Every finding on record at Avante at Melbourne Inc

Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services per standards of practice and plan of care for 3 of 3 residents reviewed for IV care, (#4, #5, and #6), of a total sample of 9 residents. Findings: A midline catheter is put into a vein by the bend in the elbow or the upper arm .a midline catheter may allow you to receive long-term intravenous (IV) medicine or treatments, (retrieved on 8/08/25 from www.drugs.com). A peripherally inserted central catheter (PICC) is a long, thin tube that's inserted through a vein in the arm. The tube is passed through to the larger veins near the heart. It is often referred to as a PICC line. A PICC line gives your healthcare professional access to the large central veins near the heart. It's generally used to give medicines or liquid nutrition, (retrieved on 8/08/25 from www.mayoclinic.org). 1. Resident #4 was admitted to the facility from an acute care hospital on 7/16/25 with diagnoses that included cellulitis of the left lower limb, sepsis due to Escherichia coli, type 2 diabetes mellitus and acquired absence of the left foot. Resident #4 had a Midline IV catheter in her right upper arm for administration of IV antibiotics. The physician's orders read, resident #4 received 1-gram (gm) Meropenem solution intravenously every 8 hours and would continue to receive it for nine days for cellulitis. The physician's orders for the midline were to change the dressing to the insertion site (right arm) every seven days and as needed using sterile technique. On 7/28/25 at approximately 10:00 AM, resident #4 was sitting up in bed. A midline IV with transparent dressing on resident #4's right upper arm was undated. Resident # 4 stated the midline dressing had not been changed since coming from the hospital. A review of the Treatment Administration Record (TAR) for July 2025 showed no documentation of dressing changes since 7/18/25. (Photographic evidence provided). 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included encounter for surgical aftercare, venous insufficiency, cardiac arrest, seizures, major depressive disorder and muscle weakness. Resident #5 had a PICC Intravenous IV line in his left upper arm for administration of antibiotics. The physician's orders showed resident #5 received 1 gram of Ertapenem Sodium Solution Reconstituted intravenously daily for infection, and he would continue to receive it until 7/30/25. There were physician orders to change the PICC line dressing every seven days and as needed using sterile technique. On 7/28/25 at approximately 10:20 AM, resident # 5 was observed sitting up at the side of his bed and spoke about the IV dressing on his left upper arm. He said the IV was inserted in the hospital and had never been changed since he was admitted to the facility. On examination of the site, the date on the dressing was marked as 7/10/25. A total of eighteen days had passed since the dressing had been changed. (Photographic evidence provided). 3. Resident # 6 was admitted to the facility on [DATE] from the hospital and had diagnoses which included Wernicke's encephalopathy (brain dysfunction related to vitamin deficiency), chronic obstructive pulmonary disease, cellulitis of the right and left lower leg, and myositis (inflammation of the muscles). Resident #6 had a PICC IV line in his right arm for administration of IV antibiotics. The physician's orders showed resident #6 received 500 milligrams (mg) Daptomycin Intravenous Solution Reconstituted intravenously daily and would continue to receive it until 7/31/25. The physician also ordered the PICC line dressing should be changed every seven days and as needed using sterile technique. On 7/28/25 at 10:30 AM, resident # 6 was observed in the common area sitting in his wheelchair. He spoke about his IV dressing, which was a little loose. The resident said he had to constantly press it down so that it would not fall off. He did not remember when it was last changed, and the date was illegible. Another nurse working nearby was unable to read what date was written on the dressing and said she could not say for sure. The nurse explained that IV dressings should be changed weekly or per the doctor's orders. The assigned nurse looked at the dressing and verified it needed to be changed. A review of the Medication Administration Record (MAR) revealed the last date documented by nurses of a dressing change was on 7/17/25, eleven days since the dressing was changed. (Photographic evidence provided). On 7/28/25 at 11:00 AM the facility's North Wing Unit Manager (UM) assisted as the Director of Nursing was unavailable. The North Wing UM confirmed all the findings for resident #4, #5 and #6's IV dressings. She looked at all three dressings and agreed that they should have been changed. She said that the expectation was for the nurses to follow the physician's orders for dressing changes and that she would take care of it. The Nursing Home Administrator along with the Regional Nurse consultant stated that it was the expectation that the dressings be changed per physician's orders. The Facility's Policy on PICC/Midline Dressing Change revised 1/20/25 indicated it was the facility policy to change PICC, and midline dressings weekly or if soiled, in a manner to decrease potential for infection, and /or cross-contamination. The policy declared physician's orders would specify the type of dressing and frequency of changes.

Based on observation, interview, and record review, the facility failed to maintain accurate documentation for Intravenous (IV) catheter dressing change for 1 out of 3 sampled residents with IV lines, (#5), of a total sample of 9 residents.Findings:Resident #5 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included encounter for surgical aftercare venous insufficiency, cardiac arrest, seizures, major depressive disorder and muscle weakness. Resident #5 had a peripherally inserted central catheter (PICC) IV line in his left upper arm for administration of antibiotics. The physician's orders indicated resident #5 received 1 gram of Ertapenem Sodium Solution Reconstituted intravenously daily for infection and he would continue to receive the medication until 7/30/25. The physician also ordered the PICC line dressing to be changed every seven days and as needed using sterile technique. A PICC IV is a long, thin tube that's inserted through a vein in the arm. It is often referred to as a PICC line. The tube is passed through to the larger veins near the heart. A PICC line gives your healthcare professional access to the large central veins near the heart, usually to give medication or liquid nutrition, (retrieved on 8/08/25 from www.mayoclinic.org). On 7/28/25 at approximately 10:20 AM, resident #5 was alert and oriented, sitting up at the side of his bed. He spoke about the dressing on his left upper arm and explained it was inserted in the hospital. Resident #5 said the IV dressing had not been changed since before he was admitted to the facility. On examination of the site, the date on the dressing was marked as 7/10/25. A total of eighteen days had passed since the dressing had been changed. (Photographic evidence provided). A review of the Treatment Administration Record (TAR) showed that nurses documented that the PICC IV-line dressing was changed on 7/13/25, 7/20/25 and 7/27/25, even though the dressing itself had a date of 7/10/25. On 7/28/25 at 11:00 AM, the North Wing Unit Manager (UM) said that the facility expectation was for nurses to follow the physician's orders for dressing changes. The Nursing Home Administrator along with the Regional Nurse consultant confirmed it was the expectation that dressings be changed according to physician order. On 7/28/25 at 12:20 PM, the North Wing UM acknowledged the documentation in the TAR for resident #5's PICC line dressing changes. She identified the two nurses by their initials who documented the dressing was changed when in fact it was not. Licensed Practical Nurse (LPN) A documented that the dressing was changed on 7/13/25 and 7/20/25 and LPN B signed that the dressing was changed on 7/27/25. The North Wing UM stated she could not answer for those nurses, but said it was unacceptable to sign that treatment was done when it was not. On 7/28/25 at 1:17 PM, in the presence of the North Wing UM, LPN B stated she remembered she hung the IV medication for resident #5 but did not change the dressing. She explained that she had worked in the facility for about three years and knew that IV dressings should be changed every seven days. LPN B further explained the TAR would prompt the nurses on the day the dressing should be changed for them to document it was changed but was unable to say why she documented it had been done when it had not. The UM said that it was the expectation for nurses to document with accuracy in the medical record. Two attempts were made to contact LPN A, without result. The Facility's Policy on PICC/Midline Dressing Change revised 1/20/25 indicated it was the facility policy to change PICC, and midline IV dressings weekly or if soiled in a manner to decrease potential for infection, and /or cross-contamination. The document detailed physician's orders would specify the type of dressing and frequency of changes. In section 24, the policy indicated nurses were to document the procedure upon completion of the dressing change. The facility did not have a policy in regard to accuracy of documentation.

Based on observation, interview, and record review, the facility neglected to ensure pre-operative testing was completed timely and per physician's orders for scheduled surgical removal of a musculoskeletal (muscle/bone) device (external fixator) for 1 of 1 resident reviewed for neglect, of a total sample of 4 residents, (#1). External fixators are metal devices attached to the bones of the arm, leg or foot with pins or wires from outside the body. Threaded pins or wires pass through the skin and muscles and are inserted into the bone, (retrieved from International Center for Limb Lengthening at limblength.org on 4/11/2025). Infection after fracture fixation (IAFF) in orthopedic surgery is a dreaded complication, leading to non-union, loss of function, and even amputation, (retrieved from pmc.ncbi.nlm.nih.gov on 4/11/2025). Findings: Resident #1, a [AGE] year old male was admitted to the facility from an acute care hospital on 1/03/25 with diagnoses that included subsequent encounter of right knee dislocation/reduction, type 2 diabetes mellitus, muscle weakness, and lack of coordination. Additional diagnoses after admission to the facility included leukocytosis (high white blood cells/infection response), right leg wound infection, right Achilles (ankle) tendon (connects muscle to bone) contracture (tightening), and right peroneal (lower leg) nerve palsy (paralysis/weakness). The State Agency hospital transfer form noted on 12/30/24 prior to admission to the facility, resident #1 used a walker to walk with two assistants, and he had good rehabilitation potential. The Body Map section noted moisture associated skin damage, but no other skin impairments other than the presence of the external fixator to the right leg. The Minimum Data Set (MDS) Comprehensive Admission Assessment with an Assessment Reference Date of 1/09/25 noted resident #1 scored 15 out of 15 on the Brief Interview for Mental Status that indicated he was cognitively intact, and there were no behavioral symptoms or rejections of evaluation or care. The resident had functional Range Of Motion (ROM) limitations to the lower extremity (hip, knee, ankle, foot) that interfered with daily functions and placed a risk of injury; he did not walk, and was dependent on staff to complete Activities of Daily Living (ADLs), and for positioning and transferring in and out of bed. The resident required scheduled and as needed pain medications, had frequent, severe pain that affected his day-to-day activities, was at risk for pressure ulcer development, had one unstageable pressure ulcer present on admission, one vascular ulcer, and surgical wounds. Over the seven day lookback, the resident required medication injections for six days, insulin injections for three days, insulin order revisions for one day, and high-risk anti-coagulant (blood thinner), opioid (narcotic pain), and hypoglycemic (blood sugar lowering) medications. Resident #1 had a care plan dated 1/05/25 for right leg surgical wounds/fixator. The goal was the resident would exhibit healing of surgical site without the onset of infection by the review date. Interventions included for nurses to monitor for infection and circulation complications, provide pressure relief and re-positioning with goals to exhibit healing without infection, dated 1/05/25. There were no interventions for follow up care for the wound/removal of the fixator. On 1/16/25 a new care plan was initiated for an actual pressure injury caused by prolonged pressure related to immobility, decreased mobility and obesity, right pin site #1 and #2. The goal was for the resident to maintain intact skin integrity, will show a reduction in the size/stage of the pressure injury and would show no signs of infection through the review date. Interventions included administer treatments as ordered and monitor for effectiveness, assist with turning/repositioning, ensure specialty mattress in place, and document any changes in skin integrity in the plan of care and notify the licensed nurse of any new open areas. The Order Summary Report revealed physician medication orders for multiple antibiotics ordered over a three month period from January to March 2025, including Intravenous (IV) Cefepime (antibiotic) 1 Gram (GM) every 8 hours for right leg infection from 1/21/25 to 3/08/25; Daptomycin (antibiotic) IV 650 Milligrams (MG) once daily for right leg infection from 2/14/25 to 3/08/25; Vancomycin (antibiotic) IV (dose adjusted 1.5 GM to 2.0 GM) twice daily for right leg infection from 1/21/25 to 3/08/25; Cephalexin (antibiotic) 500 MG by mouth for right leg infection from 2/28/25 to 3/14/25; Doxycycline 100 MG twice daily from 2/28/25 to 3/14/25; Rifampin (antibiotic) 300 MG twice daily by mouth for right leg infection on 1/06/25 to 1/20/25 and again on 2/04/25 to 3/06/25. He had no further antibiotic orders until 4/10/25. Active medication orders also included Lovenox 40 MG injection twice daily for blood clot prevention on 2/04/25; Oxycodone (narcotic/opioid pain) 9 MG extended release every 12 hours for leg pain on 1/09/25; and Oxycodone 10 MG every 4 hours as needed for pain on 1/21/25. Review of an Infectious Disease Progress Note dated 1/22/25 showed a new diagnosis of right lower extremity (leg) wound infection and leukocytosis and read, wound culture obtained and discussed with wound care specialist. Wound was noted to have increased purulent drainage from odor. An orthopedic physician progress note dated 1/30/25 revealed resident #1 had developed an Achilles tendon contracture and complete peroneal nerve palsy (inability to lift the foot at the ankle). Removal of the device was planned for around 3/27/25, or 12 weeks after it was placed which required pre-operative Venous Doppler testing completed 24-to-48 hours before surgery to identify any blood clot complications that required planning for additional potential surgical interventions. An orthopedic physician Pre-Op Exam progress note dated 3/04/25 indicated resident #1's external fixator device removal surgery was planned for 3/19/25. Noted concerns documented the resident's ankle contracture was, near-fixed and possibly required additional lengthening surgery for the resident to walk again with a flat foot. On 4/09/25 at 11:01 AM, resident #1 was awake in his room, lying in bed. An external fixator device was attached to his right leg. The resident's right foot and toes were pointed downward and the resident said he had developed foot drop since he came to the facility in early January 2025 after surgery. He explained he had missed several follow up appointments with the Orthopedic surgeon that the facility was supposed to help him arrange. The resident was tearful when he explained the facility had not arranged for testing that was needed prior to a second surgery to have the device removed on 3/19/25, in a timely manner so the surgeon had to cancel the surgery. He said the surgery was still currently unscheduled and he was fearful and anxious because the device removal was overdue. Resident #1 explained his movement was worse, and he hadn't been placed back on antibiotics after the surgery was canceled. He recalled on 3/18/25, the South Unit Manager (UM) told him the Doppler test wasn't completed yet for his surgery. The resident was tearful, pointed to the device and stated, they didn't do it (the Doppler test) until the next morning and that was too late; there has been an infection in the pins and they need to come out . In a telephone interview on 4/10/25 at 9:47 AM, the Orthopedic provider's scheduler said she was the primary point of contact with the facility and the Orthopedic physician. She explained resident #1 was supposed to have surgery to remove the hardware from his previous surgery the past December 2024. She confirmed resident #1 was supposed to have the surgery for removal nine to twelve weeks after the first surgery, but had not. The scheduler checked the medical records and said the resident missed his first post-surgical follow-up appointment on 1/17/25, and the next appointment on 3/06/25 due to lack of transportation. She confirmed he did not have a new date scheduled for surgery to remove the hardware at that time. In a telephone interview on 4/09/25 at 2:01 PM, the South UM recalled she was frequently in telephone contact with surgery schedulers who emphasized the importance of timeliness for completion of the pre-operative Doppler testing to ensure resident #1's surgery was able to be performed on 3/19/25. She explained she entered a physician's order for the Doppler test, approximately one week prior to the scheduled surgery after a telephone reminder from the scheduler. The nurse recalled the scheduler called again on 3/18/25 and indicated the surgeon had not received the Doppler test results yet, so she tried to get it done with a STAT (without delay) order, but it was completed too late and the surgery had to be canceled. She said she checked resident #1's medical record and found the physician's order for the test was processed about a week prior to the scheduled surgery (3/11/25) and was signed off by a nurse as completed. The UM said she checked the records for results and found the test was not actually done, and she knew per physician's orders it should have been completed within 24 to 48 hours before the scheduled surgery, not a week before. She did not explain why the original order she entered was set for eight days (192 hours) before surgery instead of one to two days before. The UM stated, I was in contact with them (surgeon's office) frequently, and there were a lot of pre-op instructions; it got missed and shouldn't have been signed off; we talked about it a lot and in morning meetings. The nurses should have followed up to make sure it was actually done, and that's a lesson learned. Review of the Treatment Administration Record (TAR) included physician's orders for a pre-operative Venous Doppler to be completed 24 to 48 hours before surgery to rule out Deep Vein Thrombosis (blood clot) dated from 3/11/25 to 3/13/25. The order was signed as completed by Registered Nurse (RN) A on 3/11/25 at 11:44 PM, eight days before the scheduled surgery. Another order for a STAT Doppler for pain to the right lower leg was dated 3/19/25 (the day of the scheduled surgery), with a start time of 10:00 AM and signed as completed at 3:45 PM on 3/19/25. In an interview on 4/10/25 at 3:00 PM, RN A explained the process for completion of physician's orders for a Venous Doppler included completion of a handwritten requisition placed in a binder for the technician, and a call to the radiology provider for a scheduled test when the order was entered. The RN said she did not recall entering the order or receiving any information about it from off-going/on-coming report, and she must've signed it off because it was on the TAR and she thought it was completed, but had not actually verified the test was performed. Review of the handwritten radiology provider requisition for a STAT Venous Doppler noted an untimed date of 3/18/25 signed by the South Unit Manager. The technician's signature for exam completion was undated and timed as 9:50 AM. A Progress Note completed by the South Unit Manager dated 3/18/25 at 5:36 PM noted a STAT order for a pre-operative Venous Doppler was obtained that could not be completed STAT, as it was requested at 5:03 PM. The note showed the surgery scheduler had called the facility and the note read, surgery to be re-scheduled. The Radiology Results Report noted resident #1's Venous Doppler exam was completed on 3/19/25 at 8:54 AM, read at 10:38 AM by the Radiologist, and reported to the facility physician at 10:59 AM. In a telephone interview on 4/10/25 at 2:43 PM, with the mobile radiology provider, the Customer Service Representative checked their records and said the only Venous Doppler request for resident #1 from the facility was completed on March 19, 2025 from [name] South Unit Manager at 8:54 AM, and a previous test was done on 2/11/25 at 5:28 PM. She said requests for STAT exams required a two to four hour advance window as long as the request was received by 5:00 PM for same day services. On 4/10/25 at 9:47 AM, in a telephone interview, the orthopedic provider's surgery scheduler said resident #1's surgery was scheduled in advance for 3/19/25. The scheduler explained, she was in frequent contact with the facility during the two weeks prior to surgery and emphasized timeliness of the pre-operative Doppler was required to ensure the surgical procedure was able to be performed. She described the Doppler test was needed within that time frame because additional surgical pre-planning was required in the event the resident had a blood clot. She said their records showed on 3/14/25, the surgeon's nurse called and emailed the facility for a reminder to complete the pre-operative requirements including the Doppler test, and on 3/18/25, she herself spoke to the South Unit Manager and informed her the surgeon had not received the Doppler results yet. On 4/10/25 at 2:30 PM, Licensed Practical Nurse (LPN) B explained Doppler testing was processed by nurses when they entered orders into the computer, completed a handwritten requisition with a face sheet placed in the binder kept at the nurses station, called the radiology provider to schedule the test, and then signed the TAR as completed. The nurse said no further follow up was done by nurses to ensure the order was completed and stated, we assume it gets done. On 4/09/25 at 4:09 PM, the Director of Nursing (DON) conveyed she expected nurses to follow the process to complete physician's orders and pre-operative instructions to ensure residents' care wasn't delayed. The DON said orders were discussed in morning meetings by the clinical team and follow-up was monitored by Unit Managers. She said the nurse shouldn't have signed the TAR for the Doppler order on 3/11/25 because it wasn't actually done. The DON acknowledged resident #1's surgery for 3/19/25 was canceled by the orthopedic provider. On 4/09/25 at 1:25 PM, the North UM stated resident #1 now required another physician's order for antibiotics. She explained, the Wound Care APRN ordered the antibiotics after seeing the resident the previous day. The nurse said she contacted the Infection Preventionist (IP) Advanced Practice Registered Nurse (APRN) who gave orders to continue the oral antibiotic medications until the fixator device was removed. The North UM could not explain why no one at the facility asked the provider about antibiotics for resident #1's right leg infection until today when the surveyor was present for the complaint. An Progress Note dated 4/08/25 noted resident #1 was seen by the IP APRN and treated for leukocytosis (high white blood cell count) and a right lower extremity wound infection which was discussed with a nurse and read, continue antibiotics. Purulent drainage refers to thick, milky discharge that comes out of a wound. It usually means you have infection, so it's important to get prompt medical care. Treatment can prevent cellulitis (skin infection), osteomyelitis (bone infection) and other serious conditions like sepsis, (retrieved from my.clevelandclinic.org on 4/11/2025). On 4/10/25 at 2:40 PM, the Director of Nursing (DON) said she checked resident #1's medical records and no wound culture was ever ordered or performed as per the Infectious Disease progress note dated 1/22/25. A wound culture is a test that looks for what type of microorganisms grow from a wound sample to isolate the type of organism that caused the infection. Then the appropriate/effective antibiotics can be ordered to treat the infection, (retrieved on 4/23/25 from www.surgeryencyclopedia.com). On 4/09/25 at 1:45 PM, a joint interview was conducted with the North UM and the IP APRN by telephone. The APRN said he treated the resident since his admission in January 2025 for an infection associated with the external fixator. He explained the resident was at high-risk for serious complications and had already been treated with heavy Intravenous (IV) antibiotics. The APRN said the resident was expected to remain on oral antibiotics until the hardware was removed, but he was not sure why the antibiotics weren't continued after resident #1's surgery was cancelled. He was unaware as facility nurses didn't inform him the antibiotics weren't continued after the surgery was canceled. He confirmed the antibiotics were restarted on 4/09/25, 3 weeks after the surgery was cancelled when the North UM called him for antibiotic orders. He expressed delays in the removal of the device could lead to serious infection and the resident had to remain on preventive antibiotic medications until the device was removed. The APRN explained the orthopedic surgeon wanted the device out and stated, that's the main thing to keep him stable. Review of the Wound Care Specialist's Visit Report dated 2/18/25 noted resident #1's had two new wounds with heavy purulent drainage. The two acute (of abrupt onset) stage IV (deep tissues/muscle, tendon, ligament) pressure ulcers around the fixator pin sites which had developed required debridement. A Visit Report dated 4/08/25 noted the same two wounds still with, moderate purulent drainage and continued wound treatments including antibiotics. In a telephone interview of 4/09/25 at 1:51 PM, the Wound Care APRN recalled resident #1 had two pressure wounds around the pin sites which were caused when the pin clamps with pressure against the leg/skin. She conveyed the resident's morbid obesity contributed to this pressure on his skin. The APRN did not recall obtaining a wound culture to determine what type of treatment was needed. She stated she last saw the resident on 4/08/25 when she asked staff to contact the IP APRN to restart the antibiotics. Review of the Psychiatric Mental Health Nurse Practitioner progress note dated 4/02/25 revealed resident #1 required assessment for depression and anxiety and on the last visit of 3/19/25 he was noted with agitation and frustration. The note read, prior to last visit, patient was doing well. No mood swings and behaviors noted. No other concerns were noted. During last visit, patient was agitated due to situation. Patient was agitated and anxious. A Progress Note completed by the South UM on 4/02/25 noted a discussion with resident #1 about scheduling of his surgery. The note indicated the resident had not received any calls to re-schedule, and he agreed to a joint call with the scheduler the next day. In an interview on 4/09/25 at 4:09 PM, the DON acknowledged resident #1's surgery had not yet been rescheduled but said the facility continued attempts to have it rescheduled. In a telephone interview with the resident's attending physician on 4/10/25 at 5:40 PM, the physician said he last saw him the day before. The physician said when he saw the resident, he was surprised his surgery had still not been done. He said the facility had not notified him the surgery had been canceled and was not aware the facility had not completed the required pre-operative Doppler test. The physician explained he expected nurses to notify him of surgery cancellations, changes in status, and to follow physician orders to get testing done so residents could get what was needed as he was responsible for the resident's care. The physician stated, I told them initially it will get worse; he really needs to have the fixator removed; he is suffering. Review of the facility's standards and guidelines titled, Diagnostic Services and dated 3/02/19 noted the facility was responsible for the timeliness of services whether provided by the facility or outside resources to ensure residents' needs were met for proper diagnosis and treatment. Review of the Facility assessment dated as reviewed on 12/23/24, 1/14/25, and 3/25/25 noted the facility provided ongoing training for all staff consistent with their expected roles and resident characteristics. Minimum content included identification of resident changes in condition, effective communication, and Abuse, Neglect, and Exploitation with readily accessible resources to all staff at nurses offices and nursing stations.

Based on observation, interview, and record review, the facility failed to timely assist and provide post-operative follow up transportation for 1 of 3 residents reviewed for Administration, of a total sample of 4 residents, (#1). Findings: Resident #1, a [AGE] year old male was admitted to the facility from an acute care hospital on 1/03/25 with diagnoses including subsequent encounter of right knee dislocation/reduction, type 2 diabetes mellitus, adjustment disorder with depressed mood, and anxiety disorder. Additional diagnoses after admission to the facility included leukocytosis (high white blood cells/infection response), right leg wound infection, right Achilles (ankle) tendon (connects muscle to bone) contracture (tightening), and right peroneal (lower leg) nerve palsy (paralysis/weakness). The Minimum Data Set Comprehensive Admission Assessment with an Assessment Reference Date of 1/09/25 noted during the look-back period, resident #1 scored 15 out of 15 on the Brief Interview for Mental Status that indicated he was cognitively intact, and 0 out of 30 on the Staff Assessment of Resident Mood used to identify signs of depression or mood impairment, and there were no behavioral symptoms or rejections of evaluation or care. The resident had functional Range Of Motion (ROM) limitations to the lower extremity (hip, knee, ankle, foot) that interfered with daily functions and placed him at risk of injury; he did not walk and was dependent on staff to complete Activities of Daily Living (ADLs) including positioning and transferring in and out of bed. Resident #1 had care plan focuses for staff assistance with ADL care and mechanical lift dependence, history and risk of falls with injury with an intervention to anticipate and meet the resident's needs as needed, right leg surgical wounds/fixator, and 4 staff required assisted transfers. Resident #1 had no care plan focus for discharge home until 4/09/25 with an intervention to, make arrangements with required community resources to support independence post-discharge (specify-home care, PT/OT/ST [Physical, Occupational, Speech Therapy], MD [Medical Doctor], wound nurse, etc.) On 4/09/25 at 11:01 AM, resident #1 was lying in bed in his room. An external fixator device with surgical pins was observed attached to the resident's right leg. The resident explained he was very upset that the facility caused him to miss follow-up appointments after surgery in January 2025. He said the surgery was still currently unscheduled and he was fearful and anxious because the device removal was overdue. Resident #1 explained his movement was worse, and he hadn't been placed back on antibiotics after the surgery was canceled. He recalled on 3/18/25, the South Unit Manager (UM) told him the Doppler test wasn't completed yet for his surgery. The resident was tearful, pointed to the device and stated, they didn't do it (the Doppler test) until the next morning and that was too late; there has been an infection in the pins and they need to come out . He said facility staff told him he would have to pay for the transportation services because it was too costly for the facility to cover. The resident said he had to make his own arrangements for stretcher services to and from the doctor's office and to his scheduled surgery. He explained the surgery to remove the hardware in his right leg was scheduled for 3/19/25 but was ultimately canceled because required pre-operative testing wasn't completed by the facility. On 4/09/25 at 2:01 PM, the South Unit Manager said she was very involved with and assisted resident #1 with his follow-up appointments. She recalled in January 2025, there were issues about who was responsible for the transportation cost, and some appointments were canceled and re-scheduled. In a telephone interview on 4/10/25 at 9:47 AM, the orthopedic provider's scheduler said she was the primary point of contact with the facility and the orthopedic physician. She said resident #1 was supposed to have surgery to remove the hardware from his previous surgery from December 2024. She confirmed resident #1 was supposed to have the surgery for removal nine to twelve weeks after the first surgery. The scheduler said resident #1 had missed some appointments due to transportation issues including one on 3/06/25 for a nerve evaluation, and on 1/17/25 where they were going to put the resident in a temporary immobilizer. She checked the medical records and said the resident missed his first post-surgical follow-up appointment on 1/17/25, and the next appointment on 3/06/25 due to lack of transportation. She confirmed he had no date rescheduled for the surgery he needed to remove the hardware at that time. A Infectious Disease Progress Note dated 1/22/25 noted resident #1 had missed his orthopedic follow up appointment and read, Needs follow-up with surgeon ASAP. Review of the medical record noted a form with instructions for a surgical follow-up appointment set for 1/17/25 at 1:45 PM. On 4/09/25 at 12:05 PM, the Medical Records Coordinator confirmed she was responsible for outside appointment transportation arrangements. She explained the resident required special stretcher transportation and recalled the facility had paid for one re-scheduled ride, but she wasn't sure about his surgery transportation. She said the facility used a handwritten form filled out by nurses then given to her for transportation appointment requests. She said part of her responsibility was to verify the payer source and any insurance benefits. She recalled the cost for resident #1's stretcher transportation was approximately $3,000 per occurrence, that he didn't have benefits to cover it, and any cost to the facility had to be approved by the Nursing Home Administrator (NHA). Review of resident #1's Appointment Reminder form dated 1/16/25 and signed by the Medical Records Coordinator for a 1/17/25 appointment at 1:45 PM, showed handwritten notes that read, Transport not scheduled; [provider name] to reschedule for 1/30/25. The form dated 1/28/25 for a 1/30/25 appointment at 8:30 AM noted the Responsible Party handwritten as self. An undated form for a 3/04/25 appointment at 9:00 AM noted the Responsible Party handwritten as [resident's name]. On 4/10/25 at 12:02 PM, the Medical Records Coordinator said she did not have any other forms nor did she make arrangements for the resident's appointments on 3/06/25 or 3/19/25. On 4/09/25 at 12:58 PM, a request was sent to the transportation provider for resident #1's transportation information. On 4/11/25, the transportation company provided documentation of an unpaid bill to the facility for the resident's services on 1/30/25 in the amount of $3,484.16, and for services provided on 3/04/25 at the resident's request that was paid by a charitable organization. No other requests from the facility for resident #1's transportation were documented in the record. A Progress Note dated 2/22/25 by the Social Services Discharge Planner noted a plan was in place for resident #1's discharge home on 3/04/25. The note read, Patient asked if transportation would be taking him to his appointment and then home. I explained that upon discharging, that family is responsible for setting up transportation and paying for transportation. In an interview on 4/10/25 at 9:04 AM, the Discharge Planner recalled resident #1 was previously planned for discharge home around the end of February 2025. She explained the discharge was canceled because the resident didn't want to leave until after his surgery and the current plan was for discharge home on 5/01/25. On 4/09/25 at 2:26 PM, the Nursing Home Administrator (NHA) provided an unpaid financial agreement the facility signed on 1/30/25 with the transportation provider for resident #1's transportation services on 1/30/25. The NHA conveyed the document was completed by the previous NHA and she did not provide any information or documents of financial responsibility for transportation to appointments on 1/17/25, 3/04/25, 3/06/25, or 3/19/25. The NHA acknowledged transportation to resident #1's outside appointments was the responsibility of the facility and the resident would not pay for the transportation himself. Review of the facility's standards and guidelines titled Diagnostic Services and dated 3/02/19 noted the facility was responsible for the timeliness of services whether provided by the facility or outside resources to ensure residents' needs were met for proper diagnosis and treatment. Review of the Facility assessment dated as revised 12/23/24, 1/14/24, and 3/25/24 noted the facility offered and provided care to residents with musculoskeletal disorders based on the resident's needs and the resident's chart was reviewed prior to admission to the facility.

Based on observation, interview, and record review, the facility failed to provide food to accommodate residents' preferences for 4 of 43 sampled residents, (#77, #403, #34, and #59). Findings: 1. Resident #77 was admitted to the facility on [DATE] with the diagnoses of right tibia fracture, muscle weakness, major depressive disorder, and chronic lung disease. Her physician orders revealed a regular diet was prescribed. On 2/11/25 at 9:01 AM, resident #77 stated she was not going to eat her breakfast of a small donut and sausage because she considered these foods to be unhealthy. She added she had been at the facility for three months and was not aware she could request menu items for her meals. Resident #77 explained she had just found out she could eat outside of her room after she had wandered around one morning about a month after she had arrived. She stated no one had asked her what foods she liked to eat or what foods she disliked. On 2/12/25 at 11:16 AM, the Dietetic Technician, Registered (DTR) reviewed the nutrition assessment completed for resident #77 on 1/02/25. The DTR confirmed the assessment indicated resident #77 was eating well and met her nutritional needs. The assessment did not included any information about the resident's food preferences. The DTR stated if there was not an issue with a resident's intake, she did not discuss food preferences with the residents. 2. Resident #403 was admitted on [DATE] with diagnoses of a crushing injury to his right hand, pain in right hand, cellulitis of upper right extremity, and adjustment disorder with mixed anxiety and depressed mood. His physician orders for February 2025 included a regular diet. Review of the nutrition assessment dated [DATE] indicated resident #403's caloric needs were estimated at 2189-2975 calories/day. On 2/11/25 at 9:30 AM, resident #403 stated he only got a sausage, a small donut, and a glass of juice and milk for breakfast, and he was still hungry. He stated he had been at the facility about a week and a half and he was not aware he could make food selections from the menu. Resident #403 added no one from the staff had discussed his food preferences with him. Occupational Therapist (OT) M brought the resident a 2nd meal tray because he told her he wanted more food. OT M stated the tray she brought was a leftover, untouched tray for another resident who had gone to the hospital. Resident #403 acknowledged the food provided was cold, but stated he didn't care because he was hungry. On 2/12/25 at 11:16 AM, the DTR confirmed resident #403's caloric needs were estimated at 2189-2975 calories/day and acknowledged his nutritional needs could be very difficult to meet when the menu provided approximately 2000-2200 calories per day. She added snacks were available from the nursing stations. The DTR stated the resident seemed fine with the food and confirmed she didn't discuss food preferences with this resident. The DTR acknowledged the facility did not offer resident #403 large portions or discuss options for the resident to fill out menus to better meet his hunger and nutritional needs. On 2/14/25 at 9:30 AM, the Regional Nurse stated they expected staff to check the resident's diet order and go to kitchen to get a resident fresh, warm food according to their diet order, if they asked for more food. The DON and the DTR were in agreement, and the DTR added that serving a leftover tray to another resident was not acceptable. The DON stated she would have stopped the staff and told them to get fresh food from the kitchen because any food that was out, could have been touched by someone else. 3. Resident #34 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease (ESRD) with dependence on renal dialysis, chronic pain syndrome, secondary malignant neoplasm of the breast, gout, depression, anxiety, dementia without behavioral disturbance, and primary insomnia. The physician orders for for February 2025 indicated resident #34 was on a Renal diet. Review of the Nutrition Comprehensive Evaluation dated 1/16/25 revealed resident #34's food intake varied between 25-100% of meals and was inadequate to meet her needs which were estimated to be between 2400-2800 calories and 96-112 grams protein /day. On 2/11/25 at 9:23 AM, resident #34, acknowledged she had been at the facility about 4 weeks, and stated she didn't like the food. She explained she had asked her aide to be able to select her meals herself but was never given a menu to do so. On 2/12/25 at 11:16 AM, the DTR reviewed the nutrition assessment for resident #34 dated 1/16/25. She acknowledged the assessment indicated the resident was not meeting her nutritional needs, her appetite was diminished, and she was not interested in the food served at the facility, but agreed to receive the nutrition supplement, Nepro. The DTR verified there was no indication food preferences were discussed or an attempt to try to provide foods the resident liked to eat. The DTR confirmed the Nepro supplement had not been ordered for the resident which she said was her error. The DTR added she believed someone on the nursing staff explained the option to fill out menus to the residents, but she was not sure who did it. On 2/12/25 at 9:55 AM, the Dietary Services Manager stated when residents got admitted to the facility, he visited them to get their food preferences and let them know they could get menus from the nursing station or their Certified Nursing Assistant (CNA) to select their meals. He added that the DTR or the Registered Dietitian (RD) also then met with residents when they assessed their nutritional status and would communicate any additional preferences to him through email. The Dietary Services Manager checked his computer for residents #77, #403, and #34 and found no preferences, no dislikes, and no documentation that the residents were spoken with about their food requests. On 2/11/25 at 9:08 AM, CNA D stated the 3 PM-11 PM shift CNA's gave menus to residents when they asked for one and put extra menus by the nursing station. She added new CNA's were trained to tell new residents there were menus available when they got admitted . On 2/12/25 at 5:11 PM, CNA C stated when a resident was first admitted , the CNA's explained there were menus for selecting lunch and dinner meals, but menus were not passed to residents who were on pureed, mechanical soft, or renal diets. She pointed out a couple of specific residents who received menus to fill out for the next day. She acknowledged that sometimes residents may be overwhelmed when they were first admitted , and she acknowledged it might be helpful if the information was repeated to them. 4. Resident #59 was admitted on [DATE] with diagnoses of acute respiratory failure with hypoxia, pneumonia, unspecified intracranial injury, type II diabetes mellitus, protein-calorie malnutrition, chronic pain, muscle weakness, and major depressive disorder. Review of physician orders for February 2025 indicated she was ordered a regular diet. Resident #59's Comprehensive Nutrition assessment dated [DATE] indicated she had a low Body Mass Index (BMI) of 21.3, had significant weight loss in the recent past and ate her meals independently with set-up. The assessment revealed the resident stated she was sometimes hungry between meals and desired beneficial weight gain. The document described the resident agreed to some large portions and her preferences were discussed. On 2/10/25 at 5:49 PM, CNA A delivered resident #59's dinner tray into her room, set it down and indicated to the resident the meal was there, and left the room. The resident opened the lid from her food plate and realized what she received was not what she had ordered, which was corroborated by her menu. A few minutes later CNA A stated staff were supposed to check the resident's menu ticket to ensure they actually received what was on the ticket when they delivered the meals. She added she just dropped the tray off to this resident because she knew the resident could set up her own tray and she figured the resident would ask if something was missing. She then acknowledged she left the resident's room so quickly, the resident hadn't had a chance to look at her meal or request what food items she hadn't received on her ticket. On 2/12/25 at 10:28 AM, the Director Of Nursing (DON) stated when CNA's delivered meal trays to residents, she expected them to sanitize their hands prior to getting their meal, to ensure the meal tickets matched the resident's name and food items on their tray, and the tray included the utensils and drinks listed on the ticket. The facility's policy entitled, Food and Nutritional Services dated 3/02/19, indicated the facility would provide a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of the residents, taking into consideration their preferences. The document continued that the facility employed sufficient staff with appropriate competencies and skill sets to carry out the function of food and nutrition service.

Based on observation, and interview, the facility failed to serve food items in accordance with professional standards for food service safety. Specifically, potentially hazardous food items were held and served while in the temperature danger zone having the potential to affect 95 of the 98 residents at the facility. Findings: On 2/12/25 at 4:40 PM, the dinner tray line was in process when tuna salad sandwiches were noted to be stacked in a full, deep sheet pan sitting in one of the wells of the steam table being used to plate hot entrees. The heating element for the steamtable well which held the sandwiches along with the well directly adjacent to it, were turned off but were warm to the touch as heat radiated from the other heated wells further down on the table. The Dietary Services Regional Manager took the temperatures of the sandwiches which recorded at 50 degrees Fahrenheit (F). The evening (PM) cook removed the tuna sandwiches from the tray line and put them in the freezer to re-chill. The Regional Manager removed a 2nd deep full-size steamtable pan of tuna salad sandwiches from the freezer and measured the temperature of random sandwiches, which was found to be 46.7 degrees F, in the danger zone for potentially hazardous foods. The Regional Manager put the 2nd steamtable pan of sandwiches back into the freezer and told the cook and kitchen staff that the tray line should stop and was not able to continue until the sandwiches were cooled to a safe serving temperature of at least 41 degrees F. The PM cook stated the pan of sandwiches were usually on a bed of ice in the steamtable wells, but the ice machine was not producing ice at that time, so no ice was available for the tray line. A few minutes later, the Dietary Service Manager provided the temperature log that contained the pre-tray line temperatures of foods from the tray line. The cook stated she had taken the temperatures approximately 20 minutes earlier, at the start of tray line, and the sandwich temperature was recorded at that time as 38 degrees F. The Dietary Services Manager stated he did not have an explanation for how sandwiches whose temperature was recorded at 38 degrees F twenty minutes prior then placed in the freezer had actually warmed to 46.7 degrees F. He stated at approximately 2:30 PM, he talked with the PM cook while she prepared the sandwiches and he witnessed her put the sandwiches in the freezer around that time. On 2/13/25 at 12:10 PM, the Dietary Services Regional Manager stated it was common at facilities to put cold sandwiches into the freezer to chill them quickly then move them into a refrigerator when they were at a safe temperature. He acknowledged the sandwiches that tested 46.7 degrees F in the freezer, must not have been placed there long enough to be chilled, and were not at a safe temperature to be served. The facility's Food and Nutrition Services policy dated 3/02/19 detailed the facility would store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Based on interview, and record review, the facility failed to ensure that the binding arbitration agreement explicitly granted the resident or their representative the right to rescind the agreement within 30 calendar days of signing it for 18 of 102 current residents who signed arbitration agreements. Findings: Review of the log provided by the facility revealed 18 of the current 102 residents signed the facility's arbitration agreement. On 2/13/25 at 1:59 PM, the Internal Admissions staff person verified she completed most of the admission packets with residents or their representatives within 48 hours of admission. She stated she usually read the Voluntary Binging Arbitration Agreement to the resident or their representative. She confirmed the agreement was not a requirement for admission. She explained the resident or their representative could change their mind after signing but was not sure of the time frame. The Internal Admissions staff person reviewed the arbitration agreement and confirmed it gave the resident or their representative 30 calendars of the resident's date of admission to rescind the agreement, not from the date of signature. Review of the facility's Voluntary Binding Arbitration Agreement revealed the document was voluntary and was not a requirement for admission. The document defined the parameters of an arbitration and indicated the document could be rescinded within 30 days of the resident's date of admission to the facility. On 2/13/25 at 2:03 PM, the Regional [NAME] President of Operations reviewed the right to change your mind clause in the Voluntary Binding Arbitration Agreement. She acknowledged the wording did not explicitly grant the resident/resident representative 30 days from the date of signing to rescind the agreement. The Regional [NAME] President of Operations agreed the resident/resident representative would not have 30 days from date of signature to rescind the agreement if it differed from the date of admission, but stated she did not think any residents had been affected since no one had requested to rescind the agreement.

Based on interview, and record review, the facility failed to maintain records, monitor, and effectively conduct Quality Assurance Performance Improvement (QAPI)/Quality Assurance and Assessment (QAA) activities which could affect facility wide processes impacting quality of care and quality of life for all residents. Findings: On 2/14/25 at 8:43 AM, in a joint interview with the Director of Nursing (DON) and Regional Director of Clinical Services, the Director said she initiated a Performance Improvement Plan (PIP) approximately one month prior for Pre-Admission Screening and Resident Review (PASARR). She stated in regards to resident PASARRs, I would say maybe 25% have been looked at and some were redone. She said she had to locate the documentation and audits to clarify. On 2/14/25 at 10:08 AM, the Regional Director of Clinical Services explained she was unable to locate any records for the PIPs and stated, they're not on record and not organized. On 2/14/25 at 11:59 AM, the Nursing Home Administrator (NHA) said she had been the NHA since 1/14/25. She explained she had conducted QAPI meetings on 1/14/25 and 1/16/25. She explained the last meeting included discussions concerning regulatory compliance and survey management. She said she initiated a PIP for facility wide environmental concerns and maintenance repairs. The NHA checked previous records that showed a QAPI meeting was conducted in December 2024 with notes that PIPs were implemented for facility issues with infection control, respiratory/tracheostomy care, and PASARR. A handwritten log was observed in the binder that noted the titles of PIPs she verbalized. No reports or documents related to the PIPs aside from the environmental/maintenance plans were located in the NHA's QAPI records. The NHA was unable to locate any records for clinical PIPs and said she could not speak to what occurred before she took over. The NHA stated, there are no records for clinical; QAPI is in place to monitor, analyze, and correct problems so residents get the care and services they need and have the right to. Review of the Quality Assurance Meeting minutes dated 1/14/25 provided by the NHA noted there were no QAA Committee recommendations, and read, Plan implemented based on recommendations: N/A Review of the facility's standards and guidelines titled Quality Assurance and Performance Improvement and dated 3/2/19 read, The facility will: 1. Maintain documentation and demonstrate evidence of it's ongoing QAPI program that meets the requirements of this section. This may include but is not limited to systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events, and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . 3. Present documentation and evidence of it's ongoing QAPI program's implementation and the facility's compliance with the requirements to a State Survey Agency, Federal Surveyor, or CMS (Centers for Medicare & Medicaid Services) upon request.

Based on observation, and interview, the facility failed to provide a homelike environment for residents who ate in the dining rooms on the two (North and South) nursing units. This affected all residents who chose to eat in the nursing unit's dining areas, which varied from approximately 8-20 residents per meal of the 98 residents at the facility. Findings: On 2/10/25 at 12:35 PM, four staff were observed serving trays to residents on the North unit from the food cart. There were seven residents sitting at tables in the North unit dining room waiting to be served. There were no tablecloths or centerpieces on the tables and the dishes were left on the serving trays. On 2/10/25 at 1:38 PM, lunch was provided to approximately thirteen residents in the South unit dining room. There were no tablecloths or centerpieces on the tables. All the dishes, flatware, cups and food items were left on the resident's trays while they ate. On 2/10/25 at 5:59 PM, residents were observed eating in the South unit room dining room from their trays. The undecorated tables held newspapers and pieces of paper with word puzzles on them that had been used earlier in the day. On 2/11/25 at 1:18 PM, during the lunch service on the South and North unit's dining rooms the residents ate from their trays on undecorated tables as they did the previous day. On 2/12/25 at 5:21 PM, resident #77 described the dining area felt like a cafeteria, and could be made nicer with tablecloths or decorations. On 2/12/25 at 10:28 AM, the Registered Dietetic Technician (DTR) stated she thought everyone would enjoy a little more decoration in the dining room, like centerpieces in the area in which they dine. On 2/13/25 at 1:10 PM, the Administrator observed all residents in the South unit dining room ate from trays. She acknowledged that serving all residents on trays could be considered a dignity issue because it was more institutional, than home-like.

Based on observation, interview, and record review, the facility failed to monitor identified weight loss and impaired nutrition risk for 2 residents (#52, #15); and failed to properly monitor the clinical condition for 1 resident, (#34), out of 7 residents reviewed for nutrition, of a total sample of 43 residents. Findings: 1. Review of the medical record revealed resident #52, a [AGE] year old female was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, thyroid disorder, chronic pain syndrome, major depressive disorder, persistent mood disorder, anxiety disorder, dementia, Pseudobulbar Affect (uncontrollable crying/laughing), and cognitive communication deficits. The most recent Minimum Data Set (MDS) Quarterly Assessment with an Assessment Reference Date (ARD) of 12/30/24 revealed during the look-back periods, resident #52 had impaired vision, was rarely/never understood, and unable to complete the Brief Interview for Mental Status (BIMS). Staff assessed the resident had short term and long term memory problems, was severely cognitively impaired, had continuous inattention and disorganized thinking that did not fluctuate, delusions, and she was dependent on staff to complete all Activities of Daily Living (ADL). The resident did not walk, required a wheelchair, had no weight loss or gain, required scheduled and as needed pain medication, a mechanically altered diet, and she received high-risk anti-depressant and opioid medications. The Order Summary Report included active physician's orders for monthly weights. Medication orders included Donepezil (enzyme blocker) 10 Milligrams (MG) at bedtime for dementia, Levothyroxine (thyroid hormone) 112 Micrograms once daily for thyroid disorder, Nuedexta (central nervous system agent) 20-10 MG every twelve hours for Pseudobulbar Affect, Tramadol (opioid pain) 50 MG three times daily for chronic pain, and Trazodone (anti-depressant) 25 MG at bedtime for depression. The Comprehensive Care Plan included focuses for diabetes mellitus, thyroid disorder, incontinence, risk for skin breakdown, impaired communication and hearing, risk for falls, dementia with behaviors, high-risk medication adverse effects monitoring, squamous cell cancer, required staff assistance for all ADLs, and Long Term Care (LTC) with a goal to assure maintenance of the resident's safety and comfort, and observance of distress. On 2/11/25 at 10:45 AM, resident #52 was observed awake and lying in bed in her room. The resident did not answer questions and was unable to participate in an interview. On 2/11/25 at 3:43 PM, Certified Nursing Assistant (CNA) J said resident #52 was often included in her assignment, required staff assistance to eat, and needed cues and reminders to ensure she was eating enough. Review of the Dietary Progress Note dated 10/03/24 noted resident #52 was evaluated for weight loss, insufficient intake, and a low Body Mass Index (BMI). Orders for calorically dense supplements twice daily between meals and fortified foods were implemented for weight loss and low BMI. The Weights and Vitals Report showed on 9/12/24, resident #52 had a 8.7% or 11 pound weight loss over two months. Additional weights were not completed after 11/07/24, for three months. In a joint interview with the Dietary Technician (DT) and Registered Dietician (RD) on 2/12/25 at 12:09 PM, the DT said she visited the facility once weekly to complete evaluations for new admissions and concerns when she was informed by nursing. She said weight loss was tracked from a facility provided report and was acted on for identified weight loss. She explained that typically, nutritional supplements were added to help avoid nutritional complications of weight loss and weights were often re-checked more frequently with weight loss in vulnerable, aging residents. On 2/12/25 at 1:56 PM, the Unit Manager said all residents were weighed on admission, and at least monthly and it was assigned by the Director of Nursing (DON). She explained the facility's Dietician monitored residents for any weight loss concerns. In a joint interview with the DT, RD, and DON, the DT checked resident #52's medical record and said the last progress note dated 10/03/24 showed the resident triggered for significant weight loss. She said orders were added for Med Pass (supplement) and fortified foods. She checked the medical record and said no weights had been completed for the resident since 11/07/24, so she was not aware of the resident's status since that time. The RD stated, weight maintenance is important because it affects wound healing and optimal health and well-being. 2. Review of the medical record revealed resident #15, a [AGE] year old female was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis, osteoarthritis, dementia, pulmonary embolism (blood clot of lung), major depressive disorder, seizures, muscle weakness, and vitamin D deficiency. The most recent MDS Quarterly Assessment with an ARD of 11/29/24 revealed during the look-back periods, resident #15 scored 1 out of 15 on the BIMS which indicated she was severely cognitively impaired. The assessment showed the resident had range of motion functional limitations in both upper extremities (shoulder, elbow, wrist, hand), and she was fully dependent on staff to complete all ADLs, including eating. The resident did not walk, required a wheelchair, had no weight loss or gain, and she received high-risk anti-coagulant (blood thinner) and anti-convulsant (seizure) medications. The Care Plan Report included focuses for staff dependence to complete all ADLs including eating related to limitations in both shoulders with a goal to receive assistance necessary to improve/maintain quality of life, and an intervention for physician notifications for significant intake changes. Additional focuses included, incontinence, risk for skin breakdown, depression and anxiety, risk for falls, impaired cognition and thought processes/memory loss, high-risk medication adverse effects monitoring, multiple sclerosis with interventions to monitor diet and intake, missing natural teeth, expected LTC needs due to limitations with a goal to assure maintenance of the resident's safety and comfort, and observance of distress and nutritional problems related to chronic conditions, varied intake, and vitamin deficiency with an intervention for the RD to evaluate, monitor, and make recommendations. On 2/11/25 at 9:22 AM, resident #15 was observed in her room lying in bed. She did not respond to questions and her uneaten breakfast tray was observed on the bedside table. On 2/11/25 at 3:43 PM, Licensed Practical Nurse (LPN) K said resident #15 required staff assistance to eat her meals. The nurse said the resident was confused and was dependent on staff to make sure she ate enough. Review of the Weights and Vitals Summary noted the resident was weighed on 9/12/24, 10/02/24, 10/03/24, 10/04/24, and 11/07/24. In two months, the resident had a weight loss of 5.6 pounds. The resident was not weighed again until 2/07/25, for three months and showed a weight loss of 18.8 pounds or 12.6%. Since the resident was admitted to the facility, she had a total weight loss of 24.4 pounds, or 15.8%, over 5 months. Active physician's orders included monthly weights. The Nutrition Comprehensive Evaluation/Risk Screen dated 9/05/24 noted resident #15 had abnormal nutrition related labs, other risk factors, a low Body Mass Index (BMI), and she was at nutritional risk. The dietician recommended increased larger protein portions at breakfast to meet nutritional needs. A Dietician progress note dated 2/12/25 showed resident #15 was re-evaluated for significant weight loss over 90 days with recommendations to increase protein portions for all three meals. In a joint interview with the DT, RD, and DON on 2/12/25 at 2:05 PM, the DT said she completed a comprehensive nutritional assessment for resident #15 when she was admitted in September 2024 that showed some nutritional risks, so she recommended additional protein intake at breakfast. She explained the facility did not report any weight loss in the monthly reports she received until 2/07/25 and a re-evaluation was completed on 2/12/25 for significant weight loss. The Dietary Technician explained, resident #15's weight loss wasn't reported for three months because the medical record showed the resident wasn't weighed and a re-evaluation would have been completed if the facility had reported it. She checked the medical record and confirmed resident #15 triggered for weight loss and required another assessment and possibly additional interventions. On 2/12/25 at 2:15 PM, the DON said the facility's policy was to weigh all residents at least monthly by the 8th of every month, and more frequently when needed. She explained reports were generated monthly and CNAs completed weights for all residents due, as directed by the DON. The DON said she could not explain why there were no monthly resident weights completed between November 2024 and February 2025 and stated, it's important to get weights to make sure they're not losing weight, to maintain nutrition and monitor underlying medical conditions or comorbidities that may affect their health and well-being. Review of the facilities standards and guidelines titled Weight Management and dated 3/22/19 noted all residents were weighed at least every month, monitored by Dietary, and re-weights were obtained for any gain or loss of 5 pounds from the previous weight. 50401 3. Resident #34 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (ESRD) with dependence on renal dialysis, chronic pain syndrome, secondary malignant neoplasm of breast, gout, dementia without behavioral disturbance, and primary insomnia. The Admission Evaluation completed on 1/13/25 indicated the resident's initial weight was 00000 (not taken). This evaluation also indicated the resident's skin had some redness but was intact without any skin breakdown, and had no issues with her appetite. Resident #34's care plan indicated she had a Stage IV pressure ulcer on her coccyx with interventions to monitor nutritional status and obtain weekly skin checks, document, and notify Medical Doctor (MD) of any changes in skin integrity (initiated 1/14/25). The Care Plan also indicated this resident had nutritional problem related to cancer, dementia, dialysis, therapeutic diet, and varied oral intake with a goal of resident tolerating diet and not having significant weight loss through review date. One of the interventions was to provide and serve supplements as ordered (initiated 1/16/25). The Nutrition Comprehensive Evaluation dated 1/16/25 indicated resident #34's food intake varied between 25-100% of meals and was inadequate to meet her needs which were estimated to be between 2400-2800 calories and 96-112 grams protein/day. The nutritional assessment indicated the resident did not have any skin issues/ pressure ulcers which was obtained from the resident's nursing admission assessment. This was in conflict with the care plan which indicated the stage IV pressure ulcer upon admission. The assessment indicated her current body weight was 80.27 kilograms (kg) or 176.59 pounds (lbs.) from the weight recorded during her recent hospital stay, the resident reported her appetite was diminished and she was not interested in the food being served. A recommendation for one Nepro oral nutritional supplement was made due to varied food intake and dialysis. Resident #34's medical record revealed a physician order dated 1/14/25, which indicated nurses were to complete a weekly skin observation every night shift on every Wednesday. The Weekly Skin Observation nursing reports dated 1/16, 1/30, and 2/05/25 all indicated the resident had no old or new skin conditions. On 2/11/25 at 9:23 AM, resident #34 stated she had a wound on her backside that hurt. On 2/12/25 at 10:28 AM, the DTR stated the initial admission weight used by the facility for the nutritional assessment was from a prior hospital admission because there was no initial weight obtained when resident was admitted to the facility. She acknowledged that use of a weight measurement completed by another facility was not best practice for assessments or for projected weight change in the future. The DTR stated obtaining an initial weight at the facility was important. She stated she routinely emailed recommendations to nursing to obtain initial weights if they were missing from a resident's record, but confirmed she had not requested one for resident #34 to be weighed. The DTR verified she forgot to put in the order for the nutrition supplement she had recommended, which she acknowledged was her responsibility. She indicated her email to nursing should also have indicated the start of Nepro daily for varied food intake on dialysis. The DTR confirmed that no food preferences were obtained to assist the resident to improve her food intake through alternative meal choices and trying to mimic the meals the resident normally liked to eat. At that time, the Regional Director of Clinical Services (Regional Nurse) reviewed the resident's Head and Toe Initial Assessment which she confirmed did not contain an initial weight upon admission. On 2/14/25 at 9:30 AM, the Regional Nurse stated when nursing identified a weight loss or skin breakdown, they would make the RD or DTR aware through emails. She added after the RD/DTR assessed a resident and decided on supplements, they sent their recommendations to nursing via email. The RD/DTR would keep that resident on their caseload and follow them until their issues were resolved. She added the physician oversaw the RD/DTR recommendations and orders and decided whether they were appropriate or not. The Regional Nurse was not able to provide email communication from nursing to the RD/DTR that made them aware of skin breakdown for resident #34. The RD/DTR Progress Note dated 2/13/25 reported resident #34's weight at 69.4 kg or 152.68 lbs., which was a 23.91 lb. weight difference, and a 13% weight loss from her weight reported during the initial nutrition assessment on 1/16/25, one month prior. This significant weight loss could not be verified as accurate since the initial weight used was taken from a different facility's record, but it did reinforce the high risk nature of this resident's nutritional status, and the importance for obtaining an initial weight for each resident upon admission. The facility's policy entitled, Weight Management, dated 3/2/19 indicated all residents admitted to the facility would be weighed upon admission and dietary staff would evaluate all weights each month. The policy described the facility would attempt to obtain weights at the same time of the day, preferably in the morning, and with the same scale to ensure accuracy and that the physician and resident or resident's representative would be notified by the nurse of any significant unexpected or unplanned weight changes. The facility's policy entitled, Food and Nutritional Services, dated 3/2/19 indicated the facility would ensure facility staff supported the nutritional well-being of the residents while respecting their right to make choices about his or her diet. In addition the facility would employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. A member of the Food and Nutrition Services staff must also participate on the Interdisciplinary team.

Based on observation, interview, and record review, the facility failed to complete a new Preadmission Screening and Resident Review (PASSAR) level I screen to ensure additional mental health services were not required for 1 of 5 residents reviewed for PASSAR, of a total sample of 43 residents, (#62). Findings: Resident #62 was admitted to the facility on [DATE] with diagnoses that included dementia, cognitive communication disorder, generalized anxiety disorder, and insomnia. Other diagnoses were added later and included Schizophreniform disorder on 9/14/23, persistent mood disorder on 10/02/23, and major depressive disorder on 8/01/24. Resident #62's Quarterly Minimum Data Set assessment dated [DATE], revealed he was severely cognitively impaired and required substantial to maximum assistance for activities of daily living. Review of resident #62's medical record revealed a PASSAR Level I had been completed on 8/08/23 with diagnosis of anxiety disorder listed. The facility could not provide evidence of a new screening. Review of psychiatric note dated 2/10/25, revealed that resident #62 was being treated for depression, anxiety, dementia, insomnia, mood disorder, and schizophreniform disorder. The Psychiatric consult noted that the resident had exhibited behaviors such as auditory hallucinations and sleeping issues. On 2/14/25 at 2:00 PM, the Director of Nursing (DON) jointly with the Regional Director of Clinical Services said she was not aware resident #62 had a new diagnosis that required a new PASSAR screen. The Regional Director of Clinical Services said she assisted the DON with PASSARs but was unaware a new screening was required for resident #62 after the new diagnoses.

Based on observation, interview, and record review, the facility failed to obtain insulin medications timely for 1 of 26 residents reviewed for medication administration, of a total sample of 43 residents, (#93). Findings: Review of the medical record revealed resident #93, a [AGE] year old male was admitted to the facility from an acute care hospital on 11/20/24 with diagnoses that included unspecified fall, generalized anxiety disorder, dysphagia (difficulty swallowing), high blood pressure, gastrostomy (feeding tube) status, atrial fibrillation (abnormal heart rhythm), encephalopathy (brain dysfunction), stroke, and diabetes mellitus. The most recent Minimum Data Set 5-day Assessment with an Assessment Reference Date of 11/26/24 noted during the look-back periods, resident #93 had difficulty swallowing, required a feeding tube for nutrition and hydration, received insulin injections for 7 out of 7 days, and high risk antipsychotic, antianxiety, antidepressant, anticoagulant (blood thinner), opioid, hypoglycemic (blood sugar lowering), and anticonvulsant (seizure) medications. The Order Summary Report noted active physician's medication orders included Diabetisource AC enteral (feeding tube) formula 60 milliliters per hour from 8:00 PM to 6:00 AM, Glargine Insulin 45 Units (U) twice daily for diabetes, Lispro Insulin 4 U four times daily for diabetes, and Lispro Insulin, dosage per sliding scale finger stick blood sugar results before meals for diabetes. The Comprehensive Care Plan included focuses for diabetes mellitus with interventions for nurse monitoring of blood glucose and risk of complications. On 2/10/25 at 11:32 AM, Licensed Practical Nurse (LPN) E was observed obtaining a fingerstick blood glucose level from resident #93. She said the resident required 2 U of Lispro insulin per physician's orders. She checked the medication cart and said the resident didn't have any Lispro insulin. She then left to check the facility's emergency medication kit. At 12:17 PM, LPN E explained the emergency kit did not contain Lispro insulin. She said she called the physician who said none of the emergency medications on hand could be used as an alternate, so an order was placed with the pharmacy for delivery expected later that afternoon. LPN E said the physician wanted hourly fingersticks until the insulin arrived. On 2/10/25 at 3:25 PM, LPN L said LPN E had left for the day and she received oncoming report for the 3:00 PM to 11:00 PM shift. The nurse explained that LPN E had not mentioned resident #93 was out of Lispro insulin and the afternoon pharmacy delivery had not arrived yet. On 2/12/25 at 12:46 PM, the Unit Manager recalled on 2/10/25, LPN E asked her to assist with locating Lispro insulin for resident #93 because he didn't have any, and there was none in the emergency kit. She explained medication re-orders were a simple electronic process and nurses were expected to ensure adequate insulin was available. She said nurses should have ordered the insulin when it was low before it ran out. The Unit Manager conveyed resident's insulin was very important to keep on hand, especially for brittle diabetics to ensure treatment interventions were available at the facility to avoid possible re-hospitalization and stated, it must've not been ordered on time. On 2/14/25 at 10:13 AM, the Director of Nursing (DON) explained she expected nurses to re-order medications from the pharmacy before the supply was depleted to ensure timely delivery. She conveyed insulin supplies were important to maintain so nurses could administer doses if needed to avoid possible serious complications. The DON did not explain why resident #93's insulin supply was not ordered timely. Review of the facility's standards and guidelines titled Reordering, Changing, and Discontinuing Medication Orders dated 7/01/24 noted medication reorders could be made electronically, in writing, by phone, or facsimile. Review of the facility's standards and guidelines titled Medication Shortages/Unavailable Medications dated 8/01/24 noted when insufficient medication supplies were observed, nurses were expected to immediately reorder from the pharmacy to ensure receipt by the next scheduled delivery and obtain it from the Emergency Medication Supply and/or arrange for an emergency delivery.

Based on observation, interview, and record review, the facility failed to provide emergency equipment available for accidental extubation for a resident on mechanical ventilation with a tracheostomy (trach) per nursing standards of practice for 1 of 1 residents reviewed for tracheostomy, of a total sample of 40 residents, (#22). Findings: Resident #22 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included chronic respiratory failure with hypoxia (low oxygen), anoxic brain damage, dysphagia (trouble swallowing), hypertensive heart disease, and tracheostomy status. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and to remove secretions from the lungs. The person with a tracheotomy breathes through the tracheostomy tube (trach tube or obturator) rather than through the nose and mouth. An extubation (when the trach tube is displaced) creates an emergency that requires an obturator be readily available and staff are knowledgeable to reinsert it, (retrieved on 2/16/25 from www.hopkinsmedicine.org). On 2/13/25 at 10:09 AM, resident #22 was observed in bed, calm, and awake with oxygen tubing connected to the oxygen concentrator. The oxygen tubing and the suction tip which was bedside were undated. A bag valve mask (BVM) or Ambu bag was in a clear plastic bag on the wall directly over the head of the resident's bed, but there was no emergency trach kit in the clear plastic bag nor at the bedside. The assigned Licensed Practical Nurse (LPN) G was in resident #22's room at that time and validated the observations. LPN G stated it was the night shift nurses' responsibility to change and date the oxygen tubing along with the suction tip but she did not know how often the tubing needed to be changed. LPN G explained she thought the night shift set up the equipment. She explained she knew how to perform trach care and suction the resident, but was unsure about what to do if there was an emergency and was unaware of the need for an emergency trach kit at bedside. LPN G was unsure who was responsible for the emergency trach supplies at bedside but felt it was possibly Central Supply. A review of the resident #22's medical record revealed physician orders for trach care to be done every day and as needed, oxygen mask tubing /humidifier mask to be changed every week, on night shift every Friday. The physician's orders did not contain an order for emergency supplies including replacement obturator needed for resident #22. A review of the resident's Care Plan identified the resident had a tracheostomy but did not contain interventions for emergency supplies at bedside. On 2/13/25 at approximately 10:45 AM, the Unit Manager (UM), Central Supply staff and a Regional Nurse were in resident #22's room and verified there was no emergency trach kit at the bedside. The Central Supply staff confirmed it was her responsibility to place the emergency trach kit at the bedside. The UM confirmed that emergency trach supplies were supposed to be at bedside and said, this is not what is done here, [she was] not sure what happened . On 2/13/25 at 1:47 PM, the UM said she helped with the education of staff and participated in in-services because the facility did not have a Staff Educator. She verified the importance of having the emergency kit at bedside for residents with a tracheostomy and stated the assigned nurse LPN G could get nervous at times but thought she knew what to do in an emergency. The UM explained that the Director of Nursing (DON) was responsible for staff orientation after hire. On 2/13/25 at 1:51 PM, LPN H said that she had worked with resident #22 and knew the importance of having the emergency kit at bedside because, if [the tube] accidentally dislodged they can use items in kit to replace the trach. She explained at least once a shift she should ensure that the emergency supplies were at bedside. On 2/13/25 at 2:16 PM, the DON who was working on the floor because of a nurse call out, explained the training process for new staff nurses. She said upon hire; she would go over the facility's policy then place the new nurse with a preceptor. She explained that new staff were oriented depending on how experienced they were, she would get feedback from the preceptor and proceed accordingly. The preceptor was responsible for showing the orientee most tasks and would have referred to her if they were not comfortable with something. The DON stated she had a plan to do an in-service on trach care because one nurse reached out to her specifically. On 2/14/25 at 11:51 AM, the DON stated the expectation was for the nurses to have verified that resident #22 had an emergency kit at the bedside in case of an accidental dislodgement. The Facility's Policy and Procedure for Respiratory/ Tracheostomy Care and Suctioning revised 3/26/21 indicated, the facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences.

Based on observation, interview, and record review, facility failed to ensure nurses followed physician's orders to monitor fingerstick blood glucose for 1 of 1 resident reviewed for change of condition, of a total sample of 43 residents, (#93). Findings: Review of the medical record revealed resident #93, a [AGE] year old male was admitted to the facility from an acute care hospital on 11/20/24 with diagnoses that included, hemiplegia and hemiparesis (partial paralysis), generalized anxiety disorder, dysphagia (difficulty swallowing), hypertension (high blood pressure), gastrostomy (feeding tube) status, atrial fibrillation (abnormal heart rhythm), encephalopathy (brain dysfunction), stroke, and diabetes mellitus. The most recent Minimum Data Set 5-day Assessment with an Assessment Reference Date of 11/26/24 noted during the look-back periods, resident #93 had difficulty swallowing, required a feeding tube for nutrition and hydration, received insulin injections for 7 out of 7 days, and high risk antipsychotic, antianxiety, antidepressant, anticoagulant (blood thinner), and hypoglycemic (blood sugar lowering) medications. The Order Summary Report noted active physician's medication orders included Diabetisource AC (before meals) enteral (feeding tube) formula 60 milliliters per hour from 8:00 PM to 6:00 AM, Carvedilol 6.25 Milligrams (MG) twice daily for hypertension, Doxazosin Mesylate 1 MG at bedtime for hypertension, Glargine Insulin 45 Units (U) twice daily for diabetes, Lispro Insulin 4 U four times daily for diabetes, and Lispro Insulin, dosage per sliding scale finger stick blood sugar results before meals for diabetes. The Comprehensive Care Plan included focuses for diabetes mellitus with interventions for nurse monitoring of blood glucose and risk of complications, and dependence on enteral feeding for nutrition with interventions for nurse monitoring of functioning/maintenance and risk of complications. During a medication administration observation on 2/10/25 at 11:32 AM, Licensed Practical Nurse (LPN) E collected resident #93's finger stick blood sugar with a result of 175 milligrams per deciliter (mg/dl). The nurse said physician's orders were to give the resident an extra 2 units of Lispro insulin. She explained, she was unable to locate resident #93's Lispro insulin in the medication cart. The nurse explained the facility's on hand emergency medication kit did not contain Lispro. At 12:04 PM, LPN E said she contacted the physician and obtained orders to hold the Lispro and re-check resident #93's blood glucose every hour until the refill arrived from the pharmacy. Review of a nurse progress note completed by LPN E on 2/10/25 at 12:17 PM, read, insulin unavailable at the moment awaiting pharmacy to deliver STAT [immediately/urgently] MD [physician] notified and said to keep checking bs [blood sugar] once every hour until insulin gets here. On 2/10/25 at 3:25 PM, LPN L said LPN E had left for the day and she received off-going report from her. The nurse said LPN E had not mentioned resident #93 was out of insulin nor that the doctor had given orders to check his blood glucose every hour until the refill arrived. Review of the Weights and Vitals Summary Report noted a struck-out entry by LPN L on 2/10/25 at 3:31 PM, of a finger stick blood sugar measurement of 157 mg/dl and an additional measurement of 137 mg/dl at 4:30 PM. On 2/12/25 at 10:47 AM, LPN E recalled on 2/10/25 at lunchtime, she obtained doctor's orders to re-check resident #93's blood sugar once an hour. She said she completed re-checks every hour until the end of her shift at 3:00 PM and stated, it was in a good range. On 2/12/25 at 12:46 PM, the Unit Manager recalled on 2/10/25, LPN E obtained a doctors order to hold resident #93's lunchtime insulin and re-check the blood sugar until the insulin was delivered because it wasn't in the emergency medication kit. The Unit Manager checked the medical record and was unable to locate any re-checks by LPN E on 2/10/25. She acknowledged there were no re-checks until LPN L's was recorded at 4:30 PM, four hours after LPN E received physician's orders. The nurse stated, she didn't check it every hour per the MD [physician] order; it's important for them to re-check, especially if it was a brittle person. On 2/14/25 at 10:13 AM, the Director of Nursing (DON) explained nurses were expected to follow doctor's orders and monitor residents for abnormal blood glucose to prevent re-hospitalization and complications. The DON stated, the nurse should have monitored the resident. Review of the facility's standards and guidelines titled Change in Condition Process dated 3/02/19 noted nurses were expected to evaluate the resident's status and document findings in the electronic medical record. The Facility Assessment noted the facility provided nursing services and care including management of medication and medical conditions including diabetes.

Based on observation, interview, and record review, the facility failed to conduct medication self-administration assessments to ensure safety for 2 of 2 residents reviewed for self-administration of medications, of a total sample of 43 residents (#49, and #305). Findings: 1. Resident #49 was admitted on [DATE] and readmitted on [DATE]. His diagnoses included hypertensive urgency, encephalopathy, and malignant neoplasm of the bladder. A review of the Minimum Data Set (MDS) quarterly assessment with an assessment reference date of 12/24/24 revealed resident #49 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated he was cognitively intact. On 2/10/25 at 12:27 PM, resident #49 was observed sitting upright in bed. His bedside table was over his lap, with personal items, including a 30-ounce jar of herbal blend [NAME] Neuro Ease, Vitamin D3-K2, Elderberry capsule 1000 milligrams (mg), Vitamin C tablet 400 mg, Zinc tablet 10 mg, Sea Moss, Turmeric-Curcumin capsule 1500 mg, Ultra-Magnesium complex capsule, Vital Grow male enhancement gummies, N 2 boosters capsules, Vitamin E capsules, Super Reds amino capsules, and Super Greens capsules. The resident stated he stopped taking Gabapentin because the herbal blend [NAME] Neuro Ease worked better. On 2/11/25 at 10:11 AM, Primary Registered Nurse (RN) F, observed the resident's bedside table. She acknowledged the 30-ounce jar of herbal blend [NAME] Neuro Ease, Vitamin D3-K2, Elderberry capsule 1000 milligrams (mg), Vitamin C tablet 400 mg, Zinc tablet 10 mg, Sea Moss, Turmeric-Curcumin capsule 1500 mg, Ultra-Magnesium complex capsule, Vital Grow male enhancement gummies, N 2 boosters capsules, Vitamin E capsules, Super Reds amino capsules, and Super Greens capsules. A review of the resident's physician orders with RN F revealed no orders for Gabapentin or the above items found on the resident's bedside overbed table. The RN explained that for someone to self-administer medications, they must have a physician order and a self-administration evaluation completed. RN F stated there was no order for herbs, supplements, and vitamins and that the resident had not completed a self-administration evaluation. 2. Resident #305 was admitted to the facility on [DATE] with diagnoses including a fall from a motorized mobility scooter, type 2 diabetes mellitus with diabetic neuropathy, and muscle weakness. A review of the admission the MDS admission assessment with an assessment reference date of 2/04/25 revealed resident #305 had a BIMS score of 12 out of 15, which indicates he was moderately impaired cognition. On 2/10/25 at 11:21 AM, resident #305 was observed standing next to his bed. The nightstand was observed with a bottle of 300 mg/100 caplets Tylenol 8 hour arthritis pain. The resident stated he keeps the Tylenol at his bedside because he has arthritis pain in the knees. On 2/10/25 at 12:08 PM, the resident's nightstand was observed with (RN) F Primary care nurse. She acknowledged the bottle of 300 mg/100 caplets Tylenol 8 hr arthritis pain. A review of the resident's physician orders with RN F revealed no orders for Tylenol found on the resident's nightstand. The RN explained that for someone to self-administer medications, they must have a physician order and a self-administration evaluation completed. RN F stated there was no order for Tylenol and that the resident did not have a completed medication self-administration evaluation. On 2/12/25 at 2:30 PM, the Director of Nursing (DON) stated residents should not have medications at the bedside to prevent overdose. She also explained a self-administration assessment must be completed to ensure residents could safely self-administer medication. She confirmed residents #49 and #302 were not evaluated for medication self-administration. A review of the facility's policy and procedure for Self-Administration of Medication Program dated 6/26/24 revealed, It is the policy of the facility to allow the resident and or the legal representative of the resident the right to self-administer medications when it has been deemed by the interdisciplinary team that it is clinically appropriate.

Based on observation, interview, and record review, the facility failed to ensure a call light device was within reach for 1 of 3 residents reviewed for accommodation of needs, of a total sample of 43 residents, (#52). Findings: Review of the medical record revealed resident #52, a [AGE] year old female was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, thyroid disorder, chronic pain syndrome, major depressive disorder, persistent mood disorder, anxiety disorder, dementia, Pseudobulbar Affect (uncontrollable crying/laughing), and cognitive communication deficits. The most recent Minimum Data Set Quarterly Assessment with an Assessment Reference Date of 12/30/24 revealed during the look-back periods, resident #52 had impaired vision, was rarely/never understood, and unable to complete the Brief Interview for Mental Status. Staff assessed the resident had short term and long term memory problems, was severely cognitively impaired, had continuous inattention and disorganized thinking that did not fluctuate, delusions, and was dependent on staff to complete all Activities of Daily Living (ADL). The resident did not walk, required a wheelchair, was always incontinent of bladder and bowel functions, required scheduled and as needed pain medication, a mechanically altered diet, and received high-risk anti-depressant and opioid medications. The Order Summary Report included active physician's medication orders for Donepezil (enzyme blocker) 10 Milligrams (MG) at bedtime for dementia, Levothyroxine (thyroid hormone) 112 Micrograms once daily for thyroid disorder, Nuedexta (central nervous system agent) 20-10 MG every twelve hours for Pseudobulbar Affect, Tramadol (opioid pain) 50 MG three times daily for chronic pain, and Trazodone (anti-depressant) 25 MG at bedtime for depression. The Comprehensive Care Plan included focuses for diabetes mellitus, thyroid disorder, incontinence, risk for skin breakdown, impaired communication and hearing, risk for falls, dementia with behaviors, high-risk medication adverse effects monitoring, squamous cell cancer, required staff assistance for all ADLs, and Long Term Care (LTC) with a goal to assure maintenance of the resident's safety and comfort, and observance of distress. On 2/10/25 at 10:45 AM and 3:56 PM, resident #52 was observed in her room awake and lying in bed. The call light cord with a squeeze bulb activator was lying on the floor under the resident's bed on the left side. On 2/11/25 at 3:12 PM, the resident's door was closed; the call light cord and bulb were observed on the floor in the same location. On 2/11/25 at 3:40 PM, Certified Nursing Assistant (CNA) J said she knew resident #52 well, as she was often included in her assignment. The CNA explained the resident was able to use her hand and arms to activate a call light bulb. In a joint observation on 2/11/25 at 3:43 PM, CNA J and Licensed Practical Nurse (LPN) K observed resident #52's call light cord and squeezable bulb lying on the floor under the bed. LPN K picked up the device and clipped it to the resident's bed sheet so the bulb was within reach of the resident's hand. LPN K explained, staff were expected to check and make sure the device was within reach so the resident could use it if needed. The LPN said when the room door was closed, staff were unable to hear her yell out and confirmed the call light shouldn't be on the floor. On 2/11/25 at 3:55 PM, the Unit Manager explained she expected staff to check residents' call lights and ensure they were safely within reach every time before they exited a room. She said CNAs typically checked on bedbound residents every two hours for incontinence care and repositioning and stated, they shouldn't leave the room with a call light on the floor. Review of the Facility assessment dated [DATE] noted the facility provided person-centered care for persons with dementia, staff responded to residents' requests for assistance promptly in order to promote resident dignity, and staff training and competency included resident call lights.

Based on observation, interview and record review, the facility failed to ensure respiratory therapy was provided as per physician orders for 1 of 2 residents reviewed for respiratory care, of a total sample of 5 residents, (#4). Findings: Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. Her diagnoses included acute and chronic respiratory failure, epilepsy, anoxic brain damage, dysphagia, and attention to tracheostomy. A tracheostomy is a surgically created hole (stoma) in your windpipe (trachea) that provides an alternative airway for breathing (retrieved on 6/14/24 from https://www.mayoclinic.org). On 6/06/24 at 10:55 AM, resident #4 was observed lying in bed, she was nonverbal with her eyes open. Her oxygen was connected to her tracheostomy (trach) collar and the tubing was connected to an oxygen concentrator next to her bed set on a flow rate of 0 liters per minute (LPM). On 6/06/24 at 11:13 AM, the resident was observed similarly to prior observation with the oxygen concentrator now set at 4 LPM. On 6/06/24 at 2:00 PM, the assigned Licensed Practical Nurse (LPN) A went to resident #4's room to provide care and suctioning with a tonsil tip catheter around the resident's tracheostomy neck stoma area. Pre and post suctioning LPN A verified that resident #4's oxygen was set to deliver 4 LPM as this was the current physician ordered flow rate. LPN A said she noted the oxygen delivery earlier this morning was set at 4 LPM as well. On 6/06/24 at 4:54 PM, Registered Nurse (RN) B said she had cared for resident #4 the past few weeks on the 3-11 shift and was familiar with her care. RN B went to resident #4's room and verified the resident's oxygen concentrator was presently delivering 3.5 LPM via the trach collar. On 6/06/24 at 5:00 PM, the South Unit Manager (UM) reviewed resident #4's medical record and said the facility currently had no physician's order for resident #4's oxygen flow rate. The South UM explained the only thing they had were instructions from the hospital from 4/11/24 which instructed them to give oxygen at 28%, equivalent to 2 LPM. The Unit Manager explained that nurses should check physician orders for flow rate every shift to ensure the resident received what was ordered by the physician. The UM added, the residents' last oxygen order was prior to her hospitalization in April 2024, when she was ordered to receive 2 LPM. The Unit Manager explained the resident was in the hospital from 4/02/24 until 4/11/24 and her oxygen orders were never reordered upon her return for nearly 2 months.

Based on interview, and record review, the facility failed to ensure a vulnerable, cognitively impaired resident had adequate supervision for outside medical appointments, to prevent the potential for accidents, and elopement for 1 of 3 residents reviewed for accidents of a total sample of 6 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region, lack of coordination, intervertebral disc degeneration, dementia, Chronic Obstructive Pulmonary Disease, cognitive communication disorder, Diabetes type II, repeated falls, and pain. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 11/15/23 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status (BIMS) score of 07 out of 15. The assessment revealed the resident required supervision or touching assistance for toilet transfers, chair/bed-to-chair transfers, sit to stand, and walking. The assessment noted the resident had two or more falls since his admission or prior assessment. An Elopement Risk Evaluation dated 9/10/23 revealed the resident was at risk for elopement/wandering. A care plan for elopement risk/wanderer revealed the resident attempted to leave the facility without supervision. An intervention dated 9/10/23 read, must have direct supervision when outside the facility. Review of the resident's care plan for falls risk initiated on 8/24/23 and revised 11/20/23, for risk for falls read, be aware of resident's location and monitor for signs of fatigue which may increase fall risk. Review of the appointment list for resident #1 provided by the facility revealed the resident went out to medical appointments on 9/14/23, 9/26/23, 10/06/23, 10/11/23, 10/16/23, 11/22/23, 11/28/23, 12/06/23, and 1/03/24. Review of the Grievance log from October 2023 to current revealed an entry dated 1/02/24, which indicated resident #1's wife verbalized that she wanted an escort to accompany the resident to his appointments. Review of the resident's clinical records revealed a nursing progress note dated 9/26/23 that read, Resident left to MD (Medical Doctor) appointment via wheelchair with CNA (Certified Nursing Assistant). A progress note on 1/03/24, indicated the resident went to a physician's appointment accompanied by a CNA. No other documentation could be identified to indicate the resident had supervision for the other seven medical appointments. On 1/05/24 at 3:33 PM, in a telephone interview, resident #1's wife stated the resident had dementia and had fallen several times at the facility since his admission. She explained she worked and was unable to accompany her husband to outside medical appointments. She recalled she spoke with the nurse at the resident's Primary Care Physician's (PCP) office on 12/29/23 and was told the resident was left alone at their office and was not picked up until approximately 6 PM. The PCP's nurse said she had to wait with the resident and had to give him the paperwork from the visit. The resident's wife stated her husband did not remember the visit, and she was not sure if he even took the paperwork. The resident's wife said he will wander off if he has a chance to do it, and noted he had tried to get out of the facility. She said he could have wandered out of the PCP's office, and she was not happy about it. She stated she spoke to the Director of Nursing (DON) and wanted to know why her husband was dropped off at the PCP's office and left alone. On 1/08/24 at 11:17 AM, Licensed Practical Nurse (LPN) A, stated if a resident had dementia, and family member could not accompany the resident to their medical appointment, the resident would be provided with an escort from the facility. LPN A stated the need for an escort would be documented on the appointment. On 1/09/24 at 10:14 AM, Registered Nurse (RN) B stated resident #1 was very impulsive, hard of hearing, and was at risk for falls. She explained that staff had to keep an eye on him, as he was impulsive and had very poor safety awareness. On 1/09/24 at 11:13 AM, the Director of Rehab stated resident #1 was currently on therapy caseload due to falls. He indicated the resident was confused, had poor safety awareness and was impulsive at times. On 1/09/24 at 1:05 PM, at 2:07 PM, and at 2:21 PM the Regional Director of Clinical Services (RDCS) provided a list of resident #1's out of facility medical appointments. She stated she could not find notes to indicate the resident was escorted to his appointments. The RDCS stated when residents went out for an appointment, it was considered a Leave of Absence (LOA). She noted the resident should be signed out and on return to the facility, signed in, and a progress note should be documented. Review of the resident's clinical records revealed two progress notes dated 9/26/23, and 1/03/24 that indicated the resident had supervision in the form of an escort for his appointments. Documentation could not be identified for the other seven appointments the resident attended. The RDCS stated she reviewed the resident's clinical records and could not identify documentation to correspond with the medical appointments. She stated she had attempted to get a list from the transportation company regarding escort for the resident but could not identify any additional documentation in the facility's records to indicate the resident had supervision for his appointments. On 1/09/24 at 3:28 PM, in a telephone interview, the previous Interim Administrator stated she was aware resident #1's wife filed a grievance as the resident did not have a staff member with him when he went to his medical appointments. On 1/09/24 at 4:46 PM, the [NAME] President of Operation stated the appointments should have been documented in the progress notes, and noted the facility needed improvement in documentation.

Based on interview, and record review, the facility failed to ensure medical records were complete and accurate for 1 of 2 residents reviewed for resident to resident abuse of a total sample of 6 residents, (#9). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region, lack of coordination, intervertebral disc degeneration, dementia, Chronic Obstructive Pulmonary Disease, cognitive communication disorder, falls and persistent mood disorders. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 11/15/23 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status (BIMS) score of 07 out of 15. Resident #9 was admitted to the facility on [DATE]. His diagnoses included altered mental status, opioid dependence, and alcohol abuse. Review of the resident's admission MDS assessment with ARD of 12/03/23 revealed the resident's cognition was intact with a BIMS score of 15 out of 15. Review of the facility's incident and reportable logs from October 2023 to current showed an entry dated 1/06/24 of resident-to-resident altercation between resident #1 and resident #9. The report revealed resident#1 held on to resident #9's wheelchair while resident #9 was in his wheelchair. Resident #1 struck resident #9 twice on his arm and hit the Licensed Practical Nurse (LPN) who attempted to separate the residents. The facility initiated an investigation into abuse, and the relevant state agencies were notified. Review of both residents' clinical record revealed documentation dated 1/06/23 for resident #1 of the incident, however there was no documentation in resident #9's clinical record pertaining to the incident. On 1/09/24 at 3:16 PM, resident #9 stated he had an incident with resident #1 a few days ago. He recalled he was sitting in his wheelchair in the common area close to resident #1's room. He said resident #1 thought he was sitting in his wheelchair, and grabbed me. He said resident #1 was sitting in his own wheelchair at the time of the incident. Resident #9 stated facility staff separated them, he went outside, and had no further interaction with resident #1. On 1/09/24 at 3:04 PM, Registered Nurse (RN) B recalled that on 1/06/24 resident #1, and resident #9 were sitting in their wheelchairs in front of resident #1's room door. Resident #1 held on to resident #9's wheelchair, would not let it go, and at some point hit resident #9 twice on his arm. RN B recalled that when she and another staff tried to separate the residents, resident #1 hit the other nurse. They separated them, and resident #9 was taken outside, and resident #1 was placed on one-on-one supervision. RN B stated resident #9, confirmed he was hit by resident#1, but he said he was okay, and was not in pain. She stated she completed an incident report, and called resident #9's brother, and resident #1's wife. RN B stated she completed a change in condition form for resident #1 but one was not completed for resident #9. RN B explained she did not document the interaction in resident #9's clinical records, but completed an incident report. She noted she should have documented the incident in the the resident's clinical record. On 1/09/24 at 3:44 PM, the Regional Director of Clinical Services (RDCS) stated that with resident-to-resident abuse, documentation should be completed in the clinical records of both residents involved. Review of the residents' clinical records revealed documentation regarding the incident was in place for resident #1, but documentation regarding the incident could not be identified for resident #9. This was confirmed by the RDCS.

Based on interview, and record review, the facility failed to ensure the resident's representative was notified of a change in condition pertaining to multiple falls for 1 of 2 residents reviewed for falls of a total sample of 6 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region, lack of coordination, intervertebral disc degeneration, dementia, Chronic Obstructive Pulmonary Disease, cognitive communication disorder, Diabetes type II, repeated falls, and pain. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 11/15/23 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status (BIMS) score of 07 out of 15. The assessment revealed the resident required supervision or touching assistance for toilet transfers, chair/bed-to-chair transfers, sit to stand, and walking. The assessment noted the resident had two or more falls since his admission or prior assessment. Review of the facility's SBAR (Situation, Background, Appearance, Review and Notify) Communication Form and nursing Progress Notes revealed the resident had falls on 11/05/23, 11/18/23, 12/10/23, and 12/12/23. The documentation noted, name of family/Health Care Agent notified read, resident is his own responsible party). On 1/09/24 at 12:27 PM, in a telephone interview, the resident's wife stated she was the person to be contacted if there was a change in the resident's condition. She said she expected to be called, but the facility had not called her for all the resident's falls. She stated that when she visited, she noticed her husband had bruises. She explained her husband's roommate told her he fell . She could not recall the roommate's name, and stated the resident had several roommates since his admission. On 1/09/24 at 3:44 PM the Regional Director of Clinical Services (RDCS) stated the facility's Risk Management documentation was privileged and confidential and could not be shared. The RDCS noted the resident's family was notified of the falls on 11/05/23, and 11/18/23. Review of the documentation on the SBAR form for falls on 11/05/23, 11/18/23, 12/10/23, and 12/12/23 showed the resident was his own responsible party and there was no evidence his wife was informed. The RDCS stated no additional documentation regarding the resident's falls, and notification of the resident's wife listed as his emergency contact could be found at this time for the dates identified. The facility's policy titled Change in Condition Process issued on 3/02/19 read, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify . resident's representative when there is a change requiring notification .Even when a resident is mentally competent, his or her designated resident representative or family, as appropriate, should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally, especially in the case of sudden illness or accident.

Based on observation, interview, and record review, the facility failed to ensure licensed nurses were knowledgeable and competent with skill sets to fully process physician orders for immediate care of a post hospitalized resident with high risk health conditions for 2 of 6 vulnerable residents of a total sample of 6 residents, (#1, #6). On [DATE], resident #1 was readmitted back to the facility from the hospital. The facility had transferred the resident to the hospital on [DATE] where she was diagnosed with severe health care associated pneumonia and sepsis, a serious blood infection with a high risk for total organ failure and death, (retrieved from www.mayoclinic.org on [DATE]). While hospitalized for the next two weeks, she required intensive care and a machine to breathe. She returned to the facility at approximately 9:00 PM on Friday, [DATE] with doctor's orders to continue her medications and supplemental oxygen to keep her health conditions stable. The facility's licensed nurses did not implement the physician's orders for immediate care that included critical medications and oxygen, and did not adequately monitor the resident's recent respiratory failure to prevent complications, worsening of condition and to mitigate the risk of serious injury/impairment/death. Three days later, on Monday, [DATE] at 9:55 AM, the resident was found unresponsive and without respirations or pulse. Nurses were unable to readily locate the resident's code status from the medical record, and at 10:00 AM, they initiated Cardiopulmonary Resuscitation (CPR) and notified 911. Emergency Medical Services (EMS) arrived at the resident's bedside at 10:08 AM and discontinued CPR. The resident was pronounced dead at 10:12 AM. The facility's failure to ensure nurses were competent to follow procedures, implement physician's orders for immediate care, adequately monitor, and ensure the resident received critical life sustaining medications including continuous oxygen contributed to the destabilization of resident #1's acute and chronic health conditions and placed all residents at risk for major complications from worsening and unstable high risk medical conditions and serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on [DATE]. The Immediate Jeopardy was removed on [DATE]. Findings: Cross reference F600 and F635. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE] with diagnoses of intracranial (brain) hemorrhage (bleeding) and hematoma (blood pooling), encephalopathy (brain dysfunction), meningioma (tumor of membranes surrounding the brain), dysphagia (difficulty swallowing), gastrostomy status (feeding tube), hypertension, deep tissue injury, malnutrition, and dementia. She was re-hospitalized on [DATE] and readmitted on [DATE] with newly acquired diagnoses that included acute hypoxic (low blood oxygen) respiratory failure, health care associated pneumonia, heart failure, pressure ulcers, and epilepsy. Review of the Minimum Data Set (MDS) Death in facility tracking record with an Assessment Reference Date (ARD) of [DATE] showed resident #1 died at the facility on [DATE]. The MDS 5-day assessment with ARD of [DATE] revealed there was no assessment completed for cognitive patterns or behaviors. The assessment showed resident #1 was dependent on staff for mobility and to complete her Activities of Daily Living (ADLs). The assessment noted she required an indwelling urinary catheter for bladder functions, was frequently incontinent of bowel functions, had newly added active diagnoses of epilepsy and respiratory failure, required a feeding tube to receive nutrition and hydration, had 2 unstageable pressure ulcers, did not receive anticoagulant or antibiotic medications, had no identified clinically significant medication issues, and she did not receive supplemental oxygen while a resident during the look back period. The MDS 5-day assessment with ARD of [DATE] showed resident #1 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated severe cognitive impairment. The assessment noted she had not shown any behavioral symptoms, and had 1 stage 3 pressure ulcer during the look back period. Review of the hospital's Physician Discharge Orders and Instructions dated [DATE] noted Physician Medication Instructions included Jevity 1.5 1000 ML (milliliters) for nutrition at 40 ML per hour continuous tube feeding, Docusate Sodium 100 MG twice daily as needed, Tylenol 325 MG every 6 hours as needed, and Polyethylene glycol 17 GM once daily as needed. The remaining orders read, Next dose: Morning: [DATE] for Combigan 0.2%-0.5% eye drops once daily, Latanoprost 0.005% eye drops once daily, Chlorhexidine 1.5 milliliters (ML) topical (on skin) every 12 hours, ProStat (nutritional supplement) once daily, Famotidine 20 MG (acid reducing) once daily, Memantine (dementia slowing) 10 MG twice daily, Montelukast (asthma) 10 MG once daily, Metolazone (diuretic/fluid removing) 10 MG once daily, Midodrine (blood pressure) 10 MG three times daily, Linezolid (antibiotic) 600 MG twice daily, Levofloxacin (antibiotic) 750 MG once daily, Heparin 5000 (blood thinner) units injection every 12 hours, and Valproic Acid (anti-seizure) 500 MG once daily and 750 MG at bedtime. On [DATE], the hospital physician signed a ,d+[DATE] AHCA form and documented resident #1 needed antibiotic medication, had 2 pressure wounds, required continuous oxygen with flow rate at 2 liters per minute, and she had heart failure due to an abnormal LVEF (left ventricle ejection fraction) (percentage of blood pumped out from the heart to the body) of ,d+[DATE]%. The Order Summary Report noted there were active physician's orders dated [DATE] for tube feeding monitoring and care with enteral nutrition, and Docusate Sodium 100 milligrams (MG) as needed every 12 hours for constipation. The report showed additional medication orders dated [DATE] that read, Pending confirmation for Famotidine 20 MG once daily for gastroesophageal reflux disease (GERD), Memantine HCI 10 MG once daily for dementia, Polyethylene Glycol 17 grams (GM) as needed for constipation, Latanoprost 0.005% eye drops once daily for glaucoma, Montelukast Sodium 10 MG three times daily for asthma, Metolazone 10 MG once daily for high blood pressure, Midodrine HCI 10 MG three times daily for orthostatic hypotension (low blood pressure after sitting or standing), Valproic Acid 500 MG once daily and 750 MG at bedtime for seizures, and Heparin 5000 Units by injection once daily for blood clot prevention. The Comprehensive Care Plan included focus for risk of infection complications with interventions for staff to administer antibiotics and treatments, and notifications to the physician of significant changes or shortness of breath. A care plan for neurological concern/condition included intervention for staff to administer medications per doctor's orders. A respiratory condition/concern care plan showed interventions for staff to administer oxygen and treatments per doctor's orders, monitor oxygen saturations, and assess lung sounds. During an interview on [DATE] at 10:15 AM, Licensed Practical Nurse (LPN) C said nurses were responsible for entering and processing all physician's orders when residents were newly admitted or readmitted to the facility from the hospital. She added that nurses had to ensure all medication orders were entered into the electronic system by the end of the shift so the pharmacy could timely dispense and deliver them. She stated the pharmacy delivered medications to the facility two times per day, and nurses could access the facility's automated medication dispensary that contained most antibiotics and some other emergent medications She explained that if problems arose with medication deliveries or access, nurses were expected to notify the physician by the end of their shift. On [DATE] at 2:46 PM, during a telephone interview, LPN E said nurses were expected to process admission orders for residents they were assigned. He explained occasionally, nurses were required to take over and complete the orders or assessments if the previous nurse was unable to get them done on their shift. He recalled, on [DATE], he worked the 11:00 PM to 7:00 AM shift and recalled there were five residents admitted or readmitted during the 3:00 PM to 11:00 PM shift. He stated that he and another nurse assisted and entered incomplete admission orders from the previous shift. He said all admission medication orders required a confirmation step, so they were submitted and processed by the pharmacy. He explained, on [DATE] he gave report to the oncoming 7:00 AM to 3:00 PM nurse that there were pending medication orders. He stated, the same morning, those nurses were supposed to review and confirm the medication orders so the pharmacy would deliver them. He could not recall who the oncoming nurse was, or if he had reported the issues to the Weekend Supervisor. On [DATE] at 3:11 PM, during a telephone interview, LPN F recalled on [DATE], she worked the 11:00 PM to 7:00 AM shift. She explained that during her shift she clarified an enteral feed substitution for resident #1 with the on call Advance Practice Registered Nurse (APRN) by telephone, and then confirmed the resident's feeding tube orders in the medical record so it could be administered. She said the Medication Administration Record (MAR) showed the resident's medication orders were pending confirmation status and she could not administer them. She explained on [DATE] at approximately 7:00 AM, during the next shift transition, she informed the Weekend Supervisor there were 5 admissions the previous evening with incomplete orders that needed to be reviewed and confirmed. She stated she was concerned because resident #1's medications needed to be administered. She remembered the Weekend Supervisor replied that it was being handled, so she assumed the issues were addressed. A Nursing Progress Note completed by LPN F on [DATE] at 3:52 AM, read, medications were entered by previous shift nurse and this writer spoke with on call NP (Nurse Practitioner) (name) who completed medication reconciliation. Pt. (patient) has an order for Jevity 1.5. Call made to on call to request an order for house stock parenteral feeding. Currently awaiting call back with new orders. On [DATE] at 4:06 PM, and 4:21 PM, and on [DATE] 11:34 AM, unsuccessful attempts were made to contact the on call APRN by telephone. During a telephone interview on [DATE] at 8:48 AM, the Weekend Supervisor said admission orders were expected to be entered and fully processed by the assigned nurse by the end of the shift after the resident arrived on the unit. She explained that if a nurse's workload prevented them from completing orders or assessments, the Unit Manager or Supervisor assisted in completing the order process as, it's a priority. She said on weekends, it was her job to complete any incomplete assessments and sometimes she assisted with wound care treatments. She recalled on Saturday, [DATE] and Sunday, [DATE] she worked double shifts from 7:00 AM to 11:00 PM and did not recall any nurse that asked for her assistance or reported any pending admission orders. On [DATE] at 3:30 PM, LPN G recalled on Saturday [DATE], the day after resident #1 was admitted , she was assigned to care for the resident on the 3:00 PM to 11:00 PM shift. She explained the resident's medication orders were still pending status. She said she informed the Weekend Supervisor who replied to that she was still working on them which indicated she was taking care of them. She stated she had not administered resident #1's medications during her shift because they were still not scheduled on the MAR by the end of her shift, over 24 hours after the resident returned to the facility. Review of the resident #1's [DATE] MAR showed nurses signed for enteral nutrition administered from [DATE] to [DATE]. The Treatment Administration Record (TAR) noted orders for feeding tube care and monitoring. Neither the MAR nor TAR included orders for oxygen and/or monitoring, or pressure ulcer treatments. Both records indicated no medications, supplemental oxygen, or pressure ulcer treatments were administered to the resident, for three days. On [DATE] at 4:16 PM, the Director of Nursing (DON) said she expected nurses to enter and fully process admission orders and complete resident assessments. She said when medications weren't entered and confirmed as per their process, the pharmacy was not alerted to send the medications. She explained after resident #1 died on [DATE], she reviewed the medical record and found the admission orders had not been completed, and the resident had not received any medications after she returned to the facility on [DATE]. She said she investigated and concluded that nurses who took care of the resident had not understood the process to ensure the orders were completed. In a telephone interview on [DATE] at 8:41 AM, the Weekend Supervisor said protocols for care and monitoring of a resident who was admitted from the hospital after respiratory failure included nurses' assessments of their lungs for abnormal sounds, oxygen saturation status, blood pressure, and heart rate at least every shift and most physicians requested it every 4 hours. She explained nurses needed to complete physical assessments and were to monitor residents for changes in condition so the physician was notified to determine if the treatment plan should be revised, or if a higher level of care was needed. She recalled she completed resident #1's assessments after she was admitted on [DATE]. Review of the Admission Evaluation completed and signed by the Weekend Supervisor on [DATE] showed resident #1's most recent vital signs were obtained on [DATE] at 9:19 PM, when the resident's heart rate was 108 beats per minute, her respirations were 20 breaths per minute, and her oxygen saturation was measured at 96% on room air. The neurological assessment noted the resident had a neurological condition that required medications. The Skin assessment showed there were two pressure ulcers to be treated per physician's orders. The Respiratory/pulmonary status documented the resident had dyspnea (shortness of breath), Emphysema/COPD, Respiratory failure, diminished lung sounds, required oxygen support, monitoring of lung sounds, oxygen saturation levels, and physician notification of changes, issues, or concerns. The Infections/Cancer/IV assessment section documented the resident had upper and respiratory infections with pneumonia and wound/pressure ulcers, was at risk for complications of infection, required antibiotics, treatments or therapies as ordered, and physician notification for vital sign changes or shortness of breath. The report read, 5. Date and time physician was notified, and orders were confirmed: [DATE] 6. Date and time pharmacy was sent physician orders: [DATE] . Reconciliation . Medications were reviewed and reconciled with the attending Physician . The Smoking Assessment completed by the Weekend Supervisor on [DATE] read, . Does the resident use Oxygen? . , with a marked response, No. The medical record revealed after [DATE] at 9:19 PM when the resident returned from the hospital and over the next 59 hours, two vital signs assessments were done. On [DATE] at 9:53 PM, the blood oxygen saturation read 96% without supplemental oxygen, and on [DATE] at 8:24 AM, for a respiratory rate of 20 breaths per minute and a blood oxygen saturation reading of 96% with oxygen (unknown flow rate) administered via nasal cannula. The medical record did not include any additional assessments to monitor resident #1's respiratory status. Review of the Assessments showed there was one Respiratory assessment completed by nurses with an effective date of [DATE] at 9:19 PM, that was done when the resident returned to the facility from the hospital. The medical record did not include additional nurse assessments to monitor vital signs or the resident's respiratory status. Review of a Nursing Progress Note dated [DATE] at 12:47 PM, by LPN B read, Vitals were taken by nurse at 0830 (8:30 AM). Vitals were WNL (Within Normal Limits). No c/o (complaints of) pain, pt. (patient) was alert. The therapy dept. (department) notified me at approx. (approximately) 0955 (9:55 AM). I went in to room with unit manager to evaluate pt. Patient was not breathing and had no pulse. Code status was full code, verified by 2 nurses. CPR was initiated per facility policy at approx. 1000 (10:00 AM). 911 was called at 1000 and arrived at approx. 1010 (10:10 AM). 911 team pronounced pt. deceased at 1015 (10:15 AM). MD (Medical Doctor) was notified at 1020 (10:20 AM). Son and husband both notified at 1025 (10:25 AM). (Name) funeral home notified per family request at 1025. On [DATE] at 9:30 AM, the DON stated she expected the Weekend Supervisor to ensure all nursing processes were fully completed for new admissions which included a chart check and audit form. She explained nurses were to complete a head to toe physical assessment of a newly admitted resident within one hour of their arrival, which included making sure any ordered oxygen was supplied, administered, and monitored at least every shift per standard protocols. She said she obtained statements from the nurses who were assigned to resident #1 on the weekend of [DATE], and their accounted reports conflicted with each other. She recalled her conversation with the Weekend Supervisor revealed she was not aware that her responsibilities included chart checks and to ensure orders, assessments, and nursing processes were completed. The DON conveyed she was very concerned the nurses including the Weekend Supervisor had not intervened and ensured resident #1's physician's orders for immediate care were fully processed and implemented. She acknowledged several nurses had not recognized the clinical impact and risk for resident #1's worsening health conditions, nor acted on discrepancies and contacted the physician. She said the resident should have received her medications, and nurses should have followed the process and monitored her for changes in condition or symptoms of complications because, she could have become septic. During a telephone interview on [DATE] at 10:08 AM, resident #1's son recalled on [DATE], he traveled from out of state to visit his mother and he thought she was still in the hospital. He explained he was upset no one from the facility called him to let him know she had returned to the facility on [DATE]. He said on [DATE] when he saw his mother, she did not have oxygen on. He recalled on [DATE] at about 10:30 AM, he had just returned home when the facility called him and informed him his mother died and they told him, We did all we could do. The (City) Fire Department Patient Care Report documented EMS personnel responded to a 911 call received from the facility on [DATE] at 10:01 AM and arrived at resident #1's bedside at 10:08 AM where they assessed her. The report read, Patient Dead at Scene-No Resuscitation Attempted (Without Transport) . skin cold . arrived on scene, Pt (patient) contact made, Adult ALS (Advanced Life Support) medical assessment completed, Rigor noted to the pts (patient's) jaw. On [DATE] at 3:02 PM, the DON conveyed licensed nurses were expected to possess skills and competencies within their scope of practice to safely care for vulnerable residents. She explained licensed nurses were required to recognize the importance of monitoring high risk health conditions, the need to implement actions to ensure physician's orders for immediate care were carried out, and to be qualified with adequate clinical judgement skills to contact physicians for concerns, condition changes, clarifications, and orders. During a telephone interview with the Medical Director on [DATE] at 12:45 PM, he said he was unaware that resident #1 had not received any medications for 3 days after she was admitted from the hospital and died . He recalled in the evening after he left the faciity on [DATE], the facility contacted him by phone and informed him that a technical issue caused missed medication administrations for a newly admitted resident. He stated the facility assured him they implemented a training plan, and he told them they needed to make sure it had not happened to any other resident. He said he was very concerned and expected to be contacted promptly for significant identified concerns, especially clinical ones. He explained there were processes in place and omissions of physician's admission orders was, a very scary thought, and stated, that's a big problem. Review of the Facility Assessment updated [DATE] revealed the facility provided assessment and management of medical conditions with licensed nurses with competencies that included verification of physician's orders, new admission chart/review, oxygen physician's orders, availability of medications and medication administration including IV infusions, medication administration schedule, admission process, 24 hour chart check, medical error prevention, change in condition, and resident assessment and examinations. The document read, 3.7.1 We employ a team oriented approach when working with health care professionals. Our goal is to provide the best care for patients, so communication is essential. We ensure that we are meeting regulatory requirements while implementing any patient specific protocol that the healthcare professional requires to treat the patient. 2. Review of the medical record revealed resident #6, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted from the hospital on [DATE] with diagnoses of cellulitis (tissue infection) of the left lower limb, chronic left foot ulcers (wounds), pressure ulcers to the right hip and coccyx (tailbone), Human Immunodeficiency Virus (chronic viral blood infection), Syphilis (chronic infection), chronic embolism and thrombosis (blood clot), thyroid disorder, depression, and cognitive impairment. On [DATE], a newly acquired diagnosis of osteomyelitis (bone infection) was added. Review of the MDS Admission assessment with ARD of [DATE] noted the resident scored 13 out of 15 on the BIMS that indicated he was cognitively intact. The assessment noted he had not shown any behaviors or rejections of evaluation or care. The assessment showed he required moderate assistance from staff to complete ADL's, he did not walk, was dependent on staff assistance for mobility, transfers in and out of bed, and used a wheelchair. He was always incontinent of bladder and bowel functions, and had frequent pain that interfered with his day to day activities. He had one stage 3, one stage 4, and 2 unstageable pressure ulcers, intravenous (IV) central line access, and he received antidepressant, anticoagulant, antibiotic, and opioid medications with identified potentially clinically significant medication issues during the look back period. The Comprehensive Care Plan included focus for ADL care with staff assistance, fall risks, cellulitis infection with an intervention to administer physician ordered medications, four pressure ulcers with interventions that nurses monitored for complications and provided ordered treatments, a metabolic condition that required medication, risk for infection complications with an intervention that ordered antibiotic medications would be administered, malnutrition due to infection, risk of intravenous access complications with interventions that site care and infusions were provided and monitored by nurses for patency and complications The hospital's Physician Discharge Orders and Instruction noted Medication Instructions included Tylenol 650 MG as needed for pain, medications with the next dose administration due on [DATE] for Atorvastatin (cholesterol lowering) 20 MG once daily at bedtime, Losartan (for high blood pressure) 50 MG twice daily, Atenolol (blood pressure) 50 MG twice daily, Heparin (blood thinner) 5000 units by injection every 12 hours, the next dose administration on [DATE] for Levothyroxine (thyroid stabilizing) 25 micrograms (MCG) once daily, Sertraline (antidepressant) 50 MG once daily, Levaquin (antibiotic) 750 MG once daily, Bactrim (antibiotic) ,d+[DATE] MG once daily, and Ertapenem (antibiotic) 1 gram (GM) IV infusion once daily. Additional Physician Instructions were noted and indicated the resident required aggressive wound care with IV and oral antibiotic medications per the Infectious Disease physician, and the resident had an IV access catheter in place that required continued monitoring and care. On [DATE] at 2:15 PM, resident #6 was observed in his room lying in bed covered by a blanket with his eyes closed. Inactive IV equipment was positioned at the left side of his bed. The Order Summary report showed on [DATE], physician's medication orders were entered that included Tylenol 325 MG every 6 hours as needed for pain, Atorvastatin 20 MG at bedtime for high cholesterol, Levothyroxine 25 MCG once daily for thyroid, Sertraline 50 MG once daily for depression, Losartan 50 MG twice daily for blood pressure, Atenolol 50 MG twice daily for blood pressure, Bactrim ,d+[DATE] MG once daily for chronic infection, Levaquin 750 MG once daily for wound infection, Heparin 5000 units injected once daily for blood thinner, and Ertapenem Sodium IV infusion 1 GM once daily for wound infection until [DATE]. The report showed physician's orders for nurses' care and monitoring of resident #6's right basilic vein IV access catheter was ordered [DATE], three days after he returned from the hospital. Orders for care and treatment of one stage 4, once stage 3, and two unstageable pressure ulcers that were present when the resident returned to the facility on [DATE] were not entered until [DATE], four days after he returned from the hospital. On [DATE] at 2:45 PM, LPN B recalled she worked the 7:00 AM to 3:00 PM shift on Monday [DATE], and her assignment included resident #6. She said the resident's IV antibiotic medication had not arrived from the pharmacy and she was not able to administer it. She explained it was possible the pharmacy required lab results. She noted the pharmacy often had additional information requirements before they dispensed IV antibiotics for example, height, weight, and/or laboratory results. She said she reported the IV medication was not administered to the oncoming nurse. She did not explain why she did not contact the physician to report the omissions. On [DATE] at 3:12 PM, in a telephone interview, LPN H said she had worked at the facility for about 2 months. She recalled she worked on [DATE] and had resident #6 on her assignment. She explained the resident's IV antibiotic medication had not arrived from the pharmacy and she didn't have access to the facility's medication dispensing system. She stated she thought LPN B had accessed the IV antibiotic from the dispensing system and had administered the IV to the resident. The [DATE] MAR showed from [DATE] to [DATE], the resident missed seven out of nine Heparin doses, two out of four doses of Sertraline, Atenolol, Losartan, Bactrim, and Levaquin, and four out of four doses of Ertapenem IV infusions. The report noted the resident's IV catheter access care and monitoring orders started on [DATE] that indicated nurses had not monitored the IV for three days. On [DATE] at 11:45 AM, the DON said the pharmacy usually fulfilled medication orders within hours and they delivered twice daily. She said nurses were expected to notify the physician if medication doses were not administered for any reason and that included pharmacy delivery problems. The (Pharmacy provider) Proof of Delivery Shipment Summary showed on [DATE] at 5:24 PM, the facility received medications for resident #6 that included Losartan, Bactrim, and Levaquin. The Shipment Summary dated [DATE] at 7:06 AM, showed the facility received the resident's Heparin injectable medication. The Shipment Summary indicated the facility received the residents IV Ertapenem medication and administration supplies on [DATE] at 5:51 PM, four days after the resident returned from the hospital. On [DATE] at 3:45 PM, LPN B said she had access to the facility's medication dispensing system and recalled she had removed one dose of oral Bactrim for resident #6. She asserted she had never removed an IV antibiotic medication for the resident. During a joint observation on [DATE] at 3:49 PM, LPN B accessed the facility's dispensary and retrieved resident #6's complete history report. The report showed one dose of oral Bactrim was removed on [DATE]. The inventory report showed the machine contained the IV medication Ertapenem, however it had never been dispensed for the resident. On [DATE] at 1:03 PM, during a telephone interview, the pharmacy provider's Pharmacy Technician checked their records and said they received orders for resident #6's IV medication on [DATE]. She said their IV face sheet record indicated the pharmacy made more than 5 attempts to contact the facility for further information required to dispense the medication, and the facility had not responded. On [DATE] at 2:59 PM, the DON acknowledged pharmacy shipment summaries showed resident #6's Heparin was not delivered until [DATE], and the IV Ertapenem was not delivered until [DATE]. She acknowledged the hospital discharge medication orders indicated Heparin was due [DATE], and the oral and IV antibiotics were due [DATE]. She checked the resident's [DATE] MAR and confirmed there were several missing doses of medications. She could not explain why so many nurses failed to act on the discrepancies nor contact the doctor. On [DATE] at 4:33 PM, the DON explained she contacted the pharmacy provider and learned on [DATE], LPN J responded to a fax request from the pharmacy for resident #6's lab results. She said that was the reason for the pharmacy's delay and when the lab results were received, the IV medication was dispensed and delivered on [DATE]. She could not explain why the resident's other medications were delayed. On [DATE] at 4:30 PM, the NHA, DON, Facility Regional Nurse Consultant, Regional Nurse Consultant, and [NAME] President of Operations were informed the investigation revealed there was conflicting information provided from interviews with licensed nurses, and review of their pharmacy delivery and dispensing records. Review of the Wound Care Advanced Practice Registered Nurse's progress notes dated [DATE] noted the resident was assessed and treated for pressure ulcers on his coccyx, right hip, and two ulcers on his left foot. The [DATE] TAR showed pressure ulcer wound care and treatments had not started until [DATE], four days after the resident returned from the hospital. In an interview on [DATE] at 11:41 AM, the Infectious Disease APRN explained he expected a prompt continuance of any antibiotics ordered with hospital discharges, and those from an Infectious Disease physician were considered more critical. He said he treated resident #6 at the facility and he was familiar with him. He was not aware the resident had missed multiple doses of antibiotics, especially IV infusions. He indicated the missed doses could have led to worsening of his infection and sepsis. He relayed he was concerned as nurses had not contacted him about the omissions and stated he would have likely extended the stop date to ensure the resident received the entire treatment course. Review of the Order Summary Report showed on [DATE], physician's medication orders for the antibiotic medication Ertapenem 1 GM by IV infusion once daily were revised to treat a newly added diagnosis of osteomyelitis and the treatment course required 18 additional doses. On [DATE] at 8:55 AM, the Facility Regional Nurse Consultant explained she covered and assisted with new nurse orientation and training. She said nurses received orien[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure physician orders for immediate care were fully processed and implemented to ensure provision of necessary care and services for 2 of 6 residents reviewed for Quality of Care and Treatment of a total sample of 6 residents, (#1, #6). On [DATE], resident #1 was readmitted back to the facility from the hospital. The facility had transferred the resident to the hospital on [DATE] where she was diagnosed with severe health care associated pneumonia and sepsis, a serious blood infection with a high risk for total organ failure and death, (retrieved from www.mayoclinic.org on [DATE]). While hospitalized for the next two weeks, she required intensive care and a machine to breathe. She returned to the facility at approximately 9:00 PM on Friday, [DATE] with doctor's orders to continue her medications and supplemental oxygen to keep her health conditions stable. The facility's licensed nurses did not implement the physician's orders for immediate care that included critical medications and oxygen, and did not adequately monitor the resident's recent respiratory failure to prevent complications, worsening of condition and to mitigate the risk of serious injury/impairment/death. Three days later, on Monday, [DATE] at 9:55 AM, the resident was found unresponsive and without respirations or pulse. Nurses were unable to readily locate the resident's code status from the medical record, and at 10:00 AM, they initiated Cardiopulmonary Resuscitation (CPR) and notified 911. Emergency Medical Services (EMS) arrived at the resident's bedside at 10:08 AM and discontinued CPR. The resident was pronounced dead at 10:12 AM. The facility's failure to ensure the correct procedure was followed to implement physician orders for immediate care and failure to provide critical life sustaining medications including oxygen, contributed to the destabilization of resident #1's acute and chronic medical conditions and placed all residents at risk for major complications from worsening and unstable health conditions and serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on [DATE] and was removed on [DATE]. Findings: Cross reference F600 and F726. 1. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE] with diagnoses of intracranial (brain) hemorrhage (bleeding) and hematoma (blood pooling), encephalopathy (brain dysfunction), meningioma (tumor of membranes surrounding the brain), dysphagia (difficulty swallowing), gastrostomy status (feeding tube), hypertension (high blood pressure), deep tissue injury, malnutrition, and dementia. She was re-hospitalized on [DATE] and readmitted on [DATE] with newly acquired diagnoses that included acute hypoxic (low blood oxygen) respiratory failure with a history of mechanical ventilation (breathing machine) dependence, health care associated pneumonia, heart failure, pressure ulcer, and epilepsy. Review of the Minimum Data Set (MDS) Death in facility tracking record with Assessment Reference Date (ARD) of [DATE] showed resident #1 died at the facility on [DATE]. The MDS 5-day assessment with ARD of [DATE] revealed there was no assessment completed for cognitive patterns or behaviors. The assessment showed resident #1 was dependent on staff for mobility and to complete her Activities of Daily Living (ADLs). The assessment noted she required an indwelling urinary catheter for bladder functions, was frequently incontinent of bowel functions, had newly added active diagnoses of epilepsy and respiratory failure, required a feeding tube to receive nutrition and hydration, had 2 unstageable pressure ulcers, did not receive anticoagulant or antibiotic medications, had no identified clinically significant medication issues, and she did not receive supplemental oxygen while a resident during the look back period. The MDS 5-day assessment with ARD of [DATE] showed resident #1 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated severe cognitive impairment. The assessment noted she had not shown any behavioral symptoms, and had 1 stage 3 pressure ulcer during the look back period. Review of the hospital's Physician Discharge Orders and Instructions dated [DATE] noted Physician Medication Instructions included Jevity 1.5 1000 ML (milliliters) for nutrition at 40 ML per hour continuous tube feeding, Docusate Sodium 100 MG twice daily as needed, Tylenol 325 MG every 6 hours as needed, and Polyethylene glycol 17 GM once daily as needed. The remaining orders read, Next dose: Morning: [DATE] for Combigan 0.2%-0.5% eye drops once daily, Latanoprost 0.005% eye drops once daily, Chlorhexidine 1.5 milliliters (ML) topical (on skin) every 12 hours, ProStat (nutritional supplement) once daily, Famotidine 20 MG (acid reducing) once daily, Memantine (dementia slowing) 10 MG twice daily, Montelukast (asthma) 10 MG once daily, Metolazone (diuretic/fluid removing) 10 MG once daily, Midodrine (blood pressure) 10 MG three times daily, Linezolid (antibiotic) 600 MG twice daily, Levofloxacin (antibiotic) 750 MG once daily, Heparin 5000 (blood thinner) units injection every 12 hours, and Valproic Acid (anti-seizure) 500 MG once daily and 750 MG at bedtime. On [DATE], the hospital physician signed a ,d+[DATE] AHCA form and documented resident #1 needed antibiotic medication, had 2 pressure wounds, required continuous oxygen with flow rate at 2 liters per minute, and she had heart failure due to an abnormal LVEF (left ventricle ejection fraction) (percentage of blood pumped out from the heart to the body) of ,d+[DATE]%. The Order Summary Report noted there were active physician's orders dated [DATE] for tube feeding monitoring and care with enteral nutrition, and Docusate Sodium 100 milligrams (MG) as needed every 12 hours for constipation. The report showed additional medication orders dated [DATE] that read, Pending confirmation for Famotidine 20 MG once daily for gastroesophageal reflux disease (GERD), Memantine HCI 10 MG once daily for dementia, Polyethylene Glycol 17 grams (GM) as needed for constipation, Latanoprost 0.005% eye drops once daily for glaucoma, Montelukast Sodium 10 MG three times daily for asthma, Metolazone 10 MG once daily for high blood pressure, Midodrine HCI 10 MG three times daily for orthostatic hypotension (low blood pressure after sitting or standing), Valproic Acid 500 MG once daily and 750 MG at bedtime for seizures, and Heparin 5000 Units by injection once daily for blood clot prevention. The Comprehensive Care Plan included focus for risk of infection complications with interventions for staff to administer antibiotics and treatments, and notifications to the physician of significant changes or shortness of breath. A care plan for neurological concern/condition included intervention for staff to administer medications per doctor's orders. A respiratory condition/concern care plan showed interventions for staff to administer oxygen and treatments per doctor's orders, monitor oxygen saturations, and assess lung sounds. During an interview on [DATE] at 10:15 AM, Licensed Practical Nurse (LPN) C said nurses were responsible for entering and processing all physician's orders when residents were newly admitted or readmitted to the facility from the hospital. She added that nurses had to ensure all medication orders were entered into the electronic system by the end of the shift so the pharmacy could timely dispense and deliver them. She stated the pharmacy delivered medications to the facility two times per day, and nurses could access the facility's automated medication dispensary that contained most antibiotics and some other emergent medications She explained that if problems arose with medication deliveries or access, nurses were expected to notify the physician by the end of their shift. On [DATE] at 2:46 PM, during a telephone interview, LPN E said nurses were expected to process admission orders for residents they were assigned. He explained occasionally, nurses were required to take over and complete the orders or assessments if the previous nurse was unable to get them done on their shift. He recalled, on [DATE], he worked the 11:00 PM to 7:00 AM shift and recalled there were five residents admitted or readmitted during the 3:00 PM to 11:00 PM shift. He stated that he and another nurse assisted and entered incomplete admission orders from the previous shift. He said all admission medication orders required a confirmation step, so they were submitted and processed by the pharmacy. He explained, on [DATE] he gave report to the oncoming 7:00 AM to 3:00 PM nurse that there were pending medication orders. He stated, the same morning, those nurses were supposed to review and confirm the medication orders so the pharmacy would deliver them. He could not recall who the oncoming nurse was, or if he had reported the issues to the Weekend Supervisor. On [DATE] at 3:11 PM, during a telephone interview, LPN F recalled on [DATE], she worked the 11:00 PM to 7:00 AM shift. She explained that during her shift she clarified an enteral feed substitution for resident #1 with the on call Advance Practice Registered Nurse (APRN) by telephone, and then confirmed the resident's feeding tube orders in the medical record so it could be administered. She said the Medication Administration Record (MAR) showed the resident's medication orders were pending confirmation status and she could not administer them. She explained on [DATE] at approximately 7:00 AM, during the next shift transition, she informed the Weekend Supervisor there were 5 admissions the previous evening with incomplete orders that needed to be reviewed and confirmed. She stated she was concerned because resident #1's medications needed to be administered. She remembered the Weekend Supervisor replied that it was being handled, so she assumed the issues were addressed. A Nursing Progress Note completed by LPN F on [DATE] at 3:52 AM, read, medications were entered by previous shift nurse and this writer spoke with on call NP (Nurse Practitioner) (name) who completed medication reconciliation. Pt. (patient) has an order for Jevity 1.5. Call made to on call to request an order for house stock parenteral feeding. Currently awaiting call back with new orders. On [DATE] at 4:06 PM and 4:21 PM, and on [DATE] 11:34 AM, unsuccessful attempts were made to contact the On Call Advanced Practice Registered Nurse (APRN) by telephone. During a telephone interview on [DATE] at 8:48 AM, the Weekend Supervisor said admission orders were expected to be entered and fully processed by the assigned nurse by the end of the shift after the resident arrived on the unit. She explained that if a nurse's workload prevented them from completing orders or assessments, the Unit Manager or Supervisor assisted in completing the order process as, it's a priority. She said on weekends, it was her job to complete any incomplete assessments and sometimes she assisted with wound care treatments. She recalled on Saturday, [DATE] and Sunday, [DATE] she worked double shifts from 7:00 AM to 11:00 PM and did not recall any nurse that asked for her assistance or reported any pending admission orders. On [DATE] at 3:30 PM, LPN G recalled on Saturday [DATE], the day after resident #1 was admitted , she was assigned to care for the resident on the 3:00 PM to 11:00 PM shift. She explained the resident's medication orders were still pending status. She said she informed the Weekend Supervisor who replied to that she was still working on them which indicated she was taking care of them. She stated she had not administered resident #1's medications during her shift because they were still not scheduled on the MAR by the end of her shift, over 24 hours after the resident returned to the facility. Review of the resident #1's [DATE] MAR showed nurses signed for enteral nutrition administered from [DATE] to [DATE]. The Treatment Administration Record (TAR) noted orders for feeding tube care and monitoring. Neither the MAR nor TAR included orders for oxygen and/or monitoring, or pressure ulcer treatments. Both records indicated no medications, supplemental oxygen, or pressure ulcer treatments were administered to the resident, for three days. On [DATE] at 4:16 PM, the Director of Nursing (DON) said she expected nurses to enter and fully process admission orders and complete resident assessments. She said when medications weren't entered and confirmed as per their process, the pharmacy was not alerted to send the medications. She explained after resident #1 died on [DATE], she reviewed the medical record and found the admission orders had not been completed, and the resident had not received any medications after she returned to the facility on [DATE]. She said she investigated and concluded that nurses who took care of the resident had not understood the process to ensure the orders were completed. Review of the Admission Evaluation completed and signed by the Weekend Supervisor on [DATE] showed resident #1's most recent vital signs were obtained on [DATE] at 9:19 PM, when the resident's heart rate was 108 beats per minute, her respirations were 20 breaths per minute, and her oxygen saturation was measured at 96% on room air. The neurological assessment noted the resident had a neurological condition that required medications. The Skin assessment showed there were two pressure ulcers to be treated per physician's orders. The Respiratory/pulmonary status documented the resident had dyspnea (shortness of breath), Emphysema/COPD, Respiratory failure, diminished lung sounds, required oxygen support, monitoring of lung sounds, oxygen saturation levels, and physician notification of changes, issues, or concerns. The Infections/Cancer/IV assessment section documented the resident had upper and respiratory infections with pneumonia and wound/pressure ulcers, was at risk for complications of infection, required antibiotics, treatments or therapies as ordered, and physician notification for vital sign changes or shortness of breath. The report read, 5. Date and time physician was notified, and orders were confirmed: [DATE] 6. Date and time pharmacy was sent physician orders: [DATE] . Reconciliation . Medications were reviewed and reconciled with the attending Physician . The Smoking Assessment completed by the Weekend Supervisor on [DATE] read, . Does the resident use Oxygen? . , with a response, No. The medical record revealed after [DATE] at 9:19 PM when the resident returned from the hospital and over the next 59 hours, two vital signs assessments were done. On [DATE] at 9:53 PM, the blood oxygen saturation read 96% without supplemental oxygen, and on [DATE] at 8:24 AM, for a respiratory rate of 20 breaths per minute and a blood oxygen saturation reading of 96% with oxygen (unknown flow rate) administered via nasal cannula. The medical record did not include any additional assessments to monitor resident #1's respiratory status. Review of a Nursing Progress Note dated [DATE] at 12:47 PM, by LPN B read, Vitals were taken by nurse at 0830 (8:30 AM). Vitals were WNL (Within Normal Limits). No c/o (complaints of) pain, pt. (patient) was alert. The therapy dept. (department) notified me at approx. (approximately) 0955 (9:55 AM). I went in to room with unit manager to evaluate pt. Patient was not breathing and had no pulse. Code status was full code, verified by 2 nurses. CPR was initiated per facility policy at approx. 1000 (10:00 AM). 911 was called at 1000 and arrived at approx. 1010 (10:10 AM). 911 team pronounced pt. deceased at 1015 (10:15 AM). MD (Medical Doctor) was notified at 1020 (10:20 AM). Son and husband both notified at 1025 (10:25 AM). (Name) funeral home notified per family request at 1025. On [DATE] at 9:30 AM, the DON stated she expected the Weekend Supervisor to ensure all nursing processes were fully completed for new admissions which included a chart check and audit form. She explained nurses were to complete a head to toe physical assessment of a newly admitted resident within one hour of their arrival, which included making sure any ordered oxygen was supplied, administered, and monitored at least every shift per standard protocols. She said she obtained statements from the nurses who were assigned to resident #1 on the weekend of [DATE], and their accounted reports conflicted with each other. She recalled her conversation with the Weekend Supervisor revealed she was not aware that her responsibilities included chart checks and to ensure orders, assessments, and nursing processes were completed. The DON conveyed she was very concerned the nurses including the Weekend Supervisor had not intervened and ensured resident #1's physician's orders for immediate care were fully processed and implemented. She acknowledged several nurses had not recognized the clinical impact and risk for resident #1's worsening health conditions, nor acted on discrepancies and contacted the physician. She said the resident should have received her medications, and nurses should have followed the process and monitored her for changes in condition or symptoms of complications because, she could have become septic. During a telephone interview on [DATE] at 10:08 AM, resident #1's son recalled on [DATE], he traveled from out of state to visit his mother and he thought she was still in the hospital. He explained he was upset no one from the facility called him to let him know she had returned to the facility on [DATE]. He said on [DATE] when he saw his mother, she did not have oxygen on. He recalled on [DATE] at about 10:30 AM, he had just returned home when the facility called him and informed him his mother died and they told him, We did all we could do. The (City) Fire Department Patient Care Report documented EMS personnel responded to a 911 call received from the facility on [DATE] at 10:01 AM and arrived at resident #1's bedside at 10:08 AM where they assessed her. The report read, Patient Dead at Scene-No Resuscitation Attempted (Without Transport) . skin cold . arrived on scene, Pt (patient) contact made, Adult ALS (Advanced Life Support) medical assessment completed, Rigor noted to the pts (patient's) jaw. On [DATE] at 11:04 AM, the Nursing Home Administrator (NHA) explained on [DATE], the facility investigated resident #1's death in the facility. He acknowledged the resident did not receive care and services including critical medications by the nurses. During a telephone interview with the Medical Director on [DATE] at 12:45 PM, he said he was unaware that resident #1 had not received any medications for 3 days after she was admitted from the hospital and died . He recalled in the evening after he left the faciity on [DATE], the facility contacted him by phone and informed him that a technical issue caused missed medication administrations for a newly admitted resident. He stated the facility assured him they implemented a training plan, and he told them they needed to make sure it had not happened to any other resident. He said he was very concerned and expected to be contacted promptly for significant identified concerns, especially clinical ones. He explained there were processes in place and omissions of physician's admission orders was, a very scary thought, and stated, that's a big problem. 2. Review of the medical record revealed resident #6, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted from the hospital on [DATE] with diagnoses of cellulitis (tissue infection) of the left lower limb, chronic left foot ulcers (wounds), pressure ulcers to the right hip and coccyx (tailbone), Human Immunodeficiency Virus (chronic viral blood infection), Syphilis (chronic infection), chronic embolism and thrombosis (blood clot), thyroid disorder, depression, and cognitive impairment. On [DATE], a newly acquired diagnosis of osteomyelitis (bone infection) was added. Review of the MDS Admission assessment with ARD of [DATE] noted the resident scored 13 out of 15 on the BIMS that indicated he was cognitively intact. The assessment noted he had not shown any behaviors or rejections of evaluation or care. The assessment showed he required moderate assistance from staff to complete ADL's, he did not walk, was dependent on staff assistance for mobility, transfers in and out of bed, and used a wheelchair. He was always incontinent of bladder and bowel functions, and had frequent pain that interfered with his day to day activities. He had one stage 3, one stage 4, and 2 unstageable pressure ulcers, intravenous (IV) central line access, and he received antidepressant, anticoagulant, antibiotic, and opioid medications with identified potentially clinically significant medication issues during the look back period. The Comprehensive Care Plan included focus for ADL care with staff assistance, fall risks, cellulitis infection with an intervention to administer physician ordered medications, four pressure ulcers with interventions that nurses monitored for complications and provided ordered treatments, a metabolic condition that required medication, risk for infection complications with an intervention that ordered antibiotic medications would be administered, malnutrition due to infection, risk of intravenous access complications with interventions that site care and infusions were provided and monitored by nurses for patency and complications The hospital's Physician Discharge Orders and Instruction noted Medication Instructions included Tylenol 650 MG as needed for pain, medications with the next dose administration due on [DATE] for Atorvastatin (cholesterol lowering) 20 MG once daily at bedtime, Losartan (for high blood pressure) 50 MG twice daily, Atenolol (blood pressure) 50 MG twice daily, Heparin (blood thinner) 5000 units by injection every 12 hours, the next dose administration on [DATE] for Levothyroxine (thyroid stabilizing) 25 micrograms (MCG) once daily, Sertraline (antidepressant) 50 MG once daily, Levaquin (antibiotic) 750 MG once daily, Bactrim (antibiotic) ,d+[DATE] MG once daily, and Ertapenem (antibiotic) 1 gram (GM) IV infusion once daily. Additional Physician Instructions were noted and indicated the resident required aggressive wound care with IV and oral antibiotic medications per the Infectious Disease physician, and the resident had an IV access catheter in place that required continued monitoring and care. The Order Summary report showed on [DATE], physician's medication orders were entered that included Tylenol 325 MG every 6 hours as needed for pain, Atorvastatin 20 MG at bedtime for high cholesterol, Levothyroxine 25 MCG once daily for thyroid, Sertraline 50 MG once daily for depression, Losartan 50 MG twice daily for blood pressure, Atenolol 50 MG twice daily for blood pressure, Bactrim ,d+[DATE] MG once daily for chronic infection, Levaquin 750 MG once daily for wound infection, Heparin 5000 units injected once daily for blood thinner, and Ertapenem Sodium IV infusion 1 GM once daily for wound infection until [DATE]. The report showed physician's orders for nurses' care and monitoring of resident #6's right basilic vein IV access catheter was ordered [DATE], three days after he returned from the hospital. Orders for care and treatment of one stage 4, one stage 3, and two unstageable pressure ulcers that were present when the resident returned to the facility on [DATE] were not entered until [DATE], four days after he returned from the hospital. Review of the [DATE] MAR showed from [DATE] to [DATE], the resident missed seven out of nine Heparin doses, two out of four doses of Sertraline, Atenolol, Losartan, Bactrim, and Levaquin, and four out of four doses of Ertapenem IV infusions. The report noted the resident's IV catheter access care and monitoring orders started on [DATE] that indicated nurses had not monitored and maintained the IV for three days. A Wound Care APRN progress note dated [DATE] documented the resident was assessed and treated for pressure ulcers that were present when he was admitted located on his coccyx, right hip, and two ulcers on his left foot. Review of the [DATE] TAR showed pressure ulcer wound care and treatments had not started until [DATE], four days after the resident returned from the hospital. On [DATE] at 2:15 PM, resident #6 was observed in his room lying in bed covered by a blanket with his eyes closed. Inactive IV equipment was positioned at noted to the left side of his bed. The (Pharmacy provider) Proof of Delivery Shipment Summary showed on [DATE] at 5:24 PM, the facility received medications for resident #6 that included Losartan, Bactrim, and Levaquin. The Shipment Summary dated [DATE] at 7:06 AM, showed the facility received the residents Heparin injectable medication. The Shipment Summary dated [DATE] at 5:51 PM indicated the facility received the residents IV Ertapenem medication and administration supplies, four days after the resident returned to the facility from the hospital. Review of the facility's automated dispensary machine showed a history report that noted one dose of oral Bactrim was removed on [DATE] for resident #6. The inventory reports showed the dispensary contained the IV medication Ertapenem, that resident #6 should have received, however it had not been dispensed. On [DATE] at 1:03 PM, during a telephone interview, the pharmacy provider's Pharmacy Technician checked their records and said they received orders for resident #6's IV medication on [DATE]. She said their IV face sheet record indicated the pharmacy made more than 5 attempts to contact the facility for further information required to dispense the medication, but the facility had not responded. On [DATE] at 11:45 AM, the DON said the pharmacy usually filled medication orders within hours and delivered twice daily. She said nurses were expected to notify the physician if medication doses were not administered for any reason and that included pharmacy delivery problems. On [DATE] at 2:45 PM, LPN B recalled she worked the 7:00 AM to 3:00 PM shift on Monday [DATE], and her assignment included resident #6. She said the resident's IV antibiotic medication had not arrived from the pharmacy and she was not able to administer it. She explained it was possible the pharmacy required lab results. She noted the pharmacy often had additional information requirements before they dispensed IV antibiotics for example, height, weight, and/or laboratory results. She said she reported the IV medication was not administered to the oncoming nurse. She did not explain why she did not contact the physician to report the omissions. On [DATE] at 2:59 PM, the DON acknowledged pharmacy shipment summaries showed resident #6's Heparin was not delivered until [DATE], and the IV Ertapenem was not delivered until [DATE]. She acknowledged the hospital discharge medication orders indicated Heparin was due [DATE], and the oral and IV antibiotics were due [DATE]. She checked the resident's MAR and confirmed there were multiple missed doses of medications. She could not explain why so many nurses failed to act on the discrepancies nor contact the doctor and stated she needed to look into the matter further. She explained the facility's automated dispensary was used for pharmacy delays, and it contained most antibiotics including IV Ertapenem, but the facility did not keep the required equipment on hand to infuse the IV antibiotic. Review of a Nursing Progress Note dated [DATE] at 9:06 AM, read, resident #6, (called) 911 himself, stating he must go to the hospital due to the unbearable pain in legs and feet. Rating at ,d+[DATE] (10 out of 10), because the Tylenol 2 Tab 650 mg administered was not effective. 911 responded and called for (transportation provider) to transport. Patient went out via (transportation provider) for further evaluation and treatment. Additional Progress Notes showed on the same day at 3:15 PM, the resident had returned from the emergency room , and narcotic pain reliever medication was added to his treatment. On [DATE] at 4:33 PM, the DON explained she contacted the pharmacy provider and learned on [DATE], LPN J responded to a fax request from the pharmacy for resident #6's lab results. She said that was the reason for the pharmacy's delay and when the lab results were received, the IV medication was dispensed and delivered on [DATE]. She could not explain why the resident's other medications were delayed. In an interview on [DATE] at 11:41 AM, the Infectious Disease APRN explained he expected a prompt continuance of any antibiotics ordered with hospital discharges, and those from an Infectious Disease physician were considered more critical. He said he treated resident #6 at the facility and he was familiar with him. He was not aware the resident had missed multiple doses of antibiotics, especially IV infusions. He indicated the missed doses could have led to worsening of his infection and sepsis. He relayed he was concerned as nurses had not contacted him about the omissions and stated he would have likely extended the stop date to ensure the resident received the entire treatment course. Review of the Order Summary Report showed on [DATE], physician's medication orders for the antibiotic medication Ertapenem 1 GM by IV infusion once daily were revised to treat a newly added diagnosis of osteomyelitis and the treatment course required 18 additional doses. During a telephone interview on [DATE] at 12:45 PM, the Medical Director conveyed he was unaware and even more concerned that additionally, resident #6 missed multiple medications including four days of IV antibiotic infusions. He explained that antibiotics were especially important for continuance due to the risk for developing sepsis. He stated there were processes in place for checks and balances and omissions of admission orders and did not explain why they were not followed. Review of the immediate actions implemented by the facility to remove the Immediate Jeopardy were verified by the survey team and included the following: *On [DATE], the facility reviewed all current residents' records to ensure no other residents were affected. *On [DATE], the facility began daily reviews of admissions and readmission orders and had not found additional unconfirmed orders that placed any additional residents at further risk for neglect. *On [DATE], the facility educated 100% of their facility staff for identification of neglect, and the [NAME] President of Operations provided re-education to the Nursing Home Administrator/Risk Manager on identification of instances or situations of potential neglect. *On [DATE], the facility filed an Immediate Federal report related to the allegation of neglect for resident #1 and initiated a full investigation. Review of the in-service attendance sheets noted staff participated in education on the topics listed above. From [DATE] to [DATE], interviews were conducted with 20 staff members who represented all shifts. All staff, including 3 Personal Care Attendants (PCAs), 6 CNAs, 8 LPNs, 2 RNs, and a Physical Therapist verbalized understanding of the education provided. The resident sample was expanded to include 4 additional residents admitted on [DATE], and 1 additional resident who died at the facility. Observations, interviews, and record review revealed no concerns related to Neglect for residents #2, #3, #4, and #5.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by not ensuring staff fully processed and implemented physician's orders for immediate care and ensure provision of necessary care and services and failed to complete a thorough investigation for possible neglect for 2 of 6 residents, reviewed for Quality of Care and Treatment of a total sample of 6 residents, (#1, #6). On [DATE], resident #1 was readmitted back to the facility from the hospital. The facility had transferred the resident to the hospital on [DATE] where she was diagnosed with severe health care associated pneumonia and sepsis, a serious blood infection with a high risk for total organ failure and death, (retrieved from www.mayoclinic.org on [DATE]). While hospitalized for the next two weeks, she required intensive care and a machine to breathe. She returned to the facility at approximately 9:00 PM on Friday, [DATE] with doctor's orders to continue her medications and supplemental oxygen to keep her health conditions stable. The facility's licensed nurses did not implement the physician's orders for immediate care that included critical medications and oxygen, and did not adequately monitor the resident's recent respiratory failure to prevent complications, worsening of condition and to mitigate the risk of serious injury/impairment/death. Three days later, on Monday, [DATE] at 9:55 AM, the resident was found unresponsive and without respirations or pulse. Nurses were unable to readily locate the resident's code status from the medical record, and at 10:00 AM, they initiated Cardiopulmonary Resuscitation (CPR) and notified 911. Emergency Medical Services (EMS) arrived at the resident's bedside at 10:08 AM and discontinued CPR. The resident was pronounced dead at 10:12 AM. The facility's failure to process and implement physician's orders for immediate care and to provide necessary care and services contributed to the destabilization of resident #1's acute and chronic medical conditions and placed all residents at risk for neglect and serious injury/impairment/death. This failure resulted in Immediate Jeopardy which began on [DATE] and was removed on [DATE]. Findings: Cross reference F635 and F726. 1. Review of the medical record revealed resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE] with diagnoses of intracranial (brain) hemorrhage (bleeding) and hematoma (blood pooling), encephalopathy (brain dysfunction), meningioma (tumor of membranes surrounding the brain), dysphagia (difficulty swallowing), gastrostomy status (feeding tube), hypertension, deep tissue injury, malnutrition, and dementia. She was re-hospitalized on [DATE] and readmitted on [DATE] with newly acquired diagnoses that included acute hypoxic (low blood oxygen) respiratory failure, health care associated pneumonia, heart failure, pressure ulcers, and epilepsy. The Minimum Data Set (MDS) Death in facility tracking record with an Assessment Reference Date (ARD) of [DATE] showed resident #1 died at the facility on [DATE]. The MDS 5-day assessment with ARD of [DATE] revealed there was no assessment completed for cognitive patterns or behaviors. The assessment showed resident #1 was dependent on staff for mobility and to complete her Activities of Daily Living (ADLs). The assessment noted she required an indwelling urinary catheter for bladder functions, was frequently incontinent of bowel functions, had newly added active diagnoses of epilepsy and respiratory failure, required a feeding tube to receive nutrition and hydration, had 2 unstageable pressure ulcers, did not receive anticoagulant or antibiotic medications, had no identified clinically significant medication issues, and she did not receive supplemental oxygen while a resident during the look back period. The MDS 5-day assessment with an ARD of [DATE] showed resident #1 scored 0 out of 15 on the Brief Interview for Mental Status (BIMS) that indicated severe cognitive impairment. The assessment noted she had not shown any behavioral symptoms, and had 1 stage 3 pressure ulcer during the look back period. Review of the hospital's Physician Discharge Orders and Instructions dated [DATE] noted Physician Medication Instructions included Jevity 1.5 1000 ML (milliliters) for nutrition at 40 ML per hour continuous tube feeding, Docusate Sodium 100 MG twice daily as needed, Tylenol 325 MG every 6 hours as needed, and Polyethylene glycol 17 GM once daily as needed. The remaining orders read, Next dose: Morning: [DATE] for Combigan 0.2%-0.5% eye drops once daily, Latanoprost 0.005% eye drops once daily, Chlorhexidine 1.5 milliliters (ML) topical (on skin) every 12 hours, ProStat (nutritional supplement) once daily, Famotidine 20 MG (acid reducing) once daily, Memantine (dementia slowing) 10 MG twice daily, Montelukast (asthma) 10 MG once daily, Metolazone (diuretic/fluid removing) 10 MG once daily, Midodrine (blood pressure) 10 MG three times daily, Linezolid (antibiotic) 600 MG twice daily, Levofloxacin (antibiotic) 750 MG once daily, Heparin 5000 (blood thinner) units injection every 12 hours, and Valproic Acid (anti-seizure) 500 MG once daily and 750 MG at bedtime. On [DATE], the hospital physician signed a ,d+[DATE] AHCA form and documented resident #1 needed antibiotic medication, had 2 pressure wounds, required continuous oxygen with flow rate at 2 liters per minute, and she had heart failure due to an abnormal LVEF (left ventricle ejection fraction) (percentage of blood pumped out from the heart to the body) of ,d+[DATE]%. The Order Summary Report noted there were active physician's orders dated [DATE] for tube feeding monitoring and care with enteral nutrition, and Docusate Sodium 100 milligrams (MG) as needed every 12 hours for constipation. The report showed additional medication orders dated [DATE] that read, Pending confirmation for Famotidine 20 MG once daily for gastroesophageal reflux disease (GERD), Memantine HCI 10 MG once daily for dementia, Polyethylene Glycol 17 grams (GM) as needed for constipation, Latanoprost 0.005% eye drops once daily for glaucoma, Montelukast Sodium 10 MG three times daily for asthma, Metolazone 10 MG once daily for high blood pressure, Midodrine HCI 10 MG three times daily for orthostatic hypotension (low blood pressure after sitting or standing), Valproic Acid 500 MG once daily and 750 MG at bedtime for seizures, and Heparin 5000 Units by injection once daily for blood clot prevention. The Comprehensive Care Plan included focus for risk of infection complications with interventions for staff to administer antibiotics and treatments, and notifications to the physician of significant changes or shortness of breath. A care plan for neurological concern/condition included intervention for staff to administer medications per doctor's orders. A respiratory condition/concern care plan showed interventions for staff to administer oxygen and treatments per doctor's orders, monitor oxygen saturations, and assess lung sounds. During an interview on [DATE] at 10:15 AM, Licensed Practical Nurse (LPN) C said nurses were responsible for entering and processing all physician's orders when residents were newly admitted or readmitted to the facility from the hospital. She added that nurses had to ensure all medication orders were entered into the electronic system by the end of the shift so the pharmacy could timely dispense and deliver them. She stated the pharmacy delivered medications to the facility two times per day, and nurses could access the facility's automated medication dispensary that contained most antibiotics and some other emergent medications She explained that if problems arose with medication deliveries or access, nurses were expected to notify the physician by the end of their shift. On [DATE] at 2:46 PM, during a telephone interview, LPN E said nurses were expected to process admission orders for residents they were assigned. He explained occasionally, nurses were required to take over and complete the orders or assessments if the previous nurse was unable to get them done on their shift. He recalled, on [DATE], he worked the 11:00 PM to 7:00 AM shift and recalled there were five residents admitted or readmitted during the 3:00 PM to 11:00 PM shift. He stated that he and another nurse assisted and entered incomplete admission orders from the previous shift. He said all admission medication orders required a confirmation step, so they were submitted and processed by the pharmacy. He explained, on [DATE] he gave report to the oncoming 7:00 AM to 3:00 PM nurse that there were pending medication orders. He stated, the same morning, those nurses were supposed to review and confirm the medication orders so the pharmacy would deliver them. He could not recall who the oncoming nurse was, or if he had reported the issues to the Weekend Supervisor. On [DATE] at 3:11 PM, during a telephone interview, LPN F recalled on [DATE], she worked the 11:00 PM to 7:00 AM shift. She explained that during her shift she clarified an enteral feed substitution for resident #1 with the on call Advance Practice Registered Nurse (APRN) by telephone, and then confirmed the resident's feeding tube orders in the medical record so it could be administered. She said the Medication Administration Record (MAR) showed the resident's medication orders were pending confirmation status and she could not administer them. She explained on [DATE] at approximately 7:00 AM, during the next shift transition, she informed the Weekend Supervisor there were 5 admissions the previous evening with incomplete orders that needed to be reviewed and confirmed. She stated she was concerned because resident #1's medications needed to be administered. She remembered the Weekend Supervisor replied that it was being handled, so she assumed the issues were addressed. A Nursing Progress Note completed by LPN F on [DATE] at 3:52 AM, read, medications were entered by previous shift nurse and this writer spoke with on call NP (Nurse Practitioner) (name) who completed medication reconciliation. Pt. (patient) has an order for Jevity 1.5. Call made to on call to request an order for house stock parenteral feeding. Currently awaiting call back with new orders. On [DATE] at 4:06 PM, and 4:21 PM, and on [DATE] 11:34 AM, unsuccessful attempts were made to contact the on call APRN by telephone. During a telephone interview on [DATE] at 8:48 AM, the Weekend Supervisor said admission orders were expected to be entered and fully processed by the assigned nurse by the end of the shift after the resident arrived on the unit. She explained that if a nurse's workload prevented them from completing orders or assessments, the Unit Manager or Supervisor assisted in completing the order process as, it's a priority. She said on weekends, it was her job to complete any incomplete assessments and sometimes she assisted with wound care treatments. She recalled on Saturday, [DATE] and Sunday, [DATE] she worked double shifts from 7:00 AM to 11:00 PM and did not recall any nurse that asked for her assistance or reported any pending admission orders. On [DATE] at 3:30 PM, LPN G recalled on Saturday [DATE], the day after resident #1 was admitted , she was assigned to care for the resident on the 3:00 PM to 11:00 PM shift. She explained the resident's medication orders were still pending status. She said she informed the Weekend Supervisor who replied to that she was still working on them which indicated she was taking care of them. She stated she had not administered resident #1's medications during her shift because they were still not scheduled on the MAR by the end of her shift, over 24 hours after the resident returned to the facility. Review of the resident #1's [DATE] MAR showed nurses signed for enteral nutrition administered from [DATE] to [DATE]. The Treatment Administration Record (TAR) noted orders for feeding tube care and monitoring. Neither the MAR nor TAR included orders for oxygen and/or monitoring, or pressure ulcer treatments. Both records indicated no medications, supplemental oxygen, or pressure ulcer treatments were administered to the resident, for three days. On [DATE] at 4:16 PM, the Director of Nursing (DON) said she expected nurses to enter and fully process admission orders and complete resident assessments. She said when medications weren't entered and confirmed as per their process, the pharmacy was not alerted to send the medications. She explained after resident #1 died on [DATE], she reviewed the medical record and found the admission orders had not been completed, and the resident had not received any medications after she returned to the facility on [DATE]. She said she investigated and concluded that nurses who took care of the resident had not understood the process to ensure the orders were completed. In a telephone interview on [DATE] at 8:41 AM, the Weekend Supervisor said protocols for care and monitoring of a resident who was admitted from the hospital after respiratory failure included nurses' assessments of their lungs for abnormal sounds, oxygen saturation status, blood pressure, and heart rate at least every shift and most physicians requested it every 4 hours. She explained nurses needed to complete physical assessments and were to monitor residents for changes in condition so the physician was notified to determine if the treatment plan should be revised, or if a higher level of care was needed. She recalled she completed resident #1's assessments after she was admitted on [DATE]. Review of the Admission Evaluation completed and signed by the Weekend Supervisor on [DATE] showed resident #1's most recent vital signs were obtained on [DATE] at 9:19 PM, when the resident's heart rate was 108 beats per minute, her respirations were 20 breaths per minute, and her oxygen saturation was measured at 96% on room air. The neurological assessment noted the resident had a neurological condition that required medications. The Skin assessment showed there were two pressure ulcers to be treated per physician's orders. The Respiratory/pulmonary status documented the resident had dyspnea (shortness of breath), Emphysema/COPD, Respiratory failure, diminished lung sounds, required oxygen support, monitoring of lung sounds, oxygen saturation levels, and physician notification of changes, issues, or concerns. The Infections/Cancer/IV assessment section documented the resident had upper and respiratory infections with pneumonia and wound/pressure ulcers, was at risk for complications of infection, required antibiotics, treatments or therapies as ordered, and physician notification for vital sign changes or shortness of breath. The report read, 5. Date and time physician was notified, and orders were confirmed: [DATE] 6. Date and time pharmacy was sent physician orders: [DATE] . Reconciliation . Medications were reviewed and reconciled with the attending Physician . The Smoking Assessment completed by the Weekend Supervisor on [DATE] read, . Does the resident use Oxygen? . , with a response, No. The medical record revealed after [DATE] at 9:19 PM when the resident returned from the hospital and over the next 59 hours, two vital signs assessments were done. On [DATE] at 9:53 PM, the blood oxygen saturation read 96% without supplemental oxygen, and on [DATE] at 8:24 AM, for a respiratory rate of 20 breaths per minute and a blood oxygen saturation reading of 96% with oxygen (unknown flow rate) administered via nasal cannula. The medical record did not include any additional assessments to monitor resident #1's respiratory status. Review of a Nursing Progress Note dated [DATE] at 12:47 PM, by LPN B read, Vitals were taken by nurse at 0830 (8:30 AM). Vitals were WNL (Within Normal Limits). No c/o (complaints of) pain, pt. (patient) was alert. The therapy dept. (department) notified me at approx. (approximately) 0955 (9:55 AM). I went in to room with unit manager to evaluate pt. Patient was not breathing and had no pulse. Code status was full code, verified by 2 nurses. CPR was initiated per facility policy at approx. 1000 (10:00 AM). 911 was called at 1000 and arrived at approx. 1010 (10:10 AM). 911 team pronounced pt. deceased at 1015 (10:15 AM). MD (Medical Doctor) was notified at 1020 (10:20 AM). Son and husband both notified at 1025 (10:25 AM). (Name) funeral home notified per family request at 1025. On [DATE] at 12:36 PM, LPN B recalled on [DATE] from 9:55 AM to 10:00 AM, nurses were unable to easily determine resident #1's code status because it was not included in her physician's orders in the medical record. She explained she was not able to locate a Do Not Resuscitate Order (DNRO), and nurses determined without one, the resident was a Full Code. She stated she had not expected difficulty with finding the resident's code status because it was usually located on their profile however resident #1's record did not show one. Review of the Order Summary Report revealed there were no physician's orders for resident #1's code status. The Comprehensive Care Plan did not include a focus for advanced directives nor Code Status. On [DATE] at 9:30 AM, the DON stated she expected the Weekend Supervisor to ensure all nursing processes were fully completed for new admissions which included a chart check and audit form. She explained nurses were to complete a head to toe physical assessment of a newly admitted resident within one hour of their arrival, which included making sure any ordered oxygen was supplied, administered, and monitored at least every shift per standard protocols. She said she obtained statements from the nurses who were assigned to resident #1 on the weekend of [DATE], and their accounted reports conflicted with each other. She recalled her conversation with the Weekend Supervisor revealed she was not aware that her responsibilities included chart checks and to ensure orders, assessments, and nursing processes were completed. The DON conveyed she was very concerned the nurses including the Weekend Supervisor had not intervened and ensured resident #1's physician's orders for immediate care were fully processed and implemented. She acknowledged several nurses had not recognized the clinical impact and risk for resident #1's worsening health conditions, nor acted on discrepancies and contacted the physician. She said the resident should have received her medications, and nurses should have followed the process and monitored her for changes in condition or symptoms of complications because, she could have become septic. During a telephone interview on [DATE] at 10:08 AM, resident #1's son recalled on [DATE], he traveled from out of state to visit his mother and he thought she was still in the hospital. He explained he was upset no one from the facility called him to let him know she had returned to the facility on [DATE]. He said on [DATE] when he saw his mother, she did not have oxygen on. He recalled on [DATE] at about 10:30 AM, he had just returned home when the facility called him and informed him his mother died and they told him, We did all we could do. The (City) Fire Department Patient Care Report documented EMS personnel responded to a 911 call received from the facility on [DATE] at 10:01 AM and arrived at resident #1's bedside at 10:08 AM where they assessed her. The report read, Patient Dead at Scene-No Resuscitation Attempted (Without Transport) . skin cold . arrived on scene, Pt (patient) contact made, Adult ALS (Advanced Life Support) medical assessment completed, Rigor noted to the pts (patient's) jaw. On [DATE] at 11:04 AM, the Nursing Home Administrator (NHA) explained on [DATE], the facility investigated resident #1's death in the facility and determined licensed nurses had not provided care and services. He explained regulatory non-compliance was reviewed with their Quality Assurance Performance Improvement (QAPI) program. He noted the last Ad-Hoc QAPI meeting was held on [DATE] when a nursing concern was addressed. He said the facility determined no willful intent occurred and the incident did not meet criteria for an adverse report of possible neglect. On [DATE] at 11:10 AM, the [NAME] President of Clinical Services said they determined resident #1's incident was, more of a nursing issue with compliance for poor nursing care. During a telephone interview with the Medical Director on [DATE] at 12:45 PM, he said he was unaware that resident #1 had not received any medications for 3 days after she was admitted from the hospital and died . He recalled in the evening after he left the faciity on [DATE], the facility contacted him by phone and informed him that a technical issue caused missed medication administrations for a newly admitted resident. He stated the facility assured him they implemented a training plan, and he told them they needed to make sure it had not happened to any other resident. He said he was very concerned and expected to be contacted promptly for significant identified concerns, especially clinical ones. He explained there were processes in place and omissions of physician's admission orders was, a very scary thought, and stated, that's a big problem. Review of the facility's Standards and Guidelines titled, Policies and Procedures: Abuse, Neglect, Exploitation, Mistreatment, Misappropriation of Property and Injury of Unknown Source Prevention (ANEMMI) revised on [DATE] revealed Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 2. Review of the medical record revealed resident #6, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted from the hospital on [DATE] with diagnoses of cellulitis (tissue infection) of the left lower limb, chronic left foot ulcers (wounds), pressure ulcers to the right hip and coccyx (tailbone), Human Immunodeficiency Virus (chronic viral blood infection), Syphilis (chronic infection), chronic embolism and thrombosis (blood clot), thyroid disorder, depression, and cognitive impairment. On [DATE], a newly acquired diagnosis of osteomyelitis (bone infection) was added. Review of the MDS Admission assessment with ARD of [DATE] noted the resident scored 13 out of 15 on the BIMS that indicated he was cognitively intact. The assessment noted he had not shown any behaviors or rejections of evaluation or care. The assessment showed he required moderate assistance from staff to complete ADL's, he did not walk, was dependent on staff assistance for mobility, transfers in and out of bed, and used a wheelchair. He was always incontinent of bladder and bowel functions, and had frequent pain that interfered with his day to day activities. He had one stage 3, one stage 4, and 2 unstageable pressure ulcers, intravenous (IV) central line access, and he received antidepressant, anticoagulant, antibiotic, and opioid medications with identified potentially clinically significant medication issues during the look back period. The Comprehensive Care Plan included focus for ADL care with staff assistance, fall risks, cellulitis infection with an intervention to administer physician ordered medications, four pressure ulcers with interventions that nurses monitored for complications and provided ordered treatments, a metabolic condition that required medication, risk for infection complications with an intervention that ordered antibiotic medications would be administered, malnutrition due to infection, risk of intravenous access complications with interventions that site care and infusions were provided and monitored by nurses for patency and complications The hospital's Physician Discharge Orders and Instruction noted Medication Instructions included Tylenol 650 MG as needed for pain, medications with the next dose administration due on [DATE] for Atorvastatin (cholesterol lowering) 20 MG once daily at bedtime, Losartan (for high blood pressure) 50 MG twice daily, Atenolol (blood pressure) 50 MG twice daily, Heparin (blood thinner) 5000 units by injection every 12 hours, the next dose administration on [DATE] for Levothyroxine (thyroid stabilizing) 25 micrograms (MCG) once daily, Sertraline (antidepressant) 50 MG once daily, Levaquin (antibiotic) 750 MG once daily, Bactrim (antibiotic) ,d+[DATE] MG once daily, and Ertapenem (antibiotic) 1 gram (GM) IV infusion once daily. Additional Physician Instructions were noted and indicated the resident required aggressive wound care with IV and oral antibiotic medications per the Infectious Disease physician, and the resident had an IV access catheter in place that required continued monitoring and care. The Order Summary report showed on [DATE], physician's medication orders were entered that included Tylenol 325 MG every 6 hours as needed for pain, Atorvastatin 20 MG at bedtime for high cholesterol, Levothyroxine 25 MCG once daily for thyroid, Sertraline 50 MG once daily for depression, Losartan 50 MG twice daily for blood pressure, Atenolol 50 MG twice daily for blood pressure, Bactrim ,d+[DATE] MG once daily for chronic infection, Levaquin 750 MG once daily for wound infection, Heparin 5000 units injected once daily for blood thinner, and Ertapenem Sodium IV infusion 1 GM once daily for wound infection until [DATE]. The report showed physician's orders for nurses' care and monitoring of resident #6's right basilic vein IV access catheter was ordered [DATE], three days after he returned from the hospital. Orders for care and treatment of one stage 4, one stage 3, and two unstageable pressure ulcers that were present when the resident returned to the facility on [DATE] were not entered until [DATE], four days after he returned from the hospital. Review of the [DATE] MAR showed from [DATE] to [DATE], the resident missed seven out of nine Heparin doses, two out of four doses of Sertraline, Atenolol, Losartan, Bactrim, and Levaquin, and four out of four doses of Ertapenem IV infusions. The report noted the resident's IV catheter access care and monitoring orders started on [DATE] that indicated nurses had not monitored and maintained the IV for three days. A Wound Care APRN progress note dated [DATE] documented the resident was assessed and treated for pressure ulcers that were present when he was admitted located on his coccyx, right hip, and two ulcers on his left foot. Review of the [DATE] TAR showed pressure ulcer wound care and treatments had not started until [DATE], four days after the resident returned from the hospital. On [DATE] at 2:15 PM, resident #6 was observed in his room lying in bed covered by a blanket with his eyes closed. Inactive IV equipment was positioned at noted to the left side of his bed. The (Pharmacy provider) Proof of Delivery Shipment Summary showed on [DATE] at 5:24 PM, the facility received medications for resident #6 that included Losartan, Bactrim, and Levaquin. The Shipment Summary dated [DATE] at 7:06 AM, showed the facility received the residents Heparin injectable medication. The Shipment Summary dated [DATE] at 5:51 PM indicated the facility received the residents IV Ertapenem medication and administration supplies, four days after the resident returned to the facility from the hospital. Review of the facility's automated dispensary machine showed a history report that noted one dose of oral Bactrim was removed on [DATE] for resident #6. The inventory reports showed the dispensary contained the IV medication Ertapenem, that resident #6 should have received, however it had not been dispensed. On [DATE] at 1:03 PM, during a telephone interview, the pharmacy provider's Pharmacy Technician checked their records and said they received orders for resident #6's IV medication on [DATE]. She said their IV face sheet record indicated the pharmacy made more than 5 attempts to contact the facility for further information required to dispense the medication, but the facility had not responded. On [DATE] at 11:45 AM, the DON said the pharmacy usually filled medication orders within hours and delivered twice daily. She said nurses were expected to notify the physician if medication doses were not administered for any reason and that included pharmacy delivery problems. On [DATE] at 2:45 PM, LPN B recalled she worked the 7:00 AM to 3:00 PM shift on Monday [DATE], and her assignment included resident #6. She said the resident's IV antibiotic medication had not arrived from the pharmacy and she was not able to administer it. She explained it was possible the pharmacy required lab results. She noted the pharmacy often had additional information requirements before they dispensed IV antibiotics for example, height, weight, and/or laboratory results. She said she reported the IV medication was not administered to the oncoming nurse. She did not explain why she did not contact the physician to report the omissions. On [DATE] at 2:59 PM, the DON acknowledged pharmacy shipment summaries showed resident #6's Heparin was not delivered until [DATE], and the IV Ertapenem was not delivered until [DATE]. She acknowledged the hospital discharge medication orders indicated Heparin was due [DATE], and the oral and IV antibiotics were due [DATE]. She checked the resident's MAR and confirmed there were multiple missed doses of medications. She could not explain why so many nurses failed to act on the discrepancies nor contact the doctor and stated she needed to look into the matter further. She explained the facility's automated dispensary was used for pharmacy delays, and it contained most antibiotics including IV Ertapenem, but the facility did not keep the required equipment on hand to infuse the IV antibiotic. Review of a Nursing Progress Note dated [DATE] at 9:06 AM, read, resident #6, (called) 911 himself, stating he must go to the hospital due to the unbearable pain in legs and feet. Rating at ,d+[DATE] (10 out of 10), because the Tylenol 2 Tab 650 mg administered was not effective. 911 responded and called for (transportation provider) to transport. Patient went out via (transportation provider) for further evaluation and treatment. Additional Progress Notes showed on the same day at 3:15 PM, the resident had returned from the emergency room , and narcotic pain reliever medication was added to his treatment. On [DATE] at 4:33 PM, the DON explained she contacted the pharmacy provider and learned on [DATE], LPN J responded to a fax request from the pharmacy for resident #6's lab results. She said that was the reason for the pharmacy's delay and when the lab results were received, the IV medication was dispensed and delivered on [DATE]. She could not explain why the resident's other medications were delayed. In an interview on [DATE] at 11:41 AM, the Infectious Disease APRN explained he expected a prompt continuance of any antibiotics ordered with hospital discharges, and those from an Infectious Disease physician were considered more critical. He said he treated resident #6 at the facility and he was familiar with him. He was not aware the resident had missed multiple doses of antibiotics, especially IV infusions. He indicated the missed doses could have led to worsening of his infection and sepsis. He relayed he was concerned as nurses had not contacted him about the omissions and stated he would have likely extended the stop date to ensure the resident received the entire treatment course. Review of the Order Summary Report showed on [DATE], physician's medication orders for the antibiotic medication Ertapenem 1 GM by IV infusion once daily were revised to treat a newly added diagnosis of osteomyelitis and the treatment course required 18 additional doses. During a telephone interview on [DATE] at 12:45 PM, the Medical Director conveyed he was unaware and even more concerned that additionally, resident #6 missed multiple medications including four days of IV antibiotic[TRUNCATED]