Every finding on record at Berkley West Healthcare Center

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from financial abuse (illegal or improper use of resident's funds or property) for one of two sampled resident (Resident 1) according to the facility's policy and procedures (P&P) titled, Alleged or Suspected Abuse and Crime Reporting dated 10/2025 evidenced by certified nursing assistant (CNA) 1 taking Resident 1's wallet, $200.00, and credit card and charging $78.70 on the credit card for personal use/gain. This deficient practice had the potential for Resident 1 to feel powerless and unprotected and the potential further financial abuse of residents in the facility. Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 5/4/2026 with diagnoses that included but not limited to essential hypertension (high blood pressure) and depression (ongoing sadness, emptiness, irritability, or numbness, extreme fatigue, or changes in weight and appetite, difficulty concentrating, memory issues, or negative thinking). During a review of CNA 1's certificates on abuse, neglect, exploitation, and what is abuse, indicated CNA 1 satisfactorily completed abuse, neglect, exploitation and what is abuse training on 2/1/2026. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/16/2026, the MDS indicated Resident 1 had no cognitive (the mental ability to make decisions of daily living) impairment. The MDS indicated Resident 1 needed full staff assistance for eating, activities of daily living (ADL-oral hygiene, personal hygiene, sitting/laying, toileting hygiene, shower/bath, upper and lower body dressing, personal hygiene and toilet transfer). During a review of facility's document titled Transactions dated 6/6/2026 - 6/8/2026, indicated a total of $78.70 purchases made as follows:A local Bar - $32.00Fast food Restaurant - $16.67Fast food Restaurant - $34.03Donut & Bakery - $6.00 During a review of Resident 1's History and Physical (H&P - medical document which include resident's background, physical exam and assessment) by resident's physician and signed by the same physician, dated 6/13/2026, H&P indicated Resident 1 is alert and the resident's Family member (FM) 1 is the resident's surrogate (someone appointed to make medical decisions on behalf of a person who becomes incapacitated) decision maker. During an observation and concurrent interview on 06/25/2026 at 11:55 am, Resident 1 stated that on on 6/14/2026 at 10:17am. Resident 1 noticed that $200.00, resident's wallet and his one credit card in the wallet were missing. Resident 1 stated that Resident 1's FM 1 came to the facility on 6/15/2026 at 12pm and spoke to Director of Staff Development (DSD) and Licensed Vocational Nurse (LVN) 1 regarding the missing $200.00, a wallet, and a credit card and that the facility investigated the missing money, wallet, and the credit card. Resident 1 stated Resident 1 did not want the accused (CNA 1) get arrested since the facility refunded the $ 200.00. Resident 1 stated that the credit card was canceled, and that the credit card company refunded the money that was spent during 4 transactions (unaware of the transaction amount) after the wallet was stolen. During a telephone interview with FM 1 on 6/25/2026 at 12:19 pm, with FM 1 at Resident 1's bedside, FM 1 stated that FM 1 is Resident 1's Power of Attorney (POA - Legal document which stated the FM 1 can make decision on resident's behalf if resident not able to, FM 1 can also sign checks and make financial decision for the resident). FM 1 stated that FM 1 informed the DSD right away regarding Resident 1's stolen wallet and $200.00 in cash. FM 1 stated that the facility completed investigating the allegation, refunded Resident 1 $200.00, FM 1 called the credit card company and cancelled the credit card and refunded Resident 1 the money for the 4 transactions. FM 1 stated Resident 1 did not wish for CNA 1 to be arrested and respected Resident 1's wishes. During an interview on 06/25/2026 at 12:19 pm, CNA 1 over the phone, CNA 1 stated, It was my mistake to steal. I am ready to face the consequences. I have been going through hard time; I was on disability this year. I did steal from Resident 1, but I only stole $200.00 and used Resident 1's credit card for around $70-$80. I didn't steal anything from any resident before. During the facility surveillance video footage and concurrent interview on 6/25/2026 at 1:38 pm, with Administrator (Adm) and Director of Staff Development (DSD) was present, the facility's surveillance video dated 6/6/2025 between 3:42 am - 3:44 am was reviewed. Adm identified and confirmed that CNA 1 on the surveillance video footage. CNA 1 was seen inside a donut and bakery business and was placing an order. Adm stated that the donut and bakery business is a walking distance from the facility and that CNA 1 was working in the facility during the night on 6/5/2026 from 11 pm - 7 am. Adm stated that credit card company record showed that the purchase at the same donut and bakery business was made on the same date 6/6/2026 and time as to when CNA 1 placed an order. Adm stated another transaction was made using Resident 1's credit between 6/6/2026 - 6/8/2026 at a fast s food restaurant which is a walking distance from CNA 1'a home address. Adm stated CNA 1 received abuse training upon hiring and annually. Adm stated, I know this (financial) abuse shouldn't have happened. During a review of the facility's policy and procedures (P&P) titled, Alleged or Suspected Abuse and Crime Reporting dated 10/2025, the P&P indicated, Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on interview and record review, the facility failed to provide urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) care every shift per the resident's physician order for one of four sampled resident's (Resident 12). This deficient practice had the potential to result in the development of a urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra).A review of Resident 12's admission record indicated the facility admitted Resident 12 on 11/28/2025 with diagnoses that included lumbar vertebral fracture (a broken bone in the lower back), urinary retention (inability to completely empty one's bladder) and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 12/5/2025, indicated the resident's cognition (ability to acquire and understand knowledge) was intact. The MDS also indicated the resident had an indwelling urinary catheter and was not part of a toileting program. The MDS further indicated the resident was dependent upon staff for toileting hygiene, bathing and dressing. A review of the physician orders, dated 6/10/2025, indicated Resident 12 was to receive the following care:Foley Catheter size 16 French (Fr - measurement of the catheter's outer diameter) with 10 milliliter (m-unit of measurement) bulb. Monitor for placement and function as neededCatheter care for indwelling catheter every shift. Cleanse area every shift monitor for redness, irritation, swelling, signs and symptoms of urinary tract infection (UTI). A review of Resident 12's care plan on Has Indwelling Catheter, initiated 12/8/2025, indicated Resident 12 had a urinary catheter due to urinary retention. The care plan indicated a goal was for the resident to not exhibit signs or symptoms of urinary infection. The interventions included to monitor for signs/symptoms of UTI which included pain, burning, blood tinged urine. During an interview on 1/07/2026 at 1:55 PM, Treatment Nurse (TN) 1 stated Resident 12 had a urinary catheter due to decreased urine output. TN 1 stated urinary catheter care is provided by nursing staff every shift. TN 1 further stated there was no documentation that catheter care was provided to Resident 1 on 1/2/2026 during the day shift or on 1/3/2026 during the night shift. TN 1 stated a potential of outcome of not providing catheter care was that Resident 12 could develop an infection. During an interview on 1/8/2026 at 11:42, the Director of Nursing (DON) stated if a treatment is not documented it was not done. The DON further stated it was important to provide catheter care every shift in order to prevent the resident from developing an infection. A review of the facility's policy and procedures (P&P) titled, Catheter Care, Urinary, revised 4/2025, indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections. A review of the facility's P&P titled, Charting and Documentation, revised 4/2025, indicated: 2. The following information is to be documented in the resident medical record:a. Objective observations;b. Medications administered;c. Treatments or services performed;

Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 40), who had limited range of motion (ROM - the extent of movement of a joint) in the right hand, had a right hand splint applied per the physician's order. This deficient practice placed Resident 5 at increased risk for further decline and contracture formation to the right hand. A review of Resident 40's admission Record indicated the facility admitted the resident on 10/26/2024 and readmitted the resident on 2/6/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, gait and mobility abnormalities and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 40's Quarterly Minimum Data Set (MDS - a resident assessment tool) dated 10/29/2025 indicated the resident had severely impaired cognitive skills for daily decision-making. The MDS indicated the resident moderate assistance with dressing, toileting hygiene and bathing. The MDS also indicated Resident 40 received had limited range of motion (ROM - extent of movement of a joint) on an upper extremity. A review of Resident 40's high risk for further contractures on right hand care plan, initiated 10/24/2025, indicated the resident needed a right hand splint. The care plan interventions included for RNA for right hand/wrist splint application up to 4 hours as tolerated every day five times a week and to check for further contracture of the hands and fingers during care. A review of Resident 40's Physician Orders, dated 12/11/2025 indicated the resident was to receive Restorative Nursing Aide (RNA, assistant that help residents to maintain their function and joint mobility) for right hand /wrist splint application up to four hours every day five times a week. During an observation on 1/6/2026 at 9:52 AM, at Resident 40's bedside, Resident 40 was observed sleeping in bed. Resident 40 was not wearing a right hand splint. During an observation on 1/6/2026 at 12:18 PM, inside the dining Room. Resident 40 was observed eating lunch with his left hand. Resident 40 was not wearing a right hand splint. During an interview and observation on 1/6/2026 at 12:38 PM, Resident 40 stated the last time he wore the splint was in early December 2025. Resident 40 stated he would like to wear the splint. Resident 40 also stated he did not know why the splint isn't being applied. During a concurrent interview and record review on 1/6/2026 at 1:36 PM Restorative Nurse Aide (RNA) 1 stated Resident 40's right hand contracture and Resident 40 had an order to apply a splint to Resident 40's right hand for four hours a day. RNA 1 stated Resident 40's splint has been missing for around 20 days. RNA 1 further stated they did not know if a new splint had been ordered. During a concurrent review of the RNA log book for January 2026, RNA 1 stated there was no log for Resident 40. RNA 1 further stated it was important for Resident 40 to wear the splint to prevent his right hand contracture from worsening. A review of the facility's policy and procedures (P&P) titled, Resident Mobility and Range of Motion, revised 4/2025, indicated Residents will not experience an avoidable reduction in range of motion (ROM) and residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.

Based on observation, interview and record review, the facility failed to provide daily wound treatment per physician's orders for one of one sampled residents (Resident 42) according to Physician's Orders dated 12/24/2025. This deficient practice had the potential to place Resident 42 at risk for worsening of the pressure injury.Findings: A review of the Resident 42's admission Record indicated the facility re-admitted the resident on 12/20/2025, with diagnoses that included stage 3 pressure ulcer (is tissue damage that results in full-thickness loss of skin and the layer of fat under the skin may be visible), encephalopathy (brain damage that causes severe confusion and forgetfulness) and dementia (a progressive state of decline in mental abilities). A review of Resident 42's Minimum Data Set (MDS - a resident assessment tool), dated 12/24/2025 indicated the resident had one stage 3 pressure wound (ulcer) upon admission. The MDS also indicated Resident 42 was dependent upon staff to shower, lower body dressing and toileting hygiene. A review of Resident 42's care plan on impaired skin integrity, initiated 12/21/2025, indicated the resident had a stage 3 pressure wound (ulcer). The goal was for Resident 42's wound to decrease in size to not develop skin breakdown. The care plan interventions (specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) included to cleanse the site with normal saline, apply Santyl ointment (medicine that removes dead tissue from wounds so they can start to heal) and cover with a foam dressing (wound care material) daily. A review of Resident 42's altered care plan on skin integrity, initiated 12/23/2025, indicated the resident had a pressure injury on the right lateral lower leg. The care plan indicated the goal was for the resident's skin to be from from signs and symptoms of redness, swelling and foul smelling drainage. The care plan indicated interventions included to check resident's skin condition for presence of skin breakdown and to provide the treatment as ordered. A review of Resident 42's Physician's Orders dated 12/24/2025, indicated the physician ordered the following treatment orders:- To treat the sacral pressure injury, staff were to apply Santyl (ointment used to remove damaged tissue from chronic skin ulcers and severely burned areas) to sacrum topically every day shift for stage 3 pressure injury. - To treat the right later lower leg wound, staff were to cleanse the area with normal saline (NS - is a mixture of salt and water), pat dry, apply Santyl then cover with an abdominal pad and wrap with kerlix ( a bulky, crinkled gauze bandage used to cushion, absorb fluid, and protect wounds) daily. During a concurrent interview and record review on 1/7/2026 at 1:34 PM with Treatment Nurse (TN) 1, Resident 42's Treatment Administration Records(TAR - a log used by healthcare professionals of all treatments given to a resident) for the month of December 2025 and January 2026 were reviewed. TN 1 stated Resident 42 was admitted with a stage 3 sacral pressure ulcer and a Stage 3 right lateral leg pressure ulcer. TN 1 stated Resident 42's wounds are treated daily. TN 1 stated there was no documented evidence that Resident 42's wounds were treated on 12/27/25, 12/30/2025 and on 1/2/2026. TN 1 stated treatments are documented to prove that they were completed and wounds are treated in order to improve the wound. During an interview on 1/8/2026 at 11:45 AM the Director of Nursing (DON) stated, If treatments are not documented they (treatment) are not done. Importance of wound treatment is to make sure the wound is treated properly so it doesn't get worse or become infection. The goal is to heal the wound. A review of the facility's P&P titled, Charting and Documentation, revised 4/2025, indicated the following information is to be documented in the resident medical record:a. Objective observations;b. Medications administered;c. Treatments or services performed;d. Changes in the resident's condition;e, Events, incidents or accidents involving the resident; andf. Progress toward or changes in the care plan goals and objectives

Based on observation, interview, and record review, the facility failed to ensure staff implemented its policy and procedures on Health Insurance Portability and Accountability Act (HIPAA- is a U.S. federal law that protects sensitive patient/resident/client health information (PHI) from unauthorized disclosure, ensuring privacy, security, and data integrity while also allowing for health insurance portability and administrative efficiency in healthcare) for one of one resident (Resident 52). This deficient practice violated the privacy and confidentiality rights of Resident 52. Findings: During record review, Resident 52's admission Record indicated the facility admitted Resident 52 on 12/7/2025 with diagnoses including Type 2 Diabetes Mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and hypertension (HTN-high blood pressure). During record review, Resident 52's Minimum Data Set (MDS-A resident assessment tool) dated 12/29/2025, indicated Resident 52 had intact cognitive skills (mental ability to make decisions of daily living). During an observation and concurrent record review on 01/05/2026 at 12:09 PM Resident 52 was observed in bed receiving a bag of Sodium Chloride Solution 0.9% (NS 0.9%- Is a saltwater solution used medically for fluid/electrolyte replacement, wound/eye irrigation, nebulization to loosen mucus, and in laboratories for cell washing) intravenous (IV-into a vein) infusion at 100 milliliters (ml-unit of measurement) per hour (hr) via dial flow (a manual IV administration set with a built-in dial to control the flow rate [mL/hour] of fluids or medications). A telephone physician's order was taped/attached on the NS 0.9% solution bag and had the following information:. Resident 52's name, date of birth (DOB) and room number Date of 1/4/2026 at 3:36 PM Facility name, address, fax number, and phone number. Order ID Number. Order Summary: Sodium Chloride Solution 0.9% intravenous use at 100 mL/hour. Confirmed by Registered Nurse Supervisor (RNS) 1. During an observation, interview, and concurrent record review in the presence of the director of nursing (DON) on 01/05/2026 at 2:45 PM, RNS 1 stated that HIPAA protects residents from sharing information to others who should not have their personal information; RNS 1 observed and read the physician's order attached/taped on Resident 52's IV NS 0.9% solution bag. RNS 1 stated the physician's order included Resident 52's name and DOB. RNS 1 stated the NS 0.9% solution IV bag was taken directly from the facility's emergency kit (e-kit). RNS 1 stated that IV bags do not come with a labels and so she printed the physician's order and taped it on Resident 52's IV bag. During an interview on 01/07/2026 at 2:11 PM, RNS 1 stated HIPAA protects patient privacy and that private information is not seen by other residents, staff, family members, and/or visitors and that all staff/all health care workers must comply with HIPAA law. RNS 1 stated that residents can become upset and betrayed when their protected information is displayed for anyone to see and retrieve without their permission. During record review, the facility's policy and procedures (P&P) titled HIPAA Compliance' revised on 4/2025, indicated, POLICY. It is the intent of the facility to adhere to the Omnibus Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, Enforcement and Breach Notification Rules. Transaction Code Sets, Enforcement guidance and related requirements of the Health Insurance Portability and Accountability Act (HIPAA). It is our intent to assure that policies, procedures and practices are developed, implemented, staff trained breaches avoided and compliance monitored.2. The facility will adopt guidelines and procedures that are compliant with the HIPAA Privacy and Security Rules and other related HIPAA rules and the practices established by the Rule as well as other applicable federal and state laws.3. Policies and Procedures and training will include as a minimum: a. Access to PHI - manual and electronic; b. Accounting of Disclosures including faxes; c. Amendments; d. Breach and impact rules; e. Business Associates; f. Compliance, monitoring and reporting; g. Designated Record Set; h. Disclosure with and without Authorizations; i. Marketing and Financing; j. Minimum Necessary; k. Privacy Practices and Privacy Notice; 1. Sanctions; m. Security requirements. During record review, the facility's P&P titled Protected Health Information (PHI), Authorization for Use or Disclosure of Policy Statement All uses and disclosures of revised 3/2014, indicated that, Protected health information (PHI) beyond those otherwise permitted by current HIPAA law require a signed authorization.1. Policy Interpretation and Implementation The facility and its business associates have a limited right to use and/or disclose PHI health information for purposes of treatment, payment, or for the operations of the organization.2. For other uses, there must be written authorization to release protected health information unless the law permits or requires the facility to use or disclose this information without authorization.5. Uses and disclosures of PHI that require written authorization, except as permitted by law, include: a. Use or disclosure of psychotherapy notes; b. Use or disclosure of PHI for marketing purposes; or c. The sale of PH . Uses or disclosures of PHI that require an opportunity for the individual to agree or object include:a. Use or disclosure of certain information to maintain a facility directory; (1) The facility will inform individuals of the type of information that will be used in the directory and the persons to whom the information will be disclosed.(2) Individuals will be given the opportunity to restrict some or all of the information used or disclosed in a facility directory.

Based on observation, interview and record review the facility failed to ensure insulin (a hormone that regulates blood sugar) for single-patient use (meant for multiple uses for one individual patient/resident) for Resident 34 was ordered and delivered to the facility timely for one of six residents (Resident 34). This deficient practice placed both Resident 34 and 46 at high risk for infection and transmission of bloodborne pathogens, including hepatitis B (HBV-a viral infection of the liver), hepatitis C (HCV-a viral infection causing liver inflammation), and human immunodeficiency virus (HIV- a virus that attacks the body's immune system).Cross Reference F760 Findings: During a concurrent observation and interview of medication administration on 1/6/2026 at 11:15AM, LVN 2 injected Resident 34 with 2 units of insulin per sliding scale (chart with prescribed pre-established doses) via insulin pen for a blood sugar test result of 204. An observation/review of a label on the insulin pen, the label indicated that the insulin was prescribed for Resident 46. During an interview LVN 2 apologetically stated she accidentally used Resident 46's insulin pen to administer insulin to Resident 34. LVN 2 further stated Resident 34's insulin pen was in the medication cart, however upon inspection, there was no insulin found of the medication cart and the medication refrigerator for Resident 34. During a concurrent interview and record review on 1/6/2026 at 11:46 AM, the Director of Staff Development (DSD) stated a renewal order for Resident 34's insulin pen was completed yesterday (1/5/2026) during the night shift, the DSD stated facility contracted pharmacy had not delivered Resident 34's ordered insulin medication to the facility. During an interview on 1/8/2026 at 2:45PM, the Director of Nursing (DON) stated sharing a single-patient insulin pen on any resident other than on the resident that the insulin was prescribed for, can lead to reduced intended time use of the prescribed dose for the intended Resident placing residents at risk for serious skin and blood borne diseases that can result in poor outcomes including death. A review of the facility's policy and procedures (P&P) titled Infection Prevention & Control Program dated 04/2025 indicated, An infection and control program (IPCP) is established . to help prevent the development and transmission of communicable diseases and infections. Prevention of infection includes educating staff and ensuring that they adhere to proper techniques and procedures. A review of the facility's P&P titled Medication Administration-General Guidelines dated 04/2025 indicated, Prior to administration, the medication . the Resident's medication administration record (MAR) is compared with the medication label. Medications supplied for one resident are never administered to another resident. A review of the facility Licensed Vocational Nurse Job Description dated 2003, subtitle Drug Administration Functions indicated, Ensure that prescribed medication for one resident is not administered to another.

Based on observation, interview and record review the facility failed to ensure insulin (a hormone that regulates blood sugar) for single-patient use (meant for multiple uses for one individual patient/resident) for Resident 34 was ordered and delivered to the facility timely for one of six residents (Resident 34).As a result, on 1/6/2026 at 11:15AM, licensed vocational nurse (LVN) 2, dispensed 2 units (unit of measure) insulin pen (portable medical device used for injecting doses of insulin) that was already in use/circulation and prescribed specifically for Resident 46 and administered/injected Resident 34 with the same insulin therefore decreasing/reducing the intended time and doses of the insulin prescribed for Resident 46. Cross Reference F880 Findings: During a concurrent observation and interview of medication administration on 1/6/2026 at 11:15AM, LVN 2 injected Resident 34 with 2 units of insulin per sliding scale (chart with prescribed pre-established doses) via insulin pen for a blood sugar test result of 204. An observation/review of a label on the insulin pen, the label indicated that the insulin was prescribed for Resident 46. During an interview LVN 2 apologetically stated she accidentally used Resident 46's insulin pen to administer insulin to Resident 34. LVN 2 further stated Resident 34's insulin pen was in the medication cart, however upon inspection, there was no insulin found of the medication cart and the medication refrigerator for Resident 34. During a concurrent interview and record review on 1/6/2026 at 11:46 AM, the Director of Staff Development (DSD) stated a renewal order for Resident 34's insulin pen was completed yesterday (1/5/2026) during the night shift, the DSD stated facility contracted pharmacy had not delivered Resident 34's ordered insulin medication to the facility. During an interview on 1/8/2026 at 2:45PM, the Director of Nursing (DON) stated sharing a single-patient insulin pen on any resident other than on the resident that the insulin was prescribed for, can lead to reduced intended time use of the prescribed dose for the intended Resident placing residents at risk for serious skin and blood borne diseases that can result in poor outcomes including death. A review of the facility's policy and procedures (P&P) titled Medication Administration-General Guidelines dated 04/2025 indicated, Prior to administration, the medication . the Resident's medication administration record (MAR) is compared with the medication label. Medications supplied for one resident are never administered to another resident. A review of the facility Licensed Vocational Nurse Job Description dated 2003, subtitle Drug Administration Functions indicated, Ensure that prescribed medication for one resident is not administered to another.

Based on interview and record review, the facility failed to ensure Resident 8's medical records did not contain abbreviations not approved by the facility in accordance with the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Charting and Documentation with a revision date of 7/2017. This deficient practice had the potential to result in miscommunication between medical and nursing staff causing delay in providing medical care and services to Resident 8. Findings During a review of Resident 8's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 8 was admitted to the facility on [DATE] with the following diagnoses: hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing), dysphagia (difficulty swallowing), and acute on chronic diastolic heart failure ( a sudden worsening of long-term stiffness in the heart's main pumping chamber (left ventricle), making it hard to relax and fill with blood, leading to fluid backup, shortness of breath, fatigue, and swelling, requiring urgent treatment). During a review of Resident 8's Hospice (is medical care for people who are expected to live six months or less) Comprehensive Assessment (identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) with benefit period dates of 10/17/2025 through 1/14/2026 indicated, Resident 8 was under hospice care. During a review of Resident 8's Minimum Data Set (MDS - a resident assessment tool) dated 10/23/2025, indicated, Resident 8 had moderately impaired cognition (make poor decisions, cues and supervisions required) and was dependent on all activities of daily living (ADL - routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 8's care plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) with a focus on declining health status, initiated on 10/18/2025, indicated the CP goal is to keep Resident 8 comfortable and pain will be controlled. The CP intervention included to observe/report increase pain rate and re-evaluate medication as needed through hospice. However, the same CP indicated that a staff used the abbreviation PIC but failed to indicate/spell out what PIC stood for/means. During a review of Resident 8's Hospice Visit Note Report dated 12/30/2025 indicated, Resident 8 had a recent decline in functional status in feeding, bathing, toileting, ambulation, transfers, feeding, and was now bedbound (someone confined to bed for most or all of their day due to illness, injury, or physical limitations, requiring assistance). During a review of the facility's In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) dated 1/09/2026 indicated, Several staff were educated on avoiding abbreviations in patient documentation. During a review of the facility's Abbreviations and Symbols with a revision date of 9/2013, the document did not include the abbreviation PIC as part of the facility approved abbreviations. During a review of the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Charting and Documentation with a revision date of 7/2017 indicated, To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records.

Based on observation, interview, and record review, the licensed nursing staff failed to follow their own policy and procedure to ensure one of three residents (Resident 1) had an interdisciplinary (IDT)/Bioethics review process to evaluate resident ' s care needs that required informed consent who was known to have fluctuating capacity to understand and make decisions. This deficient practice violated the residents' right to make an informed decision including the use of psychoactive medications. Findings: During a review of the admission record for Resident 1 indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a range of conditions where brain dysfunction occurs due to a systemic metabolic problem, meaning a problem with the body's overall chemical processes. This dysfunction can manifest as confusion, memory problems, changes in behavior, and even loss of consciousness), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and memory deficit following (a decline in a person's ability to remember things, encompassing difficulties in forming new memories, recalling past events, or both. It can range from mild forgetfulness to significant amnesia and may be a symptom of various conditions, including aging, brain injury, or neurological disorders) other cerebrovascular disease (a group of conditions that affect blood flow to the brain, potentially causing damage to brain tissue and affecting brain function). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated 5/1/2025, indicated Resident 1 had moderate cognitive impairment (a stage of cognitive decline where individuals experience more pronounced difficulties with thinking, memory, and judgment than what is considered normal for their age). The same MDS indicated Resident 1 was dependent on staff for his Activities of Daily Living such as: (ADLs routine tasks/activities such as eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, lower/upper body dressing, putting on/taking off footwear). During a review of the General Acute Care Hospital progress note dated 4/29/2025 at 1:27 pm, the progress note indicated under assessment/plan Acute metabolic encephalopathy with waxing/waning mental status. Unclear etiology. Query if toxic-metabolic encephalopathy and residual effect from intentional ingestion of meds at home. and/or delirium (a state of acute mental confusion and disorientation that develops rapidly). During an interview with Certified Nursing Assistant (CNA) 1 on 6/19/2025 at 12:40 pm, CNA 1 stated that Resident 1 ' s had instances where it was difficult to have conversations with him (Resident 1) because he would get confused and refer to things that were not there such as seeing a baby in his room. During an interview with the Social Worker (SW) on 6/20/2025 at 3:34 pm, the SW stated that Resident 1 had fluctuating capacity (a person's ability to make decisions or understand information varies over time). The SW stated that capacity was important for making informed decisions but stated that she was not involved in getting any type of consent from Resident 1. During an interview with the Facility administrator (FA) on 6/20/2025 at 5:16 pm, the FA confirmed that Resident 1 had fluctuating capacity to make decisions. The FA stated that during the times that Resident 1 was unable to make decisions, the facility waited until the times when Resident 1 had a moment of clarity. The FA was unable to demonstrate or verbalize how one could prove that a document was signed while the resident had capacity. The FA stated that a resident must be able to make decisions or have capacity so that he (Resident) understands what is going on with their care. During a review of a Policy and Procedure (P&P) titled, Interdisciplinary Team Review/Bioethics – Substitute Decision-Making, revised 4/16/2025, indicated, Biomedical ethical dilemmas often occur when Long-Term Care Facility (LTCF) residents do not have the cognitive capacity to make informed choices about their health care and when they do not have an advance directive and where there is no surrogate decision-maker/resident representative. The same P&P indicated, The Facility makes a reasonable effort to reach family members and friends, and if none located, take steps to search for a representative to participate in the IDT meeting, including - Interviewing residents -Reviewing medical records -Consulting with SNF staff -Document efforts made to find a legal decision-maker and/or resident representative -If unable to identify a Resident Representative, contact The Long-Term Care Office for Patient Representatives (OPR) within 72 hours of MD determination of no capacity May contact OPR before 72 hours if unlikely that a legal decision-maker, family member, or friend will be located 1) Continue to search after contacting OPR 2) Family member or friend may replace the OPR selected Resident Representative if person becomes available to serve as the resident representative

Based on interview and record review, the facility failed to ensure safe and orderly discharge from the facility to home for four of five sampled residents (Resident 1, 2, 4 and 5) by failing to: 1. Properly discharge Resident 1 to home by setting up the home health agency with complete instructions for ongoing care according to physician's order. 2. Complete a discharge plan summary upon Resident 1, 2, 4, 5's discharge to home. 3. Complete an Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) meeting with services provided by the Social Services department regarding Resident 1, 2, 4 and 5's discharge planning according to facility's policy and procedure (P&P). These deficient practices resulted in incomplete and ineffective discharge planning that led to lack of necessary care after discharge. Findings: A. During a review of Resident 1's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS - commonly known as Lou Gehrigsdisease, is a progressive neurodegenerative disease that affects the motor neurons in the brain and spinal cord), dysphagia (difficulty swallowing) and disorder of muscle (a group of conditions that affect the muscles and their function). The Admission Record also indicated; Resident 1 was discharge on 1/2/2025. During a review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/19/2024, the MDS indicated Resident 1's cognitive (relating to mental action or process of acquiring knowledge and understanding) skills for daily decisions was mildly impaired. The MDS indicated Resident 1 required maximal assistance to total dependence from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Order Summary Report (OSR), dated 1/2/2025, the OSR indicated, Discharge with Home Health Agency (HHA1) with Physical Therapy, Occupational Therapy, Speech Therapy including Durable Medical Equipment (DME -refers to medical devices like wheelchairs, walkers, oxygen equipment, and hospital beds that are designed to be used repeatedly at home): hospital bed and gastrostomy tube (g-tube - is a thin, flexible tube inserted through the abdominal wall directly into the stomach) supplies. During a review of Resident 1's IDT team meeting [notes], dated 12/17/2024, the IDT meeting [notes] did not include any services provided by Social Services Director (SSD) and any documentation regarding discharge planning of Resident 1. During a review of Resident 1's Progress Notes as of 3/3/2025, the Progress Notes indicated there were no documentations by SSD regarding Resident 1's discharge planning that included HHA1 setup, medications and DME prior to Resident 1's discharge on 1/2/2025. Additionally, there were no documented notes by SSD regarding follow-up calls regarding Resident 1's status after discharge. During an interview with Family Member 1 (FM 1) on 2/28/2025 at 2:26 p.m., FM 1 stated, Resident 1 was discharged on [DATE] and during discharge instruction, they were informed that HHA1 will be following Resident 1 for ongoing care such as g-tube feeding and physical therapy. FM 1 stated, they waited for HHA1 to call them and set-up after Resident 1 was discharged and did not receive a call. FM 1 stated, she had to call Resident 1's physician to verify the orders and she also called HHA1 to get a clarification in which they confirmed that HHA1 did not get a referral and/or physician's orders from the facility regarding home health services. During an interview with Home Health Administrative Specialist (HHAS) on 2/28/2025 at 2:53 p.m., the HHAS stated, they received the referral for Resident 1's home health services from Resident 1's physician on 2/2/2025. B. During a review of Resident 2's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including fracture of lower end of right femur (a break, crack or crush injury of the thigh bone), depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and disorder of muscle. The Admission Record indicated Resident 2 was discharged on [DATE]. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were intact. The MDS indicated Resident 2 required maximal assistance to total dependence from staff for ADLs. During a review of Resident 2's OSR, dated 1/10/2025, the OSR indicated, Discharge home with Home Health Agency (HHA2) with Physical Therapy, Occupational Therapy, Registered Nurse with left over medications. During a review of Resident 2's IDT team meeting [notes], dated 12/31/2024, the IDT meeting [notes] did not include any services provided by SSD and any documentation regarding discharge planning of Resident 2. During a review of Resident 2's Progress Notes as of 3/3/2025, the Progress Notes indicated there were no documentations by SSD regarding Resident 2's discharge planning that included HHA2 setup, and medications prior to Resident 2's discharge on 1/10/2025. Additionally, there were no documented notes by SSD regarding follow-up calls regarding Resident 2's status after discharge. C. During a review of Resident 4's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including multiple fractures of ribs, right side, chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe) and diastolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). The Admission Record indicated Resident 4 was discharged on [DATE]. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decisions were intact. The MDS indicated Resident 4 required maximal assistance from staff for ADLs. During a review of Resident 4's OSR, dated 3/1/2025, the OSR indicated, Discharge home with Home Health Agency (HHA3) with Physical Therapy, Occupational Therapy, Registered Nurse with left over medications. During a review of Resident 4's medical record as of 3/3/2025, the medical record indicated, there were no IDT team meetings conducted, and no documentations on what discharge planning had been completed for Resident 4. During a review of Resident 4's Progress Notes as of 3/3/2025, the Progress notes indicated there were no documentations by SSD regarding Resident 4's discharge planning that included HHA3 setup, and medications prior to Resident 3's discharge 3/1/2025. Additionally, there are no notes by SSD regarding follow-up calls regarding Resident 4's status after discharge. D. During a review of Resident 5's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), end stage renal disease (ESRD-a medical condition in which a person's kidney [organ in the body that lifters waste and excess fluid from the blood] function stop functioning on a permanent basis) and disorder of muscle. The Admission Record indicated Resident 5 was discharged on [DATE]. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decisions were intact. The MDS indicated Resident 2 required maximal assistance to total dependent from staff for ADLs. During a review of Resident 5's OSR, dated 1/3/2025, the OSR indicated, Discharge home with Physical Therapy, Occupational Therapy, Registered Nurse with left over medications. During a review of Resident 5's medical record as of 3/3/2025, the medical record indicated, there were no IDT team meetings conducted, and no documentations on what discharge planning had been completed for Resident 5. During a review of Resident 5's Progress Notes as of 1/3/2025, the Progress Notes indicated there were no documentations by SSD regarding Resident 5's discharge planning that included HHA setup, and medications prior to Resident 5's discharge on 1/3/2025. Additionally, there were no documented notes by SSD regarding follow-up calls regarding Resident 5's status after discharge. During a concurrent interview and record reviews with Registered Nurse (RN 1) on 3/3/2025 at 12:05 p.m., RN 1 stated, for IDT meeting regarding discharges, they would notify SSD as it is her (SSD) responsibility to setup home health. RN 1 reviewed Resident 1, 2, 4, and 5's medical record and confirmed, there were no documentations completed regarding residents' discharge planning. RN 1 stated residents who were discharged with HHA should be followed up immediately after discharge for continuity of care and for safety. During an interview with Director of Nursing (DON) on 3/3/2025 at 12:21 p.m., the DON stated, it is important to ensure the continuity of care for the services to be setup prior to discharging residents in the facility for the safety of the residents. The DON stated, it is also important to make follow-up phone calls with residents to ensure that they are safe after being discharged from the facility. During a review of facility's policy and procedure (P&P), titled, Discharge Summary and Plan, revised on 10/2024, the P&P indicated that, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge . Every resident will be evaluated for his or her discharge needs and will have an individualized post discharge plan. The post-discharge plan will be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and his or her family . A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident's medical records: a. An evaluation of the resident's discharge needs; b. The post-discharge plan; and c. The discharge summary.

Based on interview, and record review, for one of six sampled residents (Resident 1) the facility failed to 1. Monitor the vital signs (VS) which included blood pressure (BP), apical pulse (AP- a pulse point on the chest that gives the most accurate reading of a heart rate), and heart rate (HR-Pulse), according to physician's order for the following medications: a. Amiodarone HCL (Medication to treat/control very rapid and irregular pulse]) 200 milligrams (mg - unit of measurement) oral tablet a day for atrial fibrillation (A-Fib, serious medical condition of the heart: fast and irregular heartbeat) hold for apical pulse <60, Amiodarone dose was held or given with no documented apical pulse on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. b. Metoprolol Succinate (Medication to treat/control high blood pressure) Extended Release (ER) 50 mg Oral Tab ER 1 tab one time day for hypertension (HTN- high blood pressure) hold for systolic blood pressure (SBP-top number of BP ready) <100 millimeters of mercury (mmHg, unit of pressure) and HR<60, dose was held with no documented BP or HR on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Metoprolol dose administered when BP was below acceptable parameters (SBP<100mmHg) on ,d+[DATE], ,d+[DATE], and [DATE]. c. Spironolactone (Medication to treat/control HTN) oral tablet 25mg give 0.5 tab a day for congestive heart failure (CHF- weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) hold for SBP <100, dose was held with no documented BP on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Spironolactone dose administered when BP was below acceptable parameters (SBP<100mmHg) on ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. d. Entresto (Medication for heart failure) ,d+[DATE]mg give 0.5mg two times a day for HTN hold for SBP <100 as per indicated parameters. Entresto dose was held with no documented BP on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Entresto Dose administered when BP was below acceptable parameters (SBP<100mmHg) on ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. 2. Monitor for potential adverse consequences by ensuring the licensed staff will not ignore or override when amiodarone and metoprolol were triggered for severe drug to drug interaction (Adverse drug Reaction [ADR]- harmful or unpleasant reactions to a medication that can be life-threatening) if administered together could result in hypotension, bradycardia (slow heart rate), cardiac arrest, and death. 3. Monitor the responses to or effects of a medications to Resident 1 by analyzing the trend of the vital signs. 4. Resident 1 did not get an excessive dose of Lidoderm patch 5% topically (onto skin) by receiving two doses on [DATE] at 8:13 AM and [DATE] at 1:23 PM. As result, on [DATE] at 9 PM, Resident 1 received all these medications (metoprolol, spironolactone, Entresto, amiodarone, and 2 doses of Lidoderm 5% patch). On [DATE] at 1:20 PM, the facility discharged Resident 1 to the Assisted Living Facility (ALF- a facility for people who need help with daily care, but not as much help as a nursing home provides) via the facility provided non-emergency transportation. Upon arrival of Resident 1 to the AFL resident was pronounced deceased /dead upon arrival. Cross Reference: F580, F624, F760, F842 On [DATE] at 6:09 PM, while onsite, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ-a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation for the facility's failure to: 1. Adequately monitor the parameter per physician order of the following medications: Amiodarone HCL 200 mg oral tablet a day for A-Fib hold for Apical pulse <60 (per pharmacy recommendation), Metoprolol Succinate ER 50 mg Oral Tab ER 1 tab one time day for HTN hold for SBP <100 and HR<60, Spironolactone Oral tablet 25mg give 0.5 tab a day for CHF hold for SBP <100, Entresto ,d+[DATE]mg give 0.5mg two times a day for HTN hold for SBP <100 as per indicated parameters. 2. Monitor for potential adverse consequences by ensuring the licensed staff will not ignore or override when amiodarone and metoprolol were triggered for severe drug to drug interaction if administered together could result in hypotension, bradycardia, cardiac arrest, and death. 3. Resident 1 did not get an excessive dose of Lidoderm patch 5% topically by receiving two doses on [DATE] at 8:13 AM and [DATE] at 1:23 PM. Administering these medications (metoprolol, spironolactone, Entresto, amiodarone, a Lidoderm 5% patch and second Lidoderm 5% patch) which were known to have severe drug-to-drug interactions without adequate monitoring may result arrhythmias, severe hypotension, bradycardia, and cardiac arrest, including death. On [DATE] at 9 am, Resident 1 received these medications (metoprolol, spironolactone, Entresto, amiodarone, a Lidoderm 5% patch and at 1:17 PM, second Lidoderm 5% patch) and was discharged via the facility provided transportation to an assisted living, Resident 1 was pronounced deceased upon arrival to AFL. On [DATE] at 9:55 PM, while onsite, the SSA removed the IJ after the facility submitted an acceptable removal plan (interventions to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: On [DATE], the facility contracted with an outside Pharmacist Consultant to conduct a baseline Medication Regimen Review of residents who resided in the facility on [DATE] for the period beginning [DATE] through [DATE]; to identify other residents potentially affected by missing order parameters, inadequate monitoring, and/or requiring dose adjustments due to medications repeatedly being held. Recommendations were referred to Director of Nursing for follow-up and/or Physician consultation as indicated. On [DATE], the facility contracted with an outside Physician to conduct a medication regimen review of the facility residents. The outside contracted Physician will collaborate with the outside contracted Pharmacy Consultant regarding the reviews. On [DATE] the outside contracted Pharmacy Consultant reviewed in-house residents' medication regimen from [DATE] through [DATE] with the following summary of audit findings: MRR completed for 42 Residents on [DATE]. 33 Residents noted with orders for parameters and monitoring without any irregularities identified. 6 Residents noted with an irregularity in following Physician's ordered parameters. An outside Consultant Pharmacist educated Director of Nursing Services, and Clinical Nurse Resource Consultant on [DATE] at 10 PM regarding: Safe Medication Administration; Alerting Nurses of Drug-to-Drug interaction prior to Medication Administration; Importance of Adhering to Ordered Medication Parameters; Physician Notification; and Importance of Pharmacist Performing a Thorough Medication Regimen Review (MRR). On [DATE], the facility contracted with an outside Nurse Consultant to conduct in-services and complete the medication administration observations of the licensed nurses. The Director of Nursing Services (DNS) educated licensed nurses on Safe Medication Administration; Alerting Nurses of Drug-to-Drug interaction prior to Medication Administration; Importance of Adhering to Ordered Medication Parameters; Physician Notification; and Importance of Pharmacist Performing a Thorough Medication Regimen Review (MRR) and Medication Administration Technique; and expectations on consulting with physicians as indicated. This training started [DATE] for in-house staff, with remaining staff educated prior to the start of their shift. As of [DATE] at 11am, 12 of 14 nurses (5 Registered Nurses [RN] and 9 License Vocational Nurses [LVNs] total on staff) have completed training (4 RNs + 8 LVNs); for the remaining 2 nurses, 1 LVN will be trained by [DATE]; and 1 RN on LOA will receive training prior to working her shift upon her return. As of [DATE] (4) Registry-LVNs have been in-serviced. Moving forward any Registry Staff will be in-service prior to working their scheduled shift. Licensed Nurses will be educated on Safe Medication Administration; Alerting Nurses of Drug-to-Drug interaction prior to Medication Administration; Importance of Adhering to Ordered Medication Parameters; Physician Notification; and Importance of Pharmacist Performing a Thorough Medication Regimen Review (MRR) and Medication Administration Technique and follow-up expectations upon hire and annually. Training will be completed with the Director of Nursing Services (DNS) and documentation will be retained on training records. DNS educated Licensed Nurses on safe medication administration practices using the 10 Rights of administration; administering meds in accordance with physician ordered monitoring parameters, promptly notifying Physician of significant drug-to-drug interactions; and importance of facilitating new admission, change-of-condition, and monthly Medication Regimen Reviews (MRRs); and promptly reviewing and remediating MRR findings when indicated. This training will begin [DATE] for in-house staff, and remaining staff will be educated prior to the start of their shift. As of [DATE] at 7 PM, total licensed nursing staff 5 Registered Nurses (RNs) and 9 Licensed Vocational Nurses (LVNs) of which 4 RNs and 8 LVNs have completed training; the remaining 2 nurses, 1 LVN will be trained by [DATE]; and 1 RN on LOA will receive training prior to her return. As of [DATE] four (4) Registry-LVNs have been in-serviced. Moving forward any Registry Staff will be in-service prior to working their scheduled shift. Licensed Nurses will receive training upon hire and annually on safe medication administration practices using the 10 Rights of administration; administering meds in accordance with physician ordered monitoring parameters, promptly notifying Physician of significant drug-to-drug interactions; and importance of facilitating new admission, change-of-condition, and monthly Medication Regimen Reviews (MRRs); and promptly reviewing and remediating MRR findings when indicated. Training will be completed with the Director of Nursing Services and documentation will be retained on training records. Medication Pass Competency Assessments will be completed with Licensed Nurses upon hire and annually by Facility Director of Nursing Services (DON), Director of Staff Development (DSD), or Pharmacy Nurse Consultant. Competencies will include verifying proper/safe medication administration practices and compliance with physician ordered administration parameters. New admissions, those experiencing a change-of-condition, and no less often than monthly, a thorough MRR will be conducted through our contracted Pharmacy to identify drug-to-drug interactions and medications requiring dose adjustments (i.e. held frequently). The facility contracted with an outside Pharmacist Consultant [DATE] to conduct a concurrent Medication Regimen Review each month for a minimum of 3 months at which time it will be re-evaluated by the Quality Assessment and Assurance (QAA) Committee for further recommendation. The facility contracted a Medical Records Consultant to conduct concurrent audits with our facility Medical Records Director to monitor Licensed Nurse compliance adhering to ordered medication parameters and contacting Physician's for dose adjustments when indicated (i.e. frequently held). Audits started [DATE] and continue weekly for a minimum of 3 months at which time it will be re-evaluated by the QAA Committee for further recommendation. Beginning [DATE], Director of Nursing Services (DON) is responsible for monitoring Pharmacy compliance of new admission reviews, change of condition, and monthly medication regimen reviews; and coordinating prompt MRR remediation and follow-up. Each month, DON will report MRR compliance thresholds for completion and remediation to the facility's QAA Committee for analysis and remedial planning or monitoring needs as indicated. The Director of Nursing Services (DON) beginning [DATE] will conduct 3 random med pass observations each week x's 3 months, then monthly x's 3 months, then quarterly thereafter to monitor compliance with safe medication administration practices and following ordered parameters where indicated. DON will be responsible for reporting compliance with med pass observations and results to the facility's QA Committee for analysis and remedial planning or monitoring needs as indicated. Facility Medical Records Director (MRD) beginning [DATE] will conduct medication administration record audits of in-house Residents each week x's 3 months, then monthly x's 3 months, then quarterly thereafter to monitor Licensed Nurse compliance adhering to ordered medication parameters and consulting Physicians on dose adjustments when indicated (i.e. frequently held). The audit results will be reported to the Administrator and Director of Nursing for appropriate corrective action. MRD will be responsible for reporting compliance with order parameters and dose adjustment consults to facility's QA Committee for analysis and remedial planning or monitoring needs as indicated it will be re-evaluated for a minimum of 3 months at which time it by the QAA Committee for further recommendation. Findings: A review of Resident 1's Admission Record, indicated the facility admitted the resident on [DATE], with diagnosis that included acute (sudden) on chronic (long-term) systolic cardiac heart failure (a specific type of heart failure that occurs in the heart's left ventricle), paroxysmal A-Fib (fast and irregular heartbeat), essential hypertension (HTN: high blood pressure that is not due to another medical condition), ST-elevation myocardial infarction (STEMI, type of heart attack that is more serious and has a greater risk of serious complications and death) involving coronary artery of anterior wall (the artery supplies blood to the front portion of your heart), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), rheumatic disorders of both mitral valves (lies between the left atria and the left ventricle) and tricuspid valves (lies between the right atrium and the right ventricle). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], indicated the resident had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated the resident was dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. A review of Resident 1's Order Summary Report dated [DATE], indicated Resident 1 was on the following medications: a. Amiodarone HCI Oral tablet 200 mg give one tablet by mouth one time a day for A-fib hold for Apical pulse <60 (per pharmacy recommendation). b. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 Hour 50 mg give one tablet by mouth one time a day for HTN hold for SBP <100 and HR<60. c. Spironolactone Oral tablet 25mg give 0.5 tablet by mouth one time a day for CHF hold for SBP <100. d. Entresto Oral tablet ,d+[DATE]mg give 0.5mg by mouth two times a day for HTN for SBP <100. e. Lidoderm Patch 5% (Lidocaine) apply to left thigh topically one time a day for pain management and remove per schedule. The order did not indicate what the schedule was. A review of Resident 1's Progress Notes for ,d+[DATE], indicated medication administration orders had triggered a severe drug to drug interaction between Metoprolol Succinate ER and Amiodarone HCL on [DATE] at 8:37 PM, [DATE] at 10:29 AM, [DATE] at 2:38 PM, and [DATE] at 4:08 PM. The progress notes indicated Interaction: Administration of Amiodarone HCI Oral Tablet 200 mg and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 mg may result in severe bradycardia, hypotension and cardiac arrest. The progress notes did not indicate a physician was notified of the severe drug to drug interaction on any of the aforementioned dates. A review of Resident 1's Progress Notes dated [DATE] at 8:45 PM, indicated a medication administration order had triggered a severe drug to drug interaction between Metoprolol Succinate ER and Amiodarone HCL. The progress notes indicated Interaction: Administration of Amiodarone HCI Oral Tablet 200 mg and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 mg may result in severe bradycardia, hypotension and cardiac arrest. The note did not indicate the physician was notified of the severe drug to drug interaction. A review of Resident 1's Medication Administration Record (MAR) for ,d+[DATE], indicated Amiodarone HCL oral tablet a day for A-Fib hold for apical pulse <60 (per pharmacy recommendation) start date [DATE]. The MAR had a section to document the resident's BP but did not have a section to document the resident's pulse. The MAR indicated administration was as follows: ,d+[DATE]: Dose held, BP ,d+[DATE] mmHg, (per vital sign documentation pulse was 71 bpm [did not indicate if apical] on [DATE] at 9:34 am). The pulse did not indicate if checked apically. [DATE]: Dose held, BP ,d+[DATE] mmHg, pulse not indicated. No pulse documented in medical record for [DATE] at 9 am. if checked apically as ordered. A review of Resident 1's MAR for ,d+[DATE], indicated to administer Metoprolol Succinate ER oral, one tab one time day (9 AM) for HTN and to hold the medication for SBP <100 mmHg and HR<60 per minute. The MAR further indicated the following about Metoprolol ER: [DATE]: Dose held. No documented BP or HR/AP BP not indicated/documented in Resident 1's chart (no vital signs documented in medical record) [DATE]: Dose held, BP or pulse not indicated/documented (no vital signs documented in medical record) [DATE]: Dose held, BP or pulse not indicated/documented (no vital signs documented in Resident 1's chart) [DATE]: Dose held, BP or pulse not indicated/documented (no vital signs documented in medical record). [DATE]: Dose held, BP or pulse not indicated/documented on the MAR or on medical records. [DATE]: Dose administered, BP ,d+[DATE] mmHg, pulse 66. [DATE]: Dose administered, BP ,d+[DATE] mmHg, pulse 74. [DATE]: Dose administered, BP ,d+[DATE] mmHg, pulse 71. The ,d+[DATE] MAR did not indicate a physician was notified for held metoprolol ER and for VS parameters out of prescribed range. A review of Resident 1's MAR for ,d+[DATE], indicated Spironolactone Oral tablet 25mg give 0.5mg one tab a day (9am) for CHF hold for SBP <100 administration was as follows: [DATE]: Dose held; BP not documented on the MAR or on medical records. [DATE]: Dose held; BP not documented on the MAR or on medical records. [DATE]: Dose held; BP not documented on the MAR or on medical records. [DATE]: Dose administered, BP ,d+[DATE] mmHg [BP taken at 11:02 am] (parameter indicated hold for SBP <100) [DATE]: Dose administered BP ,d+[DATE] mmHg. [DATE]: Dose held, BP and pulse not documented on the MAR or on medical records. [DATE]: Dose held, BP not indicated, pulse not documented (no vital signs documented in medical record) [DATE]: Dose administered, BP ,d+[DATE] mmHg [BP taken at 11:16 am] [DATE]: Dose held; BP not indicated on MAR. [DATE]: Dose held, BP not indicated, pulse not documented (no vital signs documented in medical record). [DATE]: Dose administered, BP ,d+[DATE] mmHg. The ,d+[DATE] MAR did not indicate a physician was notified for held Spironolactone Oral tablet 25mg give 0.5mg and for VS parameters out of prescribed range. A review of Resident 1's MAR for ,d+[DATE], indicated Entresto ,d+[DATE]mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: [DATE]: Dose held; BP not documented on the MAR or on medical records. [DATE]: Dose held; BP not documented (no vital signs documented in medical record) [DATE]: Dose held; BP not documented (no vital signs documented in medical record) [DATE]: Dose administered, BP ,d+[DATE] mmHg [BP taken at 11:02 AM] (parameter indicated hold for SBP <100) [DATE]: Dose administered BP ,d+[DATE] mmHg [DATE]: Dose held, BP and pulse not documented on the MAR or on medical records. [DATE]: Dose held, BP and pulse not documented on the MAR or on medical records. [DATE]: Dose administered, BP ,d+[DATE] mmHg [BP taken at 11:16 am] [DATE]: Dose held; BP not documented on MAR. [DATE]: Dose held, BP not documented on the MAR or on medical records. [DATE]: Dose administered, BP ,d+[DATE] mmHg. The ,d+[DATE] MAR did not indicate a physician was notified for held Entresto ,d+[DATE] mg give 0.5 mg and for VS parameters out of prescribed range. A review of Resident 1's MAR for ,d+[DATE], indicated Amiodarone HCL 200mg oral tablet a day for A-Fib hold for Apical pulse <60 (per pharmacy recommendation) administration was as follows: [DATE]: Dose administered, BP ,d+[DATE] mmHg, Apical pulse not documented. [DATE]: Dose held, BP ,d+[DATE] mmHg, Apical pulse not documented. [DATE]: Dose held, BP ,d+[DATE] mmHg, Apical pulse not documented. [DATE]: Dose administered, BP ,d+[DATE] mmHg, Apical pulse not documented. [DATE]: Dose administered, BP,d+[DATE] mmHg, Apical pulse not documented. [DATE]: Dose administered, BP ,d+[DATE] mmHg, Apical pulse not documented. [DATE]: Dose administered; Apical pulse not documented. [DATE]: Dose held; Apical pulse not documented. [DATE]: dose administered, BP ,d+[DATE] mmHg, Apical pulse not documented. The ,d+[DATE] MAR did not indicate a physician was notified for held Amiodarone HCL Oral tablet 200mg and for VS parameters out of prescribed range. A review of Resident 1's MAR for ,d+[DATE], indicated Metoprolol Succinate ER Oral Tab ER 1 tab one time day for HTN hold for SBP <100 and HR<60 administration was as follows: [DATE]: Dose held, BP and pulse not documented (no vital signs documented in medical record). [DATE]: Dose held, BP and pulse not documented on the MAR or on medical records. [DATE]: Dose administered, BP ,d+[DATE] mmHg, pulse 84. A review of Resident 1's MAR for ,d+[DATE], indicated Spironolactone Oral tablet 25mg give 0.5mg one tab a day for CHF hold for SBP <100 administration was as follows: [DATE]: Dose held; no BP documented on the MAR. VS not documented on medical records. [DATE]: Dose held; no BP documented. VS not documented in medical records. [DATE]: Dose held; no BP documented. VS not documented in medical records. [DATE]: administered, BP ,d+[DATE] mmHg. A review of Resident 1's MAR for ,d+[DATE], indicated Entresto ,d+[DATE]mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: [DATE]: 9 AM: Dose held; BP not documented. [DATE]: 9 AM: Dose held; BP not documented. [DATE]: 9 AM: Dose held; BP not documented in medical records. [DATE]: 9 AM: Administered, BP ,d+[DATE] mmHg. A review of Resident 1's MAR for [DATE] at 8:13 AM, indicated Resident 1 was administered a Lidoderm patch 5% topically (onto skin). A review of Resident 1's MAR for [DATE], indicated Resident 1 was administered a second Lidoderm patch on [DATE] at 1:23 PM as recorded in MAR (a discrepancy from the time of discharge of 1:20 PM. Actual application was at 1 pm per LVN1 interview). The MAR did not indicate the Lidoderm patch applied on [DATE] at 8:13 AM was removed. A review of Resident 1's physician's Skilled Nursing Facility Discharge Medication Reconciliation Note dated [DATE] at 9:23 AM, indicated Resident 1 was to be discharged on amiodarone 200 mg 1 tablet by mouth daily, Entresto ,d+[DATE] mg 0.5 tablet by mouth twice a day, Lidocaine 5% patch 12 hours on and 12 hours off, metoprolol succinate 50 mg 1 tablet daily, Spironolactone 25mg 0.5mg tablet daily in the morning. A review of Resident 1's Nurses Notes dated [DATE] at 1:20 PM, indicated Resident discharged home with caregiver in provided transportation via wheelchair. No complaints of pain or discomfort. Resident signed all paperwork and leftover medications were given as ordered. Resident escorted to transportation by staff. MD and family aware. The nurses noted indicated Resident 1's VS were taken on [DATE] at 8:16 AM; BP ,d+[DATE], T97.2, P64, RR18, O2 97% RA. The nurses' notes did not indicate the resident's vital signs were taken prior to discharge. During an interview on [DATE] at 11:57 AM, Assisted Living Facility Staff (AFL 1) stated on [DATE] at around 1:30 PM Resident 1 arrived at the facility (AFL) there were no sign of life, paramedics were called, and cardiopulmonary resuscitation (CPR) started. Resident 1 was pronounced dead at approximately 2 PM. During an interview on [DATE] at 1:27 PM, the Director of Staff Development (DSD) stated CNAs and CNs are responsible for assessing VS, and that VS needed for medication administration are assessed by the licensed nurses 10 to 15 minutes prior to medication administration because the side effects of the medication can cause low BP, low heartrate (bradycardia), or syncope. DSD stated, it was important to check BP timely to ensure the BP remained within a normal range because BP medications could work too well and cause hypotension. DSD stated a resident's physician must be informed of three consecutive low BP readings. DSD stated VS must be within ordered parameters must be within range before the medications are administered to mitigate (lessen) adverse (negative) reactions from the medications and had to be followed for resident safety. DSD stated if BP medications are given outside of ordered parameters the residents BP could drop low, which could result in death due to lack of circulation. DSD stated if VS are ordered to such as to assess apical pulse, the documentation must indicate apical pulse was taken. DSD stated the EHR alerts the nurses of any drug-to-drug interactions. DSD defined drug to drug interactions as two drugs (medications) given together that can cause harm and can increase the likelihood of harm. DSD stated the RNS oversee and act on drug to drug to interactions. DSD stated when the EHR alerts facility staff of severe drug to drug interactions, staff must take immediate action and must contact/notify the resident's physician. During an interview on [DATE] at 10:48 AM, LVN1 stated certified nursing assistants (CNAs) are in charge of checking VS and the charge nurses (CNs) were responsible for checking medication administration VS such as BP. LVN1 stated CNAs document the VS in the VS log and the CNs document the VS on the MAR. LVN1 stated VS are taken within 15minutes before medication administration because the VS can change. LVN1 stated medications could be administered an hour before or after the ordered time. LVN1 restated it was important to take a BP timely with medication administration because the BP could change. LVN1 defined parameters as the recommended scale that must be followed to give certain medications at the proper dose such as BP and blood sugar (BS) medications. LVN1 stated if parameters are not followed the results could be detrimental (harmful) and dangerous to a resident's health. LVN1 stated if ordered, apical pulse must be assessed apically and documented as apical pulse on the MAR. LVN1 stated registered nurse supervisors (RNS) are responsible for inputting medication orders and acting upon severe drug to drug interaction warnings. LVN1 stated the physician must be notified immediately of all severe drug to drug interaction warnings. LVN1 stated physician must be notified of all changes in condition in resident status and VS taken at the time of the change of condition otherwise the residents could receive the wrong treatment. During an interview on [DATE] at 11:54 am, the Director of Nursing (DON) stated care plan must include resident's condition, diagnosis/es, . black box warnings to ensure residents are provided with appropriate care during their stay at the facility. The DON stated if specific interventions and orders for cardiac medication administration are not carried out as per physician's orders can result in the resident experiencing hypotension or hypertension. The DON stated when administering medications the CNs are responsible for assessing VS. The DON stated VS must be documented on the vital signs logs and must be taken prior to medication administration because if the BP is too low and medications are given can result in hypotension, shock (a life-threatening emergency in which the organs cannot function properly), and syncope (fainting or passing out). The DON stated parameters are placed on medication orders to ensure resident safety and that it was important to administer medications as ordered to improve the resident's condition/outcome. The DON stated BP/cardiac medications must not be administered without current VS because the VS could change. The DON stated if a physician ordered a specific VS such as apical pulse the nurses must check the apical pulse for one full minute (pointed to her [DON] left rib area of the chest location) to check the apical pulse. The DON stated she was not sure if the electronic health record (EHR) was set up to allow the nurses to document an apical pulse was taken but stated that documentation must be specific and must indicate an apical pulse was assessed. The DON stated drug to drug interactions are first reviewed by the facility's contracted pharmacy and then the pharmacy notifies the facility. The DON stated after the pharmacy notifies the facility, the facility contacts the resident the resident's physician to check if it is okay for the resident to receive medications (Spironolactone, Amiodarone, Entresto, and Metoprolol) together. The DON stated the facility must notify a resident's physicians of drug to drug-to-drug interactions immediately, regardless of if the drug-to-drug interactions indicates mild or severe. During a telephone interview on [DATE] at 12:07 PM, the pharmacy consultant (PC) stated it was important to review BP and pulse especially if a resident is on multiple blood pressure medications because of the risk for hypotension and bradycardia. The PC stated it was very important to monitor the apical pulse when a resident is on an antiarrhythmic such as amiodarone because amiodarone specifically affects the pulse, and the residents is at risk for bradycardia, fainting, and dizziness. The PC stated it was important the check the apical pulse for one full minute when a resident is on amiodarone because that is where the most accurate pulse is be obtained. The PC stated it was important the check the vital signs at the time of medication administration because the vital signs can change depending on the patient's movement, behavior, what they have eaten, and time between other medications, the blood pressure fluctuates even hour to hour you may get some variations 20 minutes. The PC stated the nurses administering the medications are responsible to adhere to the parameters set by the physician and if the medications are being held multiple days the nurses should have notified the physician of the continued need to hold the medications. The PC stated the nurses administering the medications are responsible for notifying the physician if the vital signs are continuously out of the parameters. During a follow up interview and record review of drug-to-drug interaction alerts on [DATE] at 3:15 PM, LVN1 stated, drug-to-drug interactions only appears when a medication is newly ordered. LVN1 stated when a medication is ordered and th [TRUNCATED]

Based on interview and record review, the facility failed to maintain complete and accurate medical record in accordance with accepted professional standards and practices for one out of 3 sampled residents (Resident 1) for the following medications: a. Amiodarone HCL (Medication to treat/control very rapid and irregular pulse]) 200 milligrams (mg - unit of measurement) oral tablet a day for atrial fibrillation (A-Fib, serious medical condition of the heart: fast and irregular heartbeat) hold for apical pulse <60, Amiodarone dose was held or given with no documented apical pulse on 11/29, 11/30, 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, and 12/9/2024. b. Metoprolol Succinate (Medication to treat/control high blood pressure) Extended Release (ER) 50 mg Oral Tab ER 1 tab one time day for hypertension (HTN- high blood pressure) hold for systolic blood pressure (SBP-top number of BP ready) <100 millimeters of mercury (mmHg, unit of pressure) and HR<60, dose was held with no documented BP or HR on 11/4, 11/7, 11/13, 11/19, 11/20, 12/1, 12/7, and 12/8/2024. c. Spironolactone (Medication to treat/control HTN) oral tablet 25mg give 0.5 tab a day for congestive heart failure (CHF- weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) hold for SBP <100, dose was held with no documented BP on 11/4, 11/7, 11/13, 11/19, 11/20, 11/26, 12/1, 12/7, and 12/8/2024. d. Entresto (Medication for heart failure) 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 as per indicated parameters. Entresto dose was held with no documented BP on 11/4, 11/7, 11/13, 11/19, 11/20, 11/25, 11/26, 12/1, 12/7, and 12/8/2024. These deficient practices had the potential to result in confusion in provision of care and services for Resident 1 and places Resident 1 at risk of not receiving appropriate treatment due to incomplete medical care information. Cross Reference: F580, F624, F757, F760 Findings: A review of Resident 1's Admission Record, indicated the facility admitted the resident on 10/24/24, with diagnosis that included acute (sudden) on chronic (long-term) systolic cardiac heart failure (a specific type of heart failure that occurs in the heart's left ventricle), paroxysmal A-Fib (fast and irregular heartbeat), essential hypertension (HTN: high blood pressure that is not due to another medical condition), ST-elevation myocardial infarction (STEMI, type of heart attack that is more serious and has a greater risk of serious complications and death) involving coronary artery of anterior wall (the artery supplies blood to the front portion of your heart), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), rheumatic disorders of both mitral valves (lies between the left atria and the left ventricle) and tricuspid valves (lies between the right atrium and the right ventricle). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/24/24, indicated the resident had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated the resident was dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. A review of Resident 1's Order Summary Report dated 10/24/2024, indicated Resident 1 was on the following medications: a. Amiodarone HCI Oral tablet 200 mg give one tablet by mouth one time a day for A-fib hold for apical pulse <60. b. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 Hour 50 mg give one tablet by mouth one time a day for HTN hold for SBP <100 and HR<60. c. Spironolactone Oral tablet 25mg give 0.5 tablet by mouth one time a day for CHF hold for SBP <100. d. Entresto Oral tablet 24-26mg give 0.5mg by mouth two times a day for HTN for SBP <100. A review of Resident 1's Medication Administration Record (MAR) for 11/2024, indicated Amiodarone HCL oral tablet a day for A-Fib hold for apical pulse <60 (per pharmacy recommendation) start date 11/29/24. The MAR had a section to document the resident's BP but did not have a section to document the resident's apical pulse. The MAR indicated administration was as follows: 11/292024: Dose held, BP 99/67 mmHg, (per vital sign documentation pulse was 71 bpm [did not indicate if apical] on 11/29/24 at 9:34 am). The pulse did not indicate if checked apically. 11/30/2024: Dose held, BP 99/70 mmHg, pulse not indicated. No pulse documented in medical record for 11/30/24 at 9 am. if checked apically as ordered. A review of Resident 1's MAR for 11/2024, indicated to administer Metoprolol Succinate ER oral, one tab one time day (9 AM) for HTN and to hold the medication for SBP <100 mmHg and HR<60 per minute. The MAR further indicated the following about Metoprolol ER: 11/4/2024: Dose held. No documented BP or HR/AP BP not indicated/documented in Resident 1's chart (no vital signs documented in medical record) 11/7/2024: Dose held, BP or pulse not indicated/documented (no vital signs documented in medical record) 11/13/2024: Dose held, BP or pulse not indicated/documented (no vital signs documented in Resident 1's chart) 11/19/2024: Dose held, BP or pulse not indicated/documented (no vital signs documented in medical record). 11/20/2024: Dose held, BP or pulse not indicated/documented on the MAR or on medical records. A review of Resident 1's MAR for 11/2024, indicated Spironolactone Oral tablet 25mg give 0.5mg one tab a day (9am) for CHF hold for SBP <100 administration was as follows: 11/4/2024: Dose held; BP not documented on the MAR or on medical records. 11/7/2024: Dose held; BP not documented on the MAR or on medical records. 11/13/2024: Dose held; BP not documented on the MAR or on medical records. 11/19/2024: Dose held, BP not documented on the MAR or on medical records. 11/20/2024: Dose held; BP not documented (no vital signs documented in medical record) 11/26/2024: Dose held; BP not documented (no vital signs documented in medical record). 11/30/2024: Dose administered, BP 99/70 mmHg. A review of Resident 1's MAR for 11/2024, indicated Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: 11/4/2024: Dose held; BP not documented on the MAR or on medical records. 11/7/2024: Dose held; BP not documented (no vital signs documented in medical record) 11/13/2024: Dose held; BP not documented (no vital signs documented in medical record) 11/20/2024: Dose held, BP not documented on the MAR or on medical records. 11/25/2024: Dose held; BP not documented on MAR. 11/26/2024: Dose held, BP not documented on the MAR or on medical records. A review of Resident 1's MAR for 12/2024, indicated Amiodarone HCL 200mg oral tablet a day for A-Fib hold for Apical pulse <60 (per pharmacy recommendation) administration was as follows: 12/1/2024: Dose administered; Apical pulse not documented. 12/2/2024: Dose held; Apical pulse not documented. 12/3/2024: Dose held; Apical pulse not documented. 12/4/2024: Dose administered; Apical pulse not documented. 12/5/2024: Dose administered; Apical pulse not documented. 12/6/024: Dose administered; Apical pulse not documented. 12/7/2024: Dose administered; Apical pulse not documented. 12/8/2024: Dose held; Apical pulse not documented. 12/9/2024: dose administered; Apical pulse not documented. A review of Resident 1's MAR for 12/2024, indicated Metoprolol Succinate ER Oral Tab ER 1 tab one time day for HTN hold for SBP <100 and HR<60 administration was as follows: 12/1/2024: Dose held, BP and pulse not documented (no vital signs documented in medical record). 12/7/2024: Dose held, BP and pulse not documented on the MAR or on medical records. 12/8/2024: Dose held; no BP documented. A review of Resident 1's MAR for 12/2024, indicated Spironolactone Oral tablet 25mg give 0.5mg one tab a day for CHF hold for SBP <100 administration was as follows: 12/1/24: Dose held; no BP documented on the MAR. VS not documented on medical records. 12/7/2024: Dose held; no BP documented. VS not documented in medical records. 12/8/2024: Dose held; no BP documented. VS not documented in medical records. A review of Resident 1's MAR for 12/2024, indicated Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: 12/1/2024: 9 AM: Dose held; BP not documented. 12/7/2024: 9 AM: Dose held; BP not documented. 12/8/2024: 9 AM: Dose held; BP not documented in medical records. During an interview on 12/17/24 at 1:27 PM, the Director of Staff Development (DSD) stated CNAs and CNs are responsible for assessing vital signs (VS), and that VS needed for medication administration are assessed by the licensed nurses 10 to 15 minutes prior to medication administration because the side effects of the medication can cause low BP, low heartrate (bradycardia), or syncope. DSD stated, it was important to check BP timely to ensure the BP remained within a normal range because BP medications could work too well and cause hypotension. DSD stated if VS are ordered to such as to assess apical pulse, the documentation must indicate apical pulse was taken. During an interview on 12/19/24 at 10:48 AM, LVN1 stated certified nursing assistants (CNAs) are in charge of checking VS and the charge nurses (CNs) were responsible for checking medication administration VS such as BP. LVN1 stated CNAs document the VS in the VS log and the CNs document the VS on the MAR. During an interview on 12/19/24 at 11:54 am, the Director of Nursing (DON) stated when administering medications the CNs are responsible for assessing VS. The DON stated VS must be documented on the vital signs logs and must be taken prior to medication administration because if the BP is too low and medications are given can result in hypotension, shock (a life-threatening emergency in which the organs cannot function properly), and syncope (fainting or passing out). During a telephone interview on 12/19/2024 at 12:07 PM, the pharmacy consultant (PC) stated it was important to review BP and pulse especially if a resident is on multiple blood pressure medications because of the risk for hypotension and bradycardia. The PC stated it was very important to monitor the apical pulse when a resident is on an antiarrhythmic such as amiodarone because amiodarone specifically affects the pulse, and the residents is at risk for bradycardia, fainting, and dizziness. The PC stated it was important the check the apical pulse for one full minute when a resident is on amiodarone because that is where the most accurate pulse is be obtained. The PC stated it was important the check the vital signs at the time of medication administration because the vital signs can change depending on the patient's movement, behavior, what they have eaten, and time between other medications, the blood pressure fluctuates even hour to hour you may get some variations 20 minutes. During an interview on 12/20/24 at 11:32 am, LVN2 stated BP must be checked prior to administering BP medications to ensure medications are administered only when the VS are within the ordered parameters and that a resident is in a condition to take their medications as ordered by a physician, otherwise the BP could get too low which may result in death. LVN2 stated that medications should not be given or held without checking VS. LVN2 stated that an apical pulse is checked at the apex (the pointed end of the heart) on the left side of the chest and is checked with a stethoscope for one full minute. The documentation must indicate a pulse was checked apically. A review of a Policy and Procedures (P&P) titled Administering Medications, revised 1/2024 indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The same P&P included the following policy interpretation and implementation: i. Medications must be administered in accordance with the orders, including any required time frame. ii. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. iii. The following information must be checked/verified for each resident prior to administering medication: a. Allergies to medications; and b. Vital signs, if necessary. A review of the facility's P&P, titled, Charting and Documentation, revised date 1/22024, indicated All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated;

Based on interview and record review, the facility failed to ensure, one out of 3 sampled residents (Resident 1) were free of significant medication errors (an error in medication administration that may jeopardizes a resident's health and/or safety) by not administering the following medications withhold parameters (conditions for administration indicated in the physician order based on vital sign measurements) a. Metoprolol Succinate (Medication to treat/control high blood pressure) Extended Release (ER) 50 milligrams (mg - unit of measurement) Oral Tab ER 1 tab one time day for hypertension (HTN- high blood pressure) hold for systolic blood pressure (SBP-top number of BP ready) <100 millimeters of mercury (mmHg, unit of pressure) and HR<60, Metoprolol dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/24/2024, 11/28/2024, and 11/29/2024. b. Spironolactone (Medication to treat/control HTN) oral tablet 25mg give 0.5 tab a day for congestive heart failure (CHF- weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) hold for SBP <100, Spironolactone dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/15/24, 11/17/2024, 11/24/2024, and 11/30/2024. c. Entresto (Medication for heart failure) 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 as per indicated parameters. Entresto Dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/15/2024, 11/17/24, 11/24/2024, and 11/30/2024. This significant medication error was a deficient practice that increased the risk that Resident 1could have experienced adverse effects (potentially harmful side effects) related to medication administration errors which could have resulted in medical complications possibly leading to hospitalization or death. Cross Reference: F580, F624, F757, F842 Findings: A review of Resident 1's Admission Record, indicated the facility admitted the resident on 10/24/24, with diagnosis that included acute (sudden) on chronic (long-term) systolic cardiac heart failure (a specific type of heart failure that occurs in the heart's left ventricle), paroxysmal A-Fib (fast and irregular heartbeat), essential hypertension (HTN: high blood pressure that is not due to another medical condition), ST-elevation myocardial infarction (STEMI, type of heart attack that is more serious and has a greater risk of serious complications and death) involving coronary artery of anterior wall (the artery supplies blood to the front portion of your heart), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), rheumatic disorders of both mitral valves (lies between the left atria and the left ventricle) and tricuspid valves (lies between the right atrium and the right ventricle). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/24/24, indicated the resident had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated the resident was dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. A review of Resident 1's Order Summary Report dated 10/24/2024, indicated Resident 1 was on the following medications: a. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 Hour 50 mg give one tablet by mouth one time a day for HTN hold for SBP <100 and HR<60. b. Spironolactone Oral tablet 25mg give 0.5 tablet by mouth one time a day for CHF hold for SBP <100. c. Entresto Oral tablet 24-26mg give 0.5mg by mouth two times a day for HTN for SBP <100. A review of Resident 1's Medication Administration Record (MAR) for 11/2024, indicated to administer Metoprolol Succinate ER oral, one tab one time day (9 AM) for HTN and to hold the medication for SBP <100 mmHg and HR<60 per minute. The MAR further indicated the following about Metoprolol ER: 11/24/2024: Dose administered, BP 93/66 mmHg, pulse 66. 11/28/2024: Dose administered, BP 90/60 mmHg, pulse 74. 11/29/2024: Dose administered, BP 99/67 mmHg, pulse 71. A review of Resident 1's MAR for 11/2024, indicated Spironolactone Oral tablet 25 mg give 0.5 mg one tab a day (9 AM) for CHF hold for SBP <100 administration was as follows: 11/15/2024: Dose administered, BP 90/60 mmHg [BP taken at 11:02 am] (parameter indicated hold for SBP <100) 11/17/2024: Dose administered BP 90/60 mmHg. 11/24/2024: Dose administered, BP 93/66 mmHg [BP taken at 11:16 am] 11/30/2024: Dose administered, BP 99/70 mmHg. A review of Resident 1's MAR for 11/2024, indicated Entresto 24-26mg give 0.5mg two times a day for HTN hold for SBP <100 administration was as follows: 11/15/2024: Dose administered, BP 90/60 mmHg [BP taken at 11:02 AM] (parameter indicated hold for SBP <100) 11/17/224: Dose administered BP 90/60 mmHg 11/24/2024: Dose administered, BP 93/66 mmHg [BP taken at 11:16 am] 11/30/2024: Dose administered, BP 99/70 mmHg. During an interview on 12/17/24 at 1:27 PM, the Director of Staff Development (DSD) stated DSD stated, it was important to check BP timely to ensure the BP remained within a normal range because BP medications could work too well and cause hypotension. DSD stated VS must be within ordered parameters must be within range before the medications are administered to mitigate (lessen) adverse (negative) reactions from the medications and had to be followed for resident safety. DSD stated if BP medications are given outside of ordered parameters the residents BP could drop low, which could result in death due to lack of circulation. During an interview on 12/19/24 at 10:48 AM, License Vocational Nurses (LVN1) stated certified nursing assistants (CNAs) are in charge of checking VS and the charge nurses (CNs) were responsible for checking medication administration VS such as BP. LVN1 restated it was important to take a BP timely with medication administration because the BP could change. LVN1 defined parameters as the recommended scale that must be followed to give certain medications at the proper dose such as BP and blood sugar (BS) medications. LVN1 stated if parameters are not followed the results could be detrimental (harmful) and dangerous to a resident's health. During an interview on 12/19/24 at 11:54 am, the Director of Nursing (DON) stated when administering medications the CNs are responsible for assessing VS. The DON stated VS must be documented on the vital signs logs and must be taken prior to medication administration because if the BP is too low and medications are given can result in hypotension, shock (a life-threatening emergency in which the organs cannot function properly), and syncope (fainting or passing out). The DON stated parameters are placed on medication orders to ensure resident safety and that it was important to administer medications as ordered to improve the resident's condition/outcome. During an interview on 12/20/24 at 11:32 am, LVN2 stated BP must be checked prior to administering BP medications to ensure medications are administered only when the VS are within the ordered parameters and that a resident is in a condition to take their medications as ordered by a physician, otherwise the BP could get too low which may result in death. LVN2 stated that medications should not be given or held without checking VS. On 11/28/2024, Resident 1's SBP was 90/60. LVN2 admitted to administering the following medications: Metoprolol 50 mg (Hold if SBP less [<] than 100mmHG) Entresto oral tabs 24-26mg (hold SBP < 100) Spironolactone oral tab (hold SBP < 100) On 11/29/2024, Resident 1's SBP was 99/67. LVN2 admitted to administering the following medications: Metoprolol 50 mg (Hold if SBP less [<] than 100mmHG) Entresto oral tabs 24-26mg (hold SBP < 100) Spironolactone oral tab (hold SBP < 100) LVN2 confirmed that the above medications should have been held because they were under the ordered parameters. A review of a Policy and Procedures (P&P) titled Administering Medications, revised 1/2024 indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The same P&P included the following policy interpretation and implementation: i. Medications must be administered in accordance with the orders, including any required time frame. ii. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. iii. The following information must be checked/verified for each resident prior to administering medication: . b. Vital signs, if necessary.

Based on interviews and record reviews, the facility failed to: 1. Notify Resident 1's physician of the presence of a severe drug-to-drug interaction warning between Amiodarone and Metoprolol SuccinateER on [DATE]. The facility continued to administer amiodarone and metoprolol Succinate ER despite the presence of negative side effects listed in the severe drug to drug warning (bradycardia and hypotension) from 10/24/24 to 12/9/24. 2. Notify Resident 1's physician of the need to hold medication's frequently due to low blood pressure readings or below the parameter ordered between November 2024 and 12/8/24. 3. Notify Resident 1's physician when medications: metoprolol (Medication to treat/control high blood pressure), spironolactone (Medication to treat/control high blood pressure), and Entresto (Medication for heart failure) were administered even below the ordered parameters. These deficient practices placed Resident 1 at continued risk from potential negative effects of severe drug to drug interactions between amiodarone and metoprolol succinate ER (bradycardia, hypotension, and cardiac arrest) from 10/24/24 to 12/9/24 and the risk for severe hypotension due to the unsafe administration of antihypertensive mediations on 11/28/24 and 11/29/24. Cross Reference:F624, F757, F760, F842 Findings: A review of Resident 1's Admission Record, indicated the facility admitted the resident on 10/24/24, with diagnosis that included acute (sudden) on chronic (long-term) systolic cardiac heart failure (a specific type of heart failure that occurs in the heart's left ventricle), paroxysmal A-Fib (fast and irregular heartbeat), essential hypertension (HTN: high blood pressure that is not due to another medical condition), ST-elevation myocardial infarction (STEMI, type of heart attack that is more serious and has a greater risk of serious complications and death) involving coronary artery of anterior wall (the artery supplies blood to the front portion of your heart), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), rheumatic disorders of both mitral valves (lies between the left atria and the left ventricle) and tricuspid valves (lies between the right atrium and the right ventricle). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/24/24, indicated the resident had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated the resident was dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. A review of Resident 1's Order Summary Report dated 10/24/2024, indicated Resident 1 was on the following medications: a. Amiodarone HCI Oral tablet 200 mg give one tablet by mouth one time a day for A-fib. b. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 Hour 50 mg give one tablet by mouth one time a day for HTN hold for SBP <100 and HR<60. c. Spironolactone Oral tablet 25 mg give 0.5 tablet by mouth one time a day for CHF hold for SBP <100. d. Entresto Oral tablet 24-26mg give 0.5mg by mouth two times a day for HTN for SBP <100. A review of Resident 1's Progress Notes for 10/2024, indicated medication administration orders had triggered a severe drug to drug interaction between Metoprolol Succinate ER and Amiodarone HCL on 10/24/2024 at 8:37 PM, 10/27/2024 at 10:29 AM, 10/30/2024 at 2:38 PM, and 10/30/2024 at 4:08 PM. The progress notes indicated Interaction: Administration of Amiodarone HCI Oral Tablet 200 mg and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 mg may result in severe bradycardia, hypotension and cardiac arrest. The progress notes did not indicate a physician was notified of the severe drug to drug interaction on any of the aforementioned dates. A review of Resident 1's Progress Notes dated 11/28/24 at 8:45 PM, indicated a medication administration order had triggered a severe drug to drug interaction between Metoprolol Succinate ER and Amiodarone HCL. The progress notes indicated Interaction: Administration of Amiodarone HCI Oral Tablet 200 MG and Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 100 MG may result in severe bradycardia, hypotension and cardiac arrest. The note did not indicate the physician was notified of the severe drug to drug interaction. A review of Resident 1's medication administration record (MAR) for November 2024, indicated Metoprolol Succinate ER Oral Tab ER 1 tab one time day (9 AM) for HTN hold for SBP <100 and HR<60 administration was as follows: 11/3: dose held, BP 94/58, 87 11/4: dose held, BP not indicated in MAR, pulse not indicated in MAR (no vital signs documented in medical record) 11/5: dose held, BP 94/58, pulse 85 11/6: dose held, BP 98/65, pulse 81 11/7: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 11/9: dose held, BP 90/56, pulse 79 11/10: dose held, BP 90/55, pulse 85 11/12: dose held, BP 90/60, pulse 75 11/13: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 11/14: dose held, BP 95/55, pulse 86 11/15: dose held, BP 90/60 (taken at 11:02 AM), pulse 80 11/16: dose held, BP 95/60 (taken at 12:17 PM), pulse 80 11/17: dose held, BP 90/60, pulse 71 11/18: dose held, BP 97/65, pulse 76 11/19: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 11/20: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 11/22: dose held, BP 92/61 (taken at 11:18 AM), pulse 74 11/23: dose held, BP 99/64, pulse 80 11/24: dose administered, BP 93/66 (parameter indicated hold for SBP <100), pulse 66 11/25: dose held, BP not indicated on MAR, pulse not indicated on MAR 11/26: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 11/27: dose held, BP 99/65, pulse 76 11/28: dose administered, BP 90/60 (parameter indicated hold for SBP <100), pulse 74 11/29: dose administered, BP 99/67 (parameter indicated hold for SBP <100), pulse 71 11/30: dose held, BP 99/70, pulse 63 A review of Resident 1's MAR for December 2024, indicated Metoprolol Succinate ER Oral Tab ER 1 tab one time day for HTN hold for SBP <100 and HR<60 administration was as follows: 12/1: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 12/2: dose held, BP 98/59, pulse 83 12/4: dose held, BP 96/62, pulse 68 12/7: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) 12/8: dose held, BP not indicated, pulse not indicated (no vital signs documented in medical record) During an interview on 12/17/24 at 1:27 PM, the Director of Staff Development DSD stated a resident's physician must be informed of three consecutive low BP readings. DSD stated the EHR alerts the nurses of any drug-to-drug interactions. DSD defined drug to drug interactions as two drugs (medications) given together that can cause harm and can increase the likelihood of harm. DSD stated the RNS oversee and act on drug to drug to interactions. DSD stated when the EHR alerts facility staff of severe drug to drug interactions, staff must take immediate action and must contact/notify the resident's physician. During an interview on 12/19/24 at 10:48 AM, License Vocational Nurse (LVN1) stated registered nurse supervisors (RNS) are responsible for inputting medication orders and acting upon severe drug to drug interaction warnings. LVN1 stated the physician must be notified immediately of all severe drug to drug interaction warnings. LVN1 stated physician must be notified of all changes in condition in resident status and VS taken at the time of the change of condition otherwise the residents could receive the wrong treatment. During an interview on 12/19/24 at 11:54 am, the Director of Nursing (DON) stated drug to drug interactions are first reviewed by the facility's contracted pharmacy and then the pharmacy notifies the facility. The DON stated after the pharmacy notifies the facility, the facility contacts the resident the resident's physician to check if it is okay for the resident to receive medications (Spironolactone, Amiodarone, Entresto, and Metoprolol) together. The DON stated the facility must notify a resident's physicians of drug to drug-to-drug interactions immediately, regardless of if the drug-to-drug interactions indicates mild or severe. During a telephone interview on 12/19/2024 at 12:07 PM, the pharmacy consultant (PC) stated there is no system in place that triggered drug-to-drug interaction warnings (warnings advising that certain combinations of medications can cause serious even deadly side effects) on the consultants ends in the EHR. The PC stated the nurses administering the medications are responsible to adhere to the parameters set by the physician and if the medications are being held multiple days the nurses should have notified the physician of the continued need to hold the medications. The PC stated the nurses administering the medications are responsible for notifying the physician if the vital signs are continuously out of the parameters. The PC stated the nurses are holding medications (amiodarone, metoprolol, spironolactone, Entresto) for a reason. During a follow up interview and record review of drug-to-drug interaction alerts on 12/19/24 at 3:15 PM, LVN1 stated, drug-to-drug interactions only appears when a medication is newly ordered. LVN1 stated when a medication is ordered and there is a drug-to-drug interaction present, the RN supervisor is responsible for calling the physician, to clear the drug-to-drug interaction on the MAR/EHR and the medication can be placed on the MAR after the drug-to-drug interaction has been cleared. LVN2 opened up a MAR for another unidentified resident to show the symbol/warning on the MAR that signified a drug-to-drug interaction and a symbol with 2 capsules was noted. LVN1 stated the symbol with the 2 capsules indicated drug to drug interactions between medications. LVN1 hovered over the symbol and when LVN1 clicked the legend for the symbol, the legend indicated there were 2 medications that had drug to drug interactions with each other. LVN1 stated she does not need to check what the drug-to-drug interactions were because she (LVN1) assumes the drug-to-drug interactions were already cleared by the RNS. During an interview on 12/20/24 at 11:32 AM, LVN2 stated that drug-to-drug interaction warnings often appear for the first time when a new medication is ordered on the MAR or when a new resident is admitted to the facility. LVN2 stated when she (LVN2) reads the drug-to-drug interaction alert, she takes no action and continues with the medication pass as she assumes that the licensed nurse who had initially placed the order had cleared it. LVN2 admitted that drug-to-drug interactions flagged graded as severe must have immediate action taken which included notifying the physician. LVN2 admitted and stated that Resident 1's BPs were on the lower side almost every single day with and recalled a reading of the SBP 87mmHG. LVN2 stated that she had to hold resident 1's medications often because the parameters were to hold if SBP is less than 100mmHG. On 11/28/2024, Resident 1's SBP was 90/60. LVN2 admitted to administering the following medications: Metoprolol 50 mg (Hold if SBP less [<] than 100mmHG) Entresto oral tabs 24-26mg (hold SBP < 100) Spironolactone oral tab (hold SBP < 100) On 11/29/2024, Resident 1's SBP was 99/67. LVN2 admitted to administering the following medications: Metoprolol 50 mg (Hold if SBP less [<] than 100mmHG) Entresto oral tabs 24-26mg (hold SBP < 100) Spironolactone oral tab (hold SBP < 100) LVN2 confirmed that the above medications should have been held because they were under the ordered parameters. LVN2 admitted that the physician was not notified. During a follow up interview on 12/20/2024 at 1:50 PM, LVN1 stated she (LVN1) was not aware of any drug-to-drug interactions between Resident 1's BP medications (Amiodarone and metoprolol). LVN 1 recalled and admitted that she (LVN1) held BP medications because of the resident's BPs were trending low. LVN1 stated that there was no documented evidence that Resident 1's VS were checked/recorded. LVN1 admitted and stated that she held the aforementioned medications and did not get Resident 1's VS. LVN1 stated that she did not inform a physician that Resident 1's afore mentioned medications were being held more than they were being administered. LVN1 stated that on 12/9/2024 at 1:20 PM, Resident 1 was placed in a wheelchair; was assisted into the facility provided non-emergency transportation vehicle, and then the resident was transported while sitting in the wheelchair to the ALF. LVN1 admitted and stated that she (LVN1) did not recheck Resident 1's VS. During the same interview and concurrent record review on 12/20/2024 at 1:50 PM, Resident 1's MAR for 11/2024 and 12/2024 were reviewed. LVN1 admitted and stated that she administered the following medication doses with below acceptable parameters: a) Metoprolol dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/24/2024, 11/28/2024, and 11/29/2024. b) Spironolactone dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/17/2024, 11/24/2024, and 11/30/2024. c) Entresto Dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/15/2024, 11/17/2024, 11/24/2024, and 11/30/2024. During a follow up concurrent interview and record review of Resident 1's chart with the DON on 12/20/2024 at 2:52 PM, the DON acknowledged that the DON's name was attached on the second drug-to-drug interactions severe warning dated 10/30/2024 at 2:30 PM indicating that she (DON) had cleared the flagged drug-to-drug interactions. The DON admitted and stated that she had not notified a physician about the above drug-to-drug interactions severe warning per facility protocol Adverse Consequences and Medication Errors. During an interview on 12/21/24 at 11:35 AM, the facility's Medical Director (MD- Also Resident 1's physician) stated Resident 1 had a history of cardiac issues and events. MD stated she was not aware that the facility was holding/not administering Metoprolol Succinate ER 50 mg, Amiodarone HCL 200 mg, Spironolactone 25 mg, or Entresto 24-26 mg to Resident 1. MD stated MD was not aware that Resident 1 received Metoprolol Succinate ER, Amiodarone HCL, Spironolactone, or Entresto outside ordered parameters. MD stated the facility should have notified MD immediately upon discovering medications were being held. During a review of a Policy and Procedure (P&P) titled Administering Medications, revised 1/2024 indicated, Medications shall be administered in a safe and timely manner, and as prescribed. The same P&P included the following policy interpretation and implementation: i. Medications must be administered in accordance with the orders, including any required time frame. ii. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. iii. The following information must be checked/verified for each resident prior to administering medication: a. Allergies to medications; and b. Vital signs, if necessary. During a review of a P&P titled Adverse Consequences and Medication Error, reviewed 1/2024 indicated, The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. the same P&P defined consequence as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include: a. Adverse drug/medication reaction. b. Side effect. c. Medication-medication interaction; During a review of a Policy and Procedure (P&P) titled Change in a Resident's Condition or Status, revised 1/2024 indicated, 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.). the same P&P indicated the following under policy interpretation and implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): c. adverse reaction to medication. d. significant change in the resident's physical/emotional/mental condition. e. need to alter the resident's medical treatment significantly. f. refusal of treatment or medications three (3) or more consecutive times). i. specific instruction to notify the physician of changes in the resident's condition.

Based on interviews and record reviews, the facility failed to provide a safe and orderly discharge for one of the three of the three sampled residents (Resident 1) by failing to reassess Resident 1's Vital Signs (VS - basic functions of your body. which include body temperature, blood pressure [BP], pulse, and respiratory [breathing] rate) who was known to have low BPs prior to discharging the resident on [DATE]. On [DATE] Resident 1 received these medications: metoprolol, spironolactone, Entresto, amiodarone, a Lidoderm 5% patch and a second dose of Lidoderm 5% patch. As a result, on [DATE] at 1:20 PM, the facility discharged Resident 1 to an alternate living facility (ALF) via the facility provided transportation. The ALF pronounced Resident 1 deceased /dead upon arrival. Cross reference: F580, F760, F757, F842 Findings: A review of Resident 1's Admission Record, indicated the facility admitted the resident on [DATE], with diagnosis that included acute (sudden) on chronic (long-term) systolic cardiac heart failure (a specific type of heart failure that occurs in the heart's left ventricle), paroxysmal A-Fib (fast and irregular heartbeat), essential hypertension (HTN: high blood pressure that is not due to another medical condition), ST-elevation myocardial infarction (STEMI, type of heart attack that is more serious and has a greater risk of serious complications and death) involving coronary artery of anterior wall (the artery supplies blood to the front portion of your heart), sick sinus syndrome (a disease in which the heart's natural pacemaker located in the upper right heart chamber (right atrium) becomes damaged and is no longer able to generate normal heartbeats at the normal rate), rheumatic disorders of both mitral valves (lies between the left atria and the left ventricle) and tricuspid valves (lies between the right atrium and the right ventricle). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated [DATE], indicated the resident had moderately impaired cognition (ability to think, read, learn, remember, reason, express thoughts, and make decisions). The MDS indicated the resident was dependent on staff for toileting, lower body dressing, and putting on and taking off footwear. The MDS indicated the resident required substantial/maximal assistance (helper does more than half the effort) with showering/bathing, upper body dressing, and personal hygiene. A review of Resident 1's Order Summary Report dated [DATE], indicated Resident 1 was on the following medications: a. Amiodarone HCI Oral tablet 200 mg give one tablet by mouth one time a day for A-fib. b. Metoprolol Succinate Extended Release (ER) Oral Tablet 24 Hour 50 mg give one tablet by mouth one time a day for HTN hold for SBP <100 and HR<60. c. Spironolactone Oral tablet 25mg give 0.5 tablet by mouth one time a day for CHF hold for SBP <100. d. Entresto Oral tablet ,d+[DATE]mg give 0.5mg by mouth two times a day for HTN for SBP <100. e. Lidoderm Patch 5% (Lidocaine) apply to left thigh topically one time a day for pain management and remove per schedule. The order did not indicate what the schedule was. A review of Resident 1's MAR for [DATE] at 8:13 am, indicated the resident was administered a Lidoderm patch 5% topically on [DATE] at 8:13 am. A review of Resident 1's MAR for [DATE] at 9am, indicated the resident was administered Amiodarone HCL 200 mg oral tablet a day for A-Fib hold for Apical pulse <60 (per pharmacy recommendation), Metoprolol Succinate ER (extended release) 50 mg Oral Tab ER 1 tab one time day for HTN hold for Systolic Blood Pressure (SBP - is the first/top BP number which measures the pressure blood pushing against the artery walls when the heart beats) less than (<)100 mmHg and HR<60 beats per minute, Spironolactone Oral tablet 25mg give 0.5 tab a day for Congestive Heart Failure (CHF- weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs) hold for SBP <100, and Entresto ,d+[DATE]mg give 0.5mg two times a day for HTN hold for SBP <100 as per indicated parameters. A review of Resident 1's Weights and Vitals Summary dated [DATE] at 8:16 am, indicated the resident's last documented pulse was taken on [DATE] at 8:16 am and was 84 bpm. A review of Resident 1's Weights and Vitals Summary dated [DATE] at 8:16 am, indicated the resident's last documented BP was taken on [DATE] at 8:16 am and was ,d+[DATE]mmHG (lying l/arm). A review of Resident 1's MAR for [DATE]/,d+[DATE] at 1:23 pm, indicated Resident 1 was administered a second patch on [DATE] at 1:23 pm. The MAR did not indicate the patch applied on [DATE] at 8:13 am was removed. A review of Resident 1's nurses notes dated [DATE] at 1:20 pm, indicated resident discharged home with caregiver in provided transportation via wheelchair. no complaints of pain or discomfort. resident signed all paperwork and leftover medications were given as ordered. resident escorted to transportation by staff. MD and family aware. The vital signs indicated on the note were taken on [DATE] at 8:16 am: BP ,d+[DATE], T97.2, P64, RR18, O2 97% RA. The notes did not indicate vital signs were taken prior to discharge. During an interview with Licensed Vocational Nurse (LVN)1 on [DATE] at 10:48 am, LVN1 stated if BP meds were not taken regularly, stopped, held for days, and then started again the resident's BP could fluctuate in a negative way and the body would have to readjust to taking the medication. During a telephone interview on [DATE] at 12:07 pm, the pharmacy consultant (PC) stated it was important to check BP and pulse especially if a resident was on multiple blood pressure medications because by administering multiple antihypertensives the risk was present of the BP and pulse going down. The PC stated if on an antiarrhythmic such as Amiodarone it was very important to monitor the apical pulse because Amiodarone specifically affects the pulse, and the residents ran the risk of the pulse going down and increased the risk for fainting and dizziness. The PC stated vital signs can change depending on the patient's movement, behavior, what they have eaten, and time between other medications, the blood pressure fluctuates even hour to hour you may get some variations 20 minutes you know it's not like a cholesterol where you check every now and then. The PC stated if a resident was on multiple antihypertensives and antiarrhythmics it was important to administer the medications regularly because when you take them on a regular basis your body will stabilize itself where you know if there are peaks and valleys, and the blood pressure will regulate that, so you won't have all of those up and down fluctuations. The PC was asked what could happen if the that can kind of like alter your system in terms of the blood pressure regulation that can kind of like alter your system in terms of the blood pressure regulation medication were held for two to three days at time and then administered, the PC stated, that can kind of like alter your system in terms of the blood pressure regulation. During a follow up concurrent interview and record review of Resident 1's chart with LVN1 on [DATE] at 1:50 pm, LVN 1 stated that Resident 1 did not like to get up out of bed much. LVN1 stated that she was not aware about any interactions between Resident 1's BP meds but recalled that she (LVN1) had to hold BP meds because of the low BPs. LVN1 admitted to holding Resident 1's following medication doses with no evidence of checking Resident 1's VS on the following days: a) Amiodarone dose was held with no documented apical pulse on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. b) Amiodarone dose was administered with no documented apical pulse on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. c) Metoprolol dose was held with no documented BP or pulse on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. d) Metoprolol dose administered when BP was below acceptable parameters on ,d+[DATE], ,d+[DATE], and ,d+[DATE]. e) Spironolactone dose was held with no documented BP or pulse on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. f) Spironolactone dose administered when BP was below acceptable parameters on ,d+[DATE], ,d+[DATE], ,d+[DATE]. g) Entresto dose was held with no documented BP or pulse on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. h) Entresto Dose administered when BP was below acceptable parameters on ,d+[DATE], ,d+[DATE], and ,d+[DATE]. LVN 1 stated that when someone that is usually in a lying position sits up may affect BP by lowering. On [DATE] at 8:13 am, Resident 1's BP was at 104mmHG and all four medications (metoprolol, amiodarone, Entresto, and spironolactone) were administered to Resident 1. Additionally, a lidocaine patch was applied to Resident 1's left thigh. During Resident 1's discharge about 1 pm, Resident 1 was administered an additional patch to the same site (left thigh) without any evidence of the previous patch being removed by a different LVN. Resident 1 was placed in a wheelchair and placed in the facility provided non-emergency transportation and transported while sitting in the wheelchair. LVN1 admitted that she did not recheck resident 1's VS. During a follow up concurrent interview and record review of Resident 1's chart with the DON on [DATE] at 2:52 pm, the DON stated that BP levels may drop if a person goes from lying to sitting down. The DON stated that VS signs upon discharge must be current but confirmed that Resident 1's VS were not rechecked upon discharge at 1:20 pm. During a review of a Policy and Procedure (P&P) titled TRANSFER OR DISCHARGE DOCUMENTATION dated ,d+[DATE], indicated 4. When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: . f. A summary of the resident's overall medical, physical, and mental condition: . 7.Should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider: . g. All other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care.

Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 11/9/2024 when: 1.Facility failed to follow lunch menu and portion sizes as written for residents on pureed diet. Four residents on pureed diet received 1/2 cup of pureed Salisbury steak instead of 2/3 of cup per the food portion and serving guide. This deficient practice had the potential to result in decreased nutritional intake and weight loss for Four residents who were on puree diet. Findings: According to the facility lunch menu for pureed diet on 11/9/2024, the following items will be served: Salisbury Steak All American Gravy #6 scoop (5 1/3 ounces (oz)); Twice baked mashed potato #8 scoop (1/2 cup); Confetti corn pureed #12 scoop (1/3 cup); pureed wheat roll, margarine; apples with caramel sauce pureed and milk. During an observation of the tray line service for lunch on 11/9/2024, at 11:45 a.m., for residents who were on pureed diet the cook served pureed Salisbury steak using 4oz. ladle, instead of 5 1/3 oz. per menu. During a review of the menu and interview with Cook2 and DS on 11/9/2024 at 12:30 pm. Cook2 stated she served the pureed meat with using the wrong spoon and served less protein to residents who were on pureed diet. Cook2 sated when serving less food to residents, the resident could lose weight. The dietary supervisor (DS) stated cooks should always follow the menu and the serving guide to serve the correct amount according to the planned menu. A review of facility menu and spreadsheet (portion and serving guide) on 11/9/2024 indicated serve pureed Salisbury steak using #6 scoop yielding 5 1/2 ounces. A review of facility Policy titled Menu Planning indicated, The menus are planned to meet nutritional needs of residents in accordance with .the most recent recommended dietary allowances of the Food and Nutrition Board of the national Research Council National Academy of Sciences.

Based on observations, interviews, and record reviews, the facility failed to ensure kitchen staff were competent in safe and effective food preparation and handling practices. By failing to: 1.Ensure [NAME] 1moniotored cooked roast pork for safe cool down process and storage (hot food cooled down within a certain time frame to prevent harmful bacterial growth). 2. Ensure [NAME] 1 knew the concentration strength of the chlorine sanitizer (a substance or product that is used to reduce or eliminate pathogenic agents on surfaces) used for food contact surfaces and did not follow the sanitizer solution procedures and preparation per the facility policy. These deficient practices had the potential to result in unsafe and unsanitary food production that could lead to foodborne illness (Infectious organisms or their toxins are the most common causes of food poisoning with symptoms that may include cramping, nausea, vomiting or diarrhea and death) in 42 out of 46 residents who received food from the facility kitchen. Findings: 1. During a concurrent observation and interview in the kitchen on 11/8/2024 at 6:18 p.m., one cooked roast pork was observed set on the kitchen counter. The roast pork was in a plastic bag in a large deep pan and was covered with ice. Cook1 stated she did not document the time the roast was taken out of the oven. [NAME] 1 stated the thought she removed the roast pork from the oven at 5 p.m. and she set it on the counter to cool down. Cook1 stated after the roast cooled down it will be stored in the refrigerator for Sunday lunch. Cook1 checked the temperature of the roast pork using the facility thermometer and the temperature registered at 191.3 degrees Fahrenheit (F) in the middle section of the roast and 188.4 degrees F on the side of the roast. [NAME] 1 stated she would put the roast in the refrigerator before she went home at 7:30 p.m. Cook1 did not know at what temperature to place the roast pork in the refrigerator. Cook1 sated she put ice on the roast to cool the roast down. Cook1 did not know how else to cool down the roast pork and when asked if the temperature of the roast should be monitored in the refrigerator Cook1 did not answer. During a concurrent observation and interview with cook1 and the Dietary Supervisor (DS) on 11/9/2024 at 11:05 a.m. The DS stated the facility policy was to hold cold food at 41 degrees or lower. The DS stated when improper holding temperature occurred, bacteria could grow and cause illness. The DS stated when cooking large pieces of meat ahead of time, during the cool down process, the large piece of meat should be cut into smaller pieces to cool down faster. The DS stated cook1 should have cut the roast into smaller pieces to cool down faster. DS stated cook1 should have documented the time the pork was removed from the oven and started the monitoring of the cool down process. The DS then discarded the pork. During a review of in-service records for kitchen staff on cool down process dated 5/23/24, Cook1 was not present during the in-service. A review of job description for cook indicated, the cook, prepare food in accordance with sanitary regulations as well as established policies and procedures. A review of facility policy and procedures titled Cooling and reheating of potentially hazardous or time/temperature Control for Safety Food dated 2023 indicated, when cooked PHF or TCS food will not be served right away it must be cooled as quickly as possible the method is: cool cooked food form 140 degrees (F) to 70 degrees (F) within two hours, then cool from 70 degrees F to 41 degrees F or less in an addition four hours for total cooling time of six hours. Methods of cooling Food 1) placing the food in shallow pans; 2) separate into smaller or thinner portions. 2. During an observation in the kitchen on 11/9/2024 at 9:00 a.m. [NAME] 1 was observed cleaning the food contact surfaces with a cloth that was stored in a sanitizer solution in the red bucket. When asked to test the sanitizer solution, Cook1 proceeded to demonstrate how to prepare the sanitizer solution using chlorine disinfectant. Cook1 filled the bucket with two liters of water then added a capful (1 tablespoon) of chlorine in the water. Cook1 then proceeded to test the solution and it was at 200 PPM (parts per million sanitize concentration) The recommended concentration level for chlorine sanitizer is between 50-100 parts per million (ppm). During a concurrent interview with Cook1 and DS on 11/9/2024 at 9:15 a.m., Cook1 stated the normal range for the sanitizer solution is 200 PPM, Cook1 pointed to the sanitizer testing log and stated every day we check and its 200PPM. The DS stated the normal range for the chlorine sanitizer was 200PPM. The DS stated the kitchen staff did not use Quaternary ammonia (another type of sanitizer) in the kitchen and only chlorine sanitizer was used. The DS stated the chlorine sanitizer was used to clean the kitchen counters, meal carts and equipment. During a concurrent interview with DS and review of facility policy for chlorine sanitizer solution, the DS verified that the normal concentration of the chlorine solution had to be 100 parts per million. During an interview with Registered Dietitian (RD) and the DS on 11/9/2024 at 1:40 p.m., the DS sated kitchen staff were not mixing the solution of the choline sanitizer correctly because they were not following facility policy. The DS stated the correct range for an affective chlorine sanitizer is 100 PPM as per policy. The RD stated too much chlorine could result in a potential of chemical cross contamination of food. A review of facility policy and procedures titled Sanitizers or Germicides (dated 2023) indicated, if Chlorine is used a bactericidal agent, the concentration of the solution must be 100PPM. One tables of bleach diluted with 1 gallon (a unit of volume) or (3.7 liters) of water and will yield 100 parts per million.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of residents in the facility by failing to esnure: A. Proper disposal of one open sterile intravenous (IV- inside the vein) administration set sterile intravenous medication tubing (used for delivering fluids or medications though and IV), eight expired sterile collection swabs, seven expired specimen collection tubes, and 10 expired specimen collection kits. B. Medication cart and pill cutter were clean and sanitized at all times. These deficient practices had the potential to compromise the safety and effectiveness of medications and sterile supplies which can result in medication administration error and risk for unsafe, improper medication administration use. Findings: During a concurrent observation and interview on [DATE] 6:45 p.m., with Infection Preventionist Nurse (IPN), the medication storage closet was reviewed for expired supplies. One open sterile IV administration set, eight expired sterile collection swabs (expiration date [DATE]), seven expired specimen collection tubes (expiration date [DATE]), and 10 expired specimen collection kits (expiration date [DATE]) were observed, IPN verified the expiration dates of the supplies, gathered them to throw out and stated they may not be accurate (since expired). During a review of the facility's policy and procedures (P&P), titled Medication Labeling and Storage, reviewed on [DATE], the P&P indicated, the nursing staff is responsible for maintaining the medication storage and preparation areas in a clean, safe, and sanitary manner. B. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3 on [DATE] at 4:09 p.m., observed Medication Cart 1 (East Station). Medication Cart 1's medication bottles plastic container was observed with brown and black spots that were not easily removed. Inside the cart, a pill cutter was also observed with whitish particles. LVN 2 stated the medication bottle containers should be cleaned and the pill cutter should be cleaned and sanitized after each use, so it does not cause of mixing with medications. During a review of the facility's P&P titled, Medication Labeling and Storage, revised on [DATE], the P&P indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. During a review of facility's P&P titled Medication Administration - General Guidelines, effective ,d+[DATE], the P&P indicated, Medications are crushed between two souffle cups/or in a plastic pouch . A tablet-splitter is used to avoid contact with the tablet.

Based on observation, interview, and record review, the facility failed to ensure: A.The policy and procedure for medication administration was followed for one of three sampled residents (Resident 26). On 11/9/2024 at 9:26 a.m., Licensed Vocational Nurse 2 (LVN 2) was observed crushing Apixaban (anticoagulant used to reduce the risk of stroke and blood clots), lisinopril (can treat high blood pressure and heart failure), Vitamin D (a fat-soluble vitamin that helps the body absorb calcium and perform other important functions) and multivitamin (used to treat or prevent vitamin deficiency due to poor diet, certain illnesses). This deficient practice placed resident at risk for physical and chemical incompatibilities between medications, loss of effectiveness, and worsening of medical conditions. B. The Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for one of one sampled resident (Resident 196). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug). Findings: A.A review of the Admission Record indicated Resident 26 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side, type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain). A review of the Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/20/2024, indicated Resident 26's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was mildly impaired. The MDS indicated Resident 26 required moderate to maximal assistance from staffs for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During an observation of medication pass with Licensed Vocational Nurse (LVN) 2 on 11/9/2024 at 9:26 a.m. LVN 2 was observed crushing the following four medications: i. Apixaban 5 milligram (mg - unit of measurement) oral tablet ii. Lisinopril (medication for high blood pressure) 10 mg oral tablet iii. Vitamin D oral tablet iv. Multivitamin-minerals oral tablet LVN 2 placed all four pills in a plastic pouch used for medications which was then placed in a pill crusher (a metal tool used to crush pills at the same time). LVN 2 then placed all crushed medication together in a medicine cup and mixed an apple sauce with it. During an interview with LVN 2, on 11/9/2024 at 9:35 a.m., LVN 2 stated, she crushed all four medications then put them all together in a cup and added an apple sauce with it. LVN 2 stated, this was her process on administering medications and it is acceptable to put mix all medications together after crushing it. During an interview with Registered Nurse (RN) 1, on 11/10/2024 at 10:35 a.m., RN 1 stated, medications that were crushed must be given one by one and separated on each medication cup so that the licensed nurse will know which medications is which and that if resident refuses any of the medications, then she will be able to distinguish each medication. During a review of facility's policy and procedure (P&P) titled Medication Administration - General Guidelines, effective 10/2017, the P&P indicated, Crushed medications should not be combined and given all at once, either orally or via feeding tube. B. A review of the Admission Record indicated Resident 196 was admitted to the facility on [DATE] with diagnosis including spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine), low back pain, and disorder of muscle. A review of the MDS dated [DATE], indicated Resident 196's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 required moderate to maximal assistance from staffs for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 196's Order Summary, indicated physician ordered the following: i. Oxycodone (an opioid used in the management of moderate to severe pain) oral tablet five milligram (mg - unit of measurement) - give one tablet by mouth four times a day for pain. ii. Oxycodone 5 mg tablet - give one tablet by mouth every 4 hours as needed for moderate pain. iii. Oxycodone 5 mg tablet - give 2 tablets by mouth every 4 hours as needed for severe pain. A review of Resident 196's MAR indicated the following: i. Oxycodone 5 mg - give one tablet four times a day: indicated administered to Resident 196 from 11/5/2024 to 11/9/2024 (at 9 a.m., 1 p.m., 5 p.m., and 9 p.m.) ii. Oxycodone 5 mg tablet - give one tablet every 4 hours as needed for moderate pain: the MAR indicated; Resident 196 has not received this medication as ordered by physician. iii. Oxycodone 5mg tablet - give two tablet every 4 hours as needed for severe pain: the MAR indicated; Resident 196 received three doses of this medication from 11/1/2024 to 11/4/2024). A review of Resident 196's bubble pack for the following indicated: i. Oxycodone 5 mg four times daily - 28 tablets remaining ii. Oxycodone 5 mg - one tablet for moderate pain: 30 tablets remaining iii. Oxycodone 5 mg - two tablets for severe pain: 11 tablets remaining During an interview with LVN 2, on 11/9/2024 at 9:52 a.m., LVN 2 stated, when giving Oxycodone medication to Resident 196, they don't look at the bubble pack and they don't compare it from physician's order. LVN 2 stated, the narcotic count is not accurate because they the remaining tablets is not the same as the count in each CDR. During a concurrent interview and record review of Resident 196's MAR, CDR and bubble pack with Registered Nurse 1 (RN 1) on 11/10/2024 at 10:35 a.m., RN 1 stated, the MAR, CDR and bubble pack for Resident 196's oxycodone medication orders are not accurate when matched. RN 1 stated, the nurses must remove the medication from the correct bubble pack and document on the correct CDR. During a review of facility's P&P, titled, Controlled Substances, revised on 1/2024, the P&P indicated, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications . The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on interview and record review, for four of four sampled residents (Residents 28, 144, 147, and 201), the facility failed to ensure: 1. A care plan was developed for psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications and the care plan for impaired renal (kidney) function was specific for Resident 201. 2. A care plan was developed specifically for mouth breathing and oral care for Resident 28. Cross Reference F657 and F677. 3. A care plan was developed when Resident 147 showed signs of high risk of elopement (leaving the facility unsupervised and without staff knowledge). Cross Reference F689 4. A care plan was developed for Resident 144's use of bilateral bed siderails. These failures had the potential to negatively affect the delivery of care and services for (Residents 28, 144, 147, and 201). Findings: 1. During a review of Resident 201's Admission Record dated 11/10/24 indicated, Resident 201 was admitted to the facility on [DATE], with diagnoses including, anxiety, insomnia (trouble falling or staying asleep), chronic obstructive pulmonary disease (COPD - a chronic/ongoing lung disease causing difficulty in breathing), and end stage renal disease (ESRD - irreversible kidney failure). During a review of Resident 201's Physician Progress Note, dated 10/20/24, indicated the resident had the capacity to understand and make decisions. During a review of Resident 201's MDS dated [DATE], indicated the resident had moderate memory problems, and had trouble falling and staying asleep. During a review of Resident 201's physician's orders, indicated an order for Buspirone oral tablet 15 micrograms (mcg) two times a day for anxiety disorder dated 10/17/24, and Trazodone oral tablet 50 milligrams (mg) by mouth as needed for insomnia at bedtime dated 10/17/24. During a concurrent interview and record review with Registered Nurse 1 (RN) 1 on 11/10/24 at 3:02 pm, Resident 201's care plans were reviewed. RN 1 verified there were no care plans for the two psychotropic medications ordered and stated not having a care plan could not monitor the interventions for the medications. Further review of the resident's care plan indicated a care plan initiated on 10/18/24 for impaired renal function related to (specify) - no reason specified in the care plan. RN 1 verified the care plan did not specify a reason for the impaired renal function and stated is it supposed to be for ESRD but is not complete. 2. During a review of Resident 28's Admission Record dated 11/10/24, indicated, Resident 28 was admitted to the facility on [DATE], with diagnoses including; Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), disorder of the muscles, Parkinsonism (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), gastrostomy tube (Gtube - a surgical opening fitted with a device to allow feedings/medications/hydration to be administered directly to the stomach common for people with swallowing problems) and dysphagia (difficulty swallowing). During a review of Resident 28's MDS dated [DATE], indicated Resident 28 was rarely/never understood, with severely impaired cognition rarely/never made decisions, had short and longer term memory problems, was unable to eat by mouth, and was dependent on staff for oral hygiene, toileting, showering/bathing, dressing, personal hygiene and bed mobility. During observation with concurrent interview with the facility administrator (ADM) on 11/10/24 at 7:48 a.m. Resident 28 was observed in bed with his mouth wide open and crusty buildup of yellow-brown dried secretions in this oral cavity. The AMD stated the resident mouth-breathes and builds up dried secretions quickly in the mouth shift to shift. During a review of Resident 28's care plans, indicated there was no specific care plan developed/created for oral hygiene and mouth-breathing that resulted in dry oral cavity and build up of dried secretions in Resident 2's mouth. 43454 3. A review of Resident 147's Admission Record indicated Resident 147 was admitted to the facility on [DATE] with diagnoses including degeneration of nervous system due to alcohol (there is damage to the nerves due to the direct toxic effect of alcohol and the malnutrition induced by it), spinal stenosis (narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine) and alcohol dependence with withdrawal (a condition that occurs when someone stops or reduces their alcohol consumption after long-term use, it's characterized by a range of physical and mental symptoms that can be uncomfortable and distressing). A review of Resident 147's MDS 10/28/2024, indicated Resident 147's cognition was moderately impaired for daily decision-making. A review of Resident 147's elopement (when a patient leaves a healthcare facility without permission and may be a danger to themselves or others) risk/wanderer related to disoriented to place, impaired safety awareness, initiated on 11/8/2024, had a goal of resident's safety will be maintained and resident will not leave facility unattended through the review date. A review of Resident 147's Elopement Screening, dated 11/5/2024 indicated a score of 13 (high risk for elopement). A review of Resident 147's care plan as of 11/9/2024 indicated, there was no care plan developed when Resident 147 was screened to be at high risk of elopement. During an observation of the facility on 11/8/2024 at 7:28 p.m., Resident 147 was not observed inside her room. During a follow-up observation of Resident 147's room on 11/8/2024 at 8:50 p.m., Resident 147 was not seen inside her room and inside the facility. During an interview with Resident 27 on 11/8/2024 at 7:28 p.m., Resident 27 stated, Resident 147 left the facility today and Resident 27 did not know where Resident 147 went. Resident 27 stated, Resident 147 has been wanting to leave the facility, that Resident 27 saw Resident 147 walk out of her [Resident 147] room and that Resident 147 had two luggages. During an interview with Administrator (ADM) on 11/9/2024 at 10:29 a.m., ADM stated, Resident 147 left the building yesterday (11/8/2024). ADM stated that when they (facility) found out that Resident 147 was not in the resident's room, ADM called Resident 147's cellphone but Resident 147 did not want to say where she [Resident 147] was initially and that Resident 147 was not going to come back to the facility. ADM stated, they (facility) then called Resident 147's family member and that the facility finally was able to track Resident 147. ADM stated, that on 11/8/2024 night, the Director of Nursing (DON) picked up Resident 147 at a location at a location the resident was at. ADM stated, Resident 147 left against medical advice (AMA) and that Resident 147 leaving the facility was not an elopement case. When asked if Resident 147 was given a documentation and explanation of leaving AMA, ADM stated no. When asked then why Resident 147 is back in the facility if she left AMA, ADM did not answer. During an interview with Resident 147 on 11/9/2024 at 10:29 a.m., Resident 147 stated, Resident 147 left the facility without staff's knowledge, and walked on her own to Hotel 1. Resident 147 stated, she was not provided with any discharge AMA letter or documentation that indicated Resident 147 wanted to leave AMA. During an interview with Licensed Vocational Nurse 2 (LVN 2) on 11/9/2024 at 10:47 a.m., LVN 2 stated, Resident 147 is able to walk on her own with no assistive device. LVN 2 stated, Resident 147 was anxious to go home, and staff would see Resident 147 carrying the resident's two luggage. LVN 2 stated, Resident 147 would verbalize, where is the garage, I want to grab my car and go home while carrying two luggage with her and Resident 147 would verbalize that she wants to leave the facility and go home several times in a day. During a follow-up interview with ADM on 11/9/2024 at 2:30 p.m., ADM stated, Resident 147 did not elope and that she left AMA. ADM was asked if any of the staff observed and saw Resident 147 leaving the facility and walked out of the door, ADM stated, no. ADM further stated that surveyors were not informed while surveyors were in the facility on 11/8/2024 and the State Department was not notified when Resident 147 left the facility without staff's knowledge. 4. A review of Resident 144's Admission Record indicated Resident 144 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (loss of the ability to move in one side of the body) following cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting right and left dominant side, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dysphagia (difficulty swallowing). A review of Resident 144's MDS dated [DATE], indicated Resident 144's cognition action or process, was severely impaired for daily decision-making and required maximal assistance to total dependent from staff for Activities of Daily Living. During the initial tour of the facility and observation of Resident 144 on 11/8/2024 at 7:05 p.m., Resident 144 was in bed, lying on a bed with a bilateral bed siderails up. During an observation of Resident 144 on 11/9/2024 at 9 a.m., Resident 144 was lying in bed with a bilateral bed siderails up. A review of Resident 144's medical chart on 11/9/2024, indicated, there was no care plan developed for the use of bilateral side rails for Resident 144. A review of Resident 144's Physician Order Summary Report as of 11/9/2024, indicated there was no physician order for the bilateral bed siderails. During an interview with Registered Nurse 1 (RN 1) on 11/10/2024 at 10:13 a.m., RN 1 stated, Resident 144, is utilizing bed siderails for mobility and protection since admission on 10/26/2024. RN 1 stated, a care plan should have been developed and initiated upon the use of bilateral side rails. A review of the facility's policy and procedures titled Care plans, Comprehensive Person-Centered', revised on 1/2024, indicated, a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident . describes the services that are to be furnished . includes the resident's stated goals upon admission . reflects currently recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility failed to ensure Resident 1's respiratory care was consistent with professional standards of practice to meet the resident's goal for one of six sampled residents (Resident 1) by failing to: 1.Ensure the facility had readily available supply of a nonrebreather mask (medical device used to provide constant flow supplemental oxygen in an acute medical emergency). 2.Implement the facility's policy and procedures, Emergency Supplies Planning , to maintain appropriate medical supplies to accommodate the needs of residents for emergency situations. These deficient practices resulted in delay in providing necessary lifesaving intervention before the paramedics (are healthcare professionals who responds to emergency calls for medical help outside of a hospital) arrived. Resident 1's oxygen saturation (amount of oxygen circulating in the blood) dropped to 79 percent (%, one part in every hundred - ideal range is 95% to 100%) and Resident 1was transferred to the general acute hospital (GACH 1) on 4/24/2023. Findings: A review of Resident 1's admission records indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including, acute respiratory failure with hypoxia (condition in which there is a decreased oxygen level in arterial blood.), congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle), peripheral vascular disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and dysphagia (difficulty swallowing food or liquid). A review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 2/7/2023, indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired and required extensive assistance from staff for activities of daily living (ADL-bed mobility, transfer, dressing, eating, toilet use, and personal hygiene). A review of Resident 1's Situation Background Assessment Recommendation (SBAR - a written or verbal communication tool used to provide essential and concise information, usually during crucial situations) form, dated 4/24/2023, indicated a change of condition (COC) was reported due to shortness of breath with oxygen saturation of 81% (normal oxygen saturation is 90% and above) on room air. A review of Resident 1's Progress Notes dated, 4/24/2023 indicated, Resident 1 had difficulty of breathing, oxygen saturation of 79%-83% on room air, the charge nurse put resident on oxygen via nasal canula (NC) at five liters per minute (lpm) and oxygen saturation increased to 85%. A review of Resident 1's care plan risk of cardiovascular complications dated 2/3/2023, had a goal to be free of chest pain, shortness of breath, edema . The interventions included to provide oxygen as needed per physician (Medical Doctor - MD's) order. During an interview with Paramedics 1 (PM 1), on 4/27/2023 at 1:02 p.m., PM 1 stated, when they arrived at the facility, Resident 1's oxygen saturation was in the mid 80% via simple face mask at five lpm. PM 1 stated, LVN 1 reported that Resident 1 desaturated (drops in blood oxygen level) for more than 30 minutes and facility staff was unable to increase her oxygen saturation using a NC and simple face mask. PM 1 stated, Resident 1 should have been placed on a nonrebreather mask to provide constant oxygen supplement, but the facility did not have any available nonrebreather mask. PM 1 further stated, when he asked for a nonrebreather mask from LVN 1, LVN 1 showed him a bag valve mask instead (also known as ambu-bag or generically as a manual resuscitator or self-inflating bag, is a hand-held device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately). PM 1 further stated, upon arrival, they put Resident 1 via nonrebreather mask with 15 lpm of oxygen and Resident 1's oxygen saturation increased to 96% instantly. During an interview with Licensed Vocational Nurse 1 (LVN 1), on 4/27/2023 at 2:35 p.m., stated Resident 1 has a history of respiratory failure. LVN 1 stated, Resident 1 had shortness of breath on 4/24/2023 at 5:23 p.m., which required an oxygen supplement. LVN 1 stated, she put her on oxygen supplement via nasal canula initially and then switched simple face mask (a basic disposable mask, made of clear plastic, to provide oxygen therapy) to try to increase her oxygen saturation, but Resident 1's oxygen saturation did not increase to more than 90% which prompted her to call for emergency 911 (universal telephone number the gives the public direct access to the Public Safety. Answering point where emergency services such as the fire department, police or paramedics can be dispatched to a location) at 5:30 p.m. LVN 1 stated, in that scenario, they needed to use a nonrebreather oxygen mask, but the facility did not have any available nonrebreather mask in the facility. A review of Resident 1's medical records from Fire Department 1 (FD 1) indicated, paramedics arrived at the facility on 4/24/2023 at 6:09 p.m. and found Resident 1's oxygen saturation was 88% with oxygen supplement on five lpm via simple face mask. Staff at the facility stated they did not have any nonrebreather mask available. Patient was placed on nonrebreather mask and oxygen saturation increased on 96%. A review of Resident 1's Medical Records, Emergency Department Encounter Note , from the GACH 1 indicated the following: a. Resident 1 presented in the Emergency department (ED) on 4/24/2023 for low oxygen saturation and unable to increase oxygen saturation at the facility b. Chest x-ray (an imaging study that takes pictures of bones and soft tissues) resulted Resident 1 has an extensive pulmonary infiltrate (a shadow seen on a chest x-ray and assumed to represent blood, pus, or other body fluids in the lung) or edema (a condition in which too much fluid accumulates in the lungs, interfering with a person's ability to breathe normally). During an interview with Director of Nursing (DON), on 4/27/2023 at 2:59 p.m., the DON stated and confirmed, the facility did not have any nonrebreather mask when the incident happened which prompted her to borrow from their sister's facility. The DON stated, they were not able to increase Resident 1's oxygen saturation due to unavailability of a nonrebreather mask. DON further stated, if a resident desaturated and was not given proper medical device such as a nonrebreather mask, it could lead to a resident having cardiac arrest and death. The DON further stated now the facility have nonrebreather mask on stock and was delivered within 24 hours after the incident happened. A review of the facility's policy and procedures (P&P) titled, Emergency Supplies Planning , revised on 8/2018 indicated, an adequate supply of emergency water, food, medical supplies and non-medical emergency items and equipment is maintained in appropriate quantities and in accordance with all applicable regulations to accommodate the needs of residents, staff members and their family members for emergency situations. The same P&P also indicated, supplies and equipment are stored in clearly designated locations and easily accessible.