Every finding on record at Azalea Health & Rehab Center

Based on record review, staff, residents, and Nurse Practitioner (NP) interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of taking psychotropic medications prior to the administration of psychotropic medications for 5 of 5 residents reviewed. (Resident #23, #32, #72, #80 and #105). a). Resident #80 was admitted to the facility on [DATE]. Diagnoses included major depressive disorder. A physician order written on 12/19/25 until 06/26/26 revealed Sertraline 50 mg one tablet daily for depression. Review of Resident 80's electronic health record revealed there was no psychotropic consent signed for the medication prior to administration on 12/19/25. Review of Resident #80's medication administration record for December 2025 through June 2026 revealed Resident #80 received the psychotropic medication Sertraline 50 mg as physician ordered. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #80 was cognitively intact and demonstrated no mood or behaviors. He was coded as receiving antidepressant medication. An interview was conducted with Resident #80 on 07/29/26 at 11:17 AM. Resident #80 stated that no one had actually discussed the side effects or risks versus benefits of the medication with him and was not asked to sign any consent prior to the administration of the medication upon admission in December. b). Resident #72 was admitted to the facility on [DATE]. Diagnoses included depression and anxiety. A physician order written on 04/30/26 revealed Aripiprazole (antidepressant medication) 5 mg one tablet daily and Duloxetine (antidepressant medication) 60 mg one capsule twice daily. Review of Resident 72's electronic health record revealed there was no psychotropic consent signed for the psychotropic medications Aripiprazole or Duloxetine prior to administration on 04/30/26. The MDS admission assessment dated [DATE] revealed Resident #72 was cognitively intact and demonstrated no mood or behaviors. Resident was coded as receiving antidepressant medications. Review of Resident #72's medication administration records for April, May, June and July 2026 revealed Resident #72 received the psychotropic medications Aripiprazole and Duloxetine as physician ordered. An interview was conducted with Resident #72 on 07/29/26 at 1:06 PM. Resident #72 reported that the physician nor the nursing staff had any discussion with her regarding her antidepressant medications and she did not sign a consent prior to the administration of the medications. c. Resident # 23 was admitted to the facility on [DATE] with diagnoses which included severe dementia with behavioral disturbance and anxiety. Review of Resident #23's electronic health record revealed physician orders for the following psychotropic medications: A physician order dated 4/21/26 for amitriptyline (a psychotropic medication classified as an antidepressant medication) 10 milligrams (mg) at bedtime for depression. A physician order dated 4/21/26 for fluoxetine (an antidepressant medication) 20 mg per 5 milliliters (ml) administer 10 ml daily for depression. A physician order dated 4/27/26 for lorazepam (a psychotropic medication classified as an antianxiety medication (a prescription benzodiazepine)) 0.5 mg one tablet twice per day as needed for anxiety. The order was discontinued on 5/5/26. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident # 23 was severely cognitively impaired, demonstrated no behaviors and received the following psychotropic medications: an antidepressant and an antianxiety medication during the lookback period. A review of the April 2026 electronic Medication Administration Record for Resident #23 revealed that the resident received the psychotropic medications amitriptyline, fluoxetine and lorazepam as ordered by the physician. A physician order dated 5/8/26 for lorazepam 0.5 mg one tablet twice per day as needed for anxiety. The order was discontinued on 5/11/26. A physician order dated 5/11/26 for lorazepam 0.5 mg one tablet twice per day as needed for anxiety. The order was discontinued on 5/21/26. A physician order dated 5/22/26 for lorazepam 0.5 mg one tablet twice per day as needed for anxiety. The order was discontinued on 5/26/26. A physician order dated 5/26/26 for lorazepam 0.5 mg one tablet twice per day as needed for anxiety. The order was discontinued on 6/5/26. A physician order dated 5/26/26 for lorazepam 2 mg/1 ml administer 0.25 ml twice per day as needed for anxiety. The order was discontinued on 6/5/26. A review of Resident #23's electronic health record revealed an Informed Consent for Use of Psychotropic Medication with an observation date recorded as 5/26/26. The directions indicated to use the form to provide information to the resident/representative about prescribed psychotropic medication and to complete a separate form for each medication. The medication listed on the form was lorazepam. The completion date was 6/5/26 and the date reviewed was recorded as 6/26/26. The form listed the representative gave consent to the medication. There were no consent forms in the electronic health record for the medications of amitriptyline and fluoxetine. A review of the May 2026 electronic Medication Administration Record for Resident #23 revealed that the resident received the psychotropic medications amitriptyline, fluoxetine and lorazepam as ordered by the physician. A physician order dated 6/13/26 for lorazepam 2 mg/1 ml administer 0.25 ml twice per day as needed for anxiety. The order was discontinued on 6/15/26. A physician order dated 6/22/26 for lorazepam 2 mg/1 ml administer 0.25 ml twice per day as needed for anxiety. The order was discontinued on 6/29/26. A physician order dated 6/30/26 for lorazepam 2 mg/1 ml administer 0.25 ml twice per day as needed for anxiety. The order was discontinued on 7/9/26. A review of the June 2026 electronic Medication Administration Record for Resident #23 revealed that the resident received the psychotropic medications amitriptyline, fluoxetine and lorazepam as ordered by the physician. A physician order dated 7/9/26 for lorazepam 2 mg/1 ml administer 0.25 ml twice per day as needed for anxiety. A review of the July 2026 electronic Medication Administration Record for Resident #23 revealed that the resident received the psychotropic medications amitriptyline, fluoxetine and lorazepam as ordered by the physician. A review of the electronic health record revealed there was no documentation the Resident Representative was informed in advance of the risks and benefits of taking the psychotropic medications (medications that alter mood, thoughts, feelings or behavior) amitriptyline, fluoxetine and lorazepam prior to the administration of the medications. d. Resident #32 was admitted on [DATE] with diagnoses which included dementia and insomnia. Review of Resident #32's electronic health record revealed a physician order dated 11/4/25 for trazadone 50 milligrams at bedtime for insomnia. A review of Resident #32's electronic health record revealed there was no documentation that the Resident or the Resident Representative was informed in advance of the risks and benefits of taking the psychotropic medication trazadone prior to the administration of the medications. The Medication Administration Record (MAR) from 11/4/25 through 7/30/26 indicated Resident #32 was administered trazadone as ordered. A review of the quarterly MDS assessment dated [DATE] revealed Resident # 32 was cognitively intact, and Resident # 32 received an antidepressant medication during this assessment period. e. Resident #105 was admitted to the facility on [DATE] with diagnoses including anxiety, and depression. Review of the physician orders dated 7/22/26 for Resident #105 revealed to administer buspirone 7.5 milligram (mg) tablets once daily for anxiety, duloxetine 30 mg tablets twice daily for depression, and lorazepam 0.5 mg tablets twice daily as needed for anxiety. Review of Resident #105's electronic health record revealed no signed psychotropic medication consent prior to the initiation of these medications on 7/23/26. Review of Resident #105's Medication Administration Record (MAR) dated July 2026 revealed that buspirone and duloxetine were first administered on 7/23/26, and lorazepam was administered on 7/24/26. The admission Minimum Data Set (MDS) assessment dated [DATE] was still in progress and did not contain information related to cognition or psychotropic medications. During an interview on 7/30/26 at 12:21 PM, Resident 105, who was able to correctly respond to questions regarding her name, location, and time, stated she did not recall any discussion with facility staff about the risks, benefits, or potential side effects of her medications. She further reported she was not asked to sign a consent form prior to receiving the medications. An interview with the Director of Nursing (DON) was conducted on 07/30/26 at 2:15 PM. The DON stated that she was working on a system to obtain consents prior to administering psychotropic medications. The DON indicated that she and the Unit Manager were responsible for completing the education with the resident or responsible party regarding the psychotropic medication and discussing alternate treatments prior to the administration of the medication. The facility was reviewing admissions for psychotropic medications in the morning meeting with the interdisciplinary team and then obtaining consents. The DON indicated that the system was not working and some consents were missed and obtained after the medications were initiated. The DON indicated that now the expectation was that education would be provided by the assigned nurse regarding each psychotropic medication to include the current dose and alternate treatments prior to the medication being given to a resident and whenever there were any changes to the psychotropic medications, a new psychotropic consent would be completed. An interview with the Nurse Practitioner (NP) on 07/30/26 at 3:03 PM revealed that with any psychotropic medications, the residents should be educated about the risks verses benefits of the medications prior to administration so that the resident has an understanding of the effects of the medications, and they could then decide if they wanted to take the medication or not.

Based on record review, staff and resident interviews, and Nurse Practitioner interviews, the facility failed to inform and provide written information to the residents/representatives pertaining to their right to accept or refuse medical/surgical treatment and to formulate an advanced directive (a form that indicates a resident's wish and what action to take for their health if the residents were no longer able to make their own decision). In addition, the facility failed to ensure code status was accurate throughout the medical record. This failure had the potential to affect 15 of 23 sampled residents (Resident #8, #9, #11, #12, #13, #16, #47, #71, #75, #80, #102, #103, #104, #105 and #107). Findings included: a. Resident #8 was admitted on [DATE]. Review of Resident #8's electronic health record revealed a physician order dated 4/29/24 for Do Not Resuscitate (DNR) status (a directive that designates that the resident does not wish to have Cardiopulmonary Resuscitation in the event of cardiac or respiratory arrest). Review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact. There was no indication in Resident # 8's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. b. Resident #16 was admitted on [DATE]. Review of an annual MDS assessment dated [DATE] indicated the resident was cognitively intact. Review of a physician order dated 7/14/26 indicated an order for Resident #16 for Do Not Resuscitate (DNR) status. A Nurse Practitioner progress note dated 7/15/26 indicated that Resident #16 was listed as Full Code status, meaning staff were required to use all available life saving measures, including cardiopulmonary resuscitation, if the resident's heart stopped or breathing ceased. The note did not include any documentation showing a change in code status from the DNR order written on 7/14/26 back to Full Code status. There was no new order written for Full Code status. There was no indication in Resident # 16's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. An interview with Resident #16 on 7/29/26 at 1:20 PM indicated that advanced directives were not discussed with her and she had not received information concerning her rights to formulate an advanced directive. Resident #16 stated that she was supposed to be listed as Do Not Resuscitate status and she found out accidentally that she was listed as a full code when she went out to an appointment and saw the paperwork that was sent to the doctor. Resident #16 stated that she was confused about some of the other parts of advanced directives but knew that she wanted to be listed as Do Not Resuscitate. Resident #16 stated that she would like further information and that no one from the facility had explained advanced directives. c. Resident #47 was admitted on [DATE]. Review of Resident #47's electronic health record revealed a physician order dated 4/29/24 indicated Do Not Resuscitate status. Review of Resident #47's significant change MDS dated [DATE] indicated the resident was severely cognitively impaired with impaired short- and long-term memory. There was no indication in Resident # 126's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. d. Resident #11 was admitted on [DATE]. Review of Resident #11's electronic health record revealed that the resident was listed as Full Code status. Review of Resident #11's electronic health record revealed a physician order dated 11/1/24 for Full Code status. Review of Resident #11's quarterly MDS assessment dated [DATE] indicated that the resident was cognitively intact. There was no indication in Resident # 11's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. e). Resident #12 was admitted to the facility on [DATE]. A physician order dated on 04/29/24 revealed Resident #12 was a DNR. The MDS quarterly assessment dated [DATE] revealed Resident #12 was severely cognitively impaired. There was no indication in Resident #12's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and / or formulate an advanced directive. f). Resident #102 was admitted to the facility on [DATE]. A physician order dated 07/15/26 revealed Resident #102 was a full code. The MDS admission assessment dated [DATE] revealed Resident #102 was cognitively intact. An interview was conducted with Resident #102 on 07/29/26 at 12:59 PM. Resident #102 reported he had a discussion with a staff member (he could not remember who) regarding advanced directives, but he was not provided anything in writing about it. There was no indication in Resident #102's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and / or formulate an advanced directive. g). Resident #80 was admitted to the facility on [DATE]. A physician order written on 12/19/25 revealed Resident #80 was a DNR. The MDS quarterly assessment dated [DATE] revealed Resident #80 was cognitively intact. An interview with Resident #80 on 07/29/26 at 12:27 PM revealed he knew that he was a DNR and that someone had spoken to him about living wills and his power of attorney (POA), but he had not decided on who would be his POA as yet. He stated he never received anything in writing regarding formulating an advanced directive and no one has come back to discuss his options with him since he was admitted in December 2025. There was no indication in Resident #80's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and / or formulate an advanced directive. h. Resident #71 was admitted to the facility 5/8/26. A physician's order dated 7/16/26 revealed Resident #71 was a full code. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was cognitively intact. There was no indication in Resident #71's electronic medical record that the facility had provided written information concerning the right to accept or refuse medical or surgical treatment and/or to formulate an advanced directive. i. Resident #105 was admitted to the facility on [DATE]. A physician's order dated 7/22/26 revealed Resident #105 was a full code. The admission Minimum Data Set (MDS) assessment dated [DATE] was still in progress and contained no information regarding Resident #105's cognition. There was no indication in Resident #105's electronic medical record that the facility had provided written information concerning the right to accept or refuse medical or surgical treatment and/or to formulate an advanced directive. During an interview on 7/30/26 at 12:21 PM, Resident #105, who was alert and oriented to person, place, and time, stated she had not had any conversations with facility staff regarding advance directives. j. Resident #107 was admitted to the facility 7/10/26. A physician's order dated 7/10/26 revealed Resident #107 was a full code. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #107 was cognitively intact. There was no indication in Resident #107's electronic medical record that the facility had provided written information concerning the right to accept or refuse medical or surgical treatment and/or to formulate an advanced directive. k. Resident #9 was admitted to the facility on [DATE]. A physician order dated on 10/17/25 revealed Resident #9 was a DNR. The quarterly MDS assessment dated [DATE] revealed Resident #9 had moderately impaired cognition. There was no indication in Resident #9's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. l. Resident #103 was admitted to the facility on [DATE]. A physician order dated on 07/18/26 revealed Resident #103 was a full code. The admission baseline assessment dated [DATE] revealed Resident #103 had intact cognition. The admission MDS assessment was not due at the time of the survey. There was no indication in Resident #103's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. m. Resident #104 was admitted to the facility on [DATE]. A physician order dated on 07/16/26 revealed Resident #104 was a full code. The admission MDS assessment dated [DATE] revealed Resident #104 had intact cognition. There was no indication in Resident #104's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. n. Resident #75 was admitted to the facility on [DATE]. A physician order dated on 03/22/26 revealed Resident #75 was a DNR. The quarterly MDS assessment dated [DATE] revealed Resident #75 had intact cognition. There was no indication in Resident #75's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. o. Resident #13 was admitted to the facility on [DATE]. A physician order dated 06/04/26 revealed Resident #13 was a DNR. The quarterly MDS assessment dated [DATE] revealed Resident #13 had moderately impaired cognition. There was no indication in Resident #13's electronic medical record that the facility provided written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive. An interview was conducted with the Social Worker Assistant on 07/30/26 at 1:00 PM. The Social Worker Assistant stated that she worked part time in this position and completed a questionnaire form in the computer with residents after admission. The Social Worker Assistant stated that she looked at the hospital paperwork to see if the resident was a full code or do not resuscitate status. She indicated that she verified the code status with the resident or responsible party and if they asked she explained the difference between full code and do not resuscitate. The Social Worker Assistant stated that she did not have written information regarding the formulation of advanced directives and that she did not discuss power of attorney or living will. The Social Worker Assistant stated that she thought the admission Coordinator might discuss or go over advanced directive. An interview with the admission Coordinator on 07/30/26 at 1:15 PM revealed that she was not responsible for addressing advanced directives with the resident or resident's responsible party and was not sure who was supposed to do this. The admission Coordinator stated that she did not have written information regarding advanced directives that she provided to the resident or responsible party. An interview with the Social Worker on 07/30/26 at 1:30 PM revealed that usually upon admission, she or her assistant explained full code and do not resuscitate status. The Social Worker stated that she was unaware of any written information provided to the residents/representatives pertaining to their right to accept or refuse medical/surgical treatment and to formulate an advanced directive. An interview with the Director of Nursing (DON) was conducted on 07/30/26 at 3:10 PM. The DON stated that the facility relied on the medical documentation provided by the hospital to determine a resident's code status. She explained that the hospital's advanced directive documentation was referred to as the Golden Rod form—a goldenrod colored document indicating that, in the event of cardiac and/or pulmonary arrest, cardiopulmonary resuscitation should not be initiated. The DON stated that the Golden Rod form was used by the facility to identify residents with a Do Not Resuscitate (DNR) status and was placed in the resident's medical record upon admission. The DON further stated that if a Golden Rod form was not sent with the admission paperwork, the facility assumed the resident's code status to be Full Code. The DON indicated that written information was not being provided to the resident or the Responsible Party regarding the right to formulate an advanced directive and she was not aware that this needed to be done. An interview was conducted with the Nurse Practitioner (NP) on 07/30/26 at 3:25 PM. The NP stated he referred to the advanced directive order that was documented on the hospital record. The NP explained that if the resident was admitted with a Golden Rod form from the hospital, he assumed the resident wished to continue to be a DNR and he wrote the order in the electronic record for DNR status. The NP stated that if a resident or responsible party expressed that they wished to discuss advance directives, then he would have a discussion, but he did not provide written information. An interview was conducted with the Administrator on 07/30/26 at 3:45 PM. The Administrator stated that the system failure was a result of lack of education regarding the requirement to provide written information to the residents/representatives pertaining to their right to accept or refuse medical/surgical treatment and to formulate an advanced directive. The Administrator indicated that it was important for advanced directives to be discussed, and information provided for the formulation of an advanced directive.

Based on observation and staff interviews, the facility failed to ensure expired food and food items with signs of spoilage were removed from 1 of 1 walk in refrigerator. This failure had the potential to affect food served to residents. Findings included:During the initial tour of the kitchen with the Dietary Manager on 7/27/26 at 10:15 AM, the following expired or compromised food items were observed in the walk in refrigerator:- Four (5 pound (lb.) bags of shredded lettuce, unopened, received 7/7/26, use by date 7/14/26,-Two (5 lb.) bags of shredded mixed salad (lettuce/carrots), unopened, with brown discoloration, received 6/30/26, -Four (10 lb.) bags of shredded cabbage, unopened, observed to have a slimy, wet appearance, received 6/16/26, -Four heads of lettuce that appeared wilted with brown discoloration throughout, received 7/7/26,- Six heads of cabbage that appeared wilted with brown discoloration throughout, received 7/14/26, -One (5 lb.) bag of lettuce, unopened, with a use by date of 7/20/26,-One (10 lb.) bag of shredded lettuce, unopened, with a use by date of 7/22/26,-One gallon jug of salad dressing, opened with a use by date of 10/20/25,-One (7 lb.) container of prepared coleslaw, with a use by date of 7/23/26, -One (7 lb.) container of macaroni salad with a use by date of 7/14/26, -Two (4 lb.) containers of prepared coleslaw with a use by date of 7/15/26. During an interview on 7/27/26 at 11:20 AM, the interim Dietary Manager stated the food delivery truck arrived weekly on Tuesdays, and staff should remove any items that were past their use by dates or compromised when putting away the delivery. He further stated all dietary staff were responsible for checking the refrigerators daily for expired foods and removing any items that were expired or compromised. During an interview on 7/27/26 at 11:45 AM, Dietary Aide #1 stated on Tuesdays one of the Dietary Aides typically pulled expired foods while putting away the delivery. She stated she was not aware that all staff were responsible for pulling expired foods. She indicated staff would work together to ensure expired foods were discarded as required.During an interview on 7/27/26 at 11:50 AM, Dietary Aide #2 stated all staff were responsible for checking the refrigerator for expired foods. She indicated they had not had time yet today to check for expired foods.During an interview on 7/27/26 at 11:55 AM, [NAME] #1 stated all dietary staff were responsible for checking and discarding expired foods daily. She stated she had not worked over the last several days and that the refrigerator had not been checked yet today for expired foods. During an interview on 7/30/26 at 1:00 PM, the Administrator stated all kitchen staff had received training instructing them to check the refrigerators daily for expired foods.

Based on record review, and Physician and staff interviews, the facility failed to thoroughly review the hospital discharge summary and clarify physician orders for a newly admitted resident (Resident #231) resulting in the failure to transcribe and administer an intravenous (a catheter inserted into a vein for medication administration) antibiotic medication listed on the discharge summary. Penicillin G (antibiotic) was not administered from 03/29/25 through 03/30/25 resulting in 6 missed doses of the antibiotic treatment. This deficient practice occurred for 1 of 1 resident reviewed for significant medication errors. Findings included: Resident #231 was admitted to the facility on [DATE]. Diagnoses included osteomyelitis (an infection in the bone), and discitis (an infection in the intervertebral disc space). Review of the Discharge summary dated [DATE] from the hospital on page 1 revealed Resident #231's discharge diagnoses was discitis / osteomyelitis of the thoracic region and to continue intravenous (IV) antibiotics with a tentative stop date of 05/02/25. The discharge new medications list included Heparin (a blood thinning agent) flush 10 units per milliliter (ml) solution injection; flush IV catheter daily, and Heparin flush 10 units per ml injection; flush IV catheter with 5 ml as needed after each use, Sodium Chloride 0.9% injection 10 ml; flush IV catheter daily and Sodium Chloride 0.9% 10 ml; flush IV catheter as needed before and after each use (prior to Heparin). Under the new medications list on the discharge summary there were no antibiotics noted, however, the discharge summary included 14 pages total and on page 9 under discitis and osteomyelitis of the thoracic region it stated resident transitioned from vancomycin/cefepime (types of antibiotics) to penicillin with plans of 6 to 8 weeks of IV antibiotics. Final antibiotic recommendations per infectious disease as follows: Penicillin G 4 million units IV every 4 hours, tentative stop date of antibiotics 05/02/25 (6 weeks) and in capital letters ATTENTION SKILLED NURSING FACILITY (SNF's) IF QUESTIONS REGARDING ANTIBIOTICS/DRUG LEVELS/LABS AFTER HOURS, PLEASE CALL. The discharge summary included additional orders below this statement for a peripherally inserted central catheter (PICC - used for long term or frequent IV treatments due to providing a longer lasting method of accessing the bloodstream) was placed on 03/28/25 however, had to be replaced as it was too deep on 03/29/25, PICC line care, and PICC line to be removed after last dose of antibiotics administered. A nursing note written on 03/29/25 at 6:00 PM by Nurse #6 revealed Resident #231 was admitted to the facility via transport. Resident's vital signs were stable with a PICC line to right arm. Medication orders were verified with the on call Physician Assistant and sent to pharmacy. A review of the physician orders dated 03/29/25 revealed the Heparin Flush and the Sodium Chloride Flush (medications to keep an IV line clear and unobstructed) orders were transcribed on 03/29/25 with a start date of 03/30/25. There were no orders transcribed for the Penicillin G 4 million units IV every 4 hours with a stop date of 05/02/25. A review of the Medication Administration Record for March 2025 revealed the Heparin Flush and the Sodium Chloride Flush orders were transcribed to the record. On 03/30/25 at 1:00 AM the IV line for Resident #231 was flushed with the Heparin and the Sodium Chloride as evidenced by Nurse #5's initials. There were no orders transcribed for the antibiotic on the Medication Administration Record. The Minimum Data Set admission assessment dated [DATE] revealed Resident #231 was severely cognitively impaired and was coded as being on antibiotics and having IV medications with a PICC line while in the hospital. A nursing note written on 03/30/25 at 1:52 AM by Nurse #5 revealed the PICC line was removed per discharge orders. Intravenous antibiotics course was completed in hospital. A nursing note written on 03/30/25 at 3:53 PM by Nurse #2 revealed she spoke with the physician hospitalist in the emergency room (ER) on the phone and he wanted the resident sent to the ER for PICC line insertion. A nursing note written on 03/30/25 at 7:17 PM by Nurse #7 revealed per family report from hospital, resident will be admitted . Resident will have a peripheral IV placed for IV antibiotics until the surgeon was able to place the PICC line. An interview was conducted with Nurse #6 on 05/28/25 at 3:45 PM. Nurse #6 stated she recalled doing the admission orders for Resident #231 on 03/29/25. She stated she was given a packet which contained all of the discharge summary orders. She stated she reviewed the orders and called the on call Physician Assistant to verify the orders on 03/29/25. Nurse #6 stated she entered the orders into the electronic medical record which automatically synced to the pharmacy and then the pharmacy would send the medications on their next delivery. Nurse #6 stated she reviewed the new medications list and changed medications list with the on call Physician Assistant. She stated there were no antibiotics on either of these lists. Nurse #6 stated she believed she discussed the orders for the Heparin flushes and the Sodium Chloride flushes for the IV line, but she could not remember. Nurse #6 stated she did not clarify with the on call Physician Assistant that Resident #231 had an IV line with flushes ordered but no antibiotics were ordered. Nurse #6 stated the Physician Assistant did not question it either. Nurse #6 stated she learned later that Resident #231 was sent out to the emergency room on [DATE] to get another PICC line placed because Nurse #5 removed Resident #231's PICC line during the night shift because there were no orders for antibiotics. A phone interview was conducted with Nurse #5 on 05/29/25 at 3:30 PM. Nurse #5 stated she was working the night shift on 03/29/25 into 03/30/25. She stated she was reviewing the physician discharge summary orders and doing a second check to be sure all of the medications were transcribed correctly by Nurse #6. Nurse #5 stated she had questions regarding Resident #231's orders because she saw orders for the PICC line care, but did not see orders for an antibiotic. She stated she was reading through the discharge summary and questioned if he received his last dose of antibiotics in the hospital. Nurse #5 stated there was an order to remove the PICC line after last dose of antibiotics administered and since she could not find orders for the antibiotic, she removed the PICC line because she felt Resident #231 was at risk for infection. Nurse #5 stated the next day on 03/30/25, Nurse #2 told her she reviewed the discharge summary orders and she found that there were orders in place for the antibiotic. Nurse #5 stated the order for the antibiotic was not written under the new medications list so it was not easy to find and was missed. Nurse #5 stated she should have read through the orders more clearly and if she had questions, she should have clarified them with the on call Physician Assistant before removing the PICC line. An interview was conducted with Nurse #2 on 05/30/25 at 10:30 AM. Nurse #2 stated on 03/30/25 she had asked Nurse #5 if the antibiotics were delivered from the pharmacy for Resident #231. Nurse #2 stated Nurse #5 told her she removed the PICC line because the discharge summary indicated the antibiotics had finished. Nurse #2 stated she explained to Nurse #5 there were current orders for Penicillin to be given every 4 hours and that the order was written on discharge summary above the order PICC line to be removed after last dose of antibiotics administered which Nurse #2 had circled. Nurse #2 stated there was also an order to call if there were any questions regarding the antibiotics. Nurse #2 stated no where in the discharge summary did it indicate the last dose of the antibiotic (Penicillin G) was given in the hospital. Nurse #2 stated that Nurse #5 should have called the on call physician and had the orders clarified. Nurse #2 stated as a result of her removing the PICC line, Resident #231 missed 6 doses of the antibiotic and had to be sent back to the hospital for another PICC line to be placed. A phone interview was conducted with the family member on 05/30/25 at 2:42 PM. The family member stated Resident #231 had no further difficulties when he was sent back to the ER to the get the PICC line replaced, but she had decided not to send him back to this facility. An interview was conducted with the Director of Nursing on 05/30/25 at 10:15 AM. The Director of Nursing stated there was some confusion with the discharge summary and the orders were in the packet, but it was worded as antibiotic recommendation and not listed on the new medications list along with the Heparin and Sodium Chloride flush orders. The Director of Nursing stated she would have expected Nurse #6 and Nurse #5 to read the entire discharge summary to include all the orders, and if they had questions, she would have expected them to clarify the orders with the on call physician. The Director of Nursing stated there was nothing in the discharge summary to indicate Resident #231 had completed the course of the Penicillin G antibiotic in the hospital, but that Resident #231 had completed a course of antibiotic treatments with other antibiotics. A phone interview was conducted with the Physician on 05/30/25 at 2:15 PM. The Physician stated there have been some recent problems with the discharge summary orders from the hospital due to the hospital's new system and nurses at the facility need to be reading the discharge summaries closer. The Physician stated there were red flags such as the Heparin and Sodium Chloride flush orders. She stated the nurses verifying and reviewing the orders should have used their nursing judgement and questioned the antibiotic order if they were unsure. The Physician stated an error was made which resulted in 6 missed doses of the antibiotic. She stated she did not feel there was any harm to Resident #231 since has was not acutely ill or septic at the time, but he did have to get another PICC line replaced unnecessarily. The Physician stated Resident #231 was going to be on this antibiotic for 6 weeks to treat the osteomyelitis and get rid of the bacteria and the antibiotic treatment of 6 weeks was a slow process in healing the osteomyelitis and discitis.

Based on observations, record review and staff interviews the facility failed to hold a blood pressure medication according to the physician ordered parameters and administered the blood pressure medication unnecessarily to 1 of 5 residents reviewed for unnecessary medication administration (Resident # 55). Findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses including high blood pressure. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #55 was cognitively intact. A physician order written on 12/28/24 revealed an order for Metoprolol Succinate Extended Release (a medication used to treat high blood pressure), 25 milligrams (mg) one tablet once a day. Hold for Systolic Blood Pressure (SBP) less than 110 millimeters of mercury (mm/Hg). Review of the April 2025 Medication Administration Record revealed to administer Metoprolol Succinate 25 mg and hold for SBP of less than 110 mm/Hg with a section to include the recorded blood pressure. On 04/12/25, Resident #55's blood pressure was recorded as 101/73 mm/Hg and the medication was signed off as given by Nurse #1, and on 04/19/25 the blood pressure was recorded at 105/60 mm/Hg and the medication was signed off as given by Nurse #3. The blood pressure recording was within normal limits on 04/13/25 despite the administration of the blood pressure medication given on 04/12/25, however, the blood pressure recording on 04/20/25 was lower and recorded as 100/69 mm/Hg after receiving the medication on 04/19/25. Review of the May Medication Administration Record revealed to administer Metoprolol Succinate 25 mg and hold for SBP of less than 110 mm/Hg with a section to include the recorded blood pressures. On 05/03/25 Resident #55's blood pressure was recorded as 93/60 mm/Hg and the medication was signed off as given by Nurse #3, on 05/10/25 the blood pressure was recorded as 103/67 mm/Hg and signed off as given by Nurse #2. On 05/25/25 the blood pressure was recorded as 97/69 mm/Hg and signed off as given by Nurse #3, on 05/16/25 the blood pressure was recorded as 109/80 mm/Hg and signed off as given by Nurse #1. An interview was conducted with Nurse #1 on 05/29/25 at 1:02 PM. Nurse #1 reported that Resident #55's blood pressure can run low at times and she believed there was an order to hold the medication if the systolic blood pressure was less than 100 mm/Hg. Nurse #1 reviewed the order that was written on 12/28/24 and confirmed that the Metoprolol Succinate should have been held if the SBP was less than 110 mg/Hg. Nurse #1 stated on 04/16/25 and 05/12/25 she was thinking only to hold it if the SBP was less than100 mm/Hg, but she could not say for certain if that was why she did not hold it. Nurse #1 stated she should not have given the medication since his SBP was less than 110 mm/Hg per the physician order. An interview was conducted with Nurse #2 on 05/30/25 at 10:30 AM. Nurse #2 reviewed the May Medication Administration Record and stated she did not know why she administered Resident #55 his blood pressure medication on 05/10/25. Nurse #2 stated the order read to hold the medication if the SBP was less than 110 mm/Hg and she should have held it. An interview was attempted with Nurse #3 via phone 05/30/25 at 12:19 PM by voice message and text. Nurse #3 did not return the call or the text to be interviewed. An interview was conducted with Nurse Practitioner #1 via phone on 05/30/25 at 12:30 PM. The Nurse Practitioner stated she would expect the nursing staff to be following the physician order as written. She stated the parameters were in place for a reason and although Resident #55 was receiving a low dose of the medication, receiving the medicine outside the parameters could put him at risk for hypotension and he should not have received the medication unnecessarily. An interview was conducted with the Director of Nursing on 05/30/25 at 3:35 PM. The Director of Nursing stated she would expect the physician's order to be followed and for the nursing staff to ensure they were holding the blood pressure medication per parameters. The Director of Nursing added, Resident #55's blood pressure has a history of getting low and the parameters were in place for that reason. She stated it did not matter if the blood pressure reading was just one point lower than 110 mm/hg, the order should be followed as written so that the resident would not receive the medication unnecessarily.

Based on record review and interviews with staff and Nurse Practitioner, the facility failed to have a complete and accurate medication administration record related to a blood pressure medication. This was for 1 of 5 residents (Resident #55) reviewed for unnecessary medications. Findings included: Resident #55 was admitted to the facility on [DATE]. Diagnoses included high blood pressure. A physician order written on 12/28/24 revealed an order for Metoprolol Succinate Extended Release (a medication used to treat high blood pressure), 25 milligrams (mg) one tablet once a day. Hold for Systolic Blood Pressure (SBP) less than 110 millimeters of mercury (mm/Hg). Review of the April 2025 Medication Administration Record revealed to administer Metoprolol Succinate 25 mg and hold for SBP of less than 110 mm/Hg with a section to include the recorded blood pressure. On 04/19/25, Resident #55's blood pressure was recorded as 105/60 mm/Hg and the medication was signed off as given by Nurse #3. Review of the May Medication Administration Record revealed to administer Metoprolol Succinate 25 mg and hold for SBP of less than 110 mm/Hg with a section to include the recorded blood pressures. On 05/01/25 Resident #55's blood pressure was recorded as 105/58 mm/Hg and the medication was signed off as given by Nurse #4, on 05/07/25 the blood pressure was recorded as 108/64 mm/Hg and the medication was signed off as given by Medication Aide #1, and on 05/28/25 the blood pressure was recorded as 109/80 mm/Hg and the medication was signed off as given by Nurse #1. An interview was conducted with Nurse #4 via phone on 05/30/25 at 12:50 PM. Nurse #4 revealed if there were parameters included in the order she was sure she would have held the medication. Nurse #4 stated it was an error in documenting and she should have written that the blood pressure medication was held for Resident #55 instead of signing it off to look as though it was given. An interview was conducted with Nurse #1 on 05/29/25 at 1:02 PM. Nurse #1 reported she recalled checking the blood pressure on 05/28/25 for Resident #55 and she took the blood pressure twice. Nurse #1 stated the first time the reading was 109/80 mm/Hg and then she took it again before she administered the medication and it was 116/80 mm/Hg. She stated she inaccurately documented the wrong blood pressure on the Medication Administration Record and added she should have documented 116/80 mm/Hg so the record would be clear that he was within the parameters to receive the medication. An interview was conducted with Medication Aide #1 on 05/30/25 at 1:15 PM. Medication Aide #1 reported she did not administer the blood pressure medication to Resident #55 on 05/07/25 when the reading was 108/64, and that she inaccurately documented that she did. Medication Aide #1 stated it was a documentation error and she should have recorded that it was not given and let her nurse know it was held due to the parameters to hold if SBP was less than 110 mm/Hg. An interview was conducted with Nurse Practitioner #1 via phone on 05/30/25 at 12:30 PM. The Nurse Practitioner stated she would expect the nursing staff to document accurately when a blood pressure medication was given or held. Nurse Practitioner #1 stated she relied on accurate documentation when she completed a chart review to get a clear clinical picture of how the resident was responding to the medication. An interview was conducted with the Director of Nursing on 05/30/25 at 3:35 PM. The Director of Nursing stated she would expect her nursing staff to utilize the electronic medical record system to accurately document when a blood pressure medication was given or held. The Director of Nursing stated she would provide education regarding the importance of accurate documentation.

Based on record review, observations, resident, staff, and Nurse Practitioner interviews, the facility failed to prevent Resident #1 from being left unsupervised in the facility ' s transportation van when Transporter #1 left the resident in the van with the doors and windows closed and the engine turned off midday in the summer heat ([DATE]) for approximately 10 to 30 minutes. The temperature outside was between 92 and 94 degrees Fahrenheit (F). The facility staff did not identify Resident #1 was not in the facility until his family member arrived at the facility and was unable to locate him. Resident #1 indicated he was yelling for help, he was panicked, became short of breath, was scared, and thought he was going die. Resident #1 did not sustain any physical injures, but there was a high likelihood of suffering serious harm that included heat stroke (a medical emergency that can result in permanent disability or death). This deficient practice affected 1 of 4 residents reviewed for transport in the facility van. Findings included: Resident #1 was most recently admitted to the facility on [DATE] with a diagnosis of dementia, right hip fracture, and muscle weakness. Review of a Minimum Data Set 5 day assessment dated [DATE] revealed Resident #1 had intact cognition. He had an impairment on one side of the lower extremity. He required substantial assistance for all activities of daily living. He had recent orthopedic surgery that required skilled nursing facility care. Review of the care plan for Resident #1 dated [DATE] identified initial care needs, risks, strengths, and goals. The goal was for Resident #1 to have access to necessary services to promote adjustment to his new living environment and/or post discharge from facility. Approaches included, in part: Minimize potential risk factors related to falls or injury and receive necessary assistance for activities of daily living; transfer and ambulate with rolling walker with one assist. An interview was conducted on [DATE] at 10:20 AM with the family member who accompanied Resident #1 to his doctor ' s appointment on [DATE]. She stated at 10:30 AM on [DATE] she called Transporter #1 and told her Resident #1 was ready to be picked up at the doctor ' s office and brought back to the facility. She recalled approximately 15 minutes later, Transporter #1 picked Resident #1 up in the facility van and she (Resident #1 ' s family member) left to run errands before returning to the facility. She stated she arrived back at the facility around 11:30 AM and started looking for Resident #1. She could not find him. She was going to leave his lunch with the nurse and leave when she noticed the Business Office Manager, who had been in the van during transport, was in her office. She asked the Business Office Manager where Resident #1 was, and the Business Office Manager did not know. Resident #1 ' s family member asked Nurse #1 where Resident #1 was, and the nurse replied she thought he was at a doctor ' s appointment. The family member called Transporter #1 at 12:11 PM to find out the whereabouts of Resident #1. She stated Transporter #1 told her Resident #1 was in the building somewhere. Resident #1 ' s family member indicated she and the Business Office Manager continued to look for the resident inside and outside. Then the Business Office Manager told her Transporter #1 found Resident #1 outside in the facility van. The family member watched Transporter #1 wheel him into his room. The family member stated Transporter #1 apologized and explained that there had been no place to park the van in the front of the building, so she parked the van in the back and had left Resident #1 in the van. A software application for navigation revealed the location of the doctor ' s office where Resident #1 had an appointment was 2.2 miles away from the facility and would take 7 minutes to drive to or from taking the fastest route. An interview was conducted with Resident #1 on [DATE] at 10:50 AM. Resident #1 stated if his family member had not looked for him when he was left alone on the van on [DATE] he would have died . He explained he had been transported by the facility to a doctor ' s appointment on [DATE] and when Transporter #1, the Business Office Manager, and he returned, Transporter #1 got out of the van and left him in the van alone locked in his wheelchair. He recalled he couldn ' t move his feet and couldn ' t get up. He was secured into the wheelchair in the van. No windows had been left open, but he was beside a window, and he was able to open it with his finger about a quarter of an inch. It was the emergency window beside his wheelchair, and it had to be held open, it did not stay open by itself. He stated he was yelling for help, but no one heard him. He reported the transportation van was parked in the sun, and it was hot. He thought he had been left there for about an hour. He stated as time went on, he panicked, became short of breath, and became more scared. He recalled a man walked past the van, but he couldn ' t get his attention. He was locked in and could not get out of the van. He stated he was scared he was going to die because it was hot as the devil, and he didn ' t think he was going to last very long. After Transporter #1 found him, she took him into the building, put him by the air conditioning unit in his room and gave him water. He reported he was very hot, short of breath, and sweaty. He stated he would not get back in the van with Transporter #1 or the Business Office Manager again. He never wanted to experience that again because it felt like the end of the world. He concluded he was sure if his family member had not been looking for him, he would have died in the van that day. On [DATE] review of the Weather by CustomWeather website revealed the outdoor air temperature in the town where the facility was located on [DATE] at 11:53 AM was 92 degrees Fahrenheit (F), 94 degrees F at 12:53 PM, and sunny. The Centers for Disease Control and Prevention ' s (CDC) Beat the Heat: Extreme Heat informational document indicated during extreme heat the temperature in a vehicle can be deadly. With an outside temperature of 80 degrees F the temperature inside a car rises to 109 degrees F in 20 minutes and 118 degrees F in 40 minutes. An interview was conducted with Transporter #1 on [DATE] at 12:33 PM. She stated she had been employed at the facility for six years and had been the transporter for two years. She was trained to transport by the previous transporter who retired. She stated she transported Resident #1 to a doctor ' s appointment on [DATE]. The Business Office Manager was with her because Transporter #1 couldn ' t push the resident ' s wheelchair due to a previous shoulder injury. The Business Office Manager had assisted by wheeling Resident #1 onto the van. Transporter #1 strapped him in behind the driver seat in the first wheelchair space that was located toward the back behind 3 stationary rows of seats. Resident #1 was the only resident on the van. She explained when they arrived at the facility after the resident ' s appointment, cars were parked in the driveway, and she could not pull in to get the resident off the van. She explained this was the location they normally parked to offload the residents from the van. She stated she was frustrated after she waited about 2 or 3 minutes, and she told the Business Office Manager to go back to work. She stated she tried to maneuver the van around the parked cars under the awning to offload Resident #1 in the front, and when she could not, she became frustrated, and drove to the back of the building to the space where the van was stored. After she backed the van into the designated unshaded parking space beside the Maintenance Building, she heard her phone beep. The engine was still running when her phone beeped with a message from a doctor ' s office about a different appointment for a resident that she was unaware of. Transporter #1 explained she became agitated because she knew she had not made a scheduling mistake and missed taking a different resident to an appointment. Transporter #1 stated she shut the van off and went into the building forgetting that Resident #1 was still in the van. After she went back into the building and was in her office, she began scheduling appointments for other residents and worked for about 10 to 15 minutes. She indicated at that time, a family member of Resident #1 called her on the transporter phone and asked her where Resident #1 was because she could not find him. She told the family member Resident #1 was in the building and she continued working for no more than 20 minutes. Transporter #1 recalled when she left her office she met up with the Activities Assistant in the hallway and thought, Oh, sh**! because she realized she had left Resident #1 in the van. Transporter #1 went out to the van and Resident #1 was in the van. She stated she asked Resident #1 if he was alright and he replied, it was a little warm. She observed he had removed the anchoring hooks in the front of the wheelchair but was still strapped in behind his chair. She had not noticed he had unlatched the emergency window to the left of his chair until she drove off and the window slammed shut. She did not know if the window had been open because it did not slide or prop open but had to be held when open. She reported she was scared because she thought he had tried to remove his seatbelt like he was trying to get out of the van himself. She moved the van to the loading dock area in the back of the building to get him off the van. Transporter #1 commented she had parked the van in the storage area originally because she was frustrated, agitated, and wasn ' t thinking. She estimated Resident #1 could not have been left in the van alone for more than 20 minutes. She explained that once she got him into the building, she stopped in the service hall and called for the aide to get the nurse. She was told by Nurse Aide #1 that Nurse #1 and the family member were together looking for Resident #1. She took the resident to his room, put him by the air conditioner and gave him a cup of water. When the family member came to the room, Transporter #1 explained to the family member that she had left the resident in the van alone. She went to tell Nurse #1 what had happened, she looked busy, so she went and told the Nurse Practitioner that she had left Resident #1 on the van and asked her to assess. She verified this was after she had placed him in front of the air conditioner and had given him ice water to drink. In an additional interview with Transporter #1 on [DATE] at 2:35 PM via the telephone, she stated that after she returned to her workstation and reviewed her transportation schedule, she had responded to the text from the doctor ' s office at 12:01 PM on [DATE]. She indicated she was unable to tell what time she originally heard the phone beep with the receipt of the message. She explained the original text came to her at 10:30 AM but she didn ' t know it until it beeped again to remind her to check her texts. She stated she only knew she responded to it at 12:01 PM. She said when she went back into the building the first thing she did was check the schedule and responded to the text. At that time, she was in her office working and had not yet realized she had left Resident #1 in the van. Transporter #1 did not know what time it was when she realized Resident #1 had been left in the van alone. The storage parking space for the facility van was observed on [DATE] at 11:50 AM. The parking space was located to the back of the facility along the side in the last space next to the maintenance building and in front of the tree line. There was no awing or shade in the parking space. There were 2 orange cones on the white parking lot lines that designated the space for storage of the facility van. An observation of the facility van was made on [DATE] at 11:45 AM in the presence of Transporter #1 and the Business Office Manager. Transporter #1 illustrated where Resident #1 was locked in the van on [DATE]. The area where Resident #1 was seated was the first wheelchair space behind the driver and three rows of stationary seats (for ambulatory residents). Transporter #1 demonstrated how the resident ' s wheelchair was secured into position with two hooks in the front that hooked into the floor and two hooks on the back that hooked into the floor. The seat belt was applied from back to front around the occupant and hooked in the back. Transporter #1 explained a resident secured in the wheelchair would not be able to unhook the attachments in back of the wheelchair. There was an emergency window located to the left of the location where the resident was positioned that was within reach of Resident #1 on [DATE]. The window had to be unlatched on each side and would open with pressure but would not remain open unless held. An interview was conducted with the Business Office Manager on [DATE] at 11:19 AM. She stated she had ridden along with Transporter #1 to take Resident #1 to his doctor ' s appointment on [DATE] because Transporter #1 was on restrictions for a recent shoulder injury and was not supposed to push his wheelchair. She stated it was around 11:00 AM when they picked up Resident #1 from his doctor ' s appointment. The Business Office Manager pushed him out of the doctor ' s office and loaded him onto the van then Transporter #1 strapped him in because she did not know how to strap the wheelchair. When they arrived back at the building there were 2 cars in the driveway preventing them from parking the van under the awning. They waited for about 10 minutes for the vehicles to move but it turned out they were visitors, and they did not move. The Business Office Manager stated that Transporter #1 told her to go ahead and go back to work, and Transporter #1 would wait for the cars to move and offload the resident herself. She stated she was not sure how much time had passed before Transporter #1 decided to move the van to the storage space in back of the building because she had returned to her office inside the building. The last time she saw Resident #1 was when she and Transporter #1 had been waiting for the cars to move. Around 11:30 AM Resident #1 ' s family member came to her door and stated, Oh, you ' re back! The family member told her she was looking for the resident. The Business Office Manager advised the family member to check the therapy room to find him. Nurse Aide #1 who had been looking for Resident #1 came to her and told her Resident #1 was not in the building and could not be found. She tried to call Transporter #1 on the transportation phone, but she didn ' t pick up. She got up and told the Activities Assistant to go find Transporter #1 and then she went out the front door, went down the sidewalk and saw the van parked on the side of the building. She turned around and went back into the building. The Business Office Manager stated she had sent the Activities Assistant to find Transporter #1 to determine where Transporter #1 had put the resident and that ' s when Transporter #1 realized she had left him in the van. The Activities Assistant came back to her and reported Transporter #1 had left the Resident #1 on the van. By the time she got back to the back of the building Transporter #1 had taken the resident out of the van and was wheeling him up the sidewalk. She told Transporter #1 to make sure she gave the Resident #1 water. The Business Office Manager recalled Transporter #1 took Resident #1 to his room, gave him ice water, told Nurse #1, and went to the front of the building to get the Nurse Practitioner. The Business Office Manager reported the Nurse Practitioner went immediately to assess the resident. An interview was conducted with the Activities Assistant on [DATE] a 3:49 PM. She stated Resident #1 ' s family member and a nurse aide came to the Activities Department looking for Resident #1 on [DATE] around lunchtime. The Activities Assistant saw Transporter #1 coming down the hall and she reported she asked the transporter if she had seen Resident #1 and she replied, He ' s here in the building. She explained she asked Transporter #1, Did you leave him on the van? Transporter #1 told her she would go and check the van. She concluded that she went and found the Business Office Manager, and she and the Business Office Manager went outside together. An interview was conducted with Nurse Aide #1 on [DATE] at 12:04 PM. She stated she cared for Resident #1 on [DATE] on day shift. She recalled he had an appointment on [DATE]. She stated later that day a family member stopped her and asked if she had seen Resident #1. Nurse Aide #1 explained she thought Resident #1 was still at his doctor ' s appointment at that time. She began to help the family member look for him. She asked several staff members if they had seen him, and everyone thought he had not yet returned. Other staff members joined the search. They looked in other resident rooms, therapy, activities and the dining room. She recalled the family member said she had talked to the Transporter #1 who told her Resident #1 was in the building. She stated she went to answer a call bell on her assignment and when she came back to help search, Resident #1 and the family member were in his room. She stated she immediately called the Administrator to report that Resident #1 had been left on the van. She verified on her phone that she had called the Administrator at 12:31 PM on [DATE] to make the report. A progress note written by the Nurse Practitioner recorded as a late entry on [DATE] at 1:10 PM for [DATE] at 3:50 PM documented she was notified by staff that Resident #1 was left on the facility van upon return from an appointment for a period of time up to 10 minutes. She assessed Resident #1 in his room with the family member present. He was in his wheelchair next to the air conditioning vent eating his lunch. His skin color was appropriate for his ethnicity, dry and warm to touch but not hot or feverish. He was not diaphoretic (sweating). He denied nausea, vomiting, abdominal pain or cramping, blurry vision or double vision. He stated his vision was fine. He denied headache, photophobia (sensory disturbance provoked by light) and tinnitus (ringing in ears). An interview was conducted with the Nurse Practitioner on [DATE] at 3:55 PM. She stated Transporter #1 came to her office on [DATE], explained she had left Resident #1 on the van, and asked her to come and look at him. A family member was present in the room when she arrived, and Resident #1 was seated in his wheelchair in front of the air conditioner. She assessed the resident at that time and found his color was appropriate, his skin was warm but not hot, there were no signs or symptoms of heat stroke, and his neurological assessment was at baseline. He told her he had been really hot in the van. He had no nausea or vomiting and was eating a lunch his family member had brought him. Resident #1 reported to her he had been dizzy when in was in the van. After she assessed Resident #1, she instructed Nurse #1 to take a set of vital signs, check him hourly during the shift, encourage fluids, and monitor output. She noted she also instructed the family to push fluids. She stated she determined because the resident ' s skin was not flushed or pale that he did not need to be sent to the hospital for an assessment. She stated she did not know how long he was on the van because ' 10 minutes ' was told to her by staff so that is what she documented. She did not know the exact time she assessed the resident because she had made her note 3 days later and the time of 3:50 PM was not the actual time she saw Resident #1 on [DATE]. She stated she did not have a set of vital signs at the time of her assessment but recalled she had instructed Nurse #1 to obtain his vital signs after she completed her assessment. The Nurse Practitioner stated the major risks of being left in a hot vehicle unattended could lead to heat stroke or death. An interview was conducted with Nurse #1 on [DATE] at 3:55 PM. She stated on [DATE] after being alerted by staff that Resident #1 was missing she started to help look for him in the facility. The Nurse Practitioner came to her and told her Resident #1 had been left in the van. She stated she went to his room and talked to both Resident #1 and the family member. She recalled the resident told her he had been scared. He had been eating the lunch the family brought him. In an additional interview with Nurse #1 on [DATE] at 9:05 AM she stated she had looked through her work bag and found a set of vital signs on a crumpled sticky note that she had taken on Resident #1 on [DATE] sometime between 12:30 - 1:00 PM. She stated she knew that the vital signs belonged to Resident #1 because she recalled she had been taking a blood sugar on a different resident when the Nurse Practitioner came to her on [DATE] and asked her to stop and go to Resident #1 and get a set of vital signs. Nurse #1 explained she looked at the blood sugars she recorded and determined the time to be 12:35 PM when she was asked to take Resident #1 ' s vital signs. The vital signs she had written down on the sticky note but not recorded in the medical record were blood pressure ,d+[DATE], temperature 98.8 degrees F. and heart rate 76 beats per minute. Nurse #1 stated she also monitored Resident #1 frequently throughout the shift, encouraged fluids and monitored his output. Review of a Psychotherapy Comprehensive Clinical assessment dated [DATE] documented Resident #1 was referred for evaluation after an incident on [DATE] in which he was left in the facility transport van after an appointment. Psychologist #1 documented staff reported Resident #1 was accidentally left in the van without air conditioning or windows down for between 10 and 25 minutes. Resident #1 reported to him that he was in the van for as much as 90 minutes, but this was not accurate. Resident #1 told him he was extremely frightened and stated: I thought I was going to die; if my family member hadn ' t been here, I know I would have died . Resident #1 reiterated feeling distressed and worried that he was going to die. Several times he expressed gratitude that his family member was in the facility and able to check on him. Psychologist #1 documented Resident #1 stated, I ' m OK now; I don ' t think about much about it anymore; I ' m not having any problems. Psychologist #1 recommended a follow-up Psychotherapy assessment in one week to assure ongoing stability. A concern form filed by the Nursing Home Administrator on behalf of Resident #1 dated [DATE] was reviewed. The concern was that Resident #1 had been left unattended on the facility van. The family member, the Social Worker and the Administrator met on [DATE]. The resolution of the concern included the placement of a no parking sign in the front of the building, education to staff, and the implementation of a walk through on the van by staff prior to parking after a transport. An interview was conducted with the Administrator on [DATE] at 1:35 PM. She stated she had been made aware that Resident #1 had accidentally been left unattended in the van on [DATE]. She stated Resident #1 had been immediately assessed by the Nurse Practitioner and had no injuries. She noted the family member had been in the facility and was aware Resident #1 had been left in the van. She explained Transporter #1 was suspended on [DATE] pending an investigation and returned on [DATE] to view van safety videos. The van was put out of commission until [DATE]. She stated the investigation concluded on [DATE] and education and competency was completed with Transporter #1. She explained to prevent this from occurring again an audit was developed to have a second staff member perform a walk through and sign off after transports to ensure no one is on the bus for 6 weeks. She stated the Quality Assurance Performance Improvement Committee would review the audits for 6 weeks. The Administrator concluded no resident should ever be left unattended on the facility van. The Administrator was notified of Immediate Jeopardy on [DATE] at 5:35 PM. The Administrator provided the following corrective action plan with a compliance date of [DATE]: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On [DATE], Resident #1 was transported into the facility by Transporter #1. Transporter #1 assisted Resident #1 back to the room and got Resident # 1 water. On [DATE], the Nurse Practitioner physically assessed Resident #1. The results of the physical assessment stated that Resident #1 ' s skin color was appropriate for ethnicity, dry and warm to touch but not hot or feverish. Resident #1 ' s temperature was 98.8. The temperature was obtained by Nurse assigned to Resident # 1 at approximately 12:35 p.m. On [DATE], the daughter of Resident #1 was present in the facility and made aware of the incident. On [DATE] Resident #1 was psychologically assessed by Psychiatric Provider with a follow up appointment in one week. According to Psychiatric Provider documentation Resident #1 denied any ongoing anxiety related to incident. All future appointments for Resident #1 will be scheduled with a contract transportation company. The root cause analysis was completed on [DATE] by the Administrator and determined that the normal drop off area was blocked. After an extended wait time in the transport area, Transporter #1 left the transport area and parked the van in the parking lot near the maintenance shed and forgot Resident #1 was on the van. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On [DATE], the Administrator reviewed the transportation schedules from [DATE] to [DATE] and interviewed all alert and oriented residents to ensure there were no additional residents left unattended on the facility van. On [DATE], the Director of Nursing and Unit Manager reviewed the medical record of all cognitively impaired residents that were transported by the facility from [DATE] until [DATE] to identify any change in condition that may have been the result of being left unattended on the facility van. No additional residents were affected. In house transport was ceased from [DATE] until [DATE]. All resident transportations from [DATE] until [DATE] were completed by a contract transportation company. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On [DATE], signs were added to the resident drop off area to discourage visitors and staff from blocking the entrance. The Administrator educated Transporter #1 on [DATE] regarding the new process of ensuring a second staff member validates and signs off on the transport log when residents return to the facility. Administrative staff, which include the Business Office Manager, the Social Worker, the Scheduler, the Activity Assistant, the Admissions Coordinator, the Maintenance Assistant, the facility Receptionist and the Minimum Data Set Nurse were educated on performing a second check upon any resident return from transport by the Administrator on [DATE]. The Maintenance Assistant is the only additional person that has been trained to transport residents and he was educated on the process change by the Administrator on [DATE]. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The Quality Assurance Performance Improvement team reviewed the incident and decided on the plan of correction on [DATE]. The Administrator will review the transport logs 5 times per week for 6 weeks to ensure there is a second staff member validating the residents are brought into the facility immediately upon return. The audits will be reviewed by the Quality Assurance Performance Improvement committee monthly for two months to ensure the systemic change is sustainable. The first day of monitoring started on [DATE] when the facility resumed in house transportation. Alleged date of corrective action completion: [DATE] Validation of the corrective action plan was completed on [DATE]. This included interviews with: Transporter #1, Nurse Practitioner, Nurse #1, Activities Assistant, Business Office Manager, Administrator, Scheduler, Admissions Coordinator, Maintenance Assistant, Receptionist, MDS Nurse and Human Resources Director. These interviews verified that these staff members were trained on the new policy for a second staff member to physically go on the van after transport returns to the facility to ensure no residents are left on the van and that this audit had been implemented. The Nurse Practitioner was interviewed and verified she assessed the resident and there were no injuries. The Resident Representative verified she was aware of the incident when it occurred. Suspension of Transporter #1 during the investigative stage was verified. Transports scheduled between [DATE] through [DATE] were provided by a community transport service was verified. No transportation was provided until staff had been educated. The facility ' s audit tool, education, and QAPI minutes were reviewed. Two no parking signs were observed in the front of the building near the front door on each side of the awning. The facility ' s immediate jeopardy removal date was verified as [DATE] and corrective action completion date was verified as [DATE].

Based on record review and staff interviews the facility failed to maintain complete and accurate medical records by not ensuring Nurse #1 documented the vital signs in the medical record for 1 of 5 residents (Resident #1) reviewed for medical record accuracy. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included debility and dementia. A progress note written by the Nurse Practitioner as a late entry on 07/08/24 at 1:10 PM for 07/05/24 at 3:50 PM documented she had been notified by staff and nursing that [Resident #1] was left on the facility van upon return from an appointment for a period of time up to 10 minutes. Nursing requested that she evaluate [Resident #1]. An interview was conducted with the Nurse Practitioner on 07/15/24 at 3:55 PM. She stated she had assessed Resident #1 when he was brought back into the facility after he had been left in the van unsupervised. She stated her assessment did not include vital signs but recalled she had instructed Nurse #1 to obtain his vital signs. No vital signs were recorded in the medical record between 12:00 PM and 1:00 PM when Resident #1 was returned to the facility. An interview was conducted with Nurse #1 on 07/15/24 at 3:55 PM. She stated she had been asked to obtain a set of vital signs on Resident #1 at lunchtime on 07/05/24. She recalled the timeframe because she had to stop taking blood sugars to take his vitals. She estimated it was approximately 12:30 PM when she took his vital signs. She stated she had not recorded the vital signs in the electronic medical record. In an additional interview with Nurse #1 on 07/16/24 at 9:05 AM she stated she had found a sticky note in her bag that she had written Resident #1 ' s vital signs on. The vital signs recorded on the sticky note were: Blood pressure 126/74, heart rate 76, and temperature (temple) 98.8 degrees Fahrenheit. There was no date, time, or resident name written on the sticky note. She provided a written statement dated 07/15/24 attesting to the accuracy of the vital signs taken by her on 07/05/24 for Resident #1. In an interview with the Director of Nursing on 07/15/24 at 3:55 PM she stated she had not been aware that the vital signs obtained for Resident #1 after he had been left unsupervised in the facility van had not been documented. She explained that she expected all vital signs to be documented in the medical record. A Record of In-Service form dated 07/15/24 was reviewed on 07/16/24. The title of the in-service was: Documentation. The education was provided by the Director of Nursing to Nurse #1. The objective of the in-service was: Prompt documentation of time sensitive data inclusive of vital sign documentation. Nurse #1 acknowledged in writing that she understood the in-service and had signed the form.

Based on staff, Nurse Practitioner, and resident interviews, the facility failed to treat a resident with dignity and respect when Nursing Assistant (NA) #2 spoke to Resident #1 in a manner that made her cry, feel nervous, anxious, and as if she was going to have a panic attack. Resident #1 was observed by staff crying inconsolably (unable to be comforted) following an interaction with NA #2. This deficient practice affected 1 of 3 residents reviewed for dignity and respect. Findings included: Resident #1 was admitted on [DATE] with anxiety, worsening generalized weakness, peripheral numbness, and recurrent falls. Review of Resident #1's 3/19/24 quarterly Minimum Data Set assessment indicated resident was cognitively intact with no hallucinations or delusions, no behaviors and was coded as frequently incontinent of bowel and bladder. Resident #1 required extensive assistance with bed mobility, transfers and toileting. Resident #1 received an antianxiety medication. Review of Resident #1's care plan which was most recently updated on 3/26/24 revealed problem areas related to continence and Activities of Daily Living (ADL's). The care plan indicated Resident #1 had a self-care deficit related to decline in functional abilities, physical deconditioning, and pain. Interventions included getting out of bed to wheelchair as tolerated and toilet transfers with assistance of 1. The care plan indicated Resident #1 had episodes of bladder and bowel incontinence and interventions included to provide incontinence care as needed. Observation of Resident #1 on 5/29/24 at 10:00 AM was conducted in conjunction with an interview. The resident was well groomed and was sitting in a wheelchair in her room. Resident #1 was alert with no confusion noted. Resident #1 stated she had an incident with NA #2 in April 2024. Resident #1 stated NA #2 was very aggressive, loud, heavy handed, rude and was getting worse prior to the incident on 4/6/24. Resident #1 stated NA #2 made her anxious when she came on duty but she (Resident #1) stated she had not reported this. Resident #1 stated in the afternoon when she knew NA #2 was coming on duty for 3-11 shift, she would get nervous and anxious like she was having a panic attack. Resident #1 stated her anxiety was made worse by NA #2 and how she treated her. Resident #1 stated at the time of the incident, she was weak and required increased assistance due to a recent hospital stay. Resident #1 stated on the evening of the incident on 4/6/24 she used her call bell to request assistance. NA #2 responded to her call light, screamed, What do you want? in an aggressive tone and threw the incontinent wipes at her with them landing on her stomach. NA #2 left the room and was very loud in the hallway talking about her (Resident #1) to the other staff saying, I guess she [Resident #1] can't help herself today. Resident #1 stated NA #2 returned to provide care for her with another NA. Resident #1 stated she believed NA #2 was frustrated with her for requiring assistance and she (NA #2) made her feel bad. Resident #1 stated Nurse #6 provided care for her for the rest of the shift. Resident #1 stated it had been difficult adjusting to the facility when she was admitted last year being a younger person than most residents in the facility and then she had a setback with her hospitalization that caused increased weakness. This incident with NA #2 was hard on her but she was trying to move on and stay positive. An interview was conducted with NA #2 on 5/30/24 at 12:15 PM. NA #2 stated she was assigned to Resident #1 on 4/6/24 on the 3:00 PM to 11:00 PM shift. NA #2 stated she was familiar with Resident #1 and was assigned to her frequently. NA #2 stated she thought Resident #1 was jealous when she helped her roommate and did not like her (NA#2). NA #2 indicated prior to this incident, she should not have been assigned to Resident #1 as they did not have a good rapport. NA #2 stated on 4/6/24, Resident #1 was in bed which was not her usual routine and Resident #1 stated she did not feel good that day. Around 6:30 or 7:30 PM Resident #1 activated her call bell and said she needed to be changed. NA #2 stated she gave Resident #1 the cleansing wipes to clean herself. NA #2 stated she noticed the bed was wet, so she went to get linens to change the bed. NA #2 stated she came back in the room, changed the bed and then Resident #1 needed to be pulled up. NA #2 stated she got another nursing assistant (NA #4) to assist her because she (NA #2) had a heart attack and could not pull on the residents. NA #2 said around 8:30 or 9:00 PM Nurse #6 told her not to go back in Resident #1's room but did not tell her why. NA #2 stated she continued to work the rest of the shift that evening. NA #2 stated on 4/7/24 around 1:30 PM she received a call stating she was not to come in to work for 3:00 PM to 11:00 PM shift but was not told why. NA #2 stated about a week later she was called to come for a meeting with the Administrator and Nurse #3 where she was informed, she was terminated. NA #2 stated she was terminated for incontinence abuse. An interview was conducted with NA #4 on 5/30/24 at 11:50 AM. NA #4 was working 3-11 shift on 4/6/24 on the other end of the hall from Resident #1's room. NA #4 stated that evening she was at the nurse's station when NA #2 called out requesting help with pulling Resident #1 up in the bed. NA #4 stated Resident #1 was crying when she entered the room. NA #4 stated NA #2 instructed Resident #1 to use her legs to assist with pushing up in the bed. NA #4 stated Resident #1 tried to assist but could not and she observed that NA #2 was visibly frustrated with Resident #1. NA #4 stated NA #2 told Resident #1 that she had a heart attack and could not pull on her. NA# 4 stated she helped pull Resident #1 up in the bed and left the room. NA#4 stated she had been working at the facility through an agency since December 2023. NA #4 stated she frequently worked 3-11 shift on the 100 hall. NA #4 stated Resident #1 would frequently ask who was assigned to her and when it was NA #2, she voiced that she did not want NA #2 taking care of her and would get upset. NA #4 stated she was working as a NA through an agency, so she did not get involved with asking why she did not want NA #2 to take care of her. NA #4 stated Resident #1 and NA #2 did not have a good relationship. NA #4 indicated she was familiar with Resident #1 and was assigned to her occasionally. NA #4 stated Resident #1 was cognitively intact and pleasant when she was assigned to her. An interview was conducted with Nurse #6 on 5/29/24 at 12:30 PM. Nurse #6 revealed she worked the 3:00 PM to 11:00 PM shift on 4/6/24 and was assigned to Resident #1. Nurse #6 stated she entered Resident #1's room on the evening of 4/6/24 after NA #2 provided care and found the resident crying and visibly upset. Resident #1 stated she did not want NA #2 to provide care for her again. Nurse #6 stated NA #2 continued to work the rest of the shift but did not provide care for Resident #1. Nurse #6 indicated she had not heard nor witnessed the interaction between NA #2 and Resident #1 that evening and was unaware of any prior incidents. An interview was conducted with Nurse #3 on 5/29/24 at 1:30 PM. Nurse #3 stated she was the interim DON at the time of this incident on 4/6/24. Nurse #3 stated she received a call on 4/7/24 around 12:00 PM from Nurse #6. Nurse #6 informed Nurse #3 that on 4/6/24 Resident #1 was crying inconsolably and visibly upset and stated she did not want NA #2 to provide care for her any longer. Nurse #3 stated she interviewed Resident #1 and was concerned about NA #2 refusing to provide care, her demeanor and how she spoke to the resident. Nurse #3 stated Resident #1 was cognitively intact, and she was not aware of any issues with NA #2 and Resident #1 prior to this incident. Nurse #3 stated she called NA #2 and informed her she was suspended pending investigation of the incident. Nurse #3 stated NA #2 was later terminated due to poor customer service and refusing to provide care. Nurse #3 indicated she expected all residents would be treated with dignity and respect. An interview was conducted on 5/30/24 at 2:30 PM with the Nurse Practitioner (NP). The NP stated Resident #1 was cognitively intact, pleasant and self-aware. The NP stated at the time of the incident between Resident #1 and NA #2 the resident had weakness and deconditioning due to a hospital stay for sepsis. The NP stated she was made aware of the incident that occurred on 4/6/24 between Resident #1 and NA #2. The NP indicated she was monitoring Resident #1 closely for depression and anxiety. An interview was conducted on 5/30/24 at 3:40 PM with Nurse #11. Nurse #11 was assigned to Resident #1 on 4/7/24 on the 7:00 AM to 3:00 PM shift. Nurse #11 stated she was an agency nurse. Nurse #11 stated Resident #1 approached her on 4/7/24 and asked to talk to her privately. Resident #1 indicated on 4/6/24 on the 3:00 to 11:00 PM NA #2 went in to assist her and was rough and rude to her, slamming things around. Resident #1 stated NA #2 told her she did not clean up people that were continent. Resident #1 stated NA #2 told her to pull herself up in the bed. Resident #1 stated she told NA #2 she could not pull herself up as she was not feeling well that day and was weak. NA #2 told Resident #1 she couldn't pull her up since she (NA #2) had a medical issue, so she (NA #2) yelled into the hallway for someone to help her. Resident #1 was crying visibly upset what did that look like? when describing the incident. Resident #1 stated she reported another incident to Nurse #3 in which NA #2 had talked to her in a mean way and made her feel bad. Resident #1 stated nothing was done about it. Nurse #11 stated she wrote a note about what Resident #1 said and put it under the Administrator's door to follow up. An interview was conducted with the Administrator on 5/31/24 at 10:20 AM. The Administrator stated there was an incident which occurred on the evening of 4/6/24 in which Resident #1 required assistance with incontinence care. In the interview, the Administrator initially stated she became aware of the incident in the morning on 4/8/24 but later stated she was informed by Nurse #3 in the evening on 4/7/24. The Administrator stated Resident #1 reported she was observed visibly upset and expressed that she did not want NA #2 to enter her room or provide care for her again due to the NAs demeanor. The Administrator stated she expected residents to be treated with dignity and respect and for residents to receive care as needed or requested. The facility provided the following Corrective Action Plan with a completion date of 4/10/24: 1.On 4/6/24, Resident #1 was crying and visibly upset and expressed to Nurse #6 that she did not want NA#2 to provide care for her again. Nurse #6 provided care to Resident #1 for the remainder of the shift. Resident #1 was assessed for redness or skin breakdown with no negative findings noted. On 4/7/24, the Nurse Aide in question (NA#2) was suspended pending investigation of the incident that occurred on 4/6/24. NA #2 was terminated for poor customer service and declining to preform duties per job description. On 4/7/24, Resident #1 was interviewed regarding the incident and an investigation was initiated. 2. To identify residents with the potential to be affected: The Director of Nursing (DON)/designee completed interviews by 4/8/24 with cognitively intact residents regarding mistreatment. No other issues were identified. The Unit Managers/designee completed skin checks by 4/8/24 on all cognitively impaired residents to ensure there were no signs or symptoms of mistreatment. No negative findings were noted. 3. On 4/8/24, to prevent this from happening again, the Administrator/designee educated staff on resident rights. All newly hired staff are educated on abuse and resident rights. All agency staff are educated on resident rights. 4.To monitor and maintain ongoing compliance, the Social Worker/designee will interview 5 cognitively intact residents weekly for 8 weeks to ensure they feel they are treated with dignity and respect. In addition, the DON/designee will assess 5 cognitively impaired residents weekly for 8 weeks to ensure there are no signs of mistreatment. Results of the audits will be brought to the Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations as needed. A QAPI meeting was held on 4/8/24 with the Medical Director and members of QAPI committee. The incident that occurred on 4/6/24 and the plan of corrective action was reviewed by the committee. 5. The allegation of compliance date was 4/10/24. The corrective action plan was validated on 5/31/24 and concluded the facility implemented an acceptable corrective action plan. Interviews conducted with staff revealed the facility provided education and training on the treatment of residents with dignity and respect. The initial interviews with residents and skin checks were validated as completed on 4/8/24. The ongoing monitoring audits were validated as completed weekly starting the week of 4/8/24. The facility's corrective action plan's completion date was verified as 4/10/24.

Based on observations and staff interviews the facility failed to ensure the area surrounding dumpsters remained free of garbage and debris and to close and/or replace all missing doors to the dumpsters that contained waste for 1 of 2 dumpsters reviewed. These failures had the potential to attract pests and rodents. Findings included: An observation of the dumpster area with the Dietary Manager (DM) on 03/26/24 at 12:20 PM revealed scattered debris, branches, and leaves around the sides and back area of the dumpster enclosure area. Both the right dumpster sliding door and the right half of the gate to the dumpster enclosure area were both missing, leaving trash contents and large amounts of debris to build-up around and behind the dumpsters, open to the elements, available to pests and rodents. An interview was conducted with the Dietary Manager on 03/26/24 at 12:30 PM. He stated it was the responsibility of the Environmental Services Department to keep the dumpster area clean and trash can lids closed. An interview was conducted with the Environmental Services Department -Assistant on 03/26/24 at 3:00 PM. He stated it was the responsibility of the assistant to ensure the area around the dumpsters was clean, free of debris, and in good repair. He stated the Environmental Services Department Director recently resigned and he as an assistant was left to manage the Environmental Services Department. He stated the facility was trying to hire a new Environmental Services Department -Director; but until then he was falling behind in everything. An interview was conducted with the Administrator on 03/28/24 at 9:30 AM. She stated that they were in the process of interviewing for a new Environmental Services Department -Director, and she expected maintenance to keep the dumpster area clean and free of debris, and the side sliding doors of the dumpsters should be closed and not open to the elements available to pests and rodents.

Based on observations and interviews the facility failed to have sufficient dietary staff to ensure meals were delivered at the posted mealtimes. This failure had the potential to impact 74 of 74 residents who received oral nutrition. The findings included: An interview was conducted with the Dietary Manager (DM) on 03/25/24 at 11:45 AM. He stated that two of his kitchen staff called out that morning, leaving one kitchen aide and himself to prepare both breakfast and lunch, as well as clean-up. He revealed he was struggling to obtain and maintain staff, due to other facilities paying more. The DM disclosed having an understaffed kitchen staff meant meals were not served on time according to the schedule, but dietary staff were doing the best they could. An interview was conducted on 03/25/24 at 12:43 PM with the Dietary Manager (DM). He stated due to kitchen budget cuts he was having to schedule the kitchen staff short, months in advance, which he said, it is what it is. He stated that the dietary department needed staff, which was why there was only 1 dietary aide and himself preparing breakfast that morning, and that one dietary aide usually comes around 12:00 PM and a cook comes in the afternoon to complete the evening cooking. A dining room observation was conducted on 03/25/24 at 1:00 PM with an alert and oriented resident, who stated he was waiting like everyone else for his lunch to be served, which was often served late; but there was nothing he could do about it but wait. A lunch observation was conducted with Resident #274 (200-hall) on 03/25/24 at 1:15 PM, revealed no nutritional shake on resident's lunch tray per meal tray standing order slip, which read: 4-ounce nutritional shake. An observation and interview were conducted with Resident #274 (200-hall) on 03/26/24 at 9:15 AM. She stated she was eating the breakfast she had ordered; except she was missing the nutritional shake. She said she let nursing and dietary know about not getting the nutritional shake on her meal tray, but they never provided her with one. She also stated meal trays were never delivered at a consistent time, except when you are here. Resident #274 stated she usually receives her breakfast tray around 10:00 AM and the lunch tray around 1:00 PM to 1:30 PM, and her dinner trays did not arrive until 7:00 PM to 10:00 PM. A lunch observation was conducted with Resident #274 (200-hall) on 03/26/24 at 1:15 PM, revealed no nutritional shake on her lunch tray per meal tray slip standing order: 4-ounce nutritional shake. An interview was conducted on 03/26/24 at 1:20 PM with Medication Aide (MA) #1. The MA revealed mealtimes were erratic. The MA stated the mealtime inconsistency was related to very few staff in the kitchen. The MA stated mealtimes were often erratic, and that the inconsistency was related to very few staff in the kitchen. The MA confirmed that Resident #274 did not have a 4-ounce nutritional shake on her lunch meal tray as she should have per standing order. An interview was conducted on 03/27/24 at 3:50 PM with Kitchen Cook #1. He stated the kitchen was often short staffed with 3 or less staff per shift. He stated it takes 3 Kitchen Aides and 1 Kitchen Cook to prepare meals, deliver trays timely, and clean-up. He stated the kitchen needed 3 Kitchen Aides, 1 cook, and the DM to run their kitchen and feed 74 residents, He stated the kitchen had been short staffed for over 6 months, and upper management knows about it. An interview was conducted on 03/27/24 at 3:55 PM with Kitchen Cook #2. He stated the kitchen had been short staffed a lot of the time, which required him working long hours, often two shifts. He stated resident meals were often late because they were short staffed. An interview was conducted on 03/27/24 at 3:58 PM with Kitchen Cook #3. She stated the kitchen had been short-staffed for about a year. She stated there had been times when she and the DM were the only staff to prepare meals and cleanup for 74 residents, impossible. She said with 4 staff it is doable, 2 and 3 very difficult, and 1 impossible. She said the Administrator was aware of their situation, but nothing seems to be done about it. An interview was conducted on 03/27/24 at 4:00 PM with the DM. He stated he did not have sufficient staff as some of the dietary staff had quit and his staffing budget was cut. The DM stated staffing the kitchen with 1 to 2 kitchen cooks or aides is not enough to be efficient or provide resident meals timely. He stated on Monday there was no cook in the morning as a result he was responsible for cooking breakfast and lunch for the residents. He further stated he had only two kitchen staff who assisted him with cleaning and other kitchen jobs. A follow-up interview was conducted with the Dietary manager on 03/27/24 at 4:30 PM. He stated the dietary department did not have adequate staff and he stepped in as a cook when there was no cook or any call outs. An interview was conducted on 03/28/24 at 7:55 AM with the Administrator. The Administrator stated she was hired as the Administrator 5 months ago, and since then been aware the kitchen needed more staff, and she has been actively recruiting since then. The Administrator stated the Dietary Manager's primary function has been to manage, cook, and fill in, until the facility has adequate dietary staff. A review of the dietary staff schedules from 12/24/23 - 03/25/24 (93-day total) revealed: 4-days there were 1-kitchen staff scheduled for the whole day. 13-days there were only 2-kitchen staff scheduled for the whole day. 34-days there were only 3-kitchen staff scheduled for the whole day. 44-days there were only 4-kitchen staff scheduled for the whole day. Meal schedule mealtimes provided by the Dietary Manager. Breakfast - 8:00 AM -200 Hall, 8:45 AM-Dining Room, 8:45 AM-100 Hall. Lunch - 12:00 PM -200 Hall, 12:45 PM-Dining Room, 12:45 PM-100 Hall. Dinner - 6:00 PM -200 Hall, 6:45 PM-Dining Room, 7:00 PM-100 Hall.

Based on record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) program failed to maintain implemented procedures and monitor interventions the committee put in place following a Focused Infection Control survey and complaint investigation completed on 06/23/23, a recertification survey and complaint investigation completed on 12/09/22, a Focused Infection Control survey and complaint investigation completed on 06/03/22, a recertification survey and complaint investigation completed on 09/23/21, and a revisit survey and complaint investigation completed on 04/28/21. This was for 5 deficiencies cited in the areas of Quality of Care (684), Nutrition/Hydration Status Maintenance (692), Labeling and Storing Drugs & Biologicals (761), Sufficient Dietary Support Personnel (802), and Food Procurement, Store, Prepare, and Serve (812). These deficiencies were subsequently recited during the recertification and complaint investigation survey of 04/02/24. The continued failure during six federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program. Findings included. This tag is cross-referenced to: F684: Based on record review, staff and Nurse Practitioner interviews the facility failed to administer a topical antibiotic ointment prescribed for treatment to the nasal area following a dermatology procedure and to administer antibiotic ophthalmic drops according to the physicians order for 2 of 2 residents (Resident #48, and Resident #43) reviewed for quality of care. During the revisit survey and complaint investigation on 04/28/21 the facility failed to assess and obtain orders for treatment of a right-hand skin tear and abrasion and follow the Nurse Practitioners order to obtain a urinalysis. During the recertification survey and complaint investigation on 12/09/22 the facility failed to complete neurologic assessments with vital signs and assessment of hand grasps and change in behavior. During the Focused Infection Control survey and complaint investigation on 06/23/23 the facility failed to administer topical antibiotics according to the physicians order. F692: Based on observations, record review, staff, Registered Dietician, and Nurse Practitioner interviews the facility failed to obtain physician ordered weights for 7 of 7 residents (Resident #274,#5, #31, #24,#47, #48, #26 ) and provide a nutritional supplement for 1 of 1 resident (Resident #274) reviewed for nutrition. During the recertification survey and complaint investigation on 12/09/22 the facility failed to obtain and record accurate weights and identify and verify the accuracy of weights. F761: Based on observation, staff, Corporate Nurse Consultant, and Administrator interviews the facility failed to store an opened bottle of Lorazepam in the locked bin of the medication refrigerator and label a bottle of Lispro insulin with an opened date for 1 of 1 medications storage rooms observed. During the recertification survey and complaint investigation on 09/23/21 the facility failed to discard expired medications in medication carts and the medication storage room and keep medication carts free of loose medications. During the recertification survey and complaint investigation on 12/09/22 the facility failed to remove expired insulin and keep unattended medications stored in a locked compartment. F802: Based on observations and interviews the facility failed to have sufficient dietary staff to ensure meals were delivered at the posted mealtimes. This failure had the potential to impact 74 of 74 residents who received oral nutrition. During the Focused Infection Control survey and complaint investigation on 06/03/22 the facility failed to employee sufficient dietary support staff to carry out the functions of food and nutrition services. F812: Based on observations, staff interviews and review of manufacturer's instructions, the facility failed to: 1) store the hand-held plastic scoops outside of 2 of 3 dry food bins holding flour and sugar 2) wash dishes in hot water and sanitize dishes in the facility's three-compartment sink per Food and Drug Administration Food Code recommendations in a quaternary sanitizing solution of at least 50-parts per million (ppm) and maintain sanitizing solutions used in the kitchen at the strength recommended by the manufacturer and maintain a clean and sanitized kitchen area for food preparation. These practices had the potential to affect 74 of 74 residents' food quality and kitchen sanitation safety. During the recertification survey and complaint investigation on 12/09/22 the facility failed to remove expired items from the dry goods storage and label and date items in the cooler, refrigerator, freezer, and the nourishment room. An interview was conducted on 03/28/24 at 3:30 PM with the Administrator along with the Corporate Nurse Consultant. The Administrator stated that the repeat deficiencies were primarily related to increased staff turnover over the last several months and the use of agency staff. She indicated they were actively recruiting new staff. The Corporate Nurse Consultant stated continued education would be provided to staff to ensure they adhere to facility policies and procedures.

Based on record reviews and staff interviews, the facility failed to provide effective leadership and implement effective systems to ensure the facility was able to obtain 60-gallon, 30-gallon, and 10-gallon plastic can garbage liners, toilet tissue, paper towels, and 30 ml. plastic medication cups to meet residents' needs. This failure result affected 74 of 74 residents reviewed for Administration. Findings included: Review of facility's grievances revealed an anonymous grievance filed 09/05/23 regarding; The facility ran out of supplies often. The workers were having to ration trash bags, straws, and medication cups due to the facility not obtaining the supplies. The complainant did not know what the facility was doing to obtain the supplies but said that staff had a difficult time finding supplies to work with. An interview was conducted on 03/26/24 at 3:00 PM with the Medical Records/Central Supply Manager (CSM). She stated the supply delivery truck comes once a week. CSM looks in each of the three supply rooms to assess the needs of the residents then asks the residents/staff as well as the department heads to see what supplies are needed for the following week. The CSM stated that since the Environmental Services Director resigned, she was also responsible for ordering supplies for housekeeping and maintenance, since the Environmental Service Director -Assistant does not know how to order supplies. The CSM stated they were currently very low on toilet paper and paper towels, and out of large 60-gallon and 30-gallon trash bags used for trash cans and soiled linen. She said she ordered housekeeping supplies on 03/20/24 (toilet tissue, paper towels, and 60-gallon trash bags) from their supplier, which delivery was still pending. A tour of the facility's main supply room on 03/26/24 at 2:00 PM revealed: No large/medium trash can liners, no toilet paper, no paper towels, and 800 - 30 ml. plastic medication cups. An interview was conducted on 03/26/24 at 3:55 PM with Nurse #8. She stated she was the day nurse on the 100-hall and that the large, soiled utility bins located in the hall were not being utilized due to facility being out of the large 60-gallon and medium 30-gallon trash bags. She stated nursing, housekeeping, and laundry staff were trying to make do with the small can liners until the shipment of larger can liners arrived. A facility tour on 03/26/24 at 6:05 PM revealed no large 60-gallon can liners were available for the soiled linen bins on the 100 or 200 halls. An interview was conducted on 03/27/24 at 10:05 AM with Housekeeper #1. She stated yesterday she was the day housekeeper on the 100-hall and was out of the medium and large trash can liners and were rationing out what small bags they did have. She stated housekeeping was often low or out of supplies like paper towels, toilet paper, plastic bags of all sizes, as well as other supplies. She said she did not know why supplies were low or why the situation was not fixed and continued to be an ongoing issue. An interview was conducted with the Director of Nursing (DON) on 03/28/24 at 7:55 AM. She stated we have had problems with getting supplies timely, measuring cups, straws, paper towels, garbage can liners, etc. But with the Environmental Service Director gone, existing staff have stepped up to order maintenance and housekeeping supplies and they are currently working hard to get the supplies ordered and to the residents without any problem. The DON further stated that it was her expectation that residents have the supplies that are needed. An interview was conducted on 03/28/24 at 9:30 AM with the Dietary Manager (DM). He stated on 03/27/24 he went to one of their sister facilities and picked up 1-case each of small, medium, and large trash can liners, since the facility was out, and that the Environmental Service Director - Assistant ordered supplies for the wrong date. An interview was conducted with the Administrator on 03/28/24 at 10:50 AM. She stated she did not realize staff were having issues with getting supplies from the facility's current supply vendor. She stated, going forward, she expected staff to communicate when they were having difficulty obtaining supplies from the facility's vendor so they could obtain the items from another supplier.

Based on observations, staff interviews and review of manufacturer's instructions, the facility failed to: 1) store the hand-held plastic scoops outside of 2 of 3 dry food bins holding flour and sugar 2) wash dishes in hot water and sanitize dishes in the facility's three-compartment sink per Food and Drug Administration Food Code recommendations in a quaternary sanitizing solution of at least 50-parts per million (ppm) and maintain sanitizing solutions used in the kitchen at the strength recommended by the manufacturer and maintain a clean and sanitized kitchen area for food preparation. These practices had the potential to affect 74 of 74 residents' food quality and kitchen sanitation safety. Findings included: 1. During the initial tour of the facility on 3/25/24 at 11:00 AM, an observation was made of the flour and two sugar bins. Hand-held plastic scoops were stored directly in the food items. An interview was conducted with the Dietary Manager (DM) on 03/25/24 at 11:10 AM. He stated it was his expectation that hand-held plastic scoops be stored in a closed container outside of each bin. An interview was conducted with the Administrator on 03/28/24 at 7:55 AM. She revealed it was her expectation that the dietary staff follow the sanitation guidelines taught by the facility. 2a. An observation of dietary assistant washing dishes (pots, sheet pans) in a three-compartment sink occurred on 03/25/24 at 11:15 AM. The water in the wash sink was warm to touch. The DM, using test strips, tested the concentration of the quaternary sanitizing solution which was less than 50-parts per million (ppm). Per Food and Drug Administration Food Code recommendations, the concentration of quaternary sanitizing solution should be at least 50-ppm. 2b. An observation on 03/25/24 at 11:20 AM revealed the kitchen's only red sanitizing bucket was dry and empty sitting under a food preparation area and was not being utilized to wipe down and sanitize the tops of the four stainless-steel food preparation tables. The DM stated he did not use the red bucket because he only had old test strips to check the strength of the quaternary sanitizing solution in the red bucket. Instead, he wiped down the food preparation areas with a store-bought bleach disinfectant spray. He also stated that he could not check the ppm effectiveness of the bleach sanitizing spray. A follow-up interview and kitchen observation were conducted on 03/26/24 at 12:00 PM with the DM. He said the quaternary solution in the red sanitizer bucket and three compartment dish washing sink needed to register 100 - 200 PPM when checked with the appropriate strips he picked up at a sister facility. He reported when the strength was less than this there was a chance that the surfaces being wiped down or dishes being washed were not properly disinfected. He commented that the strength of the sanitizing solutions in the bucket and dish sink should be checked throughout the day and should not have registered 0-PPM. The DM was then observed to have filled the three compartments sink with sanitation solution and had placed a red bucket under each of the four stainless steel food preparation tables with sanitizing solution. After the replacements, he tested the four red buckets and three compartment sinks with appropriate test strips, with all registering appropriate 100-200 PPM. A follow-up interview was conducted on 03/27/24 at 3:55 PM with DM. The DM stated a filled red sanitation bucket should have been kept at each of the four food preparation areas for safety and sanitation reasons. He said kitchen staff were supposed to clean and wipe down the food preparation tables with sanitizing solution from one of the red sanitizing buckets and let it dry. The DM stated the food preparation tables needed to be consistently cleaned and sanitized to prevent mold or water borne pathogens from developing. An interview was conducted with the Administrator on 03/27/24 at 6:00 PM. He reported it was his expectation for the facility's kitchen staff to follow all regulatory guidelines for food and kitchen sanitation safety; wash and sanitize dishes per the manufacturer instructions, wipe down, test disinfectant solutions, and disinfect food preparation tables per guidelines.

Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form 10055) prior to discharge from Medicare Part A skilled services (Resident #18 and Resident #66) and failed to provide a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (form 10123) prior to discharge from Medicare Part A skilled services (Resident #324) for 3 of 3 residents reviewed for beneficiary protection review. The findings included: 1. Resident #18 was admitted to the facility 9/26/23 and admitted to Medicare Part A services. Resident #18's Medicare Part A skilled services ended on 10/22/23 and she remained in the facility. The SNF ABN reviewed revealed Resident #18's name, the date services were to end, and the estimated cost of the services. There were no options checked for the decision made about continuing Medicare Part A services. An interview was conducted with the facility Social Worker on 3/27/24 at 2:51 PM who stated she neglected to have Resident #18's Resident Representative choose an option for the decision made regarding continuing Medicare Part A skilled services. The facility Social Worker stated her normal process is to contact the Resident's Representative and let them know Medicare Part A services are ending and provide them with the CMS form 10123. If the resident wishes to remain in the facility, she provides the SNF-ABN form. The facility Social Worker stated she either meets with the Resident Representative in person or contacts the Resident Representative over the telephone and mails the forms. Attempts to contact the resident and Resident Representative were unsuccessful. An interview was conducted with the facility Administrator on 3/28/24 at 10:56 AM who stated the SNF ABN should have been completed with Resident #18's Resident Representative's decision made regarding continued Medicare Part A skilled services. 2. Resident #66 was admitted to the facility on [DATE]. She was admitted to Medicare Part A skilled services on 1/17/24. Resident #66's Medicare Part A skilled services ended on 2/5/24 and she remained in the facility. The SNF ABN reviewed revealed Resident #66's name, the date services were to end, and the estimated cost of the services. There were no options checked for the decision made about continuing Medicare Part A services. The CMS form 10123 revealed the facility Social Worker had a conversation on 2/2/24 with Resident #18's Resident Representative regarding Medicare Part A skilled services ending. An interview was conducted with the facility Social Worker on 3/27/24 at 2:51 PM who stated she did not check an option for the decision made about continuing Medicare Part A services. She indicated an option should have been reflected on the SNF ABN. The facility Social Worker stated her normal process is to contact the Resident's Representative and let them know Medicare Part A services are ending and provide them with the CMS form 10123. If the resident wishes to remain in the facility, she provides the SNF-ABN form. The facility Social Worker stated she either meets with the Resident Representative in person or contacts the Resident Representative over the telephone and mails the forms. Attempts to contact the resident and Resident Representative were unsuccessful. An interview was conducted with the facility Administrator on 3/28/24 at 10:56 AM who stated that if a conversation was held with Resident #66's Resident Representative it should have been documented on the SNF ABN. 3. Resident #324 was admitted to the facility on [DATE] and admitted to Medicare Part A services. Resident #324's Medicare Part A skilled services ended on 12/6/23. He was discharged to the community on 12/7/23. Record review revealed Resident #324, nor his Resident Representative were given the CMS form from 10123. An interview was conducted with the Social Worker on 3/27/24 at 2:51 PM who stated she was out of the facility on leave during the time of Resident #324's discharge and was unable to locate the completed forms. She reported the facility Business Manager was assisting with this task during her absence. The facility Social Worker stated her normal process is to contact the Resident's Representative and let them know Medicare Part A services are ending and provide them with the CMS form 10123. If the resident wishes to remain in the facility, she provides the SNF-ABN form. The facility Social Worker stated she either meets with the Resident Representative in person or contacts the Resident Representative over the telephone and mails the forms. During an interview with the facility Business Manager on 3/27/24 at 2:55 she indicated she completed the forms for Resident #324 but was unable to locate the facility copies.

Based on observations, record review, staff, Registered Dietician, and Nurse Practitioner interviews the facility failed to obtain physician ordered weights for 7 of 7 residents (Resident #274,#5, #31, #24,#47, #48, #26 ) and provide a nutritional supplement for 1 of 1 resident (Resident #274) reviewed for nutrition. Findings included. 1.a) Resident #274 was admitted to the facility on [DATE] with diagnoses including in part; protein calorie malnutrition, and congestive heart failure. A physicians order dated 03/15/24 for Resident #274 revealed to obtain daily weights for congestive heart failure. A care plan dated 03/16/24 revealed Resident #274 was nutritionally impaired and was at risk for dehydration and weight fluctuations related to recent surgical correction of gastric volvulus, congestive heart failure, feeding tube placement, variable oral intake, diuretic use, obesity, chronic obstructive pulmonary disease, and edema. Interventions included in part; to monitor weights per order. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #274 was cognitively intact. She required moderate assistance with activities of daily living. She had no rejection of care. Review of Resident #274's electronic medical record revealed the following weights recorded as of 03/26/24. 3/27/2024 the recorded weight was 329 lbs. (pounds) 3/26/2024 the recorded weight was 329 lbs. 3/23/2024 the recorded weight was 331 lbs. 3/22/2024 the recorded weight was 331 lbs. 3/20/2024 the recorded weight was 331 lbs. 3/19/2024 the recorded weight was 330 lbs. 3/15/2024 the recorded weight was 331 lbs. Review of Resident #274's progress notes from 03/15/24 through 03/26/24 revealed no other weights recorded. During an interview on 03/27/24 at 09:29 AM Nurse Aide #4 stated she had worked at the facility for [AGE] years. She stated the wound nurse, and the Director of Nursing (DON) put together a notebook to record weights in and a notebook was kept at each nurses station. She stated the nurse would inform the nurse aides which residents needed weights each day, or the nurse aide would look in the notebook to determine which residents needed to be weighed. She stated once the weight was obtained by the nurse aide the nurse was supposed to sign the sheet which showed the recorded weight, and the sheet would be placed back into the notebook. She indicated there was a lot of agency staff working currently in the facility and indicated that could be why the weights were not getting done consistently. She indicated the wound nurse was in charge of reviewing the weight books to ensure weights were getting done. During an interview on 03/27/24 at 1:32 PM the wound care nurse stated she had recently been assigned to review the weight books to ensure weights were getting documented and recorded. She indicated she or the assigned nurse would record the weights in the residents electronic medical record. She reported that if weights weren't recorded in the residents electronic medical record, then they weren't done. She stated she reviewed the notebooks weekly, but she was currently acting as the unit manager and was the wound nurse. She indicated if daily or weekly weights weren't done then it was an oversight. She indicated the nurse aide and the residents assigned nurse should be making sure the weights were getting done according to the physicians order. During an interview on 03/27/24 at 04:18 PM Resident #274 was alert and oriented to person, place, and time. She stated she had not refused weights. During an interview on 03/28/24 at 2:00 PM the Registered Dietician stated obtaining resident weights had been an issue, but she thought the process had improved since they now had one staff member in charge of reviewing weights. She stated weights should be followed per the physicians order. She stated Resident #274 should be receiving daily weights for congestive heart failure and her weight was stable. During an interview on 03/28/24 at 2:31 PM the Director of Nursing (DON) stated the facility protocol for weights included obtaining an admission weight, then weekly weights for 4 weeks, then monthly weights unless the physician ordered a residents weight to be done more frequently. She stated weights should be obtained according to the physicians order and documented in the notebook which was kept at each nurses station and then recorded in the residents medical record. She stated she made the notebooks for weights to be recorded in and the nurse aid was responsible for obtaining the weight, then the nurse was to sign off on the weight sheet, and any refusals would be documented by the nurse. The sheet would be placed back into the notebook and the wound nurse would review and document the weights in the residents medical record. She indicated the wound nurse was recently assigned to review the weight book to ensure weights were getting done. She stated she thought the system seemed to be improving at this point and was not aware weights were getting missed. She indicated they currently employed a lot of agency staff, and more education was needed. During an interview on 03/28/24 at 4:00 PM the Nurse Practitioner stated weights should be obtained according to the physicians order and documented in the residents medical record. She stated current weights were needed for Resident #274 to determine nutritional status and she expected the weights to get done. 1.b) A dietary note dated 03/21/24 at 10:35 AM for Resident #274 revealed resident at risk for nutritional decline, dehydration, and weight fluctuations related to diagnosis of COPD, Lupus, diuretic use, and edema. Nutrition interventions include to continue non-therapeutic diet, with the resident desire to keep supplements between meals, and to provide nutritional shakes with meals. A physician's order dated 03/22/24 for Resident #274 was to give a house supplement two times per day, regular diet regular texture thin consistency, with 4-ounce nutritional shake with every meal. Observations of Resident #274's lunch tray was observed on 03/25/24 at 1:15 PM, breakfast on 03/26/24 at 9:15 AM, lunch on 03/26/24 at 1:15 PM, dinner on 03/26/24 at 5:45 PM, breakfast on 03/27/24 at 8:30 AM, and lunch on 03/27/24 at 1:15 PM, with no 4-ounce nutritional shake supplement was on the meal trays. The standing orders: 4-ounce nutritional supplement shake were listed on the meal tray tickets. An observation and interview were conducted with Resident #274 (200-hall) on 03/26/24 at 9:15 AM. She stated she was eating the breakfast she had ordered; except she was missing the nutritional shake. She said she let nursing and dietary know about not getting the nutritional shake on her meal tray, but they never provided her with one. An interview was conducted on 03/26/24 at 1:20 PM with Medication Aide (MA) #1. The MA said she gave medications to Resident #274 throughout the day without difficulty. The MA stated she was not the one who delivered resident's lunch tray, but confirmed there was no 4-ounce nutritional shake on the resident's meal tray. She also read the resident's meal tray slip, with standing orders: 4-ounce nutritional shake on tray for each meal. She then instructed a Nursing Aide (NA) to go to the kitchen and get a 4-ounce nutritional shake for the resident, which the NA did. An interview was conducted on 03/27/24 at 4:00 PM with the DM. He reviewed Resident #274's meal ticket and stated there should be a nutritional 4-ounce shake on her meal tray at breakfast, lunch, and dinner. He was unaware the nutritional shake had been missing from the meal trays. The DM added that 4-ounce supplement shakes were in stock and there were no issues with having it available. He stated the kitchen dietary aide was responsible for putting these items on the tray when the meals were being plated. And stated the kitchen dietary aides just forgot to put the shake on the meal tray for Resident #274, and it was her expectation that each meal ticket should be reviewed at the time of plating to ensure that items are not forgotten. During an interview on 03/28/24 at 7:55 AM with the Director of Nursing (DON) revealed that the nurse aide that was setting up the tray for Resident #274 should be checking the ticket on the tray to ensure it was correct. During an interview on 03/28/24 at 8:00 AM with the Administrator revealed that she had been made aware of Resident #274 not receiving the 4-ounce nutritional supplement. The Administrator said that there were several staff who should be checking the ticket. The first being the kitchen staff and Dietary Manager. Then the nurse aide should also be checking the ticket to make sure it was correct. During an interview on 03/28/24 at 1:34 PM with the Registered Dietician revealed that she did not think that the missing 4-ounce nutritional shake supplement is a routine missed item. The registered Dietician stated that Resident #274 was not currently losing weight, but she expected the kitchen to put the nutritional shake on the tray when the meals were being plated. 2. Resident #5 was readmitted to the facility on [DATE] with diagnoses including septic shock, heart failure and diabetes. The Minimum Data Set (MDS) discharge assessment dated [DATE] revealed Resident #5 required extensive assistance with activities of daily living. She exhibited no rejection of care. A physicians order dated 03/18/24 for Resident #5 revealed to obtain daily weights and to notify the physician if weight increase was greater than 3 lbs. (pounds) per day or 5 lbs. in one week. A care plan dated 03/21/24 revealed Resident #5 was at risk for nutritional decline, dehydration, and weight fluctuations related to recent sepsis and diagnosis of type 2 diabetes, chronic kidney disease, congestive heart failure, the need for a therapeutic diet, diuretic use, variable oral intake, history of weight fluctuations, edema, and dysphagia. Interventions include in part: to monitor weights per order. Review of Resident #5's electronic medical record revealed the following weights recorded: 03/28/2024 05:23 the recorded weight was 212.4 lbs. 03/27/2024 05:54 the recorded weight was 212.5 lbs. 03/26/2024 05:30 the recorded weight was 212.5 lbs. 03/24/2024 05:39 the recorded weight was 212.3 lbs. 03/23/2024 05:29 the recorded weight was 212.2 lbs. 03/20/2024 05:39 the recorded weight was 211.8 lbs. Review of Resident #5's progress notes from 03/18/24 through 03/26/24 revealed no other weights recorded. During an interview on 03/28/24 at 11:44 AM Resident #5 was observed lying in bed. She was oriented to person, place, and situation. She stated she would not refuse weights as long as the mechanical lift was used. During an interview on 03/28/24 at 4:00 PM the Nurse Practitioner stated weights should be obtained according to the physicians order and documented in the residents medical record. She indicated Resident #5 was recently readmitted and was ordered daily weights due to congestive heart failure. She indicated Resident #5's weights were stable at this time. 3. Resident #31 was admitted to the facility on [DATE] with diagnosis including severe protein calorie malnutrition, chronic obstructive pulmonary disease, and oxygen dependence. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #31 was cognitively intact. She required limited assistance with activities of daily living (ADLs. A care plan dated 10/10/23 revealed Resident #31 had impaired nutritional status and was at risk for dehydration and weight fluctuations due to respiratory failure, malnutrition, osteoporosis, emphysema, and weight gain trend. Interventions included in part: to monitor weights per order. A physicians order dated 10/03/23 for Resident #31 revealed to obtain daily weights and notify the physician of weight gain over 3 lbs. 03/20/2024 the recorded weight was 90.2 Lbs. 03/17/2024 the recorded weight was 90.3 Lbs. 03/16/2024 the recorded weight was 90.2 Lbs. 03/15/2024 the recorded weight was 89.1 Lbs. 03/14/2024 the recorded weight was 92.3 Lbs. 03/06/2024 the recorded weight was 91.0 Lbs. 03/04/2024 the recorded weight was 90.8 Lbs. 03/03/2024 the recorded weight was 91.0 Lbs. 03/02/2024 the recorded weight was 90.4 Lbs. 02/25/2024 the recorded weight was 88.8 Lbs. 02/17/2024 the recorded weight was 94.6 Lbs. 02/14/2024 the recorded weight was 91.8 Lbs. 02/11/2024 the recorded weight was 94.8 Lbs. 02/09/2024 the recorded weight was 99.3 Lbs. 02/07/2024 the recorded weight was 99.6 Lbs. 02/05/2024 the recorded weight was 100.0 Lbs. 02/03/2024 the recorded weight was 98.9 Lbs. 01/28/2024 the recorded weight was 99.2 Lbs. 01/21/2024 the recorded weight was 99.4 Lbs. 01/20/2024 the recorded weight was 99.4 Lbs. 01/19/2024 the recorded weight was 99.6 Lbs. 01/14/2024 the recorded weight was 98.8 Lbs. 01/13/2024 the recorded weight was 98.8 Lbs. 01/07/2024 the recorded weight was 99.6 Lbs. 01/06/2024 the recorded weight was 99.7 Lbs. 01/04/2024 the recorded weight was 100.0 Lbs. 12/31/2023 the recorded weight was 98.4 Lbs. 12/30/2023 the recorded weight was 98.6 Lb. 12/27/2023 the recorded weight was 99.0 Lb. 12/24/2023 the recorded weight was 96.4 Lbs. 12/23/2023 the recorded weight was 96.0 Lbs. 12/22/2023 the recorded weight was 96.0 Lbs. 12/17/2023 the recorded weight was 97.6 Lbs. 12/16/2023 the recorded weight was 97.6 Lbs. 12/15/2023 the recorded weight was 97.0 Lbs. 12/11/2023 the recorded weight was 97.6 Lbs. 12/07/2023 the recorded weight was 103.6 Lbs. 12/06/2023 the recorded weight was 103.6 Lbs. 12/03/2023 the recorded weight was 104.2 Lbs. 12/02/2023 the recorded weight was 104.0 Lbs. 12/01/2023 the recorded weight was 104.6 Lbs. 11/26/2023 the recorded weight was 104.9 Lbs. 11/25/2023 the recorded weight was 104.6 Lbs. 11/22/2023 the recorded weight was 105.0 Lbs. 11/21/2023 the recorded weight was 105.0 Lbs. 11/19/2023 the recorded weight was 105.0 Lbs. 11/18/2023 the recorded weight was 104.6 Lbs. 11/15/2023 the recorded weight was 105.2 Lbs. 11/12/2023 the recorded weight was 108.2 Lbs. 11/11/2023 the recorded weight was 108.0 Lbs. 11/07/2023 the recorded weight was 108.2 Lbs. 10/29/2023 the recorded weight was 107.6 Lbs. 10/26/2023 the recorded weight was 110.8 Lbs. 10/25/2023 the recorded weight was 111.0 Lbs. 10/24/2023 the recorded weight was 110.2 Lbs. 10/23/2023 the recorded weight was 110.2 Lbs. 10/21/2023 the recorded weight was 109.6 Lbs. 10/17/2023 the recorded weight was 109.8 Lbs. 10/15/2023 the recorded weight was 110.2 Lbs. 10/05/2023 the recorded weight was 106.8 Lbs. 10/03/2023 the recorded weight was 107.8 Lbs. During an interview on 03/27/24 at 10:06 AM Nurse Aide #4 stated Resident #31 was oriented to person, place, and time. She was independent with activities of daily living (ADLs). Her appetite was getting better, and she ate 50% of most of her meals and ate a lot of snacks. During an interview on 03/28/24 at 11:23 AM Resident #31 was oriented to person, place, and situation. She stated she had never refused weights. During an interview on 03/28/24 at 4:00 PM the Nurse Practitioner stated weights should be obtained according to the physicians order and documented in the residents medical record. She stated current weights were needed to determine nutritional status and she expected the weights to get done. 4 Resident #24 was admitted to the facility on [DATE] with diagnoses including heart failure, and chronic obstructive pulmonary disease. A physicians order dated 10/31/23 for Resident #24 revealed to obtain weekly weights. The Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident#24 was severely cognitively impaired. She required extensive assistance with activities of daily living (ADLs). She had no rejection of care. Review of Resident #24's electronic medical record revealed the following weights: 03/14/2024 the recorded weight was 97 lbs. 02/27/2024 the recorded weight was 98 lbs. 12/08/2023 the recorded weight was 104 lbs. 12/07/2023 the recorded weight was 95.8 lbs. 11/15/2023 the recorded weight was 100 lbs. 11/07/2023 the recorded weight was 101 lbs. 10/23/2023 the recorded weight was 98 lbs. Review of Resident #24s progress notes from 03/15/24 through 03/26/24 revealed no other weights recorded. During an interview on 03/28/24 at 2:00 PM the Registered Dietician stated Resident #24 was currently receiving Hospice care and weekly weights were no longer needed. She stated the order should have been discontinued when the resident started Hospice services. 5.Resident #47 was admitted to the facility on [DATE] with diagnosis including cerebral vascular accident (CVA), and dysphagia (difficulty swallowing). A physicians order dated 10/11/23 for Resident #47 revealed weigh on admission and then weekly for 4 weeks. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #47 was severely cognitively impaired. He required extensive assistance by staff with activities of daily living (ADLs). He exhibited no rejection of care. He had no weight loss and had a feeding tube in place. A care plan dated 10/19/23 revealed Resident #47 was at risk for nutritional decline, dehydration, and weight fluctuations related to CVA, anemia, dementia, history of aspiration pneumonia, dysphagia with NPO (nothing by mouth) status, and 100% reliance on tube feedings with a history of intolerance to tube feedings. Interventions included in part to; monitor weight per order, and report 5% weight loss or gain to the physician and Registered Dietician. Review of Resident #47's electronic medical record revealed the following weights recorded as of 03/26/24. 03/07/2024 the recorded weight was 191 lbs. 02/17/2024 the recorded weight was 193 lbs. 10/23/2023 the recorded weight was 186.2 lbs. Review of Resident #47's progress notes revealed no other weights recorded. During an interview on 03/28/24 at 4:00 PM the Nurse Practitioner stated weights should be obtained according to the physicians order and documented in the residents medical record. She stated current weights were needed to determine nutritional status and she expected the weights to get done. 6.Resident #48 was admitted to the facility on [DATE] with diagnosis including diabetes with left below knee amputation. A physicians order dated 09/01/23 for Resident #48 revealed to weigh on admission and then weekly for 4 weeks. The Minimum Data Set (MDS) quarterly assessments dated 12/26/23 revealed Resident #48 was cognitively intact. He had no rejection of care and received a therapeutic diet. A care plan dated 03/26/24 revealed Resident #48 was at risk for nutritional decline, and weight fluctuations related to diagnosis of type 2 diabetes, heart failure, chronic kidney disease with a need for a therapeutic diet of low concentrated sweets and no added salt. Interventions included in part; to monitor weight per order. Review of Resident #48's electronic medical record revealed the following weights recorded as of 03/26/24. 03/08/2024 the recorded weight was 245 lbs. 01/05/2024 the recorded weight was 241 lbs. 12/11/2023 the recorded weight was 235 lbs. 09/01/2023 the recorded weight was 265 lbs. Review of Resident #48's progress notes revealed no other weights recorded. During an interview on 03/26/24 at 1:00 PM Resident #48 was alert and oriented to person, place, and time, and stated he received a regular diet. He indicated he wasn't certain how often he was weighed since his admission. He stated he did not and would not refuse weights. During an interview on 03/28/24 at 1:43 PM the Registered Dietician stated Resident #48's weight was stable since January 2024. She stated weight orders should be followed and recorded in the residents medical record. 45711 7. Resident #26 was admitted to the facility on [DATE] with diagnoses which included in part: dysphagia (impaired swallowing) following a stroke and presence of a feeding tube. Review of Resident #26's 1/6/24 quarterly Minimum Data Set (MDS) assessment indicated resident had severe cognitive impairment and had a feeding tube present. The assessment indicated resident's weight was 154 pounds with no weight loss or gain and resident received 51-100% of total calories through a feeding tube. Review of the facility weight protocol indicated residents were to be weighed on admission, weekly for four weeks and then monthly or per physician order. Review of Resident #26's care plan revealed a 1/7/24 focus which indicated resident was at risk of nutritional decline due to nothing by mouth status and 100% reliance on tube feeding for nutrition and hydration with history of weight fluctuations. Interventions included monitoring weight per protocol. Review of the weight log in Resident #26's electronic health record revealed the following: 12/7/23 154.2 pounds 1/9/24 157.6 pounds No weight was recorded for February 2024. 3/6/24 150.2 pounds Review of a 2/29/2024 Registered Dietician (RD) progress note revealed in part resident with current body weight of 154.2 pounds as of 12/7/23. Resident with history of weight discrepancies. Resident continues with nothing by mouth status with 100% reliance on tube feeding for nutrition and hydration. Weigh per policy (monthly) and monitor for tolerance of tube feeding regimen. Review of a 3/7/2024 RD progress note revealed a weight note regarding significant weight loss over 2 months with a weight change of 4.7%. Resident continues with nothing by mouth status and 100% reliance on tube feeding for nutrition and hydration: Reweigh resident to verify new weight as no changes noted with tube feeding. The note indicated medications were reviewed and Resident #26 was not receiving a diuretic. The RD recommended to add weekly weights for 4 weeks to monitor closely. Review of Resident #26's electronic health record revealed a 3/7/24 physician order to weigh resident in the morning every Wednesday for weight monitoring for four weeks. Review of Resident #26's electronic health record revealed a weight of 144.6 pounds was recorded on 3/13/24 and on 3/14/24 resident's weight was 150.4 pounds. Review of Resident #26's electronic health record revealed a weight change note dated 3/14/24 due to weight loss. Tube feeding was increased from three times per day to four times per day for weight stability. Resident to be weighed frequently to monitor closely. An interview was conducted with the Unit Manager on 3/27/24 at 2:20 PM. The Unit Manager revealed the weekly and monthly weights were completed by the Nursing Assistant assigned to the resident. The monthly weights were to be completed on the 1st through the 7th of the month. The Unit Manager stated there were issues with obtaining weights due to staffing problems. An interview was conducted with the Director of Nursing (DON) on 3/27/24 at 9:30 AM. The DON revealed she was in the position as a Unit Manager since the end of November and the interim DON position since the end of February. The DON stated she was aware there were problems with obtaining residents weights. The DON stated she was working on improving the system for obtaining weights. The DON stated she expected resident weights to be obtained and recorded per facility protocol. An interview was conducted with the Registered Dietician (RD) on 3/28/24 at 1:00 PM. The RD indicated the facility had issues with not obtaining the weights per protocol and questionable weights recorded. The RD stated that at minimum monthly weights were required for a resident receiving tube feeding. The RD indicated monthly weights were essential for monitoring the nutritional status of each resident. The RD revealed she was aware that Resident #26 had not been weighed in February and she did not know why a weight was not obtained. An interview with the Administrator on 3/28/24 at 3:30 PM revealed she expected that resident weights be obtained and recorded for the residents monthly or as ordered by the physician.

Based on record review and interviews with the staff, Administrator and Regional Nursing Consultant, the facility failed to prevent the Director of Nursing (DON) from having a resident care assignment including working on the medication cart with a facility census of greater than 60 residents for 7 of 7 days reviewed. Findings included: Review of the facility assignment sheets for 11/8/23 on the 3:00 PM-11:00 PM shift for 200 hall the Director of Nursing was assigned. Review of the facility assignment sheet for 1/1/24 on the 3:00 PM-11:00 PM shift on the top of the 100 hall the Director of Nursing was assigned. Review of the facility assignment sheet for 1/12/24 on the 11:00 PM to 7:00 AM shift for the 100 hall the Director of Nursing was assigned. Review of the facility assignment sheet for 1/23/24 on the 7:00 AM to 7:00 PM shift on the top of the 100 hall the Director of Nursing was assigned. Review of the facility assignment sheet for 1/30/24 on the 3:00 PM to 11:00 PM shift for the 100 hall the Director of Nursing was assigned. Review of the Medication Administration Record (MAR) for residents on the 100 hall for 3/4/24 at 08:00 AM and 12:00 revealed the DON's electronic signature for administration of medications. Review of the Medication Administration Records (MAR) for residents on the 200 hall for 3/15/24 at 8:00 PM and 10:00 PM revealed DON's electronic signature for administration of medications. Interview with the Administrator on 3/27/24 at 8:30 AM revealed the census was above 60 residents on the above dates. The Administrator stated she was not aware of the DON working the medication cart, but she might have. The Administrator stated she was not sure if the previous or current DON had worked the medication cart. The Administrator stated the previous DON's last day was 2/21/24 and the current interim DON was in the position as of 2/22/24. An interview with the interim Director of Nursing on 3/28/24 at 09:30 AM revealed she was hired at the end of November 2023 as a unit manager and became the interim DON at the end of February. The DON indicated she was not sure if she had worked a full shift on the medication cart since she became the interim DON, but she did work it for several hours when a nurse was late. The DON stated she was in the on-call rotation for the facility and was informed that if there was a call out or the schedule was short, she was to come in and work the shift. The DON stated she was informed when she became interim DON that if she was needed to work doing resident care she was expected to work. The DON was unaware of a regulation regarding the DON being a full time DON and not performing patient care. An interview was conducted on 3/28/24 at 11:30 AM with the facility scheduler. The scheduler revealed the Director of Nursing (DON) had worked on the medication cart in the previous six months. The scheduler stated the prior DON and the current interim DON had worked the medication carts when there was an open position for a shift that could not be filled or when there was a call out that was not replaced. The scheduler stated she was unaware that the DON was not to work on a patient care assignment. If there was a call out whoever was on the on-call rotation for that day was to work the shift if unable to obtain coverage. The DON is in the on-call rotation and does work doing patient care when needed. An interview was conducted on 3/28/24 at 11:35 AM with the Regional Nursing Consultant. The Regional Nursing Consultant indicated she came to the facility for a site visit in December and the Director of Nursing was working on the medication cart. The Regional Nursing Consultant was informed in December that the DON was having to work the medication cart frequently due to nurses leaving suddenly. The Regional Nursing Consultant stated the facility recently switched to a different human resources system for hiring new staff and renewed the contracts with temporary agencies to replace nurses that had left. The Regional Nursing Consultant stated she was aware the interim DON had worked some shifts since she came into the position at the end of February. An interview with the Administrator on 3/28/24 at 3:40 PM revealed she expected that the Director of Nursing would not work the medication cart and that the facility would be adequately staffed to ensure the DON did not work on a patient care assignment.

Based on observations, record review, staff, Registered Dietician, and Nurse Practitioner interviews the facility failed to provide physician ordered low concentrated sweets therapeutic diets to 2 of 2 diabetic residents (Resident #34 and Resident #48) reviewed for nutrition. Findings included. Resident #34 was admitted to the facility on [DATE] with diagnosis including diabetes and long-term insulin use. A physicians order for Resident #34 dated 10/16/23 revealed LCS (Low Concentrated Sweets) diet. Regular texture with thin consistency. A care plan dated 10/27/23 revealed Resident #34 was at risk for impaired nutritional status in part due to type 2 diabetes. Interventions included to encourage compliance with dietary guidelines, encourage a healthy lifestyle and provide diet according to the physicians order. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #34 was cognitively intact. She had no rejection of care and received a therapeutic diet. During an interview on 03/26/24 at 1:00 PM Resident #34 stated she was told on admission that the facility didn't provide diabetic diets. She stated she received regular foods with regular portion sizes. She stated she was provided regular snacks such as peanut butter and jelly sandwiches, crackers, and cookies. An observation on 03/26/24 at 1:00 PM revealed Resident #34's lunch meal included chicken with gravy, mashed potatoes, green beans, and blueberry cobbler with regular portion sizes. An observation on 03/27/24 at 9:30 AM revealed Resident #34 was served bacon, oatmeal, toast with jelly, and cranberry juice. During an interview on 03/27/24 at 1:30 PM the Regional Dietary Manager stated the facility provided liberalized diets to residents. She stated residents that received low concentrated sweets received the same foods as liberalized diets but with smaller portion sizes. She stated for example the resident would receive 2 ounces of dessert instead of 4 ounces of dessert. During an interview on 03/27/24 at 2:30 PM the Dietary Manager stated he followed a spreadsheet which showed the meals being served each day. The spreadsheet had an X by the food that residents could be served who were to receive low concentrated sweets, a renal diet (low in sodium, potassium, protein, and phosphorus) or a no added salt diet. He stated they offered smaller portion sizes of sugar foods to residents on low concentrated sweet diets such as 2 ounces of dessert instead of 4 ounces. He stated regarding no added salt diets that he didn't cook with salt. Residents that received a renal diet would get food substitutes such as serving chicken instead of pork if a substitute was available. He stated staffing was low in the kitchen and they tried to follow diet orders as much as they could. During an interview on 03/28/24 at 1:43 PM the Registered Dietician stated many of the residents received liberalized diets and the residents on low concentrated sweets were served smaller portion sizes. She indicated residents who were ordered low concentrated sweets, renal, or no added salt diets should be provided with foods consistent with the dietary guidelines. She indicated moving forward diet orders would be reviewed and food preferences and dietary recommendations would be discussed with residents or their Responsible Party to determine dietary preference. She stated the diets would be discussed with the physician for approval. During an interview on 03/28/24 at 1:45 PM Dietary Aide /Cook #4 stated she had only worked in the facility for a month. She stated her duties in the kitchen included to cook and to serve as a dietary aide. She stated she did plate the food for residents during meal preparation. She stated all residents were served the same foods, including the same amount of foods. She indicated she didn't know what specific guidelines were used for diabetic (low concentrated sweet) diets versus regular diets. During an interview on 03/28/24 at 4:00 PM the Nurse Practitioner stated she was not aware that therapeutic diets such as low concentrated sweets, renal or no added salt diets were not being followed. She stated she expected diets to be provided according to the prescribed diet order. 2 Resident #48 was admitted to the facility on [DATE] with diagnosis including diabetes with left below knee amputation. The Minimum Data Set (MDS) quarterly assessments dated 12/26/23 revealed Resident #48 was cognitively intact. He had no rejection of care and received a therapeutic diet. A physicians order dated 09/01/23 for Resident #48 revealed low concentrated sweets and no added salt diet. Regular texture with thin consistency A care plan dated 03/26/24 revealed Resident #48 was at risk for nutritional decline, and weight fluctuations related to diagnosis of type 2 diabetes, heart failure, chronic kidney disease with a need for a therapeutic diet of low concentrated sweets and no added salt. The goal of care was to meet his nutritional needs. Interventions included in part; to encourage compliance with diet guidelines, encourage a healthy lifestyle, and provide diet according to the physicians order. During an interview on 03/26/24 at 1:00 PM Resident #48 was alert and oriented to person, place, and time, and stated he received a regular diet. He stated he was supposed to receive a low concentrated sweets diet, but he received regular foods. He stated he received foods such as jelly, syrup, and desserts with his meals. He stated snacks were provided to him, but they were not low sugar snacks. An observation on 03/26/24 at 1:00 PM revealed Resident #48's lunch meal included chicken with gravy, mashed potatoes, green beans, blueberry cobbler with regular portion sizes. An observation on 03/27/24 at 9:30 AM revealed Resident #48 was served bacon, toast with jelly, corn flakes, a cup of cranberry juice and milk. During an interview on 03/28/24 at 1:43 PM the Registered Dietician indicated Resident #48 should receive foods consistent with the prescribed low concentrated sweets and no added salt diet. During an interview on 03/28/24 at 2:30 PM the Director of Nursing (DON) stated there had been a high turnover of staff in the kitchen and they were recruiting for additional kitchen staff. She indicated that was why the diet orders weren't consistently followed. She stated diets should be provided according to the physicians order. During an interview on 03/28/24 at 4:30 PM the Administrator stated she expected therapeutic diets to be provided according to the physician orders. She stated education would be provided.

Based on resident, staff and Registered Dietician interviews, the facility failed to provide packed meals for a dialysis resident who left the facility at 6:30 AM and did not return until lunchtime three days a week for 1 of 1 resident reviewed, Resident #279. This deficiency had the potential to affect all five residents residing at the facility who received hemodialysis. Findings included: Resident #279 was admitted to the facility on [DATE] with diagnosis that included end stage renal disease and dependence on renal dialysis. Review of a Medicare 5 day Minimum Data Set (MDS) assessment revealed Resident #279 had intact cognition. He received hemodialysis and had a midline intravenous access line. Review of the care Plan dated 3/21/24 for Resident #279 revealed the following focus area: Resident at risk for nutritional decline, dehydration, and weight fluctuations related to, in part, end stage renal disease with hemodialysis. The goal was for Resident #279 to be free of signs and symptoms of dehydration, fluid overload, and electrolyte imbalance through the next review. One of the interventions was for the facility to provide a packed meal on dialysis days. In an interview with the Dietary Manager on 03/28/24 at 10:30 AM he stated the dietary staff sent a boxed lunch with the resident consisting of a sandwich, cookie, corn chips, juice and apple sauce. For residents who left early, a breakfast was prepared the night before and stored in the nourishment room for staff to give to residents in the early morning. He stated dialysis residents never left without a box lunch. In an interview with the Nurse #2 on 03/28/24 at 8:30 AM she stated Resident #279 left the facility early in the morning for dialysis before her shift started. She did not know if he was provided with a boxed meal to take with him. She was not aware of bagged meals in the nourishment room. She noted staff did save his lunch tray for when he returned. In an interview with Resident #279 on 03/28/24 at 1:54 PM he stated he did not get breakfast before he left in the mornings for dialysis. He explained he had to send a staff member to the kitchen to get him a bagged meal. He noted when he asked for a bagged meal to take with him, he usually got a peanut butter sandwich, apple sauce and some chips. He stated when he went from supper the previous night to when he returned from dialysis it was a span from 6:00 PM until 1:00 PM the next day when lunch arrived. He reported no breakfast was prepared for him unless he asked and he could not always find a staff member to go to the kitchen to get him one before he left. In an additional interview with the Dietary Manager on 3/28/24 at 2:01 pm he stated he was not at the facility in the evening because he left at 5:00 PM each day. He was not aware bagged meals were not being prepared and placed in the nutrition room the night before for staff to give to dialysis residents who left before breakfast. He called a Dietary Aide and she stated over the speaker on the phone that she had given an aide a bag lunch that morning to give to Resident #279. She stated she was not aware of bagged meals in the nourishment room. In an interview with the Registered Dietician on 3/28/24 at 14:26 PM she stated it was preferred residents were provided 3 meals a day and if they are out of the building for dialysis, they should have a packed meal to take with them; otherwise, it was too many hours between meals. She explained residents were supposed to get 3 meals a day because residents who did not get 3 meals a day with protein were at risk for protein deficiency. In an interview with the Administrator on 3/28/24 at 2:58 PM she stated she expected dietary to provide bagged meals for dialysis residents to take with them without the residents having to ask for one. She was not aware the kitchen was not putting bagged lunches in the nourishment room the night before for staff to access.

Based on record review, staff and Nurse Practitioner interviews the facility failed to administer a topical antibiotic ointment prescribed for treatment to the nasal area following a dermatology procedure and to administer antibiotic ophthalmic drops according to the physicians order for 2 of 2 residents (Resident #48, and Resident #43) reviewed for quality of care. Findings included. 1.Resident #48 was admitted to the facility on [DATE] with diagnosis including malignant melanoma of the skin, and diabetes. A physicians order dated 03/08/24 revealed Triple Antibiotic External Ointment (Neomycin-Bacitracin-Polymyxin). Apply to nose topically two times a day for Post-operative dermatology for 3 Days. During an interview on 03/25/24 at 1:00 PM Resident #48 was observed lying in bed. He was alert and oriented to person, place, and time. He stated he had a recent procedure to remove a skin cancer on his nose and he continued to be followed by a dermatologist. He stated an antibiotic cream was prescribed to apply to his nose following the procedure earlier this month, but the antibiotic was not administered every day. He stated the area on his nose was healing well and he didn't have any complaints of pain or discomfort. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #48 was cognitively intact. He had no rejection of care. Review of Resident #48's Medication Administration Record (MAR) dated March 2024 revealed Triple Antibiotic Ointment (Neomycin-Bacitracin-Polymyxin) was scheduled for administration beginning on 03/08/24 at 8:00 PM, then twice a day at 8:00 AM and 8:00 PM for a total of 6 treatments. Review of Resident #48's Medication Administration Record (MAR) dated March 2024 revealed Triple Antibiotic Ointment (Neomycin-Bacitracin-Polymyxin) was signed as administered on 03/09/24 and 03/10/24 at 8:00 PM. The medication was not administered on 03/08/24 at 8:00 PM, or 03/09, 03/10, and 3/11 at 8:00 AM. Resident #48 received 2 of the 6 treatments. Review of Resident #48's progress notes from 03/08/24 through 03/11/24 revealed no documentation as to why the antibiotic ointment was not administered. Attempts were made on 03/27/24 to contact Nurse #14 and Nurse #15 who were assigned to Resident #48 during the times the antibiotic ointment was scheduled for administration. There was no response. During an interview on 03/27/24 at 12:00 PM the Corporate Nurse Consultant stated the order for the antibiotic ointment for Resident #48 was entered into the electronic medical record on 03/08/24 and was not available from pharmacy on that date. She stated most likely it arrived from pharmacy the following day on 03/09/24 and the first dose was administered that evening at 8:00 PM. She stated the antibiotic ointment should have been available for administration for the remaining doses but there was no documentation that it was administered. She indicated Nurse #14 and Nurse #15 were agency staff and no longer employed by the facility. During an interview on 03/27/24 at 3:30 PM the Director of Nursing stated Resident #48 should have received the full course of the antibiotic treatment. She indicted there was no documentation that the full course of treatment was administered. During an interview on 03/27/24 at 4:30 PM the Nurse Practitioner stated Resident #48 should have been administered the full course of the antibiotic treatment. She indicated there was no outcome related to not receiving the missed doses. 2. Resident #43 was admitted to the facility on [DATE] with diagnosis including cerebral vascular accident (CVA) and dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #43 had severely impaired cognition. He had no rejection of care. A physicians order dated 02/05/24 for Resident #43 revealed Ciprofloxacin (antibiotic) ophthalmic solution 0.3%. Instill 2 drop in the left eye four times a day for episcleritis (inflammation of the sclera) for 5 days. (Total of 20 doses). Review of Resident #43's Medication Administration Record (MAR) dated March 2024 revealed he received 15 of the 20 scheduled doses of the antibiotic ophthalmic drops. The 1st and 2nd dose were scheduled to be administered on 02/05/24 at 4:00 PM and 8:00 PM. The 3rd, 4th, and 5th doses were scheduled for administration on 02/06/24 at 8:00 AM, 12:00 PM, and 4:00 PM. The scheduled doses on 02/05/24 and 02/06/24 were not administered. Attempts were made on 03/27/24 to contact Nurse #15 who was assigned to Resident #43 during the times the antibiotic ointment was scheduled for administration on 02/05/24 There was no response. During a phone interview on 03/27/24 at 3:00 PM Nurse #10 stated she was assigned to Resident #43 on 02/06/24 and stated if she didn't administer the eye drops to Resident #43 then the medication was not available for administration. She stated she thought she would have made a note in Resident #43's progress notes regarding the medication not being administered. Review of Resident #43's progress notes from 02/05/24 through 02/06/24 revealed no documentation as to why the antibiotic ophthalmic drops were not administered. During an interview on 03/27/24 at 3:30 PM the Director of Nursing stated Resident #43 should have received the full course of the antibiotic treatment. She indicted there was no documentation that the full course of treatment was administered. During an interview on 03/29/24 at 4:00 PM the Corporate Nurse Consultant stated the order for Resident #43 for the antibiotic ophthalmic drops was entered into the electronic medical record on 02/05/24 and the medication was not received until the following night on 02/06/24. She stated the administration dates should have been adjusted in the electronic medical record and extended another day to reflect on the Medication Administration Record (MAR) so that the total number of prescribed doses would be administered. She stated education would be provided to nursing staff to make adjustments to the order dates once the medication was received for medications that were prescribed for a certain number of days or doses such as antibiotics. During an interview on 03/27/24 at 4:30 PM the Nurse Practitioner stated Resident #43 should have been administered the full course of the antibiotic treatment. She indicated there was no outcome related to not receiving the missed doses.

Based on observations, record review, staff interviews, and Physician Assistant interview the facility failed to provide supervision and wander guard placement as ordered by the physician to prevent a resident with severely impaired cognition and exit seeking behaviors, from exiting the facility unsupervised for 1 of 1 residents (Resident #1) reviewed for accidents. Resident #1 was found unsupervised in the facility's parking lot seated in his wheelchair by a visitor approximately 100 feet from a heavily trafficked four lane road. Resident #1 was returned to the facility by staff and found to be uninjured. Findings Included: Resident #1 was admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. Review of a nursing note dated 1/1/19 documented by Nurse #1 revealed Resident #1 was at risk for elopement based upon several verbalizations about going out, home or to the hospital, and unsafe wandering. A physician's orders [REDACTED].#1 for a wander guard for safety to wheelchair, check for placement and function every shift. The current plan of care, that was initiated on 1/1/19, revealed Resident #1 was at risk for elopement with goals to include allowing the resident to wander safely within his environment. Interventions included; assessing risk factors, monitoring and reporting changes in behavior, redirection, and a wander guard for safety to wheelchair. The quarterly Minimum Data Set assessment dated [DATE] and a recent quarterly assessment dated [DATE] indicated Resident #1 had severely impaired cognition. He required one-person physical assistance with bed mobility, and two-person physical assistance with transfers. He utilized a wheelchair for mobility. He was coded as exhibiting no wandering behaviors, and no rejection of care during the seven day look back period on both the 1/14/19 and 7/8/19 assessment. In an interview with the Occupational Therapist on 8/14/19 at 12:15 PM, she stated Resident #1 was on a restorative program and had repeated falls. She commented the tires on his wheelchair were starting to get worn down and could potentially tip the wheelchair, so a new chair was ordered for safety. She reported that Resident #1 was non ambulatory, his left side was impaired, and stated he was able to propel himself in the wheelchair with his right arm and right leg. She reported that she changed his wheelchair on Friday 7/26/19 the day prior to the incident between 2:30- 2:55 PM. She stated she did not think to check the older wheelchair to see if a wander guard was attached. Following the incident, she reported the therapy department received an in service regarding the elopement policy and the therapists will now check the elopement binder to see if a resident had a wander guard in place and therapy staff will notify the nurse if a resident needs their wander guard replaced. On Resident #1's Teatment Administraion Record dated 7/26/19 Nurse #5 documented during the 11:00 PM -7:00 AM shift that Resident #1 had a wander guard and documented that the device was checked for placement and functioning. Nurse #5 was unavailable for an interview during the survey. On Resident #1's TAR dated 7/27/19 Nurse #1 documented during the 7:00 AM- 3:00 PM shift that Resident #1 had a wander guard and documented that the device was checked for placement and functioning. In an interview on 8/14/19 at 2:45 PM with Nurse #1 she acknowledged that the nurses were responsible for accurately assessing and documenting on the TAR that the residents wander guards were in place and checked for functioning. She stated it was an oversight that she signed off on the TAR on 7/27/19 during her shift that Resident #1 had a wander guard in place. She reported she thought she saw the wander guard on Resident #1 that day but obviously it was an oversight. She acknowledged that she did receive in service training on elopement procedures, wander guard device checks every shift, and documentation since the incident involving Resident #1 On Resident #1's TAR dated 7/27/19 Nurse #3 documented during the 3:00 PM - 11:00 PM shift that Resident #1 had a wander guard and documented that the device was checked for placement and functioning. A nursing note written by Nurse #3 on 7/27/19 at 8:09 PM documented that Resident #1 was found in the parking lot. Staff successfully returned the resident back into his room and placed a wander guard to his lower extremity. Resident was responsive with combative behavior. In a phone interview on 8/14/19 at 8:45 PM with Nurse #3 who was the nurse assigned to Resident #1 on 7/27/19 he reported that the resident was found outside in the parking lot after dinner on 7/27/19 but couldn't recall the exact time. He reported that it was during his 3-11 PM shift which was a very hectic time especially on weekends and around dinner time when family were visiting, and it was during his med pass. He stated that he did not know the resident had managed to get out of the building during that time until he was alerted by staff and did not know how long Resident #1 had been outside unsupervised. He reported that the resident was brought back inside, and vitals were checked, and a full body assessment was completed, and all were within normal limits with no injuries or skin tears and no complaints of pain. The family and the physician were notified of the occurrence. He stated Resident #1 was argumentative because he couldn't be outside. He reported that Resident #1 was found by another nurse earlier that day trying to push on a locked door and stated he did have a history of exit seeking behaviors. After the incident he received an in-service on the elopement policy and procedures including calling the Director of Nursing (DON) and the Administrator immediately if an elopement incident occurred, checking all residents for wander guard placement, checking that all door alarms were working properly, and documentation. Nurse #3 acknowledged that the nurses were to document on the Treatment Administration Record (TAR) that the wander guard was in place and was checked for functioning on every shift. In a phone interview with Nurse #2 on 8/14/19 at 12:40 PM she reported that she was working on the 100 hall the day of the incident (7/27/19) and a visitor came down the hall and stated she had gone out to her car and saw a resident in the parking lot. Nurse #2 went outside and saw that Resident #1 was in the parking lot attempting to get over a speed bump. She ran out to get him and he planted his feet and started cussing and wouldn't let her push him. She asked the visitor to knock on the emergency door which was the closest door to get inside of the building to get more staff to help her. Another nurse came out to help and returned Resident #1 back inside the facility. She stated it was around 7:30 - 7:45 PM and it was not dark outside at that time, and she did not know how long Resident #1 had been outside. Nurse #2 reported Resident #1 had no injuries, and no wander guard was on his wheelchair or on him. The resident told her he was looking for his car. Nurse #2 stated his cognition was very much impaired, and he had tried to open doors but had never made it outside before and stated the emergency doors stay locked and required a code to get in and out of. Nurse #2 reported the facility provided in service training after the incident regarding the elopement policy and reviewed calling the Director of Nursing (DON) and Administrator immediately if a resident exits the building unsupervised, completing an assessment of the resident, checking for wander guard placement, and documenting placement and functioning. In an interview on 8/14/19 at 12 :51 PM with Nurse Aide # 2, she stated Resident #1 was back and forth from his hallway to the dining room on 7/27/19 the day of the incident. She reported she last saw him before he exited the facility when he rolled himself in his wheelchair to his hallway between 6:50 PM - 7:20 PM. She stated she was not aware of the details of Resident #1 exiting the building unsupervised and was not certain of how long Resident #1 may have been outside. She did not recall if a wander guard was in place. She reported that she was in serviced on the elopement policy which included informing the DON and the Administrator immediately if a resident exits the building unsupervised. She was also in serviced on elopement procedures including searching for a resident, checking the notebook which lists all residents with wander guards, and making sure the wander guard device was working properly. Review of the elopement incident report dated 7/27/19 documented Resident #1 was seen outside of the building in the parking lot. Staff assisted the resident back into the building without any concerns. Immediate action taken included: Nursing staff assisted the resident back into the building, with no injuries observed, and vital signs were within normal limits. The family was notified on 7/27/19 at 8:29 PM. The facility Physician was notified on 7/27/19. Review of a witness statement dated 7/27/19 by Nurse #4 documented the last time she saw Resident #1 on 7/27/19 was around 5:45 PM when she was at the nurses station and saw him down the hall by room [ROOM NUMBER]. He jiggled the exit door; she called him and rolled him up the hallway in his wheelchair. Resident #1 was taken to the dining room for dinner. Nurse #4 was not available for interview during the survey. An observation was conducted with the DON on 8/14/19 at 2:32 PM of the parking lot at the speed bump where Resident #1 was found unsupervised during the evening of 7/27/19. The speed bump the resident was attempting to roll over in his wheel chair was approximately 2-3 inches high with a gap in the center. A 4-6 inch curb was on both sides of the parking lot where the resident was found. The speed bump was approximately 100 feet from the entrance to the facility's parking lot which was on a high trafficked four lane road which connected to a main thoroughfare with a posted speed limit of 45 miles per hour. According to the National Weather Service computer data base the temperature in Wilmington, NC where the facility is located, on 7/27/19 was 88 degrees Fahrenheit and sunset was recorded at 8:17 PM. During an observation of Resident #1 on 8/14/19 at 10:30 AM he was observed lying in bed in no acute distress. He was alert and oriented to himself only. A wander guard was in place on his right lower extremity. When asked if he went outside alone recently, he stated he didn ' t know. In an interview on 8/14/19 at 11:23 AM with Nurse Aide #1 she reported she was not working on 7/27/19 the day of the incident but was assigned to Resident #1 during most of her shifts and was familiar with his care. She did not recall if Resident #1 was wearing his wander guard when she worked with him on 7/26/19 but reported Resident #1 had a wander guard in place for months and had two in place at one time, one on his right leg and one on his wheelchair. She stated he did have exit seeking behaviors such as pushing on doors at times. She stated the resident liked to be outside so the staff including therapy would take him outside to the enclosed courtyard at times during the day. She reported he was non ambulatory, and total dependent care but could propel himself in his wheelchair with minimal difficulty. In an interview on 8/14/19 at 2:15 PM with the facility's physician assistant, she reported that Resident #1 did exhibit exit seeking behaviors. She stated the wander guard device was ordered in (MONTH) 2019 due to the resident verbalizing exit seeking behaviors and the order for placement on his wheelchair was due to him picking at the device. She reported that she was notified of the incident on 7/27/19 and the wander guard is now placed on his lower leg for safety. In an interview on 8/14/19 at 11:40 AM with the Administrator and the Director of Nursing (DON) present, the administrator acknowledged that Resident #1 did exit the building unsupervised on 7/27/19. She reported that occupational therapy gave him a new wheelchair recently without placing his wander guard on the new chair. She stated that Resident #1 did not have a wander guard device on his leg or on his wheelchair on 7/27/19. She reported on the day of the incident the front door did not alarm because the resident did not have a wander guard on. A visitor came in the facility and notified the nurse that a resident was outside in the parking lot. The nurse assisted Resident #1 back inside of the building and he had no injuries. She stated Resident #1 was a very busy person and wandered safely around the building and went outside to the courtyard with supervision at times. She reported that the wander guard had been placed on Resident #1 in (MONTH) 2019 due to him verbalizing exit seeking behaviors. She stated he had not exited the building unsupervised prior to the 7/27/19 incident. She reported that the resident would pick at the wander guard bracelet when it was on his lower leg and an order was written to place the device on his wheelchair however following the incident on 7/27/19 they changed the order for the wander guard to be placed on his lower leg. After the incident on 7/27/19 the Administrator reported that all wander guard bracelets for all residents were monitored and checked for functioning. She stated the nurses were responsible for checking placement and using the wander guard device meter to check for proper functioning on every shift. In a follow up interview with the Administrator on 8/15/19 at 12:40 PM she acknowledged staff failed to have a wander guard in place on Resident #1 on 7/26/19 and 7/27/19. She stated the nurses should have assessed the resident for wander guard placement and checked the device for proper functioning every shift and documented placement on the TAR. Her expectation was that staff were supervising residents and assessing for wander guard placement at least every shift. She stated staff should follow all precautions in order to maintain the safety of the residents. The facility's corrective action plan dated 7/28/19 was as follows: 1.An investigation was initiated on 7/28/19 to determine the root cause regarding Resident #1 ' s elopement incident. It was determined Resident #1 did not have his wander guard in place on 7/27/19 due to the occupational therapist changed his wheelchair on 7/26/19 and did not replace the wandering device which was ordered to be placed on the resident's wheelchair. The Administrator provided statements from staff that were working on 7/27/19. The DON and Administrator completed in services and provided education to all staff regarding the elopement policy including; announcing a code green (elopement), notifying the Administrator and DON immediately, searching all areas, actions to take when the resident was located, and conducting elopement drills. The corrective actions for the affected resident included: Resident #1 was returned to a secure environment with help from the staff and upon assessment the nurse applied the wander guard device to his leg. The family was notified on 7/27/19 at 8:29 PM and the physician was notified on 7/27/19. The corrective action for residents with the potential to be affected included: any resident who had been assessed as needing a wander guard had the potential to be affected. All devices were checked on all residents for placement and function on 7/28/19. A 100% audit of all residents was conducted on 7/30/19 to identify elopement risk. Elopement drills were conducted on 7/29/19 through 7/30/19 for all shifts which included practice scenarios. 2. Measures implemented to assure the deficient practice would not reoccur included: a) education was provided to all nursing staff regarding the elopement policy, checking wander guard placement every shift, and alerting administration and the DON of all elopement attempts whether successful or not, which was completed on 7/29/19. b) the elopement policy was reviewed with all staff on 7/29/19. c) occupational therapy staff was in-serviced on the elopement policy on 7/30/19. 3. Ongoing compliance with the plan of action will be monitored and maintained by: a) nurses will check all residents for wander guard placement each shift and for function nightly. c) wander guard placement will be verified and documented weekly for twelve weeks by the DON or designee and discussed during the weekly resident review. The Don will report the results of the monitoring to the monthly QA (Quality Assurance) committee for review and recommendations for twelve weeks beginning 7/30/19. As part of the validation process on 8/15/19 the plan of correction was reviewed which included dates and content of the in services that were conducted, review of the audits initiated, and copies of the facility elopement policy. During the investigation, interviews were conducted with nursing staff to ensure their understanding and knowledge of assessing for wander guard placement. Seven staff members were interviewed regarding Inservice training and knowledge of the elopement policy. Observations were conducted during the investigation of all residents with wander guards and placement and functioning were verified. The facility 's correction date of 7/30/19 was verified.

Based on observation, resident interview, family interview, staff interviews, Physician Assistant interview, Physician interview and record review the facility neglected to care for residents by omitting the administration of medication for 6 of 33 residents reviewed for medication administration (Residents #118, #4, #216, #140, #36, and #50). Resident #118 was given [MEDICATION NAME] Immediate release 15 mg (Milligrams) in error instead of [MEDICATION NAME] mg Extended Release as ordered at 8:00 PM on 10/20/18 and his pain level rose from a 6 (moderate pain) to a 10 (extreme pain) when he was assessed at 6:21 AM on 10/21/18. The facility also neglected to provide toe nail care for 1 of 3 dependent residents (Resident #27) reviewed for Activity of Daily Living (ADL) care which resulted in the resident's toe nails having grown over the toes a half inch on each toe. Findings included: 1. Resident #118 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 10/18/18 included a goal to maintain the residents comfort with palliative care services. Interventions included to administer pain/symptom relief medications as prescribed by the physician, provide palliative care, and assess for verbal and nonverbal signs and symptoms relating to pain: grimacing, guarding, crying, moaning, and increased anxiety. The resident was a new admission and had not had a Minimum Data Set Assessment completed at the time of the survey. Resident #118 was ordered [MEDICATION NAME] mg by mouth every 12 hours for pain. This medication was ordered by the physician on 10/17/18. Review of the Controlled Medication Utilization records showed that the medication had not been removed from stock and given to the resident on 10/20/18 at 8:00 PM but was initialed on the eMAR (electronic medication administration record) as given by Nurse #11 who documented the resident's pain level as 6 on a pain scale of 0-10 with 0 being no pain and 10 being extreme pain. Review of the nursing progress notes revealed that on 10/21/8 at 6:21 AM the resident had reported his pain level was 10 (prior to this the highest pain level recorded had been a 7). Review of the Controlled Medication Utilization record showed that Nurse #11 had given the resident [MEDICATION NAME] Immediate Release 15 mg on 10/20/18 at 8:00 PM and on 10/21/18 at 6:21 AM. An attempt to contact Nurse #11 on 10/26/18 at 12:47 PM was unsuccessful. A second message was left on 11/14/18 and she returned the call at 10:02 AM. She stated that she had no idea why she had given the resident an alternate dose instead of his scheduled medication. She stated that she had made a medication error. In an interview conducted with the facility consultant pharmacist on 11/19/18 at 2:08 PM she stated that [MEDICATION NAME] 15 mg Immediate Release had an onset of approximately 15 to 30 minutes after administration and was effective for 3 to 6 hours. She said [MEDICATION NAME] mg Extended Release had an onset in approximately the same amount of time as the [MEDICATION NAME] Immediate Release but was a higher dose and was effective for a longer period of time-12 hours. She stated that the [MEDICATION NAME] 15 mg Immediate Release that was given would have been less effective because it was a lower than the scheduled dose of [MEDICATION NAME] mg that was omitted and lasted less time in the body after administration. According to Lexi-Comp, a comprehensive medication data base, although the duration of action for [MEDICATION NAME] is patient dependent, the estimated duration of action for pain relief from immediate-release formulations of [MEDICATION NAME] is 3 to 5 hours. The duration of action for pain relief from extended-release [MEDICATION NAME] depends on the product formulation but is estimated to be 8 to 24 hours. The resident had been asleep when interviews were attempted on 10/24/18, 10/25/18 and 11/13/18. He passed away the evening of 11/13/18. 2. Resident #4 was ordered Modafinil 100 mg (Milligrams) via Gastrostomy Tube one time a day for lethargy at 6:00 AM. This medication was ordered by the physician on 07/17/18. Modafinil is a stimulant used to increase alertness. Review of the Controlled Medication Utilization records showed that this medication had not been removed from controlled stock and given to the resident on the following dates: a. 07/26/18 at 6:00 AM Nurse #3 did not remove the medication from controlled stock to administer b. 07/29/18 at 6:00 AM Nurse #4 did not remove the medication from controlled stock to administer c. 08/01/18 at 6:00 AM Nurse #3 did not remove the medication from controlled stock to administer d. 08/10/18 through 08/16/18 the medication was not available for administration at the facility e. 08/17/18 at 6:00 AM Nurse #4 did not remove the medication from controlled stock to administer f. 08/18/18 at 6:00 AM Nurse #4 did not remove the medication from controlled stock to administer g. 08/21/18 at 6:00 AM Nurse #3 did not remove the medication from controlled stock to administer h. 08/26/18 at 6:00 AM Nurse # 5 did not remove the medication from controlled stock to administer i. 08/27/18 at 6:00 AM Nurse # 6 did not remove the medication from controlled stock to administer j. 08/28/18 at 6:00 AM Nurse #6 did not remove the medication from controlled stock to administer k. 08/30/18 at 6:00 AM Nurse #7 did not remove the medication from controlled stock to administer l. 09/22/18 at 6:00 AM Nurse #8 did not remove the medication from controlled stock to administer m. 09/24/18 at 6:00 AM Nurse #8 did not remove the medication from controlled stock to administer n. 10/05/18 at 6:00 AM Nurse #9 did not remove the medication from controlled stock to administer 0. 10/06/18 at 6:00 AM Nurse #10 did not remove the medication from controlled stock to administer p. 10/08/18 at 6:00 AM Nurse #9 did not remove the medication from controlled stock to administer q. 10/10/18 at 6:00 AM Nurse #9 did not remove the medication from controlled stock to administer r. 10/11/18 at 6:00 AM Nurse #10 did not remove the medication from controlled stock to administer In an interview conducted on 10/24/18 at 4:30 PM with the Physician's Assistant she stated that she did not know why she had not provided the pharmacy with a hard script to refill the Modafinil 100 mg for Resident #4 between 08/10/18 and 08/16/18 because the order had not been discontinued. She said that the medication had been ordered to increase the resident's level of alertness after suffering a stroke. In an interview conducted on 10/25/18 at 10:05 AM with the Pharmacy Director she stated that the Modafinil for Resident #4 had not been refilled between 08/10/18 and 08/16/18 because the physician had not provided a hard script (which was required when refilling a controlled substance) to refill the medication until 08/17/17. In an interview conducted on 10/26/18 at 12:40 PM with Nurse #6 she stated that she had missed giving doses to Resident #4 because she couldn't find it in the medication cart and had not realized that it was a controlled substance and located in the locked drawer on the cart. She had signed the eMar as administered to the resident on 08/27/18 and 08/28/18 at 6:00 AM. In an interview conducted on 10/26/18 at 12:57 PM with Nurse #10 she said that if she had not signed a medication out on the narcotic sheet and the count was correct then she had missed giving the medication to Resident #4 but had signed the eMar as administered to the resident 10/06/18 and 10/11/18 at 6:00 AM. An attempt to contact Nurse #4 on 10/26/18 at 12:08 PM was unsuccessful. His phone would not accept a message. He was no longer employed at the facility. An attempt to contact Nurse #3 on 10/26/18 at 12:29 PM was unsuccessful. Her phone would not accept a message. She was no longer employed at the facility. An attempt to contact Nurse #5 on 10/26/18 at 12:46 PM was unsuccessful. Her phone would not accept a message. An attempt to contact Nurse #7 on 10/26/18 at 12:34 PM was unsuccessful. A message was left but she did not return the call. An attempt to contact Nurse #8 on 10/26/18 at 12:37 PM was unsuccessful. A message was left but she did not return the call. An attempt to contact Nurse #11 on 10/26/18 at 12:47 PM was unsuccessful. A message was left but she did not return the call. Attempts to contact Nurse #9 on 10/26/18 at 11:42 AM and 12:03 PM were unsuccessful. The first attempt was busy and the second attempt went straight to voice mail but would not accept a message because it was full. In an interview conducted with Physician #3 on 11/14/18 at 12:29 PM she stated that because the resident received all but two doses of the Modafinil 100mg in (MONTH) (YEAR) and had remained lethargic that it could not be determined if when he had received the medication in (MONTH) (YEAR) that his increased alertness was due to the medication. She said that because of the time lapse between (MONTH) and (MONTH) the resident's increased alertness could have been due to the natural healing of the brain after a severe stroke which was common. 3. Resident #216 was ordered [MEDICATION NAME] 150 mg one capsule by mouth three times daily for pain. This medication was ordered by the physician on 10/19/18. Review of the Controlled Medication Utilization records showed that the medication had not been removed from stock and given to the resident on 10/22/18 at 10:00 PM but was initialed on the eMAR as given by Nurse #5. Record review revealed that Resident #216 had received [MEDICATION NAME]-[MEDICATION NAME] 5-325mg for pain on 10/23/18 at 2:52 AM. An attempt to contact Nurse #5 on 10/26/18 at 12:46 PM was unsuccessful. Her phone would not accept a message. Resident #216 was discharged to home on 11/02/18. She was contacted by phone on 11/14/18 and revealed that she was pleased with the care she received at the facility. She stated that she felt her pain was controlled. 4. Resident #140 was ordered [MEDICATION NAME] HCL Extended Release Abuse Deterrent give one tablet by mouth two times a day for pain. This medication was ordered by the physician on 10/14/18. Review of the Controlled Medication Utilization records showed that the medication had not been removed from stock and given to the resident on 10/15/18, 10/16/18, 10/17/18 or 10/18/18 at 8:00 AM but was initialed on the eMAR as given by Medication Aide (MA) #1. On 10/15/18 MA#1 documented the resident's pain level as 9, on 10/16/18 as 5, on 10/17/18 as 7 and on 10/18/18 as 2 on a pain scale of 0-10 with 0 being no pain and 10 being extreme pain. In an interview conducted on 10/26/18 at 11:16 AM with Medication Aide #1 she stated that if she had signed off on the eMAR that she gave the medication but had not signed it out of the locked drawer on the cart then she must have missed giving the doses to the resident. Three unsuccessful attempts to contact Resident #4 were made on 11/13/18 who had been discharged to home on 10/27/18. Messages were left but she did not return the calls. In an interview with the Director of Therapy on 11/13/18 at 1:38 PM she reported that Resident #4 had not missed any therapy sessions due to uncontrolled pain. She said the resident did so well that she went straight to outpatient therapy when she was discharged . 5. Resident #36 was ordered [MEDICATION NAME] 50 mg one capsule by mouth one time a day for nerve pain. This medication was ordered by the physician on 9/7/17. Review of the Controlled Medication Utilization records showed that the medication had not been removed from stock and given to the resident on 10/21/18 at 9:00 AM but was initialed on the eMAR as given by Nurse 12. In an interview conducted with Nurse #12 on 10/23/18 at 6:07 PM she stated that she had signed off the medication on the eMAR but had not given it to the resident or removed it from the controlled medication drawer. In an interview conducted with Resident #36 on 11/13/18 at 10:30 AM she stated that she could not remember any days when she had worse or different pain. She stated that she always had some discomfort in her neck but that the pain medication helped. 6. Resident #50 was ordered [MEDICATION NAME] 50 mg by mouth two times a day for pain. This medication was ordered by the physician on 10/06/18. Review of the Controlled Medication Utilization records showed that the medication had not been removed from stock and given to the resident on 10/15/18 at 8:00 AM but was initialed on the eMAR as given by Nurse #13. In an interview conducted on 10/25/18 at 4:04 PM with Nurse #13 she stated that she had signed the eMAR as having given the medication to Resident #50 but forgot to go back and give it. She said that she had not taken it out of the controlled substance locked drawer when she passed his other medications and intended to go back and give it later but forgot. In an interview conducted with Resident #50 on 11/14/18 at 11:30 AM he stated that he could not recall any days when his pain level was greater than normal. He stated that he received 8 or 9 pills every morning and they were generally effective. He said that there had been no days on which he noticed his pain level to be worse or different. In an interview with the Director of Nursing on 10/26/18 at 7:56 AM she stated that she expected all medications to be given to residents as ordered by the physician. 7. Resident #27 was admitted to the facility on [DATE]. The resident ' s [DIAGNOSES REDACTED]. A review of a mycotic (infected with fungus) nail evaluation from the podiatrist dated 09/20/17 revealed Resident #27 ' s toe nails were callused. The evaluation stated the toe nails were trimmed, filed, and cut and to follow up with podiatry in 3 months or sooner if necessary. The Minimum Data Set ((MDS) dated [DATE] quarterly assessment revealed Resident #27 was severely cognitively impaired and required total dependence with one to two person physical assistance with all activities of daily living (ADLs). A care plan updated on 09/26/18 revealed a plan of care for requiring assistance with ADLs related to impaired mobility. Interventions included, in part, to assist resident with all ADLs as needed or requested and monitor for any decline. An observation of Resident #27 on 10/22/18 at 10:00 AM revealed an alert resident lying in bed. The resident ' s toenails were noted to have grown 1/2 inch over the toe and into the skin for each toe. Resident #27 was non-verbal and did not express any pain to her feet. An interview with Nursing Assistant (NA) #8 on 10/24/18 at 9:00 AM revealed the NA worked at the facility for over a year and usually worked on the hall Resident #27 resided on. NA #8 stated she knew Resident #27 well. NA #8 stated Resident #27 was completely dependent, did not get out of bed and would get a full bed bath daily. NA #8 reported she washed the resident ' s fingernails and toenails and would cut them if it were okay with the nurse or let the nurse know they needed to be cut. NA #8 stated Resident #27 ' s fingernails were long, but she did clean them and washed her hands and nails during care. NA #8 stated she washed Resident #27 ' s feet as well and stated that her toenails looked fine. An observation of Resident #27 ' s feet was conducted with NA #8 on 10/24/18 at 9:10 AM. NA #8 reported the resident ' s toe nails were very long and noted they were growing over her toes and into her skin. NA #8 stated she had not noticed the toe nails being that long when she did care and she would tell the nurse to see what she should do. An interview was conducted with Nurse #18 on 10/24/18 at 10:00 AM. Nurse #18 revealed she was aware of the length and condition of Resident #27 ' s toe nails and stated that a podiatrist had seen her about a year ago. Nurse #18 stated the last she had known the Director of Nursing (DON) was cutting her fingernails and toenails. Nurse #18 stated she was aware of the excessive length of the toenails and stated they definitely needed to be trimmed. Nurse #18 reported she was not sure the last time they were trimmed, but given the length of them, it had to be awhile. An interview was conducted with the facility ' s Scheduler who made the appointments with the podiatrist, on 10/24/18 at 11:15 AM. The Scheduler revealed the last time Resident #27 was on the list to be seen by the podiatrist was 11/27/17. The Scheduler reported she did not have any information or paperwork to support Resident #27 had been seen on 11/27/17. An interview was conducted with the DON on 10/25/18 at 9:15 AM. The DON reported she had previously cut Resident #27 ' s fingernails but she did not have any knowledge about her toe nails needing to be cut. The DON stated her expectation of the staff was to ensure that both fingernail and toenail care was being provided with each bath and if the nails were long, the staff should be filing and trimming them. The DON confirmed the toenails for Resident #27 were very long and had been neglected.

Based on observation, Medical Director interview, family interview, staff interview, and record review the facility failed to implement measures to identify an outside curb as a hazard which resulted in 1 of 3 residents (Resident #45) reviewed for falls falling from his wheelchair when it got caught on the curbing. Resident #45 hit his head on pavement, and sustained a subdural hematoma from this fall. Findings included: Review of an incident report documented on [DATE] Resident #37 fell from her wheelchair after one of its wheels got caught on curbing outside the building, resulting in a fractured humerus and a laceration above the eye requiring seven sutures. The interdisciplinary (IDT) committee developed interventions to keep this resident and other residents from falling in the future as a result of the drop created by the curbing. Painting the curb was documented as an intervention on Resident #37's accident/incident report and on her care plan. However, in an interview with the Maintenance Manager (MM) on [DATE] at 1:35 PM he stated he did not paint the curbing until after Resident #45's [DATE] fall off the curbing because the IDT committee could not make up its mind what color to paint the curbing until then. Record review revealed Resident #45 was admitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. As part of Resident #45's [DATE] Admission/Readmission Nursing Assessment a Fall Evaluation was conducted, and the resident was determined to be at high risk for falls. On [DATE] the resident's care plan identified, Resident is at risk for falls as a problem. Interventions for this problem included, Implement preventative fall interventions/devices. Maintain call light within reach. Educate resident to use call light. Maintain needed items within reach. PT/OT/SLP (physical therapy, occupational therapy, speech language pathology) evaluation. Resident/family education regarding preventative fall interventions/devices and safety devices. Resident #45's [DATE] admission minimum data set (MDS) documented his cognition was moderately impaired, he exhibited no behaviors including rejection of care, he required limited assistance from a staff member with bed mobility/transfers/locomotion on and off the unit, he had no falls six months prior to his nursing home admission, and he experienced no falls since being admitted to the nursing home. Nurse #19 wrote a late entry nursing note on [DATE] at 9:06 AM for [DATE] 9:00 PM. The note documented, Resident found lying in grass outside of building, reported 'wheelchair went off of edge of sidewalk and I fell into the grass.' Brought into building by staff member at approximately (7:00 PM) this evening. (Family member) in attendance. Alert, (oriented) x 1, reported headache ,[DATE] (3 out of 10 on pain scale). Noted quarter sized abrasion/ecchymosis (bruising) left anterior-lateral forehead; 0.8 (centimeter) laceration left nose, presumably from glasses. Given ice pack. Neuro checks: (pupils equal, round, and reactive to light). No other injuries noted. Moves all extremities well. Given ice pack for forehead. Face washed with soap and water. Bleeding left nose stopped. Further (neurological) checks resulted in orientation returning to (oriented) x 3. Reported pain relieved to head by (8:00 PM). Currently, denied complaints. Stated 'I am ok, do not need to go to hospital ' Assisted to bed, positioned for comfort. Will continue to monitor A [DATE] 11:17 AM physician progress notes [REDACTED]. Patient reports he was outside in his wheelchair. His wheel slipped off the curb and he fell out of his wheelchair. He has slight bruising over his left eye and on his forehead. He didn't lose consciousness. He denies any pain with eye movement A [DATE] 1:25 PM nursing note documented, Resident presented with slurred speech, left sided weakness, weak left side hand grasp, and left side facial drooping at (1:05 PM). (Vital Signs) ,[DATE], pulse 71, (oxygen saturation) 97%, 18 respirations, (blood sugar) 116 (Physician Assistant) notified and assessed resident. Orders to send to (emergency room ) for evaluation. Left with (emergency medical services) at (1:25 PM). A [DATE] 2:05 PM Emergency Department Encounter note documented in the Physical Exam section, hematoma over left forehead, normocephalic (head and all major organs of the head in normal condition). CT (computed tomography) results captured in the [DATE] hospital History and Physical documented, A subdural hemorrhage is seen over the left frontal lobe region. This measures about 10 (millimeters) in thickness. A [DATE] 2:54 PM physician progress notes [REDACTED]. Patient's left side of his face was drooping when he smiled and his left hand was unable to squeeze my fingers. After several minutes his face no longer had a drooping look and he was able to squeeze my fingers with both hands. He continued to slur his speech and was difficult to understand. (Physical Therapy) also reports that his left side of his chest looks larger today and he has swelling in his lower extremities. He was having difficulty walking in (Physical Therapy) today. Patient denies any (chest pain) or (shortness of breath). He nods his head yes when asked if he would like to go to the hospital Possible ([MEDICAL CONDITION]), sent to hospital for head (computed tomography). On [DATE] at 9:24 AM, during a telephone interview, Nursing Assistant (NA) #1 stated on [DATE] she was coming out of the lobby restroom when a person approached her stating that a resident had fallen in the parking lot of the building. The NA reported when she got outside Resident #45 was laying on the pavement in the parking lot in the circle drive area in front of the building. She commented his standard wheelchair was still on the sidewalk with the brakes locked. She stated the resident was kind of laying on his side with his face held up off the pavement. She commented there was a red bump/raised area above one of the resident's eyes. She reported there was a small amount of blood coming from somewhere. She remarked the resident stated he was waiting on a family member to arrive at the facility The NA commented a nurse (Nurse #20) and an administrative person (Business office Manager) came out of the building and took the resident back inside the facility. She stated the resident could not explain what caused him to end up on the pavement. The NA reported Resident #45 told her that his head was hurting. On [DATE] at 10:03 AM, during a telephone interview, Nurse #20 stated she was informed there was an empty wheelchair caught on the curbing. She reported she went out to the circular drive in front of the facility entrance, and found the resident laying of his left side on the blacktop pavement. She stated that this was to the right of the front porch/patio (in the center of the building) as you exited the building. She commented she assisted the resident to his wheelchair, and explained that the resident's wheelchair was half on the pavement and half on the sidewalk. According to Nurse #20, Resident #45 had no range of motion issues, and did not have complaints about pain. She stated a hematoma had started to form above the left eye, and there was a small laceration to the resident's left nare (nostril). She reported the resident was taken back into the building where the resident's primary hall nurse completed a full assessment. On [DATE] at 11:31 AM, during a telephone interview, Nurse #19 stated he was told by a facility nurse and someone from administration that Resident #45 was found outside where he rolled off the sidewalk in his wheelchair and fell forward into the grass. Nurse #19 reported the resident had a bruise and elevated abrasion to his left temple/forehead, and had a laceration to his left nare consistent with injury from his glasses. He commented there was bleeding from the resident's nose laceration which was minimal and easy to stop, and the resident's neuro-checks and vitals were okay. According to Nurse #19, when Resident #45 first returned to the building after his fall on [DATE] he was disoriented, but within 30 minutes returned to his baseline of alert and oriented x 3. The nurse stated a family member arrived during his assessment, and was informed of the fall and how it happened. According to the nurse, he decided not to send Resident #45 out because the resident fell in the grass, his neuro-checks and vitals were within normal limits, and the resident stated he did not want to go out to the hospital. However, the nurse stated he did not discuss with the resident why it might be important to go to the hospital after falling and hitting his head or what the repercussions might be if he did not go the hospital. Nurse #19 reported Resident #45 did have a bump to his left forehead which could have been anything from a contusion to a sign of possible [MEDICAL CONDITION]. The nurse stated he told the resident he would keep any eye on him, and he asked the resident to report to him if he experienced any changes to his health status. He commented Resident #45 got around the building in a standard wheelchair using his feet and hands. He stated the resident had no safety awareness issues, so as the nurse he had no concerns about the resident going in and out of the building independently. On [DATE] at 1:45 PM the Director of Nursing (DON) stated the facility had two courtyards, but the residents liked to sit on the front porch/patio. As a result she reported sometimes there were a lot of resident outside on the patio getting fresh air. On [DATE] at 2:12 PM an observation revealed, when exiting the building, the curbing to the right (where Resident #45 fell ) and left (where Resident #37 fell ) of the front porch/patio was painted red. There was a drop of two to three inches from the top of the curb to the pavement in the drive which circled in front of the porch. On [DATE] at 2:34 PM a family member of Resident #45 stated during a telephone conversation that the resident expired on [DATE] in hospice, after being discharged from the hospital. (A death certificate documented Resident #45 passed away on [DATE], and the immediate cause of death was [MEDICAL CONDITION]). The family member stated she arrived in the facility on [DATE] after the resident was brought back into the building following his fall. She reported she heard that her father had stated he did not want to go to the hospital. She commented the resident stated he was outside waiting for her to arrive, saw a car drive up that looked very similar to hers, went out on the sidewalk to meet her, realized it was not her, and turned around to go back when one of his wheels got caught on the curb. She reported the resident told her that he had gotten the wheel of his wheelchair caught on the curb earlier the same week, but someone, she thought a staff member, had lifted the wheel off the curb. On [DATE] at 3:27 PM the DON stated in-servicing was begun on [DATE] about incident/risk management reporting. She commented the emphasis of the training was to remind the nursing staff about all the components that should be included in documentation concerning falls. She reported so far about ,[DATE] of the nursing staff have been in-serviced (there were nine signatures on the sign-in sheet). On [DATE] 5:22 PM the DON stated the IDT committee debated about the effectiveness of painting the curbing as a fall intervention for Resident #37, but this interventions was documented as an intervention on the accident/incident report and the resident's care plan anyway so she expected that the intervention be carried out. On [DATE] at 11:22 AM the Business Office Manager stated she was just driving up to the building on [DATE] when she saw Nurse #20 and NA #1 running out the front door of the facility. She reported when she looked closer she saw Resident #45 laying on the pavement in the circular drive in front of the front patio/porch. She commented his wheelchair had tipped over, and there was blood on his face. She stated the resident was helped back into his wheelchair and taken into the building where a nurse on duty could assess him. On [DATE] at 11:52 AM, during a telephone interview, the facility's Medical Director stated Resident #45 had a very small hematoma, had a neurosurgery consult in the hospital, and his family did not want to pursue surgery. She explained while in the hospital it was discovered the rate of Resident #45'[MEDICAL CONDITION] metastasis had increased, and the family wanted the resident placed on hospice because of [MEDICAL CONDITION]. According to the Medical Director, the resident's fall and hematoma were incidental, and the cause of death, as listed on the death certificate, was metastatic [MEDICAL CONDITION].

Based on staff interviews, resident interviews, Physician Assistant interview, Physician interview and record review the facility failed to administer medications as ordered by the physician for 6 of 33 residents (Residents #118, #4, #216, #140, #36 and #50) whose electronic Medication Administration Records and Controlled Medication Utilization records were reviewed. Resident #118 was given [MEDICATION NAME] Immediate release 15 mg (Milligrams) in error instead of [MEDICATION NAME] mg Extended Release as ordered at 8:00 PM on 10/20/18 and his pain level rose from a 6 (moderate pain) to a 10 (extreme pain) when he was assessed at 6:21 AM on 10/21/18. Findings included: 1. Resident #118 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 10/18/18 included a goal to maintain the residents comfort with palliative care services. Interventions included to administer pain/symptom relief medications as prescribed by the physician, provide palliative care, and assess for verbal and nonverbal signs and symptoms relating to pain: grimacing, guarding, crying, moaning, and increased anxiety. The resident was a new admission and had not had a Minimum Data Set Assessment completed at the time of the survey. Resident #118 was ordered [MEDICATION NAME] mg by mouth every 12 hours for pain. This medication was ordered by the physician on 10/17/18. Review of the Controlled Medication Utilization records showed that the medication had not been removed from stock and given to the resident on 10/20/18 at 8:00 PM but was initialed on the eMAR (electronic medication administration record) as given by Nurse #11 who documented the resident's pain level as 6 on a pain scale of 0-10 with 0 being no pain and 10 being extreme pain. Review of the nursing progress notes revealed that on 10/21/8 at 6:21 AM the resident had reported his pain level was 10 (prior to this the highest pain level recorded had been a 7). Review of the Controlled Medication Utilization record showed that Nurse #11 had given the resident [MEDICATION NAME] Immediate Release 15 mg on 10/20/18 at 8:00 PM and on 10/21/18 at 6:21 AM. An attempt to contact Nurse #11 on 10/26/18 at 12:47 PM was unsuccessful. A second message was left on 11/14/18 and she returned the call at 10:02 AM. She stated that she had no idea why she had given the resident an alternate dose instead of his scheduled medication. She stated that she had just started working at the facility on (MONTH) 1, (YEAR). She commented that she only worked with the resident one time and was not that familiar with him. She stated that she had made a medication error. In an interview conducted with the facility consultant pharmacist on 11/19/18 at 2:08 PM she stated that [MEDICATION NAME] 15 mg Immediate Release had an onset of approximately 15 to 30 minutes after administration and was effective for 3 to 6 hours. She said [MEDICATION NAME] mg Extended Release had an onset in approximately the same amount of time as the [MEDICATION NAME] Immediate Release but was a higher dose and was effective for a longer period of time-12 hours. She stated that the [MEDICATION NAME] 15 mg Immediate Release that was given would have been less effective because it was a lower than the scheduled dose of [MEDICATION NAME] mg that was omitted and lasted less time in the body after administration. According to Lexi-Comp, a comprehensive medication data base, although the duration of action for [MEDICATION NAME] is patient dependent, the estimated duration of action for pain relief from immediate-release formulations of [MEDICATION NAME] is 3 to 5 hours. The duration of action for pain relief from extended-release [MEDICATION NAME] depends on the product formulation but is estimated to be 8 to 24 hours. The resident had been asleep when interviews were attempted on 10/24/18, 10/25/18 and 11/13/18. He passed away the evening of 11/13/18. 2. Resident #4 was ordered Modafinil 100 mg via Gastrostomy Tube one time a day for lethargy at 6:00 AM. This medication was ordered by the physician on 07/17/18. Modafinil is a stimulant used to increase alertness. Review of the Controlled Medication Utilization records showed that this medication had not been removed from controlled stock and given to the resident on the following dates: a. 07/26/18 at 6:00 AM Nurse #3 did not remove the medication from controlled stock to administer b. 07/29/18 at 6:00 AM Nurse #4 did not remove the medication from controlled stock to administer c. 08/01/18 at 6:00 AM Nurse #3 did not remove the medication from controlled stock to administer d. 08/10/18 through 08/16/18 the medication was not available for administration at the facility e. 08/17/18 at 6:00 AM Nurse #4 did not remove the medication from controlled stock to administer f. 08/18/18 at 6:00 AM Nurse #4 did not remove the medication from controlled stock to administer g. 08/21/18 at 6:00 AM Nurse #3 did not remove the medication from controlled stock to administer h. 08/26/18 at 6:00 AM Nurse # 5 did not remove the medication from controlled stock to administer i. 08/27/18 at 6:00 AM Nurse # 6 did not remove the medication from controlled stock to administer j. 08/28/18 at 6:00 AM Nurse #6 did not remove the medication from controlled stock to administer k. 08/30/18 at 6:00 AM Nurse #7 did not remove the medication from controlled stock to administer l. 09/22/18 at 6:00 AM Nurse #8 did not remove the medication from controlled stock to administer m. 09/24/18 at 6:00 AM Nurse #8 did not remove the medication from controlled stock to administer n. 10/05/18 at 6:00 AM Nurse #9 did not remove the medication from controlled stock to administer 0. 10/06/18 at 6:00 AM Nurse #10 did not remove the medication from controlled stock to administer p. 10/08/18 at 6:00 AM Nurse #9 did not remove the medication from controlled stock to administer q. 10/10/18 at 6:00 AM Nurse #9 did not remove the medication from controlled stock to administer r. 10/11/18 at 6:00 AM Nurse #10 did not remove the medication from controlled stock to administer In an interview conducted on 10/24/18 at 4:30 PM with the Physician's Assistant she stated that she did not know why she had not provided the pharmacy with a hard script to refill the Modafinil 100 mg for Resident #4 between 08/10/18 and 08/16/18 because the order had not been discontinued. She said that the medication had been ordered to increase the resident's level of alertness after suffering a stroke. In an interview conducted on 10/25/18 at 10:05 AM with the Pharmacy Director she stated that the Modafinil for Resident #4 had not been refilled between 08/10/18 and 08/16/18 because the physician had not provided a hard script (which was required when refilling a controlled substance) to refill the medication until 08/17/17. In an interview conducted on 10/26/18 at 12:40 PM with Nurse #6 she stated that she had missed giving doses to Resident #4 because she couldn't find it in the medication cart and had not realized that it was a controlled substance and located in the locked drawer on the cart. She had signed the eMar as administered to the resident on 08/27/18 and 08/28/18 at 6:00 AM. In an interview conducted on 10/26/18 at 12:57 PM with Nurse #10 she said that if she had not signed a medication out on the narcotic sheet and the count was correct then she had missed giving the medication to Resident #4 but had signed the eMar as administered to the resident 10/06/18 and 10/11/18 at 6:00 AM. An attempt to contact Nurse #4 on 10/26/18 at 12:08 PM was unsuccessful. His phone would not accept a message. He was no longer employed at the facility. An attempt to contact Nurse #3 on 10/26/18 at 12:29 PM was unsuccessful. Her phone would not accept a message. She was no longer employed at the facility. An attempt to contact Nurse #5 on 10/26/18 at 12:46 PM was unsuccessful. Her phone would not accept a message. An attempt to contact Nurse #7 on 10/26/18 at 12:34 PM was unsuccessful. A message was left but she did not return the call. An attempt to contact Nurse #8 on 10/26/18 at 12:37 PM was unsuccessful. A message was left but she did not return the call. An attempt to contact Nurse #11 on 10/26/18 at 12:47 PM was unsuccessful. A message was left but she did not return the call. Attempts to contact Nurse #9 on 10/26/18 at 11:42 AM and 12:03 PM were unsuccessful. The first attempt was busy and the second attempt went straight to voice mail but would not accept a message because it was full. In an interview conducted with Physician #3 on 11/14/18 at 12:29 PM she stated that because the resident received all but two doses of the Modafinil 100mg in (MONTH) (YEAR) and had remained lethargic that it could not be determined if when he had received the medication in (MONTH) (YEAR) that his increased alertness was due to the medication. She said that because of the time lapse between (MONTH) and (MONTH) the resident's increased alertness could have been due to the natural healing of the brain after a severe stroke which was common. 3. Resident #216 was ordered [MEDICATION NAME] 150 mg one capsule by mouth three times daily for pain. This medication was ordered by the physician on 10/19/18. Review of the Controlled Medication Utilization records showed that the medication had not been removed from stock and given to the resident on 10/22/18 at 10:00 PM but was initialed on the eMAR as given by Nurse #5. Record review revealed that Resident #216 had received [MEDICATION NAME]-[MEDICATION NAME] 5-325mg for pain on 10/23/18 at 2:52 AM. An attempt to contact Nurse #5 on 10/26/18 at 12:46 PM was unsuccessful. Her phone would not accept a message. Resident #216 was discharged to home on 11/02/18. She was contacted by phone on 11/14/18 and revealed that she was pleased with the care she received at the facility. She stated that she felt her pain was controlled. 4. Resident #140 was ordered [MEDICATION NAME] HCL Extended Release Abuse Deterrent give one tablet by mouth two times a day for pain. This medication was ordered by the physician on 10/14/18. Review of the Controlled Medication Utilization records showed that the medication had not been removed from stock and given to the resident on 10/15/18, 10/16/18, 10/17/18 or 10/18/18 at 8:00 AM but was initialed on the eMAR as given by Medication Aide (MA) #1. On 10/15/18 MA#1 documented the resident's pain level as 9, on 10/16/18 as 5, on 10/17/18 as 7 and on 10/18/18 as 2 on a pain scale of 0-10 with 0 being no pain and 10 being extreme pain. In an interview conducted on 10/26/18 at 11:16 AM with Medication Aide #1 she stated that if she had signed off on the eMAR that she gave the medication but had not signed it out of the locked drawer on the cart then she must have missed giving the doses to the resident. Three unsuccessful attempts to contact Resident #4 were made on 11/13/18 who had been discharged to home on 10/27/18. Messages were left but she did not return the calls. In an interview with the Director of Therapy on 11/13/18 at 1:38 PM she reported that Resident #4 had not missed any therapy sessions due to uncontrolled pain. She said the resident did so well that she went straight to outpatient therapy when she was discharged . 5. Resident #36 was ordered [MEDICATION NAME] 50 mg one capsule by mouth one time a day for nerve pain. This medication was ordered by the physician on 9/7/17. Review of the Controlled Medication Utilization records showed that the medication had not been removed from stock and given to the resident on 10/21/18 at 9:00 AM but was initialed on the eMAR as given by Nurse 12. In an interview conducted with Nurse #12 on 10/23/18 at 6:07 PM she stated that she had signed off the medication on the eMAR but had not given it to the resident or removed it from the controlled medication drawer. In an interview conducted with Resident #36 on 11/13/18 at 10:30 AM she stated that she could not remember any days when she had worse or different pain. She stated that she always had some discomfort in her neck but that the pain medication helped. 6. Resident #50 was ordered [MEDICATION NAME] 50 mg by mouth two times a day for pain. This medication was ordered by the physician on 10/06/18. Review of the Controlled Medication Utilization records showed that the medication had not been removed from stock and given to the resident on 10/15/18 at 8:00 AM but was initialed on the eMAR as given by Nurse #13. In an interview conducted on 10/25/18 at 4:04 PM with Nurse #13 she stated that she had signed the eMAR as having given the medication to Resident #50 but forgot to go back and give it. She said that she had not taken it out of the controlled substance locked drawer when she passed his other medications and intended to go back and give it later but forgot. In an interview conducted with Resident #50 on 11/14/18 at 11:30 AM he stated that he could not recall any days when his pain level was greater than normal. He stated that he received 8 or 9 pills every morning and they were generally effective. He said that there had been no days on which he noticed his pain level to be worse or different. In an interview with the Director of Nursing on 10/26/18 at 7:56 AM she stated that she expected all medications to be given to residents as ordered by the physician.

Based on record review and staff interviews the facility failed to ensure that staff reported an incident when a resident ' s leg was caught under the bed during a transfer resulting in delayed treatment for [REDACTED].#1) of 3 sampled residents reviewed for transfers and fall related injuries. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan initiated 3/21/14 revealed the resident was to be transferred with the assist of one to two persons. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory loss and was moderately cognitively impaired. The MDS revealed the resident required extensive assistance of one person for transfers. The MDS revealed that with surface to surface transfers the resident was not steady and only able to stabilize with staff assistance. The MDS revealed the resident used a wheelchair for mobility and had experienced no recent falls. The Care Area Assessment (CAA) for Falls dated 4/2/14 revealed the resident did not attempt to get out of bed, had a long history of Polio with Paralyti[DIAGNOSES REDACTED] and had been bed bound for many years. A Witness Statement of Incident/Accident or Injury of Unknown Origin by the Administrator dated 5/2/14 revealed the RP for Resident #1 came to the administrator ' s office on the morning of 5/2/14 saying the staff had broken the resident ' s foot. The statement revealed the RP stated the resident told her his foot got caught in the wheelchair and the NAs did not stop to dislodge it but kept pulling until his foot was free. The statement revealed the RP stated she told the nurse last night on the 3PM-11PM shift. The statement revealed the RP was accompanied to the nurse ' s station by the administrator and the resident ' s nurse was questioned about an incident with the resident ' s foot but the nurse was not aware of such an incident. A nursing progress note dated 5/2/14 at 10:23 AM revealed at 8:30 that morning the resident ' s Responsible Party (RP) reported that Resident #1 had swelling and pain in the left foot that increased with movement. The Nurse documented the resident had pain of the left lower extremity at a level of 4 on a pain scale of 0-10, 0 being no pain and 10 being unbearable pain. The progress note revealed the administrator and the physician ' s assistant (PA) was notified. A physician ' s progress note dated 5/2/14 revealed Resident #1 stated he got his left lower leg stuck under the bed during an assisted transfer from his wheelchair to the bed. The note revealed the resident was unsure as to when it happened or the name of the staff member assisting him at the time. The note revealed a STAT x-ray of the lower leg and ankle was done that revealed a non-displaced mid shaft tibia fracture. A nursing progress note dated 5/2/14 at 12:19 PM revealed the PA had assessed Resident #1 and ordered a STAT x-ray of the left lower extremity. The note revealed the resident stated he thought his lower extremity got caught when he was being transferred back to bed the night before. The note revealed a positive x-ray and that an order had been given to send the resident to the Emergency Department (ED) for evaluation and treatment. A physician ' s progress note dated 5/5/14 revealed Resident #1 was seen on follow-up of an ED visit. The note revealed the resident was sent to the ED on 5/2/14 with a complaint of severe left lower extremity pain due to a mid-shaft tibia fracture. The note revealed the RP stated the resident got his foot caught under the bed while being transferred from the bed to the chair. The note revealed the resident returned from the ED with an order for [REDACTED]. Review of the record for the resident revealed Resident #1 had a follow-up visit with an orthopedist on 5/9/14. The orthopedist note revealed the resident had a spiral non-displaced [MEDICAL CONDITION] tibia. The note revealed repeat x-rays were done during the visit that showed a non-displaced fracture with excellent alignment. On 5/14/14 at 2:35 PM an interview was conducted with the nurse assigned to Resident #1 on 5/1/14 on the 3PM to 11PM shift. Nurse #1 stated the resident ' s RP frequently asked for pain medication for the resident. The Nurse stated when she would assess the resident for pain he would say he had no pain or would not say anything. The Nurse stated on 5/1/14 the RP told her the resident ' s ankle was swollen and asked if he could have anything for pain. The Nurse stated there were PRN (as needed) pain medications ordered for the resident. The Nurse stated she assessed the ankle and leg by palpating the area and inspecting for redness, swelling and heat. The Nurse stated there was no obvious swelling of the ankle or leg and when she moved the leg the resident did not complain of pain. The Nurse stated the RP grabbed the resident ' s leg and the resident winced but she thought it had to do with the way the RP grabbed the leg. The Nurse stated she was not aware of an injury to the resident ' s ankle or leg. NA #1 stated in a telephone interview on 5/14/14 at 3:20 PM that during a transfer on 5/1/14 the resident ' s leg was stuck under the bed. The NA stated the resident denied pain and told her he was OK. The NA stated she was going to tell the nurse about the incident but something came up with another resident and she forgot. The Director of Nursing (DON) stated in an interview on 5/14/14 at 3:30 PM that as part of their plan of correction, the nursing staff had been in-serviced that the NAs (nursing assistants) were to report immediately any injury or medical concerns to the nurse and the nurse was to report any injury of unknown origin to the DON or the administrator. The DON stated the staff monitored care on a daily basis but did not include specific monitoring in the plan of correction. The DON stated she had added monitoring the plan of correction and provided a copy of the plan of correction with handwriting at the top that read: " Revised 5/14/14 to include monitoring. "

Based on record review and staff interviews the facility failed to ensure that staff transferred a resident per physical and occupational therapy instructions resulting in a fractured leg for 1 of 3 sampled residents (Resident #1) reviewed for transfer and fall related injuries. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 3/21/14 revealed the resident was to be transferred with the assist of one to two persons. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had short and long term memory loss and was moderately cognitively impaired. The MDS revealed the resident required extensive assistance of one person for transfers. The MDS revealed that with surface to surface transfers the resident was not steady and only able to stabilize with staff assistance. The MDS revealed the resident used a wheelchair for mobility and had experienced no recent falls. The Care Area Assessment (CAA) for Falls dated 4/2/14 revealed the resident did not attempt to get out of bed, had a long history of Polio with Paralyti[DIAGNOSES REDACTED] and had been bed bound for many years. A Record of In-Service form revealed transfer training for Resident #1 was initiated on 4/17/14 with the staff based on physical and occupational therapy evaluations. The record listed the following: Gait belt must be used. Must be two person assist. (Name of mechanical lift) if necessary. The signature sheet revealed NA (nursing assistant) #1 attended the in-service on 4/21/14. An Occupational Therapy Discharge Summary for Resident #1 dated 4/23/14 under Discharge Status and Recommendations revealed caregiver education was complete and staff training focused on mobility and transfers. The summary revealed the resident required maximum assist of 2 persons for transfers and used a wheelchair for mobility. A Physical Therapy Discharge Summary for Resident #1 dated 4/30/14 under Discharge Status and Recommendations revealed the resident was totally dependent on staff for transfers and that in-service training was performed with the NAs with instruction on positioning, use of gait belt, transfer with assist of 2 persons at all times and use of (name of mechanical lift) if necessary to decrease the risk of caregiver and patient injury. The summary revealed the NAs had signed an in-service form in the medical record to acknowledge agreement. A Witness Statement of Incident/Accident or Injury of Unknown Origin by the Administrator dated 5/2/14 revealed the RP came to the administrator ' s office on the morning of 5/2/14 saying the staff had broken the resident ' s foot. The statement revealed the RP stated the resident told her his foot got caught in the wheelchair and the NAs did not stop to dislodge it but kept pulling until his foot was free. The statement revealed the RP stated she told the nurse last night on the 3PM-11PM shift. The statement revealed the RP was accompanied to the nurse ' s station by the administrator and the resident ' s nurse was questioned about an incident with the resident ' s foot but the nurse was not aware of such an incident. The note revealed the PA was in the facility at the time and saw the resident and a portable x-ray was done which showed an acute fracture. The note revealed the resident was sent to the ED and the RP was informed that an investigation would be conducted. A nursing progress note dated 5/2/14 at 10:23AM revealed at 8:30 that morning the resident ' s Responsible Party (RP) reported that Resident #1 had swelling and pain in the left foot that increased with movement. The Nurse documented the resident had pain of the left lower extremity at a level of 4 on a pain scale of 0-10, 0 being no pain and 10 being unbearable pain. The progress note revealed the administrator and the physician ' s assistant (PA) was notified. A nursing progress note dated 5/2/14 at 12:19 PM revealed the PA had assessed the resident and ordered a STAT x-ray of the left lower extremity. The note revealed the resident stated he thought his lower extremity got caught when he was being transferred back to bed the night before. The note revealed a positive x-ray and an order had been given to send the resident to the Emergency Department (ED) for evaluation and treatment. A physician ' s progress note dated 5/2/14 revealed Resident #1 stated he got his left lower leg stuck under the bed during an assisted transfer from his wheelchair to the bed. The note revealed the resident was unsure as to when it happened or the name of the staff member assisting him at the time. The note revealed a STAT x-ray of the lower leg and ankle was done that revealed a non-displaced mid shaft tibia fracture (There are 2 bones in the leg between the knee and the ankle, the larger of the two being the tibia). Review of the resident ' s record revealed Resident #1 had a follow-up visit with an orthopedist on 5/9/14. The orthopedist note revealed the resident had a spiral non-displaced fracture of the left tibia. An interview was conducted with the Administrator and the Director of Nursing (DON) on 5/14/14 at 1:50 PM. The DON stated the NAs had been in-serviced to transfer Resident #1 with a gait belt and 2 persons. The DON stated Resident #1 gave several variations of the incident. The DON stated Resident #1 described the NA that transferred him when his leg was injured and described NA #1 who was assigned to the resident on the 3PM to 11PM shift on 5/1/14. The DON stated that she interviewed NA #1 on three separate occasions and the NA ' s story changed each time she interviewed her. The DON stated on the initial interview with NA #1 on 5/2/14, the NA stated she was not aware of the problem with the resident ' s foot until the RP told her the resident ' s foot was broken. The DON stated the NA did not mention she transferred the resident or that anything happened during a transfer. The DON stated the NA was off on the weekend and she called her back in on Monday 5/5/14. The DON stated NA #1 told her that she and another NA pulled the resident up in the bed and noted his foot was caught between the wheels of the bed. The DON stated the NA stated she could not remember who assisted her to pull the resident up in bed. The DON stated the NA told her the resident was OK and was not injured. The DON stated she asked NA #1 to demonstrate how she transferred the resident and the NA put her arm under the DON ' s arm and held onto the waist band of her pants for the transfer. The DON stated the NA did not refer to the positioning of another staff member assisting with the transfer. The DON stated the NA told her she forgot to tell the nurse that the resident ' s leg got caught during the transfer. The DON provided written statements from the NAs working on 5/1/14 and according to the statements all the NAs wrote they did not assist NA #1 to transfer Resident #1 on 5/1/14. The DON stated that NA #1 was suspended on 5/5/14 pending results of the investigation. The DON stated she interviewed NA #1 again on 5/6/14 and the NA denied that she ever transferred Resident #1 on 5/1/14. The DON stated the NA had received training in April 2014 to transfer Resident #1 with a gait belt and 2 person assist and NA #1 signed the in-service signature sheet. The DON stated the x-ray showed the resident had a spiral fracture of the tibia and the resident ' s physician told her the fracture was no more than 24 hours old. The DON stated that based on the investigation, she believed NA #1 transferred Resident #1 independently and caused the fracture of the resident ' s leg. On 5/14/14 at 2:35 PM an interview was conducted with Nurse #1 who worked the 3PM to 11PM shift on 5/1/14. Nurse #1 stated on the evening of 5/1/14, the RP told her she thought the resident ' s ankle was swollen and could he have something for pain. The Nurse stated she did an assessment of the ankle and leg by inspecting the extremity for redness, swelling and heat and palpated the area. The Nurse stated she moved the resident ' s leg and he did not complain of pain. The Nurse stated there was no obvious problem with the extremity. The Nurse stated the RP grabbed his leg and the resident winced but thought it had to do with the way the RP grabbed his leg. The Nurse stated the RP did not say anything about an injury to the resident ' s foot or leg. The Nurse stated she observed no obvious swelling of the leg or ankle and was not aware of an injury to the resident ' s foot or leg. NA #1 stated in a telephone interview on 5/14/14 at 3:20 PM that she did not transfer Resident #1 by herself on 5/1/14 but could not remember who assisted her with the transfer. The NA stated during the transfer the resident ' s leg was stuck under the bed and when the resident was back in bed the resident denied pain and said he was OK. The NA stated she was going to tell the nurse about the incident but something came up with another resident and she forgot. Review of the facility ' s investigation of the incident revealed the facility filed a 24 hour and 5 day report to the state. The DON stated in an interview on 5/14/14 at 3:30 PM that in-services had been provided for the nursing staff regarding proper transfer procedures for residents and information provided regarding the NA ' s responsibility to report immediately any injury or medical concerns to the nurse and the responsibility of the nurse to report any injury of unknown origin to the DON or Administrator. The DON stated the NAs were required to use a gait belt when manually transferring residents and according to NA #1 ' s demonstration, the NA did not use a gait belt for the transfer. The DON stated all resident care guides were reviewed to ensure they had proper instructions for transferring the residents. The DON stated that orientation of all nursing staff would include a return demonstration that the staff could successfully use the gait belt to transfer residents. The DON stated the staff were always monitoring resident care but did not institute a specific monitoring plan in the plan of correction. The DON stated she had spoken with the medical director and the physician ' s assistant about the incident but did not include the incident in their last Quality Improvement (QI) meeting on 5/13/14. The DON stated she planned to include the information in the next QI meeting along with the monthly statistics. Occupational Therapist Assistant (OTA) #1 stated in an interview on 5/15/14 at 8:36AM that he conducted an in-service for the NAs in April 2014 regarding transfers for Resident #1. The OTA stated the NAs were instructed to use 2 persons and a gait belt for manual transfer and if the resident was not assisting with the transfer to use the (name of mechanical lift). The OTA stated that the staff were to always use 2 persons when using a (name of mechanical lift) to transfer a resident.