Every finding on record at Benbrook Nursing & Rehabilitation Center

Based on interview and record review, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systemically organized in accordance with accepted professional standards for 1 of 3 residents (Resident #2) reviewed for medical records.LVN C failed to administer Resident #2's Advair HFA Inhalation Aerosol (inhaler) and Albuterol Sulfate Inhalation (inhaler); however, she documented on the resident's MAR that the medication was given on 08/13/26.This failure placed resident at risk for delayed or inaccurate medication administration which could result in decline in health and well-being.Findings included:Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (lung and airway diseases that restrict breathing), mild cognitive impairment, and hyperlipidemia (high cholesterol). The MDS reflected Resident #2's cognition was intact with a BIMS score of 13.Record review of Resident #2's care plan, revised 08/10/26 reflected, Focus: The resident has COPD. Goal: The resident will display optimal breathing patterns daily through review date. Interventions: Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. - Advair HFA Inhalation Aerosol - Albuterol Sulfate nebulization.Record review of Resident #2's August 2026 active physician orders reflected the following orders: Advair HFA Inhalation Aerosol 45-21 MCG/ACT (Fluticasone-Salmeterol) 1 inhalation inhale orally twotimes a day for COPD Rinse mouth after each use. Start date 03/29/2026. Albuterol Sulfate Inhalation Nebulization Solution 1.25 MG/3ML (Albuterol Sulfate) 1 vial inhale orally vianebulizer every 6 hours for Chest congestion. Start date 07/07/26. Record review of Resident #2's August 2026 MAR revealed medication Advair HFA Inhaler was administered at 08:00 AM and Albuterol Sulfate inhaler was administered at 12:00 PM by LVN C. Observation and interview on 08/13/26 at 9:55 a.m., Resident #2 was in his room, sitting in his wheelchair. At the end of Resident #2 bed were personal items and 2 inhalers. The inhalers were Advair HFA and Albuterol Sulfate. Resident #2 stated he had COPD and he would administer the inhalers once a day. He stated the inhalers were left in his room. Resident #2 stated no one would check on him to ensure if took the medication. Observation on 08/13/26 at 12:25 p.m. Resident #2 was in his room and the 2 inhalers were still at the end of his bed.Observation on 08/13/26 at 12:36 p.m. Resident #2 was in his room and the 2 inhalers were still at the end of his bed. Observation and interview on 08/13/26 at 12:43 p.m. LVN C was observed to entered Resident #2 room to wash her hands and then stepped out of the room. LVN C stated she was the nurse assigned to 200 Hall, and she had no residents who could self-administer any medications or inhalers. She stated inhalers were not to be left in the rooms. Observed LVN C entered the room, and the 2 inhalers were gone. LVN C asked Resident #2 about the inhalers and Resident #2 stated they were just there on the bed a second ago. LVN C was unable to locate the inhalers in the room. At 12:47 p.m. LVN C checked her medication cart and located the inhalers boxes but could not locate the inhalers. She stated the inhalers were missing. LVN C was observed to go back to Resident 2 room to search for the inhalers. She stated in the morning she was on her way to administer the inhalers to Resident #2 when she was told that the resident had an unwitnessed fall. She stated she went to the room to check on Resident #2 and placed the inhalers on the bed so she could assess the resident. LVN C stated she forgot the inhalers in the room and was not sure if she administered the medication. LVN C asked Resident #2 if she administered the medication and Resident #2 responded You did not but I did. She stated it was a mistake and left the inhalers in the room and had not administered the medication at all. Follow-up interview on 08/13/26 at 1:54 p.m. LVN C stated she documented that she administered the medication in the morning, but she did not administer it. She stated she does not know why she documented that she administered the medication. LVN C stated it was an honest mistake. She stated the Treatment Nurse located the inhalers but does not know where. She stated the potential risk of not accurately documenting would be falsifying information. Interview on 08/13/26 at 4:23 p.m. the ADON stated they had no residents who could self-administer any medications. She stated inhalers should not be left in the rooms. She stated the expectation when administering medications the nurses should review the orders, follow the MAR, administer the inhalers, rinse mouth and then put the medication back in the nurses' cart. She stated once the medication was administered then the nurse should document. The ADON stated nurses should not document until the medication was administered. Nurses should not document something that was not done. She stated potential risk of not accurately documenting would be MAR discrepancies and would not know if the medication was given or not. Interview on 08/13/26 at 4:36 p.m., the Administrator stated he expected the nurses to document any care or medication provided to the residents in a timely manner. Nurses should not document what was not given.Record review of facility Charting and Documentation policy, revised July 2017, reflected the following: 2. The following information is to be documented in the resident medical record: b. Medications administered; .3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on 1 of 3 residents (Resident #2) reviewed for pharmacy services.LVN C failed to ensure that Resident #2's Advair HFA Inhalation Aerosol (inhaler) and Albuterol Sulfate Inhalation (inhaler) were administered and stored properly on 08/13/26.This failure could place residents at risk for drug diversion, delay in medication administration and at risk of receiving medications that were effective.Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease (lung and airway diseases that restrict breathing), mild cognitive impairment, and hyperlipidemia (high cholesterol). The MDS reflected Resident #2's cognition was intact with a BIMS score of 13.Record review of Resident #2's care plan, revised 08/10/26 reflected, Focus: The resident has COPD. Goal: The resident will display optimal breathing patterns daily through review date. Interventions: Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. - Advair HFA Inhalation Aerosol - Albuterol Sulfate nebulization.Record review of Resident #2's August 2026 active physician orders reflected the following orders: Advair HFA Inhalation Aerosol 45-21 MCG/ACT (Fluticasone-Salmeterol) 1 inhalation inhale orally twotimes a day for COPD Rinse mouth after each use. Start date 03/29/2026. Albuterol Sulfate Inhalation Nebulization Solution 1.25 MG/3ML (Albuterol Sulfate) 1 vial inhale orally vianebulizer every 6 hours for Chest congestion. Start date 07/07/26. Record review of Resident #2's August 2026 MAR revealed medication Advair HFA Inhaler was administered at 08:00 AM and Albuterol Sulfate inhaler was administered at 12:00 PM by LVN C. Observation and interview on 08/13/26 at 9:55 a.m., Resident #2 was in his room, sitting in his wheelchair. At the end of Resident #2 bed were personal items and 2 inhalers. The inhalers were Advair HFA and Albuterol Sulfate. Resident #2 stated he had COPD and he would administer the inhalers once a day. He stated the inhalers were left in his room. Resident #2 stated no one would check on him to ensure if he took the medication. Observation on 08/13/26 at 12:25 p.m. Resident #2 was in his room and the 2 inhalers were still at the end of his bed.Observation on 08/13/26 at 12:36 p.m. Resident #2 was in his room and the 2 inhalers were still at the end of his bed. Observation and interview on 08/13/26 at 12:43 p.m. LVN C was observed to enter Resident #2's room to wash her hands and then stepped out of the room. LVN C stated she was the nurse assigned to 200 Hall, and she had no residents who could self-administer any medications or inhalers. She stated inhalers were not to be left in the rooms. Observed LVN C entered the room, and the 2 inhalers were gone. LVN C asked Resident #2 about the inhalers and Resident #2 stated they were just there on the bed a second ago. LVN C was unable to locate the inhalers in the room. At 12:47 p.m. LVN C checked her medication cart and located the inhalers boxes but could not locate the inhalers. She stated the inhalers were missing. LVN C was observed to go back to Resident #2's room to search for the inhalers. She stated in the morning she was on her way to administer the inhalers to Resident #2 when she was told that the resident had an unwitnessed fall. She stated she went to the room to check on Resident #2 and placed the inhalers on the bed so she could assess the resident. LVN C stated she forgot the inhalers in the room and was not sure if she administered the medication. LVN C asked Resident #2 if she administered the medication and Resident #2 responded You did not but I did. She stated it was a mistake and left the inhalers in the room and had not administered the medication at all. LVN C stated the potential risk of leaving medication in the room would be someone else grabbing the medication and using it. Interview on 08/13/26 at 4:23 p.m. the ADON stated they had no residents who could self-administer any medications. She stated inhalers should not be left in the rooms. She stated the nurses were responsible for administering medications correctly. She stated the expectation when administering medications the nurses should review the orders, follow the MAR, administer the inhalers, rinse mouth and then put the medication back in the nurses' cart. She stated once the medication was administered then the nurse should document. She stated the potential risk of leaving medications in the rooms would be another resident taking the medication or the resident administering too much and having a negative drug reaction. Interview on 08/13/26 at 4:36 p.m., the Administrator stated his expectations were for nurses to administer the correct medication, witness the resident take the medication and store it correctly. Potential risk of leaving medication in the room would be that the resident takes the medication in a way that could be harmful. Record review of facility Documentation of Medication Administration policy, revised April 2007, reflected the following: The facility shall maintain a medication administration record to document all medications administered. 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR). 2. Administration of medication must be documented immediately after (never before) it is given. Policy provided did not address medication administration or procedures.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 (Resident #1) residents reviewed for accidents.The facility failed to have a fall mat in place, while in bed, for Resident #1. This failure could place residents at risk for serious injury or harm and decreased quality of life.Findings include:Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness affecting one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, muscle wasting and atrophy (loss of muscle mass), unspecified abnormalities of gait and mobility, and muscle weakness. The MDS reflected Resident #1's cognition was moderately impaired with a BIMS score of 09 and she had a history of falls.Record review of Resident #1's care plan, revised 07/06/26, reflected: Focus: The resident is a Moderate risk for falls r/t self trying to turn in bed. Goal: The resident will be free of falls through the review date. Interventions: The resident needs a safe environment with: adequate, glare-free light; a working and reachable call light, the bed in low position at night; floor matt in place and personal items within reach.Observation and interview on 08/13/26 at 9:27 a.m., Resident #1 was observed in bed. She stated she was doing well. Resident #1 stated she had falls but could not recall when the last time was or where she had the falls. There was no fall mat in place next to the bed or anywhere in the room.Observation on 08/13/26 at 11:56 a.m., Resident #1 was in bed and there was no fall mat in place next to the bed. Observation on 08/13/26 at 1:27 p.m., Resident #1 was in bed and there was no fall mat in place next to the bed.Interview on 08/13/26 at 2:01 p.m., CNA A stated Resident #1 had recently been moved to the 100 Hall from another Hall after she was admitted from the hospital. She stated when the resident moved over, she did not have a floor mat, and she was not sure if Resident #1 needed to have one in place while she was in bed. CNA A stated Resident #1 was a fall risk, and she was not aware she was care plan to have a floor mat. She stated if a floor mat was an intervention, then Resident #1 should have a floor mat in place. She stated the potential risk of not following fall risk interventions would be the resident falling. Interview on 08/13/26 at 2:12 p.m. by phone, LVN B stated he was the nurse assigned to Resident #1 during the morning shift. Resident #1 was a fall risk and the interventions in place were bed at low position, call light within reach and a floor mat. He stated Resident #1 was admitted to hospice yesterday (08/12/26) and hospice had not brought in a floor mat. LVN B stated he thought Resident #1 had a floor mat in the meantime but was not sure. He stated the potential risk of not placing a floor mat would be Resident #1 falling and caused an injury. Interview on 08/13/26 at 4:23 p.m., the ADON stated Resident #1 was a fall risk and the interventions in place were floor mat at bedside, wedges, and bed at low position. She stated Resident #1 floor mat was removed because it needed to be cleaned. She stated she was not sure at what time or who removed the floor mat. The ADON stated it should had been put back in place once it was done being cleaned. She stated the potential risk would be the resident having a fall and hitting the floor instead of a soft mat. Interview on 08/13/26 at 4:36 p.m., the Administrator stated Resident #1 was a fall risk, she would get restless in bed. He stated a floor mat was an intervention that was in place. He stated if the floor mat was care planned, then it should be in the room. He stated the potential risk of not following the care plan interventions would be the resident having a fall. Record review of facility Falls and Fall risk, Managing policy, revised March 2018, reflected the following: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.1. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.

Based on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 1 (Rooms 210) of 6 rooms observed.The facility failed to maintain Rooms 210 in a safe and sanitary condition when the windowsill was noted to be splintered/cracked, and the window blinds were broken. This failure could place residents at risk for decreased quality of life.Observation and interview on 07/21/26 at 10:23 AM room [ROOM NUMBER] revealed the board of the windowsill was splintered/cracked and under that were three nails approximately 1/4 inch sticking out of the wall and the resident was near where the cracked/splintered board and nails were. The window blinds were also noted to be broken and some if the blind slats appeared to be missing. Interview on 07/21/26 at 3:01 PM with LVN B revealed she had noticed the cracked/splintered board of the windowsill and the exposed nails and broken blinds for about a month. LVN B said she did not notify anyone of the broken windowsill or the broken blinds. LVN B further stated if broken things like that were noted in resident rooms, the Maintenance Director should be notified so it can be fixed to keep the residents safe but LVN B did not say why she had not reported the broken windowsill. Interview on 07/21/26 at 4:38 PM with the Maintenance Director revealed he had worked at the facility for about three months and was not aware room [ROOM NUMBER] had a broken windowsill, the exposed nails or the broken blinds. The Maintenance Director said staff should report things like that immediately so he could fix it because it was a big safety issue for the resident. Interview on 07/21/26 at 5:37 PM with the Administrator revealed he was not aware of room [ROOM NUMBER]'s broken windowsill, the exposed nails on the wall, or the broken blinds. The Administrator said things like that should be reported right away so they can get fixed because they are a safety issue to the residents. Record review of the facility's policy titled Maintenance Service revised December 2009 reflected the following: .1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to:.b. maintaining the building in good repair and free of hazards.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #2) of two residents observed for catheter care. The facility failed to keep Resident #2's Foley bag below her bladder while in her wheelchair. This failure place residents with catheters at risk for the development of urinary tract infections. Findings included:Review of Resident #2's significant change in status MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had a BIMS score of 9 which indicated her cognition was moderately impaired. Her diagnoses included non-Alzheimer's dementia, hemiplegia (paralysis that affects one side of the body), seizure disorder, and muscle wasting. The MDS reflected the resident used a wheelchair and had an indwelling catheter and was dependent for most ADLs. Review of Resident #2's care plan revised on 06/05/26 reflected the resident had a Foley catheter (medical tube inserted through the urethra into the bladder to drain urine) related to kidney stones. Interventions included positioning the catheter bag and tubing below the level of the bladder. Observation on 07/21/26 at 9:36 AM of Resident #2 revealed she was in the TV room sitting in a high-back wheelchair. Her Foley bag was hanging from the top of her head rest and not below bladder level. Resident #2 was sitting across the nurses' station where multiple staff were observed to walk back and forth past the resident. Observation on 07/21/26 at 9:43 AM revealed CNA D was seen taking Resident #2 to her room and LVN A stopped the CNA and lowered the resident's foley bag. Interview on 07/21/26 at 10:10 AM with CNA D revealed she worked with Resident #2 but said she had not gotten the resident out of bed and did not know who had gotten her up for the day. CNA D said she noticed Resident #2's Foley catheter bag above her head and was taking her to the room to fix it but she had been stopped by LVN A and she had lowered the Foley bag. CNA D further stated Foley bags should be placed below the resident's bladder so urine can drain down to gravity freely. Interview on 07/21/26 at 1:05 PM with LVN A revealed she was the nurse for Resident #2 and she was not aware the Foley bag was above the resident's head until she noticed it when CNA D was wheeling her down the hall. LVN A said she did not know who got the resident up for the day and put the Foley bag on the resident's headrest but said it should be placed below the bladder so the urine did not backflow which could put the resident at risk for an infection.Interview on 07/21/26 at 1:41 PM with CNA E revealed when she got to work that morning (07/21/26) Resident #2 was already up in her wheelchair when she arrived to work but had not noticed the Foley bag was above the resident's head. CNA E stated Foley bags should be placed below the bladder so the urine can flow into the bag freely with no issues. Interview on 07/21/26 at 4:02 PM with the ADON revealed Foley bags should always be placed below the bladder so urine does not flow back up the tubing and cause the resident an infection. Interview on 07/21/26 at 4:55 PM with the DON revealed that when residents were up in their wheelchairs, their Foley bag should be placed below the bladder because they ran the risk of urine flowing back and could cause an infection. Review of the facility's policy titled Catheter Care, Urinary revised August 2022 reflected the following: PurposeThe purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.

Based on observation, interview and record review, the facility failed to ensure the residents' environment remained free of accident hazards for 1 (Resident #1) of 3 residents reviewed for accidents.The facility failed to ensure Resident #1's room was maintained free of hazards when the windowsill had a broken/splintered board and exposed nails on the wall. This failure put the resident at risk for injury. Findings included:Review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included diabetes, stroke, hemiparesis (weakness or partial paralysis affecting only one side of the body), anxiety disorder, and muscle weakness. The resident had a BIMS score of 13 which indicated his cognition was intact. The MDS further reflected the Resident #1 required partial/moderate assistance for most ADLs and he was always incontinent with bowel and bladder. Review of Resident #1's care plan initiated on 03/05/26 reflected the resident frequently lowered himself on the floor, crawled around the room, and would bang on nearby objects. The behavior increased the risk for injuries. Interventions included maintaining a clutter-free environment to reduce risk of injury while crawling. Observation and interview on 07/21/26 at 10:23 AM of Resident #1 revealed he was in bed that had been lowered. His left knee leaned against the wall/windowsill. The board of the windowsill was splintered/cracked and under that were three nails approximately 1/4 inch sticking out of the wall and the resident was near where the cracked/splintered board and nails were. Resident #1 said the splintered board and nails had been like that for a while and could not give an approximate timeframe. He said the staff knew about it but could not stay which staff. The resident also said he often scraped his legs and foot on the splintered board and nails. Observation on 07/21/26 at 1:24 PM of Resident #1's leg skin assessment done by LVN A revealed there were no scrapes/scratches to the outside of the resident's leg that leaned against the wall. LVN A said the resident had been out to the hospital for about a month and he had recently been re-admitted . She had not noticed the broken windowsill and the nails sticking out of the wall. LVN A said if things like that were noted, they were to report it to the Maintenance Director.Interview on 07/21/26 at 3:01 PM with LVN B revealed she had noticed the cracked/splintered board and the exposed nails of Resident #1's windowsill for about a month. LVN B said she did not notify anyone of the broken windowsill. LVN B further stated if broken things like that were noted in resident rooms, the Maintenance Director should be notified so it can be fixed to keep the residents safe, but LVN B did not say why she had not reported the broken windowsill. Interview on 07/21/26 at 4:38 PM with the Maintenance Director revealed he had worked at the facility for about three months and was not aware Resident #1 had a broken windowsill or of the exposed nails. The Maintenance Director said staff should report things like that immediately so he could fix it because it was a big safety issue for the resident. Interview on 07/21/26 at 5:37 PM with the Administrator revealed he was not aware of Resident #1's broken windowsill or the exposed nails on the wall. The Administrator said things like that should be reported right away so they can get fixed because they are a safety issue to the residents. Record review of the facility's policy titled Maintenance Service revised December 2009 reflected the following: .1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to:.b. maintaining the building in good repair and free of hazards.

Based on interview and record review, the facility failed to ensure the appropriate information was communicated and follow a written policy on immediate discharge of Resident #1 reviewed for discharge processes.The facility failed to ensure resident was sufficiently prepared and oriented to ensure safe and orderly transfer or discharge from the facility.This failure could place the residents in an unsafe discharge.Findings Included:Record review of Resident #1's MDS Quarterly Set assessment dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with a BIMS score of 13 (cognitive function is intact). Primary active diagnoses included medically complex conditions; Coronary artery Disease(a common heart problem caused by plaque buildup), Heart failure, Hypertension(a common condition where the force of blood pushing against your artery walls is consistently too high), diabetes mellitus, seizure disorder, anxiety disorder, depression, bipolar disorder, post traumatic stress disorder and chronic pulmonary disease (condition that affects the airways, lung tissue, or blood vessels in the lungs, making it hard to breathe). Section E- Behavior reflected no physical, verbal, or other behavioral symptoms directed towards others Record Review of Resident #1's discharge MDS assessment dated [DATE] revealed an unplanned discharge on [DATE]to the home/ communityRecord review of Resident #1's care plan revealed Focus - Resident #1 was a smoker; date initiated: 03/16/2026; interventions included: instruct resident about smoking risks and hazards and about smoking cessations aids that are available. Instruct residents about the facility policy on smoking: locations, times, safety concerns. Focus- resident has a behavior problem r/t BIPOLAR DISORDER- Resident #1 tends to make irrational untrue statements, and calls staff conartist when she does not get her way as desired, False accusations against staff (06/27/2026). Interventions- Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Record review of Resident #1's Smoking assessment dated [DATE] revealed 8. Does resident need facility to store lighter and cigarettes -No. Notes on safety from IDTC- Resident #1 met criteria for safe smoker. Record review of Resident #1's notice of involuntary Transfer or discharge and opportunity for appeal dated 06/23/2026 revealed Date of notice 06/23/2026- Effective date of transfer or discharge 07/23/2026. Reason for Discharge- the safety of individuals in this facility was endangered, as document in clinical record. Location to which Resident #1 would be discharged : community shelterRecord review of Resident #1's EMR progress notes dated 06/28/2026 revealed Resident #1 stated multiple staff members came into her room at night and beat her up by punching her stomach, then walked away. The resident refused the nurse to perform any kind of assessment on her. Police department called and abuse coordinator made aware. Record review of Resident #1's EMR progress notes dated 06/30/2026 revealed Resident #1's discharge planning needs were discussed with the resident's family member, who expressed concerns regarding the alternate placement option. Resident transported to facility by the family member. Resident transition appeared successful at this time.Record review of Resident #1's Immediate Discharge notice dated 06/30/2026 revealed reason for discharge- This discharge, or transfer is necessary for your welfare because your needs cannot be met in this facility, as documented in your clinical record by your physician. (c) the safety of individuals in this facility is endangered, as document in clinical record. Discharge location- community shelter. Record review of Resident #1's Patient Dismissal for Services dated 06/30/2026 This letter serves as notice of dismissal of all medial services for Resident #1, as she had continued to behaviors towards others, not following the smoking policy, as she had been seen smoking in her room, and the facility not being able to meet her needs, despite interventions being in place of behavior contracts, medication management, and redirection from staff in attempts to address behavior. Recommend alternative placement at his time. The homeless shelter is a safe discharge and she is able to administer her own mediations. Signed by medical doctor. An interview on 07/16/2026 at 12:01 PM with the Ombudsman revealed; she was not contacted regarding the discharge. She stated she was informed of the discharge from State Office. An interview on 07/16/2026 at 1:13 pm with the Social Worker revealed she presented resident #1 with discharge paperwork on 06/23/2026. She stated during the 06/30/2026 immediate discharge, she assisted with transportation and discharge communication with the medical doctor. An interview on 07/16/2026 at 1:38 pm with LVN 1 revealed during morning meeting on 06/30/2026, a staff member came and stated Resident #1 was smoking in her room. The administrator went to resident #1's room, at that time, due to the safety of other residents she would be discharged . Her family member came to the building, and he was upset because of the discharge of smoking in the building. The Family member did not believe she was smoking in the building. Resident #1 and the family member were resistant to the discharge. The social worker planned transportation for the discharge. Clinical staff signed off on the medication and medication list.An interview on 07/16/2026 at 2:40 pm with Resident #1's family member revealed Resident #1 was given a 30-day discharge because they accused her of assaulting a nurse. He stated then they accused her of smoking in her room. He stated there was no evidence of her smoking in her room. He stated Resident #1 called him and informed him that she received an immediate discharge, and he drove to the facility. He stated he was given 45 minutes to find somewhere for her to go because they were discharging her to a homeless shelter. He stated he drove Resident #1 to the group home. An interview on 07/16/2026 at 4:11 PM with Activity Director revealed on the morning of 06/30/2026, she was walking in the hallway on her way to the morning meeting. She stated when she got close to resident #1's room, she could tell there was cigarette smoke coming from Resident #1's room. She stated she informed the Administrator and when he opened the resident's door she stated, the smoke got to me. She stated she did not see a lit cigarette or the resident smoking in her room; just the smoke triggered her asthma. She stated Resident #1 became enraged and then Activity Director removed herself from the situation. An interview on 07/16/2026 at 4:42 pm with the admin revealed he stated Resident #1 was given a 30-day discharge notice after she made allegations of abuse. She stated the nighttime staff physically abused her, but would not allow any assessments. At that time, it was determined that the facility could not meet her needs based on Resident #1's refusal of staff care. On the morning of 06/30/2026, staff members informed him that Resident #1 was smoking in her room. He stated that the room was smokey when he entered, but he did not see a lit cigarette or Resident #1 smoking. He stated there was evidence that she had cigarettes in her possession. He stated there were no previous documented incident of the resident not smoking in designated areas. He then stated the following steps were taken for the immediate discharge;He stated he did not call the family member because Resident #1 was her own responsible party.Review of Cretia- danger to yourself and others and cannot meet resident needs.Notified Long Term Care Program managerNotified the medical doctorEmailed discharge paperwork to Program Manager and Ombudsman Supervisor.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Resident #1, #2 and $4) of 7 residents reviewed for reasonable accommodation of needs. 1.The facility failed to ensure the call light system in Resident #1's rooms was in a position that was accessible to the resident on 07/14/2026. 2.The facility failed to ensure the call light system in Resident #2's rooms was in a position that was accessible to the resident on 07/14/2026. 3.The facility failed to ensure the call light system in Resident #4's rooms was in a position that was accessible to the resident on 07/14/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency and not having their needs met.Findings included: 1.Record Review of Resident #1's Face Sheet, dated 07/14/26, revealed a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with Dementia (A progressive loss of memory, reasoning and communication skills). Record Review of Resident #1's MDS assessment dated [DATE], revealed the Resident had a BIMS score of 10 (moderate cognitive impairment). The MDS Assessment indicated that the residents required partial to moderate assistance for toileting and transfer. Record Review of Resident #1's Comprehensive Care Plan, dated 03/31/26, revealed the resident has an ADL self-care performance deficit r/t Dementia. During an observation and interview on 07/14/26 at 9:50 a.m. revealed Resident #1 was in his bed, awake. It was observed that the resident's call light was on a nightstand that was located at the foot of Resident #1's bed out of his reach. The resident did not respond when asked about the location of the call bell. 2.Record Review of Resident #2's Face Sheet, dated 07/14/26, revealed a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with Dementia (A progressive loss of memory, reasoning and communication skills). Record Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed the Resident had a BIMS score of 4 (severe cognitive impairment). The MDS Assessment indicated that the residents required partial to moderate assistance for toileting/personal hygiene. Record Review of Resident #2's Comprehensive Care Plan, dated 01/03/22, revealed The resident is High risk for falls r/tGait/balance problems, Psychoactive drug, with intervention to Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During an observation on 07/14/26 at 10:02 a.m. revealed Resident #2's was in his bed awake, his call light was stuck between his mattress and the head of his bed and was out of his reach. 3.Record Review of Resident #4's Face Sheet, dated 07/14/26, revealed an [AGE] year-old male admitted on [DATE]. The resident was diagnosed with Dementia (A progressive loss of memory, reasoning and communication skills) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills) Record Review of Resident #4's Quarterly MDS assessment dated [DATE], revealed the Resident had a BIMS score of 9 (moderate cognitive impairment). The MDS Assessment indicated that the residents required supervision or touching assistance for toileting hygiene, toilet transfer and chair to bed transfer. Record Review of Resident #4's Comprehensive Care Plan, dated 07/28/24, revealed the resident had an ADL self-care performance deficit r/t Disease Process UNSPECIFIED DISPLACED FRACTURE OF FIFTH CERVICAL VERTEBRA, SEQUELA (aftereffects of previous disease). Intervention revealed to Encourage the resident to use bell to call for assistance. During an observation and interview on 07/14/26 at 10:08 a.m. it was observed that Resident #4's call light was hanging on the wall at off the base of the call light station. It was pointed out to LVN K, and she moved the call light from the wall and placed it on Resident #4's bed next to him. LVN K stated that per the facility policy all staff make rounds on the residents every 2 hours making sure that call lights are within reach of the residents. She stated that Resident #4 moved things around a lot. During an observation and interview on 07/14/26 at 10:10 a.m. with Resident #4, he stated that he was not sure who moved his call light, he stated that he likes it next to him on his bed. During an interview on 07/14/26 at 1:12 p.m. with Housekeeper E, she stated that if a call bell is observed on the floor she picks it up, sanitizes it and clips it to the bed to be compliant with the facility policy to have the call bell always reachable to the resident. She stated that if the call bell does not have a clip, she reports it to the housekeeping supervisor to have it replaced. She stated that if the call bell is not reachable the residents will not be able to call for assistance when needed. She stated that if they tried to reach the bell if it was not within reach, they could fall and injure themselves. During an interview on 07/14/26 at 1:53 p.m. with LVN K, she stated that the facility policy requires that call bells should always be within reach for each resident even when the resident cannot use the call bell. She stated that all staff are responsible for making sure that all call bells are within reach of the residents when they make rounds. She stated that if the call bell is not within reach the resident will not be able to call for assistance, she stated that this is especially important if they are having an emergency. She stated that not having the call bell in place will result in the residents need not being met in a timely fashion. During an interview on 07/14/26 at 3:50 p.m. with CNA A, she stated that per the facility policy, call lights needed to always be within reach of the resident and answered in a timely manner to meet the resident needs. She stated that prompt answering of the call bell prevents any possible falls, prevents residents from sitting in their urine which would lead to skin breakdown. She stated that all CNA's are responsible to answer any call lights even if it was not their assigned residents. During an interview on 07/14/26 at 4:42 p.m. with the Administrator, he stated that all call lights must always be within reach. He stated that some residents don't want them to be clipped to their bed which they have the right to request. He stated we go round every two hours but that it is usually more frequent. He stated that every staff member is responsible for making sure the call bell is withing reach of every resident even if they can't use it. He stated that if the call light is not within reach or not answered in a timely manner, the residents' needs will be unaddressed. During an interview on 07/14/26 at 5:38 p.m. with the DON she stated that the facility policy is that the call light must always be within reach of each resident. She stated that all facility staff are responsible for making sure that all call bells are within reach to each resident. She stated that they have provided training for staff on this. She stated that the call bell placed within reach enabled the residents to call for help when they needed to and get prompt help for all their needs. She stated that falls and a variety of accidents could occur and the residents' needs would not meet. A record review of the facility's Resident Rights Policy statement revealed that: Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include theresident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints notrequired to treat the resident's symptoms;e. self-determination;f. communication with and access to people and services, both inside and outside the facility;

Based on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for 3 of 8 residents' rooms and 1 resident hallway (Resident #5, #7,#8 and 200 hall) reviewed for pest control. 1. The facility failed to ensure that Resident #5's room was free from gnats on 07/14/26. 2. The facility failed to ensure that the 200 hall was free from gnats on 07/14/26. 3.The facility failed to ensure that Resident #7's room was free from gnats on 07/14/26. 4.The facility failed to ensure that Resident #8's room was free from gnats on 07/14/26. This failure could place residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and a diminished quality of life. Findings included: 1.Record review of Resident #5's face sheet, dated 07/14/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with Cerebral palsy (a lack of muscle control). Record review of Resident #5's Quarterly MDS Assessment, dated 07/09/26, revealed had a BIMS score of 10 (moderate cognitive impairment). The resident was coded as being dependent for all ADLs Record review of Resident #5's Comprehensive Care Plan, dated 09/08/25, revealed the resident has limited physical mobilityr/t CEREBRAL PALSY, with intervention to Provide supportive care, assistance with mobility as needed. Document assistanceas needed. During an observation on 07/14/26 at 10:21 a.m. multiple gnats were observed flying in Resident #5's room while wound care was being observed. This was also noticed by LVN K. 2.During an observation on 07/14/26 at 10:58 a.m. revealed that gnats were flying around the 200 hall. 3.Record review of Resident #7's face sheet, dated 07/14/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with Lack of coordination, generalized anxiety (constant worry, chronic fretting, or being stuck in what-if mode). Record review of Resident #7's annual MDS Assessment, dated 06/15/26, revealed had a BIMS score of 12 (moderate memory and thinking problems). The resident was coded as needing supervision or touching assistance with ADLs. During an observation on 07/14/26 at 11:00 am, it was revealed that Resident #7 was in his room resting in bed and multiple gnats were observed flying around in his room. 4.Record review of Resident #8's face sheet, dated 07/14/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with Type 2 diabetes (high blood sugar). Record review of Resident #8's Quarterly MDS Assessment, dated 06/06/26, revealed had a BIMS score of 14 (no cognitive impairment). The resident was coded as needing supervision and assistive touch with ADLs.During an interview on 07/14/26 at 11:55 a.m. with Resident # 8 stated that she saw cockroaches, water bugs, flies and gnats throughout the facility. She stated that the bugs should not be in the facility where people must live. During an interview on 07/14/26 at 1:12 p.m. with Housekeeper E, she stated that she has noticed gnats and other flying insects in the facility. She stated that she logs any sightings in the pest control logbook and informs the maintenance supervisor about it. She stated that pest control comes out to spray the facility for insects. She stated that no one wants to live in an environment with gnats flying all over the place. She stated that the gnats could bite the residents and even spread disease if not eliminated. During an interview on 07/14/26 at 1:53 p.m. with LVN K, she stated that if she notices any insects she writes it down in the pest control log and makes a verbal report to the maintenance department. She stated that gnats, flies and roaches have been an issue for a while and they have been trying to get rid of them and their source. She stated as residents go in and out of the building they let the flying insects in the building. She stated that having the gnats in the building could be a nuisance to the residents and can bite and spread disease. During an interview on 07/14/26 at 3:50 p.m. with CNA A, she stated that she has noticed gnats, flies and roaches in the building. She stated that this is due to food sitting around. She stated that she does her rounds to clean as much as possible and housekeeping does rounds also to clean. She stated that the residents should live in a pest-free environment since the pest can bite and get in the food, she stated that it is unsanitary to have pests. She stated that she reports any sighting of pest to housekeeping. She stated that being in an environment that has pests can affect the residents emotionally and frustrate them if they keep having to fight of pest. During an interview on 07/14/26 at 4:42 p.m. with the Administrator, he stated that they had a pest control issue in the past six months and that staff are aware to log any issues in the pest control logbook and then report the issue to the maintenance department. He stated that the pest control company comes in routinely every 2 weeks for routine visits and more frequently if needed. She stated that they do their best to provide a pest free environment. He stated that the risk to the residents is that they will not be in a pest free environment and the facility will not be a homelike environment for them. During an interview on 07/14/26 at 5:38 p.m. with the DON, she stated that the goal is to have a pest-free environment for all residents. She stated pest issues should be handled as soon as they are noted. She stated that they have a logbook to report any pest issues and make a verbal report to maintenance. She stated that all facility staff are responsible for logging and report any pest issues they come across. She stated that the pest control company comes out every 2 weeks routinely and as needed if a pest issue is reported. She states that in could be a nuisance and annoying to the residents to live in an environment with insects. Record review of the facility Pest Control Policy Statement revealed: This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.Garbage and trash are not permitted to accumulate and are removed from the facility daily.Maintenance services assist, when appropriate and necessary, in providing pest control services. A record review of the facility pest sightings / corrective actions logbook revealed the following: On 05/20/26 cockroaches were observed in room [ROOM NUMBER]On 5/26/26 gnats were observed in room [ROOM NUMBER]On 06/17/26 water bug was observed in 100 hall shower roomOn 06/25/26 little ants were observed in room [ROOM NUMBER]On 07/01/26 roaches were observed in room [ROOM NUMBER] A&BOn 07/02/26 roaches were observed in room [ROOM NUMBER] A&BOn 07/06/26 roaches were observed in room [ROOM NUMBER]On 07/14/26 gnats were observed in room [ROOM NUMBER] A

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable environment for residents', staff and the public for 1 of 3 halls (300 Hall) and 1 of 7 rooms (Resident #6's room) reviewed for environment. The facility failed to ensure that the floor in 300 halls was clean was clean and dry on 07/14/26. The facility failed to ensure that the floor in Resident #6's room and its bathroom was clean and dry on 07/14/26. This failure could affect residents living in these halls by placing them at risk for diminished quality of life due to the lack of a well-kept environment.Findings included: Observation on 07/14/26 at 9:50 a.m. revealed in 300 hall, 2 water poodles on the floor while walking the 300 hall. Record Review of Resident #6's Face Sheet, dated 07/14/26, revealed a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with Depression and Preglaucoma (suspected glaucoma) Record Review of Resident #6's admission MDS assessment dated [DATE], revealed the Resident had a BIMS score of 15 (no cognitive impairment). Record Review of Resident #6's Comprehensive Care Plan, dated 07/12/26, revealed the resident is risk for falls, with the goal of the resident will be free of falls through the review date. Interventions were: The residents needs a safe environment with: (SPECIFY: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach) A record review of the facility's grievance log revealed that on 07/11/26 Resident #6 was upset regarding the condition of the bathroom upon admission. It revealed Resident #6 was moved to room [ROOM NUMBER] as a resolution on 07/11/26. During an observation and interview on 07/14/26 at 10:35 a.m. with Resident #6, a water poodle was observed on the room floor and the bathroom floor. Resident #6 stated that she had reported that the floor in her room and bathroom is always wet due to her roommate having accidents when trying to reach the bathroom and it had not been addressed. She stated that she does not want to fall. During an interview and observation on 07/14/26 at 11:05 a.m. it was observed that Housekeeper S was cleaning the floor in room [ROOM NUMBER]. She stated that she was the housekeeper for the 200 hall. She stated that another housekeeper informed he that there was a spill in room [ROOM NUMBER]. She stated that she cleans every room upon her arrival and checks several times throughout her shift. She stated that if she noticed a spill, she stops what she was doing and immediately cleans it up to avoid any slip and falls of residents or staff. During an interview on 07/14/26 at 1:12 p.m. with Housekeeper E, she stated that she makes daily rounds to clean up her halls and rooms, she stated she checks twice a day and as needed. She stated that for residents who have been identified for spilling liquids in their rooms or who are known for having urine leakages before they make it to the restroom, she checks those rooms 2-3 times a day. She stated that the CNA's and the nurses let her know if there are spills in any rooms or hallways. She stated that spills should be cleaned up as soon as they occur to prevent falls and injuries. During an interview on 07/14/26 at 1:53 p.m. with LVN K, she stated that if she notices a spill she cleans it up or if she is in the middle of a task, she places a spill cone and notifies housekeeping for assistance. She stated that every staff member who makes rounds is required to keep an eye out for spills since it is a safety concern for residents who are a falls risk to fall and hurt themslves. She stated that some residents spill things and pass urine on the floor due to inability to reach the restroom on time and that sometimes poses a challenge to clean up spills in a timely manner since they may not be aware of them. She stated that they try to mitigate this by doing frequent rounds as much as they can. She stated that if spills are not cleaned in a timely manner it can result in slips and falls that could cause serious injuries. During an interview on 07/14/26 at 3:50 p.m. with CNA A, she stated that when she notices a spill she wipes it off and puts a wet floor sign over it and she also reports to housekeeping. She states that every staff is responsible for reporting spills as they make their rounds. She stated that wiping spills prevent slips and falls and can hurt the residents if they break a bone. During an interview on 07/14/26 at 4:42 p.m. with the Administrator, he stated that a lot of the residents who are independent spill tea and coffee when they move around with their drinks. He stated that some residents with incontinent issues tend to have accidents trying to reach the bathroom and refuse to wear briefs. He stated that they keep a few mops where staff can reach them to clean up spills. He stated that the expectation is that all spills should be cleaned as soon as possible to avoid falls which can lead to injury to the residents. During an interview on 07/14/26 at 5:38 p.m. with the DON, she stated that any spills should be taken care of as soon as possible. She stated that any staff member who notes a spill are responsible for making sure it is wiped off the floor to avoid slip and fall injuries which could cause injuries for the residents and staff.

Based on observation, interview and record review, the facility failed to store drugs in a safe and secured manner to permit only authorized personnel to have access for 1 of 2 areas (Administrator's desk drawer and oxygen supply room on hall 100). The facility failed on 06/17/2026 to ensure that medications were secured behind a locked mechanism (either in the medication supply room or a medication cart) to ensure the safety of the residents when medications were found in an unsecured desk drawer in an unsecured office and in an unsecured oxygen room on hall 100 with the DON. This failure placed residents at risk of being able to access medications not prescribed to them, with the potential to have side effects or possible overdoses.Findings included: Observation on 06/17/26 at 1:40 PM revealed the DON was able to open the Administrator's door without key access as well as the Administrator's desk drawer without key access. The Administrator's desk did not have a locking mechanism on his desk. And the Administrator's office also had no working lock on his office door. Therefore, the door was unable to be locked. Observation revealed numerous packs of medications in the administrator's top right desk drawer including: 1 Simvastatin tab 20 mg, Prazosin Cap 1mg, Risperidone tab 2mg, Buspirone tab 7.5mg, Famotidine tab 20mg, Atorvastatin tab 10mg, Duloxetine DR cap 30mg, Baclofen tab 10mg, Carvedilol tab 25mg, Losartan tab 50mg, Olanzapine tab 10mg, and Hydralazine tab 25mg. Observation on 06/17/26 at 1:46 PM of the oxygen supply room behind the nurses' station on the 100-hall revealed the DON was able to open the door without key access. Observation also revealed there was a bottle of Atorvastatin tab 40 mg with 100 tablets inside the bottle as well as a bottle of Benzonatate cap 100mg with 26 capsules inside the bottle. The two bottles of medications were found behind an unlocked cabinet with no locking mechanism in the oxygen supply room. Interview on 06/17/26 at 1:50 PM with the DON revealed that the Administrator was out of town on vacation and unavailable for interview. Interview with the DON also revealed that it was the responsibility of all nurses to ensure that all medications were placed in a secure area. The DON stated that the facility policy was that all medications should be stored in the 200-hall medication room behind the locked door. The DON said that all narcotics are to be placed under a double locking system. The DON stated that all narcotics should be placed in her office behind her locked door and in a locked cabinet or in a locked drawer on a locked medication cart. The DON stated that discarded medications should be placed in the 200-hall medication room in a large trash can which has a lock on it. The DON stated that narcotics that are discarded as well as duplicate cards of narcotics are also placed in her locked office inside the locked cabinet in her office. The DON stated that management rounds daily in the medication rooms to look for items such as these to ensure that they are secure and not accessible to residents. The DON was unable to explain how or why medications were in the unsecured Administrator's desk drawer of the Administrator's unsecured office or in the unsecured oxygen supply room. The DON stated that if a resident had ingested any of these medications, the medication could have interacted with their own medications. The DON stated that their policy states to secure all medications. The DON revealed that if a staff member (not including a nurse) had found the medications, they should have reported it to a nurse or nurse management on site immediately and brought it to them. The DON stated that she would in-service her nursing staff to ensure that they secure all medications. The DON stated that she would address the unsecured medications in the next QAPI meeting as well. Interview on 06/18/26 at 1:00 PM with LVN A revealed that she was unaware of the unsecured medications in the oxygen supply room behind the nurses' station on the 100-hall. LVN A also was unaware of any unsecured medications in the Administrator's desk drawer in his unsecured office. LVN A stated that the facility policy and procedure of receiving medications should prevent unsecured medications from being accessible to unlicensed staff because a nurse must sign for all medications. LVN A stated that if anyone finds medications unsecured, they should report it to nursing management immediately. The LVN A also stated that if residents found unsecured medications, they could take the medication inappropriately and possibly have an allergic reaction, change in blood pressure, or change in their heart rate. LVN A revealed that nurses and medication aides were responsible for securing all medications in the building. Interview on 06/18/26 at 5:09 PM with ADON revealed she was unaware of the unsecured medications in the oxygen supply room behind the nurses' station on the 100-hall. LVN A also was unaware of any unsecured medications in the Administrator's desk drawer in his unsecured office. The ADON said that the facility policy was that all incoming medications were signed by a nurse on duty. The ADON said that if medications are found unsecured, the DON should be notified immediately. The ADON also stated that it was the nurses' responsibility to ensure that medications are secured properly in the medication room and locked medication carts and medication bins. ADON stated that if residents consume medications that are not their medications, it could lead to abnormal vital signs. Review of facility's current Storage of Medications policy, revised November 2020, reflected the following: 1. Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications have access to locked medications.3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use.

Based on interview and record review the facility failed to review and revise the resident's comprehensive care plan after each assessment including both the comprehensive and quarterly review assessments for 1 of 2 residents (Resident #1) reviewed for care plans. The facility failed to update Resident #1's care plan to reflect change in behavior needs for a resident with change in condition. This failure put residents at risk of not having their needs met and a decreased quality of life. Findings Included:Record Review of Resident #1's admission Record revealed- [AGE] year old male admitted to the facility on [DATE] with the following diagnosis: paraplegia (a term used to describe the inability to voluntarily move the lower parts of the body). Record Review of Resident #1's Care Plan revision date 04/02/2026 revealed; The resident has an alteration in neurological status r/t mild cognitive impairment of uncertain or unknown etiology. Interventions- Monitor/document and report PRN s/sx of tremors, rigidity, dizziness, changes in consciousness, slurred speech. Report to LPN and RN. Record Review of Resident #1's Minimum Data Set (MDS) Nursing Home Quarterly dated 05/29/2026 revealed- BIMS score of 13 (indicated no cognitive impairment). Section E-Behavior; Potential indicators of Psychosis- None of the above. Behavioral Symptoms-Presence and Frequency. Physical behavioral symptoms directed toward others (Behavior not exhibited), Verbal behavioral symptoms directed toward others (Behavior not exhibited), Other behavioral symptoms not directed toward others (Behavior not exhibited). Rejection of Care-Presence and Frequency. Did the resident reject evaluation of care that is necessary to achieve the resident goals for health and well-being? (Behavior not exhibited).Record Review of Resident #1's Physicians Orders dated 02/26/2026 revealed, Behavior Monitoring- Antianxiety Behavior Code: 0 None 1. Restlessness 2. Pacing 3. Continuous cry for help 4. Afraid/panic 5. Repetitious movements 6. Verbalizations of anxiety 7. Other (Document in PN) Interventions: Document in PN every shift. Record Review of Resident #1's Progress notes created by RN A dated 05/23/2026 at 14:39 revealed; Resident #1 acting in a non normal way. Upon assessment Resident #1 had taken apart wheel chair, and requesting it to be put back together, he had taken the seat and put it behind the HOB. Resident #1 had taken broken cigarettes and put them in his shorts, he kept turning from side to side constantly moving in bed, kept moving pillow from top of bed to side of bed appears to be tweaking . Demanding lights to be turned off, and blinds closed. Pupils dilated. 1115 CNA attempted to change brief, he refused to turn. Kept saying thing shat very non understandable . 1130 resident had removed all clothing, thrown about room. 1200 refused to eat lunch, requested lights on had turned completely around in bed. Attempted to call resident family member no answer, called to inform administrator of condition. Will continue to monitor. 1300 stated he (Resident #1) stated he was alright. 1400 Appears to be acting more like self 1430 up in w/c about the facility, will continue monitor. During an interview on 06/04/2026 at 11:50 AM Resident #1 stated he feels safe in the facility but does not like being in the facility because it is a bunch of old people. He stated he will sign himself out and go to various retail shops in the area. During an interview on 06/04/2026 at 3:42 PM with DON revealed; the expectation was the medical director should be contacted when there is a change of condition and refusal. The risk is a change of condition could not be handled correctly, and the resident's condition worsens.

Based on observation, interview, and record review , the facility failed to provide a safe, clean, comfortable and homelike environment for 5 of 12 residents (Resident # 1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for environment. The facility failed to ensure bathroom floors were clean and in good repair for Resident #1, Resident #2, Resident #3, Resident #4's and Resident #5's bathrooms on the 300 hall male secured unit. This failure could place residents at risk for diminished quality of life due to unclean, unhealthy, and un-homelike living conditions and possible infections. Findings included:Record review of Resident #1's quarterly MDS, dated [DATE], reflected Resident #1 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with active diagnoses that included non-Alzheimer's dementia (any form of cognitive decline not caused by Alzheimer's diseases encompassing dozens of conditions) and psychotic disorder than than schizophrenia (group of conditions defined by a loss of contact with reality, primarily characterized by hallucinations, delusions, or disorganized thinking). Record review of Resident #2's quarterly MDS, dated [DATE], reflected Resident #2 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with active diagnoses that included non-Alzheimer's dementia (any form of cognitive decline not caused by Alzheimer's diseases encompassing dozens of conditions) and psychotic disorder than schizophrenia (group of conditions defined by a loss of contact with reality, primarily characterized by hallucinations, delusions, or disorganized thinking). Record review of Resident #3's quarterly MDS, dated [DATE], reflected Resident #3 was initially admitted on [DATE] and re-admitted on [DATE] with active diagnoses that included non-Alzheimer's dementia (any form of cognitive decline not caused by Alzheimer's diseases encompassing dozens of conditions) and schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). Record Review of Resident #4's quarterly MDS, dated [DATE], reflected Resident #4 was admitted on [DATE] with active diagnoses that included non-Alzheimer's dementia (any form of cognitive decline not caused by Alzheimer's diseases encompassing dozens of conditions) and schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). Record review of Resident #5's admission record, dated 06/01/26, reflected Resident #5 was admitted on [DATE] with diagnoses of unspecified dementia, severe, with agitation (an advanced stage of cognitive decline paired with significant behavioral disturbances) and schizophrenia, unspecified (group of conditions defined by a loss of contact with reality, primarily characterized by hallucinations, delusions, or disorganized thinking). Observation on 05/19/26 at 11:10 A.M. of Resident # 3, Resident #4 and Resident #5's bathroom revealed approximately 11 missing tiles on the wall and a dark black substance on the floor at the base of the toilet. Observation on 05/20/26 at 11:40 A.M. of Resident #1 and Resident #2's bathroom revealed approximately 10 missing tiles on the wall and a dark black substance on the floor at the base of the toilet. Interview on 05/19/26 at 9:36 AM with Resident #4 revealed that Resident #4 was unable to answer questions during interview due to cognitive decline. Interview on 05/19/26 at 10:00 AM with Resident #3 revealed that Resident #3 was unable to answer questions during interview due to cognitive decline. Interview on 05/19/26 at 10:19 AM with Resident #2 revealed that Resident #2 was unable to answer questions during interview due to cognitive decline. Interview on 05/19/26 at 10:37 AM with Resident #1 revealed that Resident #1 was unable to answer questions during interview due to cognitive decline. Interview with Resident #5 was not attempted on 05/19/26.Interview on 05/20/26 at 11:46 AM with CNA B revealed that she primarily worked the men's secured unit Monday through Friday 6:00 AM through 2:00 PM. CNA B also stated she had not noticed the missing tiles and black substance on the floors of the bathrooms of Resident #1, Resident #2, and Resident #3, Resident #4, and Resident #5. CNA B stated both residents were incontinent in room [ROOM NUMBER], but they could wander in the bathroom, or other residents could go in their bathroom. CNA B stated that the residents in rooms 302 and room [ROOM NUMBER] utilize their bathrooms. CNA B stated it was the facility's policy that if nursing staff observed maintenance issues, they should report it as soon as possible to the Maintenance Director or the nurse. CNA B revealed it was everyone's responsibility to notify someone if there were broken items or if something needed repair in residents' rooms and bathrooms. CNA B also stated that if she saw broken items in a room or bathroom, she should report the needed repairs to the nurse. CNA B also said that if she saw the maintenance director in the hallway, she would report the issue directly to him. CNA B stated broken tiles could affect a resident by causing the residents to trip, thereby hurting them. CNA B revealed the black substance on the bathroom floors could cause harm to residents because it could be an infection control issue. Interview on 05/20/26 at 12:02 PM with LVN A revealed she was employed at the facility for approximately a week. LVN A stated it was the nurses' and CNAs' responsibility to report maintenance issues to ensure the residents' rooms and bathrooms stayed in good repair for the residents' safety. LVN A stated that nurses should report maintenance issues to the Maintenance Director. LVN A revealed that she had not seen the black substance on the bathrooms' floors and had not noticed the missing tiles in either of the bathrooms. LVN A stated she should have reported these issues to the Maintenance Director. LVN A stated that the missing tiles could affect the residents by causing the residents to trip and fall or the residents could be cut from the tile. LVN A stated that the black substance on the bathroom floors could be an infection control issue. Observation and interview on 05/20/26 at 12:20 PM with the Maintenance Director revealed he was employed at the facility for approximately two weeks. The Maintenance Director stated his primary responsibility was to ensure the facility was kept in good working order. The Maintenance Director also stated he received information on repairs needed from an application on his phone or verbally in-person from the staff and residents as well. The Maintenance Director stated that when he received notice of needed repairs that were a safety concern, he completed them immediately because it prevented residents from being hurt. The Maintenance Director stated it was everyone's responsibility to notify him of repairs needed throughout the building, including residents' rooms and bathrooms. The Maintenance Director also revealed that it was his responsibility and his assistant's responsibility to complete maintenance requests. The Maintenance Director stated he was not notified about the two bathrooms prior to this surveyor's entrance. The Maintenance Director revealed missing tiles in residents' bathrooms were a health and safety concern because they were sharp and could also cause a resident to trip and fall. The Maintenance Director stated that the dark black substance could be a result from the water leak or not being cleaned thoroughly. The Maintenance Director stated that if he could not repair something in the building, the facility's process and procedure would be to obtain an estimate and provide it to the Administrator. Interview on 05/20/26 at 12:29 PM with the ADON revealed she had not seen the missing tiles and had not seen the dark black substance around the toilets in the bathrooms of Resident #1, Resident #2, and Resident #3, Resident #4, and Resident #5. The ADON stated it was everyone's responsibility to look at residents' rooms and bathrooms to ensure they were in good working order. The ADON stated the facility had champion rounds in which department heads made rounds entering all rooms to look for items that needed repair. The ADON stated all staff should speak up and report any item needing repair. The ADON said she expected the staff to use the maintenance application posted throughout the facility to report needed repairs. The ADON stated that the facility policy for residents was that they must have a clean, safe homelike environment, and she expected staff to use effective communication to create that homelike environment. The ADON also stated the facility policy was that all maintenance issues should be reported to the Maintenance Director and the Administrator. The ADON stated that missing tile could cause residents to harm themselves, and a dark black substance could cause harm to the residents. Interview on 05/20/26 at 1:26 PM the Administrator stated he expected staff to report the missing tile and the dark black substance. The Administrator stated staff were to use the maintenance application provided by the facility to report maintenance issues. The Administrator stated that any staff could report maintenance issues. The Administrator said the CNAs could report maintenance issues to their charge nurse or use the maintenance application. The Administrator stated it was everyone's responsibility to report items that needed repair in residents' rooms and bathrooms. The Administrator stated the Maintenance Director was responsible for facility repairs, and it was his (Administrator's) responsibility for following up on the repairs to ensure they are completed. The Administrator stated that missing tile could affect residents because residents could accidentally hurt themselves on the broken tile. The Administrator said that water build up could cause environmental issues. Record review of the facility policy titled, Homelike Environment Policy, dated 02/2021, reflected: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:Clean and sanitary environment.

Based on observation, interview, and record review, the facility failed to ensure all alleged violations involving abuse and neglect were investigated and reported to other officials (including the State Agency) and the administrator of the facility for 2 of 6 residents (Resident #1 and Resident #2) reviewed for reporting.The facility failed to follow its abuse policy by not reporting to the ADM of the alleged incident regarding Resident #1 pulling Resident #2 out their bed, so the ADM could not report the alleged incident to HHSC and the ADM could not investigate the alleged incident.This failure could place residents at risk for abuse and neglect.Findings included: Record review of Resident #2's face sheet, dated 05/01/2026, revealed an [AGE] year-old female, with a primary diagnosis of zoster (shingles, painful rash caused by reactivation of chicken pox virus). Other pertinent diagnoses included encephalopathy (group of condition that cause brain dysfunction), dementia, unspecified severity, with agitation (brain disease that alters brain function and causes a cognitive decline and agitated behaviors), Alzheimer's disease (brain condition that progressively destroys memory and other important mental functions), muscle weakness, lack of coordination, and abnormalities of gait and mobility. Record review of Resident #2's SNF Part A PPS Discharge MDS assessment (evaluation for when a resident's Medicare Part A coverage ends), dated 04/11/2026, revealed a BIMs (a standardized assessment to measure long and short-term memory) of 04, indicated severe cognitive impairment. Resident #2's functional abilities revealed she required full dependence or maximal assistance from staff; she could not walk 10 feet and used a wheelchair. Record review of Resident #2's progress notes, dated 04/29/2026, reflected, The nurse's aide informed us at the time of report that the resident was on the floor in front of her bed. Aide said it may have been her roommate that pulled her but could not be confirmed. Resident assessed w/ no injuries or pain. Vitals wnls. No bumps bruises or broken skin. Neuros started. DON, ADON, Family and Provider notified. Patient is sleeping in bed with eyes closed, respirations regular, even, and unlabored, no signs of distress noted. Bed is in lowest position with wheels locked. Call light and personal items within reach. Fluids and snacks offered. WCTM.Record review of Resident #1's face sheet, dated 05/01/2026, revealed a [AGE] year-old female, with a primary diagnosis of metabolic encephalopathy (brain disorder that occurs when a chemical imbalance of the blood affects the brain). Other pertinent diagnoses included severe dementia with agitation (brain disease that alters brain function and causes a cognitive decline and agitated behaviors), and delirium (rapidly developing severe confusion).Record review of Resident #1's MDS BIMS Staff Interview assessment, dated 04/07/2026, revealed Resident #1 had short-term and long-term memory problems and was severely impaired cognitively to make daily decisions. There was no score on the assessment document. Record review of Resident #1's progress notes, dated 04/01/2026 - 05/01/2026, did not reveal documentation about the alleged incident.Record review of Resident #2's Un-witnessed Fall incident report, dated 04/28/2026, reflected, . Nursing Description: The nurse's aide informed us at the time of report that the resident was on the floor in front of her bed. Aide said it may have been her roommate that pulled her but could not be confirmed. The resident was assessed, no injuries, bumps, bruises or broken skin. Resident states no pain. Vitals were obtained. DON, ADON, Provider and family notified. WCTM.During an observation and attempted interview on 05/01/2026 at 9:54 a.m., Resident #1 wandered the hall and interacted with other residents without behaviors. Resident #1 was not interviewable; Resident #1 did not respond directly to the questions asked and appeared to be confused. During an interview on 05/01/2026 at 12:51 p.m. CNA A stated she saw Resident #1 pull Resident #2 out of her bed. She said the residents were roommates and it happened on 04/28/2026 at about 10:00 p.m. CNA A said she came in the next day and saw Resident #2's hospice nurse, who said they did not receive a call about the incident. CNA A said she asked Resident #1 about her actions and Resident #1 said she was just trying to help Resident #2. The CNA said she did not tell the ADM but told the 2:00 PM - 10:00 PM nurse and 10:00 PM - 6:00 AM nurse. CNA A said she felt weird (uncomfortable) about the situation because Resident #1 was still living in the room with Resident #2. CNA A said when the 10:00 PM - 6:00 AM CNA arrived at shift change, she told her about the alleged incident too. During an interview on 05/01/2026 at 1:45 p.m. with LVN B, she said she came into her shift on the morning of 4/29/2026 and received a report Resident #2 fell. LVN B said the nurse on shift said CNA A told him Resident #1 may have pulled Resident #2 out of bed. LVN B said the hospice nurse talked to CNA A that morning (04/29/2026), and CNA A informed hospice of what she saw. LVN B said she reported the alleged incident in the morning meeting on 04/29/2026 with the ADON and SW, she was not sure if the ADM was there that morning. LVN B said she would report the alleged incident because it was different from what was said (the unwitnessed fall). She said residents may need to change rooms because Resident #2 could not speak for herself. During an interview on 05/01/2026 at 2:57 p.m., the ADON said she was alarmed by Resident #2's progress notes regarding the incident and that it was a reported fall by the 10:00 p.m. - 6:00 a.m. nurse. The ADON said no one informed her of the alleged incident in the morning meetings or throughout the day. The ADON said the nurse that wrote the progress note told her it was an unwitnessed fall. The ADON said Resident #1 had not been aggressive and her actions had been pleasant and sweet. The ADON stated Resident #1 and Resident #2 were not roommates, and Resident #2 had not had a roommate in a while. The ADON said she read the progress note this morning and showed the ADM. She said she was told the progress note was mis-documentation and it was an unwitnessed fall. The ADON said she expected nursing staff to report any allegation of physical abuse to the ADM. She said the risk of not reporting was the behavior could be repeated if Resident #1 did not like Resident #2. During an attempted interview and observation on 05/01/2026 at 3:15 p.m., Resident #2 was asleep with no signs of distress or injuries observed. During another attempted interview and observation on 05/01/2026 at 4:10 p.m. of Resident #2, LVN C came to Resident #2's room with the state surveyor. Resident #2's cognitive impairment limited her ability to talk to the surveyor. LVN C assessed Resident #2's head to ensure of no injuries. Resident #2 was able to communicate with LVN C that she needed changed, the state surveyor left the room. During an interview on 05/01/2026 at 4:15 p.m., LVN C said there were no injuries on Resident #2. LVN C said if an incident occurred when she was not in the facility, she would check on that resident when she came in for her next shift. LVN C said she was not aware of the incident regarding Resident #1 and Resident #2. She said after a fall or an incident occurred, she would do head-to-toe assessments, ask residents to move their limbs to make sure there was no range of motion issues, and do visual assessments. LVN C said the facility would then call the doctor and the doctor would want to know of any injury and what warranted the incident. During an interview on 05/01/2026 at 4:32 p.m., the ADM said he was not aware of the alleged incident, and he had just read the progress note an hour or two before the interview. He said he had not heard a statement from CNA A. He said he had the ADON interview CNA A and she had said the same thing (witnessing Resident #1 pulling Resident #2 out of bed). The ADM said he did not know why CNA A did not call about the incident. The ADM said that was something he would normally report. The ADM said if there was reasonable belief, he would treat the alleged incident the same. He said Resident #2 could not get up and walk. He said Resident #1 was very agitated when she was first admitted but had adjusted a lot but needed redirection. The ADM said this was an allegation and it needed to be reported correctly. The ADM said his perspective of the note was that he would have questioned if it should have been reported. He said the entire staff were taught on who to report to and mandatory reporting, and part of it was notifying supervisors and himself. He said if staff believed they saw abuse or neglect or someone reported it, the facility had to report it. During an interview on 05/04/2026 at 8:50 a.m., Resident #2's hospice nurse said she was told about the alleged incident after it occurred by CNA A. The hospice nurse said she came to the facility for a routine visit, the day after the alleged incident, and CNA A asked if she knew about the fall and she said no. The hospice nurse said she asked the ADON to pull up the report so she could review the incident report and vital signs. The hospice nurse said she heard the ADON saying what CNA A was reporting was wrong. The hospice nurse said she saw the note where CNA A said she witnessed the roommate (Resident #1) pulling Resident #2 out of bed. The hospice nurse said, at that time, Resident #1 and Resident #2 were roommates. The hospice nurse said Resident #2 could not tell her about the alleged incident. She said she did not see any change or injury to Resident #2 and Resident #2 did not bear any weight. She said she initially had no idea about the alleged incident because no one reported it to her and the facility was always supposed to notify her. The hospice nurse said the ADON knew but did not know why the ADON did not contact her. The hospice nurse said staff were saying the incident was not confirmed by CNA A, but CNA A said she was helping Resident #1 to bed and turned around and saw Resident #2 on the floor. The hospice nurse said she asked CNA A to clarify, and CNA A then said she saw Resident #1 pull Resident #2 out of bed.Record review of the facility's Accident and Incidents - Investigating and Reporting policy, dated 07/2017, reflected: Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator.Policy Interpretation and Implementation1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.5. The nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. 6. The director of nursing services shall ensure that the administrator receives a copy of the Report of Incident/Accident form for each occurrence. Record review of the facility's Abuse Investigation and Reporting policy, dated 07/2017, reflected: Policy StatementAll reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Reporting 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies:a. The State licensing/certification agency responsible for surveying/licensing the facility.2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:a. two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on observations, interviews, and record review, the facility failed to ensure that residents receive treatment and car in accordance with professional standards of practices for 1 of 6 residents (Resident #3) reviewed for quality of care. The facility failed to identify and provide treatment for the wound on Resident #3's hand, that was present for at least 3 days. This failure could place residents at risk for not receiving appropriate treatment and care, developing skin infections and decreased quality of life. Findings included:Record review of Resident #3's face sheet, dated 04/13/2026, revealed a [AGE] year-old female admitted with a primary diagnosis of metabolic encephalopathy (brain disorder that occurs when a chemical imbalance of the blood affects the brain). Other pertinent diagnoses included dementia (Brain disease that alters brain function and causes a cognitive decline), chronic lymphocytic leukemia of B-cell type not having achieved remission (slow-growing blood cancer, that shows signs of presence in blood despite treatment), epilepsy (seizure disorder), and type 2 diabetes mellitus with diabetic polyneuropathy (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels and causes numbness, pain, and impairment to the legs and feet). Record review of Resident #3's quarterly MDS assessment (a set of standardized assessments done on admission, quarterly, and with a significant change of condition, on each resident), dated 04/02/2026, revealed she had a BIMs score of 13, indicating intact cognitive function with minimal to no impairments in memory or thinking abilities. Resident #3's functional abilities revealed she only needed setup or clean-up assistance and supervision. Record review of Resident #3's progress notes, dated 04/01/2026 - 05/01/2026, did not indicate compromised skin integrity or wounds.Record review of Resident #3's most recent weekly skin assessment, dated 04/27/2026, revealed no new skin issues. Record review of Resident #3's ADL tasks MONITOR - Skin Observation for 04/02/2026 - 05/01/2026, revealed None of the above observed or Not Applicable was selected for each day over the course of the 30 days. The other skin observations options included scratched, red area, discoloration, skin tear, open area, resident not available, and resident refused. During an observation and interview on 05/01/2026 at 9:35 a.m., Resident #3 showed the state surveyor an injury on her hand. Resident #3 said she injured her hand on the shower handle, where a metal wire was sticking out. She said the injury hurt and nothing had been done about it except she was given naproxen (medication to reduce pain and inflammation). Resident #3 said the injury occurred on Tuesday, 04/28/2026 on hall 200's shower. She said she was independent when she showered, so no one was in the shower when the injury occurred. Resident #3 said she told someone on Thursday, 04/30/2026, around 3:00 PM about the injury but she could not remember who. She said the wound was infected and she would hate to lose her hand. Resident #3 gave the state surveyor permission to take a picture of the wound on her hand. Observation of the wound revealed the wound was in the bottom right corner of the left hand. The wound was slightly larger than pea-sized, with dark purple discoloration in the center of the wound, a ring of blue and purple discoloration, and surrounded with a ring of redness. The bottom right quarter of the palm of the hand was pink and red. During an observation and interview on 05/01/2026 at 10:41 a.m., the ADON was observed checking both showers in the facility, on hall 100 and 200 hall, which revealed no metal wires sticking out of the handles. The ADON tested both handles and there were no hazardous materials that could cause an injury to a resident. The ADON said she was not aware of a wound on Resident #3's hand. The state surveyor showed the ADON the image of the wound and she said the nurse practitioner was at the facility and she would have him look at it. The ADON said the wound looked gnarly (unpleasant, gross). The ADON said CNAs were usually good about texting her and telling her about injuries. She said she expected CNAs to notify nurses immediately, and nurses to call the doctors, do skin assessments, and find out the cause. The ADON said because Resident #3's wound was open, the doctor needed to be notified and to provide treatment. She said LVN B was currently helping with wound care for residents on Monday, Wednesdays, and Fridays. During an interview on 05/01/2026 at 12:47 p.m., CNA A said last night, Thursday, 04/30/2026, Resident #3 told her that she had hurt herself in the shower. She said Resident #3 showed her the wound and said it happened from a wire in the shower. CNA A said she did not know of there being a wire in the shower. CNA A said she told LVN B and LVN B told her she already knew and Resident #3 just needed a bandage. CNA A said she did her part and it was her job to report to the nurse. During an interview on 05/01/2026 at 1:45 p.m., LVN B said she was just notified about Resident #3's wound and it occurred on Tuesday 04/28/2026. She said she asked Resident #3 about any pain and Resident #3 only told her about her migraine. LVN B said she asked Resident #3 why she did not tell anyone and Resident #3 said she told a CNA. LVN B said she did not think the wound was from a wire, but with the redness and purpleness on the wound, it was probably infected. She said it was infected from the wound being open and Resident #3 touched a lot of stuff. LVN B said Resident #3 was receiving triple antibiotic (ointment) and Bactrim (antibiotic oral medication). LVN B said she could not say how old the wound was but believed it could have happened Tuesday 04/28/2026. During an interview on 05/01/2026 at 2:57 p.m., the ADON said she made calls to staff and no one was aware of the injury to Resident #3's hand. The ADON said she called CNA A and CNA A told her she was not aware of anything happening to Resident #3's hand. The ADON said Resident #3 did not tell anyone about her hand and no one was aware. She said she did not know how old the injury was but believed Resident #3 picked at the wound because she was known to pick at wounds . The ADON said the wound was not new and definitely some days old. The ADON said Resident #3 was seen by the nurse practitioner and received antibiotics and treatment. The ADON said it was important to know about these types of injuries, so it did not happen to other residents. She said she did educate staff about notifying of new injuries to residents. During an interview on 05/01/2026 at 4:32 p.m., the ADM said he had maintenance check the showers for any wires sticking out. He said there was no indication that there were wires in the shower room. The ADM said Resident #3's wound did not look new, and he was surprised they only found out about it today. The ADM said weekly head-to-toe skin assessments were done. He said, in addition to the weekly skin assessments, direct care staff saw most stuff and knew observed skin issues were to be reported. The ADM said Resident #3 was independent and he would not be surprised if staff stood in the shower room with Resident #3 and not right next to her because she was reasonably independent. The ADM said the facility called the doctor, and ordered antibiotics because the wound looked red. He said he would probably have the showers looked at again because he was curious where the injury could have happened and it looked like a puncture. The ADM said all he could do was get it fixed and corrected.A policy regarding identifying and treatment of skin conditions was requested prior to exit; the policies provided were not applicable.

Based on interviews and record reviews, the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 out 3 residents reviewedLVN A failed to notify Resident #1's representative that he was found unresponsive and was transported to the local hospital. This failure placed residents at risk of not having representatives informed of changes in conditions, preventing representatives from being informed and making informed decisions about the residents' care. Findings included:Record review of Resident #1's face sheet dated [DATE] reflected, Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 was diagnosed with Type 2 diabetes mellitus with diabetic chronic kidney disease (high blood sugar damages kidney filters (nephrons), causing protein leakage), long term (current)insulin, chronic kidney disease stage 3 unspecified (mild-to-moderate kidney damage with an eGFR between 30-59, meaning kidneys are not filtering waste efficiently) and unspecified Dementia (diagnosis used when cognitive decline, memory loss, and functional impairment are present). Record review of Resident #1 face sheet reflected Resident #1 had a POA representative. Record review of Resident #1's quarterly MDS, dated [DATE] reflected a BIMS of 11 which indicated Resident #1 had moderate cognitive impairment. Record review of Resident #1's incident report on [DATE] at 8:00 PM reflected, At approximately 2000 [8:00 PM] During routine rounds the nurse heard a thump from the hallways the door was closed. Upon entering the resident was behind the door of the room. The shoes were several feet away next to the bed, along with his wheelchair the call light was on the pillow. Resident did not call for help. Resident was able to stand up and get himself in the wheelchair denies pain no open areas, no lumps, no bruising tolerates Rom [Range of motion]. 149/78 [Blood pressure] 97.8[Temperature] 80 [heart rate] 18 [Respiratory rate] . Resident Description: Resident Unable to give Description.Record review of Resident #1's neurological flow sheet documented by LVN B reflected on [DATE], Resident #1's vitals were within range. Resident #1 was checked every 15 minutes at 8:00 pm, 4 times. Resident #1's vitals were checked every 30 minutes twice; then on [DATE] Resident #1 vitals were checked every hour.Record review of Resident #1's progress notes dated [DATE] to [DATE] reflected:On [DATE] a progress note written by LVN B at 8:45 PM reflected At approximately 2000 [8:00 PM] During routine rounds the nurse heard a thump from the hallways the door was closed. Upon entering the resident was behind the door of the room. The shoes were several feet away nest to the bed, along with his wheelchair . Resident was able to stand up and get himself in the wheelchair denies pain no open areas, no lumps, no bruising tolerates Rom. Resident drinks a regular soda, fried fish the family [NAME] earlier. BS 507 refused insulin provided coaching asymptomatic. NP. POA, Adon notified.Record review of Resident #1's order summary dated [DATE] reflected no new orders given.On [DATE] a progress note written by LVN B at 9:41 PM reflected, Resident up in his wheelchair denies pain or dizziness s/p fall incident. Drinks a cup a coffee with regular sugar provided education.On [DATE] a progress note written by LVN A at 3:04 AM reflected: observed ambulating via w/c during first half of shift. around 0245 [2:45 AM] res observed in chair diaphoretic (excessive seating) and unresponsive. Could not get BP on res. O2 99 p 78 BS 550. sternum rubmedical technique used to assess a person's level of consciousness or responsiveness) ineffective, unable to take anything by mouth, EMS called. BS read as HI [Blood glucose level is extremely high] still unable to read BS res unarousable but breathing steady and unlabored. Res transported to ER.Record review of Resident #1's hospital records dated [DATE] reflected, Resident #1 was transferred from the SNF to the ER on [DATE] at 3:21 AM. The chief complaint reflected high blood sugar (Registered high on EMS equipment). Visit diagnoses reflected subdural hematoma (Collection of blood that forms between the brain and outer covering, often due to head trauma, hypertensive (very high blood pressure that happens without warning and cause organ damage), and chronic anticoagulation (long-term use of blood-thinning medications to reduce the body's ability to form clots). The hospital records revealed Resident #1 was transferred to another local hospital for hospice within the hospital on [DATE] at 2:48 PM and expired on [DATE] at 9:45 AM.During an interview on [DATE] at 5:30 AM, LVN A stated LVN B reported Resident #1 had an unwitnessed fall earlier in the evening. LVN A stated she continued with Resident #1 neurocheck. LVN A stated she let the ADON, Admin and NP know that Resident #1 was sent out to the hospital. LVN A stated with everything going on she forgot to call Resident #1's POA. During an interview on [DATE] at 5:50 AM LVN C stated a resident representative should be contacted when there was a change in condition, fall or sent out to the hospital so that family was aware of the resident status.During an interview on [DATE] at 7:06 AM, LVN D stated the resident representative needed to be contacted when residents were sent out to the hospital in case additional information was needed that the facility did not know.During an interview on [DATE] at 9:22 AM Resident #1's Family Member stated they received a call on [DATE] at night that Resident #1 had a fall and was doing ok. Resident #1's Family Member stated at 2 AM they received a call from the hospital, that Resident #1 was in the hospital. Resident #1's Family Member stated they were told by the facility that the resident was fine after the fall. Resident #1's family member stated they wanted to know what happened after the fall and how did he end up in the hospital. Attempted to call LVN B on [DATE] at 9:52 AM and could not leave a voicemail. Attempted to call the NP on [DATE] at 10:53 AM and left a voicemail. During an interview on [DATE] at 11:35 AM, the facility Doctor called back and stated he was not for sure if the facility called him about Resident #1's being sent to the hospital. During an interview on [DATE] at 2:00 PM, the interim DON stated staff should have called the resident representative to make sure the family was aware of what happened. The interim DON stated she collaborated with staff to make sure they understood what was expected of them.Record review of facility policy title Resident Rights, (revised 12/2016) reflected, o. be notified of his or her medical condition and of any changes in his or her condition.Record review of facility policy titled Change in a Resident's condition or status, revised 02/2021 reflected, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status;.

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three of five residents (Residents #1 #2, and #3) reviewed pressure ulcers. 1. The facility failed to consistently identify, measure and stage pressure ulcers on skin assessments for Residents #1, #2 and #3 from January 2026 through March 2026.2. The facility failed to update care plans to reflect current wounds for Resident #1 and Resident #2. 3. The facility failed to ensure wound care to skin and treatment orders for pressure ulcers were provided as directed for Resident #1 and Resident #3. These failures could place residents at risk of inconsistent tracking of wound status and progression, placing residents at risk for worsening pressure injuries, delayed healing and development of more advanced wounds. Findings included:1. Record review of Resident #1's face sheet, dated 03/28/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hemiplegia and hemiparesis (paralysis and weakness on one side of the body), vascular dementia (cognitive impairment caused by reduced blood flow to the brain), muscle wasting and atrophy (loss of muscle mass and strength) and chronic kidney disease-stage 2 (mild kidney damage with decreased kidney function). Record review of Resident #1's admission MDS assessment, dated 02/05/26, reflected she had a BIMS score of 11, which indicated moderate cognitive impairment. Resident #1 had no physical or verbal behaviors directed towards others but had at least one episode of rejection of care during the previous assessment period. Resident #1 had range of motion impairment on one side of her lower extremity and used a wheelchair for mobility. Resident #1 was dependent and/or physically dependent on staff to complete bed mobility (rolling left to right, sitting up, laying down and bed/chair transfers). Resident #1 was always incontinent of urine and frequently incontinent of bowel. She weighed 85 pounds and was five foot five inches tall and was at risk of developing pressure ulcers. Resident #1 had one unhealed pressure wound that was a Stage 3 (a full-thickness skin injury that extends into the subcutaneous fat) that was present upon admission. Skin and wound treatments included a pressure reducing device for the bed and pressure wound/injury care. Record review of Resident #1's care plan, dated 01/27/26 and last revised 03/03/26, reflected [Resident #1] has pressure wound (lt heel); Interventions.Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate (Date Initiated: 01/27/26). Resident #1's care plan did not reflect she had a sacral wound. Record review of Resident #1's Physician Order Summary, dated 03/31/26, reflected she was prescribed the following treatments:-Weekly Skin Assessment (start date 01/27/26)-Apply betadine-soaked gauze to pressure of Left heel; cover with ABD pad, wrap with kerlix and an ace wrap daily and as needed for soilage, as needed for to promote wound healing (start date 02/17/26)-Triad paste to be applied to sacral area every day shift to promote healing (start date 03/26/26) Record review of Resident #1's admission Braden Scale for Predicting Pressure Sore Risk, dated 01/28/26, reflected she had a score of 15, which indicated she was at risk. Record review of the following weekly skin assessments for Resident #1 reflected the sacral wound was repeatedly omitted from assessments after initial identification and heel wounds were inconsistently documented with absent measurements and staging on the following dates:01/27/26- Sacral wound identified; no measurements or stage documented.02/03/26-Sacral wound was not documented. New pressure areas to right and left heels identified. 02/10/26-Sacral wound not documented. Right heel pressure wound identified; no measurements or staging documented. 02/17/26-Sacral wound not documented. Right heel noted as redness only. Left heel documented as Stage 3 pressure wound; no measurements documented. 02/24/26-Sacral wound not documented. Left heel wound documented with no measurements of staging. Notes reflected excessive exudate and podiatry involvement. 03/03/26-Skin assessment left blank; no wound documented. 03/13/26- Left heel pressure wound identified; no measurements documented. Notes indicate Stage 3 pressure wound with treatment in progress. 03/17/26-Pressure wound of left heel -no measurements or stage reflected. 03/25/26- Sacral redness identified. Stage 3 pressure wound to left heel documented. Record review of Resident #1's March 2026 TAR reflected no wound treatment was documented as provided to her sacral area on 03/27/26, and to her left heel on 03/14/26, 03/17/26, 03/18/26 and 03/27/26. Record review of Resident #1's nursing progress notes on the dates of missing wound treatment on the TAR do not indicate any wound care was documented as provided. Record review of Resident #1's wound care physician visits reflected she was seen twice since admission, 02/03/26 and 02/10/26. On 02/03/26, the wound care physician noted Resident #1 had wounds on her left and right heels, with the left heel being a Stage 3 pressure injury with the wound description post op debridement at 2.8 x 3.1 x 0.3 cm with a wound area of 8.68 cm with the wound increasing in size. Resident #1's right heel was noted to be a deep tissue injury with a measurement of 1x2xUTD cm with a wound area of 2.00 cm and decreased in size. During the second wound care visit on 02/10/26, the wound care physician noted Resident #1's left heel had progressed to a stage 4 pressure injury and surgical debridement was completed with the post op wound bed measured at 2.9 cm x 3.4 cm x 0.3 cm (9.86 cm^2 surface area) and had increased in size, while the right heel DTI was measuring at 00 and the wound was noted to be epithelized. The facility did not provide any additional wound doctor visits notes for Resident #1 and no other visits were available in her clinical chart. An observation on 03/29/26 at 2:23 PM revealed Resident #1's wound care. Resident #1's left foot was observed wrapped in kerlix secured with Coban (a breathable cohesive bandage for securing dressings) and the dressing was dated 03/29/26. Resident #1 did not want the wound dressing to be redone. An interview with Resident #1 on 03/29/26 at 2:25 PM revealed her wound care was done in the morning every day. She said she was also seen by a podiatrist and reported no complaints. 2. Record review of Resident #2's face sheet, dated 03/28/26, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had diagnoses which included hemiplegia and hemiparesis (paralysis and weakness on one side of the body), muscle wasting and atrophy (loss of muscle mass and strength), vascular dementia (cognitive impairment caused by reduced blood flow to the brain), type 2 diabetes (a condition affecting blood sugar control), mild protein-calorie malnutrition (inadequate intake of protein and calories affecting overall nutrition), peripheral vascular disease (reduced blood flow to the extremities, especially the legs and feet), joint contracture (permanent tightening of muscles or joints limited movement) and osteoporosis (weak and brittle bones at increased risk for fracture). Record review of Resident #2's quarterly MDS assessment, dated 02/24/26, reflected she most recently re-admitted to the facility after an acute hospital stay on 02/16/26. Resident #2's BIMS score was 07, which indicated severe cognitive impairment. Resident #2 had no signs or symptoms of delirium, no negative mood concerns, no physical or verbal behaviors directed towards others and no rejection of care issues. Resident #2 had range of motion issues on one side in her lower extremity and used a wheelchair for mobility. She was dependent on staff for bed and chair mobility, which included rolling from side to side. Resident #2 had an indwelling catheter and was always incontinent of bowel. Resident #2 weighed 144 pounds, was five foot seven inches tall and had significant weight loss during the last assessment period. She was at risk for developing pressure wounds but did not have any identified pressure wounds and required no skin or wound treatments required. Record review of Resident #2's Care Plan, initiated 12/26/21 and last updated 04/07/25, reflected 1) The resident has potential for pressure ulcer development r/t limited mobility, incontinence, 2) [Resident #1] has potential/actual impairment to skin integrity of the (Lt posterior thigh) r/t MASD, 3) The resident has potential impairment to skin integrity r/t psoriasis (an autoimmune skin condition that causes itchiness and discomfort and causes thick, scaly areas of skin), dermatitis (a skin condition that causes dry and itchy patches of skin). Interventions included, Follow facility protocols for treatment of injury. Resident #2's care plan did not reflect any current pressure wounds. Record review of Resident #2's Physician Order Summary, dated 03/31/26, reflected the following orders: 1) Cleanse pressure to sacrum with NS/WC; pat dry and apply calcium alginate to the wound bed and cover with dry dressing every day shift and as needed to promote wound healing (Start date 03/06/26); and 2) Weekly skin assessment (start date 02/18/26). Record review of Resident #2's March 2026 TAR reflected wound treatment was provided to her sacrum per physician orders. Record review of the following weekly skin assessments for Resident #2 reflected on 02/18/26-Sacral wound identified with no measurements or staging documented; 02/25/26-Sacral wound-no staging documented-Notes reflected the wound measured 3.0cm x 2.1cm; 03/03/26- Sacral wound- no staging documented- Notes reflected the wound measured 6.8 cm x 5.0 cm x UTD; 03/13/26- Sacral wound identified; no measurements or staging documented. New areas of MASD to left and right lower buttock identified; 03/17/26- Sacral wound measured at 8.5 cm x 7.5cm x 0.4 cm and was Unstageable; 03/24/26-Sacral wound identified at a Stage 4, with measurements of 9.0 x 5.5x 0.5 cm. Notes reflected the wound had increased in size and the resident was seen by a wound physician. Record review of Resident #2's wound care physician notes reflected on 02/16/26, a wound to the sacrum was identified as MASD and measured 3.1 cm in length by 1.0 cm in width, with a depth unable to be determined. No signs of infection were noted and wound progress was documented as undetermined as it was the initial visit. Resident #2 was seen five more times and on 03/24/26, the wound care physician again evaluated the sacral wound again, which had become a Stage 4 pressure injury. Measurements reflected 9.0 cm x 5.5 cm with a post procedure depth of 0.6 cm and a total wound area of 49.50 cm. Documentation reflected the wound had evolved into a pressure injury requiring surgical debridement of devitalized tissue, which included subcutaneous tissue, muscle fascia and tendon. The physician noted evidence of tissue decline and the need for ongoing treatment. An observation on 03/29/26 at 1:44 PM of wound care for Resident #2 revealed the old wound dressing was dated 03/28/26, the wound was observed to be open with a deep, full-thickness tissue injury on the lower back/tailbone area where skin loss was complete, which exposed subcutaneous fat with a large amount of drainage. LVN B completed Resident #2's wound care appropriately and without concern. An interview with Resident #2 on 03/29/26 at 1:50 PM revealed staff took good care of her and treated her wound every day. Resident #2 said she was also seen by the wound doctor and reported no complaints. An observation of Resident #2's on 03/29/26 at 3:44 PM revealed her wound was on the sacrum, the resident was on an air loss mattress and wound care had been completed prior to the RN state surveyor viewing it. The dressing was dated 03/29/2026. With Resident #2's permission, LVN D pulled back the dressing with resident's permission and an open area was observed with redness around it, full-thickness tissue injury was on the lower back/tailbone area where skin loss was complete, exposing subcutaneous fat, moderate amount of dressing noted, no foul smell noted. An interview with LVN B on 03/31/26 at 3:45 PM revealed Resident #2 developed the pressure ulcer in-house after her overall health declined resulted in the resident being placed on hospice and started spending more time in bed. LVN B stated the facility did everything to prevent the development of the pressure ulcer to include having the resident on an air loss mattress and turning/repositioning the resident every two hours and as needed. 3. Record review of Resident #3's face sheet, dated 03/28/26, reflected a [AGE] year old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included unspecified dementia (decline in memory and thinking abilities without a specific identified cause), Alzheimer's disease (a progressive brain disorder that causes memory loss and cognitive decline) and muscle weakness (reduced strength affecting mobility and physical function). Record review of Resident #3's significant change MDS assessment, dated 02/27/26, reflected a BIMS score of 05, which indicated severe cognitive impairment. Resident #3 had no verbal or physical behaviors towards others and did not have any rejection of care issues. She had no range of motion issues and used a wheelchair for mobility and required partial/moderate assistance for bed mobility and transfers. Resident #3 was always incontinent of bowel and bladder and was at risk of developing pressure ulcers/injuries. The MDS reflected she had one unhealed pressure ulcer that was unstageable and was present upon admission. Additional skin conditions were MASD and treatments included a pressure reducing device for the bed and pressure ulcer/injury care. Record review of Resident #3's Care Plan related to wounds, initiated on 12/31/25 and last updated on 03/25/26, reflected: 1) The resident has potential for pressure ulcer development r/t immobility (Date Initiated: 12/31/2025)- Follow facility policies/protocols for the prevention/treatment of skin breakdown; 2) The resident has (unstageable) pressure ulcer (sacrum) r/t immobility (Date Initiated: 03/17/2026)- Administer treatments as ordered and monitor for effectiveness and follow facility policies; 3) The resident has infection of the wound to her sacrum (Date Initiated: 03/25/2026)-Administer antibiotic PO BID until 4/8/26 as per MD orders. Record review of Resident #3's Physician Order Summary, dated 03/31/26, reflected the following orders: 1) Weekly skin assessment (start date 12/23/25), 2) May be seen by facility wound physician as needed (start date 12/23/2025), and 3) Cleanse unstageable pressure to sacrum with NS/WC; pat dry; apply betadine; calcium alginate to be applied and dry dressing. every day and evening shift to promote wound healing (start date 03/30/26). Record review of Resident #3's March 2026 TAR reflected no treatment was documented as provided to her sacrum on 03/16/26, 03/21/26 and 03/22/26, and no medication was documented as applied to her left upper buttock redness to promote wound healing on 03/21/26, 03/22/26, 03/26/26 and 03/27/26. Record review of Resident #3's nursing progress notes on the dates of missing wound treatment on the TAR do not indicate that any wound care was provided. Record review of Resident #3's Braden Scale for Predicting Pressure Sore Risk at admission on [DATE] was 22, which indicated she was initially not at risk. A quarterly Braden Scale assessment on 03/19/26 indicated her score had decreased to 13, which indicated she was at moderate risk for pressure wound development. Record review of the following weekly skin assessments for Resident #3 reflected inconsistent identification and measurement of her sacral wound, with multiple skin assessments noted as refused or incomplete: In early January 2026, several weekly skin assessments were documented as refused or limited, with the nurses noting the resident did not allow a full skin assessment. During this time, documentation alternated between arm discoloration and no skin issues identified. On 02/05/26, multiple skin concerns were identified, which included bruising, redness and MASD. On 03/20/26, a sacral pressure wound measuring 6.5cm x 4.0 cm was identified and documented as unstageable. On 02/12/26, the sacral wound was not listed. Subsequent assessments on 02/24/26 reflected no identification of a wound concern. On 03/13/26, the skin assessment reflected a sacral wound again, with no measurements or staging. A new area of MASD was noted to Resident #3's left and lower right buttock. Record review of Resident #3's wound care physician notes reflected on 02/10/26, she was evaluated for a sacral wound identified as an unstageable pressure injury, measuring 4.0cm x6.5cm (26.0 cm). Documentation noted moderate serous drainage (thin, clear to pale yellow liquid-watery part of blood) and described the wound as demonstrating rapid, significant clinical decline at that time. No procedure was performed and treatment consisted of calcium alginate and dry dressing. Wound progress was documented as undetermined. Resident #3 continued to have six more weekly visits and on 03/24/26, the follow-up evaluation reflected the wound as a Stage 3 pressure injury, measuring 8.4cm x 4.1 cm (34.44cm). Drainage remained moderate and serious. Wound progress was specifically noted as increased in size. Treatment at that time included betadine, calcium alginate and dry dressing, with recommendation for antibiotic therapy. An interview with LVN A on 03/31/26 at 9:41 AM revealed the treatment nurse (WC LVN B) usually staged a resident's pressure injury, or the wound doctor. She stated when a resident developed a pressure injury, she was not sure who updated the care plan. She said, I give it to the treatment nurse and it goes from there down the line. LVN A stated the treatment nurse was responsible for all the residents' wound/skin treatments and related documentation. She stated if a charge nurse did wound care for a resident, it would only be PRN and there was a place to click off in the e-chart that it was completed, or the nurse could write a nursing note. LVN A stated the treatment nurse was responsible for weekly skin assessments for the residents but would sometimes delegate other charge nurses to complete them if she had too many to do. LVN A said she completed a weekly skin assessment before, but the wound care nurse did them for the whole facility. LVN A stated she had not measured any wounds on residents in the facility. She stated if a wound inconsistently appeared on the weekly skin assessments, it could be that the wound doctor came in and did an assessment and the wound had resolved and the resident's treatment orders were discontinued. She stated if that was the case, there would need to be a discontinued order to reflect it. An interview with the DON on 03/31/26 at 10:17 AM revealed a pressure injury could be staged by the facility nurses, but if they were not sure or uncomfortable, they could identify and document the general area and the treatment nurse could stage it with the doctor later. The DON stated treatment documentation included weekly measurements of resident wounds and weekly skin assessments completed by the treatment nurse, the purpose of which was to determine if a wound was getting larger or deteriorated. The DON stated she ensured wounds were measured consistently each week by checking the treatment nurses' skin assessments, reviewing wound doctor notes and asking about any skin concerns in the morning meetings. She stated a wound not documented correctly on a skin assessments were important because the wounds needed to be measured so the facility could know if they were getting better or worse. The DON stated if she noticed that it was occurring, she would reach out to the treatment nurse to inquire. The DON stated when a resident developed a pressure injury, the treatment nurse should update the care plan, stage the pressure injury and list the wound care interventions. She stated verification of resident wound treatment completion was done daily by nursing management by running an audit to review in the morning meeting of any missed treatments or medications. The DON stated if there were missing treatments on the TAR, she would have the treatment nurse follow up on it, since it is her area. The DON stated the treatment nurse (LVN B) chose to do all the residents' skin assessments (around 96) in the facility Mondays through Thursdays, so everyone should have one every seven days. The DON stated the treatment nurse (LVN B) scheduled completion of all residents' weekly skin assessments (approximately 96) from Monday through Thursday, with the expectation that each resident was assessed every seven days. She stated this scheduled was determined by the treatment nurse, and she had sufficient time during her eight-hour shifts and that additional support would be provided if needed. The DON further stated she reviewed resident charts to monitor wound care delivery but had not identified that wound measurements were not consistently documented or completed during weekly skin assessments. The DON stated that ensuring compliance with wound care planning and documentation was the responsibility of LVN B. An interview with the treatment nurse, LVN B on 03/31/26 at 10:40 AM revealed she could not stage a wound, only describe it, but the DON could stage a wound since she was an RN. LVN B stated she could also wait and go over it with the wound doctor when he came for his weekly visit. LVN B stated when a resident developed a pressure injury, she should be the person to update the care plan when she saw the wound. She stated she did not know the time frame to update the care plan, but she tried to do it as quickly as possible. LVN B stated wound treatment was documented on a resident's TAR and floor nurses were responsible for any treatment to wounds when she was not present at the facility. LVN B stated she was mainly responsible for the weekly skin assessments for all the residents in the facility and she had recently started getting the assessments to trigger on the e-chart each day from Monday through Thursday, and on Friday she wanted a break. She stated on Fridays, no skin assessment should trigger unless it was a new admission. She stated this was a new system she was implementing to help her break up the number of weekly skin assessments she had to do during the week. LVN B stated residents' wound measurements were typically done when the wound doctor came for his weekly visit and she felt she had not missed measuring any residents' wounds. She stated when the wound doctor measured the wound, he documented it and she then transferred his measurements to the resident's weekly skin assessments. LVN B stated measurements were important, So we can monitor if it is getting better or worse, shrinking or growing. If we skip measuring, then now you lose track of monitoring.Then there is the possibility of something progressing or getting worse based on measurements. An interview with ADON C on 03/31/26 at 12:25 PM revealed when a new wound was identified, the charge nurses could not stage, so she expected them to notify the treatment nurse who would then complete a full skin assessment head to toe and notify the wound doctor or the primary physician. ADON C stated when a resident developed a pressure injury, the treatment nurse was responsible to update the care plan, She is all things wound care. ADON C stated she wanted to see the treatment interventions for a resident's wound on their care plan, such as a low-air loss mattress, cushions and physician ordered wound treatment. ADON C stated if a wound was worsening she expected the treatment nurse to notify the doctor because maybe something the facility was doing was not working and the resident needed more physician oversight. ADON C stated the treatment nurse was responsible for completing all residents' weekly skin assessments and she did not have oversight of her position, the DON did. ADON C said missing wound measurements on weekly skin assessments could result in the facility not being able to determine if a wound was getting better or worse and could leave gaps and holes for that specific wound care. Record review of the facility's policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, (revised April 2018) reflected, Assessment and Recognition-. 1.In addition, staff or practitioner will describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions; 4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. Record review of the facility's policy titled, Wound Care, (revised October 2010) reflected, Documentation- The following information should be recorded in the resident's medical record: 1. The type of wound care given; 2. The date and time the wound care was given; 3.The name and title of the individual performing the wound care; 4. Any change in the resident's condition; 5.All assessment data obtained when inspecting the wound; 6. Any problems or complaints made by the resident related to the procedure; 7. If the resident refused the treatment and the reason(s) why; 8.The signature and title of the person recording the data.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 Residents (Resident#1) reviewed for infection control. The facility failed to maintain a clean resident environment when dried fecal matter was observed smeared on Resident#1's bed frame. This failure could place residents at risk to exposed fecal matter which would increase the risk of health-associated infections.Record review of Resident 1#'s Quarterly MDS Assessment, dated 2/19/2026, reflected a [AGE] year-old female who was admitted on [DATE]. No BIMS score was recorded which indicated there was no interview. The resident had diagnoses which included pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus, resulting in cough, fever, chills, and breathing difficulties), muscle weakness, and Non-Alzheimer's Dementia (various incurable, progressive conditions that cause nerve cells [neurons] in the brain or spinal cord to malfunction and die, leading to cognitive decline). Record review of Resident #1's Comprehensive Care Plan, Date Initiated: 12/24/2025 Revision on: 01/22/2026 reflected The resident has an ADL self-care performance deficit r/t Dementia (a progressive decline in memory, language, problem-solving, and cognitive abilities severe enough to interfere with daily life). Interventions: Toileting Hygiene: Substantial/maximal assist). Record review of Resident #1's Comprehensive Care Plan Date Initiated: 03/25/2026 reflected: [Resident#1] has infection of the wound to her sacrum. [Resident#1] will be free from complications related to infection through the review date. Goal: [Resident#1] will be free from complications related to infection through the review date. Interventions included: Administer antibiotic (Bactrim DS 800-160 (is a double-strength, prescription combination antibiotic used to treat bacterial infections) (1) tab PO BID until 4/8/26) as per MD orders. Record review of Resident #1's active physician ordered reflected: Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) (is a double-strength, prescription combination antibiotic used to treat bacterial infections) Give 1 tablet by mouth two times a day for wound infection for 14 Days Phone Active 03/24/2026. During an observation on 03/29/2026 at 3:00 PM revealed brownish dried substance on Resident#1 bed frames. The resident was not interview able. During an interview on 03/29/2026 at 3:05 PM with the Administrator he identified the smear as feces and stated all residents bed should be clean. He stated the risk to the resident was infection and stated he was going to have someone clean the feces immediately. He stated the nursing staff were responsible for cleaning bodily fluid then housekeeping would sanitize. He stated the staff had been in serviced on infection control to include keeping the residents' beds clean. During an interview on 03/29/2026 at 3:15 PM with LVN A, she stated the brown stuff was unsanitary and she was not sure if it was pudding or something else. She stated the CNAs were primarily responsible for cleaning any body fluids because they provided most of the incontinent care. She stated the nurses were also responsible for ensuring the residents were living in sanitary environments. She stated the risk to the residents was infection due to exposure to fecal matter. She stated she had been Inservice on infection control. During an interview on 03/29/2026 at 3:35 PM with CNA B reflected she had not observed the fecal smeared on the resident's bed before the state surveyor brought it to her attention. She stated it was the CNA's responsibility to ensure residents' beds were cleaned and free of bodily fluids and fecal matter. She stated the risk of the resident was infection. She stated she had been in serviced on infection control. During an interview on 03/29/2026 at 4:15 PM with the DON revealed her expectation was the nurses and CNAs were ensuring the residents were living in clean and sanitary environments. She stated it was the nursing staff's primary responsibility to clean any body fluids and feces on the resident's bed frame then housekeeping would sanitize and clean. She stated she was the interim DON but believed the staff had been in serviced on infection control. She stated the risk to the resident was health related infections. Record review of the facility policy titled: Standard Precautions reflected: 6. Environmental Control: Environmental surfaces, bedrails, bedside equipment, and other frequently touched surfaces are appropriately cleaned.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 out of 2 medication carts (MC#1) reviewed for medication storage. The facility failed to ensure the male secure unit medication cart was free of undated and unlabeled insulin on [DATE]. This failure could place residents at risk of poor insulin blood sugar control from expired insulin.Findings include:During an observation and interview on [DATE] at 7:30 AM the state surveyor and LVN-PRN F observed: *Basaglar Kwik pen with no open date on the secure male unit medication cart.*Lantus Kwik pen with no open date on the secure male unit medication cart.*Lantus Kwik pen with no name and no open date on the secure male unit medication cart.During an interview on [DATE] at 7:35 AM, LVN-PRN F stated insulin should be dated as soon as the nurse opened it. LVN-PRN F stated insulin could not be effective after 28 days. LVN-PRN F stated insulin that did not have the resident name needed to have the resident name to make sure the correct resident got their medication. LVN-PRN F removed the undated and unnamed insulin from the medication cart and took it to the interim DON.During an interview on [DATE] at 7:40 AM, LVN A stated insulin should be dated as soon as it was opened and a resident identification sticker should be on the Kwik pen. LVN A stated insulin did not last a month and should be removed from the medication cart within 30 days. LVN A stated undated insulin could be expired and could cause residents to be hypoglycemic (blood sugar (glucose) level is lower than the standard range), hyperglycemic (lack of insulin) .or make residents sick. Each nurse was responsible for checking their cart and making sure the insulin was properly labeled. During an interview on [DATE] at 7:55 AM, LVN G stated insulin was dated as soon as it was opened to make sure the insulin was not expired and effective. During an interview on [DATE] at 10:30 AM, the interim DON stated nursing staff were responsible for checking their medication cart on every shift and making sure the insulins were labeled and dated. The interim DON stated insulin not labeled and dated were removed from the medication carts. The interim DON stated opened insulin was considered expired after 28 days.Record review of the facility's policy titled Administering Medications, revised 04/2019, reflected 12.When opening a multi-dose container, the date opened is recorded on the container.16. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen.

Based on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, the facility maintained medical records on each resident that were complete and accurately documented for one of five residents (Resident #1) reviewed for medical records. The facility failed to document physician-ordered weekly weights for Resident #1. The failure could place residents at risk for incomplete clinical records and an inability to accurately monitor nutritional status and changes in condition such as worsening pressure injuries, delayed healing and additional skin breakdown. Findings include:Record review of Resident #1's face sheet, dated 03/28/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hemiplegia and hemiparesis (paralysis and weakness on one side of the body), vascular dementia (cognitive impairment caused by reduced blood flow to the brain), muscle wasting and atrophy (loss of muscle mass and strength) and chronic kidney disease-stage 2 (mild kidney damage with decreased kidney function). Record review of Resident #1's admission MDS assessment, dated 02/05/26, reflected she had a BIMS score of 11, which indicated moderate cognitive impairment. Resident #1 had no physical or verbal behaviors directed towards others but did have at least one episode of rejection of care during the previous assessment period. She weighed 85 pounds and was five foot five inches tall and was at right of developing pressure ulcers. Resident #1 had one unhealed pressure wound that was a Stage 3 (a full-thickness skin injury that extends into the subcutaneous fat) )and was present upon admission. Skin and wound treatments included a pressure reducing device for the bed and pressure wound/injury care. Record review of Resident #1's care plan, dated 01/27/26 and last revised 03/03/26, reflected The resident has the potential for a nutritional problem r/t chronic kidney disease, cancer to the lung, history of pneumonitis (general inflammation of lung tissue (alveoli) not caused by infection)due to inhalation or vomit; Interventions: Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Record review of Resident #1's Physician Order Summary, dated 03/31/26, reflected Weigh weekly for 4 weeks every day shift every Thursday for weight monitoring for 4 Weeks (start 03/12/26). Record review of Resident #1's e-chart, which included her March 2026 MAR/TAR and vitals tab, reflected no weights were documented after the order was given on 03/12/26 through 03/31/26. An interview with LVN A on 03/31/26 at 9:41 AM revealed when weight loss was identified, she usually brought it up in the morning meeting and informed staff the resident's intake and output needed to be monitored, possibly reach out to the registered dietician and get supplements to get weight back on and maybe start putting them on weekly weights. LVN A stated the weights triggered on the wound care TAR and she believed the treatment nurse (LVN B) took care of it and sometimes distributed the task to the CNAs to help her record them on certain days. LVN A stated she looked to see if a resident's interventions were working nutrition wise by looking for weight changes and better appetite. She stated a resident's weight was supposed to be recorded on the MAR/TAR. LVN A stated she was not responsible for verifying if weights were taken or their accuracy. An interview with the DON on 03/31/26 at 10:17 AM revealed residents' weights should be recorded under the vitals tab on their e-chart, unless they refused, then the nurses had to complete a progress note. The DON stated newly admitted and re-admission residents should have a weekly weight for the first four weeks post admit, and then all residents should have one monthly thereafter. An interview with the treatment nurse, LVN B, on 03/31/26 at 10:40 AM revealed she was the weight loss monitoring nurse and she tried to keep up with monitoring resident weight losses and whether it was healthy or an unhealthy changes. She stated residents' weights were ideally done once a month and some had weekly weights which triggered on the e-chart. LVN B stated, I try to do them for the weekdays and if not, I have CNAs split them because I cannot do them all every single month. She stated she had no restorative aides to assist with taking weights. LVN B stated if a resident's weight was missing, she tried to obtain it right away. If she noticed weight appeared to be changing for a resident, then she tried to put them on weekly weights to monitor. An interview with the ADM on 03/31/26 at 12:10 PM revealed resident weights were taken, recorded and followed by the treatment nurse, LVN B. He stated she oversaw the facility's weight loss/gain system and he believed she had the CNAs doing the weights for the halls they worked on. The ADM stated when a resident was a new admission, his understanding was they got weekly weights for 3-4 weeks because, It gives a better weekly baseline versus a monthly which is a snapshot, you may not notice those changes. An interview with ADON C on 03/31/26 at 12:25 PM revealed LVN B was over the facility's weight system because she followed wounds and nutrition, which play together as a whole. She stated if weights were not being completed weekly as ordered, then it could cause the facility to miss any trends down or up in weight. LVN B stated when a resident admitted , the facility had to establish a baseline and consistently weigh the resident over a four week period. If no weights were recorded weekly after admission, ADON C stated she would expect to see a nursing note explaining why there was no weight recorded for that week. Record review of Resident #1's nursing progress notes from 03/12/26 through 03/31/26 reflected no recorded weights or refusals of weights to be taken. Record review of the facility's policy titled, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, (revised September 2017) reflected, 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits comparisons over time;.4. The staff will report to the physician and dietitian any significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake.

Based on observation, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for elopement. The facility failed to prevent Resident #1 from eloping from the facility on an unknown date in July 2025. The failure could place residents at risk for possible elopement, serious injuries, and harm. An Immediate Jeopardy (IJ) was identified on 08/08/25. The IJ template was provided to the facility on [DATE] at 3:32 pm. While the IJ was removed on 08/09/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm, and a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.Findings include: Review of Resident #1's Face Sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS dated [DATE] reflected diagnoses including Chronic Obstructive Pulmonary Disease (condition caused by damage to the lungs), coronary artery disease (disease caused by buildup of plaque in the arteries of the heart), anxiety disorder, and Depression. A BIMS score of 10 was reflected, indicating moderate cognitive impairment. Resident #1 scored 0 on wandering behaviors, which indicated the behavior was not exhibited. Review of Resident #1's Care Plan with start date 6/13/25 reflected Resident #1 had a focus of elopement risk r/t history of attempts to leave the facility unattended, and with impaired safety awareness with date initiated 9/09/24 and revised solely on 12/24/24. In an interview on 8/05/25 at 12:41 pm, CNA A stated that approximately two weeks prior (exact date unknown), Resident #1 had climbed out of a window on the female locked unit. She stated that she saw Resident #1's wheelchair sitting empty by an open window and had notified LVN B. She reported staff searched the unit and then the property, but that Resident #1 was not located, and staff began using their vehicles to search the community. She stated she found Resident #1 coming out of [an auto parts store], the property adjacent to the facility, and escorted her back to the facility. She stated that the ADM arrived a short while later and threatened the jobs of staff if they were to say anything about the incident to anyone. In a telephone interview on 8/05/25 at 4:00 pm, LVN B stated about two weeks ago (exact date unknown), she was notified by CNA A that Resident #1 had gone out a window on the female locked unit. She stated that Resident #1 was not found at the facility but that she was returned to the facility by CNA A who reported that Resident #1 had been found at a nearby auto parts store. She stated she assessed Resident #1 upon her return to the facility and that she did not have any injuries. She stated that she called and notified the ADM and that he arrived approximately thirty minutes later and fixed the window that Resident #1 had kicked out. She stated she did not chart the elopement or her injury assessment because she was told by the ADM that he had to do an investigation, and he would take care of it. She stated she was not aware of any prior elopement attempts by Resident #1. Review of Resident #1's June 2025, July 2025, and August 2025 progress notes did not reflect any documentation to indicate an elopement or elopement attempt. A few progress notes reflected Resident #1 was on Q15 minute checks and had exhibited no exit seeking behaviors during a shift but did not indicate the reason for these checks and observations. The facility incident report log was reviewed for May 2025, June 2025, and July 2025 and no elopement incidents were reflected. The facility in-service training attendance roster titled, Elopement Drill and dated 6/13/25 was reviewed with 53 staff signatures noted present. In an interview on 8/05/25 at 1:30 PM LVN C stated while working the evening shift approximately two weeks ago (exact date unknown) she was notified by CNA A that Resident #1 had gone out of a window on the female locked unit. She stated she immediately started looking for the resident after notifying LVN B. She stated she and other staff had driven around the community looking for Resident #1. She reported she next saw Resident #1 walking up to the front of the building escorted by CNA A and was told that Resident #1 was found next door at an auto parts store. She stated that Resident #1 had not appeared to have any injuries. She stated she was not aware of any prior elopement attempts by Resident #1. She reported that the ADM came to the facility about thirty minutes later but did not speak to her. She denied she was threatened or told not to say anything about the incident. She stated that when she worked the day shift the following day, she was told in report that Resident #1 had tried to elope, and she thought this was strange because Resident #1 had actually eloped. She stated that Resident #1 was placed on Q15 minute checks for elopement risks. She stated she had thought the windows were secured but that she noted someone working on the window the day following the incident. In an interview on 8/05/25 at 1:40 PM CNA D stated she was told by a CNA (name unknown) the day following the incident (date unknown) that Resident #1 had eloped and been found at an auto parts store on the prior evening shift and had been escorted back to the facility. She stated she was not aware of Resident #1 having eloped or attempting to elope prior to this incident. She declined to state if her job had been threatened or she had been told not to say anything about the incident stating, I don't want to lose my job. They will retaliate against you and I don't want you writing anything that will cost me my job. In an interview and observation on 8/05/25 at 3:07 pm, Resident #1 stated she had left the facility through a window she had pushed through, maybe the start of last week (exact date unknown). She stated she went next door to an auto parts store and borrowed a lighter from a staff at the store because she wanted to smoke. She stated a female facility staff (name unknown) rolled up approximately twenty minutes later and escorted her back to the facility. She stated she left the facility because she missed her belongings and her apartment. She stated she did not think she spoke to the ADM that day. She denied she experienced any injury or adverse effects from leaving the facility. Resident #1 was observed with no obvious sign of injury. A bolt and nail were observed preventing Resident #1's window from opening more than a few inches. In an interview on 8/5/25 at 4:17 pm, the DON stated that Resident #1, sometimes gets on a rant about wanting to leave but that she had not heard anything about her going out a window or being over at an auto parts store. She reported that residents' windows have screws that prevent them from being raised enough for a resident to elope. She reported that preventing elopement for Resident #1 had included that Resident #1 was accommodated to go out for activities, she was on a secure unit, she was seeing psychiatric services, and she was placed on Q15 minute checks for behaviors as needed including aggression and elopement. She stated that staff were free to report any incidents without fear of retaliation and she had not received any complaints of staff being fearful of retaliation. The DON stated that all staff had received training on elopement and actions to take. She reported that part of the training included that the staff would notify the Administrator of an elopement incident. She stated in the event of a missing resident, all staff were to immediately search indoors and if not found would expand the search to the outdoor property, the Administrator would be notified, and a decision would be made if authorities needed to be notified. She stated she was not aware of any staff having been told not to document an incident and that a facility supervisor would do it instead. In an interview on 8/05/25 at 3:20 pm, the ADM stated he was not informed of Resident #1 going out a window. He reported to his knowledge Resident #1 had never exited or tried to exit the facility. He stated Resident #1 had called a ride service and friends to come pick her up in the past. He stated there had not been any windows repaired in the past month except one window on the male unit. He stated he was not aware that Resident #1 was placed on Q15 minute checks but that this can be done for excessive wandering as well as aggressive or other behaviors. He reported that if a resident exited the facility, he expected staff to count all residents, search the facility, call a code silver, search the exterior property, and then the surrounding properties, and notify the DON, himself, the MD, and the family. He reported that he was not aware of Resident #1 having any injuries in the past three weeks. He reported that staff had received training on handling and reporting elopements/code silver training. He stated that if staff had informed him, he would have notified the police if the Resident was not immediately found. He stated he would have notified the state if a resident had eloped. He denied he ever threatened staff with their jobs if they said anything about the incident. He stated that he would be beginning an investigation now, and if he finds that Resident #1 did in fact elope, he will report it to the state. Review of the facility policy titled, Wandering and Elopements dated 2001 and revised March 2019 stated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy stated that, when a resident returns to the facility, the director of nursing services or charge nurse shall a.) examine the resident for injuries, b.) contact the attending physician and report findings and conditions of the resident; c.) notify the resident's legal representative (sponsor); d.) notify search teams that the resident has been located; e.) complete and file an incident report; and f.) document relevant information in the resident's medical record. In an interview on 8/08/25 at 11:05 am, an auto parts store Employee was interviewed at the store located adjacent to the facility. The employee stated that about two weeks ago (exact date unknown) an elderly white female came into the store and asked for a cigarette lighter and to call a taxi. He stated this occurred sometime between 2 pm and 4 pm. He reported about 30 minutes later a black male staff and black female staff member from the nursing home across the street came and got the resident. He reported the taxi called back after the resident left and he told them she had been taken back to the nursing home. He reported the elderly resident was walking steadily but that he had noted her hands were shaky. He stated the resident had not appeared to have any injuries. He confirmed by the picture of the facility face sheet that the resident he saw was Resident #1. He did not remember the exact date this occurred or what other employees might have been present. In an interview on 8/08/25 at 1:00 pm, the DON stated that Resident #1 was on the locked unit because she had fluctuations in her cognition that could cause her safety issues due to confusion at times. She reported that Resident #1'samily member had tried to take her home for a trial placement in the past (date unknown) but that Resident #1's family member noted she was unsafe. She was not sure what occurred that her family member felt like it was unsafe for Resident #1 to be home. The DON stated that Resident #1 had become agitated one day this week and had screamed, get me the fuck out of here. She reported that Resident #1 has always been on the locked unit since her admission to the facility. In an interview on 8/08/25 at 2:42 PM, Resident #1's family member revealed the facility had notified her when Resident #1 had behaviors, and that when Resident #1 was first admitted to the facility staff had informed her that the resident had broken a window. She said that on 8/05/25 the ADM had called and informed her Resident #1 had said she had escaped through a window at the facility, but not that she had actually done it. She stated the ADM informed her there was an investigation about Resident #1 escaping through a window and he asked if she knew anything about that and she told him she did not. She said Resident #1 had a history of drug addiction, definitely has some behavioral problems, and sometimes she acted out to get attention. She said Resident #1 had been in nursing facilities closer to their home, but they would not keep her, because of her behaviors. She said the family had been trying to work with a program that could give the resident the help she needed in her home, but when people from the program went to interview her, all Resident #1 had talked about was how she was leaving and was not going to stay at the facility for another minute (date unknown). The Administrator was notified on 8/08/25 at 3:26 pm that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 08/08/25 at 3:32 pm. The facility's Plan of Removal was accepted on 8/09/25 at 10:31 am and included: Corrective Actions: On 8/6/2025, the DON and the ADM in-serviced direct care staff on Code Silver Policy and Procedure (Code Silver is the code called in the facility if a resident is missing), and notification. On 8/6/2025, all windows on locked units were permanently secured so that they could only open 4-6 inches for safety and security by maintenance to ensure they did not open fully, and no residents were able to exit via the window.On 8/6/2025 all residents wandering assessments were updated by the DON, the ADON, and the MDS Coordinator. Any resident who were designated at risk as determined by the DON, the ADON, and the MDS Coordinator were placed on the secure unit with an order from the physician. All residents who were determined to be at risk of wandering had their care plan updated by the MDS Coordinator.On 8/6/2025 it was verified by the DON that all residents on the secure unit had a physician order for appropriate placement.By 8/6/2025, Ad hoc QAPI (Quality Assurance and Performance Improvement) committee meeting was conducted with the Interdisciplinary Team and the Medical Director to review the elopement policy for effectiveness, and this will be reviewed quarterly going forward for effectiveness.By 8/6/2025 all staff had been educated by the DON, the ADON and the MDS Coordinator on the definition of elopement and that if an employee observed a resident leaving the premises, he/she should:- Attempt to prevent the residents from leaving in a courteous manner.- Get help from other staff members in the immediate vicinity if necessary.- Always stay with the patient.- Instruct another staff member to inform the charge nurse or Director of Nursing services that a resident is attempting to leave or has left the premises. Call if necessary.If the door alarm sounds, but no resident is found outside the premises all staff members will conduct a thorough search for the resident in the facility, including areas such as kitchen, closets, and bathroom to ensure all residents are accounted for.If a resident is missing, initiate the elopement/missing resident emergency procedure.- Determine if the resident is out on an authorized Leave or Pass.- If the resident was not authorized to leave, initiate a search of the building and premises.- If the resident is not located, notify the Administrator and Director of Nursing services, the legal representative, the attending physician, law enforcement officials, and if needed volunteer agencies.When the resident returns to the facility the DON and/or charge nurse shall- Examine the resident for injuries.- Contact the physician, report finding and condition of resident.- Notify resident's legal representative (RP)- Notify everyone in search that the resident has been located.- Complete incident report- Document relevant information in [Electronic Medical Record]Any PRN staff member or newly hired employee who had not received in-service by end of business on 8/6/2025 would not work the floor until in-service had been received.On 8/6/2025 the DON, the ADON, and the ADM educated all staff in the event a resident had exit seeking behaviors on the secure unit, the charge nurse is to be notified, and he/she will be care planned. On 8/8/2025 the LNFA COO educated the ADM and the DON on reportable guidelines and investigation. All reportable events will be reported immediately to COO for investigation oversight. If the COO is out of office, the CEO shall be notified in her stead. Documentation:On 8/8/2025 the DON and the ADON in-serviced all licensed nurses on the importance of documentation, assessment, notification and follow up after an elopement.Monitoring:As of 8/8/2025 going forward the DON will question licensed staff regarding elopements during clinical meetings.As of 8/6/2025 window inspections will be conducted 3x week for 30 days then weekly ongoing by the Maintenance Director, a Weekend Supervisor, or the ADM. Monitoring the plan of removal: Interviews with the following staff between 3:00 PM on 08/08/25, and 2:00 PM on 08/09/25: MDS Coordinator, CNA E (6:00 AM to 2:00 PM shift), LVN F (all shifts), CNA G (6:00 AM to 2:00 PM shift), LVN H (6:00 AM to 2:00 PM and 10:00 PM to 6:00 AM shifts), LVN I (6:00 AM to 2:00 and 2:00 PM to 10:00 PM shifts), Med Aide J (all shifts), CNA K (all shifts), LVN L (6:00 AM to 2:00 and 2:00 PM to 10:00 PM shifts), and CNA M (6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM shifts), revealed staff had been in-serviced on the definition of elopement, Code Silver procedures (the code called in the facility if a resident was missing), interventions for exit-seeking behaviors, and what to do if a resident was found to be missing, notifications, documentation, assessment, follow up, reporting of exit seeking behaviors and elopements/elopement attempts. They also were knowledgeable about contacting their corporate number if they were not comfortable reporting to administration, were aware of the HHSC number for Abuse and Neglect reporting and denied having any discomfort reporting to Administration. In observations on 8/9/25 at 12:42 pm, the windows on the male and female locked units were observed to have been changed to be openable from 4-6 inches only. Review of clinical records for Residents #2, #3, #4 and #5 included progress notes, care plans, and wandering assessments done prior to 8/08/25, and wandering assessments updated on 8/08/25 as part of the facility's plan of removal. No concerns were noted, and there were no significant changes in assessments. In a review of records, Resident #1's care plan reflected interventions for elopement were updated on 8/08/2025 and included the following: activities will take Resident #1 on out of facility activities on one to one, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, Resident #1 prefers going outdoors to smoke and sit in the sun, one on one with the Activity Director including out to eat, Walmart trips, watching movies, reading books, outings with family, medication adjustment made on 8/06/25 to risperidone, monitor for fatigue and weight loss, provide structured activities- regular toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes, and resident will reside on secure unit for safety. A review of Resident #1's progress note dated 8/6/25 and created by LVN B reflected Resident #1's Risperidone was increased to one milligram twice daily and resident was placed on Q15 minute checks for exit seeking behaviors. In an interview on 8/09/25 at 10:24 am the DON reported that based on the assessments of the DON, the ADM, and the MDS Coordinator, no residents were deemed at risk requiring a move to a secure unit. A record review of the facility Order Listing Report reflected physician orders were present for residents on the locked units. A record review of the facility QAPI minutes dated 8/6/25 reflected elopement was reviewed by the facility, and 7 signatures were observed including the ADM and Medical Director as well as others. A record review of the facility in-service training record dated8/8/25 and titled, COC (Change of Condition) Charting, I/A (Incidents and Accidents) reports, Abuse/Neglect Reporting, Corporate Reporting was reviewed and included the signatures of 11 nurses and one CNA. A record review of the facility in-service training record dated 8/6/25 and titled, Elopement/Code Silver, Policy and Procedure, Documentation/Charting was reviewed and noted with 54 signatures including LVN, dietary manager, CNA, Social services, PT, dietary aide, laundry, staffing, BOM, housekeeping, and other staff. The ADM provided a list of employees who had not signed the training documenting and they were called and provided with verbal training. A review of a word document provided by the ADM dated 8/08/25 documented education was provided to the ADM and the DON on reportable guidelines and investigations by the LNFA COO and included signatures of the ADM, the DON, and the LNFA COO. In a review of records, a word document provided by the facility reflected the initial window inspection was completed on 8/6/25 and signed by the Maintenance Director with a statement noting that all windows in the female and male secure units had been verified as fixed. In an interview on 8/09/25 at 2:26 pm, the ADM reported that he and the DON received training on 8/09/25 by the regional LNFA COO who went over all the trainings that they were to provide to staff, the plan of removal, and reportable guidelines and investigation. The ADM reported he will report all reportable events immediately to the LNFA COO for investigation oversight, and if the COO is out of office, he will notify the CEO. He reported that as an Administrator he plans to talk to the staff more thoroughly and watch how he is talking to staff as something that was meant as a precautionary statement had been taken as a threat. He stated he intended to make sure that documentation is thorough. The ADM reported that this was IJ as the resident was at risk due to possible elopement that wasn't reported in a correct or timely manner and there was an allegation that the Administrator threatened retaliation against staff for documenting and reporting. In an interview on 8/09/25 at 4:17 PM the DON stated that she and the ADM had received training from corporate on all training involved in the plan of care and all the in-service trainings that they were to provide to the staff. She stated that she feels the reeducation of staff on all the topics will make a difference and that now the corporate number has been made available to staff. The DON stated that this situation was an IJ because there was an allegation of an elopement that was not processed or addressed, and it was an IJ because the situation presented a risk. She reported she will be questioning staff regarding elopements during clinical meetings going forward and will be monitoring to ensure that any PRN staff who have not received the appropriate training are not allowed to work. On 8/09/25 at 2:46 pm the ADM was notified the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate their corrective actions.

Based on observations, interviews, and record review, the facility failed to provide adequate supervision for 1 of 10 residents (Resident #1) reviewed for wandering and elopement risk. The facility failed to implement effective interventions for Resident #1 identified as at-risk for elopement and had a history of elopement. On 12/03/23 at approximately 1:15 PM, Resident #1 was demonstrating exit-seeking (actively trying to leave the boundaries of a particular area) behaviors by attempting to go out the exit door when the alarm sounded off. LVN A verbally redirected Resident #1 to come to the nurse's station. On 12/03/23, Resident #1 eloped (an unauthorized departure of a resident from an around-the-clock care setting) from the secured unit unnoticed by facility staff. On 12/03/23 at 1:43 PM, Resident #1 was struck by a vehicle while crossing a major intersection 1.4 miles from the facility, sustaining an injury to his right arm. An Immediate Jeopardy (IJ) was identified on 12/06/23. The IJ template was provided to the facility on [DATE] at 5:00 PM. While the IJ was lowered on 12/07/23, the facility remained out of compliance at a scope of isolated and severity level of actual harm that was not IJ due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. These deficient practices placed residents at considerable risk of serious injury, harm, impairment, developing complications, or death by not receiving services necessary, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of Resident #1's Admission Record, revealed a 69 y.o. male, who admitted to the facility on [DATE] with the following diagnoses: Schizoaffective Disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), Depressive Type (feelings of sadness, emptiness, feelings of worthlessness or other symptoms of depression); Dementia, Moderate, with Mood Disturbance; Generalized Anxiety Disorder; Alzheimer's Disease with Late Onset; Depression, uns.; Uns. Psychosis; Unqualified Visual Loss (visual impairment), Both Eyes . Record review of Resident #1's Quarterly MDS review assessment, dated 09/29/23, revealed Resident #1 had a BIMS of 06 which suggested severe cognitive impairment. Resident #1's functional status required one-person physical assist with ADLs. Resident #1 was occasionally incontinent of bladder and always continent of bowel. Record review of Resident #1's progress notes indicated: - Nurse's Note Effective Date: 12/03/23 at 1:45 PM, written by LVN A, reflected, At approximately 1:45 PM [CNA B] returned to relieve [LVN A] from unit, while [LVN A] and CNA B were performing walking rounds [Resident #1] was not accounted for at this time. Code silver called with all staff involved and searching facility for resident. While staff conducting search for [Resident #1] police arrived at facility noting that resident was noted outside of facility and taken to [hospital] due to minor injuries. Administrator/DON/ADON notified. Administrator notified [RP] of situation. ADON called [hospital ER] with report given and clinicals sent to hospital at which time ER informed ADON that current injury was road rash to right arm and will inform of any further concerns. - Nurse's Note Effective Date: 12/03/23 at 8:18 PM, written by LVN A, reflected, LATE ENTRY: [Resident #1] returned to SNF from hospital, alert with some confusion, denied pain. Upon skin assessment right arm, right elbow, and bright redness noted. RP was notified of [Resident #1] return from hospital. Resident #1's clinical physician orders reflected: - Order date 11/22/22: Divalproex (used to treat certain types of seizures and bipolar disorder [manic-depressive illness]) Tablet Delayed Release 250 mg. Give 1 table by mouth at bedtime for seizures. - Order date 04/19/23: Behavior Monitoring - Antipsychotic Behavior Code every shift. - Order date 04/19/23: Behavior Outcome every shift. - Order date 04/19/23: Risperidone Tablet 2 mg. Give 1 tablet by mouth two times a day r/t Schizoaffective Disorder, Depressive Type. - Order date 05/22/23: May admit resident to secure unit r/t dementia. - Order date 06/28/23: Psychological Services may provide psychiatric and medication management services. - Order date 08/07/23: Sertraline Tablet 25 mg. Give one tablet by mouth one time a day r/t Schizoaffective Disorder, Depressive Type. Give with 50 mg (1) tab to equal 75 mg total. - Order date 08/07/23: Sertraline Tablet 50 mg. Give one tablet by mouth one time a day r/t Schizoaffective Disorder, Depressive Type. Give with 25 mg (1) tab to equal 75 mg total. - Order date 09/25/23: Antidepressant monitoring for Zoloft (used to treat some types of depression) every shift for side effects. - Order date 09/25/23: Antipsychotic monitoring for Risperdal (used to treat certain mental/mood disorders) every shift for side effects. - Order date 09/25/23: Behavior Monitoring - Antidepressants Behavior Code every shift. - Order date 12/04/23: Monitor abrasions to right arm until resolved every Day shift. Record review of Resident #1's digital Comprehensive Care Plan, revealed: Focus [Initiated: 04/11/22; Revised: 04/24/23]: Resident #1 was at risk for elopement and wandering around facility with/without purpose r/t Dementia with behavioral disturbances. The goal(s) [Initiated: 04/11/22; Revised: 10/31/23; Target date: 03/03/24] reflected Resident #1 would be redirected from other residents' rooms, out of unauthorized area without injury to self or others through next review date; have no reports of wandering into unsafe area or wandering away from facility through next review date. Interventions [Initiated: 04/11/22] reflected If noted attempting to wander away from facility, attempt to redirect back to facility. Offer distraction for example food, activity, call family, and if they become agitated and continue to wander, seek assistance, and continue to observe for safety till hewasback in building. Notify Nurse; . If wandering increases and place resident at risk for injury, or leaving facility, Notify MD, RP, NFA, DON, USW and assess, discuss possible need for secure unit. Resident prefers to sleep throughout the day and ambulates throughout the night.; . Observe for change in mental status to include but not limited to: increased confusion, hallucinations, delusions. Notify MD and implement ordered interventions; . observe him when out of room for wandering in/out of other room, wandering to unauthorized area and provide redirection as needed; . Offer verbal cues and redirection as needed to find own room, dining areas, activities area as needed; and Refer to Psychological services as needed. Focus [Initiated: 05/22/23]: Resident #1wasan elopement risk/wanderer r/t Impaired safety awareness and Dementia, history of elopement. The goal(s) [Initiated: 05/22/23; Revised: 10/31/23; Target: 03/03/24] reflected Resident #1's safety will be maintained through the review date. Interventions [Initiated: 05/22/23] reflected Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers:; . Monitor for fatigue and weight loss; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes . WANDER ALERT: will reside in the secured unit. Focus [Initiated: 12/04/23]: Resident #1 had an elopement episode r/t Dementia, history of elopement. The goal(s) [Initiated: 12/04/23; Target: 03/03/24] reflected Resident #1's safety will be maintained through the review date. Interventions [Initiated: 12/04/23] reflected Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television . Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes . WANDER ALERT: continue placement in the secured unit. Record review of EMS Incident Report dated 12/03/23 at 7:58 PM, reflected EMS received a call and was dispatched 12/03/23 at 1:43 PM and arrived on scene at 1:47 PM. The EMS narrative reflected, Arrived on scene to find an SUV parked in the second lane, a pickup truck parked in the third lane, and an elderly male [Resident #1] sitting on the ground in the third lane. [Resident #1] was conscious, sitting upright on the ground, and wearing yellow non-slip socks. No notable injuries on approach. [Resident #1] reported that he was walking with the flow of traffic when he was hit by a vehicle. When asked, he complained of right forearm pain from an 8-inch road rash/abrasion, not actively bleeding. No complaints of head pain, no neck, back pain, no vision changes, no notable deformities. [Resident #1] reported that he was walking from his sister's house, then reported that he was walking across the street, then that he was walking from his home. Itwasunknown how [Resident #1] got out of the facility and walked to where the event occurred. Information gathered from bystanders found [Resident #1] walking across the road (not in a crosswalk) when he was struck by the SUV in the second lane driving approximately 30 mph and slid into the 3rd lane. Unknown the accuracy of the speed at which [Resident #1] was hit. [Resident #1] was questioned by [the police department] in the back of the ambulance and was unable to answer questions completely/appropriately. [Resident #1] continued to report the only pain as being the burning sensation from the road rash. Resident #1 was transported to the hospital for assessment, evaluation, and treatment as needed. Record review of the Police Department Incident Report, dated 12/03/23, reflected the officer was dispatched to an accident on 12/03/23 at 1:43 PM. The officer report indicated the officer observed a compact SUV stopped in the center lane. A male later identified as Resident #1 sat in the right lane being attended by an off-duty officer. The off-duty officer advised he observed a vehicle swerve to avoid hitting Resident #1. [Resident #1] was in the center lane and appeared to be crossing the highway from west to east. The vehicle that swerved was in front of the compact SUV. The compact SUV did not appear to have sufficient time to react to Resident #1 being in the street. The front right of the compact SUV struck Resident #1. The officer spoke with a witness who corroborated the off-duty officer's statement. The witness had been driving in the right lane when the accident occurred and stopped in the right lane to keep traffic off Resident #1. The witness estimated traffic to be heavy and moving approximately 30 mph. The witness confirmed the collision occurred in the center lane and that the momentum of the collision pushed Resident #1 into the right lane. The witness indicated that Resident #1 was not intentionally trying to be struck by the vehicle, he was trying to cross the street. The officer revealed that Resident #1 seemed confused, had trouble identifying himself, and suffered several abrasions to the right arm. The driver of the compact SUV said that she was traveling north in the right lane and made a lane change into the center lane. A vehicle in front of the [compact SUV] driver swerved and thatwaswhen the driver observed Resident #1 in front of her. The driver slowed but was not able to avoid hitting Resident #1. The front right of the compact SUV struck Resident #1 on the left hip. The officer's report indicated by all witness and involved party accounts Resident #1 was crossing the highway not at a designated pedestrian crosswalk, and without a signal. The officer measured the distance from the pavement to the accident scene at approximately 160 feet. The officer indicated that dispatch was unable to reach the SNF by phone. The officer relocated to the SNF and spoke with RN C who confirmed Resident #1 was a resident at the facility on the secured unit. The officer advised the facility of Resident #1 being transported to the hospital. The officer spoke with LVN A who relayed the following: Resident #1's RP left from visiting him just before 12:30 PM. Resident #1 was often upset when the RP left and wanted to go with her. Resident #1 was upset in that manner when the RP left [12/03/23]. LVN A had been looking for Resident #1 but was not yet concerned because was known to often hide in closets. LVN A suspected Resident #1 had possible left through the north side door of the secured unit (towards Hall 200) as the door sometimes does not secure all the way when someone passed through. The officer indicated he later spoke with the DON who advised that a preliminary investigation at the SNF revealed that Resident #1 likely went out a window and climbed the fence using a chair. During an interview on 12/05/23 at 12:34 PM, the DON stated that she received a call from the ADON on Sunday, 12/03/23 around 2:22 PM to inform that [Resident #1] could not be located and initiated a Code Silver (facility response when a residentwasmissing). The DON said the ADON informed that during the internal search of the facility for the resident, the police arrived and stated the resident was located and transported to the hospital for assessment. The DON said that she received an incoming call from RN C (the weekend supervisor) while she was speaking with the ADON. The DON instructed the ADON to contact the hospital for information about the status of Resident #1. The DON said she returned the call to RN C at 2:24 PM and instructed him to complete the Code Silver by conducting a head count of all residents in the facility, check all exit doors if alarms worked, and to initiate watch (remain by exit door to prevent unauthorized resident exit(s) until fixed). The DON said that she called the NFA at 2:26 PM to verify if he was aware but the call was unanswered. The DON said she notified the C.O.O. (executive in charge of the daily operations of an organization) at 2:27 PM. The DON said she called the police department at 2:44 PM, on her way to the facility. The DON said she arrived at the facility between 3:30 PM and 4:00 PM. The DON said that she received a call back from the officer who responded to the traffic accident that involved Resident #1. The DON said that the officer informed her that Resident #1 was observed on the ground upon arrival on scene, noted abrasions to the right arm, and EMS took Resident #1 to hospital for assessment and treatment. The DON said that immediate actions taken [12/03/23] included, removing all non-permanent furniture, securing the window [Resident #1] exited, changed all the access codes, and initiated an in-service on Elopement Prevention/Management and Code Silver protocol. The DON said that it was her expectation for staff to monitor resident whereabouts every two hours or as needed and the on-coming/off-going staff to conduct walking rounds together at the beginning and end of shifts. Observation on 12/05/23 at 2:45 PM of the secured unit with the DON revealed frosted magnetic locked doors operated with a keypad to enter an access code at two separate hall entryways. There were two emergency exits, one exit at the south end of the unit and one exit in the dining area. Each emergency exit door had an alarm that would sound if the door panel was pressed without entering an access code. The emergency exit door at the south end accessed an enclosed courtyard. The room Resident #1 passed through to elope from the facility, was the room before the south end emergency exit. The room had one single-hung window (allows ventilation through a single operable lower sash that slides up and down) that faced the center of the courtyard. The windowsill height was approx. 24-inches from the floor. There was no screen on the window. The window was secured with screws on both sides of the window jambs that prevented the window from being raised at the time of observation [the window was not secured and there was not a window screen when Resident #1 eloped from the facility]. The DON said when the exit point was discovered, the window was raised in the opened position and a mattress was placed across the windowsill. There were footprints in the mud beneath the window. The DON entered the code to exit the secured unit through the south end emergency exit onto the courtyard. A 6-foot wood fence enclosed the courtyard. After exited through the door, had to make two right turns to see the courtyard in its entirety and the center of the courtyard that the [exit] window faced. There were benches that were bolted to the ground for security and stabilization. The DON stated there was patio furniture in the courtyard that could be moved around and rearranged. The DON said that Resident #1 moved one of the patio chairs, placed the back of the chair against the fence (near the exit door), and climbed over the fence. The fence separated the courtyard and the sidewalk along a six, 12-foot-wide lanes (three lanes in each direction) highway. During an observation on 12/05/23 at 2:56 PM, the DON knocked on [Resident #1's] door and opened slowly. Resident #1 was observed lying in a right lateral position at the foot of his bed. Resident #1 sat up to the side of the bed upon entry to the room. Resident #1 could answer closed ended questions and simple questions, such as, he replied, I'm okay when asked how are you? Resident #1 could make his needs known by stating he was thirsty. Resident #1 could not meaningfully engage in an interview. Observation of Resident #1's right forearm, above the wrist and at the elbow, revealed an abrasion where the skin was scraped off when injured. During an interview on 12/05/23 at 5:21 PM, the NFA indicated he first learned about the incident on Sunday, 12/03/23 at 2:21 PM when he returned a missed call to LVN D. The NFA said that LVN D informed that the police showed up at the facility around 2:19 PM to advise that Resident #1 was found down the street, was hit by a car, and was transported to the hospital. The NFA said that he immediately headed to the facility and arrived before 3:00 PM. The NFA said that the facility did not utilize WanderGuards (Code Alert wander management system) because there was a secured/locked unit. The NFA said that he spoke with staff when he arrived at the facility to obtain more information, but the staff could not say a whole lot. The NFA said that RN C had discovered the way Resident #1 exited the facility through the window. The NFA said that RN C arrived to work around the same time the police approached the facility to notify Resident #1 was located. The NFA said as part of his investigation, he called the fire department [on Sunday, 12/03/23] and was told that the call came in around 12:31 PM. The NFA said he then spoke with Resident #1's RP and they stated they visited and left the facility between 12:15 PM and 12:30 PM, so [Resident #1] had not been out the facility for very long. When statements were requested for review, the NFA said that he had obtained verbal statements. The NFA said that RN C had texted his statement to the NFA phone and gave [the NFA] permission to type up the statement. The NFA said that he spoke with the EMS Chief on Monday, 12/04/23 who spoke with the Captain of the Fire Department on Sunday. The NFA said that the EMS Chief and Fire Captain both agreed that Resident #1's wound did not align with a person who was struck by a car going 30 mph. The NFA then said he verified with the fire department [12/05/23] that the call was received at 1:43 PM and emergency vehicles arrived on scene at 1:47 PM. During an interview on 12/06/23 at 11:20 AM, the ADON stated she received a call Sunday, 12/03/23 at 2:19 PM on the on-call phone from RN C to inform [Resident #1] was missing. The ADON acknowledged understanding and called the DON to notify. The ADON said while she was on the phone with the DON, she received a call on her personal cell phone at 2:22 PM to inform that the police were on-site at the facility, had located Resident #1, and was being transported to the hospital after he was struck by a vehicle. The ADON said she ended the call with the DON to call the ER as instructed. The ADON said that she did not come to the facility on Sunday because she lived to far away. During an interview on 12/06/23 at 3:18 PM, the DOM stated he missed a call from the NFA on Sunday, 12/03/23 at 2:37 PM and returned the call at 2:46 PM. The DOM said that the NFA told him that the police came to the facility to inform that a resident got out of the building. The DOM said he arrived at the facility about 30 - 40 minutes later. The DOM said that he normally goes around the facility once a week to check the alarms on all the exit doors to ensure function correctly. The door would buzz once the bar was pressed to open the door if the access code was not entered or entered incorrectly. The door should not open. The DOM said that the one window on the secured unit was not locked or secured in a way to prevent from opening. The DOM said that it was not a normal part of his environmental rounds to check the windows of the secured unit. The DOM said as of Sunday [12/03/2023] all entry/access points had been checked to ensure they were secured, and door alarms functioned properly as a step in the prevention of elopement. During a phone interview on 12/06/23 at 3:44 PM, CNA E said that she arrived at work around 2:15 PM. CNA E said that when she entered the secured unit, the nurse [LVN A] asked if had seen Resident #1 then said to start looking on other hallways in the facility. CNA E said that there was only the CNA on the secured unit with the ten residents and the assigned nurse would come to the unit to pass medications. CNA E said that another CNA that works the same shift as she does, would check on her to see if she needed a break. CNA E said that she was checking the hall near the front entrance when an officer entered the facility and told [LVN D] that Resident #1 was located. During a phone interview on 12/06/23 at 4:23 PM, CNA B said that Resident #1's RP visited Sunday, 12/03/23 around lunchtime. CNA B said that the RP left the facility around 12:45 PM. CNA B said LVN A came to relieve her for break around 1:15 PM. CNA B said Resident #1 wanted to go with the RP when she left and was upset. CNA B said that Resident #1 was pacing up and down the hallway and right before she left for break, had pushed on the [south end] emergency exit door and the alarm buzzed. CNA B said that LVN A told Resident #1 to come sit at the nurses' station with him. CNA B said she left for break and returned around 1:50 PM - 1:55 PM. CNA B said when LVN A was checking on the residents before he left was when he discovered Resident #1 was missing. CNA B said she checked Resident #1's room and a couple other rooms before LVN A told her to check the dining area [located on the secured unit]. During an interview on 12/07/23 at 8:08 PM, LVN A said that he worked weekend doubles and was assigned Hall 200 and Hall 300 (Secured Unit). LVN A said that he sat on Hall 200 but would go back and forth to check on the residents in the secured unit. LVN A said when he arrived to work, he would receive report and conduct walking rounds on Hall 200 and Hall 300, then monitor the breakfast trays in the kitchen to ensure residents were served the correct diet and texture modified foods. LVN A said he checked blood sugars on Hall 200, then prepared medications for Hall 300 and administered. LVN A said that he would check on every resident when he administered medications on Hall 300 as part of his resident rounds. LVN A said after he administered medications on Hall 200 if was almost time to check blood sugars again. LVN A said on Sunday, 12/03/23 he received two residents to readmit, one around 12:00 PM and the other around 12:30 PM. LVN A said around that time, he observed Resident #1's RP pass by [Hall 200] nurses' station and noted she was crying. LVN A said that the CNA from Hall 100 approached him (around 1:00 PM) and told him that CNA B needed a break to go to the store. LVN A said he acknowledged understanding. LVN A said that he went to the secured unit [Hall 300] to relieve CNA B for a break, around 1:15 PM. LVN A said he checked on the residents before CNA B left and all residents were accounted for. LVN A said just as CNA B was leaving, Resident #1 tried to go out the south end emergency exit door. LVN A said when the alarm buzzed, he told Resident #1 to come down to the nurses' station. LVN A said that Resident #1 walked away from the emergency exit and sat down with the other residents in front of the television near the nurses' station. LVN A said he was sitting at the nurses' station and would periodically look up from the computer at the residents to make sure no one tried to get up and that no one presented signs of acute distress. LVN A said that CNA B returned from break between 1:45 PM and 1:50 PM, closer to 2:00 PM. LVN A said that he walked down the hall to check on the two residents that were in their rooms and as he walked back up the hallway, realized Resident #1 was not sitting with the other residents where he was last seen. LVN A said he asked CNA B what happened to [Resident #1], where did he go? LVN A said that CNA B said that Resident #1 would sit in his closet sometimes. LVN A said that he checked Resident #1's closet. LVN A said that he recalled Resident #1 went into the female rooms in the past, checked their rooms, Resident #1 was not in there. LVN A said at that time he told CNA B to start checking all the rooms. LVN A said he exited the secured unit and checked the other rooms on Hall 300. LVN A said as he turned to walked down the hall towards the facility entrance, he saw an officer in the lobby. Record review of the facility's Abuse Prevention Program policy statement, revised June 2021, revealed: The Administrator was responsible for the overall coordination and implementation of our abuse prevention program policies and procedures. Itwasthe policy that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. Definitions: To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: Neglect was the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Prevention . The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by: Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property more likely to occur . has deployed the correct number of competent staff on each shift to meet the needs of the residents. Assuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which includes, butwasnot limited to, the completion of a Facility Assessment to determine what resources are necessary to care for its residents competently. Identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect . Identification, Investigation, Protection, Reporting / Response . staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Record Review of the facility's Elopements policy revised April 2014 reflected: Policy Statement Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation Staff shall promptly report any resident who tries to leave the premises or was suspected of being missing to the Charge Nurse or Director of Nursing. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: Complete and file an incident report; and Document relevant information in the resident's medical record. Record Review of the facility's Wandering, Unsafe Resident policy revised April 2014 reflected: Policy Statement The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Policy Interpretation and Implementation The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at-risk individuals for potentially correctible risk factors related to unsafe wandering. The resident's care plan will indicate the resident at risk for elopement . Interventions to try to maintain safety, such as a detailed monitoring plan will be included. A missing resident was considered a facility-wide emergency. If a resident was missing, the elopement/missing resident emergency procedure will be initiated . When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: Complete and file an incident report; and Document relevant information in the resident's medical record. The NFA was notified of an Immediate Jeopardy (IJ) on 12/06/23 at 5:00 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 12/07/23 at 5:00 PM and included: Corrective Actions: By 12/6/2023, COO in-serviced DON and NFA on Code Silver Policy and Procedure, updating wandering assessments, changing door codes, and checking all door exits and windows. By 12/6/2023, all windows on locked unit have been permanently secured by DOM to ensure they do not open fully, and no resident was able to exit via the window. By 12/6/2023, all non-permanent furniture has been removed from the secure unit courtyard. All staff have been in-serviced by the DON, ADON, and Administrator on the prohibition of non-permanent furniture in the secure unit courtyard. By 12/6/2023 all residents have updated wandering assessments completed by DON, ADON, and MDS. Any resident who was designated at risk - which will be determined by the IDT (DON, ADON, and MDS) was placed on the secure unit with an order from the physician. All residents who are determined to be at risk of wandering will have a personalized care plan updated by DON, ADON, and MDS. On 12/6/2023 DON, ADON contacted all Responsible Parties of residents on the secure unit to personalize interventions to aide with redirection during periods of exit seeking. Each Care Plan has been updated, and specifics added to the Kardex for the staff to access. All new admission to the unit will be updated by DON-, ADON, or MDS nurse. On 12/6/2023 DON and ADON in-serviced all direct care staff on how to access the Kardex for personalized interventions. On 12/6/2023 it was verified by DON that all residents on the secure unit had a physician order for appropriate placement. By 12/6/2023, all door codes have been changed to ensure only staff members are aware of the code. By 12/6/2023, Ad hoc QAPI conducted with Interdisciplinary Team and Medical Director to review the elopement policy for effectiveness and will be reviewed quarterly going forward for effectiveness. On 12/6/2023 DON issued a final written warning to LVN A for not immediately notifying NFA and DON of Code Silver per policy. Monitoring- On 12/6/2023 DON-, ADON,

Based on observations, interviews, and record reviews, the facility failed to provide timely emergency respiratory care consistent with professional standards of practice, including maintaining training for nursing staff regarding expectations for suctioning residents in the on-site dialysis center, for a resident in respiratory distress in the facility's in-house, contracted dialysis center for one (Resident #1) of one resident reviewed for tracheostomy care. 1. Facility staff failed to respond immediately to a request by contract dialysis staff to provide suction for Resident #1 when she had respiratory distress on 10/25/22, at which time Resident #1's distress increased, and she stopped breathing and became unresponsive for an estimated 45 seconds. At this time facility staff began to provide trach suctioning, approximately 12 minutes after dialysis staff initially started attempting to get help from facility staff. 2. A nurse (thought to be LVN J by dialysis staff), refused to provide immediate trach suctioning for Resident #1 on 11/11/22, as requested by contract dialysis staff, when Resident #1 was having gurgling and wet rattling during breathing, and felt she was having increased trouble breathing, and anxiety. This required dialysis staff to attempt to find other nursing facility staff to suction Resident #1's trach, causing a delay in making her comfortable, and a delay in their ability to begin her dialysis treatment timely, and deliver the full treatment. These failures could affect residents with a tracheostomy and in-house dialysis services by placing them at risk of a delay in receiving life-saving treatment which could result in serious injury, harm, and death. Findings included: Review of Resident #1's face sheet dated 12/08/22 reflected she was admitted on [DATE] with diagnoses of acute and chronic respiratory failure, diabetes, malnutrition, pneumonia due to pseudomonas, colostomy, tracheostomy, dialysis for end-stage renal disease, and a feeding tube. Review of Resident #1's MDS assessment, dated 10/20/22, reflected Resident #1 had adequate hearing and clear speech, and was able to understand others and be understood by others. She had A BIMS score of 12, indicating moderate cognitive impairment. During the assessment period she had no behavioral issues or indicators of psychosis. She required limited assistance from one person for dressing and hygiene, and extensive assistance by two people for transferring, moving around in her bed, and toileting. Resident #1 had shortness of breath when sitting, lying, and exerting. Review of Resident #1's dialysis orders, provided by the contract dialysis staff on 12/08/22, reflected she was to receive dialysis for 2 hours and 48 minutes, five times per week. Review of Resident #1's care plans reflected the following: - Care plan dated 10/03/22 The resident needs hemodialysis. The care plan did not address emergencies which occur while in dialysis treatment. - Care plan dated 10/26/22 The resident has a tracheostomy r/t respiratory failure. Goals: the resident will have clear and equal breath sounds bilaterally through the review date. The care plan did not address emergency suctioning of the tracheostomy. - Care plan dated 10/26/22 I chose to have FULL CODE. 1. Review of a dialysis progress note for Resident #1 by Dialysis RN Charge, dated 10/25/22, reflected Summary: respiratory distress post-dialysis Note: patient complained something is wrong with her trach after returning blood post HD. I went to look for the SNF nurse to check pt's trach if suction is needed. SNF nurse said, if you can roll the pt in her room, as I am doing something (pertaining to another pt). This nurse went back to dialysis den and pt is having respiratory distress, not responding to verbal stimulus with blank stare approximately 45 seconds, with palpable pulse. Pt is hooked to 02 via trach the whole time. Ambu bag started by nurse (Dialysis LVN). This nurse went to shout for help, while another nurse stays with pt. SNF nurse came with e-cart and suctioning was done and pt became responsive. EMS arrived and evaluated pt. Patient refused to be sent to hospital. (Physician name) notified. Review of a dialysis progress note for Resident #1 by Dialysis LVN, dated 10/25/22, reflected notes throughout Resident #1's treatment on that date, with the last note at 4:00 PM reflecting Tx ended. Pt experience respiratory distress post Tx. SNF staff informed. 12 minutes for Facility respond. Writer administered rescue breaths vi ambu-bag. Staff responded and began suctioning pt. Pt responsive to suctioning. Returned to room /c no further distress. A late entry nursing progress note for Resident #1, entered on 10/27/22 with an effective date of 10/25/22 by MDS Nurse, reflected Notified daughter when daughter arrived at snf of resident having breathing issues during dialysis. Resident was noted to have a readable pulse and O2 but resident appeared to have a change of appearance. Suction was preformed [sic] and O2 was given, 911 was called per Dr. (physician name). Resident was able to resume back to her normal baseline after interventions were done. EMS also stated resident was medically clear. Resident declines wanting to go to hospital. Daughter verbalized understanding. Review of Resident #1's progress note dated 10/26/22, by Corporate Compliance RN (at that time acting as interim Director of Nursing), reflected call RP (RP name) to follow up with resident's episode of difficulty breathing during dialysis. (RP name) did state that she was in the facility and the (MDS nurse) had informed her at the time, she did request to be notified immediately, I did assure her that I would be speaking to staff about her concerns and gave her my personal cell phone so she could contact me for any concerns she may have so they can be handled timely as per her request. I informed her that her mother was doing well this morning and is in no distress. MD was also notified of yesterday's event. Review of Resident #1's progress notes from 10/15/22 and 09/18/22 reflected two prior incidents in which the resident became non-responsive (not in the dialysis center) and facility staff had to call 911, and the resident was taken to the hospital. 2. Resident #1's progress note dated 09/18/22 reflected PT pushed call light; CNA went in to answer resident was not responding correctly. CNA called nurse, pt was not making eye contact, 20min prior pt was alert and waving, went to check DNR status and grab VS CNA yelled she is not breathing, ran back to room, called for other nurse to call 911, sternal rub applied with agonal breathing, pulse noted strong and regular, inner canula removed scant amount of blood noted to end of canula rinsed, reapplied, fell ow nurse placed ambu bag with 02 per oxygen tank, pt began to open her eyes, suction given to fell ow nurse at this time pt suctioned still continues to have agonal breating [sic], ambu bag reapplied, paramedics arrived on scene. Review of Resident #1's dialysis progress notes by Dialysis LVN, dated 11/11/22, reflected 2:23 PM- Tx started 83 minutes late due to late arrival and request for suction from SNF staff. Writer spoke to (MDS nurse's name) after waiting 40 minutes for suction. (MDS Nurse) stated she believed pt's discomfort was from a history of anxiety and medication refusal. She also stated that there are 3 nurses, capable of suctioning, on the floor, and was unhappy that none of them would come to take care of the pt. (MDS Nurse) proposed that the supplies be held on hand and in the event pt required immediate suction, she would do so personally, and that Social Work would come to speak /c t [sic] the pt to calm her nerves. Tx started w/o further complication art this time. 4:00 PM- Tx ended 72 minutes [NAME] y due to late arrival and pt awaiting suctioning per tx. Tx ended w/o complication. Pt in tx chair to room. Offers no c/o at this time. Review of Resident #1's dialysis progress notes by Dialysis RN, dated 11/11/22, reflected 1:30 PM Upon LATE arrival, DD [sic] nurse (Dialysis LVN) assessing pt nurse noticed wet cough, fluid rattles in trach, and heavy sputum sounds during cough and pt breaths. He then requested for an SNF nurse (LVN J) to suction pt prior to starting HD tx for pt safety reasons. I then left HD unit and found pts nurse (LVN J) and relayed the message for need for trach suctioning. 1:35 PM SNF nurse (LVN J) arrived to HD unit attempting to hand suction supplies to DD nurse (Dialysis LVN). He replied, we are not allowed to do suctioning trach care, that snf nurse must do suctioning. SNF nurse (LVN J) explained that she suctioned pts trach 2.0 hours ago and that these wet breath sounds were normal trach sounds. 1:45 PM SNF nurse (LVN J) left hd unit taking suction supplies with her t [NAME] returned approx 15 min later with the (MDS Nurse's name) who then spoke w/ pt, assessed pts breath sounds through trach. Placed pulse ox on pt, lowered O2 to 3L, read 98% on 3L O2 via trach, and asked pt if she would like to be suctioned, pt replied Yes. HD Nurse (Dialysis LVN name) reminded both (MDS Nurse's name) and SNF nurse (believed to be LVN I) that this pt has previously stopped breathing d/t plugged up trach. 2:00 PM nurse (LVNJ's name) said she was not comfortable to suction the pt. (MDS Nurse's name) said that all snf nurses are capable of performing trach suctioning. (MDS Nurse's name) said she would suction pt (Resident #1's name) and left hd unit. 2:15 PM waiting for (MDS Nurse's name) to return and suction pt before starting dialysis. 2:47 PM SNF SW came to hd unit and spoke with pt regarding anxiety and making chit chat conversation with pt. 4:00 PM (MDS Nurse's name) never returned to suction pt before end of day cutoff time. Review of Resident #1's dialysis progress note by Dialysis RN Charge, dated 11/11/22, reflected Summary: 1:33 PM Pt needing trach suctioned before HD tx. Review of Resident #1's nursing progress note dated 11/11/22 at 11:24 AM by LVN J reflected Trach care provided for patient and hour 30 minutes before dialysis, during this shift and well tolerated. Review of Resident #1's dialysis progress note by Dialysis RN, dated 11/11/22, reflected Summary: 3:58 PM Reminded SNF staff to bring Pt on time- Note: Reminded SNF staff to bring Pt on time 5-10 minutes for patient to get complete dialysis treatment, thus have a better chance of (successful treatment) This was endorsed as well to communication sheet. Review of Resident #1's nursing progress note dated 11/11/22 at 6:38 PM by LVN J reflected the resident's vital signs and respiratory status within normal range, and the resident was sent to the hospital per family request due to Resident #1 feeling weak and nauseated. An interview on 12/08/22 at 1:20 PM with Dialysis RN revealed she was filling in while Dialysis RN Charge had a day off. She explained they did in-home dialysis, which was a little different from sending residents out to dialysis. They were a contracted company, housed within the facility. It was different in that they dialyzed residents 5 days a week, instead of three, Monday through Friday, and had shorter treatment times. She said it was beneficial to the residents and facility because they did not have to transport residents, and the shorter, more frequent times allowed residents to be more stable if they came for their full treatment times. She said Resident #1 had treatment time at 1:00 PM, and the 1:00 PM treatment time had a cut-off time of 4:10 PM, which allowed time for dialysis staff to clean the room, re-stock, and prepare the machines for the following days 8:00 AM chair times. She said they had some problems with the facility staff not being responsive to dialysis staff, and not getting residents to the dialysis room (referred to as the dialysis den) on time. During this interview, when Dialysis LVN said that they had trouble getting staff to suction the resident sometimes, and the dialysis staff was not allowed to, Dialysis RN affirmed this. Dialysis RN said that when a resident had high care needs, like a g-tube, or trach, the facility did not seem to have enough staff to get them ready on time for their chair time, and it was detrimental to the residents to have shortened chair times, especially cumulative, over time. An interview on 12/08/22 at 1:26 PM with Dialysis LVN revealed the dialysis staff had trouble with facility staff getting the residents to dialysis on time, and with the facility staff not knowing that they had to attend to resident's trach care during dialysis treatments, because the dialysis staff could not. He said he was not trained for trach care, and their contract said they were not to do it. An interview on 12/08/22 at 1:48 AM with Dialysis RN and Dialysis LVN revealed on 11/11/22 Resident #1 came to her treatment late, and her breathing was wet sounding, mucous, loose rumbling, cracking. Dialysis LVN went to find the resident's nurse to suction the resident before they started her treatment. He said the nurse went over the notes with him, and that she had suctioned her already. The nurse wanted him to suction the resident, and he told her they (dialysis staff) could not do it. After that, MDS Nurse came with LVN J to assess the resident and said that the resident had normal trach sounds. Dialysis LVN said they were not normal trach sounds, and he was familiar with the resident. Dialysis RN affirmed that the resident did not normally sound like that during her treatments, and she needed to be suctioned for her own comfort during the treatment. Dialysis LVN said the resident was anxious, and uncomfortable, and she wanted to be suctioned. He said that the nurse he requested to suction her said that she had already done so, and she would hurt the resident if she did it again. He said by that time, she had done it two hours earlier, and she would only hurt the resident if she did it incorrectly, and when a resident needed suctioning, they needed suctioning, even if they were already suctioned previously. He said after assessing Resident #1, MDS Nurse and LVN J, who had refused to suction Resident #1, left the room. He said during this event, when he talked to MDS Nurse, she said to have the (suctioning) supplies ready, and she would come suction in the event of an emergency. He said MDS Nurse seemed annoyed that there were three nurses on the floor who could suction and could not believe any would refuse. He said he believed the resident's nurse that day was an agency nurse. He had never seen her before, and never saw her after that day. Dialysis LVN said that they did put a pulse oximeter (fingertip device for measuring oxygen levels in blood) on the resident during the assessment, and her oxygen was at 98%, but he was concerned because of something that happened before that. He said that there had been a day about a month prior to 11/11/22 when the resident stopped breathing, and it took the facility staff 12 minutes to get there to help. Dialysis RN said they did not come until she started running down the hall yelling for help, because they would not come when initially requested, and when they got there, the cart did not have what it needed, which caused a further delay. An interview on 12/09/22 at 7:55 AM with Dialysis LVN, Dialysis RN, and Dialysis RN Charge revealed Dialysis LVN described an incident on 10/25/22 in which LVN J refused to suction Resident #1. He said the resident had been at the end of her dialysis treatment, and he was rinsing her back (returning the blood to her body), when the resident started to show signs of strained breathing, and gasping, and the resident complained about it being hard to breathe. Dialysis RN Charge said she was just outside of the room at this time, and Dialysis LVN told her the resident was having respiratory distress, and needed to be suctioned, so she went to find someone from the facility to do it. Dialysis RN said the resident's eyes were as big as saucers. Dialysis RN said that the resident passed out before facility staff got to her to suction her, and she was not responsive to vocalization, or sternum rub, and she estimated she was unconscious for a solid 45 seconds. She said facility staff got there within that 45 second period, but it had taken them 12 minutes to get there with the cart, which was missing something. She was not sure it was tubing, because it had been a while, but she thought it was tubing. She said the 45 seconds was an estimate, because she was not looking at her watch, and everything moved very fast when something like that was happening. An interview on 12/09/22 at 8:22 AM with MDS Nurse revealed she felt like they responded fast on 11/11/22, when dialysis staff called out for help with Resident #1. She said when they got to the dialysis room, Resident #1 was lying back in the chair, and they put her upright, to try to clear her (airway), and that helped. She said the dialysis people should have sat her up. She said Resident #1 was very anxious, and the feeling of mucus in her trach was overwhelming for her to swallow and she would panic. She said Resident #1 often refused her antianxiety meds, because she did not want to feel tired when her daughter visited, and her breathing was better when she took them. She said the resident could swallow, but she felt like she could not. She said she and Corporate Compliance RN went into the dialysis room together, and Resident #1's O2 sats were OK, and she had a heartbeat, and she was fine, and normal for herself. She said they called out to everyone to get what they needed, You get the crash cart. You call the doctor. She said someone had to check the resident's code status. She said the resident already had the pulse oximeter and wrist band on, and the dialysis staff was assuming something was wrong, but Resident #1 was not actively passing. She said she and Regional Compliance RN sat the resident up some, brought the crash cart in, and hooked it up. She said everything they needed was on the crash cart. They held Resident #1's hand, and suctioned her, and the resident was not passed out for a long period of time. She said Resident #1 would sometimes become so anxiety-ridden she would pass out a little bit. She said her anxiety was about the trach, and any sort of distress would make her anxious. MDs Nurse said what the resident needed to do was to take deep breaths, but if she could not, she would get anxious and pass out. She said they checked on the resident a lot and reminded her to calm down and take deep breaths. She just needed to be reminded to calm down and breathe. MDS Nurse said Resident #1's eyes were closed, and after they suctioned her, she opened them. She said a person's mental state had an effect on their physical well-being, and Resident #1 passed out from anxiety. MDS Nurse said after they suctioned her, the resident was talking to them, like nothing happened. They had called 911, but the resident refused to go with the ambulance. Transferring was painful for Resident #1, and she was like her normal self-afterwards. She did not require any additional monitoring over what they normally did. MDS Nurse said this was a normal occurrence for Resident #1. She said right after this happened, she thought Corporate Compliance RN talked to the nurses and drilled them about the crash cart and checked the cart. MDS Nurse denied knowledge of dialysis staff attempting to get assistance before she and Corporate Compliance RN went with the crash cart to the dialysis room. She said she thought they had RT come in once a week. She said she felt they had ample staff at the facility, but there might have been a communication barrier between facility staff and dialysis staff. She said the dialysis staff were in their room working and did not always know what was going on with a patient behind the scenes. She said on 11/11/22 she talked to Resident #1's nurse, to see if she could suction the resident, and went to the dialysis room to see the resident. She said they could suction the resident 20 times, and she had a lot of congestion, and would still have congestion. She said if a resident had congestion in their lungs, you could not suction that. She did not feel like the resident was in respiratory distress that day, and she just needed to cough up what was in her chest. She said she felt the dialysis staff were panicked because the resident was a trach patient, even though her vitals were fine. She said she took out Resident #1's canula, and there was no phlegm, and her airway was clear. She said that was expected, and normal for Resident #1. She said they did what they were supposed to do, they assessed the resident, and she did not know what else they needed to do in order to soothe him (Dialysis LVN.) She said if Resident #1 was feeling anxious, and like she needed to be suctioned, they suctioned her. She said Resident #1 had refused her antianxiety medication that day, though she reminded the agency nurses to give it first thing in the morning. The resident refused it often, which was the cause of a lot of her breathing problems, and it was helped by the staff just talking to her and calming her down. She said if she did not feel comfortable with a resident's state, she did not hesitate to send them out, and that she was not here to play with people's lives. An interview on 12/09/22 at 8:54 AM with Corporate Compliance RN revealed he denied the incident on 10/25/22 occurred the way it was described by dialysis staff. He denied any knowledge of a staff member refusing to help before he and MDS Nurse heard about it. He said Dialysis RN went down the hall yelling Code blue! Code blue! when he was in the DON's office, in close proximity. He said Dialysis RN panicked, and started yelling, and he and MDS Nurse got up and ran behind her to the dialysis room. He said when they entered the room, Resident #1 was reclined, and she had a pulse, and blood pressure, and she was blinking her eyes and never lost consciousness. He asked the dialysis staff why they did not suction her, and Dialysis RN said they were not allowed to. He said they got the cart, which was fully stocked, into the dialysis room immediately when they went in, and Dialysis LVN was using the ambu-bag on Resident #1's face, even though the resident had a trach, and he explained the ambu bag needed to go through the trach. He said the resident never lost consciousness, and he thought maybe she had a plug. He said they suctioned Resident #1 and she coughed and had a response. He stated she never completely stopped breathing. He said Resident #1 was able to voice, and say she was OK, and they took her back to her room. He said he and MDS Nurse made sure her trach care was done, and that was that. He said Resident #1 never looked any different, and never lost consciousness or had concerning vitals, and refused to go to the hospital. He said after the incident on 10/25/22 they did in-services on trachs, and had the respiratory therapist validate, and do training on trach care and suctioning . He said a couple of days after that, the manager for the contract dialysis company came to meet with him and affirmed that the dialysis staff are not allowed to suction patients. He said the state already reviewed the incident which occurred on 10/25/22. An interview and observation on 12/09/22 at 9:02 AM with Corporate Compliance RN revealed he showed the surveyor each item on the crash cart checklist, as the surveyor read the items off, and explained how some of the items were used. All items on the list were on the cart. Review of the crash cart checklist for October reflected the checklist was checked off and initialed through 10/22/22 but was blank on the dates of 10/23/22 and 10/24/22. An interview on 12/09/22 at 9:10 AM with Dialysis RN Charge revealed she was present on 10/25/22. She said she was not sure how much time elapsed between when she went to get help for Resident #1 and when nursing facility staff came with the crash cart, but she felt it was way too long. She said as a hospital nurse, when someone needed to be suctioned, she would expect a response to be urgent, within a minute, but she estimated at least five to six minutes for the facility to respond, though she was not sure, because she was not looking at her watch, she was trying to get help. She said that airway problems were number one priority, and a nurse should drop what they were doing, to attend to it. She said she was outside the dialysis room at first, and when she stepped in, the resident's blood was not in the machine (the dialysis had not been started), and Dialysis LVN said there was something wrong with Resident #1's trach. She said she told him to take Resident #1's oxygen saturation reading, and she would go get a facility nurse to suction. She said the resident was responsive when she left the room, and OK. She said she was rushing and was looking through all the rooms when she found a nurse (identity unknown) in a resident room, the nurse told Dialysis RN Charge to move the resident out of the dialysis room and she would come take care of it. Dialysis RN Charge said she told the nurse the resident was in the dialysis chair, and she needed to go to the dialysis room. Dialysis RN Charge said she stood there by the door for an unknown number of minutes and could see the nurse was not going to go with her, so she went to check on Resident #1. When she got back the resident was worse and Dialysis RN went out into the hall to yell for help and she (Dialysis RN Charge) stood in the door of the dialysis room and yelled. She said MDS Nurse and Corporate Compliance RN came and brought the crash cart, but it was missing a part, so she went to find the thing they were missing. She said she thought it was a connector for the suction, but she was not sure, because of how long ago it was. She said Dialysis LVN had started using the ambu bag but that would not help if the trach was blocked. She said she returned with the part, and they had found what they needed on the cart. She said the resident had become unresponsive when she returned. Dialysis RN Charge said someone had already called 911, and when they arrived Resident #1 was fully awake. She said the resident was evaluated and refused to go to the hospital. She said after the incident she called her manager, because they were not allowed to suction a resident, and needed a faster response form the facility. She said they had a meeting attended by herself, her manager, and Corporate Compliance RN, and Corporate Compliance RN said it would be better to not admit trach patients, because the staff might not be able to respond fast enough. She said there were no trach patients on dialysis in the facility now, and she felt that was safer, because the dialysis staff were not allowed to suction, and they did not receive training from their company. She said she knew how to do it but had been instructed repeatedly by her manager that they do not, and it had to be done by facility staff. She felt this happened because there was not enough staff in the facility, and always different staff, so there was no continuity for patients. She said she wished she had taken more detailed notes, and some of the details were not clear in her memory, but it was clear that suctioning did not happen fast enough, and the nurse she informed should have dropped what she was doing and gone to help Resident #1 immediately. On 11/11/22 when Resident #1 needed to be suctioned, and Dialysis LVN was trying to get someone from the nursing facility to suction her. She said the resident was 30 minutes late for her appointment, and they did not want to start her treatment until she was comfortable. She said staff had been instructed to suction residents 30 minutes to an hour before their dialysis treatment time. When Dialysis LVN told the nurse (LVN J), who was not familiar to her and she had not seen since that day, that the resident needed suctioning, the nurse said she already did it two hours prior, and the wet sounds were normal for a trach patient. The LVN J tried to get Dialysis LVN to suction the resident, and he told her they were not allowed to. Dialysis RN Charge said the resident did not usually have the gurgling and wet breathing sounds she had that day or complain about it during dialysis. She said the nursing facility had the pulse oximeter and the dialysis center did not have one, so they were unable to check her O2 sat. Dialysis RN Charge said when they tried to get the resident suctioned on 11/11/22, the facility nurse stood there and talked and argued and refused for 10 minutes then left with the suction supplies she had brought to give to Dialysis LVN so he could suction the resident. Dialysis RN Charge said 15 minutes later, the facility nurse returned with MDS Nurse, who spoke with the resident, took her O2 sat, and assessed the resident's breath sounds. She said MDS Nurse asked the resident if she would like to be suctioned, and Resident #1 said yes. She said during this time Dialysis LVN reminded MDS Nurse and the facility nurse that the resident had previously stopped breathing the month prior, so he had a higher level of concern about this. Dialysis RN Charge said LVN J said she was not comfortable suctioning the resident again, and MDS Nurse said all the nurses were capable, and she (MDS Nurse) would do it. Dialysis RN Charge said they had to get residents safe and comfortable before beginning the treatment, and it was 2:00 PM, an hour late. She said the resident was responsive and not real distressed at this time and was talking to Dialysis LVN about her treatment. She said at 2:27 PM on 11/11/22, MDS Nurse still had not come to suction the resident, and the Social Worker came to talk to the resident about her anxiety. Dialysis RN Charge said the resident was anxious about things, not really scared, but anxious. She said the resident never got suctioned, but they started the treatment because it was so late, and she was stable. She said the facility staff were not familiar with dialysis, or their responsibilities regarding patients in the dialysis room. An interview on 12/09/22 at 10:59 AM with the Administrator revealed the staff would normally do an incident report on something like the incident in the dialysis center on 10/25/22. She said they did do notes on it. She did not indicate why an incident report was not done. An interview on 12/09/22 at 11:23 AM with RT revealed he had worked full time at the facility for about seven years, but that was years ago. He said occasionally he would go in when they called him, but it was infrequently. He said he could not remember exactly when, but months ago he had gone there to do an in-service for them on suction of trach, emergency airway maintenance, and such. He said August sounded about right (when surveyor asked about in-service documentation with his name on it, from August 2022), and he had not done an in-service since then. He said he was not directly involved with Resident #1 but knew who she was and had checked on her when he was there. He said he did not make notes, and it was too long to remember details. He said the nurses should have made notes on it. He did not in-service in October and was not involved with any incident with the resident then. He did not know about it. An interview on 12/09/22 at 11:32 AM with Corporate Compliance RN revealed they currently had no patients with a trach in the facility and had not since Resident #1 was discharged . An interview on 12/09/22 at 12:19 PM with the Administrator revealed they did QAPI the incident but the only staff member they still had from the administrative team at the time of the incident on 10/25/22was MDS Nurse. She said LVN I was no longer an employee. She said they did discuss the incident, and maybe she should have done a PIP, but she has no people and had a brand-new DON and ADON. She said when the incident in October happened, she could hear the nurses yelling, and MDS Nurse and Corporate Compliance RN ran, as fast as they could, to help. She was not aware that a nurse had already been asked to help, and only knew about the dialysis nurses yelling in the hall, and Corporate Compliance RN and MDS Nurse running out of the office to help them. She said that they w [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure each resident received adequate assistance to prevent accidents for one (Resident #1) of seven residents reviewed who required staff assistance with transfers. CNA A and CNA B failed to transfer Resident #1, who was care planned to be transferred utilizing a Hoyer lift, with a Hoyer lift which resulted in the resident being injured and sustaining a fracture to her right upper arm. This failure could affect the facility's 18 residents, who required staff assistance utilizing a Hoyer lift and placed them at risk for falls, lacerations, fractures and the need for hospitalization . Findings included: Resident #1's face sheet, dated 07/21/17, reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's MDS assessment, dated 06/08/17, reflected Resident #1 had clear speech, was able to be understood by others, and understand others. Resident #1 had a BIMS score of 13 which indicated her cognition was intact. Resident #1 required extensive assistance with two or more persons' physical assistance for transfers and bed mobility. Resident #1's care plan with an initiation date of 10/31/16, revision date of 03/06/17, and target date of 09/12/17 reflected: Resident is to be transferred with two staff members and a Hoyer lift Mechanical Hoyer Lift: The resident is TOTAL ASSIST for transfers and requires Mechanical lift for transfers. Provide 2 person for transfers. Provide reassurance as needed. Observe extremities and devices during transfers and position for comfort. Encourage and remind resident to use handles as able during transfers. The provider Investigation Report, dated 07/28/17, reflected: Description of Allegation: CNA A and CNA B brought the mechanical Hoyer lift into Resident #1's room to get her into her wheelchair to go to therapy. Resident #1 refused to use the Hoyer lift and told the aides she wanted them to use the sit-to-stand lift because she had used it in therapy and knew how to get up with that lift. The aides, wanting to respect the resident's right of self-determination of care, gave in to her desire to use the sit-to-stand lift. The aides got her secured with the sling and began lifting her. Resident #1 stated she was trying to pulling herself up with her arms at the same time the lift was bringing her up and that is when she heard the pop in her shoulder. Description of Injury: Spiral fracture of the right humerus. Description of Assessment: Under order of the doctor the resident was sent to the ER for further evaluation and treatment. Provider Action Taken Post-Investigation: Resident #1's cardiologist said she was not a candidate to go under for surgery so her arm is in a hard plastic brace to keep it mostly immobile but surgery is not an option to repair the arm. Resident #1's radiology report, dated 07/21/17, reflected an acute moderately displaced fracture through the proximal diaphysis of the humerus (upper arm bone). The report also noted a probable dislocation of the right shoulder. Observation on 08/04/17 at 10:01 AM of Resident #1 revealed she was lying in bed. Her right arm was immobilized in a hard plastic brace. Resident #1 stated at the time of the observation on the day of the incident she was impatient. She stated she tried to pull herself up (while in the sit-to-stand lift) and her bone snapped. She stated the machine was working right but was moving too slow. Resident #1 stated it was not the aides' fault and she did not want them to get in trouble. Resident #1 stated the aides had brought the Hoyer lift to her room and she told them she wanted to use the standing lift. She stated they told her they did not know how to use and she told them they were going to learn because she was going to teach them. Resident #1 stated therapy had used a stand lift with her. She stated the aides knew they were not to use the stand lift with her and she knew better as well. Resident #1 stated the aides put the belt (sit-to-stand lift swing) around her and she was sitting on the side of the bed when they started to lift her and she heard a pop and had pain. Resident #1 stated they sat her back down on the bed. She stated an x-ray was done at the facility and she was sent to the hospital. Resident #1 stated she did not have surgery due to her condition. She stated she wore a brace to her right arm. Interview on 08/04/17 at 10:38 AM with LVN C revealed she had worked with Resident #1 for six months and the resident had always been a Hoyer lift transfer. She stated the resident had been in the hospital a week prior to the incident and returned on skilled services. She stated the resident had motivation to do more than usual. LVN C stated she was not sure if therapy had been using the sit-to-stand lift with Resident #1 and she was unsure if the resident had requested to use the sit-to-stand lift prior to the incident. She stated the aides could use the Kardex system that was in the wall kiosk to view ADL care. She stated CNA and CNA B had worked with Resident #1 previously and they were aware she was s Hoyer lift transfer. She stated the day of the incident the staff came to her and said they had utilized the sit-to-stand lift at the resident's request. LVN C stated the resident might have let the machine chicken wing (arms bent and flapping up) her instead of utilizing the bar to assist herself up. She stated one needed upper body strength to use the sit-to-stand lift. LVN C stated a pop noise was heard during the transfer. She stated the staff had placed her back on the bed. Resident #1 could not move her right arm and had pain. She assessed the resident, administered pain medication, and notified the physician, and an x-ray was ordered. LVN C stated the x-ray showed a fracture and the resident was sent to the hospital. Interview on 08/04/17 at 10:56 AM with CNA A revealed she assisted CNA B with transferring Resident #1 out of bed. She stated Resident #1 was a Hoyer lift transfer. She stated therapy had used the sit-to-stand lift with Resident #1. She stated Resident #1 said she could use the sit-to-stand lift. CNA A stated when Resident #1 requested to use the sit-to-stand lift CNA A said, I don't know about this. She stated they hooked the resident up to the sit-to-stand lift and as they were lifting her they heard a pop sound and the resident wanted to be put back on the bed. She stated the nurse came to the room. CNA A stated when one used the sit-to-stand they were supposed to hold onto the handles. She stated Resident #1 let her arms flap because she was in a hurry. CNA A stated Resident #1 said it was her fault because she was in a rush. CNA A stated no one told her she could use the sit-to-stand lift with Resident #1 and even CNA B was questioning using it. She stated a resident's level of care was located in the Kardex system on the kiosk. CNA A stated after the incident she was counseled and received training on how to use the sit-to-stand lift and in-serviced on abuse/neglect and following care plans. Interview on 08/04/17 at 12:58 PM with CNA B revealed the day of the incident she went to get Resident #1 up and took the Hoyer lift with her to Resident #1's room. She stated the resident asked her what she was doing and said she wanted to use the sit-to-stand lift. She stated she told Resident #1 she could not use the sit-to-stand lift because it did not work for her. CNA B stated she retrieved an aide (CNA A) that was familiar with the sit-to-stand lift. She stated she asked CNA A if she knew how to use the sit-to-stand lift and CNA A said yes. She stated she was going to get the nurse to explain why they could not use the sit-to-stand lift however, she did not retrieve the nurse because the resident was in her right mind and per the resident she would use the sit-to-stand lift. CNA B stated the resident said she would show them how to use the sit-to-stand lift. She stated CNA A and she got the resident hooked up in the lift and while lifting her they heard a pop. She stated the resident complained of pain to her shoulder. The aides laid the resident down and retrieved the nurse. She stated the resident said it was not their (the aides) fault because she (resident) refused to use the Hoyer lift. CNA B stated Resident #1 said she used the sit-to-stand lift with therapy. She stated she (CNA B) talked to someone from therapy, the day of the incident, and they told her they had used the sit-to-stand lift with the resident the day before the incident. She stated they did not tell her not to use the sit-to-stand lift. CNA B stated they should have used the Hoyer lift and followed the resident's care plan. She stated prior to the incident she had not been trained to use the sit-to-stand lift. CNA B stated a resident's level of care was in the Kardex system on the kiosk. Interview on 08/04/17 at 1:25 PM with PT D revealed Resident #1 had practiced using the sit-to-stand lift with therapy. She stated the second time they used the lift with the resident they did not feel the lift was appropriate. She stated the day of the incident the aide (did not specify which aide) had asked about the sit-to-stand lift and she was told the lift was not appropriate to use with Resident #1 and to use the Hoyer lift. PT D stated when they changed care needs for a resident they communicate the information to the appropriate staff and train staff. Interview on 08/04/17 at 2:03 PM with the DON revealed staff typically follow the care plan. He stated Resident #1 was alert and oriented and would say she was not going to use the Hoyer lift. He stated she worked staff into a panic mode and that was why he educated staff on involving the nurse in that type of situation. He stated resident safety trumped resident rights. The general guidelines for the stand-up patient lift, undated, Section 4- Lifting The Patient reflected the following: Warning- Individuals that use the standing patient sling MUST be able to support the majority of their own weight, otherwise injury may occur. The facility's policy on Comprehensive Care Plans, undated, reflected the following, Procedures: 1. The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident' (sic) medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental and psychological well-being 4. The services provided or arranged by the facility must a . b. in accordance with each resident's written pan of care. A facility resident roster, dated 08/03/17, reflected 18 residents were identified as utilizing a Hoyer lift for transfers.

Based on interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 45 (Resident #1 through Resident #45) of 52 residents reviewed. 1. The Administrator failed to supervise and monitor the DON to ensure she carried out her responsibilities in the areas of medication administration and medication errors. 2. The Administrator and DON failed to follow their policy and procedure for medication errors. 3. The Administrator failed to supervise and monitor nursing administration staff to ensure medications were being administered to residents as prescribed. 4. The Administrator and DON failed to monitor and supervise nursing administration staff to ensure Resdinet #1's medication was admiinstered per ohyscian order. Faciity failed to administer physician ordered [MEDICATION NAME] (prevents [MEDICAL CONDITION]), Levetiracetam (prevents [MEDICAL CONDITION]), [MEDICATION NAME] Acid (prevents [MEDICAL CONDITION]), and [MEDICATION NAME] (treats hypertension) on 03/10/17 to Resident #1 which resulted in Resident #1 having a [MEDICAL CONDITION] and having to go to the hospital to receive IV [MEDICATION NAME] and [MEDICATION NAME] to control his [MEDICAL CONDITION]. 4. ADON A failed to administer morning medications on 03/10/17 to Resident #2 through Resident #20. An Immediate Jeopardy situation was identified on 03/21/17. The Immediate Jeopardy was removed on 03/26/17. The facility remained out of compliance at a pattern of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. These failures could affect all 74 residents by placing them at risk for death, exacerbation of medical conditions, and not receiving the therapeutic benefits of their medications. Findings included: 1. Review of Administering Medication - Oral policy and procedure (undated) revealed 18. Document medications given following policy including date, time, dosage, route, signature, and title. Chart and/or report pertinent observations of resident and nursing actions according to facility policy. Review of Medication Errors and Drug Reactions (undated) revealed: 1. All medication errors and drug reactions must be promptly reported to the Director of Nursing Services, attending physician, and the pharmacist. 2. A detailed account of the incident must be recorded and should include documentation of: a. time and date of incident b. name, strength, and dosage of medication administered c. resident's reaction to the medication d. condition of the resident e. any treatment administered; f. date and time the physician was notified and instructions given. 3. Monitor closely any resident who has received incorrect medication or is having a drug reaction. Immediately report to the Director of Nursing Services and attending physician any change in the resident's condition. Review of Prevention and Reporting of Suspected Resident Abuse and Neglect policy and procedure (undated) revealed neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 1. Neglect is reportable if the injury, harm or death of a resident was due to failure to provide services, treatment or care to a resident. 2 Review of the Provider Investigation Report dated 03/10/17 revealed ADON A did not pass the morning medications off the Med Aide cart to the residents who resided on Hall 100 because the other shift nurse had not arrived and she refused to give possession of the keys to the medication aide so she could pass her medications. Twenty residents should have received medications between the time of 6:00 a.m. and 8:30 a.m. from ADON A on 03/10/17. Later that afternoon, Resident #1 was at the receptionist's desk when he had a [MEDICAL CONDITION]. He was transported by EMS to the hospital. Resident #1 received IV [MEDICATION NAME] and [MEDICATION NAME] at the hospital and returned to the facility on [DATE] at 11:10 p.m. Review of Resident #1's face sheet dated 03/10/17 reflected Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed he had severe cognitive impairment. Review of Resident #1's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give one 200 mg tablet by mouth two times a day Levetiracetam Solution (Prevents [MEDICAL CONDITION]) Give 3000 mg by mouth three times a day [MEDICATION NAME] Acid (Prevents [MEDICAL CONDITION]) Give 250 mg by mouth three times a day [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 25 mg by mouth once a day Review of Resident #1's March 2017 MAR indicated [REDACTED]. Resident #1 went to the hospital before the medications could be administered at a later time. Review of Resident #1's nurses notes dated 03/10/17 at 12:30PM signed by DON revealed Resident sitting in wheelchair at receptionist desk shaking as if he was cold and clammy. Resident looking at staff but not answering questions. Resident stood from wheelchair and laid himself down on the couch with standby assist of staff. Blood sugar taken 106. Started to take blood pressure when resident started having [MEDICAL CONDITION]. At 12:35 resident stiffened up and turned blue. 911 notified. Blood pressure 144/111, pulse 109, O2 sat 97%. Resident assisted to gurney and transported to hospital. An attempt was made to interview Resident #1 on 03/23/17 at 2:45 p.m. The resident would not answer any of the questions. 3. Review of Resident #2's face sheet dated 03/10/17 reflected Resident #2 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 100 mg by mouth in the morning [MEDICATION NAME] (Treats high blood pressure) Give 10 mg by mouth in the morning [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning [MEDICATION NAME] (Treats anxiety) Give 0.5 mg by mouth two times a day Review of Resident #2's March 2017 MAR indicated [REDACTED]. Interview with Resident #2 on 03/21/17 at 10:50 a.m. revealed that she has not been getting her medications on time. She does not receive her morning medications until 2 p.m. Review of the vital sign monitoring tool dated 03/10/17, Resident #2's blood pressure spiked to 172/67 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of [MEDICATION NAME] and [MEDICATION NAME] Tartate. Review of Resident #2's March 2017 MAR indicated [REDACTED]. 4. Review of Resident #3's face sheet dated 03/10/17 reflected Resident #3 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood pressure) Give 6.25 mg by mouth twice a day. Review of Resident #3's March 2017 MAR indicated [REDACTED]. Resident #3 did not receive another dose of [MEDICATION NAME] until 7:00 a.m. on 03/11/17. 5. Review of Resident #4's face sheet dated 03/10/17 reflected Resident #4 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #4's March 2017 Consolidated physician's orders [REDACTED]. Entacapone Tablet (Anti-[MEDICAL CONDITION] medication) Give 200 mg by mouth three times a day. [MEDICATION NAME] Tablet (Anti-[MEDICAL CONDITION] medication) Give 100 mg by mouth three times a day. Review of Resident #4's March 2017 MAR indicated [REDACTED]. Resident #4 did not receive a dose of Entacapone and [MEDICATION NAME] until 1:00 p.m. 6. Review of Resident #5's face sheet dated 03/10/17 reflected Resident #5 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #5's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] tablet (Treats high blood pressure) Give 10 mg by mouth three times a day Carvedilol Tablet (Treats high blood pressure) Give 12.5 mg by mouth two times a day Review of Resident #5's March 2017 MAR indicated [REDACTED]. He did not receive his next dose of [MEDICATION NAME] until 1:00 p.m. on 03/10/17. His next recorded blood pressure was 177/89 (normal range is 120/70) at 1:00 p.m. on 03/10/17. Resident #5 received his next scheduled dose of Carvedilol at 7:00 p.m. on 03/10/17 and his blood pressure was still elevated at 172/69. After receiving both of his doses of blood pressure medication, his blood pressure decreased to 147/61 (taken on 03/11/17 at midnight). Review of Resident #5's March 2017 MAR indicated [REDACTED]. 7. Review of Resident #6's face sheet dated 03/10/17 reflected Resident #6 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #6's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give 50 mg by mouth two times a day. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth three times a day. Review of Resident #6's March 2017 MAR indicated [REDACTED]. 8. Review of Resident #7's face sheet dated 03/10/17 reflected Resident #7 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #7's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 25 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 100 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day Review of Resident #7's March 2017 MAR indicated [REDACTED]. They were administered later in the day at 11:00 a.m. By that time, Resident #7's blood pressure had risen to 154/96. Resident #7's blood pressures were usually in the 130s/60s. Interview with Resident #7 on 03/23/17 at 9:20 a.m. revealed she may have missed a dose from the MA on 03/10/17 and sometimes her medications were late. 9. Review of Resident #8's face sheet dated 03/10/17 reflected Resident #8 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #8's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 2.5 mg by mouth in the morning [MEDICATION NAME] Tartate (Treats high blood pressure) Give 50 mg by mouth twice a day Review of Resident #8's March 2017 MAR indicated [REDACTED]. Resident #8 did not receive a dose of [MEDICATION NAME] until 03/11/17 at 7:00 a.m. He received a dose of [MEDICATION NAME] on 03/10/17 at 7:00 p.m. 10. Review of Resident #9's face sheet dated 03/10/17 reflected Resident #9 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #9's March 2017 MAR indicated [REDACTED] [MEDICATION NAME] tablet (Treats high blood pressure) Give 25 mg by mouth three times a day. Review of Resident #9's March 2017 MAR indicated [REDACTED]. Resident #9 did not receive a dose of [MEDICATION NAME] until 03/10/17 at 3:00 p.m. 11. Review of Resident #10's face sheet dated 03/10/17 reflected Resident #10 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #10's March 2017 Consolidated physician's orders [REDACTED]. Eliquis Tablet (Prevents blood clots) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day [MEDICATION NAME] Tablet (Treats anxiety) Give 2 mg by mouth three times a day Review of Resident #10's March 2017 MAR indicated [REDACTED]. She did not receive the next dose of Eliquis until 03/11/17 at 7:00 a.m. Review of the FDA's Medication Guide for Eliquis revised August 2016 revealed do not change your dose or stop taking it unless your doctor tells you to. If you miss a dose of ELIQUIS, take it as soon as you remember, and do not take more than one dose at the same time. If you are taking ELIQUIS for [MEDICAL CONDITION], stopping ELIQUIS may increase your risk of having a stroke. Do not run out of ELIQUIS. Refill your prescription before you run out. 12. Review of Resident #11's face sheet dated 03/10/17 reflected Resident #11 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #11's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 100 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats muscle spasms) Give 10 mg by mouth two times a day [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day Review of Resident #11's March 2017 MAR indicated [REDACTED]. Resident #11 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 3:00 p.m. on 03/10/17. She did not receive a dose of [MEDICATION NAME] until 3:00 p.m. on 03/10/17. Resident #11 received her next dose of [MEDICATION NAME] on 03/10/17 at 11:00 a.m. as scheduled. 13. Review of Resident #12's face sheet dated 03/10/17 reflected Resident #12 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #12's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood sugar) Give 500 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats muscle spasms) Give 4 mg by mouth three times a day Review of Resident #12's March 2017 MAR indicated [REDACTED]. 14. Review of Resident #13's face sheet dated 03/10/17 reflected Resident #13 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #13's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 10 mg by mouth twice per day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth twice per day Review of Resident #13's March 2017 MAR indicated [REDACTED]. 15. Review of Resident #14's face sheet dated 03/10/17 reflected Resident #14 was a [AGE] year old female who was admitted to the facility 02/25/17. Her admitting [DIAGNOSES REDACTED]. Review of Resident #14's March 2017 Consolidated physician's orders [REDACTED]. Lorsartan Tablet (Treats high blood pressure) Give 50 mg by mouth once per day. [MEDICATION NAME] Tablet (Treats muscle spasms) Give 5 mg by mouth twice per day Review of Resident #14's March 2017 MAR indicated [REDACTED]. Resident #14 did not receive a dose of Lorsartan until the next scheduled dose at 7:00 a.m. on 03/11/17. Review of the vital sign monitoring tool dated 03/10/17, Resident #14's blood pressure spiked to 176/89 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of Lorsartan. Review of Resident #14's March 2017 MAR indicated [REDACTED]. 16. Review of Resident #15's face sheet dated 03/10/17 reflected Resident #15 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #15's March 2017 MAR indicated [REDACTED] Carvedilol Tablet (Treats high blood pressure) Give 3.125 mg by mouth twice a day Review of Resident #15's March 2017 MAR indicated [REDACTED]. Resident #15 did not receive a dose of carvedilol until 7:00 p.m. on 03/10/17. 17. Review of Resident #16's face sheet dated 03/10/17 reflected Resident #16 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #16's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood sugar) Give 500 mg by mouth twice per day Review of Resident #16's March 2017 MAR indicated [REDACTED]. 18. Review of Resident #17's face sheet dated 03/10/17 reflected Resident #17 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #17's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] capsule (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth twice per day [MEDICATION NAME] Tablet (Treats high blood sugar) Give 1000 mg by mouth twice per day Nebivolol Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning Review of Resident #17's March 2017 MAR indicated [REDACTED]. Resident #17 did not receive her Nebivolol and [MEDICATION NAME] until their next scheduled doses on 03/11/17 at 7:00 a.m. Resident #17 did not receive a dose of [MEDICATION NAME] until 3:00 p.m. on 03/10/17. She did not receive a dose of [MEDICATION NAME] until 4:00 p.m. on 03/10/17. Review of the vital signs monitoring tool dated 03/10/17, Resident #17's blood pressure was 160/89 (her normal ranges were around 150/75) on 03/10/17 at 8:00 p.m. 19. Review of Resident #18's face sheet dated 03/10/17 reflected Resident #18 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #18's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood pressure) Give 5 mg by mouth in the morning Review of Resident #18's March 2017 MAR indicated [REDACTED]. 20. Review of Resident #19's face sheet dated 03/10/17 reflected Resident #19 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #19's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 50 mg by mouth twice a day Review of Resident #19's March 2017 MAR indicated [REDACTED]. Resident #19 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 7:00 p.m. on 03/10/17. Review of the FDA Medication Guide for [MEDICATION NAME] revised December of 2016 revealed to take [MEDICATION NAME] at the same times each day. If [MEDICATION NAME] is stopped suddenly (such as missing a dose) side effects such as headaches, nausea, diarrhea, trouble sleeping, increased sweating, and anxiousness may occur. 21. Review of Resident #20's face sheet dated 03/10/17 reflected Resident #20 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #20's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 20 mg by mouth once a day Review of Resident #20's March 2017 MAR indicated [REDACTED]. 22. Interview with ADON A on 03/21/17 at 3:05 p.m. revealed that on 03/10/17 she had worked the 6:00 p.m. to 6:00 a.m. shift for 100 Hall. The DON had come in around 5:00 a.m. and given her some work to do. At 6:00 a.m. MA P came to ADON A and reported she was assigned to halls 100 and 300. ADON A instructed her to check in with the DON, as she was waiting for the on-coming nurse to relieve her. ADON A did not give the keys to the medication cart to MA P. ADON A asked the DON about her relief nurse and was instructed to continue working as the next on-coming nurse was late. She asked the DON for help as she had a dentist appointment and was told, sorry, no. When the oncoming nurse relieved her they counted the carts together around 8:30 a.m. ADON A stated she did not pass any morning medications off of the Med Aide's cart. She did not know if MA P had passed medications for Hall 100. Interview with MA P on 03/21/17 at 12:00 pm revealed that she works 6:00 a.m. to 6:00 p.m. On 03/10/17 she reported to ADON A and asked her to count the cart with her. ADON A instructed her to wait until the day shift nurse came on duty. MA P asked ADON A three times to count the cart for Hall 100 with her so she could pass medications and ADON A instructed her to wait. MA P went to pass medications on the 300 hall. MA P did not inform the DON that she had not been given the keys to the medication cart for hall 100 and had not passed the medications. MA P stated she did not inform the oncoming nurse or the DON about not passing the medications on Hall 100. Interview with the DON on 03/21/17 at 9:50 a.m. revealed she was working the morning of 03/10/17 and instructed ADON A to continue with her work because the on-coming nurse was late. The DON did not offer to help and did not know medications were not being passed. She stated when she learned from LVN O at 11:00 a.m. on 03/10/17 that ADON A had not passed morning medications, she instructed the nurses to call the doctors and take vital signs. She stated they took vital signs of the residents who had missed their medications every four hours for 24 hours. She revealed ADON A was suspended because of the incident. Review of ADON A's employee record revealed an Employee Memorandum dated 03/10/17. ADON A received a written warning and was suspended. The subject of code of conduct rule violated was neglect. The date of violation is listed as 03/10/17. The description of the warning states med pass was not passed at 7:00 a.m. on Hall 100 to several residents. ADON A signed the warning on 03/10/17. ADON A also received a written warning on 03/06/17 regarding blanks in MARs. An in-service was provided on proper medication administration. The corrective action of not signing the MAR indicated [REDACTED]. Interview with the DON on 03/21/17 at 2:10 p.m. revealed ADON A had refused assignments in the past. ADON A refused to work Hall 200 on 03/04/17 and the DON assumed ADON A passed all the medications for Hall 200 on 03/04/17. All nurses and MAs had received a written warning regarding medication administration on 03/06/17 because of another medication error. The DON stated on the night shift Hall 200 is split between the nurse on Hall 300 and the nurse on Hall 100. The nurse assigned to Hall 100 is responsible for the residents in rooms 200-205 and rooms [ROOM NUMBER]. The nurse assigned to Hall 300 is responsible for the residents in rooms 206-211 and room [ROOM NUMBER]. 23. Review of Resident #29's face sheet dated 03/23/17 reflected Resident #29 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #29's MDS assessment dated [DATE] revealed she was cognitively intact. Review of Resident #29's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject 20 units twice a day Insulin [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale before meals and at bedtime [MEDICATION NAME] Tablet (Treats anxiety) Give 0.25 mg by mouth at bedtime Pramipexole [MEDICATION NAME] Tablet (Treats Restless Leg Syndrome) Give 0.5 mg by mouth in the afternoon Eliquis Tablet (Anticoagulant) Give 2.5 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 12.5 mg by mouth twice a day Review of Resident #29's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 and 03/02/17's 8:00 p.m. dose of Eliquis. LVN C failed to administer 03/02/17 and 03/03/17's 2:00 a.m. dose of [MEDICATION NAME]. LVN J failed to administer 03/03/17's 8:00 p.m. dose of Eliquis. LVN J failed to administer Resident #29's 9:00 p.m. dose of [MEDICATION NAME] on 03/03/17. LVN J failed to administer Resident #29's 03/04/17's 5:00 p.m. and 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN J failed to administer 03/04/17's 2:00 p.m. dose of Pramipexole [MEDICATION NAME] . LVN J failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/04/17. RN D failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/04/17 and 03/05/17. RN D also failed to administer Resident #29's 7:00 a.m. and 11:00 a.m. dose of Insulin [MEDICATION NAME] on 03/05/17. LVN E failed to administer 03/08/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN E failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/08/17. LVN L failed to administer Resident #29's 8:00 p.m. dose of Insulin [MEDICATION NAME] on 03/09/17. LVN E failed to administer 03/18/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN I failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/19/17. LVN K failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/20/17. Interview with Resident #29 on 03/21/17 at 2:40 p.m. revealed she has missed doses of medications and did not get most of her medications on 03/03/17 and 03/04/17. She stated there were new nurses those days. She stated she has experienced pain when she does not receive her pain medications and her medication for Restless Leg Syndrome. 24. Review of Resident #21's face sheet dated 03/23/17 reflected Resident #21 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #21's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject as per sliding scale before meals. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject 60 units at bedtime. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 40 mg by mouth at bedtime Review of Resident #21's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 through 03/04/17's 9:00 p.m. dose of [MEDICATION NAME]. LVN C failed to administer Resident #21's [MEDICATION NAME] Insulin 8:00 p.m. dose on 03/04/17. LVN B failed to administer Resident #21's [MEDICATION NAME] Insulin 4:30 p.m. dose on 03/13/17. On 03/22/17, LVN I had not administered Resident #21's 8:00 p.m. [MEDICATION NAME] when the MAR indicated [REDACTED]. Interview with the Administrator on 03/23/17 at 10:25 a.m. revealed LVN G helped LVN I pass the missed medications around 11:00 p.m. on 03/22/17. He stated they had notified all residents' doctors who had missed insulin. 25. Review of Resident #22's face sheet dated 03/23/17 reflected Resident #22 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #22's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale after meals [MEDICATION NAME] Tablet (Treats pain) Give 7.5-325 mg tablet by mouth twice a day Review of Resident #22's March 2017 MAR indicated [REDACTED] RN D failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 8:30 a.m. and 1:30 p.m. LVN E failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 6:30 p.m. LVN C also failed to administer Resident #22's 6:00 a.m. and 8:00 p.m. dose of [MEDICATION NAME] on 03/01/17 and 03/02/17. LVN C failed to administer Resident #22's 8:00 p.m. dose of [MEDICATION NAME] on 03/03/17 and 6:00 a.m. dose on 03/04/17. On 03/22/17, LVN E had not administered Resident #22's 6:30 p.m. dose of [MEDICATION NAME]when the MAR indicated [REDACTED] 26. Review of Resident #23's face sheet dated 03/23/17 reflected Resident #23 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #23's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Hyciate Tablet (Antibiotic to treat upper respiratory infection) Give 100 mg by mouth twice a day to start on 03/13/17 at 2:00 a.m. [MEDICATION NAME] Tablet (Treats pain) Give 50 mg by mouth every 12 hours. Review of Resident #23's March 2017 MAR indicated [REDACTED] LVN E failed to administer Resident #23's 9:00 a.m. dose of [MEDICATION NAME] on 03/03/17. LVN C did not administer Resident #23's 9:00 p.m. dose of [MEDICATION NAME] on 03/04/17. The DON did not administer the third dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 a.m. LVN H did not administer the fourth dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 p.m. Review of Resident #23's March 2017 MAR indic

Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administration of all drugs and biologicals) to meet the needs of 45 (Resident #1 through Resident #45) of 52 residents reviewed for pharmacy services. 1. The facility failed to administer physician ordered Vimpat (prevents seizures), Levetiracetam (prevents seizure), Valproic Acid (prevents seizures), and Metoprolol Tartrate (treats hypertension) on 03/10/17 to Resident #1 which resulted in Resident #1 having a seizure and having to go to the hospital to receive IV Depakote and Ativan to control his seizures. 2. The facility failed to administer morning medications on 03/10/17 to Resident #2 through Resident #20. 3. The facility failed to administer physician ordered medications to Residents #21 through Resident #45 on different days and times in March 2017. An Immediate Jeopardy situation was identified on 03/21/17. The Immediate Jeopardy was removed on 03/26/17. The facility remained out of compliance at a pattern of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. These failures could affect all 74 residents by placing them at risk for death, exacerbation of medical conditions, and not receiving the therapeutic benefits of their medications. Findings included: 1. Review of the Provider Investigation Report dated 03/10/17 revealed ADON A did not pass the morning medications off the Med Aide cart to the residents who resided on Hall 100 because the other shift nurse had not arrived and she refused to give possession of the keys to the medication aide so she could pass her medications. Twenty residents should have received medications between the time of 6:00 a.m. and 8:30 a.m. from ADON A on 03/10/17. Later that afternoon, Resident #1 was at the receptionist's desk when he had a seizure. He was transported by EMS to the hospital. Resident #1 received IV Depakote and Ativan at the hospital and returned to the facility on [DATE] at 11:10 p.m. Review of Resident #1's face sheet dated 03/10/17 reflected Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed he had severe cognitive impairment. Review of Resident #1's March 2017's Consolidated physician's orders [REDACTED]. Vimpat Tablet (Prevents seizures) Give one 200 mg tablet by mouth two times a day Levetiracetam Solution (Prevents seizures) Give 3000 mg by mouth three times a day Valproic Acid (Prevents seizures) Give 250 mg by mouth three times a day Metoprolol Tartate Tablet (Treats high blood pressure) Give 25 mg by mouth once a day Review of Resident #1's March 2017 MAR indicated [REDACTED]. Resident #1 went to the hospital before the medications could be administered at a later time. Review of Resident #1's nurses notes dated 03/10/17 at 12:30PM signed by DON revealed Resident sitting in wheelchair at receptionist desk shaking as if he was cold and clammy. Resident looking at staff but not answering questions. Resident stood from wheelchair and laid himself down on the couch with standby assist of staff. Blood sugar taken 106. Started to take blood pressure when resident started having seizure. At 12:35 resident stiffened up and turned blue. 911 notified. Blood pressure 144/111, pulse 109, O2 sat 97%. Resident assisted to gurney and transported to hospital. An attempt was made to interview Resident #1 on 03/23/17 at 2:45 p.m. The resident would not answer any of the questions. 2. Review of Resident #2's face sheet dated 03/10/17 reflected Resident #2 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. Gabapentin (Treats neuropathy pain) Give 100 mg by mouth in the morning Lisinopril (Treats high blood pressure) Give 10 mg by mouth in the morning Metoprolol Tartate Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning Ativan (Treats anxiety) Give 0.5 mg by mouth two times a day Review of Resident #2's March 2017 MAR indicated [REDACTED]. Interview with Resident #2 on 03/21/17 at 10:50 a.m. revealed that she has not been getting her medications on time. She does not receive her morning medications until 2 p.m. Review of the vital sign monitoring tool dated 03/10/17, Resident #2's blood pressure spiked to 172/67 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of Lisinopril and Metoprolol Tartate. Review of Resident #2's March 2017 MAR indicated [REDACTED]. 3. Review of Resident #3's face sheet dated 03/10/17 reflected Resident #3 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. Coreg (Treats high blood pressure) Give 6.25 mg by mouth twice a day. Review of Resident #3's March 2017 MAR indicated [REDACTED]. Resident #3 did not receive another dose of Coreg until 7:00 a.m. on 03/11/17. 4. Review of Resident #4's face sheet dated 03/10/17 reflected Resident #4 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #4's March 2017 Consolidated physician's orders [REDACTED]. Entacapone Tablet (Anti-Parkinson's medication) Give 200 mg by mouth three times a day. Sinemet Tablet (Anti-Parkinson's medication) Give 100 mg by mouth three times a day. Review of Resident #4's March 2017 MAR indicated [REDACTED]. Resident #4 did not receive a dose of Entacapone and Sinemet until 1:00 p.m. 5. Review of Resident #5's face sheet dated 03/10/17 reflected Resident #5 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #5's March 2017's Consolidated physician's orders [REDACTED]. Midodrine tablet (Treats high blood pressure) Give 10 mg by mouth three times a day Carvedilol Tablet (Treats high blood pressure) Give 12.5 mg by mouth two times a day Review of Resident #5's March 2017 MAR indicated [REDACTED]. He did not receive his next dose of Midodrine until 1:00 p.m. on 03/10/17. His next recorded blood pressure was 177/89 (normal range is 120/70) at 1:00 p.m. on 03/10/17. Resident #5 received his next scheduled dose of Carvedilol at 7:00 p.m. on 03/10/17 and his blood pressure was still elevated at 172/69. After receiving both of his doses of blood pressure medication, his blood pressure decreased to 147/61 (taken on 03/11/17 at midnight). Review of Resident #5's March 2017 MAR indicated [REDACTED]. 6. Review of Resident #6's face sheet dated 03/10/17 reflected Resident #6 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #6's March 2017's Consolidated physician's orders [REDACTED]. Topamax Tablet (Prevents seizures) Give 50 mg by mouth two times a day. Gabapentin (Treats neuropathy pain) Give 300 mg by mouth three times a day. Review of Resident #6's March 2017 MAR indicated [REDACTED]. 7. Review of Resident #7's face sheet dated 03/10/17 reflected Resident #7 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #7's March 2017 Consolidated physician's orders [REDACTED]. Aldactone Tablet (Treats high blood pressure) Give 25 mg by mouth in the morning Cozaar Tablet (Treats high blood pressure) Give 100 mg by mouth in the morning Hydrochlorothiazide Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning Norvasc Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning Gabapentin Tablet (Treats neuropathy pain) Give 600 mg by mouth three times a day Review of Resident #7's March 2017 MAR indicated [REDACTED]. They were administered later in the day at 11:00 a.m. By that time, Resident #7's blood pressure had risen to 154/96. Resident #7's blood pressures were usually in the 130s/60s. Interview with Resident #7 on 03/23/17 at 9:20 a.m. revealed she may have missed a dose from the MA on 03/10/17 and sometimes her medications were late. 8. Review of Resident #8's face sheet dated 03/10/17 reflected Resident #8 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #8's March 2017 Consolidated physician's orders [REDACTED]. Norvasc Tablet (Treats high blood pressure) Give 2.5 mg by mouth in the morning Metoprolol Tartate (Treats high blood pressure) Give 50 mg by mouth twice a day Review of Resident #8's March 2017 MAR indicated [REDACTED]. Resident #8 did not receive a dose of Norvasc until 03/11/17 at 7:00 a.m. He received a dose of metoprolol on 03/10/17 at 7:00 p.m. 9. Review of Resident #9's face sheet dated 03/10/17 reflected Resident #9 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #9's March 2017 MAR indicated [REDACTED] Hydralazine tablet (Treats high blood pressure) Give 25 mg by mouth three times a day. Review of Resident #9's March 2017 MAR indicated [REDACTED]. Resident #9 did not receive a dose of hydralazine until 03/10/17 at 3:00 p.m. 10. Review of Resident #10's face sheet dated 03/10/17 reflected Resident #10 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #10's March 2017 Consolidated physician's orders [REDACTED]. Eliquis Tablet (Prevents blood clots) Give 5 mg by mouth in the morning Gabapentin Tablet (Treats neuropathy pain) Give 600 mg by mouth three times a day Clonazepam Tablet (Treats anxiety) Give 2 mg by mouth three times a day Review of Resident #10's March 2017 MAR indicated [REDACTED]. She did not receive the next dose of Eliquis until 03/11/17 at 7:00 a.m. Review of the FDA's Medication Guide for Eliquis revised August 2016 revealed do not change your dose or stop taking it unless your doctor tells you to. If you miss a dose of ELIQUIS, take it as soon as you remember, and do not take more than one dose at the same time. If you are taking ELIQUIS for atrial fibrillation, stopping ELIQUIS may increase your risk of having a stroke. Do not run out of ELIQUIS. Refill your prescription before you run out. 11. Review of Resident #11's face sheet dated 03/10/17 reflected Resident #11 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #11's March 2017 Consolidated physician's orders [REDACTED]. Lyrica Tablet (Treats neuropathy pain) Give 100 mg by mouth twice a day Baclofen Tablet (Treats muscle spasms) Give 10 mg by mouth two times a day Gabapentin Tablet (Treats neuropathy pain) Give 600 mg by mouth three times a day Review of Resident #11's March 2017 MAR indicated [REDACTED]. Resident #11 did not receive a dose of Lyrica until the next scheduled dose at 3:00 p.m. on 03/10/17. She did not receive a dose of baclofen until 3:00 p.m. on 03/10/17. Resident #11 received her next dose of gabapentin on 03/10/17 at 11:00 a.m. as scheduled. 12. Review of Resident #12's face sheet dated 03/10/17 reflected Resident #12 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #12's March 2017 Consolidated physician's orders [REDACTED]. Metformin (Treats high blood sugar) Give 500 mg by mouth twice a day Tizanidine Tablet (Treats muscle spasms) Give 4 mg by mouth three times a day Review of Resident #12's March 2017 MAR indicated [REDACTED]. 13. Review of Resident #13's face sheet dated 03/10/17 reflected Resident #13 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #13's March 2017 Consolidated physician's orders [REDACTED]. Lisinopril Tablet (Treats high blood pressure) Give 10 mg by mouth twice per day Metoprolol Tablet (Treats high blood pressure) Give 50 mg by mouth twice per day Review of Resident #13's March 2017 MAR indicated [REDACTED]. 14. Review of Resident #14's face sheet dated 03/10/17 reflected Resident #14 was a [AGE] year old female who was admitted to the facility 02/25/17. Her admitting [DIAGNOSES REDACTED]. Review of Resident #14's March 2017 Consolidated physician's orders [REDACTED]. Lorsartan Tablet (Treats high blood pressure) Give 50 mg by mouth once per day. Baclofen Tablet (Treats muscle spasms) Give 5 mg by mouth twice per day Review of Resident #14's March 2017 MAR indicated [REDACTED]. Resident #14 did not receive a dose of Lorsartan until the next scheduled dose at 7:00 a.m. on 03/11/17. Review of the vital sign monitoring tool dated 03/10/17, Resident #14's blood pressure spiked to 176/89 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of Lorsartan. Review of Resident #14's March 2017 MAR indicated [REDACTED]. 15. Review of Resident #15's face sheet dated 03/10/17 reflected Resident #15 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #15's March 2017 MAR indicated [REDACTED] Carvedilol Tablet (Treats high blood pressure) Give 3.125 mg by mouth twice a day Review of Resident #15's March 2017 MAR indicated [REDACTED]. Resident #15 did not receive a dose of carvedilol until 7:00 p.m. on 03/10/17. 16. Review of Resident #16's face sheet dated 03/10/17 reflected Resident #16 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #16's March 2017 Consolidated physician's orders [REDACTED]. Metformin Tablet (Treats high blood sugar) Give 500 mg by mouth twice per day Review of Resident #16's March 2017 MAR indicated [REDACTED]. 17. Review of Resident #17's face sheet dated 03/10/17 reflected Resident #17 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #17's March 2017 Consolidated physician's orders [REDACTED]. Gabapentin capsule (Treats neuropathy pain) Give 300 mg by mouth twice per day Metformin Tablet (Treats high blood sugar) Give 1000 mg by mouth twice per day Nebivolol Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning Cozaar Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning Review of Resident #17's March 2017 MAR indicated [REDACTED]. Resident #17 did not receive her Nebivolol and Cozaar until their next scheduled doses on 03/11/17 at 7:00 a.m. Resident #17 did not receive a dose of gabapentin until 3:00 p.m. on 03/10/17. She did not receive a dose of metformin until 4:00 p.m. on 03/10/17. Review of the vital signs monitoring tool dated 03/10/17, Resident #17's blood pressure was 160/89 (her normal ranges were around 150/75) on 03/10/17 at 8:00 p.m. 18. Review of Resident #18's face sheet dated 03/10/17 reflected Resident #18 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #18's March 2017 Consolidated physician's orders [REDACTED]. Norvasc (Treats high blood pressure) Give 5 mg by mouth in the morning Review of Resident #18's March 2017 MAR indicated [REDACTED]. 19. Review of Resident #19's face sheet dated 03/10/17 reflected Resident #19 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #19's March 2017 Consolidated physician's orders [REDACTED]. Lyrica (Treats neuropathy pain) Give 50 mg by mouth twice a day Review of Resident #19's March 2017 MAR indicated [REDACTED]. Resident #19 did not receive a dose of Lyrica until the next scheduled dose at 7:00 p.m. on 03/10/17. Review of the FDA Medication Guide for Lyrica revised December of 2016 revealed to take LYRICA at the same times each day. If Lyrica is stopped suddenly (such as missing a dose) side effects such as headaches, nausea, diarrhea, trouble sleeping, increased sweating, and anxiousness may occur. 20. Review of Resident #20's face sheet dated 03/10/17 reflected Resident #20 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #20's March 2017 Consolidated physician's orders [REDACTED]. Lisinopril Tablet (Treats high blood pressure) Give 20 mg by mouth once a day Review of Resident #20's March 2017 MAR indicated [REDACTED]. 21. Interview with ADON A on 03/21/17 at 3:05 p.m. revealed that on 03/10/17 she had worked the 6:00 p.m. to 6:00 a.m. shift for 100 Hall. The DON had come in around 5:00 a.m. and given her some work to do. At 6:00 a.m. MA P came to ADON A and reported she was assigned to halls 100 and 300. ADON A instructed her to check in with the DON, as she was waiting for the on-coming nurse to relieve her. ADON A did not give the keys to the medication cart to MA P. ADON A asked the DON about her relief nurse and was instructed to continue working as the next on-coming nurse was late. She asked the DON for help as she had a dentist appointment and was told, sorry, no. When the oncoming nurse relieved her they counted the carts together around 8:30 a.m. ADON A stated she did not pass any morning medications off of the Med Aide's cart. She did not know if MA P had passed medications for Hall 100. Interview with MA P on 03/21/17 at 12:00 pm revealed that she works 6:00 a.m. to 6:00 p.m. On 03/10/17 she reported to ADON A and asked her to count the cart with her. ADON A instructed her to wait until the day shift nurse came on duty. MA P asked ADON A three times to count the cart for Hall 100 with her so she could pass medications and ADON A instructed her to wait. MA P went to pass medications on the 300 hall. MA P did not inform the DON that she had not been given the keys to the medication cart for hall 100 and had not passed the medications. MA P stated she did not inform the oncoming nurse or the DON about not passing the medications on Hall 100. Interview with the DON on 03/21/17 at 9:50 a.m. revealed she was working the morning of 03/10/17 and instructed ADON A to continue with her work because the on-coming nurse was late. The DON did not offer to help and did not know medications were not being passed. She stated when she learned from LVN O at 11:00 a.m. on 03/10/17 that ADON A had not passed morning medications, she instructed the nurses to call the doctors and take vital signs. She stated they took vital signs of the residents who had missed their medications every four hours for 24 hours. She revealed ADON A was suspended because of the incident. Review of ADON A's employee record revealed an Employee Memorandum dated 03/10/17. ADON A received a written warning and was suspended. The subject of code of conduct rule violated was neglect. The date of violation is listed as 03/10/17. The description of the warning states med pass was not passed at 7:00 a.m. on Hall 100 to several residents. ADON A signed the warning on 03/10/17. ADON A also received a written warning on 03/06/17 regarding blanks in MARs. An in-service was provided on proper medication administration. The corrective action of not signing the MAR indicated [REDACTED]. Interview with the DON on 03/21/17 at 2:10 p.m. revealed ADON A had refused assignments in the past. ADON A refused to work Hall 200 on 03/04/17 and the DON assumed ADON A passed all the medications for Hall 200 on 03/04/17. All nurses and MAs had received a written warning regarding medication administration on 03/06/17 because of another medication error. The DON stated on the night shift Hall 200 is split between the nurse on Hall 300 and the nurse on Hall 100. The nurse assigned to Hall 100 is responsible for the residents in rooms 200-205 and rooms [ROOM NUMBER]. The nurse assigned to Hall 300 is responsible for the residents in rooms 206-211 and room [ROOM NUMBER]. 22. Review of Resident #29's face sheet dated 03/23/17 reflected Resident #29 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #29's MDS assessment dated [DATE] revealed she was cognitively intact. Review of Resident #29's March 2017 Consolidated physician's orders [REDACTED]. Levemir FlexPen Solution (Treats high blood sugar) Inject 20 units twice a day Insulin Aspart Solution (Treats high blood sugar) Inject as per sliding scale before meals and at bedtime Xanax Tablet (Treats anxiety) Give 0.25 mg by mouth at bedtime Pramipexole Dihydrochloride Tablet (Treats Restless Leg Syndrome) Give 0.5 mg by mouth in the afternoon Eliquis Tablet (Anticoagulant) Give 2.5 mg by mouth twice a day Metoprolol Tartrate Tablet (Treats high blood pressure) Give 12.5 mg by mouth twice a day Review of Resident #29's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 and 03/02/17's 8:00 p.m. dose of Eliquis. LVN C failed to administer 03/02/17 and 03/03/17's 2:00 a.m. dose of Metoprolol. LVN J failed to administer 03/03/17's 8:00 p.m. dose of Eliquis. LVN J failed to administer Resident #29's 9:00 p.m. dose of Xanax on 03/03/17. LVN J failed to administer Resident #29's 03/04/17's 5:00 p.m. and 8:00 p.m. dose of Insulin Aspart. LVN J failed to administer 03/04/17's 2:00 p.m. dose of Pramipexole Dihydrochloride . LVN J failed to administer Resident #29's 8:00 p.m. dose of Levemir on 03/04/17. RN D failed to administer Resident #29's 8:00 a.m. dose of Levemir on 03/04/17 and 03/05/17. RN D also failed to administer Resident #29's 7:00 a.m. and 11:00 a.m. dose of Insulin Aspart on 03/05/17. LVN E failed to administer 03/08/17's 8:00 p.m. dose of Insulin Aspart. LVN E failed to administer Resident #29's 8:00 p.m. dose of Levemir on 03/08/17. LVN L failed to administer Resident #29's 8:00 p.m. dose of Insulin Aspart on 03/09/17. LVN E failed to administer 03/18/17's 8:00 p.m. dose of Insulin Aspart. LVN I failed to administer Resident #29's 8:00 p.m. dose of Levemir on 03/19/17. LVN K failed to administer Resident #29's 8:00 a.m. dose of Levemir on 03/20/17. Interview with Resident #29 on 03/21/17 at 2:40 p.m. revealed she has missed doses of medications and did not get most of her medications on 03/03/17 and 03/04/17. She stated there were new nurses those days. She stated she has experienced pain when she does not receive her pain medications and her medication for Restless Leg Syndrome. 23. Review of Resident #21's face sheet dated 03/23/17 reflected Resident #21 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #21's March 2017 Consolidated physician's orders [REDACTED]. Novolog FlexPen Solution Pen Injector (Treats high blood sugar) Inject as per sliding scale before meals. Levemir FlexPen Solution Pen Injector (Treats high blood sugar) Inject 60 units at bedtime. Pravachol Tablet (Treats high blood pressure) Give 40 mg by mouth at bedtime Review of Resident #21's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 through 03/04/17's 9:00 p.m. dose of Pravachol. LVN C failed to administer Resident #21's Levemir Insulin 8:00 p.m. dose on 03/04/17. LVN B failed to administer Resident #21's Novolog Insulin 4:30 p.m. dose on 03/13/17. On 03/22/17, LVN I had not administered Resident #21's 8:00 p.m. Levemir when the MAR indicated [REDACTED]. Interview with the Administrator on 03/23/17 at 10:25 a.m. revealed LVN G helped LVN I pass the missed medications around 11:00 p.m. on 03/22/17. He stated they had notified all residents' doctors who had missed insulin. 24. Review of Resident #22's face sheet dated 03/23/17 reflected Resident #22 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #22's March 2017 Consolidated physician's orders [REDACTED]. Novolog Solution (Treats high blood sugar) Inject as per sliding scale after meals Norco Tablet (Treats pain) Give 7.5-325 mg tablet by mouth twice a day Review of Resident #22's March 2017 MAR indicated [REDACTED] RN D failed to administer Resident #22's Novolog insulin on 03/05/17 at 8:30 a.m. and 1:30 p.m. LVN E failed to administer Resident #22's Novolog insulin on 03/05/17 at 6:30 p.m. LVN C also failed to administer Resident #22's 6:00 a.m. and 8:00 p.m. dose of Norco on 03/01/17 and 03/02/17. LVN C failed to administer Resident #22's 8:00 p.m. dose of Norco on 03/03/17 and 6:00 a.m. dose on 03/04/17. On 03/22/17, LVN E had not administered Resident #22's 6:30 p.m. dose of Novolog insulin when the MAR indicated [REDACTED] 25. Review of Resident #23's face sheet dated 03/23/17 reflected Resident #23 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #23's March 2017 Consolidated physician's orders [REDACTED]. Doxycycline Hyciate Tablet (Antibiotic to treat upper respiratory infection) Give 100 mg by mouth twice a day to start on 03/13/17 at 2:00 a.m. Tramadol Tablet (Treats pain) Give 50 mg by mouth every 12 hours. Review of Resident #23's March 2017 MAR indicated [REDACTED] LVN E failed to administer Resident #23's 9:00 a.m. dose of Tramadol on 03/03/17. LVN C did not administer Resident #23's 9:00 p.m. dose of Tramadol on 03/04/17. The DON did not administer the third dose of Doxycycline Hyciate to Resident #23 on 03/14/17 at 2:00 a.m. LVN H did not administer the fourth dose of Doxycycline Hyciate to Resident #23 on 03/14/17 at 2:00 p.m. Review of Resident #23's March 2017 MAR indicated [REDACTED]. Resident #23 indicated increased pain of 3 on 03/04/17 and 03/05/17 (after the missed doses of Tramadol) and she normally did not have any pain. 26. Review of Resident #24's face sheet dated 03/23/17 reflected Resident #24 is a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #24's March 2017 MAR indicated [REDACTED] Tramadol Tablet (Treats pain) Give 50 mg by mouth three times a day Review of Resident #24's March 2017 MAR indicated [REDACTED]. Review of Resident #24's March 2017 MAR indicated [REDACTED]. 27. Review of Resident #25's face sheet dated 03/23/17 revealed Resident #25 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #25's March 2017's Consolidated physician's orders [REDACTED]. Gabapentin Capsule (Treats neuropathy pain) Give 300 mg by mouth three times a day Hydrocodone-Acetaminophen Tablet (Treats pain) Give 5-325mg tablet by mouth three times a day Metoprolol Tartate Tablet (Treats high blood pressure) Give 50 mg by mouth two times a day Phenytoin Sodium Extended Capsule (Prevents seizures) Give 100 mg by mouth at bedtime Review of Resident #25's March 2017 MAR indicated [REDACTED]. LVN F failed to administer Resident #25

Based on interview and record review the facility failed to ensure sufficient staffing to provide nursing related services to ensure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for 45 (Resident #1 through Resident #45) of 52 residents reviewed for nursing services. 1. The facility failed to ensure there was enough nursing staff to ensure all resident's medications were administered as ordered by the physicians. 2. The facility failed to administer physician ordered [MEDICATION NAME] (prevents [MEDICAL CONDITION]), Levetiracetam (prevents [MEDICAL CONDITION]), [MEDICATION NAME] Acid (prevents [MEDICAL CONDITION]), and [MEDICATION NAME] (treats hypertension) on 03/10/17 to Resident #1 which resulted in Resident #1 having a [MEDICAL CONDITION] and having to go to the hospital to receive IV [MEDICATION NAME] and [MEDICATION NAME] to control his [MEDICAL CONDITION]. 3. The facility failed to administer morning medications on 03/10/17 to Resident #2 through Resident #20. 4. The facility failed to administer physician ordered medications to Residents #21 through Resident #45 on different days and times in March 2017. An Immediate Jeopardy situation was identified on 03/21/17. The Immediate Jeopardy was removed on 03/26/17. The facility remained out of compliance at a pattern of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. These failures could affect all 74 residents by placing them at risk for death, exacerbation of medical conditions, and not receiving the therapeutic benefits of their medications. Findings included: 1. Review of the Provider Investigation Report dated 03/10/17 revealed ADON A did not pass the morning medications off the Med Aide cart to the residents who resided on Hall 100 because the other shift nurse had not arrived and she refused to give possession of the keys to the medication aide so she could pass her medications. Twenty residents should have received medications between the time of 6:00 a.m. and 8:30 a.m. from ADON A on 03/10/17. Later that afternoon, Resident #1 was at the receptionist's desk when he had a [MEDICAL CONDITION]. He was transported by EMS to the hospital. Resident #1 received IV [MEDICATION NAME] and [MEDICATION NAME] at the hospital and returned to the facility on [DATE] at 11:10 p.m. Review of Resident #1's face sheet dated 03/10/17 reflected Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed he had severe cognitive impairment. Review of Resident #1's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give one 200 mg tablet by mouth two times a day Levetiracetam Solution (Prevents [MEDICAL CONDITION]) Give 3000 mg by mouth three times a day [MEDICATION NAME] Acid (Prevents [MEDICAL CONDITION]) Give 250 mg by mouth three times a day [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 25 mg by mouth once a day Review of Resident #1's March 2017 MAR indicated [REDACTED]. Resident #1 went to the hospital before the medications could be administered at a later time. Review of Resident #1's nurses notes dated 03/10/17 at 12:30PM signed by DON revealed Resident sitting in wheelchair at receptionist desk shaking as if he was cold and clammy. Resident looking at staff but not answering questions. Resident stood from wheelchair and laid himself down on the couch with standby assist of staff. Blood sugar taken 106. Started to take blood pressure when resident started having [MEDICAL CONDITION]. At 12:35 resident stiffened up and turned blue. 911 notified. Blood pressure 144/111, pulse 109, O2 sat 97%. Resident assisted to gurney and transported to hospital. An attempt was made to interview Resident #1 on 03/23/17 at 2:45 p.m. The resident would not answer any of the questions. 2. Review of Resident #2's face sheet dated 03/10/17 reflected Resident #2 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 100 mg by mouth in the morning [MEDICATION NAME] (Treats high blood pressure) Give 10 mg by mouth in the morning [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning [MEDICATION NAME] (Treats anxiety) Give 0.5 mg by mouth two times a day Review of Resident #2's March 2017 MAR indicated [REDACTED]. Interview with Resident #2 on 03/21/17 at 10:50 a.m. revealed that she has not been getting her medications on time. She does not receive her morning medications until 2 p.m. Review of the vital sign monitoring tool dated 03/10/17, Resident #2's blood pressure spiked to 172/67 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of [MEDICATION NAME] and [MEDICATION NAME] Tartate. Review of Resident #2's March 2017 MAR indicated [REDACTED]. 3. Review of Resident #3's face sheet dated 03/10/17 reflected Resident #3 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood pressure) Give 6.25 mg by mouth twice a day. Review of Resident #3's March 2017 MAR indicated [REDACTED]. Resident #3 did not receive another dose of [MEDICATION NAME] until 7:00 a.m. on 03/11/17. 4. Review of Resident #4's face sheet dated 03/10/17 reflected Resident #4 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #4's March 2017 Consolidated physician's orders [REDACTED]. Entacapone Tablet (Anti-[MEDICAL CONDITION] medication) Give 200 mg by mouth three times a day. [MEDICATION NAME] Tablet (Anti-[MEDICAL CONDITION] medication) Give 100 mg by mouth three times a day. Review of Resident #4's March 2017 MAR indicated [REDACTED]. Resident #4 did not receive a dose of Entacapone and [MEDICATION NAME] until 1:00 p.m. 5. Review of Resident #5's face sheet dated 03/10/17 reflected Resident #5 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #5's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] tablet (Treats high blood pressure) Give 10 mg by mouth three times a day Carvedilol Tablet (Treats high blood pressure) Give 12.5 mg by mouth two times a day Review of Resident #5's March 2017 MAR indicated [REDACTED]. He did not receive his next dose of [MEDICATION NAME] until 1:00 p.m. on 03/10/17. His next recorded blood pressure was 177/89 (normal range is 120/70) at 1:00 p.m. on 03/10/17. Resident #5 received his next scheduled dose of Carvedilol at 7:00 p.m. on 03/10/17 and his blood pressure was still elevated at 172/69. After receiving both of his doses of blood pressure medication, his blood pressure decreased to 147/61 (taken on 03/11/17 at midnight). Review of Resident #5's March 2017 MAR indicated [REDACTED]. 6. Review of Resident #6's face sheet dated 03/10/17 reflected Resident #6 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #6's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give 50 mg by mouth two times a day. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth three times a day. Review of Resident #6's March 2017 MAR indicated [REDACTED]. 7. Review of Resident #7's face sheet dated 03/10/17 reflected Resident #7 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #7's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 25 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 100 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day Review of Resident #7's March 2017 MAR indicated [REDACTED]. They were administered later in the day at 11:00 a.m. By that time, Resident #7's blood pressure had risen to 154/96. Resident #7's blood pressures were usually in the 130s/60s. Interview with Resident #7 on 03/23/17 at 9:20 a.m. revealed she may have missed a dose from the MA on 03/10/17 and sometimes her medications were late. 8. Review of Resident #8's face sheet dated 03/10/17 reflected Resident #8 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #8's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 2.5 mg by mouth in the morning [MEDICATION NAME] Tartate (Treats high blood pressure) Give 50 mg by mouth twice a day Review of Resident #8's March 2017 MAR indicated [REDACTED]. Resident #8 did not receive a dose of [MEDICATION NAME] until 03/11/17 at 7:00 a.m. He received a dose of [MEDICATION NAME] on 03/10/17 at 7:00 p.m. 9. Review of Resident #9's face sheet dated 03/10/17 reflected Resident #9 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #9's March 2017 MAR indicated [REDACTED] [MEDICATION NAME] tablet (Treats high blood pressure) Give 25 mg by mouth three times a day. Review of Resident #9's March 2017 MAR indicated [REDACTED]. Resident #9 did not receive a dose of [MEDICATION NAME] until 03/10/17 at 3:00 p.m. 10. Review of Resident #10's face sheet dated 03/10/17 reflected Resident #10 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #10's March 2017 Consolidated physician's orders [REDACTED]. Eliquis Tablet (Prevents blood clots) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day [MEDICATION NAME] Tablet (Treats anxiety) Give 2 mg by mouth three times a day Review of Resident #10's March 2017 MAR indicated [REDACTED]. She did not receive the next dose of Eliquis until 03/11/17 at 7:00 a.m. Review of the FDA's Medication Guide for Eliquis revised August 2016 revealed do not change your dose or stop taking it unless your doctor tells you to. If you miss a dose of ELIQUIS, take it as soon as you remember, and do not take more than one dose at the same time. If you are taking ELIQUIS for [MEDICAL CONDITION], stopping ELIQUIS may increase your risk of having a stroke. Do not run out of ELIQUIS. Refill your prescription before you run out. 11. Review of Resident #11's face sheet dated 03/10/17 reflected Resident #11 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #11's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 100 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats muscle spasms) Give 10 mg by mouth two times a day [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day Review of Resident #11's March 2017 MAR indicated [REDACTED]. Resident #11 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 3:00 p.m. on 03/10/17. She did not receive a dose of [MEDICATION NAME] until 3:00 p.m. on 03/10/17. Resident #11 received her next dose of [MEDICATION NAME] on 03/10/17 at 11:00 a.m. as scheduled. 12. Review of Resident #12's face sheet dated 03/10/17 reflected Resident #12 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #12's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood sugar) Give 500 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats muscle spasms) Give 4 mg by mouth three times a day Review of Resident #12's March 2017 MAR indicated [REDACTED]. 13. Review of Resident #13's face sheet dated 03/10/17 reflected Resident #13 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #13's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 10 mg by mouth twice per day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth twice per day Review of Resident #13's March 2017 MAR indicated [REDACTED]. 14. Review of Resident #14's face sheet dated 03/10/17 reflected Resident #14 was a [AGE] year old female who was admitted to the facility 02/25/17. Her admitting [DIAGNOSES REDACTED]. Review of Resident #14's March 2017 Consolidated physician's orders [REDACTED]. Lorsartan Tablet (Treats high blood pressure) Give 50 mg by mouth once per day. [MEDICATION NAME] Tablet (Treats muscle spasms) Give 5 mg by mouth twice per day Review of Resident #14's March 2017 MAR indicated [REDACTED]. Resident #14 did not receive a dose of Lorsartan until the next scheduled dose at 7:00 a.m. on 03/11/17. Review of the vital sign monitoring tool dated 03/10/17, Resident #14's blood pressure spiked to 176/89 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of Lorsartan. Review of Resident #14's March 2017 MAR indicated [REDACTED]. 15. Review of Resident #15's face sheet dated 03/10/17 reflected Resident #15 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #15's March 2017 MAR indicated [REDACTED] Carvedilol Tablet (Treats high blood pressure) Give 3.125 mg by mouth twice a day Review of Resident #15's March 2017 MAR indicated [REDACTED]. Resident #15 did not receive a dose of carvedilol until 7:00 p.m. on 03/10/17. 16. Review of Resident #16's face sheet dated 03/10/17 reflected Resident #16 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #16's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood sugar) Give 500 mg by mouth twice per day Review of Resident #16's March 2017 MAR indicated [REDACTED]. 17. Review of Resident #17's face sheet dated 03/10/17 reflected Resident #17 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #17's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] capsule (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth twice per day [MEDICATION NAME] Tablet (Treats high blood sugar) Give 1000 mg by mouth twice per day Nebivolol Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning Review of Resident #17's March 2017 MAR indicated [REDACTED]. Resident #17 did not receive her Nebivolol and [MEDICATION NAME] until their next scheduled doses on 03/11/17 at 7:00 a.m. Resident #17 did not receive a dose of [MEDICATION NAME] until 3:00 p.m. on 03/10/17. She did not receive a dose of [MEDICATION NAME] until 4:00 p.m. on 03/10/17. Review of the vital signs monitoring tool dated 03/10/17, Resident #17's blood pressure was 160/89 (her normal ranges were around 150/75) on 03/10/17 at 8:00 p.m. 18. Review of Resident #18's face sheet dated 03/10/17 reflected Resident #18 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #18's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood pressure) Give 5 mg by mouth in the morning Review of Resident #18's March 2017 MAR indicated [REDACTED]. 19. Review of Resident #19's face sheet dated 03/10/17 reflected Resident #19 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #19's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 50 mg by mouth twice a day Review of Resident #19's March 2017 MAR indicated [REDACTED]. Resident #19 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 7:00 p.m. on 03/10/17. Review of the FDA Medication Guide for [MEDICATION NAME] revised December of 2016 revealed to take [MEDICATION NAME] at the same times each day. If [MEDICATION NAME] is stopped suddenly (such as missing a dose) side effects such as headaches, nausea, diarrhea, trouble sleeping, increased sweating, and anxiousness may occur. 20. Review of Resident #20's face sheet dated 03/10/17 reflected Resident #20 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #20's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 20 mg by mouth once a day Review of Resident #20's March 2017 MAR indicated [REDACTED]. 21. Interview with ADON A on 03/21/17 at 3:05 p.m. revealed that on 03/10/17 she had worked the 6:00 p.m. to 6:00 a.m. shift for 100 Hall. The DON had come in around 5:00 a.m. and given her some work to do. At 6:00 a.m. MA P came to ADON A and reported she was assigned to halls 100 and 300. ADON A instructed her to check in with the DON, as she was waiting for the on-coming nurse to relieve her. ADON A did not give the keys to the medication cart to MA P. ADON A asked the DON about her relief nurse and was instructed to continue working as the next on-coming nurse was late. She asked the DON for help as she had a dentist appointment and was told, sorry, no. When the oncoming nurse relieved her they counted the carts together around 8:30 a.m. ADON A stated she did not pass any morning medications off of the Med Aide's cart. She did not know if MA P had passed medications for Hall 100. Interview with MA P on 03/21/17 at 12:00 pm revealed that she works 6:00 a.m. to 6:00 p.m. On 03/10/17 she reported to ADON A and asked her to count the cart with her. ADON A instructed her to wait until the day shift nurse came on duty. MA P asked ADON A three times to count the cart for Hall 100 with her so she could pass medications and ADON A instructed her to wait. MA P went to pass medications on the 300 hall. MA P did not inform the DON that she had not been given the keys to the medication cart for hall 100 and had not passed the medications. MA P stated she did not inform the oncoming nurse or the DON about not passing the medications on Hall 100. Interview with the DON on 03/21/17 at 9:50 a.m. revealed she was working the morning of 03/10/17 and instructed ADON A to continue with her work because the on-coming nurse was late. The DON did not offer to help and did not know medications were not being passed. She stated when she learned from LVN O at 11:00 a.m. on 03/10/17 that ADON A had not passed morning medications, she instructed the nurses to call the doctors and take vital signs. She stated they took vital signs of the residents who had missed their medications every four hours for 24 hours. She revealed ADON A was suspended because of the incident. Review of ADON A's employee record revealed an Employee Memorandum dated 03/10/17. ADON A received a written warning and was suspended. The subject of code of conduct rule violated was neglect. The date of violation is listed as 03/10/17. The description of the warning states med pass was not passed at 7:00 a.m. on Hall 100 to several residents. ADON A signed the warning on 03/10/17. ADON A also received a written warning on 03/06/17 regarding blanks in MARs. An in-service was provided on proper medication administration. The corrective action of not signing the MAR indicated [REDACTED]. Interview with the DON on 03/21/17 at 2:10 p.m. revealed ADON A had refused assignments in the past. ADON A refused to work Hall 200 on 03/04/17 and the DON assumed ADON A passed all the medications for Hall 200 on 03/04/17. All nurses and MAs had received a written warning regarding medication administration on 03/06/17 because of another medication error. The DON stated on the night shift Hall 200 is split between the nurse on Hall 300 and the nurse on Hall 100. The nurse assigned to Hall 100 is responsible for the residents in rooms 200-205 and rooms [ROOM NUMBER]. The nurse assigned to Hall 300 is responsible for the residents in rooms 206-211 and room [ROOM NUMBER]. 22. Review of Resident #29's face sheet dated 03/23/17 reflected Resident #29 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #29's MDS assessment dated [DATE] revealed she was cognitively intact. Review of Resident #29's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject 20 units twice a day Insulin [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale before meals and at bedtime [MEDICATION NAME] Tablet (Treats anxiety) Give 0.25 mg by mouth at bedtime Pramipexole [MEDICATION NAME] Tablet (Treats Restless Leg Syndrome) Give 0.5 mg by mouth in the afternoon Eliquis Tablet (Anticoagulant) Give 2.5 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 12.5 mg by mouth twice a day Review of Resident #29's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 and 03/02/17's 8:00 p.m. dose of Eliquis. LVN C failed to administer 03/02/17 and 03/03/17's 2:00 a.m. dose of [MEDICATION NAME]. LVN J failed to administer 03/03/17's 8:00 p.m. dose of Eliquis. LVN J failed to administer Resident #29's 9:00 p.m. dose of [MEDICATION NAME] on 03/03/17. LVN J failed to administer Resident #29's 03/04/17's 5:00 p.m. and 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN J failed to administer 03/04/17's 2:00 p.m. dose of Pramipexole [MEDICATION NAME] . LVN J failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/04/17. RN D failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/04/17 and 03/05/17. RN D also failed to administer Resident #29's 7:00 a.m. and 11:00 a.m. dose of Insulin [MEDICATION NAME] on 03/05/17. LVN E failed to administer 03/08/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN E failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/08/17. LVN L failed to administer Resident #29's 8:00 p.m. dose of Insulin [MEDICATION NAME] on 03/09/17. LVN E failed to administer 03/18/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN I failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/19/17. LVN K failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/20/17. Interview with Resident #29 on 03/21/17 at 2:40 p.m. revealed she has missed doses of medications and did not get most of her medications on 03/03/17 and 03/04/17. She stated there were new nurses those days. She stated she has experienced pain when she does not receive her pain medications and her medication for Restless Leg Syndrome. 23. Review of Resident #21's face sheet dated 03/23/17 reflected Resident #21 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #21's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject as per sliding scale before meals. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject 60 units at bedtime. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 40 mg by mouth at bedtime Review of Resident #21's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 through 03/04/17's 9:00 p.m. dose of [MEDICATION NAME]. LVN C failed to administer Resident #21's [MEDICATION NAME] Insulin 8:00 p.m. dose on 03/04/17. LVN B failed to administer Resident #21's [MEDICATION NAME] Insulin 4:30 p.m. dose on 03/13/17. On 03/22/17, LVN I had not administered Resident #21's 8:00 p.m. [MEDICATION NAME] when the MAR indicated [REDACTED]. Interview with the Administrator on 03/23/17 at 10:25 a.m. revealed LVN G helped LVN I pass the missed medications around 11:00 p.m. on 03/22/17. He stated they had notified all residents' doctors who had missed insulin. 24. Review of Resident #22's face sheet dated 03/23/17 reflected Resident #22 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #22's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale after meals [MEDICATION NAME] Tablet (Treats pain) Give 7.5-325 mg tablet by mouth twice a day Review of Resident #22's March 2017 MAR indicated [REDACTED] RN D failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 8:30 a.m. and 1:30 p.m. LVN E failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 6:30 p.m. LVN C also failed to administer Resident #22's 6:00 a.m. and 8:00 p.m. dose of [MEDICATION NAME] on 03/01/17 and 03/02/17. LVN C failed to administer Resident #22's 8:00 p.m. dose of [MEDICATION NAME] on 03/03/17 and 6:00 a.m. dose on 03/04/17. On 03/22/17, LVN E had not administered Resident #22's 6:30 p.m. dose of [MEDICATION NAME]when the MAR indicated [REDACTED] 25. Review of Resident #23's face sheet dated 03/23/17 reflected Resident #23 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #23's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Hyciate Tablet (Antibiotic to treat upper respiratory infection) Give 100 mg by mouth twice a day to start on 03/13/17 at 2:00 a.m. [MEDICATION NAME] Tablet (Treats pain) Give 50 mg by mouth every 12 hours. Review of Resident #23's March 2017 MAR indicated [REDACTED] LVN E failed to administer Resident #23's 9:00 a.m. dose of [MEDICATION NAME] on 03/03/17. LVN C did not administer Resident #23's 9:00 p.m. dose of [MEDICATION NAME] on 03/04/17. The DON did not administer the third dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 a.m. LVN H did not administer the fourth dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 p.m. Review of Resident #23's March 2017 MAR indicated [REDACTED]. Resident #23 indicated increased pain of 3 on 03/04/17 and 03/05/17 (after the missed doses of [MEDICATION NAME]) and she normally did not have any pain. 26. Review of Resident #24's face sheet dated 03/23/17 reflected Resident #24 is a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #24's March 2017 MAR indicated [REDACTED] [MEDICATION NAME] Tablet (Treats pain) Give 50 mg by mouth three times a day Review of Resident #24's March 2017 MAR indicated [REDACTED]. Review of Resident #24's March 2017 MAR indicated [REDACTED]. 27. Review of Resident #25's face sheet dated 03/23/17 revealed Resident #25 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #25's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Capsule (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth three times a day [MEDICATION NAME]-[MEDICATION NAME] Tablet (Treats pain) Give 5-325mg tablet by mouth three times a day [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 50 mg by mouth two times a day [MEDICATION NAME] Sodium Extended Capsule (Prevents [MEDICAL CONDITION]) Give 100 mg by mouth at bedtime Review of Resident #25's March 2017 MAR indicated [REDACTED]

Based on interview and record review, the facility failed to ensure that residents were free of any significant medication errors for 25 (Residents #1, Resident #2, Resident #4, Resident #5, Resident #6, Resident #7, Resident #10, Resident #11, Resident #14, Resident #17, Resident #19, Resident #21, Resident #22, Resident #23, Resident #24, Resident #25, Resident #26, Resident #27, Resident #29, Resident #30, Resident #32, Resident #35, Resident #36, Resident #37, Resident #41, and Resident #44) of 52 residents reviewed for medication errors. 1. The facility failed to administer physician ordered [MEDICATION NAME] (prevents [MEDICAL CONDITION]), Levetiracetam (prevents [MEDICAL CONDITION]), [MEDICATION NAME] Acid (prevents [MEDICAL CONDITION]), and [MEDICATION NAME] (treats hypertension) on 03/10/17 to Resident #1 which resulted in Resident #1 having a [MEDICAL CONDITION] and having to go to the hospital to receive IV [MEDICATION NAME] and [MEDICATION NAME] to control his [MEDICAL CONDITION]. 2. The facility failed to administer Resident #2's [MEDICATION NAME] (treats hypertension) and [MEDICATION NAME] (treats hypertension) on 03/10/17. 3. The facility failed to administer Resident #4's Entacapone (treats [MEDICAL CONDITION]) and [MEDICATION NAME] (treats [MEDICAL CONDITION]) on 03/10/17. 4. The facility failed to administer Resident #5's [MEDICATION NAME] (treats hypertension) and carvedilol (treats hypertension) on 03/10/17. 5. The facility failed to administer Resident #6's [MEDICATION NAME] (prevents [MEDICAL CONDITION]) on 03/10/17. 6. The facility failed to administer Resident #7's [MEDICATION NAME] (treats hypertension), [MEDICATION NAME] (treats hypertension), [MEDICATION NAME] (treats hypertension), and [MEDICATION NAME] (treats hypertension) on 03/10/17. 7. The facility failed to administer Resident #10's Eliquis (prevents blood clots) on 03/10/17. 8. The facility failed to administer Resident #11's [MEDICATION NAME] (treats [MEDICAL CONDITION] pain) on 03/10/17. 9. The facility failed to administer Resident #14's Lorsartan (treats hypertension) on 03/10/17. 10. The facility failed to administer Resident #17's nebivolol (treats hypertension) and [MEDICATION NAME] (treats hypertension) on 03/10/17. 11. The facility failed to administer Resident #19's [MEDICATION NAME] (treats [MEDICAL CONDITION] pain) on 03/10/17. 12. The facility failed to administer Resident #29's [MEDICATION NAME] Insulin (treats diabetes), insulin [MEDICATION NAME] Solution (treats diabetes), [MEDICATION NAME] (treats anxiety), pramipexole [MEDICATION NAME] (treats restless leg syndrome), Eliquis (prevents blood clots), and [MEDICATION NAME] (treats hypertension) several days in March of 2017 which resulted in the resident being in pain. 13. The facility failed to administer Resident #21's [MEDICATION NAME](treats diabetes), [MEDICATION NAME](treats diabetes) and [MEDICATION NAME] (treats hypertension) several days from 03/01/17 to 03/22/17. 14. The facility failed to administer Resident #22's [MEDICATION NAME](treats diabetes) and [MEDICATION NAME] (treats pain) several days from 03/01/17 to 03/22/17. 15. The facility failed to administer Resident #23's [MEDICATION NAME] hyciate (antibiotic) and [MEDICATION NAME] (treats pain) several days from 03/03/17 to 03/14/17. 16. The facility failed to administer Resident #24's [MEDICATION NAME] (treats pain) several days from 03/04/17 to 03/22/17. 17. The facility failed to administer Resident #25's [MEDICATION NAME] (treats hypertension) and [MEDICATION NAME] sodium (prevents [MEDICAL CONDITION]) several days from 03/01/17 to 03/08/17. 18. The facility failed to administer Resident #26's Bactrim DS (antibiotic) several days from 03/03/17 to 03/17/17. 19. The facility failed to administer Resident #27's [MEDICATION NAME] (prevents blood clots), [MEDICATION NAME] (treats anxiety), [MEDICATION NAME] (treats anxiety), [MEDICATION NAME] (treats pain), and [MEDICATION NAME] (treats hypertension) several days from 03/01/17 to 03/19/17. 20. The facility failed to administer Resident #30's [MEDICATION NAME] (treats pain), [MEDICATION NAME] (treats pain), and [MEDICATION NAME] sulfate (treats pain) several days from 03/01/17 to 03/19/17. 21. The facility failed to administer Resident #32's Apixaban (prevents blood clots) on 03/22/17. 22. The facility failed to administer Resident #35's Tylenol with [MEDICATION NAME] (treats pain), [MEDICATION NAME] (treats hypertension), [MEDICATION NAME] (treats anxiety), [MEDICATION NAME] (treats hypertension), [MEDICATION NAME] (treats hypertension), [MEDICATION NAME] (treats diabetes), and Robaxcin (treats symptoms of [MEDICAL CONDITION]) several days from 03/18/17 to 03/19/17. 23. The facility failed to administer Resident #36's [MEDICATION NAME] (treats hypertension), [MEDICATION NAME] (treats hypertension), [MEDICATION NAME] (treats irregular heartbeat), and [MEDICATION NAME] (prevents [MEDICAL CONDITION]) several days from 03/04/17 to 03/19/17. 24. The facility failed to administer Resident #37's [MEDICATION NAME] (treats [MEDICAL CONDITION]) several doses on 03/19/17. 25. The facility failed to administer Resident #41's [MEDICATION NAME] several days from 03/17/17 to 03/22/17. 26. The facility failed to administer Resident #44's [MEDICATION NAME] (treats hypertension) and [MEDICATION NAME] (prevents [MEDICAL CONDITION]) on 03/19/17. An Immediate Jeopardy situation was identified on 03/21/17. The Immediate Jeopardy was removed on 03/26/17. The facility remained out of compliance at a pattern of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. These failures could affect all 74 residents by placing them at risk for death, exacerbation of medical conditions, and not receiving the therapeutic benefits of their medications. Findings included: 1. Review of the Provider Investigation Report dated 03/10/17 revealed ADON A did not pass the morning medications off the Med Aide cart to the residents who resided on Hall 100 because the other shift nurse had not arrived and she refused to give possession of the keys to the medication aide so she could pass her medications. Twenty residents should have received medications between the time of 6:00 a.m. and 8:30 a.m. from ADON A on 03/10/17. Later that afternoon, Resident #1 was at the receptionist's desk when he had a [MEDICAL CONDITION]. He was transported by EMS to the hospital. Resident #1 received IV [MEDICATION NAME] and [MEDICATION NAME] at the hospital and returned to the facility on [DATE] at 11:10 p.m. Review of Resident #1's face sheet dated 03/10/17 reflected Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed he had severe cognitive impairment. Review of Resident #1's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give one 200 mg tablet by mouth two times a day Levetiracetam Solution (Prevents [MEDICAL CONDITION]) Give 3000 mg by mouth three times a day [MEDICATION NAME] Acid (Prevents [MEDICAL CONDITION]) Give 250 mg by mouth three times a day [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 25 mg by mouth once a day Review of Resident #1's March 2017 MAR indicated [REDACTED]. Resident #1 went to the hospital before the medications could be administered at a later time. Review of Resident #1's nurses notes dated 03/10/17 at 12:30PM signed by DON revealed Resident sitting in wheelchair at receptionist desk shaking as if he was cold and clammy. Resident looking at staff but not answering questions. Resident stood from wheelchair and laid himself down on the couch with standby assist of staff. Blood sugar taken 106. Started to take blood pressure when resident started having [MEDICAL CONDITION]. At 12:35 resident stiffened up and turned blue. 911 notified. Blood pressure 144/111, pulse 109, O2 sat 97%. Resident assisted to gurney and transported to hospital. An attempt was made to interview Resident #1 on 03/23/17 at 2:45 p.m. The resident would not answer any of the questions. 2. Review of Resident #2's face sheet dated 03/10/17 reflected Resident #2 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood pressure) Give 10 mg by mouth in the morning [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning Review of Resident #2's March 2017 MAR indicated [REDACTED]. Interview with Resident #2 on 03/21/17 at 10:50 a.m. revealed that she has not been getting her medications on time. She does not receive her morning medications until 2 p.m. Review of the vital sign monitoring tool dated 03/10/17, Resident #2's blood pressure spiked to 172/67 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of [MEDICATION NAME] and [MEDICATION NAME] Tartate. Review of Resident #2's March 2017 MAR indicated [REDACTED]. 3. Review of Resident #4's face sheet dated 03/10/17 reflected Resident #4 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #4's March 2017 Consolidated physician's orders [REDACTED]. Entacapone Tablet (Anti-[MEDICAL CONDITION] medication) Give 200 mg by mouth three times a day. [MEDICATION NAME] Tablet (Anti-[MEDICAL CONDITION] medication) Give 100 mg by mouth three times a day. Review of Resident #4's March 2017 MAR indicated [REDACTED]. Resident #4 did not receive a dose of Entacapone and [MEDICATION NAME] until 1:00 p.m. 4. Review of Resident #5's face sheet dated 03/10/17 reflected Resident #5 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #5's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] tablet (Treats high blood pressure) Give 10 mg by mouth three times a day Carvedilol Tablet (Treats high blood pressure) Give 12.5 mg by mouth two times a day Review of Resident #5's March 2017 MAR indicated [REDACTED]. He did not receive his next dose of [MEDICATION NAME] until 1:00 p.m. on 03/10/17. His next recorded blood pressure was 177/89 (normal range is 120/70) at 1:00 p.m. on 03/10/17. Resident #5 received his next scheduled dose of Carvedilol at 7:00 p.m. on 03/10/17 and his blood pressure was still elevated at 172/69. After receiving both of his doses of blood pressure medication, his blood pressure decreased to 147/61 (taken on 03/11/17 at midnight). Review of Resident #5's March 2017 MAR indicated [REDACTED]. 5. Review of Resident #6's face sheet dated 03/10/17 reflected Resident #6 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #6's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give 50 mg by mouth two times a day. Review of Resident #6's March 2017 MAR indicated [REDACTED]. 6. Review of Resident #7's face sheet dated 03/10/17 reflected Resident #7 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #7's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 25 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 100 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning Review of Resident #7's March 2017 MAR indicated [REDACTED]. They were administered later in the day at 11:00 a.m. By that time, Resident #7's blood pressure had risen to 154/96. Resident #7's blood pressures were usually in the 130s/60s on 03/01/17 through 03/09/17. Interview with Resident #7 on 03/23/17 at 9:20 a.m. revealed she may have missed a dose from the MA on 03/10/17 and sometimes her medications were late. 7. Review of Resident #10's face sheet dated 03/10/17 reflected Resident #10 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #10's March 2017 Consolidated physician's orders [REDACTED]. Eliquis Tablet (Prevents blood clots) Give 5 mg by mouth in the morning Review of Resident #10's March 2017 MAR indicated [REDACTED]. She did not receive the next dose of Eliquis until 03/11/17 at 7:00 a.m. Review of the FDA's Medication Guide for Eliquis revised August 2016 revealed do not change your dose or stop taking it unless your doctor tells you to. If you miss a dose of ELIQUIS, take it as soon as you remember, and do not take more than one dose at the same time. If you are taking ELIQUIS for [MEDICAL CONDITION], stopping ELIQUIS may increase your risk of having a stroke. Do not run out of ELIQUIS. Refill your prescription before you run out. 8. Review of Resident #11's face sheet dated 03/10/17 reflected Resident #11 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #11's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 100 mg by mouth twice a day Review of Resident #11's March 2017 MAR indicated [REDACTED]. Resident #11 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 3:00 p.m. on 03/10/17. Review of the FDA Medication Guide for [MEDICATION NAME] revised December of 2016 revealed to take [MEDICATION NAME] at the same times each day. If [MEDICATION NAME] is stopped suddenly (such as missing a dose) side effects such as headaches, nausea, diarrhea, trouble sleeping, increased sweating, and anxiousness may occur. 9. Review of Resident #14's face sheet dated 03/10/17 reflected Resident #14 was a [AGE] year old female who was admitted to the facility 02/25/17. Her admitting [DIAGNOSES REDACTED]. Review of Resident #14's March 2017 Consolidated physician's orders [REDACTED]. Lorsartan Tablet (Treats high blood pressure) Give 50 mg by mouth once per day. Review of Resident #14's March 2017 MAR indicated [REDACTED]. Resident #14 did not receive a dose of Lorsartan until the next scheduled dose at 7:00 a.m. on 03/11/17. Review of the vital sign monitoring tool dated 03/10/17, Resident #14's blood pressure spiked to 176/89 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of Lorsartan. Review of Resident #14's March 2017 MAR indicated [REDACTED]. 10. Review of Resident #17's face sheet dated 03/10/17 reflected Resident #17 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #17's March 2017 Consolidated physician's orders [REDACTED]. Nebivolol Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning Review of Resident #17's March 2017 MAR indicated [REDACTED]. Resident #17 did not receive her Nebivolol and [MEDICATION NAME] until their next scheduled doses on 03/11/17 at 7:00 a.m. Review of the vital signs monitoring tool dated 03/10/17, Resident #17's blood pressure was 160/89 (her normal ranges were around 150/75) on 03/10/17 at 8:00 p.m. 11. Review of Resident #19's face sheet dated 03/10/17 reflected Resident #19 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #19's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 50 mg by mouth twice a day Review of Resident #19's March 2017 MAR indicated [REDACTED]. Resident #19 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 7:00 p.m. on 03/10/17. Review of the FDA Medication Guide for [MEDICATION NAME] revised December of 2016 revealed to take [MEDICATION NAME] at the same times each day. If [MEDICATION NAME] is stopped suddenly (such as missing a dose) side effects such as headaches, nausea, diarrhea, trouble sleeping, increased sweating, and anxiousness may occur. 12. Interview with ADON A on 03/21/17 at 3:05 p.m. revealed that on 03/10/17 she had worked the 6:00 p.m. to 6:00 a.m. shift for 100 Hall. The DON had come in around 5:00 a.m. and given her some work to do. At 6:00 a.m. MA P came to ADON A and reported she was assigned to halls 100 and 300. ADON A instructed her to check in with the DON, as she was waiting for the on-coming nurse to relieve her. ADON A did not give the keys to the medication cart to MA P. ADON A asked the DON about her relief nurse and was instructed to continue working as the next on-coming nurse was late. She asked the DON for help as she had a dentist appointment and was told, sorry, no. When the oncoming nurse relieved her they counted the carts together around 8:30 a.m. ADON A stated she did not pass any morning medications off of the Med Aide's cart. She did not know if MA P had passed medications for Hall 100. Interview with MA P on 03/21/17 at 12:00 pm revealed that she works 6:00 a.m. to 6:00 p.m. On 03/10/17 she reported to ADON A and asked her to count the cart with her. ADON A instructed her to wait until the day shift nurse came on duty. MA P asked ADON A three times to count the cart for Hall 100 with her so she could pass medications and ADON A instructed her to wait. MA P went to pass medications on the 300 hall. MA P did not inform the DON that she had not been given the keys to the medication cart for hall 100 and had not passed the medications. MA P stated she did not inform the oncoming nurse or the DON about not passing the medications on Hall 100. Interview with the DON on 03/21/17 at 9:50 a.m. revealed she was working the morning of 03/10/17 and instructed ADON A to continue with her work because the on-coming nurse was late. The DON did not offer to help and did not know medications were not being passed. She stated when she learned from LVN O at 11:00 a.m. on 03/10/17 that ADON A had not passed morning medications, she instructed the nurses to call the doctors and take vital signs. She stated they took vital signs of the residents who had missed their medications every four hours for 24 hours. She revealed ADON A was suspended because of the incident. Review of ADON A's employee record revealed an Employee Memorandum dated 03/10/17. ADON A received a written warning and was suspended. The subject of code of conduct rule violated was neglect. The date of violation is listed as 03/10/17. The description of the warning states med pass was not passed at 7:00 a.m. on Hall 100 to several residents. ADON A signed the warning on 03/10/17. ADON A also received a written warning on 03/06/17 regarding blanks in MARs. An in-service was provided on proper medication administration. The corrective action of not signing the MAR indicated [REDACTED]. Interview with the DON on 03/21/17 at 2:10 p.m. revealed ADON A had refused assignments in the past. ADON A refused to work Hall 200 on 03/04/17 and the DON assumed ADON A passed all the medications for Hall 200 on 03/04/17. All nurses and MAs had received a written warning regarding medication administration on 03/06/17 because of another medication error. The DON stated on the night shift Hall 200 is split between the nurse on Hall 300 and the nurse on Hall 100. The nurse assigned to Hall 100 is responsible for the residents in rooms 200-205 and rooms [ROOM NUMBER]. The nurse assigned to Hall 300 is responsible for the residents in rooms 206-211 and room [ROOM NUMBER]. 13. Review of Resident #29's face sheet dated 03/23/17 reflected Resident #29 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #29's MDS assessment dated [DATE] revealed she was cognitively intact. Review of Resident #29's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject 20 units twice a day Insulin [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale before meals and at bedtime [MEDICATION NAME] Tablet (Treats anxiety) Give 0.25 mg by mouth at bedtime Pramipexole [MEDICATION NAME] Tablet (Treats Restless Leg Syndrome) Give 0.5 mg by mouth in the afternoon Eliquis Tablet (Anticoagulant) Give 2.5 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 12.5 mg by mouth twice a day Review of Resident #29's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 and 03/02/17's 8:00 p.m. dose of Eliquis. LVN C failed to administer 03/02/17 and 03/03/17's 2:00 a.m. dose of [MEDICATION NAME]. LVN J failed to administer 03/03/17's 8:00 p.m. dose of Eliquis. LVN J failed to administer Resident #29's 9:00 p.m. dose of [MEDICATION NAME] on 03/03/17. LVN J failed to administer Resident #29's 03/04/17's 5:00 p.m. and 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN J failed to administer 03/04/17's 2:00 p.m. dose of Pramipexole [MEDICATION NAME] . LVN J failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/04/17. RN D failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/04/17 and 03/05/17. RN D also failed to administer Resident #29's 7:00 a.m. and 11:00 a.m. dose of Insulin [MEDICATION NAME] on 03/05/17. LVN E failed to administer 03/08/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN E failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/08/17. LVN L failed to administer Resident #29's 8:00 p.m. dose of Insulin [MEDICATION NAME] on 03/09/17. LVN E failed to administer 03/18/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN I failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/19/17. LVN K failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/20/17. Interview with Resident #29 on 03/21/17 at 2:40 p.m. revealed she has missed doses of medications and did not get most of her medications on 03/03/17 and 03/04/17. She stated there were new nurses those days. She stated she has experienced pain when she does not receive her pain medications and her medication for Restless Leg Syndrome. 14. Review of Resident #21's face sheet dated 03/23/17 reflected Resident #21 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #21's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject as per sliding scale before meals. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject 60 units at bedtime. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 40 mg by mouth at bedtime Review of Resident #21's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 through 03/04/17's 9:00 p.m. dose of [MEDICATION NAME]. LVN C failed to administer Resident #21's [MEDICATION NAME] Insulin 8:00 p.m. dose on 03/04/17. LVN B failed to administer Resident #21's [MEDICATION NAME] Insulin 4:30 p.m. dose on 03/13/17. 15. Review of Resident #22's face sheet dated 03/23/17 reflected Resident #22 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #22's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale after meals [MEDICATION NAME] Tablet (Treats pain) Give 7.5-325 mg tablet by mouth twice a day Review of Resident #22's March 2017 MAR indicated [REDACTED] RN D failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 8:30 a.m. and 1:30 p.m. LVN E failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 6:30 p.m. LVN C also failed to administer Resident #22's 6:00 a.m. and 8:00 p.m. dose of [MEDICATION NAME] on 03/01/17 and 03/02/17. LVN C failed to administer Resident #22's 8:00 p.m. dose of [MEDICATION NAME] on 03/03/17 and 6:00 a.m. dose on 03/04/17. On 03/22/17, LVN E had not administered Resident #22's 6:30 p.m. dose of [MEDICATION NAME]when the MAR indicated [REDACTED] 16. Review of Resident #23's face sheet dated 03/23/17 reflected Resident #23 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #23's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Hyciate Tablet (Antibiotic to treat upper respiratory infection) Give 100 mg by mouth twice a day to start on 03/13/17 at 2:00 a.m. [MEDICATION NAME] Tablet (Treats pain) Give 50 mg by mouth every 12 hours. Review of Resident #23's March 2017 MAR indicated [REDACTED] LVN E failed to administer Resident #23's 9:00 a.m. dose of [MEDICATION NAME] on 03/03/17. LVN C did not administer Resident #23's 9:00 p.m. dose of [MEDICATION NAME] on 03/04/17. The DON did not administer the third dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 a.m. LVN H did not administer the fourth dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 p.m. Review of Resident #23's March 2017 MAR indicated [REDACTED]. Resident #23 indicated increased pain of 3 on 03/04/17 and 03/05/17 (after the missed doses of [MEDICATION NAME]) and she normally did not have any pain. 17. Review of Resident #24's face sheet dated 03/23/17 reflected Resident #24 is a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #24's March 2017 MAR indicated [REDACTED] [MEDICATION NAME] Tablet (Treats pain) Give 50 mg by mouth three times a day Review of Resident #24's March 2017 MAR indicated [REDACTED]. Review of Resident #24's March 2017 MAR indicated [REDACTED]. 18. Review of Resident #25's face sheet dated 03/23/17 revealed Resident #25 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #25's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 50 mg by mouth two times a day [MEDICATION NAME] Sodium Extended Capsule (Prevents [MEDICAL CONDITION]) Give 100 mg by mouth at bedtime Review of Resident #25's March 2017 MAR indicated [REDACTED]. Review of Resident #25's March 2017 MAR indicated [REDACTED]. Resident #25's blood pressures were 138/91 on 03/01/17, 157/93 on 03/02/17, 152/88 on 03/03/17, and 136/79 on 03/04/17. Resident #25's normal blood pressure range was around 110/70. 19. Review of Resident #26's face sheet dated 03/23/17 reflected Resident #26 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #26's March 2017 Consolidated physician's orders [REDACTED]. Bactrim DS Tablet (Treat urinary tract infection) Give 800-160 mg tablet via pe[DEVICE] twice a day on 02/27/17 through 03/04/17 Review of Resident #26's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/03/17's 2:00 a.m. dose of Bactrim. 20. Review of Resident #27's face sheet dated 03/23/17 reflected Resident #27 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #27's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Anticoagulant) Give 2 mg via [DEVICE] in the evening [MEDICATION NAME] Tablet (Treats anxiety) Give 0.25 mg via [DEVICE] twice a day [MEDICATION NAME] HCl Tablet (Treats anxiety) Give 7.5 mg via [DEVICE] twice a day [MEDICATION NAME] HCl Tablet (Treats pain) Give 50 mg via [DEVICE] twice a day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg via [DEVICE] twice a day Review of Resident #27's March 2017 MAR indicated [REDACTED]. LVN C failed to administer 03/01/17 through 03/03/17's 5:00 a.m. doses of [MEDICATION NAME] and [MEDICATION NAME]. LVN C also failed to administer Resident #27's 03/01/17 through 03/03/17's 2:00 a.m. dose of [MEDICATION NAME] and [MEDICATION NAME]. LVN J failed to administer Resident #27's 03/04/17 5:00 a.m. dose of [MEDICATION NAME] and [MEDICATION NAME]. LVN J also failed to administer 03/04/17's 2:00 a.m. and 2:00 p.m. dose of [MEDICATION NAME]. LVN J failed to administer 03/04/17's 2:00 p.m. dose of [MEDICATION NAME]. LVN K failed to administer Resident #27's 03/02/17's 2:00 p.m. dose of [MEDICATION NAME] and 03/07/17's 5:00 p.m. dose of [MEDICATION NAME]. LVN E failed to administer Resident #27's 03/09/17 5:00 p.m. dose of [MEDICATION NAME] and failed to administer 03/19/17's 5:00 a.m. dose of [MEDICATION NAME]. LVN M failed to administer Resident #27's 03/17/17's 2:00 p.m. dose of [MEDICATION NAME]. 21. Review of Resident #30's face sheet dated 03/23/17 reflected Resident #30 was a [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #30's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats pain) Give 2 mg by mouth every four hours [MEDICATION NAME] Capsule (Treats pain) Give 300 mg by mouth three times a day [MEDICATION NAME] ER Capsule (Treats pain)

Based on interview and record review, the facility failed to provide or arrange for services as outlined by the comprehensive care plan that met professional standards of quality for 45 (Resident #1 through Resident #45) of 52 residents reviewed for medication administration. 1. ADON A failed to administer Resident #1's morning medications, which included [MEDICAL CONDITION] prevention medications, on 03/10/17. Resident #1 had [MEDICAL CONDITION] on 03/10/17 and was sent to the hospital to receive IV [MEDICATION NAME] and [MEDICATION NAME] to control his [MEDICAL CONDITION]. 2. ADON A failed to administer morning medications to Residents #2 through Resident #20. 3. The DON, RNs D and M, LVNs B, C, E, F, H, I, K, L, and MA N failed to administer and document for Residents #21 through Resident #45. 3. The facility failed to administer physician ordered medications to Residents #21 through Resident #45 on different days and times in March 2017. An Immediate Jeopardy situation was identified on 03/21/17. The Immediate Jeopardy was removed on 03/26/17. The facility remained out of compliance at a pattern of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. These failures could affect all 74 residents by placing them at risk for death, exacerbation of medical conditions, and not receiving the therapeutic benefits of their medications. Findings included: Review of The Standards of Nursing Practice on http://www.bne.state.tx.us/ retrieved on 03/26/17 (22 TAC §217.11) applicable to LVNs (as well as RNs) includes the following standards that specifically relate to medication administration: (1) (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (iv) administration of medications and treatments; . (N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment; 1. Review of the Provider Investigation Report dated 03/10/17 revealed ADON A did not pass the morning medications off the Med Aide cart to the residents who resided on Hall 100 because the other shift nurse had not arrived and she refused to give possession of the keys to the medication aide so she could pass her medications. Twenty residents should have received medications between the time of 6:00 a.m. and 8:30 a.m. from ADON A on 03/10/17. Later that afternoon, Resident #1 was at the receptionist's desk when he had a [MEDICAL CONDITION]. He was transported by EMS to the hospital. Resident #1 received IV [MEDICATION NAME] and [MEDICATION NAME] at the hospital and returned to the facility on [DATE] at 11:10 p.m. Review of Resident #1's face sheet dated 03/10/17 reflected Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed he had severe cognitive impairment. Review of Resident #1's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give one 200 mg tablet by mouth two times a day Levetiracetam Solution (Prevents [MEDICAL CONDITION]) Give 3000 mg by mouth three times a day [MEDICATION NAME] Acid (Prevents [MEDICAL CONDITION]) Give 250 mg by mouth three times a day [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 25 mg by mouth once a day Review of Resident #1's March 2017 MAR indicated [REDACTED]. Resident #1 went to the hospital before the medications could be administered at a later time. Review of Resident #1's nurses notes dated 03/10/17 at 12:30PM signed by DON revealed Resident sitting in wheelchair at receptionist desk shaking as if he was cold and clammy. Resident looking at staff but not answering questions. Resident stood from wheelchair and laid himself down on the couch with standby assist of staff. Blood sugar taken 106. Started to take blood pressure when resident started having [MEDICAL CONDITION]. At 12:35 resident stiffened up and turned blue. 911 notified. Blood pressure 144/111, pulse 109, O2 sat 97%. Resident assisted to gurney and transported to hospital. An attempt was made to interview Resident #1 on 03/23/17 at 2:45 p.m. The resident would not answer any of the questions. 2. Review of Resident #2's face sheet dated 03/10/17 reflected Resident #2 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 100 mg by mouth in the morning [MEDICATION NAME] (Treats high blood pressure) Give 10 mg by mouth in the morning [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning [MEDICATION NAME] (Treats anxiety) Give 0.5 mg by mouth two times a day Review of Resident #2's March 2017 MAR indicated [REDACTED]. Interview with Resident #2 on 03/21/17 at 10:50 a.m. revealed that she has not been getting her medications on time. She does not receive her morning medications until 2 p.m. Review of the vital sign monitoring tool dated 03/10/17, Resident #2's blood pressure spiked to 172/67 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of [MEDICATION NAME] and [MEDICATION NAME] Tartate. Review of Resident #2's March 2017 MAR indicated [REDACTED]. 3. Review of Resident #3's face sheet dated 03/10/17 reflected Resident #3 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood pressure) Give 6.25 mg by mouth twice a day. Review of Resident #3's March 2017 MAR indicated [REDACTED]. Resident #3 did not receive another dose of [MEDICATION NAME] until 7:00 a.m. on 03/11/17. 4. Review of Resident #4's face sheet dated 03/10/17 reflected Resident #4 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #4's March 2017 Consolidated physician's orders [REDACTED]. Entacapone Tablet (Anti-[MEDICAL CONDITION] medication) Give 200 mg by mouth three times a day. [MEDICATION NAME] Tablet (Anti-[MEDICAL CONDITION] medication) Give 100 mg by mouth three times a day. Review of Resident #4's March 2017 MAR indicated [REDACTED]. Resident #4 did not receive a dose of Entacapone and [MEDICATION NAME] until 1:00 p.m. 5. Review of Resident #5's face sheet dated 03/10/17 reflected Resident #5 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #5's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] tablet (Treats high blood pressure) Give 10 mg by mouth three times a day Carvedilol Tablet (Treats high blood pressure) Give 12.5 mg by mouth two times a day Review of Resident #5's March 2017 MAR indicated [REDACTED]. He did not receive his next dose of [MEDICATION NAME] until 1:00 p.m. on 03/10/17. His next recorded blood pressure was 177/89 (normal range is 120/70) at 1:00 p.m. on 03/10/17. Resident #5 received his next scheduled dose of Carvedilol at 7:00 p.m. on 03/10/17 and his blood pressure was still elevated at 172/69. After receiving both of his doses of blood pressure medication, his blood pressure decreased to 147/61 (taken on 03/11/17 at midnight). Review of Resident #5's March 2017 MAR indicated [REDACTED]. 6. Review of Resident #6's face sheet dated 03/10/17 reflected Resident #6 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #6's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give 50 mg by mouth two times a day. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth three times a day. Review of Resident #6's March 2017 MAR indicated [REDACTED]. 7. Review of Resident #7's face sheet dated 03/10/17 reflected Resident #7 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #7's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 25 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 100 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day Review of Resident #7's March 2017 MAR indicated [REDACTED]. They were administered later in the day at 11:00 a.m. By that time, Resident #7's blood pressure had risen to 154/96. Resident #7's blood pressures were usually in the 130s/60s. Interview with Resident #7 on 03/23/17 at 9:20 a.m. revealed she may have missed a dose from the MA on 03/10/17 and sometimes her medications were late. 8. Review of Resident #8's face sheet dated 03/10/17 reflected Resident #8 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #8's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 2.5 mg by mouth in the morning [MEDICATION NAME] Tartate (Treats high blood pressure) Give 50 mg by mouth twice a day Review of Resident #8's March 2017 MAR indicated [REDACTED]. Resident #8 did not receive a dose of [MEDICATION NAME] until 03/11/17 at 7:00 a.m. He received a dose of [MEDICATION NAME] on 03/10/17 at 7:00 p.m. 9. Review of Resident #9's face sheet dated 03/10/17 reflected Resident #9 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #9's March 2017 MAR indicated [REDACTED] [MEDICATION NAME] tablet (Treats high blood pressure) Give 25 mg by mouth three times a day. Review of Resident #9's March 2017 MAR indicated [REDACTED]. Resident #9 did not receive a dose of [MEDICATION NAME] until 03/10/17 at 3:00 p.m. 10. Review of Resident #10's face sheet dated 03/10/17 reflected Resident #10 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #10's March 2017 Consolidated physician's orders [REDACTED]. Eliquis Tablet (Prevents blood clots) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day [MEDICATION NAME] Tablet (Treats anxiety) Give 2 mg by mouth three times a day Review of Resident #10's March 2017 MAR indicated [REDACTED]. She did not receive the next dose of Eliquis until 03/11/17 at 7:00 a.m. Review of the FDA's Medication Guide for Eliquis revised August 2016 revealed do not change your dose or stop taking it unless your doctor tells you to. If you miss a dose of ELIQUIS, take it as soon as you remember, and do not take more than one dose at the same time. If you are taking ELIQUIS for [MEDICAL CONDITION], stopping ELIQUIS may increase your risk of having a stroke. Do not run out of ELIQUIS. Refill your prescription before you run out. 11. Review of Resident #11's face sheet dated 03/10/17 reflected Resident #11 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #11's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 100 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats muscle spasms) Give 10 mg by mouth two times a day [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day Review of Resident #11's March 2017 MAR indicated [REDACTED]. Resident #11 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 3:00 p.m. on 03/10/17. She did not receive a dose of [MEDICATION NAME] until 3:00 p.m. on 03/10/17. Resident #11 received her next dose of [MEDICATION NAME] on 03/10/17 at 11:00 a.m. as scheduled. 12. Review of Resident #12's face sheet dated 03/10/17 reflected Resident #12 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #12's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood sugar) Give 500 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats muscle spasms) Give 4 mg by mouth three times a day Review of Resident #12's March 2017 MAR indicated [REDACTED]. 13. Review of Resident #13's face sheet dated 03/10/17 reflected Resident #13 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #13's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 10 mg by mouth twice per day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth twice per day Review of Resident #13's March 2017 MAR indicated [REDACTED]. 14. Review of Resident #14's face sheet dated 03/10/17 reflected Resident #14 was a [AGE] year old female who was admitted to the facility 02/25/17. Her admitting [DIAGNOSES REDACTED]. Review of Resident #14's March 2017 Consolidated physician's orders [REDACTED]. Lorsartan Tablet (Treats high blood pressure) Give 50 mg by mouth once per day. [MEDICATION NAME] Tablet (Treats muscle spasms) Give 5 mg by mouth twice per day Review of Resident #14's March 2017 MAR indicated [REDACTED]. Resident #14 did not receive a dose of Lorsartan until the next scheduled dose at 7:00 a.m. on 03/11/17. Review of the vital sign monitoring tool dated 03/10/17, Resident #14's blood pressure spiked to 176/89 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of Lorsartan. Review of Resident #14's March 2017 MAR indicated [REDACTED]. 15. Review of Resident #15's face sheet dated 03/10/17 reflected Resident #15 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #15's March 2017 MAR indicated [REDACTED] Carvedilol Tablet (Treats high blood pressure) Give 3.125 mg by mouth twice a day Review of Resident #15's March 2017 MAR indicated [REDACTED]. Resident #15 did not receive a dose of carvedilol until 7:00 p.m. on 03/10/17. 16. Review of Resident #16's face sheet dated 03/10/17 reflected Resident #16 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #16's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood sugar) Give 500 mg by mouth twice per day Review of Resident #16's March 2017 MAR indicated [REDACTED]. 17. Review of Resident #17's face sheet dated 03/10/17 reflected Resident #17 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #17's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] capsule (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth twice per day [MEDICATION NAME] Tablet (Treats high blood sugar) Give 1000 mg by mouth twice per day Nebivolol Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning Review of Resident #17's March 2017 MAR indicated [REDACTED]. Resident #17 did not receive her Nebivolol and [MEDICATION NAME] until their next scheduled doses on 03/11/17 at 7:00 a.m. Resident #17 did not receive a dose of [MEDICATION NAME] until 3:00 p.m. on 03/10/17. She did not receive a dose of [MEDICATION NAME] until 4:00 p.m. on 03/10/17. Review of the vital signs monitoring tool dated 03/10/17, Resident #17's blood pressure was 160/89 (her normal ranges were around 150/75) on 03/10/17 at 8:00 p.m. 18. Review of Resident #18's face sheet dated 03/10/17 reflected Resident #18 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #18's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood pressure) Give 5 mg by mouth in the morning Review of Resident #18's March 2017 MAR indicated [REDACTED]. 19. Review of Resident #19's face sheet dated 03/10/17 reflected Resident #19 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #19's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 50 mg by mouth twice a day Review of Resident #19's March 2017 MAR indicated [REDACTED]. Resident #19 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 7:00 p.m. on 03/10/17. Review of the FDA Medication Guide for [MEDICATION NAME] revised December of 2016 revealed to take [MEDICATION NAME] at the same times each day. If [MEDICATION NAME] is stopped suddenly (such as missing a dose) side effects such as headaches, nausea, diarrhea, trouble sleeping, increased sweating, and anxiousness may occur. 20. Review of Resident #20's face sheet dated 03/10/17 reflected Resident #20 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #20's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 20 mg by mouth once a day Review of Resident #20's March 2017 MAR indicated [REDACTED]. 21. Interview with ADON A on 03/21/17 at 3:05 p.m. revealed that on 03/10/17 she had worked the 6:00 p.m. to 6:00 a.m. shift for 100 Hall. The DON had come in around 5:00 a.m. and given her some work to do. At 6:00 a.m. MA P came to ADON A and reported she was assigned to halls 100 and 300. ADON A instructed her to check in with the DON, as she was waiting for the on-coming nurse to relieve her. ADON A did not give the keys to the medication cart to MA P. ADON A asked the DON about her relief nurse and was instructed to continue working as the next on-coming nurse was late. She asked the DON for help as she had a dentist appointment and was told, sorry, no. When the oncoming nurse relieved her they counted the carts together around 8:30 a.m. ADON A stated she did not pass any morning medications off of the Med Aide's cart. She did not know if MA P had passed medications for Hall 100. Interview with MA P on 03/21/17 at 12:00 pm revealed that she works 6:00 a.m. to 6:00 p.m. On 03/10/17 she reported to ADON A and asked her to count the cart with her. ADON A instructed her to wait until the day shift nurse came on duty. MA P asked ADON A three times to count the cart for Hall 100 with her so she could pass medications and ADON A instructed her to wait. MA P went to pass medications on the 300 hall. MA P did not inform the DON that she had not been given the keys to the medication cart for hall 100 and had not passed the medications. MA P stated she did not inform the oncoming nurse or the DON about not passing the medications on Hall 100. Interview with the DON on 03/21/17 at 9:50 a.m. revealed she was working the morning of 03/10/17 and instructed ADON A to continue with her work because the on-coming nurse was late. The DON did not offer to help and did not know medications were not being passed. She stated when she learned from LVN O at 11:00 a.m. on 03/10/17 that ADON A had not passed morning medications, she instructed the nurses to call the doctors and take vital signs. She stated they took vital signs of the residents who had missed their medications every four hours for 24 hours. She revealed ADON A was suspended because of the incident. Review of ADON A's employee record revealed an Employee Memorandum dated 03/10/17. ADON A received a written warning and was suspended. The subject of code of conduct rule violated was neglect. The date of violation is listed as 03/10/17. The description of the warning states med pass was not passed at 7:00 a.m. on Hall 100 to several residents. ADON A signed the warning on 03/10/17. ADON A also received a written warning on 03/06/17 regarding blanks in MARs. An in-service was provided on proper medication administration. The corrective action of not signing the MAR indicated [REDACTED]. Interview with the DON on 03/21/17 at 2:10 p.m. revealed ADON A had refused assignments in the past. ADON A refused to work Hall 200 on 03/04/17 and the DON assumed ADON A passed all the medications for Hall 200 on 03/04/17. All nurses and MAs had received a written warning regarding medication administration on 03/06/17 because of another medication error. The DON stated on the night shift Hall 200 is split between the nurse on Hall 300 and the nurse on Hall 100. The nurse assigned to Hall 100 is responsible for the residents in rooms 200-205 and rooms [ROOM NUMBER]. The nurse assigned to Hall 300 is responsible for the residents in rooms 206-211 and room [ROOM NUMBER]. 22. Review of Resident #29's face sheet dated 03/23/17 reflected Resident #29 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #29's MDS assessment dated [DATE] revealed she was cognitively intact. Review of Resident #29's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject 20 units twice a day Insulin [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale before meals and at bedtime [MEDICATION NAME] Tablet (Treats anxiety) Give 0.25 mg by mouth at bedtime Pramipexole [MEDICATION NAME] Tablet (Treats Restless Leg Syndrome) Give 0.5 mg by mouth in the afternoon Eliquis Tablet (Anticoagulant) Give 2.5 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 12.5 mg by mouth twice a day Review of Resident #29's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 and 03/02/17's 8:00 p.m. dose of Eliquis. LVN C failed to administer 03/02/17 and 03/03/17's 2:00 a.m. dose of [MEDICATION NAME]. LVN J failed to administer 03/03/17's 8:00 p.m. dose of Eliquis. LVN J failed to administer Resident #29's 9:00 p.m. dose of [MEDICATION NAME] on 03/03/17. LVN J failed to administer Resident #29's 03/04/17's 5:00 p.m. and 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN J failed to administer 03/04/17's 2:00 p.m. dose of Pramipexole [MEDICATION NAME] . LVN J failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/04/17. RN D failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/04/17 and 03/05/17. RN D also failed to administer Resident #29's 7:00 a.m. and 11:00 a.m. dose of Insulin [MEDICATION NAME] on 03/05/17. LVN E failed to administer 03/08/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN E failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/08/17. LVN L failed to administer Resident #29's 8:00 p.m. dose of Insulin [MEDICATION NAME] on 03/09/17. LVN E failed to administer 03/18/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN I failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/19/17. LVN K failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/20/17. Interview with Resident #29 on 03/21/17 at 2:40 p.m. revealed she has missed doses of medications and did not get most of her medications on 03/03/17 and 03/04/17. She stated there were new nurses those days. She stated she has experienced pain when she does not receive her pain medications and her medication for Restless Leg Syndrome. 23. Review of Resident #21's face sheet dated 03/23/17 reflected Resident #21 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #21's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject as per sliding scale before meals. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject 60 units at bedtime. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 40 mg by mouth at bedtime Review of Resident #21's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 through 03/04/17's 9:00 p.m. dose of [MEDICATION NAME]. LVN C failed to administer Resident #21's [MEDICATION NAME] Insulin 8:00 p.m. dose on 03/04/17. LVN B failed to administer Resident #21's [MEDICATION NAME] Insulin 4:30 p.m. dose on 03/13/17. On 03/22/17, LVN I had not administered Resident #21's 8:00 p.m. [MEDICATION NAME] when the MAR indicated [REDACTED]. Interview with the Administrator on 03/23/17 at 10:25 a.m. revealed LVN G helped LVN I pass the missed medications around 11:00 p.m. on 03/22/17. He stated they had notified all residents' doctors who had missed insulin. 24. Review of Resident #22's face sheet dated 03/23/17 reflected Resident #22 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #22's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale after meals [MEDICATION NAME] Tablet (Treats pain) Give 7.5-325 mg tablet by mouth twice a day Review of Resident #22's March 2017 MAR indicated [REDACTED] RN D failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 8:30 a.m. and 1:30 p.m. LVN E failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 6:30 p.m. LVN C also failed to administer Resident #22's 6:00 a.m. and 8:00 p.m. dose of [MEDICATION NAME] on 03/01/17 and 03/02/17. LVN C failed to administer Resident #22's 8:00 p.m. dose of [MEDICATION NAME] on 03/03/17 and 6:00 a.m. dose on 03/04/17. On 03/22/17, LVN E had not administered Resident #22's 6:30 p.m. dose of [MEDICATION NAME]when the MAR indicated [REDACTED] 25. Review of Resident #23's face sheet dated 03/23/17 reflected Resident #23 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #23's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Hyciate Tablet (Antibiotic to treat upper respiratory infection) Give 100 mg by mouth twice a day to start on 03/13/17 at 2:00 a.m. [MEDICATION NAME] Tablet (Treats pain) Give 50 mg by mouth every 12 hours. Review of Resident #23's March 2017 MAR indicated [REDACTED] LVN E failed to administer Resident #23's 9:00 a.m. dose of [MEDICATION NAME] on 03/03/17. LVN C did not administer Resident #23's 9:00 p.m. dose of [MEDICATION NAME] on 03/04/17. The DON did not administer the third dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 a.m. LVN H did not administer the fourth dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 p.m. Review of Resident #23's March 2017 MAR indicated [REDACTED]. Resident #23 indicated increased pain of 3 on 03/04/17 and 03/05/17 (after the missed doses of [MEDICATION NAME]) and she normally did not have any pain. 26. Review of Resident #24's face sheet dated 03/23/17 reflected Resident #24 is a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #24's March 2017 MAR indicated [REDACTED] [MEDICATION NAME] Tablet (Treats pain) Give 50 mg by mouth three times a day Review of Resident #24's March 2017 MAR indicated [REDACTED]. Review of Resident #24's March 2017 MAR indicated [REDACTED]. 27. Review of Resident #25's face sheet dated 03/23/17 revealed Resident #25 was

Based on interview and record review, the facility failed to ensure the resident was free from neglect for 45 (Resident #1 through Resident #45) of 52 residents reviewed for neglect. 1. The facility failed to administer physician ordered [MEDICATION NAME] (prevents [MEDICAL CONDITION]), Levetiracetam (prevents [MEDICAL CONDITION]), [MEDICATION NAME] Acid (prevents [MEDICAL CONDITION]), and [MEDICATION NAME] (treats hypertension) on 03/10/17 to Resident #1 which resulted in Resident #1 having a [MEDICAL CONDITION] and having to go to the hospital to receive IV [MEDICATION NAME] and [MEDICATION NAME] to control his [MEDICAL CONDITION]. 2. The facility failed to administer morning medications on 03/10/17 to Resident #2 through Resident #20. 3. The facility failed to administer physician ordered medications to Residents #21 through Resident #45 on different days and times in March 2017. An Immediate Jeopardy situation was identified on 03/21/17. The Immediate Jeopardy was removed on 03/26/17. The facility remained out of compliance at a pattern of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. These failures could affect all 74 residents by placing them at risk for death, exacerbation of medical conditions, and not receiving the therapeutic benefits of their medications. Findings included: 1. Review of Administering Medication - Oral policy and procedure (undated) revealed 18. Document medications given following policy including date, time, dosage, route, signature, and title. Chart and/or report pertinent observations of resident and nursing actions according to facility policy. Review of Medication Errors and Drug Reactions (undated) revealed: 1. All medication errors and drug reactions must be promptly reported to the Director of Nursing Services, attending physician, and the pharmacist. 2. A detailed account of the incident must be recorded and should include documentation of: a. time and date of incident b. name, strength, and dosage of medication administered c. resident's reaction to the medication d. condition of the resident e. any treatment administered; f. date and time the physician was notified and instructions given. 3. Monitor closely any resident who has received incorrect medication or is having a drug reaction. Immediately report to the Director of Nursing Services and attending physician any change in the resident's condition. Review of Prevention and Reporting of Suspected Resident Abuse and Neglect policy and procedure (undated) revealed neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 1. Neglect is reportable if the injury, harm or death of a resident was due to failure to provide services, treatment or care to a resident. 2 Review of the Provider Investigation Report dated 03/10/17 revealed ADON A did not pass the morning medications off the Med Aide cart to the residents who resided on Hall 100 because the other shift nurse had not arrived and she refused to give possession of the keys to the medication aide so she could pass her medications. Twenty residents should have received medications between the time of 6:00 a.m. and 8:30 a.m. from ADON A on 03/10/17. Later that afternoon, Resident #1 was at the receptionist's desk when he had a [MEDICAL CONDITION]. He was transported by EMS to the hospital. Resident #1 received IV [MEDICATION NAME] and [MEDICATION NAME] at the hospital and returned to the facility on [DATE] at 11:10 p.m. Review of Resident #1's face sheet dated 03/10/17 reflected Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed he had severe cognitive impairment. Review of Resident #1's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give one 200 mg tablet by mouth two times a day Levetiracetam Solution (Prevents [MEDICAL CONDITION]) Give 3000 mg by mouth three times a day [MEDICATION NAME] Acid (Prevents [MEDICAL CONDITION]) Give 250 mg by mouth three times a day [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 25 mg by mouth once a day Review of Resident #1's March 2017 MAR indicated [REDACTED]. Resident #1 went to the hospital before the medications could be administered at a later time. Review of Resident #1's nurses notes dated 03/10/17 at 12:30PM signed by DON revealed Resident sitting in wheelchair at receptionist desk shaking as if he was cold and clammy. Resident looking at staff but not answering questions. Resident stood from wheelchair and laid himself down on the couch with standby assist of staff. Blood sugar taken 106. Started to take blood pressure when resident started having [MEDICAL CONDITION]. At 12:35 resident stiffened up and turned blue. 911 notified. Blood pressure 144/111, pulse 109, O2 sat 97%. Resident assisted to gurney and transported to hospital. An attempt was made to interview Resident #1 on 03/23/17 at 2:45 p.m. The resident would not answer any of the questions. 3. Review of Resident #2's face sheet dated 03/10/17 reflected Resident #2 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 100 mg by mouth in the morning [MEDICATION NAME] (Treats high blood pressure) Give 10 mg by mouth in the morning [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning [MEDICATION NAME] (Treats anxiety) Give 0.5 mg by mouth two times a day Review of Resident #2's March 2017 MAR indicated [REDACTED]. Interview with Resident #2 on 03/21/17 at 10:50 a.m. revealed that she has not been getting her medications on time. She does not receive her morning medications until 2 p.m. Review of the vital sign monitoring tool dated 03/10/17, Resident #2's blood pressure spiked to 172/67 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of [MEDICATION NAME] and [MEDICATION NAME] Tartate. Review of Resident #2's March 2017 MAR indicated [REDACTED]. 4. Review of Resident #3's face sheet dated 03/10/17 reflected Resident #3 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood pressure) Give 6.25 mg by mouth twice a day. Review of Resident #3's March 2017 MAR indicated [REDACTED]. Resident #3 did not receive another dose of [MEDICATION NAME] until 7:00 a.m. on 03/11/17. 5. Review of Resident #4's face sheet dated 03/10/17 reflected Resident #4 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #4's March 2017 Consolidated physician's orders [REDACTED]. Entacapone Tablet (Anti-[MEDICAL CONDITION] medication) Give 200 mg by mouth three times a day. [MEDICATION NAME] Tablet (Anti-[MEDICAL CONDITION] medication) Give 100 mg by mouth three times a day. Review of Resident #4's March 2017 MAR indicated [REDACTED]. Resident #4 did not receive a dose of Entacapone and [MEDICATION NAME] until 1:00 p.m. 6. Review of Resident #5's face sheet dated 03/10/17 reflected Resident #5 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #5's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] tablet (Treats high blood pressure) Give 10 mg by mouth three times a day Carvedilol Tablet (Treats high blood pressure) Give 12.5 mg by mouth two times a day Review of Resident #5's March 2017 MAR indicated [REDACTED]. He did not receive his next dose of [MEDICATION NAME] until 1:00 p.m. on 03/10/17. His next recorded blood pressure was 177/89 (normal range is 120/70) at 1:00 p.m. on 03/10/17. Resident #5 received his next scheduled dose of Carvedilol at 7:00 p.m. on 03/10/17 and his blood pressure was still elevated at 172/69. After receiving both of his doses of blood pressure medication, his blood pressure decreased to 147/61 (taken on 03/11/17 at midnight). Review of Resident #5's March 2017 MAR indicated [REDACTED]. 7. Review of Resident #6's face sheet dated 03/10/17 reflected Resident #6 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #6's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give 50 mg by mouth two times a day. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth three times a day. Review of Resident #6's March 2017 MAR indicated [REDACTED]. 8. Review of Resident #7's face sheet dated 03/10/17 reflected Resident #7 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #7's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 25 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 100 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day Review of Resident #7's March 2017 MAR indicated [REDACTED]. They were administered later in the day at 11:00 a.m. By that time, Resident #7's blood pressure had risen to 154/96. Resident #7's blood pressures were usually in the 130s/60s. Interview with Resident #7 on 03/23/17 at 9:20 a.m. revealed she may have missed a dose from the MA on 03/10/17 and sometimes her medications were late. 9. Review of Resident #8's face sheet dated 03/10/17 reflected Resident #8 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #8's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 2.5 mg by mouth in the morning [MEDICATION NAME] Tartate (Treats high blood pressure) Give 50 mg by mouth twice a day Review of Resident #8's March 2017 MAR indicated [REDACTED]. Resident #8 did not receive a dose of [MEDICATION NAME] until 03/11/17 at 7:00 a.m. He received a dose of [MEDICATION NAME] on 03/10/17 at 7:00 p.m. 10. Review of Resident #9's face sheet dated 03/10/17 reflected Resident #9 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #9's March 2017 MAR indicated [REDACTED] [MEDICATION NAME] tablet (Treats high blood pressure) Give 25 mg by mouth three times a day. Review of Resident #9's March 2017 MAR indicated [REDACTED]. Resident #9 did not receive a dose of [MEDICATION NAME] until 03/10/17 at 3:00 p.m. 11. Review of Resident #10's face sheet dated 03/10/17 reflected Resident #10 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #10's March 2017 Consolidated physician's orders [REDACTED]. Eliquis Tablet (Prevents blood clots) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day [MEDICATION NAME] Tablet (Treats anxiety) Give 2 mg by mouth three times a day Review of Resident #10's March 2017 MAR indicated [REDACTED]. She did not receive the next dose of Eliquis until 03/11/17 at 7:00 a.m. Review of the FDA's Medication Guide for Eliquis revised August 2016 revealed do not change your dose or stop taking it unless your doctor tells you to. If you miss a dose of ELIQUIS, take it as soon as you remember, and do not take more than one dose at the same time. If you are taking ELIQUIS for [MEDICAL CONDITION], stopping ELIQUIS may increase your risk of having a stroke. Do not run out of ELIQUIS. Refill your prescription before you run out. 12. Review of Resident #11's face sheet dated 03/10/17 reflected Resident #11 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #11's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 100 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats muscle spasms) Give 10 mg by mouth two times a day [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day Review of Resident #11's March 2017 MAR indicated [REDACTED]. Resident #11 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 3:00 p.m. on 03/10/17. She did not receive a dose of [MEDICATION NAME] until 3:00 p.m. on 03/10/17. Resident #11 received her next dose of [MEDICATION NAME] on 03/10/17 at 11:00 a.m. as scheduled. 13. Review of Resident #12's face sheet dated 03/10/17 reflected Resident #12 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #12's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood sugar) Give 500 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats muscle spasms) Give 4 mg by mouth three times a day Review of Resident #12's March 2017 MAR indicated [REDACTED]. 14. Review of Resident #13's face sheet dated 03/10/17 reflected Resident #13 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #13's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 10 mg by mouth twice per day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth twice per day Review of Resident #13's March 2017 MAR indicated [REDACTED]. 15. Review of Resident #14's face sheet dated 03/10/17 reflected Resident #14 was a [AGE] year old female who was admitted to the facility 02/25/17. Her admitting [DIAGNOSES REDACTED]. Review of Resident #14's March 2017 Consolidated physician's orders [REDACTED]. Lorsartan Tablet (Treats high blood pressure) Give 50 mg by mouth once per day. [MEDICATION NAME] Tablet (Treats muscle spasms) Give 5 mg by mouth twice per day Review of Resident #14's March 2017 MAR indicated [REDACTED]. Resident #14 did not receive a dose of Lorsartan until the next scheduled dose at 7:00 a.m. on 03/11/17. Review of the vital sign monitoring tool dated 03/10/17, Resident #14's blood pressure spiked to 176/89 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of Lorsartan. Review of Resident #14's March 2017 MAR indicated [REDACTED]. 16. Review of Resident #15's face sheet dated 03/10/17 reflected Resident #15 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #15's March 2017 MAR indicated [REDACTED] Carvedilol Tablet (Treats high blood pressure) Give 3.125 mg by mouth twice a day Review of Resident #15's March 2017 MAR indicated [REDACTED]. Resident #15 did not receive a dose of carvedilol until 7:00 p.m. on 03/10/17. 17. Review of Resident #16's face sheet dated 03/10/17 reflected Resident #16 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #16's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood sugar) Give 500 mg by mouth twice per day Review of Resident #16's March 2017 MAR indicated [REDACTED]. 18. Review of Resident #17's face sheet dated 03/10/17 reflected Resident #17 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #17's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] capsule (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth twice per day [MEDICATION NAME] Tablet (Treats high blood sugar) Give 1000 mg by mouth twice per day Nebivolol Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning Review of Resident #17's March 2017 MAR indicated [REDACTED]. Resident #17 did not receive her Nebivolol and [MEDICATION NAME] until their next scheduled doses on 03/11/17 at 7:00 a.m. Resident #17 did not receive a dose of [MEDICATION NAME] until 3:00 p.m. on 03/10/17. She did not receive a dose of [MEDICATION NAME] until 4:00 p.m. on 03/10/17. Review of the vital signs monitoring tool dated 03/10/17, Resident #17's blood pressure was 160/89 (her normal ranges were around 150/75) on 03/10/17 at 8:00 p.m. 19. Review of Resident #18's face sheet dated 03/10/17 reflected Resident #18 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #18's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood pressure) Give 5 mg by mouth in the morning Review of Resident #18's March 2017 MAR indicated [REDACTED]. 20. Review of Resident #19's face sheet dated 03/10/17 reflected Resident #19 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #19's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 50 mg by mouth twice a day Review of Resident #19's March 2017 MAR indicated [REDACTED]. Resident #19 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 7:00 p.m. on 03/10/17. Review of the FDA Medication Guide for [MEDICATION NAME] revised December of 2016 revealed to take [MEDICATION NAME] at the same times each day. If [MEDICATION NAME] is stopped suddenly (such as missing a dose) side effects such as headaches, nausea, diarrhea, trouble sleeping, increased sweating, and anxiousness may occur. 21. Review of Resident #20's face sheet dated 03/10/17 reflected Resident #20 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #20's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 20 mg by mouth once a day Review of Resident #20's March 2017 MAR indicated [REDACTED]. 22. Interview with ADON A on 03/21/17 at 3:05 p.m. revealed that on 03/10/17 she had worked the 6:00 p.m. to 6:00 a.m. shift for 100 Hall. The DON had come in around 5:00 a.m. and given her some work to do. At 6:00 a.m. MA P came to ADON A and reported she was assigned to halls 100 and 300. ADON A instructed her to check in with the DON, as she was waiting for the on-coming nurse to relieve her. ADON A did not give the keys to the medication cart to MA P. ADON A asked the DON about her relief nurse and was instructed to continue working as the next on-coming nurse was late. She asked the DON for help as she had a dentist appointment and was told, sorry, no. When the oncoming nurse relieved her they counted the carts together around 8:30 a.m. ADON A stated she did not pass any morning medications off of the Med Aide's cart. She did not know if MA P had passed medications for Hall 100. Interview with MA P on 03/21/17 at 12:00 pm revealed that she works 6:00 a.m. to 6:00 p.m. On 03/10/17 she reported to ADON A and asked her to count the cart with her. ADON A instructed her to wait until the day shift nurse came on duty. MA P asked ADON A three times to count the cart for Hall 100 with her so she could pass medications and ADON A instructed her to wait. MA P went to pass medications on the 300 hall. MA P did not inform the DON that she had not been given the keys to the medication cart for hall 100 and had not passed the medications. MA P stated she did not inform the oncoming nurse or the DON about not passing the medications on Hall 100. Interview with the DON on 03/21/17 at 9:50 a.m. revealed she was working the morning of 03/10/17 and instructed ADON A to continue with her work because the on-coming nurse was late. The DON did not offer to help and did not know medications were not being passed. She stated when she learned from LVN O at 11:00 a.m. on 03/10/17 that ADON A had not passed morning medications, she instructed the nurses to call the doctors and take vital signs. She stated they took vital signs of the residents who had missed their medications every four hours for 24 hours. She revealed ADON A was suspended because of the incident. Review of ADON A's employee record revealed an Employee Memorandum dated 03/10/17. ADON A received a written warning and was suspended. The subject of code of conduct rule violated was neglect. The date of violation is listed as 03/10/17. The description of the warning states med pass was not passed at 7:00 a.m. on Hall 100 to several residents. ADON A signed the warning on 03/10/17. ADON A also received a written warning on 03/06/17 regarding blanks in MARs. An in-service was provided on proper medication administration. The corrective action of not signing the MAR indicated [REDACTED]. Interview with the DON on 03/21/17 at 2:10 p.m. revealed ADON A had refused assignments in the past. ADON A refused to work Hall 200 on 03/04/17 and the DON assumed ADON A passed all the medications for Hall 200 on 03/04/17. All nurses and MAs had received a written warning regarding medication administration on 03/06/17 because of another medication error. The DON stated on the night shift Hall 200 is split between the nurse on Hall 300 and the nurse on Hall 100. The nurse assigned to Hall 100 is responsible for the residents in rooms 200-205 and rooms [ROOM NUMBER]. The nurse assigned to Hall 300 is responsible for the residents in rooms 206-211 and room [ROOM NUMBER]. 23. Review of Resident #29's face sheet dated 03/23/17 reflected Resident #29 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #29's MDS assessment dated [DATE] revealed she was cognitively intact. Review of Resident #29's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject 20 units twice a day Insulin [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale before meals and at bedtime [MEDICATION NAME] Tablet (Treats anxiety) Give 0.25 mg by mouth at bedtime Pramipexole [MEDICATION NAME] Tablet (Treats Restless Leg Syndrome) Give 0.5 mg by mouth in the afternoon Eliquis Tablet (Anticoagulant) Give 2.5 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 12.5 mg by mouth twice a day Review of Resident #29's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 and 03/02/17's 8:00 p.m. dose of Eliquis. LVN C failed to administer 03/02/17 and 03/03/17's 2:00 a.m. dose of [MEDICATION NAME]. LVN J failed to administer 03/03/17's 8:00 p.m. dose of Eliquis. LVN J failed to administer Resident #29's 9:00 p.m. dose of [MEDICATION NAME] on 03/03/17. LVN J failed to administer Resident #29's 03/04/17's 5:00 p.m. and 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN J failed to administer 03/04/17's 2:00 p.m. dose of Pramipexole [MEDICATION NAME] . LVN J failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/04/17. RN D failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/04/17 and 03/05/17. RN D also failed to administer Resident #29's 7:00 a.m. and 11:00 a.m. dose of Insulin [MEDICATION NAME] on 03/05/17. LVN E failed to administer 03/08/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN E failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/08/17. LVN L failed to administer Resident #29's 8:00 p.m. dose of Insulin [MEDICATION NAME] on 03/09/17. LVN E failed to administer 03/18/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN I failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/19/17. LVN K failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/20/17. Interview with Resident #29 on 03/21/17 at 2:40 p.m. revealed she has missed doses of medications and did not get most of her medications on 03/03/17 and 03/04/17. She stated there were new nurses those days. She stated she has experienced pain when she does not receive her pain medications and her medication for Restless Leg Syndrome. 24. Review of Resident #21's face sheet dated 03/23/17 reflected Resident #21 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #21's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject as per sliding scale before meals. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject 60 units at bedtime. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 40 mg by mouth at bedtime Review of Resident #21's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 through 03/04/17's 9:00 p.m. dose of [MEDICATION NAME]. LVN C failed to administer Resident #21's [MEDICATION NAME] Insulin 8:00 p.m. dose on 03/04/17. LVN B failed to administer Resident #21's [MEDICATION NAME] Insulin 4:30 p.m. dose on 03/13/17. On 03/22/17, LVN I had not administered Resident #21's 8:00 p.m. [MEDICATION NAME] when the MAR indicated [REDACTED]. Interview with the Administrator on 03/23/17 at 10:25 a.m. revealed LVN G helped LVN I pass the missed medications around 11:00 p.m. on 03/22/17. He stated they had notified all residents' doctors who had missed insulin. 25. Review of Resident #22's face sheet dated 03/23/17 reflected Resident #22 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #22's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale after meals [MEDICATION NAME] Tablet (Treats pain) Give 7.5-325 mg tablet by mouth twice a day Review of Resident #22's March 2017 MAR indicated [REDACTED] RN D failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 8:30 a.m. and 1:30 p.m. LVN E failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 6:30 p.m. LVN C also failed to administer Resident #22's 6:00 a.m. and 8:00 p.m. dose of [MEDICATION NAME] on 03/01/17 and 03/02/17. LVN C failed to administer Resident #22's 8:00 p.m. dose of [MEDICATION NAME] on 03/03/17 and 6:00 a.m. dose on 03/04/17. On 03/22/17, LVN E had not administered Resident #22's 6:30 p.m. dose of [MEDICATION NAME]when the MAR indicated [REDACTED] 26. Review of Resident #23's face sheet dated 03/23/17 reflected Resident #23 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #23's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Hyciate Tablet (Antibiotic to treat upper respiratory infection) Give 100 mg by mouth twice a day to start on 03/13/17 at 2:00 a.m. [MEDICATION NAME] Tablet (Treats pain) Give 50 mg by mouth every 12 hours. Review of Resident #23's March 2017 MAR indicated [REDACTED] LVN E failed to administer Resident #23's 9:00 a.m. dose of [MEDICATION NAME] on 03/03/17. LVN C did not administer Resident #23's 9:00 p.m. dose of [MEDICATION NAME] on 03/04/17. The DON did not administer the third dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 a.m. LVN H did not administer the fourth dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 p.m. Review of Resident #23's March 2017 MAR indicated [REDACTED]. Resident #23 indicated increased pain of 3 on 03/04/17 and 03/05/17 (after the missed doses of [MEDICATION NAME]) and she normally did not have any pain. 27. Review of Resident #24's face sheet dated 03/23/17 reflected Resident #24 is a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #24's March 2017 MAR indicated [REDACTED]

Based on interview and record review, the facility failed to ensure the resident was free from neglect for 45 (Resident #1 through Resident #45) of 52 residents reviewed for neglect. 1. The facility failed to administer physician ordered [MEDICATION NAME] (prevents [MEDICAL CONDITION]), Levetiracetam (prevents [MEDICAL CONDITION]), [MEDICATION NAME] Acid (prevents [MEDICAL CONDITION]), and [MEDICATION NAME] (treats hypertension) on 03/10/17 to Resident #1 which resulted in Resident #1 having a [MEDICAL CONDITION] and having to go to the hospital to receive IV [MEDICATION NAME] and [MEDICATION NAME] to control his [MEDICAL CONDITION]. 2. The facility failed to administer morning medications on 03/10/17 to Resident #2 through Resident #20. 3. The facility failed to administer physician ordered medications to Residents #21 through Resident #45 on different days and times in March 2017. An Immediate Jeopardy situation was identified on 03/21/17. The Immediate Jeopardy was removed on 03/26/17. The facility remained out of compliance at a pattern of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and to evaluate the effectiveness of the corrective systems. These failures could affect all 74 residents by placing them at risk for death, exacerbation of medical conditions, and not receiving the therapeutic benefits of their medications. Findings included: 1. Review of the Provider Investigation Report dated 03/10/17 revealed ADON A did not pass the morning medications off the Med Aide cart to the residents who resided on Hall 100 because the other shift nurse had not arrived and she refused to give possession of the keys to the medication aide so she could pass her medications. Twenty residents should have received medications between the time of 6:00 a.m. and 8:30 a.m. from ADON A on 03/10/17. Later that afternoon, Resident #1 was at the receptionist's desk when he had a [MEDICAL CONDITION]. He was transported by EMS to the hospital. Resident #1 received IV [MEDICATION NAME] and [MEDICATION NAME] at the hospital and returned to the facility on [DATE] at 11:10 p.m. Review of Resident #1's face sheet dated 03/10/17 reflected Resident #1 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] revealed he had severe cognitive impairment. Review of Resident #1's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give one 200 mg tablet by mouth two times a day Levetiracetam Solution (Prevents [MEDICAL CONDITION]) Give 3000 mg by mouth three times a day [MEDICATION NAME] Acid (Prevents [MEDICAL CONDITION]) Give 250 mg by mouth three times a day [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 25 mg by mouth once a day Review of Resident #1's March 2017 MAR indicated [REDACTED]. Resident #1 went to the hospital before the medications could be administered at a later time. Review of Resident #1's nurses notes dated 03/10/17 at 12:30PM signed by DON revealed Resident sitting in wheelchair at receptionist desk shaking as if he was cold and clammy. Resident looking at staff but not answering questions. Resident stood from wheelchair and laid himself down on the couch with standby assist of staff. Blood sugar taken 106. Started to take blood pressure when resident started having [MEDICAL CONDITION]. At 12:35 resident stiffened up and turned blue. 911 notified. Blood pressure 144/111, pulse 109, O2 sat 97%. Resident assisted to gurney and transported to hospital. An attempt was made to interview Resident #1 on 03/23/17 at 2:45 p.m. The resident would not answer any of the questions. 2. Review of Resident #2's face sheet dated 03/10/17 reflected Resident #2 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 100 mg by mouth in the morning [MEDICATION NAME] (Treats high blood pressure) Give 10 mg by mouth in the morning [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning [MEDICATION NAME] (Treats anxiety) Give 0.5 mg by mouth two times a day Review of Resident #2's March 2017 MAR indicated [REDACTED]. Interview with Resident #2 on 03/21/17 at 10:50 a.m. revealed that she has not been getting her medications on time. She does not receive her morning medications until 2 p.m. Review of the vital sign monitoring tool dated 03/10/17, Resident #2's blood pressure spiked to 172/67 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of [MEDICATION NAME] and [MEDICATION NAME] Tartate. Review of Resident #2's March 2017 MAR indicated [REDACTED]. 3. Review of Resident #3's face sheet dated 03/10/17 reflected Resident #3 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #2's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood pressure) Give 6.25 mg by mouth twice a day. Review of Resident #3's March 2017 MAR indicated [REDACTED]. Resident #3 did not receive another dose of [MEDICATION NAME] until 7:00 a.m. on 03/11/17. 4. Review of Resident #4's face sheet dated 03/10/17 reflected Resident #4 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #4's March 2017 Consolidated physician's orders [REDACTED]. Entacapone Tablet (Anti-[MEDICAL CONDITION] medication) Give 200 mg by mouth three times a day. [MEDICATION NAME] Tablet (Anti-[MEDICAL CONDITION] medication) Give 100 mg by mouth three times a day. Review of Resident #4's March 2017 MAR indicated [REDACTED]. Resident #4 did not receive a dose of Entacapone and [MEDICATION NAME] until 1:00 p.m. 5. Review of Resident #5's face sheet dated 03/10/17 reflected Resident #5 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #5's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] tablet (Treats high blood pressure) Give 10 mg by mouth three times a day Carvedilol Tablet (Treats high blood pressure) Give 12.5 mg by mouth two times a day Review of Resident #5's March 2017 MAR indicated [REDACTED]. He did not receive his next dose of [MEDICATION NAME] until 1:00 p.m. on 03/10/17. His next recorded blood pressure was 177/89 (normal range is 120/70) at 1:00 p.m. on 03/10/17. Resident #5 received his next scheduled dose of Carvedilol at 7:00 p.m. on 03/10/17 and his blood pressure was still elevated at 172/69. After receiving both of his doses of blood pressure medication, his blood pressure decreased to 147/61 (taken on 03/11/17 at midnight). Review of Resident #5's March 2017 MAR indicated [REDACTED]. 6. Review of Resident #6's face sheet dated 03/10/17 reflected Resident #6 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #6's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Prevents [MEDICAL CONDITION]) Give 50 mg by mouth two times a day. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth three times a day. Review of Resident #6's March 2017 MAR indicated [REDACTED]. 7. Review of Resident #7's face sheet dated 03/10/17 reflected Resident #7 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #7's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 25 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 100 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day Review of Resident #7's March 2017 MAR indicated [REDACTED]. They were administered later in the day at 11:00 a.m. By that time, Resident #7's blood pressure had risen to 154/96. Resident #7's blood pressures were usually in the 130s/60s. Interview with Resident #7 on 03/23/17 at 9:20 a.m. revealed she may have missed a dose from the MA on 03/10/17 and sometimes her medications were late. 8. Review of Resident #8's face sheet dated 03/10/17 reflected Resident #8 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #8's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 2.5 mg by mouth in the morning [MEDICATION NAME] Tartate (Treats high blood pressure) Give 50 mg by mouth twice a day Review of Resident #8's March 2017 MAR indicated [REDACTED]. Resident #8 did not receive a dose of [MEDICATION NAME] until 03/11/17 at 7:00 a.m. He received a dose of [MEDICATION NAME] on 03/10/17 at 7:00 p.m. 9. Review of Resident #9's face sheet dated 03/10/17 reflected Resident #9 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #9's March 2017 MAR indicated [REDACTED] [MEDICATION NAME] tablet (Treats high blood pressure) Give 25 mg by mouth three times a day. Review of Resident #9's March 2017 MAR indicated [REDACTED]. Resident #9 did not receive a dose of [MEDICATION NAME] until 03/10/17 at 3:00 p.m. 10. Review of Resident #10's face sheet dated 03/10/17 reflected Resident #10 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #10's March 2017 Consolidated physician's orders [REDACTED]. Eliquis Tablet (Prevents blood clots) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day [MEDICATION NAME] Tablet (Treats anxiety) Give 2 mg by mouth three times a day Review of Resident #10's March 2017 MAR indicated [REDACTED]. She did not receive the next dose of Eliquis until 03/11/17 at 7:00 a.m. Review of the FDA's Medication Guide for Eliquis revised August 2016 revealed do not change your dose or stop taking it unless your doctor tells you to. If you miss a dose of ELIQUIS, take it as soon as you remember, and do not take more than one dose at the same time. If you are taking ELIQUIS for [MEDICAL CONDITION], stopping ELIQUIS may increase your risk of having a stroke. Do not run out of ELIQUIS. Refill your prescription before you run out. 11. Review of Resident #11's face sheet dated 03/10/17 reflected Resident #11 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #11's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 100 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats muscle spasms) Give 10 mg by mouth two times a day [MEDICATION NAME] Tablet (Treats [MEDICAL CONDITION] pain) Give 600 mg by mouth three times a day Review of Resident #11's March 2017 MAR indicated [REDACTED]. Resident #11 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 3:00 p.m. on 03/10/17. She did not receive a dose of [MEDICATION NAME] until 3:00 p.m. on 03/10/17. Resident #11 received her next dose of [MEDICATION NAME] on 03/10/17 at 11:00 a.m. as scheduled. 12. Review of Resident #12's face sheet dated 03/10/17 reflected Resident #12 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #12's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood sugar) Give 500 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats muscle spasms) Give 4 mg by mouth three times a day Review of Resident #12's March 2017 MAR indicated [REDACTED]. 13. Review of Resident #13's face sheet dated 03/10/17 reflected Resident #13 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #13's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 10 mg by mouth twice per day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth twice per day Review of Resident #13's March 2017 MAR indicated [REDACTED]. 14. Review of Resident #14's face sheet dated 03/10/17 reflected Resident #14 was a [AGE] year old female who was admitted to the facility 02/25/17. Her admitting [DIAGNOSES REDACTED]. Review of Resident #14's March 2017 Consolidated physician's orders [REDACTED]. Lorsartan Tablet (Treats high blood pressure) Give 50 mg by mouth once per day. [MEDICATION NAME] Tablet (Treats muscle spasms) Give 5 mg by mouth twice per day Review of Resident #14's March 2017 MAR indicated [REDACTED]. Resident #14 did not receive a dose of Lorsartan until the next scheduled dose at 7:00 a.m. on 03/11/17. Review of the vital sign monitoring tool dated 03/10/17, Resident #14's blood pressure spiked to 176/89 (normal blood pressure is 120/70) after not receiving her 7:00 a.m. dose of Lorsartan. Review of Resident #14's March 2017 MAR indicated [REDACTED]. 15. Review of Resident #15's face sheet dated 03/10/17 reflected Resident #15 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #15's March 2017 MAR indicated [REDACTED] Carvedilol Tablet (Treats high blood pressure) Give 3.125 mg by mouth twice a day Review of Resident #15's March 2017 MAR indicated [REDACTED]. Resident #15 did not receive a dose of carvedilol until 7:00 p.m. on 03/10/17. 16. Review of Resident #16's face sheet dated 03/10/17 reflected Resident #16 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #16's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood sugar) Give 500 mg by mouth twice per day Review of Resident #16's March 2017 MAR indicated [REDACTED]. 17. Review of Resident #17's face sheet dated 03/10/17 reflected Resident #17 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #17's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] capsule (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth twice per day [MEDICATION NAME] Tablet (Treats high blood sugar) Give 1000 mg by mouth twice per day Nebivolol Tablet (Treats high blood pressure) Give 5 mg by mouth in the morning [MEDICATION NAME] Tablet (Treats high blood pressure) Give 50 mg by mouth in the morning Review of Resident #17's March 2017 MAR indicated [REDACTED]. Resident #17 did not receive her Nebivolol and [MEDICATION NAME] until their next scheduled doses on 03/11/17 at 7:00 a.m. Resident #17 did not receive a dose of [MEDICATION NAME] until 3:00 p.m. on 03/10/17. She did not receive a dose of [MEDICATION NAME] until 4:00 p.m. on 03/10/17. Review of the vital signs monitoring tool dated 03/10/17, Resident #17's blood pressure was 160/89 (her normal ranges were around 150/75) on 03/10/17 at 8:00 p.m. 18. Review of Resident #18's face sheet dated 03/10/17 reflected Resident #18 was an [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #18's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats high blood pressure) Give 5 mg by mouth in the morning Review of Resident #18's March 2017 MAR indicated [REDACTED]. 19. Review of Resident #19's face sheet dated 03/10/17 reflected Resident #19 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #19's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] (Treats [MEDICAL CONDITION] pain) Give 50 mg by mouth twice a day Review of Resident #19's March 2017 MAR indicated [REDACTED]. Resident #19 did not receive a dose of [MEDICATION NAME] until the next scheduled dose at 7:00 p.m. on 03/10/17. Review of the FDA Medication Guide for [MEDICATION NAME] revised December of 2016 revealed to take [MEDICATION NAME] at the same times each day. If [MEDICATION NAME] is stopped suddenly (such as missing a dose) side effects such as headaches, nausea, diarrhea, trouble sleeping, increased sweating, and anxiousness may occur. 20. Review of Resident #20's face sheet dated 03/10/17 reflected Resident #20 was an [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #20's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 20 mg by mouth once a day Review of Resident #20's March 2017 MAR indicated [REDACTED]. 21. Interview with ADON A on 03/21/17 at 3:05 p.m. revealed that on 03/10/17 she had worked the 6:00 p.m. to 6:00 a.m. shift for 100 Hall. The DON had come in around 5:00 a.m. and given her some work to do. At 6:00 a.m. MA P came to ADON A and reported she was assigned to halls 100 and 300. ADON A instructed her to check in with the DON, as she was waiting for the on-coming nurse to relieve her. ADON A did not give the keys to the medication cart to MA P. ADON A asked the DON about her relief nurse and was instructed to continue working as the next on-coming nurse was late. She asked the DON for help as she had a dentist appointment and was told, sorry, no. When the oncoming nurse relieved her they counted the carts together around 8:30 a.m. ADON A stated she did not pass any morning medications off of the Med Aide's cart. She did not know if MA P had passed medications for Hall 100. Interview with MA P on 03/21/17 at 12:00 pm revealed that she works 6:00 a.m. to 6:00 p.m. On 03/10/17 she reported to ADON A and asked her to count the cart with her. ADON A instructed her to wait until the day shift nurse came on duty. MA P asked ADON A three times to count the cart for Hall 100 with her so she could pass medications and ADON A instructed her to wait. MA P went to pass medications on the 300 hall. MA P did not inform the DON that she had not been given the keys to the medication cart for hall 100 and had not passed the medications. MA P stated she did not inform the oncoming nurse or the DON about not passing the medications on Hall 100. Interview with the DON on 03/21/17 at 9:50 a.m. revealed she was working the morning of 03/10/17 and instructed ADON A to continue with her work because the on-coming nurse was late. The DON did not offer to help and did not know medications were not being passed. She stated when she learned from LVN O at 11:00 a.m. on 03/10/17 that ADON A had not passed morning medications, she instructed the nurses to call the doctors and take vital signs. She stated they took vital signs of the residents who had missed their medications every four hours for 24 hours. She revealed ADON A was suspended because of the incident. Review of ADON A's employee record revealed an Employee Memorandum dated 03/10/17. ADON A received a written warning and was suspended. The subject of code of conduct rule violated was neglect. The date of violation is listed as 03/10/17. The description of the warning states med pass was not passed at 7:00 a.m. on Hall 100 to several residents. ADON A signed the warning on 03/10/17. ADON A also received a written warning on 03/06/17 regarding blanks in MARs. An in-service was provided on proper medication administration. The corrective action of not signing the MAR indicated [REDACTED]. Interview with the DON on 03/21/17 at 2:10 p.m. revealed ADON A had refused assignments in the past. ADON A refused to work Hall 200 on 03/04/17 and the DON assumed ADON A passed all the medications for Hall 200 on 03/04/17. All nurses and MAs had received a written warning regarding medication administration on 03/06/17 because of another medication error. The DON stated on the night shift Hall 200 is split between the nurse on Hall 300 and the nurse on Hall 100. The nurse assigned to Hall 100 is responsible for the residents in rooms 200-205 and rooms [ROOM NUMBER]. The nurse assigned to Hall 300 is responsible for the residents in rooms 206-211 and room [ROOM NUMBER]. 22. Review of Resident #29's face sheet dated 03/23/17 reflected Resident #29 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #29's MDS assessment dated [DATE] revealed she was cognitively intact. Review of Resident #29's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject 20 units twice a day Insulin [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale before meals and at bedtime [MEDICATION NAME] Tablet (Treats anxiety) Give 0.25 mg by mouth at bedtime Pramipexole [MEDICATION NAME] Tablet (Treats Restless Leg Syndrome) Give 0.5 mg by mouth in the afternoon Eliquis Tablet (Anticoagulant) Give 2.5 mg by mouth twice a day [MEDICATION NAME] Tablet (Treats high blood pressure) Give 12.5 mg by mouth twice a day Review of Resident #29's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 and 03/02/17's 8:00 p.m. dose of Eliquis. LVN C failed to administer 03/02/17 and 03/03/17's 2:00 a.m. dose of [MEDICATION NAME]. LVN J failed to administer 03/03/17's 8:00 p.m. dose of Eliquis. LVN J failed to administer Resident #29's 9:00 p.m. dose of [MEDICATION NAME] on 03/03/17. LVN J failed to administer Resident #29's 03/04/17's 5:00 p.m. and 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN J failed to administer 03/04/17's 2:00 p.m. dose of Pramipexole [MEDICATION NAME] . LVN J failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/04/17. RN D failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/04/17 and 03/05/17. RN D also failed to administer Resident #29's 7:00 a.m. and 11:00 a.m. dose of Insulin [MEDICATION NAME] on 03/05/17. LVN E failed to administer 03/08/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN E failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/08/17. LVN L failed to administer Resident #29's 8:00 p.m. dose of Insulin [MEDICATION NAME] on 03/09/17. LVN E failed to administer 03/18/17's 8:00 p.m. dose of Insulin [MEDICATION NAME]. LVN I failed to administer Resident #29's 8:00 p.m. dose of [MEDICATION NAME] on 03/19/17. LVN K failed to administer Resident #29's 8:00 a.m. dose of [MEDICATION NAME] on 03/20/17. Interview with Resident #29 on 03/21/17 at 2:40 p.m. revealed she has missed doses of medications and did not get most of her medications on 03/03/17 and 03/04/17. She stated there were new nurses those days. She stated she has experienced pain when she does not receive her pain medications and her medication for Restless Leg Syndrome. 23. Review of Resident #21's face sheet dated 03/23/17 reflected Resident #21 was a [AGE] year old female who was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. Review of Resident #21's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject as per sliding scale before meals. [MEDICATION NAME] Solution Pen Injector (Treats high blood sugar) Inject 60 units at bedtime. [MEDICATION NAME] Tablet (Treats high blood pressure) Give 40 mg by mouth at bedtime Review of Resident #21's March 2017 MAR indicated [REDACTED] LVN C failed to administer 03/01/17 through 03/04/17's 9:00 p.m. dose of [MEDICATION NAME]. LVN C failed to administer Resident #21's [MEDICATION NAME] Insulin 8:00 p.m. dose on 03/04/17. LVN B failed to administer Resident #21's [MEDICATION NAME] Insulin 4:30 p.m. dose on 03/13/17. On 03/22/17, LVN I had not administered Resident #21's 8:00 p.m. [MEDICATION NAME] when the MAR indicated [REDACTED]. Interview with the Administrator on 03/23/17 at 10:25 a.m. revealed LVN G helped LVN I pass the missed medications around 11:00 p.m. on 03/22/17. He stated they had notified all residents' doctors who had missed insulin. 24. Review of Resident #22's face sheet dated 03/23/17 reflected Resident #22 was a [AGE] year old male who was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. Review of Resident #22's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Solution (Treats high blood sugar) Inject as per sliding scale after meals [MEDICATION NAME] Tablet (Treats pain) Give 7.5-325 mg tablet by mouth twice a day Review of Resident #22's March 2017 MAR indicated [REDACTED] RN D failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 8:30 a.m. and 1:30 p.m. LVN E failed to administer Resident #22's [MEDICATION NAME]on 03/05/17 at 6:30 p.m. LVN C also failed to administer Resident #22's 6:00 a.m. and 8:00 p.m. dose of [MEDICATION NAME] on 03/01/17 and 03/02/17. LVN C failed to administer Resident #22's 8:00 p.m. dose of [MEDICATION NAME] on 03/03/17 and 6:00 a.m. dose on 03/04/17. On 03/22/17, LVN E had not administered Resident #22's 6:30 p.m. dose of [MEDICATION NAME]when the MAR indicated [REDACTED] 25. Review of Resident #23's face sheet dated 03/23/17 reflected Resident #23 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #23's March 2017 Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Hyciate Tablet (Antibiotic to treat upper respiratory infection) Give 100 mg by mouth twice a day to start on 03/13/17 at 2:00 a.m. [MEDICATION NAME] Tablet (Treats pain) Give 50 mg by mouth every 12 hours. Review of Resident #23's March 2017 MAR indicated [REDACTED] LVN E failed to administer Resident #23's 9:00 a.m. dose of [MEDICATION NAME] on 03/03/17. LVN C did not administer Resident #23's 9:00 p.m. dose of [MEDICATION NAME] on 03/04/17. The DON did not administer the third dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 a.m. LVN H did not administer the fourth dose of [MEDICATION NAME] Hyciate to Resident #23 on 03/14/17 at 2:00 p.m. Review of Resident #23's March 2017 MAR indicated [REDACTED]. Resident #23 indicated increased pain of 3 on 03/04/17 and 03/05/17 (after the missed doses of [MEDICATION NAME]) and she normally did not have any pain. 26. Review of Resident #24's face sheet dated 03/23/17 reflected Resident #24 is a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #24's March 2017 MAR indicated [REDACTED] [MEDICATION NAME] Tablet (Treats pain) Give 50 mg by mouth three times a day Review of Resident #24's March 2017 MAR indicated [REDACTED]. Review of Resident #24's March 2017 MAR indicated [REDACTED]. 27. Review of Resident #25's face sheet dated 03/23/17 revealed Resident #25 was a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #25's March 2017's Consolidated physician's orders [REDACTED]. [MEDICATION NAME] Capsule (Treats [MEDICAL CONDITION] pain) Give 300 mg by mouth three times a day [MEDICATION NAME]-[MEDICATION NAME] Tablet (Treats pain) Give 5-325mg tablet by mouth three times a day [MEDICATION NAME] Tartate Tablet (Treats high blood pressure) Give 50 mg by mouth two times a day [MEDICATION NAME] Sodium Extended Capsule (Prevents [MEDICAL CONDITION]) Give 100 mg by mouth at bedtime Review of Resident #25's March 2017 MAR indicated [REDACTED]. LVN F failed to administer Resident #25's 6:00 a.m. dose of [MEDICATION NAME]-[MEDICATION NAME] on 03/07/17 and 03/08/17. Review of Resident #25's March 2

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurate administration of all drugs and biologicals to meet the needs of each resident for one (Resident #1) of 19 residents who were reviewed for medication administration, was free of significant medication errors. LVN A failed to ensure she administered medications for Resident #1 on 03/03/17 that she dispensed, and instead delegated the responsibility to RN B who failed to administer the correct medications to Resident #1, and instead administered five medications that did not belong to the Resident #1 but to Resident #2. As a result of the errors, Resident #1's heart rate and blood pressure dropped and the resident was sent to the hospital and is currently in the Intensive Care Unit. An Immediate Jeopardy was identified on 03/06/17. While the IJ was removed on 03/07/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the 19 residents who received their medications from LVN A and RN B by placing the residents at risk for adverse drug reactions, overdose, and change in condition. Findings included: Review of The Standards of Nursing Practice on 03/07/17 (22 TAC §217.11) applicable to LVNs (as well as RNs) includes the following standards that specifically relate to medication administration: (1)(D) Accurately and completely report and document: (iv) administration of medications and treatments; Resident #1's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and required extensive assistance with his ADLs. Review of Medication Administration Record [REDACTED]. Review of incident report for Resident #1, dated 03/03/17 at 5:36 PM and revised on 03/04/17 at 8:27 AM, reflected LVN A prepared the report documenting the medication error; the error involved the wrong patient and wrong medication. LVN A gave Resident #1 the wrong medication due to the distraction of another resident in distress at 10:00 AM. Resident #1 was assessed, 911 was called, and the physician and family member were notified. Resident #1's vital signs were obtained every five to 10 minutes until paramedics arrived. Resident #1 was oriented to person. Review of a nurse's note dated 03/03/17 at 8:07 PM by LVN A reflected Resident #1 had been admitted to the Hospital ICU in stable condition at that time. A note dated 03/03/17 by the DON in the incident report documented speaking to LVN A concerning the medication error. LVN A told the DON that she was getting medication ready for Resident #1 when transport for another resident arrived. LVN A then put Resident #1's medication in the top of the medication cart drawer and started to prepare other residents medication so that he could go to dialysis. The Activity Director interrupted LVN A to assist a resident who was leaning out of wheelchair. LVN A placed the medication on the cart to assist the resident. She then asked the nurse she was training, RN B, to go ahead and administer the prepared medications to Resident #1. RN B picked up the medication on the cart and administered it to Resident #1. The medication administered belonged to another resident. The DON spoke LVN A for one-on-one in-service on proper medication administration. A note by the DON in the incident report, dated 03/04/17, reflected the DON called hospital to inquire on Resident #1's condition. She spoke to the Nurse/RN in the ICU. Resident #1 was admitted to the ICU yesterday (03/03/17) and was placed on glucagon drip to reverse beta blocker (low blood pressure medication), but Resident #1 began to have nausea and vomiting, so the glucagon drip was discontinued. Resident #1 was given a dopamine drip at that time, treatment for [REDACTED]. Telephone Interview on 03/04/17 at 12:10 PM with LVN A revealed she was orienting RN B on 03/03/17 on the 200 hall and giving medications along with RN B. She had gotten medications ready for Resident #1, which were put in a medication cup in front of RN B who witnessed the process. Transport arrived to take Resident #2 to dialysis, so Resident #1's medication was kept in his medication cup and put in drawer of medication cart in view of RN B. Medication for Resident #2 was then dispensed so that he could go to dialysis. This was also done with RN B witnessing the medication of for Resident #2 being put in a medication cup on top of the cart. At that time, the Activity Director alerted LVN A that Resident #2 was unresponsive and leaning out of his wheelchair. LVN A instructed RN B to go ahead and give medications that were ready in the drawer of the medication cart to Resident #1 so that she could care for Resident #2. RN B instead gave Resident #1 the medications that were on top of the cart, which were in fact medications for Resident #2. Telephone Interview on 03/04/17 at 12:40 PM with RN B revealed she was oriented by LVN A on 03/03/17. She saw medications dispensed for Resident #1 and put on top of the medication cart. Medications for Resident #2 were also dispensed and put in a cup due to transport for Resident #2 having arrived to take him to dialysis. RN B said she left to take blood pressure for Resident #1, and when she returned, was handed a cup with medications by LVN A and told to give them to Resident #1. LVN A then put medications, who RN B thought belonged to Resident #2 into the cart, but were actually medications belonging to Resident #1. The medications were put back into the medication cart by LVN A so that she could attend to Resident #2 because the Activity Director had alerted LVN A that Resident #2 was unresponsive at that time. Interview with the DON on 03/04/17 at 1:30 PM revealed she was in the facility on the afternoon of 03/04/17 and had investigated the medication error of Resident #1 being given medications that were supposed to have been given to Resident #2. She said she in-serviced LVN A following medication error policy/procedure of 5 rights when administering medication. She was also in the process of in-servicing nurses on medication administration. Resident #1 was sent to the hospital for treatment and was currently in the ICU. Best practice was for the nurse preparing medications to administer them and not to delegate the task to another nurse. She said LVN A and RN B worked on the 200 hall on 03/07/17. RN B was disciplined on 03/06/17. Review of In-Service dated 03/04/17 reflected two CMAs and one LVN were in-serviced on Medication Administration. Review of Policy and Procedure for Medication Administration reflected general guidelines and precautions: .#3. Given only medicines that you have prepared. .#5. the six rights of medication administration: Right patient, right drug, right dose, right route, right time and right documentation. An Immediate Jeopardy was identified on 03/06/17 at 1:03 PM. The Administrator and DON were informed and a plan of removal was requested at that time. The plan of removal was accepted on 03/07/17 at 11:35 PM and reflected the following steps taken to remove the immediacy: 1. In-Service Training on Medication Administration Policy and Process, oral, monitored by DON. In-services began on 03/05/17 and were completed on 03/06/17 with DON conducting the medication administration training. All nurses and medication aides will pass a medication administration quiz and a Med Pass Competency before taking charge of a medication cart. Any part-time or PRN staff will not be allowed to take charge of a medication cart until they have passed both the quiz and competency check. Med Pass Competency is being is being performed by DON and case mix managers LVN I and LVN J. Med pass monitoring will be completed each shift for 24 hours. 2. Facility policy on Abuse, neglect and Exploitation with a focus on Neglect monitored by Administrator. In-services for nurses and medication aides began 03/06/17 and completed on 03/07/17 by 10:00 PM. 3. Not administering medication that wasn't prepared by the nurse personally, monitored by the DON. In-services began on 03/05/17 and were completed on 03/06/17. 4. All nurses required to complete Medication Administration quiz prior to assuming any medication administration responsibility and determine knowledge retention. Staff Reprimands: 1. LVN A - written up per facility policy related medication error, elevated to 3rd degree discipline with any further medication errors resulting in termination of employment. a. Nurse was provided with re-education related appropriate medication administration and destroying of medications if interrupted during medication pass. b. A medication administration quiz was administered to this nurse who scored 85%. 2. RN B - written up per facility policy related to medication error at first offense level and administering medication that nurse didn't personally prepare as an offense. a. Nurse was provided with re-education related appropriate medication administration and destroying of medications if interrupted during medication pass or administering medication that you did not personally prepare. b. A medication administration quiz was administered to this nurse who scored 90%. The medical director was notified on 03/06/17 at 5:15 PM. Interview with the Medical Director on 03/07/17 at 12:31 PM revealed he was aware of the Immediate Jeopardy and met at the facility last night (03/06/17) about the issues. He said the physician would normally expect the nursing staff to contact the supervising nurse and contact the physician under the circumstances of the incident. He said monitor the resident's blood pressure until medication clears from his (resident #1) system. He said he had been informed of Resident #1's condition. He said the Immediate Jeopardy occurred due to the wrong medications being given to the Resident #1. He also said the Immediate Jeopardy could have been avoided by staying focused on the one resident, Resident #1. He said the nurse should have finished what she was doing and that would have solved the issue. Interview with the Attending Physician on 03/07/17 at 9:13 AM revealed he had been notified pretty quickly, soon after the incident. He said he would expect nursing staff during an emergency to watch the resident's blood pressure, monitor the changes, and send the patient to the hospital. He said the Immediate Jeopardy occurred due to the nurse giving the wrong medication to the Resident #1. He also said the Immediate Jeopardy could have been avoided if the nurse double checked medications and the resident before administering. Interview with the Administrator on 03/07/17 at 10:07 AM revealed he was supervising staff to ensure policies and procedures were being followed by having morning clinical meetings where review of the previous 24-hours, noting new occurrences, and any follow-ups needed were being discussed. He said the Standard of Care Meeting was held weekly, along with monthly Quality Assurance Meetings. All new employees had Abuse/Neglect training during orientation. The DON and other administrative staff were supervised during morning clinical meetings, making assignments, and following up with the DON, ADON, SW, Activity Director, Dietary, Respiratory and MDS Coordinator / Case Mix Managers. The Administrator was looking at systems in place at the Standard of Care weekly meetings and Monthly QA meeting with the Medical Director involved. He said he also had daily contact and interactions with the DON. He was going out on the floor and interacting and observing nursing staff, housekeeping and dietary staff. He believed the Immediate Jeopardy occurred because the nurse was trying to do several things at once. To prevent reoccurrence, the nurses were in-serviced on policies and procedures that were in place. To follow the six rights of medication administration, right patient, right drug, right dose, right route, right time and right documentation. To give only medicines that you have prepared. He said the nurses were also in-serviced to finish a task that had been started before going to the next task. LVN A was reprimanded on 03/03/17. RN B was reprimanded on 03/06/17. Interview with the DON on 03/07/17 at 9:47 AM revealed she was supervising staff to ensure policies and procedures were being followed by being out on the floor, watching staff assist residents. She also had staff complete competency evaluations. She said she was following up on nurses' notes and incident reports. She said she was having staff meetings and communicating with staff through computer notes which showed up on the computer screen when nurses and CNAs logged on. The DON was supervising nursing staff, and the ADON during morning meetings would review clinical reports and follow up on labs, medications and skin issues. She said she was out on the floor monitoring nurses and CNAs. The DON said the Immediate Jeopardy occurred because there were too many distractions. The nurses were expected to follow policies and procedures for medication administration. To prevent the reoccurrence, is nurses had been in-serviced that if distracted during medication pass and unable to complete administration of medication to resident, they were to destroy the medications. Nurses were also in-serviced to only administer one person's medications at a time, even if in a hurry, and the nurse needed to finish what they were doing first. LVN A was reprimanded on 03/03/17 and RN B was reprimanded on 03/06/17. Review of Employee Memorandom for RN B, dated 03/06/17, reflected a medication error date of 03/03/17 for nurse orienting to the facility when medication was administered to the wrong resident. The employee was to follow proper administration protocol as in-serviced to prevent medication errors. If the employee was interrupted in medication pass, destroy medications and start over. The corrective action: if future medication errors occur then immediate termination would result. The form was signed by the employee as having received notification on 03/06/17, and also by the DON and Administrator on 03/06/17. Review of Employee Memorandom for LVN A, dated 03/03/17, reflected a medication error date of 03/03/17 for an employee orienting a new nurse to the facility when the wrong medications were administered to the wrong resident. The employee was to follow proper administration protocol as in-serviced to prevent medication errors. If the employee was interrupted in medication pass, destroy medications and start over. The corrective action: if future medication errors occur then immediate termination would result. The form was signed by the employee as having received notification on 03/03/17, signed by the DON on 03/03/17 and the Administrator on 03/06/17. Interviews on 03/07/17 between 12:20 PM and 2:20 PM with the following individuals, from the following shifts, regarding in-services on abuse/neglect, medication administration and the facility medication quizzes revealed no concerns: PRN - LVN C, LVN D; 6:00 PM to 6:00 AM - LVN C, LVN D; 6:00 AM to 6:00 PM - LVN D, LVN F, LVN A, RN B, LVN G, LVN H; 6:00 AM. to 2:00 PM - CMA D; 2:00 PM to 10:00 PM - CMA A; 10:00 PM to 6:00 AM - LVN C, LVN D Review of in-services given by the DON on 03/04/17 reflected two CMAs and two LVNs were trained on Medication Administration. In-Service given by the DON on 03/05/17 reflected 10 out of 17 staff were trained on Medication Monitoring. In-service given by the DON on 03/06/17 reflected 10 out of 16 staff were trained on Oral Medication Administration, including to only give medications that they had prepared; also, refraining from delegating someone to give medications that had not been prepared by them. Follow the six rights of administration. No presetting of medication will be tolerated. Review of in-service presented on 03/06/17 by the DON reflected 9 out of 29 employees trained on reporting of suspected resident abuse and neglect. Review of Medication Administration Review Quiz with 21 questions on medication administration reflected it was completed by 13 out of 13 staff. Review of Medication Pass Competency reflected 13 areas observed in administration of medication by 5 staff out of 5 staff on 03/07/17 (LVN A at 8:54 AM. CMA A at 9:05 AM; LVN F at 12:12 PM; CMA D at 9:05 AM; LVN H at 9:06 AM.) Review of Medication Pass Observation of 6 staff out of 6 staff with competency demonstrated on 03/06/17. (LVN H, LVN G, LVN E, LVN M, LVN N, RN B) LVN A and RN B worked 200 hall on 03/04/17 with 19 residents on the hall. On 03/07/17 the IJ was removed. On 03/07/17 at 11:30 AM the Administrator were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope pattern because the facility still implementing its Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure one (Resident #1) of 19 residents who were reviewed for medication administration, was free of significant medication errors. LVN A failed to ensure she administered medications for Resident #1 on 03/03/17 that she dispensed, and instead delegated the responsibility to RN B who failed to administer the correct medications to Resident #1, and instead administered five medications that did not belong to the Resident #1 but to Resident #2. As a result of the errors, Resident #1's heart rate and blood pressure dropped and the resident was sent to the hospital and admitted into the Intensive Care Unit. An Immediate Jeopardy was identified on 03/06/17. While the IJ was removed on 03/07/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the 19 residents who received their medications from LVN A and RN B by placing the residents at risk for adverse drug reactions, overdose, and change in condition. Findings included: Resident #1's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and required extensive assistance with his ADLs. Review of Medication Administration Record [REDACTED]. Review of incident report for Resident #1, dated 03/03/17 at 5:36 PM and revised on 03/04/17 at 8:27 AM, reflected LVN A prepared the report documenting the medication error; the error involved medication dispensed by LVN A and given to the wrong patient and wrong medication by RN B, due to the distraction of another resident in distress at 10:00 AM. Resident #1 was assessed, 911 was called, and the physician and family member were notified. Resident #1's vital signs were obtained every five to 10 minutes until paramedics arrived. Resident #1 was oriented to person. Review of a nurse's note dated 03/03/17 at 8:07 PM by LVN A reflected Resident #1 had been admitted to the Hospital ICU in stable condition at that time. A note dated 03/03/17 by the DON in the incident report documented speaking to LVN A concerning the medication error. LVN A told the DON that she was getting medication ready for Resident #1 when transport for another resident arrived. LVN A then put Resident #1's medication in the top of the medication cart drawer and started to prepare other residents medication so that he could go to [MEDICAL TREATMENT]. The Activity Director interrupted LVN A to assist a resident who was leaning out of wheelchair. LVN A placed the medication on the cart to assist the resident. She then asked the nurse she was training, RN B, to go ahead and administer the prepared medications to Resident #1. RN B picked up the medication on the cart and administered it to Resident #1. The medication administered belonged to another resident. The DON spoke to LVN A for one-on-one in-service on proper medication administration. A note by the DON in the incident report, dated 03/04/17, reflected the DON called hospital to inquire on Resident #1's condition. She spoke to the Nurse/RN in the ICU. Resident #1 was admitted to the ICU yesterday (03/03/17) and was placed on [MEDICATION NAME] drip to reverse beta blocker (low blood pressure medication), but Resident #1 began to have nausea and vomiting, so the [MEDICATION NAME] drip was discontinued. Resident #1 was given a [MEDICATION NAME] drip at that time, treatment for [REDACTED]. Telephone Interview on 03/04/17 at 12:10 PM with LVN A revealed she was orienting RN B on 03/03/17 on the 200 hall and giving medications along with RN B. She had gotten medications ready for Resident #1, which were put in a medication cup in front of RN B who witnessed the process. Transport arrived to take Resident #2 to [MEDICAL TREATMENT], so Resident #1's medication was kept in his medication cup and put in drawer of medication cart in view of RN B. Medication for Resident #2 was then dispensed so that he could go to [MEDICAL TREATMENT]. RN B witnessed LVN A dispense the medication for Resident #2 being put in a medication cup on top of the cart. At that time, the Activity Director alerted LVN A that Resident #2 was unresponsive and leaning out of his wheelchair. LVN A instructed RN B to go ahead and give medications that were ready in the drawer of the medication cart to Resident #1 so that she could care for Resident #2. RN B instead gave Resident #1 the medications that were on top of the cart, which were in fact medications for Resident #2. Telephone Interview on 03/04/17 at 12:40 PM with RN B revealed she was oriented by LVN A on 03/03/17. She saw medications dispensed for Resident #1 and put on top of the medication cart. Medications for Resident #2 was also dispensed and put in a cup due to transport for Resident #2 having arrived to take him to [MEDICAL TREATMENT]. RN B said she left to take blood pressure for Resident #1, and when she returned, was handed a cup with medications by LVN A and told to give them to Resident #1. LVN A then put medications, who RN B thought belonged to Resident #2 into the cart, but were actually medications belonging to Resident #1. The medications were put back into the medication cart by LVN A so that she could attend to Resident #2 because the Activity Director had alerted LVN A that Resident #2 was unresponsive at that time. Interview with the DON on 03/04/17 at 1:30 PM revealed she was in the facility on the afternoon of 03/03/17 and had investigated the medication error of Resident #1 being given medications that were supposed to have been given to Resident #2. She said she in-serviced LVN A following medication error policy/procedure of 5 rights when administering medication. She was also in the process of in-servicing nurses on medication administration. Resident #1 was sent to the hospital for treatment and was currently in the ICU. Best practice was for the nurse preparing medications to administer them and not to delegate the task to another nurse. RN B was disciplined and educated on 03/06/17. DON said LVN A and RN B worked on the 200 hall on 03/07/17. Review of In-Service dated 03/04/17 reflected two CMAs and one LVN were in-serviced on Medication Administration. Review of Policy and Procedure for Medication Administration reflected general guidelines and precautions: .#3. Given only medicines that you have prepared.#5. the six rights of medication administration: Right patient, right drug, right dose, right route, right time and right documentation. An Immediate Jeopardy was identified on 03/06/17 at 1:03 PM. The Administrator and DON were informed and a plan of removal was requested at that time. The plan of removal was accepted on 03/07/17 at 11:35 PM and reflected the following steps taken to remove the immediacy: 1. In-Service Training on Medication Administration Policy and Process, oral, monitored by DON. In-services began on 03/05/17 and were completed on 03/06/17 with DON conducting the medication administration training. All nurses and medication aides will pass a medication administration quiz and a Med Pass Competency before taking charge of a medication cart. Any part-time or PRN staff will not be allowed to take charge of a medication cart until they have passed both the quiz and competency check. Med Pass Competency is being is being performed by DON and case mix managers LVN I and LVN J. Med pass monitoring will be completed each shift for 24 hours. 2. Facility undated policy on Abuse, neglect and Exploitation with a focus on Neglect monitored by Administrator. In-services for nurses and medication aides began 03/06/17 and completed on 03/07/17 by 10:00 PM. 3. Not administering medication that wasn't prepared by the nurse personally, monitored by the DON. In-services began on 03/05/17 and were completed on 03/06/17. 4. All nurses required to complete Medication Administration quiz prior to assuming any medication administration responsibility and determine knowledge retention. Staff Reprimands: 1. LVN A - written up per facility policy related medication error, elevated to 3rd degree discipline with any further medication errors resulting in termination of employment. a. Nurse was provided with re-education related appropriate medication administration and destroying of medications if interrupted during medication pass. b. A medication administration quiz was administered to this nurse who scored 85%. 2. RN B - written up per facility policy related to medication error at first offense level and administering medication that nurse didn't personally prepare as an offense. a. Nurse was provided with re-education related appropriate medication administration and destroying of medications if interrupted during medication pass or administering medication that you did not personally prepare. b. A medication administration quiz was administered to this nurse who scored 90%. The medical director was notified on 03/06/17 at 5:15 PM. Interview with the Medical Director on 03/07/17 at 12:31 PM revealed he was aware of the Immediate Jeopardy and met at the facility last night (03/06/17) about the issues. He said the physician would normally expect the nursing staff to contact the supervising nurse and contact the physician under the circumstances of the incident. He said monitor the resident's blood pressure until medication clears from his (resident #1) system. He said he had been informed of Resident #1's condition. He said the Immediate Jeopardy occurred due to the wrong medications being given to the Resident #1. He also said the Immediate Jeopardy could have been avoided by staying focused on the one resident, Resident #1. He said the nurse should have finished what she was doing and that would have solved the issue. Interview with the Attending Physician on 03/07/17 at 9:13 AM revealed he had been notified pretty quickly, soon after the incident. He said he would expect nursing staff during an emergency to watch the resident's blood pressure, , monitor the changes, and send the patient to the hospital. He said the Immediate Jeopardy occurred due to the nurse giving the wrong medication to the Resident #1. He also said the Immediate Jeopardy could have been avoided if the nurse double checked medications and the resident before administering. Interview with the Administrator on 03/07/17 at 10:07 AM revealed he was supervising staff to ensure policies and procedures were being followed by having morning clinical meetings where review of the previous 24-hours, noting new occurrences, and any follow-ups needed were being discussed. He said the Standard of Care Meeting was held weekly, along with monthly Quality Assurance Meetings. All new employees had Abuse/Neglect training during orientation. The DON and other administrative staff were supervised during morning clinical meetings, making assignments, and following up with the DON, ADON, SW, Activity Director, Dietary, Respiratory and MDS Coordinator / Case Mix Managers. The Administrator was looking at systems in place at the Standard of Care weekly meetings and Monthly QA meeting with the Medical Director involved. He said he also had daily contact and interactions with the DON. He was going out on the floor and interacting and observing nursing staff, housekeeping and dietary staff. He believed the Immediate Jeopardy occurred because the nurse was trying to do several things at once. To prevent reoccurrence, the nurses were in-serviced on policies and procedures that were in place. To follow the six rights of medication administration, right patient, right drug, right dose, right route, right time and right documentation. To give only medicines that you have prepared. He said the nurses were also in-serviced to finish a task that had been started before going to the next task. LVN A was reprimanded on 03/03/17. RN B was reprimanded on 03/06/17. Interview with the DON on 03/07/17 at 9:47 AM revealed she was supervising staff to ensure policies and procedures were being followed by being out on the floor, watching staff assist residents. She also had staff complete competency evaluations. She said she was following up on nurses' notes and incident reports. She said she was having staff meetings and communicating with staff through computer notes which showed up on the computer screen when nurses and CNAs logged on. The DON was supervising nursing staff, and the ADON during morning meetings would review clinical reports and follow up on labs, medications and skin issues. She said she was out on the floor monitoring nurses and CNAs. The DON said the Immediate Jeopardy occurred because there were too many distractions. The nurses were expected to follow policies and procedures for medication administration. To prevent the reoccurrence, nurses had been in-serviced that if distracted during medication pass and unable to complete administration of medication to resident, they were to destroy the medications. Nurses were also in-serviced to only administer one person's medications at a time, even if in a hurry, and the nurse needed to finish what they were doing first. LVN A was reprimanded on 03/03/17 and RN B was reprimanded on 03/06/17. Review of Employee Memorandom for RN B, dated 03/06/17, reflected a medication error date of 03/03/17 for nurse orienting to the facility when medication was administered to the wrong resident. The employee was to follow proper administration protocol as in-serviced to prevent medication errors. If the employee was interrupted in medication pass, destroy medications and start over. The corrective action: if future medication errors occur then immediate termination would result. The form was signed by the employee as having received notification on 03/06/17, and also by the DON and Administrator on 03/06/17. Review of Employee Memorandom for LVN A dated 03/03/17, reflected a medication error date of 03/03/17 for an employee orienting a new nurse to the facility when the wrong medications were administered to the wrong resident. The employee was to follow proper administration protocol as in-serviced to prevent medication errors. If the employee was interrupted in medication pass, destroy medications and start over. The corrective action: if future medication errors occur then immediate termination would result. The form was signed by the employee as having received notification on 03/03/17, signed by the DON on 03/03/17 and the Administrator on 03/06/17. Interviews on 03/07/17 between 12:20 PM and 2:20 PM with the following individuals, from the following shifts, regarding in-services on abuse/neglect, medication administration and the facility medication quizzes revealed no concerns: PRN - LVN C, LVN D; 6:00 PM to 6:00 AM - LVN C, LVN D; 6:00 AM to 6:00 PM - LVN D, LVN F, LVN A, RN B, LVN G, LVN H; 6:00 AM. to 2:00 PM - CMA D; 2:00 PM to 10:00 PM - CMA A; 10:00 PM to 6:00 AM - LVN C, LVN D Review of in-services given by the DON on 03/04/17 reflected two CMAs and two LVNs were trained on Medication Administration. In-Service given by the DON on 03/05/17 reflected 10 out of 17 staff were trained on Medication Monitoring. In-service given by the DON on 03/06/17 reflected 10 out of 16 staff were trained on Oral Medication Administration, including to only give medications that they had prepared; also, refraining from delegating someone to give medications that had not been prepared by them. Follow the six rights of administration. No presetting of medication will be tolerated. Review of in-service presented on 03/06/17 by the DON reflected 9 out of 29 employees trained on reporting of suspected resident abuse and neglect. Review of Medication Administration Review Quiz with 21 questions on medication administration reflected it was completed by 13 out of 13 staff. Review of Medication Pass Competency reflected 13 areas observed in administration of medication by 5 staff out of 5 staff on 03/07/17 (LVN A at 8:54 AM. CMA A at 9:05 AM; LVN F at 12:12 PM; CMA D at 9:05 AM; LVN H at 9:06 AM.) Review of Medication Pass Observation of 6 staff out of 6 staff with competency demonstrated on 03/06/17. (LVN H, LVN G, LVN E, LVN M, LVN N, RN B) LVN A and RN B worked 200 hall on 03/04/17 with 19 residents on the hall. On 03/07/17 the IJ was removed. On 03/07/17 at 11:30 AM the Administrator were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope pattern because the facility still implementing its Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (Resident #1) of 19 residents who were reviewed for medication administration. LVN A failed to ensure she administered medications for Resident #1 on 03/03/17 that she dispensed, and instead delegated the responsibility to RN B who failed to administer the correct medications to Resident #1, and instead administered five medications that did not belong to the Resident #1 but to Resident #2. As a result of the errors, Resident #1's heart rate and blood pressure dropped and the resident was sent to the hospital and is currently in the Intensive Care Unit. An Immediate Jeopardy was identified on 03/06/17. While the IJ was removed on 03/07/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the 19 residents who received their medications from LVN A and RN B by placing the residents at risk for adverse drug reactions, overdose, and change in condition. Findings included: Review of The Standards of Nursing Practice on 03/07/17 (22 TAC §217.11) applicable to LVNs (as well as RNs) includes the following standards that specifically relate to medication administration: (1)(D) Accurately and completely report and document: (iv) administration of medications and treatments; Resident #1's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and required extensive assistance with his ADLs. Review of Medication Administration Record [REDACTED]. Care Plan Review for Resident #1, dated 01/26/17, reflecting has Resident #1 has a [DIAGNOSES REDACTED]. Goal for Resident #1 was to have no reports of complications due to hypo/hypertensive episodes. Interventions included to provide medications as ordered; notify MD and RP of change in status; observe for signs/symptoms of hypertensive episode to include but not limited to: Headache, elevated pulse, sweating, pallor, cyanosis, dizziness, change in mental status and to notify nurse. Interventions also included to observe for signs and symptoms of hypotensive episode to include but not limited to: cool clammy skin, cyanosis, change in mental status, dizziness, nausea and to notify nurse. Review of incident report for Resident #1, dated 03/03/17 at 5:36 PM and revised on 03/04/17 at 8:27 AM, reflected LVN A prepared the report documenting the medication error; the error involved the wrong patient and wrong medication. LVN A gave Resident #1 the wrong medication due to the distraction of another resident in distress at 10:00 AM. Resident #1 was assessed, 911 was called, and the physician and family member were notified. Resident #1's vital signs were obtained every five to 10 minutes until paramedics arrived. Resident #1 was oriented to person. Review of a nurse's note dated 03/03/17 at 8:07 PM by LVN A reflected Resident #1 had been admitted to the Hospital ICU in stable condition at that time. A note dated 03/03/17 by the DON in the incident report documented speaking to LVN A concerning the medication error. LVN A told the DON that she was getting medication ready for Resident #1 when transport for another resident arrived. LVN A then put Resident #1's medication in the top of the medication cart drawer and started to prepare other residents medication so that he could go to [MEDICAL TREATMENT]. The Activity Director interrupted LVN A to assist a resident who was leaning out of wheelchair. LVN A placed the medication on the cart to assist the resident. She then asked the nurse she was training, RN B, to go ahead and administer the prepared medications to Resident #1. RN B picked up the medication on the cart and administered it to Resident #1. The medication administered belonged to another resident. The DON spoke to LVN A for one-on-one in-service on proper medication administration. A note by the DON in the incident report, dated 03/04/17, reflected the DON called hospital to inquire on Resident #1's condition. She spoke to the Nurse/RN in the ICU. Resident #1 was admitted to the ICU yesterday (03/03/17) and was placed on [MEDICATION NAME] drip to reverse beta blocker (low blood pressure medication), but Resident #1 began to have nausea and vomiting, so the [MEDICATION NAME] drip was discontinued. Resident #1 was given a [MEDICATION NAME] drip at that time, treatment for [REDACTED]. Telephone Interview on 03/04/17 at 12:10 PM with LVN A revealed she was orienting RN B on 03/03/17 on the 200 hall and giving medications along with RN B. She had gotten medications ready for Resident #1, which were put in a medication cup in front of RN B who witnessed the process. Transport arrived to take Resident #2 to [MEDICAL TREATMENT], so Resident #1's medication was kept in his medication cup and put in drawer of medication cart in view of RN B. Medication for Resident #2 was then dispensed so that he could go to [MEDICAL TREATMENT]. This was also done with RN B witnessing the medication for Resident #2 being put in a medication cup on top of the cart. At that time, the Activity Director alerted LVN A that Resident #2 was unresponsive and leaning out of his wheelchair. LVN A instructed RN B to go ahead and give medications that were ready in the drawer of the medication cart to Resident #1 so that she could care for Resident #2. RN B instead gave Resident #1 the medications that were on top of the cart, which were in fact medications for Resident #2. Telephone Interview on 03/04/17 at 12:40 PM with RN B revealed she was oriented by LVN A on 03/03/17. She saw medications dispensed for Resident #1 and put on top of the medication cart. Medications for Resident #2 were also dispensed and put in a cup due to transport for Resident #2 having arrived to take him to [MEDICAL TREATMENT]. RN B said she left to take blood pressure for Resident #1, and when she returned, was handed a cup with medications by LVN A and told to give them to Resident #1. LVN A then put medications, who RN B thought belonged to Resident #2 into the cart, but were actually medications belonging to Resident #1. The medications were put back into the medication cart by LVN A so that she could attend to Resident #2 because the Activity Director had alerted LVN A that Resident #2 was unresponsive at that time. Interview with the DON on 03/04/17 at 1:30 PM revealed she was in the facility on the afternoon of 03/04/17 and had investigated the medication error of Resident #1 being given medications that were supposed to have been given to Resident #2. She said she in-serviced of LVN A following medication error policy/procedure of 5 rights when administering medication. She was also in the process of in-servicing nurses on medication administration. Resident #1 was sent to the hospital for treatment and was currently in the ICU. Best practice was for the nurse preparing medications to administer them and not to delegate the task to another nurse. She said LVN A and RN B worked on the 200 hall on 03/07/17. RN B was disciplined on 03/06/17. Record review of In-Service dated 03/04/17 reflected two CMAs and one LVN were in-serviced on Medication Administration. Professional standard as reflected in policy and procedure for administering oral medications: [REDACTED]. Review of Policy and Procedure for Medication Administration reflected general guidelines and precautions: .#3. Given only medicines that you have prepared. .#5. the six rights of medication administration: Right patient, right drug, right dose, right route, right time and right documentation. Review of Policy and Procedure for Prevention and Reporting of Suspected Resident Abuse and Neglect reflected procedure for screening, training, prevention, identification, protection, investigation and reporting. An Immediate Jeopardy was identified on 03/06/17 at 1:03 PM. The Administrator and DON were informed and a plan of removal was requested at that time. The plan of removal was accepted on 03/07/17 at 11:35 PM and reflected the following steps taken to remove the immediacy: 1. In-Service Training on Medication Administration Policy and Process, oral, monitored by DON. In-services began on 03/05/17 and were completed on 03/06/17 with DON conducting the medication administration training. All nurses and medication aides will pass a medication administration quiz and a Med Pass Competency before taking charge of a medication cart. Any part-time or PRN staff will not be allowed to take charge of a medication cart until they have passed both the quiz and competency check. Med Pass Competency is being is being performed by DON and case mix managers LVN I and LVN J. Med pass monitoring will be completed each shift for 24 hours. 2. Facility policy on Abuse, neglect and Exploitation with a focus on Neglect monitored by Administrator. In-services for nurses and medication aides began 03/06/17 and completed on 03/07/17 by 10:00 PM. 3. Not administering medication that wasn't prepared by the nurse personally, monitored by the DON. In-services began on 03/05/17 and were completed on 03/06/17. 4. All nurses required to complete Medication Administration quiz prior to assuming any medication administration responsibility and determine knowledge retention. Staff Reprimands: 1. LVN A - written up per facility policy related medication error, elevated to 3rd degree discipline with any further medication errors resulting in termination of employment. a. Nurse was provided with re-education related appropriate medication administration and destroying of medications if interrupted during medication pass. b. A medication administration quiz was administered to this nurse who scored 85%. 2. RN B - written up per facility policy related to medication error at first offense level and administering medication that nurse didn't personally prepare as an offense. a. Nurse was provided with re-education related appropriate medication administration and destroying of medications if interrupted during medication pass or administering medication that you did not personally prepare. b. A medication administration quiz was administered to this nurse who scored 90%. The medical director was notified on 03/06/17 at 5:15 PM. Interview with the Medical Director on 03/07/17 at 12:31 PM revealed he was aware of the Immediate Jeopardy and met at the facility last night (03/06/17) about the issues He said the physician would normally expect the nursing staff to contact the supervising nurse and contact the physician under the circumstances of the incident. He said monitor the resident's blood pressure until medication clears from his (resident #1) system. He said he had been informed of Resident #1's condition. He said the Immediate Jeopardy occurred due to the wrong medications being given to the Resident #1. He also said the Immediate Jeopardy could have been avoided by staying focused on the one resident, Resident #1. He said the nurse should have finished what she was doing and that would have solved the issue. Interview with the Attending Physician on 03/07/17 at 9:13 AM revealed he had been notified pretty quickly, soon after the incident. He said he would expect nursing staff during an emergency to watch the resident's blood pressure, , monitor the changes, and send the patient to the hospital. He said the Immediate Jeopardy occurred due to the nurse giving the wrong medication to the Resident #1. He also said the Immediate Jeopardy could have been avoided if the nurse double checked medications and the resident before administering. Interview with the Administrator on 03/07/17 at 10:07 AM revealed he was supervising staff to ensure policies and procedures were being followed by having morning clinical meetings where review of the previous 24-hours, noting new occurrences, and any follow-ups needed were being discussed. He said the Standard of Care Meeting was held weekly, along with monthly Quality Assurance Meetings. All new employees had Abuse/Neglect training during orientation. The DON and other administrative staff were supervised during morning clinical meetings, making assignments, and following up with the DON, ADON, SW, Activity Director, Dietary, Respiratory and MDS Coordinator / Case Mix Managers. The Administrator was looking at systems in place at the Standard of Care weekly meetings and Monthly QA meeting with the Medical Director involved. He said he also had daily contact and interactions with the DON. He was going out on the floor and interacting and observing nursing staff, housekeeping and dietary staff. He believed the Immediate Jeopardy occurred because the nurse was trying to do several things at once. To prevent reoccurrence, the nurses were in-serviced on policies and procedures that were in place. To follow the six rights of medication administration, right patient, right drug, right dose, right route, right time and right documentation. To give only medicines that you have prepared. He said the nurses were also in-serviced to finish a task that had been started before going to the next task. LVN A was reprimanded on 03/03/17. RN B was reprimanded on 03/06/17. Interview with the DON on 03/07/17 at 9:47 AM revealed she was supervising staff to ensure policies and procedures were being followed by being out on the floor, watching staff assist residents. She also had staff complete competency evaluations. She said she was following up on nurses' notes and incident reports. She said she was having staff meetings and communicating with staff through computer notes which showed up on the computer screen when nurses and CNAs logged on. The DON was supervising nursing staff, and the ADON during morning meetings would review clinical reports and follow up on labs, medications and skin issues. She said she was out on the floor monitoring nurses and CNAs. The DON said the Immediate Jeopardy occurred because there were too many distractions. The nurses were expected to follow policies and procedures for medication administration. To prevent the reoccurrence, is nurses had been in-serviced that if distracted during medication pass and unable to complete administration of medication to resident, they were to destroy the medications. Nurses were also in-serviced to only administer one person's medications at a time, even if in a hurry, and the nurse needed to finish what they were doing first. LVN A was reprimanded on 03/03/17 and RN B was reprimanded on 03/06/17. Review of Employee Memorandom for RN B, dated 03/06/17, reflected a medication error date of 03/03/17 for nurse orienting to the facility when medication was administered to the wrong resident. The employee was to follow proper administration protocol as in-serviced to prevent medication errors. If the employee was interrupted in medication pass, destroy medications and start over. The corrective action: if future medication errors occur then immediate termination would result. The form was signed by the employee as having received notification on 03/06/17, and also by the DON and Administrator on 03/06/17. Review of Employee Memorandom for LVN A, dated 03/03/17, reflected a medication error date of 03/03/17 for an employee orienting a new nurse to the facility when the wrong medications were administered to the wrong resident. The employee was to follow proper administration protocol as in-serviced to prevent medication errors. If the employee was interrupted in medication pass, destroy medications and start over. The corrective action: if future medication errors occur then immediate termination would result. The form was signed by the employee as having received notification on 03/03/17, signed by the DON on 03/03/17 and the Administrator on 03/06/17. Interviews on 03/07/17 between 12:20 PM and 2:20 PM with the following individuals, from the following shifts, regarding in-services on abuse/neglect, medication administration and the facility medication quizzes revealed no concerns: PRN - LVN C, LVN D; 6:00 PM to 6:00 AM - LVN C, LVN D; 6:00 AM to 6:00 PM - LVN D, LVN F, LVN A, RN B, LVN G, LVN H; 6:00 AM. to 2:00 PM - CMA D; 2:00 PM to 10:00 PM - CMA A; 10:00 PM to 6:00 AM - LVN C, LVN D Review of in-services given by the DON on 03/04/17 reflected two CMAs and two LVNs were trained on Medication Administration. Review of in-services given by the DON on 03/04/17 reflected two CMAs and two LVNs were trained on Medication Administration. In-Service given by the DON on 03/05/17 reflected 10 out of 17 staff were trained on Medication Monitoring. In-service given by the DON on 03/06/17 reflected 10 out of 16 staff were trained on Oral Medication Administration, including to only give medications that they had prepared; also, refraining from delegating someone to give medications that had not been prepared by them. Follow the six rights of administration. No presetting of medication will be tolerated. Review of in-service presented on 03/06/17 by the DON reflected 9 out of 29 employees trained on reporting of suspected resident abuse and neglect. Review of Medication Administration Review Quiz with 21 questions on medication administration reflected it was completed by 13 out of 13 staff. Review of Medication Pass Competency reflected 13 areas observed in administration of medication by 5 staff out of 5 staff on 03/07/17 (LVN A at 8:54 AM. CMA A at 9:05 AM; LVN F at 12:12 PM; CMA D at 9:05 AM; LVN H at 9:06 AM.) Review of Medication Pass Observation of 6 staff out of 6 staff with competency demonstrated on 03/06/17. (LVN H, LVN G, LVN E, LVN M, LVN N, RN B) LVN A and RN B worked 200 hall on 03/04/17 with 19 residents on the hall. On 03/07/17 the IJ was removed. On 03/07/17 at 11:30 AM the Administrator were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope pattern because the facility still implementing its Plan of Removal.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibited and prevented neglect for one (Resident #1) of 19 residents who were reviewed for neglect. LVN A failed to ensure she administered medications for Resident #1 on 03/03/17 that she dispensed, and instead delegated the responsibility to RN B who failed to administer the correct medications to Resident #1, and instead administered five medications that did not belong to the Resident #1 but to Resident #2. As a result of the errors, Resident #1's heart rate and blood pressure dropped and the resident was sent to the hospital and is currently in the Intensive Care Unit. An Immediate Jeopardy was identified on 03/06/17. While the IJ was removed on 03/07/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the 19 residents who received their medications from LVN A and RN B by placing the residents at risk for adverse drug reactions, overdose, and change in condition. Findings included: Review of The Standards of Nursing Practice on 03/07/17 (22 TAC §217.11) applicable to LVNs (as well as RNs) includes the following standards that specifically relate to medication administration: (1)(D) Accurately and completely report and document: (iv) administration of medications and treatments; Review of undated Policy and Procedure for Prevention and Reporting of Suspected Resident Abuse and Neglect reflected procedures for screening, training, prevention, identification, protection, investigation and reporting. Neglect is defined under 7. A. D. Neglect Allegation, as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness Review of undated Policy and Procedure for Medication Administration reflected general guidelines and precautions: .#3. Given only medicines that you have prepared. .#5. the six rights of medication administration: Right patient, right drug, right dose, right route, right time and right documentation. Resident #1's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and required extensive assistance with his ADLs. Review of Medication Administration Record [REDACTED]. Review of incident report for Resident #1, dated 03/03/17 at 5:36 PM and revised on 03/04/17 at 8:27 AM, reflected LVN A prepared the report documenting the medication error; the error involved the wrong patient and wrong medication. LVN A gave Resident #1 the wrong medication due to the distraction of another resident in distress at 10:00 AM. Resident #1 was assessed, 911 was called, and the physician and family member were notified. Resident #1's vital signs were obtained every five to 10 minutes until paramedics arrived. Resident #1 was oriented to person. Review of a nurse's note dated 03/03/17 at 8:07 PM by LVN A reflected Resident #1 had been admitted to the Hospital ICU in stable condition at that time. A note dated 03/03/17 by the DON in the incident report documented speaking to LVN A concerning the medication error. LVN A told the DON that she was getting medication ready for Resident #1 when transport for another resident arrived. LVN A then put Resident #1's medication in the top of the medication cart drawer and started to prepare other residents medication so that he could go to [MEDICAL TREATMENT]. The Activity Director interrupted LVN A to assist a resident who was leaning out of wheelchair. LVN A placed the medication on the cart to assist the resident. She then asked the nurse she was training, RN B, to go ahead and administer the prepared medications to Resident #1. RN B picked up the medication on the cart and administered it to Resident #1. The medication administered belonged to another resident. The DON spoke LVN A for one-on-one in-service on proper medication administration. A note by the DON in the incident report, dated 03/04/17, reflected the DON called hospital to inquire on Resident #1's condition. She spoke to the Nurse/RN in the ICU. Resident #1 was admitted to the ICU yesterday (03/03/17) and was placed on [MEDICATION NAME] drip to reverse beta blocker (low blood pressure medication), but Resident #1 began to have nausea and vomiting, so the [MEDICATION NAME] drip was discontinued. Resident #1 was given a [MEDICATION NAME] drip at that time, treatment for [REDACTED]. Telephone Interview on 03/04/17 at 12:10 PM with LVN A revealed she was orienting RN B on 03/03/17 on the 200 hall and giving medications along with RN B. She had gotten medications ready for Resident #1, which were put in a medication cup in front of RN B who witnessed the process. Transport arrived to take Resident #2 to [MEDICAL TREATMENT], so Resident #1's medication was kept in his medication cup and put in drawer of medication cart in view of RN B. Medication for Resident #2 was then dispensed so that he could go to [MEDICAL TREATMENT]. This was also done with RN B witnessing the medication for Resident #2 being put in a medication cup on top of the cart. At that time, the Activity Director alerted LVN A that Resident #2 was unresponsive and leaning out of his wheelchair. LVN A instructed RN B to go ahead and give medications that were ready in the drawer of the medication cart to Resident #1 so that she could care for Resident #2. RN B instead gave Resident #1 the medications that were on top of the cart, which were in fact medications for Resident #2. Telephone Interview on 03/04/17 at 12:40 PM with RN B revealed she was oriented by LVN A on 03/03/17. She saw medications dispensed for Resident #1 and put on top of the medication cart. Medications for Resident #2 were also dispensed and put in a cup due to transport for Resident #2 having arrived to take him to [MEDICAL TREATMENT]. RN B said she left to take blood pressure for Resident #1, and when she returned, was handed a cup with medications by LVN A and told to give them to Resident #1. LVN A then put medications, who RN B thought belonged to Resident #2 into the cart, but were actually medications belonging to Resident #1. The medications were put back into the medication cart by LVN A so that she could attend to Resident #2 because the Activity Director had alerted LVN A that Resident #2 was unresponsive at that time. Interview with the DON on 03/04/17 at 1:30 PM revealed she was in the facility on the afternoon of 03/04/17 and had investigated the medication error of Resident #1 being given medications that were supposed to have been given to Resident #2. She said she in-serviced LVN A following medication error policy/procedure of 5 rights when administering medication. She was also in the process of in-servicing nurses on medication administration. Resident #1 was sent to the hospital for treatment and was currently in the ICU. Best practice was for the nurse preparing medications to administer them and not to delegate the task to another nurse. She said LVN A and RN B worked on the 200 hall on 03/07/17. RN B was disciplined on 03/06/17. Record review of In-Service dated 03/04/17 reflected two CMAs and two LVN's were in-serviced on Medication Administration. An Immediate Jeopardy was identified on 03/06/17 at 1:03 PM. The Administrator and DON were informed and a plan of removal was requested at that time. The plan of removal was accepted on 03/07/17 at 11:35 PM and reflected the following steps taken to remove the immediacy: 1. In-Service Training on Medication Administration Policy and Process, oral, monitored by DON. In-services began on 03/05/17 and were completed on 03/06/17 with DON conducting the medication administration training. All nurses and medication aides will pass a medication administration quiz and a Med Pass Competency before taking charge of a medication cart. Any part-time or PRN staff will not be allowed to take charge of a medication cart until they have passed both the quiz and competency check. Med Pass Competency is being is being performed by DON and case mix managers LVN I and LVN J. Med pass monitoring will be completed each shift for 24 hours. 2. Facility policy on Abuse, neglect and Exploitation with a focus on Neglect monitored by Administrator. In-services for nurses and medication aides began 03/06/17 and completed on 03/07/17 by 10:00 PM. 3. Not administering medication that wasn't prepared by the nurse personally, monitored by the DON. In-services began on 03/05/17 and were completed on 03/06/17. 4. All nurses required to complete Medication Administration quiz prior to assuming any medication administration responsibility and determine knowledge retention. Staff Reprimands: 1. LVN A - written up per facility policy related medication error, elevated to 3rd degree discipline with any further medication errors resulting in termination of employment. a. Nurse was provided with re-education related appropriate medication administration and destroying of medications if interrupted during medication pass. b. A medication administration quiz was administered to this nurse who scored 85%. 2. RN B - written up per facility policy related to medication error at first offense level and administering medication that nurse didn't personally prepare as an offense. a. Nurse was provided with re-education related appropriate medication administration and destroying of medications if interrupted during medication pass or administering medication that you did not personally prepare. b. A medication administration quiz was administered to this nurse who scored 90%. The medical director was notified on 03/06/17 at 5:15 PM. Interview with the Medical Director on 03/07/17 at 12:31 PM revealed he was aware of the Immediate Jeopardy and met at the facility last night (03/06/17) about the issues. He said the physician would normally expect the nursing staff to contact the supervising nurse and contact the physician under the circumstances of the incident. He said monitor the resident's blood pressure until medication clears from his (resident #1) system. He said he had been informed of Resident #1's condition. He said the Immediate Jeopardy occurred due to the wrong medications being given to the Resident #1. He also said the Immediate Jeopardy could have been avoided by staying focused on the one resident, Resident #1. He said the nurse should have finished what she was doing and that would have solved the issue. Interview with the Attending Physician on 03/07/17 at 9:13 AM revealed he had been notified pretty quickly, soon after the incident. He said he would expect nursing staff during an emergency to watch the resident's blood pressure, , monitor the changes, and send the patient to the hospital. He said the Immediate Jeopardy occurred due to the nurse giving the wrong medication to the Resident #1. He also said the Immediate Jeopardy could have been avoided if the nurse double checked medications and the resident before administering. Interview with the Administrator on 03/07/17 at 10:07 AM revealed he was supervising staff to ensure policies and procedures were being followed by having morning clinical meetings where review of the previous 24-hours, noting new occurrences, and any follow-ups needed were being discussed. He said the Standard of Care Meeting was held weekly, along with monthly Quality Assurance Meetings. All new employees had Abuse/Neglect training during orientation. The DON and other administrative staff were supervised during morning clinical meetings, making assignments, and following up with the DON, ADON, SW, Activity Director, Dietary, Respiratory and MDS Coordinator / Case Mix Managers. The Administrator was looking at systems in place at the Standard of Care weekly meetings and Monthly QA meeting with the Medical Director involved. He said he also had daily contact and interactions with the DON. He was going out on the floor and interacting and observing nursing staff, housekeeping and dietary staff. He believed the Immediate Jeopardy occurred because the nurse was trying to do several things at once. To prevent reoccurrence, the nurses were in-serviced on policies and procedures that were in place. To follow the six rights of medication administration, right patient, right drug, right dose, right route, right time and right documentation. To give only medicines that you have prepared. He said the nurses were also in-serviced to finish a task that had been started before going to the next task. LVN A was reprimanded on 03/03/17. RN B was reprimanded on 03/06/17. Interview with the DON on 03/07/17 at 9:47 AM revealed she was supervising staff to ensure policies and procedures were being followed by being out on the floor, watching staff assist residents. She also had staff complete competency evaluations. She said she was following up on nurses' notes and incident reports. She said she was having staff meetings and communicating with staff through computer notes which showed up on the computer screen when nurses and CNAs logged on. The DON was supervising nursing staff, and the ADON during morning meetings would review clinical reports and follow up on labs, medications and skin issues. She said she was out on the floor monitoring nurses and CNAs. The DON said the Immediate Jeopardy occurred because there were too many distractions. The nurses were expected to follow policies and procedures for medication administration. To prevent the reoccurrence, is nurses had been in-serviced that if distracted during medication pass and unable to complete administration of medication to resident, they were to destroy the medications. Nurses were also in-serviced to only administer one person's medications at a time, even if in a hurry, and the nurse needed to finish what they were doing first. LVN A was reprimanded on 03/03/17 and RN B was reprimanded on 03/06/17. Review of Employee Memorandum for RN B, dated 03/06/07, reflected a medication error date of 03/03/17 for nurse orienting to the facility when medication was administered to the wrong resident. The employee was to follow proper administration protocol as in-serviced to prevent medication errors. If the employee was interrupted in medication pass, destroy medications and start over. The corrective action: if future medication errors occur then immediate termination would result. The form was signed by the employee as having received notification on 03/06/17, and also by the DON and Administrator on 03/06/17. Review of Employee Memorandum for LVN A, dated 03/03/17, reflected a medication error date of 03/03/17 for an employee orienting a new nurse to the facility when the wrong medications were administered to the wrong resident. The employee was to follow proper administration protocol as in-serviced to prevent medication errors. If the employee was interrupted in medication pass, destroy medications and start over. The corrective action: if future medication errors occur then immediate termination would result. The form was signed by the employee as having received notification on 03/03/17, signed by the DON on 03/03/17 and the Administrator on 03/06/17. Interviews on 03/07/17 between 12:20 PM and 2:20 PM with the following individuals, from the following shifts, regarding in-services on abuse/neglect, medication administration and the facility medication quizzes revealed no concerns: PRN - LVN C, LVN D; 6:00 PM to 6:00 AM - LVN C, LVN D; 6:00 AM to 6:00 PM - LVN D, LVN F, LVN A, RN B, LVN G, LVN H; 6:00 AM. to 2:00 PM - CMA D; 2:00 PM to 10:00 PM - CMA A; 10:00 PM to 6:00 AM - LVN C, LVN D Review of in-services given by the DON on 03/04/17 reflected two CMAs and two LVNs were trained on Medication Administration. In-Service given by the DON on 03/05/17 reflected 10 out of 17 staff were trained on Medication Monitoring. In-service given by the DON on 03/06/17 reflected 10 out of 16 staff were trained on Oral Medication Administration, including to only give medications that they had prepared; also, refraining from delegating someone to give medications that had not been prepared by them. Follow the six rights of administration. No presetting of medication will be tolerated. Review of in-service presented on 03/06/17 by the DON reflected 9 out of 29 employees trained on reporting of suspected resident abuse and neglect. Review of Medication Administration Review Quiz with 21 questions on medication administration reflected it was completed by 13 out of 13 staff. Review of Medication Pass Competency reflected 13 areas observed in administration of medication by 5 staff out of 5 staff on 03/07/17 (LVN A at 8:54 AM. CMA A at 9:05 AM; LVN F at 12:12 PM; CMA D at 9:05 AM; LVN H at 9:06 AM.) Review of Medication Pass Observation of 6 staff out of 6 staff with competency demonstrated on 03/06/17. (LVN H, LVN G, LVN E, LVN M, LVN N, RN B) LVN A and RN B worked 200 hall on 03/04/17 with 19 residents on the hall. On 03/07/17 the IJ was removed. On 03/07/17 at 11:30 AM the Administrator were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope pattern because the facility still implementing its Plan of Removal.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect, for one (Resident #1) of 19 residents who were reviewed for neglect. LVN A failed to ensure she administered medications for Resident #1 on 03/03/17 that she dispensed, and instead delegated the responsibility to RN B who failed to administer the correct medications to Resident #1, and instead administered five medications that did not belong to the Resident #1 but to Resident #2. As a result of the errors, Resident #1's heart rate and blood pressure dropped and the resident was sent to the hospital and is currently in the Intensive Care Unit. An Immediate Jeopardy was identified on 03/06/17. While the IJ was removed on 03/07/17, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. This failure could affect the 19 residents who received their medications from LVN A and RN B by placing the residents at risk for adverse drug reactions, overdose, and change in condition. Findings included: Review of The Standards of Nursing Practice on 03/07/17 (22 TAC §217.11) applicable to LVNs (as well as RNs) includes the following standards that specifically relate to medication administration: (1)(D) Accurately and completely report and document: (iv) administration of medications and treatments; Review of Policy and Procedure for Prevention and Reporting of Suspected Resident Abuse and Neglect reflected procedures for screening, training, prevention, identification, protection, investigation and reporting. Neglect is defined under 7. A. D. Neglect Allegation, as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness Resident #1's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment and required extensive assistance with his ADLs. Review of Medication Administration Record [REDACTED]. Review of incident report for Resident #1, dated 03/03/17 at 5:36 PM and revised on 03/04/17 at 8:27 AM, reflected LVN A prepared the report documenting the medication error; the error involved the wrong patient and wrong medication. LVN A gave Resident #1 the wrong medication due to the distraction of another resident in distress at 10:00 AM. Resident #1 was assessed, 911 was called, and the physician and family member were notified. Resident #1's vital signs were obtained every five to 10 minutes until paramedics arrived. Resident #1 was oriented to person. Review of a nurse's note dated 03/03/17 at 8:07 PM by LVN A reflected Resident #1 had been admitted to Hospital ICU in stable condition at that time. A note dated 03/03/17 by the DON in the incident report documented speaking to LVN A concerning the medication error. LVN A told the DON that she was getting medication ready for Resident #1 when transport for another resident arrived. LVN A then put Resident #1's medication in the top of the medication cart drawer and started to prepare other residents medication so that he could go to [MEDICAL TREATMENT]. The Activity Director interrupted LVN A to assist a resident who was leaning out of wheelchair. LVN A placed the medication on the cart to assist the resident. She then asked the nurse she was training (RN B) to go ahead and administer the prepared medications to Resident #1. RN B picked up the medication on the cart and administered it to Resident #1. The medication administered belonged to another resident. The DON spoke to LVN A for one-on-one in-service on proper medication administration. A note by the DON in the incident report, dated 03/04/17, reflected the DON called hospital to inquire on Resident #1's condition. She spoke to the Nurse/RN in the ICU. Resident #1 was admitted to the ICU yesterday (03/03/17) and was placed on [MEDICATION NAME] drip to reverse beta blocker (low blood pressure medication), but Resident #1 began to have nausea and vomiting, so the [MEDICATION NAME] drip was discontinued. Resident #1 was given a [MEDICATION NAME] drip at that time, treatment for [REDACTED]. Telephone Interview on 03/04/17 at 12:10 PM with LVN A revealed she was orienting RN B on 03/03/17 on the 200 hall and giving medications along with RN B. She had gotten medications ready for Resident #1 which were put in a medication cup in front of RN B who witnessed the process. Transport arrived to take Resident #2 to [MEDICAL TREATMENT], so Resident #1's medication was kept in his medication cup and put in drawer of medication cart in view of RN B. Medication for Resident #2 was then dispensed so that he could go to [MEDICAL TREATMENT]. This was also done with RN B witnessing medication for Resident #2 being put in a medication cup on top of the cart. At that time the Activity Director alerted LVN A that Resident #2 was unresponsive and leaning out of his wheelchair. LVN A instructed RN B to go ahead and give medications that were ready in the drawer of medication cart to Resident #1 so that she could care for Resident #2. RN B instead gave Resident #1 the medications that were on top of the cart which were in fact medications for Resident #2. Phone Interview on 03/04/17 at 12:40 PM with RN B revealed she was oriented by LVN A on 03/03/17. She saw medication dispensed for Resident #1 and put on top of the medication cart. Medications for Resident #2 were also dispensed and put in a cup due to transport for Resident #2 having arrived to take him to [MEDICAL TREATMENT]. RN B said she left to take blood pressure for Resident #1 and when she returned, was handed a cup with medications by LVN A and told to give them to Resident #1. LVN A then put medications, who RN B thought belonged to Resident #2 into the cart, but were actually medications belonging to Resident #1. The medications were put back into the medication cart by LVN A so that she could attend to Resident #2. The Activity Director had alerted LVN A that Resident #2 was unresponsive at that time. Interview with DON on 03/04/17 at 1:30 PM revealed she was in the facility in the afternoon of 03/04/17 and had investigated the medication error of Resident #1 being given medications that were supposed to have been given to Resident #2. She said she in-service of LVN A following medication error on policy/procedure of 5 rights when administering medication. She was also in the process of in-servicing nurses on medication administration. Resident #1 was sent to the hospital for treatment and is currently in the ICU. Best practice was for the nurse preparing medications to administer them and not delegate the task to another nurse. She said LVN A and RN B worked on the 200 hall on 03/07/17. LVN A was disciplined on 03/03/17. RN B was disciplined on 03/06/17. Record review of In-Service dated 03/04/17 reflected two CMA's and one LVN in-serviced on Medication Administration. Record review of In-Service dated 03/05/17 reflected RN B and LVN A, along with 5 LVN's and 2 CMA's on Medication Monitoring. Record review of In-Service dated 03/06/17 reflected RN B and LVN A, along with 5 LVN's and 2 CMA's on Oral Medication Administration. Record review of Policy and Procedure for Medication Administration reflected general guidelines and precautions #3. Given only medicines that you have prepared. Also reflected general guidelines and precaution #5. the six rights of medication administration: Right patient, right drug, right dose, right route, right time and right documentation. Review of undated Policy and Procedure for Prevention and Reporting of Suspected Resident Abuse and Neglect reflected procedures for screening, training, prevention, identification, protection, investigation and reporting. Neglect is defined under 7. A. D. Neglect Allegation, as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness An Immediate Jeopardy was identified on 03/06/17 at 1:03 PM. The Administrator and DON were informed and a plan of removal was requested at that time. The plan of removal was accepted on 03/07/17 at 11:35 PM and reflected the following steps taken to remove the immediacy: 1. In-Service Training on Medication Administration Policy and Process, oral, monitored by DON. In-services began on 03/05/17 and were completed on 03/06/17 with DON conducting the medication administration training. All nurses and medication aides will pass a medication administration quiz and a Med Pass Competency before taking charge of a medication cart. Any part-time or PRN staff will not be allowed to take charge of a medication cart until they have passed both the quiz and competency check. Med Pass Competency is being is being performed by DON and case mix managers LVN I and LVN J. Med pass monitoring will be completed each shift for 24 hours. 2. Facility policy on Abuse, neglect and Exploitation with a focus on Neglect monitored by Administrator. In-services for nurses and medication aides began 03/06/17 and completed on 03/07/17 by 10:00 PM. 3. Not administering medication that wasn't prepared by the nurse personally, monitored by the DON. In-services began on 03/05/17 and were completed on 03/06/17. 4. All nurses required to complete Medication Administration quiz prior to assuming any medication administration responsibility and determine knowledge retention. Staff Reprimands: 1. LVN A - written up per facility policy related medication error, elevated to 3rd degree discipline with any further medication errors resulting in termination of employment. a. Nurse was provided with re-education related appropriate medication administration and destroying of medications if interrupted during medication pass. b. A medication administration quiz was administered to this nurse who scored 85%. 2. RN B - written up per facility policy related to medication error at first offense level and administering medication that nurse didn't personally prepare as an offense. a. Nurse was provided with re-education related appropriate medication administration and destroying of medications if interrupted during medication pass or administering medication that you did not personally prepare. b. A medication administration quiz was administered to this nurse who scored 90%. The medical director was notified on 03/06/17 at 5:15 PM. Interview with the Medical Director on 03/07/17 at 12:31 PM revealed he is aware of the Immediate Jeopardy and met at the facility last night (03/06/17) about the issues. He said the physician would normally expect the nursing staff to contact the supervising nurse and contact the physician under the circumstances of the incident. He said the resident's blood pressure should be monitored until medication clears from his (resident #1) system. He said he had been been informed of resident's #1 condition. He said the Immediate Jeopardy occurred due to the wrong medications being given to resident #1. He also said the Immediate Jeopardy could have been avoided by staying focused on the one resident, Resident #1. He said the nurse should have finished what she was doing and that would have solved the issue. Interview with the Attending Physician on 03/07/17 at 9:13 AM revealed he had been notified pretty quickly, soon after the incident. He said he would expect nursing staff during an emergency to watch the resident's blood pressure, monitor the changes and send the patient to the hospital. He said the Immediate Jeopardy occurred due to the nurse giving the wrong medication to the Resident #1. He also said the Immediate Jeopardy could have been avoided if the nurse double checked medications and the resident before administering. Interview with the Administrator on 03/07/17 at 10:07 AM revealed he was supervising staff to ensure policies and procedures are being followed by having morning clinical meeting where review of the previous 24 hours, noting new occurrences and any follow-up needed were being discussed. He said the Standard of Care Meeting was held weekly along with monthly Quality Assurance Meetings. All new employees had Abuse/Neglect training during orientation. The DON and other administrative staff are supervised during morning clinical meetings, making assignments and following up with the DON, ADON, SW, Activity Director, Dietary, Respiratory and MDS Coordinator / Case Mix Managers. The Administrator was looking at systems in place at the Standard of Care weekly meetings and Monthly QA meeting with the Medical Director involved. He said he also had daily contact and interactions with the DON. He was going out on the floor and interacting and observing nursing staff, housekeeping and dietary staff. He believed the Immediate Jeopardy occurred because the nurse was trying to do several things at once. To prevent reoccurrence, the nurses were in-serviced on policies and procedures that were in place. To follow the six rights of medication administration, right patient, right drug, right dose, right route, right time and right documentation. To give only medicines that you have prepared. He said the nurses were also in-serviced to finish a task that has been started before going to next task. LVN A was reprimanded on 03/03/17. RN B was reprimanded on 03/06/17. Interview with DON on 03/07/17 at 9:47 AM revealed she was supervising staff to ensure policies and procedures were being followed by being out on the floor watching staff assist residents. She also had staff complete competency evaluations. She said she was following up on nurses' notes and incident reports. She said she was having staff meetings and communicating with staff through computer notes which showed up on the computer screen when nurses and CNA's logged on. The DON was supervising nursing staff, and the ADON during morning meetings would review clinical reports and follow up on labs, medications and skin issues. She said she was out on the floor monitoring nurses and CNA's. the DON said the Immediate Jeopardy occurred because there were too many distractions. The nurses were expected to follow policies and procedures for medication administration. To prevent the reoccurrence, nurses had been in-serviced that if distracted during medication pass and unable to complete administration of medication to resident, they were to destroy the medications. Nurses were also in-serviced to only administer one person's medications at a time, even if in a hurry, and the nurse needed to finish what they were doing first. LVN Awas reprimanded on 03/03/17 and RN B was reprimanded on 03/06/17. Review of Employee Memorandum for RN B, dated 03/06/17 reflected medication error date of 03/06/17 for nurse orienting to the facility when medication was administered to the wrong resident. The employee was to follow proper administration protocol as in-serviced to prevent medication errors. If the employee was interrupted in medication pass, destroy medications and start over. The corrective action: if future medication errors occur then immediate termination would result. The form was signed by the employee as having received notification on 03/06/17, and also by the DON and administrator on 03/06/17. Review of Employee Memorandum for LVN A, dated 03/03/17, reflected a medication error date of 03/03/17 for an employee orienting a new nurse to the facility when wrong medications were administered to the wrong resident. The employee was to follow proper administration protocol as in-serviced to prevent medication errors. If the employee is interrupted in medication pass, destroy medications and start over. The corrective action: if future medication errors occur then immediate termination would result. The form was signed by the employee as having received notification on 03/03/17, signed by the DON on 03/03/17 and the administrator on 03/06/17. Interviews on 03/07/17 between 12:20 PM and 2:20 PM with the following individuals, from the following shifts, regarding in-services on abuse/neglect, medication administration and the facility medication quizzes revealed no concerns. PRN - LVN C, LVN D; 6:00 PM to 6:00 AM - LVN C, LVN D; 6:00 AM to 6:00 PM - LVN D, LVN F, LVN A, RN B, LVN G, LVN H; 6:00 AM. to 2:00 PM - CMA D; 2:00 PM to 10:00 PM - CMA A; 10:00 PM to 6:00 AM - LVN C, LVN D Review of In-Service given by the DON on 03/04/17 reflected two CMA's and two LVN's were trained on Medication Administration. In-Service given by the DON on 03/05/17, reflected 10 staff out of 17 trained on Medication Monitoring. In-service given by the DON on 03/06/17 reflected 10 staff out of 16 trained on Oral Medication Administration including to only give medications that they had prepared: also, refraining from delegating someone to give medications that had not been prepared by them. Follow the six rights of administration. No presetting of medication will be tolerated. Review of in-service presented on 03/06/17 by the DON reflected 9 (CMA and LVN's) employees out of 29 employees trained on reporting suspected resident abuse and neglect. Review of Medication Administration Review Quiz with 21 questions on medication administration completed by 13 staff out of 13 staff. Review of Medication Pass Competency reflected 13 areas observed in administration of medication by 5 staff out of 5 staff on 03/07/17 (LVN A at 8:54 AM. CMA A at 9:05 AM; LVN F at 12:12 PM; CMA D at 9:05 AM; LVN H at 9:06 AM.) Review of Medication Pass Observation of 6 staff out of 6 staff with competency demonstrated on 03/06/17. (LVN H, LVN G, LVN E, LVN M, LVN N, RN B) LVN A and RN B worked 200 hall on 03/04/17 with 19 residents on the hall. On 03/07/17 the IJ was removed. On 03/07/17 at 11:30 AM the Administrator were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope pattern because the facility still implementing its Plan of Removal.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary services to maintain good grooming to a resident who was unable to carry out activities of daily living for one (Resident #13) of 13 residents reviewed for incontinence. The facility failed to provide Resident #13 with bladder incontinent care when it was needed. Resident #13 experienced depression and isolation due to these failures. She also had a reddened and excoriated buttocks. This failure could affect the facility's other 63 residents, who were incontinent of bowel and bladder, by placing them at risk for discomfort, skin breakdown, embarrassment, decreased self-esteem, poor physical hygiene, and isolation from others due to body odor. Findings included: 1) The confidential group interview on 04/15/14 at 3:00 p.m., revealed six of six residents complained about not receiving incontinent care timely. All six residents were alert, oriented and interviewable, according to the facility. Six of six residents stated if they have an incontinent episode during meal times, they had to wait until after the trays were passed out before incontinent care was provided. These six residents stated they were told by the CNAs providing incontinent care while trays were being served resulted in cross-contamination. All six residents stated if they were in the dining room and had to be changed, not only did they have to wait to be changed, but their food would be cold by the time incontinent care was provided. These six residents did not mention any staff names concerning this cross-contamination rule. Resident #13 stated, during the group interview, when she was wet and needed to be changed, the CNAs told her, "If you go to bed, you stay in bed." The resident stated she had to choose between going to activities or getting changed. She stated the CNAs left her in the room the rest of the day if she chose to have incontinent care provided. Resident #13 stated sometimes if they chose incontinent care, the CNA would transfer them to the bed, but still would not provide the incontinent care. This resident revealed she had a rash on her buttocks from sitting in her soiled brief for long periods at a time. Resident #13 stated she was depressed and felt isolated. The surveyor observed she had a strong odor of urine at this time. during this time. The surveyor stopped the confidential group interview at 4:00 p.m. and summoned a nurse to assist the resident to her room for incontinent care. The CNA came to assist the resident out of group at approximately 4:00 p.m. because the resident could not propel her wheelchair. The group continued at approximately 4:07 p.m. Five of five residents revealed they were depressed and embarrassed because they were left to sit in a soiled brief for hours before getting changed (especially during meal times). One resident from the confidential group stated he/she was depressed and felt belittled. 2) Review of Resident #13's MDS assessment dated [DATE], revealed the resident was a [AGE] year-old female who required extensive assistance of two persons with the Hoyer lift for transfers, toileting, and dressing. The MDS assessment reflected the resident was incontinent of bowel and bladder, and was cognitively intact. Resident #13 had the following Diagnoses: [REDACTED]. Review of Resident #13's Care Plan dated 10/14/13, revealed the resident was on diuretic therapy and had bladder incontinence. The interventions for the incontinence would be to ensure she was checked every two hours and as needed for incontinence and incontinent care would be provided. An observation and interview on 04/15/14 at 5:25 p.m. revealed Resident #13 sitting in her room in her wheelchair wearing the same pair of pants. The resident stated she was still waiting on someone to provide her care. Resident #13 revealed CNA A "just dropped me off." Observation on 04/15/14 at 5:50 p.m. revealed Resident #13 sitting in her wheelchair in her room with the same pair of pants she was wearing when she was taken out of the confidential group interview. Resident #13 stated the staff still had not provided incontinent care at that time. On 04/15/14 at 6:05 p.m., CNA A and MA B entered Resident #13's room he room and stated they were there to change the resident. They used the Hoyer Lift to transfer the Resident #13 from her wheelchair to the bed. Urine had seeped through the back of her pants at the panty-line. MA B provided peri-care (incontinent care) while CNA A assisted by positioning the resident on her left side. While Resident #13 was turned on her left side, both lower creases of her buttocks were observed to be reddened and excoriated (skin with opened areas). The resident's brief was soaked with urine. MA B stated Resident #13's "buttock looked like that all the time." MA B also stated Resident #13 buttocks looks like that all the time because she likes to stay up in her wheelchair. 3) An interview with Resident #5 on 04/17/14 at 10:40 a.m., revealed the staff took from one hour to an hour and a half to provide her with assistance with transfers to urinate or have a bowel movement. She stated this upset her. She stated that happened on the 6:00 a.m. to 2:00 p.m. shift. Resident #5 revealed she had not reported this to anyone. 4) An interview with LVN S on 05/10/14 at 10:30 a.m., revealed on 04/14/14 the CNAs did not provide incontinent care while the meal trays were out because of cross-contamination. He stated the previous DON informed him of this. 5) An interview with CNA T, on 05/10/14 at 10:38 a.m., revealed staff could not provide incontinent care while the meal trays were being served. She stated it had always been like that since she was hired. CNA T stated the previous DON made the rule. 6) An interview with CNA A on 05/10/14 at 11:30 a.m., revealed she provided incontinent care as soon as she propelled the resident to her room. CNA A stated she did not propel Resident #13 in her room and leave her without providing incontinent care. 7) The facility's Form CMS-672 (Residents Census and Conditions of Residents) dated 04/14/14 reflected 64 residents were identified with bowel and bladder incontinence.

Based on observation, interview, and record review, the facility failed to promote care and services for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for one (Resident #13) out of 18 residents reviewed for incontinent care and for six of six residents, who attended the confidential group interview, including Resident #13, who participated for part of the interview. The facility failed to provide incontinent care to Resident #13 when needed. Resident #13 experienced depression and isolation due to these failures. She also had a reddened and excoriated buttocks. The facility also failed to provide incontinent care to the other five residents in the group interview, when it was needed. The residents experienced depression and embarrassment as a result of these failures. These failures could affect the other 63 residents, who were incontinent of bowel and bladder, by placing them at risk for embarrassment, isolation, depression, skin breakdown, and discomfort. Findings included: 1) The confidential group interview on 04/15/14 at 3:00 p.m., revealed six of six residents complained about not receiving incontinent care timely. All six residents were alert, oriented and interviewable, according to the facility. Six of six residents stated if they have an incontinent episode during meal times, they had to wait until after the trays were passed out before incontinent care was provided. These six residents stated they were told by the CNAs providing incontinent care while trays were being served resulted in cross-contamination. All six residents stated if they were in the dining room and had to be changed, not only did they have to wait to be changed, but their food would be cold by the time incontinent care was provided. These six residents did not mention any staff names concerning this cross-contamination rule. Resident #13 stated, during the group interview, when she was wet and needed to be changed, the CNAs told her, "If you go to bed, you stay in bed." The resident stated she had to choose between going to activities or getting changed. She stated the CNAs left her in the room the rest of the day if she chose to have incontinent care provided. Resident #13 stated sometimes if they chose incontinent care, the CNA would transfer them to the bed, but still would not provide the incontinent care. This resident revealed she had a rash on her buttocks from sitting in her soiled brief for long periods at a time. Resident #13 stated she was depressed and felt isolated. The surveyor observed she had a strong odor of urine during this time. The surveyor stopped the confidential group interview at 4:00 p.m. and summoned a nurse to assist the resident to her room for incontinent care. The CNA came to assist the resident out of group at approximately 4:00 p.m., because the resident could not propel her wheelchair. The group continued at approximately 4:07 p.m. Five of five residents revealed they were depressed and embarrassed because they were left to sit in a soiled brief for hours before getting changed (especially during meal times). One resident from the confidential group stated he/she was depressed and felt belittled. 2) Review of Resident #13's MDS assessment dated [DATE], revealed the resident was a [AGE] year-old female who required extensive assistance of two persons with the Hoyer lift for transfers, toileting, and dressing. The MDS assessment reflected the resident was incontinent of bowel and bladder, and was cognitively intact. Resident #13 had the following Diagnoses: [REDACTED]. An observation and interview on 04/15/14 at 5:25 p.m. revealed Resident #13 sitting in her room in her wheelchair wearing the same pair of pants. The resident stated she was still waiting on someone to provide her care. Resident #13 revealed CNA A "just dropped me off." Observation on 04/15/14 at 5:50 p.m. revealed Resident #13 sitting in her wheelchair in her room with the same pair of pants she was wearing when she was taken out of the confidential group interview. Resident #13 stated the staff still had not provided incontinent care at that time. On 04/15/14 at 6:05 p.m., CNA A and MA B entered Resident #13's room he room and stated they were there to change the resident. They used the Hoyer Lift to transfer Resident #13 from her wheelchair to the bed. Urine had seeped through the back of her pants at the panty-line. MA B provided peri-care (incontinent care) while CNA A assisted by positioning the resident on her left side. While Resident #13 was turned on her left side, both lower creases of her buttocks were observed to be reddened and excoriated (skin with opened areas). The resident's brief was soaked with urine. MA B stated Resident #13's "buttock looked like that all the time." MA B also stated Resident #13 buttocks looks like that all the time because she likes to stay up in her wheelchair. An interview with CNA A on 05/10/14 at 11:30 a.m. revealed she changed Resident #13 at 5:30 p.m. on 04/15/14 after the surveyor inquired about when the incontinent care was performed. The resident incontinence care was the observed at 6:00 p.m. The resident was still wearing the same clothes she had on from 3:00 p.m. CNA A stated she had provided incontinent care to Resident #13 at 4:00 p.m. on 04/15/14. 4) An interview with Resident #5 on 04/17/14 at 10:40 a.m., revealed the staff took from one hour to an hour and a half to provide her with assistance with transfers to urinate or have a bowel movement. She stated this upset her. She stated that happened on the 6:00 a.m. to 2:00 p.m. shift. Resident #5 revealed she had not reported this to anyone. 5) An interview with LVN S on 05/10/2014 at 10:30 a.m., revealed that on 04/14/2014 the CNAs did not provide incontinent care while the meal trays were out because of cross-contamination. He stated the previous Director of Nursing informed him of this. 6) An interview with CNA T, on 05/10/2014 at 10:38 a.m., revealed she stated the staff could not provide incontinent care while the meal trays were being served. She stated, "it has always been like this since she was hired." CNA stated the previous Director of Nursing set up this rule. 7) The facility's Form CMS-672 (Residents Census and Conditions of Residents) dated 04/14/2014 reflected 64 residents were identified with bowel and bladder incontinence.

xc Based on observation, interview and record review, it was determined the facility failed to follow it's written policies and procedures that prohibit neglect for one (Resident #1) of seven residents reviewed for supervision while eating. The facility failed to provide Resident #1, who had [DIAGNOSES REDACTED]. Resident #1 was served the wrong diet by CNA A and was not checked on again for 40 minutes. Resident #1 became unresponsive and did not have a pulse or respirations. Staff initiated CPR and he was transferred to the local hospital where he expired later that day, [DATE]. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 23 residents, who ordered mechanically altered diets, by placing them at risk for not receiving their correct diet and not receiving appropriate supervision while eating, which could result in choking, aspiration, and/or death. Findings included: The facility's current Abuse Prohibition Policy and Procedure, revised [DATE], reflected, "Neglect* - A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident...." The policy also reflected, "III. Prevention of Abuse...C...The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned has knowledge of the individual residents care needs...The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect...those that require heavy nursing care and/or totally dependent on staff...." Resident #1's Admission Record, dated [DATE], from a prior facility reflected [DIAGNOSES REDACTED]. Dsyphagia Oral Phase (inability to coordinate chewing and swallowing a bolus of food placed in the mouth), Dsyphagia Pharyngeal Phase (aspiration of food into the trachea during the act of swallowing), Pneumonititis (inflammation of the lung) due to Inhalation of Food or Vomitus and Pneumonititis due to Other Solids and Liquids. Resident #1's physician's orders [REDACTED]. The Orders also reflected he needed a mechanical soft diet. Resident #1's MDS assessment, dated [DATE], reflected he needed supervision and set-up assistance with eating, was totally dependent on staff for mobility and transfers, and required extensive assistance with grooming, personal hygiene, and toileting. The MDS assessment also reflected he was cognitively intact, did not have any signs/symptoms of a swallowing problem, and had a mechanically altered diet. Resident #1's undated Interim Plan of Care reflected he was independent with eating and did not need supervision. The Plan of Care also reflected he needed a mechanical soft diet. Resident #1's Care Plan, initiated on [DATE] and revised on [DATE], regarding nutritional problems reflected an intervention of serving his diet as ordered by the physician, but it did not indicate his diet was mechanical soft. Resident #1's Care Plan, initiated on [DATE], did not reflect his need for supervision and set- up assistance for eating. Although Resident #1 had a history of [REDACTED]. The facility's Provider Investigation Report, dated [DATE], reflected Resident #1 was served a regular diet, which included a hamburger, instead of a mechanical soft diet on [DATE]. CNA A said she cut up the hamburger in small pieces for him and then went to the Dietary Department to request a mechanical soft diet for him. When CNA A returned to the resident's room, Resident #1 was unresponsive in his wheelchair and staff immediately called 911. Staff also initiated CPR and the resident was transferred to the hospital with a pulse of 34. He expired later that day in the hospital. Attached to the Provider Investigation Report was an undated Associate Memorandum, which reflected CNA A was suspended on [DATE]. Attached to the Provider Investigation Report, dated [DATE], was the DON's statement, dated [DATE], which reflected, "I was in my office with the administrator when I heard someone yelling 'hurry (DON) something is wrong with (Resident #1).' I started walking towards (Resident #1's room) and I seen (sic) staff running back and forth so I started running down there. I entered room, (Resident #1) was in the bed, he was gray, with gray lip (sic). I cannot remember if anyone else was in the room or not. I sent someone after the crash cart, I had someone roll down HOB, felt for a carotid pulse (none found) and I preceded to perform CPR. Pulse of 34 bpm was obtained (sic) per EMS monitor on there (sic) arrival.. I cannot recall the time that this occurred. (Resident #1) never had a swallowing problem; he just did not chew his food good." An interview with the DON on [DATE] at 2:10 p.m. revealed she was at the facility on Saturday, [DATE], at the time of the incident involving Resident #1. She stated most of the time Resident #1 ate his meals in the dining room, but she thought the reason he stayed in his room that day was because a football game was on television. The DON revealed she heard people yelling something was wrong with Resident #1. She stated she went to his room and found him unresponsive and gray in color with gray lips. She said she could not remember who else was in the room, but she recalled sending someone for the "crash" cart. The DON revealed the RT attempted to suction Resident #1 and was unsuccessful. She stated she initiated CPR and had the staff call 911. She said she saw a meal tray on a table with ? of a hamburger on it, and her first thought was "they had killed (Resident #1) and served him the wrong tray." The DON revealed he should have received a mechanical soft diet. She stated Resident #1 did not have a swallowing problem, but he ate too fast and did not chew his food up. She said he had a history of [REDACTED]. The DON revealed CNA A told her she had delivered the meal tray with the regular hamburger, and she had cut it into four pieces. CNA A's Witness Statement, dated [DATE], was also attached to the Provider Investigation Report. The Statement reflected, "At approximately 12:30 pm I took (Resident #1) tray to him. It had 1 hamburger (2 buns, 1 piece of meat, 1 piece of cheese), zucchini squash, and bowl of fruit. I seen (sic) his diet card and it said 'mechanical soft' with whole bacon and something else which I cannot remember. I cut his hamburger up into several pieces, but cannot remember how many. I then took this diet card back to dietary and spoke with (Cook L) and asked her about his whole hamburger. (Cook L) said that he was on a Mechanical soft diet but could have bacon and something else; I can't remember what (Cook L) said. (Cook L) then took the diet card and said she would fix him another tray at the end of the tray line. I went and finished passing my trays, as I knew when his other tray was fixed, someone would take it to him. At approx. (approximately) 1:10pm I went back to his room to pick up his tray and resident was sitting in a chair, his face and fingers were blue and he was unresponsive, I stepped into the hall, yelled for a nurse who came into the room, the nurse and I assisted him to bed, (Receptionist) called 911 and someone went and got (DON)." On [DATE] at 2:05 p.m., the surveyor attempted to contact CNA A. The surveyor left a message for a return call. On [DATE] at 4:45 p.m., the surveyor attempted to contact CNA A. The surveyor left another message for a return call. CNA A did not return either telephone call as of exit on [DATE]. LVN C's Witness Statement, dated [DATE], was attached to the Provider Investigation Report and reflected, "(LVN C) said she was coming out of the Sun Room when she heard (CNA A) holler nurse. (LVN C) then went directly into (Resident #1's) room. (Resident #1) was sitting in his wheel chair and she started to shake him and say his name. She hollered to (RN B) who was standing at the nursing station. (LVN C) said that she and (CNA A) immediately lifted (Resident #1) out of his wheel chair and laid him in his bed. (LVN C) said that she was not able to start the [MEDICATION NAME] maneuver or CPR due to the height of the wheel chair back. By the time they got him into the bed, (DON) came into the room and started CPR. All of this happened within 2 or 3 minutes." The statement was signed by LVN C. An interview with LVN C on [DATE] at 5:30 p.m. confirmed she was on duty on [DATE] at the time of the incident involving Resident #1. She stated CNA A called her to Resident #1's room. She stated she entered his room and he was slumped over in his wheelchair. She stated he was unresponsive. LVN C revealed she completed an assessment and found he was not breathing, his pupils were fixed and his fingers were blue. She stated he was not cold to the touch, nor was there any evidence of vomit on or around him. She stated she did think of a possible aspiration because she saw his tray in his room. LVN C revealed she immediately yelled for RN B. RN B's, Weekend Supervisor's, Witness Statement, dated [DATE], was attached to the Provider Investigation Report and reflected, "I, (name), at (sic) lunch checked the Sun Room food cart and rolled it into the Sun Room. Then I told (LVN C) that the trays were ready. (LVN C) went into the Sun Room and began serving the trays. I can't say that I checked the Lakeside cart because I seen (sic) (LVN D) entering the lunchroom to do his assigned lunch room duty and I think I just kept walking through the dining room. I do know that I went down to Ivy Lane to see which CNA was going to the dining room. I saw (staff member) passing trays. I went back to the break room and (CNA) was eating lunch. I told her that the trays were out. She put her lunch up and went to pass trays. I got a pillow from the laundry then went back through the dining room. (Staff member) was in the dining room passing trays. Then I took the pillow into the room to make up the bed for the new admit that is coming." An interview with RN B on [DATE] at 9:50 a.m. confirmed she was on duty on [DATE] at the time of the incident involving Resident #1. She stated the nurse assigned to the dining room was not in there on time, and she had to start grabbing carts and tray cards to review them. She revealed LVN D was assigned to assist in the dining room that day. She said when she was around the nurses' station, she heard CNA A call for LVN C to come. RN B revealed she then heard her name called and went to Resident #1's room. She stated she entered his room and saw Resident #1 and began tapping him in an attempt to arouse him. She said she assessed him and he was unresponsive. RN B revealed she did not recall observing any vomit, but he may have had been drooling. She stated she grabbed his wrist and felt nothing, if there had been a pulse it was very faint. She said CNA A and LVN C were trying to get him in his bed. RN B revealed she knew the DON was in the building and told a CNA U to get the DON and told the Receptionist to call 911. She stated she then got the "crash" cart and RT M. She stated when she returned, LVN D had the Ambu bag going, and staff had started chest compressions. RN F's Statement, dated [DATE], was attached to the Provider Investigation Report and reflected, "After interviews and obtaining statements from facility staff, at approximately 12;30 pm (CNA A) took (Resident #1) (sic) lunch tray to his room. Resident was sitting up in his wheel chair (sic); the (CNA A) stated that resident received regular diet. She cut his hamburger up into several bite size pieces, left the tray in the room and took his diet card to dietary and spoke with (Cook L). She stated she ask (sic) (Cook L) if resident was supposed to get a regular hamburger, and (Cook L) stated 'No' he usually gets a mechanical soft diet but can have whole bacon. (Cook L) stated she would fix (Resident #1) another tray at end of tray line. (CNA A) stated she went back to unit and proceeded to pass the rest of the trays as she knew someone would take (Resident #1) his tray. As approximately 1:10 pm she went back to (Resident #1's) room to pick up his lunch tray and noted (Resident #1) in his wheelchair, his face and hands were purple and not responding when she attempted to talk to him. (CNA A) stated she went to the door and yelled for a nurse. (LVN C) came immediately to the room, she stated she tried shaking and talking with resident, and he was unresponsive, she hollered for weekend supervisor who was at nurses (sic) station and she came to room immediately. (LVN C) stated that she had no way to start CPR or the [MEDICATION NAME] maneuver as he was in a high back wheelchair so she and (CNA A) assisted to him to bed while weekend supervisor went and got the DON. (LVN C) stated that DON walked into room just as they got resident into bed. (LVN C) stated it was 2 to 3 minutes from the time she had entered the room until the DON arrived and took over the situation. DON had then (sic) go get crash cart, DON check (sic) for carotid pulse, none was found, HOB was lowered and CPR was begun. DON stated that when she got into room resident was turning gray, with gray lips. 911 was notified, DON stated they had obtained a pulse of 34 bpm on EMS monitor prior to resident leaving facility. Resident left facility via EMS at 1:25pm." Interview on [DATE] at 3:40 p.m. with RN F, Director of Quality Assessment Performance Improvement, revealed she conducted the investigation of Resident #1's accident. She stated she received a text from the DON indicating she was in the building working and was going to the hospital with Resident #1. The text reflected, "They may have killed (Resident #1)." RN F immediately called the Administrator and he relayed what occurred with Resident #1. RN F stated she had the nursing staff immediately review the diet orders and reassess residents with swallowing disorders. She revealed she spoke with CNA A over the telephone on the night of [DATE] regarding the incident with Resident #1. RN F revealed CNA A told her she took Resident #1 his meal tray to him, and when she removed the lid from the food, she saw a regular hamburger. Then she looked at his tray card, which reflected he was supposed to have a mechanical soft diet. RN F stated CNA A cut the hamburger into small pieces and went to the kitchen to see about a new tray. CNA A told RN F dietary staff would take him the correct tray. CNA A left the tray with the cut up hamburger in his room. CNA A said dietary staff took Resident #1's tray card and said they would take him a new tray. She then went back to the hall to continue passing trays. When CNA A went back to pick up Resident #1's tray, she found him slumped over and non-responsive. RN F then stated LVN C told her Resident #1 was gray and non-responsive, she called to RN B to call 911. RN F revealed LVN C and CNA A moved Resident #1 to his bed to start CPR. The DON then came to the room and started CPR until the Emergency Medical Response arrived. RN F stated CNA A was suspended and then terminated. RN F said she went into the facility the next day and began in-service training for all staff in the areas of Dietary and Emergency Response. The Dietary Manager and Regional Dietician were to begin in-servicing dietary staff. RN F revealed the facility had a Registered Dietician at the facility every meal since Resident #1's incident to ensure meal trays were consistent with the diet orders prior to serving the meal to the residents. A Diet Roster was printed every day for all residents. A Communication Book was at each Nurse's Station for the CNAs to reference. A Dietary Notebook was posted in both dining areas as a reference to double check a diet order. A two check system was implemented, which included a person in dietary checked the diet card against the meal served and the person serving the meal checked again to ensure the meal was consistent with the diet order. She stated the Red Napkin Program was implemented to visually identify mechanical soft and pureed meals. Interview conducted with CNA G on [DATE] at 1:20 p.m. revealed she was familiar with Resident #1 and knew he was on a mechanical soft diet, mostly the meats. CNA G revealed Resident #1 normally went to the dining room to eat. Some days he did not want to go to the dining room and would eat in his room. She stated on those days someone was supposed to stay in his room with him. Since that day she revealed she had received training in dietary and trays with altered diets. On the day of the event with Resident #1 she knew the aide that had assisted him was CNA A and was aware that she no longer worked at the facility. She thought CNA A had been terminated due to what happened with Resident #1. Resident #1's Emergency Department Note, dated [DATE], reflected, "Per EMS, pt went unresponsive while in dining room eating, unwitnessed. Upon EMS arrival pt (Resident #1) was in PEA (Pulseless Electrical Activity), and when they placed the ETT (Endotracheal Tube) large chunks of food were suctioned out. EMS gave 2 doses of 1 mg EPI ([MEDICATION NAME]) and 40mg [MEDICATION NAME] PTA. CPR was still in progress upon arrival to ED." Resident #1's Emergency Department Note, dated [DATE], reflected, "...Per EMS: Pt was eating alone in his room at NH (Nursing Home). Pt was found not breathing on his own ...EMS had to clear airways. They found lots of food around him...unsure how long he was down, but found on his bed. Hx (History) of choking and aspiration. Pt had no pulse upon EMS arrival. Pt was warm and pupils were not blown when found...." Resident #1's Pulmonology Consult Note, [DATE], reflected, "Assessment: Aspiration into lower respiratory tract [MEDICAL CONDITION] [MEDICAL CONDITION] (absence of oxygen) [MEDICAL CONDITION] [MEDICAL CONDITION] and Atelectasis (collapse of the expanded lung)...." Resident #1's Emergency Department Physician Note, dated [DATE], reflected Resident #1's time of death was 5:48 p.m. The facility's current policy, Dining Communication Book, revised [DATE] reflected, "...Staff will be aware of all residents requiring texture or consistency modification, as well as any therapeutic restrictions ...Residents who have dysphagia and/or are at risk for aspiration or choking require special attention at meal time to assist in preventing these potential problems. This may include modification in food or fluid consistency and/or swallow precautions ...8. All residents requiring swallow precautions will receive adequate supervision, assistance and cueing as necessary during dining...." An IJ was identified on [DATE]. On [DATE] at 12:05 p.m., the Administrator, DON, RN F, and the Corporate Regional Nurse were informed of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on [DATE], reflected on [DATE] the Administrator implemented the following quality action plan: "...One charge nurse and one nursing assistant from each unit monitors patients that eat on the unit during meals to provide supervision, set up and assistance with meals during the course of meal services. The Charge Nurse and nursing assistant that monitor is assigned to monitoring only. The charge nurse uses the QAA Unit Meal Service Rounds Tool to document the following: Tray is set up with food items open (sic) or cut up per pt (patient) choice Patient requires assistance eating If patient needs assistance, tray is not taken to patient room until c.n.a. is ready to feed/assist C.N.A. set up meal tray (illegible) requested C.N.A. assisting patient per patient needs Food items and diet on tray card are correct Patient is silting (sic) upright (sic) (90 degree angle) Call light within reach ...Nursing and nursing assistants have been trained on meal consistencies on therapeutic diets and checking the meal ticket. Patients that have an (sic) chewing and swallowing problems receive a red napkin to identify they are at risk for chewing and swallowing problems. Staff can locate a list of residents who are at risk for chewing and swallowing problems in the C.N.A. assignment book located at each nurses station...." Observation on [DATE] at approximately 12:17 p.m. revealed the Cook checked the diet on the meal tray against the diet orders. The meal was checked again at the end of the tray line by the dietary aide. The meal went to the floor and was checked again by a manager and then again by an aide who delivered the tray to the resident. The meals on the carts were delivered to the hall, the Charge Nurse checked the tray, the meal was delivered to the resident, and was checked again. Diet Order Reference Books were observed in the main dining room and in the assisted dining room, so staff could check residents' diet orders. On the halls the CNAs had a Hall Monitor Book with a Unit Meal Service Monitoring Tool. Interview at 1:55 p.m. on [DATE] with CNA T revealed a CNA and nurse were always on the hall to monitor the residents' trays and check the diet orders. Interview at 1:35 p.m. on [DATE] with CNA U revealed in the dining room a paper was posted with the residents and their diet orders, and there was a book on the hall. CNA U stated there was also a list in the CNAs' book at the nurse's station. Interview at 1:45 p.m. on [DATE] with CNA V revealed they went over the dietary process and the difference in the mechanical soft and pureed meals. The training was to ensure the residents received the correct meals. Now there was a red napkin program to identify the residents who were on altered diets. There were postings in the dining rooms and at the nurse's stations. Interview at 2:00 p.m. on [DATE] with LVN C revealed they also covered dietary and residents on altered diets. Interview at 2:05 p.m. on [DATE] with LVN X revealed dietary checks were done by nurses, managers and the aides, on the hall it was checked again by the nurse and the CNA delivering the meal. Interview at 2:10 p.m. on [DATE] with LVN Y revealed dietary now used red napkins to identify the residents who were on altered diets. She stated she walks the hall during meal service to check the residents dining in their room at least twice during the meal time. Interview at 2:20 p.m. on [DATE] with CNA Z revealed the trainers also reviewed dietary services and the ability to tell the difference between pureed and mechanical soft diets, meal cards and diet orders, and the red napkin program which identified residents who were on altered diets. Interview at 10:40 a.m. on [DATE] with RN F revealed there was not a policy for the nurses to monitor the residents on the hall eating in their rooms. It was up to the professional judgment of the nurse on that hall and the facility staff could not force residents to come to the dining room to eat to ensure their safety. A new procedure was put into place since Resident #1's incident which included copies of residents on altered diets were put in the CNA book each day. The facility's in-service records, dated [DATE], reflected training was by RN F in the areas of Dietary Services and Emergency Response. The IJ was removed on [DATE]. The Administrator and RN F were notified on [DATE] at 10:25 a.m. that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's undated Residents on Mechanically Altered Diets reflected 23 residents.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of seven residents reviewed for supervision while eating. The facility failed to provide Resident #1, who had [DIAGNOSES REDACTED]. Resident #1 was served the wrong diet by CNA A and was not checked on again for 40 minutes. Resident #1 became unresponsive and did not have a pulse or respirations. Staff initiated CPR and he was transferred to the local hospital where he expired later that day, [DATE]. On [DATE], an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 23 residents, who ordered mechanically altered diets, by placing them at risk for not receiving their correct diet and not receiving appropriate supervision while eating, which could result in choking, aspiration, and/or death. Findings included: Resident #1's Admission Record, dated [DATE], from a prior facility reflected [DIAGNOSES REDACTED]. Dsyphagia Oral Phase (inability to coordinate chewing and swallowing a bolus of food placed in the mouth), Dsyphagia Pharyngeal Phase (aspiration of food into the trachea during the act of swallowing), Pneumonititis (inflammation of the lung) due to Inhalation of Food or Vomitus and Pneumonititis due to Other Solids and Liquids. Resident #1's physician's orders [REDACTED]. The Orders also reflected he needed a mechanical soft diet. Resident #1's MDS assessment, dated [DATE], reflected he needed supervision and set-up assistance with eating, was totally dependent on staff for mobility and transfers, and required extensive assistance with grooming, personal hygiene, and toileting. The MDS assessment also reflected he was cognitively intact, did not have any signs/symptoms of a swallowing problem, and had a mechanically altered diet. Resident #1's undated Interim Plan of Care reflected he was independent with eating and did not need supervision. The Plan of Care also reflected he needed a mechanical soft diet. Resident #1's Care Plan, initiated on [DATE] and revised on [DATE], regarding nutritional problems reflected an intervention of serving his diet as ordered by the physician, but it did not indicate his diet was mechanical soft. Resident #1's Care Plan, initiated on [DATE], did not reflect his need for supervision and set- up assistance for eating. Although Resident #1 had a history of [REDACTED]. The facility's Provider Investigation Report, dated [DATE], reflected Resident #1 was served a regular diet, which included a hamburger, instead of a mechanical soft diet on [DATE]. CNA A said she cut up the hamburger in small pieces for him and then went to the Dietary Department to request a mechanical soft diet for him. When CNA A returned to the resident's room, Resident #1 was unresponsive in his wheelchair and staff immediately called 911. Staff also initiated CPR and the resident was transferred to the hospital with a pulse of 34. He expired later that day in the hospital. Attached to the Provider Investigation Report was an undated Associate Memorandum, which reflected CNA A was suspended on [DATE]. Attached to the Provider Investigation Report, dated [DATE], was the DON's statement, dated [DATE], which reflected, "I was in my office with the administrator when I heard someone yelling 'hurry (DON) something is wrong with (Resident #1).' I started walking towards (Resident #1's room) and I seen (sic) staff running back and forth so I started running down there. I entered room, (Resident #1) was in the bed, he was gray, with gray lip (sic). I cannot remember if anyone else was in the room or not. I sent someone after the crash cart, I had someone roll down HOB, felt for a carotid pulse (none found) and I preceded to perform CPR. Pulse of 34 bpm was obtained (sic) per EMS monitor on there (sic) arrival.. I cannot recall the time that this occurred. (Resident #1) never had a swallowing problem; he just did not chew his food good." An interview with the DON on [DATE] at 2:10 p.m. revealed she was at the facility on Saturday, [DATE], at the time of the incident involving Resident #1. She stated most of the time Resident #1 ate his meals in the dining room, but she thought the reason he stayed in his room that day was because a football game was on television. The DON revealed she heard people yelling something was wrong with Resident #1. She stated she went to his room and found him unresponsive and gray in color with gray lips. She said she could not remember who else was in the room, but she recalled sending someone for the "crash" cart. The DON revealed the RT attempted to suction Resident #1 and was unsuccessful. She stated she initiated CPR and had the staff call 911. She said she saw a meal tray on a table with ? of a hamburger on it, and her first thought was "they had killed (Resident #1) and served him the wrong tray." The DON revealed he should have received a mechanical soft diet. She stated Resident #1 did not have a swallowing problem, but he ate too fast and did not chew his food up. She said he had a history of [REDACTED]. The DON revealed CNA A told her she had delivered the meal tray with the regular hamburger, and she had cut it into four pieces. CNA A's Witness Statement, dated [DATE], was also attached to the Provider Investigation Report. The Statement reflected, "At approximately 12:30 pm I took (Resident #1) tray to him. It had 1 hamburger (2 buns, 1 piece of meat, 1 piece of cheese), zucchini squash, and bowl of fruit. I seen (sic) his diet card and it said 'mechanical soft' with whole bacon and something else which I cannot remember. I cut his hamburger up into several pieces, but cannot remember how many. I then took this diet card back to dietary and spoke with (Cook L) and asked her about his whole hamburger. (Cook L) said that he was on a Mechanical soft diet but could have bacon and something else; I can't remember what (Cook L) said. (Cook L) then took the diet card and said she would fix him another tray at the end of the tray line. I went and finished passing my trays, as I knew when his other tray was fixed, someone would take it to him. At approx. (approximately) 1:10pm I went back to his room to pick up his tray and resident was sitting in a chair, his face and fingers were blue and he was unresponsive, I stepped into the hall, yelled for a nurse who came into the room, the nurse and I assisted him to bed, (Receptionist) called 911 and someone went and got (DON)." On [DATE] at 2:05 p.m., the surveyor attempted to contact CNA A. The surveyor left a message for a return call. On [DATE] at 4:45 p.m., the surveyor attempted to contact CNA A. The surveyor left another message for a return call. CNA A did not return either telephone call as of exit on [DATE]. LVN C's Witness Statement, dated [DATE], was attached to the Provider Investigation Report and reflected, "(LVN C) said she was coming out of the Sun Room when she heard (CNA A) holler nurse. (LVN C) then went directly into (Resident #1's) room. (Resident #1) was sitting in his wheel chair and she started to shake him and say his name. She hollered to (RN B) who was standing at the nursing station. (LVN C) said that she and (CNA A) immediately lifted (Resident #1) out of his wheel chair and laid him in his bed. (LVN C) said that she was not able to start the [MEDICATION NAME] maneuver or CPR due to the height of the wheel chair back. By the time they got him into the bed, (DON) came into the room and started CPR. All of this happened within 2 or 3 minutes." The statement was signed by LVN C. An interview with LVN C on [DATE] at 5:30 p.m. confirmed she was on duty on [DATE] at the time of the incident involving Resident #1. She stated CNA A called her to Resident #1's room. She stated she entered his room and he was slumped over in his wheelchair. She stated he was unresponsive. LVN C revealed she completed an assessment and found he was not breathing, his pupils were fixed and his fingers were blue. She stated he was not cold to the touch, nor was there any evidence of vomit on or around him. She stated she did think of a possible aspiration because she saw his tray in his room. LVN C revealed she immediately yelled for RN B. RN B's, Weekend Supervisor's, Witness Statement, dated [DATE], was attached to the Provider Investigation Report and reflected, "I, (name), at (sic) lunch checked the Sun Room food cart and rolled it into the Sun Room. Then I told (LVN C) that the trays were ready. (LVN C) went into the Sun Room and began serving the trays. I can't say that I checked the Lakeside cart because I seen (sic) (LVN D) entering the lunchroom to do his assigned lunch room duty and I think I just kept walking through the dining room. I do know that I went down to Ivy Lane to see which CNA was going to the dining room. I saw (staff member) passing trays. I went back to the break room and (CNA) was eating lunch. I told her that the trays were out. She put her lunch up and went to pass trays. I got a pillow from the laundry then went back through the dining room. (Staff member) was in the dining room passing trays. Then I took the pillow into the room to make up the bed for the new admit that is coming." An interview with RN B on [DATE] at 9:50 a.m. confirmed she was on duty on [DATE] at the time of the incident involving Resident #1. She stated the nurse assigned to the dining room was not in there on time, and she had to start grabbing carts and tray cards to review them. She revealed LVN D was assigned to assist in the dining room that day. She said when she was around the nurses' station, she heard CNA A call for LVN C to come. RN B revealed she then heard her name called and went to Resident #1's room. She stated she entered his room and saw Resident #1 and began tapping him in an attempt to arouse him. She said she assessed him and he was unresponsive. RN B revealed she did not recall observing any vomit, but he may have had been drooling. She stated she grabbed his wrist and felt nothing, if there had been a pulse it was very faint. She said CNA A and LVN C were trying to get him in his bed. RN B revealed she knew the DON was in the building and told a CNA U to get the DON and told the Receptionist to call 911. She stated she then got the "crash" cart and RT M. She stated when she returned, LVN D had the Ambu bag going, and staff had started chest compressions. RN F's Statement, dated [DATE], was attached to the Provider Investigation Report and reflected, "After interviews and obtaining statements from facility staff, at approximately 12;30 pm (CNA A) took (Resident #1) (sic) lunch tray to his room. Resident was sitting up in his wheel chair (sic); the (CNA A) stated that resident received regular diet. She cut his hamburger up into several bite size pieces, left the tray in the room and took his diet card to dietary and spoke with (Cook L). She stated she ask (sic) (Cook L) if resident was supposed to get a regular hamburger, and (Cook L) stated 'No' he usually gets a mechanical soft diet but can have whole bacon. (Cook L) stated she would fix (Resident #1) another tray at end of tray line. (CNA A) stated she went back to unit and proceeded to pass the rest of the trays as she knew someone would take (Resident #1) his tray. As approximately 1:10 pm she went back to (Resident #1's) room to pick up his lunch tray and noted (Resident #1) in his wheelchair, his face and hands were purple and not responding when she attempted to talk to him. (CNA A) stated she went to the door and yelled for a nurse. (LVN C) came immediately to the room, she stated she tried shaking and talking with resident, and he was unresponsive, she hollered for weekend supervisor who was at nurses (sic) station and she came to room immediately. (LVN C) stated that she had no way to start CPR or the [MEDICATION NAME] maneuver as he was in a high back wheelchair so she and (CNA A) assisted to him to bed while weekend supervisor went and got the DON. (LVN C) stated that DON walked into room just as they got resident into bed. (LVN C) stated it was 2 to 3 minutes from the time she had entered the room until the DON arrived and took over the situation. DON had then (sic) go get crash cart, DON check (sic) for carotid pulse, none was found, HOB was lowered and CPR was begun. DON stated that when she got into room resident was turning gray, with gray lips. 911 was notified, DON stated they had obtained a pulse of 34 bpm on EMS monitor prior to resident leaving facility. Resident left facility via EMS at 1:25pm." Interview on [DATE] at 3:40 p.m. with RN F, Director of Quality Assessment Performance Improvement, revealed she conducted the investigation of Resident #1's accident. She stated she received a text from the DON indicating she was in the building working and was going to the hospital with Resident #1. The text reflected, "They may have killed (Resident #1)." RN F immediately called the Administrator and he relayed what occurred with Resident #1. RN F stated she had the nursing staff immediately review the diet orders and reassess residents with swallowing disorders. She revealed she spoke with CNA A over the telephone on the night of [DATE] regarding the incident with Resident #1. RN F revealed CNA A told her she took Resident #1 his meal tray to him, and when she removed the lid from the food, she saw a regular hamburger. Then she looked at his tray card, which reflected he was supposed to have a mechanical soft diet. RN F stated CNA A cut the hamburger into small pieces and went to the kitchen to see about a new tray. CNA A told RN F dietary staff would take him the correct tray. CNA A left the tray with the cut up hamburger in his room. CNA A said dietary staff took Resident #1's tray card and said they would take him a new tray. She then went back to the hall to continue passing trays. When CNA A went back to pick up Resident #1's tray, she found him slumped over and non-responsive. RN F then stated LVN C told her Resident #1 was gray and non-responsive, she called to RN B to call 911. RN F revealed LVN C and CNA A moved Resident #1 to his bed to start CPR. The DON then came to the room and started CPR until the Emergency Medical Response arrived. RN F stated CNA A was suspended and then terminated. RN F said she went into the facility the next day and began in-service training for all staff in the areas of Dietary and Emergency Response. The Dietary Manager and Regional Dietician were to begin in-servicing dietary staff. RN F revealed the facility had a Registered Dietician at the facility every meal since Resident #1's incident to ensure meal trays were consistent with the diet orders prior to serving the meal to the residents. A Diet Roster was printed every day for all residents. A Communication Book was at each Nurse's Station for the CNAs to reference. A Dietary Notebook was posted in both dining areas as a reference to double check a diet order. A two check system was implemented, which included a person in dietary checked the diet card against the meal served and the person serving the meal checked again to ensure the meal was consistent with the diet order. She stated the Red Napkin Program was implemented to visually identify mechanical soft and pureed meals. Interview conducted with CNA G on [DATE] at 1:20 p.m. revealed she was familiar with Resident #1 and knew he was on a mechanical soft diet, mostly the meats. CNA G revealed Resident #1 normally went to the dining room to eat. Some days he did not want to go to the dining room and would eat in his room. She stated on those days someone was supposed to stay in his room with him. Since that day she revealed she had received training in dietary and trays with altered diets. On the day of the event with Resident #1 she knew the aide that had assisted him was CNA A and was aware that she no longer worked at the facility. She thought CNA A had been terminated due to what happened with Resident #1. Resident #1's Emergency Department Note, dated [DATE], reflected, "Per EMS, pt went unresponsive while in dining room eating, unwitnessed. Upon EMS arrival pt (Resident #1) was in PEA (Pulseless Electrical Activity), and when they placed the ETT (Endotracheal Tube) large chunks of food were suctioned out. EMS gave 2 doses of 1 mg EPI ([MEDICATION NAME]) and 40mg [MEDICATION NAME] PTA. CPR was still in progress upon arrival to ED." Resident #1's Emergency Department Note, dated [DATE], reflected, "...Per EMS: Pt was eating alone in his room at NH (Nursing Home). Pt was found not breathing on his own ...EMS had to clear airways. They found lots of food around him...unsure how long he was down, but found on his bed. Hx (History) of choking and aspiration. Pt had no pulse upon EMS arrival. Pt was warm and pupils were not blown when found...." Resident #1's Pulmonology Consult Note, [DATE], reflected, "Assessment: Aspiration into lower respiratory tract [MEDICAL CONDITION] [MEDICAL CONDITION] (absence of oxygen) [MEDICAL CONDITION] [MEDICAL CONDITION] and Atelectasis (collapse of the expanded lung)...." Resident #1's Emergency Department Physician Note, dated [DATE], reflected Resident #1's time of death was 5:48 p.m. The facility's current policy, Dining Communication Book, revised [DATE] reflected, "...Staff will be aware of all residents requiring texture or consistency modification, as well as any therapeutic restrictions ...Residents who have dysphagia and/or are at risk for aspiration or choking require special attention at meal time to assist in preventing these potential problems. This may include modification in food or fluid consistency and/or swallow precautions ...8. All residents requiring swallow precautions will receive adequate supervision, assistance and cueing as necessary during dining...." The facility's current Abuse Prohibition Policy and Procedure, revised [DATE], reflected, "Neglect* - A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident...." The policy also reflected, "III. Prevention of Abuse...C...The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned has knowledge of the individual residents care needs...The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect...those that require heavy nursing care and/or totally dependent on staff...." An IJ was identified on [DATE]. On [DATE] at 12:05 p.m., the Administrator, DON, RN F, and the Corporate Regional Nurse were informed of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on [DATE], reflected on [DATE] the Administrator implemented the following quality action plan: "...One charge nurse and one nursing assistant from each unit monitors patients that eat on the unit during meals to provide supervision, set up and assistance with meals during the course of meal services. The Charge Nurse and nursing assistant that monitor is assigned to monitoring only. The charge nurse uses the QAA Unit Meal Service Rounds Tool to document the following: Tray is set up with food items open (sic) or cut up per pt (patient) choice Patient requires assistance eating If patient needs assistance, tray is not taken to patient room until c.n.a. is ready to feed/assist C.N.A. set up meal tray (illegible) requested C.N.A. assisting patient per patient needs Food items and diet on tray card are correct Patient is silting (sic) upright (sic) (90 degree angle) Call light within reach ...Nursing and nursing assistants have been trained on meal consistencies on therapeutic diets and checking the meal ticket. Patients that have an (sic) chewing and swallowing problems receive a red napkin to identify they are at risk for chewing and swallowing problems. Staff can locate a list of residents who are at risk for chewing and swallowing problems in the C.N.A. assignment book located at each nurses station...." Observation on [DATE] at approximately 12:17 p.m. revealed the Cook checked the diet on the meal tray against the diet orders. The meal was checked again at the end of the tray line by the dietary aide. The meal went to the floor and was checked again by a manager and then again by an aide who delivered the tray to the resident. The meals on the carts were delivered to the hall, the Charge Nurse checked the tray, the meal was delivered to the resident, and was checked again. Diet Order Reference Books were observed in the main dining room and in the assisted dining room, so staff could check residents' diet orders. On the halls the CNAs had a Hall Monitor Book with a Unit Meal Service Monitoring Tool. Interview at 1:55 p.m. on [DATE] with CNA T revealed a CNA and nurse were always on the hall to monitor the residents' trays and check the diet orders. Interview at 1:35 p.m. on [DATE] with CNA U revealed in the dining room a paper was posted with the residents and their diet orders, and there was a book on the hall. CNA U stated there was also a list in the CNAs' book at the nurse's station. Interview at 1:45 p.m. on [DATE] with CNA V revealed they went over the dietary process and the difference in the mechanical soft and pureed meals. The training was to ensure the residents received the correct meals. Now there was a red napkin program to identify the residents who were on altered diets. There were postings in the dining rooms and at the nurse's stations. Interview at 2:00 p.m. on [DATE] with LVN C revealed they also covered dietary and residents on altered diets. Interview at 2:05 p.m. on [DATE] with LVN X revealed dietary checks were done by nurses, managers and the aides, on the hall it was checked again by the nurse and the CNA delivering the meal. Interview at 2:10 p.m. on [DATE] with LVN Y revealed dietary now used red napkins to identify the residents who were on altered diets. She stated she walks the hall during meal service to check the residents dining in their room at least twice during the meal time. Interview at 2:20 p.m. on [DATE] with CNA Z revealed the trainers also reviewed dietary services and the ability to tell the difference between pureed and mechanical soft diets, meal cards and diet orders, and the red napkin program which identified residents who were on altered diets. Interview at 10:40 a.m. on [DATE] with RN F revealed there was not a policy for the nurses to monitor the residents on the hall eating in their rooms. It was up to the professional judgment of the nurse on that hall and the facility staff could not force residents to come to the dining room to eat to ensure their safety. A new procedure was put into place since Resident #1's incident which included copies of residents on altered diets were put in the CNA book each day. The facility's in-service records, dated [DATE], reflected training was by RN F in the areas of Dietary Services and Emergency Response. The IJ was removed on [DATE]. The Administrator and RN F were notified on [DATE] at 10:25 a.m. that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's undated Residents on Mechanically Altered Diets reflected 23 residents.

Based on observation, interview and record review, it was determined the facility failed to provide adequate supervision to prevent accidents for one (Resident #1) of seven residents reviewed for supervision while eating. The facility failed to provide Resident #1, who had [DIAGNOSES REDACTED]. Resident #1 was served the wrong diet by CNA A and was not checked on again for 40 minutes. Resident #1 became unresponsive and did not have a pulse or respirations. Staff initiated CPR and he was transferred to the local hospital where he expired later that day, [DATE]. On [DATE] at 11:55 a.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect the 23 residents, who ordered mechanically altered diets, by placing them at risk for not receiving their correct diet and not receiving appropriate supervision while eating, which could result in choking, aspiration, and/or death. Findings included: Resident #1's Admission Record, dated [DATE], from a prior facility reflected [DIAGNOSES REDACTED]. Dsyphagia Oral Phase (inability to coordinate chewing and swallowing a bolus of food placed in the mouth), Dsyphagia Pharyngeal Phase (aspiration of food into the trachea during the act of swallowing), Pneumonititis (inflammation of the lung) due to Inhalation of Food or Vomitus and Pneumonititis due to Other Solids and Liquids. Resident #1's physician's orders [REDACTED]. The Orders also reflected he needed a mechanical soft diet. Resident #1's MDS assessment, dated [DATE], reflected he needed supervision and set-up assistance with eating, was totally dependent on staff for mobility and transfers, and required extensive assistance with grooming, personal hygiene, and toileting. The MDS assessment also reflected he was cognitively intact, did not have any signs/symptoms of a swallowing problem, and had a mechanically altered diet. Resident #1's undated Interim Plan of Care reflected he was independent with eating and did not need supervision. The Plan of Care also reflected he needed a mechanical soft diet. Resident #1's Care Plan, initiated on [DATE] and revised on [DATE], regarding nutritional problems reflected an intervention of serving his diet as ordered by the physician, but it did not indicate his diet was mechanical soft. Resident #1's Care Plan, initiated on [DATE], did not reflect his need for supervision and set- up assistance for eating. Although Resident #1 had a history of [REDACTED]. The facility's Provider Investigation Report, dated [DATE], reflected Resident #1 was served a regular diet, which included a hamburger, instead of a mechanical soft diet on [DATE]. CNA A said she cut up the hamburger in small pieces for him and then went to the Dietary Department to request a mechanical soft diet for him. When CNA A returned to the resident's room, Resident #1 was unresponsive in his wheelchair and staff immediately called 911. Staff also initiated CPR and the resident was transferred to the hospital with a pulse of 34. He expired later that day in the hospital. Attached to the Provider Investigation Report was an undated Associate Memorandum, which reflected CNA A was suspended on [DATE]. Attached to the Provider Investigation Report, dated [DATE], was the DON's statement, dated [DATE], which reflected, "I was in my office with the administrator when I heard someone yelling 'hurry (DON) something is wrong with (Resident #1).' I started walking towards (Resident #1's room) and I seen (sic) staff running back and forth so I started running down there. I entered room, (Resident #1) was in the bed, he was gray, with gray lip (sic). I cannot remember if anyone else was in the room or not. I sent someone after the crash cart, I had someone roll down HOB, felt for a carotid pulse (none found) and I preceded to perform CPR. Pulse of 34 bpm was obtained (sic) per EMS monitor on there (sic) arrival.. I cannot recall the time that this occurred. (Resident #1) never had a swallowing problem; he just did not chew his food good." An interview with the DON on [DATE] at 2:10 p.m. revealed she was at the facility on Saturday, [DATE], at the time of the incident involving Resident #1. She stated most of the time Resident #1 ate his meals in the dining room, but she thought the reason he stayed in his room that day was because a football game was on television. The DON revealed she heard people yelling something was wrong with Resident #1. She stated she went to his room and found him unresponsive and gray in color with gray lips. She said she could not remember who else was in the room, but she recalled sending someone for the "crash" cart. The DON revealed the RT attempted to suction Resident #1 and was unsuccessful. She stated she initiated CPR and had the staff call 911. She said she saw a meal tray on a table with ? of a hamburger on it, and her first thought was "they had killed (Resident #1) and served him the wrong tray." The DON revealed he should have received a mechanical soft diet. She stated Resident #1 did not have a swallowing problem, but he ate too fast and did not chew his food up. She said he had a history of [REDACTED]. The DON revealed CNA A told her she had delivered the meal tray with the regular hamburger, and she had cut it into four pieces. CNA A's Witness Statement, dated [DATE], was also attached to the Provider Investigation Report. The Statement reflected, "At approximately 12:30 pm I took (Resident #1) tray to him. It had 1 hamburger (2 buns, 1 piece of meat, 1 piece of cheese), zucchini squash, and bowl of fruit. I seen (sic) his diet card and it said 'mechanical soft' with whole bacon and something else which I cannot remember. I cut his hamburger up into several pieces, but cannot remember how many. I then took this diet card back to dietary and spoke with (Cook L) and asked her about his whole hamburger. (Cook L) said that he was on a Mechanical soft diet but could have bacon and something else; I can't remember what (Cook L) said. (Cook L) then took the diet card and said she would fix him another tray at the end of the tray line. I went and finished passing my trays, as I knew when his other tray was fixed, someone would take it to him. At approx. (approximately) 1:10pm I went back to his room to pick up his tray and resident was sitting in a chair, his face and fingers were blue and he was unresponsive, I stepped into the hall, yelled for a nurse who came into the room, the nurse and I assisted him to bed, (Receptionist) called 911 and someone went and got (DON)." On [DATE] at 2:05 p.m., the surveyor attempted to contact CNA A. The surveyor left a message for a return call. On [DATE] at 4:45 p.m., the sureveyor attempted to contact CNA A. The sureveyor left another message for a return call. CNA A did not return either telephone call as of exit on [DATE]. LVN C's Witness Statement, dated [DATE], was attached to the Provider Investigation Report and reflected, "(LVN C) said she was coming out of the Sun Room when she heard (CNA A) holler nurse. (LVN C) then went directly into (Resident #1's) room. (Resident #1) was sitting in his wheel chair and she started to shake him and say his name. She hollered to (RN B) who was standing at the nursing station. (LVN C) said that she and (CNA A) immediately lifted (Resident #1) out of his wheel chair and laid him in his bed. (LVN C) said that she was not able to start the Heimlich maneuver or CPR due to the height of the wheel chair back. By the time they got him into the bed, (DON) came into the room and started CPR. All of this happened within 2 or 3 minutes." The statement was signed by LVN C. An interview with LVN C on [DATE] at 5:30 p.m. confirmed she was on duty on [DATE] at the time of the incident involving Resident #1. She stated CNA A called her to Resident #1's room. She stated she entered his room and he was slumped over in his wheelchair. She stated he was unresponsive. LVN C revealed she completed an assessment and found he was not breathing, his pupils were fixed and his fingers were blue. She stated he was not cold to the touch, nor was there any evidence of vomit on or around him. She stated she did think of a possible aspiration because she saw his tray in his room. LVN C revealed she immediately yelled for RN B. RN B's, Weekend Supervisor's, Witness Statement, dated [DATE], was attached to the Provider Investigation Report and reflected, "I, (name), at (sic) lunch checked the Sun Room food cart and rolled it into the Sun Room. Then I told (LVN C) that the trays were ready. (LVN C) went into the Sun Room and began serving the trays. I can't say that I checked the Lakeside cart because I seen (sic) (LVN D) entering the lunchroom to do his assigned lunch room duty and I think I just kept walking through the dining room. I do know that I went down to Ivy Lane to see which CNA was going to the dining room. I saw (staff member) passing trays. I went back to the break room and (CNA) was eating lunch. I told her that the trays were out. She put her lunch up and went to pass trays. I got a pillow from the laundry then went back through the dining room. (Staff member) was in the dining room passing trays. Then I took the pillow into the room to make up the bed for the new admit that is coming." An interview with RN B on [DATE] at 9:50 a.m. confirmed she was on duty on [DATE] at the time of the incident involving Resident #1. She stated the nurse assigned to the dining room was not in there on time, and she had to start grabbing carts and tray cards to review them. She revealed LVN D was assigned to assist in the dining room that day. She said when she was around the nurses' station, she heard CNA A call for LVN C to come. RN B revealed she then heard her name called and went to Resident #1's room. She stated she entered his room and saw Resident #1 and began tapping him in an attempt to arouse him. She said she assessed him and he was unresponsive. RN B revealed she did not recall observing any vomit, but he may have had been drooling. She stated she grabbed his wrist and felt nothing, if there had been a pulse it was very faint. She said CNA A and LVN C were trying to get him in his bed. RN B revealed she knew the DON was in the building and told a CNA U to get the DON and told the Receptionist to call 911. She stated she then got the "crash" cart and RT M. She stated when she returned, LVN D had the Ambu bag going, and staff had started chest compressions. RN F's Statement, dated [DATE], was attached to the Provider Investigation Report and reflected, "After interviews and obtaining statements from facility staff, at approximately 12;30 pm (CNA A) took (Resident #1) (sic) lunch tray to his room. Resident was sitting up in his wheel chair (sic); the (CNA A) stated that resident received regular diet. She cut his hamburger up into several bite size pieces, left the tray in the room and took his diet card to dietary and spoke with (Cook L). She stated she ask (sic) (Cook L) if resident was supposed to get a regular hamburger, and (Cook L) stated 'No' he usually gets a mechanical soft diet but can have whole bacon. (Cook L) stated she would fix (Resident #1) another tray at end of tray line. (CNA A) stated she went back to unit and proceeded to pass the rest of the trays as she knew someone would take (Resident #1) his tray. As approximately 1:10 pm she went back to (Resident #1's) room to pick up his lunch tray and noted (Resident #1) in his wheelchair, his face and hands were purple and not responding when she attempted to talk to him. (CNA A) stated she went to the door and yelled for a nurse. (LVN C) came immediately to the room, she stated she tried shaking and talking with resident, and he was unresponsive, she hollered for weekend supervisor who was at nurses (sic) station and she came to room immediately. (LVN C) stated that she had no way to start CPR or the Heimlich maneuver as he was in a high back wheelchair so she and (CNA A) assisted to him to bed while weekend supervisor went and got the DON. (LVN C) stated that DON walked into room just as they got resident into bed. (LVN C) stated it was 2 to 3 minutes from the time she had entered the room until the DON arrived and took over the situation. DON had then (sic) go get crash cart, DON check (sic) for carotid pulse, none was found, HOB was lowered and CPR was begun. DON stated that when she got into room resident was turning gray, with gray lips. 911 was notified, DON stated they had obtained a pulse of 34 bpm on EMS monitor prior to resident leaving facility. Resident left facility via EMS at 1:25pm." Interview on [DATE] at 3:40 p.m. with RN F, Director of Quality Assessment Performance Improvement, revealed she conducted the investigation of Resident #1's accident. She stated she received a text from the DON indicating she was in the building working and was going to the hospital with Resident #1. The text reflected, "They may have killed (Resident #1)." RN F immediately called the Administrator and he relayed what occurred with Resident #1. RN F stated she had the nursing staff immediately review the diet orders and reassess residents with swallowing disorders. She revealed she spoke with CNA A over the telephone on the night of [DATE] regarding the incident with Resident #1. RN F revealed CNA A told her she took Resident #1 his meal tray to him, and when she removed the lid from the food, she saw a regular hamburger. Then she looked at his tray card, which reflected he was supposed to have a mechanical soft diet. RN F stated CNA A cut the hamburger into small pieces and went to the kitchen to see about a new tray. CNA A told RN F dietary staff would take him the correct tray. CNA A left the tray with the cut up hamburger in his room. CNA A said dietary staff took Resident #1's tray card and said they would take him a new tray. She then went back to the hall to continue passing trays. When CNA A went back to pick up Resident #1's tray, she found him slumped over and non-responsive. RN F then stated LVN C told her Resident #1 was gray and non-responsive, she called to RN B to call 911. RN F revealed LVN C and CNA A moved Resident #1 to his bed to start CPR. The DON then came to the room and started CPR until the Emergency Medical Response arrived. RN F stated CNA A was suspended and then terminated. RN F said she went into the facility the next day and began in-service training for all staff in the areas of Dietary and Emergency Response. The Dietary Manager and Regional Dietician were to begin in-servicing dietary staff. RN F revealed the facility had a Registered Dietician at the facility every meal since Resident #1's incident to ensure meal trays were consistent with the diet orders prior to serving the meal to the residents. A Diet Roster was printed every day for all residents. A Communication Book was at each Nurse's Station for the CNAs to reference. A Dietary Notebook was posted in both dining areas as a reference to double check a diet order. A two check system was implemented, which included a person in dietary checked the diet card against the meal served and the person serving the meal checked again to ensure the meal was consistent with the diet order. She stated the Red Napkin Program was implemented to visually identify mechanical soft and pureed meals. Interview conducted with CNA G on [DATE] at 1:20 p.m. revealed she was familiar with Resident #1 and knew he was on a mechanical soft diet, mostly the meats. CNA G revealed Resident #1 normally went to the dining room to eat. Some days he did not want to go to the dining room and would eat in his room. She stated on those days someone was supposed to stay in his room with him. Since that day she revealed she had received training in dietary and trays with altered diets. On the day of the event with Resident #1 she knew the aide that had assisted him was CNA A and was aware that she no longer worked at the facility. She thought CNA A had been terminated due to what happened with Resident #1. Resident #1's Emergency Department Note, dated [DATE], reflected, "Per EMS, pt went unresponsive while in dining room eating, unwitnessed. Upon EMS arrival pt (Resident #1) was in PEA (Pulseless Electrical Activity), and when they placed the ETT (Endotracheal Tube) large chunks of food were suctioned out. EMS gave 2 doses of 1 mg EPI (Epinephrine) and 40mg vasopressin PTA. CPR was still in progress upon arrival to ED." Resident #1's Emergency Department Note, dated [DATE], reflected, "...Per EMS: Pt was eating alone in his room at NH (Nursing Home). Pt was found not breathing on his own ...EMS had to clear airways. They found lots of food around him ...unsure how long he was down, but found on his bed. Hx (History) of choking and aspiration. Pt had no pulse upon EMS arrival. Pt was warm and pupils were not blown when found ...." Resident #1's Pulmonology Consult Note, [DATE], reflected, "Assessment: Aspiration into lower respiratory tract Cardiac arrest Anoxic (absence of oxygen) brain injury Respiratory failure and Atelectasis (collapse of the expanded lung) ...." Resident #1's Emergency Department Physician Note, dated [DATE], reflected Resident #1's time of death was 5:48 p.m. The facility's current policy, Dining Communication Book, revised [DATE] reflected, "... Staff will be aware of all residents requiring texture or consistency modification, as well as any therapeutic restrictions ...Residents who have dysphagia and/or are at risk for aspiration or choking require special attention at meal time to assist in preventing these potential problems. This may include modification in food or fluid consistency and/or swallow precautions ...8. All residents requiring swallow precautions will receive adequate supervision, assistance and cueing as necessary during dining .... " An IJ was identified on [DATE]. On [DATE] at 12:05 p.m., the Administrator, DON, RN F, and the Corporate Regional Nurse were informed of the IJ and a Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on [DATE], reflected on [DATE] the Administrator implemented the following quality action plan: "...One charge nurse and one nursing assistant from each unit monitors patients that eat on the unit during meals to provide supervision, set up and assistance with meals during the course of meal services. The Charge Nurse and nursing assistant that monitor is assigned to monitoring only. The charge nurse uses the QAA Unit Meal Service Rounds Tool to document the following: Tray is set up with food items open (sic) or cut up per pt (patient) choice Patient requires assistance eating If patient needs assistance, tray is not taken to patient room until c.n.a. is ready to feed/assist C.N.A. set up meal tray (illegible) requested C.N.A. assisting patient per patient needs Food items and diet on tray card are correct Patient is silting (sic) upright (sic) (90 degree angle) Call light within reach ...Nursing and nursing assistants have been trained on meal consistencies on therapeutic diets and checking the meal ticket. Patients that have an (sic) chewing and swallowing problems receive a red napkin to identify they are at risk for chewing and swallowing problems. Staff can locate a list of residents who are at risk for chewing and swallowing problems in the C.N.A. assignment book located at each nurses station...." Observation on [DATE] at approximately 12:17 p.m. revealed the Cook checked the diet on the meal tray against the diet orders. The meal was checked again at the end of the tray line by the dietary aide. The meal went to the floor and was checked again by a manager and then again by an aide who delivered the tray to the resident. The meals on the carts were delivered to the hall, the Charge Nurse checked the tray, the meal was delivered to the resident, and was checked again. Diet Order Reference Books were observed in the main dining room and in the assisted dining room, so staff could check residents' diet orders. On the halls the CNAs had a Hall Monitor Book with a Unit Meal Service Monitoring Tool. Interview at 1:55 p.m. on [DATE] with CNA T revealed a CNA and nurse were always on the hall to monitor the residents' trays and check the diet orders. Interview at 1:35 p.m. on [DATE] with CNA U revealed in the dining room a paper was posted with the residents and their diet orders, and there was a book on the hall. CNA U stated there was also a list in the CNAs' book at the nurse's station. Interview at 1:45 p.m. on [DATE] with CNA V revealed they went over the dietary process and the difference in the mechanical soft and pureed meals. The training was to ensure the residents received the correct meals. Now there was a red napkin program to identify the residents who were on altered diets. There were postings in the dining rooms and at the nurse's stations. Interview at 2:00 p.m. on [DATE] with LVN C revealed they also covered dietary and residents on altered diets. Interview at 2:05 p.m. on [DATE] with LVN X revealed dietary checks were done by nurses, managers and the aides, on the hall it was checked again by the nurse and the CNA delivering the meal. Interview at 2:10 p.m. on [DATE] with LVN Y revealed dietary now used red napkins to identify the residents who were on altered diets. She stated she walks the hall during meal service to check the residents dining in their room at least twice during the meal time. Interview at 2:20 p.m. on [DATE] with CNA Z revealed the trainers also reviewed dietary services and the ability to tell the difference between pureed and mechanical soft diets, meal cards and diet orders, and the red napkin program which identified residents who were on altered diets. Interview at 10:40 a.m. on [DATE] with RN F revealed there was not a policy for the nurses to monitor the residents on the hall eating in their rooms. It was up to the professional judgment of the nurse on that hall and the facility staff could not force residents to come to the dining room to eat to ensure their safety. A new procedure was put into place since Resident #1's incident which included copies of residents on altered diets were put in the CNA book each day. The facility's in-service records, dated [DATE], reflected ttraining was by RN F in the areas of Dietary Services and Emergency Response. The IJ was removed on [DATE]. The Administrator and RN F were notified on [DATE] at 10:25 a.m. that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "actual harm that is not immediate jeopardy" and a scope of "isolated" because the facility was still monitoring the effectiveness of the Plan of Removal. The facility's undated Residents on Mechanically Altered Diets reflected 23 residents.