Every finding on record at Avir at Athens

Based on observation, interviews and record review, the facility failed to ensure residents were free from physical abuse for 1 of 8 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from physical abuse when CNA B slapped Resident #1's arm during patient care on 5/10/26.This failure could place residents at risk for physical abuse, mental abuse, emotional abuse, and harm.Findings included:Record review of an undated Face sheet printed on 5/30/26 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] with diagnoses including dementia without behavioral disturbance (a clinical presentation where a person experiences progressive decline in cognitive functions (like memory, thinking, or language) that interferes with daily life, but without accompanying psychiatric or behavioral symptoms such as aggression, severe agitation, or delusions), chronic kidney disease (the progressive loss of kidney function over time, impairing the organ's ability to filter waste and excess fluid from your blood) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.)Record review of Resident #1's undated care plan indicated the following:Focus: The resident is/has potential to be physically aggressive due to poor impulse control. Intervention: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later.Focus: The resident is resistive to care due to impaired cognition and poor impulse control. Resident has refused oral care, oxygen, pericare, assistance with ADLs, overall care with well-being. Interventions: -If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. - Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible - Praise the resident when behavior is appropriate.Record review of quarterly MDS dated [DATE] indicated Resident #1 responded adequately to simple, direct communications only and his ability was limited to making concrete requests with a BIMS score of 2 which indicated he had severely impaired cognition and was not able to answer questions. He required extensive assistance in performing most ADLs. He was incontinent of bowel and incontinent of bladder. Resident #1 had no physical, verbal or other behavioral symptoms directed towards others.Record review of Resident #1's incident report dated 5/10/26 completed by the DON indicated the incident happened in Resident #1's room. Nursing Description: [CNA C] reported that during shift change rounds that [CNA B] hit [Resident #1's] hand when he grabbed [CNA B] Incident was reported to DON on 5/12/26 and Abuse coordinator, the Administrator. Report was filed with HHSC #1089798. We [facility] also reported incident to [Resident #1's family member] by phone and with local Police department. Office [name of police office] responded to call and stated, after speaking with his supervisor stated that no report would be filed and there were no criminal charges. He stated he would log the call and we [facility] should handle the issue internally. Resident Description: Unable to respond to questions; Immediate Action Taken: [CNA B], was suspended and left the building. [Resident #1] was interviewed and was unable to answer questions due to [stroke]. He [did] have a history of hitting staff. [CNA B's] other residents assigned to her care were interviewed and no one had any concerns about their treatment of care.Record review of Resident #1's Progress notes indicated the following: -On 05/12/26 at 8:13am; completed by DON: Met with [Resident #1] at bedside to evaluate his mental state. [Resident #1] is mostly non- verbal but occasionally will say yes/ no or thank you when offered a drink. [Resident #1] will grab at staff when they attempt to turn him or move any of his extremities but is easily refocused once they stop moving him . -On 05/13/26 at 12:21pm; completed by DON: Meeting held with [CNA B] [Administrator] DON, and HR to discuss incident. [CNA B] admits to swatting residents' hand away after he violently grabbed her arm. [CNA B] admits to being unaware that this was abuse and agrees to not ever do this again. She [CNA B] is permitted to return to work, and DON will continue to follow her closely. Record review of written statement dated 5/12/26 completed by CNA C indicated the following: On May 10th after 6pm I [CNA C] was doing the exchange with [CNA B]. As we got to [Resident #1], [CNA B] hit [Resident #1] hard on his arm. [Resident #1] did not touch [CNA B]. After [CNA B] hit [Resident #1] she proceeded to yell at [Resident #1]. I [CNA C] stepped away and told [LVN D]. [LVN D] told me that the DON would reach out to me [CNA C], and DON [had] not. [LVN D] said [DON] forgot to address the issue. I [CNA C] was unaware I [CNA C] didn't report this correctly.Record review of written statement dated 5/12/26 completed by CNA B indicated the following: During an interaction with patient [Resident #1], he struck my arm violently (it should be noted that this was the second such instance, as a report has already been filed). In response- much as one would do with a child, I [CNA B] tapped his [Resident #1] hand gently, telling him not to do it again. He [Resident #1] suffered no harm. I [CNA B] do not consider my conduct towards [Resident #1] to have been abusive, as I [CNA B] am committed to providing [Resident #1] with all the care to which he is entitled to.Record review of CNA Bs suspension employee counseling form dated 5/12/26, completed by the ADON indicated Details of Situation: [CNA B] to be suspended pending abuse allegation of a resident.Record review of CNA B written employee counseling form dated 5/13/26, completed by the Administrator indicated Details of Situation: Investigation Interview and resolution/ determination of inconclusive/guiltExpected outcome: [CNA B] was interviewed and questioned by [Administrator] DON and HR Regional Consultant. Determination - No intent to harm, reflective move to avoid second time from being slapped by [Resident #1]. Comment: Unsubstantiated allegation of Abuse, Reinstatement Authorized and payment due for one shift 5/12/26.Record review of the provider investigation report dated 5/15/26 indicated the facility reported an allegation of abuse involving Resident #1 and CNA B to HHSC on 5/12/26 at 7:25am. Further review indicated the alleged incident occurred on 5/10/26 at approximately 6:00pm.Record review of facility's typed investigation summary dated 5/15/26 completed by [Administrator] abuse/neglect coordinator revealed On Sunday evening, May 10, 2026, at approximately 6:00pm, [CNA B] and [CNA C] were tending to the needs of [Resident #1] in his room. During the care, [Resident #1] reached up to grab [CNA B's] face, and [CNA B] batted [Resident #1's] hand away. [CNA C] said she reported the physical contact to her nurse [LVN D] however the information did not arrive to the abuse coordinator until Tuesday morning May 12, 2026, at 5:45am. Treatment Nurse, performed a head-to-toe assessment on May 12, 2026, at 7:00am and found no injuries.Regarding late reporting: Witness [CNA C] was counselled for not following proper abuse reporting procedure.During an observation and attempted interview on 5/31/26 at 4:55pm, Resident #1 was in DR waiting for the dinner meal. He was not able to answer what his name was or the day and date when the Administrator asked Resident #1. Resident #1 was clean, well-groomed with no unpleasant odor. There were no visible bruising, skin tears or marks to Resident #1's upper body area.During an interview on 05/30/26 at 6:45 p.m., CNA C stated she had been employed at the facility since 4/12/26 and worked the 6:00pm to 6:00am shift. CNA C stated that on 5/10/26 she witnessed CNA B strike Resident #1 on the arm after the resident raised his arm. CNA C stated Resident #1 had a history of physical aggression toward staff; however, at the time of the incident, Resident #1 had not physically acted toward CNA B. CNA C stated she exited the room and reported the allegation of abuse to LVN D. CNA C stated LVN D informed her that the DON had been notified via text message and showed CNA C the text message sent to the DON. CNA C stated that by 5/12/26 she had not been contacted by the DON regarding the allegation and subsequently notified LVN E of the incident. CNA C stated LVN E then sent a group text message notifying the Administrator and DON of the allegation involving CNA B and Resident #1. CNA C stated she later received disciplinary action for failing to notify the abuse coordinator. CNA C stated she was a new employee and was unaware of the facility's abuse reporting procedure, including the requirement to notify the abuse coordinator/Administrator directly.During an attempted interview on 5/31/2026 at 3:27pm, LVN D was called but she did not answer, and it went to voice mail, and a message was left to return the call related to the investigation. During an interview on 05/31/26 at 5:04 p.m., The DON stated she first became aware of the alleged abuse incident involving Resident #1 on 05/12/26 after LVN E sent a group text message to the DON and abuse coordinator reporting that CNA C had witnessed CNA B physically abuse Resident #1 on 05/10/26 and had previously reported the allegation to another staff member. During an interview on 05/31/26 at 5:55 p.m., the Administrator said he was the abuse coordinator and followed their abuse policy, did criminal history checks upon hire, did in-services with his staff and reported everything to the state. The Administrator said CNA B was written up due to the incident.During an attempted interview on 6/09/26 at 3:57pm, CNA B was called; however, there was no answer and the phone number did not have a voicemail option available.Record review of an undated abuse/ reportable events policy indicated the following: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms .

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the Administrator of the facility for 1 of 8 (Resident #1) residents reviewed for abuse. The facility failed to ensure CNA C and LVN D immediately reported an allegation of staff-to-resident abuse on 5/10/26 when CNA B slapped Resident #1's arm to the facility Administrator This failure could place residents at risk of injuries, abuse, and/or neglect.Findings included: Record review of an undated Face sheet printed on 5/30/26 indicated Resident #1 was a [AGE] year-old male who admitted on [DATE] with diagnoses including dementia without behavioral disturbance (a clinical presentation where a person experiences progressive decline in cognitive functions (like memory, thinking, or language) that interferes with daily life, but without accompanying psychiatric or behavioral symptoms such as aggression, severe agitation, or delusions), chronic kidney disease (the progressive loss of kidney function over time, impairing the organ's ability to filter waste and excess fluid from your blood) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs, causing shortness of breath.) Record review of Resident #1's undated care plan indicated the following:Focus: The resident is/has potential to be physically aggressive due to poor impulse control. Intervention: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Focus: The resident is resistive to care due to impaired cognition and poor impulse control. Resident has refused oral care, oxygen, pericare, assistance with ADLs, overall care with well-being. Interventions: -If resident resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. - Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible - Praise the resident when behavior is appropriate. Record review of quarterly MDS dated [DATE] indicated Resident #1 responded adequately to simple, direct communications only and his ability was limited to making concrete requests with a BIMS score of 2 which indicated he had severely impaired cognition and was not able to answer questions. He required extensive assistance in performing most ADLs. He was incontinent of bowel and incontinent of bladder. Resident #1 had no physical, verbal or other behavioral symptoms directed towards others. Record review of Resident #1's incident report dated 5/10/26 completed by the DON indicated the incident happened in Resident #1's room. Nursing Description: [CNA C] reported that during shift change rounds that [CNA B] hit [Resident #1's] hand when he grabbed [CNA B] Incident was reported to DON on 5/12/26 and Abuse coordinator, the Administrator. Report was filed with HHSC #1089798. We [facility] also reported incident to [Resident #1's family member] by phone and with local Police department. Office [name of police office] responded to call and stated, after speaking with his supervisor stated that no report would be filed and there were no criminal charges. He stated he would log the call and we [facility] should handle the issue internally. Resident Description: Unable to respond to questions; Immediate Action Taken: [CNA B], was suspended and left the building. [Resident #1] was interviewed and was unable to answer questions due to [stroke]. He [did] have a history of hitting staff.[CNA B's] other residents assigned to her care were interviewed and no one had any concerns about their treatment of care. Record review of Resident #1's Progress notes dated 05/12/26 indicated the following:- at 7:20am; Completed by DON: LATE ENTRY - [Administrator], abuse coordinator contacted and self-reported incident to HHSC, report number 1089798. -at 8:13am; completed by DON: Met with [Resident #1] at bedside to evaluate his mental state. [Resident #1] is mostly non- verbal but occasionally will say yes/ no or thank you when offered a drink. [Resident #1] will grab at staff when they attempt to turn him or move any of his extremities but is easily refocused once they stop moving him. Record review of written statement dated 5/12/26 completed by CNA C indicated the following: On May 10th after 6pm I [CNA C] was doing the exchange with [CNA B]. As we got to [Resident #1], [CNA B] hit [Resident #1] hard on his arm. [Resident #1] did not touch [CNA B]. After [CNA B] hit [Resident #1] she proceeded to yell at [Resident #1]. I [CNA C] stepped away and told [LVN D]. [LVN D] told me that the DON would reach out to me [CNA C], and DON [had] not. [LVN D] said [DON] forgot to address the issue. I [CNA C] was unaware I [CNA C] didn't report this correctly. Record review of CNA C's verbal employee counseling form dated 5/12/26, completed by the ADON indicated Details of Situation: [CNA C] did not report abuse allegation to the administrator at the time of incident. Expected outcome: Any and All abuse allegation are to be reported straight to the admin. Record review of the provider investigation report dated 5/15/26 indicated the facility reported an allegation of abuse involving Resident #1 and CNA B to HHSC on 5/12/26 at 7:25am. Further review indicated the alleged incident occurred on 5/10/26 at approximately 6:00pm. Record review of facility's typed investigation summary dated 5/15/26 completed by [Administrator] abuse/neglect coordinator revealed On Sunday evening, May 10, 2026, at approximately 6:00pm, [CNA B] and [CNA C] were tending to the needs of [Resident #1] in his room. During the care, [Resident #1] reached up to grab [CNA B's] face, and [CNA B] batted [Resident #1's] hand away. [CNA C] said she reported the physical contact to her nurse [LVN D] however the information did not arrive to the abuse coordinator until Tuesday morning May 12, 2026, at 5:45am. Treatment Nurse, performed a head-to-toe assessment on May 12, 2026, at 7:00am and found no injuries.Regarding late reporting: Witness [CNA C] was counselled for not following proper abuse reporting procedure. During an observation and attempted interview on 5/31/26 at 4:55pm, Resident #1 was in DR waiting for the dinner meal. He was not able to answer what his name was or the day and date when the Administrator asked Resident #1. Resident #1 was clean, well-groomed with no unpleasant odor. There were no visible bruising, skin tears or marks to Resident #1's upper body area. During an interview on 05/30/26 at 6:45 p.m., CNA C stated she had been employed at the facility since 4/12/26 and worked the 6:00pm to 6:00am shift. CNA C stated that on 5/10/26 she witnessed CNA B strike Resident #1 on the arm after the resident raised his arm. CNA C stated Resident #1 had a history of physical aggression toward staff; however, at the time of the incident, Resident #1 had not physically acted toward CNA B. CNA C stated she exited the room and reported the allegation of abuse to LVN D. CNA C stated LVN D informed her that the DON had been notified via text message and showed CNA C the text message sent to the DON. CNA C stated that by 5/12/26 she had not been contacted by the DON regarding the allegation and subsequently notified LVN E of the incident. CNA C stated LVN E then sent a group text message notifying the Administrator and DON of the allegation involving CNA B and Resident #1. CNA C stated she later received disciplinary action for failing to notify the abuse coordinator. CNA C stated she was a new employee and was unaware of the facility's abuse reporting procedure, including the requirement to notify the abuse coordinator/Administrator directly. During an attempted interview on 5/31/2026 at 3:27pm, LVN D was called but she did not answer, and it went to voice mail, and a message was left to return the call related to the investigation. During an attempted interview on 5/31/26 at 3:50pm, CNA B was called; however, there was no answer and the phone number did not have a voicemail option available. During an interview on 05/31/26 at 5:04 p.m., the DON stated she never received a text message from LVN D regarding the alleged abuse incident on 05/10/26. The DON stated she later discovered LVN D did not have the correct contact number for her. The DON stated she first became aware of the alleged abuse incident involving Resident #1 on 05/12/26 after LVN E sent a group text message to the DON and abuse coordinator reporting that CNA C had witnessed CNA B physically abuse Resident #1 on 05/10/26 and had previously reported the allegation to another staff member. The DON stated both CNA C and LVN D should have notified the abuse coordinator directly and expected staff to immediately report all allegations of abuse and neglect to the abuse coordinator. The DON stated LVN D was a newly hired nurse and that 05/10/26 was LVN D's first solo shift as charge nurse. The DON stated it was possible LVN D was unaware she was required to contact the abuse coordinator directly rather than only notifying the DON. The DON stated LVN D no longer worked at the facility and had worked only a few shifts following the 05/10/26 incident prior to resigning. During an interview on 05/31/26 at 5:55 p.m., the Administrator stated he served as the facility's Abuse Coordinator and was responsible for ensuring compliance with the facility's abuse policy and State reporting requirements. The Administrator stated the facility became aware of an allegation of potential staff-to-resident abuse involving CNA B and Resident #1 on 05/10/26 at approximately 6:00 p.m.; however, he was not notified of the allegation until the morning of 05/12/26. The Administrator stated the allegation was reported to the State agency upon his notification. The Administrator stated staff was expected to immediately report allegations of abuse to the Abuse Coordinator. The Administrator said the facility failed to report the allegation to the State agency within the required timeframe after the allegation became known to the facility, due to CNA C not following the facility's reporting procedures. The Administrator further stated CNA C received disciplinary action for failure to timely report the allegation to facility administration. During an attempted interview on 6/09/26 at 3:57pm, CNA B was called; however, there was no answer and the phone number did not have a voicemail option available. Record review of an undated abuse/ reportable events policy indicated the following: .Reporting: Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC.If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

Based on record reviews and interviews, the facility failed to notify the representative immediately of a significant change in condition and transfer to the hospital for 1 of 5 residents reviewed for notification requirements. The facility failed to notify Resident #1's representative on (1/21/2026) when there was a change in the resident's condition requiring the resident to be sent to the local hospital. This failure could place residents at risk of not having family members or representatives notified of changes in condition and allowing them to participate in care decisions. Resident #1 was a [AGE] year-old female born 11/26/1954 and admitted on [DATE]. According to a face sheet dated 3/10/2026, she had a diagnosis including cerebral infarction due to embolism of left middle cerebral, type 2 diabetes mellitus, primary hypertension, congestive heart, failure chronic kidney disease stage 3, aphasia (nonfluent slow speech with difficulty producing language) following cerebrovascular disease. According to a Minimum Data Set (MDS) dated [DATE], and with a Brief Interview for Mental Status (BIM's) score of (00) which indicated she could not complete the BIM's questionnaire. Review of the nursing noted date 1/21/2026 at 7:45a.m., Indicated a therapist reported to LVN B, Resident #1 was minimally responsive and breathing abnormally. LVN B reported the resident was hyperventilating, not verbally responsive, but made eye contact when spoken to. Vital signs were obtained; manual blood pressure could not be obtained, pulse was 100, respirations 24, temperature 97.7*F, blood glucose 371, and oxygen saturation 91% room air. The resident was diaphoretic and cold to the touch. Provider made aware of changes in condition and order received to send to ER. Resident left facility in stable condition at approximately 08:00a.m. accompanied by EMS. Review of the medical record showed no documented evidence that the resident's representative or family was notified of the change in condition. A review of Resident#1 hospital discharge summary showed an admission date of 1/21/2026 with chief complaints of altered mental status and an admission diagnosis of acute lower urinary tract infection. The discharge note indicated that the resident's representative attributed the hospitalization to the prior nursing facility, but the hospital physician clarified that the resident had pneumonia and a urinary tract infection on admission to the ER. And further documented the resident had been in the facility for approximately eight hours, and the hospitalization was not caused by care provided at the facility. During an interview on 3/10/2026 at 10:30 a.m., the resident's representative stated Resident #1 was admitted to the facility on [DATE] at approximately 5:00 p.m . The representative reported he and another family member visited the resident from approximately 5:00 p.m. to 6:00 p.m. on the day of admission. Resident #1's representative stated the other family member returned to the facility 1/21/2026 approximately 6:30 a.m. to bring breakfast for Resident #1. The representative reported that he was notified by the other family member that Resident #1 was not in her bed, and at that time staff informed the family member of the change in condition, and Resident #1 had been transferred to the local hospital emergency room. Resident's #1's representative stated the facility did not notify him prior to the transfer and he was not informed of any changes in the resident's condition or incident involving the resident that required transfer to a local hospital emergency room. Resident #1s representative stated he expected to be notified by the facility staff if there was a change in the resident's condition or if an incident occurred. Durning an interview on 03/10/2026 at 2:44 p.m., CNA A stated on 1/21/2026 at approximately 6 a.m. she arrived at the unit and observed Resident # 1's bathroom light on and the resident not in bed. CNA A stated she went into the bathroom and found Resident #1 seated on the commode leaning backward. CNA A stated Resident #1 was able to communicate, but the resident was unable to state how she got to the bathroom. CNA A stated she attempted to assist the resident to stand with one-person assistance, but the resident staggered backward, and she returned the resident to a seated position on the commode for safety. CNA A stated she called for additional assistance, and LVN B responded to the room. CNA A stated staff obtained a wheelchair and assisted Resident #1 back to bed. Durning an interview on 03/10/20226 at 2:54 p.m., LVN B stated on 1/21/2026 at approximately 7:45 a.m., a therapist reported Resident #1 was minimally responsive and breathing abnormally. LVN B stated the resident was hyperventilating, not verbally responsive, but made eye contact when spoken to. He stated the vital signs were obtained; manual blood pressure could not be obtained, pulse was 100, respirations 24, temperature 97.7*F, blood glucose 371, and oxygen saturation 91% room air. He said the resident was diaphoretic and cold to the touch. LVN B stated the physician was notified of the change in condition, and orders were received to transfer the resident to the emergency room. He said the resident left the facility at approximately 8:00 a.m. with EMS. LVN B stated that at the time of Resident #1's emergency, another resident also required urgent attention. LVN B stated he left to assist the other resident with immediate care needs. LVN B stated the Admin. was present at the time of the incident and he believed the Admin. was notifying the resident's representative, but he could not confirm whether the representative was notified and stated he could not verify notification as it was not documented in the medical record. During an interview on 3/10/2026 at 3:30 p.m., the ADON stated the facility policy requires staff to notify the resident's physician and resident representative when there is a significant change in the resident's condition and to document the notification in the medical record. The ADON stated she could not confirm that Resident #1's representative was notified of the change of condition and transfer, as no documentation of notification was found in the medical record. Durning an interview on 3/10/2026 at 3:45 p.m., RNC stated facility policy requires notification of the resident's representative for significant changes in condition, with documentation in the medical record. He stated the resident's representative may not have been notified and stated he would review the policy with staff to ensure timely notification and proper documentation. The RNC stated that the current Admin. was unavailable due to approved absence. A record review on 3/10/2026 at 4:00 p.m. of the facility Policy Change in a Resident's Condition or Status dated 2001, Revised February 2021 and April 2025: Policy Statement; the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/ mental condition and/or status (e. g. changes in level of care, billing/payments, resident rights, etc.).

Based on observations, interviews, and record review, the facility failed to ensure medications were available and administered for 1 of 6 residents (Resident #87) reviewed for medication administration. The facility failed to ensure that Resident #87's medications Clonazepam (a benzodiazepine medication that produces a calming effect, reducing anxiety) and Hydrocodone-Acetaminophen (an opioid medication that relieves pain) were available for 6 consecutive days following admission. This failure could place residents at an increased risk of and exacerbation of underlying medical conditions, avoidable discomfort, and a decline in physical or psychosocial well-being. A record review of an undated face sheet indicated Resident #87 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of encephalopathy (a group of conditions that cause brain dysfunction, leading to altered mental states and various neurological symptoms), hypothyroidism (a condition in which the thyroid gland does not produce enough hormones), hyperlipidemia (a condition of high cholesterol or fats in the blood), depression, Parkinsonism (a brain condition that causes slowed movements, rigidity, and tremors), and acute kidney failure. A record review of Resident #87's active medications included Acetaminophen Oral Tablet 325 MG, 2 tablets by mouth every 4 hours as needed; Clonazepam Oral Tablet 0.5 (a benzodiazepine medication that produces a calming effect, reducing anxiety), 1 tablet by mouth 2 times a day; Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (an opioid medication that relieves pain), 1 tablet by mouth 4 times a day; and Meloxicam Oral Tablet 15 MG (a nonsteroidal anti-inflammatory drug that helps relieve pain, inflammation, and stiffness), 1 tablet by mouth 1 time a day. A record review of Resident #87's medication administration record indicated that Resident #87 did not receive Clonazepam Oral Tablet 0.5 MG ranging from 02/13/2026 through 02/17/2026, resulting in a total of 9 missed doses. A record review of Resident #87's medication administration record indicated that Resident #87 did not receive Hydrocodone-Acetaminophen Oral Tablet 10-325 MG ranging from 02/13/2026 through 02/18/2026, resulting in a total of 19 missed doses. During an observation on 02/17/2026 at 1:26 PM, Resident #87 was observed listening to music in the living room area. Resident #87 smiled when she was spoken to, had her hair braided, and did not exhibit any facial grimacing to indicate that she was experiencing pain. During an interview and observation on 02/18/2026 at 9:17 AM, Resident #87 was observed sitting in a wheelchair in her room. Resident #87 appeared comfortable and did not exhibit any facial grimacing to indicate that she was experiencing pain. Resident #87 indicated that she felt some anxiety and pain, but indicated that it did not prevent her from participating in activities of daily living including eating, speaking, or participating in activities. During an interview on 02/18/2026 at 9:20 AM, LVN B indicated that Resident #87 had not received her ordered Clonazepam or Hydrocodone-Acetaminophen. LVN B indicated that she had gone to obtain these medications from the facility's automated medication dispensing machine on 02/16/2026 but was unable to as these medications required a triplicate prescription form from Resident #87's physician. LVN B indicated that she did not receive the notification that these medications were unavailable until after she had left for the day on 02/16/2026. LVN B indicated that she notified Resident #87's physician on 02/17/2026 at 9:50 AM that these medications required his authorization. During an interview on 02/18/2026 at 9:42 AM, MA D indicated that when a resident does not have their medications available on the medication cart she reports this information to the charge nurse who contacts the pharmacy or physician. MA D indicated she was aware Resident #87 did not receive her scheduled orders of Clonazepam and Hydrocodone-Acetaminophen on 02/15/2026 and that she notified the charge nurse at that time. During an interview on 02/18/2026 at 10:11 AM, LVN C indicated that he was working on 02/14/2026 assisting with medication administration. LVN C indicated that the facility did not have all of Resident #87's medications and that they were waiting on Resident #87's physician to send the triplicate prescription form to the pharmacy. LVN C indicated that he was told by the ADON that Resident #87's NP was aware of the issue. LVN C indicated that he should have contacted the NP or pharmacy to verify the triplicate prescription form was completed. LVN C indicated that the risk to Resident #87 of not being provided with these medications could include unmanaged pain control and resident safety. During an interview on 02/18/2026 at 10:25 AM, the ADON indicated she had been unaware that Resident #87 was not receiving her scheduled Clonazepam and Hydrocodone-Acetaminophen until 02/16/2026. The ADON indicated that she believed this medication was not provided to Resident #87 due to miscommunication between staff. The ADON indicated that despite the NP being contacted on 02/17/2026, Resident #87 was still not receiving these medications. The ADON indicated that she was ultimately responsible for ensuring that Resident #87 received her medications. The ADON indicated that the risk to Resident #87 for not receiving these medications could be a decline in her overall well-being. During a phone interview on 02/18/2026 at 11:05 AM, the NP indicated he sent the triplicate prescription form to the pharmacy on the afternoon of 02/17/2026. The NP indicated that he was notified of Resident #87 not receiving her Clonazepam and Hydrocodone-Acetaminophen on 02/15/2026 by LVN A and on 02/17/2026 by LVN B. The NP indicated that he needed further information on these medications from Resident #87's previous physicians and did not obtain this until 02/17/2026. The NP indicated that the risk to Resident #87 for not receiving these medications could be withdrawals if Resident #87 had been on them for a long time. During a phone interview on 02/18/2026 at 11:21 AM with a family member of Resident #87 indicated that Resident #87 had been taking medications for pain for at least the last 5 years. During a phone interview on 02/18/2026 at 1:43 PM, LVN E indicated she had worked on 02/15/2026 and that a staff member reported to her that Resident #87 did not have the medications Clonazepam and Hydrocodone-Acetaminophen. LVN E indicated that she sent a message to the NP on 02/15/2026 at 1:14 PM. During an interview on 02/18/2026 at 2:20 PM, the ADM indicated that the believed Resident #87 did not receive her medications of Clonazepam and Hydrocodone-Acetaminophen due to miscommunication between the admitting hospital, the facility, and the physician's office, though the nursing facility was ultimately responsible for ensuring Resident #87's medications were received. The ADM indicated that the risk to Resident #87 for not receiving these medications could be anxiety that could affect not only Resident #87 but other residents. A record review of 24 Hour Report/Change of Condition report from dates ranging 02/14/2026 to 02/18/2026 indicated Resident #87 was not experiencing any pain or discomfort. A record review of Resident #87's skilled nursing assessments on dates 02/13/2026 through 02/18/2026 did not indicate that Resident #87 was experiencing any pain. A record review of the facility's policy dated November 2014, updated February 2025 titled Physician Orders indicated the following: 11. admission orders - the licensed nurse will verify admission or readmission order with the physician or physician extender for all residents admitting or readmitting. A record review of the facility's policy dated July 2022 titled Psychotropic Medication Use indicated the following: 9. Use of psychotropic medications may be considered appropriate in specific circumstances, as specified in F605. These include: . c. new admissions where the resident is already on a psychotropic medication. Resident EvaluationsSituations which may prompt an evaluation or re-evaluation of the resident include:admission or re-admission

Based on observation, interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for 3 of 5 residents (Residents #53, #59, #73) reviewed for medical records accuracy. The facility failed to ensure Resident #53's physician's orders included an order for oxygen use. The facility failed to ensure Resident #59's physician's orders included an order for a foley catheter. The facility failed to ensure resident #73's physician's orders included orders for diet and dialysis treatments. These failures could place residents at risk for errors in care and treatment. Findings included: 1.Record review of a face sheet dated 02/18/2026 indicated Resident #53 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included tracheostomy status (opening in the neck into the windpipe to facilitate breathing, traumatic hemorrhage of the cerebrum (the rupture of blood vessels within the brain due to head trauma), heart failure, post cardiac arrest, and gastrostomy status (tube inserted through an opening in the abdomen into the stomach for provision of liquid nutrition). Record review of a 5-day MDS assessment dated [DATE] noted Resident #53 had a BIMS score of 3, indicating his cognition was severely compromised. Further review of the MDS indicated Resident #53 had a tracheostomy and was receiving continuous oxygen. Record review of Resident #53's physician's orders dated 02/17/2026 indicated he did not have an order for oxygen therapy. During observations made on 02/16/2026 at 10:32 AM, on 02/17/2026 at 09:50 AM, and on 02/18/2026 at 10:00 AM, Resident #53 was noted receiving oxygen AT 3.5 LPM via a mask placed over his tracheostomy. During an interview on 02/18/2026 at 10:25 AM, RN F said Resident #53 had a physician's order for him to receive oxygen via his tracheostomy at 2-4 LPM to maintain his oxygen saturation at greater than 90%. When RN was unable to locate a physician's order for oxygen therapy, she said the nurses had been verbalizing Resident #53's oxygen use during change of shift report and she thought there was an order for it. RN F said it was important to have an order for oxygen therapy to ensure the rate of oxygen administration was at a rate beneficial to the resident. 2.Record review of a face sheet dated 02/18/2026 indicated Resident #59 was a [AGE] year-old female who initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] after a stay in the hospital. She had diagnoses on re-admission which included bullous pemphigoid (a rare, autoimmune, chronic skin disorder causing large, tense, itchy, fluid-filled blisters), chronic kidney disease, and Parkinson's disease. Record review of a significant change MDS dated [DATE] noted Resident #59 had a BIMS score of 9 indicating her cognition was moderately impaired. Record review of a significant change MDS dated [DATE] indicated Resident #59 had a foley catheter. Record review of Resident #59's physician's orders 02/17/2026 indicated she did not have an order for a foley catheter. During observations made on 02/16/2026 at 10:17 AM and on 02/17/2026 at 12:15 AM, Resident #59 was noted to have a foley catheter in place and draining urine to a closed collection bag suspended from her wheelchair. During an interview on 02/17/2026 at 01:05 PM, RN F said Resident #59 had a foley catheter due to skin issues on her buttocks. She said Resident #59 should have an order for the foley catheter in her chart to ensure she received the care needed for it. 3. Record review of a face sheet dated 02/18/2026 indicated Resident #73 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included diabetes and end-stage kidney disease requiring renal dialysis. Record review of an incomplete admission MDS indicated Resident #73 had a BIMS score of 15 indicating his cognition was intact. Record review of the Baseline Care Plan Indicated Resident #73 was on a renal diet and required dialysis treatments. Record review of Resident #73's physician's orders indicated he did not have an order for dialysis. Further review of the physician's orders indicated Resident #73 did not have a diet. During an interview on 02/16/2026 at 10:14 AM, Resident #73 said he went to the dialysis center three times a week on Tuesdays, Thursdays, and Saturdays. He said the facility provided transportation to and from the center. He said he had been receiving his meals in his room and said the food was good. During an interview on 02/18/2026 at 02:10 PM, RN F said Resident #73 was taken to the dialysis center on Tuesdays, Thursdays, and Saturdays. She said she could not find an order for dialysis nor a diet in the physician's orders. RN F said the DON usually transcribed the physician orders from the hospital to the facility's computer system during regular business hours and the charge nurses did it after hours. She said she was not sure who checked the orders to ensure the accuracy of transcribed orders. During an interview on 02/18/2026 at 02:55 PM, the ADON said the DON usually reviewed the admission orders from the hospital to ensure the accuracy of the facility's transcribed orders. She said the DON quit the previous Friday. The ADON said the accuracy of the physician's orders was important for ensuring the residents receive needed care and treatment. She said was responsible for ensuring the accuracy of the physician's orders since the DON left. During an interview on 02/18/2026 at 03:15 PM, the Administrator said he expected the physician's orders of all the residents to accurately reflect the residents' care and treatment needs. He said the DON and ADON were both responsible for ensuring the physician's orders were accurately transcribed on admission to the facility. A record review of the facility's policy updated February 2025 and titled Physician's Orders indicated the following: PurposeThe purpose of this procedure is to establish uniform guidelines in the receiving and recording of physician orders to ensure the resident receives the necessary care and services.Supervision by a Physician 3. A current list of orders must be maintained in the electronic record of each resident. 5. Physician orders are essential for the comprehensive care of the residents. These orders encompass various aspects, including .medication and treatment regimen, . dietary plans . and any other orders as needed. Recording Orders 3. Oxygen Orders - When recording orders for oxygen, specify the rate of flow, route, and rationale. 6. Treatment Orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment. 8. Foley Catheter b. Specify the size and diagnosis/indication (i.e. Catheter Size (18French), catheter type, and indication:c. Catheter care- specify what is to be done or according to facility procedure. 11. admission orders- the licensed nurse will verify admission or readmission order with the physician or physician extender for all residents admitting or re-admitting.

Based on interviews and record review, the facility failed to develop and implement baseline care plan within 48 hours of admission that includes the instructions needed to provide effective and person-centered care for 1 of 6 residents (Resident #87) reviewed for care plans. The facility failed to ensure that Resident #87 had a completed baseline care plan within 48 hours of admission. This failure could place residents at an increased risk of decline in physical or functional well-being, of not receiving necessary care or services, and of having personalized plans developed/implemented to address their needs. The findings included: A record review of an undated face sheet indicated Resident #87 was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of encephalopathy (a group of conditions that cause brain dysfunction, leading to altered mental states and various neurological symptoms), hypothyroidism (a condition in which the thyroid gland does not produce enough hormones), hyperlipidemia (a condition of high cholesterol or fats in the blood), depression, Parkinsonism (a brain condition that causes slowed movements, rigidity, and tremors), and acute kidney failure. A record review on 02/17/2026 at 11:31 AM of Resident #87's baseline care plan indicated an undated, incomplete, and unsigned care plan. Completed information on Resident #87's baseline care plan included her identification information, modes of communication, vision and hearing, daily preferences, and advance directive. Resident #87's care plan did not include initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, or any PASARR recommendations. During an interview on 02/18/2026 at 10:33 AM, the ADON confirmed baseline care plans were to be completed within 48 hours. The ADON indicated that usually the DON or MDS coordinator initiates the baseline care plan and the admitting nurse inputs the information required. The ADON indicated that she was unsure if Resident #87 had a completed baseline care plan. During an interview on 02/18/2026 at 10:41 AM, the MDS coordinator indicated that a registered nurse initiates the baseline care plan and the DON would ensure that it was completed and sign it. The MDS coordinator stated that she initiated Resident #87's baseline care plan and that typically the interdisciplinary team would complete it, then the DON would sign it as completed. The MDS coordinator denied that there was any one person that was ultimately responsible for ensuring that the baseline care plan was completed. The MDS coordinator indicated that the baseline care plan provides staff with an overall idea of what a resident's goals and outcomes could be, but denied that completing the baseline care plan would affect their overall health and well-being. During an interview on 02/18/2026 at 2:30 PM, the ADM indicated that the DON usually completes resident's baseline care plans. The ADM indicated that in the case of Resident #87, there was no DON on staff at the time of her admission. The ADM indicated that each member of the interdisciplinary team was responsible for completing their assigned sections of the baseline care plan. The ADM indicated that the MDS coordinator should have signed off on Resident #87's baseline care plan and ensured that it was completed. The ADM indicated that the risk to residents not having a complete baseline care plan would include no guide or direction to their care that would come from the baseline care plan. During an interview on 02/18/2026 at 2:35 PM, LVN A indicated she was the admitting nurse for Resident #87. LVN A indicated that when she completes her nursing assessment on admission that information is put into the baseline care plan. LVN A admitted that she was not sure if she completed her section of the baseline care plan and was unaware of the time frame in which it is to be completed. LVN A indicated that typically the DON or MDS coordinator are assigned to ensure the baseline care plan was completed and stated that the DON was no longer employed at the facility. LVN A indicated that the MDS coordinator was responsible for making sure the baseline care plan was completed. A record review of the facility's policy dated March 2022 titled Care Plans - Baseline indicated the following: Policy StatementA baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and ImplementationThe baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:Initial goals based on admission orders and discussion with the resident/representative;Physician orders;Dietary orders;Therapy services; Social services; and PASARR recommendation, if applicable.

Based on interview and record review the facility failed to ensure accurate MDS assessments were completed for 6 of 9 residents (Residents #1, #2, #17, #50, #60, and #65) reviewed for accuracy of MDS assessments. The facility failed to ensure Residents #1, #2, #17, #50, #60, and #65's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #1's face sheet for December 2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included traumatic brain injury, anxiety, psychosis, schizophrenia and depressive disorder. A review of Resident #1's PASRR Level 1 screening done 11/07/2022 indicated she was positive for MI/ID/DD. A review of Resident #1's PASRR Evaluation done 11/08/2022 indicated she was negative for ID and negative for DD. The resident was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #1's annual MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety disorder, depression, and schizophrenia. 2. A review of Resident #2's face sheet for December 2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included cerebral palsy, depressive episodes, bipolar disorder, schizophrenia and anxiety disorder. A review of Resident #2's PASRR Level 1 screening done 08/17/2024 indicated she was positive for MI/ID/DD. A review of Resident #2's PASRR Evaluation done 09/17/2024 indicated she was positive for ID and positive for DD. The resident was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #2's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Neurological indicated the resident had cerebral palsy and under Psychiatric/Mood Disorder indicated the resident had anxiety disorder, depression, bipolar disorder and schizophrenia. 3. A review of Resident #17's face sheet for December 2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included bipolar disorder. A review of Resident #17's PASRR Level 1 screening done 11/03/2022 indicated she was positive for mental illness. A review of Resident #17's PASRR Evaluation done 12/06/2022 indicated she was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #17's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had bipolar disorder. 4. A review of Resident #50's face sheet for December 2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included anxiety disorder, mild intellectual disabilities, and bipolar disorder with psychotic features. A review of Resident #50's PASRR Level 1 screening done 09/08/2023 indicated he was positive for ID. A review of Resident #50's PASRR Evaluation done 09/22/2023 indicated he was positive for ID and positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #50's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety disorder and bipolar disorder and other active diagnoses he had mild intellectual disabilities. 5. A review of Resident #60's face sheet for December 2024 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included psychotic disorder with delusions, major depressive disorder, and other symbolic dysfunctions. A review of Resident #60's PASRR Level 1 screening done 03/27/2023 indicated he was negative for MI/ID/ID. A second PASRR Level 1 screening dated 04/03/2023 indicated he had a primary diagnosis of dementia and was considered negative for mental illness for specialized services. A review of Resident #60's PASRR Evaluation done 09/26/2023 indicated he had a primary diagnosis of dementia and was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #60's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had depression and psychotic disorder. 6. A review of Resident #65's face sheet December 2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, major depressive disorder, psychotic disorder with delusions, and anxiety disorder. A review of Resident #65's PASRR Level 1 screening done 11/03/2022 indicated she had a primary diagnosis of dementia and was considered negative for mental illness for specialized services. A PASRR Evaluation was not done because she had a primary diagnosis of dementia and would not qualify for specialized services. A review of Resident #65's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had anxiety disorder, depression and psychotic disorder. During an interview on 12/04/2024 at 10:05 AM, the Regional Reimbursement Consultant said she was in the process of training the recently hired MDS Coordinator. She said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said she had been auditing some of the residents MDS files and noted some residents' coding was incorrect and she was submitting changes to the MDS to CMS. She said Section A 1500 indicated if the resident was positive for mental illness, intellectual disability or developmental disability. She said she did not realize the Section I Active Diagnoses was related to Section A PASRR screening documentation. She said the local authority had found residents that did not qualify for PASRR services because they did not meet the PASRR definition for mental illness for specialized services. She said she did not know Section A had to be coded as positive for mental illness, intellectual disability or developmental disability even though they did not qualify for PASRR services. During an interview on 12/04/2024 at 1:35 PM the administrator said the facility did not have a specific policy regarding maintaining accuracy of MDS assessments. He said the RAI manual was used to ascertain accuracy. 37495 47204 47723

Based on observation, interviews and record reviews, the facility failed to notify the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications) for 1 of 4 residents (Resident #54) reviewed for change in condition. LVN B failed to notify the physician when she did not administer Resident #54's scheduled insulin dose due to low blood sugar level. This failure could place residents at risk for non-therapeutic effects of the medication and decline in health status. Findings included: A record review of Resident #54's face sheet indicated she was a [AGE] year-old female who admitted to the facility on [DATE]. She had multiple diagnoses which included diabetes mellitus, dysphagia (difficulty swallowing) following a stroke, gastrostomy status (refers to the presence of a surgical opening into the stomach that allows for nutritional support), and cerebral infarction (stroke) with hemiplegia and hemiparesis (conditions that cause weakness or paralysis) of both sides of the body. A record review of the quarterly MDS dated [DATE] noted Resident #54 had a BIMS of 2 indicating her cognition was severely impaired and was dependent on staff for all activities of daily living. The same MDS indicated Resident #54 had a diagnosis of diabetes and received insulin injections. A record review of Resident #54's physician orders dated 12/03/2024 indicated Resident #54 had orders for routine (medications taken at the same time each day at the same time and by the same route) and sliding scale injections of insulin (amount of insulin given based on the patient's blood sugar level). The physician's order dated 06/26/2024 indicated Resident #54 was to routinely receive 5 units of Humalog insulin by subcutaneous injection 3 (three) times a day at 08:00 AM, 01:00PM, and 05:00 PM. The order did not require Resident #54's blood sugar to be checked prior to administering the insulin nor parameters for withholding the insulin. During observation and interview on 12/03/2024 at 01:00 PM, LVN B was observed to use a glucometer to check Resident #54's blood sugar. LVN B said Resident #54's sugar level was 71. LVN B said the insulin was not to be given if the if Resident #54's blood sugar was less than 100. During an interview on 12/03/2024 at 01:45 PM, LVN B said the order to administer 5 units of Humalog insulin did not require Resident #54's blood sugar to be checked prior to administering the insulin. She said the order did not include instructions for holding (not giving) insulin. She said the nurses just knew to check blood sugar levels before administering insulin and to not administer insulin if any resident's blood sugar was below 100. During an interview on 12/04/2024 at 10:05 AM, LVN B said she did not notify the physician of holding Resident #54's insulin. LVN B said she did not call the doctor to request an order for glucometer checks prior to insulin administration and to request parameters for holding insulin. LVN B said she did not know why the routine insulin was withheld on the 2 days Resident #54's blood sugar was 150 and 103. A record review of Resident #54's insulin administration record dated 12/01/2024-12/03/2024 indicated Resident #54's blood sugar levels were checked 9 times prior to administering the routinely scheduled insulin using a glucometer. The blood sugar levels were noted to be less than 100 (one hundred) for 4 (four) of the 9 (nine) glucometer checks. The insulin administration record indicated the 5 units Humalog insulin were withheld (not given) at those times. The insulin administration record indicated the routine doses of insulin were held 2 (two) of the 9 (nine) times when the blood sugar levels were greater than 100. There was no indication of the physician being notified of the 6 (six) withheld insulin doses nor the glucometer levels on 12/01/24 08:00 AM BS 150, 12/01/24 01:00 PM - BS 93, 12/01/24 05:00 PM - BS 103, 12/02/24 05:00 PM BS - 79, 12/03/24 13:00 PM - BS 71, and 12/03/24 05:00 PM BS - 91). During an interview on 12/04/2024 at 02:00 PM, the DON said if a nurse decides to hold an insulin dose per nursing judgement based on the blood sugar level without having pre-established parameters, the physician or nurse practitioner should be notified as soon as possible. She said Resident #54 had an order for sliding scale insulin (a prescription that adjusts the amount of insulin a person receives based on their blood sugar level) 4 times a day plus the order for 5 units of regularly scheduled insulin 3 times a day. The DON said the physician should have been notified of the withheld insulin doses. The DON said the physician should also have been consulted about the 2 (two) separate orders for insulin administration resulting in 7 finger sticks a day to check blood sugar levels. The DON said she spoke with the Nurse Practitioner and Resident #54's order for the routinely scheduled insulin (5 units Humalog 3 times a day) was placed on hold until the physician was consulted. The DON said the routine order for insulin would probably be discontinued since Resident #54 had an order for sliding scale insulin administration 4 times a day. The DON said Resident #54 was at risk for a lower-than-normal blood sugar level and a decline in status. The DON said the facility did not have a policy specific to insulin. A review of the facility's policy dated 12/2018 and titled Change of Condition - Observing, Reporting, and Recording indicated the following: Policy: It is the policy of this home to inform the resident, the resident's physician, and if indicated the resident's responsible party of the following: 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications. 4. A need to alter treatment significantly.

Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3(Resident #22) reviewed for pharmacy services. MA C failed to administer a correct dose of a scheduled medication, lactulose solution (to treat constipation and liver disease) to Resident #22 as ordered by the physician. This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications which could result in diminished health and well-being. Findings included: A record review of Resident #22's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included stroke, slow transit constipation (condition where the large intestine moves waste too slowly, leading to constipation and other issues), and chronic hepatic failure (liver is permanently damaged and can no longer function properly). A record review of the quarterly MDS dated [DATE] indicated Resident #22 had a BIMS of 3 indicating his cognition was severely impaired. A record review of the physician orders dated 12/03/2024 indicated an order for Resident #22 to be given lactulose solution; 10 gram/15 ml; Amount to Administer: 30 ml oral - 4 Times A Day for the treatment of chronic liver failure. During observation of medication administration on 12/03/2024 at 09:25 AM, MA C was noted to pour 20 ml of lactulose from a bottle labeled lactulose 20 gm/30 ml. MA C said she poured 20 ml of the solution. MA C gave Resident #22 his meds including the 20 ml of the lactulose 10 gm/15 ml solution. After Resident #22 had taken his medications MA C returned to the cart, documented the medications administered, and said she was finished. During an interview on 12/03/2024 at 10:30, MA C said she gave the correct dose of lactulose solution. MA C pointed to the 20gm portion of the order and said the order said to give 20 ml. After discussing the variance in the order as written on the MAR (lactulose 10mg/15ml give 30 ccl) and the label on the bottle that read lactulose 20mg/30cc give 30 cc, MA C said she did not understand the error. During an interview on 12/03/2024 at 10:45 AM, the DON said MA C misunderstood the order. DON said the concentration of lactulose on the physician's order should match the pharmacy label on the lactulose container (bottle). She said MA C misinterpreted the 20gm to mean 20cc. The DON said understanding liquid concentrations (ratios of medication amount to liquid amount) was important to ensuring the correct doses of medication are given. She said she would re-train MA C on liquid medications and add additional administration instructions for the lactulose order to the MAR's Special Instructions section. A record review of the facility's policy dated 12/20/2018 and titled Medication Administration: indicated the following: Policy: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. 13. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.

Based on observation, record review and interview the facility failed to ensure a resident had the right to be free from abuse for 1 of 7 residents reviewed for abuse (Resident #1). LVN E and CNA D witnessed CNA C abusing Resident #1. CNA C hit Resident #1 and was allowed to remain in the facility for over three hours with access to Resident #1 and other Residents. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began. The facility failures could have caused residents serious physical injury. Findings Included: Record review of Resident #1's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. She had a diagnosis of Alzheimer's disease (progressive disease that destroys memory), and unsteadiness on feet. Record review of Resident #1's Quarterly MDS dated [DATE] indicated she was severely cognitively impaired with a BIMS score of 5. The MDS did not indicate any mood or behavior issues. The resident required substantial to maximum assist with all ADLS except eating, and oral hygiene. Record review of Resident #1's care plan indicated a problem start date of 1/7/22 of frequent incontinence of bowel and bladder. An approach was to provide peri care after each incontinent episode. The plan indicated a problem of ADL Self Care Performance Deficit. Some of the approaches were the resident required maximum assist for bathing, supervised assist for bed mobility, and one person assist for toileting. The plan indicated a problem of Cognitive loss due to dementia. One of the approaches was to provide the resident with necessary cues, stop, and return if the resident was agitated. Record review a Provider Investigation Report indicated an incident occurred on 4/19/24 at 3:30 a.m. The report indicated LVN E and CNA D witnessed CNA C hit Resident #1 in the stomach area. The nurse heard Resident #1 screaming and yelling in her room. The nurse went to assess the resident in her room. When the nurse opened the door, CNA C was changing Resident #1. The resident was grabbing the blankets and yelling to get CNA C away from her and for CNA C to leave her alone. CNA C was seen balling up her fist on her right hand and to hit Resident #1 on her right side in the rib area. The nurse immediately yelled what are you doing? You cannot do that. CNA C stated, I'm tired of her pinching The investigation indicated Resident #1 was assessed by LVN E on 4/19/24 at 3:45 a.m. with no visible injuries noted and no complaints of pain. CNA C was suspended pending investigation 4/19/24 at 6:30 a.m. The resident received another head-to-toe assessment on 4/19/24 at 10:00 a.m. with no injuries noted from this morning's incident. The family, the physician and the police department were notified. LVN E and CNA D were given one on one education on 4/19 by the DON regarding the importance of reporting allegations of abuse immediately. LVN E and CNA D were issued a three-day suspension on 4/19/2024 for failing to report allegations of abuse immediately. CNA C was terminated due to abuse allegation on 4/19/24 being confirmed. All interview able residents were interviewed by the administrator and social worker regarding abuse on 4/19/24. All non-resident received head to toe assessment, to assess for any injuries or evidence of abuse, by Nurses on 4/19/24. The direct care staff were interviewed on 4/19/24 by the administrator and DON regarding abuse and reporting requirements. The Abuse/Reportable Event policy was reviewed on 4/19/24 at 11:00 a.m. by the Administrator, Regional Director of Operations, Regional Nurse, and DON no changes made to the policy at this time. The DON provided education to all staff regarding abuse/reportable events policy, including types of abuse, and reporting requirements all staff present in the facility were educated on 4/19/24. Staff that were not present for education would receive the education prior to their next shift. The social services, Director or design would continue to interview and assess Resident #1 for emotional distress. During an observation and interview on 11/25/24 at 3:10 p.m. Resident #1 was sitting in a wheelchair by the nursing station. She said she was fine; she said she was still breathing. The rest of her conversation was about her childhood. She was unable to answer any questions about the incident. Attempts were made to contact CNA C, but phone numbers for her appeared to be disconnected. During an interview on 11/26/24 at 11:40 a.m. the Administrator said after the incident with Resident #1 he did interviews with all staff available at that time. He said he was notified on 4/19/24 around 6:00 a.m. of the abuse. He said CNA C had already left, and he talked to CNA C on the phone. He said at first, CNA C denied the incident. He said he told her he had two witnesses, she seemed frustrated, and did not say much. He said she just asked if she was terminated. He said they had implemented corrective actions such as terminating CNA C immediately, calling the police, the physician and updated Resident #1's care plan. He said they monitored Resident #1 for three days after the incident from 4/19/24 through 4/22/24, and they completed safe surveys with Resident #1 on each shift to make sure she did not have any reoccurring memories of the event. He said CNA C went home that morning and she never came back. The Administrator said he received statements from LVN E and CNA D, they did specific in services with LVN E and CNA D. He said they conducted safe surveys with the residents and follow up interviews with any concerns voiced by residents and there no concerns with abuse. The Administrator said they conducted skin assessments on all the residents. He said they also talked to staff about burn out and he conducted regular training on abuse, at least once a month. During a telephone interview on 11/26/24 at 10:38 a.m. CNA D said Resident #1 had never hit or scratched her. She said the incident happened on the 10 to 6 a.m. shift on 4/19/24. CNA D said it could have been the way the aide approached Resident #1 in the middle of the night to make her resistive to care. She said Resident #1 was clutching the covers and saying, Stop leave me alone. She said she did not see Resident #1 trying to strike CNA C. CNA D said she was sitting in the lounge and LVN E was sitting at the nursing station. She said they kept hearing through the door a resident grunting and saying, no and stop can D said at first, they did not know which room the noise was coming from, there were two rooms right by the nurse's station. She said they thought someone had fallen. She said she had gotten up to follow the nurse. When LVN E opened Resident #1's, she opened the door abruptly. CNA D said as the door opened CNA C had her forearm up with her fist balled up and hit Resident #1 in the stomach area. CNA D said she could see CNA C and Resident #1 quite well. She said all CNA C said was I am tired of her hitting and scratching me. CNA D said LVN E told her she could not do that and to leave the room. CNA D said CNA C walked out of the room. She said Resident #1 was saying to get CNA C out of her room and she appeared upset at the time, but later she was back to her old self. CNA D said it appeared Resident #1 had forgotten the incident. She said she was in shock because had worked with CNA C a long time and had not expected that type of behavior from her. During a telephone interview on 11/26/24 at 2:24 p.m. LVN E said she was sitting at the nursing station and heard a resident saying stop. She said she kept hearing words, grunting, and wanted to know where the noise was coming from. She said she and CNA D opened Resident # 1's and saw CNA C appeared to have just changed Resident #1. LVN E said Resident #1 was holding tight to the covers. She said CNA C was standing facing the door, over Resident #1 and the bed. She said CNA C was yakking on the covers, bulled up her fist, and punched Resident #1 in her side area. LVN E said she told the aide she could not do that, and to leave the room. She said CNA C left the room. LVN E said she assessed Resident #1 after the incident. She said she had two or three blankets on her, and there was no redness or busies. She said Resident #1 said she did not want CNA C in her room and for CNA C to leave her alone. She said she had gone back later, and Resident #1 was asleep. She said she and CNA D had gone in later to provide care to Resident #1 on the last round of the night and she appeared fine. The LVN said she knew to protect Resident #1 and get the aide away from the Resident #1. LVN E said she and CNA D were both in disbelief at the actions of CNA C. LVN E said CNA C disappeared for about 30 minutes. She finished working that night, but she was not allowed to go back into Resident #1's room. The LVN said she had never had anything like that happen before and her concern was protecting Resident #1. LVN E said she did not report the incident until the end of her shift. She said she was written up and in serviced on abuse and reporting. She said the next time she would notify they Administrator and everybody. Record review of the facility policy on Abuse/Reportable Events (not dated) indicated all residents have the right to be fee from abuse. Resident should not be subjected to abuse by anyone. The facility will provide and ensure the promotion and protection of resident's rights. Abuse is the willful infliction of injury. Willful individual must have intended to inflict injury or harm. Physical abuse includes hitting, slapping, pinching, and kicking. The facility took the following actions to correct the noncompliance on 4/19/24. Record review of Resident #1's care plan indicated a problem with a start date of 4/19/24 of psychosocial wellbeing, the resident was a victim of abuse related to an inappropriate interaction by staff. Some of the approaches were the resident received a full head to toe skin assessment. She would have emotional distress monitoring every shift for 72 hours. Record review of Resident #1's skin assessment dated [DATE] indicated no new areas. Review of Safe Surveys indicated a questionnaire was completed on Resident #1 each shift from 4/19/24 through 4/22/24 with no concerns noted. Record review of one-hour checks indicated they were completed on Resident #1 every hour with her vital signs from 4/19/24 through 4/22/24. Record review of Abuse pre and posttest and Abuse/Reporting in service was completed on 4/19/24 by more than 70 staff to include all departments and agency staff. The in service included the Resident Rights Policy, Abuse/Reporting Events policy the Abuse Coordinator information and to report immediately. Record review of CNA C's Employee Timecard indicated her last date of employment was 4/19/24 and she clocked out on 4/19/24 at 6:06 a.m. Record review of CNA C's employee training indicated she received abuse training on 5/2/23 prior to the incident on 4/19/24. Record review of CNA C's employee file indicated she received a disciplinary action of discharge form employment and to be banned from the property dated 4/19/24. The employee was discharged due to resident abuse or neglect or directly related to the safety and wellbeing of a resident. Record review of LVN E's employee training indicated LVN E received abuse training on 5/5/23 prior to the incident on 4/19/24. Record review of LVN E's employee file indicated LVN E received a disciplinary action with unpaid suspension on 4/19/24. Due to failure to promptly report to the immediate supervisor on the job injury or accident involving an employee. The employee did not report witnessed resident abuse immediately instead reported 3 hours after the incident. Record review of CNA D's employee training indicated she received abuse training on 4/17/23 prior to the incident on 4/19/24. Record review of CNA D's employee file indicated CNA D received a disciplinary action with unpaid suspension on 4/19/24. Due to failure to promptly report to the immediate supervisor on the job injury or accident involving an employee. The employee did not report witnessed resident abuse immediately instead reported 3 hours after the incident. During an interview on 11/26/24 at 8:49 a.m. CNA F said she had worked at the facility for [AGE] years. She said she had heard CNA C had hit Resident #1, but she had not seen the incident. CNA F said she was shocked because she and CNA F had worked at the facility together for about the same amount of time. CNA F said Resident #1 would holler out occasionally, but she was not resistive to care. CNA F said she was in serviced on abuse regularly. She said she had not seen or heard any abuse and if she did, she would report to the administrator immediately. During an interview on 11/26/24 at 9:08 a.m. CNA G said she had worked at the facility for a little over a year. She said Resident #1 was a sweet and confused. She said she did not holler out. CNA G said Resident #1 would sometimes be resistive to getting up in the morning but if you give her a little while she was fine. She said she was aware of the multiple types of abuse. She said if she saw or heard abuse, she would report it immediately to the administrator. During an interview on 11/26/24 at 9:30 a.m. CNA I said she did aid Resident #1. She said Resident #1 did not holler out. She said Resident #1 could be stubborn especially in the morning when she did not want to get up. She said she was familiar with what abuse was and if she saw or head abuse, she would report it to the administrator immediately. During an interview on 11/26/24 at 9:41 a.m. CNA J said she was aware of what abuse was and if she saw or heard any abuse she would report to the Administrator immediately. She said Resident #1 did not holler out and was not resistive to care. During an interview on 11/26/24 at 9:50 a.m. LVN K said Resident #1 did not holler out and she was not resistive to care. LVN K said she had never known Resident #1 to hit. LVN K said the only way Resident #1 would strike was if they were forcing her to do something she did not want to do. During an interview on 11/26/24 at 1:20 p.m. LVN L said she worked at the facility for two weeks. She said she received training on abuse and neglect. She said if she saw or heard abouts she would report immediately to the administrator. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the alleagtion involve abuse or result in serious bodily injury, to the Administrator of the facility and to other officials in accordance with State law for 1 of 7 residents reviewed for abuse (Resident #1.) LVN E and CNA D did not immediately report abuse to the Administrator after they witnessed CNA C abusing Resident #1. CNA C hit Resident #1 and was allowed to remain in the facility for over three hours with access to Resident #1 and other Residents. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began. This failure could have caused continued abuse to Resident #1 and possibly other residents. Findings included: Record review of Resident #1's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. She had a diagnosis of Alzheimer's disease (progressive disease that destroys memory), and unsteadiness on feet. Record review of Resident #1's Quarterly MDS dated [DATE] indicated she was severely cognitively impaired with a BIMS score of 5. The MDS did not indicate any mood or behavior issues. The resident required substantial to maximum assist with all ADLS except eating, and oral hygiene. Record review of Resident #1's care plan indicated a problem start date of 1/7/22 of frequent incontinence of bowel and bladder. An approach was to provide peri care after each incontinent episode. The plan indicated a problem of ADL Self Care Performance Deficit. Some of the approaches were the resident required maximum assist for bathing, supervised assist for bed mobility, and one person assist for toileting. The plan indicated a problem of Cognitive loss due to dementia. One of the approaches was to provide the resident with necessary cues, stop, and return if the resident was agitated. Record review a Provider Investigation Report indicated an incident occurred on 4/19/24 at 3:30 a.m. The report indicated LVN E and CNA D witnessed CNA C hit Resident #1 in the stomach area. The nurse heard Resident #1 screaming and yelling in her room. The nurse went to assess the resident in her room. When the nurse opened the door, CNA C was changing Resident #1. The resident was grabbing the blankets and yelling to get CNA C away from her and for CNA C to leave her alone. CNA C was seen balling up her fist on her right hand and hit Resident #1 on her right side in the rib area. The nurse immediately yelled what are you doing? You cannot do that. CNA C stated, I'm tired of her pinching The investigation indicated Resident #1 was assessed by LVN E on 4/19/24 at 3:45 a.m. with no visible injuries noted and no complaints of pain. CNA C was suspended pending investigation 4/19/24 at 6:30 a.m. The allegation of abuse was reported to HHSC on 4/19/24 at 8:33 a.m. The resident received another head-to-toe assessment on 4/19/24 at 10:00 a.m. with no injuries noted from this morning's incident. The family, the physician and the police department were notified. LVN E and CNA D were given one on one education on 4/19 by the DON regarding the importance of reporting allegations of abuse immediately. LVN E and CNA D were issued a three-day suspension on 4/19/2024 for failing to report allegations of abuse immediately. CNA C was terminated due to abuse allegation on 4/19/24 being confirmed. All interview able residents were interviewed by the administrator and social worker regarding abuse on 4/19/24. All non-resident received head to toe assessment, to assess for any injuries or evidence of abuse, by Nurses on 4/19/24. The direct care staff were interviewed on 4/19/24 by the administrator and DON regarding abuse and reporting requirements. The Abuse/Reportable Event policy was reviewed on 4/19/24 at 11:00 a.m. by the Administrator, Regional Director of Operations, Regional Nurse, and DON no changes made to the policy at this time. The DON provided education to all staff regarding abuse/reportable events policy, including types of abuse, and reporting requirements all staff present in the facility were educated on 4/19/24. Staff that were not present for education would receive the education prior to their next shift. The social services, Director or design would continue to interview and assess Resident #1 for emotional distress. During an interview on 11/26/24 11:40 a.m. the Administrator after the incident with Resident #1 he did interviews with all staff available at that time. The Administrator said he was notified about the incident on 4/19/24 around 6:00 a.m. He said CNA C had already left, and he talked to CNA C on the phone. He said at first, CNA C denied the incident. He said he told her he had two witnesses, she seemed frustrated, and did not say much. He said she just asked if she was terminated. He said LVN E or CNA D did not notify him that night, they informed him the first thing the next morning. He called the incident into the state at that time around 8:30 a.m. He said they had implemented corrective actions such as terminating CNA C immediately, calling the police, the physician and updated Resident #1's care plan. He said they monitored Resident #1 for three days after the incident from 4/19/24 through 4/22/24, and the completed safe surveys with Resident #1 on each shift to make sure she did not have any reoccurring memories of the event. He said CNA C went home that morning and she never came back. The Administrator said he wrote LVN E and CNA D up for not reporting the incident immediately. He said CNA C was allowed to remain in the building for over three hours before the incident was reported. The Administrator said he received statements from LVN E and CNA D, and they did specific in services with LVN E and CNA D. He said they conducted safe surveys with the residents and follow up interviews with any concerns voiced by residents and there no concerns with abuse. The Administrator said they conducted skin assessments on all the residents. He said they also talked to staff about burn out and he conducted regular training on abuse, at least once a month. During an observation and interview on 11/25/24 at 3:10 p.m. Resident #1 was sitting in a wheelchair by the nursing station. She said she was fine; she said she was still breathing. The rest of her conversation was about her childhood. She was unable to answer any questions about the incident. Attempts were made to contact CNA C, but phone numbers for her appeared to be disconnected. During a telephone interview on 11/26/24 at 10:38 a.m. CNA D said Resident #1 had never hit or scratched her. She said the incident happened on the 10 to 6 a.m. shift on 4/19/24. CNA D said it could have been the way the aide approached Resident #1 in the middle of the night to make her resistive to care. She said Resident #1 was clutching the covers and saying, Stop leave me alone. She said she did not see Resident #1 trying to strike CNA C. CNA D said she was sitting in the lounge and LVN E was sitting at the nursing station. She said they kept hearing through the door a resident grunting and saying, no and stop CNA said at first, they did not know which room the noise was coming from, there are two rooms right by the nurse's station. She said they thought someone had fallen. She said she had gotten up to follow the nurse. When LVN E Resident #1's door, she opened the door abruptly. CNA D said as the door opened CNA C had her forearm up with her fist balled up and hit Resident #1 in the stomach area. CNA D said she could see CNA C and Resident #1 quite well. She said all CNA C said was I am tired of her hitting and scratching me. CNA D said LVN E told her she could not do that and to leave the room. She said CNA C left the room. CNA D said CNA C left the room. She said Resident #1 was saying to get CNA C out of her room and she appeared upset at the time, but later she was back to her old self. CNA D said it appeared Resident #1 had forgotten the incident. She said she was a shock because had worked with CNA C a long time and had not expected that type of behavior from her. During a telephone interview on 11/26/24 at 2:24 p.m. LVN E said she was sitting at the nursing station and heard a resident saying stop. She said she kept hearing words, grunting, and wanted to know where the noise was coming from. She said she and CNA D opened Resident #1's door and saw CNA C appeared to have just changed Resident #1. LVN E said Resident #1 was holding tight to the covers. She said CNA C was standing facing the door, over Resident #1 and the bed. She said CNA C was yakking on the covers, bulled up her fist, and punched Resident #1 in her side area. LVN E said she told the aide she could not do that, and to leave the room. LVN E said she assessed Resident #1. She said she had two or three blankets on her, and there was no redness or busies. She said Resident #1 said she did not want CNA C in her room and for CNA C to leave her alone. LVN E said CNA C left the room. She said she was gone for about 30 minutes but did finish her shift. LVN E said she had gone back later, and Resident #1 was asleep. She said she and CNA D had gone in on the last round of the night to provide care to Resident #1 and she appeared fine. The LVN said she knew to protect the patient and get the aide away from the Resident #1. LVN E said she and CNA D were both in disbelief at the actions of CNA C. She said she had never had anything like that happen before, and had not sent CNA C home. She was only thinking of keeping Resident #1 safe and not allowing the aide back in her [NAME]. LVN E said she had reported the incident when the dayshift staff came in. She said she was suspended for three days for not reporting the incident immediately. The LVN said if anything like that happened, she would call everybody as soon as possible. LVN E said CNA C had already left by the time she had reported the incident. Record review of the facility policy on Abuse/Reportable Events with no dated indicated all residents have the right to be fee from abuse. Resident should not be subjected to abuse by anyone. The facility will provide and ensure the promotion and protection of resident's rights. Abuse is the willful infliction of injury. Willful individual must have intended to inflict injury or harm. Physical abuse includes hitting, slapping, pinching, and kicking. Facility employees must report all allegations of abuse. If the allegations involve abuse or result in serious bodily injury, the report is to be made within two hours of the allegation. The facility took the following actions to correct the noncompliance on 4/19/24. Record review of Resident #1's care plan indicated a problem with a start date of 4/19/24 of psychosocial wellbeing, the resident was a victim of abuse related to an inappropriate interaction by staff. Some of the approaches were the resident received a full head to toe skin assessment. She would have emotional distress monitoring every shift for 72 hours. Record review of Resident #1's skin assessment dated [DATE] indicated no new areas. Review of Safe Surveys indicated a questionnaire was completed on Resident #1 each shift from 4/19/24 through 4/22/24 with no concerns noted. Record review of one-hour checks indicated they were completed on Resident #1 every hour with her vital signs from 4/19/24 through 4/22/24. Record review of Abuse pre and posttest and Abuse/Reporting in service was completed on 4/19/24 by more than 70 staff to include all departments and agency staff. The in service included the Resident Rights Policy, Abuse/Reporting Events policy the Abuse Coordinator information and to report immediately. Record review of CNA C's Employee Timecard indicated her last date of employment was 4/19/24 and she clocked out on 4/19/24 at 6:06 a.m. Record review of CNA C employee training indicated she received abuse training on 5/2/23 prior to the incident on 4/19/24. Record review of CNA C employee file indicated she received a disciplinary action of discharge form employment and to be banned from the property dated 4/19/24. The employee was discharged due to resident abuse or neglect or directly related to the safety and wellbeing of a resident. Record review of LVN E's employee training indicated LVN E received abuse training on 5/5/23 prior to the incident on 4/19/24. Record review of LVN E's employee file indicated LVN E received a disciplinary action with unpaid suspension on 4/19/24. Due to failure to promptly report to the immediate supervisor on the job injury or accident involving an employee. The employee did not report witnessed resident abuse immediately instead reported 3 hours after the incident. Record review of CNA D's employee training indicated she received abuse training on 4/17/23 prior to the incident on 4/19/24. Record review of CNA D's employee file indicated CNA D received a disciplinary action with unpaid suspension on 4/19/24. Due to failure to promptly report to the immediate supervisor on the job injury or accident involving an employee. The employee did not report witnessed resident abuse immediately instead reported 3 hours after the incident. During an interview on 11/26/24 at 8:49 a.m. CNA F said she had worked at the facility for [AGE] years. She said she had heard CNA C had hit Resident #1, but she had not seen the incident. CNA F said she was shocked because she and CNA F had worked at the facility together for about the same amount of time. CNA F said Resident #1 would holler out occasionally, but she was not resistive to care. CNA F said she was in serviced on abuse regularly. She said she had not seen or heard any abuse and if she did, she would report to the administrator immediately. During an interview on 11/26/24 at 9:08 a.m. CNA G said she had worked at the facility for a little over a year. She said Resident #1 was a sweet and confused. She said she did not holler out. CNA G said Resident #1 would sometimes be resistive to getting up in the morning but if you give her a little while she is fine. She said she was aware of the multiple types of abuse. She said if she saw or heard abuse, she would report it immediately to the administrator. During an interview on 11/26/24 at 9:30 a.m. CNA I said she did aid Resident #1. She said Resident #1 did not holler out. She said Resident #1 could be stubborn especially in the morning when she did not want to get up. She said she was familiar with what abuse was and if she saw or head abuse, she would report it to the administrator immediately. During an interview on 11/26/24 at 9:41 a.m. CNA J said she was aware of what abuse was and if she saw or heard any abuse. She said she would report to the Administrator immediately. She said Resident #1 did not holler out and was not resistive to care. During an interview on 11/26/24 at 9:50 a.m. LVN K said Resident #1 did not holler out and she was not resistive to care. LVN K said she had never known Resident #1 to hit. LVN K said the only way Resident #1 would strike was if they were forcing her to do something she did not want to do. During an interview on 11/26/24 at 10:14 a.m. the DON said LVN E did immediately remove CNA C from Resident #1 and the LVN assessed the resident. The DON said LVN E did not call immediately, the incident occurred about 3:30 a.m. The DON said they were not informed until the end of the shift about 6:00 a. she said the LVN worked for agency and the aide no longer worked for the facility. During an interview on 11/26/24 at 1:20 p.m. LVN L said she worked at the facility for two weeks. She said she received training on abuse and neglect. She said if she saw or heard abouts she would report immediately to the administrator. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began.

Based on interview and record review the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 of 7 residents reviewed for accidents (Resident #2). CNA A failed to ensure two staff members provided a Hoyer lift transfer. A family member assisted with the transfer, the Hoyer lift sling strap was not attached properly, and Resident #2 fell out of the Hoyer lift. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 3/3/24 and ended 3/3/24. The facility had corrected the noncompliance before the survey began. This failure could have caused serious injury. Findings included: Record review of Resident #2's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were muscle weakness, obesity, and lack of coordination. Record review of Resident #2's admission MDS dated [DATE] indicated the resident had a BIMs score of 13 indicating she was cognitively intact. Her ADLs were listed as partial to moderate assist for transfers with the helper doing less than half the effort. Record review of Resident #2's care plan indicated a problem with a start date of 2/20/24. Resident #2 had limited ability to transfer herself related to morbid obesity and recent hospitalization . The goal was the resident would transfer with the use of a mechanical lift by staff and a transfer belt with therapy with an edited dated of 3/25/24. The resident had a problem with a start date of 2/20/24 with the category of falls, and an edited date of 3/5/24. The resident had the potential for injury related to falls due to a decline in medical condition, attempts to stand unassisted, impulsiveness, and recent hospitalization . Resident had an actual fall since admission. Some of the approaches were Resident #2 was to be transferred with a Hoyer lift by two staff for all transfers. Record review of Resident #2's physician orders dated 3/4/24 indicated an order for Tylenol 325 mg, two tablets every six hours as need or pain. Record review of a nursing note dated 3/3/24 at 10:58 a.m. indicated LVN B found Resident #2 on the floor in her room beside the bed. CNA A and Resident #2's family member was also in the room. CNA A was attempting to transfer Resident #2 from the bed to the shower chair with the mechanical lift when the resident fell . Resident #2 complained of a sharp pain in her neck and back at a pain scale of 10 out of 10(with 10 being the worst pain possible.) Resident #2 was assessed, and no abnormalities found. She had a small red area over her left eyebrow. Resident #2 did not complain of head pain. Resident #2 was assisted back to bed. Resident #2 wanted Tylenol and Tylenol was administered. Resident #2 did not want to go to the hospital. Resident #2 and the family member were educated on the benefits of going to the hospital for an evaluation and Resident #2 continued to refuse. The nurse practitioner gave orders for an immediate imaging of the head spine and neck. Resident #2 was checked for a pain level 10 minutes later and voiced her pain was a 7 out of 10. Resident #2's vital signs were within normal limits. Resident #2 was checked again for pain at 10:45 a.m. and said her pain was a 3 out of 10. Resident #2 continued to refuse to go to the hospital. Review of a radiology report dated 3/3/24 indicated Resident #2's x-ray of the skull, and three views of the spine were all negative. Record review of the facility Provider Investigation Report indicated on 3/3/24 at 8:50 a.m. CNA A was transferring Resident #2 from the bed to the wheelchair. The resident was transferred with a Hoyer lift, and her family member was in the room along with CNA A. During the transfer Resident #2 slipped out of the Hoyer sling and fell to the floor. Charge nurse LVN B inspected the Hoyer lift and discovered a strap was not completely in place and caused the resident to slip out. At the time of the incident Resident #2 said her neck and back hurts. The initial assessment indicated Resident #2 had range of motion in all 4 extremities within normal limits. LVN B tried to send Resident #2 to the hospital, but Resident #2 adamantly refused. The nurse practitioner was notified, and neuro checks were initiated. Resident #2 was alert and oriented and her own medical power of attorney. X rays were ordered in house, and they were negative for any fractures. The resident was provided as needed Tylenol for pain. All lifts and slings were checked for proper functioning with no issues noted. Education and disciplinary actions were given to CNA A. The investigation findings were confirmed. The facility took the following actions to correct the noncompliance on 3/3/24. Record review dated 3/3/24 indicated in- services were conducted on Hoyer transfers, Abuse /Reportable events, and Resident Rights. Mechanical lift competency check offs were also completed by staff. Record review an Employee Disciplinary Report dated 3/3/24 indicated CNA A received a written counseling and education training on the mechanical lift transfer safety with a skills competency check. A thirty-day probation, a one-day suspension. Record reviews indicated CNA A had a Certificate of [NAME] Completion on Fall Prevention competed 3/5/24 and Certificate of [NAME] Completion on Position and Transfer Techniques dated 3/5/24. Record review of In-Service Training report dated 3/3/24 indicated staff were in serviced on Abuse Reportable Events, Resident Rights and Mechanical Lift Transfer. Record review of Using a Mechanical Lifting Machine competency demonstration indicated they were conducted on 3/4/24. Record review of the facility Mechanical Lift policy with and effective August 2020. The policy stated it is the policy of this home to utilize the Hoyer or similar lift when it is necessary to safely transfer a resident due to body wight or physical condition. Lifting a resident with a mechanical lift is always a two-person procedure. One of the procedures indicated to check chains and hooks to make [NAME] they are properly positioned. Record review of a Discharge Summary indicated Resident #2 was discharged to home on 3/10/24. During an interview on 11/25/24 at 9:15 a.m. the Administrator said CNA A had been educated on not allowing family members to help her with transfers. He said she was educated on always having another staff member with her for Hoyer lift transfers. She was also given a disciplinary action and was required to take some online courses. He said Resident # 2 did not want to go to the hospital and had no injuries. The Administrator said the resident had since discharged home. During an interview on 11/26/24 at 8:57 a.m. CNA A said she worked at the facility for [AGE] years. CNA A said on the morning of 3/3/24 she was transferring Resident #2 from the bed to the shower chair. CNA A said she did not get another staff member to help her with the Hoyer lift transfer because Resident #2's family member was in the room. CNA A said the family member had assisted with transfers in the past. She said they had placed the loops on the transfer pad/sling to the Hoyer lift. CNA A said she had worked the controls on the mechanical/Hoyer lift and the family member had guided the resident towards the chair. She said they had lifted her from the bed and pivoted around toward the chair. CNA A said right before Resident #2 was at the chair one of the loops connected to the pad/sling came off, and Resident #2 slid to the floor. She said the family member likely did not secure the loop on the Hoyer securely. CNA A said she was in serviced on abuse neglect, and Hoyer lift transfers. She said she was also written up and was now aware to always get another staff for Hoyer lift transfers. She said she was told family members were not to assist with transfers.

Based on interview, and record review the facility failed to ensure the drug regimen was free from unnecessary medication for 1 of 5 (Resident #74) residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #74 did not receive a medication she was allergic to (ibuprofen) ordered for a swollen right hand on 5/22/23. 2. The facility failed to ensure Resident #74 was not given medications she was allergic to as ordered (ibuprofen 400 mg by mouth 4 times a day for 14 days). Resident #1 received ibuprofen from 05/22/23 to 07/23/23 (63 days). 3. The facility failed to ensure Resident #74's ibuprofen was discontinued after Resident #1 returned from the hospital from an upper GI bleed. Resident #1 received scheduled ibuprofen on 07/26/23 through 07/27/23 (4 doses). An Immediate Jeopardy (IJ) was identified on 10/20/23. While the IJ was removed on 10/21/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate threat due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm or death related to receiving unnecessary medications. Findings included: Record review of Resident #74's face sheet, dated 10/20/23, indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia (damage to or loss of nerve cells in the brain that causes memory loss, confusion, the ability to think or make decisions), gastrointestinal hemorrhage (bleeding in the digestive tract caused by a disease or condition) and gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #74's Care Plan dated 04/27/21 and last revised on 07/31/23 indicated she had an allergy to Lisinopril and Pravastatin and interventions included do not administer allergen, make note on chart of allergies and notify the physician if allergen is ordered. Resident #74's care plan did not address an allergy to ibuprofen. Record review of Resident #74's MDS dated [DATE] indicated she usually made herself understood and sometimes understood others. Resident #74 had severely impaired cognition. Record review of Resident #74's admission History and Physical dated 04/27/21by the Nurse Practitioner indicated she had a past medical history of dementia, anemia (blood disorder in which the blood has a reduced ability to carry oxygen due to a lower-than-normal number of red blood cells), gastro-esophageal reflux disease and peptic ulcer disease (open sores that develop on the inside lining of your stomach and the upper portion of your small intestine causing dark or black stool and vomiting). Resident #74 had an allergy to lisinopril, and pravastatin. Resident #74's admission History and Physical did not list ibuprofen as an allergy. Record review of hospital records dated 04/30/21 indicated Resident #74 had a fall and was sent to the hospital. Records indicated Resident #74 had an allergy to ibuprofen, lisinopril, and pravastatin. Record review of hospital records dated 08/28/21 indicated Resident #74 had a fall and was sent to the hospital. Records indicated Resident #74 had an allergy to ibuprofen, lisinopril, and pravastatin. Record review of a handwritten telephone order dated 05/22/23 indicated Resident #74 had an order to receive ibuprofen 400 mg by mouth 4 times a day for 14 days. The telephone order was signed by LVN E. Record review of Resident #74's physician's order dated 05/22/23 indicated she had an order for ibuprofen 400 mg by mouth 4 times a day. Resident #74's ibuprofen was discontinued on 07/31/23. Record review of Resident #74's MAR for the month of May, June, and July of 2023 indicated she received ibuprofen on the following dates: *05/22 through 05/31 (10 days) *06/01 through 06/30 (30 days) *07/01 through 07/23 (23 days) Record review of Resident #74's nursing progress notes dated 07/24/23 at 3:00 a.m. by LVN E, indicated at 2:50 a.m. she was called to the shower room. The resident had a black tarry bowel movement with blood. LVN E notified the hospice nurse. Record review of Resident #74's nursing progress notes dated 07/24/23 at 3:59 a.m. by LVN E, indicated she was instructed by the hospice nurse to check the resident's blood pressure and to send her to the hospital for possible gastrointestinal bleed if it was low. Resident's manual blood pressure was 98/54 (normal blood pressure 120/80). Resident was transported to the hospital. Record review of Resident #74's nursing progress notes dated 07/26/23 at 10:22 a.m. by the ADON, indicated she called the hospital, and informed the resident was admitted for a gastrointestinal bleed. Record review of Resident #74 hospital records dated 07/26/23 indicated she had dark bloody stools and was transferred to the hospital on 07/24/23. She had an allergy to ibuprofen and a history of peptic ulcer disease (an open sore that develops on the inside lining of your stomach and the upper portion of your small intestine). She had a hemoglobin (a protein in blood that carries oxygen to the body) level of 6.0 (Normal range 12.0-16.0) and was transfused with 2 units (approximately 2 pints) of blood in the emergency department. She was admitted to the intensive care unit (unit with specialized staff, equipment, and standards that handles severe, potentially life-threatening cases) diagnosed with an upper gastrointestinal bleed. She was transfused with 1 unit (approximately 1 pint) of blood in the intensive care unit 07/25/23. She was discharged back to the nursing facility on 07/26/23. Record review of Resident #74's MAR for July 2023 indicated she received ibuprofen on the following dates: *07/26 and 07/27 (2 days) Record review of Resident #74's nursing progress notes dated 07/26/23 at 8:17 p.m. by RN G, indicated she returned to the nursing facility and had dark blood in her brief upon arrival. Record review of Resident #74's nursing progress notes dated 07/27/23 at 6:10 p.m. by RN G, indicated the family notified her the resident had vomited. RN F observed a moderate amount of coffee ground emesis and the family requested for the resident to be sent to the emergency room . Record review of Resident #74's nursing progress notes dated 07/27/23 at 6:22 p.m. by RN G, indicated the resident was transferred to the hospital. Record review of Resident #74 hospital records dated 07/31/23 indicated she had vomited blood at the nursing facility and was transferred to the emergency department on 07/27/23. She had an allergy to ibuprofen and a history of peptic ulcer disease. She had a hemoglobin level of 9.8 (Normal range 12.0-16.0) on arrival and trended to a hemoglobin level of 6.9. She received 2 units (approximately 2 pints) of blood and was admitted . She was discharged to the nursing facility on 07/31/23. Record review of Resident #74's allergy history indicated ibuprofen was added as an allergy on 08/01/23 by the ADON. Record review of Resident #74's census dated 10/21/23 indicated she was discharged from the facility on 08/16/23 to another nursing facility. During an interview on 10/20/23 at 2:14 p.m., LVN E said she worked the 6:00 a.m.-2:00 p.m. shift and was the charge nurse for Resident #74 when the ibuprofen was ordered on 05/22/23. LVN E said Resident #74 had a swollen wrist, and she notified the hospice nurse. LVN E said the hospice nurse came to the facility to assess Resident #74 then notified the physician. LVN E said the hospice nurse hand wrote an order for Resident #74 to take ibuprofen 4 times a day for 14 days. LVN E said she signed the hospice nurse's handwritten order then entered it into Resident #74's electronic chart. LVN E said she did not enter the date to discontinue the ibuprofen after 14 days. LVN E said Resident #74 received ibuprofen for almost 2 months because she entered the incorrectly. LVN E said a resident taking ibuprofen with peptic ulcer disease is at risk of bleeding. LVN E said Resident #74 had peptic ulcer disease and was taking ibuprofen when she was sent to hospital for a gastrointestinal bleed. LVN E said she did not know Resident #74 had an allergy to ibuprofen prior to going to the hospital. During an interview on 10/20/23 at 2:23 p.m., the DON said the charge nurse was responsible for entering physician's orders in a resident's chart and she was responsible they were entered in correctly. The DON said Resident #74 had a swollen wrist and was ordered ibuprofen for 14 days. The DON said LVN E entered the order in Resident #74's chart and she did not enter the date to discontinue the ibuprofen after 14 days. The DON said she did not check Resident #74's chart to see if LVN E entered the order correctly. The DON said Resident #74 received ibuprofen for almost 2 months. The DON said Resident #74 was sent to hospital twice for a gastrointestinal bleed. The DON said the ibuprofen was discontinued and added as an allergy to her electronic chart when Resident #74 returned from the hospital the second time . The DON said she did not know Resident #74's past hospital records listed ibuprofen as an allergy. The DON said she did not review Resident #74's hospital records because she assumed they were reviewed by the previous DON before she was hired. The DON said a resident taking ibuprofen with peptic ulcer disease is at risk of bleeding. The DON said Resident #74 had peptic ulcer disease and was taking ibuprofen when she went to the hospital. The DON said she did not know Resident #74 had an allergy to ibuprofen prior to going to the hospital and have since changed how they monitored medications. The DON said a list of new medications ordered from the previous day is printed out and reviewed during their daily clinical meeting for resident allergies and to ensure orders are entered accurately. Record review of the facility's Medication-Administration policy dated 08/2020 indicated, It is the policy of this home that medication will be administered and documented as ordered by the physician and in accordance with state regulations . Record review of the facility's Physician Services policy dated 08/2020 indicated, .Procedure .8. Physician's orders for treatment and medication shall be recorded in the medical record and shall be signed by the attending physician. Such orders shall be in effect for the number of days specified by the physician .11. The DON/Administrator will be responsible to monitor physician visits to assure that the resident is receiving appropriate care and services . The Administrator was notified on 10/20/23 at 6:38 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 10/20/23 at 6:44 p.m. The facility's Plan of Removal was accepted on 10/21/23 at 3:00 p.m. and included: Resident Specific o An allergy for ibuprofen was added into Resident #1's electronic medical record on 8/1/23 due to having the GI bleed. o Resident #1 no longer resides at the facility as Resident #1 was discharged on [DATE]. o Medical Director notified of IJ on 10/20/2023 at 7:58 PM by Administrator. o Notified Pharmacy Consultant of IJ on 10/20/2023 at 7:58 PM by Director of Nursing. System Changes o Audit of all medication orders for NSAID use and stop dates completed on 10/20/2023 for all residents by Director of Nursing and Assistant Director of Nursing at 10:30 PM. o Head to toe assessment completed for all residents on 10/20/2023 by Treatment Nurse/LVN at 11:50 PM. o During stand up/clinical meeting DON and/or ADON to review new orders with stop dates if applicable to ensure correct transcription into EMR. Education o Director of Nursing provided education to all staff on signs/symptoms of GI Bleeding. If signs and/or symptoms of GI Bleeding are identified the staff member should report to charge nurse immediately. Once notified the charge nurse should contact physician. All staff present in the facility were educated on 10/20/2023. Staff not present for the education will receive education prior to their next shift. o Director of Nursing provided education to nursing staff regarding Medication Administration of Long Term NSAID's and Risks. All nursing staff present in the facility were educated on 10/20/2023. Staff not present for the education will receive education prior to their next shift. o Director of Nursing provided education to nursing staff regarding The 5 Rights of Medication Administration. All nursing staff present in the facility were educated on 10/20/2023. Staff not present for the education will receive education prior to their next shift. o Administrator, Director of Nursing, and Assistant Director of Nursing in-serviced on 10/20/2023 at 9:43 PM by Regional Clinical Consultant in regard to Monitoring New Orders for Accurate Transcription into EMR. Monitoring o Order obtained from Medical Director by Director of Nursing for every resident on 10/20/2023 to monitor for abnormal bleeding i.e. excessive bruising, bleeding gums, nose bleeds, tarry stools, etc. This is documented Q Shift on the medication administration record in the EMR. On 10/21/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director had been informed of the Immediate Jeopardy from documentation signed by the Administrator. Verifying the Pharmacy Consulted had been informed of the Immediate Jeopardy from documentation signed by the DON. Record review of in services revealed staff were educated on signs and symptoms of gastrointestinal bleeding, report signs and symptoms of bleeding to charge nurse, long term NSAID's and Risks, and The 5 Rights of Medication Administration. Record review of in services revealed the Administrator, DON and ADON were educated on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. Record reviews on four resident charts taking ibuprofen were completed to ensure medication orders for NSAID use and stop dates were completed, head to toe assessment were completed and orders to monitor for abnormal bleeding, excessive bruising, bleeding gums, nose bleeds, tarry stools, etc. each shift. There were no issues identified. Interviews with 5 Licensed Nurses, 3 MA and 9 CNAs (on all shifts 6 a.m.- 2 p.m., 2 p.m.-10 p.m., 10 p.m.- 6 a.m., 6 a.m.-6 p.m., and Weekend Doubles) were performed on 10/21/23. All licensed nursing staff were able to correctly identify signs and symptoms of gastrointestinal bleeding, who to report it to, monitoring for bleeding each shift and documenting it on the MAR. Licensed nurses and MA were able to correctly identify medication administration of long-term use and risks of NSAIDs (nonsteroidal anti-inflammatory drugs) and 5 Rights of Medication Administration. During an interview on 10/21/23 at 4:31 p.m., the DON said she in-serviced the nursing staff on signs and symptoms of gastrointestinal bleeding, report signs and symptoms of bleeding to charge nurse, long term NSAID's and Risks, and The 5 Rights of Medication Administration. The DON said staff who were not in serviced would be prior to their next shift. The DON said she was in serviced on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. The DON said clinical meetings are held daily. During an interview on 10/21/23 at 4:44 p.m., the ADON said she was in serviced on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. The ADON said clinical meetings are held daily. During an interview on 10/21/23 at 4:53 p.m., the Administrator said he was in serviced on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. The Administrator said clinical meetings are held daily. On 10/21/23 at 5:30 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review Level 1(PASRR 1) Screening for 3 of 12 residents reviewed for PASRR (Residents #12, 23, and #45). The facility failed to ensure Residents #12, #23, and #45 had accurate PASRR Level 1 Screenings indicating diagnoses of mental illness. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Resident #12 Record review of Resident 12's PASRR Level 1 Screening completed on 03/27/2023 indicated in section C0100 this resident did not have evidence of having a mental illness. Record review of an undated face sheet indicated Resident #12 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including major depressive disorder. Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated Resident #12 had a BIMS score of 0 (zero), indicating severely impaired cognition. The MDS section for PASRR indicated Resident #12 did not have a serious mental illness. The MDS section I, Active Diagnoses, indicated Resident #12 had a diagnosis of major depressive disorder. Record review of the physician's orders dated 09/25/23-10/25/2023 indicated an order dated 03/26/2023 for Resident #12 to receive venlafaxine (a psychotropic medication) for treatment of major depressive disorder. Resident #23 Record review of Resident 23's PASRR Level 1 Screening completed on 04/17/2023 indicated in section C0100 this resident did not have evidence of having a mental illness. Record review of an undated face sheet indicated Resident #23 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including schizophrenia and major depressive disorder. Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated, Resident #23 had a BIMS score of 5 (five) indicating severely impaired cognition. The MDS section for PASRR indicated Resident #23 did not have a serious mental illness. The MDS section, Psychiatric/Mood Disorder, indicated Resident #23 to have a diagnosis of schizophrenia. Record review of physician orders dated 09/25/2023-10/25/2023 indicated orders dated 05/01/2023 for resident #23 to receive Seroquel (psychotropic drug) 3 times a day and Zyprexa (psychotropic drug)1 time daily for treatment of schizophrenia. Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated Resident #23 was receiving antipsychotic medications on a routine basis. Resident #45 Record review of Resident 45's PASRR Level 1 Screening completed on 03/27/2023 indicated in section C0100 this resident did not have evidence of having a mental illness. Record review of an undated face sheet indicated Resident #45 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder, and PTSD. Record review of the Comprehensive (admission) MDS assessment dated [DATE] indicated Resident #45 had a BIMS score of 15(indicating his cognition to be intact) and dependent on staff for ADLs due to a diagnosis of quadriplegia (paralysis of all four limbs). The MDS section for PASRR indicated Resident #12 did not have a serious mental illness. The MDS section I, Active Diagnoses, indicated Resident #12 had diagnoses of depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. The Medications section of the MDS indicated Resident #45 was receiving antipsychotic medications on a routine basis. Record review of the physician's orders dated 09/25/23-10/25/2023 indicated orders for Resident #45 to receive Depakote, Seroquel, and Zyprexa (medications used to treat schizophrenia and bipolar disease) on a routine basis. Record review of Resident #45's care plan dated 03/29/2023 indicated resident required drugs for the treatment of schizoaffective disorder and interventions were aimed at reducing the risk of drug-related complications. During an interview with the MDS Nurse on 10/24/2023 at 9:45 AM, she said she was responsible for tasks related to PASRR and MDS processes. She said she was hired in May of 2023 and was new to the PASRR and MDS process. She said at the time of Residents #'s 12, 23, and 45, she thought the PASRRs completed by the discharging facility were incorrect and said she notified the local authority of her concerns. She said the local authority told her she would follow up on her concerns. She said she did not do anything else because she did not know she was supposed to. The MDS Nurse said she understood the importance of PASRR Level 1 Screenings being accurate because the facility needed to make sure eligible residents were getting the correct resources.

Based on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 1 of 4 residents reviewed for pharmacy services. (Resident #127). The facility failed to ensure pantoprazole granules DR for oral suspension were administered correctly to Resident #127. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them correctly as directed by manufacturer's directions. Findings included: Record review of Resident #127's face sheet, dated 10/22/2023, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. She had diagnoses which included gastro-esophageal reflux disease (acid indigestion), congestive heart failure, fractured femur, high blood pressure, dementia, and anxiety. Record review of Resident #127's admission progress notes, dated 10/03/2023, indicated she was alert and oriented to herself only; she had a BIMS (Brief Interview for Mental Status) of 99 indicating she was unable to complete the interview and was severely cognitively impaired; required assistance of 1 staff with ADLs; frequently incontinent of bowel and bladder, but could use the bedside commode. Record review of Resident 127's consolidated physician orders dated October 2023 indicated the resident had an order entered on 10/12/2023 to start pantoprazole granules DR for suspension in packet, 40 mg. orally with special instructions to mix with water or juice for her gastro-esophageal reflux disease. Record review of Resident #127's MAR, dated 10/2023, indicated she received the pantoprazole granules DR every day at 8:00 AM starting on 10/13/23 through 10/24/23. The MAR indicated the medication was to be mixed with water or juice. During an interview and observation on 10/25/23 at 8:45 AM MA C pulled up the MAR for Resident # 127 and the order indicated to give pantoprazole granules in water or juice. She said she would give the resident a full glass of water (7 oz) indicating the plastic cups on her cart. She said she tried to get residents to drink as much water as she can to keep them from getting dehydrated and getting UTIs. She also had healthshakes on her cart where the first ingredient was nonfat milk. She said she only used water with Resident # 127. MA C pulled the medication packet from the medication cart and the pharmacy label indicated to give 1 pkt as directed and give by mouth daily. Another small label on the bottom of the medication bag indicated Do not crush. Give with apple juice or applesauce. The label did not indicate any specific amounts of applesauce or apple juice. MA C said she never used apple juice or applesauce and indicated she had not noticed the additional label indicating to use apple juice. During an interview on 10/25/23 at 9:05 AM the ADON was asked to pull up the physician orders in the electronic record for viewing for Resident # 127. She said she entered the order for pantoprazole granules given by the NP on 10/12/23 to discontinue the pantoprazole tablet and to begin the pantoprazole granules. She said the NP did not indicate how to prepare the suspension. She said she added give with water or juice and she said any juice the resident preferred could be used and she would expect it to be administered using 6-8 oz. She said she did not know the specific parameters regarding the administration of the pantoprazole granules. During an interview on 10/25/23 at 9:10 AM the DON said she was not aware pantoprazole suspension granules had to be given in a specific way. She said new medication orders are reviewed every morning in stand-up meeting. She said she tried to review resident charts and physician orders for accuracy weekly. She did not indicate whether she had reviewed Resident # 127's physician orders for accuracy. During an interview on 10/25/23 at 9:15 AM the RN Consultant had pulled the directives from the manufacturer concerning the preparing of the pantoprazole suspension using only apple juice or applesauce when administering the pantoprazole granules and said staff would be in-serviced regarding the administration. Review of the manufacturer's instructions on 10/25/2023 at Pfizer's website at pfizermedicalinformation.com indicated the following: Instructions for Use: PROTONIX (pantoprazole sodium) for delayed-release oral suspension .should only be taken with applesauce or apple juice; should not be mixed in water or other liquids, or other foods; packet should not be divided to make a smaller dose. Taking PROTONIX for oral suspension with applesauce: 1. Open the packet of PROTONIX for oral suspension. 2. Sprinkle all of the granules in the packet on 1 teaspoon of applesauce. 3. Swallow the granules and applesauce within 10 minutes of putting the granules on the teaspoon of applesauce. 4. Take sips of water to make sure the granules are washed down into the stomach. Take more sips of water as needed. Taking PROTONIX for oral suspension with apple juice: 1. Open the packet of PROTONIX for oral suspension. 2. Empty all of the granules in the packet into a small cup that contains 1 teaspoon of apple juice. 3. Stir the granules-apple juice mixture for 5 seconds. The granules will not break up. 4. Swallow the mixture right away. 5. To make sure that the entire dose is taken, add more apple juice to the cup, stir and swallow the apple juice right away. 6. Repeat step 5 if there are granules left in the cup .

Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to 1 of 2 rooms (DON's office) and 1 of 3 medication carts used for storage of medications and other biological chemicals. The facility failed to ensure MA B kept OTC medications secured in the medication cart and unable to be accessed by unauthorized personnel. The facility failed to ensure the DON's office was secured and unable to be accessed by unauthorized personnel. These failures could place residents at risk for misuse of medication and overdose, drug diversions, and adverse reactions to medications. Findings included: During observation of medication administration on 10/23/2023 beginning at 09:10 AM, MA B opened a new bottle containing 100 generic multivitamins, removed 1 (one) tablet from the bottle, put the vitamin tablet in a medicine cup, put the lid on the bottle, and set the bottle on top of the medication cart. MA B obtained other medications from the cart, put those medications in the cup with the vitamin in it, and put those containers back inside the cart. MA B locked the cart, leaving the bottle of multivitamins on top of the cart. MA B left the cart parked against the wall at the entrance to 200 hall, turned her back to the cart and walked across the area (approximately 7 feet) to the resident she was to administer the medications to. MA B administered the medications to the resident and returned to the cart. MA B said she had done all she needed to do. This surveyor pointed to the Multivitamin bottle. MA B said she forgot to put the bottle into the cart. She said someone could have taken it. During observation and interview on 10/25/2023 at 11:20 AM, the DON's office door was noted to be unlocked and fully open. Upon following the DON into her office, a box, measuring approximately 8x16x10 inches and containing multiple cards of medications including medications for high blood pressure, depression, mental illness, nausea, high cholesterol, etc., was noted setting on the floor in front of a locked closet where discontinued narcotics were kept. The DON was observed to count 57 cards containing 1 to 30 medications on each card, 2 bottles of unknown number of vitamin C tablets, 1 partial bottle of lactulose, and 1 hand-held nebulizer for respiratory treatment. The drugs were not secured and were available to anyone who walked into the DON's office. The DON said the medications were to be processed for destruction and she had just put the box in there. The DON did not offer a rationale for not securing the drugs. Record review of the facility's policy dated 08-2020 and titled Medication-Discontinued Medication/Destruction of Drugs indicated the following: 1. When a medication has passed its expiration date or is otherwise deteriorated, or has been discontinued, or for a resident no longer residing at the home, it should be removed from the medication cart as soon as possible and accounted for and kept under lock and key in the medication room.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for infection control and based on observations, interviews, and record reviews, the facility failed to implement infection control practices designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 6 of 7 residents (Resident #'s 6, 27, 32, 46, 68 and 70) reviewed for infection control practices, in that:. *Resident #'s 6, 42, and 68's O2 tubing was not covered and Resident #46's oxygen tubing was not labeled correctly. *Resident #70's Nebulizer tubing was not covered. *Resident #32's CPAP tubing was dirty and not covered; and *Facility staff did not disinfect the glucometer properly before and after it was used on Resident #27. This failure placed residents' risk for exposure to possible transmission of communicable diseases and infections. Findings included: Observations on 10/22/2023 to 10/25/2023 between 9:00 am and 3:30 PM during facility tour revealed the following: *During an observation resident#6 oxygen tubing was not covered in a plastic bag and was hanging on the concentrator. Portable oxygen tubing was hanging from wheelchair being used. *During an observation resident #46 lying in the bed oxygen tubing was not covered in a plastic bag and was hanging on the concentrator. Oxygen tubing had label date of 7/31/2023 and was not in a plastic bag. *During an observation and interview 10/22/23 at 12:07pm with Resident#70 stated he gets Nebulizer treatment and uses oxygen at night. Was noted Nebulizer tubing had the date of 9/27/2023 and was on top of the machine on the side of the table uncovered. *During an observation and interview on 10/22/23 at 12:11pm with resident#32 said he uses the CPAP machine at night., the CPAP mask was on top of the machine, there was dirty tubing on side table uncovered no date indicating when changed and the O2 tubing on floor uncovered. *During an observation on 10/25/23 at 1:15pm In room [ROOM NUMBER]A (Resident #68 was not in the room) oxygen tubing was not covered in a plastic bag and was hanging on the concentrator dangling to the floor and not dated. In an interview on 10/24/2023 at 10:50 AM, the DON stated the oxygen tubing is changed weekly and the oxygen tubing is placed in a zip lock bag for infection control to prevent contamination. She stated the CPAP mask are to be cleaned after each use and placed inside zip lock bag. In an interview and Record review on 10/24/2023 at 2pm with the DON she was asked who is responsible to make sure O2 tubing is changed and dated, she said it is the night shift on Sunday's nurse responsibility to change tubing and it's my responsibility to perform infection control audits to review that policies are being followed. Record review revealed the Night shift was signing tasks being done but observation revealed task was not done. In an interview on 10/25/2023 at 1:40 PM, the ADON/IP stated the oxygen tubing and CPAP mask should be placed in a zip lock bag after each use. She stated, the facility did not have an Infection Control policy for cross contamination it is best practice to bag the items as a best practice for infection control. She said it was a system failure that the facility was not monitoring this to ensure it was being done and residents are at risk for respiratory infections. Resident #27 Review of Resident #27's undated face sheet indicated Resident #27 to be a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including diabetes. Record review of Resident #27's Annual MDS assessment dated [DATE] indicated her cognition to be severely impaired as indicated by a BIMS score of 7 out of 15 and requiring moderate to maximum assistance with most ADLs. Review of Resident #27's physician orders dated 09/23/2023-10/23/2023 indicated an order dated 05/06/2023 for Resident #27's blood glucose level to be checked 4 (four) times a day with additional instructions to administer doses of Humalog insulin according to a prescribed sliding scale (A sliding scale varies the dose of insulin based on blood glucose level). During observation and interview on 10/23/2023 at 11:40 AM, LVN A cleansed her hands with an alcohol-based hand sanitizer, put on a pair of disposable gloves, and removed a glucometer (a handheld meter used to measure how much glucose is in the blood) and a lancet (a small, sterile needle used to obtain a blood sample to check blood glucose levels) from the drawer of her medication cart and set them on top of the cart. Using her gloved fingers, she obtained a test strip from its container and inserted the test strip into the glucometer. She then picked up the glucometer and lancet and entered Resident #27's room. After cleaning Resident #27's finger with an alcohol pad, LVN B obtained a blood sample from her finger and applied it to the glucometer test strip. LVN A said Resident #27's blood sugar level was 117 and would not be receiving any insulin. LVN A returned to the medication cart, disposed of the lancet, alcohol pad, and test strip, and set the glucometer on top of the medication cart. LVN A then obtained an alcohol pad and used the pad to clean the glucometer. She disposed of the alcohol pad, removed her gloves, and placed the glucometer in the medication cart drawer. She said she had several residents requiring point-of-care blood glucose testing daily but had no more to be done at that time. LVN A said she used an alcohol pad to clean the glucometer before this surveyor arrived at the medication cart. LVN A said she always used alcohol pads to clean the glucometers. During an interview with the DON on 10/23/2023 at 12:05 PM, she said she expected the nurses to follow infection prevention and control practices during point-of-care testing using glucometers. She said the nurses should use an EPA Registered germicidal disposable wipe referred to as Purple Top (PDI Super Sani-Cloth Germicidal Disposable wipes packaged in a purple and white plastic container with a purple top) wipes. Record review of the User's Guide for the Evencare G2 glucometer used by LVN A indicated EPA Registered wipes were to be used to disinfect the glucometer. Record review of the facility policy titled Finger Stick Blood Sampling dated 12/1/2018 indicated the following: Equipment and Supplies 2. Germicidal Wipes Procedure 8. Clean the glucometer with germicidal wipes unless otherwise indicated or bleach/water solution diluted with a 1 to 10 ratio before initial use, after final use and between each resident following manufacturer directions. The facility's policy, Respiratory Therapy Equipment dated 12/2018, reflected, [NAME] bottle with date and initials upon opening and discard after seven days or as needed, change oxygen cannula and tubing every seven (7) days and as necessary, keep oxygen cannula and tubing used PRN in a plastic bag when not in use. Nebulizer equipment, store circuit in plastic bag, marked with date and residents name between uses. The Director of Nursing will perform infection control audits to review staff procedure in observation of standard precautions, Infection control and isolation procedures. 47204

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment was completed prior to admission. For 1 of 12 residents (Residents #60) reviewed for PASRR Level I screenings. The facility failed to have a level 1 PASRR assessment for Resident #60 available/documented. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #60's face sheet, date 09/20/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Resident #60 diagnoses included non-Alzheimer's dementia unspecified severity, with other behavioral disturbance on admission, psychotic disorder with delusions due to known physiological condition, major depressive disorder, recurrent severe without psychotic features, anxiety disorder, and Parkinson's disease. Record review of Resident #60's admission MDS assessment, dated 06/07/23, indicated section A1500 was marked 0 or no. This indicated the resident was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section A1510 was not marked for level II PASRR conditions. The assessment indicated she had a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. Record review of Resident #60's electronic medical record a PASRR level 1 screening assessment was unable to be identified or located. During an interview on 10/25/23 at 1:16 PM, the MDS Coordinator said she was still working on the facility's PASRR forms, and it was possible the PASRR forms had not been uploaded to the electronic record. She said she would try to locate Resident 60's PASRR Level 1 assessment forms. During an interview on 10/25/23 at 3:38, the MDS Coordinator said she was unable to locate documentation on Resident #60's PASRR Level 1 Screening assessment forms. Resident #60 was admitted to facility on 5/25/23 from another long-term care facility. Record review of the resident Assessment and Care Screening (Nursing Home Comprehensive Item Set indicated on 06/07/23 section A1500 assessment was completed as the most recent admission entry. Record review of the facility's policy, specialized rehabilitative services, stated: .Specialized services for MI [mental illness] or MR [mental retardation] For a resident with MI or MR, the community will ensure that the individual receives the services necessary to assist him or her in maintaining or achieving as much independence and self-determination as possible. The preadmission screening and resident review (PASRR) indicates specialized services required by the resident. The state is required to list those services in the report, as well as to provide or arrange for the provision of the services. Even if the state determines that the resident does not require specialized services, the community is still responsible for providing all services necessary to meet the resident's mental health or mental retardation needs. The community provides interventions that complement, reinforce, and are consistent with any specialized services (as defined by the resident's PASRR)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less that 5 percent. There were 3 errors out of 34 opportunities, resulting in an 8 percent medication error rate involving 1 of 3 residents (Resident #13). MA B failed to administer 2 scheduled medications, spironolactone (to treat excess fluid in the tissues) and vitamin D3 (to treat vitamin deficiency), to Resident #13 as ordered by the physician. MA B failed to follow physician's orders regarding specific instructions for the administration of polyethylene glycol 3350 (for treatment of constipation). These failures could place the resident at risk of not receiving the therapeutic effect of the mediations and could result in a decline health status. Findings included: Record review of an undated face sheet indicated Resident #13 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including hypertension (elevated/high blood pressure), chronic peripheral venous insufficiency (improper functioning of the valves in the leg causing swelling), acute pulmonary edema (excess fluid in the lungs), vitamin deficiency, and constipation. During observation and interview on 10/23/2023 at 09:10 AM, MA B administered the following scheduled medications to Resident #13: aspirin, citalopram, loratadine, cranberry tablet, vitamin B12, duloxetine, lactulose, Lasix, rivastigmine, and polyethylene glycol mixed in a liquid supplement, multivitamin, ferrous sulfate, and prednisolone eye drops. MA B was not able to locate two medications, a multivitamin and ferrous sulfate, in the cart and obtained them from the nurse. Record review on 10/23/2023 at 11:20 AM of the physician orders dated for 09/23/2023-10/23/2023 indicated Resident #13 was also to receive the following medications at 09:00 AM daily: o Spironolactone 25mg daily to help treat edema (excess fluid in the tissues) and o Vitamin D3 50mcg (2000 units) for vitamin deficiency. These 2 (two) medications were not administered during the observed medication pass at 09:10 on 10/23/2023. Record review on 10/23/2023 at 11:20 A of the physician orders dated 09/23/2023-10/23/2023 indicated an order for polyethylene glycol 3350 powder was to be administered as follows: o Polyethylene glycol 3350 powder 17gm/dose 1 scoop Special Instructions: Stir in 4-8 ounces water, juice, soda, coffee, or tea until dissolved and administer immediately. On 10/23/2023 at 09:10 AM, MA B was observed to place 17gm/dose of polyethylene glycol 3350 powder in a plastic cup. She then poured an unmeasured amount of a liquid supplement (Hi-Cal 2 calories/per 1 ml) into the same cup and used a wooden spoon to mix the two together. After placing the other medications in Resident #13's mouth, MA B attempted to give Resident #13 the polyethylene glycol 3350 mixed with the liquid supplement but the mixture would not pour from the cup. MA B then waked over to the medication cart and added an unmeasured amount of water to the cup, stirred the mixture again, and returned to the resident. MA B held the cup to Resident #13's mouth and poured the thickened mixture, a little at a time, into the resident's mouth. MA B said she had poured 30 mls of liquid supplement and a splash of water into the cup with the polyethylene glycol 3350 powder. MA B did not give Resident #13 any water after administering the medications and polyethylene glycol 3350. On 10/23/2023 at 09:28, MA B said she was finished giving Resident #13 her medications. During the observation of this medication pass, MA B did not go to the medication room to see if the needed medications (spironolactone and vitamin D3) were there, nor did she tell the charge nurse about the missing medications. During an interview on 10/23/2023 at 01:10 PM with the DON and MA B, MA B said she did not give Resident #13 her spironolactone and vitamin D3 because they were not in the cart and said she had documented the medications were not available. She said if she did not have a scheduled medication in the cart, she would look for it in the medication room and if she did not find it, she would document the medication was not available on the medication administration record (MAR). The DON said the medication aide should notify the nurse if a scheduled medication was not available and the charge nurse could access the facility's emergency drug container and obtain needed medication from it. The DON said if a needed medication was not in the emergency container, then the charge nurse would notify the pharmacy and the pharmacy would either deliver it or obtain it from a local pharmacy for delivery. The DON said she would obtain the needed medications from the medication room and have MA B administer them. Record review of the MAR on 10/23/2023 at 01:55 PM indicated MA B had documented the spironolactone as Not Administered: Drug/Item unavailable. The vitamin D3 medication was documented as being administered at 09:00 AM. During an interview on 10/23/2023 at 02:30 PM, MA B said she made a mistake and should have documented the vitamin D3 as not being administered. MA B also said she used the Hi-Cal liquid supplement to mix with the polyethylene glycol powder because she felt Resident #13 needed it. She said she estimated how much water and liquid supplement she used and did not know why she did not measure the amounts given. She said she should have used the ordered amount of water to mix the drug with. Review of the facility's policy titled Medication - Administration dated 08-2020 indicated the following: Policy It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. Procedure .4. Current medications and dosage schedules, except topical used for treatments, are listed on the resident's medication record (MAR) .7. Supplies and equipment, which are needed during a medication pass, are to be placed on the medication cart. The following equipment and materials are needed for the medication pass: Routine medications needed, including house stock medications. 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the Physician.

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents (Resident #13) reviewed for medication administration accuracy. MA B failed to administer a scheduled medication, spironolactone (used to treat high blood pressure and excess fluid in the tissues, to Resident #13 as ordered by the physician. This failure could place the resident at risk of not receiving the therapeutic effects of the mediation and could result in a decline health status. Findings included: Record review of an undated face sheet indicated Resident #13 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including hypertension (elevated/high blood pressure), chronic peripheral venous insufficiency (improper functioning of the valves in the leg causing swelling), and acute pulmonary edema (excess fluid in the lungs). Record review of Resident #13's Quarterly MDS assessment dated [DATE] indicated her cognition to be severely impaired as indicated by a BIMS score of 2 out of 15 and dependent on staff for most ADLs. During observation and interview on 10/23/2023 at 09:10 AM, MA B administered medications to Resident #13 including aspirin, citalopram, loratadine, cranberry tablet, vitamin B12, multivitamin, duloxetine, lactulose, Lasix, iron, rivastigmine, polyethylene glycol, and prednisolone eye drops. Record review on 10/23/2023 at 11:20 AM of the physician orders dated for 09/23/2023-10/23/2023 indicated Resident #13 was also to receive the following medication at 09:00 AM daily: o Spironolactone 25mg daily (to help treat edema and hypertension). This medication was not administered during the observed medication pass at 09:10 on 10/23/2023. In an interview on 10/23/2023 at 09:28, MA B said she was finished giving Resident #13 her medications. MA B did not go to the medication room to see if the needed medication (spironolactone) was there, nor did she tell the charge nurse about the missing medication during this observation of the medication pass. During an interview on 10/23/2023 at 01:10 PM with the DON and MA B, MA B said she did not give Resident #13 her spironolactone because it was not in the cart. She said if she did not have a scheduled medication in the cart, she would look for it in the medication room and if she did not find it, she would document the medication was not available on the MAR. The DON said the medication aide should notify the nurse if a scheduled medication was not available and the charge nurse could access the facility's emergency drug container and obtain needed medication from it. The DON said if a needed medication was not in the emergency container, then the charge nurse would notify the pharmacy and the pharmacy would either deliver it or obtain it from a local pharmacy for delivery. Record review of the MAR on 10/23/2023 at 01:55 PM indicated MA B had documented the spironolactone as Not Administered: Drug/Item unavailable. Review of the facility's policy titled Medication - Administration dated 08-2020 indicated the following: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. Procedure .4. Current medications and dosage schedules, except topical used for treatments, are listed on the resident's medication record (MAR) .7. Supplies and equipment, which are needed during a medication pass, are to be placed on the medication cart. The following equipment and materials are needed for the medication pass: Routine medications needed, including house stock medications. 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the Physician.

Based on interview and record review, the facility did not ensure adequate supervision and assistive devices was provided for 1 of 3 residents reviewed for accidents. (Resident #1) CNA A did not properly secure Resident #1 in the facility van for a transport to [MEDICAL TREATMENT]. Resident #1 fell from her wheelchair onto the floor and sustained a laceration to her right foot and a fractured right femur that required surgical repair. This was determined to be past non-compliance with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents traveling in the facility van at risk of serious injury or death. Findings included: An undated face sheet indicated Resident #1 was [AGE] years old, admitted on [DATE], and transferred to a local hospital on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had intact cognition, made her needs known, and understood others. She required extensive assistance with ADLs. She used a wheelchair for mobility. A care plan dated [DATE] indicated Resident #1 required [MEDICAL TREATMENT] for end stage [MEDICAL CONDITION] and received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. She had limited physical mobility and required extensive assistance with transfers. An updated care plan dated [DATE] indicated Resident #1 had a fall with a possible injury to her right leg and was transported to a local hospital and diagnosed with [REDACTED].#1 was at risk for falls and the resident, family, and caregivers should be educated on safety measures to reduce risk of falls. An incident report dated [DATE] indicated on [DATE] at 11:00 a.m., Resident #1 fell while on the facility van in route to her [MEDICAL TREATMENT] appointment. The report indicated Resident #1 had a rotation/deformity to her right leg and a laceration to her right foot. Resident #1 complained of 10 out of 10 pain to her right leg and right foot. Resident #1 was alert and responded appropriately. Resident #1 received pain medication and EMS transported her to a local hospital for evaluation. Resident #1's physician and family were notified of the incident. Hospital emergency room records dated [DATE] indicated Resident #1 arrived at the emergency room from a nursing facility with 10 out of 10 pain to her right lower extremity. The record indicated a right femur x-ray dated [DATE] showed Resident #1 had a displaced spiral fracture of her midshaft right femur. The record indicated Resident #1 was transferred to another hospital on [DATE] for surgical repair of her right femur fracture. A provider investigation report dated [DATE] indicated on [DATE] at approximately 11:00 a.m., CNA A transported Resident #1 in the facility van to her routine [MEDICAL TREATMENT] treatment located 0.5 miles from the facility. CNA A left the facility and returned to the facility a few minutes later with Resident #1 on the floor of the van. LVN B and a corporate nurse observed CNA A return to the facility in the van and opened the van door and heard faint moaning and saw Resident #1 on the floor of the van. Resident #1 was immediately assessed by LVN B, LVN C, and the ADON. Resident #1 was transported to a local hospital by EMS. The report indicated CNA A was suspended during the investigation. The DON in-serviced staff on abuse and neglect and fall prevention. The administrator completed the orientation of transportation personnel check list for competency and the wheelchair securement system handout with the maintenance supervisor. The maintenance supervisor completed the orientation of transportation personnel check list for competency and the wheelchair securement system handout with LVN C, CNA D, and CNA F. The DON completed safe surveys with residents regarding safety and no concerns were found. CNA A's employment was terminated on [DATE]. During an interview on [DATE] at 9:40 a.m., the administrator and DON said on the morning of [DATE] CNA F tested positive and was sent home. CNA F was the van driver and Resident #1 needed to be transported to her scheduled [MEDICAL TREATMENT] appointment. The administrator said she asked CNA A to take Resident #1 to her [MEDICAL TREATMENT] appointment. She said CNA A was one of the staff that drove the van when CNA F was unavailable. The administrator said CNA A said he would transport Resident #1 to her appointment. They said Resident #1's [MEDICAL TREATMENT] center was 2 blocks from the facility. They said around 11:00 a.m., CNA A left the facility with Resident #1 and returned within a few minutes. They said CNA A said he was slowing down and Resident #1 fell out of the wheelchair. The administrator said she asked CNA A if he buckled Resident #1 in and CNA A said he did not buckle the lap or shoulder belt. He said it was not his fault because nobody showed him how to buckle a resident in the van. They said instead of stopping when Resident #1 fell , CNA A drove back to the facility with Resident #1 in the floor. They said staff who witnessed Resident #1 in the floor of the van said Resident #1's wheelchair was secured to the van. The DON said Resident #1 was transported by EMS to the local hospital and diagnosed with [REDACTED]. They said Resident #1 did well after surgery, but the hospital tested Resident #1 for COVID-19 and she tested positive. They said the resident was moved to the COVID-19 area of the hospital and transferred to a facility that had a COVID-19 unit on [DATE]. The administrator said the accepting nursing facility notified them that Resident #1 continued to decline and was moved to an inpatient hospice facility where she died on [DATE]. The administrator said after the incident they in-serviced nursing staff on falls and their abuse policy and she and the maintenance supervisor completed in-servicing and competency checks with the drivers to ensure they knew how to properly secure residents and wheelchairs in the van. The DON said she completed safe surveys and no residents felt unsafe during transports and said they were secured in the van by the driver. They said CNA A was suspended during the investigation and was terminated. The administrator said they were unable to find CNA A's transportation check off list, but CNA A did sign the in-service sheet dated [DATE] that he was trained on the new facility van's securement system to secure residents in the van for transporting. During an interview on [DATE] at 6:51 p.m., CNA A said he came into the facility on the morning of [DATE] around 10:00 a.m. for routine COVID-19 testing. He said while he was at the facility, CNA F tested positive for COVID-19 and the administrator asked him if he could transport Resident #1 to her [MEDICAL TREATMENT] appointment. CNA A said he was not working at the time and told the administrator he only had 2 hours of sleep but agreed to transport Resident #1 to [MEDICAL TREATMENT]. CNA A said he had to wait about an hour for Resident #1 to get ready and around 11:00 a.m. he loaded Resident #1 in the van just like the maintenance supervisor showed him. He said he secured Resident #1's wheelchair to the floor of the van with 4 straps but did not secure Resident #1's lap or shoulder belt because nobody showed him how to secure the lap and shoulder belts. He said they left the facility and the [MEDICAL TREATMENT] facility was about a minute down the road and when he slowed down to turn into the [MEDICAL TREATMENT] parking lot, Resident #1 fell forward out of her wheelchair and her right leg bent backwards. He said Resident #1 was crying in pain, but she was able to sit up on her own. CNA A said he called the administrator and the facility and got no answer. He said he drove back to the facility with Resident #1 sitting on the floor of the van. CNA A said there were a few staff standing outside when he parked but he ran inside the facility and hollered for help. He said the ADON and LVN C came out to assess Resident #1. He said EMS arrived and transported Resident #1 to the hospital. CNA A said the facility got a new van in [DATE] and the maintenance supervisor was supposed to train the drivers on securing residents in the new van but the maintenance supervisor did not train him. He said LVN C went over strapping the wheelchair into the van but did not go over the lap or shoulder belts. He said he may have signed off that he was trained but he did not get trained. He said he consistently transported Resident #1 every Friday evening from [MEDICAL TREATMENT] to the facility and did not secure Resident #1 with the shoulder or lap belts. During an interview on [DATE] at 2:26 p.m., the maintenance supervisor said on [DATE], he was notified that a resident fell on the van and he went outside. He said Resident #1 was sitting on the floor and the wheelchair was lowered to the ground. He said Resident #1's wheelchair was secured with all 4 straps, but the lap and shoulder harness were not secured. He said CNA A was outside and yelling at him (maintenance supervisor) that it was his fault Resident #1 fell because he (maintenance supervisor) never showed him (CNA A) how to strap a resident in the van. The maintenance supervisor said the facility received a new van in [DATE] and he in-serviced the drivers, including CNA A, on securing residents in the van for transport. An in-service dated [DATE] indicated drivers were trained by literature, video, handout, and hands on training on securing the tie down straps and safe handling of residents during transportation. CNA A, CNA D, CNA F, and LVN C signed the sign in sheet and the maintenance supervisor was the instructor. During an interview on [DATE] at 1:26 p.m., the social worker said she called Resident #1 on [DATE] while she was admitted to the hospital for surgery of her femur. She said Resident #1 said she already had surgery and she was in good spirits. The social worker said she asked Resident #1 if she remembered the accident that occurred on [DATE] and Resident #1 said he (CNA A) put me in the van and did not strap me down, and then he started up and my chair fell over and I broke my leg in 2 places. They had to call the ambulance to come get me. The social worker said she asked Resident #1 if she knew where the accident took place and Resident #1 said it happened on facility property. She said Resident #1 said after she fell , CNA A apologized and said he loved her. The social worker said Resident #1 told her that CNA A stopped the van, there was blood, and everyone came running out of the facility. During an interview on [DATE] at 12:57 p.m., LVN B said on [DATE] about 11:00 a.m., she and a corporate nurse were standing outside the facility and saw CNA A load Resident #1 onto the van for her [MEDICAL TREATMENT] appointment. She said she was not able to see if he secured Resident #1 or her wheelchair in the van. LVN B said CNA A and Resident #1 left the facility parking lot and less than 5 minutes later she saw the van return to the facility parking lot. She said CNA A got out of the van and ran to the back of the van and opened the door, but she could not tell what he was doing. She said CNA A then ran to the side of the van and opened the side door and she heard a noise that sounded like yelling. She said she saw Resident #1 on the floor of the van and saw blood on the van floor. She said Resident #1 was sitting on her bottom, leaned up against a folded-up seat, with her left leg straight out and her right leg bent outwards. She said she ran inside the facility and grabbed gloves and notified staff to call 911. She said she applied pressure to Resident #1's bleeding right foot. LVN B said Resident #1 had a large cut to the top of her right foot and her right leg was deformed. She said she asked Resident #1 what happened and Resident #1 said he is an idiot (referring to CNA A) and he did not strap me in and I fell when he backed up when we were leaving here. She said Resident #1's wheelchair was secured in the van but Resident #1 was not secured in the wheelchair. She said the ADON and LVN C came outside and assisted with assessing Resident #1. She said Resident #1 said she had pain to her right lower extremity. LVN B said EMS arrived quickly and Resident #1 was transported to the local hospital. During an interview on [DATE] at 11:08 a.m., the ADON said on [DATE] at about 11:00 a.m., she heard LVN B yell that she needed towels and nursing staff outside because Resident #1 had fallen and was bleeding. She said she gathered supplies and told LVN C to go outside with her to assess Resident #1. She said Resident #1 was in front of her wheelchair and sitting on her bottom. She said Resident #1 was leaned up against a folded-up chair with her left leg straight out and her right leg straight out and bent out to the right at her knee. The ADON said she saw that Resident #1's wheelchair was secured in the van. She said Resident #1's right foot was bleeding, and it looked like she cut her foot on the locking mechanism that secured the wheelchair to the van. She said Resident #1 said she was not secured in her wheelchair when she fell . The ADON said Resident #1 complained of right leg pain and was grimacing. She said CNA A said the accident was the maintenance supervisor's fault because he did not tell him to strap residents in the van. She said she and the maintenance supervisor were able to remove the wheelchair from the van and EMS transported the resident to the hospital. During an interview on [DATE] at 11:36 a.m., LVN C said he was working on [DATE] when the ADON asked him to get some towels and he went outside to the van. He said Resident #1 was sitting on her bottom and there was blood on her right foot. He said LVN B was holding pressure to Resident #1's right foot laceration and there was obvious deformity to her right leg at the knee area. LVN C said Resident #1's inner right foot was laying flat against the van floor and Resident #1 said she was in pain. He said Resident #1 said that idiot (referring to CNA A) dropped me. LVN C said Resident #1's wheelchair was secured in the van and he unlatched the locking mechanism to remove Resident #1's wheelchair. He said EMS arrived and Resident #1 told EMS that her pain was 10 out of 10. He said Resident #1 received pain medication and EMS was able to get Resident #1 onto the stretcher and in the ambulance. LVN C said the facility received a new van in [DATE] and he was one of the drivers. He said he was trained on securing wheelchairs and residents in the van by the maintenance supervisor before driving the new van. He said he trained CNA A in [DATE] on securing the 4 locks that secure the wheelchair in place and securing the lap and shoulder harness for a resident in a wheelchair. LVN C said CNA A was very attentive and said the harnesses were the same as their old van. During an interview on [DATE] at 1:51 p.m., CNA E said on [DATE] around 11:00 a.m., she was outside and saw the van parked in the parking lot. She said she heard someone hollering and LVN B went to the van. She said she went over to the van and saw Resident #1 sitting on the floor hollering and crying. She said Resident #1's left leg was straight out, and her right leg was bent at the knee to the right. She said the right front wheel of Resident #1's wheelchair was sitting on her foot. She said Resident #1's right foot was bleeding, and she saw a gash on top of her foot. CNA E said she asked Resident #1 what happened and Resident #1 said that idiot (referring to CNA A) didn't strap me in. She said CNA A was in the parking lot yelling that he had not been trained on how to strap a resident in the van. CNA E said more nursing staff came outside to assess Resident #1. During an interview on [DATE] at 10:47 a.m., CNA D said she was usually the driver's back up, but she was off the morning of [DATE]. She said CNA A would drive the van if she and the driver both were not available. She said the maintenance supervisor called her after Resident #1's accident and told her she needed to come to the facility. She said while she was at the facility, CNA A told her that nobody showed him how to strap a resident in the van. She said CNA A said while transporting Resident #1 to [MEDICAL TREATMENT], he had to slam on the brakes and Resident #1 fell on to the floor. CNA D said CNA A did not say anything else about Resident #1's fall. She said no residents complained about CNA A being unsafe or not buckling them in the van. She said the facility received a new van in [DATE] and the driver in-serviced her on strapping a wheelchair and resident into the van. She said she was checked off to ensure she properly knew how to safely strap a resident and wheelchair in the van. CNA D said after Resident #1's accident, she came to the facility and the administrator in-serviced her on the correct way to strap a wheelchair and resident in the van. During an interview on [DATE] at 4:14 p.m., CNA F said he was the regular facility van driver and on [DATE] he tested positive for COVID-19. He said he was sent home and the administrator asked CNA A if he could transport Resident #1 to her [MEDICAL TREATMENT] appointment. CNA F said he transported Resident #1 to her [MEDICAL TREATMENT] appointments and CNA A would usually pick up Resident #1 from [MEDICAL TREATMENT] on Friday evening and bring her back to the facility. He said Resident #1 did not say anything to him about CNA A not securing her in the van properly. He said he was trained to secure a wheelchair in the van with 4 straps and the resident was secured in the wheelchair with a lap belt and shoulder harness. CNA F said there were no current residents in the facility that CNA A transported. The facility's transportation personnel policy dated [DATE] indicated .prior to providing transportation to any resident in the community van they will be completely trained on transportation requirements. If personnel fail any area on the checklist they will not be allowed to perform transportation until 100% competency is obtained. An orientation checklist with trainer's initials along with a pass (checkmark) verifying competency will be completed. General areas covered: general practice, driver's duties, driving, wheelchair lift, and wheelchair and occupant securement system. Copy of signed orientation checklist will go into the personnel file . The surveyor determined the facility was in non-compliance from [DATE] to [DATE]. The facility took the following actions to correct the non-compliance. An in-service dated [DATE] for nursing staff indicated they were trained on falls, fall prevention, and interventions for fall prevention including wheelchair safety. An in-service dated [DATE] for all facility staff indicated they were trained on the facility's abuse and neglect policy and reportable events. An employee disciplinary report dated [DATE] indicated CNA A was suspended pending investigation. An employee disciplinary report dated [DATE] indicated CNA A was terminated. Orientation of transportation personnel check lists dated [DATE] and [DATE] indicated the administrator completed van competency checks for CNA F, maintenance supervisor, LVN C, and CNA D. The check lists indicated the drivers were competent in general practice, driver's duties, driving, wheelchair lift, and wheelchair and occupant securement system. During an interview on [DATE] at 2:26 p.m., the maintenance supervisor said on [DATE], the administrator checked him for competency on how to use the wheelchair lift, driving, and how to secure a resident and a wheelchair in the van. During an interview on [DATE] at 11:36 a.m., LVN C said on [DATE], the maintenance supervisor checked him for competency on how to use the wheelchair lift, driving, and how to secure a resident and a wheelchair in the van. During an interview on [DATE] at 4:14 p.m., CNA F said on [DATE], the maintenance supervisor checked him for competency on how to use the wheelchair lift, driving, and how to secure a resident and a wheelchair in the van. During an interview on [DATE] at 10:47 a.m., CNA D said on [DATE], the maintenance supervisor checked her for competency on how to use the wheelchair lift, driving, and how to secure a resident and a wheelchair in the van. An in-service dated [DATE] for facility van drivers indicated if a resident had a fall or change of condition while being loaded or during transport in the facility van, pull to a safe place, stop the van, and call 911. Do not move the resident and do not continue the transport. Safe surveys of 11 residents were completed by the DON on [DATE] for dignity and safety and no residents voiced concern. The safe surveys indicated residents that were transported by the facility van said they felt safe during transport. During an interview on [DATE] at 3:12 p.m., Resident #2 said he rode in the facility van and his wheelchair was secured to the van floor and he was secured in his wheelchair. He said he had no concerns riding in the van. During an interview on [DATE] at 4:02 p.m. Resident #3 said she rode in the facility van in her wheelchair and she was secured in her wheelchair and her wheelchair was secured in the van. She said she felt safe while riding in the facility van.

Based on interview and record review the facility failed to ensure the right to be free from any significant medication errors was provided for 1 of 3 residents reviewed for significant medication errors. (Resident #1) The facility did not administer medications as ordered for Resident #1. MA B administered medications belonging to Resident #2 to Resident #1 which resulted in Resident #1 having low blood pressure, dizziness, and an overnight stay in the hospital for evaluation. This failure could place residents at risk of an adverse reaction, injury, or death from medication. Findings included: 1. Physician orders [REDACTED].#2 was to receive the following scheduled medications: [REDACTED]. A face sheet dated 03/11/20 indicated Resident #2 had the following Diagnoses: [REDACTED]. 2. Physician orders [REDACTED].#1 was to receive the following scheduled medications: [REDACTED]. An MDS dated [DATE] indicated Resident #1 understood other and was understood, she was moderately impaired cognitively. The MDS indicated Resident #1 had an active [DIAGNOSES REDACTED]. A care plan dated 02/10/20 indicated Resident #1 had a self-care deficit that required assistance as needed. The care plan indicated she had impaired physical mobility. A Provider Note dated 3/5/20 from the ER indicated Resident #1's pulse and blood pressure (normal blood pressure range is less than 120/80) were the following: *03/05/20 at 12:30 p.m. pulse was 82 and blood pressure was 92/59, *03/05/20 at 12:08 p.m. pulse 86 and blood pressure 99/67, *03/05/20 at 12:00 p.m. blood pressure 83/61, *03/05/20 at 11:48 a.m. blood pressure 92/68, *03/05/20 at 11:22 a.m. pulse 79 and blood pressure 108/69, *03/05/20 at 11:11 a.m. pulse 84 and blood pressure 89/63, *03/05/20 at 10:17 a.m. blood pressure 96/69, *03/05/20 at 10:00 a.m. pulse 86 and blood pressure 96/71, and *03/05/20 at 9:37 a.m. pulse 83 and blood pressure 116/77. The note documented MD C indicated Resident #1 was hypotensive (low blood pressure) while she was in the emergency department and had a history of [REDACTED]. MD C decided Resident #1 needed to stay at the hospital overnight to be observed. MD C indicated at 12:56 p.m. on 03/05/20 Resident #1 was in stable condition. Resident #1's admitting [DIAGNOSES REDACTED]. A Medication Error Report dated 03/05/20 indicated LVN A discovered on 03/05/20 at 8:53 a.m. Resident #1 received the wrong medications from MA B on 03/05/20 at 8:15 a.m. The following were medications ordered for Resident #1 to be administered : [MEDICATION NAME]-[MEDICATION NAME] 25 mg-100 mg disintegrating tablets two tablets sublingually three time a day, [MEDICATION NAME] Migraine 250 mg-250 mg-65 mg tablet two tablets by mouth twice a day as needed for pain/headache, Potassium Chloride ER 20 mEq tablet by mouth twice a day with food or after meal with 4-8 ounces of water/juice, Pramipexole 0.5 mg tablet by mouth three times a day, and [MEDICATION NAME] 40 mg by mouth twice a day. The report indicated the error was the wrong medications to the wrong patient due to failure to identify patient. MA B indicated while she was doing her morning medication administration Resident #1 was sitting in her wheelchair in the doorway when she asked MA B for her medications. MA B indicated there was no name on the door label, so she pulled the medications by the room number. MA B said Resident #1 asked her what the red pill was for, so MA B told her it would help with Resident #1's bowel movements. MA B indicated Resident #1 took the red pills out and took the rest of the medications. MA B indicated later LVN A told her Resident #1 had come to him and told him MA B had given her the wrong medications. The resident was sent to the ER and returned to the facility. The error was classified at a D level which indicated it was an error that resulted in the need for increased patient monitoring but no patient harm. An undated list included in the facility's investigation packet indicated Resident #1 was given the following medications in error: [MEDICATION NAME] (oral medication for blood pressure) 25 mg tablet, [MEDICATION NAME] ER (oral medication for blood pressure) 30 mg two tablets, Aspirin (blood thinner) 81 mg tablet, [MEDICATION NAME] (oral medication for fluid retention and blood pressure) 1 mg tablet, Carvedilol (oral medication for blood pressure) 6.25 mg tablet, [MEDICATION NAME] CD (oral medication for blood pressure and chest pain) 180 mg capsule, [MEDICATION NAME] Sodium (stool softener) 100 mg two capsules, Apixaban (blood thinner) 2.5 mg tablet, and [MEDICATION NAME] (oral form of Vitamin B12 to treat Vitamin B12 deficiency) 1,000 mcg tablet. A nursing note dated 03/05/20 at 12:25 p.m., completed by LVN A indicated he was making rounds at approximately 8:15 a.m. on 03/05/20 when Resident #1 asked him if she had any new medication changes. He told her he was not aware of any changes and asked Resident #1 why she was asking. LVN A indicated Resident #1 told him she had a few extra pills that morning when she received her medications from MA B. LVN A indicated he immediately reviewed Resident #1's chart and saw there were no medications changes, he had Resident #1 describe the medications she was given and said they were consistent with medications for Resident #2 who previously lived in Resident #1's room. LVN A assessed Resident #1, she reported feeling dizzy, took her vital signs and recorded as low, and notified the DON and doctor. LVN A indicated Resident #1 was transferred to the hospital. A typed and signed statement dated 03/05/20 by MA B indicated while she was passing morning medications, Resident #1 was sitting in her wheelchair in the doorway and asked for her medications. MA B said there was no name on the door label, so she pulled the medications by the room number. MA B said Resident #1 asked what the red pill was for and she told her it was to help her bowel movements. MA B said Resident #1 removed the red pills and took the rest of the medications. MA B said later LVN A told her Resident #1 indicated she had given Resident #1 the wrong medications. An in-service training form dated 03/05/20 at 9:00 a.m., indicated MA B was in-serviced on the rights of medication administration. The in-service indicated the first step was to make sure you had the right patient by: checking the name on the order and the patient, using 2 identifiers, asking the patient to identify himself/herself, and when available use technology (for example bar-code system, photo). An undated Medication Administration Module included in the facility's investigation paperwork indicated, e. Right Resident: before giving a medication, the nurse needs to ensure that he/she is giving it to the right person. The nurse should use two identifiers, which may vary by facility policy and generally include the resident's name and birth day. These identifiers should be checked against the resident's identification band or by using the MAR. No matter how long the nurse has been caring for the resident or how well the nurse knows the resident, each time medication is to be administered; two identifiers should be used to confirm that it is the right resident. During an interview on 03/11/20 at 3:14 p.m., the DON said MA B had been trained in each area of the building. She said she wants the PRN staff to be able to work in any area of the building. The DON said the MAs and nurses can identify a resident for medication administration by verbally asking them their name, picture identification, or the computer. She said Resident #1 had changed rooms the night prior to being administered the wrong medications. She said room changes usually take place during normal business hours, so all parts of the facility are aware of the room change. She said for some reason Resident #1's room change took place after normal business hours, she said the medication error was due to this room change. She said not all the pieces of a room change had been implemented such as the resident's name being put on the door. The DON said MA B identified Resident #1 by the room number and not by her name. She said MA B could have called Resident #1 by the prior patient's name, and Resident #1 just did not hear her. The DON said MA B has an accent, so it is difficult to understand her at times, she said Resident #1 may not have understood what MA B was saying. The DON said she was told Resident #1 questioned MA B about some of the pills she received, and MA B explained them to her. She said about 30 minutes passed between Resident #1 being given the wrong medications and reporting the incident to LVN A. She said Resident #1 was hypotensive (low blood pressure) after receiving the medications belonging to Resident #2. The DON said Resident #1's blood pressure rises and falls frequently, so that was not abnormal for her. The DON denied Resident #1 having any other symptoms. She said most of the medications had not affected Resident #1 because they were extended release medications. She said EMS was called, and Resident #1 was transferred to the hospital to be observed. The DON said she was going to implement a policy if a resident does not have a picture ID on their eMAR, a nurse was required to lay eyes on the resident and verify the resident before any medications were given. During an interview on 03/11/20 at 4:37 p.m., LVN D said identifiers that can be used to identify a resident for medication administration include the resident telling their name, the room number, the picture on the resident's eMAR, and asking other staff to identify the resident. During an interview on 03/11/20 at 4:43 p.m., LVN E said she says the resident's name before she gives medications. She said if it is a new resident, the prior nurse would introduce her to the resident. LVN E said she does not use the picture on the eMAR because it is tiny and hard to tell if it is the resident or not. She said if she had any doubt in identifying a resident, she would get someone else to verify with her. A Medication Administration Policy dated 2007 indicated, .5. Review and confirm MEDICATION ORDERS FOR [REDACTED]

Based on observation, interview, and record review, the facility failed to implement their policies and procedures to prohibit neglect for 1 of 3 residents reviewed for neglect. (Resident #1) Resident #1 had a history of [REDACTED]. The care plans and MDS assessment for Resident #1 indicated she required assistance with showers. The facility nurses and CNAs were aware she was taking showers unassisted. She was unassisted in the shower, fell , suffered a large hematoma, and died on [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 3 residents who took showers without assistance at risk for accident, injury or death. Findings included: A computerized physician order [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had little or no cognitive impairment. She required extensive assistance with ADLs, including bed mobility, transfers, walking in the room, and in the corridor of one person. She also required the assistance of one staff for toilet use and personal hygiene. Resident #1's functional status for bathing was physical help limited to transfer only. Her balance during transitions and walking was not steady, but she was able to stabilize without staff assistance. She used a walker and a wheelchair. A care plan dated [DATE] indicated Resident #1 was at risk for falls, due to impaired physical mobility, problems with balance, and she used a walker. Resident #1 was to receive assistance with showers. She was to use the rolling walker to cue for safety, and a wheelchair for long distances. A Change of Condition report dated [DATE] indicated Resident #1 had a fall due to hypoglycemic episode (low blood sugar). At 5:45 a.m., the resident was found in the bathroom on the floor. Her blood sugar was 32. There were no injuries noted. A nursing note dated [DATE] indicated at about 4:15 a.m., Resident #1's blood sugar was 27. She was non-responsive, cold, clammy, and her eyes were slightly open. She was given [MEDICATION NAME] injection and at 4:45 a.m., her blood sugar level was 57 and she became responsive. The note indicated by 5:45 a.m., Resident #1's blood sugar level had increased to 157 and she returned to her normal self. The physician was notified. A physician progress notes [REDACTED].#1 had a hypoglycemic episode last week. Her blood sugar continued to be erratic due to her eating habits. This was discussed with the staff. The physician documented .severe hypoglycemic episodes are very dangerous . An Incident Report dated [DATE] indicated at 6:15 a.m., Resident #1 was bathing/showering unassisted and sustained a head injury. The resident got out of the shower chair by herself, lost her balance, and fell forward, hitting her face on the floor. Resident #1 was independent with supervision for transfers. She used a walker and a wheelchair for assistance. She was provided first aid and neurological checks. Her blood sugar was checked and was 34. Resident #1 was sent to the emergency room at 7:45 a.m. The form indicated the DON and administrator signed the form electronically. The neurological checks for Resident #1 dated [DATE] indicated at 6:30 a.m., her pupils were equally reactive to light. At 7:00 a.m., the pupils were sluggish and the resident's level of consciousness was drowsy. At 7:15 a.m., Resident #1's level of consciousness was stuporous and her pupils and extremities were sluggish. A hospital History and Physical dated [DATE] indicated Resident #1 fell and hit her face this morning, and her blood sugar was 34. She was given [MEDICATION NAME] and put back to bed. An hour later she was found unresponsive. Resident #1 had a lot of blood in her throat that was suctioned. She was transferred to an outside facility for evaluation. A computed tomography (CT) scan of the head demonstrated a large left sided subdural hematoma with approximately 3.3 centimeter (cm) shift. Resident #1 was intubated for airway protection. She was placed in a higher level of care. The resident was at high risk for acute physiological deterioration and death. A Hospital Critical Care Progress note dated [DATE] indicated Resident #1 sustained a severe [MEDICAL CONDITION]. She had a subdural hemorrhage with midline shift. Resident #1 was deemed to have a non-operable and non-survivable inury. During an interview on [DATE] at 11:11 a.m., Resident #1's family member said when the resident was hospitalized on [DATE] they were told she would not live, due to the severity of her injury. They said Resident #1 was taken off life support and died on [DATE]. During an interview on [DATE] at 1:51 p.m., CNA A said when she arrived at the facility on [DATE] at approximately 6:00 a.m., Resident #1 was in the shower alone. CNA A said Resident #1 took showers alone, all the time. CNA A said CNA I called her to the shower about 15 minutes later; when Resident #1 was heard hollering for help. When she got to the shower room, Resident #1 was on her knees with her head facing the wall. She said Resident #1 appeared to be dazed and had blood coming from her lip. CNA A said she dressed her and took her to the dining room. She said LVN J took Resident #1's blood sugar and it was 34. CNA A said LVN J gave her something to eat, but Resident #1 threw it up. She said Resident #1 was talking, but appeared dazed. CNA A said the only injury she saw was some bruising and blood on Resident #1's lip. During an interview on [DATE] at 2:06 p.m., LVN B said it was their protocol that no resident took a shower alone, due to the possibility of accidents. During an interview on [DATE] at 2:10 p.m., CNA C said she worked with Resident #1 on [DATE], but did not give her a shower. CNA C said she heard Resident #1 fell , because she had a low blood sugar episode, but said the resident was not a fall risk. During an interview on [DATE] at 3:37 p.m., the DON said she did not know Resident #1 was taking showers unsupervised. She said the facility did not have a policy on supervision during showers. The DON said all residents should be supervised during showers because they are at the facility for a reason and need someone in the shower with them. The DON said Resident #1 was non-compliant with her diet, but was compliant with care. She said Resident #1 was care planned to have assistance during showers, but the CNAs apparently saw Resident #1 as being independent. During an interview on [DATE] at 4:15 p.m., CNA D said she worked with Resident #1 a few times, but never gave her a shower. She said residents were not supposed to be left in the shower unattended. During an interview on [DATE] at 4:19 p.m., LVN E said Resident #1 was not compliant with her diet, but she was compliant with her care. She said she would not allow residents to take a shower unassisted. LVN E said people get hurt, and there are safety issues associated with wet floors, and falls. During an interview on [DATE] at 4:24 p.m., CNA F said she would never leave residents alone in the shower. She said after the incident with Resident #1, several CNAs told her Resident #1 took showers unassisted all the time. During an interview on [DATE] at 5:11 p.m., the administrator said she was not aware of any policy about supervision during showers. She said she was not responsible for resident nursing care issues. The administrator said showers were a nursing issue and the DON was in charge of those issues. The administrator said she did not know about care plans. She was not in charge of those, and did not know Resident #1 suffered a hematoma when she fell . The administrator said she knew Resident #1 died , but did not know the reason. The administrator said she thought it was from blood sugar issues. During a telephone interview on [DATE] at 5:32 p.m., LVN G said on [DATE] at approximately 6:00 a.m., she went in the shower to put some dirty linens in the barrel and heard the shower running. She said Resident #1 was taking a shower, unassisted. LVN G said she asked Resident #1 if she was okay and the resident said she was fine. She said Resident #1 was allowed to take a shower, unassisted, all the time. She said she walked out and saw two CNAs coming in and told them Resident #1 was in the shower alone. LVN G said the CNAs said Resident #1 took showers alone, all the time. She said she did report with the day nurse and left. LVN G said she heard Resident #1 fell that same morning, and hit her head on the tile in the bathroom. During an interview on [DATE] at 6:34 p.m., RN H said he knew Resident #1 had showered, unassisted, on two occassions in the past (dates unrecalled.) The Provider Letter ,[DATE] dated [DATE] indicated . Neglect is the failure to provide services necessary to avoid physical harm. The facility must determine if the injury, harm or death of a resident was due to facility failure to provide services to the resident. Examples include: Physician orders [REDACTED]. The undated facility Abuse Prohibition Management Policy with no date indicated .to prevent abuse/neglect: deploy staff on each shift to meet the needs of residents and assure that the staff assigned has knowledge of the individual resident care needs. The assessment, care planning, and monitoring of residents with needs might lead to neglect The administrator, DON, and ADON were notified on [DATE] at 5:50 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] at 8:05 p.m., and included: Plan of Correction [DATE] SUPERVISION OF PREVENTING ACCIDENTS 1. Resident assessed by Licensed Nurse, neuros started immediately, along with interventions for [DIAGNOSES REDACTED]. Upon noted changes in neuros, the resident was transported to hospital ER. 2. All residents that shower unassisted have the potential to be affected. 3. To assure accuracy, a 100% assessment of the residents in need of supervision during showers by DON/ADON started on [DATE] to be completed on [DATE] and cross referenced with the most recent fall risk assessment. Direct Care Staff will be in-service by DON on [DATE] to review the assessment results and to ensure appropriate supervision during showers. A 100% audit of Care Plans beginning on [DATE] and updated by DON/ADON/Designee, to be completed by [DATE] to make sure the Care Plan is accurate and compared to the ADL Plan of Care and followed. Residents in disagreement with shower supervision will be reflected in the Care Plan. Direct Care Staff will be instructed by the DON/ADON to offer a shower chair, non-skid socks, or some other means to make them safe along with remaining close in the event of being needed. These residents will be educated on the hazards of showering alone, and direct care staff will be in-serviced on the care plans by the DON/Designee. 4. As part of the morning clinical meetings, all of the I/A Reports will be reviewed and Care Plans updated accordingly with the nursing management team as a part of the care plan update. Fall risk assessments will be completed upon admission, quarterly, and change of conditions. QA will monitor results for ongoing compliance. 5. Completion Date: [DATE] with all staff unavailable to attend the in-services to be addressed by the DON/ADON/Designee prior to beginning their shift. On [DATE] the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Two LVNs, and 5 CNAs on different shifts said they were in-serviced that all residents were to be supervised while in the shower and following care plans. The LVNs said they also received additional in-service regarding assessments. On [DATE] at 2:50 p.m., the administrator, DON, and ADON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on [DATE] at 3:10 p.m., DON said 3 residents showered without assistance.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures to prohibit mistreatment, neglect, abuse or misappropriation of resident property for 1 of 2 residents reviewed for abuse/neglect. (Resident # 1) Resident #1 had a history of [REDACTED]. The care plans and MDS assessment for Resident #1 indicated she required assistance with showers. The facility nurses and CNAs were aware she was taking showers unassisted. She was unassisted in the shower, fell and suffered a large hematoma, and died on [DATE]. The facility did not report the incident immediately to the State agency. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 3 residents who took showers without assistance at risk for accident, injury or death. Findings included: The undated facility Abuse Prohibition Management Policy indicated .to prevent abuse/neglect: deploy staff on each shift to meet the needs of residents and assure that the staff assigned has knowledge of the individual resident care needs. The assessment, care planning, and monitoring of residents with needs might lead to neglect. The responsibilities of the abuse coordinator are to assure the timely identification, and reporting of incidences of abuse/neglect A computerized physician order [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. A computerized physician order [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had little or no cognitive impairment. She required extensive assistance of one person with ADLs including bed mobility, transfers, walking in the room, and in the corridor. She also required the assistance of one staff for toilet use and personal hygiene. Resident #1's functional status for bathing was physical help limited to transfer only. Her balance during transitions and walking was not steady, but she was able to stabilize without staff assistance. She used a walker and a wheelchair. A care plan dated [DATE] indicated Resident #1 was at risk for falls, due to impaired physical mobility, problems with balance, and she used a walker. Resident #1 was to receive assistance with showers. She was to use the rolling walker to cue for safety, and a wheelchair for long distances. A Change of Condition report dated [DATE] indicated Resident #1 had a fall due to a hypoglycemic episode (low blood sugar). At 5:45 a.m., the resident was found in the bathroom on the floor. Her blood sugar was 32. There were no injuries noted. A nursing note dated [DATE] indicated at about 4:15 a.m., Resident #1's blood sugar was 27. She was non-responsive, cold, clammy, and her eyes were slightly open. She was given [MEDICATION NAME] injection and at 4:45 a.m., her blood sugar level was 57 and she became responsive. The note indicated by 5:45 a.m., Resident #1's blood sugar level had increased to 157 and she returned to her normal self. The physician was notified. A physician progress notes [REDACTED].#1 had a hypoglycemic episode last week. Her blood sugar continued to be erratic due to her eating habits. This was discussed with the staff. The physician documented .severe hypoglycemic episodes are very dangerous . An Incident Report dated [DATE] indicated at 6:15 a.m., Resident #1 was bathing/showering unassisted and sustained a head injury. The resident got out of the shower chair by herself, lost her balance, and fell forward, hitting her face on the floor. Resident #1 was independent with supervision for transfers. She used a walker and a wheelchair for assistance. She was provided first aid and neurological checks. Her blood sugar was checked and was 34. Resident #1 was sent to the emergency room at 7:45 a.m. The form indicated the DON and administrator signed the form electronically. The neurological checks for Resident #1 dated [DATE] indicated at 6:30 a.m., her pupils were equally reactive to light. At 7:00 a.m., the pupils were sluggish and the resident's level of consciousness was drowsy. At 7:15 a.m., Resident #1's level of consciousness was stuporous and her pupils and extremities were sluggish. A hospital History and Physical dated [DATE] indicated Resident #1 fell and hit her face this morning, and her blood sugar was 34. She was given [MEDICATION NAME] and put back to bed. An hour later she was found unresponsive. Resident #1 had a lot of blood in her throat that was suctioned. She was transferred to an outside facility for evaluation. A computed tomography (CT) scan of the head demonstrated a large left sided subdural hematoma with approximately 3.3 centimeter (cm) shift. Resident #1 was intubated for airway protection. She was placed in a higher level of care. The resident was at high risk for acute physiological deterioration and death. A Hospital Critical Care Progress note dated [DATE] indicated Resident #1 sustained a severe [MEDICAL CONDITION]. She had a subdural hemorrhage with midline shift. Resident #1 was deemed to have a non-operable and non-survivable injury. During an interview on [DATE] at 11:11 a.m., Resident #1's family member said when the resident was hospitalized on [DATE] they were told she would not live, due to the severity of her injury. They said Resident #1 was taken off life support and died on [DATE]. During an interview on [DATE] at 1:51 p.m., CNA A said when she arrived at the facility on [DATE] at approximately 6:00 a.m., Resident #1 was in the shower alone. CNA A said Resident #1 took showers alone, all the time. CNA A said CNA I called her to the shower about 15 minutes later; when Resident #1 was heard hollering for help. When she got to the shower room, Resident #1 was on her knees with her head facing the wall. She said Resident #1 appeared to be dazed and had blood coming from her lip. CNA A said she dressed her and took her to the dining room. She said LVN J took Resident #1's blood sugar and it was 34. CNA A said LVN J gave her something to eat, but Resident #1 threw it up. She said Resident #1 was talking, but appeared dazed. CNA A said the only injury she saw was some bruising and blood on Resident #1's lip. During an interview on [DATE] at 2:06 p.m., LVN B said it was their protocol that no resident took a shower alone, due to the possibility of accidents. During an interview on [DATE] at 2:10 p.m., CNA C said she worked with Resident #1 on [DATE], but did not give Resident #1 a shower. CNA C said she heard that Resident #1 fell , because she had a low blood sugar episode, but was not a fall risk. During an interview on [DATE] at 3:37 p.m., the DON said she did not know Resident #1 was taking showers unsupervised. She said the facility did not have a policy on supervision during showers. The DON said all residents should be supervised during showers because they are at the facility for a reason and need someone in the shower with them. The DON said Resident #1 was non-compliant with her diet, but was compliant with care. She said Resident #1 was care planned to have assistance during showers, but the CNAs apparently saw The DON said they had not considered Resident #1's incident to be reportable to the State agency because they knew Resident #1 fell . During an interview on [DATE] at 4:15 p.m., CNA D said she worked with Resident #1 a few times, but never gave her a shower. She said residents were not supposed to be left in the shower unattended. During an interview on [DATE] at 4:19 p.m., LVN E said Resident #1 was not compliant with her diet, but she was compliant with her care. She said she would not let residents take a shower unassisted. LVN E said people get hurt, and there are safety issues associated with wet floors, and falls. During an interview on [DATE] at 4:24 p.m., CNA F said she would never leave residents alone in the shower. She said after the incident with Resident #1 several CNAs told her Resident #1 took showers unassisted all the time. During an interview on [DATE] at 5:11 p.m., the administrator said she was not aware of any policy about supervision during showers. She said she was not responsible for resident nursing care issues. The administrator said showers were a nursing issue and the DON was in charge of those issues. The administrator said she did not know about care plans. She was not in charge of those, and did not know Resident #1 suffered a hematoma when she fell . The administrator said she knew Resident #1 died , but did not know the reason. The administrator said she thought it was from blood sugar issues. She said she did not report the incident to the State agency, because it was not a suspicious death and the resident did not die at the facility. The administrator did not consider the incident neglectful on the part of the staff. During a telephone interview on [DATE] at 5:32 p.m., LVN G said on [DATE] at approximately 6:00 a.m., she went in the shower to put some dirty linens in the barrel and heard the shower running. She said Resident #1 was taking a shower, unassisted. LVN G said she asked Resident #1 if she was okay and the resident said she was fine. She said Resident #1 was allowed to take a shower, unassisted all the time. She said she walked out and saw two of the CNAs coming in and told them Resident #1 was in the shower alone. LVN G said the CNAs said Resident #1 took showers, alone all the time. She said she did report with the day nurse and left. LVN G said she heard the Resident #1 fell that same morning and hit her head on the tile in the bathroom. During an interview on [DATE] at 6:34 p.m., RN H said he knew Resident #1 had showered, unassisted on two previous occassions (dates unrecalled.) The administrator, DON, and ADON was notified on [DATE] at 5:50 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] at 8:05 p.m., and included: Plan of Correction [DATE] SUPERVISION OF PREVENTING ACCIDENTS 1. Resident assessed by Licensed Nurse, neuros started immediately, along with interventions for [DIAGNOSES REDACTED]. Upon noted changes in neuros, the resident was transported to hospital ER. 2. All residents that shower unassisted have the potential to be affected. 3. To assure accuracy, a 100% assessment of the residents in need of supervision during showers by DON/ADON started on [DATE] to be completed on [DATE] and cross referenced with the most recent fall risk assessment. Direct Care Staff will be in-service by DON on [DATE] to review the assessment results and to ensure appropriate supervision during showers. A 100% audit of Care Plans beginning on [DATE] and updated by DON/ADON/Designee, to be completed by [DATE] to make sure the Care Plan is accurate and compared to the ADL Plan of Care and followed. Residents in disagreement with shower supervision will be reflected in the Care Plan. Direct Care Staff will be instructed by the DON/ADON to offer a shower chair, non-skid socks, or some other means to make them safe along with remaining close in the event of being needed. These residents will be educated on the hazards of showering alone, and direct care staff will be in-serviced on the care plans by the DON/Designee. 4. As part of the morning clinical meetings, all of the I/A Reports will be reviewed and Care Plans updated accordingly with the nursing management team as a part of the care plan update. Fall risk assessments will be completed upon admission, quarterly, and change of conditions. QA will monitor results for ongoing compliance. 5. Completion Date: [DATE] with all staff unavailable to attend the in-services to be addressed by the DON/ ADON/Designee prior to beginning their shift. On [DATE] the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Two LVNs, and 5 CNAs on different shifts said they were in-serviced that all residents were to be supervised while in the shower and following care plans. The LVNs said they also received additional in-service regarding assessments. On [DATE] at 2:50 p.m., the administrator, DON, and ADON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on [DATE] at 3:10 p.m., DON said 3 residents showered without assistance.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision for 1 of 3 residents reviewed for accident/hazards. (Resident #1) Resident #1 had a history of [REDACTED]. The care plans and MDS assessment for Resident #1 indicated she required assistance with showers. The facility nurses and CNAs were aware she was taking showers unassisted. She was unassisted in the shower, fell and suffered a large hematoma, and died on [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 3 residents who took showers without assistance at risk for accident, injury or death. Findings included: A computerized physician order [REDACTED].#1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had little or no cognitive impairment. She required extensive assistance of one person with ADLs including bed mobility, transfers, walking in the room, and in the corridor. She also required the assistance of one staff for toilet use and personal hygiene. Resident #1's functional status for bathing was physical help limited to transfer only. Her balance during transitions and walking was not steady, but she was able to stabilize without staff assistance. She used a walker and a wheelchair. A care plan dated [DATE] indicated Resident #1 was at risk for falls, due to impaired physical mobility, problems with balance, and she used a walker. Resident #1 was to receive assistance with showers. She was to use the rolling walker to cue for safety, and a wheelchair for long distances. A Change of Condition report dated [DATE] indicated Resident #1 had a fall due to a hypoglycemic episode (low blood sugar). At 5:45 a.m., the resident was found in the bathroom on the floor. Her blood sugar was 32. There were no injuries noted. A nursing note dated [DATE] indicated at about 4:15 a.m., Resident #1's blood sugar was 27. She was non-responsive, cold, clammy, and her eyes were slightly open. She was given GlucaGen injection and at 4:45 a.m., her blood sugar level was 57 and she became responsive. The note indicated by 5:45 a.m., Resident #1's blood sugar level had increased to 157 and she returned to her normal self. The physician was notified. A physician progress notes [REDACTED].#1 had a hypoglycemic episode last week. Her blood sugar continued to be erratic due to her eating habits. This was discussed with the staff. The physician documented .severe hypoglycemic episodes are very dangerous . An Incident Report dated [DATE] indicated at 6:15 a.m., Resident #1 was bathing/showering unassisted and sustained a head injury. The resident got out of the shower chair by herself, lost her balance, and fell forward, hitting her face on the floor. Resident #1 was independent with supervision for transfers. She used a walker and a wheelchair for assistance. She was provided first aid and neurological checks. Her blood sugar was checked and was 34. Resident #1 was sent to the emergency room at 7:45 a.m. The form indicated the DON and administrator signed the form electronically. The neurological checks for Resident #1 dated [DATE] indicated at 6:30 a.m., her pupils were equally reactive to light. At 7:00 a.m., the pupils were sluggish and the resident's level of consciousness was drowsy. At 7:15 a.m., Resident #1's level of consciousness was stuporous and her pupils and extremities were sluggish. A hospital History and Physical dated [DATE] indicated Resident #1 fell and hit her face this morning, and her blood sugar was 34. She was given dextrose and put back to bed. An hour later she was found unresponsive. Resident #1 had a lot of blood in her throat that was suctioned. She was transferred to an outside facility for evaluation. A computed tomography (CT) scan of the head demonstrated a large left sided subdural hematoma with approximately 3.3 centimeter (cm) shift. Resident #1 was intubated for airway protection. She was placed in a higher level of care. The resident was at high risk for acute physiological deterioration and death. A Hospital Critical Care Progress note dated [DATE] indicated Resident #1 sustained a severe traumatic brain injury. She had a subdural hemorrhage with midline shift. Resident #1 was deemed to have a non-operable and non-survivable injury. During an interview on [DATE] at 11:11 a.m., Resident #1's family member said when the resident was hospitalized on [DATE] they were told she would not live, due to the severity of her injury. They said Resident #1 was taken off life support and died on [DATE]. During an interview on [DATE] at 1:51 p.m., CNA A said when she arrived at the facility on [DATE] at approximately 6:00 a.m., Resident #1 was in the shower alone. CNA A said Resident #1 took showers alone, all the time. CNA A said CNA I called her to the shower about 15 minutes later; when Resident #1 was heard hollering for help. When she got to the shower room, Resident #1 was on her knees with her head facing the wall. She said Resident #1 appeared to be dazed and had blood coming from her lip. CNA A said she dressed her and took her to the dining room. She said LVN J took Resident #1's blood sugar and it was 34. CNA A said LVN J gave her something to eat, but Resident #1 threw it up. She said Resident #1 was talking, but appeared dazed. CNA A said the only injury she saw was some bruising and blood on Resident #1's lip. During an interview on [DATE] at 2:06 p.m., LVN B said it was their protocol that no resident took a shower alone, due to the possibility of accidents. During an interview on [DATE] at 2:10 p.m., CNA C said she worked with Resident #1 on [DATE], but did not give Resident # 1 a shower. CNA C said she heard Resident #1 fell , because she had a low blood sugar episode, but was not a fall risk. During an interview on [DATE] at 3:37 p.m., the DON said she did not know Resident #1 was taking showers unsupervised. She said the facility did not have a policy on supervision during showers. The DON said all residents should be supervised during showers because they are at the facility for a reason and need someone in the shower with them. The DON said Resident #1 was non-compliant with her diet, but was compliant with care. She said Resident #1 was care planned to have assistance during showers, but the CNAs apparently saw Resident #1 as being independent. During an interview on [DATE] at 4:15 p.m., CNA D said she worked with Resident #1 a few times, but never gave her a shower. She said residents were not supposed to be left in the shower unattended. During an interview on [DATE] at 4:19 p.m., LVN E said Resident #1 was not compliant with her diet, but she was compliant with her care. She said she would not let residents take a shower unassisted. LVN E said people get hurt, and there are safety issues associated with wet floors, and falls. During an interview on [DATE] at 4:24 p.m., CNA F said she would never leave residents alone in the shower. She said after the incident with Resident #1 several CNAs told her Resident #1 took showers unassisted all the time. During an interview on [DATE] at 5:11 p.m., the administrator said she was not aware of any policy about supervision during showers. She said she was not responsible for resident nursing care issues. The administrator said showers were a nursing issue and the DON was in charge of those issues. The administrator said she did not know about care plans. She was not in charge of those, and did not know Resident #1 suffered a hematoma when she fell . The administrator said she knew Resident #1 died , but did not know the reason. The administrator said she thought it was from blood sugar issues. During a telephone interview on [DATE] at 5:32 p.m., LVN G said on [DATE] at approximately 6:00 a.m., she went in the shower to put some dirty linens in the barrel and heard the shower running. She said Resident #1 was taking a shower, unassisted. LVN G said she asked Resident #1 if she was okay and the resident said she was fine. She said Resident #1 was allowed to take a shower, unassisted all the time. She said she walked out and saw two of the CNAs coming in and told them Resident #1 was in the shower alone. LVN G said the CNAs said Resident #1 took showers, alone all the time. She said she did report with the day nurse and left. LVN G said she heard the Resident #1 fell that same morning and hit her head on the tile in the bathroom. During an interview on [DATE] at 6:34 p.m., RN H said he knew Resident #1 had showered, unassisted on two previous occasions (dates unrecalled.) The administrator, DON, and ADON was notified on [DATE] at 5:50 p.m., an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on [DATE] at 8:05 p.m., and included: Plan of Correction [DATE] SUPERVISION OF PREVENTING ACCIDENTS 1. Resident assessed by Licensed Nurse, neuros started immediately, along with interventions for [DIAGNOSES REDACTED]. Upon noted changes in neuros, the resident was transported to hospital ER. 2. All residents that shower unassisted have the potential to be affected. 3. To assure accuracy, a 100% assessment of the residents in need of supervision during showers by DON/ADON started on [DATE] to be completed on [DATE] and cross referenced with the most recent fall risk assessment. Direct Care Staff will be in-service by DON on [DATE] to review the assessment results and to ensure appropriate supervision during showers. A 100% audit of Care Plans beginning on [DATE] and updated by DON/ADON/Designee, to be completed by [DATE] to make sure the Care Plan is accurate and compared to the ADL Plan of Care and followed. Residents in disagreement with shower supervision will be reflected in the Care Plan. Direct Care Staff will be instructed by the DON/ADON to offer a shower chair, non-skid socks, or some other means to make them safe along with remaining close in the event of being needed. These residents will be educated on the hazards of showering alone, and direct care staff will be in-serviced on the care plans by the DON/Designee. 4. As part of the morning clinical meetings, all of the I/A Reports will be reviewed and Care Plans updated accordingly with the nursing management team as a part of the care plan update. Fall risk assessments will be completed upon admission, quarterly, and change of conditions. QA will monitor results for ongoing compliance. 5. Completion Date: [DATE] with all staff unavailable to attend the in-services to be addressed by the DON/ ADON/Designee prior to beginning their shift. On [DATE] the surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Two LVNs, and 5 CNAs on different shifts said they were in-serviced that all residents were to be supervised while in the shower and following care plans. The LVNs said they also received additional in-service regarding assessments. On [DATE] at 2:50 p.m., the administrator, DON, and ADON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on [DATE] at 3:10 p.m., DON said 3 residents showered without assistance.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent falls for 1 of 6 residents reviewed for accidents. (Resident #1) Resident #1 was assessed as requiring assistance of 2 staff members for transfers. Resident #1 was assisted by one staff member to transfer from the bed to the wheelchair, fell and sustained a fractured leg. This failure could place 82 residents who required assistance with transfers at risk for falls. Findings included: A face sheet dated 05/07/15 indicated Resident #1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. A Fall Risk assessment dated [DATE] indicated Resident #1 was high risk for falls, required extensive assistance for transfers, and had a history of [REDACTED]. An Admission Data assessment dated [DATE] indicated Resident #1 was 6' 3" tall; weighed 208 pounds; had problems with balance and required assistance; was total dependent for transfers; and had pain in the right and left leg affecting his mobility. The most recent MDS dated [DATE] indicated Resident #1 had moderately impaired cognition, required extensive assistance of 2 staff members for transfers; was not steady, only able to stabilize with staff assistance during surface to surface transfers (transfer between bed and chair or wheelchair); and had no history of falls or falls since admission. The most recent care plan dated 09/03/14 indicated Resident #1 required total assistance for transfers and was a fall risk. The most recent Fall Risk assessment dated [DATE] indicated Resident #1 was at high risk for falls, was total dependent for transfers, and had a history of [REDACTED]. An Incident Report dated 04/30/15 indicated Resident #1 was transferred from bed to wheelchair, the resident slid from the wheelchair and went down on his left leg. Nursing notes dated 04/30/15 indicated Resident #1 was transferred to the wheelchair; the resident slid from the wheelchair and went down on his left leg. The physician was notified and an order was obtained to send the resident to the emergency room . A hospital History and Physical dated 04/30/15 indicated Resident #1 was admitted to the hospital with [REDACTED]. During an interview on 05/06/15 at 4:00 p.m., Resident #1 ' s family member said the facility usually used the Hoyer lift to transfer the resident. She said they did not use the lift when transferring him from the bed to the wheelchair when his leg was fractured. During an observation and interview on 05/06/15 at 5:00 p.m., Resident #1 was at the local hospital. The resident was in bed with a cast to the left lower leg. The resident said the " swing " was not used when he hurt his leg. During an interview on 05/06/15 at 5:15 p.m., the hospital nurse said Resident #1 had a fractured tibia and fibula (bones in the lower leg). He said due to the resident's condition he was not a candidate for surgery to repair the fracture and the orthopedic physician casted the leg. A written statement dated 04/30/15 from CNA A indicated she transferred Resident #1 to his chair but he was not all the way in the chair. She said as she pulled him back in the chair he started sliding out of the chair. She said when he slid out to the floor his left ankle "popped". She said she laid him on the floor, went to the door and called the nurse. During an interview on 05/07/15 at 9:45 a.m., LVN B said Resident #1 required extensive assistance for transfers. During an interview on 05/07/15 at 1125 a.m. CNA C and CNA D said Resident #1 was a high risk for falls. They said he was a 2 person transfer with the Hoyer lift. They said the resident was a tall and large person. They said because he was unsteady it was unsafe to transfer him with just one person. During an interview on 05/07/15 at 8:55 a.m., the administrator said Resident #1 was transferred from the bed to the wheelchair by one staff member. She said he was not positioned completely in the wheelchair; he was on the edge of the seat. She said before CNA A was able to position him correctly in the wheelchair, the resident slid out and onto his left leg. During an interview on 05/07/15 at 9:05 a.m., the DON said Resident #1 assistance depended on how he was for the day. She said he sometimes required 1 staff member, sometimes required 2 staff members, sometimes required the Hoyer lift and sometimes he could stand up by himself. She said the MDS reflected the assistance required by a resident during the 7 day assessment period. During an interview on 05/18/15 the administrator said 5 residents required 2 person transfer assistance.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent falls for 1of 6 residents reviewed for accidents (Resident #8). Resident #8 sustained a fall in July that resulted in a fractured hip and another fall in September that resulted in a fractured arm. The facility did not revise interventions to prevent further falls or ensure interventions were implemented in accordance with the care plan. Resident #8 was assessed to be a high risk for falls. This failure could place 86 residents needing assistance with transfers at risk of injuries due to falls. Findings included: Physician orders [REDACTED].#8 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #8 could usually understand others and made herself understood, had a history of [REDACTED]. An initial care plan dated 04/20/14 indicated Resident #8 was a fall risk. The plan indicated interventions to prevent the resident from falling included reminding the resident to use the call light for assistance, as well as the use of a bed and chair alarm as assistive devices. A Fall Risk assessment dated [DATE] indicated Resident #8 was at high risk for falls. An incident report dated 07/13/14 at 11:00 p.m. indicated Resident #8 fell and was noted on the floor next to her bed covered in fecal material. Resident #8 sustained a laceration to the top of the right hand measuring 1.25 centimeters. The resident was instructed to use the call light. The incident report indicated the need for a bed alarm, but no working units were available. A care plan last revised on 7/14/14 indicated Resident #8 had cognitive deficits and required assistance with transfers. The care plan indicated Resident #8 was a fall risk with interventions of a chair and bed alarm, a fall mat, and a falling star symbol on door. An incident report dated 07/17/14 at 01:20 p.m. indicated Resident #8 fell next to her bed. Resident #8 was transferring to the restroom without assist and went to her knees. Resident #8 reported pain to left hip with movement. Interventions included placing call light in reach, bed in low position, fall mat, chair alarm, and a bowel and bladder program. This report did not specify if the fall mat was in place. Nursing noted dated 07/17/14 at 05:40 p.m. noted x-ray results indicated a fracture to the left hip. During an interview on 10/30/14 at 9:25 a.m., the DON said there were no other revisions to the care plan after the fall on 07/17/14 because she was unable to identify any other interventions that could be done for Resident #8. An incident report dated 09/10/14 at 11:20 p.m. indicated Resident #8 fell causing a fracture to the right upper arm. The incident report did not indicate the alarm sounding or the use of a fall mat. The interventions included call light place in reach, chair alarm, and wheel chair with auto brakes. Nursing notes dated 09/10/14 at 11:20 p.m. indicated Resident #8 fell and was holding her right shoulder which had a laceration noted. The resident was sent to the emergency room by ambulance. A radiology report dated 09/25/14 indicated a right upper arm fracture. During an interview on 10/29/14 at 04:25 p.m., the DON said Resident #8 ' s fall mat was removed because she was ambulatory and at risk for tripping over the mat. She said she did not think the fall mat was in the room at the time the resident fractured her arm. She said she was aware that the resident ' s care plan listed a fall mat as an intervention. She was unable to recall the date that the fall mat was removed. She said it was her responsibility along as well as the ADON and the MDS coordinator to revise care plans. She said she did not think the fall mat was in the room at the time the resident fractured her arm. During an observation on 10/27/14 at 3:30 p.m., Resident #8 was lying in bed without a fall mat in place. The bed alarm was in place. During an observation on 10/28/14 at 9:20a.m., Resident was lying in bed without a fall mat in place. The bed alarm was in place. During an observation and interview on 10/29/14 at 09:30 a.m., CNAs D and E transferred Resident #8 from the wheel chair to the bed. The chair alarm did not sound when the resident was assisted to a standing position. No fall mat was observed in the resident ' s room. When the resident was transferred from the bed to the wheel chair the bed alarm did not sound. CNA D said she noticed neither alarm sounded. CNA D observed the alarms for functioning and said there was not a battery pack attached to either alarm. CNA D said staff removed the battery pack and used it for another resident frequently. CNA D said she was aware that the resident was a fall risk. CNA D said the resident did not have a fall mat. CNA E said she noticed the alarm did not sound after the resident stood from the wheel chair. CNA E said she did not see a battery pack on the chair alarm or the bed alarm. During an observation and interview on 10/29/14 at 09:55 a.m., the DON entered Resident #8 ' s room and observed the wheel chair alarm and the bed alarm for proper functioning. She said the chair alarm and the bed alarm did not have a battery pack. She inspected the room for the battery pack and found the battery pack on the resident ' s night stand, underneath a pack of wipes and washcloths. She said it was the nurse ' s responsibility to check the placement and function of these alarms. During an interview on 10/29/14 at 10:15 a.m., LVN C said it was her responsibility to check alarms for placement and function every 4 hours. She said the last time she checked Resident #8 ' s alarm was at 8:00 a.m. in the dining room. She said she was aware the resident was a fall risk and attempted to ambulate without assistance. During an interview on 10/29/14 at 4:15 p.m., CNA G said Resident #8 did not have a fall mat and had not had a fall mat for over a month. During an interview on10/29/14 at 04:20 p.m., LVN F said Resident #8 had a history of [REDACTED].#8 required assistance with transfers and many times did not call for assistance. LVN F said Resident #8 did not have a fall mat. The CMS 672 dated 10/27/14 indicated 86 residents required assistance with transfers.

Based on observation, interview, and record review, the facility failed to provide supervision to prevent falls for 1 of 6 residents reviewed for accidents. (Resident #1) Resident #1 was assessed as being at high risk for falls. Resident #1 sustained a fall from a rolling shower chair that resulted in a fractured leg. Staff were not trained on the procedure for assistance with showers and baths. This failure contributed to Resident #1 sustaining a fractured leg. This failure could place 15 residents requiring mechanical lift transfers and a rolling shower chair, at risk of injuries due to falls. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 usually understood others and usually made herself understood, had a history of [REDACTED]. A nursing care plan dated 06/20/14 indicated Resident #1 was at risk for falls and staff needed to assess the environment for potential hazards. An Incident Report indicated Resident #1 fell in the hallway on 08/23/14 and was assessed with [REDACTED]. Resident #1 was sent to the emergency room for evaluation and diagnosed with [REDACTED]. During an observation and interview on 09/10/14 at 11:30 a.m., Resident #1 was lying in bed with a knee immobilizer on her right leg. Resident #1 said a CNA was pushing her in the shower chair down the hallway toward the shower room. She said she was covered with a bed sheet. Resident #1 said the chair stopped rolling suddenly and she fell out of the shower chair. She said her leg hurt and she was sent to the emergency room and it was determined she had a broken leg. Resident #1 said her leg still hurt; she did not get up out the bed anymore, and had to have bed baths now. During an interview on 09/10/14 at 1:15 p.m., CNA A said on 08/23/14 she covered Resident #1 with a bed sheet and pushed her to the shower room in a rolling shower chair. She said the sheet got caught in the wheel of the chair; the chair stopped rolling, and tilted forward causing Resident #1 to fall. She said Resident #1 did not hit the floor, but her right leg got tangled in the sheet and went backward when the resident began to fall. CNA A said she had been employed at the facility one week and was not trained to provide assistance to Resident #1 with bathing. She said she followed CNA B one day but did not observe the procedure for bathing residents that require staff to roll them in the shower chair and was assigned to residents by herself after that. CNA A said she was not aware she should have used a bath blanket to cover Resident #1 when rolling her to the shower room in the rolling shower chair. During an interview on 09/10/14 at 2:15 p.m., CNA B said she was trained on the use of bath blankets with residents. She said CNA A followed her for on the job training for one day. She said she showed CNA A where the bath blankets were kept, but she did not bathe any residents to show the procedure for residents who required the use of a bath blanket. During an interview on 09/10/14 at 10:20 a.m., CNA C said she was not provided training at the facility on the shower and bath procedure. During an interview on 09/10/14 at 11:15 a.m., CNA D said she was not provided training on the shower and bath procedure, but she knew about the use of the bath blankets after observing other CNAs use the bath blankets. During an interview on 09/10/14 at 12:00 p.m., CNA E said she was trained regarding shower and bath procedures. She said she was told to never use a bed sheet to cover a resident because it could drag and get caught up. She said since the incident, Resident #1 complained of leg pain, she did not get up out the bed anymore, and had to have bed baths now. During interviews on 09/10/14 at 9:20 a.m. and 1:45 p.m., the DON said CNA A took Resident #1 to the shower room covered by a sheet in a rolling shower chair. She said the sheet got caught on the wheel of the chair causing Resident #1 to fall on her knees. The DON said Resident #1 was assessed with [REDACTED]. The DON said most residents were transported in their wheelchairs to the shower room; however, if the resident required a mechanical lift and did not want to be transferred several times, staff rolled them down the hallway in the shower chair. She said staff were trained on the shower and bath procedures, but CNA A had not been on duty the day of the training and did not attend. She said since the incident, staff were trained on the shower and bath procedures including CNA A. The Shower/Tub Bath policy, undated, indicated residents should be transferred to the bath chair and covered from the neck down with a bath blanket before transport to the bath area. The in-services records indicated staff were trained on 08/13/14 regarding transporting residents in their wheelchairs to the shower room, CNA A had not signed the summary report to indicate she attended the training. On 08/23/14 staff were trained regarding transporting residents to the shower room in their wheelchair unless they require mechanical lift, the attendance record included CNA A's signature. The DON provided a list on 09/10/14 at 2:30 p.m. that indicated 15 residents required mechanical lift for transfers.