Every finding on record at Bellevue Health & Rehabilitation Center

Based on record review and interview, the facility failed to ensure 18 of 18 dietary contract employees received abuse training.The DON identified 141 residents resided in the facility. Findings:A facility policy titled Abuse Prevention Program, revised 08/2006, read in part, Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern at a minimum: .b. Mandated staff training/orientation programs that includes topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behaviors or catastrophic reactions, etc.The facility's contract with the dietary contractor titled Management Service Agreement, dated 10/06/25, read in part, The [name of dietary contractor agency withheld] Mangers will train and manage the Service Employees and oversee the provision of the management services.On 12/17/25 at 4:23 p.m., human resources stated the dietary contractor was responsible for ensuring all dietary staff hired received abuse training. On 12/17/25 at 4:59 p.m., the regional director of operations stated they learned on 12/16/25 that the contract agency they were employed with was responsible for training dietary staff on abuse. The regional director of operations stated dietary staff had not been trained on abuse. The regional director of operations stated that the abuse training was not part of their contract. On 12/17/25 at 6:59 p.m., the DON stated there was an abuse addendum training through the dietary contractor for dietary staff that was not included during dietary staff orientation. The DON stated 18 dietary staff members were not trained on identifying and reporting abuse prior to working. On 12/18/25 at 1:10 p.m., the DON stated the dietary contractor was supposed to train their service employees on abuse, but they forgot the supplemental abuse training for the staff. On 12/18/25 at 2:11 p.m., the administrator stated the facility was expecting the dietary contractor to complete the abuse training and the dietary contractor forgot the supplement for abuse in their training. The administrator stated they were not sure if it was in the contract with the dietary contractor.

Based on observation, record review, and interview, the facility failed to ensure bathrooms accessible to residents had call lights for 2 of 2 bathrooms observed accessible to residents.The DON identified 141 residents resided in the facility. Findings: On 12/16/25 at 1:13 p.m., a bathroom located outside of the therapy hall accessible to residents was observed unlocked, the door open, and a sign on the door that read, restroom for patients only. The restroom did not have a call light to alert for assistance. On 12/16/25 at 1:15 p.m., the bathroom on hall 500 was observed to be accessible to residents and did not have a call light to alert in the event of an accident. A facility policy titled Quality of Life- Accommodation of Needs, revised 08/2009, read in part, The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. On 12/16/25 at 1:11 p.m., medical records was asked about the bathroom outside the therapy room on the main hall. Medical Records stated it was an unlocked and open bathroom residents who were mobile and were able to self-transfer could use without supervision. Medical Records stated there was not a call light in the bathroom. Medical Records stated resident could have a slip and fall would not be able to call for help. On 12/16/25 at 1:21 p.m., LPN #1 stated all resident accessible bathrooms should have a call light. LPN #1 stated the bathroom on the main hall by the therapy room was unlocked, accessible to residents, and did not have a call light. LPN #1 stated residents using that bathroom could have an unforeseen fall or a medical emergency. On 12/16/25 at 1:31 p.m., the DON stated resident accessible bathrooms should have handicap rails, grab bars, and call lights. The DON stated the bathroom on hall 500 was accessible to residents and did not have a call light.

Based on observation, record review, and interview the facility failed to ensure:a. prepared food items were labelled with the preparation and use-by dates,b. food items were discarded after the expiration date,c. fresh food items with visible mold, discoloration, or soft to touch were discarded,d. opened food items were stored in airtight packaging,e. monitoring of temperatures for refrigerators and freezers containing food, andf. food was prepared in a sanitary environment for 2 of 2 kitchen observations.The DON identified 138 residents received nutrition from the kitchen.Findings:On 12/15/25 at 9:00 a.m., the following temperature log observations were made:a. a freezer temperature log for the reach in freezer, with opening and closing temperature documentation areas, was not completed for 12/15/25, andb. a refrigerator temperature log for the walk-in refrigerator, with opening and closing temperature documentation areas, was not completed for 12/15/25.On 12/15/25 at 9:05 a.m., four clear plastic covered pitchers were observed on a four wheeled cart near the food preparation area. Two had yellow-colored liquid and two had tea colored liquid, without labels or preparation/use-by dates.On 12/15/25 at 9:10 a.m., the hot food holding box was observed in the food preparation area with a small metal container with a plastic lid with cereal looking substance and a small metal container without a lid with a cereal looking substance. Both items did not have a label or date indicating content, preparation and use-by information.On 12/15/25 at 9:14 a.m., the following bread products were observed on shelving unit in food preparation area without manufacturer best-by dates or facility marked dates:a. two packages of unopened hamburger buns,b. two loaves of opened sliced bread,c. four loaves of unopened sliced bread, andd. five packages of unopened English muffins.On 12/15/25 at 9:17 a.m., the following observations were made in the walk-in refrigerator:a. ten fresh cucumbers that were soft to touch and had visible mold,b. an opened plastic package of shredded lettuce that was discolored, soft, and without label or date,c. a plastic zip locked bag labelled ham without open or use-by dates, andd. a plastic container with red colored tomato sauce type contents that was not labeled or dated.On 12/15/25 at 9:19 a.m., the following observations were made in the walk-in freezer without labels, date opened or use-by dates:a. an opened bag of tator tots,b. an opened bag of French fries,c. an opened bag of chicken tenders,d. a plastic zip locked bag labelled fajita chicken, with use-by date of 11/30/25, ande. an open plastic bag of sausage patties, not sealed, and with no label or dates.On 12/15/25 at 9:30 a.m., the following was observed in the dry storage area:a. a package of buttermilk pancake mix was opened, not sealed, labelled, or dated,b. a 16 oz container of cornstarch was opened, not sealed, labelled, or dated,c. a 29.77 oz container of refried pinto bean constitute was opened and not sealed, andd. a Zip lock plastic bag labelled croutons had a use by date of 11/30/25.On 12/15/25 at 9:35 a.m., a 3-compartment sink was observed being utilized for dishwashing since the dishwasher was out of service. The sanitizer dispenser log was not completed for 12/15/25. On 12/15/25 at 9:44 a.m., the salt and pepper storage containers were observed in the dining room drawers with a moderate amount of debris.On 12/15/25 at 9:45 a.m., an ice machine was observed in the dining room with an out of service sign that had brown colored standing water in the drainage tray. On 12/18/25 at 1:20 p.m., the room in the kitchen where the dishwasher was being repaired was observed to have a foggy haze type appearance in the air as well as debris from construction and leaves on the floor. There were maintenance workers in the area, no separation between work area and food storage and preparation areas, and an air curtain was not in use between the exit door and work area per facility policy.A facility provided policy titled Food Storage: Cold, dated 10/2019, read in part, a written record of daily temperatures is recorded.A facility provided policy titled Receiving, dated 10/2019, read in part, all food items will be appropriately labeled and dated either through manufacturer packaging or staff notation.A facility provided policy titled Ware Washing, dated 10/2019, read in part, the dining services director is responsible for ensuring appropriate completion of temperature and/or sanitizer logs as appropriate.A facility provided policy titled Construction and Remodeling Policy, dated 6/01/25, read in part, install temporary barriers (plastic sheeting, zip walls, hard barriers) to isolate work areas.On 12/15/25 at 9:02 a.m., the dietary manager stated the temperatures had not been checked or logged this morning for the refrigerators, freezers, and dry storage area.On 12/15/25 at 9:10 a.m., the dietary manager stated the cardboard box with the dressing packets showed the date the item was received and there should be another date on the box showing the open date and use-by date.On 12/15/25 at 9:12 a.m., the dietary manager stated containers with prepared drinks and items in the hot box should be covered, labelled, and dated.On 12/15/25 at 9:14 a.m., the dietary manager stated they were unsure of the factory dating processes. They stated they did not label and date bread products when they came in or when they were opened.On 12/15/25 at 9:35 a.m., the dietary manager stated all items should be fresh, opened items should be stored in sealed containers, and packaged items should be labelled and dated with received by, preparation, and use-by dates. The dietary manager stated all items that were past the use-by date should be discarded.On 12/15/25 at 9:36 a.m., the dietary manager stated they thought the sanitizer and temperature was to be checked with every load of dishes washed in the sink to ensure appropriate temperatures and solutions were used.On 12/15/25 at 9:45 a.m., the dietary manager stated the dining room drawers needed to be cleaned and the ice machine needed to have the standing water removed.On 12/18/25 at 1:30 p.m., the maintenance supervisor stated the workers were not using any cutting type of equipment that would produce particles in the air, so they did not need to use a barrier between the work area and food storage or preparation areas. The maintenance supervisor stated the air curtain would help prevent outside debris from coming into the kitchen and it was not in use at this time.

Based on observation, record review, and interview the facility failed to ensure there were enough trained staff at set meal times for 4 of 4 dining observations.The DON identified 138 residents received nutrition from the kitchen.Findings:On 12/15/25 at 8:48 a.m., kitchen staff were observed preparing trays for a hall cart for delivery to residents. Posted mealtimes for breakfast showed 8:00 a.m.On 12/15/25 at 12:51 p.m., lunch hall trays were delivered to hall 300. Dining room residents had not been served lunch yet. Posted mealtimes for lunch showed 12:00 p.m.On 12/16/25 at 9:00 a.m., breakfast trays were delivered to hall 400. Dining room residents had not been served breakfast yet. Posted mealtimes for breakfast showed 8:00 a.m.On 12/18/25 at 12:50 p.m., dining room residents were observed receiving trays for lunch. Posted mealtimes for lunch showed 12:00 p.m.An undated facility document titled [NAME] Meal Times, read in part, breakfast 8:00 a.m., lunch 12:00 p.m., and dinner 5:00 p.m.On 12/15/25 at 10:57 a.m., Resident #104 stated they ate meals in their room and did not eat breakfast that morning since they received cold pancakes and it was not appetizing. Resident #104 stated meal times were an issue and had been late for last several weeks.On 12/16/25 at 12:51 p.m., CNA #2 stated meal trays had been late coming out since the new company took over the kitchen. CNA #2 stated it was a problem for the residents since they did not know when they would get their meals and some got anxious when they were not on time.On 12/18/25 at 2:50 p.m., the dietary manager stated they were working with several new staff members and not everyone knew what their roles were yet. The dietary manager stated the kitchen was slower getting food prepared and served than they needed to be.

Based on record review and interview, the facility failed to implement their abuse policy by not ensuring all staff working in the facility were trained on identifying and reporting abuse for 18 of 18 dietary contractor staff members. The DON identified 141 residents resided in the facility. Findings: A facility policy titled Abuse Prevention Program, revised 08/2006, read in part, Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern at a minimum: .b. Mandated staff training/orientation programs that includes topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behaviors or catastrophic reactionsThe facility's contract with the dietary contractor titled Management Service Agreement, dated 10/06/25, read in part, The [name of dietary contractor agency withheld] Mangers will train and manage the Service Employees and oversee the provision of the management services.On 12/17/25 at 4:23 p.m., human resources stated the dietary contractor was responsible for ensuring all dietary staff hired received abuse training. On 12/17/25 at 4:59 p.m., the regional director of operations stated they learned on 12/16/25 the contract agency they were employed with was responsible for training dietary staff on abuse. The regional director of operations stated dietary staff had not been trained on abuse. The regional director of operations stated the abuse training was not part of their contract. On 12/17/25 at 6:59 p.m., the DON stated there was an abuse addendum training through the dietary contractor for dietary staff that was not included during dietary staff orientation. The DON stated 18 dietary staff members were not trained on identifying and reporting abuse prior to working. On 12/18/25 at 1:10 p.m., the DON stated the dietary contractor was supposed to train their service employees on abuse, but they forgot the supplemental abuse training for the staff. On 12/18/25 at 2:11 p.m., the administrator stated the facility was expecting the dietary contractor to complete the abuse training and the dietary contractor forgot the supplement for abuse in their training. The administrator stated they were not sure if it was in the contract with the dietary contractor.

Based on observation, record review, and interview, the facility failed to ensure:a. walls and paint were in good repair for 2 (#3 and #6), and b. a resident's bed was in good repair for 1 (#3) of 28 sampled residents reviewed for a safe home like environment. The DON identified 141 residents resided in the facility. Findings:1.On 12/15/25 at 4:25 p.m., Resident #6's room was observed to have chipped and peeled paint in several areas on the wall behind the bed. The sheetrock had deep scratches and was white in color. Sheetrock was observed on the floor from the damaged wall. A facility policy titled Maintenance Service, revised 12/2009, read in part, Maintenance service shall be provided to all areas of the building, grounds, and equipment.Function of maintenance personnel include but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.Resident #6's comprehensive assessment, dated 09/08/25, showed they were admitted with a diagnosis of Alzheimer's disease. The assessment showed Resident #6's cognition was moderately impaired with a BIMS score of 08. On 12/15/25 at 4:25 p.m., family representative #1 stated the damaged wall bothered the resident and them.On 12/16/25 at 4:10 p.m., CNA #1 was asked to discuss the walls in Resident #6's room. CNA #1 stated the paint was chipped on the wall at the head of the bed, the sheetrock was damaged, and it had been damaged since 10/2025. CNA #1 stated the damaged wall made the room look like it was not taken care of and maintained. On 12/16/25 at 4:16 p.m., the maintenance supervisor stated they did not have any outstanding work orders to repair the wall in Resident #6's room. The maintenance supervisor was asked to look in Resident #6's room and discuss what they saw. The maintenance supervisor stated the bed was an older style bed and it was pushed too close to the wall which caused the damage to the wall. The maintenance supervisor stated two walls in Resident #6's room were damaged and there was chipped paint and sheet rock dust on the floor. 2. On 12/17/25 at 8:59 a.m., Resident #3 was observed in bed. The bed had padding added under the mattress. The resident was positioned at the side of the bed and not in the center. The wall at the foot of the bed was damaged with missing paint and deep scratches in the sheet rock. The wall the bed was pushed against was missing paint and was white in color. Resident #3's quarterly assessment, dated 10/01/25, showed they were admitted on [DATE] with diagnoses which included dementia and diabetes. The assessment showed Resident #3's cognition was intact with a BIMS score of 14. The assessment showed Resident #3 was dependent for bed mobility. On 12/17/25 at 9:03 a.m., CMA #1 stated they reported to the administrator the bed was uncomfortable, and the resident could not sit in the middle because they felt the bars under the bed. CMA #1 stated the family put padding under the mattress to try and make it more comfortable. CMA #1 stated the walls in Resident #3's room at the foot of the bed and side were damaged for the last six months. On 12/17/25 at 9:06 a.m., Resident #3 stated they felt the bar under the bed on their bottom. Resident #3 stated their family put padding under the bed. Resident #3 stated when they laid in the middle of the bed, they could feel a bar or something on their bottom that caused discomfort. On 12/17/25 at 9:44 a.m., the ADON stated they were not aware of any residents with a broken bed and repositioning issues. The ADON stated Resident #3's bed was not level. On 12/17/2025 at 9:50 a.m., the administrator was shown Resident #3's bed. The administrator stated the bed was never reported to them and they had put the bed in Resident #3's room two weeks prior. The administrator stated the bed was not level and needed to be lowered and readjusted. They stated staff did not place the padding under the bed.

Based on observation, record review, and interview, the facility failed to handle and process linens to prevent the spread of infection for residents on contact isolation in the laundry room. The infection preventionist identified five residents on contact precautions. Findings: On 12/18/25 at 3:00 p.m., an observation of the laundry area was completed. There were no gowns available. A facility policy titled Laundry and Bedding, Soiled, dated September 2022, read in part, Hand hygiene products, as well as appropriate PPE [personal protective equipment] (i.e., gloves and gowns) are available and used while sorting and handling contaminated linen. On 12/18/25 at 3:04 p.m., the housekeeping/laundry manager stated the staff wore gloves to transport the red biohazard to the laundry area. The housekeeping/laundry manager stated the staff would open the bags and place the soiled linen in the washing machine. The housekeeping/laundry manager stated gowns were not worn to place the soiled linen in the washing machine. On 12/18/25 at 3:12 p.m., the infection preventionist stated laundry staff should wear gloves and a gown when handling soiled linen from a room with contact precautions/isolation precautions to prevent the possible spread of infection.

Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan intervention for transfers for 2 (#12 and #13) of 3 sampled residents reviewed for care plans.The DON identified 152 residents resided in the facility. Findings: 1.On 09/09/25 at 11:27 a.m., Resident #12 was observed transferring from their bed to a wheelchair with the assistance of CNA #3 and CNA #5 using a slider board and a gait belt.A facility policy titled Care Plans, Comprehensive Person-Centered, dated 03/2022, read in part, The care plan interventions are derived through analysis of the information gathered as part of the comprehensive assessment.The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes.b. describes the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.An admission record for Resident #12, dated 06/12/25, showed they were admitted with a diagnosis of acquired absence of the right leg below the knee. An annual assessment for Resident #12, dated 06/18/25, showed their cognition was intact with a BIMS score of 15. The assessment showed Resident #12 was dependent for chair to bed transfers and used a wheelchair to ambulate. An assessment for Resident #12 titled PT Evaluation & Plan of Treatment, dated 08/19/25, showed the resident was dependent for transfers. A care plan for Resident #12, last revised 09/02/25, showed they had an ADL performance deficit for a focus. The care plan did not show interventions for transferring. On 09/09/25 at 11:27 a.m., Resident #12 stated two staff members always assisted them with transfers from the bed to the wheelchair using a slide board. On 09/09/25 at 11:40 a.m., CNA #2 stated Resident #12 transferred from the bed to a wheelchair with the assistance of two staff and a slider board. 2. On 09/09/25 at 11:55 a.m., Resident #13 was observed transferring from their bed to a wheelchair with the assistance from CNA #1 and CNA #2 using a gait belt and a sit to stand lift. An admission record for Resident #13, dated 06/04/25, showed they were admitted with diagnoses which included Parkinsons disease and schizophrenia.A quarterly assessment for Resident #13, dated 08/24/25, showed their cognition was intact with a BIMS score of 14. The assessment showed Resident #13 required substantial to maximal assistance with bed mobility and all transfers. An assessment for Resident #13 titled PT Evaluation & Plan of Treatment, dated 08/20/25, showed they required substantial to maximal assistance with chair to bed transfers.A care plan for Resident #13, last revised 09/03/25, showed they had an ADL performance deficit for a focus. The care plan did not show interventions for transferring. On 09/09/25 at 12:05 p.m., Resident #13 stated they transferred from the bed to a wheelchair with the assistance of two staff and a sit to stand lift. On 09/11/25 at 9:27 a.m., MDS coordinator #1 stated interventions for transfers should be documented in the residents' care plan. MDS Coordinator #1 was asked to review Resident #12 and Resident #13's care plan and asked what interventions were documented for transfers. MDS Coordinator #1 stated there were no interventions for Resident #12 and Resident #13's care plan for transferring. MDS Coordinator #1 stated they were unsure why the interventions were not in the care plans, but they should have been documented there because Resident #12 and Resident #13 were dependent for transfers. On 09/11/25 at 11:30 a.m., the DON stated all interventions for how a resident transferred should be documented in the residents' care plan. The DON stated Resident #12 transferred from the bed to a wheelchair with the assistance of two staff members and a slider board. The DON stated Resident #13 transferred from the bed to a wheelchair with the assistance of two staff and a sit to stand lift. The DON stated there was no documentation in Resident #12 and Resident #13's care plan for interventions to assist with transfers.

Based on observation, record review, and interview, the facility failed to ensure: a. staff used personal protective equipment and sanitized a blood pressure cuff for a resident with contact precautions for one (#93) of two sampled residents reviewed for transmission based precautions; b. staff used personal protective equipment for a resident with enhanced barrier precautions for one (#56) of one enhanced barrier precaution observation; and c. staff maintain infection control practices during incontinent care for one (#52) of seven incontinent care observation. The infection preventionist identified eight residents who were on transmission based precautions and 31 residents who were on enhanced barrier precautions resided in the facility. The DON identified 45 residents required assistance with incontinent care. Findings: The Isolation-Categories of Transmission-Based Precautions policy, revised 09/22, read in part, Staff and visitors wear gloves .when entering the room. The policy also read, Staff and visitors wear a disposable gown on entering the room. The Enhanced Barrier Precautions policy, revised 04/01/24, read in part, An order for enhanced barrier precautions will be obtained for residents with any of the following: feeding tubes. The policy also read, PPE for enhanced barrier precautions is only necessary when performing high contact care activities. The Equipment and Supplies Used During Isolation policy, revised 10/18, read in part, Nursing staff shall be responsible for cleaning and sanitizing supplies between residents, i.e., BP cuffs. 1. Resident #93 had diagnoses which included MRSA bacteremia and osteomyelitis of the left great toe. A physician's order, dated 04/30/24, documented contact precautions every shift for MRSA bacteremia. On 06/02/24 at 1:16 p.m., LPN #3 was observed assisting Resident #93 in bed. LPN #3 was not wearing a gown and did not have gloves on while providing care to the Resident. They did not sanitize or washed their hands. Resident #93's posted sign on their door documented contact isolation, to clean hands, wear a gown and gloves before entering the room. Remove gown and gloves, clean hands when leaving the room. On 06/03/24 at 9:45 a.m., CMA #1 was observed entering Resident #93's room without a gown and gloves. They took the Resident's blood pressure and walked out. They did not clean or sanitize the blood pressure cuff after completing the task. CMA #1 did not wash or sanitized their hands. On 06/03/24 at 12:40 p.m., CMA #1 stated they did not wear a gown or gloves because they only took the Resident's blood pressure. They stated they were not aware they had to clean or sanitize the medical equipment. On 06/03/24 at 12:46 p.m., the ADON stated anyone who entered Resident #93's room should wear a gown and put on gloves. They stated the posted sign is visible to all who entered the room. The ADON stated they have bleach wipes and disinfecting wipes for cleaning equipment used in contact isolation rooms. 2. Resident #56 had a diagnosis of gastrostomy. A physician's order, dated 03/29/24, documented enhanced barrier precautions every shift related to peg tube. On 06/04/24 at 6:17 a.m., CNA #2 and CNA #3 went into Resident #56's room to provide care. Neither CNA used PPE per enhanced barrier precautions guidelines. On 06/04/24 at 7:15 a.m., CNA #2 and CNA #3 got Resident #56 up and took them to the shower. Neither CNA wore a gown or gloves. On 06/04/24 at 7:47 a.m., CNA #2 stated they did not wear a gown or gloves while providing care to Resident #56. On 06/04/24 at 7:59 a.m., CNA #3 stated Resident #56 had a feeding tube and they were on enhanced barrier precautions. They stated they had to wear a gown and gloves while proving care. On 06/04/24 at 8:09 a.m., the ADON stated Resident #56 was on enhanced barrier precautions. 3. Resident #52 admitted on [DATE] with diagnosis which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. On 06/04/24 at 6:08 a.m., CNA #1 was observed to don gloves to provide incontinent care to Resident #52. Upon completion of providing incontinent care, CNA #1 asked Resident #52 if they would like a drink. Without changing gloves, CNA #1 touched the handle of the cup on the bedside table, gave Resident #52 a drink and placed the cup back on the bedside table. CNA #1 wearing the same gloves pulled the bedside table up to Resident #52's bed and leaned over and pulled the cord to turn off the light. On 06/04/24 at 6:19 a.m., CNA #1 stated they had not changed their gloves prior to touching the cup, the bedside table, or the light cord. 46216

Based on record review and interview, the facility failed to complete ongoing assessments of a resident pre and post dialysis for one (#67) of one resident reviewed for dialysis services. Findings: The Facility's Dialysis Care/Arterial-Venous Fistula policy, approved 01/20/23, read in parts, All residents receiving dialysis will have monitoring before and after their dialysis treatment to ensure condition is stable after treatment. The policy also read, The Charge Nurse prior to and upon return from dialysis shall evaluate the resident's condition, including but not limited to vital signs and the graft/fistula site. Resident #67 admitted on [DATE] with diagnoses which included dependence on renal dialysis and end stage renal disease. A physician's order, dated 01/11/23, documented to monitor each shift for complications of dialysis. A physician's order, dated 01/11/23, documented, to dialysis Monday, Wednesday, and Friday; notify dialysis center, attending physician and responsible party if refused. Complete Pre and Post Dialysis Progress Note for patient evaluation. Send copy of physician orders, recent labs and blank progress note. One time a day every Monday, Wednesday, and Friday for end stage renal disease. The May 2024 pre and post dialysis notes were reviewed. There was no documentation on 05/01/24, 05/03/24, 05/15/24, 05/20/24, and 05/29/24 for pre dialysis assessment. There was no documentation on 05/24/24 and 05/31/24 for post dialysis assessment. On 06/05/24 at 8:52 a.m., the DON stated staff were required to document dialysis assessment before and after each dialysis visit. On 06/05/24 at 9:17 a.m., the DON stated the dialysis assessment for the dates above were not done.

Based on observation, record review, and interview, the facility failed to administer O2 according to physician orders and/or label O2 tubing for two (#13 and #54) of three sampled residents reviewed for respiratory care. The DON identified 29 residents received O2. Findings: 1. Res #13 had diagnoses which included SOB. A physician order, dated 01/01/24, documented oxygen 2 LPM via nasal cannula as needed to maintain O2 saturations. On 06/02/24 at 8:24 a.m., there was an O2 concentrator observed the resident's room. The O2 tubing was not labeled. On 06/02/24 at 8:50 a.m., LPN #1 was asked to verify when the resident's O2 tubing was last changed. They stated O2 tubing should be changed weekly and labeled. They stated the O2 tubing was not labeled. 2. Res #54 had diagnoses which included SOB. A physician orders, dated 05/21/24, documented administer O2 at 2 LPM via nasal cannula every shift; and change O2 tubing weekly on Wednesdays and date with tape. On 06/02/24 at 8:37 a.m., the resident was observed with O2 being administered via nasal cannula. The O2 concentrator was set at 1.5 LPM. The O2 tubing was not labeled. On 06/02/24 8:44 a.m., LPN #1 was asked how many LPM of O2 the resident was to be administered. They stated 2 LPM and the O2 tubing should be changed weekly. They were asked to verify the O2 setting on the resident's O2 concentrator and when their O2 tubing was last changed. They stated the resident's O2 was set at 1.5 LPM and it should have been set at 2 LPM. They stated there was no indication when the O2 tubing was changed. They stated the O2 tubing should be labeled.

Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for one (#24) of three sampled residents reviewed for respiratory care. The DON identified 148 residents resided in the facility. Findings: Res #24 had diagnoses which included congestion an allergic rhinitis. A physician order, dated 10/04/23, documented loratadine (an antihistamine) 10 mg tablet. Give one tablet by mouth every 24 hours as needed. A significant change assessment, dated 03/12/24, documented the resident's cognition was intact. A physician order, dated 05/26/24, documented guaifenesin ER (an expectorant) tablet 600 mg. Give one tablet by mouth every 12 hours for seven days. An order administration note, dated 05/26/24 at 7:56 p.m., documented guaifenesin was on order. The May and June 2024 MARs documented guaifenesin was administered 12 out of 14 opportunities. On 06/02/24 at 10:45 a.m., the Resident #24 stated the had a respirator infection over the holiday weekend and was not able to take their prescribed medication. A health status note, dated 06/03/24 at 2:48 p.m., documented the resident reported they had sinus drainage. It was documented loratadine was on order from the pharmacy. There was no documentation loratadine had been administered. On 06/04/24 at 7:41 a.m., the Administrator was ask to to provide documentation when the Resident #24 guaifenesin was received from the pharmacy. On 06/04/24 at 7:46 a.m., the Administrator stated guaifenesin was a house stock medication. They stated the facility had the medication all of the time. On 06/04/24 at 10:16 a.m., the DON was made aware it was documented the Resident #24 received 12 out of 14 doses of the guaifenesin the physician ordered on 05/26/24. They stated they should have received all of the doses. On 06/04/24 at 11:23 a.m., ACMA #3's medication cart was observed. There were two packages with a total of three tablets of loratadine for the Resident #24. The fill date on the packages was 06/03/24. On 06/04/24 at 11:41 a.m., the ADON was asked when the Resident #24 loratadine was received from the pharmacy. They stated the medication packages documented the medication was filled on 06/03/24. They stated the medication would have been delivered between 10:00 p.m. and 11:00 p.m. or earlier. On 06/04/24 at 11:45 a.m., the ADON was shown the progress note where the Resident #24 reported they had sinus drainage and their loratadine was on order from the pharmacy. They were made aware there was no documentation the medication had been administered to the Resident #24. The ADON called the pharmacy and stated the medication was delivered to the facility at 12:08 a.m. on 06/04/24. They stated nursing staff should have reported to each other during shift change they were waiting on the Resident #24 medication.

Based on observation, record review, and interview, the facility failed to provide double portions as ordered for one (#52) of three residents observed for meal service. The DON identified 143 residents received meal service from the kitchen. Findings: Resident #52 admitted on [DATE] with diagnoses which included DM II, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. A physician's order, dated 10/13/23, documented, LCS diet, mechanical soft texture, regular consistency, double portions for heart healthy. On 06/02/24 at 12:07 p.m., Resident #52 was observed to receive their meal tray. Resident observed to receive a tray with single portions. On 06/02/24 at 12:12 p.m., CNA #4 verified there were no double portions on Resident #52's tray. They stated they had not noticed double portions on the meal ticket.

Based on observation, record review, and interview, the facility failed to ensure an enteral tube feeding bottle was properly labeled for one (#54) of two sampled residents reviewed for tube feeding management. The DON identified three residents received enteral tube feeding via continuous pump. Findings: A Enteral Tube Feeding via Continuous Pump policy, dated November 2018, read in part, .The purpose of this procedure is to provide a guideline for the use of a pump for enteral feedings .On the formula .document initials, date and time the formula was hung/administered . Res #54 had diagnoses which included dysphagia, oropharyngeal phase gastrostomy status. A physician order, dated 05/21/24, documented Vital AF 1.2 Cal. Give 55 ml/hr via PEG-tube every shift. A physician order, dated 05/25/24, documented enteral H2O. Auto flush PEG-tube every shift with 23 cc of H2O every hour. 06/02/24 at 8:37 a.m., the resident was observed receiving 55 ml/hr of Vital AF 1.5 Cal via PEG-tube. There were no staff initials, date, or time on the formula bottle or H2O bag. On 06/02/24 at 8:44 a.m., LPN #1 was asked what was the protocol when tube feeding was initiated. They stated the the formula bottle and the H2O bag should be labeled with staff initials, date, and time. They were asked to verify when the resident's tube feeding was initiated. They stated the tube feeding was not labeled and it should have been.

Based on observation, record review, and interview, the facility failed to: A. ensure hands were washed/sanitized during resident medication pass for two (#13 and #53) of two sampled resident observed during medication pass, and B. provide wound care in a manner which prevented cross contamination for one (#222) of one sampled resident reviewed for pressure ulcers. The Resident Census and Conditions of Residents report, dated 04/24/23, reported 143 residents resided in facility and 16 of those residents had pressure ulcers. Findings A Dressings policy, revised 09/13, read in parts, .Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area . 1. On 04/25/23 at 3:28 p.m., CMA #1 was observed administering oral medications to resident #13. CMA #1 did not sanitize their hands prior to or after administering the medications, then punched two oral medications added chocolate pudding, and with a spoon, fed the pudding and medication to resident #53. CMA #1 did not sanitize their hands prior to the medication preparation and administration to resident #53. On 04/25/23 at 3:39 p.m., CMA #1 was asked, what the facility policy was for washing/sanitizing their hands. They stated they were to wash their hands when they arrived at the facility. They were asked what the policy was for sanitizing their hands during medication administration. CMA #1 stated, they should have sanitized between the residents. 35389 2. Resident #222 had diagnoses which included stage two pressure ulcer of the left and right buttock. A Physician Order, dated 04/24/23, documented staff were to apply Triad Hydrophilic wound paste to bilaterally buttocks every shift for redness related to stage two pressure ulcer to left and right buttock. It documented to cleanse the coccyx, pat dry, then apply the paste. On 04/26/23 at 9:53 a.m., LPN #1 washed their hands with soap and water. On 04/26/23 at 9:55 a.m., LPN #1 donned a pair of gloves, rolled Resident #222 onto their right side, then used a handful of sterile water soaked gauze and patted the resident's right buttock wound multiple times in no distinct order. LPN #1 then moved to the left buttock wound and used the same gauze to pat the wound several times. LPN #1 folded the same wet gauze in half and patted the surrounding tissue of both wounds all over in no particular order, then patted both wounds again and then patted the surrounding tissue crossing back and forth over both wound beds. On 04/26/23 at 9:58 a.m., LPN #1 changed their gloves, grabbed another stack of sterile water soaked gauze and began patting both the right and left buttock pressure ulcers, which were actively bleeding, with the same gauze. LPN #1 used their right gloved hand and scooped Triad cream out of the disposable cup on the table next to the resident. LPN #1 used the gloved hand to put Triad cream on the right buttock pressure ulcer, then left buttock pressure ulcer, then using the same gloved hand rubbed Triad cream in an up and down motion, crossing over both wounds back and forth, and rubbing over all of the surrounding tissue. LPN #1 failed to change their gloves or clean their hands after cleaning the wound prior to applying the Triad cream. On 04/26/23 at 10:01 a.m., LPN #1 removed their gloves, threw away dressing supplies, and washed their hands with soap and water. On 04/26/23 at 10:22 a.m., LPN #1 was asked the policy for changing gloves and cleaning hands during wound care. They stated they were to change gloves and wash hands when they were visibly soiled. They stated they would change gloves during a cream change also. LPN #1 stated they would change gloves before and during care, and in between dirty and clean supplies. On 04/26/23 at 10:23 a.m. LPN #1 was asked if they were doing anything else besides changing gloves. They stated they would also sanitize or wash their hands when changing gloves. LPN #1 acknowledged they did not change gloves or sanitize their hands after cleaning the wounds prior to applying Triad cream. LPN #1 stated the wounds were actively bleeding so they had to clean them again. On 04/26/23 at 10:27 a.m., LPN #1 was asked what the policy was for cleaning a residents wound. They stated they used sterile water to clean, then made sure the wound was dry, then placed cream on the wound. LPN #1 was asked to explain the reason they used moistened gauze and patted both of Resident #222 wounds multiple times and the surround tissue multiple times with the same gauze. LPN #1 stated they should have grabbed more gauze. On 04/26/23 at 10:29 a.m., LPN #1 was asked to explain the reason they used a gloved hand and placed Triad cream on both the right and left pressure ulcer then rubbed all over both wounds and surrounding tissue with the same gloved hand. LPN #1 stated they thought they could use the same gloved hand and rub everywhere even with open wounds. On 04/26/23 at 1:46 p.m., the DON was asked the policy for cleaning hands and changing gloves during wound care. They stated staff were to wash or sanitize hands/change gloves before providing resident care, after cleaning the wound, anytime they became visibly soiled, and after they applied the treatment to the wound. On 04/26/23 at 1:49 p.m., the DON was asked the policy for cleaning a resident's wound using sterile water and gauze. They stated they would take the moistened gauze and start in the center of the wound and wipe in a circular motion working from the center to the outside of the wound, then throw the gauze away. They stated staff should not go back and forth over the wound. On 04/26/23 at 1:51 p.m., the DON was asked the policy for applying Triad cream to more than one wound. They stated staff should complete the wound care process for one wound, then start the wound care process for the second wound. The DON stated they did not want to take the germs from one wound to the other.

Based on record review and interview, the facility failed to ensure: a. physician orders were in place for wound care and dressing changes, b. a surgical wound was assessed and monitored, and c. a resident was monitored as ordered for side effects related to a medication error for one (#269) of three sampled residents reviewed for wound care and medication errors. The Resident Census and Conditions of Residents report, dated 04/25/23, documented 143 residents resided in the facility. The ADON identified four residents with surgical wounds. Findings: A Dressing, Dry/Clean policy, revised September 2013, read in parts, .Verify there is a physician's order for this procedure .Check the treatment record .Assess the wound and surrounding skin for edema, redness drainage, tissue, healing progress and wound .The following should be recorded in the resident's medical record .wound appearance .the type of dressing used and wound care given .All assessment data . An Admission Assessment and Follow Up: Role of the Nurse policy, revised 09/17, read in parts, .The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident . Resident #269 had diagnoses which included, a fracture of the right femur, and atrial fibrillation. A hospital Operative Note, dated 03/30/23, read in part, .the skin incision were closed with staples . A hospital After Visit Summary, dated 04/03/23, read in parts, .Wound care .You may change your dressing as needed .after 14 days .you will come in and see us at our office .we will remove your sutures/staples . A Hospital Report, dated 04/03/23, read in parts, .Skin/Wound/Treatments Silverloin dressing [right] thigh . There was no instructions for a dressing change. A Physician Order, dated 04/03/23, did not contain any orders to perform wound care or dressing changes to the surgical site. A Clinical Admission Evaluation, dated 04/03/23 at 8:00 p.m., read in part .(R) Hip surgical site. Dressing intact . A SKIN OBSERVATION TOOL, dated 04/03/23 at 8:07 p.m., read in part, .(R)Hip surgical site . A skilled daily charting note, dated 04/04/23 at 12:46 a.m., did not contain any documentation related to the surgical site. A nurse Progress Note, dated 04/04/23 at 2:46 p.m., read in part, . Resident has drainage from [their] incision site. Called [their] surgeon .advised me to bring [the resident] in Wednesday at 9:00 a.m . An Occupational Therapy Treatment Encounter Note(s), dated 04/04/23 at 4:02 p.m., read in part, .COTA noticed patient wound on [their] RLE draining into the floor. COTA obtained the nurse who looked over the wound . A skilled daily charting note, dated 04/04/23 at 4:15 p.m., documented there was light discharge noted to the (R) hip dressing. An undated Physician's Progress Note, by the Surgeon, read in part, .some clear drainage .wound is non tender .concern for infection is low .will place on Bactrum[sic] .for 7 day as prevention . There were no orders to change the dressing. A skilled daily charting note, dated 04/04/23 at 7:26 p.m., did not contain any documentation the wound/dressing had been assessed. A skilled daily charting note, dated 04/05/23 at 12:29 a.m., did not contain any documentation the wound/dressing had been assessed. A skilled daily charting note, dated 04/05/23 at 9:31 p.m., did not contain any documentation the wound/dressing had been assessed. An incident report, dated 04/06/23, read in part, .During medication pass medication was administered to patient that belonged to someone else .[Name] NP notified new order received and noted for blood pressure and heart rate monitoring initiated for it to start every 15 minutes for 1 hour every 30 mins for 2 hours every hour for 4 hours and every 2 hours for remainder of the 24 hr . A Neurological Evaluation Flow Sheet, did not contain documentation Resident #269 had been monitored every two hours for the remainder of 24 hours as ordered by the nurse practitioner. A skilled daily charting note, dated 04/08/23 at 9:43 p.m., did not contain any documentation the wound/dressing had been assessed. A skilled daily charting note, dated 04/09/23 at 9:53 p.m., did not contain any documentation the wound/dressing had been assessed. There was no documentation a skilled nursing assessment had been completed on 04/11/23. On 04/27/23 at 8:55 a.m., the DON was asked to review the admission orders for Resident #269 and asked if there were any dressing changes ordered. The DON reviewed the admission orders and stated there were no dressing change orders. The DON stated, the resident was to see the surgeon after 14 days and change the dressing as needed, but these were discharge instructions from the hospital. On 04/27/23 at 8:58 a.m., the DON was shown the admission assessment and asked if there was documentation of the description of the wound and if it documented staples were in place. The DON and ADON reviewed the admission assessment and the ADON stated It just says right hip surgical site dressing was intact. The ADON stated, there was no assessment that documented there were staples in place. On 04/27/23 at 9:06 a.m., the DON was asked if there is an order to change the dressing. The DON stated, there was not a specific order to change the dressing. On 04/27/23 at 9:06 a.m., the DON was asked to explain the process for dressing changes with a new surgical resident. The DON stated, Sometimes the doctor does not want you messing with the dressing, we would have a specific order for that. The DON stated if they noted no orders for the surgical incision, the daily skilled note was monitoring the skin. The DON stated if there was a closed wound with no issues, then they monitored it on their daily skin assessment. The DON was asked if there was any documentation of the wound on the daily skilled notes from 04/04/23 to 04/10/23. The DON reviewed the documentation and stated staff had documented the drainage, and made an appointment. 04/27/23 at 9:23 a.m., LPN #5 was asked what the process was for monitoring surgical wound sites. They stated, We watch for drainage on the outside of the dressing, we don't typically remove surgical dressings. On 04/27/23 at 9:25 a.m., LPN #5 was shown the COTA note, dated 04/04/23, and asked if the dressing had been changed at that time. LPN #5 stated, I personally changed the dressing at that time. They were asked where it was documented the dressing had been changed. They stated in the progress note. The DON stated, LPN #1 had made a note about calling the surgeon. They were asked how did they know what dressing to use. They stated, the surgeon gave orders to use silver. LPN #5 stated they dressed the wound with silverlon. LPN #5 reviewed the progress notes and stated, they had not documented the dressing change or wound assessment. On 04/27/23 at 9:28 a.m., LPN #5 was asked what did the surgical site look like on 04/04/23. They stated, the wound had some redness, and the drainage was coming from the top of the wound. They stated there was some drainage, when pressure was applied. LPN #5 stated, I usually count the staples when I change a dressing but I didn't do that and don't have documentation of that. LPN #5 stated, When we turned [the resident] to the side [the resident] had more drainage. They were asked to describe the drainage. LPN #5 stated, It was tan tinged color drainage, not bright red, no odor noted. On 04/27/23 at 9:33 a.m., LPN #5 was asked when assessing skin integrity on the skilled notes does that mean overall skin. They stated, Yes. They were asked if the skilled assessment wound care portion would be where wound care was documented. They stated, not usually, unless there was an order. On 04/27/23 at 9:35 a.m., the DON was asked where would it be documented if the dressing had been changed and the wound had been assessed. The DON stated, it could be either a progress note or a skilled note. On 04/27/23 at 9:46 a.m., the DON was shown Resident #269's monitoring for neuro changes and asked if it had been completed as ordered. The DON started to review the documentation. On 04/27/23 at 9:50 a.m., the NP was asked if they had observed the surgical wound on admission. They stated, I don't observe wounds typically if there is a dressing. They were asked who oversees the surgical wound care of the residents. They stated internal medicine or the resident's surgeon. On 04/27/23 9:52 a.m., the DON was asked if the neuro checks had been completed as ordered. They stated It looks like they missed an hour and did not complete the end of it. On 04/27/23 at 9:59 a.m., the COTA note dated 04/10/23, was shown to the DON and asked if the wound had been assessed due to the increased pain reported by the resident during occupational therapy. LPN #5 stated, from what the nurse who was involved said, there was no drainage so they would not have touched the dressing. The DON stated an order was obtained for an ice pack. On 04/27/23 at 10:22 a.m., LPN #3 was asked if they had ever changed Resident #269's dressing. They stated, they changed it on 04/06/23 when the dressing got wet after a shower. They stated there was no redness, or drainage and the staples were intact. They stated when they sent the resident to the hospital on 04/11/23 they observed the dressing and it did not have any discharge. They were asked if they had documented the dressing change on the 6th. They stated, No. LPN #3 was asked what was their understanding for dressing changes. They stated, it depends on the order, if it says not to remove the dressing, they would monitor the dressing. They were asked what if there were no orders that addressed the wound. They stated, they would get an order. On 04/27/23 at 12:19 p.m., LPN #4 was asked if they had changed Resident #269's dressing. They stated, I did on 04/08/23. They were asked where was it documented. They stated, there was no documentation. LPN #4 was asked if they could recall what the wound looked like. They stated, It was a little red around the incision. They stated the dressing had started to come off. LPN #4 was asked if there was an order to change the dressing. They stated, the doctor was in the facility and gave an order to change it, but they had not put the order in the clinical health record. They were asked if that was a one time order. They stated, it was a one time order. They were asked where would they have documented the dressing change. They stated in the progress notes.

Based on record review and interview, the facility failed to ensure medications were administered as ordered for three (#62, 70 and #269) of three sampled residents reviewed for medication errors. The Resident Census and Conditions of Residents report, dated 04/25/23, documented 143 residents resided in the facility. Findings: An Adverse Consequences and Medication Errors policy, revised 04/2014, read in parts, .A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders .or accepted professional standards . 1. Resident #269 had diagnoses which included, a fracture of the right femur, and atrial fibrillation. An incident report, dated 04/06/23, read in part, .During medication pass medication was administered to patient that belonged to someone else . On 04/26/23 at 11:06 a.m., ACMA #4 was asked to explain what happened when Resident #269 had been administered another resident's medications. They stated, I was training on the cart, I popped the medications and asked CMA #5 to give the medications to Resident #57. They stated, CMA #5 gave Resident #57's medications to Resident #269. They were asked how often they had trained new staff on the medication cart. They stated, that was the first time. They were asked what did they do when they realized what had been done. ACMA #4 stated, they notified the nurse. 2. Resident #70 had diagnoses which included congestive heart failure and pain. An Incident Report, dated 04/06/23 at 6:34 p.m., read in parts, .Medication aid stated [they] give pt other pt's medication by mistake (diltiazem and lasix) .4/26/23 .CMA .came to this nurse to report medication error, gave medications to wrong patient . On 04/27/23 at 8:49 a.m., the DON was asked to explain what happened when Resident #70 had been administered another residents medications. They stated, it was an agency CMA #6 and they no longer use CMA #6 because they had made another mistake. 3. Resident #62 had diagnoses which included, type two diabetes mellitus, pain, dementia, vitamin d deficiency and schizoaffective disorder. An Incident report, dated 04/07/23, read in parts, .Resident pm medication on 4-7-23 was omitted .4/26/23 .CMA failed to administer medication . Resident #3's MAR had no documentation the following medications had been administered on 04/07/23. Atorvastatin Calcium 20 mg one tablet, Melatonin 5 mg one tablet, Baclofen 10 mg one tablet, and Fluticasone Proprionate Suspension 50 MCG/ACT one spray in each nostril. On 04/27/23 at 8:54 a.m., the DON was asked if Resident #62's medications had been omitted on 04/07/23. They stated, Yes.

Based on record review and interview, the facility failed to ensure residents were offered the choice to formulate advance directives and a code status had been determined for one (#15) of 32 sampled residents reviewed for advanced directives and code status. The Resident Census and Conditions of Residents report, dated 04/25/23, documented 143 residents resided in the facility. Findings: An Advance Directives policy, revised December 2016, read in parts, .Upon admission, the resident will be provided with written information concerning the right to .formulate an advance directive if he or she chooses to do so .Written information will include a description of the facility's policies to implement advance directives .Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record .If the resident indicated that he or she has not established advance directives, the facility will offer assistance in establishing advance directives . Resident #15 was admitted to the facility on [DATE]. There was no documentation the resident and/or their representative were offered the choice to formulate an advance directive. Resident #15 had code status documented as both DNR and full code. On 04/25/23 at 3:52 p.m., the DON was asked to provide documentation the resident and/or their representative was offered the choice to formulate an advance directive. On 04/25/23 at 4:14 p.m., the DON stated they were unable to locate the advance directive acknowledgement form. On 04/26/23 at 8:43 a.m., the DON was asked when advance directives were offered to the residents. They stated upon admission they would ask if the resident would like to fill out an advanced directive. They stated the advanced directive acknowledgement form to accept or decline was in the admission packet and was scanned into the residents' chart. On 04/26/23 at 8:45 a.m., the DON stated Resident #15's code status documented both DNR and full code.

Based on record review and interview the facility failed to ensure (CMA #5) had completed a clinical skills check prior to passing medications for one (#269) of three sampled residents reviewed for medication errors. The Resident Census and Conditions of Residents report, dated 04/25/23, documented 143 residents resided in the facility. Findings: An Adverse Consequences and Medication Errors policy, revised 04/2014, read in parts, .A 'medication error' is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders .or accepted professional standards . Resident #269 had diagnoses which included, a fracture of the right femur, and atrial fibrillation. An Incident report, dated 04/06/23, read in part, .During medication pass medication was administered to patient that belonged to someone else .notified new order received and noted for blood pressure and heart rate monitoring initiated . CMA #5's Medication Pass Observation checklist, was completed 04/07/23. On 04/26/23 at 11:06 a.m., ACMA #4 was asked to explain what happened when Resident #269 had been administered another resident's medications. They stated, I was training on the cart, I popped the medications and asked CMA #5 to give the medications to Resident #57. They stated, CMA #5 administered the medications to Resident #269. They were asked how often they had trained new staff on the medication cart. They stated, that was the first time. They were asked what did they do when they realized what had been done. ACMA #4 stated, they notified the nurse. On 04/27/23 at 1:46 p.m., the DON was asked when was it determined staff were competent to pass medication. They stated, It is case by case, we have not been writing down med pass observations and documenting that process. They were asked if CMA #5 had a skills checklist prior to passing medications. They stated, No. The DON was asked if the skills checklist was completed after the medication error on 04/06/23. They stated, Yes. 41872

Based on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed and/or implemented for two (#62 and #254) of three residents reviewed for new admissions. The Director of Nursing (DON) reported 66 residents were admitted to the facility in the previous 30 days. Findings: 1. Resident (Res) #62 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record was reviewed and contained no baseline care plan to address the resident's recent fracture, pain, or the fact that the resident was a smoker. On 02/16/22 at 10:00 a.m., Res #62 reported she was a smoker and staff allowed her to smoke outside independently. On 02/17/22 at 1:06 p.m., the DON reported she was unable to find a baseline care plan for the resident. On 02/17/22 at 3:04 p.m., the Minimum Data Set (MDS) coordinator reported Res #62 did not have a baseline care plan. She reported the resident was admitted on a Thursday, the baseline care plan would have been due over the weekend, and the person designated to complete the baseline care plan did not work due to an emergency. 2. Resident (Res) #254 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Summary, dated 02/10/22 at 6:53 p.m., for Res #254 read in part .[CONDITION(S)] fistula L arm paper tape noted and removed +bruit and + thrill with [CONDITION(S)] treatment today. The resident's Baseline Care Plan, dated 02/10/22, contained no documentation regarding [CONDITION(S)] treatments or dependence of renal [CONDITION(S)]. On 02/17/22 at 12:55 p.m., the Assistant Director of Nursing (ADON) reported [CONDITION(S)] should have been included on the baseline care plan.

On [DATE] at 12:22 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health regarding the facility's failure to accurately transcribe the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #9. This resulted in a significant medication error and the resident was subsequently transferred to the hospital and later died due to complications of [MEDICATION(S)] toxcity. At 1:19 p.m., the facility administrator and the DON were informed of the IJ situation related to the facility's failure to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #9. A plan of removal for the IJ situation was requested. At 5:49 p.m., the administrator provided the survey team with an acceptable written plan of removal. The facility's plan of removal, dated [DATE], documented the following: .Plan for Removal of IJ 1-- Review and revision of current policy regarding admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2 -- Inservice admission nurses, unit managers and ADON regarding new policy for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3 -- Inservice admissions nurses and unit managers regarding general procedures for reduction of medication errors, with particular focus on accurate transcription of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4 -- Inservice ,d+[DATE] & ,d+[DATE] staff on medication errors (to be completed by end of day [DATE]) 5 -- In process of auditing any black box or dosage warnings for all current residents. Ensure any issues are resolved by contacting physician for clarification or correction as needed. This will be accomplished by end of day [DATE]. In process: Any staff on vacation or otherwise on extended leave will be inserviced regarding medication errors and transcription errors prior to being allowed to return to work. In process today [DATE]: Inservice all LPN/RN/CMA staff on reduction of medication errors. Within 10 days: Design and implement training package for all new hires regarding accuracy of transcribed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Within 10 days: Ongoing QAPI PIP as a means to gather and process information regarding compliance with new admissions policy. Within 10 days: Ensure continuing and ongoing education to licensed staff and CMAs regarding reduction of medication errors and accurate transcription of physicians orders . A review of the facility's audit forms and training logs documented the facility had completed the audits and trainings by [DATE] at 3:37 p.m. On [DATE] at 3:37 p.m., the administrator was informed the IJ had been removed as of [DATE] at 3:37 p.m. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to follow the physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] #9. This resulted in an IJ situation. This had the potential to affect all 127 residents residing in the facility. Findings: Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's hospital discharge order, dated [DATE], documented .[MEDICATION(S)] 10 mg Tablet Commonly known as [MEDICATION(S)] Take 20 mg by mouth every seven days . The facility's Residents Physicians Order Summary, dated [DATE], documented .[MEDICATION(S)] Sodium Tablet 10 MG Give 2 tablet by mouth in the morning .for 7 Days . The Physicians Order Summary had been cosigned by RN # 1 and LPN #1 and dated [DATE]. An order note, dated [DATE] at 5:45 p.m., documented, .The order you have entered [MEDICATION(S)] Sodium Tablet 10 MG Give 2 tablet by mouth in the morning .for 7 Days Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction . A Black Box Warning Detail documented, .[MEDICATION(S)] should be used only by health care providers whose knowledge and experience include the use of antimetabolite therapy. Because of the possibility of serious toxic reactions, which can be fatal, use [MEDICATION(S)] only in life-threatening neoplastic diseases, or in patients with psoriasis or [CONDITION(S)] (RA) with severe, recalcitrant, disabling disease that is not adequately responsive to other forms of therapy. Deaths have been reported with use of [MEDICATION(S)] in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patients should be informed by their health care provider of the risks involved and be under a health care provider's care throughout therapy . A copy of the Black Box Warning detail had been made and a hand written note on the copy documented the information had been faxed to [physicians name deleted] on [DATE]. The note documented, Call Hall 5 charge nurse for changes . and was signed by RN #1. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. An order note, dated [DATE] at 5:45 p.m., documented, .The system has identified this order as being outside of the recommended dose for this drug . A Drug Overdose Detail documented, .[MEDICATION(S)] Sodium Tablet 10 MG Min Age (Inclusive): Max Age (Exclusive): Min Dose: Max Dose: 15 65 0.1 tablet 0.43 tablet 65+ 0.1 tablet 0.43 tablet . A copy of the Drug Overdose Detail had been made and a hand written note on the copy documented the information had been faxed to [physicians name deleted] on [DATE]. The note documented, Call .Hall 5 charge nurse for changes . and was signed by RN #1. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. A Drug Regimen Review for Section N, dated [DATE] at 6:44 p.m., documented, . 1. Did a complete drug regimen review identify potential clinically significant medication issues? . The Yes - Issues found during review box was marked. The Drug Regimen Review for Section N, dated [DATE] at 6:44 p.m., also documented, .2. Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? . The Yes box was marked. The form documented RN#1 as the person completing this section and documented LPN #1 as the second signature for admission/hospital discharge orders reconciliation. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. The resident's Medication Administration Record (MAR) documented the resident had been administered two 10 mg [MEDICATION(S)] sodium tablets by mouth in the morning from [DATE] through [DATE]. A nurse's note, dated [DATE] at 6:30 p.m., documented, .Patient is very hard to arouse. Sternal rub given, patient did not open eyes. BP ,d+[DATE], Pulse 145, Resp 18, O2 85%. Oxygen placed on patient and [emergency medical service name deleted] was called. [Emergency medical service name deleted] arrived. Pulse 200, BP ,d+[DATE]. Patient in a-fib RVR. Cardioversion given. Pulse down to 88 at this time. Patient more alert. Face Sheet, Order summary, recent labs, and recent hospital paperwork sent with [emergency medical service name deleted]. Patient being transferred to [hospital name deleted]. Patient son notified. Call sister with no answer . A hospital physician's note, dated [DATE] at 10:21 p.m., documented, .Per MAR send [sic] from [NAME], patient is taking 20 mg DAILY for 7 days only starting on [DATE] and stopping on [DATE]; was previously taking 20 mg WEEKLY. Unclear if this is an error. We will hold off further MTX given kidney dysfunction leukopenia. Need further clarification before administration MTX . A hospital discharge summary, dated [DATE] at 10:45 p.m., documented, .Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .AKI (acute kidney injury) .Patient was recently admitted to [hospital name deleted] about a week prior (,d+[DATE]-,d+[DATE]) for altered mental status, urinary tract infection and rhabdomyolysis and she was treated with [MEDICATION(S)] and IV hydration. Mental status and kidney function improved. Patient was then discharged to [facility name deleted] rehab. (Emergency medical service name deleted) was called due to patient was found to be [CONDITION(S)]. Per [emergency medical service name deleted], patient heart rate was found to be in 200s upon arrival. Patient was cardioverted with 100 J. On arrival to ER, patient heart rate 85. She went into [CONDITION(S)] with RVR again shortly after arrival. Cardiology was consulted from ER .Hospitalist called for admission. Patient was admitted to ICU .She was also found to have pancytopenia from [MEDICATION(S)] and we were following her labs daily and transfusing. She then developed acute respiratory failure due to [CONDITION(S)] and hemopyptysis and was intubated and placed on mechanical ventilation .Patient was transferred to inpatient hospice in the late hours of [DATE] . A hospice nurse's note, dated [DATE] at 11:00 p.m., documented, Pt [Resident #9 name deleted] arrived via stretcher [medical transport service name deleted] from (hospital named deleted) for hospice diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Pt was at [facility name deleted] Nursing home and was accidentally given [MEDICATION(S)] every day instead of once a week .Pt is DNR . A hospice nurse's note, dated [DATE] at 12:07 a.m., documented, Pt [resident #9 name deleted] passed away peacefully .from complications of pancytopenia secondary to [MEDICATION(S)] overdose .Medical examiner notified via phone regarding pt death. Pt. will be taken in to Medical examiner's office. Report given to [medical examiner's name deleted] ME on call . The State Medical Examiner's Report of Autopsy, for resident #9, dated [DATE] at 1:00 p.m., documented, .CAUSE OF DEATH: COMPLICATIONS OF [MEDICATION(S)] TOXICITY . The State of Oklahoma Certificate of Death, for resident #9, received [DATE] and certified [DATE], documented, .CAUSE OF DEATH .IMMEDIATE CAUSE .COMPLICATIONS OF [MEDICATION(S)] TOXICITY . On [DATE] at 9:40 a.m., the Admitting Nurse (AN) was asked, who transcribed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she did not know who did it on her days off. The AN was asked how she ensured orders were accurately transcribed. She stated after she inputted them they were checked by another nurse. She stated LPN #1 was the person that usually checked with her. The AN was asked what she did if she had a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked what she did if she received a Black Box warning from the pharmacy system. She stated she would print off the warning and fax it to the physician. She stated she put a note on the sheet for the physician to contact the floor nurse if they wished to make any changes. She stated, Honestly, I can't tell you if they do or not. The AN was asked what she should know before administering medication to a resident. She stated potential side effects, the reason for administration, allergies, if it was the right person, the right dose, the right route and the right time. The AN was asked if she should know the recommended dose of a medication that was being administered. She stated she thought it was a good idea to know but she did not know if the CMAs knew or not. She stated she hoped they would have a general idea. She stated PCC notified her if a dosage was out of range. She was asked what she did. She stated she would call the physician. The AN was asked if there was a question about the dose of a medication, was information regarding the recommended dose easily accessible. She stated, Yes. She stated if she could not find any other way, she would call the pharmacy. She stated she had good resources. At 10:02 a.m., RN #1 was asked who transcribed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she sometimes went in to help her. RN #1 was asked how she ensured orders were accurately transcribed. She stated they usually had a double check with another nurse. RN#1 was asked what she did if she had a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked what she did if she received a Black Box warning from the pharmacy system. She stated they usually faxed them to the physician and hopefully the physician would see the Black Box warning. She was asked if anyone followed up on the med warnings faxed to the physicians. She stated she did not know. RN #1 was asked what she should know before administering medication to a resident. She stated what the medication was for, the dose, the reason and the correct route. RN #1 was asked if she should know the recommended dose of a medication that was being administered. She stated, Yes. RN #1 was asked if there was a question about the dose of a medication, was information regarding the recommended dose easily accessible. She stated she would usually look it up and notify the physician if there was a question about the dose. She was asked if she documented when she called the physician about a medication. She stated, Usually no. RN #1 was asked if she was one of the nurses who did the order transcription for resident #9 when she had been admitted to the facility on [DATE]. She stated, Yes. She was asked to review the physician's hospital discharge orders for that date. She reviewed the orders and was asked what the order was for [MEDICATION(S)]. She stated 20 milligrams by mouth every seven days. RN #1 was asked to review the facility's Residents Physicians Order Summary, dated [DATE]. She reviewed the orders and was asked what it documented as the order for [MEDICATION(S)]. She stated a two ten milligram tablets by mouth for seven days. She was asked if this was the correct order. She stated, No. RN #1 was asked if someone had verified the order with her. She stated LPN #1. RN #1 was asked if there had been a Black Box warning for the metotrexate. She stated there had been. She was asked what the warning had said. She stated that it could be fatal. RN #1 was asked what she had done about the Black Box warning. She stated she had faxed it to (physician's name deleted). She was asked if he had responded back. She stated, No or I don't know. She was asked if she had followed up with the physician. She stated, No. She was asked if someone should have followed up. She stated yes they should have. RN #1 was asked if there had been a system warning about about the dosage of the [MEDICATION(S)]. She stated, Yes. She was asked what it said. She stated it said it was outside the recommended dose. She was asked if this information was faxed to the physician. She stated it should have been, that it usually was. RN #1 was asked if she had received any follow-up regarding the [MEDICATION(S)]. She stated, No. She was asked if someone had followed up with the physician. She stated, No. RN #1 was asked if medications had been given appropriately according to orders from the physician. She stated, Not in this case, no. At 10:20 a.m., LPN #1 was asked was asked who transcribed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 was asked how she ensured orders were accurately transcribed. She stated after the orders were put in PCC she checked them off from transcription from the discharge order and the MAR and she checked them against each. LPN#1 was asked what she did if she had a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked what she did if she received a Black Box warning from the pharmacy system. She stated she would print off the Black Box warning and send it as a fax to the physician. She stated they would write on it to communicate any changes to the charge nurse. She was asked if follow-up would be done. She stated she did not have an answer for that. LPN #1 was asked what she should know before administering medication to a resident. She stated she needed to make sure the five rights were there. LPN #1 was asked if she should know the recommended dose of a medication that was being administered. She stated, Yes, you should. LPN #1 was asked if there was a question about the dose of a medication, was information regarding the recommended dose easily accessible. She stated they could call the physician. She was asked if she documented when she called the physician about a medication. She stated yes in the chart. LPN #1 was asked if she was one of the nurses who did the order transcription for resident #9 when she had been admitted to the facility on [DATE]. She stated, Yes. She was asked to review the physician's hospital discharge orders for that date. She reviewed the orders and was asked what the order was for [MEDICATION(S)]. She stated 10 milligram tablet two tablets 20 milligrams by mouth every seven days. LPN #1 was asked to review the facility's Residents Physicians Order Summary, dated [DATE]. She reviewed the orders and was asked what it documented as the order for [MEDICATION(S)]. She stated 10 milligram tablet give two tablets by mouth in the morning for seven days. She was asked if this was the correct order. She stated, No, sir, it's not. She was asked if someone had verified the order with her. She stated RN #1. LPN #1 was asked if there had been a Black Box warning for the [MEDICATION(S)]. She stated there had been. She was asked what the warning had said. She stated there could be a possibility for serious toxicity. LPN #1 was asked what she had done about the Black Box warning. She stated the nurse had called the charge nurse and she had faxed it to (physician's name deleted). She was asked if anyone had followed up with the physician. She stated, I do not know. LPN #1 was asked if there had been a system warning about the dosage of the [MEDICATION(S)]. She stated, Yes. She stated the system had identified the dose as being over the recommended dose. She was asked what had been done regarding this dosage warning. She stated it had been sent to the physician. LPN #1 was asked if she had received any follow-up regarding the [MEDICATION(S)]. She stated, I don't have an answer for that. She was asked if someone should have followed up with the physician. She stated, Yes. LPN #1 was asked if medications for resident #9 had been entered into the system incorrectly. She stated one of the medications had been transcribed wrong. At 11:05 a.m., the DON was asked who transcribed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON #1 was asked how they ensured orders were accurately transcribed. He stated there was a second check with another nurse. The DON was asked what was done if there was a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He was asked what was done if they received a Black Box warning from the pharmacy system. He stated the same. The DON was asked what he should know before administering medication to a resident. He stated the five rights and knowing the correct order in the MAR. The DON was asked if those administering medication should know the recommended dose of a medication that was being administered. He stated, I don't think the CMAs, but a nurse would, should. The DON was asked if there was a question about the dose of a medication, was information regarding the recommended dosage easily accessible. He stated staff could ask him or the ADON, they could access the information on the computer and they had the pharmacy's phone number. The DON was asked to review the physician's hospital discharge orders for resident #9 for [DATE]. He reviewed the orders and was asked what the order was for [MEDICATION(S)]. He stated 20 milligrams by mouth every seven days. The DON was asked to review the facility's Residents Physicians Order Summary, dated [DATE]. He reviewed the orders and was asked what it documented as the order for [MEDICATION(S)]. He stated give two tablets by mouth in the morning for ischemia for seven days. He was asked if this was the correct order. He stated, No, it is not. The DON was asked if the order had been verified by more than one person. He stated, Yes. The DON was asked if there had been a Black Box warning for the [MEDICATION(S)]. He stated, Yes. He was asked what had been done about the Black Box warning. He stated the information had been faxed to the physician. He was asked if there had been follow-up with the physician. He stated, No. He was asked if there should have follow-up. He stated, Yes. The DON was asked if there had been a system warning about the dosage of the [MEDICATION(S)]. He stated, Yes. He was asked what it said. He stated it said the dose was out of range. The DON was asked if the resident had received medication per the physician's discharge order. He stated, It was not.

On [DATE] at 12:22 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health regarding the facility's failure to accurately transcribe the physician's orders, recognize improper medication dosages, follow up on black box warnings, and dosage warnings for the medication [MEDICATION(S)] for resident #9. The resident was subsequently transferred to the hospital and later died due to complications of [MEDICATION(S)] toxcity. At 1:19 p.m., the facility administrator and the DON were informed of the IJ situation related to the facility's failure to follow the physician's orders for the dispensing of the medication [MEDICATION(S)] for resident #9. A plan of removal for the IJ situation was requested. At 5:49 p.m., the administrator provided the survey team with an acceptable written plan of removal. The facility's plan of removal, dated [DATE], documented the following: .Plan for Removal of IJ 1-- Review and revision of current policy regarding admission orders. (Completed [DATE]) 2 -- Inservice admission nurses, unit managers and ADON regarding new policy for admission orders (see attached). (Completed [DATE]) 3 -- Inservice admissions nurses and unit managers regarding general procedures for reduction of medication errors, with particular focus on accurate transcription of admission orders (Completed [DATE]) 4 -- Inservice ,d+[DATE] & ,d+[DATE] staff on medication errors (to be completed by end of day [DATE]) 5 -- In process of auditing any black box or dosage warnings for all current residents. Ensure any issues are resolved by contacting physician for clarification or correction as needed. This will be accomplished by end of day [DATE]. In process: Any staff on vacation or otherwise on extended leave will be inserviced regarding medication errors and transcription errors prior to being allowed to return to work. In process today [DATE]: Inservice all LPN/RN/CMA staff on reduction of medication errors. Within 10 days: Design and implement training package for all new hires regarding accuracy of transcribed physician's orders. Within 10 days: Ongoing QAPI PIP as a means to gather and process information regarding compliance with new admissions policy. Within 10 days: Ensure continuing and ongoing education to licensed staff and CMAs regarding reduction of medication errors and accurate transcription of physicians orders . A review of the facility's audit forms and training logs documented the facility had completed the audits and trainings by [DATE] at 3:37 p.m. On [DATE] at 3:37 p.m., the administrator was informed the IJ had been removed as of [DATE] at 3:37 p.m. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to: ~ accurately transcribe the physician's admission orders, recognize improper medication dosages, follow up on black box warnings, and dosage warnings the medication [MEDICATION(S)] for resident #9. This resulted in an IJ situation. ~ ensure medications were available to be administered as ordered by the physician for one (#2) of two sampled residents who were reviewed for pharmacy services. This had the potential to affect all 127 residents who currently resided in the facility. Findings: 1. Resident #9 had diagnoses which included traumatic ischemia of muscle, type 2 diabetes and [CONDITION(S)]. A physician's hospital discharge order, dated [DATE], documented .[MEDICATION(S)] 10 mg Tablet Commonly known as [MEDICATION(S)] Take 20 mg by mouth every seven days . The facility's Residents Physicians Order Summary, dated [DATE], documented .[MEDICATION(S)] Sodium Tablet 10 MG Give 2 tablet by mouth in the morning .for 7 Days . The Physicians Order Summary had been cosigned by RN # 1 and LPN #1 and dated [DATE]. An order note, dated [DATE] at 5:45 p.m., documented, .The order you have entered [MEDICATION(S)] Sodium Tablet 10 MG Give 2 tablet by mouth in the morning .for 7 Days Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction . A Black Box Warning Detail documented, .[MEDICATION(S)] should be used only by health care providers whose knowledge and experience include the use of antimetabolite therapy. Because of the possibility of serious toxic reactions, which can be fatal, use [MEDICATION(S)] only in life-threatening neoplastic diseases, or in patients with psoriasis or [CONDITION(S)] (RA) with severe, recalcitrant, disabling disease that is not adequately responsive to other forms of therapy. Deaths have been reported with use of [MEDICATION(S)] in the treatment of malignancy, psoriasis, and RA. Closely monitor patients for bone marrow, liver, lung, and kidney toxicities. Patients should be informed by their health care provider of the risks involved and be under a health care provider's care throughout therapy . A copy of the Black Box Warning detail had been made and a hand written note on the copy documented the information had been faxed to [physicians name deleted] on [DATE]. The note documented, Call Hall 5 charge nurse for changes . and was signed by RN #1. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. An order note, dated [DATE] at 5:45 p.m., documented, .The system has identified this order as being outside of the recommended dose for this drug . A Drug Overdose Detail documented, .[MEDICATION(S)] Sodium Tablet 10 MG Min Age (Inclusive): Max Age (Exclusive): Min Dose: Max Dose: 15 65 0.1 tablet 0.43 tablet 65+ 0.1 tablet 0.43 tablet . A copy of the Drug Overdose Detail had been made and a hand written note on the copy documented the information had been faxed to [physicians name deleted] on [DATE]. The note documented, Call .Hall 5 charge nurse for changes . and was signed by RN #1. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. A Drug Regimen Review for Section N, dated [DATE] at 6:44 p.m., documented, . 1. Did a complete drug regimen review identify potential clinically significant medication issues? . The Yes - Issues found during review box was marked. The Drug Regimen Review for Section N, dated [DATE] at 6:44 p.m., also documented, .2. Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? . The Yes box was marked. The form documented RN#1 as the person completing this section and documented LPN #1 as the second signature for admission/hospital discharge orders reconciliation. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. The resident's Medication Administration Record (MAR) documented the resident had been administered two 10 mg [MEDICATION(S)] sodium tablets by mouth in the morning from [DATE] through [DATE]. A nurse's note, dated [DATE] at 6:30 p.m., documented, .Patient is very hard to arouse. Sternal rub given, patient did not open eyes. BP ,d+[DATE], Pulse 145, Resp 18, O2 85%. Oxygen placed on patient and [emergency medical service name deleted] was called. [Emergency medical service name deleted] arrived. Pulse 200, BP ,d+[DATE]. Patient in a-fib RVR. Cardioversion given. Pulse down to 88 at this time. Patient more alert. Face Sheet, Order summary, recent labs, and recent hospital paperwork sent with [emergency medical service name deleted]. Patient being transferred to [hospital name deleted]. Patient son notified. Call sister with no answer . A hospital physician's note, dated [DATE] at 10:21 p.m., documented, .Per MAR send [sic] from [NAME], patient is taking 20 mg DAILY for 7 days only starting on [DATE] and stopping on [DATE]; was previously taking 20 mg WEEKLY. Unclear if this is an error. We will hold off further MTX given kidney dysfunction leukopenia. Need further clarification before administration MTX . A hospital discharge summary, dated [DATE] at 10:45 p.m., documented, .Discharge Diagnoses: Active Hospital Problems Diagnosis .Principal - [CONDITION(S)] with RVR .AKI (acute kidney injury) .Patient was recently admitted to [hospital name deleted] about a week prior (,d+[DATE]-,d+[DATE]) for altered mental status, urinary tract infection and rhabdomyolysis and she was treated with [MEDICATION(S)] and IV hydration. Mental status and kidney function improved. Patient was then discharged to [facility name deleted] rehab. (Emergency medical service name deleted) was called due to patient was found to be [CONDITION(S)]. Per [emergency medical service name deleted], patient heart rate was found to be in 200s upon arrival. Patient was cardioverted with 100 J. On arrival to ER, patient heart rate 85. She went into [CONDITION(S)] with RVR again shortly after arrival. Cardiology was consulted from ER .Hospitalist called for admission. Patient was admitted to ICU .She was also found to have pancytopenia from [MEDICATION(S)] and we were following her labs daily and transfusing. She then developed acute respiratory failure due to [CONDITION(S)] and hemopyptysis and was intubated and placed on mechanical ventilation .Patient was transferred to inpatient hospice in the late hours of [DATE] . A hospice nurse's note, dated [DATE] at 11:00 p.m., documented, Pt [Resident #9 name deleted] arrived via stretcher [medical transport service name deleted] from (hospital named deleted) for hospice diagnosis of Pancytopenia secondary to [MEDICATION(S)] overdose. Pt was at [facility name deleted] Nursing home and was accidentally given [MEDICATION(S)] every day instead of once a week .Pt is DNR . A hospice nurse's note, dated [DATE] at 12:07 a.m., documented, Pt [resident #9 name deleted] passed away peacefully .from complications of pancytopenia secondary to [MEDICATION(S)] overdose .Medical examiner notified via phone regarding pt death. Pt. will be taken in to Medical examiner's office. Report given to [medical examiner's name deleted] ME on call . The State Medical Examiner's Report of Autopsy, for resident #9, dated [DATE] at 1:00 p.m., documented, .CAUSE OF DEATH: COMPLICATIONS OF [MEDICATION(S)] TOXICITY . The State of Oklahoma Certificate of Death, for resident #9, received [DATE] and certified [DATE], documented, .CAUSE OF DEATH .IMMEDIATE CAUSE .COMPLICATIONS OF [MEDICATION(S)] TOXICITY . On [DATE] at 9:40 a.m., the Admitting Nurse (AN) was asked, who transcribed physician orders for residents on admission. She stated she usually did. She stated she did not know who did it on her days off. The AN was asked how she ensured orders were accurately transcribed. She stated after she inputted them they were checked by another nurse. She stated LPN #1 was the person that usually checked with her. The AN was asked what she did if she had a question or concern about a physician's order. She stated she called the physician to get clarification. She was asked what she did if she received a Black Box warning from the pharmacy system. She stated she would print off the warning and fax it to the physician. She stated she put a note on the sheet for the physician to contact the floor nurse if they wished to make any changes. She stated, Honestly, I can't tell you if they do or not. The AN was asked what she should know before administering medication to a resident. She stated potential side effects, the reason for administration, allergies, if it was the right person, the right dose, the right route and the right time. The AN was asked if she should know the recommended dose of a medication that was being administered. She stated she thought it was a good idea to know but she did not know if the CMAs knew or not. She stated she hoped they would have a general idea. She stated PCC notified her if a dosage was out of range. She was asked what she did. She stated she would call the physician. The AN was asked if there was a question about the dose of a medication, was information regarding the recommended dose easily accessible. She stated, Yes. She stated if she could not find any other way, she would call the pharmacy. She stated she had good resources. At 10:02 a.m., RN #1 was asked who transcribed physician orders for residents on admission. She stated the AN usually did. She stated she sometimes went in to help her. RN #1 was asked how she ensured orders were accurately transcribed. She stated they usually had a double check with another nurse. RN#1 was asked what she did if she had a question or concern about a physician's order. She stated she usually called the physician. She was asked what she did if she received a Black Box warning from the pharmacy system. She stated they usually faxed them to the physician and hopefully the physician would see the Black Box warning. She was asked if anyone followed up on the med warnings faxed to the physicians. She stated she did not know. RN #1 was asked what she should know before administering medication to a resident. She stated what the medication was for, the dose, the reason and the correct route. RN #1 was asked if she should know the recommended dose of a medication that was being administered. She stated, Yes. RN #1 was asked if there was a question about the dose of a medication, was information regarding the recommended dose easily accessible. She stated she would usually look it up and notify the physician if there was a question about the dose. She was asked if she documented when she called the physician about a medication. She stated, Usually no. RN #1 was asked if she was one of the nurses who did the order transcription for resident #9 when she had been admitted to the facility on [DATE]. She stated, Yes. She was asked to review the physician's hospital discharge orders for that date. She reviewed the orders and was asked what the order was for [MEDICATION(S)]. She stated 20 milligrams by mouth every seven days. RN #1 was asked to review the facility's Residents Physicians Order Summary, dated [DATE]. She reviewed the orders and was asked what it documented as the order for [MEDICATION(S)]. She stated a two ten milligram tablets by mouth for seven days. She was asked if this was the correct order. She stated, No. RN #1 was asked if someone had verified the order with her. She stated LPN #1. RN #1 was asked if there had been a Black Box warning for the metotrexate. She stated there had been. She was asked what the warning had said. She stated that it could be fatal. RN #1 was asked what she had done about the Black Box warning. She stated she had faxed it to (physician's name deleted). She was asked if he had responded back. She stated, No or I don't know. She was asked if she had followed up with the physician. She stated, No. She was asked if someone should have followed up. She stated yes they should have. RN #1 was asked if there had been a system warning about about the dosage of the [MEDICATION(S)]. She stated, Yes. She was asked what it said. She stated it said it was outside the recommended dose. She was asked if this information was faxed to the physician. She stated it should have been, that it usually was. RN #1 was asked if she had received any follow-up regarding the [MEDICATION(S)]. She stated, No. She was asked if someone had followed up with the physician. She stated, No. RN #1 was asked if medications had been given appropriately according to orders from the physician. She stated, Not in this case, no. At 10:20 a.m., LPN #1 was asked was asked who transcribed physician orders for residents on admission. She stated the AN. LPN #1 was asked how she ensured orders were accurately transcribed. She stated after the orders were put in PCC she checked them off from transcription from the discharge order and the MAR and she checked them against each. LPN#1 was asked what she did if she had a question or concern about a physician's order. She stated she would call the physician. She was asked what she did if she received a Black Box warning from the pharmacy system. She stated she would print off the Black Box warning and send it as a fax to the physician. She stated they would write on it to communicate any changes to the charge nurse. She was asked if follow-up would be done. She stated she did not have an answer for that. LPN #1 was asked what she should know before administering medication to a resident. She stated she needed to make sure the five rights were there. LPN #1 was asked if she should know the recommended dose of a medication that was being administered. She stated, Yes, you should. LPN #1 was asked if there was a question about the dose of a medication, was information regarding the recommended dose easily accessible. She stated they could call the physician. She was asked if she documented when she called the physician about a medication. She stated yes in the chart. LPN #1 was asked if she was one of the nurses who did the order transcription for resident #9 when she had been admitted to the facility on [DATE]. She stated, Yes. She was asked to review the physician's hospital discharge orders for that date. She reviewed the orders and was asked what the order was for [MEDICATION(S)]. She stated 10 milligram tablet two tablets 20 milligrams by mouth every seven days. LPN #1 was asked to review the facility's Residents Physicians Order Summary, dated [DATE]. She reviewed the orders and was asked what it documented as the order for [MEDICATION(S)]. She stated 10 milligram tablet give two tablets by mouth in the morning for seven days. She was asked if this was the correct order. She stated, No, sir, it's not. She was asked if someone had verified the order with her. She stated RN #1. LPN #1 was asked if there had been a Black Box warning for the [MEDICATION(S)]. She stated there had been. She was asked what the warning had said. She stated there could be a possibility for serious toxicity. LPN #1 was asked what she had done about the Black Box warning. She stated the nurse had called the charge nurse and she had faxed it to (physician's name deleted). She was asked if anyone had followed up with the physician. She stated, I do not know. LPN #1 was asked if there had been a system warning about the dosage of the [MEDICATION(S)]. She stated, Yes. She stated the system had identified the dose as being over the recommended dose. She was asked what had been done regarding this dosage warning. She stated it had been sent to the physician. LPN #1 was asked if she had received any follow-up regarding the [MEDICATION(S)]. She stated, I don't have an answer for that. She was asked if someone should have followed up with the physician. She stated, Yes. LPN #1 was asked if medications for resident #9 had been entered into the system incorrectly. She stated one of the medications had been transcribed wrong. At 11:05 a.m., the DON was asked who transcribed physician orders for residents on admission. He stated now it was the AN's primary job. The DON #1 was asked how they ensured orders were accurately transcribed. He stated there was a second check with another nurse. The DON was asked what was done if there was a question or concern about a physician's order. He stated they would follow-up with the physician. He was asked what was done if they received a Black Box warning from the pharmacy system. He stated the same. The DON was asked what he should know before administering medication to a resident. He stated the five rights and knowing the correct order in the MAR. The DON was asked if those administering medication should know the recommended dose of a medication that was being administered. He stated, I don't think the CMAs, but a nurse would, should. The DON was asked if there was a question about the dose of a medication, was information regarding the recommended dosage easily accessible. He stated staff could ask him or the ADON, they could access the information on the computer and they had the pharmacy's phone number. The DON was asked to review the physician's hospital discharge orders for resident #9 for [DATE]. He reviewed the orders and was asked what the order was for [MEDICATION(S)]. He stated 20 milligrams by mouth every seven days. The DON was asked to review the facility's Residents Physicians Order Summary, dated [DATE]. He reviewed the orders and was asked what it documented as the order for [MEDICATION(S)]. He stated give two tablets by mouth in the morning for ischemia for seven days. He was asked if this was the correct order. He stated, No, it is not. The DON was asked if the order had been verified by more than one person. He stated, Yes. The DON was asked if there had been a Black Box warning for the [MEDICATION(S)]. He stated, Yes. He was asked what had been done about the Black Box warning. He stated the information had been faxed to the physician. He was asked if there had been follow-up with the physician. He stated, No. He was asked if there should have follow-up. He stated, Yes. The DON was asked if there had been a system warning about the dosage of the [MEDICATION(S)]. He stated, Yes. He was asked what it said. He stated it said the dose was out of range. The DON was asked if the resident had received medication per the physician's discharge order. He stated, It was not. 2. Resident #2 had diagnoses which included [CONDITION(S)], localized [CONDITION(S)], major depressive disorder and diabetes mellitus type II. Physician orders, dated [DATE], documented the resident was to receive the following orders: ~ [MEDICATION(S)] (thyroid med) 112 MCG one tab daily, ~ [MEDICATION(S)] ER 10 mEq one tab daily, ~ [MEDICATION(S)] (antidepressant) 5 mg every morning, ~ furoseemide (diuretic) 20 mg one tab every morning, and ~ [MEDICATION(S)] (diabetic med)100 mg one tab every morning. Physician orders, dated [DATE], documented the resident was to receive Vitamin C 1000 mg one tab daily. The MAR, dated [DATE] - [DATE], documented, 9, which according to the Chart Codes at the end of the MAR stands for Other/See Progress Notes, for the following: ~ [MEDICATION(S)] 112 MCG one tab daily - on [DATE] through [DATE] (nine continuous days), ~ [MEDICATION(S)] ER 10 mEq one tab daily - on [DATE] and [DATE] through [DATE] (one day and three continuous days), ~ [MEDICATION(S)] 5 mg every morning - on [DATE], ~ [MEDICATION(S)] 20 mg one tab every morning - [DATE] through [DATE] (three continuous days), ~ [MEDICATION(S)] 100 mg one tab every morning - [DATE] and [DATE] through [DATE] (one day and three continuous days), and ~ Vitamin C 1000 mg one tab daily - [DATE] and [DATE] through [DATE] (one day and three continuous days). The orders administration notes in the electronic clinical record documented the following: ~ [DATE] at 5:33 a.m. - meds on order, ~ at 7:37 a.m. - med not here will call family again, ~ at 9:10 a.m. - awaits pharmacy to supply, ~ at 1:49 p.m. - med not here called family, ~ at 9:07 p.m. - med not here, ~ [DATE] at 5:37 a.m. - on order, ~ at 11:57 a.m., 11:58 a.m. and 11:59 a.m. - med not available notified the nurse, and ~ at 1:58 p.m. - med not available nurse notified. On [DATE] at 3:04 p.m., the ADON was asked what the numeral 9 documented in the daily spaces on the MAR indicated. She stated it usually meant the medication was not available and the pharmacy had been contacted. She was asked if there was any documentation why the medication was not administered. She stated the staff was supposed to document the reason why in the E-MAR [electronic medication administration record] progress notes. The ADON was shown the above meds on the printed MAR and asked if she could show where this had been documented. After looking in the computer, she stated the resident's family was supplying her medication from their pharmacy, so the staff was notifying the resident's family when the resident needed more medication and they were not bringing the medication to the facility.

On [DATE] at 12:22 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health regarding the facility's failure to accurately transcribe the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #9. The resident was subsequently transferred to the hospital and later died due to complications of [MEDICATION(S)] toxcity. At 1:19 p.m., the facility administrator and the DON were informed of the IJ situation related to the facility's failure to to accurately transcribe the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #9. A plan of removal for the IJ situation was requested. At 5:49 p.m., the administrator provided the survey team with an acceptable written plan of removal. The facility's plan of removal, dated [DATE], documented the following: .Plan for Removal of IJ 1-- Review and revision of current policy regarding admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2 -- Inservice admission nurses, unit managers and ADON regarding new policy for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3 -- Inservice admissions nurses and unit managers regarding general procedures for reduction of medication errors, with particular focus on accurate transcription of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4 -- Inservice ,d+[DATE] & ,d+[DATE] staff on medication errors (to be completed by end of day [DATE]) 5 -- In process of auditing any black box or dosage warnings for all current residents. Ensure any issues are resolved by contacting physician for clarification or correction as needed. This will be accomplished by end of day [DATE]. In process: Any staff on vacation or otherwise on extended leave will be inserviced regarding medication errors and transcription errors prior to being allowed to return to work. In process today [DATE]: Inservice all LPN/RN/CMA staff on reduction of medication errors. Within 10 days: Design and implement training package for all new hires regarding accuracy of transcribed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Within 10 days: Ongoing QAPI PIP as a means to gather and process information regarding compliance with new admissions policy. Within 10 days: Ensure continuing and ongoing education to licensed staff and CMAs regarding reduction of medication errors and accurate transcription of physicians orders . A review of the facility's audit forms and training logs documented the facility had completed the audits and trainings by [DATE] at 3:37 p.m. On [DATE] at 3:37 p.m., the administrator was informed the IJ had been removed as of [DATE] at 3:37 p.m. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to ensure that nursing staff accurately transcribed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This had the potential to affect all 127 residents residing in the facility. Findings: Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's hospital discharge order, dated [DATE], documented .[MEDICATION(S)] 10 mg Tablet Commonly known as [MEDICATION(S)] Take 20 mg by mouth every seven days . The facility's Residents Physicians Order Summary, dated [DATE], documented .[MEDICATION(S)] Sodium Tablet 10 MG Give 2 tablet by mouth in the morning .for 7 Days . The Physicians Order Summary had been cosigned by RN # 1 and LPN #1 and dated [DATE]. An order note, dated [DATE] at 5:45 p.m., documented, .The order you have entered [MEDICATION(S)] Sodium Tablet 10 MG Give 2 tablet by mouth in the morning .for 7 Days Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction . A Black Box Warning Detail documented, .[MEDICATION(S)] should be used only by health care providers whose knowledge and experience include the use of antimetabolite therapy. Because of the possibility of serious toxic reactions, which can be fatal, use [MEDICATION(S)] only in life-threatening neoplastic diseases, or in patients with psoriasis or [CONDITION(S)] (RA) with severe, recalcitrant, disabling disease that is not adequately responsive to other forms of therapy. Deaths have been reported with use of [MEDICATION(S)] in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patients should be informed by their health care provider of the risks involved and be under a health care provider's care throughout therapy . A copy of the Black Box Warning detail had been made and a hand written note on the copy documented the information had been faxed to [physicians name deleted] on [DATE]. The note documented, Call Hall 5 charge nurse for changes . and was signed by RN #1. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. An order note, dated [DATE] at 5:45 p.m., documented, .The system has identified this order as being outside of the recommended dose for this drug . A Drug Overdose Detail documented, .[MEDICATION(S)] Sodium Tablet 10 MG Min Age (Inclusive): Max Age (Exclusive): Min Dose: Max Dose: 15 65 0.1 tablet 0.43 tablet 65+ 0.1 tablet 0.43 tablet . A copy of the Drug Overdose Detail had been made and a hand written note on the copy documented the information had been faxed to [physicians name deleted] on [DATE]. The note documented, Call .Hall 5 charge nurse for changes . and was signed by RN #1. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. A Drug Regimen Review for Section N, dated [DATE] at 6:44 p.m., documented, . 1. Did a complete drug regimen review identify potential clinically significant medication issues? . The Yes - Issues found during review box was marked. The Drug Regimen Review for Section N, dated [DATE] at 6:44 p.m., also documented, .2. Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? . The Yes box was marked. The form documented RN#1 as the person completing this section and documented LPN #1 as the second signature for admission/hospital discharge orders reconciliation. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. The resident's Medication Administration Record (MAR) documented the resident had been administered two 10 mg [MEDICATION(S)] sodium tablets by mouth in the morning from [DATE] through [DATE]. A nurse's note, dated [DATE] at 6:30 p.m., documented, .Patient is very hard to arouse. Sternal rub given, patient did not open eyes. BP ,d+[DATE], Pulse 145, Resp 18, O2 85%. Oxygen placed on patient and [emergency medical service name deleted] was called. [Emergency medical service name deleted] arrived. Pulse 200, BP ,d+[DATE]. Patient in a-fib RVR. Cardioversion given. Pulse down to 88 at this time. Patient more alert. Face Sheet, Order summary, recent labs, and recent hospital paperwork sent with [emergency medical service name deleted]. Patient being transferred to [hospital name deleted]. Patient son notified. Call sister with no answer . A hospital physician's note, dated [DATE] at 10:21 p.m., documented, .Per MAR send [sic] from [NAME], patient is taking 20 mg DAILY for 7 days only starting on [DATE] and stopping on [DATE]; was previously taking 20 mg WEEKLY. Unclear if this is an error. We will hold off further MTX given kidney dysfunction leukopenia. Need further clarification before administration MTX . A hospital discharge summary, dated [DATE] at 10:45 p.m., documented, .Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .AKI (acute kidney injury) .Patient was recently admitted to [hospital name deleted] about a week prior (,d+[DATE]-,d+[DATE]) for altered mental status, urinary tract infection and rhabdomyolysis and she was treated with [MEDICATION(S)] and IV hydration. Mental status and kidney function improved. Patient was then discharged to [facility name deleted] rehab. (Emergency medical service name deleted) was called due to patient was found to be [CONDITION(S)]. Per [emergency medical service name deleted], patient heart rate was found to be in 200s upon arrival. Patient was cardioverted with 100 J. On arrival to ER, patient heart rate 85. She went into [CONDITION(S)] with RVR again shortly after arrival. Cardiology was consulted from ER .Hospitalist called for admission. Patient was admitted to ICU .She was also found to have pancytopenia from [MEDICATION(S)] and we were following her labs daily and transfusing. She then developed acute respiratory failure due to [CONDITION(S)] and hemopyptysis and was intubated and placed on mechanical ventilation .Patient was transferred to inpatient hospice in the late hours of [DATE] . A hospice nurse's note, dated [DATE] at 11:00 p.m., documented, Pt [Resident #9 name deleted] arrived via stretcher [medical transport service name deleted] from (hospital named deleted) for hospice diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Pt was at [facility name deleted] Nursing home and was accidentally given [MEDICATION(S)] every day instead of once a week .Pt is DNR . A hospice nurse's note, dated [DATE] at 12:07 a.m., documented, Pt [resident #9 name deleted] passed away peacefully .from complications of pancytopenia secondary to [MEDICATION(S)] overdose .Medical examiner notified via phone regarding pt death. Pt. will be taken in to Medical examiner's office. Report given to [medical examiner's name deleted] ME on call . The State Medical Examiner's Report of Autopsy, for resident #9, dated [DATE] at 1:00 p.m., documented, .CAUSE OF DEATH: COMPLICATIONS OF [MEDICATION(S)] TOXICITY . The State of Oklahoma Certificate of Death, for resident #9, received [DATE] and certified [DATE], documented, .CAUSE OF DEATH .IMMEDIATE CAUSE .COMPLICATIONS OF [MEDICATION(S)] TOXICITY . On [DATE] at 9:40 a.m., the Admitting Nurse (AN) was asked, who transcribed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she did not know who did it on her days off. The AN was asked how she ensured orders were accurately transcribed. She stated after she inputted them they were checked by another nurse. She stated LPN #1 was the person that usually checked with her. The AN was asked what she did if she had a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked what she did if she received a Black Box warning from the pharmacy system. She stated she would print off the warning and fax it to the physician. She stated she put a note on the sheet for the physician to contact the floor nurse if they wished to make any changes. She stated, Honestly, I can't tell you if they do or not. The AN was asked what she should know before administering medication to a resident. She stated potential side effects, the reason for administration, allergies, if it was the right person, the right dose, the right route and the right time. The AN was asked if she should know the recommended dose of a medication that was being administered. She stated she thought it was a good idea to know but she did not know if the CMAs knew or not. She stated she hoped they would have a general idea. She stated PCC notified her if a dosage was out of range. She was asked what she did. She stated she would call the physician. The AN was asked if there was a question about the dose of a medication, was information regarding the recommended dose easily accessible. She stated, Yes. She stated if she could not find any other way, she would call the pharmacy. She stated she had good resources. At 10:02 a.m., RN #1 was asked who transcribed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she sometimes went in to help her. RN #1 was asked how she ensured orders were accurately transcribed. She stated they usually had a double check with another nurse. RN#1 was asked what she did if she had a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked what she did if she received a Black Box warning from the pharmacy system. She stated they usually faxed them to the physician and hopefully the physician would see the Black Box warning. She was asked if anyone followed up on the med warnings faxed to the physicians. She stated she did not know. RN #1 was asked what she should know before administering medication to a resident. She stated what the medication was for, the dose, the reason and the correct route. RN #1 was asked if she should know the recommended dose of a medication that was being administered. She stated, Yes. RN #1 was asked if there was a question about the dose of a medication, was information regarding the recommended dose easily accessible. She stated she would usually look it up and notify the physician if there was a question about the dose. She was asked if she documented when she called the physician about a medication. She stated, Usually no. RN #1 was asked if she was one of the nurses who did the order transcription for resident #9 when she had been admitted to the facility on [DATE]. She stated, Yes. She was asked to review the physician's hospital discharge orders for that date. She reviewed the orders and was asked what the order was for [MEDICATION(S)]. She stated 20 milligrams by mouth every seven days. RN #1 was asked to review the facility's Residents Physicians Order Summary, dated [DATE]. She reviewed the orders and was asked what it documented as the order for [MEDICATION(S)]. She stated a two ten milligram tablets by mouth for seven days. She was asked if this was the correct order. She stated, No. RN #1 was asked if someone had verified the order with her. She stated LPN #1. RN #1 was asked if there had been a Black Box warning for the metotrexate. She stated there had been. She was asked what the warning had said. She stated that it could be fatal. RN #1 was asked what she had done about the Black Box warning. She stated she had faxed it to (physician's name deleted). She was asked if he had responded back. She stated, No or I don't know. She was asked if she had followed up with the physician. She stated, No. She was asked if someone should have followed up. She stated yes they should have. RN #1 was asked if there had been a system warning about about the dosage of the [MEDICATION(S)]. She stated, Yes. She was asked what it said. She stated it said it was outside the recommended dose. She was asked if this information was faxed to the physician. She stated it should have been, that it usually was. RN #1 was asked if she had received any follow-up regarding the [MEDICATION(S)]. She stated, No. She was asked if someone had followed up with the physician. She stated, No. RN #1 was asked if medications had been given appropriately according to orders from the physician. She stated, Not in this case, no. At 10:20 a.m., LPN #1 was asked was asked who transcribed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 was asked how she ensured orders were accurately transcribed. She stated after the orders were put in PCC she checked them off from transcription from the discharge order and the MAR and she checked them against each. LPN#1 was asked what she did if she had a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked what she did if she received a Black Box warning from the pharmacy system. She stated she would print off the Black Box warning and send it as a fax to the physician. She stated they would write on it to communicate any changes to the charge nurse. She was asked if follow-up would be done. She stated she did not have an answer for that. LPN #1 was asked what she should know before administering medication to a resident. She stated she needed to make sure the five rights were there. LPN #1 was asked if she should know the recommended dose of a medication that was being administered. She stated, Yes, you should. LPN #1 was asked if there was a question about the dose of a medication, was information regarding the recommended dose easily accessible. She stated they could call the physician. She was asked if she documented when she called the physician about a medication. She stated yes in the chart. LPN #1 was asked if she was one of the nurses who did the order transcription for resident #9 when she had been admitted to the facility on [DATE]. She stated, Yes. She was asked to review the physician's hospital discharge orders for that date. She reviewed the orders and was asked what the order was for [MEDICATION(S)]. She stated 10 milligram tablet two tablets 20 milligrams by mouth every seven days. LPN #1 was asked to review the facility's Residents Physicians Order Summary, dated [DATE]. She reviewed the orders and was asked what it documented as the order for [MEDICATION(S)]. She stated 10 milligram tablet give two tablets by mouth in the morning for seven days. She was asked if this was the correct order. She stated, No, sir, it's not. She was asked if someone had verified the order with her. She stated RN #1. LPN #1 was asked if there had been a Black Box warning for the [MEDICATION(S)]. She stated there had been. She was asked what the warning had said. She stated there could be a possibility for serious toxicity. LPN #1 was asked what she had done about the Black Box warning. She stated the nurse had called the charge nurse and she had faxed it to (physician's name deleted). She was asked if anyone had followed up with the physician. She stated, I do not know. LPN #1 was asked if there had been a system warning about the dosage of the [MEDICATION(S)]. She stated, Yes. She stated the system had identified the dose as being over the recommended dose. She was asked what had been done regarding this dosage warning. She stated it had been sent to the physician. LPN #1 was asked if she had received any follow-up regarding the [MEDICATION(S)]. She stated, I don't have an answer for that. She was asked if someone should have followed up with the physician. She stated, Yes. LPN #1 was asked if medications for resident #9 had been entered into the system incorrectly. She stated one of the medications had been transcribed wrong. At 11:05 a.m., the DON was asked who transcribed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON #1 was asked how they ensured orders were accurately transcribed. He stated there was a second check with another nurse. The DON was asked what was done if there was a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He was asked what was done if they received a Black Box warning from the pharmacy system. He stated the same. The DON was asked what he should know before administering medication to a resident. He stated the five rights and knowing the correct order in the MAR. The DON was asked if those administering medication should know the recommended dose of a medication that was being administered. He stated, I don't think the CMAs, but a nurse would, should. The DON was asked if there was a question about the dose of a medication, was information regarding the recommended dosage easily accessible. He stated staff could ask him or the ADON, they could access the information on the computer and they had the pharmacy's phone number. The DON was asked to review the physician's hospital discharge orders for resident #9 for [DATE]. He reviewed the orders and was asked what the order was for [MEDICATION(S)]. He stated 20 milligrams by mouth every seven days. The DON was asked to review the facility's Residents Physicians Order Summary, dated [DATE]. He reviewed the orders and was asked what it documented as the order for [MEDICATION(S)]. He stated give two tablets by mouth in the morning for ischemia for seven days. Hr was asked if this was the correct order. He stated, No, it is not. The DON was asked if the order had been verified by more than one person. He stated, Yes. The DON was asked if there had been a Black Box warning for the [MEDICATION(S)]. He stated, Yes. He was asked what had been done about the Black Box warning. He stated the information had been faxed to the physician. He was asked if there had been follow-up with the physician. He stated, No. He was asked if there should have follow-up. He stated, Yes. The DON was asked if there had been a system warning about about the dosage of the [MEDICATION(S)]. He stated, Yes. He was asked what it said. He stated it said the dose was out of range. The DON was asked if the resident had received medication per the physician's discharge order. He stated, It was not.

On [DATE] at 12:22 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health regarding the facility's failure to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #9. The resident was subsequently transferred to the hospital and later died . At 1:19 p.m., the facility administrator and the DON were informed of the IJ situation related to the facility's failure to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #9. A plan of removal for the IJ situation was requested. At 5:49 p.m., the administrator provided the survey team with an acceptable written plan of removal. The facility's plan of removal, dated [DATE], documented the following: .Plan for Removal of IJ 1-- Review and revision of current policy regarding admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2 -- Inservice admission nurses, unit managers and ADON regarding new policy for admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3 -- Inservice admissions nurses and unit managers regarding general procedures for reduction of medication errors, with particular focus on accurate transcription of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 4 -- Inservice ,d+[DATE] & ,d+[DATE] staff on medication errors (to be completed by end of day [DATE]) 5 -- In process of auditing any black box or dosage warnings for all current residents. Ensure any issues are resolved by contacting physician for clarification or correction as needed. This will be accomplished by end of day [DATE]. In process: Any staff on vacation or otherwise on extended leave will be inserviced regarding medication errors and transcription errors prior to being allowed to return to work. In process today [DATE]: Inservice all LPN/RN/CMA staff on reduction of medication errors. Within 10 days: Design and implement training package for all new hires regarding accuracy of transcribed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Within 10 days: Ongoing QAPI PIP as a means to gather and process information regarding compliance with new admissions policy. Within 10 days: Ensure continuing and ongoing education to licensed staff and CMAs regarding reduction of medication errors and accurate transcription of physicians orders . A review of the facility's audit forms and training logs documented the facility had completed the audits and trainings by [DATE] at 3:37 p.m. On [DATE] at 3:37 p.m., the administrator was informed the IJ had been removed as of [DATE] at 3:37 p.m. The deficient practice remained at a level of actual harm, isolated. Based on record review and interview, it was determined the facility failed to: ~ follow-up on requests for clarification of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #9) of five sampled residents who were reviewed for significant changes in resident condition. This resulted in an IJ situation, ~ notify resident representatives for two (#1 and #4), and ~ notify the physician of medication not administered as ordered for one (#2). This had the potential to affect all 127 residents residing in the facility. Findings: 1. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's hospital discharge order, dated [DATE], documented .[MEDICATION(S)] 10 mg Tablet Commonly known as [MEDICATION(S)] Take 20 mg by mouth every seven days . The facility's Residents Physicians Order Summary, dated [DATE], documented .[MEDICATION(S)] Sodium Tablet 10 MG Give 2 tablet by mouth in the morning .for 7 Days . The Physicians Order Summary had been cosigned by RN # 1 and LPN #1 and dated [DATE]. An order note, dated [DATE] at 5:45 p.m., documented, .The order you have entered [MEDICATION(S)] Sodium Tablet 10 MG Give 2 tablet by mouth in the morning .for 7 Days Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction . A Black Box Warning Detail documented, .[MEDICATION(S)] should be used only by health care providers whose knowledge and experience include the use of antimetabolite therapy. Because of the possibility of serious toxic reactions, which can be fatal, use [MEDICATION(S)] only in life-threatening neoplastic diseases, or in patients with psoriasis or [CONDITION(S)] (RA) with severe, recalcitrant, disabling disease that is not adequately responsive to other forms of therapy. Deaths have been reported with use of [MEDICATION(S)] in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patients should be informed by their health care provider of the risks involved and be under a health care provider's care throughout therapy . A copy of the Black Box Warning detail had been made and a hand written note on the copy documented the information had been faxed to [physicians name deleted] on [DATE]. The note documented, Call Hall 5 charge nurse for changes . and was signed by RN #1. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. An order note, dated [DATE] at 5:45 p.m., documented, .The system has identified this order as being outside of the recommended dose for this drug . A Drug Overdose Detail documented, .[MEDICATION(S)] Sodium Tablet 10 MG Min Age (Inclusive): Max Age (Exclusive): Min Dose: Max Dose: 15 65 0.1 tablet 0.43 tablet 65+ 0.1 tablet 0.43 tablet . A copy of the Drug Overdose Detail had been made and a hand written note on the copy documented the information had been faxed to [physicians name deleted] on [DATE]. The note documented, Call .Hall 5 charge nurse for changes . and was signed by RN #1. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. A Drug Regimen Review for Section N, dated [DATE] at 6:44 p.m., documented, . 1. Did a complete drug regimen review identify potential clinically significant medication issues? . The Yes - Issues found during review box was marked. The Drug Regimen Review for Section N, dated [DATE] at 6:44 p.m., also documented, .2. Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? . The Yes box was marked. The form documented RN#1 as the person completing this section and documented LPN #1 as the second signature for admission/hospital discharge orders reconciliation. No documentation was found for follow-up on the information provided to the physician during a review of the resident's record. The resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse's note, dated [DATE] at 6:30 p.m., documented, .Patient is very hard to arouse. Sternal rub given, patient did not open eyes. BP ,d+[DATE], Pulse 145, Resp 18, O2 85%. Oxygen placed on patient and [emergency medical service name deleted] was called. [Emergency medical service name deleted] arrived. Pulse 200, BP ,d+[DATE]. Patient in a-fib RVR. Cardioversion given. Pulse down to 88 at this time. Patient more alert. Face Sheet, Order summary, recent labs, and recent hospital paperwork sent with [emergency medical service name deleted]. Patient being transferred to [hospital name deleted]. Patient son notified. Call sister with no answer . A hospital physician's note, dated [DATE] at 10:21 p.m., documented, .Per MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Unclear if this is an error. We will hold off further MTX given kidney dysfunction leukopenia. Need further clarification before administration MTX . A hospital discharge summary, dated [DATE] at 10:45 p.m., documented, .Discharge Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .AKI (acute kidney injury) .Patient was recently admitted to [hospital name deleted] about a week prior (,d+[DATE]-,d+[DATE]) for altered mental status, urinary tract infection and rhabdomyolysis and she was treated with [MEDICATION(S)] and IV hydration. Mental status and kidney function improved. Patient was then discharged to [facility name deleted] rehab. (Emergency medical service name deleted) was called due to patient was found to be [CONDITION(S)]. Per [emergency medical service name deleted], patient heart rate was found to be in 200s upon arrival. Patient was cardioverted with 100 J. On arrival to ER, patient heart rate 85. She went into [CONDITION(S)] with RVR again shortly after arrival. Cardiology was consulted from ER .Hospitalist called for admission. Patient was admitted to ICU .She was also found to have pancytopenia from [MEDICATION(S)] and we were following her labs daily and transfusing. She then developed acute respiratory failure due to [CONDITION(S)] and hemopyptysis and was intubated and placed on mechanical ventilation .Patient was transferred to inpatient hospice in the late hours of [DATE] . A hospice nurse's note, dated [DATE] at 11:00 p.m., documented, Pt [Resident #9 name deleted] arrived via stretcher [medical transport service name deleted] from (hospital named deleted) for hospice diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Pt was at [facility name deleted] Nursing home and was accidentally given [MEDICATION(S)] every day instead of once a week .Pt is DNR . A hospice nurse's note, dated [DATE] at 12:07 a.m., documented, Pt [resident #9 name deleted] passed away peacefully .from complications of pancytopenia secondary to [MEDICATION(S)] overdose .Medical examiner notified via phone regarding pt death. Pt. will be taken in to Medical examiner's office. Report given to [medical examiner's name deleted] ME on call . The State Medical Examiner's Report of Autopsy, for resident #9, dated [DATE] at 1:00 p.m., documented, .CAUSE OF DEATH: COMPLICATIONS OF [MEDICATION(S)] TOXICITY . The State of Oklahoma Certificate of Death, for resident #9, received [DATE] and certified [DATE], documented, .CAUSE OF DEATH .IMMEDIATE CAUSE .COMPLICATIONS OF [MEDICATION(S)] TOXICITY . On [DATE] at 9:40 a.m., the Admitting Nurse (AN) was asked what she did if she had a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked what she did if she received a Black Box warning from the pharmacy system. She stated she would print off the warning and fax it to the physician. She stated she put a note on the sheet for the physician to contact the floor nurse if they wished to make any changes. She stated, Honestly, I can't tell you if they do or not. At 10:02 a.m., RN #1 was asked what she did if she had a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked what she did if she received a Black Box warning from the pharmacy system. She stated they usually faxed them to the physician and hopefully the physician would see the Black Box warning. She was asked if anyone followed up on the med warnings faxed to the physicians. She stated she did not know. RN #1 was asked if there was a question about the dose of a medication, was information regarding the recommended dose easily accessible. She stated she would usually look it up and notify the physician if there was a question about the dose. She was asked if she documented when she called the physician about a medication. She stated, Usually no. RN #1 was asked if she was one of the nurses who did the order transcription for resident #9 when she had been admitted to the facility on [DATE]. She stated, Yes. She was asked to review the physician's hospital discharge orders for that date. She reviewed the orders and was asked what the order was for [MEDICATION(S)]. She stated 20 milligrams by mouth every seven days. RN #1 was asked to review the facility's Residents Physicians Order Summary, dated [DATE]. She reviewed the orders and was asked what it documented as the order for [MEDICATION(S)]. She stated a two ten milligram tablets by mouth for seven days. She was asked if this was the correct order. She stated, No. RN #1 was asked if someone had verified the order with her. She stated LPN #1. RN #1 was asked if there had been a Black Box warning for the [MEDICATION(S)]. She stated there had been. She was asked what the warning had said. She stated that it could be fatal. RN #1 was asked what she had done about the Black Box warning. She stated she had faxed it to (physician's name deleted). She was asked if he had responded back. She stated, No or I don't know. She was asked if she had followed up with the physician. She stated, No. She was asked if someone should have followed up. She stated yes they should have. RN #1 was asked if there had been a system warning about about the dosage of the [MEDICATION(S)]. She stated, Yes. She was asked what it said. She stated it said it was outside the recommended dose. She was asked if this information was faxed to the physician. She stated it should have been, that it usually was. RN #1 was asked if she had received any follow-up regarding the [MEDICATION(S)]. She stated, No. She was asked if someone had followed up with the physician. She stated, No. At 10:20 a.m., LPN #1 was asked who transcribed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN#1 was asked what she did if she had a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She was asked what she did if she received a Black Box warning from the pharmacy system. She stated she would print off the Black Box warning and send it as a fax to the physician. She stated they would write on it to communicate any changes to the charge nurse. She was asked if follow-up would be done. She stated she did not have an answer for that. LPN #1 was asked if there was a question about the dose of a medication, was information regarding the recommended dose easily accessible. She stated they could call the physician. She was asked if she documented when she called the physician about a medication. She stated yes in the chart. LPN #1 was asked if there had been a Black Box warning for the [MEDICATION(S)]. She stated there had been. She was asked what the warning had said. She stated there could be a possibility for serious toxicity. LPN #1 was asked what she had done about the Black Box warning. She stated the nurse had called the charge nurse and she had faxed it to (physician's name deleted). She was asked if anyone had followed up with the physician. She stated, I do not know. LPN #1 was asked if there had been a system warning about about the dosage of the [MEDICATION(S)]. She stated, Yes. She stated the system had identified the dose as being over the recommended dose. She was asked what had been done regarding this dosage warning. She stated it had been sent to the physician. LPN #1 was asked if she had received any follow-up regarding the [MEDICATION(S)]. She stated, I don't have an answer for that. She was asked if someone should have followed up with the physician. She stated, Yes. LPN #1 was asked if medications for resident #9 had been entered into the system incorrectly. She stated one of the medications had been transcribed wrong. At 11:05 a.m., the DON was asked what was done if there was a question or concern about a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He was asked what was done if they received a Black Box warning from the pharmacy system. He stated the same. The DON was asked if those administering medication should know the recommended dose of a medication that was being administered. He stated, I don't think the CMAs, but a nurse would, should. The DON was asked if there had been a Black Box warning for the [MEDICATION(S)]. He stated, Yes. He was asked what had been done about the Black Box warning. He stated the information had been faxed to the physician. He was asked if there had been follow-up with the physician. He stated, No. He was asked if there should have follow-up. He stated, Yes. The DON was asked if there had been a system warning about about the dosage of the [MEDICATION(S)]. He stated, Yes. He was asked what it said. He stated it said the dose was out of range. 2. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Skin/Wound Note, dated [DATE] at 10:45 a.m. documented, .This nurse in resident room to treat wound to right upper thigh. While in room noticed incision to right groin has scant serosanguinous drainage and also has areas that has dehisced. This incision measures 0.2 cm x 13.0 cm x 0.2 cm,thin scant serosanguinous drainage, no odor, no s/s of infection, no pain, wound has areas that are approximated(which is approximately 50% of incision) and also has areas that are dehisced(which is approximately 50% of incision and 30% of dehisced area is yellow adherent slough and 20% is pink),margins are partially closed and partially regular, surrounding tissue moist. This nurse spoke with ,d+[DATE] nurse notified of findings .,d+[DATE] nurse to call surgeon and notify . There was no documentation that the resident's representative had been notified. On [DATE] at 8:51 a.m. the ADON was asked who notified resident representatives of significant changes in resident condition. She stated anyone could but it usually started with the charge nurse. The ADON was asked what were some examples of changes resident representative would be notified about. She stated falls, changes in clinical status and decrease in appetite. At 2:00 p.m. the DON was asked if surgical wound dehiscence was something that should be reported to a resident's representative. He stated, Yes, of course. The DON was asked to review resident #1's medical record for [DATE]. After reviewing the record he was asked if the resident had a surgical wound dehisce on that date. He stated, It's what it looks like according to the documentation. The DON was asked if the resident's representative had been notified. He stated, No. He was asked if they should have been notified. He stated, Yes. 3. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A lab report, dated [DATE], documented the resident had a positive COVID test result. There was no documentation that the resident's representative had been notified. On [DATE] at 8:51 a.m. the ADON was asked who notified resident representatives of significant changes in resident condition. She stated anyone could but it usually started with the charge nurse. The ADON was asked what were some examples of changes resident representative would be notified about. She stated falls, changes in clinical status and decrease in appetite. The ADON was asked if the resident had been diagnosed with COVID. She stated, Yes. She was asked when the resident had been diagnosed . She stated on [DATE]. The ADON was asked if the resident's representative had been notified. She stated they had been notified by text from the administrators cell phone. She was asked where the notification had been documented. She stated it had not been documented in the Progress Notes. She was asked if it should have been documented. She stated, Yes. 4. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders, dated [DATE], documented the resident was to receive the following orders: ~ [MEDICATION(S)] (thyroid med) 112 MCG one tab daily, ~ [MEDICATION(S)] ER 10 mEq one tab daily, ~ [MEDICATION(S)] (antidepressant) 5 mg every morning, ~ furoseemide (diuretic) 20 mg one tab every morning, and ~ [MEDICATION(S)] (diabetic med)100 mg one tab every morning. Physician orders, dated [DATE], documented the resident was to receive Vitamin C 1000 mg one tab daily. The MAR, dated [DATE] - [DATE], documented, 9, which according to the Chart Codes at the end of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ~ [MEDICATION(S)] 112 MCG one tab daily - on [DATE] through [DATE] (nine continuous days), ~ [MEDICATION(S)] ER 10 mEq one tab daily - on [DATE] and [DATE] through [DATE] (one day and three continuous days), ~ [MEDICATION(S)] 5 mg every morning - on [DATE], ~ [MEDICATION(S)] 20 mg one tab every morning - [DATE] through [DATE] (three continuous days), ~ [MEDICATION(S)] 100 mg one tab every morning - [DATE] and [DATE] through [DATE] (one day and three continuous days), and ~ Vitamin C 1000 mg one tab daily - [DATE] and [DATE] through [DATE] (one day and three continuous days). The orders administration notes in the electronic clinical record documented the following: ~ [DATE] at 5:33 a.m. - meds on order, ~ at 7:37 a.m. - med not here will call family again, ~ at 9:10 a.m. - awaits pharmacy to supply, ~ at 1:49 p.m. - med not here called family, ~ at 9:07 p.m. - med not here, ~ [DATE] at 5:37 a.m. - on order, ~ at 11:57 a.m., 11:58 a.m. and 11:59 a.m. - med not available notified the nurse, and ~ at 1:58 p.m. - med not available nurse notified. On [DATE] at 3:26 p.m., the ADON was asked if the physician had been notified of the above medications not being administered as ordered. After looking at the electronic clinical record, she stated, I don't see it documented. She was asked if the physician should have been notified. She stated, Yes.