Every finding on record at August Healthcare at Wilmington

Based on record review and staff and Responsible Party (RP) interviews and Physician and Physician Assistant interviews, the facility failed to accurately document the administration of insulin when two Medication Aides (Medication Aide #1 and Medication Aide #2) signed the medication administration record which indicated they administered physician ordered insulin instead of the assigned Nurses (Nurse #11 and Nurse #1) for 1 of 5 residents (Resident #5) reviewed for unnecessary medications; failed to accurately document the completion of weekly skin assessments (Nurse #5); and when Medication Aide #3 documented in the electronic medical record that she had completed the weekly skin assessment instead of the assigned Nurse (Unit Manager #2) for 1 of 1 resident (Resident #43) reviewed for bilateral leg wounds; and failed to accurately document consent and education of the RP in advance of the risks and benefits of taking psychotropic medications (medications that alter mood, thoughts, feelings or behavior) for 1 of 5 residents (Resident #1) reviewed for unnecessary medications. Findings included: Resident #5 was admitted to the facility on [DATE]. Diagnoses included diabetes. a). Review of the July Medication Administration Record (MAR) revealed on 07/04/26, Medication Aide (MA) #1's initials were recorded indicating the administration of 5 units of insulin before meals at 8:00 AM, 11:30 AM, and 4:30 PM. On 07/04/26 at 8:00 AM Resident #5's blood sugar was recorded as 212 milligrams/deciliter (mg/dL). MA #1 signed off with her initials in the MAR indicating the administration of 2 units of insulin per the sliding scale. On 07/04/26 at 11:30 AM Resident #5's blood sugar was recorded as 293 mg/dL. MA #1 signed off with her initials in the MAR indicating the administration of 4 units of insulin per the sliding scale. On 07/04/26 at 4:30 PM Resident #5's blood sugar was recorded as 204 mg/dL. MA #1 signed off with her initials in the MAR indicating the administration of 2 units of insulin per the sliding scale. Review of the July MAR revealed on 07/05/26, MA #1's initials were recorded indicating the administration of 5 units of insulin before meals at 8:00 AM, 11:30 AM, and 4:30 PM. On 07/05/26 at 8:00 AM Resident #5's blood sugar was recorded as 208 mg/dL. MA #1 signed off with her initials in the MAR indicating the administration of 2 units of insulin per the sliding scale. On 07/05/26 at 11:30 AM Resident #5's blood sugar was recorded as 219 mg/dL. MA #1 signed off with her initials in the MAR indicating the administration of 2 units of insulin per the sliding scale. On 07/05/26 at 4:30 PM Resident #5's blood sugar was recorded as 210 mg/dL. MA #1 signed off with her initials in the MAR indicating the administration of 2 units of insulin per the sliding scale. An interview was conducted with Medication Aide #1 on 07/17/26 at 11:15 AM. MA #1 stated that she did not actually administer the scheduled 5 units of insulin before each meal on 07/04/26 and 07/05/26 or the insulin given according to the sliding scale on 07/04/26 and 07/05/26, but she did sign off with her initials in the MAR instead of having Nurse #11 sign it off after Nurse #11 administered the insulin. MA #1 stated she should have signed out of the electronic record and Nurse #11 should have signed in under her name when she administered the scheduled 5 units of insulin and the sliding scale insulin so that her initials would have been recorded on the Medication Administration Record. Nurse #11 who worked on 07/04/26 and 07/05/26 was unavailable for an interview. b). Review of the July MAR revealed on 07/08/26, MA #2's initials were recorded indicating the administration of 5 units of insulin before meals at 8:00 AM, 11:30 AM, and 4:30 PM. On 07/08/26 at 4:30 PM Resident #5's blood sugar was recorded as 213 mg/dL. MA #2 signed off with her initials in the MAR indicating the administration of 2 units of insulin per the sliding scale. An interview was conducted with MA #2 on 07/16/26 at 11:52 AM. MA #2 stated she did not administer the scheduled 5 units of insulin or the insulin based on the sliding scale on 07/08/26. She stated Nurse #1 administered the insulin. MA #2 stated she should not have signed it off with her initials as it looked as though she administered the insulin. MA #2 stated she was told she could not leave any blank spots on the Medication Administration Record so she just signed the MAR off instead of signing out of the electronic record and having Nurse #1 sign into the electronic record so her initials would have been recorded after she administered the insulin. Attempted to interview Nurse #1 via text message on her phone on 07/16/26 at 1:31 PM and 07/17/26 at 11:11 AM. Nurse #1 received the text messages indicating she would call back, but she did not return the calls. An interview was conducted with the Director of Nursing (DON) on 07/17/26 at 11:42 AM. The DON stated the nurses should always be signing into the electronic record with their password anytime they are going to sign off a medication to accurately document with their initials the administration of a medication. The DON added the Medication Aides were leaving their screen accessed and signed the administration of the insulin for the nurses after the insulin was given. The DON stated the Medication Aides should not be signing off the administration of insulin and that was inaccurate documentation and looked as though they administered the insulin which was not within their scope of practice. The DON added that the assigned nurses needed to take the time to sign into the electronic record to ensure their initials would be recorded as given the medication. 2) Resident #43 was admitted to the facility on [DATE] with a most recent readmission on [DATE]. Record review showed Nurse #5 had documented on the Medication Administration Record that skin assessments had been completed for Resident #43 on 05/05/26, 05/19/26, and 07/07/26. However, there were no documented skin assessments on 05/05/26, 05/19/26, or 07/07/26 in the electronic medical record. An interview was conducted with Nurse #5 on 07/17/26 at 8:30 AM. Nurse #5 stated her assignment which included the 600 hall along with covering the medication aide on the 500 hall was a little much with too much to do and that could have been why she documented that she completed a weekly skin assessment on 05/05/26 and 05/19/26 for Resident #43 but had not completed the assessments. Nurse #5 recalled looking at Resident #43's leg wounds and thought she had completed the weekly skin assessment on 07/07/26 in the computer but forgot to save it. Nurse #5 stated she should have signed off in the Mar that she had completed the weekly skin assessments. Record review showed Medication Aide #3 documented in the electronic Medication Administration Record that she had completed the weekly skin assessment on 06/23/26 for Resident #43. An interview was conducted with Medication Aide #3 on 07/15/26 at 12:40 PM. Medication Aide #3 stated that it was beyond her scope of practice to complete a skin assessment and that she had signed it off by mistake. She explained the nurse who was covering her was supposed to complete the weekly skin assessment. Medication Aide #3 could not remember if she had alerted the nurse that the skin assessment was due. An interview was conducted with Unit Manager #2 on 07/15/26 at 3:45 PM. Unit Manager #2 stated she was covering Medication Aide #3 on 06/23/26 and working the 600 hall. She explained that unless Medication Aide #3 had notified her that the skin assessment was due, she would have no way of knowing. She concluded that Medication Aide #3 should not have documented that the assessment had been done and instead, Medication Aide #3 should have notified her that it was due. An interview was conducted with the Director of Nursing on 07/17/26 at 3:10 PM. The DON expected the nursing staff to accurately document on the MAR after a task was completed. She explained that Medication Aides were not qualified to complete assessments and should not have documented in the medical record that an assessment was done. 3. Review of Resident #1's electronic health record revealed physician orders for the following psychotropic medications: A physician order dated 2/23/26 for alprazolam 0.5 milligrams (mg) twice per day for anxiety. A physician order dated 3/13/26 for quetiapine (antipsychotic medication) 12.5 mg every evening at 5:00 PM for dementia with behaviors. Review of a psychotropic medication informed consent form dated 5/26/26 completed by Nurse #7 indicated that the staff present at the oral discussion of medications was Nurse #7. The form indicated that Resident #1's RP gave verbal consent via telephone and was verbally informed of the information in the consent on 5/26/26. An interview was conducted with Nurse #7 on 7/15/26 at 2:42 PM. Nurse #7 stated that she had not completed the psychotropic medication informed consent form dated 5/26/26 and had not provided educational information regarding psychotropic medication to Resident #1's RP. Nurse #7 revealed that she was not aware of the requirement to complete education and consent with the resident or Responsible Party prior to the initial administration of a psychotropic medication. An interview conducted via phone with Resident #1's RP on 7/17/26 at 10:48 AM revealed that the nursing staff had not discussed the psychotropic medications alprazolam and quetiapine with her. Resident #1's Responsible Party indicated that she recently asked one of the nurses, she did not recall which nurse, about Resident #1's medications and was informed that the resident was receiving alprazolam and quetiapine. The RP did not recall giving verbal consent to Nurse #7 via telephone nor did she recall being verbally informed of the information in the consent form. An interview conducted with the Administrator on 7/17/26 at 4:50 PM revealed that it was her expectation that consent for psychotropic medications was obtained prior to the initial administration of the medication and that the consent would be documented accurately in the medical record.

Based on record review, and staff, Physician Assistant (PA) and Physician interviews, the facility failed to have a system in place to inform and provide written information to the residents/representatives pertaining to their right to accept or refuse medical/surgical treatment and to formulate an advanced directive (a form that indicates a resident's wish and what action to take for their health if the residents were no longer able to make their own decision) for 15 of 22 sampled residents (Resident #1, #21, #71, #80, #105, #126, #5, #11 #20, #55, #14, #17, #7, #10, and #43.) Findings included: A review of the facility Advanced Directives Policy dated 11/02/22 indicated that: Code status (an intervention if a resident's heart stops beating) shall be discussed with every resident or the resident's representative upon admission and readmission to the facility. The policy further stated that the nursing staff shall review existing advanced directives, DNR (do not resuscitate - no cardiopulmonary resuscitation if heart stops beating) orders, or other legally recognized documents. The admitting nurse shall notify the attending practitioner of the resident's code status. Advanced care planning discussions shall occur upon admission and re-admission, following a significant change in condition, following hospitalization, and upon request of the resident or resident representative. The policy indicated that the medical record shall include documentation of advanced care planning discussions. a. Resident #126 was admitted on [DATE]. A physician order dated 1/12/26 indicated Resident #126 was a Full Code (if a resident heart stopped beating, resuscitation would be done in an attempt to save the life). Resident #126's admission Minimum Data Set (MDS) assessment dated [DATE] indicated resident was cognitively intact. Resident #126's Full Code order was discontinued on 2/26/26. Review of Resident #126's electronic health record revealed that the resident was transferred to the emergency department on 2/26/26. A hospital Discharge summary dated [DATE] indicated that Resident #126's code status was Do Not Resuscitate (DNR). A physician order dated 2/27/26 indicated Resident #126 was a Do Not Resuscitate status. There was no indication in Resident # 126's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. b. Resident #21 was admitted on [DATE]. A physician order dated 2/14/25 indicated Resident #21 was a DNR status. Resident #21's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a severe cognitive impairment. There was no indication in Resident # 126's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. c. Resident #1 was admitted on [DATE]. Review of Resident #1's physician orders revealed an order dated 12/11/25 which indicated the resident was a Full Code. Resident #1's quarterly MDS dated [DATE] indicated the resident had severe cognitive impairment. A Social Service progress note dated 5/29/26 indicated advanced directives were Do Not Resuscitate. An interview was conducted with Resident #1's Responsible Party (RP) on 7/16/26 at 9:50 AM. The RP stated that the facility did not discuss or provide information concerning formulating an advanced directive for the resident. There was no indication in Resident # 1's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. d. Resident #71 was admitted on [DATE]. A physician order dated 7/5/24 indicated that Resident #71 was listed as DNR status. Resident #71's quarterly MDS dated [DATE] indicated the resident had a cognitive impairment. There was no indication in Resident # 71's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. e. Resident #80 was admitted on [DATE]. A physician order dated 7/6/26 indicated that Resident #80 was listed as DNR status. Resident #80 did not have an MDS assessment completed. There was no indication in Resident # 80's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. f. Resident #105 was admitted on [DATE]. A physician order dated 4/11/26 indicated that Resident #105 was listed as DNR status. Resident #105's admission MDS assessment dated [DATE] indicated that resident had a cognitive impairment. There was no indication in Resident # 105's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. g. Resident #5 was admitted to the facility on [DATE]. A physician order dated 08/28/25 indicated Resident #5 was a full code. The MDS quarterly assessment dated [DATE] revealed Resident #5 was cognitively intact. There was no indication in Resident #5's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. h. Resident #11 was admitted to the facility on [DATE]. A physician order dated 07/01/24 indicated Resident #11's code status changed from a Full Code to Do Not Resuscitate. The MDS quarterly assessment dated [DATE] revealed Resident #11 was moderately cognitively impaired. There was no indication in Resident #11's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. i. Resident #20 was admitted to the facility on [DATE]. A physician order dated 01/09/26 indicated Resident #20 was a Full Code. The MDS quarterly assessment dated [DATE] revealed Resident #20 was moderately cognitively impaired. There was no indication in Resident #20's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. j. Resident #55 was admitted to the facility on [DATE]. A physician order dated 08/22/25 indicated Resident #55 was a Full Code. The MDS quarterly assessment dated [DATE] revealed Resident #55 was cognitively intact. There was no indication in Resident #55's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. k. Resident #14 was admitted to the facility on [DATE]. A physician order dated 12/19/25 indicated Resident #14 was a DNR (Do Not Resuscitate). The quarterly MDS assessment dated [DATE] revealed Resident #14 was severely cognitively impaired. There was no indication in Resident #14's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. l. Resident #17 was admitted to the facility on [DATE]. A physician order dated 5/22/26 indicated Resident #17 was a full code. The admission MDS assessment 5/27/26 revealed Resident #17 was moderately cognitively impaired. There was no indication in Resident #17's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and or/formulate an advance directive. m. Resident #7 was admitted to the facility on [DATE]. A physician order dated 12/29/25 indicated Resident #7 was a DNR (Do Not Resuscitate). The MDS significant change in status assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired. There was no indication in Resident #7's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. n. Resident #10 was admitted to the facility on [DATE]. A physician order dated 03/05/26 indicated Resident #10 was a DNR. The MDS quarterly assessment dated [DATE] revealed Resident #10 had intact cognition. There was no indication in Resident #10's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. o. Resident #84 was admitted to the facility on [DATE]. A physician order dated 03/06/26 indicated Resident #84 was a full code. The MDS quarterly assessment dated [DATE] revealed Resident #84 was cognitively intact. There was no indication in Resident #84's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. p. Resident #43 was admitted to the facility on [DATE]. A physician order dated 07/31/24 indicated Resident #43 was a DNR. The MDS annual assessment dated [DATE] revealed Resident #43 had intact cognition. There was no indication in Resident #43's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. An interview with the Director of Nursing (DON) was conducted on 07/15/26 at 9:15 AM. The DON stated that the facility relied on the medical documentation provided by the hospital to determine a resident's code status. She explained that the hospital's advanced directive documentation was referred to as the Golden Rod form—a goldenrod colored document indicating that, in the event of cardiac and/or pulmonary arrest, cardiopulmonary resuscitation should not be initiated. The DON stated that the Golden Rod form was used by the facility to identify residents with a Do Not Resuscitate (DNR) status and was placed in the resident's medical record upon admission. The DON further stated that if a Golden Rod form was not sent with the admission paperwork, the facility assumed the resident's code status to be Full Code. An interview was conducted with the Physician on 07/15/26 at 12:45 PM. The Physician stated that he referred to the advanced directives from the hospital documentation and wrote and signed orders for the residents' code status as needed. The Physician stated that sometimes he would discuss advanced directives or goals of care with a resident or responsible party as needed. The Physician stated that sometimes the Social Worker informed him of the advanced directives and if orders were needed. An interview was conducted with Nurse #8 on 07/15/26 at 3:50 PM. Nurse #8 indicated that upon admission to the facility, the staff looked for a Golden Rod form and if the resident had one, this meant the resident's code status was Do Not Resuscitate. If the resident did not have a Golden Rod form, it meant the resident was a Full Code. Nurse #8 indicated that she was not sure who discussed advanced directives with a resident or the resident's representative but thought it was either the Social Worker, Physician Assistant or the Physician who discussed advanced directives. Nurse #8 stated the Golden Rod form would get placed in a book at the nurse's station and whenever the resident was discharged from the facility, the Golden Rod form would go along with them. An interview was conducted with the Physician Assistant (PA) on 07/16/26 at 10:45 AM. The PA stated she referred to the advanced directive order that was documented on the hospital record. The PA explained that if the resident was admitted with a Golden Rod form from the hospital, she assumed the resident wished to continue to be a DNR and she wrote the order in the electronic record for DNR status. The PA indicated that she considered the Golden Rod the resident's advanced directives and was unaware that further discussion or written information should be provided to the resident or representative. An interview with the Social Worker on 07/16/26 at 12:57 PM revealed that usually upon admission the residents were admitted with an advanced directive and he would go by what the hospital had written or the Golden Rod form. He stated if the resident was admitted with a Golden Rod form, he would upload the form on the computer. The Social Worker stated the Golden Rod form indicated the resident was a DNR and that form would go with the resident whenever they would go to the hospital or when they were discharged . The Social Worker stated if there was no documentation on the hospital record indicating what the code status of the resident was upon admission, then the Physician or Physician Assistant would speak with the resident with their initial visit. The Social Worker stated that he was unaware of any written information provided to the residents/representatives pertaining to their right to accept or refuse medical/surgical treatment and to formulate an advanced directive. An interview was conducted with the Administrator on 07/17/26 at 5:30 PM. The Administrator stated that the system failure was a result of the changes in staff with the Social Worker being new to the position and a lack of education regarding the requirement to provide written information to the residents/representatives pertaining to their right to accept or refuse medical/surgical treatment and to formulate an advanced directive. The Administrator indicated that it was important for advanced directives to be discussed, and information provided and not assumed that when a Golden Rod was received on admission it replaced the need for the formulation of an advanced directive.

Based on record review, staff and Physician Assistant (PA) interviews, the facility failed to follow up on a urine analysis (U/A) that was ordered for 1 of 1 resident (Resident #124) reviewed for laboratory services. Findings included: Resident #124 was admitted to the facility on [DATE]. Diagnoses included altered mental status. The Minimum Data Set 5 day assessment dated [DATE] revealed resident was moderately cognitively impaired, demonstrated no behaviors, and was frequently incontinent of bladder. A physician order entered by the Physician Assistant was written on 12/22/25 for nursing to collect urine via in and out catheter (a process to obtain urine without inserting an indwelling urinary catheter) one time only for 2 days; laboratory company to transport to laboratory for completion of urine analysis (U/A), and culture and sensitivity (C & S). Review of a progress note documented as late entry by the Physician Assistant (PA) on 12/23/25 revealed, in part, Resident's responsible party (RP) was asking about a possible hospice consult on 12/22/25. The progress note indicated the PA and RP discussed checking for a urinary tract infection (UTI). The progress note indicated the U/A was pending. A nursing progress note written by the Unit Manager #2 on 12/23/25 at 6:04 PM revealed 2 attempts were made to obtain urine; 1st attempt, resident was in day room and refused to be returned to room for short period to obtain urine; 2nd attempt, resident sitting in Geri chair in another resident's room visiting and refused to return to room for this nurse to obtain urine and return her back to her visitor afterward. An interview with Unit Manager #2 on 07/16/26 at 3:30 PM revealed she really did not remember Resident #124 even after she reviewed the progress note she had written. Unit Manager #2 stated if the order was for two days then the nurses would have had the full two days to obtain the U/A and report to the PA whether we were able to obtain it. Unit Manager #2 stated since she was not able to obtain the U/A on her shift; the task would then get passed on to the next shift. She stated usually if she needed to notify a provider about anything she would text, call or put a note in the provider's notification book. She stated she would not have put a note in the book on 12/23/25 since the order was put in for 2 days. A nursing progress note written by Nurse #3 on 12/24/25 at 5:33 AM revealed Resident refused in and out catheter times 2 attempts to obtain urine sample. A phone interview was conducted with Nurse #3 on 07/17/26 at 5:17 AM. Nurse #3 revealed she could not recall Resident #124 or trying to obtain a U/A but if her progress notes indicated she could not obtain it, then she did not obtain the U/A and she would have passed the task on the next shift nurse. Nurse #3 stated she could not recall telling Nurse #9 (who she reported off too) the morning of 12/24/25 that she could not get the U/A. Nurse #9 added there have been a lot of problems with the lab company in getting results back to the facility. Nurse #9 continued and stated they lose samples, tell the facility they never received the sample, or the lab staff do not call the facility to let staff know what the results were. Nurse #9 stated she did not know who was responsible for following up on the labs that were sent because she worked night shift. Nurse #9 stated she would have left a note for the PA or MD if she could not obtain the U/A and would have passed it on in report after the two days per the order. Review of the Medication Administration Record (MAR) revealed the urine analysis was signed of as being obtained by Nurse #9 at 8:31 AM on 12/24/25. Review of the laboratory services log book kept at the nurse's station for 12/24/25 revealed there was no documentation to support that a U/A had been obtained and sent to the lab on 12/24/25 for Resident #124. Review of the electronic medication record revealed there were no results for the UA that was drawn on 12/24/25. A phone interview with Nurse #9 on 07/17/26 at 10:12 AM. Nurse #9 stated he recalled Resident #124 and the order for the U/A. He stated Resident #124 did not want a male nurse to use an in an out catheter on her. He stated he asked a female nurse who was working near his hall (could not remember her name) do get the U/A for him. Nurse #9 stated he was present in the room when the nurse obtained the U/A just in case she needed any assistance but kept his distance. He stated the female nurse took the sample and said she would complete the paperwork and send it to the lab. Review of the schedule for 12/24/25 revealed Nurse #12 was assigned to the hall adjacent to the hall Resident #124 resided on. An interview was conducted with Nurse #12 (a female nurse who worked beside Resident #124's hall) on 07/17/26 at 2:57 PM. Nurse #12 stated she remembered Resident #124 but she did not collect a urine sample from her at the request of Nurse #9. Nurse #12 had no knowledge of Resident #124 needing a U/A sample. Nurse #12 stated if she had obtained the urine she would have labeled the container with the resident name and room number, date and time, filled out a lab reconciliation form indicating the urine was for a urine analysis and culture and sensitivity and refrigerated the urine until the lab company picked it up. Nurse #12 stated she would also document the information in the lab book located at the nurse's station the date and time she obtained the specimen along with resident's name and room number. An interview with the Physician Assistant on 07/16/26 at 10:45 AM revealed she reported she recalled having a discussion with the RP regarding getting a U/A to rule out a UTI due to her increased confusion. The PA stated the RP inquired about possibly admitting Resident #124 into hospice but it was decided by the RP that she would wait until the U/A was done first due to her confusion. The PA stated she put the order to obtain a U/A on 12/22/25 for 2 days to allow the staff time to get the urine. The PA stated she had followed up with the nursing staff (did not know which nurse or which day) about the result of the U/A but no one seemed to know if was even obtained or if there was a result of the U/A. The PA stated she would have wanted to know whether the U/A was obtained and the result of it because she would have called the RP to let her either know the result or to see if the RP would want the facility to continue trying to obtain the U/A; or if the RP wanted Resident #124 to be sent to the hospital to obtain. The PA added that nursing staff would usually text her, call her or leave a note in the physician notification book. The PA stated she reviewed her physician notification book and did not see any documentation about staff not being able to obtain the U/A as ordered on 12/22/24, but the nurses had two days to obtain it and the MAR looked as though it was obtained. The PA stated she was not able to see the result of the U/A in the electronic medical record and would have expected a result within 72 hours. The PA confirmed there seemed to be some ongoing issues with the present lab company and she has had to reorder labs in the past because of missing labs. The PA added that when she followed back up with Resident #124 on 12/23/25 she seemed to be less confused and mental status was improved. She was seen up in her Geri chair and she was much more alert and was eating lunch. She answered yes and no questions but also offered additional conversation and at the time she did not feel she needed to order another U/A. An interview was conducted with the Director of Nursing (DON) on 07/16/26 at 1:00 PM. The DON confirmed the medication administration record indicated the U/A was obtained at 8:31 AM on 12/24/25 but she could not find any results for the U/A for Resident #124 anywhere in the electronic record or in the lab services log for 12/24/25. The DON stated the lab company the facility was using was having trouble with the company stating they never received the labs and the facility was having to redraw the labs because the paperwork was filled out incorrectly. She stated the current laboratory service they used came to the facility Monday thru Friday and for STAT (immediate) lab results, the nursing staff would send the sample to the nearby Hospital. The DON added she had noticed there were problems where the facility nursing staff were not following up with pending lab results and was trying to implement a system to ensure that they were getting followed up on. The DON stated she was not sure why the lab results were not getting follow up on but she was going to assign one person such as a supervisor or one of the Unit Managers to follow up on any pending labs. The DON stated she also felt it was a problem with the lab company and the hospital losing the specimens and stated she instructed the staff that whenever they dropped off a specimen at the hospital to make sure they got the name of the person in the lab that they left the specimen with.

Based on observations and Responsible Party and staff interviews, the facility failed to obtain informed consent for a contactless monitoring system installed in resident rooms above the bed to monitor resident information for 2 of 9 residents reviewed for privacy (Resident #21 and Resident #1).Findings included: Review of an informed consent form indicated that the facility contracted with a private communication technology-based company to provide contactless remote monitoring. The form indicated that by signing the document the resident/Responsible Party consented to allowing the company to provide monthly services such physiological monitoring (healthcare teams tracking vital signs including heart rate and respirations remotely) and communication of health information with other health care providers. a. Resident #21 was admitted to the facility on [DATE] with diagnosis which included dementia. Resident #21's admission Minimum Data Set (MDS) dated [DATE] indicated that the resident was severely cognitively impaired. Resident #21's quarterly MDS dated [DATE] indicated that the resident was severely cognitively impaired. The facility provided an informed consent form which indicated in part: the facility has contracted with a private communication technology-based company to provide contactless remote monitoring. These services provide clinical information and insights. By signing this consent, you allow the company to provide chronic care management. The form was dated 9/23/25 and had a check in a box which indicated I have read and understood the information and consent to the above. The form included a typed entry which stated that Resident #21 verbally consented to the monitoring service. An observation of Resident #21's room on 7/15/26 at 3:10 PM indicated a small white device was mounted on the wall above the resident's bed. An interview with Resident #21 on 7/15/26 at 3:15 PM revealed that the resident was not oriented to time or place and was unaware of the device above the bed or the purpose of the device. An interview with the Clinical Services Director on 7/16/26 at 11:50 AM indicated that Resident #21's room was one of nine rooms in the facility that were being monitored and that a representative from the company obtained the consent form from Resident #21. The Clinical Services Director stated that she spoke with the representative from the company via phone on 7/16/26 and obtained clarification that the representative reviewed Resident #21's admission Minimum Data Set (MDS) assessment that indicated that the resident was moderately cognitively impaired. The Clinical Services Director stated that the representative should not have obtained a consent form from a cognitively impaired resident. b. Resident #1 was admitted on [DATE]. Resident #1's medical diagnosis included severe dementia with behavioral disturbance. A review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] indicated that the resident was severely cognitively impaired. The facility provided an informed consent form which indicated in part: the facility has contracted with a private communication technology-based company to provide contactless remote monitoring. These services provide clinical information and insights. By signing this consent, you allow the company to provide chronic care management. The form was dated 2/20/26 and had a check in a box which indicated I have read and understood the information and consent to the above. The form included a typed entry which stated that Resident #1 verbally consented to the monitoring service. An observation of Resident #1's room on 7/15/26 at 3:00 PM indicated a small white device was mounted on the wall above the resident's bed. An interview with Resident #1 on 7/15/26 at 3:05 PM revealed that the resident was not oriented to time or place and was unaware of the device above the bed or the purpose of the device. An interview was conducted with Resident #1's Responsible Party on 7/16/26 at 9:50 AM. The Responsible Party indicated that she was unaware that a monitoring device was being used in Resident #1's room. Resident #1's RP stated that the facility had not contacted her about the monitoring device. She stated that she had noticed the device in the room and wondered what it was. During an interview with the Clinical Services Director on 7/16/26 at 11:50 AM she indicated that only some resident rooms in the facility were being monitored. The Clinical Services Director confirmed that Resident #1's room was one of the nine rooms in the facility that were being monitored. She stated that a representative from the company obtained the consent form from the resident. The Clinical Services Director stated that she spoke with the representative from the company via phone on 7/16/26 and obtained clarification that the representative reviewed Resident #1's admission Minimum Data Set (MDS) assessment that indicated that the resident was cognitively intact. The Clinical Services Director stated that the representative should not have obtained a consent form from a cognitively impaired resident. The Clinical Services Director stated that the representative was unaware that Resident #1 had a change in cognition with quarterly MDS assessment dated [DATE] which indicated severely cognitively impaired. The Clinical Services Director indicated that the process for the use of the monitoring device was that the devices were installed in all the resident rooms in the facility. The devices were mounted above the beds in the resident rooms, but monitoring was turned off until the consent was obtained. The Clinical Services Director stated that the facility contacted the representative from the company and then the representative came to the facility to obtain the consent. An interview conducted with the Administrator on 7/17/26 at 4:50 PM revealed that the facility must obtain informed consent prior to the use of the monitoring device being initiated. The Administrator stated that consent should be obtained from the Responsible Party if the resident was cognitively impaired. The Administrator stated that this device was confusing, and she acknowledged that she did not know much about it. The Administrator stated that the facility did not have a process in place to educate and inform the family members and residents about the monitoring device.

Based on observations, record review, and staff interviews, the facility failed to implement their infection control policy and procedures when 1) a nurse (the Staff Development Coordinator) was observed not wearing a gown while administering medications through Resident #17's feeding tube; and 2) the Treatment Nurse was observed cleaning and dressing wounds at two different wound sites without washing her hands and wearing the same gloves during Resident #43's bilateral leg dressing changes. This deficient practice occurred for 2 of 5 staff members observed for infection control practices. Findings included: The Infection Control Policy dated 1/9/23 revealed Enhanced Barrier Precautions referred to an infection control intervention designed to reduce the transmission of multi-drug-resistant organisms by requiring the use of gown and gloves during high contact resident care activities. During an observation of administration of medications on 7/15/26 at 9:20 AM Resident #17 was lying in bed with the head of the bed up. There was an Enhanced Barrier Precautions sign observed on the door and personal protective equipment (PPE) was observed on the closed door of another resident 2 doors down on the same side of the hallway. The Staff Development Coordinator (SDC) was observed washing her hands and applying gloves and she did not apply a gown. The SDC then stopped Resident #17's tube feeding machine and disconnected the feeding tube from the administration set and administered the medications through the feeding tube without wearing a gown. An interview with the SDC was conducted on 7/15/26 at 9:52 AM. The SDC stated that she should have been wearing a gown while administering medications through Resident #17's feeding tube. She indicated she was just nervous and forgot to put on the gown. The SDC explained that she was the person responsible for identifying and implementing EBP for residents that required them. She stated staff were provided education during orientation and through their online healthcare education site. An interview with the Director of Nursing (DON) was completed on 7/17/26 at 9:43 AM. The DON stated that she expected the nursing staff to follow EBP when providing high contact care to residents. She explained that the SDC should have been wearing a gown when administering medications through Resident #17's feeding tube. 2. Review of the facility Handwashing/Hand Hygiene infection control policy last updated on 01/09/23 revealed in part to use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before handling clean or soiled dressings, gauze pads, etc.; after contact with blood or bodily fluids; and after handling used dressings, contaminated equipment, etc. Wound care performed by the Treatment Nurse on 07/16/26 at 9:30 AM was observed. The Treatment Nurse put on a gown, washed her hands and put on gloves. The Treatment Nurse removed the old dressing from the right lower leg wounds and cleansed the wound area with a 4 x 4 gauze soaked in normal saline. The cluster of open vascular wounds on Resident #43's front right leg were open and weeping with a yellow drainage. The Treatment Nurse did not change her gloves or wash her hands and proceeded to remove the old dressing from the left lower leg and cleanse the wound area with a 4 x 4 gauze soaked in normal saline. The cluster of open vascular wounds on the left lower leg were open and weeping a yellow drainage. The Treatment Nurse discarded her gloves, washed her hands, and put on a new pair of gloves. The Treatment Nurse then applied the calcium alginate to the wounds on the right front lower leg and covered the wounds with a border gauze dressing and then applied the calcium alginate to the wounds on the left lower leg and covered the wounds with a border gauze dressing without changing her gloves or washing her hands. In an interview with the Treatment Nurse on 07/16/26 at 9:45 AM she stated she had not realized that she had not changed her gloves or washed her hands as she cleansed both wounds and applied the treatments to Resident #43's bilateral leg wounds. The Treatment Nurse explained that she knew to wash her hands and put on new gloves between wounds when treating multiple wounds. She stated she did not know why she had not treated the right leg wounds completely before treating the left leg wounds. In an interview with the Director of Nursing on 07/17/26 at 3:10 PM she stated that she was also the Infection Preventionist for the facility. She stated she expected one wound to be treated at a time and for the Treatment Nurse to wash her hands and change her gloves between wounds when treating multiple wounds. The Director of Nursing stated it was an infection control issue.

Based on observations, record review, staff and Physician Assistant (PA) interviews, the facility failed to follow the physician order for the administration of insulin. Nurse #1 was observed obtaining a blood sugar (a blood sample indicating the concentration of sugar in the blood) for a resident after the resident's meal and then administered scheduled insulin and sliding scale (a scale used to measure amount of insulin to be given based on residents' blood sugar results) insulin based on the blood sugar result for 1 of 5 residents (Resident #5) observed for Unnecessary Medications. Findings included: Resident #5 was admitted to the facility on [DATE]. Diagnoses included diabetes. A physician order written on 10/02/25 for Novolog Flex pen 100 units/milliliter solution pen injector. Inject 5 units subcutaneous (applied under the skin) before meals for diabetes. A physician order written on 10/02/25 for NovoLog Flex pen 100 units/milliliter solution pen injector. Inject per sliding scale. The sliding scale for amount of insulin to administer was as follows: If the blood sugar was 0 - 200 = 0 units of insulin 201 - 250 = 2 units of insulin 251 - 300 = 4 units of insulin 301 - 350 = 5 units of insulin 351 - 400 = 8 units of insulin 401 and over give 10 units of insulin and notify physician. Give insulin according to sliding scale subcutaneously before meals for Diabetes Mellites. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #5 was cognitively intact and received 7 injections of insulin medications during this assessment. An interview with Resident #5 on 07/13/26 at 8:30 AM was conducted. Resident #5 reported he had finished all of his breakfast. An observation of Resident #5's food tray on 07/13//26 at 8:30 AM revealed 100% of his meal tray had been consumed. An observation of Nurse #1 on 07/13/26 at 9:08 AM revealed Nurse #1 was taking Resident #5's blood sugar and reported to Resident #5 that his blood sugar reading was 372. Nurse #1 returned with an insulin pen and told Resident #5 he was getting a total of 10 units of insulin and administered the insulin to Resident #5. An interview with Nurse #1 on 07/13/26 at 9:10 AM revealed she knew the physician order was to administer the scheduled insulin and check his blood sugar for the sliding scale insulin before Resident #5 ate his meal, but she had so many blood sugars to check on her hall that she was not able to administer the insulin and do the blood sugars before the breakfast trays came out. Nurse #1 stated she, more often than not, would have to administer the insulin and check his blood sugar after Resident #5 ate because she did not have enough time in the morning to get them before the breakfast trays were delivered between 8:15 AM and 8:30 AM. Nurse #1 stated she knew it was wrong, but that was how she had to do it due to time. An interview was conducted with the Physician Assistant (PA) on 07/16/26 at 10:45 AM. The PA stated she would have expected Nurse #1 to obtain the blood sugar before Resident #5 ate and administer the required / ordered dose of insulin before Resident #5 ate as the order was written. The PA stated getting a blood sugar reading and giving the insulin after his meal could have caused Resident #5 to potentially require more insulin than he needed because the food would raise the blood sugar reading. An interview was conducted with the Director of Nursing (DON) on 07/17/26 at 4:29 PM. The DON stated the nurses should be prioritizing their medication administration during their medication pass for all the residents that have orders to obtain a blood sugar before meals or to administer insulin before meals. The DON stated Nurse #1 should not have checked Resident #5's blood sugar after he ate and then give the ordered insulin. She added, Nurse #1 should have followed the physician order as written.

Based on record review, and staff and Physician Assistant (PA) interviews, the facility failed to ensure a resident's (Resident #14) medication regime was free from unnecessary medications for administering an as needed antianxiety medication without a discontinue date. This deficient practice occurred for 1 of 5 residents reviewed for unnecessary medications.Findings included:Resident #14 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease with late onset and anxiety.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was severely cognitively impaired. The MDS documented Resident #14 had inattention and disorganized thinking present and fluctuated. The resident was documented as receiving antianxiety medication.Physician order dated 6/1/26 for lorazepam oral concentrate 2 milligrams (mg) per milliliter (ml). Give 0.5 mg by mouth every 6 hours as needed for anxiety. There was no discontinue date.The June 2026 Medication Administration Record (MAR) for Resident #14 revealed she was administered lorazepam 0.5 mg by mouth every 6 hours as needed for anxiety on:6/1/26 at 12:00 PM and it was effective6/2/26 at 6:59 AM and it was effective6/2/26 at 2:42 PM and it was effective6/19/26 at 3:05 PM and it was effective6/29/26 at 9:07 AM and it was effectiveResident #14's active care plan revised on 7/1/26 revealed a problem with mood related to dementia and anxiety. The goal for Resident #14 was for her to have a happier calmer appearance with no signs and symptoms of sadness. The interventions included administering medications as ordered and monitoring for effectiveness.During an interview with the Physician Assistant (PA) on 7/16/26 at 11:20 AM, the PA stated she had put a 14 day stop date on a previous order for lorazepam for Resident #14 and when she wrote the order on 6/1/26 she had written 14 ml for the amount to be dispensed but forgot to write a stop date. She indicated it was just an error on her part, and she was aware that as needed psychotropic medications needed a stop date. An interview with the Director of Nursing (DON) was conducted in the presence of the Administrator on 7/17/26 at 9:40 AM. The DON stated the PA had explained to her what happened when she ordered Resident #14's as needed lorazepam. The DON confirmed the PA had ordered 14 ml of lorazepam to be dispensed, but the PA had not written a stop date. She stated she expected all as needed psychotropic medications to have the correct stop date. The Administrator stated she was aware that psychotropic medications were supposed to have a stop date, and the PA had just forgotten to write one for Resident #14's as needed lorazepam.

Based on record review, observation, staff interviews, Physician Assistant interview and Physician interview, the facility failed to provide wound care to a resident with bilateral lower extremity leg wounds that were open and weeping, for 1 of 1 resident reviewed for vascular wound care, Resident #43.Findings included:Resident #43 was admitted to the facility on [DATE] with a most recent readmission on [DATE]. Diagnoses included, in part: Chronic peripheral venous insufficiency, varicose veins of unspecified lower extremity with ulcer of unspecified site, and Type 2 Diabetes Mellitus with diabetic polyneuropathy.Review of a physician order dated 04/08/25 revealed the following order: Weekly skin observation every Tuesday 11-7, document assessment every night shift every Tuesday for skin monitoring complete head-to-toe skin check and document under assessment tab.Review of an annual Minimum Data Set assessment dated [DATE] revealed Resident #43 had intact cognition. He did not have any wounds during the assessment look back period.Review of the care plan for Resident #43 initiated 04/25/23 and revised on 04/20/26 revealed the following focus areas: Peripheral Vascular disease and potential impairment to skin integrity related to medication use, Diabetes Mellitus, obesity, incontinence, and decreased mobility. Goals included that Resident #43 would remain free of complications related to peripheral vascular disease and maintain or develop clean and intact skin by the review date. Interventions included to educate the resident of causative factors and measures to prevent skin injury, encourage good nutrition and hydration, follow facility protocols for treatment of injury, use caution during transfers, weekly skin checks by the nurse to monitor the extremities for signs of injury, infection or ulcers, and monitor/document/report any skin problems related to peripheral vascular disease.Weekly skin assessments for the past three (3) months were reviewed. A skin assessment completed on 05/27/26 documented pre-existing redness and edema to both legs more than usual with no open areas. No other skin assessments were completed in May 2026. Skin assessments completed on 06/02/26 and 06/09/26 documented bilateral edema with multiple areas of skin discoloration and no open areas. No other skin assessments were completed in June 2026.A weekly skin assessment was completed on 07/02/26 by Nurse #10. She documented that Resident #43 had weeping, turgid, open, and blistered skin over the front of the right lower leg and weeping, turgid, open and blistered skin over the front of the left lower leg.An interview was conducted with Nurse #10 on 07/15/26 at 11:30 AM. Nurse #10 stated that she had completed a skin assessment on Resident #43 on 07/02/26. She stated she did not initiate any treatments or notify anyone of her assessment findings. Nurse #10 explained she had not notified the oncoming shift, nor had she notified the physician or the nurse practitioner that Resident #43 had untreated bilateral open, weeping wounds on both lower legs. Nurse #10 stated that she normally would initiate a treatment and notify the physician if she assessed an untreated open wound but in this instance she had not notified any other staff members of the wounds or initiate a treatment.Record review showed Nurse #5 had documented on the Medication Administration Record that a skin assessment was completed on Resident #43 on 07/07/26. There was no documented skin assessment on 07/07/26.An interview was conducted with Nurse #5 on 07/17/26 at 8:30 AM. She stated she originally thought maybe she had completed the skin assessment in the computer but forgot to save it. She explained she had assessed Resident #43's leg wounds and recalled he had yellow craters on both lower legs. Nurse #5 stated she asked the resident why his legs were not covered and he had told her that his legs were supposed to be covered but no one was doing the treatment. Nurse #5 explained that because she had not seen any oozing from the wounds that she had not initiated a treatment or notified any other staff of the open areas. She concluded her assignment that included the 600 hall along with covering the medication aide on the 500 hall was a little much and could have possibly been why she had not completed a weekly skin assessment document on 07/07/26 for Resident #43.On 07/14/26 at 1:30 PM Resident #43 was observed to have large cluster wounds that ran together on both lower legs that were weeping a yellow colored fluid. The wounds were open to air.In an interview with Resident #43 on 07/14/26 at 1:30 PM he stated his legs had been open and weeping for a little over a month. He stated he had asked for his legs to be wrapped but no one had provided him wound care. Resident #43 reported that he maintained a small garden in the courtyard and had been using the garden hose to wash the puss off his lower legs.An interview was conducted with the physician on 07/15/26 at 12:48 PM. He stated he had been on vacation from 07/02/26 through 07/13/26. He had not received any notification that Resident #43 had open wounds on his lower legs.An interview was conducted with the Physician Assistant on 07/16/26 at12:45 PM. She stated she had covered the physician during his vacation. She explained she had not received any notification that Resident #43 had open wounds on his legs. She expected the first nurse to assess an open wound to initiate temporary treatment and notify the physician until the treatment nurse could assess the wound and obtain a wound care order.An interview was conducted with the Director of Nursing on 07/17/26 at 3:10 PM. She stated that she expected the first nurse to assess an open wound to initiate treatment and then notify the physician and the treatment nurse to continue treatment of the area.

Based on record review, staff, resident and Physician Assistant (PA) interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of taking psychotropic medications prior to the administration and/or dosage change of the medications for 3 of 5 residents reviewed for unnecessary medications (Resident #5, #1, #14). Findings included: 1). Resident #5 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, depression and anxiety. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #5 was cognitively intact, demonstrated no behaviors, and received the following psychotropic medications: antipsychotic, antianxiety and antidepressant medications. Review of Resident #5's electronic health record revealed physician orders for the following psychotropic medications: Sertraline (a medication to treat depression) 50 milligrams (mg); one tablet once per day written on 08/28/25. This order was discontinued on 04/21/26. On 4/22/26, a physician order was written for Sertraline 100 mg; one tablet once per day. Lamictal (a medication to treat moods related to bipolar disorder) 25 mg; give one tablet daily written on 04/24/26. This order was discontinued on 05/20/26. On 05/21/26 a physician order was written for Lamictal 25 mg; give 2 tablets (50 mg) daily. Buspirone (a medication to treat anxiety) 5 mg; give two tablets (10 mg) daily written on 04/21/26. Review of a psychotropic medication informed consent form dated and signed by Resident #5 on 06/08/26 and completed by Nurse #8 revealed the following medications were recorded on the consent: Lamictal 25 mg. The correct order at the time this consent was signed was Lamictal 25 mg; 2 tablets daily = 50 mg., the Sertraline medication had no dose documented on the consent form. The correct order at the time this consent was signed was Sertraline 100 mg; one tablet daily, and Buspirone 5 mg. The correct order at the time this consent was signed was Buspirone 5 mg; give two tablets daily = 10 mg. The consent form indicated, in part, that no medication will be administered without resident being informed and written consent. The consent also indicated that alternative modes of treatment other than or in addition to the medications included a check mark under environmental or staff changes and use of behavior intervention techniques. Review of Resident #5's medication administration record for July 2026 revealed Resident #5 was receiving the psychotropic medications Lamictal, Sertraline and Buspirone as physician ordered. An interview with Resident #5 on 07/16/26 at 11:22 AM revealed he received a consent form for psychotropic medications to sign about a month ago (he could not recall the exact date) but he did not recall any discussion about the medication dose changes. Resident #5 stated this was the first consent he was asked to sign regarding his medications since his admission. An interview with the Director of Nursing (DON) was conducted on 07/15/26 at 9:15 AM. The DON stated that there was a lot of staff turnover and some things in the facility such as the obtaining psychotropic consents had not been getting done. The DON stated that the psychotropic consents were now being completed by Nurse #8 who was recently hired. The DON indicated Nurse #8 was responsible for completing the education with the resident or responsible party regarding the psychotropic medication and discussing alternate treatments prior to the administration of the medication. The DON indicated that at this time, the expectation was that education would be provided by Nurse #8 regarding each psychotropic medication to include the current dose and alternate treatments prior to the medication being given to a resident and whenever there were any changes to the psychotropic medications, a new psychotropic consent would be completed. An interview with the Physician Assistant on 07/16/26 at 11:03 AM revealed that with any psychotropic medications, the residents should be educated about the risks verses benefits of the medications prior to administration so that the resident has an understanding of the effects of the medications. An interview with Nurse #8 on 07/16/26 at 2:00 PM revealed the psychotropic consent form should have been completed on 08/28/25 upon admission to the facility for Resident #5 and each psychotropic medication should have been discussed by the admitting nurse prior to administration of the medication to make sure Resident #5 understood the effects of each drug. Nurse #8 stated she started working at the facility in March 2026 and was responsible for obtaining psychotropic consents for any residents who were currently receiving psychotropic medications. Nurse #8 stated consents should be obtained prior to the administration of the psychotropic medications but that did not always happen. Nurse #8 added that when she obtained a consent for a resident or responsible party, she would inform them what the medication was, the dose of the medication, and how it was helping the resident and what would happen to the resident if it was discontinued. Nurse #8 stated she was unaware that a new psychotropic consent needed to be obtained if there were any changes to the psychotropic medications. 2. Resident #1 was admitted to the facility on [DATE] with diagnosis which included severe dementia with behavioral disturbance and anxiety. Review of Resident #1's electronic health record revealed physician orders for the following psychotropic medications: A physician order dated 1/29/26 for alprazolam (antianxiety medication) 0.5 milligrams (mg) twice per day for anxiety for 30 days. The order was discontinued on 2/16/26. A physician order dated 2/16/26 for alprazolam 0.25 mg twice daily for 30 days. A physician order dated 2/23/26 for alprazolam 0.5 mg twice per day for anxiety. A review of the February 2026 electronic Medication Administration Record for Resident #1 revealed that the resident received the psychotropic medication alprazolam as ordered by the physician. A physician order dated 3/13/26 for quetiapine (antipsychotic medication) 12.5 milligrams (mg) every evening at 5:00 PM for dementia with behaviors. A review of the March 2026 electronic Medication Administration Record for Resident #1 revealed that the resident received the psychotropic medications alprazolam and quetiapine as ordered by the physician. A review of the April 2026 electronic Medication Administration Record for Resident #1 revealed that the resident received the psychotropic medications alprazolam and quetiapine as ordered by the physician. Review of a psychotropic medication informed consent form dated and signed by Resident #1's Responsible Party on 5/26/26 and completed by Nurse #7 revealed the following medications were recorded on the consent: alprazolam 0.5 mg and quetiapine 12.5 mg. The consent form indicated, in part, that no medication will be administered without resident being informed and written consent provided. The consent also indicated that alternative modes of treatment other than or in addition to the medications included a check mark under environmental or staff changes and use of behavior intervention techniques. A review of the May 2026 electronic Medication Administration Record for Resident #1 revealed that the resident received the psychotropic medications alprazolam and quetiapine as ordered by the physician. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #1 was moderately cognitively impaired, demonstrated no behaviors and received the following psychotropic medications: an antipsychotic and antianxiety medications during the lookback period. A review of the July 2026 electronic Medication Administration Record for Resident #1 revealed that the resident received the psychotropic medications alprazolam and quetiapine as ordered by the physician. An interview was conducted with Nurse #7 on 7/15/26 at 2:42 PM. Nurse #7 stated that she had not completed a psychotropic consent form nor had she provided educational information regarding psychotropic medication to Resident #1's Responsible Party. Nurse #7 revealed that she was not aware of the requirement to complete education and consent with the resident or Responsible Party prior to the initial administration of a psychotropic medication. An interview with the Director of Nursing (DON) was conducted on 07/15/26 at 9:15 AM. The DON stated that there was a lot of staff turnover and some things in the facility such as the obtaining psychotropic consents had not been getting done. The DON stated that the psychotropic consents were now being completed by Nurse #8 who was recently hired. The DON indicated Nurse #8 was responsible for completing the education with the resident or responsible party regarding the psychotropic medication and discussing alternate treatments prior to the administration of the medication. The DON indicated that at this time, the expectation was that education would be provided by Nurse #8 regarding each psychotropic medication to include the current dose and alternate treatments prior to the medication being given to a resident and whenever there were any changes to the psychotropic medications, a new psychotropic consent would be completed by Nurse #8. An interview with the Physician Assistant on 07/16/26 at 11:03 AM revealed that with any psychotropic medications, the residents should be educated about the risks verses benefits of the medications prior to administration so that the resident has an understanding of the effects of the medications. An interview with Nurse #8 on 07/16/26 at 2:00 PM revealed that she started at the facility in March 2026 and was responsible for obtaining the consents for psychotropic medications. Nurse #8 stated that the psychotropic consent forms should be completed prior to the administration of the psychotropic medications but that did not always happen. Nurse #8 indicated that she worked only 4 days per week and was still trying to learn the electronic health record system. Nurse #8 added that when she obtained consent from a resident or responsible party, she would inform them what the medication was, the dose of the medication, and how it was helping the resident and what would happen to the resident if it was discontinued. Nurse #8 stated that she did not inform them of alternate treatment options. Nurse #8 stated she was unaware that a new psychotropic consent needed to be obtained if there were any changes to the psychotropic medications. An interview conducted via phone with Resident #1's Responsible Party (RP) on 7/17/26 at 10:48 AM revealed that the nursing staff had not discussed the psychotropic medications alprazolam and quetiapine with her. Resident #1's Responsible Party indicated that she recently asked one of the nurses, she did not recall which nurse, about Resident #1's medications and was informed that the resident was receiving alprazolam and quetiapine. The RP did not recall signing the consent form dated 05/26/26. 3. Resident #14 was admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance and anxiety. Review of Resident #14's electronic health record revealed physician orders for the following psychotropic medications: A physician order dated 2/23/26 for quetiapine 25 milligrams (mg) by mouth every 12 hours for compulsive behaviors and wandering related to Alzheimer's disease with late onset. A physician order dated 12/23/25 for lorazepam tablet 0.5 mg tablet by mouth two times a day related to anxiety disorder. A physician order dated 6/1/26 for lorazepam oral concentrate 2 mg per milliliter (ml) by mouth every 6 hours as needed for anxiety. This order was discontinued on 7/3/26. A physician order dated 3/16/26 for mirtazapine tablet 7.5 mg give 2 tablets by mouth at bedtime for appetite stimulus. A physician order dated 12/16/26 for buspirone hydrochloride (HCl) 15 mg tablet by mouth two times a day for anxiety. A physician order dated 12/20/25 for sertraline HCl 100 mg tablet by mouth one time a day for anxiety. A review of the June 2026 electronic Medication Administration Record revealed the resident received the psychotropic medications mirtazapine, quetiapine, sertraline HCL, buspirone HCl, and lorazepam as ordered by the physician. A review of the July 2026 electronic Medication Administration Record for Resident #14 revealed the resident received the psychotropic medications mirtazapine, quetiapine, sertraline HCl, buspirone HCl, and lorazepam as ordered by the physician. Review of the electronic health record for Resident #14 did not reveal a consent form for psychotropic medications. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was severely cognitively impaired and displaced inattentive behavior and received the following psychotropic medications: antianxiety, antipsychotic, and antidepressant medications. An interview with Nurse #8 was completed on 7/15/26 at 3:43 PM. Nurse #8 revealed that she started at the facility in March 2026 as the Support Nurse, and she was responsible for obtaining the consents for psychotropic medications. Nurse #8 indicated that the consent form was on paper but was going to be on computer. She stated that if there was not a consent form on Resident #14's chart it must have been overlooked. Nurse #8 indicated that she worked 4 days per week and was still learning the computer health system. Nurse #8 added that when she obtained consent from a resident or responsible party, she would inform them what the medication was, the dose of the medication, and how it was helping the resident and what would happen to the resident if it was discontinued. Nurse #8 stated that she did not inform them of alternate treatment options. Nurse #8 stated she was unaware that a new psychotropic consent needed to be obtained if there were any changes to the psychotropic medications. An interview with the Director of Nursing (DON) was conducted on 07/15/26 at 9:15 AM. The DON stated that there was a lot of staff turnover and some things in the facility such as the obtaining psychotropic consents had not been getting done. The DON stated that the psychotropic consents were now being completed by Nurse #8 who was recently hired. The DON indicated Nurse #8 was responsible for completing the education with the resident or responsible party regarding the psychotropic medication and discussing alternate treatments prior to the administration of the medication. The DON indicated that at this time, the expectation was that education would be provided by Nurse #8 regarding each psychotropic medication to include the current dose and alternate treatments prior to the medication being given to a resident and whenever there were any changes to the psychotropic medications, a new psychotropic consent would be completed by Nurse #8. An interview via phone with Resident #14's Responsible Party (RP) on 7/16/26 at 10:09 AM revealed the RP was aware Resident #14 was receiving psychotropic medications. She explained that she was told the names of the medications, but they did not discuss the side effects associated with the antipsychotic. The RP indicated she had questions regarding the side effects and risks and benefits of taking an antipsychotic and she would be reaching out to the nursing staff for answers. An interview with the Physician Assistant on 07/16/26 at 11:03 AM revealed that with any psychotropic medications, the residents should be educated about the risks versus benefits of the medications prior to administration so that the resident has an understanding of the effects of the medications. A follow up interview was conducted with the DON on 7/17/26 at 9:40 AM. The DON stated that she was unable to find the psychotropic medication consent for Resident #14. She explained that Nurse #8 must have forgotten to get the consent prior to the administration of the psychotropic medications.

Based on record review, staff interviews, physician and physician assistant interviews, the facility failed to notify the physician of a change in status related to bilateral lower leg wounds that were open and weeping for 1 of 2 residents (Resident #43) reviewed for wound care; and failed to provide notification to the Responsible Party (RP) of the resident's death. This was for 1 of 1 resident (Resident #126) reviewed for death in facility. Findings included: 1) Resident #43 was admitted to the facility on [DATE] with a most recent readmission on [DATE]. Diagnoses included, in part: Chronic peripheral venous insufficiency, varicose veins of unspecified lower extremity with ulcer of unspecified site, and Type 2 Diabetes Mellitus with diabetic polyneuropathy. Record review revealed that weekly skin assessments were completed on [DATE] and [DATE]. Both assessments identified bilateral lower leg edema and discoloration with no open areas. No other weekly skin assessments were documented in the electronic medical record in [DATE]. Record review revealed a weekly skin assessment was completed on [DATE] by Nurse #10. She documented that Resident #43 had weeping, turgid, open, and blistered skin over the front of the right lower leg and weeping, turgid, open and blistered skin over the front of the left lower leg. An interview was conducted with Nurse #10 on [DATE] at 11:30 AM. Nurse #10 stated that she had completed a skin assessment on Resident #43 on [DATE]. Nurse #10 explained she had not notified the oncoming shift, nor had she notified the physician or the nurse practitioner that Resident #43 had untreated bilateral open, weeping wounds on both lower legs. Nurse #10 stated that she normally would initiate a treatment and notify the physician if she assessed an untreated open wound but in this instance she had not notified any other staff members of the wounds or initiate a treatment. An interview was conducted with Nurse #5 on [DATE] at 8:30 AM. Nurse #5 remembered she had assessed Resident #43's leg wounds on [DATE] and recalled he had yellow craters on both lower legs. Nurse #5 explained that because she had not seen any oozing from the wounds that she had not initiated a treatment or notified the physician or treatment nurse of the open areas. On [DATE] at 11:47 AM Resident #43 was observed to have large cluster wounds that ran together on both lower legs that were weeping a yellow colored fluid. The wounds were open to air. Review of the physician orders on [DATE] at 12:15 PM revealed there was no treatment orders for Resident #43's right or left lower leg vascular wounds. In an interview with Resident #43 on [DATE] at 1:30 PM he stated his legs had been open and weeping for a little over a month. He stated he had asked for his legs to be wrapped but no one had provided him wound care. An interview was conducted with the physician on [DATE] at 12:48 PM. He stated he had been on vacation from [DATE] through [DATE]. He had not received any notification that Resident #43 had open wounds on his lower legs. An interview was conducted with the Physician Assistant on [DATE] at12:45 PM. She stated she had covered the physician during his vacation. She explained she had not received any notification that Resident #43 had open wounds on his legs. She expected that Nurse #10 would have initiated a temporary treatment and notified the physician until the treatment nurse could assess the wound and obtain a wound care order. An interview was conducted with the Director of Nursing on [DATE] at 3:10 PM. She stated that she expected that Nurse #10 would have initiated a treatment and then notified the physician and the treatment nurse of the wound to continue treatment. 2. Resident #126 was admitted on [DATE]. A nursing progress note dated [DATE] written by Nurse #13 at 8:15 PM indicated that Resident #126 had no measurable vital signs and the medical provider was notified. A nursing progress note dated [DATE] at 8:35 PM written by Nurse #13 indicated that Resident #126's emergency contacts were called, and two numbers did not go through to a caller or a voice mail. The note indicated that a voice mail message was left to call the facility on one number (the note did not specify what phone number, or which contact). An interview with Nurse #13 was conducted via phone on [DATE] at 1:35 PM. Nurse #13 stated that she did not recall who she notified on [DATE] when Resident #126 passed away. Nurse #13 stated to refer to her progress note and that it would provide information regarding who she attempted to contact. The Nurse stated that she no longer worked at the facility and did not feel comfortable providing any additional information. A nursing progress note dated [DATE] at 9:53 PM written by Nurse #13 indicated that the Director of Nursing was notified that Resident #126 expired and the nurse was unable to reach a family member. An interview was conducted via phone with the previous Director of Nursing (DON) on [DATE] at 12:30 PM. The previous DON stated that she started in the position at the facility on February 16, 2026, and was the DON when Resident #126 passed away at the facility. The previous DON stated that Nurse # 13 called her and informed her that Resident #126 had passed away. Nurse # 13 reported to the DON that she placed a call to the Responsible Party on Resident #126's electronic health record and received no answer. The previous DON stated she instructed Nurse #13 to continue to call the Responsible Party. The previous DON stated that she was new to the position and unfamiliar with the facility protocol for a death in the facility, so she called the Administrator. The previous DON stated that she reported to the Administrator that Resident #126 had passed away and the RP was not contacted. The previous DON indicated that she did not attempt to notify Resident #126's RP and did not follow up later to determine if the RP was contacted. She indicated that she expected that the nurse would have attempted more than once to contact an emergency contact when a resident passed away. A nursing progress note written by Nurse #13 dated [DATE] at 1:26 AM revealed that Resident #126's body was released to the funeral home. Review of Resident #126's electronic health record revealed there were no further attempts to contact Emergency Contact #1/ RP, Emergency Contact #2 or Emergency Contact #3. An interview was conducted via phone with Resident #126's Emergency Contact #2 on [DATE] at 10:40 AM. Emergency Contact #2 stated that she was not notified by the facility of Resident #126's death. Emergency Contact #2 stated that she had voice mail set up on her cell phone on [DATE]. Emergency Contact #2 stated that she checked her phone for missed calls or a voice mail message from the facility on [DATE] and [DATE] and found neither one. An interview was conducted via phone on [DATE] at 8:45 AM with Resident #126's Emergency Contact #1/Responsible Party (RP)/Power of Attorney. Emergency Contact #1/RP indicated that she had voice mail set up on her cell phone on [DATE]. Emergency Contact #1/RP stated that she received a phone call from a funeral home on the morning of [DATE] and was informed that Resident #126's body had been taken there. Emergency Contact #1/RP indicated that she checked her phone for missed calls or a voice mail message from the facility regarding Resident #126's demise and found neither one. Emergency Contact #1/RP stated that she was not notified by the facility of Resident #126's death. An interview was conducted by phone with Emergency Contact #3 on [DATE] at 9:45 AM. Emergency Contact #3 reported that on the morning of [DATE], he was informed by Emergency Contact #1/RP that Resident #126's body had been taken to the funeral home. He also stated that he had voicemail set up on his phone on [DATE]. Emergency Contact #3 noted that he checked his phone for any missed calls or voicemail messages from the facility but found none. Emergency Contact #2 stated that she was not notified by the facility of Resident #126's death. An interview conducted with the Administrator on [DATE] at 4:50 PM revealed that she would expect that the RP would be notified of a resident's death. The Administrator indicated that she expected that the assigned nurse would continue to call the emergency contacts in the electronic health record until one of the contacts was notified.

Based on observations, record review and staff and resident interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of vision for a resident with visual impairment. This was for 1 of 32 residents reviewed for MDS accuracy (Resident #61). Findings included: Resident #61 was admitted to the facility on [DATE] with diagnosis of glaucoma. The Minimum Data Set admission assessment dated [DATE] revealed Resident #61 was cognitively intact and was coded has having adequate vision. The care area assessment (CAA) indicated a care plan should be triggered for vision. An observation of Resident #61 on 05/12/25 at 11:30 AM revealed upon entry to his room it was noted to be very bright with all overhead lights on. An interview with Resident #61 on 05/12/25 at 11:30 AM was conducted. Resident #61 stated he needed all the lights on so that he could see. He stated he was nearly blind. Resident stated he had a reaction to cancer treatment to his brain and it affected his vision. An interview was conducted with the Social Worker Assistant on 05/15/25 at 10:25 AM. The Social Worker Assistant stated he was the one who completed the MDS assessment for vision and hearing and coded Resident #61's vision as adequate. He stated he was not made aware by the Resident that he was blind. The Social Worker Assistant stated he did not complete the care area assessment so he did not realize the resident had triggered for a vision care plan. The Social Worker Assistant stated he thought he had asked Resident #61 if he wore glasses and if he had any problems with his vision and he did not recall the resident saying he did. The Social Worker Assistant stated he did not remember if he was aware of the Resident's diagnoses or past history. A follow up interview was conducted with Social Worker Assistant on 05/15/24 at 1:15 PM. He stated he interviewed Resident #61 and Resident #61 shared with him that he was visually impaired. The Social Worker Assistant stated he should have coded the resident has having impaired vision and added, the resident had an issue with vision, and it was triggered on the CAA as a problem and should be reflected accurately on the vision section of the MDS assessment. An interview was conducted with the Administrator on 05/15/25 at 4:45 PM. The Administrator stated she expected the MDS assessments to be coded accurately to make sure nursing staff were aware of the resident's care needs and safety.

Based on observations, record review, and staff interviews the facility failed to implement care planned interventions by not placing a fall mat at the bedside of residents with a history of a fall with major injury. This occurred for 2 of 6 residents reviewed for accidents and care plan interventions (Residents #24 and #81). Findings included: 1. Resident #24 was admitted to the facility on [DATE] with diagnoses of Alzheimer's and muscle weakness. An incident note dated 10/12/2024 at 6:21 PM indicated Resident #24 had an unwitnessed fall from his bed and was sent to the hospital for evaluation. A care plan revised on 10/14/24 revealed Resident #24 was at risk of falls due to poor safety awareness, right sided hemiplegia, and poor communication and comprehension. Interventions included fall mat at the bedside and keep the call light within reach. The hospital Discharge summary dated [DATE] revealed Resident #24 was discharged with a diagnosis of a femur fracture sustained from the fall. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #24 was severely cognitively impaired. He required staff assistance with activities of daily living and had no falls during this assessment period. An observation was conducted on 05/14/25 at 10:04 AM of Resident #24. He was in bed and in no distress. He was unable to communicate due to severe cognitive impairment. There was no fall mat at the bedside. During an interview on 05/14/25 at 4:20 PM, Nurse Aide #1 stated she provided care to Resident #24 at times. She stated she was not aware there was no fall mat at his bedside, but stated that he used to have one. She stated the nurses usually put the fall mats down when needed. She indicated she was not aware of any further falls. During an interview on 05/14/25 at 4:30 PM, Nurse #2 stated she was routinely assigned to Resident #24 and was not aware he was supposed to have a fall mat at the bedside. She stated usually when fall mats were initiated the nurse would make sure it was placed by the bed. She stated she would get a fall mat placed on both sides of his bed now. She indicated he has had no recent falls. During an interview on 05/15/25 at 11:32 AM, the Director of Nursing stated during morning standup meetings they discussed falls and reviewed and added interventions. If fall mats were added to the care plan the Nurse Manager, Assistant Director of Nursing, or the Rehab Director would get the fall mat from central supply and place at the bedside. She stated she did not know why it was missed but she expected care plan interventions to be followed. She stated education would be provided. 2. Resident #81 was admitted to the facility on [DATE] with diagnoses that included altered mental status. A progress note written on 11/21/24 indicated Resident #81 had an unwitnessed fall from his bed during the night and he was transferred to the hospital for evaluation. A care plan initiated on 10/15/24 and revised on 11/21/24 revealed Resident #81 was at risk for falls related to history of falls, weakness, and impaired mobility and had an actual fall with subdural (part of the brain) bleed related to poor balance and unsteady gait. Resident #81's goal was that he would be free from major injury from falls related to history of falls. Interventions included a fall mat next to his bed. The hospital Discharge summary dated [DATE] revealed Resident #81 was discharged back to facility with diagnoses of left hip hematoma and stable traumatic subdural (location in brain) hemorrhage (bleed). The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #81 was cognitively impaired, required supervision or touching assistance with ambulation, toileting and transferring from chair to bed. Resident #81 used a walker and had no falls during this assessment period. An observation of Resident #81 was conducted on 05/12/25 at 11:00 AM. Resident #81 was lying in his bed and not have any fall mats beside his bed or anywhere stored in his room. An observation was conducted on 05/15/25 at 9:37 AM of Resident #81's room. Resident was out of bed, standing next to his food tray. He was noted to have a steady gait and not using his wheelchair which was located beside him. Observation of the room revealed there was no fall mat in the room or stored in the bathroom. During an interview with Nurse Aide #5 on 05/15/25 at 2:10 PM, Nurse Aide #5 revealed she usually worked on a different hall and had only been on the hall Resident #81 resided on for a couple of weeks. Nurse Aide #5 stated if she needed to know how to take care of a resident she would either look at a resident's [NAME] (a care card about resident's activity of daily living care needs) or ask other nurse aides, the nurses, or therapy how residents transfer, eat, bath, etc. Nurse Aide #5 stated she did not know Resident #81 needed a fall mat and had never seen one his room. Nurse Aide #5 reviewed the [NAME] and saw that Resident #81 required a fall mat. During an interview with Nurse Aide #4 on 05/15/25 at 2:30 PM, Nurse Aide #4 revealed he was assigned to Resident #81 and was familiar with him. Nurse Aide #4 stated he was not aware nor has he ever seen a fall mat in Resident #81's room. Nurse Aide #4 stated he had access to the [NAME] to review if he was unsure how to provide care to a resident, but he did not review Resident #81's care card. He added, if he was unsure how to take care of a resident he would ask the staff nurse or other nurse aides. During an interview with Nurse #5 on 05/15/25 at 3:00 PM, Nurse #5 revealed she was familiar with Resident #81 and worked with him frequently. Nurse #5 stated she was not aware that Resident #81 needed a fall mat and did not look at the care plan and that this was the first time she was hearing about it. Nurse #5 stated she would make sure a fall mat was in his room and at his bedside while he was in bed. During an interview with the Director of Nursing on 05/15/25 at 4:32 PM, the Director of Nursing stated during morning standup meetings they discussed falls and reviewed and added interventions. If fall mats were added to the care plan the Nurse Manager, Assistant Director of Nursing, or the Rehab Director would get the fall mat from central supply and place at the bedside. She stated she did not know why it was missed but she expected care plan interventions to be followed. She stated education would be provided.

Based on record review, and staff, family and physician interviews, the facility failed to obtain orders from a Pulmonologist for the appropriate setting for a resident's (Resident #189) Continuous Positive Airway Pressure (CPAP) machine (used as a type of ventilator with diagnoses of obstructive sleep apnea; a health condition that causes brief pauses in breathing during sleep) upon resident's admission and during the resident's stay at the facility for 8 days. This was for 1 of 1 resident reviewed that utilized a CPAP machine. Findings included: Review of the discharge summary from the hospital Resident #189 was discharged from on 11/23/24 revealed there were no orders written for Resident #189 for a CPAP machine. Resident #189 was admitted to the facility on [DATE] and discharged to the hospital on 12/02/24. Diagnoses included, in part, obstructive sleep apnea (OSA). The admitting physician orders revealed there were no orders written for CPAP use. The physician orders dated 11/23/24 included: Advair discus 100-50 microgram (mcg) per dose - 1 inhalation orally one time daily for shortness of breath Albuterol Sulfate 108 mcg - 2 puffs inhale orally every 4 hours as needed for shortness of breath or wheezing Albuterol Sulfate 2.5 milligrams (mg) /3 milliliters (ml) 0.083% nebulization solution inhale 3 ml by mouth every 6 hours as needed for bronchospasm Spiriva Respimat 2.5 mcg -1 inhalation inhale orally twice a day for shortness of breath. A nursing note written on 11/23/24 by Nurse #4 revealed Resident was alert and oriented and was able to make all his needs known with clear speech. Resident was aware of his medication list and vital signs were stable. Resident vocalized no discomforts. Nurse will ask for an order for resident's CPAP that he brought from home. An interview was attempted with Nurse #4 who wrote the nursing note on 11/23/24 regarding obtaining an order for the resident's CPAP that he brought in from home. A voicemail message and text message were left for a returned call on 05/15/25 at 9:48 AM. Nurse #4 did not respond to voicemail message or text message. Review of Resident #189's care plan dated 11/23/24 revealed a plan of care was in place for altered respiratory status related to obstructive sleep apnea, shortness of breath, and bronchospasm (constriction of the smooth muscle layers of the small airways that can cause swelling or irritation of the airway). Interventions included administering medications as ordered and monitor, elevate head of bed to prevent shortness of breath, pace and schedule activities providing rest periods. There was no plan of care in place for the use of a CPAP machine. Review of a hand written form titled Resident Personal Possessions Inventory dated 11/23/24 under the clothing and shoes section the following was included: 1 pair of shoes, 3 bibs, 8 shirts, 9 pair of pants, 1 underwear, 9 socks, 3 tanks. In the equipment section of the form the list included a knee Brace, phone and charger. In the other personals section, the list included CPAP, electric razor, shoe horn and wedge. The form was not signed by staff or resident. A physician note written on 11/27/24 revealed, in part, resident was feeling okay overall and denied any shortness of breath. Resident knew his history and had been asking about his prescribed medications. Resident stated he had obstructive sleep apnea and has a CPAP machine next to his bed but did not use it last night because it was too far away for him to reach. Resident stated he has had the same settings on his CPAP for four years and used the machine while in hospital with no changes. Will recommend he start CPAP at night. The Minimum Data Set admission assessment dated [DATE] revealed Resident #189 was alert and cognitively intact. Resident #189 was coded as having shortness of breath and required extensive assistance with one staff physical assistance with bed mobility, and supervision with two staff physical assistance with transfers. A physician note written on 11/29/24 revealed, in part, resident stated he has not used his CPAP as yet. Discussed CPAP issue with nursing and they will be getting a hold of resident's pulmonary doctor to see what his settings are supposed to be. Resident denied any current shortness of breath or complaints of pain. Resident stated he has had same settings for four years and used the CPAP machine while in the hospital with no changes. Will recommend he start CPAP at night and discussed with nursing to reach out to his pulmonary doctor. Review of the hospital emergency room (ER) admission note on 12/02/24 revealed the resident presented with increased confusion. Resident had a history of sleep apnea and reportedly uses CPAP at night but did not use it last night (12/01/24). The emergency note indicated that the facility reported resident was refusing CPAP, resident reported facility denied giving CPAP. Under the Past Medical History section of the ER note sleep apnea was listed as a diagnosis with a sentence in italics pt. states that he does not wear CPAP. There were no other notes regarding use of CPAP at this local hospital. An interview was conducted with the Physician who wrote the progress notes on 11/27/24 and 11/29/24 on 05/14/25 at 11:20 AM. The Physician stated that anytime a resident was on a CPAP machine, the settings for the CPAP had to be ordered by a Pulmonologist. The Physician stated the nursing staff had called the pulmonologist and were waiting to hear back from the office to get the settings so that the order could be entered. The Physician stated he was not able to set the settings and although Resident #189 was aware of the settings for his CPAP, the settings needed to be confirmed with a pulmonologist. The Physician stated the nurses did their due diligence to obtain the settings. The Physician stated Resident #189 was discharged to the hospital for acute kidney injury and it was not related to not using his CPAP. The Physician also added that the resident was known to be non-compliant with the CPAP. The Physician stated when the resident was sent to the local hospital on 12/02/24 there were notes indicating that he was non-compliant. An interview with a family member via phone on 05/14/25 at 2:44 PM stated Resident #189 was using the CPAP machine at the hospital prior to his admission to the facility and he was admitted to the facility with his CPAP machine. The family member stated whenever she visited, the CPAP machine was unplugged and Resident #189 stated he had not been using it. The family member stated Resident #189 had been using the CPAP for 4 years and used it every night. An interview was attempted with Nurse #6 who worked with Resident #189 on the night of 11/27/24 and 11/29/24. A voicemail message and text message were left for a returned call on 05/15/25 at 10:17 AM. Nurse #6 did not response to voicemail message or text message. An interview was conducted with the Unit Manager on 05/15/25 at 12:45 PM. The Unit Manager stated there were no orders for the residents' CPAP so the nursing staff could not allow the resident to use it. She stated there were no orders written on the discharge summary from the hospital. The Unit Manager stated she believed the resident was not admitted with the CPAP and that the family member had brought it in a couple days after Resident #189 was admitted . She stated the family member gave her the number to the Pulmonologist. The Unit Manager stated she tried to contact the Pulmonologist to get the settings for the CPAP machine and had left a message but no one returned her call. The Unit Manager stated she only tried one time to reach the Pulmonologist. She stated she did not remember who the Pulmonologist was, which day she tried to call or the phone number of the pulmonologist, but that it was in Onslow County. The Unit Manager stated she should have followed up with the pulmonology office, but the resident was discharged after only a short stay at the facility. An interview was conducted with the Director of Nursing on 05/15/25 at 4:30 PM. The Director of Nursing stated she believed that the family brought the CPAP in after the resident was at the facility for a few days and that he was not admitted with the CPAP. She stated she thought the nurses were making an effort to reach the Pulmonologist to get the settings for the CPAP machine and did not realize the Unit Manager only tried once. The DON stated she would have expected the nursing staff to follow up with the Pulmonologist until they obtained the settings for the CPAP.

Based on record review, observations and staff interviews, the facility failed to have a system in place to train nurses and nursing assistants (NAs) and verify their competency with infection control procedures necessary for providing care to meet residents' needs. Nurse #4 failed to follow infection control protocol by not wearing a gown and not changing gloves after touching items in the resident's environment while providing care to a peripherally inserted central catheter (PICC) line, a thin flexible tube inserted into a vein in the arm and threaded up to a larger vein in the chest close to the heart used for long term intravenous therapy. NA #2 and NA #4 failed to follow infection control protocol by repositioning a resident on Enhanced Barrier Precautions due to a feeding tube and a wound that was positive for MRSA (Methicillin Resistant Staphylococcus Aureus) without the required Personal Protective Equipment (PPE). The deficient practice was identified for 1 of 1 nurse (Nurse #4) and 2 of 2 NAs (NA #2 and NA #4) reviewed for competency. Findings included: This tag is cross referenced to: F880: Based on observations, record review, and staff interviews the facility failed to implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to residents. 1. Nurse # 4 provided care to a resident with a peripherally inserted central catheter (PICC) line, a thin flexible tube inserted into a vein in the arm and threaded up to a larger vein in the chest close to the heart used for long term intravenous therapy. The nurse donned gloves but no gown during the procedure and did not change gloves after obtaining items from the bedside table. 2. Nursing Assistant #2 and Nursing Assistant # 4 provided turning and repositioning for a resident on EBP due to a gastrostomy tube and a wound to the right upper chest that was positive for MRSA (methicillin resistant staphylococcus aureus) without donning gowns or gloves. This occurred for 3 of 3 staff members who were observed for infection control practices. a. Review of Nurse #4's employee record revealed she was hired on 9/23/24 as a Registered Nurse (RN). There was no evidence of competency and training regarding administration of medication via a PICC line. An interview with Nurse #4 on 5/13/25 at 3:00 PM revealed she had worked previously as an RN and had worked with PICC lines in the past. Nurse #4 stated she was in her position as an RN at the facility since September 2024. Nurse #4 indicated she did not recall if she received training regarding administration of medication via a PICC line or if her skills were verified upon hire. b. Review of NA #2's employee file revealed she was employed since 2022, and the file did not contain evidence that the NAs skills or competencies were checked. The file did not contain infection control in-service education. c. Review of NA #4's employee file revealed he was employed since 2024, and the file did not contain evidence that the NAs skills or competencies were checked. The file did not contain infection control in-service education. Review of a mandatory Inservice Education sign in sheet regarding infection control dated 1/31/25 indicated the sheet was signed by 3 Licensed Practical Nurses (LPNs) and 10 NAs. The sign in sheet was not signed by Nurse #4, NA #2 or NA #4. Review of an Inservice Education sign in sheet dated 5/12/25 revealed that Personal Protective Equipment, contact precautions, and hand washing was reviewed. The sign in sheet indicated that the Social Services Assistant, a housekeeper, 2 nurses and 1 NA signed the sheet. Nurse #4, NA #2 and NA #4 did not sign that they received the in-service education. An interview with the Infection Preventionist on 5/15/25 at 1:00 PM revealed that she was in the position since last year and she was responsible for staff education. The Infection Preventionist stated that education regarding Personal Protective Equipment (PPE), Infection Control precautions and Enhanced Barrier Precautions was provided to all staff on hire and as needed. The Infection Preventionist indicated that education modules were assigned on-line randomly for all staff to complete. The Infection Preventionist was unable to explain how training was tracked to ensure all nursing staff received the training required to meet residents' needs and how competencies were verified. An interview with the Director of Nursing (DON) on 5/15/25 at 6:15 PM revealed that she was not aware of any training provided or verification of skills to provide PICC line care and the need to change gloves after touching items in the resident's environment while providing care. The DON stated that adherence to infection control protocols during PICC line care and while repositioning residents on Enhanced Barrier Precautions was important to prevent infection. The DON indicated that Nurse #4, NA #2, and NA #4 should have been trained in infection control protocols and been competent to provide care to meet resident needs.

Based on observations, record review, and staff interviews the facility failed to implement the infection control policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to residents. 1. Nurse # 4 provided care to a resident with a peripherally inserted central catheter (PICC) line, a thin flexible tube inserted into a vein in the arm and threaded up to a larger vein in the chest close to the heart used for long term intravenous therapy. The nurse donned gloves but no gown during the procedure and did not change gloves after obtaining items from the bedside table. 2. Nursing Assistant #2 and Nursing Assistant # 4 provided turning and repositioning for a resident on EBP due to a gastrostomy tube and a wound to the right upper chest that was positive for MRSA (methicillin resistant staphylococcus aureus) without donning gowns or gloves. This occurred for 3 of 3 staff members who were observed for infection control practices. Findings included: The facility's Guidelines for Preventing Intravenous Catheter-related Infections Policy dated April 2017 indicated in part that aseptic technique (a set of techniques used to prevent contamination of objects with microorganisms) shall be observed at all times when working with IV (intravenous) equipment and that all times equipment shall remain aseptic (free from microorganisms) and if it becomes contaminated it must be changed. Hand hygiene is to be completed either by hand washing or with alcohol-based hand rub before and after intravenous catheter care. Clean, non-sterile gloves are to be worn. The facility's Enhanced Barrier Precautions policy dated 3/20/24 revealed it was the policy of the facility to utilize Enhanced Barrier Precautions (EBP), an infection control intervention intended to prevent the transmission of multi-drug-resistant organisms (MDRO's) via contaminated hands and clothing to high-risk residents. Enhanced Barrier Precautions were indicated for high contact care activities for residents with wounds or indwelling medical devices including central lines and gastrostomy feeding tubes and required hand hygiene before and after leaving the room and the use of gloves and a gown. 1. Observation of Resident #46's room on 5/13/25 at 2:50 PM revealed that there was no signage outside the resident's room indicating that Enhanced Barrier Precautions (EBP) were to be used. An observation was conducted with Nurse # 4, the nurse assigned to Resident #46 on 5/13/25 at 2:50 PM. Nurse #4 entered Resident #46's room to administer the normal saline and heparin flushes, a procedure to maintain patency of the PICC line, following the completion of the intravenous antibiotic. Nurse #4 entered Resident #46's room with gloves on. Nurse #4 with gloved hands opened the drawer to resident's bedside table to obtain alcohol wipes and a cap for the resident's peripherally inserted central catheter. Nurse #4 did not change gloves after touching the items in the bedside table. Nurse #4 disconnected the intravenous tubing and administered the normal saline and heparin flush via the PICC line with the same gloves on, opened the new cap and applied it to the end of the tubing. An interview with Nurse # 4 on 5/13/25 at 3:00 PM revealed she was unaware that she was supposed to wear a protective gown while performing procedures involving a PICC line. Nurse #4 stated she went by the sign outside the door to know if a resident required any type of precautions while providing care. Nurse #4 stated she thought precautions were required for residents with wounds and Clostridium difficile (C. diff) but she did not know if a PICC line or any drains or tubes required precautions. Nurse #4 stated she did not realize she should have changed gloves after obtaining the items from the bedside table or that she should have had the needed supplies prior to beginning the procedure. Nurse #4 stated she received training on the computer and by the Infection Preventionist regarding Enhanced Barrier Precautions and that she worked at the facility since September of 2024. An interview with the Assistant Director of Nursing was conducted on 5/14/25 at 5:00 PM. The Assistant Director of Nursing stated the staff should follow the EBP and wear the personal protective equipment as designated for care activities including intravenous catheter care and turning and repositioning as well as handling of bed linens. An interview with the Unit Manager on 5/15/25 at 10:15 AM revealed that precautions were determined based on the residents' condition. The Infection Preventionist determined what type of precautions were required and placed the signage outside the resident rooms. The Unit Manager stated that a resident with a PICC line should be placed on Enhanced Barrier Precautions and a mask, gown and gloves were required to provide PICC line care. The Unit Manager indicated that she did not know why Resident #46 was not placed on precautions. An interview was conducted with the Wound Care Nurse on 5/15/25 at 12:30 PM. The Wound Care Nurse revealed that residents with open wounds and invasive lines such as a PICC line required Enhanced Barrier Precautions. The Wound Care Nurse stated she reviewed the residents with wounds weekly with the Infection Preventionist to ensure that residents were placed on precautions as needed. The Wound Care Nurse indicated that Resident #46 should have been placed on Enhanced Barrier Precautions, and she did not know why he was not. An interview with the Infection Preventionist on 5/15/25 at 1:00 PM revealed that she was in the position for nearly a year. She stated she was also the Staff Development Coordinator (SDC) and was responsible for staff education and training. The Infection Preventionist stated the nursing staff were educated regarding Enhanced Barrier Precautions through in-person and on-line in-services. The Infection Preventionist stated Nurse #4 should have worn a protective gown while performing PICC line care for Resident #46. An interview was conducted with the Director of Nursing (DON) on 5/15/25 at 1:30 PM. The DON stated that she expected that appropriate personal protective equipment would be used when providing care to a resident with a peripheral intravenous central catheter. The DON indicated that the PICC line was invasive and presented an increased risk of infection therefore Enhanced Barrier Precautions should be maintained. The DON indicated that she was not aware of the training provided or verification of skill to provide intravenous care. 2. A blue Enhanced Barrier Precautions (EBP) sign was noted outside Resident #7's door on 5/13/25 at 1:25 PM. The sign read in part, Everyone must clean hands before entering and after leaving the room .Wear gown and gloves for the following High Contact Resident Care Activities which include: Dressing, bathing/showering, Transferring, changing linens, changing briefs or assisting with toileting, and Device care or use; central lines, urinary catheter, feeding tubes, tracheostomy, Wound care: any skin opening requiring a dressing. An interview and observation was conducted on 5/13/25 at 1:30 PM with Nursing Assistants (NA) #2 and NA #4. Resident #7 requested to be moved up and repositioned in bed prior to eating her lunch. NA's #2 and NA #4 were observed entering Resident #7's room and did not wash their hands and did not don gowns or gloves. NA #2 and NA #4 approached Resident #7's bed with no Personal Protective Equipment (PPE) on and with one NA on each side of the bed used the draw sheet, a sheet placed under the resident's mid-section, standing close to the resident, grabbed the sheet and moved the resident up towards the head of the bed. The NAs adjusted Resident #7's pillows, elevated the head of the bed and exited the room. After exiting the room, the NAs applied alcohol based handrub to their hands. NA #2 and NA #4 stated they thought repositioning a resident using a draw sheet wasn't direct care and did not require PPE. NA #2 and NA #4 stated they had received training regarding Enhanced Barrier Precautions, but it was confusing which activities required PPE. Handling bed linens and high contact care activities required PPE according to the EBP signage. An interview with the Assistant Director of Nursing was conducted on 5/14/25 at 5:00 PM. The Assistant Director of Nursing stated the staff should follow the EBP and wear the personal protective equipment as designated for care activities including intravenous catheter care and turning and repositioning as well as handling of bed linens. An interview was conducted with the DON on 5/15/25 at 1:30 PM. The DON stated that residents on Enhanced Barrier Precautions required PPE for all high-contact resident care activities. The DON indicated she expected that these precautions would be maintained. The DON indicated that EBP should be followed as written and this included gloves and gown for high contact resident care activities including using the bed linens to move a resident. The DON indicated that Resident #46 was receiving intravenous antibiotics due to endocarditis and he was a high risk for further infection and complications and therefor adherence with infection control measures was important. The DON stated that Resident #7 was on Enhanced Barrier Precautions due to a gastrostomy tube and a wound that was positive for MRSA (Methicillin Resistant Staphylococcus Aureus).

Based on observations, resident and staff interviews the facility 1a) failed to repair torn floor linoleum in resident rooms (513 and 515), 1b) failed to remove the black greenish substance from the commode base caulking in resident rooms (511, 513, 515, 606, and 608), 1c) failed to repair a broken free standing clothes cabinet doors in resident rooms (510, 513, and 608), 1d) failed to repair leaking commode bases in resident rooms (506, 511, 513, 515, 608, 612, and 615), 1e) failed to replace broken or missing bathroom door threshold strip in resident rooms (500, 510, 612, 613, and 615), 1f) failed to replace broken or missing toilet paper dispensers in resident rooms (612), 1g) failed to repair resident's overhead lights that were either non-functioning, missing a light cover, or had broken light covers in rooms (515 and 601), 1h) failed to replace broken window blinds in resident rooms (515, 606, and 608); and 2a) failed to eliminate a strong urine and feces odor noted on the 500 and strong urine odor on the 600 hall which was also detected in residents' rooms. These failures occurred on 2 of 6 hallways (500 Hall and 600 Hall) observed for a safe, clean, homelike environment. Findings included: 1a. An initial observation on 04/30/24 at 8:30 AM revealed torn floor linoleum in resident rooms (513 and 515). 1b. An observation on 04/30/24 at 8:30 AM revealed resident commodes (511, 513, 515, 606, and 608), were noted to have black greenish substance located around the base of the commodes. 1c. An observation on 04/30/24 at 8:30 AM revealed broken free standing clothes cabinet door broken (510, 513, and 608). 1d. An observation on 04/30/24 at 8:30 AM revealed resident room commodes were leaking at their bases with strong sewage smell emanating from the leaking toilets in rooms (506, 511, 513, 515, 608, 612, and 615). 1e. An observation on 04/30/24 at 8:30 AM revealed resident rooms with broken or missing bathroom door threshold strip (500, 510, 612, 613, and 615). 1f. An observation on 04/30/24 at 8:30 AM revealed broken or missing toilet paper dispensers in resident rooms (612). 1g. An observation on 04/30/24 at 8:15 AM revealed overhead lights that were either non-functioning, missing a light cover, or had broken covers in rooms (515 and 601). 1h. An observation on 04/30/24 at 8:30 AM revealed broken window blinds in resident rooms (515, 606, and 608). An interview and observation was conducted on 04/30/24 at 3:45 PM with the Maintenance Director (MD). The MD stated there were multiple areas on the 500 and 600 halls that still needed to be addressed, repaired, or replaced. He stated he had an assistant but was slowly keeping up with facility repairs. He said he did not know what the black greenish substance was around some of the commodes on the 500 and 600 halls and did not know about the leaking commodes. He said maintenance was responsible for repairing or replacing items in the facility, and that the stained or torn bathroom linoleum needed to be repaired, along with the other items that were pointed out to him during the 500 and 600 hall tour. A follow-up facility tour was conducted on 05/01/24 at 10:20 AM of the 500 and 600 halls with the Administrator. The tour revealed: Black greenish substance around the base of resident commodes, leaking commodes, torn linoleum, missing or broken threshold strips, broken above bed lights, broken toilet paper dispenser, broken resident clothing cabinets, and broken blinds. She stated the areas observed on the 500 and 600 halls needed to be addressed and fixed. 2a. An observation on 04/30/24 at 8:35 revealed a strong smell of urine and feces which was detected in a resident's room (room [ROOM NUMBER]) and throughout the 500-hallway. This odor was also evident in Resident #50 and Resident #73's room located in the 500-hall on 04/30/24 and 05/01/24. A follow-up observation was conducted on 04/30/24 at 9:45 AM on the 500 and 600 hallways and room [ROOM NUMBER] and was noted to smell strongly of urine and feces. An interview was conducted on 04/30/24 at 8:40 AM with Resident #50. Resident #50's Minimum Data Set, dated dated dated [DATE] revealed the resident had no cognitive impairments. She stated there was always a strong odor of urine and feces in their room and the 500-hall. She said she let staff and administration know about the strong odor for at least the last 6-months, and still, it smelled awful. She said she had to ask staff to keep the hallway door shut most of the time due to the strong odor. An interview was conducted with Resident #73 Resident #73's Minimum Data Set, dated dated dated [DATE] revealed the resident had no cognitive impairments. on 04/30/24 at 8:40 AM. She stated there was always a strong odor of urine and feces in the hall, which seeps into her room. She said she let staff and administration know of the strong odor for a long time and it still smelled awful. She said she kept her door shut most of the time due to the strong foul odor. A follow-up observation was conducted on 04/30/24 at 9:45 AM of the 500 and 600 halls. Strong urine and feces odor was still present in the two hallways. An interview and observation were conducted on 04/30/24 at 3:45 PM of the 500 and 600 halls with the Maintenance Director. He stated the 500 and 600 halls odor needed to be addressed. A follow-up facility tour was conducted on 05/01/24 at 10:20 AM of the 500 and 600 halls with the Administrator. The Administrator said the strong urine odor down the 500 and 600 halls were never brought to her attention by staff or residents. An interview on 05/02/24 at 11:00 AM with the Administrator revealed that she was not aware of the strong odor of urine down the 500 and 600 halls. She stated that the facility was working hard to keep the facility clean and odor free. An interview on 05/02/24 at 11:10 AM with the Director of Nursing revealed that she was aware that occasionally there was urine odors down the 500 and 600 halls, but she felt that the strong odor down the 500-hall was from a resident with an ostomy, which is a hole in the abdominal wall allows waste to leave the body and collects the waste in a bag. An interview on 05/02/24 at 12:00 PM with Nursing Assistant (NA) #11 revealed that she worked on the 500-hall frequently. She stated that the urine smell was bad on 500-hall. She stated staff would spray down the hall but felt they did not have enough housekeeping staff, or they weren't doing their job. An interview on 05/02/24 at 12:08 PM with NA #10 revealed that she worked on the 500-hall at times. She stated that the 500 and 600 halls usually had a strong urine odor, but in the last couple of days it has been better since surveyors were in the facility. An interview on 05/02/24 at 12:10 PM with NA #9 revealed that she worked on the 500 and 600-halls. She stated the two halls had a strong urine odor. An interview was conducted with the Administrator on 05/02/24 at 5:15 PM. She revealed they were making progress and were improving residents' living environment to make it more home-like, and that it would take time. She said there were still areas in the facility that still needed to be addressed and they were actively putting plans in place through their Quality Assurance and Performance Improvement (QAPI) plan to address those areas she observed during the survey. She said her additional concerns included: repair and paint needed in resident rooms/bathrooms, repair or replace of commodes, and repair or replace of any other identified physical plant concerns that needed to be addressed. She said she was not sure where the strong odors down the 500 and 600 halls were coming from but did say a few of the residents' bathrooms had strong urine and feces odor which could have been caused by leaking toilets, the black greenish substance from the commode base caulking, or from the stained torn linoleum around the bases of some of the commodes observed. The Administrator stated it was her expectation for all the residents to have a safe and homelike environment that was clean and in good repair. 35173 2b. An initial tour of the facility was conducted on 04/29/24 at 10:55 AM. Prior to entering the 600 hall, which was noted to have an entry way where the 600 hall was to right of the entrance, a very strong odor of urine was detected. Once on 600 hall the odor was stronger and more pungent. There was a dirty linen bin and a trash bin noted on each end of the hall. Each bin had a closed lid, and they were not overflowing with dirty linens. A room deodorizing wall unit was noted to be in place at the top end of the 600 hall. An interview was conducted with Resident #49 on 04/29/24 at 11:00 AM. Resident #49 was alert and oriented and resided on the lower end of the 600 hall. Resident #49 stated the urine smell was so bad at times, she had to keep her door closed. Resident #49 stated some days were worse than others and today (04/29/24) it was bad. Resident #49 stated the strong odor had been present for a couple of months. Resident #49 stated she notified the nursing staff of her concerns regarding the odor in the past but she did not think anything was done about it. An interview was conducted with Housekeeper #1 on 04/29/24 at 11:17 AM. Housekeeper #1 stated she noticed the urine odor as well, but she did not have any more room deodorizer on her cart to spray in the hall way. Housekeeper #1 was not sure if the deodorizer on the wall was working or if it needed to be refilled. She stated the Maintenance Director managed the unit. An observation of the 600 hall during the lunch meal on 04/29/24 at 1:07 PM revealed the urine odor was still strong and pungent prior to entering the 600 hall entrance and while walking through the 600 hall. The dirty linen bins and the trash bins were not on the units during this observation. An observation of the 600 hall on 04/29/24 at 4:10 PM revealed the urine odor remained strong and pungent and unchanged. An observation of the 600 hall on 04/30/24 at 1:30 PM revealed the urine odor remained strong and pungent and unchanged. There was a dirty linen bin and a trash bin noted on each end of the hall. Each bin had a closed lid, and they were not overflowing with dirty linens. An interview was conducted with the Maintenance Director on 05/01/24 at 1:55 PM. The Maintenance Director stated he did not notice the smell because he had sinus issues. He stated the wall unit deodorizers were put in place to help with the odor. At this time, he checked the unit to make sure the canister was full of deodorizer and that the unit was in working condition. The Maintenance Director stated the unit was working and had plenty of deodorizer in the canister. He stated the unit will send off a small mist every 5 minutes. While standing near the unit and while it was misting, the odor it sent out was very light and barely noticeable. The Maintenance Director stated he could not smell the deodorizer but felt that he was desensitized to it. An interview was conducted with the Administrator on 05/02/24 at 5:00 PM. The Administrator stated the facility was actively working on making improvements to the 600 hall to improve the environment and she thought that the odor had improved.

Based on record review, staff, Pharmacy Consultant, and the Physician Assistant interviews the facility failed to: 1a) administer an as needed antihypertensive medication as prescribed by the physician for blood pressure greater than 160 millimeters of mercury (mm Hg) resulting in 2 missed doses (Resident #3), and 1b) failed to check a blood pressure prior to administering an antihypertensive medication with parameters to hold the medication if systolic (the top number of a blood pressure reading that measures the pressure in the arteries when the heart beats) blood pressure was less than 100 (Resident #3), and 2) failed to check a resident's blood pressure prior to administering a scheduled nitrate medication used to treat angina (chest pain) with parameters to hold the medication if systolic blood pressure was less than 100 (Resident #10), and 3.) administer the full course of the oral antibiotic Ciprofloxacin prescribed for treatment of a urinary tract infection according to the Physicians order (Resident #91), and 4.) discontinue an order for the antibiotic Clindamycin and an opioid medication Oxycodone. This resulted in the resident receiving 16 additional doses of Clindamycin and 15 additional doses of Oxycodone. This occurred for 4 of 5 residents reviewed for medication administration. Findings included: 1a. Resident #3 was admitted to the facility on [DATE]. Diagnoses included, in part, stroke with left side weakness and high blood pressure. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #3 was cognitively intact. A review of the physician orders for Resident #3 revealed an order written on 01//18/23 for Clonidine HCI (high blood pressure medication) oral tablet 0.1 milligrams give one tablet every 6 hours as needed for hypertension if systolic blood pressure greater than 160 mm/hg. A review of the blood pressure recordings for Resident #3 for February 2024 revealed on 02/15/24, Resident #1's blood pressure was recorded at 5:27 AM on 02/15/24 by Nurse #7 as 189 /93 mm/hg and on 2/15/24 at 10:25 AM as 172 / 88 mmHg by Nurse #1. A review of the February Medication Administration Record revealed the Clonidine 0.1 milligram was not administered as ordered on 02/15/24 by Nurse #7 or Nurse #1. Nurse #7 no longer worked at the facility and was unavailable for interview. Nurse #1 was interviewed on 05/02/24 at 9:37 AM and she reported when a medication was administered it was signed off in the medication administration record and a check mark would appear with the nursing initials. She stated if there was no checkmark or initials then it was not given. She stated in regard to the Clonidine 0.1 mg on 02/15/24, she said she may have given the medication to Resident #3 but could not say with 100% certainty because she did not sign it off. She stated it was important to sign off any medication that was administered so nursing staff would know that a medication was given and could monitor for effectiveness. Nurse #1 reviewed the blood pressure recordings and confirmed that the blood pressure was high at 5:27 AM with a reading of 189/93 mm/hg and it was not signed off as given by Nurse #7. She stated she could not recall if Nurse #7 passed on in report that as needed Clonidine was given due to systolic blood pressure greater than 160 mm at 5:27 AM. An interview with the Physician Assistant on 05/02/24 at 11:10 AM revealed the resident's blood pressure was elevated at 5:27 AM and remained elevated at 10:25 AM. She would have expected the medication to be given at 5:27 AM and if it had, it may not have remained elevated at 10:25 AM. The Physician Assistant stated the medication should have been administered when the nurse noted the blood pressure was 172/88mm/hg. An interview with the Director of Nursing on 05/02/24 at 4:48 PM revealed she would have expected the nursing staff to administer the ordered as needed Clonidine to help with lowering Resident #1's blood pressure. She stated the necessity of blood pressure medication was to lower the blood pressure and the nurses should have administered the medication on 02/15/24. The DON added that documenting whether or a not a medication was given was important because it was your verification that the medication was given. 1b. A review of the physician orders for Resident #3 revealed an order written on 03/01/24 for Enalapril Maleate tablet 20 milligrams give one tablet in the morning for hypertension; hold for systolic blood pressure less than 100, and an order written on 03/22/23 Amlodipine Besylate tablet 5 milligrams give one tablet every 12 hours for hypertension; hold for systolic blood pressure less than 100. A review of the Medication Administration Record for May 2024 revealed on 05/01/24 Nurse #1 administered the ordered Enalapril 20 milligrams and Amlodipine 5 milligrams at 9:00 AM as evidenced by her nursing initials and a check mark. An interview with Nurse #1 on 05/01/24 at 10:50 AM revealed she did not obtain a blood pressure prior to administering Resident #1's blood pressure medications. Nurse #1 reviewed the current physician orders in the medication administration record and confirmed the order for the blood pressure medications had parameters to hold if the systolic blood pressure was less 100 mm/hg. Nurse #1 stated she did not check the blood pressure before she administered the two medications and she should have per the order. She stated it was important to check the blood pressure before administering blood pressure medications because if her blood pressure was too low and she received the medications it could be dangerous. Nurse #1 reported according to the medical record the last time the blood pressure was taken for Resident #1 was at 3:00 AM on 05/01/24 and it was recorded as 120/63mm/hg. An interview with the Physician Assistant on 05/02/24 at 11:10 AM revealed she would have expected the nursing staff to follow the orders and obtain a blood pressure prior to administering the blood pressure medications. She added, the parameters were in the order for a reason and if the systolic blood pressure was less than 100 the medication should have been held. She stated without obtaining the blood pressure prior to administration a resident was at risk for lowering the blood pressure unnecessarily. An interview with the Director of Nursing on 05/02/43 at 4:48 PM revealed she would expect the nursing staff to follow the physician orders and obtain a blood pressure before administering blood pressure medications if the order indicated parameters to hold the medication. She added, the blood pressures medications were given to manage blood pressures and it was important to know what their blood pressure was before administering. The necessity of the drug was to lower the blood pressure and if a nurse gives a blood pressure medication when your blood pressure was already too low it could affect the resident with a negative outcome. 45711 2). Resident #10 was admitted on [DATE] with diagnosis which included in part: heart disease and hypertension. Review of Resident #10's care plan revealed a focus last revised on 4/18/24 indicated a focus of altered cardiovascular status related to angina (chest pain) and coronary artery disease. Interventions indicated in part administer medications as order and monitor for side effects and effectiveness. Review of Resident #10's 3/13/24 quarterly Minimum Data Set (MDS) assessment revealed resident was cognitively intact. Review of Resident #10's physician orders revealed a 4/8/24 order for Isosorbide Dinitrate Oral Tablet 5 milligrams. Give 1 tablet by mouth two times a day for angina. Hold for systolic blood pressure less than100. Review of Resident #10's April 2024 Medication Administration Record (MAR) revealed the following entry: Isosorbide Dinitrate Oral Tablet 5 milligrams. Give 1 tablet by mouth two times per day for Antianginal. Hold for systolic blood pressure less than100. Start date 4/08/2024. The entry did not include an entry for blood pressure monitoring. The MAR indicated the medication Isosorbide Dinitrate was administered daily at 8:30 AM and 8:30 PM. Review of Resident #10's electronic health record revealed the following blood pressures were recorded: 4/10/2024 5:31 AM 128/87 millimeters of mercury (mm/Hg) 4/12/2024 5:35 AM 132 / 82 mmHg 4/13/2024 4:24 AM 130 / 78 mmHg 4/14/2024 4:18 AM 159 / 77 mmHg 4/15/2024 4:05 AM 148 / 87 mmHg 4/16/2024 4:30 AM 145 / 80 mmHg 4/17/2024 5:34 AM 136 / 78 mmHg 4/18/2024 5:38 AM 128 / 76 mmHg 4/19/2024 6:21 AM 142 / 71 mmHg 4/20/2024 5:24 AM 136 / 76 mmHg 4/21/2024 6:06 AM 137 / 80 mmHg 4/22/2024 6:05 AM 134 / 74 mmHg 4/23/2024 4:41 AM 131 / 87 mmHg 4/24/2024 5:45 AM 136 / 83 mmHg 4/25/2024 5:34 AM 128 / 76 mmHg 4/26/2024 5:19 AM 130 / 72 mmHg 4/27/2024 6:04 AM 142 / 68 mmHg 4/28/2024 5:41 AM 138 / 77 mmHg 4/30/2024 4:00 AM 107 / 61 mmHg Review of a 4/24/24 pharmacy recommendation for nursing follow up indicated Resident #10 had an order to withhold Isosorbide Dinitrate if systolic blood pressure was less than 100. Review of the electronic MAR indicated the blood pressure was not routinely charted prior to medication administration. Recommendation was made to update the electronic MAR to include charting of the blood pressure with each dose of medication. Review of the May 2024 MAR revealed on 5/2/24 Nurse #2 administered the ordered Isosorbide Dinitrate at 9:00 AM as evidenced by her initials and a check mark. An interview on 5/2/24 at 10:10 AM with Nurse #2 revealed she administered Resident #10's 9:00 AM medications including Isosorbide Dinitrate. Nurse #2 stated she must have missed the part of the order that indicated to hold the medication if the systolic blood pressure was less than 100. An interview was conducted on 5/2/24 at 10:30 AM with the Unit Manager. The Unit Manager stated when an order for a medication was entered into the computer, if there was a parameter to hold for a certain blood pressure reading, then the blood pressure monitoring should be linked to the order so that the readings are documented with the administration of the medication. The Unit Manager stated the order for Isosorbide Dinitrate for Resident #10 was entered incorrectly and did not include the required blood pressure monitoring and documentation. An interview on 5/2/24 at 11:30 AM with the Physician Assistant revealed she expected that the blood pressure would be taken prior to each administration of a medication with a parameter. If the resident received the medication twice per day, the Physician Assistant stated she expected the blood pressure to be checked and documented twice per day. The PA stated it was important to document the blood pressure readings to determine if there was a trend and she would need the complete documentation to evaluate this. She added the parameters were in the order for a reason and if the systolic blood pressure was less than 100 the medication should have been held. Interview on 5/2/24 at 3:30 PM with the Director of Nursing revealed she expected the nursing staff to follow the physician order and obtain a blood pressure prior to each administration of a medication if the order indicated a parameter to hold the medication. 40044 3.)Resident #91 was admitted to the facility on [DATE] with diagnoses including urinary tract infection. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #91 was cognitively intact. He had no rejection of care and received antibiotics. A care plan dated 04/30/24 revealed Resident #91 had a urinary tract infection and was at risk for complications. Interventions included to administer antibiotic therapy as ordered. A physicians order dated 04/22/24 for Resident #91 revealed Ciprofloxacin 250 milligrams, give 1 tablet by mouth every 12 hours for Infection for 5 Days. Review of the Medication Administration Record (MAR) dated April 2024 for Resident #91 revealed Ciprofloxacin 250 milligrams to give 1 tablet by mouth every 12 hours for infection for 5 Days. The medication was scheduled to be administered at 9:00 AM and 9:00 PM. The first dose was scheduled to be given on 04/22/24 at 9:00 PM. The MAR revealed only 7 of the 10 prescribed doses were administered. The MAR revealed the following: 04/22/24 at 9:00 PM the medication was not administered. 04/23/24 at 9:00 AM the medication was signed as administered. 04/23/24 at 9:00 PM the medication was not administered. Code 9 was entered on the MAR which indicated to see nursing notes. 04/24/24 at 9:00 AM the medication was not administered. Code 9 was entered on the MAR which indicated to see nursing notes. 04/24/24 at 9:00 PM the medication was signed as administered. 04/25/24 at 9:00 AM the medication was signed as administered. 04/25/24 at 9:00 PM the medication was signed as administered. 04/26/24 at 9:00 AM the medication was signed as administered. 04/26/24 at 9:00 PM the medication was signed as administered. 04/27/24 at 9:00 AM the medication was signed as administered. Review of the nursing progress notes for Resident #91 dated 04/23/24 at 9:00 PM and 04/24/24 at 9:00 AM revealed no documentation as to why Ciprofloxacin 250 mgs was not administered. During an interview on 05/01/24 at 10:00 AM the Physician indicated the full course of antibiotics should have been administered to Resident #91 according to the order. He stated there would be no significant outcome from not receiving the full 10 days of antibiotic treatment. He indicated Resident #91 had improved and had no further concerns. During an interview on 05/02/24 at 12:42 PM the unit manager stated she was not aware Resident #91 did not receive the full course of Ciprofloxacin. She indicated the missed doses were likely due to the medication not being received from Pharmacy at that time. She reported she had discussed with the Physicians to hold antibiotic orders until the medication was received from Pharmacy so that the administration dates were accurate in order for the resident to get the full course. She stated the dates should have been adjusted on the MAR when the medication was received from Pharmacy to ensure the exact doses were given. She indicated that was not done. The assigned nurses for Resident #91 on 04/22/24, 04/23/24, and 04/24/24 were not in the facility during the investigation and unavailable for interview. During an interview with the Director of Nursing on 05/02/24 at 2:30 PM she stated medication orders should be followed and administered according to the physicians orders. She indicated education would be provided to nursing staff on medication administration. 4.) Resident #401 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the left lower limb and history of opioid dependence. The hospital discharge summary dated 04/22/24 included orders for Resident #401 for Clindamycin 150 milligrams (mg) take 3 capsules (450 mg) by mouth every 8 hours for 4 days. The hospital discharge summary dated 04/22/24 included orders for Resident #401 for Oxycodone 5 mgs immediate release. Take one tablet by mouth every 4 hours as needed for pain for up to 5 days. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #401 was cognitively intact. Review of the Medication Administration Record (MAR) dated April 2024 for Resident #401 revealed Clindamycin 150 milligrams (mg) take 3 capsules (450 mg) by mouth every 8 hours for 4 days. Clindamycin was initialed as administered to Resident #401 on the following dates and times which resulted in Resident #401 receiving 16 additional doses: The order should have been discontinued after 12 doses. 04/22/24 at 11:00 PM 04/23/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/24/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/25/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/26/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/27/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/28/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/29/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/30/24 at 7:00 AM, 3:00 PM, and 11:00 PM Review of the Medication Administration Record (MAR) dated May 2024 revealed Clindamycin was administered to Resident #401 on the following dates and times: 05/01/24 at 7:00 AM, 3:00 PM, and 11:00 PM 05/02/24 at 7:00 AM Review of the Medication Administration Record (MAR) dated April 2024 for Resident #401 revealed Oxycodone 5 mgs give 1 tablet by mouth every 4 hours as needed for pain for 4 days. Oxycodone 5 mgs as needed was initialed as administered to Resident #401 on the following dates and times: This order should have been discontinued on 04/26/24. 04/22/24 at 10:43 PM 04/23/24 at 05:21 AM and 01:30 PM. 04/24/24 at 06:24 AM and 08:20 PM. 04/25/24 at 04:14 AM, 09:28 AM, and 03:46 PM. 04/26/24 at 06:22 AM, 01:22 PM, and 08:52 PM. 04/27/24 at 06:33 AM, 01:14 PM and 09:22 PM. 04/28/24 at 08:01AM and 03:34 PM. 04/29/24 at 12:15 AM, 09:36 AM, and 05:14 PM 04/30/24 at 05:50 AM, 10:21 AM, 02:34 AM, and 06:33 PM. Review of the Medication Administration Record (MAR) dated May 2024 revealed Oxycodone 5 mgs was administered to Resident #401 on the following dates and times: 05/01/24 at 04:39 AM, 10:52 AM, and 02:25 AM 05/02/24 at 07:00 AM. During an interview on 05/02/24 at 2:00 PM Nurse #3 acknowledged that she was the nurse that entered the orders from the hospital discharge summary for Resident #401 and indicated she should have entered a date for the Clindamycin to be discontinued after 4 days and entered a date for the Oxycodone to be discontinued after 4 days. Nurse #3 stated that if she did not enter dates for discontinuing the medications for Resident #401's Clindamycin or Oxycodone that it was done in error. During an interview with Resident #401 on 05/01/24 at 11:00 AM she was observed sitting in her wheelchair in her room. She indicated she had no concerns with receiving her medications. She had no complaints of nausea, vomiting or loose stools. During an interview on 05/02/24 at 10:30 AM the Physician Assistant stated Resident #401 did not experience any significant outcome from receiving this medication beyond the ordered time period. She stated receiving an antibiotic for a longer period of time could put a resident at risk of an infection such as C-Diff (clostridium difficile - a bacteria that causes infection of the colon which often occurred after using antibiotics). She stated overuse of an opioid could lead to dependence. During a phone interview on 05/02/24 at 5:00 PM the Consultant Pharmacist stated she had not completed the medication regimen review for Resident #401 at this time. She indicated there would be no significant outcome for receiving extra doses of Clindamycin. She indicated antibiotics could cause infection such as Clostridium Difficile. She stated the additional doses of Oxycodone that Resident #401 should not cause her any adverse outcome. During an interview on 05/02/24 at 4:43 PM the Director of Nursing (DON) stated she was not aware the orders for Resident #401 were not discontinued according to the physicians order. She stated she expected the nursing staff to follow the hospital discharge summary and enter orders correctly. She indicated the nurses or unit managers entered medications into the electronic medical record. She stated the physician would be notified and education would be provided on medication administration.

Based on observations, record review, staff and Physician Assistant interviews the facility failed to discontinue an order for the antibiotic Clindamycin and an opioid medication Oxycodone. This resulted in the resident receiving 16 additional doses of the Clindamycin and 15 additional doses of the Oxycodone. This occurred for 1 of 5 residents reviewed for unnecessary medications (Resident #401). Findings included. Resident #401 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the left lower limb and history of opioid dependence. The hospital discharge summary dated 04/22/24 included orders for Resident #401 for Clindamycin 150 milligrams (mg) take 3 capsules (450 mg) by mouth every 8 hours for 4 days. The hospital discharge summary dated 04/22/24 included orders for Oxycodone 5 mgs immediate release. Take one tablet by mouth every 4 hours as needed for pain for up to 5 days. Review of the Medication Administration Record (MAR) dated April 2024 for Resident #401 revealed Clindamycin 150 milligrams (mg) take 3 capsules (450 mg) by mouth every 8 hours for 4 days. Clindamycin was initialed as administered to Resident #401 on the following dates and times which resulted in Resident #401 receiving 16 additional doses. The order should have been discontinued after 12 doses. 04/22/24 at 11:00 PM 04/23/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/24/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/25/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/26/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/27/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/28/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/29/24 at 7:00 AM, 3:00 PM, and 11:00 PM 04/30/24 at 7:00 AM, 3:00 PM, and 11:00 PM Review of the Medication Administration Record (MAR) dated May 2024 revealed Clindamycin was administered to Resident #401 on the following dates and times: 05/01/24 at 7:00 AM, 3:00 PM, and 11:00 PM 05/02/24 at 7:00 AM Review of the Medication Administration Record (MAR) dated April 2024 for Resident #401 revealed Oxycodone 5 mgs give 1 tablet by mouth every 4 hours as needed for pain for 4 days. Oxycodone 5 mgs as needed was initialed as administered to Resident #401 on the following dates and times. The order should have been discontinued on 04/26/24. 04/22/24 at 10:43 PM 04/23/24 at 05:21 AM and 01:30 PM. 04/24/24 at 06:24 AM and 08:20 PM. 04/25/24 at 04:14 AM, 09:28 AM, and 03:46 PM. 04/26/24 at 06:22 AM, 01:22 PM, and 08:52 PM. 04/27/24 at 06:33 AM, 01:14 PM and 09:22 PM. 04/28/24 at 08:01AM and 03:34 PM. 04/29/24 at 12:15 AM, 09:36 AM, and 05:14 PM 04/30/24 at 05:50 AM, 10:21 AM, 02:34 AM, and 06:33 PM. Review of the Medication Administration Record (MAR) dated May 2024 revealed Oxycodone 5 mgs was administered to Resident #401 on the following dates and times: 05/01/24 at 04:39 AM, 10:52 AM, and 2:25 AM. 05/02/24 at 07:00 AM. During an interview on 05/02/24 at 2:00 PM Nurse #3 acknowledged that she was the nurse that entered the orders from the hospital discharge summary for Resident #401 and indicated she should have entered a date for the Clindamycin to be discontinued after 4 days and entered a date for the Oxycodone to be discontinued after 5 days. Nurse #3 indicated that if she did not enter dates for discontinuing the medications for Resident #401's Clindamycin or Oxycodone that it was done in error. During an interview on 05/02/24 at 10:30 AM the Physician Assistant stated the order for Resident #401's Clindamycin and Oxycodone should have been discontinued according to the hospital discharge summary. During an interview on 05/02/24 at 4:43 PM the Director of Nursing (DON) stated she was not aware the orders for Resident #401 were not discontinued according to the physicians order. She stated she expected the nursing staff to follow the hospital discharge summary and enter orders correctly. She indicated the nurses or unit managers entered medications into the electronic medical record. She stated the physician would be notified and education would be provided on medication administration.

Based on record review and staff, Registered Dietician (RD) and Physician Assistant (PA) interviews, the facility failed to 1.) obtain and record accurate weights per physician order and verify the accuracy of a resident with a significant change in weight (Resident #47), and 2.) obtain weekly weights according to the physicians order and provide nutritional supplements for a resident with weight loss (Resident #81). This occurred for 2 of 2 residents reviewed for nutrition (Resident # 47 and Resident # 81). The findings included: 1). Resident #47 was admitted to the facility on [DATE] with medical diagnosis stroke, diabetes, and dysphagia (swallowing difficulty). Review of Resident #47's electronic health record revealed a 3/10/23 physician order for Osmolite 1.5 100 cubic centimeters (cc's) per hour for 13 hours daily related to moderate protein calorie malnutrition and dysphagia. The order was discontinued on 3/10/24. The following weights were recorded in Resident #47's electronic medical record: 1/2/24 150.0 pounds (lbs.) wheelchair 1/8/24 147.8 lbs. chair scale 1/10/24 142.0 lbs. wheelchair scale 2/2/24 190.8 lbs. wheelchair scale Review of Resident #47's electronic health record revealed a 2/19/24 physician order for weekly weights. The following weights were recorded in Resident #47's electronic medical record: 2/19/24 no weight recorded. 2/26/24 no weight recorded. 3/6/24 190.5 lbs. chair scale Review of Resident #47's electronic health record revealed a 3/10/24 physician order for Osmolite 1.5 100 milliliters per hour for 12 hours daily related to moderate protein calorie malnutrition and dysphagia. The following weights were recorded in Resident #47's electronic medical record: 3/13/24 no weight recorded. 3/18/24 192.2 lbs. wheelchair scale 3/25/24 192.6 lbs. mechanical lift scale 3/27/24 152.8 lbs. wheelchair scale 4/3/24 156.0 lbs. sitting. 4/7/24 136.0 lbs. wheelchair scale 4/14/24 no weight recorded. 4/21/24 no weight recorded. 4/28/24 no weight recorded. No weight was recorded during the survey. Review of Resident #47's 4/5/24 annual Minimum Data Set (MDS) assessment revealed resident had severe cognitive impairment, weight of 156 pounds, with no weight loss or gain and received all nutrition via feeding tube. A revised 4/17/24 care plan focus indicated Resident #47 had a nutritional problem related to malnutrition with a history of weight fluctuations with dysphagia and needing all nutrition via tube feeding. An intervention indicated Resident #47 was to be weighed at the same time of the day and recorded per the physician order. Review of Resident #47's electronic health record revealed a dietary progress note dated 4/30/2024. The registered dietician (RD) progress note indicated weight and enteral review for resident was completed. Resident with significant weight loss in the past 1 month, previously with significant weight gain. The RD note indicated to monitor weight trends and adjusted the nutrition plan of care with recommendations as appropriate. An interview was conducted with Nursing Assistant (NA)# 2 on 5/1/24 at 11:55 AM. NA # 2 indicated she was frequently assigned to Resident #47. NA #2 stated the nursing assistants were responsible for obtaining and recording the weights. NA # 2 stated the nurse informed the NAs which residents needed to be weighed each day. NA #2 stated she often did not have enough time during her shift to obtain resident weights, including the weights for Resident #47 An interview was conducted with the Registered Dietitian (RD) on 5/1/24 at 3:20 PM. The RD stated she had observed inaccurate weights and had a concern regarding the accuracy of the weights. The RD stated she expected the weight would be stable for a resident that received enteral feeding for their primary nutrition. The RD stated she was not sure if the weights recorded for Resident #47 were accurate. The RD stated if a resident had a significant weight change, a reweigh should be obtained as soon as possible after the change was observed. The RD further stated if a resident had an order for weekly weights, she expected the weights to be obtained and recorded. The RD indicated accurate weights were important for evaluation of Resident #47's tube feeding and nutritional status. The RD stated the weights recorded for Resident #47 were questionable. An interview was conducted with the Director of Nursing (DON) on 5/1/24 at 4:30 PM. The DON stated the facility had recently started a performance improvement plan on weights. Review of the Quality Assurance Performance Improvement (QAPI) program provided by the DON indicated a 4/16/24 plan was initiated for weight management and accuracy of weights. The plan indicated weights would be accurate and entered timely and followed up on accordingly. Interventions and systemic changes indicated weights would be reviewed monthly by the DON prior to data entry to alert for any questionable inaccuracies for reweight, prior to entering in the electronic medical record. The plan indicated no in-service training was implemented with staff. Monthly Quality Assurance Performance Improvement (QAPI) will review compliance with weight plan and make recommendations. QAPI will review for 3 months or longer as needed. An interview was conducted on 5/2/24 at 10:30 AM with the Unit Manager. The Unit Manager revealed there had been issues with the weights. The Unit Manager stated the nurse informed the NA each day which residents required weights to be obtained. The Unit Manager indicated the Director of Nursing was responsible for reviewing the weights. An interview was conducted with the Physician Assistant (PA) on 5/2/24 at 12:05 PM. The PA revealed she was not aware that weekly weights were not obtained on Resident #47 and was not aware of the weight change for the resident. The PA stated she expected that weights would be obtained according to the order, and she expected a resident receiving tube feeding would not exhibit weight changes. The PA further indicated she expected a reweigh would be obtained when a change in weight was observed. A follow-up interview was conducted with the Director of Nursing on 5/2/24 at 3:30 PM. The DON indicated she expected that weights would be obtained per physician orders and would be accurate. The DON stated there was a systems process failure that caused the problems with weights not being obtained as ordered or not accurate. 40044 2.) Resident #81 was admitted to the facility on [DATE] with diagnoses including dementia, chronic kidney disease, heart disease, and dehydration. A care plan dated 04/27/23 for Resident #81 revealed the potential for alteration in hydration and nutrition related to requiring fortified foods, dementia, and chronic kidney disease. The goal of care was to maintain adequate nutritional status. Interventions included in part to provide and serve nutrition supplements as ordered and obtain weights per protocol. A physicians order dated 05/03/23 for Resident #81 was to obtain weekly weights every Wednesday for monitoring. Review of Resident #81's weights recorded in the electronic medical record revealed the following: 05/01/2024 120.0 Lbs. 04/07/2024 122.8 Lbs. 03/13/2024 128 .1 Lbs. 03/01/2024 125.2 Lbs. 02/28/2024 126.4 Lbs 02/15/2024 130.8 Lbs 02/01/2024 131.4 Lbs 01/31/2024 130.6 Lbs 01/18/2024 131.8 Lbs 12/27/2023 140.7 Lbs 12/20/2023 140.6 Lbs 11/29/2023 142.1 Lbs 11/22/2023 142.0 Lbs 11/15/2023 141.5 Lbs 11/08/2023 137.6 Lbs 10/25/2023 141.4 Lbs 10/18/2023 141.5 Lbs 10/11/2023 141.6 Lbs 10/04/2023 176.0 Lbs 09/20/2023 176.0 Lbs 08/30/2023 173.6 Lbs 08/23/2023 173.6 Lbs 08/09/2023 172.4 Lbs. 08/02/2023 174.1 Lbs 07/26/2023 169.4 Lbs 07/19/2023 169.2 Lbs 07/12/2023 169.1 Lbs 07/01/2023 169.2 Lbs 06/28/2023 168.1 Lbs 06/21/2023 168.0 Lbs 06/14/2023 168.1 Lbs 06/07/2023 168.0 Lbs 06/02/2023 168.8 Lbs. 05/31/2023 167.4 Lbs 05/24/2023 166.2 Lbs 05/10/2023 170.3 Lbs 05/03/2023 170.3 Lbs. A physicians order dated 02/23/24 for Resident #81 revealed Fortified diet and Nutritional Supplement three times a day for supplement to be provided on the meal tray. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #81 had severely impaired cognition. She required staff assistance with activities of daily living. She had weight loss and received a therapeutic diet. She had no rejection of care. During an observation on 04/29/24 at 1:00 PM Resident #81 was observed lying in bed. She could not answer detailed questions regarding her nutrition. Her family member was at the bedside and stated she usually visited daily for lunch. She reported her appetite was poor. There was no nutritional supplement provided on the meal tray. During an observation on 04/30/24 at 9:15 AM Resident #81 was observed lying in bed. There was no nutritional supplement on her breakfast tray. Her breakfast meal included eggs, sausage, and milk. During an observation on 04/30/24 at 01:59 PM Resident #81 was observed lying in bed. Her family member was at the bedside and stated she visited daily during lunch, and she had not been receiving supplements lately. She stated with her poor appetite she thought the supplements would benefit her. During an interview on 05/01/24 at 03:29 PM the Dietary Manager stated she did not have the order for the nutritional supplement in her order system for Resident #81 and that was why it did not populate on the meal slip. She indicated she did not know why it was missed and was not in her system. She stated she would correct the order immediately and ensure Resident #81 was provided the nutritional supplement three times a day on her meal tray. During a phone interview on 05/02/24 at 10:15 AM the Registered Dietician indicated she last reviewed Resident #81 on 04/09/24 and she had weight loss. She reported Resident #81 received a fortified diet, appetite stimulants, and nutritional supplements. She indicated there had been issues with weight consistencies and they had discussed this in the Interdisciplinary Team (IDT) meetings. She reported she was not aware Resident #81 was not receiving the nutritional supplement according to the order that was dated February 2024. She stated they recently did audits of the nutritional supplements 2 or 3 weeks ago and thought they had captured any inconsistencies and didn't know how this was missed. She stated the Dietary Manager spoke with her yesterday about this order and it was corrected. She reported she didn't know what the miscommunication was regarding not obtaining weekly weights for Resident #81. She stated weekly weights were needed to assess for weight loss and the nutritional supplement should be provided according to the order. During an interview on 05/02/24 at 12:05 PM Nurse Aide #8 stated the nurse would write on the assignment sheet which residents needed to be weighed each day. She stated Resident #81 was weighed in a weight chair or with the mechanical lift. She stated she usually gets her to stand up with 2-person assistance to obtain her weight. Once she gets the weight she reports it to the nurse. She stated she relied on the nurses to notify the nurse aides of who needed weights each day. She stated Resident #81 did get a nutritional supplement sometimes but not consistently and stated the nutritional supplements were provided by the Kitchen staff. She stated she looked at the meal slips most of the time to make sure the diet was accurate, and everything was on the tray. She indicated she didn't realize Resident #81 was supposed to get a nutritional supplement with each meal. During an interview on 05/02/24 at 11:00 AM the Physician Assistant stated she evaluated Resident #81 today and she was not aware weekly weights weren't getting done. She indicated Resident #81 was at risk for nutritional decline and had weight loss and expected weights to get done according to the order. She stated she was not aware she was not receiving the nutritional supplement with each meal and expected she received the nutritional supplement three times a day. During an interview on 05/02/24 at 12:32 PM the Unit Manager stated there had been issues with obtaining weights. She stated the nurse was supposed to let the nurse aides know each day who needed weights. She reported they tried to get the weights on the residents' shower days. They had discussed getting a weekly weight schedule posted behind the nurses station so that staff could see who needed weights done. She indicated more work was needed to improve the process for obtaining weights. She stated the nutritional supplements were provided by the Kitchen staff and should have been provided on Resident #81's meal tray. During an interview with the Director of Nursing (DON) on 05/02/24 at 10:45 AM she stated they had identified an issue with obtaining weights and accuracy of weights. She stated they had been working on correcting the process. She stated they were now having nurse aides obtain weekly weights on shower days so that if the resident refused, they could get the weight on the next shower day that week due to residents getting showers twice a week. She indicated more work including education was needed to correct their process. She stated weights should be obtained and nutritional supplements provided according to the physicians order.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of Hospice services, respiratory care, nutrition and weight loss, unnecessary medications, and communication and sensory for 5 of 35 residents whose MDS assessments were reviewed (Residents #19, #47, #35, #17 and # 1). Findings included: 1. Resident #35 was admitted to the facility on [DATE] with diagnosis which included in part vascular dementia with behaviors and dementia with agitation. Review of Resident #35's electronic health record revealed a 1/23/24 Physician Assistant progress note which indicated a problem of debility with decline and was followed by Hospice. Review of Resident #35's electronic health record revealed a Hospice progress note dated 2/1/24. Further review of Resident #35's health record revealed a Hospice Team Care Plan Hospice program note which indicated resident was admitted to Hospice services on 10/20/23 and continued to receive Hospice services. Review of Resident #35's 2/1/24 quarterly Minimum Data Set (MDS) assessment revealed Hospice services while a resident was coded as No. An interview was conducted on 5/1/24 at 3:35 PM with the MDS Coordinator. The MDS Coordinator stated it was an error that Hospice was not coded on the 2/1/24 quarterly MDS assessment. An interview was conducted on 5/2/24 at 3:30 PM with the Director of Nursing (DON). The DON revealed that she expected that the MDS assessments would be completed accurately. 2. Resident #47 was admitted to the facility on [DATE] with medical diagnosis stroke, diabetes, and dysphagia (swallowing difficulty). The following weights were recorded in Resident #47's electronic medical record: 1/2/24 150.0 lbs. wheelchair 1/8/24 147.8 lbs. chair scale 1/10/24 142.0 lbs. wheelchair 2/2/24 190.8 lbs. wheelchair 3/6/24 190.5 lbs. chair scale 3/18/24 192.2 lbs. wheelchair scale 3/25/24 192.6 lbs. mechanical lift scale 3/27/24 152.8 lbs. wheelchair scale 4/3/24 156.0 lbs. sitting. Review of Resident #47's 4/5/24 annual Minimum Data Set (MDS) assessment revealed resident had severe cognitive impairment and a weight of 156 pounds. Resident #47's assessment was coded as had no weight loss or gain in the past 30 days or 180 days. An interview was conducted on 5/2/24 at 3:05 PM with the MDS Coordinator. The MDS Coordinator revealed that she was aware of how to calculate a weight change per the Resident Assessment Instrument (RAI) manual and Resident #47's 4/5/24 MDS assessment was coded in error. An interview was conducted on 5/2/24 at 3:30 PM with the Director of Nursing (DON). The DON revealed that she expected that the MDS assessments would be completed accurately. 3. Resident #19 was admitted to the facility on [DATE] with diagnosis which included obstructive sleep apnea, obesity hypoventilation syndrome, chronic obstructive pulmonary disease, asthma, and chronic congestive heart failure. Review of Resident #19's physician orders revealed an order dated 9/2/23 to place Continuous Positive Applied Pressure (CPAP) 10 centimeters water on resident every night at bedtime related to obstructive sleep apnea. Remove per schedule. Review of Resident #19's January 2024 Medication Administration Record (MAR) revealed entries for CPAP every night apply at bedtime related to obstructive sleep apnea were recorded. Review of Resident #19's 1/29/24 quarterly Minimum Data Set (MDS) indicated oxygen was received while a resident. CPAP while a resident was not coded on Resident #19's MDS. An interview was conducted on 5/2/24 at 3:05 PM with the MDS Coordinator. The MDS Coordinator revealed that Resident #19's 4/5/24 MDS assessment was coded in error, and it was a mistake that CPAP was not coded. An interview was conducted on 5/2/24 at 3:30 PM with the Director of Nursing (DON). The DON revealed that she expected that the MDS assessments would be completed accurately. 37673 4. Resident #17 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation and behavioral disturbance. The MDS assessment dated [DATE] for Resident #17 documented antipsychotic medication was not received on a daily basis. Review of the February 2024 Medication Administration Record for Resident #17 revealed he had been administered the antipsychotic medication Risperidone 1 milligram (mg) each morning and Risperidone 2.5 mg each evening. In an interview with the MDS Coordinator on 05/01/24 at 13:46 PM she stated the assessment was coded incorrectly and should have been coded to reflect that Resident #17 had received an antipsychotic medication on a daily basis. In an interview with the DON on 05/02/24 at 4:00 PM she stated she expected the MDS assessments to be coded correctly. 35173 5. Resident #1 was admitted to the facility on [DATE]. Diagnoses included hearing loss. The Minimum Data Set annual assessment dated [DATE] revealed Resident #1 was cognitively intact and was coded as having adequate hearing. A review of Resident #1's care plan revealed a plan of care dated 4/3/23 for at risk for communication declines related to hard of hearing. During an interview with Resident #1 on 04/29/24 she stated she was very hard of hearing and to speak loudly or write down any questions. Resident #1 reported she had hearing aids, but she did not wear them because they did not work right. An interview with Social Worker #1 on 05/02/24 at 2:15 PM revealed Resident #1 has been extremely hard of hearing since admission. Social Worker #1 confirmed he coded Resident #1 inaccurately regarding her hearing and instead of adequate it should have been coded as severely impaired. An interview with the Administrator on 05/02/24 at 5:30 PM revealed she expected the MDS assessments to accurately reflect the resident's condition.

Based on observations, record review, staff, Physician Assistant, Physician, Emergency Medical Service Responder, Adult Day Care staff nurse, and Pharmacist Consultant interviews, the facility failed to prevent a significant medication error when Medication Aide #1 administered Resident #1 medications prescribed to Resident #3 to include Clonazepam (a medication to treat anxiety classified as benzodiazepine) 1 milligram (mg) and Buprenorphine HCI-Naloxone (a medication to treat opioid addiction) 8mg/2 mg causing Resident #1 to become unresponsive. Resident #1 required 2 doses of Narcan (medication given to reverse opioid overdose) administered by Emergency Medical Services and was sent to the emergency room for further evaluation where it was determined he had a drug overdose as evidenced by the lab results testing positive for benzodiazepine and buprenorphine in Resident #1's blood stream. This deficient practice affected 1 of 4 residents reviewed for significant medication errors. Findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1 did not have a diagnosis of anxiety or opioid addiction. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and was not coded as receiving opioid medications or antianxiety medications. Review of the October 2023 physician orders for Resident #1 revealed there were no orders written for Clonazepam 1 mg or Buprenorphine HCI-Naloxone 8mg/2 mg. Resident #1 had no orders for antianxiety medication or opioids. Review of the Medication Administration Record (MAR) on 10/05/23 revealed Resident #1 received all of his scheduled medications as ordered and received Lispro insulin for a glucose blood sugar of 243 milligrams per deciliter (mg/dL) as evidenced by nursing initials and a checkmark on the MAR. Resident #3 was admitted to the facility on [DATE]. Review of the October 2023 active physician orders (initially written on 04/27/23) for Resident #3 revealed Clonazepam 1 mg three times daily for anxiety and Buprenorphine HCI-Naloxone sublingual (under the tongue) tablet 8mg/2 mg, give one tablet sublingually two times a day. A review of the Medication Administration Record on 10/05/23 revealed Resident #3 received his scheduled Buprenorphine HCI-Naloxone and Clonazepam as ordered as evidenced by nursing initials and a checkmark on the MAR. The Medication Monitoring Control Record used to record when controlled medications were given to a resident showed a control record for Resident #3 for Buprenorphine HCI-Naloxone 8mg/2mg one tablet sublingually twice daily. The control record was lined and numbered 1 through 20. It also included a column for date the medication was given, a column for the time it was given, a column for how many were left on hand, how many were administered and how many were remaining. On line number 17 of the control record it was recorded to have Medication Aide (MA) #1's name, the date 10/05/23, the time 9:31 AM with 14 on hand, removing 1 and remaining 13. There was a line drawn through what MA #1 recorded and the word error written. On the bottom half of the control record revealed a section labeled Record of waste and spoilage. The columns included a column for which line item number was being wasted, the date, the quantity, description of the waste, signature #1 and signature #2. MA #1 recorded for the item: #17 (to reference line #17), dated 10/05/23, with 1 tablet for the quantity and dropped in room by pt. under description. Nurse #4 signed under signature #1 and error was written under signature #2. There was a line drawn through this written documentation. The control record revealed on line #18 that MA #1 administered one tablet of Buprenorphine HCI-Naloxone 8mg/2mg at 9:30 AM verifying Resident #3 did receive the ordered medication. The Medication Monitoring Control Record for Resident #3 for Clonazepam 1mg one tablet three times daily revealed on line number 15 of the control record it was recorded to have Medication Aide #1's name, the date 10/05/23, the time 4:40 PM with 16 on hand, removing 1 and remaining 15. There was a line drawn through line #15 what MA #1 recorded and the word error written. On the bottom of the control record under Record of waste and spoilage revealed MA #1 recorded for the item column: #15, dated 10/05/23, 1 tablet for the quantity and dropped in room by pt. at 9:31 AM under description. Nurse #4 signed under signature #1 and error was written under signature #2. There was a line drawn through this written documentation. The control record revealed on line #14 that MA #1 administered one tablet of Clonazepam 1 mg at 9:30 AM and on line #16 at 4:40 PM verifying Resident #3 did receive the ordered medication. An interview was conducted with the Nurse Staff from the Adult Day Care Program (PACE) via phone on 11/07/23 at 3:17 PM. The PACE nurse discussed an incident with Resident #1 that occurred on 10/05/23. She stated the timeline of what had occurred at the center was as follows: - Driver from PACE arrived at the facility at 9:00 AM. Resident was alert and oriented and talkative. - At 10:00 AM the nurse aide assigned to Resident #1 was toileting him and he was very sleepy. - At 10:30 AM the nurse aide reported to the nurse that Resident #1 was very groggy. Nurse assessed the resident and he reported he was tired and did not sleep well last evening. - At 12:00 PM Resident #1 was noted to not have eaten his lunch and was lethargic. - At 12:50 PM nurse aide brought him to the restroom to toilet him and he required the sternum rub to stimulate him to wake up. Nurse was called to assess and vital signs were taken Blood Pressure (BP) was 130/77 millimeters of mercury (mm/Hg), heart rate (HR) 74 beats per minute (bpm), respiration rate (RR) 18 breaths per minute (bpm), temperature 97.8 and blood sugar was 110 milligrams per deciliter (mg/dL). The nursing note stated Resident #1 was able to follow commands with sternum rub (applying stimulus with knuckles of closed fist to the center of chest for a resident who was not alert and does not respond to verbal stimuli) and when asked to go back to his room, he replied yes, baby. - At 2:00 PM he appeared to be sleeping and nurse aide assisted the resident on to the van. - At 3:00 PM Resident #1 arrived at the facility and he was unable to be wakened, but he was breathing. The PACE nurse stated during the 11/07/23 phone interview that while at the center, Resident #1 received his ordered 8 units of long acting insulin Lispro and a nebulizer treatment, but he did not receive any other medications and Buprenorphine was not a medication that was dispensed from their pharmacy. A statement from the Adult Day Care Program dated 10/06/23 revealed To whom it may concern, Buprenorphine has not been prescribed by any Senior Care provider for the involved participant and there was no record of administration of this medication to this participant by Senior Care staff. This medication is not stocked in the onsite automated dispensing machine pharmacy. A change in condition summary report written by Nurse #2 on 10/05/23 at 3:10 PM revealed Resident #1 presented with abnormal vital signs to include BP 158/88 (mmHg) and HR 102 bpm. Resident had altered mental status at the time of evaluation. Resident's RR was 14 bpm and his oxygen level was 96% on room air. Resident opened his eyes in response to chest stimuli but did not respond to voice or touch. Resident's right eye pupillary reaction was 0.3 millimeters (mm), and left eye pupillary reaction was 0.1mm (normal pupil size is 2mm-8mm) and they did not respond to light. Provider assessed the Resident and determined he needed to be sent to the emergency room for further evaluation. A nursing progress note written by Nurse #1 at 3:45 PM revealed this writer was alerted by another staff member that Resident #1 was in the main lobby unresponsive. He had just arrived and was brought inside from the Adult Day Program by their transport van driver. This writer immediately went to the lobby and Resident #1 was surrounded by staff including a medication aide, a nurse aide, and a nurse from the day care program visiting the facility. Sternum rubs were being performed by the day care nurse with very little response noted. This writer called the physician who was in the facility to assess resident. A new order was obtained by the physician to send the resident to the hospital. Resident was assisted via wheelchair to an empty room and transferred using a mechanical lift. Emergency Medical Services (EMS) arrived in the room around 3:25 PM. Resident #1 remained unresponsive and EMS noted resident had pinpoint pupils and administered Narcan, but resident did not respond to the Narcan. Staff assisted EMS with transferring Resident onto the gurney and EMS left facility around 3:35PM. A phone interview was conducted with Nurse #1 on 11/07/22 at 12:46 PM. Nurse #1 reported on 10/05/23 she was the charge nurse for the hall Resident #1 and Resident #3 resided on and was overseeing MA #1. She stated at the beginning of her shift she checked on all of the residents and Resident #1 was his usual alert and oriented self. She stated her responsibility was to oversee the Medication Aides if they needed any assistance, calling the physician if they needed new orders, etc. Nurse #1 stated on the morning of 10/05/23, Resident #1 had gone to the Adult Day Care Program and when he returned a staff member had notified her that he was in the lobby and unresponsive and she immediately went to the lobby and there were two other nurses with him. She stated Resident #1 responded very little to the sternum rub. She stated she notified the provider who was in the facility and the physician did a full assessment and gave a verbal order to send him to the ER. Nurse #1 stated EMS arrived and she prepared all the paperwork needed for his transfer to the ER. The EMS report dated 10/05/23 revealed Resident #1's blood sugar was 77 mg/dL, BP was 163/94 mmHg, Oxygen 98% on room air, Respiration Rate (RR) 16 bmp, and heart rate (HR) 69 bmp. A phone interview was conducted with the EMS Responder on 11/20/23 at 1:00 PM. The EMS Responder stated when she arrived on scene, Resident #1 was on the mechanical lift. She stated upon assessment she initiated an intravenous (IV) access; he was noted to be non-responsive and had pinpoint pupils. She stated 2 mg of Narcan was administered via IV, his blood glucose level was 77 mg/dL (normal 80 - 120) and added it was low, but not low enough to make unresponsive, his BP was 110/70 mm/Hg manually, HR 58 bpm, oxygen level 99% on room air, skin was normal and temperature was 97.9. The EMS responder stated Resident #1 had a slow response to the 2 mg of Narcan and presented with a response to pain when doing the sternum rub. She stated after the dose of Narcan his pupils remained pinpoint. She stated the hospital was 4 minutes away and she gave a second dose of Narcan 2mg enroute to the hospital with slight improvement. The emergency room (ER) record dated 10/05/23 at 4:01 PM revealed Resident #1 presented to the ER for unresponsiveness. Resident came in from facility and did have some response to Narcan given by EMS. The resident awoke but now was unresponsive again and had small pinpoint pupils. A urine drug screen was obtained and results indicated Resident #1 was positive for Benzodiazepines and Buprenorphine. The ER course and medical decision making revealed Resident #1's BP was 110/72 mm/Hg, HR 58 bpm, temperature 98.7, oxygen saturation 97% and blood glucose was 82 mg/dL. Symptoms were improved with Narcan and on reassessment resident was awake and alert. Observed for worsening symptoms and will be discharged to follow up as an outpatient. Final Impression/diagnosis: drug intoxication without complication. A nursing progress note written by Nurse #3 on 10/06/23 at 7:05 AM revealed Resident #1 returned from hospital with a diagnosis of opioid overdose. Vital signs were within normal limits and resident was stable and resting in bed. A physician's visit progress note written on 10/06/23 at 5:15 PM by Physician #1 revealed, in part, Resident #1 was being evaluated since he had a decreased level of consciousness on 10/05/23 and was brought to the local emergency room where he was evaluated and discharged back to the nursing home. Buprenorphine HCI-Naloxone (Suboxone) and Benzodiazepine material reportedly were discovered in his urine drug screen. Per nursing staff, he has returned to his baseline mentation/cognition. A written statement dated 10/06/23 by MA #1 revealed Passing meds on the hall. At one point, it became overwhelming due to the trays, medications, blood sugars, the traffic on the hall, and residents getting ready for transport to Adult Day Care. I got overwhelmed with questions until I started rushing. I placed medication on cart and then passed it to the nurse [Unit Manager] who then took the medications from me to administer to resident. Everything happened so fast. I am not sure what was in the cup. I spilled a cup and I am not sure what happened. I noticed later that I was short [on control record] so I told [Nurse #4] I had to have dropped them somewhere. An interview with Medication Aide (MA) #1 via phone on 11/06/23 at 2:36 PM revealed she was assigned to the hall that Resident #1 and #3 lived on 10/05/23. She stated she had prepared Resident #1's medications and she was going to bring them into the dayroom where he was sitting but she noted he was no longer in the dayroom. She stated she placed the medication cup in the medication cart and began to prepare Resident #3's medications. She stated the Unit Manager (UM) came by and asked where Resident #1 was because she had to get him to the lobby to be ready to put on the van to go to his adult day care center. MA #1 reported she told the UM that Resident #1 had not received his medications yet and he needed them before he left. MA #1 reported she took Resident #1's medication cup out of the medication cart because the UM was getting ready to take him out of the building. MA #1 reported that when she removed Resident #1's medications from the cart, the drawer to the cart was still opened and at that time Resident #3's medication cup spilled and the medications fell into the cart and around the cart. MA #1 stated she was rushing to get Resident #1 his medications and she quickly picked up the medications that spilled but somehow some of Resident #3's medications must have gotten into Resident #1's cup. She stated she could not remember the details because it was very hectic and she was rushing. MA #1 added she had pre poured medication for more than one resident in the past and she pre poured the medications for more than one resident on this day (10/05/23). She stated she pre poured the medications to try and keep her head above water without asking someone for help. MA #1 stated, unfortunately, Resident #1 received medications that were not ordered for him. She added, Resident #1 also received the medications that were ordered for him. MA #1 reported at around 3:00 PM, Resident #1 came back to the facility and everyone just started running toward the lobby and were concerned Resident #1 had a stroke because he was unresponsive. She stated he was sent to the emergency room (ER) and she had learned later that he had an overdose from benzodiazepines and Buprenorphine HCI-Naloxone. MA #1 stated she knew she was not supposed to pre pour medications and received in servicing and training when she was hired back in January 2023. During a phone interview on 11/07/22 at 12:46 PM Nurse #1 stated the hall MA #1 worked on was a busy hall and it was an especially busy day and she was assisting MA #1 with any requests she had, but MA #1 never informed Nurse #1 that she dropped any medications and had to waste them on the control sheet. Nurse #1 stated MA #1 never asked for any assistance or indicated that she was falling behind. Nurse #1 added she had not seen MA #1 prepare more than one resident's medications at a time. A written statement from the Unit Manager (UM) dated 10/06/23 revealed I went to [the hall] at approximately 9:10 AM [10/05/23] to get Resident [#1] for his day program. He was usually in the dayroom. I was told he was in his room, so I went to get him to bring him up front to the main lobby. As I passed the Medication Aide [MA #1], she asked me to bring him to her so she could give him his medications. I turned him around and wheeled him over to her medication cart, at that time [MA #1] had a cup of medications in her hand and poured them into Resident [#1's] mouth followed by a cup of water. I did not pay attention to what medications were or the color of the medications as they were already poured and in the medication cup. A written addendum by the Unit Manager dated 10/10/23 to a previous statement related to Resident #1 and MA #1. I observed a few medication cups with medications in them on her medication cart prior to her giving [Resident #1] his medications. An interview was conducted with the Unit Manager (UM) on 11/06/23 at 4:40 PM. The UM stated MA #1 had been coached before regarding pre pouring medications and not signing off on her narcotics by the Nurse Educator. The UM stated on the morning of 10/05/23 at around 9:00 AM or so she noticed MA #1 had a couple of medication cups on the medication cart but she (the UM) was rushing and did not say anything to MA #1 at that time. She stated the Adult Day Care van was waiting for the residents who went to the day care and she was running around getting residents gathered up. The UM stated she went to get Resident #1 in the dayroom, but he was not there and had asked MA #1 where he was. She reported in his room. The UM stated Resident #1 was in his room in his wheelchair and she quickly began to bring him to the front lobby when MA #1 had said hold on, I need to give him his medications. The UM stated MA #1 gave the medication cup to Resident #1 and he took them all from the cup and drank his water and the UM wheeled him to the front lobby. The UM stated Resident #1 was his normal self-alert and oriented and he was communicating. The UM stated MA #1 had called her after the UM went home and she was very upset saying the ER reported Resident #1 had overdosed. The UM stated MA #1 stated Resident #1 did not receive any medications that could cause him to overdose. The UM reported she mentioned to MA #1 that perhaps Resident #1 received the wrong medications at the Adult Day Care center. The UM stated, later that night, she received a call from Nurse #4. Nurse #4 reported to her that MA #1 had asked her to sign off on some medications because she dropped them, but MA #1 did not actually have the pills that she said she dropped so Nurse #4 did not want to waste them and sign them off on the narcotic control sheet. The UM stated the two medications that she asked Nurse #4 to sign off were Clonazepam and Buprenorphine HCI-Naloxone. The UM stated later when we realized Resident #1 had benzodiazepines and Buprenorphine HCI-Naloxone in his system, MA #1 told Nurse #5 she spilled Resident #3's medication and she believed Resident #1 must have received some of his medications. An undated written statement by Nurse #4 revealed on 10/05/23, I was about to enter the building, [MA #1] approached me outside and asked if I had heard about what happened to [Resident #1]. I said no, I have not heard anything, what happened? [MA #1] began telling me that he had been at PACE all day and had come back unresponsive and the facility had to call 911. She stated that EMS had to give him a dose of Narcan. She said they must have given him something at PACE. She then said can you please look at my narcotic book [control record] (which she had in her hand) because my count was off. [MA #1] said I need you to sign off a narcotic for me and she opened the book to the page. She pointed to the last one entered on the page. I began to close the book and [MA #1] stated I have 2 sheets I needed you to sign. [MA #1] turned to another page and stated that both pills were in the same cup. I began to write them and noticed the times were different. I asked [MA #1] what happened and why she did not ask her nurse to sign the sheet. She stated the nurse had been disrespectful, rude and on her butt all day. I then asked where the pills were that I had just signed for the Buprenorphine HCI-Naloxone 8mg/2mg and the Clonazepam 1 mg. [MA #1] said that when she was giving the resident the cup of pills they spilled and she could not find them all so she threw the ones that she found in the trash. I then drew a line through my name at the bottom of the narcotic [control] sheet where you make corrections and wrote ERROR beside it cause at that point I was unable to verify the medication or what actually happened to the medication. I later found out the medications she was trying to get me to sign out was the same medications that [Resident #1] tested positive for. A phone interview was conducted with Nurse #4 on 11/07/23 at 1:00 PM. Nurse #4 reported she worked the night shift from 7:00 PM to 7:00 AM. She stated on 10/05/23 at around 7:00 PM, MA #1 approached her at the door and asked her if she could go over her narcotic (control) book because the count was not right. Nurse #4 reported that when she and MA #1 started going through the count sheet, MA #1 informed Nurse #4 she took the medications (Clonazepam and Buprenorphine HCI-Naloxone) out of their packages, but somebody knocked them over. Nurse #4 stated she signed the control sheet with MA #1 to waste the medications and then asked where the pills were. Nurse #4 stated MA #1 said she did not have them and she then told MA #1 she could not sign for pills that she did not have so she scratched her name from the waste portion and wrote error. Nurse #4 continued and stated later on that night around midnight, Nurse #5 informed her that Resident #1 was found to have benzodiazepines and Buprenorphine HCI-Naloxone in his blood stream and she wanted to let her know that the medications MA #1 was asking her to sign off were the same ones found in Resident #1's blood stream. Nurse #4 stated MA #1 claimed that when she went to give them to Resident #3 they knocked over in his room and she gathered up all the pills she could and threw them in the trash. Nurse #4 asked why she did not ask her Charge Nurse (Nurse #1) to waste the narcotics with her and stated that MA #1 said she did not tell Nurse #1 what had happened. Nurse #4 stated she realized later when the nurse told her at midnight it was the same pills that she asked me sign off for, and at this point it was realized by the nursing staff that Resident #1 received the medications belonging to Resident #3. Nurse #4 stated she immediately called the Director of Nursing and the Unit Manager and was instructed to write a statement. An interview was conducted with Nurse #5 on 11/06/23 at 4:30 PM. Nurse #5 reported on 10/05/23 MA #1 had come into her office and was trying to find out what was going on with Resident #1. Nurse #5 stated she informed MA #1 she spoke with the charge nurse at the ER and he had stated Resident #1 was given Narcan and at this time he was alert and talking and recovering with intravenous fluids. Nurse #5 recalled she was confused as to why Resident #1 would need Narcan because he did not have any narcotics prescribed to him, but the charge nurse stated his urine analysis was positive for Buprenorphine HCI-Naloxone and benzodiazepines which she added, he did not have an order for benzodiazepines either. Nurse #5 stated MA #1 was asked if the resident received any of those medications and MA #1 did not mention anything about medications being spilled, having a hectic day or pre pouring medications, but stated that he may have received those medications at the Adult Day Care Center. Nurse #5 stated it was not until later on that evening when she realized MA #1 was asking Nurse #4 to sign off the Buprenorphine HCI-Naloxone and Clonazepam as wasted drugs and learned from Nurse #4 that MA #1 said she dropped the medications but did not have them in her possession to waste. An interview was conducted with the facility's Physician Assistant (PA) on 11/07/23 at 11:05 AM. The PA revealed given that Resident #1 had pinpoint pupils and responded to the Narcan it was evident that he was overdosing from the Buprenorphine HCI-Naloxone. The PA added his blood sugar was at 77 mg/dL which was low but not low enough for someone to become unresponsive. An interview was conducted with Physician #2 on 11/07/22 at 1:10 PM. Physician #2 reported he was in the facility and nursing staff notified him stating Resident #1 was unresponsive. He added, the nursing staff stated his blood sugar was checked and he had come to assess Resident #1 in the lobby. Physician #2 stated he remained unresponsive and EMS had given him Narcan and the resident was sent to the ER. Physician #2 stated he heard Resident #1 received another dose of Narcan and had labs done at the ER and the blood work was positive for opioids and benzodiazepines but that he had returned to base line and was sent back to the hospital. Physician #2 stated he could not speculate as to what could have happened as a result of the resident receiving those medications (Clonazepam and Buprenorphine HCI-Naloxone) and that it would depend on the patient and their condition. He added, he received Narcan and it worked. An interview was conducted with the facility's Pharmacist Consultant on 11/07/23 via phone at 3:25 PM. The Pharmacist Consultant revealed that Buprenorphine HCI-Naloxone also known as Suboxone was a combination drug containing 8 mg of Buprenorphine and 2 mg of naloxone. She added what she would be most concerned about with an overdose of Buprenorphine HCI-Naloxone was respiratory depression, but she did not feel that one dose would cause death. A list of Resident #1's additional medications that he received that morning were reviewed with the Pharmacist and she had no concerns regarding mixing the Buprenorphine and Clonazepam with his already prescribed medications. An interview was conducted with the Nurse Supervisor via phone on 11/08/23 at 11:55 AM. She stated in the past 6 months she had done in services for medication administration for competencies that had to be done. She stated she could not recall if MA #1 had been in serviced regarding pre pouring medications. An interview was conducted with the Administrator on 11/07/23 at 3:00 PM. The Administrator revealed there has been a complete change of administration staff to include the Administrator, the Director of Nursing and the Assistant Director of Nursing and he believed the transition of change caused a breakdown in the monitoring that was in place previously for significant medication errors. He stated the process did not continue as it should have in the transition. The facility provided the following corrective action plan: F760 Failure to prevent significant medication errors: 1. The facility identified how correction action will be accomplished for those residents to have been affected by the deficient practice: On 10/5/23, as soon as Resident #1 returned from the Adult Day Program, while in the front lobby, Resident #1 was assessed to have a change of condition to include decrease in cognition and constricted pupils. EMS was notified. Emergency Services administered Resident #1 Narcan prior to transport and one dose in route to the Emergency Department. Resident #1 was transferred to the Emergency Department for further evaluation and treatment. During Resident #1's evaluation and treatment at the Emergency Department, Resident #1 received laboratory tests which were positive for Buprenorphine and Clonazepam. On 10/06/23 the DON interviewed Medication Aide #1 and Licensed Nurse #1 assigned to Resident #1 regarding medication administration and any new, different, or changes in behavior or change of condition for Resident #1 to determine how the resident could have a change of condition upon returning from the Adult Day Program. Medication Aide #1 and Licensed Nurse #1 did not observe any changes of condition prior to Resident #1 leaving for the Adult Day Program. Resident #1 was noted to have a change of condition when he returned from Adult Day Program while in the front lobby. EMS was notified at that time. 2. The facility identified other residents having the potential to be affected by the same deficient practice: On 10/06/23, an audit was conducted by the DON, ADON, and Unit Manager to determine residents with physician's orders for Buprenorphine. One resident, Resident #3, was identified with a physician's order for Buprenorphine. On 10/06/23 a Root Cause Analysis was conducted and determined the Root Cause of the alleged medication error was medication administration was not performed per the facility policy following the rights of medication administration by Certified Medication Aide #1, include not using two resident identifiers, the resident picture on the Medication Administration Record and the resident name, for medication administration as well as preparing resident prescription medication prior to actual resident medication administration. Certified Medication Aide #1 administered Resident #1 and Resident #3 medication on the morning of 10/05/23. Out of an abundance of caution, a plan of correction was implemented to include Medication Aides will no longer be permitted to administer Buprenorphine. Beginning 10/07/23, Buprenorphine was currently being administered by the Licensed Nurse. Residents who have physician's orders for medication, specifically Buprenorphine, have been identified as having the potential to be affected. Since all residents with medications prescribed have the potential to be affected by significant medication errors, beginning 10/06/23 Licensed Nurses and Certified Medication Aides were educated by the SDC, DON, ADON, Unit Manager or Nurse Supervisor on medication administration rights to include right resident, right medication, right dose, right route, right time, right reason, and right documentation, not to hurry during their medication administration pass. Beginning 10/06/23 Licensed Nurses and Certified Medication Aides performed Medication Administration Competencies with the Staff Development Coordinator (SDC), DON, ADON, Unit Manager, or Nurse Supervisor. Each Licensed Nurse and Certified Medication Aides were required to pass with a 100% in order to administer medication. On 10/06/23 Residents who receive Buprenorphine and Clonazepam medication were identified by the DON, ADON and Unit Manager to determine if any other residents on the same medication assignment as Resident #1 received Buprenorphine and Clonazepam. Resident #3 has physician's orders for both medications. Resident #3 is on the same assignment as Resident #1. Beginning 10/07/23, Resident #1 and Resident #3 had their medications administered only by Licensed Nurses. 3. The facility implemented systemic changes to ensure that the deficient practice will not recur: Beginning 10/06/23 each Licensed Nurse and Medication Aide will have a Medication Administration Pass Competency to include observation of medication administration pass with the Director of Nursing, Assistant Director of Nursing, Unit Manager, Staff Development Coordinator, or Nursing Supervisor completed prior to scheduled shift. A score of 100% is required to be considered as passing the competency. Any Licensed Nurse and Medication Aide who does not pass the Medication Administration Pass Competency will have immediate one to one re-education and will not be permitted to work without direct supervision by the Director of Nursing, Assistant Director of Nursing, Unit Manager, Staff Development Coordinator, or Nursing Supervisor. The Licensed Nurse or Medication Aide will be given another Medication Administration Pass Competency and must pass the competency in order

Based on record review and staff, Nurse Practitioner, Physician Assistant and Physician interviews, the facility failed to accurately administer medications when Resident #1 was administered medications prescribed to Resident #6 to include [MEDICATION(S)] (a blood pressure medication) 50 milligrams (mg) extended release and [MEDICATION(S)] (an antianxiety medication) 1 mg resulting in Resident #1 having increased sleepiness and a decrease in blood pressure which required her to be sent to the emergency room for further evaluation for 1 of 2 residents reviewed for medication errors. Findings included: Resident #1 was admitted to the facility on [DATE] with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #1 was cognitively intact and was noted to not have received any antianxiety medications during this assessment period. Resident #1 was not available for an interview. Review of Resident #1's blood pressures (BP) revealed on 09/20/22 BP was 98/68 mm/Hg and 102/74 mm/Hg, on 09/21/22 BP was 105/74 mm/Hg and 90/56 mm/Hg, on 09/22/22 BP was 89/58 mm/Hg, on 09/23/22 BP was 124/66 mm/Hg and 110/64 mm/hg. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #3. A nursing progress note written by the Nurse Supervisor on 09/23/22 at 9:40 PM revealed, in part, the on-call physician was contacted regarding reported medications given to resident. Resident was sent out to the hospital for evaluation. A review of the Emergency Medical Services (EMS) transfer form dated 09/23/22 revealed Resident #1's blood pressure was 79/51 mm/Hg (millimeters of mercury). The documentation indicated EMS implemented treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Last blood pressure recorded on the EMS report was 89/57 mm/Hg with no time recorded. The emergency room (ER) report dated 09/24/22 at 12:17 AM revealed, in part, the resident presented for evaluation after she was given multiple medications in error this evening. According to the resident's Family Member, the nurse [Nurse #3] gave her 6 medications that the resident does not take. The medications included [MEDICATION(S)] 1 mg and [MEDICATION(S)] [MEDICATION(S)] Extended Release 50 mg. The Family Member noted that her mother was extremely drowsy. The resident denied any headache, nausea, or vomiting. The resident denied any chest discomfort trouble breathing or abdominal pain. The resident felt tired but otherwise had no complaints. Vital Signs were noted to be blood pressure 96/58 mm/Hg, heartrate 82 beats per minutes (bpm), respiration rate 18 breaths per minutes (bmp). Resident was tired but arousable and in no acute distress with non-labored breathing, normal heart rate and rhythm. Resident was awake and appropriate. The ER course and medical decision making on 09/24/22 revealed, in part, the physician reviewed the residents' labs that were retained upon arrival. The [MEDICATION(S)] was likely to provide the most [MEDICATION(S)] sedation. The resident was given the medications a little over 3 hours ago. The vital signs at 1:30 AM read blood pressure 97/63 mm/Hg, heartrate 84 bpm, and respiration rate 18 bpm. Final impression was documented as: accidental overdose, [CONDITION(S)], and [CONDITION(S)]. Resident #1 returned back to the facility on [DATE] at 10:33 AM via Emergency Medical Services. A phone interview was conducted with Nurse #3 via phone on 11/04/22 at 4:30 PM. Nurse #3 confirmed she had prepared Resident #1 and Resident #6's medications and when she went to give Resident #1 her medication cup she brought in the cup of pre poured medications belonging to Resident #6. Nurse #3 stated as she was attempting to administer the Potassium, Resident #1 questioned what the medication was and when she informed the resident and the Family Member it was Potassium, the Family Member stated the resident was not on Potassium. Nurse #3 stated she went back to look at the electronic medical record (eMAR) and saw that there was a Potassium order, so she reported that back to the Family Member and Resident #1. Nurse #3 reported the Family Member stated No, that was not right, she was not on potassium. Nurse #3 stated she went back to look at the eMAR again and saw that she had Resident #6's eMAR up on the screen and not Resident #1 and she realized she made a medication error and reported it to Nurse #2 and the Nursing Supervisor. Nurse #3 stated the Nurse Supervisor had her write a statement of which medications she gave in error. Nurse #3 stated her statement only had [MEDICATION(S)] on it because that was all she gave. Nurse #3 denied giving any other medications. Nurse #3 confirmed she should not have pre poured the medications for more than one resident and added, it would have avoided the medication error. A phone interview was conducted with the Family Member on 11/07/22 at 10:45 AM. The Family Member reported on 09/23/22 she recalled Nurse #3 coming in to give Resident #1 her medications. She stated she did not see how many pills were in the cup but there were more than she usually received at bedtime. The Family Member stated Nurse #3 gave all the medications that were in the cup to Resident #1, but it was not until Resident #1 took her Potassium that she began to question Nurse #3 about Resident #1's medications. The Family Member stated Resident #1 inquired as to what the big pill was, and Nurse #3 told her it was Potassium and Resident #1 took the medication. The Family Member stated she questioned this because she knew Resident #1 was not on Potassium. The Family Member stated Nurse #3 left the room and when she returned she confirmed to the Resident and the Family Member Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Family Member stated it was at this time Nurse #3 told Nurse #2 and Nursing Supervisor there had been a medication error and Resident #1 received all of Resident #6's medication. The Family Member stated the Nursing Supervisor informed her that Resident #1 was going to be getting sent to the ER due to receiving the wrong medications, a low blood pressure and increased sleepiness. A phone interview was conducted with Nurse #2 on 11/01/22 at 3:10 PM. Nurse #2 reported a Family Member of Resident #1 was visiting and came to her on the evening of 09/23/22 and asked her when the facility started Resident #1 on Potassium. Nurse #2 stated she did not believe the resident was on Potassium. Nurse #2 stated at the same time that the Family Member had come to her, Nurse #3 notified her that she administered the wrong medications to Resident #1. Nurse #2 explained that Nurse #3 reported to her that when she went in to bring Resident #1 her medications for the evening, the family had questioned Nurse #3 about the Potassium and when it was ordered. Nurse #2 stated that Nurse #3 informed the family and the resident that the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 stated Nurse #3 reported to her that she went back to the eMAR to confirm the order, and realized she was on another residents' (Resident #6) eMAR. Nurse #2 stated she saw a medication cup filled with medications in Nurse #3's medication cart and stated Nurse #3 reported she had prefilled the medications for Resident #1 and Resident #6 and had Resident #6's eMAR record open. Nurse #2 stated she notified the Nurse Supervisor immediately and instructed Nurse #3 to get a set of vital signs and check for any allergies and to write down all the medications that she had given to Resident #1 in error which included [MEDICATION(S)] [MEDICATION(S)] Extended Release 50 mg and [MEDICATION(S)] 1 mg. Nurse #2 reported she assessed Resident #1 and she had begun to have a change in condition including increased sleepiness. Nurse #2 stated Resident #1 was arousable but very sleepy and she had had the medications in her system for about 15 minutes or more and her blood pressure was 88/68 mm/Hg. Nurse #2 stated she did not recall what the blood pressure was when Nurse #3 took it upon discovering the medication error and Nurse #3 did not document it, but when EMS arrived it had lowered to 79/51 mm/Hg. Nurse #2 stated the resident was responsive, she was really sleepy, and her eyes were rolling back. A phone interview was conducted with the Nurse Supervisor on 11/03/22 at 12:15 PM. She stated Nurse #3 had come to her stating the Family Member was questioning why Resident #1 was receiving Potassium and the Nurse Supervisor added, she was sure the resident was not on Potassium. The Nurse Supervisor questioned Nurse #3 and she reported to the Nurse Supervisor that the resident was on Potassium. The Nurse Supervisor stated she and Nurse #2 reviewed the orders and learned Resident #1 was not on Potassium. The Nurse Supervisor stated when she became aware of the medication errors she had gone in to see Resident #1 and the Family Member to make them aware and noted Resident #1 was more tired than usual but arousable. The Nurse Supervisor stated she let the on-call physician know what medications were given in error, the resident's change of condition symptoms, and the most recent blood pressure which she recalled was 90/58 mm/Hg. The Nurse Supervisor stated she was concerned about the residents' blood pressure getting lower once the [MEDICATION(S)] started to kick in. She stated EMS arrived and she provided them with all the paperwork and a list of the medications that Nurse #3 provided her which indicated the medications that were given in error which included the [MEDICATION(S)] [MEDICATION(S)] Extended Release 50 mg and the [MEDICATION(S)] 1 mg. The Nursing Supervisor reported Resident #6 received all of her ordered medications by Nurse #3. A follow up phone conversation was conducted with the Nurse Supervisor on 11/07/22 at 9:30 AM. The Nurse Supervisor stated Nurse #3 provided her with a written statement, and it included all the medications she had given to Resident #1 in error including [MEDICATION(S)] [MEDICATION(S)] Extended Release 50 mg, [MEDICATION(S)] 1 mg, [MEDICATION(S)] 300 mg, Aspirin 81 mg, [MEDICATION(S)] 10 mg, and Potassium Chloride 20 mEq. She stated she provided this list to the family and EMS and shortly after the resident was sent out, Nurse #3 provided her with another list which indicated she had only given the [MEDICATION(S)] and the Potassium. The Nurse Supervisor stated the Family Member reported to her that there were a lot of medications in the cup and the resident usually would only get 2 or 3 medications at night and the Family Member stated Resident #1 took all the medications that were in the cup that Nurse #3 brought in. The Nurse Supervisor stated Nurse #3 reported to her initially that she gave Resident #1 all the medications that were ordered for Resident #6 to be given at bed time to Resident #1 and she reminded Nurse #3 about the 5 rights (right resident, right drug, right dose, right route, and right time) of medication administration and stated that nurses are never to prepare other residents medications while preparing to administer medications to another resident. An interview was conducted with the Nurse Practitioner (NP) on 11/02/22 at 11:22 AM. The NP reported that she was aware the medication error occurred and stated that receiving the [MEDICATION(S)] [MEDICATION(S)] Extended Release caused Resident #1's blood pressure to lower and the [MEDICATION(S)] caused the resident increased sleepiness which both resulted in her being sent to the ER. A phone interview was conducted with the Physician Assistant (PA) on 11/04/22 via phone at 10:38 AM. The PA stated she could not be sure that the [MEDICATION(S)] [MEDICATION(S)] Extended Release contributed to Resident #1's blood pressure being lower with just one dose, but added, her blood pressure did run low at times, and it was lower than normal when she was sent out to the ER. The PA also stated she felt the [MEDICATION(S)] contributed to her increased lethargy (sleepiness) which also required her to be sent to the ER for further evaluation. A phone interview was conducted with the Physician on 11/04/22 at 10:51 AM. The Physician stated since Resident #1 had received the [MEDICATION(S)] [MEDICATION(S)] Extended Release and the [MEDICATION(S)] it had caused [CONDITION(S)] (low B/P) and sedation. He added, although it did not cause any harm, it could have caused harm. He indicated the other medications listed would not have caused any harm. An interview was conducted with the Director of Nursing (DON) on 11/03/22. The DON reported she had only been at the facility for one week and could not find any written statements regarding the medication error that occurred by Nurse #3 on 09/23/22 for Resident #1. She stated her expectation of the nursing staff was that all nursing staff should complete one residents' medication pass at a time before starting another medication pass on another resident. The DON added, if Nurse #3 had not prepared another residents' medication, this error may not have happened.

Based on observation, physician interview, physician assistant (PA) interview, staff interview, and record review the facility failed to put effective interventions in place to prevent 1 of 4 sampled residents (Resident #1) who smoked from sustaining smoking-[MEDICAL CONDITION] his mouth, pharynx (cavity behind the nose and mouth, connecting them to the esophagus), and toes. It had been reported previously to supervisors at least 13 times that the resident was smoking unsupervised with his oxygen running in areas not designated for smoking. After [MEDICAL CONDITION] the nursing home the resident was sent to the local hospital which then transferred him to a hospital burn unit. The resident spent three and a half months in the burn unit, and was then transferred back to the local hospital. In addition, the facility failed to ensure that 1 of 4 sampled residents (Resident #3) who smoked had a No Smoking, Oxygen in Use sign posted at her room door. Immediate Jeopardy (IJ) began on 07/21/19 when the facility failed to enforce their smoking policy, and Resident #1 began smoking unsupervised in undesignated areas with his oxygen on. IJ was removed on 12/19/19 when the facility implemented an acceptable credible allegation of IJ removal. The facility remains out of compliance with this tag at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for example 2. Findings included: The facility's Smoking Policy, which was revised in (MONTH) (YEAR), revealed the following: Policy Statement: This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation: 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Electronic cigarettes may be permitted inside in designated areas only. Otherwise, smoking is not allowed inside the facility under any circumstances. 3. Oxygen use is prohibited in smoking areas 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include: a. Current level of tobacco consumption, b. Method of tobacco consumption, c. Desire to quit smoking, if a current smoker, d. Ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). 7. The staff shall consult with the Attending Physician and the Director of Nursing Services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking 13. Residents are not permitted to give smoking articles to other residents. 14. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc, except when they are under direct supervision 1. Resident #1's 08/16/18 hospital Discharge Summary documented, Inhalation injury, burn injury to oropharynx. Patient was smoking while wearing oxygen which resulted in a tank explosion on 08/05/18, flame flashed in his face which resulted in some oropharynx burns-sent to (hospital) burn unit singed facial hairs around the lips, some soot present on the tongue, blistering to the hard palate concerning for second-[MEDICAL CONDITION] a result of this incident his home was destroyed by fire and he is now homeless. Record review revealed that Resident #1 was admitted to the facility on [DATE]. His documented [DIAGNOSES REDACTED]. On 09/17/18 Resident #1's smoking assessment documented he had cognitive loss and dexterity problems, and liked to smoke 1 - 2 cigarettes in the afternoon. The assessment determined he was safe to smoke only with supervision. On 09/26/18 Resident #1's care plan, which was in place on 07/21/19, identified The resident is a dependent smoker as a problem. Interventions for this problem included, Continue to cue and educate (resident) on dangers of smoking with 02 and continue to offer cessation. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Monitor oral hygiene. (Resident) requires supervision while smoking. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette burns. Resident #1's 04/25/19 quarterly minimum data set (MDS) documented his cognition was intact, he exhibited no behaviors including resistance to care, he required staff assistance that ranged from supervision to dependence with his activities of daily living (ADLs), and he was receiving oxygen therapy. Review of Resident #1's (MONTH) 2019 physician orders [REDACTED]. In a 07/21/19 1:56 PM progress note Nurse #1 documented, Resident (#1) was noted to be sitting outside on front porch smoking while wearing O2 (oxygen) two times, once by supervisor and once by Speech Therapy. This nurse educated resident both times on the dangers of smoking while utilizing O2. Resident verbalized understanding. During an interview with Nurse #1 on 12/17/19 at 11:53 AM she stated Resident #1 quit smoking after a hospitalization in (MONTH) 2019, but was found on the front porch of the building smoking unsupervised on 07/21/19 with his oxygen running. She commented Resident #1 told her that he had started smoking again, and was not interested in cessation. According to Nurse #1, she told Resident #1 that she needed his smoking supplies, and he stated that he only had the cigarette which he was in the process of smoking. Nurse #1 reported another staff member caught the resident smoking on the front porch with his oxygen on 30 minutes later, and again the resident insisted that he only had the cigarette which he was smoking. She commented the supervisor was requested to talk to the resident about his abuse of the smoking policy, and this supervisor may have collected smoking supplies off the resident. However, Nurse #1 stated she never saw any more smoking supplies on Resident #1 after 07/21/19. She reported Resident #1 was alert and oriented so she felt searching his room and person for smoking supplies was a violation of his rights. Nurse #1 commented she had a talk with Resident #1 telling him that smoking with his oxygen on was putting himself and the other residents in the facility in extreme danger. She explained the resident shook his head that he understood, and stated he would comply with the smoking policy; smoking in the designated area, letting the nurses keep his supplies, and not smoking with his oxygen in use. In a 07/21/19 3:47 PM progress note Nurse #2 documented, Resident noted by staff to be outside in front of building smoking several times today with his oxygen on. Resident educated on smoking safety and instructed that he may smoke safely in designated areas only and he must remove his oxygen while smoking. Resident educated on the dangers to himself and others that smoking with oxygen could potentially cause. Resident instructed to notify staff when he wants to go outside to smoke so staff may remove his oxygen during that time and reapply it upon entering the building after smoking. Resident asked to turn over his smoking supplies to his nurse on the hall per our smoking policy. Resident verbalized understanding. During a telephone interview with Nurse #2, a weekend supervisor, on 12/17/19 at 1:29 PM she stated she was asked to address Resident #1 at least once, possibly twice, about smoking on the front porch of the building (not the designated smoking area) and smoking with his oxygen on. She reported she never collected any smoking materials from the resident because he denied having any supplies other than the cigarettes he was smoking at the time. However, she commented she told the resident that he needed to turn over any smoking materials which would be kept in a lock box until he needed them when smoking in the designated smoking area. She remarked she also educated the resident about the dangers of smoking with oxygen on, and the resident stated he understood what he was being told. During an observation on 12/19/19 at 9:05 AM there were two no-smoking signs on the front porch, a placard posted on the glass vestibule surrounding the front door, and the other a computer-generated sign in a stand on the front porch. When facing the exterior of the exit door on Resident #1's hall there was a commercial sign warning No smoking beyond this point on the left side of the building six to eight feet away from the door itself. Resident #1's 07/21/19 smoking assessment documented the following information: he was currently smoking, he intended to smoke, he did not wish to stop smoking, the resident smoked at least 10 times daily, the resident had a history of [REDACTED]. safely, the resident used supplemental oxygen, the resident could not safely be without oxygen during smoking times, and the resident could not extinguish cigarettes safely. During an interview with Nurse #3 on 12/17/19 at 2:21 PM he stated Resident #1 was alert and oriented, smoked on and off after a home incident, and was discovered smoking with oxygen on in (MONTH) 2019 on the front porch. He reported he only saw smoking supplies on the resident once, and thought it might have been a couple of days after the 07/21/19 incident. He explained when the resident opened a dresser drawer in search of a pen or pencil two cigarettes were in view. Nurse #3 stated he removed the cigarettes, and re-educated the resident that he could not keep smoking materials on his person or in his room. A 07/22/19 psychotherapy consult documented .staff reported/documented concerns regarding patient (Resident #1) being found twice over the weekend sitting outside on the front porch smoking while his oxygen was on. Each time patient was educated on the seriousness of this and he gave up his smoking materials. Staff reported that patient seemed unconcerned about the danger of his behaviors even though the reason for his admission to this facility is because of explosion and fire in his home started by his smoking with oxygen. Patient maintains that his oxygen was not turned on even though staff reports that this is not true. Also, patient apparently stated repeatedly that smoking with oxygen was not dangerous, despite his previous history. Patient was rather argumentative today when confronted about this. He presents with constricted affect but denied any worsening of depression or anxiety. He denied any thoughts of self-harm. Patient is cognitively intact and was reassured that if he wants to go smoke, staff will make accommodations for this, namely without him using oxygen while smoking. Patient voiced understanding and will alert staff when he wants to smoke. Focus of session was offering patient support and validation of feeling while exploring ways in which he might improve safety while smoking, per his choice. I spoke with nursing staff about this and they will make arrangements for patient to switch wheelchairs to go outside without oxygen when he would like to smoke. Patient responded well to this intervention with mood being stable at end of session. During a telephone interview with Resident #1's psychotherapist on 12/18/19 at 5:03 PM he stated the resident was in complete denial, stating he was not smoking in unsupervised areas with his oxygen on, and then commenting that there was no danger from smoking with oxygen running. He reported the resident had a you can't tell me what to do attitude. According to the psychotherapist, he educated Resident #1 that it was his right to smoke as long as he followed the facility's smoking policy. He stated the resident did not have dementia, and did not exhibit suicidal ideation. He reported he continued to educate Resident #1 about the dangers of smoking with oxygen on during follow-up sessions in early and mid-August 2019. He commented people had the right to make bad decisions. Resident #1's 07/25/19 annual MDS documented his cognition was intact, he exhibited no behaviors including resistance to care, staff assistance with ADLs ranged from supervision only with toileting/dressing/transfers/walking in room and corridor/and locomotion on and off unit to dependence on staff for bathing, the resident currently used tobacco products, and the resident was receiving oxygen therapy. On 07/29/19 Resident #1's care plan problem was updated to reflect, I continue to be a dependent smoker. At times non-compliant with smoking policy. Goals for this updated problem were, I will not smoke without supervision through the review date. I will not suffer injury from unsafe smoking practices through the review date. No new interventions were developed for this problem and no interventions were revised for this problem after they were initially developed on 09/26/18. In a 08/07/19 9:59 PM progress note Nurse #4 documented, (Resident #1) found outside smoking with O2 on at 3 L (liters). Resident educated multiple times regarding smoking and diagnosis. During an interview with Nurse #4 on 12/18/19 at 3:15 PM he stated he had not observed Resident #1 smoking with his oxygen on, but was informed of such behavior by several care providers. He reported he found the resident outside a lot on the front porch and on the side of the building outside his hall exit door, and he was suspicious the resident was smoking unsupervised. He commented the facility's Social Worker (SW) and nurse supervisors educated the resident about his violations of the smoking policy. In a 08/08/19 11:12 AM progress note the facility's SW documented, Spoke with (Resident #1). Went over the smoking policy with the resident (copy was given). There is a designated area for smoking, and we are asking you to let a nurse know (when) you want to smoke. It is not safe for you to smoke with your oxygen on. 'Okay I will follow the rules.' Record review revealed the SW had Resident #1 sign on 08/08/19 that he had been educated on the facility's smoking policy, and how he had violated that policy. In a 08/20/19 2:16 PM progress note the SW documented, (Resident #1) is not following smoking policy/schedule/designated place to smoke. It was brought to this writer's attention that (resident) was smoking out front. This writer spoke with (resident) and went over the smoking policy again. Record review revealed the SW had Resident #1 sign on 08/20/19 that he had been educated on the facility's smoking policy, and how he had violated that policy. During an interview with the facility's SW on 12/17/19 at 11:42 AM she stated Resident #1 was unhappy that he had to be supervised and hand over his smoking supplies. She commented she completed group in-servicing about the facility's smoking policy with residents who smoked and their family members on 05/15/19, but she was not sure if Resident #1 attended since she did not think he was actively smoking at that time. The SW stated if residents remained non-compliant with the smoking policy the facility tried to involve the family and re-educate the residents. The SW reported she left voice mails and talked with a family member of Resident #1 about his inability to follow the smoking policy. According to the SW, the family member commented she would try and talk with the resident, but she was not sure she would have any success because the resident seemed to be determined to smoke with oxygen his oxygen on as he did in his own home. During an interview with the Director of Nursing (DON) on 12/18/19 at 10:18 AM she stated Resident #1 smoked for a little while in the facility and was compliant with the smoking policy, but then had a [MEDICAL CONDITION] exacerbation, quit smoking, and started back up without informing staff. She reported the resident began smoking unsupervised outside of the designated smoking area, and began smoking while his oxygen was running. She commented the main intervention used to try and keep Resident #1 safe was education by various different people including the psychotherapist, SW, nurses, and a nurse/friend. According to the DON, Resident #1 was placing himself and other residents in danger by smoking without supervision with his oxygen running. She reported smoking assessments were completed initially and then quarterly for residents who were actively smoking. She stated when the resident started defying the smoking policy in late (MONTH) 2019, the facility asked the resident where he was getting his smoking supplies, but the resident refused to reveal the source. According to the DON, when residents failed to follow the smoking policy, staff were instructed to inform management when they found infractions and what transpired. She stated Resident #1 was very alert and oriented so the staff educated the resident about the dangers of smoking with his oxygen on, and staff were told to keep a close eye on the resident since he was smoking outside the designated smoking area, but this seemed to irritate the resident. She reported the facility's SW also attempted to find Resident #1 placement in other nursing homes which might have a more liberal smoking policy. She commented the facility did not give the resident a 30-day discharge notice although they would have been justified since the resident failed to follow the smoking policy multiple times after he was re-educated about how he was breaking it. According to the DON, the facility did not like to resort to giving many 30-day discharge notices, and the facility chose to react to Resident #1's smoking misbehavior with [MEDICATION NAME] since he was making friends in the facility and becoming more social after being admitted in a withdrawn state. She also stated the resident had burned his home down while smoking with oxygen on so if the facility discharged him, there were few choices where the resident could reside. During a follow-up interview with the DON on 12/18/19 at 1:21 PM she stated the direct care staff were asked by the supervisors to keep a close eye on Resident #1 after it became apparent he was having problems following the smoking policy, but this extra supervision was not quantified and staff members weren't officially assigned to check on the resident at certain intervals. She stated dependent smokers were educated that they could not keep smoking supplies on their person or in their room, including Resident #1. She commented numbered lock boxes were kept for each dependent resident so the Personal Care Assistants (PCAs)/Smoke Aides could get their smoking supplies for the residents as they headed out onto the smoking porch. During an interview with Nursing Assistant (NA) #1 on 12/17/19 at 2:29 PM she stated Resident #1 was very alert and oriented, and was able to travel throughout the building in his wheelchair. She reported she never saw the resident with smoking materials on him or in his room. She commented it was difficult to keep an eye on the resident because he was independent with his ADLs and could navigate his wheelchair about the building when she was providing ADL care to other residents. During an interview with NA #2 on 12/17/19 at 4:19 PM she stated Resident #1 was alert and oriented and in and out of his room a lot in the in the last 3 - 4 months. She reported the resident was very independent, and did not rely on staff. She commented staff could tell the resident something, he would nod like he understood, but would not always do what he had been told. She stated she did not see smoking materials on the resident or in the resident's room. During an interview with NA #3 on 12/17/19 at 4:32 PM she stated Resident #1 was very alert and oriented, and she did not see any smoking materials on the resident or in his room. She reported the resident did his own ADLs, dressed himself, took care of his own hygiene so she did not get a close look at his person, and she did not search his room for cigarettes because the resident was alert and oriented and informed that he could not keep his own smoking materials. She commented it was difficult to keep watch over Resident #1 since the NAs usually had at least ten residents to care for on their assignments. During an interview with NA #4 on 12/18/19 at 1:40 PM she stated Resident #1 was in and out of his room and could move quickly in his wheelchair. She reported it was difficult to keep an eye on him when she was trying to provide care to the other residents on her assignment. She commented the resident smoked on and off during the time she cared for him, but she never saw any smoking supplies on him. During a 12/18/19 11:14 AM interview with Nurse #6, the former 3 - 11 supervisor who held the position during the time that Resident #1 was not following the smoking policy, she stated staff reported to her over ten times that the resident was smoking with oxygen on, unsupervised, in an area not designated for smoking. She reported Resident #1 was alert and oriented and able to make his own decisions. She commented he was independent with care and transfers, and could navigate in the building and outside in his wheelchair. She reported she mostly found the resident smoking out on the front porch of the facility which was a no-smoking area. She remarked that one time she found him smoking with his oxygen on in front of the generator on the front porch which was very dangerous since the generator fumes, lit cigarette, and oxygen could have blown the building up. She stated other than the lit cigarettes she found the resident smoking, the only other smoking supply she found on the resident was a lighter which he dropped when she approached him, but Resident #1 refused to tell where he got the lighter or cigarettes he was smoking. However, Nurse #6 stated that she had heard from other staff that a family member of the resident was bringing him the smoking supplies. She reported she personally did not confront this family member, but had a conversation with another family member who stated she might see if the resident would be willing to give up regular cigarettes for e-cigarettes, but the family member never got a chance to do so because the resident was hospitalized in late-August 2019. According to Nurse #6, she also offered to take the resident out to the designated smoking area if he needed to smoke, but he continued to smoke with his oxygen on in undesignated areas. During a 12/19/19 10:42 AM phone interview with Nurse #7, former 7 to 3 supervisor, she stated she was told by staff three times that Resident #1 was smoking unsupervised in an undesignated area with his oxygen on. She stated she educated the resident that he could burn himself and harm other residents by smoking with his oxygen on. She explained Resident #1 would state that he understood, reporting he would not smoke with his oxygen on any more, and he would apologize. She stated she reviewed the facility's smoking policy with Resident #1 when he decided he was going to smoke for the first time in the facility, and again when the policy was revised due to changes in the smoking times. However, she reported she could not remember whether she had the resident sign and dates these policies. She stated it would have been good if the facility could have tracked the resident's whereabouts, but the facility could not use a Wanderguard on the resident because he was alert and oriented. She stated the resident was followed by psychiatric and psychotherapy services for depression, and they discussed his smoking non-compliance with him. According to the supervisor, when Resident #1 decided he was no longer going to follow the smoking policy, he became very sneaky in about a four-week period, seeming to plan quick trips outside to smoke unsupervised with his oxygen on. She stated it was difficult for staff to keep track of him. She reported Resident #1 had a couple of male friends who signed him out and took him off campus, and when the resident was found smoking cigarettes unsupervised with oxygen on, she talked with the visitors. She commented she educated them that it was okay to buy smoking supplies for the resident if he insisted, but the supplies needed to be turned into nursing so they could be locked away in a lock box. In a 08/26/19 2:32 AM progress note Nurse #5 documented, Overheard alarms going off and walked the halls to investigate. Approached (Resident #1's room) and smelled burned smoky odor. Noted toilet was completely blackened and filled with soot, melted nasal cannula on floor, burned tiles on floor, cigarette butt noted floating in toilet and standing in the bedroom floor was a shakened, burned resident. In a 08/26/19 2:40 AM progress note Nurse #5 documented, Removed (Resident #1) from bedroom, removed oxygen tank from bedroom Emergency services treated and transported resident to emergency room . Fire Department assessed the area for safety and smoke damage. During a telephone interview with Nurse #5 on 12/30/19 at 10:01 AM she stated she had limited contact with Resident #1 since she only worked every other weekend on night shift. She reported the resident was in his room most of the night, maybe coming out occasionally for ice and sodas. She commented the resident appeared to be alert and oriented. According to Nurse #5, she had never personally seen the resident smoking in undesignated areas or smoking with his oxygen on. However, she stated she was told by another staff member that he was found outside the building in an undesignated smoking area smoking with his oxygen on during her shift. She reported she had not seen any smoking materials on Resident #1 or in his room. She commented she also heard from other staff members that Resident #1 was bumming cigarettes off other residents in the facility who smoked. Nurse #5 stated she heard the resident's smoke alarm sound on 08/26/19, and when she got to his bathroom there was a cigarette butt in his toilet, the toilet set was blackened, and his nasal cannula was burnt up. She reported it appeared the resident had tried to stomp out fire in his sock feet. She explained she could not determine the extent of [MEDICAL CONDITION] there was so much smoke debris and soot around his eyes, nose, the palms of his hands, and the soles of his feet. A 08/26/19 Change in Condition form documented, Burn of mouth and pharynx, respiratory condition due to smoke inhalation, hypoxic, smoking in the bathroom, O2 in use, aerosol can in use.[MEDICAL CONDITION] smoke inhaled. Face: swelling and redness around eyes, nose and mouth. Right [MEDICAL CONDITION] on lateral aspect of foot and toes, left [MEDICAL CONDITION] on inner aspect of toes. Resident was smoking while having oxygen in use and using an aerosol deodorant can. Cigarette butt found in toilet. Toilet blackened. 08/26/19 hospital records documented, Facial burn-per EMS pt (patient) is coming from nursing home. Patient was caught smoking in the bathroom at the facility, oxygen caught on fire, now has soot around nostrils and singed hairs in moustache. Pt also has soot [MEDICAL CONDITION] bilateral toes. Pt is usually at 3 liters, is currently on 4 liters and 93% (oxygen saturation) presents to the emergency department after his nasal cannula caught on fire Now has soot in his nostrils and around his nose with a burned moustache. He also [MEDICAL CONDITION] his bilateral feet from attempting to put out the nasal cannula with his feet. Patient has difficulty breathing through his nose .Physical Exam: Soot and 2nd and 3rd [MEDICAL CONDITION] the bilateral nares (nostrils).[MEDICAL CONDITION] the upper lip and moustache Patient transferred to (hospital burn unit) without incident. Multiple bedside evaluations. Continues to protect his airway with no significant respiratory distress. At one point in the emergency department I did move his nasal cannula to his mouth rather than his nose as his nares are completely obstructed by soot and scarring at this point During an interview with the facility's Staff Development Coordinator (SDC) on 12/17/19 at 11:24 AM she stated she completed a facility-wide in-service about the smoking policy, involving all disciplines, on 08/26/19. Handouts from the in-servicing documented, Residents must turn in all cigarettes and lighters when entering the building! All smoking materials must be locked up. No exceptions! No borrowing lighters and cigarettes. Any violations will be reported to administration. Smoking hours: 8:00 AM - 8:00 PM. Riverwalk (hall off which the facility's designated smoking area was located) only. Smoking times: 9:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, 5:00 PM, and 7:00 PM. All smokers will be supervised during smoking without exception. Smoking is only allowed in designated smoking areas. No person shall be permitted to smoke while wearing oxygen, with an oxygen tank/concentrator on or near their chair or with any oxygen source within the designated smoking area. (Riverwalk smoking area). She also reported she in-serviced the nursing staff about 30-day discharge notices on 08/26/19. She explained Resident #1 qualified for such a notice because he repeatedly violated the smoking policy, but the facility did not want to take such action against a resident who was homeless and who had made many friends in the facility. During an interview with the facility's SW on 12/17/19 at 11:42 AM she stated she completed in-servicing about the facility's smoking policy with all residents who were active smokers and their family members on 08/26/19. During an interview with the DON on 12/18/19 at 10:18 AM she stated after the 08/26/19 incident two packs of cigarettes were found in one Resident #1's dresser drawers. However, she reported the facility did not incorporate smoking accidents into their QA program because the problem with Resident #1 was an isolated incident, and there had been no problems with other smokers following the smoking policy. During a follow-up interview with the DON on 12/18/19 at 5:32 PM she stated the interdisciplinary approach to solving Resident #1's problem with smoking was demonstrated during care plan meetings. She explained during these meetings the resident was asked why he continued to smoke with his oxygen on, but he could not explain why. The resident did comment that he wanted to smoke more frequently than was allowed. According to the DON, the root cause of the resident's behavior seemed to be an addiction which was out of control, and the resident made an informed decision to remain non-compliant. She reported the interventions were