Resident #28 the nebulizer treatment yesterday nor today. On 06/03/2026 1:41 PM an interview was conducted with the Director of Nurses [DON]. The DON stated the expectation is all medication should be given as ordered. Nebulizer masks should be stored in a bag when not in use and the bags are dated when the bag is changed, typically weekly. Review of the facility policy titled, Equipment Change Schedule Revision date 08/28/2017 showed policy: An equipment changes schedule providers a schedule for change disposable equipment ay regular intervals as determined by manufacturer's recommendations and standards of practice. Procedure: Equipment/ When changed. Nebulizer set-up: Once, every seven (7) days along with equipment bag labeled with name, date, and room number.

Based on observations, interviews and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and four errors were identified for two (Resident #4, and 23) out of six residents observed. These errors constituted a 12.5% medication error rate.Findings include: On 6/02/2026 at 8:55 a.m., an observation was made during medication administration for Resident #23. Staff E, Licensed Practical Nurse (LPN) pulled the following medication:Folic Acid 800 micrograms one tablet from the medication cart's over the counter drawer designated over the counter drawer and administered the medication to Resident #23. A record review of Resident #23's physician orders showed an order dated 4/28/2026 for Folic acid one milligram to give one tablet by mouth in the morning for supplement. On 6/02/2026 at 10:01 a.m., an observation was made during medication administration for Resident #4. Staff F, Registered Nurse (RN) pulled the following medications:Methocarbamol 75 milligrams (mg), one tabletOxycodone HCL (hydrochloride) 20 mg one tabletGabapentin 600 mg one tablet A record review of Resident #4's physician orders showed an order for the following:Methocarbamol oral tablet 75 mg, give one tablet by mouth every 6 hours as needed for muscle spasms, ordered 5/08/2026Oxycodone HCL 20 mg, give one tablet by mouth every 4 hours as needed for non-acute pain, ordered 5/202/2026Gabapentin 600 mg, give one tablet by mouth every 8 hours for neuropathy, ordered 5/13/2026 Upon review of the Medication Administration Record (MAR) for the month of June 2026, Resident #4's Gabapentin was due at 8:00 a.m. but was administered 10:01 a.m. Upon review of the MAR for the month of June 2026, documentation for both the Methocarbamol and the Oxycodone were not documented as administered to Resident #4. On 6/03/2026 at 5:04 p.m., an interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC). Both were notified of the erroneous concerns post medication administration. A review of the facility's policy titled: Administering Medications, revised April 2019 showed the following policy statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation include but not limited to:.4. Medications are administered in accordance with prescriber orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Based on observations, interviews and record reviews, the facility failed to provide Resident #17 had a dignified existence that included transportation to outpatient appointments.Findings include: On 5/31/2026 at 12:10 p.m., an observation was made of Resident #17 in her room. Resident #17 stated a recent event at the facility in which she fractured her leg, went to the hospital for treatment (a non-operative approach) and a knee immobilizer was the best treatment plan. Resident #17 lifted her blanket to the side to show a knee immobilizer in place. Resident #17 stated she knew she was supposed to see the orthopedic surgeon for a follow up but stated no one has updated her on when the appointment would be. Resident #17 stated she had an appointment at the end of last year (2025) to see a rheumatologist to rule out a potential diagnosis of Lupus (Systemic Lupus Erythematosus). Resident #17 stated she on multiple occasions the facility had arranged an appointment to see a rheumatologist but each time the appointment was cancelled because of her weight. Resident #17 stated she herself called her insurance company the last time her appointment was cancelled and was told next time she would have to go in a boxed unit vehicle. Resident #17 stated her symptoms have included hot spots on her upper extremities as well as a red butterfly appearance across her face. A review of Resident #17's admission Record showed an original admit date of 9/23/2024 with a readmission date of 4/23/2026 and diagnoses to include but not limited to:Broken internal left knee prothesis, subsequent encounterDisplaced bicondylar fracture of left tibia, subsequent encounter for closed fracture with routine healingChronic respiratory failure with hypoxiaChronic Obstructive Pulmonary DiseaseMorbid (severe) obesity due to excess caloriesRheumatoid arthritis without rheumatoid factor, unspecified site A record review of Resident #17's Minimum Data Set (MDS) dated Mar (March) 30, 2026, showed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #17 is cognitively intact. A record review of Resident #17's progress note on 12/29/2025 at 16:11 p.m. (Military time for 4:11 p.m.) showed the following:Appointment with Dr. [Name of Rheumatologist], with the address in [NAME], including the physician office phone number on 12/29/25 @ 10:30 a.m. Pick up will be 9:15-9:45 a.m. Transport through [commercial transport service] phone number. Confirmation number. refused to go to appt, authored by Staff E, Licensed Practical Nurse (LPN). A record review was conducted in the electronic medical record for Resident #17 and no further follow up appointment for a rheumatologist was documented. On 6/03/2026 at 9:40 a.m., an interview was conducted with Staff E, LPN who stated she remembered the resident's appointment but could not state if the resident ever had her appointment rescheduled. Staff E, LPN stated if she had a resident with an appointment, either a prescription or from the discharged hospital, she would place the order in the resident's electronic medical records. Staff E, LPN stated Staff I, Certified Nursing Assistant (CNA)/Transportation/Appointments will locate a physician, obtain approval through the insurance company and arrange transportation. Staff E, LPN stated Staff I, CNA would notify the nurses under orders when the arrangements have been made. On 6/03/2026 at 9:40 a.m., an interview was conducted with Staff C, LPN. Staff C, LPN stated she is the Unit Manager for the assigned hallway for Resident #17. Staff C, LPN/UM reviewed Resident #17's medical record and confirmed the last appointment/order for Resident #17 for a rheumatologist was 12/29/2025. Staff C, LPN/UM stated she recalled her wheelchair was too wide to fit into the transport vehicle. Staff C, LPN/UM stated physical therapy assisted at one point to transport Resident #17 into a narrower wheelchair to accommodate transport to her appointments, but she was too uncomfortable. On 6/03/2026 at 10:06 a.m., an interview was conducted with Staff I, CNA. Staff I, CNA confirmed he is responsible for arranging appointments and transportation for the facility. Staff I, CNA stated he has made multiple arrangements for Resident #17, but each time transportation would show up to transport her to the appointment(s), accommodations could not be met due to the size (width) of her wheelchair. Staff I, CNA stated at one point the facility tried a stretcher for transport of Resident #17 but the lift to the transport van could not lift the stretcher up to enter the van. Staff, I CNA stated the facility's van had recently been repaired but stated it could not accommodate her transport needs. Staff I, CNA stated he does not know what a box transport means. Upon further interview, Staff I, CNA stated he did not schedule anymore due to her refusing and disheartening and embarrassed attitude. Staff I, CNA stated every time transportation was arranged, the service did not have what she needed to accommodate her transport safely. Staff I, CNA stated he did not know what to do other than arrange transport through an ambulance service. Staff I, CNA stated he had mentioned the transport issues to her primary physician. Staff I, CNA stated the facility does not have a rheumatologist come to their facility and the closest one he could locate for Resident #17 was in another city. Staff I, CNA confirmed therapy got involved to assist her with her transport but with no success. Staff I, CNA stated it was not her weight but the width of her lower pelvic area. Staff I, CNA stated the referral should still be good and he will investigate ambulance service for transport. On 6/03/2026 at 10:29 a.m., an interview was conducted with the Advanced Nurse Practitioner (ARNP) for Resident #17's primary physician. The ARNP stated she thinks the appointment to see a rheumatologist was resident driven. The ARNP stated she did not recall conversations with her primary physician in which a rheumatologist was recommended. The ARNP stated she would follow-up with the primary physician and if Resident #17 wants to see a rheumatologist she would make sure it happens. On 6/03/2026 at 11:03 a.m., an interview was conducted with Resident #17 in her room. Resident #17 was in her wheelchair with her immobilizer in place to her left lower extremity. Resident #17 stated it was her primary physician who had referred her to a rheumatologist, not her request. She stated no one had ever gotten back with her after her last attempted appointment at the end of December. Resident #17 stated she did not refuse her appointment. Resident #17 stated on the day of her appointment she was ready to go but the transport van showed up, brought her to the van and stated the van could not accommodate her. She stated a second transport service came an hour later with the same result. She stated a third attempt was offered but she stated by then she would have for sure missed her appointment. Resident #17 stated, since then no further appointments have been offered and she feels sad about the situation. Resident #17 stated she fractured her leg a month ago and she knows she has to have a follow up appointment with the orthopedic surgeon in six weeks post fracture but again no one has gotten back with her on when the appointment has been made and it has already been 4 weeks. Resident #17 stated she is currently non-weight bearing but after the follow-up appointment is hopeful she can start physical therapy. A review of Resident #17's hospital Discharge summary, dated [DATE], showed the following:Non weightbearing to the affected extremity for 6 weeks and use of a well-padded knee immobilizer.Follow up with Dr. [physician name], Orthopedic surgery within 3-5 days. On 6/03/2026 at 5:04 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated they are in the process of planning for her appointment but was unaware of the orthopedic follow-up appointment. The DON stated arrangements for the orthopedic appointment will be arranged as well. A review of the facility's policy titled: Transportation, effective date 11/30/2014 showed the following policy statement: It is the policy of The Company to ensure residents access to medical services.Procedure: .2. When the resident has no personal resources, transportation will be arranged. This may be: a. Free transportation through social agency b. Taxi c. Medical transportation d. Ambulance e. Facility provided3. The social service department will maintain a list of available medical transportation resources in the community

Based on record review and interview, the facility failed to provide care and treatments in accordance with professional standards of practices as evidence by the lack of documentation of blood pressures prior to the administration of blood pressure medication for two (#3 and #7) of seven residents sampled, failed to document the blood sugars as ordered by the physician for two (#5, and #8) of three sampled residents for monitoring of blood sugar levels, and failed to administer medications as ordered for two diabetic residents (#4 and #10) out of three residents reviewed. Findings included: 1. Review of the Admission Record showed Resident #3 was admitted to the facility on [DATE] and discharged on [DATE]. The resident was admitted for a thirty day respite stay. The admitting diagnoses included end stage renal disease, type 2 diabetes mellitus with hyperglycemia, orthostatic hypotension, unspecified dementia and dependence on renal dialysis. Review of Resident #3's Minimum Data Set Assessment (MDS) dated [DATE], Section C-Cognitive Patterns, showed the resident had a Brief Interview for Mental Status (BIMS) score of 8 revealing moderate cognitive impairment. Review of Resident #3's Care Plan dated 09/30/2024 showed Resident #3 was at risk for cardiovascular complications related to: atrial fibrillation, hypertension, pacemaker, orthostatic hypotension. The interventions included: administer medication as ordered, assess for signs and symptoms of hypotension. Review of the Medication Reconciliation dated 09/19/2024 for Resident #3, given to the facility upon the resident's admission, showed the resident was prescribed Midodrine HCL Tablet, 2.5 milligram (MG) tablet by mouth three times a day as needed for hypotension; hold for systolic blood pressure more than 150 millimeters of mercury (mmHg). Review of the History and Physical dated 08/20/2024 from the hospital for Resident #3, revealed the resident had orthostatic hypotension and it is not uncommon for the resident to lose consciousness and his blood pressure to drop twenty points. Review of Order Summary Report dated 09/27/2024 for Resident #3's admission to the facility shows the medication Midodrine HCL Tablet 2.5 MG was ordered from the pharmacy by the facility on 09/28/2024 for the resident. Review of Resident #3's Medication Administration Record (MAR) from 10/01/2024 through 10/31/2024, showed the medication Midodrine HCL Tablet 2.5 MG was to be administered to Resident #3 one tablet by mouth for orthostatic hypotension, hold if systolic blood pressure (SBP) over 150 mmHg. Review of the MAR showed no record of Resident #3 being given the medication or having his blood pressure checked on the following dates and times: 1. 10/01/2024 - 6:00 am, 2:00 pm, 10:00 pm 2. 10/02/2024 - 6:00 am, 2:00 pm, 10:00 pm 3. 10/03/2024 - 6:00 am (this was the day of the resident's discharge from the facility) 2. Review of the Admission Record, dated 11/5/24, revealed Resident #7 was originally admitted on [DATE] and readmitted on [DATE]. The clinical record for the resident revealed a discharge on 10/26/24 to an acute care facility. The record included diagnoses not limited to atherosclerotic heart disease of native coronary artery without angina pectoris, non-ruptured cerebral aneurysm, chronic diastolic (congestive) heart failure, and essential (primary) hypertension. Review of the October Medication Administration Record (MAR), printed on 11/4/24 at 3:24 p.m., showed Resident #7 was to receive, per physician orders, Midodrine Hydrochloride (HCl) oral tablet 5 milligram (mg) - Give 1 tablet by mouth one time a day every Tuesday (Tue), Thursday (Thu), (and) Saturday (Sat) for hypotension, Hold if less than 100. The MAR revealed the order started on 8/13/24. The MAR revealed a chart code showing 4 equaled (=) Vitals Outside of Parameters for Administration, 9 = Other/See progress notes, ineffective date 2024-01-09, and a checkmark revealed the medication had been administered. The vasoconstrictor medication, Midodrine, was scheduled to be administered at 9:00 a.m. and on 10/1/24 (Tue) the medication was held due to 4 vitals outside of parameters. On 10/3, 10/8, 10/17, 10/19, 10/22, and 10/26/24, the medication was not given due to 9 see progress notes. On 10/5, 10/10, 10/12, 10/15, and 10/24/24 the medication had been administered. The MAR and Treatment Administration Record (TAR) did not include documentation of the resident's blood pressures and the order to administer Midodrine did not include an area to document the resident's blood pressures. Review of the Weights and Vitals Summary for Resident #7 showed one blood pressure had been documented during October. The resident's blood pressure was documented as 112/63 on 10/26/24 at 3:28 p.m. The summary did not reveal the resident's blood pressure on 10/1/24 causing staff to hold the medication. Review of the progress notes dated 10/11 to 10/27/24 for Resident #7 showed on 10/26/24 the Advanced Practitioner Registered Nurse (APRN) documented a blood pressure of 112/63 for the resident. The review of additional progress notes, including electronic MAR (eMAR) notes did not reveal any documentation of other blood pressures being taken or the physician being notified the medication, Midodrine, had been held due to a blood pressure of less than 100. Review of the Care Plan for Resident #7 showed the resident was at risk for cardiovascular complications related to: heart failure, coronary artery disease (CAD), peripheral vascular disease (PVD), anemia, cerebral vascular accident (CVA), right middle cerebral artery (MCA) aneurysm, morbid obesity, (and) history (hx) myocardial infarction (MI). The goal revealed the resident would be free from cardiac complications through review date (12/4/24) and included interventions not limited to: - Administer medication as ordered (Refer to POS/MAR for current order), monitor for side effects. - Assess for signs/symptoms (s/s) of bradycardia, hypotension, dizziness, etc. - Vital signs as ordered and as needed (prn) (Refer to POS/TAR for current order). 3. Review of the Admission Record showed Resident #5 was admitted to the facility on [DATE] with admitting diagnosis including type 2 diabetes mellitus. Review of Minimum Data Set (MDS) assessment dated [DATE], Part C-Cognitive Patterns, showed the resident had a Brief Interview for Mental Status (BIMS) score of 14 revealing the resident was cognitively intact. Review of the Care Plan for Resident #5, dated 08/24/2024, showed the resident had a diagnosis of diabetes and was at risk for hyperglycemia and hypoglycemia. Care plan interventions included blood glucose monitoring and sliding scale insulin as ordered, administer medications as ordered and observe for signs and symptoms of unstable blood sugars. An interview was conducted with the Director of Nursing (DON) on 11/05/2024 at 4:30 pm. The DON said blood glucose test results are charted by exception meaning if the blood glucose level is within normal limits it is not documented on the resident's chart or in a progress note. Review of a Health Status Note dated 10/07/2024 at 7:15 am, written by Staff J, Registered Nurse (RN) the resident was alert with altered mental status revealed Resident #5's blood glucose level was 61. The resident was given an intramuscular diabetic medication with positive results of the resident becoming alert and oriented after fifteen minutes. The resident's physician's office was notified and Staff J received orders for blood glucose checks twice per day. Review of physician order dated 10/07/2024 at 7:09 am, showed an order for Resident #5 for the hypoglycemia protocol: continue to check blood glucose every fifteen minutes until blood sugar is over 70 milligrams per deciliter (mg/dl). Review of physician order dated 10/07/2024 at 7:13 am, showed an order for glucose finger stick and call physician if Resident #5's blood sugar is below 70 mg/dl or over 400 mg/dl. Review of the Medication Administration Record for Resident #5 dated 10/21/2024 through 10/31/2024 showed blood glucose levels were not recorded on the following dates: 1. 10/08/2024 day 2. 10/08/2024 night 3. 10/09/2024 day 4. 10/09/2024 night 5. 10/10/2024 day 6. 10/10/2024 night 7. 10/11/2024 day 8. 10/11/2024 night 9. 10/12/2024 day 10. 10/12/2024 night 4. On 11/4/24 and 11/5/24 random observations were made of Resident #8 propelling self in a wheelchair in the hallway or sitting in the doorway of her room. Review of the Admission Record showed Resident #8 was admitted on [DATE]. The record included diagnoses not limited to type 2 diabetes mellitus without complications and morbid (severe) obesity due to excess calories. Review of the October Medication Administration Record (MAR) for Resident #8 revealed a physician order dated 10/4/24 instructing staff to Blood sugar check twice daily (BID) x 7 days, two times a day for Diabetes Mellitus. Check blood sugar daily before meal **Call MD if <60 or >400**. The order had been scheduled for 6 a.m. and 9 p.m. then discontinued on 10/20/24. The order did not include an area for staff to document blood glucose levels and the MAR and TAR did not include an additional area for staff to document the resident's blood glucose levels. The electronic MAR did show the blood sugar checks had been completed from 10/4 at 9:00 p.m. till 10/20 at 9:00 p.m. Review of the Blood Sugar Summary on 11/4/24 at 4:05 p.m. revealed documentation of Resident #8's blood sugars: - 10/5/24 at 1:23 a.m. - 123.0 milligram/deciliter (mg/dl) - 10/5/24 at 5:32 a.m. - 135.0 mg/dl No documentation of a blood glucose level before the noon or evening meal per the physician order or at the scheduled time of 9:00 p.m. The MAR revealed staff had documented a blood sugar level had been obtained on 10/5/24 at the scheduled time of 9:00 p.m. - 10/6/24 at 6:36 a.m. - 122.0 mg/dl - 10/6/24 at 9:03 p.m. - 153.0 mg/dl No documentation of a blood glucose level had been obtained prior to the noon or evening meal per the physician order. - 10/7/24 at 5:06 a.m. - 125.0 mg/dl No documentation of a blood glucose level had been obtained prior to the noon or evening meal per the physician order or at the scheduled time of 9:00 p.m. The MAR showed staff had obtained a level at 9:00 p.m. on 10/7/24. - No documentation of a blood glucose level on 10/8 or 10/9/24. Staff had electronically documented levels had been obtained on those dates. - 10/10/24 at 5:24 a.m. - 122.0 mg/dl No documentation of a blood glucose level had been obtained prior to the noon or evening meal per the physician order or at the scheduled time of 9:00 p.m. on 10/10/24. Staff had documented on the MAR a 9:00 p.m. level had been obtained and progress notes showed staff had documented the resident had received as needed medication administrations at 7:49 p.m. and 7:50 p.m. with electronic documentation of their effectiveness at 9:25 p.m. - 10/11/24 at 7:31 a.m. - 114.0 mg/dl The progress notes, MAR, and blood sugar summary showed no documentation of a blood glucose level had been obtained prior to the noon or evening meals or at the scheduled time of 9:00 p.m. on 10/11/24 however staff documented on the MAR a level had been obtained as scheduled at 9:00 p.m. Review of the Care Plan for Resident #8 revealed the resident had a diagnosis of diabetes and was at risk for hyper/hypo glycemia. The goal was for the resident to remain free from complications related to hyper/hypoglycemia through (the) next review date. The interventions instructed staff to (obtain) Accu-checks (blood glucose levels) and sliding scale insulin as ordered (Refer to POS/MAR for current orders) and labs as ordered and report results to physician (Refer to POS/TARs for current orders). Review of the policy - Blood Glucose Monitoring & Disinfecting, revised 5/1/23 included instructions for the procedure. The procedure instructed staff to: - Prepare glucose meter for testing. - Wipe tip of finger with alcohol swab and allow to dry. - [NAME] the site with lancet. - Transfer drop of blood to test strip. - Apply pressure to puncture site with gauze pad or alcohol swab. - Test blood specimen per manufactures guidelines. - Read results. - Discard test strip and other materials. - Discard lancet in sharps container. - Remove gloves. - Perform hand hygiene. - Clean and disinfect the meter with disinfecting wipes (per manufacture guidelines). - Place meter in medication cart. - Document result in electronic medical record. An interview was conducted with the Director of Nursing (DON) on 11/4/24 at 4:00 p.m. The DON reviewed Resident #8's MAR and said it shows up on the order and depends on how staff put it in. A review of the Blood Glucose Vital Summary was completed with the DON showing the blood glucose levels are not documented as ordered. During an interview on 11/5/24 at 4:29 p.m. with the DON and Executive Director (ED), the DON stated she would document a blood sugar but the order hadn't been put in (the computer) like that and the facility documents by exception so she would expect if outside the parameters there would be a note. 49227 5. During an observation and interview with Resident #4 on 11/4/24 at 3:30 P.M. she said sometimes she got her insulin late and they forget to take my fingerstick. Review of Resident #4's admission record showed 3/15/24 was the initial admitted . -Resident #4's diagnoses include type 1 DM with hyperglycemia. Review of Resident #4's order summary report for active orders as of 11/5/24, and October 2024 Medication Administration report, showed the following orders: -Blood sugar checks as needed of signs and symptoms of hypoglycemia or hyperglycemia -Hypoglycemia protocol: continue to check blood glucose every 15 minutes until blood sugar is over 70 mg/dl, -Byetta 0.2 ml every Monday for DM -Glucagon Emergency Kit for blood sugar less than 70 mg/dl and unable to take oral [swallow] -Humalog insulin 14 units before meals for DM bring snack with 6:30 A.M. Insulin -Humalog insulin inject as per sliding scale: If 151-200 give 2 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 10 units, greater than 400 give 12 units and notify the doctor, before meals and at bedtime for DM. Bring snack with 06:30 A.M. insulin. -Lantus Insulin 60 units every 12 hours for DM -Trulicity 0.75 once every seven days for DM Review of Resident #4's Care Plan showed -Focus: Resident #4 has a diagnosis of diabetes and is at risk for hypo/hyper glycemia, initiated 3/15/24 -Goal: Resident #4 will remain free from complications related to hypoglycemia and hyperglycemia . -Intervention to include: Accu-Check and sliding scale insulin as ordered., administer medications as ordered. Observe for signs and symptoms of unstable blood sugars tremors/shaking/nausea/vomiting, drowsiness increased thirst rapid/bounding pulse deep respirations change in mental status . Review of Resident #4's medication administration audit report, schedule date 10/1/24 to 10/31/24 showed the following: On 10/1/24 Humalog insulin 14 units before meals scheduled 8:30 A.M. was administered at 10:13 A.M. On 10/1/24 Humalog insulin per sliding scale (SS) scheduled 8:30 A.M. was administered at 10:13 A.M. On 10/1/24 Lantus insulin 60 units scheduled at 9:00 A.M. was administered at 10:13 A.M. On 10/1/24 Humalog insulin per SS before meals scheduled 9:00 P.M. was administered at 11:48 P.M. On 10/1/24 Lantus insulin 60 units scheduled at 9:00 P.M. was administered at 11:48 P.M. On 10/2/24 Humalog insulin 14 units before meals scheduled 8:30 A.M. was administered at 10:45 A.M. On 10/2/24 Humalog insulin per SS before meals scheduled 8:30 A.M. was administered at 10:45 A.M. On 10/2/24 Humalog insulin 14 units before meals scheduled 11:30 A.M. was administered at 12:47 P.M. On 10/2/24 Humalog insulin per SS before meals scheduled 11:30 A.M. was administered at 12:47 P.M. On 10/3/24 Humalog insulin 14 units before meals scheduled 4:30 P.M. was administered at 6:20 P.M. On 10/3/24 Humalog insulin per SS before meals scheduled 4:30 P.M. was administered at 6:20 P.M. On 10/3/24 Humalog insulin per SS before meals scheduled 9:00 PM was administered at 10:19 P.M. On 10/3/24 Lantus insulin 60 units scheduled at 9:00 P.M. was administered at 10:18 P.M. On 10/5/24 Humalog insulin per SS before meals scheduled 8:30 A.M. was administered at 9:55 A.M. On 10/5/24 Humalog insulin 14 units before meals scheduled 08:30 A.M. was administered at 9:56 A.M. On 10/5/24 Humalog insulin per SS before meals scheduled 9:00 PM was administered at 10:37 P.M. On 10/5/24 Lantus insulin 60 units scheduled at 9:00 P.M. was administered at 10:37 P.M. On 10/6/24 Humalog insulin 14 units before meals scheduled 4:30 P.M. was administered at 5:59 P.M. On 10/6/24 Humalog insulin per SS before meals scheduled 4:30 P.M. was administered at 6:00 P.M On 10/7/24 Humalog insulin 14 units before meals scheduled 8:30 A.M. was administered at 10:55 A.M. On 10/7/24 Humalog insulin per sliding scale (SS) before meals scheduled at 8:30 A.M. was administered at 10:54 A.M. On 10/7/24 Lantus insulin 60 units scheduled at 9:00 A.M. was administered at 10:55 A.M. On 10/7/24 Humalog insulin 14 units before meals scheduled at 11:3 A.M. was administered at 4:06 P.M. On 10/7/24 Humalog insulin per SS before meals scheduled 4:30 P.M. medication administration time not documented On 10/7/24 Humalog insulin 14 units before meals scheduled at 4:30 P.M., medication administration time was not documented On 10/7/24 Byetta 0.2 ml scheduled at 5:00 P.M., medication administration was not documented. On 10/8/24 Humalog insulin per sliding scale (SS) before meals scheduled at 8:30 A.M. was administered at 9:56 A.M. On 10/8/24 Humalog insulin 14 units before meals scheduled 8:30 A.M. was administered at 9:56 A.M. On 10/8/24 Humalog insulin per sliding scale (SS) before meals scheduled at 4:30 P.M. medication administration time is not documented On 10/8/24 Lantus insulin 60 units scheduled for 9:00 P.M. was administered at 10:22 P.M. On 10/8/24 Humalog insulin per sliding scale (SS) before meals scheduled at 9:00 P.M. was administered at 10:14 P.M. On 10/12/24 Humalog insulin per SS before meals scheduled 9:00 P.M., medication administration time not documented On 10/12/24 Humalog insulin 14 units before meals scheduled 9:00 P.M., medication administration time was not documented On 10/9/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. the medication administration time is not documented. On 10/9/24 Humalog insulin 14 units before meals scheduled 11:30 A.M. the medication administration time was not documented. On 10/11/24 Humalog insulin per SS before meals scheduled 8:30 A.M. was administered at 2:42 P.M. On 10/11/24 Humalog insulin 14 units before meals scheduled 08:30 A.M. was administered at 2:43 P.M. On 10/11/24 Lantus insulin 60 units scheduled at 9:00 A.M. was administered at 2:43 PM. On 10/12/24 Humalog insulin 14 units before meals scheduled at 11:30 was administered at 8:59 A.M. On 10/12/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 8:59 A.M. On 10/13/24 Humalog insulin 14 units before meals scheduled at 11:30 was administered at 9:30 A.M. On 10/13/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 9:30 A.M. On 10/13/24 Lantus insulin 60 units scheduled for 9:00 P.M. was administered at on 10/14/24 at 2:39 A.M. On 10/13/24 Humalog insulin per sliding scale (SS) before meals scheduled at 9:00 P.M. was administered at 10/14/24 at 2:40 A.M. On 10/14/24 Humalog insulin 14 units before meals scheduled at 11:30 was administered at 9:18 A.M. On 10/14/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 9:18 A.M. On 10/15/24 Humalog insulin per sliding scale (SS) before meals scheduled at 8:30 A.M. was administered at 11:50 A.M. On 10/15/24 Humalog insulin 14 units before meals scheduled at 8:30 A.M. was administered at 11:50 A.M. On 10/15/24 Lantus insulin 60 units scheduled at 9:00 A.M. was administered at 10:50 A.M. On 10/15/24 Lantus insulin 60 units scheduled for 9:00 P.M. was administered at 11:16 P.M. On 10/15/24 Humalog insulin per sliding scale (SS) before meals scheduled at 9:00 P.M. was administered at 11:16 P.M. On 10/16/24 Humalog insulin per sliding scale (SS) before meals scheduled at 8:30 A.M. was administered at 1:44 P.M. On 10/16/24 Humalog insulin 14 units before meals scheduled at 8:30 A.M. was administered at 1:44 P.M. On 10/16/24 Lantus insulin 60 units scheduled at 9:00 A.M. was administered at 1:44 P.M. On 10/16/24 Humalog insulin 14 units before meals scheduled at 11:30 A.M. was administered at 1:44 P.M. On 10/16/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 1:44 P.M. On 10/16/24 Humalog insulin per sliding scale (SS) before meals scheduled at 9:00 P.M. the medication administration time was not documented. On 10/16/24 Humalog insulin 14 units before meals scheduled 9:00 P.M. the medication administration time was not documented. On 10/17/24 Humalog insulin 14 units before meals scheduled at 11:30 A.M. was administered at 7:46 A.M. On 10/17/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 7:47 A.M. On 10/17/24 Humalog insulin per sliding scale (SS) before meals scheduled at 9:00 P.M. the medication administration time was not documented. On 10/17/24 Humalog insulin 14 units before meals scheduled 9:00 P.M. the medication administration time was not documented. On 10/18/24 Humalog insulin 14 units before meals scheduled at 11:30 was administered at 7:29 A.M. On 10/18/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 7:29 A.M. On 10/18/24 Humalog insulin per sliding scale (SS) before meals scheduled at 9:00 P.M. the medication administration time was not documented. On 10/18/24 Humalog insulin 14 units before meals scheduled 9:00 P.M. the medication administration time was not documented On 10/19/24 Humalog insulin 14 units before meals scheduled at 8:30 was administered at 12:14 P.M. On 10/19/24 Humalog insulin per sliding scale (SS) before meals scheduled at 8:30 A.M. was administered at 12:14 P.M. On 10/19/24 Lantus insulin 60 units scheduled at 9:00 A.M. was administered at 12:14 P.M On 10/19/24 Humalog insulin per sliding scale (SS) before meals scheduled at 9:00 P.M. the medication administration time was not documented. On 10/19/24 Humalog insulin 14 units before meals scheduled 9:00 P.M. the medication administration time was not documented On 10/20/24 Humalog insulin 14 units before meals scheduled at 8:30 A.M. was administered at 2:21 P.M. On 10/20/24 Humalog insulin per sliding scale (SS) before meals scheduled at 8:30 A.M. was administered at 2:21 P.M. On 10/20/24 Lantus insulin 60 units scheduled at 9:00 A.M. was administered at 2:21 P.M. On 10/20/24 Humalog insulin 14 units before meals scheduled at 11:30 was administered at 2:21 P.M. On 10/20/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 2:21 P.M. On 10/20/24 Humalog insulin 14 units before meals scheduled at 4:30 P.M. was administered at 2:21 P.M. On 10/20/24 Humalog insulin per sliding scale (SS) before meals scheduled at 4:30 P.M. was administered at 2:21 P.M. On 10/22/24 Humalog insulin 14 units before meals scheduled at 11:30 was administered at 7:25 A.M. On 10/22/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 7:25 A.M. On 10/22/24 Humalog insulin per sliding scale (SS) before meals scheduled at 9:00 P.M. was administered at 10:48 P.M. On 10/22/24 Lantus insulin 60 units scheduled at 9:00 P.M. was administered at 10:48 P.M. On 10/23/24 Humalog insulin 14 units before meals scheduled at 11:30 was administered at 8:19 A.M. On 10/23/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 8:19 A.M. On 10/24/24 Humalog insulin 14 units before meals scheduled at 11:30 was administered at 9:41 A.M. On 10/24/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 9:41 A.M. On 10/25/24 Humalog insulin 14 units before meals scheduled at 8:30 A. M. was administered at 3:12 P.M. On 10/25/24 Humalog insulin per sliding scale (SS) before meals scheduled at 8:30 A.M. was administered at 3:12 P.M. On 10/25/24 Lantus insulin 60 units scheduled at 9:00 A.M. was administered at 3:13 P.M. On 10/25/24 Trulicity .75 mg scheduled at 9:00 A.M. was administered at 3:15 P.M. On 10/25/24 Humalog insulin 14 units before meals scheduled at 11:30 was administered at 3:14 P.M. On 10/25/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 3:14 P.M. On 10/26/24 Humalog insulin 14 units before meals scheduled for 8:30 A.M. was administered at 7:18 A.M. On 10/26/24 Humalog insulin per sliding scale (SS) before meals scheduled at 8:30 A.M. was administered at 7:18 A.M. On 10/27/24 Humalog insulin per sliding scale (SS) before meals scheduled at 9:00 P.M. was administered at 10:58 P.M. On 10/27/24 Lantus insulin 60 units scheduled at 9:00 P.M. was administered at 10:57 P.M. On 10/29/24 Humalog insulin per sliding scale (SS) before meals scheduled at 4:30 P.M. was administered at 5:45 P.M. On 10/29/24 Humalog insulin 14 units before meals scheduled at 4:30 P.M. was administered at 5:45 P.M. On 10/31/24 Humalog insulin 14 units before meals scheduled at 11:30 was administered at 12:43 P.M. On 10/31/24 Humalog insulin per sliding scale (SS) before meals scheduled at 11:30 A.M. was administered at 12:44 P.M. 6. Review of Resident #10 admission record showed 6/14/2015 was the initial admitted . Resident #10's diagnoses include Type 2 diabetes mellitus with hyperglycemia (high blood sugar levels), type 2 diabetes mellitus with hypoglycemia (low blood sugar levels), and diabetic polyneuropathy (nerve disease). Review of Resident #10's order summary report for active orders as of 11/5/24, and October 2024 Medication Administration report, showed the following orders, controlled carbohydrate diet, hypoglycemia protocol: continue to check blood glucose every 15 minutes until blood sugar is over 70 mg/dl, Basaglar Kwik Pen 30 units daily for DM, Basaglar Kwik Pen 10 units daily at bedtime for DM, Trulicity 3 mg every seven days for diabetes, and Metformin 500 mg twice daily for diabetes. Review of Resident #10's medication administration report, schedule date 10/1/24 to 10/31/24 showed the following: On 10/1/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 12:27 P.M. On 10/2/24 Basaglar 30 units scheduled at 9:00 A.M. and was administered at 12:53 P.M. On 10/2/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 12:38 P.M. On 10/2/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 12:38 P.M On 10/3/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 12:38 P.M On 10/3/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 12:50 P.M. On 10/4/24 Metformin 500 mg scheduled for 9:00 A.M. administered at 12:44 P.M. On 10/4/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 12:51 P.M On 10/5/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 12:18 P.M On 10/5/24 Trulicity 3 mg scheduled at 9:00 A.M. and was administered at 12:19 P.M. On 10/6/24 at 9:00 A.M. Resident #10's blood sugar (BS) was 48 mg/dl, unable to find documentation the hypoglycemia protocol was initiated. On 10/6/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 11:19 A.M. On 10/7/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 1:44 P.M. On 10/7/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 1:58 P.M. On 10/9/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 1:09 P.M. On 10/9/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 1:09 P.M. On 10/12/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 1:28 P.M. On 10/17/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 10:32 A.M. On 10/17/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 10:32 A.M. On 10/22/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 10:28 A.M. On 10/22/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 10:30 A.M. On 10/25/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 12:12 P.M. On 10/26/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 12:54 P.M. On 10/26/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 1:05 P.M. On 10/28/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 11:06 A.M. On 10/28/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 11:06 A.M. On 10/29/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 11:13 A.M. On 10/29/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 2:13 P.M. On 10/30/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 12:14 A.M. On 10/30/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 12:13 P.M. On 10/31/24 Metformin 500 mg scheduled for 9:00 A.M. was administered at 12:34 P.M. On 10/31/24 Basaglar 30 units scheduled at 9:00 A.M. was administered at 2:37 P.M. On 11/5/24 at 4:32 P.M. during record review and interview, the Director of Nursing (DON) was shown an entry in Resident #10's medication administration audit report for Metformin 500 mg scheduled for 9:00 A.M. The DON said her expectations was for medications to be given on time Review of the facility's policy titled, administering medications revised, April 2019, showed the information below. Policy Statement: medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: . 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: 5a. enhancing optimal therapeutic effect of the medication; . 7. Medications are administered within (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders) 21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record (MAR) space provided for that drug and dose 50732

Based on observations, record reviews, and interviews the facility failed to ensure one (#7) out of two residents received Dialysis as scheduled per physician orders, failed to arrange transportation to an alternate site during a period of evacuation, failed to notify the Healthcare Proxy and physician of missed Dialysis treatments, failed to coordinate treatments with the Dialysis center resulting in a wellness check by law enforcement. Findings included: Review of the Admission Record revealed Resident #7 was originally admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to End Stage Renal Disease (ESRD) and dependence on renal dialysis. Review of the Skilled Nursing Facility/Nursing Facility (SNF/NF) Transfer form, dated 10/26/24, showed Resident #7 had been transferred to an acute care facility on that date at 00:01 a.m. The form showed the resident was alert and disoriented but could follow simple instructions. Review of progress notes for Resident #7 showed on 10/26/24 at 10:56 a.m., Staff E, Registered Nurse (RN) reported contacting the transport (company) to follow up (f/u) on this resident's transport to Dialysis. Transport was set up for 10/31/24 - 1/31/25, at this time transport was set up for 10/29/24 pick up (p/u) is between 9:40 a.m. and 10:10 a.m., confirmation number 2521250. Asked if they could be her (here) this am (a.m.) for transport, and they stated it would be 3 to 4 hours before they could get here. Her Dialysis chair time is at 10:30 am. Contacted (transport vendor) to transport (Resident #7) to the emergency room (ER), estimated time of arrival (ETA) is approximately 30 minutes. A note 10/26/24 at 11:05 a.m. showed Staff E had encouraged the resident to drink water. The note written by Staff E on 10/26/24 at 11:08 a.m. showed the transport vendor arrived at 11:10 a.m. to transport the resident to an acute care facility for dialysis with no complaints of pain or discomfort. The note written by Staff E on 10/26/24 at 4:27 p.m. showed the acute care facility did not provide outpatient dialysis and resident was admitted for dialysis. Review of the Advanced Practitioner Registered Nurse (APRN) note dated 10/27/24 at 6:36 p.m. revealed Resident #7 was seen on 10/26/24 for follow up dialysis. The APRN documented the resident is seen today for missing her dialysis appointment and had informed the resident of being transferred to hospital for treatment. The note revealed the resident was dependent on dialysis for ESRD, was resting in bed and denied complaints of pain or distress. The assessment/plan revealed the resident's ESRD was unstable and the plan was for hemodialysis as per schedule. Review of Resident #7's care plan showed the following: - had the potential for complications related to dialysis diagnosis End Stage Renal Disease (ESRD) renal failure. On occasion (the resident) will choose not to attend regularly scheduled dialysis appointments. Dialysis: May go to dialysis on Tuesday, Thursday, and Saturdays, chair time 11:30 a.m., pick up time 10:30. The interventions included instructions for staff to make transportation arrangements for dialysis. - (Resident) has an advance directive; Health Proxy naming son as decision maker on file in center. Lack of capacity documentation on file. The interventions instructed staff to Discuss life-prolonging procedures with the appointed health care representative as (resident) has been determined to be incapacitated. Review of the facilities timeline for Resident #7's Dialysis during the period the facility had to evacuate for a storm and the return to the property showed the following: - 10/8 evacuation - Dialysis (vendor) New Port [NAME] (NPR) - 10/10 Dialysis closed - missed - 10/12 to ER for Dialysis - 10/15 Dialysis center Brooksville - 10/17 Dialysis center Brooksville - 10/19 Dialysis center Brooksville - 10/22 Dialysis center Brooksville - planned to repopulate - 10/24 Missed Dialysis - 10/25 Repopulated - unable to set up transport - needs 3 business days. - 10/26 to ER for Dialysis An interview was conducted with a Registered Nurse of the Dialysis Center in Brooksville where Resident #7 had been evacuated to, the RN stated the center had reopened in the afternoon of 10/10/24 and was unable to say whether there had been issues with transportation on that day. The RN was unable to answer any further questions for this writer and asked if the centers administrator could call, as of 11/8/24 no return call has been received. Review of an acute care facility notes regarding Resident #7 showed on 10/12/24 at 7:05 p.m. the resident presented with need of dialysis treatment. The history of present illness revealed a female with history of dementia presents to the ED via Emergency Medical Services (EMS) with complaints of the patient being in need of dialysis. EMS states that the patients living facility called them due to the patient not being able to receive dialysis treatment from the hurricane. An echocardiogram, on 10/12/24 at 7:17 p.m. revealed normal sinus rhythm and no chest pain. An chest Xray, 10/12/24 at 7:59 p.m. was completed for chest pain. The Impression and Plan related to the visit on 10/12/24 revealed a sacral decubitus ulcer, dialysis patient, and a urinary tract infection (UTI) and the disposition of the patient was to the Observation Telemetry Unit. The nephrology consult note dated 10/13/24 at 4:32 p.m. showed the resident had 'a history of ESRD, on hemodialysis Tuesday, Thursday, (and) Saturday was admitted to the hospital secondary not being able get dialysis. The nephrology assessment/plan included will schedule for hemodialysis in a.m. The discharge summary dated 10/14/24 at 10:39 a.m. showed Resident #7 had no distress, no new complaints, and Dialysis today. The facility provided the hospital's notes which showed they had been sent to this facility on 11/5/24 at 3:55 p.m., 22 days after the resident had been discharged from the hospital following dialysis treatments. Review of Resident #7's progress notes and Medication Administration Record (MAR) did not reveal information the resident had been admitted to an acute care facility on 10/12 and had not returned to the evacuation facility until 10/14/24. A note dated 10/12/24 at 1:57 p.m. showed an attempt was made to contact the resident's healthcare proxy to notify that the facility was keeping track of the day to day status of our ability to return. The review showed no progress note dated 10/12- 10/14/24 showing the resident's healthcare proxy had been notified of the resident's transfer to an acute care facility. An interview was conducted on 11/5/24 at 9:55 a.m. with the Executive Director (ED). The ED reported the facility was still in it's investigation phase of the allegation related to Resident #7's Dialysis care. The ED reported interviewing the nurse (Staff F) who had cared for the resident on Thursday 10/24/24 (the day Resident #7 had missed Dialysis) and Staff F (Licensed Practical Nurse, LPN) statement said on 10/24/24 Staff F asked Staff G (Staffing Coordinator) if the staff member could verify the chair time for Resident #7's dialysis and transportation. Staff F reported Staff G's response was transportation was not happening. Staff F reported to the ED of not documenting Resident #7 had missed dialysis. The DON entered the interview, providing the Treatment reports from the Dialysis center where the resident had received dialysis during the evacuation, and stated she had arranged chair times with the Dialysis Center in the city of evacuation to happen at 10:30 on Tuesday, Thursday, and Saturday and the resident had missed Dialysis on 10/10 due to the hurricane so she told staff to transport to the hospital on 10/12. The DON stated the resident had gone to the Dialysis center on 10/15, 10/17, 10/19, and 10/22/24. She stated she had received a telephone call from her staff members at 6 a.m. while in Vegas (regarding the resident's transport). The DON stated she had attempted to set up transport for 10/26 but was told transport needed 3 business day notice and had called another transport company who could transport after a 3-4 hour wait so the patient was sent to the emergency room for Dialysis on 10/26/24. The ED reported Staff G had reported an attempt was made with the staff member at the sister facility to find out why transport was not there on 10/24/24 to transport the resident to Dialysis and was unable to secure transport and had informed Staff F so other alternatives could have been implemented. Review of the Dialysis Centers Treatment Detail Reports showed Resident #7 had received Dialysis services on 10/17, 10/19, and 10/22/24. The reports did not include documentation the resident had received Dialysis on 10/15 per the documented facility timeline and as the DON had reported. The treatment reports showed they had been sent on 11/5/24 at 10:42 a.m., 14 days after the resident had received the last dialysis session at the Brooksville location. Review of the hospital's documentation for the Resident's admission on 10/26/24, revealed, .history of end-stage renal disease on dialysis Tuesday, Thursday, (and) Saturday. (Resident) is here due to missed dialysis. (Resident) has no complaints however reports that (pronoun) last dialysis was Tuesday, (pronoun) missed Thursday because (pronoun) dialysis center was evacuated, and when (pronoun) came for dialysis today, was told that the center schedule is too busy and subsequently brought here by EMS. Labs were reviewed. (Resident) potassium is within normal limits, no evident of critical fluid overload. Regardless, (pronoun) does require dialysis due to (pronoun) scheduling difficulties and significant delay. Discussed with nephrology. Will be admitted for dialysis and further management. Will need case management consult as may need a new dialysis center. An interview was conducted on 11/1/24 at 3:16 p.m. with the originating Dialysis Centers administrator. The staff member stated Resident #7 was to receive Dialysis on Tuesday, Thursday, and Saturdays. The center had attempted to contact the facility on 10/11/24 for a safety check as the resident had missed a treatment on 10/10. The administrator reported receiving a call on 10/14 from the Brooksville hospital for orders to dialyze Resident #7 and on 10/15/24 the center was told by the hospital the resident was no longer there. The administrator contacted the Director of Nursing (DON) on 10/15 and was told they didn't have any plans to set up Dialysis and if the resident didn't feel good they would transport to the hospital for treatment. The Dialysis administrator reported setting up treatment at the local Dialysis center for 10/17, 10/19, and 10/22 which the DON was notified of. After Resident #7 missed the treatment on 10/24, the administrator attempted to contact the facility DON and was informed she was on vacation and the facility had not returned to the New Port [NAME] facility. The center requested a wellness check on 10/25/24 from law enforcement for Resident #7. The Dialysis center administrator reported there had been a lack of communication between the facility and Dialysis center. An interview was conducted on 11/5/24 at 9:32 a.m. with Resident #7's family member and healthcare proxy (HCP). The family member reported not being informed of the resident's missed Dialysis appointments and the nurse at the hospital had informed them the resident had missed 2 appointments. The family member stated on 10/27/24, day after the resident was transferred to the acute care facility, the resident would not talk to them and was not eating or drinking. The HCP reported the resident still was not eating, was drinking very little, and the nurses were giving the resident liquid Morphine for pain. An interview was conducted with the DON and ED on 11/5/24 at 4:29 p.m., the DON stated Resident #7 had received treatment on 10/15/24 from the Dialysis Center in Brooksville. The DON stated she had set up dialysis treatment for Resident #7 at the dialysis center in Brooksville for 10/15, 10/17, 10/19, and 10/22/24 with a chair time of 10:30 a.m. She reported she did not know what the dialysis center had sent to the facility (the morning of 11/5) as she had given the reports to this writer as soon as they had been received. The DON reiterated Resident #7 would have gone to the dialysis center on 10/15, 10/17, 10/19, and 10/22/24. The ED stated the facility did not know why transport did not show up for Resident #7 on 10/25 and the nurse (Staff F) had not followed up. The ED reported law enforcement was in the facility for Resident #7(wellness check) on Friday (10/25/24). Review of the facility contracts with Dialysis centers (3) revealed the contracts were entered into with previous facility owners and did not include a contract with the current owners. Also the contracts did not include the Dialysis center in which Resident #7 was currently scheduled to receive treatments. Review of the policy - Coordination of Hemodialysis Services, revised 7/2/2019, revealed residents requiring an outside ESRD facility will have services coordinated by the facility. There will be communication between the facility and the ESRD facility regarding the resident. The facility will establish a dialysis the agreement/ arrangement if there are any residents requiring dialysis services. The agreement shall include how the residents care is to be managed. The procedure revealed the facility should initiated pre- Dialysis communication forms to be sent to the Center, the Center should complete the communication form or provide the treatment information to the facility and upon the resident's return to the facility, nursing was to review the communication form, complete the post-dialysis information on the Dialysis communication form and file the completed form in the resident's record.

Based on record review and interview, the facility failed to ensure the accounting of narcotic medications were accurately documented for one (#7) of two residents. Findings included: Review of the Admission Record, dated 11/5/24, showed Resident #7 was originally admitted on [DATE], readmitted on [DATE], and discharged to an acute care facility on 10/26/24. The record included diagnoses not limited to chronic pain syndrome and unspecified gout. Review of the October Medication Administration Record (MAR) revealed Resident #7's physician order for oxyCODONE-Acetaminophen Oral Tablet 5-325 milligram (mg) (Oxycodone w/ Acetaminophen) - Give 1 tablet by mouth every 6 hours as needed for pain. The start date for this order was 8/11/24. The MAR revealed the resident received Oxycodone-Acetaminophen on 10/3, 10/7, 3 times on 10/9 (12:39 a.m., 8:16 a.m., and 2:14 p.m.), 10/10, 10/15, 10/19, 10/22, 10/23, and twice on 10/25 (5:48 a.m. and 9:13 p.m.). The MAR showed the resident had received a total of 12 doses during the month of October. Review of one of two Medication Monitoring/Control Records for Resident #7's oxyCODONE/Acetaminophen 5-325 mg tablets revealed 30 tablets of the medication had been received on 8/20/24. The descending count of tablets showed 2 tablets were administered during September, leaving a total of 28 tablets available for administration. The second Control Record showed 26 tablets had been received on 10/7/24. The record instructed for the name of the receiving Licensed Nurse to be printed, the name written appeared to be a S with a humped squiggle, the name was illegible. The records revealed the following was removed from the available tablets of the residents scheduled II narcotic medication during the month of October: 10/3, 10/7, 10/8/24 at an illegible time, twice on 10/9/24 at 8:17 a.m. and 2:14 p.m., three times on 10/10/24 at 7:40 a.m., 2:30 p.m., and one illegible time, 10/11/24 at an illegible time, 10/14/24 at 10:50 p.m., 10/15/24 at 12 noon, twice on 10/16/24, 10/19/24 at an illegible time, 10/22/24 at an illegible time, 10/23/24, 10/24/24, 10/25/24 at 9:15 p.m. The Control Records revealed Resident #7 had received 18 doses and 2 tablets had been wasted. Review of the MAR and Control Records for Resident #7 showed the following discrepancies: - Control record documentation of administration on 10/8/24 at an illegible time was not recorded on MAR. - Control record documentation of administration on 10/9/24 at 12:39 a.m. was not recorded on MAR. - Control record documentation of administration on 10/10/24 at 7:40 a.m. was not recorded on MAR. - Control record documentation of administration on 10/10/24 at an illegible time was not recorded on MAR. - Control record documentation showed on 10/10/24 at an illegible time was wasted. The Record did not show in the Record of Waste and Spoilage that the medication had been wasted by 2 staff members as shown. - Control record documentation of administration on 10/11/24 at an illegible time was not recorded on MAR. - Control record documentation of administration on 10/14/24 at 10:50 p.m. was not recorded on MAR. - Control record documentation of administrations on 10/16/24 at 3 p.m. and 9:32 p.m. were recorded on MAR. Review of Policy - Preparation and General Guidelines IIA7: Controlled Substances, dated August 2019, revealed Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal state laws and regulations. The procedure included the following: A. The Director of Nursing and the consultant pharmacist in collaboration maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to the controlled medications. E. Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substances administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration (MAR, Accountability Record). 2) Amount administered (Accountability Record). 3) Remaining quantity (Accountability Record). 4) Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record). An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 11/5/24 at 9:19 a.m. The staff member reported the process of administering narcotic medications was to sign off the narcotic on the computer and sign off the narcotic sheet. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 11/5/24 at 9:23 a.m. The staff member reported the process for administering narcotic medications was after popping the medication out (of blister card), sign it out on the narcotic record and in the computer. During an interview on 11/5/24 at 4:29 p.m. with the Director of Nursing (DON) and the Executive Director (ED), the DON reviewed Resident #7's Control Records for Oxycodone/Acetaminophen tablets and confirmed nurses were to sign out on both the MAR and the record. She confirmed not knowing who had signed the record in area of S with a squiggle as it was illegible, stating she would have to check the schedule. The DON stated the expectation would be for the document to legible.

Based on observations, interviews, and record review, the facility failed to confirm the accuracy and make corrections to the Pre-Admission Screening and Resident Review (PASRR) for seven residents (#6, #26, #44, #55, #68, #50, and #28) out of thirty-five residents sampled when mental illness or suspected mental illness diagnoses were identified and/or added to the resident's medical diagnoses. Findings included: 1) Review of Resident #6's Admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident #6's PASRR, dated 7/8/22, revealed a diagnosis of depressive disorder and a Level II PASRR was not required. The review of Resident #6's Admission Record showed the resident was admitted with diagnoses of bipolar-type schizoaffective disorder, generalized anxiety disorder, and brief psychotic disorder. The following diagnoses were added after the resident's PASRR was completed and the resident was admitted : - in-partial remission recurrent major depressive disorder, onset date 11/22/22; - Dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The onset date was 5/22/23. - mild recurrent major depressive disorder, onset date 7/10/23. The clinical record did not reveal Resident #6's PASRR was revised to include the resident's mental illnesses. 2) Review of Resident #26's Admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident #26's PASRR, dated 1/4/21, did not reveal the resident had a diagnoses of any Mental Illness (MI), a suspected MI or a Level II PASRR was required. The review of Resident #26's Admission Record showed the resident had diagnoses to include: - generalized anxiety disorder, onset date 3/28/21; - psychotic disorder with hallucinations due to known physiological condition, onset date 5/2/22; - unspecified severity vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The onset date was 6/1/22. - delirium due to known physiological condition, onset date 11/18/22. - mild recurrent major depressive disorder, onset date 11/18/22. - dementia in other diseases classified elsewhere, severe, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The onset date was 1/5/23. Review of Resident #26's clinical record did not show the resident's PASRR was revised after the addition of mental illness diagnoses or the facility received a revised PASRR prior to the readmission on 3/14/23 of the resident. On 1/10/24 at 4:54 p.m. the Social Service Director (SSD) confirmed Resident #26's PASRR did not show any MI illnesses and the PASRR should have been revised. 46498 3) Resident #44 was admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction to unspecified occlusion or stenosis of unspecified cerebral artery, major depressive disorder, recurrent, mild, dementia in other disease classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, generalized anxiety disorder. Review of Resident #44's Preadmission Screening and Resident Review (PASRR), dated 10/09/2017, revealed only one qualifying mental health diagnosis (depressive disorder), no dementia diagnosis and that no PASRR Level II was required. Review of Resident #44's Preadmission Screening and Resident Review (PASRR), dated 4/30/2021, revealed no qualifying mental health diagnoses, no dementia diagnosis and that no PASRR Level II was required. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS), score of 13 indicating cognitively intact. Further review showed, Section I Active Diagnoses Non- Alzheimer's Dementia, anxiety disorder, and depression. Review of the medical record revealed the resident was not assessed for PASRR Level II. 4) Resident #55 was admitted on [DATE] with diagnoses of generalized anxiety disorder, Bipolar II disorder, and major depressive disorder, recurrent, mild. Review of Resident #55's Preadmission Screening and Resident Review (PASRR), dated 8/25/2023, revealed no qualifying mental health diagnosis and that no PASRR Level II was required. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed Section C, Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Further review showed Section I Active Diagnoses anxiety disorder, depression, and Bipolar disorder. Review of the medical record revealed the resident was not assessed for PASRR Level II. 48223 5) Review of the Admission Record showed Resident #28 was admitted on [DATE] and readmitted on [DATE] with diagnoses of major depressive disorder, Schizoaffective Disorder, Bipolar type, alcohol abuse, dementia, and psychotic disorder with hallucinations, due to known psychological conditions, and other comorbidities. Review of Resident #28's PASRR Level I Assessment, dated 08/04/2021, did not reveal a qualifying mental health diagnosis marked in section I A. nor was the diagnosis of dementia. A Level II PASRR should be completed due to the qualifying diagnoses. During an interview on 1/10/2024 at 04:27 PM, the Social Service Director (SSD) confirmed the diagnoses should be listed on the PASRR. The SSD confirmed the PASRR was inaccurate, and a new PASRR should be completed. Review of the Admission Record showed Resident #50 was admitted on [DATE] with diagnoses of dementia, mood disorder, adjustment disorder with depressed mood, major depressive disorder, and other comorbidities. Review of Resident #50's PASRR Level I Assessment, dated 06/05/2021, did not reveal a qualifying mental health diagnosis marked in section I A. nor was the diagnosis of dementia. A Level II PASRR should be completed due to the qualifying diagnoses. During an interview on 1/10/2024 at 04:27 PM, the Social Service Director (SSD) confirmed the diagnoses should be listed on the PASRR. The SSD confirmed the PASRR was inaccurate, and a new PASRR should be completed. Review of the Admission Record showed Resident #68 was admitted on [DATE] with diagnoses of Alzheimer's disease, mood disorder, depression, anxiety, violent behavior, and other comorbidities. Review of Resident #68's PASRR Level I Assessment, dated 11/28/2023, revealed a qualifying mental health diagnosis marked in section I A. depressive disorder, no other diagnoses indicated. Section II: 5. Indicated resident has a primary diagnosis of dementia. 7. Indicates the resident does have validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease). A Level II PASRR should be completed due to the qualifying diagnoses. During an interview on 1/10/2024 at 04:27 PM, the Social Service Director (SSD) confirmed the diagnoses should be listed on the PASRR. The SSD confirmed the PASRR was inaccurate, and a new PASRR should be completed. Review of the facilities policy and procedures titled Preadmission Screening and Resident Review (PASRR), revision date of 11/08/2021, showed the following: Policy: The center will assure that all Seriously Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure: 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agencies to conduct the screenings and obtain the results. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate section of the resident's records.

Based on observations, interviews, and record review, the facility 1) failed to change the dressings and maintain midline catheters for two residents (#198 and #17) out of three sampled residents with intravenous access, 2) failed to provide wound care for two residents (#44 and #196) out of five sampled residents for wound care as ordered by the physician. Findings included: 1) An observation was conducted on 1/8/24 of Resident #198's intravenous catheter in the resident's upper left arm. The dressing was dated 12/30/23. Immediately following the observation, Staff V, Licensed Practical Nurse (LPN) observed Resident #198's catheter dressing and revealed the resident was admitted on [DATE]. The staff member stated the facility doesn't necessarily change the dressing upon admission if they did not have to then added it (the dressing) should have been changed on 1/6/23. Staff V reviewed Resident #198's physician orders and confirmed there was no order for the midline intravenous catheter dressing change. An interview on 1/8/24 at 1:40 p.m., the Regional Nurse Consultant (RNC) stated she would not have changed the dressing if it was intact when the resident was admitted but would go off the date of the dressing, if was nasty she would expect staff to have changed it, and yes there should be orders to care for it. An interview on 1/8/24 at 4:08 p.m., Staff N, Registered Nurse/Unit Manager, stated the facility pulled Resident #198's PICC and stated the dressing should have been removed on admission so nursing could evaluate the area, then redress the catheter. Review of Resident #198's Admission Record revealed the resident was admitted on [DATE] with diagnoses not limited to dehiscence of amputation stump and right lower extremity infection of amputation stump. Review of Resident #198's January Medication and Treatment Administration Records (MAR and TAR) did not show an order was received on the resident's admission (1/5/24) to change the dressing to the midline catheter or an order to flush the intravenous catheter to ensure the patency. Review of Resident #198's progress notes revealed at 2:29 p.m. on 1/8/24 (approximately 55 minutes after the observation with Staff V) Staff N documented a physician order was obtained to remove midline to left upper extremity (LUE) due to (d/t) non-use. 2) An observation was conducted on 1/8/24 at 12:08 p.m. of Resident #17 sitting upright in bed with a meal tray on the overbed table. The resident reported not needing assistance with eating. An observation was conducted on 1/10/24 at 5:45 p.m. of a single lumen midline catheter in Resident #17's right upper arm. The dressing to the catheter was undated and pulled away from the resident's arm in the upper right corner. An observation and interview was conducted on 1/10/24 at 5:46 p.m. with Staff M, Licensed Practical Nurse, of Resident #17's intravenous access and dressing. The staff member confirmed the dressing was not dated, did not know when it (dressing) was last changed. Staff M stated the dressing should be dated, knew the resident had received (intravenous) fluids last week, and was going to check with the Unit Manager to see if an order could be received to discontinue the access. Review of Resident #17's January 2024 Medication and Treatment Administration Records (MAR and TAR) did not reveal an order to flush the resident's midline catheter to maintain patency. The TAR did not include an order to change the intravenous access dressing either scheduled or as needed. On 1/10/24 at approximately 6:35 p.m., the facility provided a handwritten Medication Record with an order started on 1/10/24 to Change PICC dressing (drsg) every (Q) weekly. The record showed the dressing was scheduled to be changed during the 7-3 shift and Staff M documented the dressing had been changed. The record included an order started on 1/10/24 to Flush PICC q shift for maintenance (maint), Staff M documented that during the 7-3 shift the resident's PICC catheter had been flushed. The order did not include with what substance staff were to flush the PICC with. An order had been obtained to discontinue the PICC on 1/11/24. During an interview on 1/10/24 at 6:42 p.m., Staff M stated the dressing had been changed after our observation and had been flushed with 5 milliliter's of heparin and normal saline. The staff member reviewed the orders and stated the catheter had been flushed per the MAR. Staff M confirmed the order written on the MAR did not identify what type of solution should be used to flush the midline. Review of Resident #17's clinical record showed on 12/28/23 at 6:17 p.m. a midline catheter had been inserted into the resident's right brachial vein for the administration of intravenous fluid. Review of Resident #17's December 2023 MAR showed the resident had received Dextrose-Sodium Chloride solution (5-0.45%) 3 liters intravenously every shift for dehydration at 80 milliliter/hour (mL/hr) until completion of 3 liters then discontinue (d/c) order. The order was discontinued on 1/1/24. The MAR did not reveal an order to flush the midline to ensure patency of the midline after the IV fluids had been administered. Review of Resident #17's December 2023 TAR did not reveal an order to change the midline dressing, either scheduled or as needed. Review of Resident #17's progress notes and assessments on 1/10/24 at 6:16 p.m., did not show the resident's midline dressing had been changed during the period of 12/28/23 to 1/4/24 (last progress note electronically written). A progress note dated 12/31/23 at 11:55 a.m., showed the midline was patent and flushes easily but did not reveal what staff had used to flush the midline. During an interview on 1/11/24 at 9:31 a.m., the facility Medical Director stated the expectation was for nursing to follow the facility protocol regarding peripherally inserted central catheter (PICC) line dressing changes and flushes. An interview was conducted on 1/11/24 at 10:12 a.m., with Staff N regarding the orders received on 1/10/24 for care of Resident #17's midline catheter. The staff member stated That was my mess up, reporting leaving off the 0.9% normal saline and 50 units/5 mL heparin flushes. The staff member stated PICC line dressings should be changed every 7 days and the nurse should have put orders in for dressing changes, flushes, and observation of site during admission or the insertion of the IV access. Staff N reported not knowing why the order wasn't added when Resident #17 had the midline inserted. The staff member reported the orders received had been written for 7-3 shift. Review of Resident #17's Admission Record revealed the resident had been admitted on [DATE] and readmitted on [DATE]. The record showed the resident was admitted with diagnoses of unspecified elevated white blood cell count, unspecified severe protein-calorie malnutrition, and unspecified hematuria. On 1/11/24 at 12:50 p.m. the Director of Nursing stated she had found the orders for one of the two (residents) as the nurse had put them into the previous corporations electronic record platform despite education that it would be unavailable after Sunday (1/7/24) at 7 p.m. and no one was going to be able to see it. A review of the policy - Midline Dressing Changes, dated October 2019, showed the following: Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. The general guidelines of the policy revealed midline catheter dressings should be changed 24 hours after insertion if placed with gauze, every seven days or if it is wet, dirty, not intact, or compromised in any way. The instructions on how to apply a sterile dressing instructed staff to label the dressing with initials, date, and time. The following information should be recorded in the resident's medical record: date and time dressing was changed, location and objective description of the insertion site, any complications, interventions that were done, whether flushed positive blood return; and whether needless connection device or extension tubing was changed, and type of dressing placed. A review of the policy - Flushing Midline and Central Line IV Catheters, dated April 2017, showed the following: Midline and Central Line IV catheters (CVADs) will be flushed to maintain patency; to prevent mixing of incompatible medications and solutions; and to ensure entire dose of solution or medication is administered into the venous system. The general guidelines of the policy instructed prior to procedure, assess catheter type for flushing protocols, and the use of normal saline only or normal saline slash heparin. The flushing protocol showed that catheters should be flushed at regular intervals to maintain patency AND before and after the following: administration of intermittent solutions, administration of medication, administration of blood or blood products, obtaining blood samples, and converting from continuous to intermittent therapies. The flushing protocol showed the use of 10 unit/mL of heparin should be used to flush a midline, tunneled, non-tunneled, and PICC's. 3) Review of Resident #196's Admission Record revealed the resident was admitted on [DATE] and readmitted on [DATE] and 11/13/23, and discharged on [DATE]. The record included diagnoses not limited to stage 2 pressure ulcer of sacral region, unspecified severe protein-calorie malnutrition, adult failure to thrive, and unspecified malignant neoplasm of tonsil. The record showed the onset of the stage 2 pressure ulcer of the sacral region was 11/13/23 during readmission of the resident. Review of the Wound Assessment Report from the Wound Care provider, dated 11/14/23, for Resident #196 revealed an unstageable sacral pressure injury measuring 2 x 2 x 0.1 centimeters (cm) that was not acquired in-house. The report did include orders for treatment to the area. Review of Wound Assessment Reports from the Wound Care provider revealed Resident #196 was seen on 11/21, 11/28, and 12/5/23. The report dated 12/5/23 showed worsening of the pressure injury (2 x 2.3 x 0.3 cm). The provider continued with the same treatment of cleansing with normal saline, applying medical grade honey, calcium alginate and covering with bordered foam. Review of Resident #196's November 2023 Treatment Administration Record (TAR) revealed the following physician orders with start and discontinue dates if applicable: - Clean open area to sacral/coccyx area with normal saline (NS), pat dry, and cover with a bordered dressing every day shift, start 11/14 and discontinued on 11/15/23 at 10:42 a.m. - Sacrum - Cleanse with NS, pat dry. Apply Medihoney then cover with calcium alginate and dry clean dressing (DCD) every day shift for unstageable, started on 11/16/23 and discontinued on 12/18/23. - Sacrum - Cleanse with NS, pat dry. Apply Medihoney then cover with calcium alginate and dry clean dressing (DCD) as needed for soiled/dislodged dressing, started on 11/15/23 and discontinued on 12/18/23. Review of Resident #196's November 2023 TAR showed the staff did not provide wound care to the area on 11/15, 11/19, 11/22-11/23, 11/25 and 11/26/23, six times out of 16 opportunities. Review of Resident #196's December 2023 TAR showed the staff did not provide wound care to the sacral pressure injury on 12/1 and 12/7/23, twice out of eight opportunities. The care plan for Resident #196 showed the resident choose not to allow care in the areas of hygiene/bathing with the interventions including but not limited to if refusing or resisting try again later. The care plan revealed Resident #196 had an actual skin breakdown related to skin tear and pressure injury. The interventions instructed staff to provide wound care as ordered, see current treatment record and physician's orders, (and to) monitor effectiveness of /response to treatment as ordered. During an interview on 1/11/24 at 1:29 p.m., the Director of Nursing (DON) reviewed the November 2023 and December 2023 TAR's regarding the sacral pressure injury treatment. The DON confirmed the resident's wound care was not completed daily (as ordered) and stated they probably did it just did not sign it off. Review of the policy - Dressing Change (N-1310), revised 12/6/17, showed the following: A clean dressing will applied by a nurse to a wound as ordered to promote healing. 46498 4) On 01/08/2024 at 10:28 a.m., Resident # 44 was observed laying flat on her back with her call light placed behind her, yelling out for staff to help her. she was observed with a foul body odor and disheveled hair. She said she can't see, and she has to yell to get staff to assist her with turning her on her side, but no one will assist her. She said she has a sore on her butt that has been itchy her for a while and it hurts bad. She said she has requested staff to just put some hot water on her butt where the sore is located because it itches so bed, but staff will not do it for her, staff even refuses to give me a shower. Resident bed wedge for position was observed up against the wall next to the resident's bed. On 01/08/2024 at 1:00 p.m., Resident # 44 was observed sleeping laying flat on her back in bed, dressed in her night shirt. Resident bed wedge for position was observed up against the wall next to the resident bed. Resident said she was still waiting for a staff member to turn her off her back. Resident #44 was admitted originally on 10/09/2017 and readmitted on [DATE] with diagnoses of dementia in other disease classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, generalized anxiety disorder, blindness right eye category 5, blindness left eye category 5, acquired absence of right leg below knee, acquired absence of left leg below knee, acquired absence of left fingers, dependence on renal dialysis, Type II Diabetes Mellitus with hyperglycemia. Review of a Quarterly Minimum Data Set (MDS), dated [DATE], showed Section C, Cognitive Patterns, Brief Interview for Mental Status (BIMS), score of 13 indicating cognitively intact. Further review showed Section GG- Functional Abilities and Goals showed the resident is dependent on staff for all her care needs and always incontinent. Additionally, review showed Section M- Skin Condition revealed number 1 was coded to indicate the resident is at risk of developing pressure ulcers/injures. Has open lesions other than ulcers, rashes, cuts. Review of a care plan, review date 12/22/2023, showed Resident # 44 has actual skin breakdown related to abscess on her buttocks. Review of the care plan goals showed resident will remain free from signs and symptoms of infection related to actual skin issues. Review of the care plan interventions initiated on 03/13/2022 showed to monitor for sign and symptoms, s/s infections or delayed healing and report to physician as needed, PRN: Redness/ Erythema Drainage purulent or bloody Separation of incision. Followed by wound care nurse, encourage/assist to turn, and reposition as tolerated. Review of a Skin and Wound note dated , 12/05/2023, and 12/12/2023 by Staff R, Advanced Registered Nurse Practitioner, ARNP showed Resident was seen for skin and wound care. Wound status revealed wound was worsening, stage severity partial thickness. Size 2cm x 1 cm x 0.1 cm. Calculated area is 2 sq cm. It was noted for preventative measure to keep area clean and dry, prevent skin to skin contact and continue with turning and repositioning schedule per protocol for pressure prevention. Further review showed a new recommendation revealing the right buttocks abscess was worsening with increased size and increased drainage. It was noted to defer to Primary Care Provider to consider repeating Antibiotic, ABT regimen with kidney status. Review of a Skin and Wound note dated 12/26/2023 by Staff S, Advanced Registered Nurse Practitioner, ARNP showed Resident # 44 was not able to be evaluated because she was at dialysis. Further review showed Resident #44 was not provided with coordination of wound care for further evaluation by a practitioner for three weeks due to her dialysis appointments. Review of practitioner note dated 01/09/2024 by Staff T, the Advanced Registered Nurse Practitioner, ARNP showed Resident was seen with a primary diagnosis of sacral pressure ulcer. According to the note the wound care provider is recommending a Magnetic Resonance Imaging, MRI for sacral unstageable pressure ulcer due to tunneling and deepening of wound. High concern for osteomyelitis noted. On 01/10/2024 at 1:00 PM., an interview was conducted with Staff O, License Practical Nurse, LPN/ Wound care Nurse. She said she just started working as a wound care nurse recently and she is still in training to learn more about her position. She said she does not document or measure wounds at this time, she only does treatments because she is still learning her role as the wound care nurse. Residents with wounds are followed by a wound nurse practitioner every Tuesday. When she started her position as the wound care nurse three weeks ago, she noticed resident # 44 wound was worsening, and she expressed increased itchiness in her wound. In addition, the wound nurse practitioner was not able to see the resident for three weeks due to the resident's dialysis schedule. She reached out to the facility's nurse practitioner on 01/09/2024 so he could assess her wound. On 01/10/24 at 04:58 p.m., an interview was conducted with Staff R, Advanced Nurse Practitioner, ARNP/ Wound Care. She said that she comes to the facility at least once a week, sometimes even twice a week if a resident was not seen. The ARNP who usually sees the resident was out on maternity leave after her last assessment 12/12/2023. She said she was not able to see the resident because every time she come to the facility the resident is usually at dialysis. She was not notified to come back out to see the resident when she came back from her appointments. The She said that she does not believe that she has ever seen this patient. On 01/10/24 02:30 p.m., an interview was conducted with Staff T, Advanced Nurse Practitioner, ARNP. He said he just started at the facility two weeks ago and this is the first time he has seen this patient. He received a call from the facility yesterday to see Resident #44 regarding her wound. From his review of her wound it looked bad, it looked unstageable. He ordered a Magnetic Resonance Imaging MRI because there's another ulcer that she has had for years that's started to open back up next to the one that's already opened, she has a couple of things going on with her wound. On 01/10/24 at 05:26 p.m., an interview was conducted with the Director of Nurses, DON. She said Resident # 44 has an abscess on her buttocks. The practitioner couldn't see her because the resident is at dialysis every Tuesday. My expectation is that staff should have notified the physician if her wound condition was worsening, and it was not done. On 01/11/24 09:20 a.m., an interview was conducted with the Medical Director. He said he has followed Resident # 44 for a long while now. She has had abscess on and off. He doesn't follow the wounds as he has several individuals that are following the wounds ie., wound consultant and my nurse practitioner. He was unaware the wound nurse practitioner went out on maternity leave a month ago. I am not sure why the current company nurse practitioner is ordering an MRI; I will have to investigate. The company just hired a full time Nurse Practitioner, and I am not familiar with him. As for the 12/12/23 note from the Nurse Practitioner - to follow up with Primary Care Provider for Antibiotic due to wound worsening and renal function. I would have expected the facility to reach out to me to inform me of what was going on with the resident. He sees Resident # 44 weekly and speaks with the nurses here on a regular basis. He does not recall discussion of the wound worsening. The facility did not have a policy to include for this citation

Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and eleven errors were identified for three residents (#3, #42, and #76) of seven residents observed. These errors constituted a 34.38% medication error rate. Findings included: 1) On 1/9/24 at 10:31 a.m., an observation of medication administration with Staff D, Registered Nurse (RN), was conducted with Resident #3. The staff member dispensed the following medications: - Fluoxetine 10 milligram (mg) capsule - Famotidine 20 mg over-the-counter (OTC) tablet Review of Resident #3's Medication Administration Record revealed Resident #3 was scheduled to be administered the following medications at 9:00 a.m.: - Mirtazapine 7.5 mg - Give 1 tablet by mouth one time a day for depression; - Prozac (Fluoxetine) 10 mg - Give 2 capsules by mouth one time a day for depression; - Pepcid (Famotidine) 20 mg - Give one tablet by mouth two times a day for Gastroesophageal reflux disease (GERD). The observation revealed Staff D initialed the individual medications prior to dispensing the medications. The observation revealed the staff member administered 2 oral tablet/capsule medications to Resident #3. 2) On 1/9/24 at 10:49 a.m., an observation of medication administration with Staff D, Registered Nurse (RN), was conducted with Resident #42. Staff D obtained the resident's blood pressure of 95/65. The observation revealed the staff member documenting medications were dispensed prior to dispensing the medications. The staff member dispensed the following medications: - Escitalopram 5 mg tablet - Oxybutynin 5 mg Extended Release (ER) tablet - Pantoprazole 40 mg tablet - Eliquis 2.5 mg tablet - Senna (sennosides) 8.6 mg tablet - Gabapentin 300 mg capsule Staff D confirmed dispensing 6 oral tablets/capsules. Review of Resident #42's Medication Administration Record revealed the following errors in administration: - Lexapro (Escitalopram Oxalate) 5 mg tablet - Give 10 mg by mouth one time a day for depression; - Senna S (Sennosides-Docusate Sodium) 8.6-50 mg - Give 2 tablets by mouth one time a day for constipation; - Cardizem 120 mg tablet - Give 1 tablet by mouth one time a day for HTN; - Iron 325 mg tablet - Give 1 tablet by mouth one time a day every 2 day(s) for anemia, scheduled to be administered on 1/9/24; - Isosorbide Dinitrate 30 mg tablet - Give 1 tablet by mouth one time a day for Atrial fibrillation (Afib); - Metoprolol Tartrate 50 mg tablet - Give 1 tablet by mouth every 12 hours for hypertension (HTN); - Nifedipine Extended Release (ER) 24 hour 30 mg - Give 1 tablet by mouth every 12 hours for HTN. The review of the MAR showed the medications observed, held, and unobserved were scheduled to be administered at 9:00 a.m. Staff D reported holding the medications of Metoprolol, Cardizem, and Isosorbide due to blood pressure (95/65) and putting a zero (0) on top (of MAR) to indicate the medication was not given. Staff D reported the medications observed were due at 8-9 a.m. and having to administer medications to 30 people. The staff member did not document the Iron or Nifedipine was administered or held. The physician orders for the resident's hypertension medication did not include parameters to hold the medication for blood pressures. Staff D reported charting on the residents was done in the computer (which was not available during the survey due to the facility transitioning) which they were not doing at this time. On 1/11/24 at 12:38 p.m., the Director of Nursing (DON) stated the expectation was to call the physician before holding medications. 3) On 1/10/24 at 9:01 a.m., an observation of medication administration with Staff M, Registered Nurse (RN), was conducted with Resident #76. The staff member signed the medication on the MAR as removing the medication packaging from the medication cart, prior to dispensing. Staff D dispensed the following medications: - Vitamin D 25 microgram (mcg) - 5 otc tablets over-the-counter (otc) - Guaifenesin 400 mg otc tablet - Multi Vitamin with mineral otc tablet - Jardiance 25 mg tablet - 1/2 tab - Eliquis 5 mg tablet - Metformin 1000 mg tablet - Lopressor 25 mg - 1/2 tablet - Flecainide 150 mg tablet - Escitalopram 20 mg tablet - Loratadine 10 mg otc tablet - Prostat 30 milliliter (mL) The staff member confirmed dispensing 14 tablets. Staff M stated she would have to contact pharmacy as the facility did not have Resident #76's Wixela Aerosol Inhalation medication. Review of Resident #76's Medication Administration Record (MAR) revealed the following physician orders and errors in administration: - Guaifenesin Extended Release (ER) 600 mg - Give 1 tablet by mouth every 12 hours for congestion; - Wixela Inhub Inhalation Aerosol Powder Breath Activated (500-50 mcg/act) (Fluticasone-Salmeterol) - I puff inhale orally two times a day for Chronic Obstructive Pulmonary Disease (COPD). Rinse mouth and spit after use. On 1/10/24 at 9:30 a.m. Staff M reporting thinking the facility had educated staff on Monday regarding the use of paper MAR's but stated she wasn't here. On 1/11/24 at 12:40 p.m., the Director of Nursing (DON) stated if a medication was not available, the pharmacy should be called, the staff should verify the medication was not available in the emergency stock, and if not the physician be notified. On 1/11/24 at 12:33 p.m., an interview was conducted with the DON and Regional Nurse Consultant (RNC) to reveal the observations of the medication administration, at which time the Director of Nursing stated the facility had received an order from the Medical Director that it was okay for late medications during the time the facility was utilizing paper MAR's. On 1/11/24 at 1:40 p.m., the DON provided a copy of a physician order, dated 1/8/24 reading All residents medications can be late during Point Click Care (PCC) transition. The DON confirmed the order and shrugged shoulders that it did not reveal how late medications were allowed. The policy - Medication Administration - General Guidelines, dated April 2018, showed the following: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly orientated to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The policy revealed the following: - The procedure revealed medications were to be administered by the five rights: right resident, right drug, right dose, right route, and right time. A triple check of these five rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. - The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record are compared with the medication label. - If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit. - If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g. the resident is not in the facility at scheduled dose time or a starter dose of antibiotics is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record.

Based on observations, interviews, and record review, the facility failed to ensure two residents (#42 and #69) were assessed for the self-administration of medications out of 35 sampled residents. Findings included: 1) An observation was conducted on 1/9/24 at 10:45 a.m. with Staff D, Registered Nurse (RN) of medication administration. During the observation, a medication cup containing 2 round pink tablets was observed on Resident #42's over-bed table. The staff member and resident reported the tablets were (name brand) chewable antacid tablets. Staff D reported the resident should not have the tablets in her room. The staff member asked Staff C, Licensed Practical Nurse/Unit Manager (LPN), if the resident was allowed to have the tablets and Staff C shook her head. Review of Resident #42's physician orders did not reveal an order for the chewable antacid tablets and no documentation for the resident to self-administer any medications. A request was made to the facility for a list of all residents assessed for the self-administration of medications. The facility provided a list which did not include Resident #42 or Resident #69. An interview was conducted on 1/11/24 at 1:46 p.m. with the Director of Nursing (DON). The DON stated (name brand) antacid tablets should not have been left at (Resident #42's) bedside. She stated the resident had not been assessed for self-administration of medications and there was only one resident in the facility allowed to self-administer with supervision in preparation for discharge. 48223 2) On 1/08/2024 at 10:08 AM, Resident #42 was observed in bed, the over the bed table beside the bed, within reach. On the over the bed table were two small medication cups, 7 medications were in one cup (1 small round blue, 1 small oblong yellow, 1 small round beige, 1 small round yellow, 1 round medium white, 1 small round white, and 1 yellow capsule) and 4 pills in the second cup (2 round pink and 2 round orange). (Photographic Evidence Obtained). An interview was conducted with Resident #42, on 1/08/2024 at 10:08 AM. Resident #42 stated, I was not ready to take the medications when the nurse brought them, therefore the nurse left them for me to take when I was ready. During an interview on 1/08/2024 at 11:15 AM, Staff L, Licensed Practical Nurse (LPN) stated the medications had been left at the bedside, per the resident's request. Staff L, LPN confirmed the medications were documented as given, and should not have been left at bedside, as the resident does not have an order for self-administration. Review of Resident #42's Order Summary Report for January 2024, confirmed Resident #42 did not have an order for self-administration of medications. On 1/09/2024 at 1:07 PM, Resident #69 was observed in bed with lunch on the over the bed table across her lap. Next to the lunch tray was a medication cup full of a clear liquid. An interview was conducted with Resident #69, on 1/09/2024 at 1:07 PM. Resident #69 stated That is my Potassium. During an interview on 1/09/2024 at 1:15 PM, Staff D, Registered Nurse (RN) stated, I left the medication with [Resident #69], and I'll go back and check on the resident. Staff D, RN continued to state that none of the long-term residents on the hall had orders for self-administration. I should not have left the medication, stated Staff D, RN. Review of Resident #69's Order Summary Report for January 2024, confirmed Resident #69 did not have an order for self-administration of medications. Review of the facility's policy and procedure, titled Self-Administration of Medications at Bedside, Document Name: N-872 with a revision dated: 8/22/2017 revealed the following: Policy: The resident may request to keep medications at bedside for self-administration in accordance with Residents Rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medications and to keep accurate documentation of these actions. Procedure: Verify physician's order in the resident's chart for self-administration of specific medications under consideration. Complete self-administration of medications evaluations. The interdisciplinary team will review the evaluation and will document Section III. Approval granted must be checked yes or no. Interdisciplinary team members sign the evaluation section. If approval is not granted, a statement must be written as to reason for denial. Complete the care plan for approved self-administered drugs. Self-administration of meds is reviewed by the care plan team with each quarterly review, and with any change in status noted. The medication administration record (MAR) must identify meds that are self-administered, and the medication nurse will need to follow-up with resident as to documentation and storage of medication during each pass. If kept at bedside, the medication must be kept in a locked drawer. When a resident is unable to self-administer medications, they will be given by the nursing staff until the resident can be reevaluated by the interdisciplinary team.

Based on interviews and record review, the facility failed to honor a resident's decision to formulate an advance directive and did not ensure a current copy of the Advance Directive was in the resident's medical record for one resident (#68) of one resident sampled. Findings included: An interview was conducted with Resident #68's Resident Representative (RR) on 1/08/2024 at 2:11 PM. Resident #68's representative stated the resident was admitted to the facility under hospice care. The RR stated the family had implemented a Do Not Resuscitate Order (DNR) with hospice prior to admission and was told the family needed to come into the facility to sign another form. The RR tried to explain they were unable to come into the facility at this time as they had been quite ill. The RR stated they did not understand why the DNR was not able to be utilized in the facility as the hospice nurse had told them it was transferable to any institution. An interview was conducted with Staff L, Licensed Practical Nurse (LPN) on 1/08/2024 at 3:47 PM. Staff L, LPN stated Resident #68 was a Full Code and on hospice. An interview was conducted with the Social Service Director (SSD) on 1/08/2024 at 3:47 PM. The SSD stated Resident #68 came in with a bad DNR as the form had an electronic signature. The SSD continued to state the facility had taken the steps to have the resident deemed incompetent and to have the physician sign a new DNR. The facility was only waiting for the family to bring the form back into the facility, and the facility Had to follow 401 to the letter. The SSD confirmed the RR had informed the facility of the choice to enact a DNR for the resident. Review of the resident's Admission Record showed the resident was admitted to the facility on [DATE]. The resident had a Power of Attorney (POA) for Financial and Health Care. The resident was being seen by Hospice. Review of the resident's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008), dated 11/28/2023, was signed by the Advanced Practice Registered Nurse (APRN). The form revealed the resident was a DNR. Review of the resident's physician order for 12/1/2023 revealed Resident #68 was a Full Code. Review of the Social Service Admission Assessment, dated 12/06/2023, signed by the SSD showed the resident had a Durable Power of Attorney (DPOA). No other resident rights were indicated. The SSD documented, the resident has a POA for Finance and Health, would like DNR, explained need to have MDs sign Lack of Capacity and Terminal Declaration to allow him to sign, forms out for physician to sign, request sent to Psychologist. Facility will integrate services with Hospice Team. No other social service notes were presented. Review of the Certificate of Terminal Illness, dated 10/04/2023, and signed by the physician. The documentation additionally revealed the physician's discussion with the DPOA regarding the DNR process. The DPOA elected DNR. DNR was executed. An interview was conducted with the Director of Nursing (DON) on 1/08/2023 at 4:10 PM. The DON stated electronic signatures are acceptable. An interview was conducted with the SSD on 1/08/2023 at 4:30 PM. The SSD stated the family must come into the facility and sign the paperwork. The SSD stated the RR does request the resident to be a DNR but has not been able to make it into the facility. Review of the resident's medical record revealed a State of Florida Do Not Resuscitate Order, dated 10/04/2023, signed by the RR and an electronic signature of the physician. Review of the facility policy and procedure titled Advanced Directives, revision date of 11/14/2018, revealed the following: Policy: The center will abide by state and federal laws regarding Advanced Directives. The center will honor all properly executed advanced directives that have been provided by the resident and/or representative. Process: .2. Social Service Director and/or Business Development Coordinator/designee will assist the resident/resident representative to complete the Advanced Directives Discussion Document. If an advanced directive exists, the Social Services and/or Business Development Coordinator/designee will obtain a copy and place it in the resident's medical record.5. Advanced directives will be reviewed: *quarterly *Hospice Admission Review of the facility policy and procedures titled Florida Do Not Resuscitate (DNR), dated 10/25/2018, revealed the following: Policy: The center will follow Florida law regarding obtaining and honoring Do Not Resuscitate orders. Procedure: 1. The State of Florida Do Not Resuscitate order (DNRO or DH form 1896) must be signed by the attending physician/covering physician or medical director and by the resident or, if the resident is incapacitated, the resident representative a. Electronic or fax physician signature is acceptable 3. The properly executed DNRO will be placed in the resident's medical record.

Based on observations, interviews, and record review, the facility failed to ensure two of two Minimum Data Set (MDS) assessments were accurate to include an active diagnosis of trauma/Post Traumatic Stress Disorder (PTSD), for one resident (#5) of four sampled residents diagnosed with long standing trauma/PTSD. Findings included: On 1/8/2024 at 11:00 a.m. the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Nursing Home Administrator (NHA) provided the survey team with a completed Resident Matrix tool, which contained all ninety-six facility residents with detailed problem indictors checked for each of those residents. In the Post Traumatic Stress Disorder (PTSD)/Trauma section of the matrix, Resident #5 was not indicated as having PTSD/Trauma. On 1/8/2024 at 9:30 a.m. an interview was conducted with Staff A, Certified Nursing Assistant (CNA), and Staff F, CNA who stated they were knowledgeable of Resident #5 related to her care needs. Staff A and F stated they had Resident #5 on their work assignment. Staff A and F stated Resident #5 had vision impairment and she required staff to explain where things are located throughout her room. Staff A and F stated Resident #5 had cognition impairment and she was not able to be interviewed but could answer some simple yes and no questions. Staff A and F stated Resident #5 does call out and scream at times but they were not aware of her having any type of trauma or PTSD. Staff A and F stated they would not know what to look for with relation to any type of past trauma behaviors. They stated Resident #5 screams aloud at times and is most times easily redirected. On 1/8/2024 at 9:35 a.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). Staff D stated she was new to the facility and did not feel she would be able to explain any of the residents on her hall or what there care needs were. Staff D stated Resident #5 did present with screaming and yelling behaviors, but was not aware as to why she presented with those behaviors. On 1/8/2024 at 10:20 a.m. Resident #5 was observed seated in her wheelchair next to her bed. She was observed dressed for the day and well groomed. She was observed with her eyes closed making noises aloud and then started to yell out. She yelled out for approximately three to four minutes prior to staff responding. A staff member who was walking by the room, knocked on the door and entered the room to redirect and calm the resident. After the staff member was able to calm Resident #5, she then left the room. Resident #5 was noted in the main dining room on 1/8/2024 at 12:15 p.m., receiving assistance with her meal from Staff U, CNA. Resident #5 had no behaviors, pain or discomfort during the entire meal service. At 1:30 p.m. Staff U was asked about Resident #5's calling out and screaming behaviors and she stated she was newer to the facility and was not totally aware why she screams out at times. She stated Resident #5 was usually easily redirected. Staff U was not aware Resident #5 had any type of past trauma or PTSD. A review of Resident #5's Care Plans, next review date of 2/28/2024, revealed a care plan problem area to include: Resident has a history of trauma that affect her negatively. On 1/9/2024 at 7:45 a.m. an interview was conducted with the NHA. The NHA stated they were changing/updating electronic systems and found the Resident Matrix was not totally accurate and would need to bring a corrected one for review. At 8:00 a.m. the NHA provided the corrected and updated Resident Matrix for review. The corrected Resident Matrix did not reflect Resident #5 as having PTSD/Trauma. The Resident Matrix reflected three other residents who have PTSD/Trauma. On 1/10/2024 at 8:15 a.m. an interview with Staff F, CNA was conducted. Staff F stated she was aware Resident #5 yells and screams at times and she requires light redirecting and she will usually stop with those behaviors. Staff F confirmed Resident #5 has vision impairment and required staff to assist her with all Activities of Daily Living (ADL) to include eating, dressing, bathing, and transferring. Staff F was not aware of Resident #5 having any type of past trauma or PTSD. Review of Resident #5's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed she had a Power of Attorney (POA) in place to make her medical and financial decisions. Review of the diagnosis sheet revealed diagnoses to include dementia, Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus Type II, legal blindness, fibromyalgia, anxiety, insomnia, history of falls, pain, and major depression. The record revealed no evidence of Resident #5 having a diagnosis of any past trauma or PTSD. Review of the Social Service Trauma care evaluation, dated 11/21/2023, revealed the following: (3) - Have you ever been in a major natural or technological disaster? yes. (4) - Have you ever had a life threatening illness such as cancer, a heart attack etc.? yes. (4a) - If the event happened, did you think your life was in danger or might be seriously injured? yes. (5) - Before age 18, were you ever physically punished or beaten by a parent, care taker, or teacher so that you were very frightened, or thought you would be injured with injuries? yes. (7) - Has anyone ever made you pressured into some type of unwanted sexual contact? yes. (12) - Can you identify triggers that may cause you re traumatization? - Does not want personal care from male caregiver unless female staff is also present and involve in care. Resident provided limited response, stated, you know all of that, nothing has changed, and was able to repeat her preference for female care givers. She was able to add that she will accept help from male staff if female staff are present. Review of the care plan, with next review date 2/28/2024, revealed the following: Focus: Resident has a history of trauma that affect her negatively related to: Raised in an orphanage, experienced abuse, she has difficulty discussing this experience (reviewed 11/21/2023). Interventions included: Approach with calm compassion when Resident #5 is anxious, frightened and confused. Speak clearly, offer reassurance that you want to help her to feel safe; use caution with physical touch if Resident #5 pulls away; Greet verbally on approach and state name and purpose d/t Resident #5's vision loss; Resident #5 requests no male care givers for tasks of bathing, toileting and dressing. Will accept assistance with repositioning from male staff if female staff are also present. Review of the Quarterly MDS, dated [DATE], revealed the following: Cognition/Brief Interview Mental Status or BIMS score - 13 of 15 which indicated the resident was able to speak related to her care and services; Vision = Highly impaired; Behaviors = None exhibited during assessment period timeframe; Active Diagnosis = PTSD section was checked no. Review of the Annual MDS, dated [DATE], revealed the following: Cognition/BIMS score - 9 of 15 which indicated the resident's cognition had declined since last assessment; Vision = Highly impaired; Behaviors = None exhibited during assessment period timeframe; Active Diagnosis = PTSD section was checked no. On 1/11/2024 at 10:40 a.m. an interview with the MDS Coordinators, Staff G and Staff H was conducted. They stated Resident #5 had long standing behaviors of screaming and yelling out but they were not aware of her having past trauma/PTSD. They confirmed after review of the current care plan, Resident #5 had a problem area to include behaviors related to trauma and PTSD. They confirmed the past three comprehensive MDS assessments did not reveal Resident #5 had a diagnosis of trauma/PTSD. They stated the resident was being seen by psychiatric services, but they were not sure if psychiatric services were assessing and treating for trauma/PTSD. They confirmed all three MDS assessments were not accurate and should have reflected Resident #5 having an active diagnosis of trauma/PTSD. An interview on 1/11/2024 at 11:40 a.m. was conducted with the Staff C, LPN, North Unit Manager. She stated Resident #5 did have routine behaviors of screaming and yelling, and was care planned for those behaviors. She stated she was aware Resident #5 had a history of trauma/PTSD and did not want male CNAs to care for her. She stated Resident #5 had a history of past experiences that were traumatizing and care from males brings back memories of that trauma. She stated behaviors and care planning related to trauma/PTSD have been in place since the resident's admission. She stated staff were aware not to have males care for Resident #5 but was unable to provide documentation related to education for staff working with residents who have had past trauma/PTSD. On 1/11/2024 at 2:15 p.m. an interview with the Director of Nursing was asked for an accuracy of assessment/accuracy of MDS assessment policy and procedure for review. She revealed the facility did not have a policy with that specific information. She did confirm it is expected that MDS assessments are completed timely and accurately.

Based on observations, interviews, and record review the facility failed to ensure respiratory equipment was stored in a sanitary manner for two residents (#14 and #69) of three residents sampled. Findings included: 1) On 1/08/2024 at 09:41 AM and 1/09/2024 at 01:11 PM, Resident #14's nebulizer machine was observed on the bedside table. The tubing and pipe were sitting on the machine. A concentrator machine was next to the bed. The tubing was wrapped around the concentrator with the nasal cannula draped over the top. Neither was in a bag, or dated. (Photographic Evidence Obtained) An interview was conducted with Staff A, Certified Nursing Assistant (CNA) on 1/08/2024 at 11:25 AM. Staff A, CNA stated the tubing and pipe should be dated and in a bag. Staff A, CNA confirmed the tubing and pipe for the nebulizer and the tubing and nasal cannula attached to the concentrator were not dated and not in bags. A review of Resident #14's Admission Record revealed an admitted [DATE]. A review of Resident #14's Medication Administration Record (MAR) for January 2024, revealed an order for: Change and date nebulizer tubing and external bag every Thursday. The MAR did not have any signatures indicating the task was completed as ordered. 2) On 1/08/2024 at 10:19 AM, Resident #69's nebulizer machine was observed laying at the foot of the bed. The tubing and mask were laying from the foot board of the bed to the floor. The tubing on the floor was dated 11/02/2023. (Photographic Evidence Obtained) An interview was conducted with Staff L, Licensed Practical Nurse (LPN) on 01/08/2024 at 11:15 AM. Staff L, LPN confirmed Resident #69 received nebulizer treatments on a regular basis. Staff L, LPN stated the nurses change the tubing to the nebulizers and oxygen machines weekly. Staff L, LPN stated the nurses just have to remember to complete this task as the order is on some residents Treatment Administration Records (TAR) and not on others. Staff L, LPN confirmed the nebulizer was at the foot of the bed and the tubing was on the floor, dated 11/02/2023. Staff L, LPN stated this tubing and mask should be in a bag and dated. Staff L, LPN removed the nebulizer machine and discarded the tubing and mask dated 11/02/2023. An interview was conducted with the Director of Nursing on 1/11/2024 at 12:00 PM. The DON stated, I expect the tubing to be changed, dated and bagged. Review of the facilities policy and procedures titled Equipment Change Schedule, revision date of 8/28/2017, revealed the following: Policy: An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer's recommendations and standards of practice. Procedure: Equipment/When Changed Aerosol Tubing and Aerosol Nebulizer once every seven (7) days.Nasal Cannula every seven (7) days or when contaminated Nebulizer Set-up Once, every seven (7) days along with equipment bag labeled with name, date, and room number.

Based on observations, interviews, and record review the facility failed to ensure coordination of services occurred between the facility and hospice for one resident (#68) of one resident sampled for hospice. Findings included: An interview was conducted with Resident #68's Resident Representative (RR) on 1/08/2024 at 2:11 PM. Resident #68's representative stated the resident was admitted to the facility under hospice care. The RR stated the family had implemented a Do Not Resuscitate Order (DNR) with hospice prior to admission and was told the family needed to come into the facility to sign another form. The RR tried to explain they were unable to come into the facility at this time as they had been quite ill. The RR stated they did not understand why the DNR was not able to be utilized in the facility as the hospice nurse had told them it was transferable to any institution. An interview was conducted with Staff L, Licensed Practical Nurse (LPN) on 1/08/2024 at 3:47 PM. Staff L, LPN stated Resident #68 was a Full Code and on hospice. An interview was conducted with the Social Service Director (SSD) on 1/08/2024 at 3:47 PM. The SSD stated Resident #68 came in with a bad DNR as the form had an electronic signature. The SSD continued to state the facility had taken the steps to have the resident deemed incompetent and to have the physician sign a new DNR. The facility was only waiting for the family to bring the form back into the facility, and the facility Had to follow 401 to the letter. The SSD confirmed the RR had informed the facility of the choice to enact a DNR for the resident. Review of the resident's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (AHCA Form 5000-3008), dated 11/28/2023, was signed by the Advanced Practice Registered Nurse (APRN). The form revealed the resident was a DNR. Review of the resident physician order for 12/1/2023 reveals resident #68 was a Full Code. Review of the Social Service Admission assessment dated [DATE] signed by the SSD showed the resident had a Durable Power of Attorney (DPOA). No other resident rights were indicated. The SSD documented, the resident has a POA for Finance and Health, would like DNR, explained need to have MD sign Lack of Capacity and Terminal Declaration to allow him to sign, forms out for physician to sign, request sent to Psychologist. Facility will integrate services with Hospice Team. No other social service notes were presented. Review of the Certificate of Terminal Illness, dated 10/04/2023, signed by the physician. The documentation revealed the physician's discussion with the DPOA regarding the DNR process. The DPOA elected DNR. A DNR was executed. An interview was conducted with the Director of Nursing (DON) on 1/08/2023 at 4:10 PM. The DON stated electronic signatures are acceptable. An interview was conducted with the SSD on 1/08/2023 at 4:30 PM. The SSD stated the family must come into the facility and sign the paperwork. The RR did request the resident to be a DNR but has not been able to make it into the facility. Review of the resident's medical record revealed a State of Florida Do Not Resuscitate Order, dated 10/04/2023, signed by the RR and an electronic signature of the physician. An interview was conducted with Staff L, LPN and Staff J, LPN on 1/09/2024 at 4:12 PM. Staff J, LPN and Staff L, LPN both stated, they did not receive anything from hospice after the initial communication binder, although they did not have a binder for Resident #68. They stated If they need to communicate with the hospice nurse, they call them. An interview was conducted on 1/10/2024 at 11:57 AM with Registered Nurse (RN) from Hospice who follows Resident #68 at the facility. The Hospice RN stated when visiting with Resident #68 communication occurs between the nurse on the cart at the facility. The Hospice RN stated, I don't have anything to do with the facility receiving paperwork. My manager drops off the care plan and other documentation on a routine basis to the facility. An interview was conducted on 1/10/2024 at 12:10 PM with the SSD. The SSD confirmed responsibility for the coordination of communication with the Hospice vendor. We have binders for the [Vendor] Hospice here in my office. The Hospice manager drops off the paperwork and places the documents in the binder. The hospice nurse who visits and the manager do not necessarily speak with me upon their visits. [Vendor] hospice has not given us paperwork since September 2023. [Vendor] hospice has been going through several personnel changes and informing of us of a rollout of a new system, but this has not happened. The SSD confirmed no additional documentation has been provided to the facility on Resident #68. Review of the [Vendor] hospice binder provided by the SSD revealed the most current signature sheet was dated September 2023. An interview was conducted on 1/10/2024 at 12:15 PM with the [Vendor] hospice RN Clinical Care Manager. The RN Clinical Care Manager confirmed responsibility for overseeing the coordination of communication with the facility. RN Clinical Care Manager stated a new system was implemented at the facility on 12/4/2023. The [Vendor] hospice liaison met with DON at the facility. The facility agreed to participate in the new data sharing of documentation on the new data platform as the facility is familiar with the platform already. On 12/8/2023, the RN Clinical Care Manager created the account and uploaded the [Vendor] hospice residents who are at the facility. This platform has the updated care plan, DNR, medications etc This is how we share data and ensure coordination of services. RN Clinical Care Manager confirmed no one has followed up with the facility after the rollout. An interview was conducted on 1/10/2024 at 12:17 PM with the SSD. The SSD stated no-one had confirmed the roll out of the platform had occurred. Review of the facility Inpatient Services Agreement between [Vendor] hospice and facility dated December 5, 2017 with an automatic renewal for successive one-year terms, unless terminated with written notice. Under section 2. Responsibilities of Facility page 5 of 18, sub section (e) Coordination of Care. Facility shall participate in any meetings, when requested, for the coordination, supervision and evaluation by Hospice of the provision of Inpatient Services. Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day. Page 7 of 18, sub section (iii) Coordination and Evaluation. Hospice shall retain responsibility for coordinating, evaluating and administering the hospice program, as well as ensuring the continuity of care of Hospice Patients, which shall include coordination of Inpatient Services. Methods used to evaluate the care may include: [a] periodic supervisory visits; [b] review of qualifications of personnel providing services; [c] review of documentation; [d] evaluation of of the response of Hospice Patient to the Plan of Care; [e] discussion with patient and patient's caregivers; . (e) Provision of Information. Hospice shall promote open and frequent communication with Facility and shall provide Facility with sufficient information to ensure that the provision of Inpatient Services under this Agreement is in accordance with the Hospice Patient's Plan of Care, assessments, treatment planning and care coordination.