Every finding on record at Camden Health and Rehabilitation

Based on observations, record review, and interviews with the Pharmacist and Pharmacy Services Nurse from the dispensing pharmacy and facility staff, the facility failed to ensure medications were stored consistent with manufacturer recommendations for temperature control in 1 of 3 medication refrigerators (located in the 1100/1200 hall medication room) and in 3 of 3 medication rooms (400/500 hall, 1100/1200 hall, and 700/800 hall) observed for storage and labeling of medications. The facility also failed to label medications in 1 of 4 medication carts (400/500 hall medication cart) observed for proper storage and labeling of medications. Findings included: 1. Review of the 1100/1200 hall refrigerator temperature log form for the month of June 2026 revealed that the expected temperature range was 36-46 Fahrenheit ( F) and if the temperature was not in range, one must document corrective action under the comments section of the form and recheck the temperature in one hour and record the recheck temperature on the form. If the temperature was still out of range, one would contact the nursing supervisor. The 5 temperatures out of range were recorded by Nurse #5 and Nurse #2 collectively.In the presence of the Director of Nursing (DON), an observation was made on 6/11/2026 at 8:50 AM of the medication refrigerator in the 1100/1200 hall medication room. The refrigerator's temperature was 40 F. The observation revealed that 5 of the 11 days on the temperature log form for June 2026 were recorded as: 30 F on 6/2/2026 by Nurse #2, 35 F on 6/3/2026 by Nurse #2, 35 F on 6/6/2026 by Nurse #2, 35 F on 6/7/2026 by Nurse #2, and 34 F on 6/9/2026 by Nurse #5. The refrigerator's log form had no comments or rechecks documented.An interview with Nurse #5 on 6/11/2026 at 1:56 PM confirmed she was responsible for recording refrigerator temperatures and for the medications stored in the 1100/1200 hall medication room while on shift on 6/9/2026. She said she knew if the temperature was out of the 36 to 46 F range to continue to recheck temperatures. She understood she needed to fill out the form fully and notify the manager if it was not in range. She said in June 2026 she continued to recheck the out-of-range temperatures she recorded but did not document what she did or the rechecked values. An interview with Nurse #2 on 6/11/2026 at 2:08 PM confirmed she was responsible for recording refrigerator temperatures and for the medications stored in the 1100/1200 hall medication room and that she was on shift on 6/2/2026 and she did record a temperature of 30 F. She said she did understand that if the temperature was out of the 36 to 46 F range she would continue to recheck it and if it was not in range, she would contact her manager or maintenance. She said she did recheck it on 6/2/2026 but failed to write it down on the form. She confirmed she was to write a comment and record the rechecked value, but she kept forgetting. An interview with the DON at 6/11/2026 at 8:51AM confirmed that the facility's process required the nurse to document a comment when temperatures were out of range and to contact the Unit Manager if temperatures remained out of range. If the Unit Manager could not confirm the temperature was in the acceptable range after attempts were made to cool it, then they would get maintenance involved. An interview with Nurse #3 on 6/11/2026 at 10:50 AM, revealed she was not aware of temperatures being out of range in the refrigerator in the 1100/1200 hall medication room and was unable to provide additional information.An inventory of the refrigerator in the 1100/1200 hall medication room was conducted on 6/11/2026 at 11:44 AM. The following items were in the refrigerator: 1 box of Comirnaty (Covid-19 vaccination), 1 box of Pneumovax, 2 Trulicity (medication that is injected to help control blood sugar) boxes, 4 Lantus insulin pens, 2 Lantus insulin vials, and 1 Humulin N insulin vial. No medications stored in the refrigerator were labeled to indicate exposure to temperatures outside the manufacturer's recommended storage range. The package insert for Comirnaty stated store refrigerated at 35 F to 46 F and do not freeze. Manufacturer labeling for Pneumovax stated the vaccine should be refrigerated and instructed, Do not freeze. If frozen, discard the vaccine. The manufacturer labeling for Trulicity states it must be stored in the refrigerator at 36 F to 46 F and it must never be frozen. The manufacturer of Lantus stated store unopened insulin in the refrigerator at 36 F to 46 F and to discard if frozen. The package insert of Humulin N stated to store in the refrigerator at 36 F to 46 F and discard if frozen.An interview with the Director of Facility Services on 6/11/2026 at 9:30 AM confirmed that he had had no complaints about any refrigerators recently. He stated maintenance checks of the refrigerators were conducted monthly, and he would clean the refrigerators and did not recall any issues. In an interview with the Pharmacy Services Nurse from the dispensing pharmacy on 6/11/2026 at 1:04 PM stated, he last visited the facility on 5/19/2026. He stated he expects all medications to be properly stored at the correct temperature to ensure the quality of the medications. He confirmed he had seen the refrigerator log form on each refrigerator in the medication storage rooms. The Pharmacy Services Nurse explained as part of his duties he would carry a thermometer and check the temperature of all the refrigerators monthly. He last checked the 1100/1200 hall medication room refrigerator on 5/19/2026 and he did not report that the refrigerator was out of range. He said if the temperature was not within range he reported it to the Administrator. He expected that the refrigerator temperature would be within 36-46 F.2. Review of the facility's policy, Medication Storage with last reviewed date 1/2/2026, contained only the following verbiage on how the facility ensured medications were stored under proper temperature controls, All drugs and biologicals will be stored in locked compartments (i.e, medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. In the presence of the DON and Nurse #4, an observation of the 400/500 hall medication room was made on 6/11/2026 at 8:14 AM. The observation revealed there was no thermometer in the medication room where over-the-counter (OTC) medications and controlled medications stored in a narcotic cart were maintained.The DON and Nurse #4 stated during an interview on 6/11/2026 at 8:17 AM, that they do not monitor the temperature of the 400/500 hall medication room. They confirmed the closest thermometer was in the 400/500 hall nursing station.In the presence of the DON, an observation was made on 6/11/2026 at 8:50 AM at the 1100/1200 hall medication room that stored OTC tablets and capsules, solutions, enemas, creams and ointments, patches, and powders. A thermometer was seen on top of the refrigerator within range of 68-77 F. The DON in an interview on 6/11/2026 at 8:51 AM confirmed they do not use the thermometer in the 1100/1200 hall medication room and was unsure why the thermometer was even in there.The observation of the 700/800 hall medication room, with the DON, on 6/11/2026 at 9:09 AM revealed the thermometer displayed 81 F and a 48-hour temperature range of 79 to 82 F. The temperature on the thermometer was pointed out to the DON and the DON confirmed it read 81 F.During an interview on 6/11/2026 at 9:10 AM the DON stated that the thermometer was not used because the facility did not monitor temperatures in the 700/800 hall medication room. She then said maintenance would have more information. An observation of medications stored in the 700/800 hall medication room on 6/11/2026 at 9:22 AM revealed the room contained OTC tablets and capsules, solutions, enemas, creams and ointments, patches, and powders. The label on the bottle of aspirin tablets (used for pain relief and cardiovascular protection) stated it, must be stored at 68-77 F. A magnesium oxide (used as a mineral supplement and constipation), bottle's label stated it must be stored at room temperature, a controlled range between 68-77 F. No medications stored in the room were labeled to indicate exposure to temperatures outside the manufacturer's recommended storage range.Review of manufacturer storage recommendations revealed aspirin tablets, magnesium oxide tablets, Biofreeze Gel (used for temporary relief of minor muscle and joint pain), Fleet Enema (used for constipation), hydrocortisone cream (used to relieve itching and swelling associated with skin irritations), athlete's foot cream (used to treat fungal skin infections), and polyethylene glycol 3350 powder (used for constipation) were recommended to be stored at a controlled room temperature of 68 to 77 F. An interview with the Director of Facility Services on 6/11/2026 at 9:30 AM confirmed that the thermometer in the 700/800 hall medication room did show that the medication room temperature was 81 F and 79-82 F for the last 48 hours. He said he was currently having a mechanic check on the air conditioning unit due to the medication room temperature being elevated. He stated that each medication room in the facility, along with the nursing office, bathroom, and nursing station in that area of the building were all under the same temperature reading in his temperature application (app) on his phone. The app will alarm if above 80 F. He confirmed he cannot monitor and isolate any medication room in the facility, and he was only monitoring the nursing station thermometer outside of the medication room. The Director of Facility Services indicated the facility's air flow was grouped into one unit in these nursing unit areas (400/500 hall, 1100/1200 hall, 700/800 hall, etc.). Each unit for the area will provide a percentage of airflow. The medication room received 20%, nursing office received 20%, bathroom received 10%, and the nursing station received 50% of the airflow. The Director of Facility Services stated the process of maintenance being notified of a temperature issue in the medication room was for the nurses to put in a work order. He said his process was to make rounds of the nursing stations to check the box for any work orders and if there was an urgent issue he would be called. The Director of Facility Services confirmed he had no complaints about the 700/800 hall medication room recently and was unsure why the thermometer inside the 700/800 hall medication room was even in the room because they do not monitor it. Observations of the 700/800 hall medication room on 6/11/2026 at 9:22 AM, 10:13 AM, and 11:37 AM revealed that the room was 81F displayed on the thermometer in the medication room. An interview with Nurse #3 at the 700/800 hall nursing station on 6/11/2026 at 10:13 AM revealed she did not know how long the medication room had been this hot. An interview with Nurse # 1 at the 700/800 hall nursing station on 6/11/2026 at 10:50 AM stated the medication room was warmer than normal and the staff does not monitor the temperature of the medication room only the refrigerator. An interview with the Administrator on 6/11/2026 at 11:00 AM stated that the air conditioning system was only an issue this morning in the 700/800 hall medication room, 6/11/2026, and that this was a new identification today. An interview in the Azelea medication room with the Director of Facility Services on 6/11/2026 at 11:37 AM revealed that he had visited the 700/800 hall medication room last Thursday (6/4/2026) and noted no issues and no work orders. He said he heard about the room temperature issues in the 700/800 hall medication room [ROOM NUMBER] days ago (6/9/2026) and he received a work order. He also stated they were working on the air conditioning now and they needed to order a part. Review of the maintenance work order request for the elevated temperature of the 700/800 hall medication room showed it was dated 6/10/2026 by a staff member with no specific name listed. Review of the air conditioning maintenance job details for the ticket for the 700/800 hall nurse station area including the 700/800 hall medication room showed that it had a start date of 6/10/2026 and end date of 6/10/2026. It stated what service was required and what service performed. An interview with the Pharmacist on 6/11/2026 at 12:45 PM confirmed her company had been servicing the facility for many years. She stated they send a Pharmacy Services Nurse from the dispensing pharmacy out to the facility monthly. The Pharmacist indicated she would expect medications to be properly stored and to follow proper guidelines to maintain temperatures to ensure the medications are being stored properly. When asked what the facility does to ensure medications were stored at the correct temperature, she stated she knows the refrigerators have daily logs, but she was unsure about the medication room. She stated that the Pharmacy Services Nurse may know. An interview with the Pharmacy Services Nurse on 6/11/2026 at 1:04 PM stated, he last visited the facility on 5/19/2026. He stated he expected all medications to be properly stored at the correct temperature to ensure the quality of the medications. The Pharmacy Services Nurse indicated he did not know how the facility ensured this for the medication rooms, but he had seen the refrigerator log form. He explained as part of his duties he would carry a thermometer and check the temperature of all the medication rooms and refrigerators monthly. The Pharmacy Services Nurse explained if the temperature of any medication room or refrigerator was not within range he reported it to the Administrator. He also stated, if the medication room was above 77 F, he would report it to the Administrator. When asked if he recalls any temperatures out of range, he stated he did have one instance recently on 5/19/2026 where they needed to remove a narcotic cart storing medications from the medication room because it was out of range. The Pharmacy Services Nurse confirmed it would appear in the report he submitted monthly to the Administrator. An interview with the Administrator on 6/11/2026 at 1:09 PM, confirmed the Pharmacy Services Nurse comes to the facility monthly. He retrieved the last report submitted by the Pharmacy Services Nurse which was dated 5/19/2026. The report stated that the 400/500 hall medication room was above 77 F and he recommended facility to temporarily move the narcotic cart out of the room. When asked how the facility was ensuring they were following their medication storage policy that states all medications, including the medication rooms, were under proper temperature controls, the Administrator stated he visited each medication room daily and he would feel if the room was fine. He stated he does not take the temperature of the medication rooms, and he also stated he does not document that he visited the medication rooms on a specific date. When asked about the thermometers in 2 of the 3 medication rooms (700/800 hall and 1100/1200 hall), the Administrator indicated they did not use them.3. In the presence of the DON, an observation was made on 6/11/2026 at 8:26 AM of the 400/500 hall medication cart. An open box of dorzolamide-timolol 2%-0.5% eye drops, used to treat ocular hypertension (a condition where the pressure inside the eye was higher than normal), dispensed for Resident #114 was stored in the medication cart. The box contained three unopened foil pouches and one opened pouch with one missing single-use container. The opened pouch was not labeled with an opened date. The DON stated that she was sure it was just opened either this morning or last night by Medication Aide #1 or Medication Aide #2. The DON stated her expectations for nursing staff were to ensure foil pouches are dated immediately upon opening. The DON took the opened pouch of eye drops and removed them from the medication cart. In an interview with Medication Aide #2 on 6/11/2026 at 2:03 PM, she said that when she opened a medication in a foil pouch, she was supposed to date it. Medication Aide #2 confirmed she administered medications to Resident #114 the previous night, 6/10/2026. She confirmed she opened a foil pouch of eye drops for Resident #114 on that shift, and she was distracted and did not go back and date it. Medication Aide #2 stated she thought she could make it to the facility on 6/11/2026 and date it then. Medication Aide #1 was present in the hall on another medication cart on 6/11/2026 at 8:26 AM and the DON asked her what do you do if you open a foil pouch and Medication Aide #1 confirmed you date it immediately. An interview with Medication Aide #1 on 6/11/2026 at 10:46 AM confirmed she understood when she opened a pouch she knew to date it. She confirmed the pouch she opened this morning for Resident #114 was dated correctly.

Based on observation, record review and interview the facility failed to: label and date foods in the walk-in and reach-in refrigerators; date opened nutritional supplements and food brought in by resident's family member in 3 of 4 Nourishment refrigerator (Nourishment refrigerator #1, Nourishment refrigerator #2 and Nourishment refrigerator #3); and maintain the ice scoop holder clean in 1 of 4 nourishment rooms (Dogwood Nourishment room). These practices had the potential to affect food served to 122 of 124 residents. Findings included: 1 a. Observation of the walk-in refrigerator on 3/24/24 at 9:50 AM, revealed a plastic bag with 4 boiled eggs with no label, a white plastic bag with sliced meat with no label, a blue plastic bag with diced meat with no label, two individual plastic bags - one with 1/4 tomato and another with 1/2 tomato that was cut and had no label, and one plastic bag with half cut onion with no label. During an interview on 3/24/23 at 9:51 AM, the Dietary cook stated the sliced meat in the white plastic bag was sliced turkey and was used as an alternate for the previous meal. The Dietary cook further stated the diced meat in the blue plastic bag was diced chicken. He indicated all food placed in the walk-in refrigerator should be dated with the date the food was placed in the refrigerator. The cook stated he was unsure when the tomatoes and onion were placed in the refrigerator. 1b. Observation of the reach -in refrigerator on 3/24/23 at 9:55 AM revealed a plastic pitcher 3/4th filled with a pink colored liquid dated 3/19/24. There was another plastic pitcher 1/4th filled with yellowish colored fluid with no label or date. During an interview on 3/24/23 at 9:55 AM, the Dietary cook indicated the pink colored liquid was fruit punch. He indicated he was unsure why the pitcher containing the fruit punch was still in the refrigerator. The Dietary cook stated the yellowish fluid was lemonade, and he was unsure why it was not labeled or dated. 2. Review of the policy Food Brought by Family/ Visitor revealed perishable foods should be stored in re-sealable containers with tight fitting lids in the refrigerator. The container should be labeled with the resident's name. The policy read in part Staff will discard perishable foods on or before the use by date. 2 a. Observation of the nourishment refrigerator #1 (on Magnolia) on 3/24/24 at 10:10 AM, revealed a takeout cardboard pizza box with pizza in it with no label or date, two plastic bags with takeout food container with resident's name and room number, but no date indicating when it was placed in the refrigerator. A plastic bag containing 1/2 cheese sandwich dated 3/17. During an interview on 3/24/24 at 10:10 AM, Nurse #1 stated any food brought in by residents' families for residents should be labeled with resident's name and date before it was placed in the nourishment refrigerator. Nurse #1 indicated the resident's family members and residents placed foods in the nourishment refrigerator without informing any staff. 2 b. Observation of the nourishment refrigerator #2 (on [NAME]) on 3/24/24 at 10:20 AM revealed a sandwich bag with half egg salad sandwich dated 3/20/24. An opened 42 fluid ounce carton labeled, 100% pure orange juice, with no date. During an interview on 3/24/24 at 10:10 AM, Nurse Aide (NA) #1 indicated she was unsure why the orange juice carton was not dated. She stated the dietary staff were responsible for removing old sandwiches from the nourishment refrigerator. 2c. Observation of the nourishment refrigerator #3 (on Southern Rose) on 10/24/24 at 10:40 AM revealed an opened 32 fluid ounce nutritional supplement, Med Pass 2.0, with no date. During an interview on 3/24/24 at 10:40 AM, Dietary Manager stated all opened nutritional supplements should be dated prior to placing them in the nourishment refrigerator. 3. Observation of the ice scoop holder on 3/24/24 at 10:15 AM in the nourishment room on Dogwood station revealed the ice scoop holder had white colored paper towels on the inside base of the holder. These paper towels had yellow-colored stains on them. The ice scoop was placed on these paper towels. During an interview on 3/24/24 at 10:15 AM, NA #2 stated she was unsure who placed the paper towel in the ice scoop holder. She indicated the ice scoop was sent to the kitchen once a week to be run through the dishwasher. During an interview on 3/26/24 at 2:30 PM, the Dietary Manager stated that all left over and opened foods should be labeled and dated prior to placement in the refrigerators or freezers. She further stated that the sandwiches in the nourishment refrigerators should be discarded after 3 days. All opened nutritional supplements should be discarded after 3 days. The Dietary Manager indicated she does a daily sweep of all nourishment refrigerators and discarded resident's food brought by families that were past 3 days or if they were spoiled. Any packaged foods were discarded per their expiration date. She indicated the dietary staff were not responsible for the labeling and dating the resident's food that were placed in the nourishment refrigerators, as the dietary staff were not aware when these foods were brought in by families or when these foods were placed in the refrigerator. During an interview on 3/36/24 at 3:50 PM, the Director of Nursing (DON), stated nutritional supplements used on medication carts should be dated by the nursing. DON further stated occasionally the residents do put their own food or families put their food in the nourishment refrigerator without notifying the nursing staff. The nursing staff would not be able to label and date the foods that were directly placed in the nourishment refrigerator by the resident or their family members. The DON indicated nursing staff should label and date the food brought in by families if given to them to be placed in the nourishment refrigerator. The DON stated the Dietary and Housekeeping staff were responsible to ensure residents' foods in the nourishment refrigerator were labeled and dated. The DON indicated the Dietary and Housekeeping staff conduct daily sweeps of the nourishment refrigerators to ensure the food brought for the residents was within 3 days and all packaged foods were within the expiration date. During an interview on 3/27/24 at 8:21 AM, the Administrator stated the foods placed in the nourishment refrigerator should be labeled and dated, however the challenge was when the residents or resident's family members directly placed food in the nourishment refrigerator without notifying the staff. The nourishment refrigerators were checked frequently to ensure the food placed in these refrigerators was safe. The Administrator indicated the ice scoop holder had a crack on the bottom and the staff had placed paper towels to prevent water from dripping down on the floor. He indicated the entire ice scoop unit was replaced recently. The Administrator stated the ice scoop holder and ice scoop should be sent to the kitchen to be washed daily.

Based on observations, record review, physician, Rehab Consultant Physician Assistant (PA), resident, resident family, and staff interviews the facility failed to notify the physician that Resident #114 reported he had a scheduled outpatient dental appointment. The outpatient dental appointment was for teeth extractions and the facility physician was not given the opportunity prior to the appointment to review medications or consider holding the anticoagulant medication prior to the procedure. This was for 1 of 1 residents reviewed for anticoagulant use. (Resident #114). Findings included: Resident #114 was admitted on [DATE] with a diagnosis of acute on chronic combined systolic (congestive and diastolic (congestive) heart failure, chronic kidney disease, diabetes, and unspecified atrial flutter. A review of physician order dated 4/7/23 revealed an order for Eliquis 2.5 milligrams to be administered by mouth twice a day. This order was discontinued on 1/31/24. A review of the January 2024 Medication Administration Record (MAR) revealed Resident #114 received 2.5 mg of Eliquis and was administered on 1/1/24-1/31/24. A review of the Rehab Consultant PA note dated 1/15/24 indicated that Resident #114 reported some oral discomfort and made the Rehab Consultant PA aware of a pending outpatient dental appointment and that his son would provide the transportation to the appointment. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #114 was cognitively intact. A review of Resident #114's dental patient note history on 1/25/24 revealed that Resident #114 had teeth extractions for teeth #4-10 and #15 and a bone graft on #9 and no bleeding was documented in the note. A review of the Rehab Consultant PA note dated 1/29/24 revealed the PA noted Resident #114 upper gums were healing with no obvious bruising or bleeding observed. An observation of Resident #114 was made on 3/24/24 at 1:26 PM. Resident #114 was observed in his room sitting in wheelchair. He was alert, able to make needs known and with no signs of discomfort or bleeding of the mouth. During an interview with Resident #114 on 3/27/24 at 11:08 AM he revealed that the facility did not stop his anticoagulant medication prior to dental extractions that occurred on 1/25/24. He further revealed that he thought he told someone at the facility about the appointment but could not recall the staff member's name. A telephone interview was conducted with Resident #114's son on 3/27/24 at 11:12 AM. He indicated that he takes his dad out of the facility for outings and appointments on a regular basis. He further revealed he made the dental appointment and transported his dad to the appointment on 1/25/24 and did not recall making the facility aware of the dental appointment until after the appointment. An attempt was made to interview the oral surgeon on 3/27/24 at 11:36 AM but he was not available for interview. The office manager did confirm that the oral surgeon had a list of medications on file at the time of the procedure. A telephone interview was attempted on 3/27/24 at 1:11 PM with Nurse #3 who was assigned to this resident on 1/15/24. Nurse #3 was out on leave and did not return the phone call for interview. An interview as conducted with the Physician on 3/27/24 at 2:39 PM revealed she was not made aware of the outpatient dental appointment or that Resident #114 had extractions until after the extractions had occurred. She further revealed if she had been made aware prior to the appointment she would have consulted with the oral surgeon and recommended holding Eliquis 3-4 days prior to the surgery. An interview was conducted with the Rehab Consultant PA on 3/27/24 at 3:26 PM. She revealed that during her 1/15/24 visit Resident #114 made her aware he had oral discomfort and that he had an upcoming outpatient dental appointment for extractions. She further revealed that she did not make his physician aware as she assumed that the facility was already made aware by the resident and/or his son. An interview was conducted with the Director of Nursing (DON) on 3/27/24 at 5:51 PM and she indicated that once the Rehab Consultant PA was notified of the pending dental appointment, she needed to report the information to the facility staff. An interview was conducted with the Administrator on 3/27/24 at 5:55 PM and indicated that he would not have expected the Rehab Consultant PA to notify the facility of the outpatient dental appointment as she assumed the facility already knew of the appointment.

Based on record reviews and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of dental care for 1 of 1 residents reviewed for dental care. (Resident #89). The findings included: Resident #89 was admitted to the facility on [DATE] with dysphagia and unspecified severe protein-calorie malnutrition. A review of dental consultation note dated 8/29/23 revealed resident #89 had root tips present for teeth #1,7,8,9,12, 18, and 20. A review of Resident #89's Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment and to have no broken natural teeth. A telephone interview was conducted on 3/26/24 at 3:20 PM with the dental provider. She confirmed that Resident #89 has had root tips present since 8/29/23 for teeth #1,7,8,9,12, 18, and 20 which indicated these natural teeth had been broken. An interview was conducted with MDS nurse #1 on 03/26/24 at 3:53 PM. She revealed that she completed the dental section of the 1/4/24 significant change assessment and that she did not recall looking into Resident #89's mouth to assess the status of his teeth. She further revealed that she was not aware that Resident #89 had broken teeth and must have missed it, and it should have been coded accordingly on the 1/4/24 significant change assessment. An interview was conducted with the Administrator on 3/27/24 at 5:54 PM and he revealed that Residents #89's significant change assessment should have reflected the resident's dental status at the time of the assessment.

Based on observations, record reviews, resident and staff interviews, the facility's Quality's Assessment and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that were put in place following the complaint survey conducted on 8/23/23. This was for a repeat deficiency in the area of Notification of Change (F580). This deficiency was recited during the annual recertification survey conducted on 3/27/24. The repeated citations during the two surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assessment Assurance program (QAA). Findings included: This tag is cross referenced to: F 580 Based on observations, record review, physician, Rehab Consultant Physician Assistant (PA), resident, resident family, and staff interviews the facility failed to notify the physician that Resident #114 reported he had a scheduled outpatient dental appointment. The outpatient dental appointment was for teeth extractions and the facility physician was not given the opportunity prior to the appointment to review medications or consider holding the anticoagulant medication prior to the procedure. This was for 1 of 1 resident reviewed for anticoagulant use. (Resident #114). During the recertification and complaint survey dated 8/23/23 the facility failed to notify the medical provider and resident representative after a resident, who did not have a diagnosis of diabetes or an order to receive insulin, was mistakenly administered 50/50 insulin (combination of intermediate and fast acting insulin) for 1 of 1 resident reviewed for notification. An interview with the Administrator was conducted on 03/27/24 at 6:00 PM. He indicated that the QAPI team helps to identify areas of concern through the grievance process and weekly interdisciplinary team meetings. The data is used for root cause analysis purposes. He further revealed that his expectation was for the team to work together to maintain an effective Quality Assurance Performance Improvement Committee to ensure the facility does not repeat a previous deficient practice

Based on record review and staff, Nurse Practitioner (NP), and Regional Nurse Consultant interviews, the facility failed to notify the medical provider and resident representative after a resident, who did not have a diagnosis of diabetes or an order to receive insulin, was mistakenly administered 50/50 insulin (combination of intermediate and fast acting insulin) for 1 of 1 resident reviewed for notification (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's admission physician orders dated 3/21/23 indicated no orders for the resident to receive insulin. A review of Progress Notes by Nurse #1 for Resident #1 dated 3/23/23 at 6:20 PM (Recorded as Late Entry on 03/24/2023 12:24 AM) revealed Nurse #1 gave 4 units of 50/50 insulin to Resident #1. Patient has remained stable with no adverse effects noted. There was no documentation in Nurse #1's progress of notification to inform the medical provider or resident representative of the medication error. A review of the facility reported medication error investigation report conducted and provided by the Corporate Nurse Consultant dated 3/25/23 at 10:30 AM revealed that on 3/22/23 Resident #1 received an injection of 4 units of 50/50 Insulin, in error, during medication administration by Nurse #1 (the Director of Nursing). The investigation further revealed Nurse #1 failed to report the medication error immediately and failed to notify the medical provider and the resident representative. Attempts made to contact Nurse #1 by phone were not successful. A telephone interview was completed on 8/22/23 at 5:15 PM with the NP who revealed the DON called her on Thursday evening, 3/23/23, and said she had administered 4 units of 50/50 to Resident #1 who was not a diabetic and did not have an order for insulin. The NP reported she had talked to the DON on Wednesday 3/22/23 and the DON never told her she had made a medication error on 3/22/23. The NP explained the DON led her to believe the error occurred the afternoon of 3/23/23. The NP stated she found out on Saturday 3/25/23 the DON had lied about the date of the med error. The NP added had she been made aware the medication error had occurred on 3/22/23 she would have ordered the blood sugar checks at that time. During an interview with the Corporate Nurse Consultant on 8/22/23 at 3:11 PM she revealed Nurse #1 admitted that she did not immediately report she administered insulin to Resident #1, nor did she inform the family and medical provider when the error occurred. Nurse #1 did not follow facility procedure for notification of medication errors to the medical provider or responsible person. The facility provided the following Corrective Action Plan with a completion date of 3/25/23. 1. Responsible Person (RP) and Nurse Practitioner (NP) made aware of Insulin administered to Resident #1 in error by DON on 3/23/2023. DON was educated on 6 Rights of Medication Administration and notification of the RP/NP or MD by Regional Clinical Manager on 3/24/2023. 2. All in house residents progress notes and medication errors for the previous 30 days were reviewed by the Assistant Director of Nursing on 3-24-23 for notification to the RP/NP or MD. No other residents were affected. 3. The Director of Nursing and Assistant Director of nursing were educated by the Regional Clinical Manager on 3-24 -2023 on Notifications to RP of any/all changes with Resident, to include medication errors. The Assistant Director of Nursing/Designee will educate licensed Nurses regarding Notifications to RP of any/all changes with Resident. This will be completed on 3/24/2023. No Nurse will be allowed to work if In-service not completed by 3/24/2023. This will be implemented into a new hire orientation by the Assistant Director of Nursing on 3/24/2023. 4. The DON/Designee will review all progress notes and medication errors for notification to the RP/NP or MD daily at Clinical Meeting 5x/week, beginning 3/27/2023. ADON/Designee will review all progress notes and medication errors on weekends starting 3/25/2023. x 4 weeks, then weekly x 4 weeks then monthly x 1 month. 5. The Administrator/Designee will bring these audits to the Quality Assurance Committee monthly x 3 consecutive months. The Quality Assurance Committee will review these results and make the determination of further auditing needs. 6. Allegation of Compliance: 3/25/2023. The Corrective Action plan was validated on 8/22/23 and concluded the facility had implemented an acceptable corrective action plan on 3/25/23. Interviews with nursing staff, including agency staff, revealed the facility had provided education and training on medication administration and notification. Staff interviewed all verbalized they received reeducation on medication administration and notification prior to starting their next shift. Review of the monitoring tools of notification were completed weekly as outlined in the corrective action plan with no concerns identified.

Based on record review and staff, Nurse Practitioner (NP), and Regional Nurse Consultant interviews, the facility failed to prevent a significant medication error when a nurse administered 50/50 insulin (combination of intermediate and fast acting insulin) subcutaneously (into the fat layer under the skin through an injection) to a resident who had no diagnosis of diabetes and no physician's order for the administration of insulin for 1 of 1 resident reviewed for medication errors (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that did not include diabetes mellitus. Review of Resident #1's care plan dated 3/21/23 revealed no care area for diabetes. Review of Resident #1's admission physician orders dated 3/21/23 indicated no orders for the resident to receive insulin. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was severely cognitively impaired, and Resident #1 did not receive insulin injections. A review of Progress Notes for Resident #1 dated 3/23/23 at 6:20 PM (Recorded as Late Entry by Nurse #1 on 03/24/2023 at 12:24 AM) revealed Nurse #1 gave 4 units of 50/50 insulin to Resident #1. Patient has remained stable with no adverse effects noted. A review of the facility reported medication error investigation conducted by the Corporate Nurse Consultant dated 3/25/23 at 10:30 AM revealed on 3/22/23 Resident #1 received an injection of 4 units of 50/50 Insulin, in error, during medication administration by Nurse #1 (Director of Nursing). Nurse #1 did not provide an explanation as to why the error occurred except to say it was hectic on the unit. Review of Resident #1's blood sugar checks revealed the following blood sugar readings and information: 03/22/2023 04:21 PM Blood Sugar: 115 mg/dL documented by the Nurse #1 03/22/2023 06:24 PM Blood Sugar: 100 mg/dL documented by the Nurse #1 03/22/2023 10:25 PM Blood Sugar: 102 mg/dl documented by the Nurse #1 03/23/2023 06:34 AM Blood Sugar: 110 mg/dL documented by the Nurse #1 03/23/2023 10:35 AM Blood Sugar: 115 mg/dL documented by the Nurse #1 03/23/2023 02:35 PM Blood Sugar: 111 mg/dL documented by the Nurse #1 03/23/2023 04:23 PM Blood Sugar: 110 mg/dL documented by the Nurse #1 A telephone interview was completed on 8/22/23 at 5:15 PM with the NP who revealed the DON called her on Thursday evening, 3/23/23, and said she had administered 4 units of 50/50 to Resident #1 who was not a diabetic and did not have an order for insulin. The NP further revealed that 4 units of 50/50 was a very small dose and probably would not cause harm to the resident. The NP said she researched the peak time of the insulin so that she could order the times for CBGs (capillary blood sugar also known as finger stick blood sugar) and monitoring to be done. The NP reported she had talked to the DON on Wednesday 3/22/23 and the DON never told her that she had made a medication error on 3/22/23, the DON led her to believe the error occurred the afternoon of 3/23/23. The NP stated she found out on Saturday, 3/25/23, the DON had lied about the date of the med error. The NP stated the times she called the DON to check the CBGs, the DON never clarified the med error had occurred on 3/22/23. The NP added, had she been made aware the medication error had occurred on 3/22/23, she would have ordered the blood sugar checks at that time. During an interview with the Corporate Nurse Consultant on 8/22/23 at 3:11 PM she revealed during her extended investigation into the medication error she was made aware Nurse #1 administered insulin to Resident #1 in error on 3/22/23 not on 3/23/23 as originally reported by Nurse #1. Nurse #1 did not practice the 5 rights of medication administration prior to the administration of insulin to Resident #1. 1. Facility failed to prevent a significant medication error for Resident #1 by administering Insulin injection not prescribed for Resident. Four units of 50/50 Insulin were administered to wrong Resident on 3/22/2023. Resident was monitored by the nurse for Blood sugars over the next 6 hours. On 3-23-23, the NP and RP were notified of the medication error. Resident did not show adverse reaction to the medication error. On 3-24-23, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were educated by the Regional Clinical Manager on Medication Administration and Notification of changes to RP and NP/MD. 2. The administering Nurse failed to follow the Seven Rights to Medication Administration. Resident received Insulin not prescribed for Resident. DON was educated by Regional Clinical Nurse on 3/24/2023. All Residents receiving medications have the potential to be affected by this deficient practice. 3. The Regional Clinical Manager and ADON educated all Licensed Nurses and Medication Aides to include Seven Rights of Medication Administration and was completed on 3/24/23. No Nurse or Medication Aide will be allowed to work if Inservice if not completed by 3/24/23. The Education will be conducted on Orientation and annually thereafter by SDC/Designee. 4. Med Pass Observations will be conducted by ADON/Designee to ensure medication administration rights are followed. The DON or designee will conduct 5 medication pass observations weekly x 4 weeks, then 3 medication pass observations x 4 weeks, then 1 medication pass observation x 1 month. 5. All Findings will be reported to QAPI monthly ongoing by the DON or designee x 3 consecutive Quality Assurance Meetings. The Quality Assurance Committee will determine if further auditing or education is needed. 6. Allegation of Compliance: 3/25/23. The Corrective Action plan was validated on 8/22/23 and concluded the facility had implemented an acceptable corrective action plan on 3/25/23. Interviews with nursing staff, including agency staff and medication aides, revealed the facility had provided education and training on medication administration and notification. Staff interviewed all verbalized they received reeducation on medication administration and notification prior to starting their next shift. Review of the monitoring tools of medication administration were completed weekly as outlined in the corrective action plan with no concerns identified.

Based on record review and staff interview, the facility failed to implement their abuse policy in the area of investigation by not interviewing Nursing Assistant #1 who provided care to the resident on alleged abuse dates (Resident #1) for 1 of 3 residents reviewed for abuse. The findings included: Review of the facility policy titled Abuse dated 10/2022, read in part: Section III, Procedure: C. Investigation 2. Documentation of the investigation findings is maintained on applicable forms or reports. 6. Activities conducted in the investigative process include, at a minimum: a. Review of the following: iii. Personnel records if an employee(s) is suspected or accused. b. completion of the following interviews: ii. (d) Staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. 7. General guidelines for interviewing that are to be incorporated in an investigation include: d. Witness reports are documented in writing by the investigator and signed and dated by both the interviewer and witness. The facility had an allegation of sexual abuse and submitted an initial report of abuse on 11/22/22 and their investigation on 11/25/22 when there was a transmission error. The investigation was resubmitted on 12/8/22 successfully. A review of the facility reported incident (FRI) at 24 hours and 5 days documented an investigation for allegation of sexual abuse. The resident alleged that a male nursing assistant inappropriately touched her vagina either on 11/17/22 or 11/18/22 which was reported on 11/22/22. The facility's investigation report dated 11/25/22 indicated they first became aware of the incident on 11/22/22. Resident #1 told Nursing Assistant (NA) #6 that there was a sexual pervert. The NA informed Social Work (SW) and the Administrator. SW interviewed the resident who shared the alleged perpetrator was a male staff who provided care to her. SW reported her findings to the Administrator. The Administrator and DON interviewed Resident #1 and received more information from the resident and determined the incident happened on 11/17/22 or 11/18/22. The NA was a male that had provided care 3 or 4 times before. The resident was taken to another room (other than the resident's room) to be prepared for bed. The time was approximately 8:00 pm. When asked the last time the NA was seen, the resident responded doing laundry. The resident stated the NA was Cuban and talked normal. Staff members that took care of the resident from 7:00 am to 11:00 pm were females on 11/17/22 and 11/18/22. The psychiatric Nurse Practitioner (NP) interviewed the resident and found there were inconsistencies with the resident's account of the incident. The allegation was unsubstantiated. On 1/18/23 at 1:41 pm an interview was conducted with the Social Worker (SW). SW stated she was informed of the abuse allegation from NA #6 but could not remember the date. She interviewed Resident #1 and reported back to the Administrator and Director of Nursing (DON). The SW was not aware that a male NA (NA #1) was assigned to Resident #1 and provided incontinence care on 1/17/22 and 1/18/22 night shift. The Administrator provided a type-written interview of Resident #1 on 11/22/22 which was not signed. The resident recognized the man who touched her as he was walking by in the hall and he provided care on 11/17/22 and 11/18/22. This man had provided care 3 or 4 times before. The touching incident did not happen in her room. It was in a room that had a table and was barren (of furniture). The resident stated the man was Cuban. The resident could not describe the staff member. During an interview with the Administrator on 1/18/23 at 2:40 pm, the Administrator provided the hand-written list of nursing staff on schedule for 11/17/22 and 11/18/22 which totaled 18 for all 3 shifts that she interviewed in response to Resident #1's allegation that she was inappropriately touched by a male nursing assistant. She stated that the staff were asked if the resident reported any abuse or anything unusual to them and all answered no. The interviews were not documented. She concluded none of the nursing staff were a suspect of the allegation nor were they asked what happened with care provided to the resident. The resident's activity of daily living record was not reviewed to determine who provided care. A review of the nurse staffing schedule for 11/17/22 and 11/18/22 documented NA #1 was listed on 11/17/22 and not on 11/18/22. A review of Resident #1's incontinence care documentation revealed NA #1 electronically signed he provided care to the resident on 11/17/22 and 11/18/22. The Administrator went on to say that NA #1 was not on the 11/18/22 schedule and worked night shift so he could not have been a suspect because the resident alleged the abuse occurred about 8:00 pm on 11/17/22 or 11/18/22 and NA #1 worked nights (11:00 pm to 7:00 am). The resident was cognitively intact and would know what time this allegation occurred. The Administrator then went on to say that the resident had paranoia and a history of hallucination, and her story was inconsistent. The Administrator further stated that NA #1 never had a problem, was a male, and had an accent, but it was African. The Administrator stated she was not aware the resident had cognitive communication deficit and was not aware that NA #1 (male) was on staff both 11/17/22 and 11/18/22 night shift assigned to the resident and provided incontinence care both nights. The Administrator stated that NA #1 resigned shortly after the abuse allegation investigation by the police.

Based on observation, record and manufacturer's instruction review, and staff interviews, the facility failed to assess the resident for safe mechanical lift transfer by one person (Resident #2) for 1 of 2 residents reviewed for accidents. The findings included: Resident #2 was admitted to the facility on [DATE] with the diagnoses of muscle wasting and quadriplegia. Resident #2's care plan dated 8/6/21 documented the resident was at risk for falls and was dependent for mobility and transfer. Resident #2's readmission from the hospital Minimum Data Set, dated dated dated [DATE] documented an intact cognition and feeling tired 7-11 days out of 14 days. The resident was transferring dependent of 2 staff and bed mobility dependent of 1 staff. The resident's diagnosis was quadriplegia and muscle wasting. On 1/17/23 at 3:25 pm an observation was done of Resident #2 in his room. Upon entry to the room, it was observed that Resident #2 was in the sling hanging being transferred from his wheelchair to his bed by mechanical lift by the Physical Therapy Assistant (PTA). (A PTA follows a plan developed for the resident by the Occupational or Physical Therapist). Concurrent interview: The PTA stated he assisted the nursing staff to transfer the resident to the bed when they are busy. Nursing mechanical lift transfers the resident with 2 persons. He stated that he used 2 people to transfer the resident by mechanical lift when the resident was being transferred out of the bed into the wheelchair because the wheelchair was narrow and if the resident swings he cannot aim onto that narrow surface (of the wheelchair). The PTA stated that he transferred the resident alone (1 person) when getting him back into the bed from the wheelchair because the bed was wider and if the resident swings he could aim easily. It was easier. He further stated that nursing does not do this (one person transfer). The PTA commented that he had been doing the transfer this way with Resident #1 and had no problems. He made the decision to transfer the resident by himself. On 1/17/23 at 3:40 pm an interview was conducted with the Therapy Director. The Therapy Director stated she was familiar with Resident #2 and that he had the diagnosis of quadriplegia and required a mechanical lift transfer to get out of bed. The mechanical lift procedure was normally two-people assisted into and out of the bed. The Therapy Director stated that a two-people transfer was safer for this resident because he is large and dead weight and would be a risk. The therapy plan for the resident did not include mechanical lift transfer by one person. The resident was not evaluated for a one-person transfer by the PTA. She further stated that she would provide one-on-one education to the PTA to transfer this resident by mechanical lift with two staff members for safety. The PTA was an assistant to the therapy staff and the decision to transfer 1 person was not discussed with the Therapy Department for Resident #2. She stated there was a fall risk. On 1/17/23 at 4:10 pm an interview was conducted with the Administrator. She was not aware that the PTA had transferred Resident #2 by mechanical lift by himself (1 person). No further comments were made. On 1/17/23 at 4:20 pm the manufacturer's instructions consisting of 27 pages for use of the facility's mechanical lift was provided by the Administrator. The manufacturer's instructions were reviewed which recommended 2 people for mechanical lift transfer. For 2 people: one manages the controls, and one guides the resident. All 10 example pictures on how to operate the mechanical lift had 2 people. There was a warning example use of 1 person that the situation would need a health care professional evaluation for each individual case and to use caution. There were no instructions on how to use the mechanical lift with 1 person. Concurrent interview with the Administrator: She stated she was not aware that the Therapy Director wanted the PTA not to use the mechanical lift transfer alone, there should be 2 people. No further statements were made. On 1/18/23 at 3:25 pm an interview was conducted with the Therapy Director. She stated Resident #2 was not a good candidate for a one-person use of the transfer device because of his quadriplegia and muscle wasting and that 2 people would be safer and would provide education to the staff. A decision to make a mechanical transfer one person would have had to be evaluated by the Therapy staff: Physical or Occupational Therapist.

Based on record review, observations and staff interviews, the Nurse (Nurse #1) failed to follow procedure for gastrostomy tube (g-tube) care, when she was observed to push water through a syringe into the g- tube, instead of allowing the water to flow in the syringe by gravity through the g- tube to prevent discomfort in the abdomen for 1 of 3 residents reviewed for g- tube care (Resident #28). The findings included: Resident #28 was originally admitted to the facility on [DATE] with diagnoses that included hemiplegia, cerebral infarction, dysphagia, gastrostomy status, moderate protein-calorie malnutrition, dementia, hypertension, aphasia, and type 2 diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 had severe cognitive impairment. She was coded as receiving 51% of more of his total calories through a tube feeding and an average fluid intake of 501 cubic centimeters (cc) per day or more by tube feeding. A review of Resident #28's active care plan, last reviewed 7/1/22, revealed Resident was at risk for weight loss due to need for nutrition support via gastrostomy tube (g-tube). Interventions included to give tube feeding as ordered. A review of Resident #28's active physician orders included an order dated 6/24/21 to flush the feeding tube with 200 milliliters (ml) of water daily. On 11/16/22 at 9:34 am, an observation of Resident #28 occurred. Nurse #1 pushed water with a syringe into Resident #28's g-tube instead of allowing the water to flow in the syringe by gravity through the g- tube to prevent discomfort in the abdomen. During an interview with Nurse #1 on 11/16/22 at 9:42 am, she indicated she usually push the fluids through the g-tube. Nurse #1 indicated upon hire at the facility she did not receive g-tube training or perform competency check off for g-tube care. An interview was conducted with the Assistant Director of Nursing (ADON) on 11/16/22 at 9:45 am and she indicated the correct way to flush a g-tube was to allow the water to flow by gravity in the syringe through the tube to prevent discomfort in the abdomen. An observation was conducted on 11/16/22 at 10:04 am with the ADON perform g-tube flush on Resident #28 with Nurse #1 present. The ADON placed water into Resident's g-tube through syringe and allowed water to flow by gravity into g-tube. On 11/17/22 at 12:54 pm an interview was conducted with the DON, and it was indicated she expected Nurses to follow the correct procedure for g-tube flushing. She indicated she had just started in the facility and a new Staff Development Coordinator was in place and they would be working together to ensure staff were competent and trained prior to working with the residents in the facility.

Based on observations, record review, and staff interview the facility failed to ensure they had competent nursing staff trained and competent in skills and techniques necessary to care for residents with needs for gastrostomy (g-tube) care for 1 of 1 nurse (Nurse #1) observed for g-tube care. The findings included: A review of the facility assessment indicated competent staff were required to care for residents with feeding tubes. An observation was made on 11/16/22 at 9:34 am of Resident #28 receiving a g-tube flush. Nurse #1 pushed 50 milliliters of sterile water with a syringe through Resident #28's g-tube instead of allowing the water to flow by gravity into her abdomen to prevent discomfort. During an interview with Nurse #1 on 11/16/22 at 9:42 am. Nurse #1 indicated her start date was 10/27/22 and during her orientation or prior to her work assignment she did not receive g-tube training or perform competency check off for g-tubes. A review was completed of Nurse #1's employee file and there were no skills checklist or competencies found. An interview was conducted on 11/17/22 at 12:44 pm with the Assistant Director of Nursing (ADON) and she indicated she helped with the orientation process before and would be helping the new Staff Development Coordinator (SDC). She indicated after Nurses received general orientation, they then were setup with someone that should be with them on the floor for at least 3 days and should be checked off with the orientation skilled checklist, which included basic nursing skills. The ADON indicated the person that is assigned to train the new hire was responsible for ensuring the checklist was completed and returned to the SDC. She indicated she was not aware that some Nurses did not have skills checklist check offs or competencies. On 11/17/22 at 12:54 pm an interview was conducted with the Director of Nursing (DON), and it was indicated she was not aware Nursing staff did not have basic nursing skills check offs and competencies prior to working with residents. The DON indicated she had just started in the facility and a new SDC was in place, and they would be working together to ensure staff were competent and trained prior to working with the residents in the facility. An interview was conducted on 11/18/22 at 2:19 pm with the Administrator and she indicated she was not aware that Nursing staff did not have basic skills nursing check offs and competencies, but it was her expectation that they did.

Based on record review and staff interviews the facility failed to have a Registered Nurse scheduled for 8 consecutive hours a day for 2 (10/30/22 and 11/13/22) of 30 days reviewed. Findings included: A review of the Nursing schedule dated 10/14/22 through 11/14/22 revealed no scheduled Registered Nurse (RN) on 10/30/22 and 11/13/22. Review of the timecards and RN scheduled staffing assignment sheets revealed the facility had no documentation of an RN present in the facility on 10/30/22 and 11/13/22 to meet the requirement for an RN at least 8 consecutive hours per day on each day. During an interview conducted with the Scheduler on 11/16/22 at 9:30am she stated there should have been an RN scheduled every day. The scheduler indicated the Staff Development Coordinator (SDC), was the RN in the facility and was not named on the staffing assignment sheets, from 10/14/22-11/14/22. She stated she had knowledge an RN needed to be present daily in the facility. An interview was conducted with the Payroll Staff on 11/18/22 at 2:55pm. The Payroll Staff could not verify there was RN coverage for at least 8 hours on 10/30/22 and 11/13/22. The Payroll Staff confirmed the SDC did not work those dates. An interview was conducted with the Director of Nursing on 11/18/22 at 3:10 pm. She stated she expected the facility to have an RN staffed to meet the regulation for 8 consecutive hours a day, 7 days a week. During an interview conducted with the Administrator on 11/18/22 at 3:30pm she stated she expected the Scheduler to staff an RN for 8 hours per day, 7 days a week.

Based on record review and staff interviews the facility failed to provide written notice of discharge to the ombudsman for 1 of 2 residents reviewed for hospital discharge (Resident #41). Resident #41 was admitted on [DATE] and readmitted on [DATE]. Resident #41's minimum data set assessment dated [DATE] indicated Resident #41 had severe cognitive impairment. Review of nursing note dated 9/3/22 revealed Resident #41 was sent to the hospital emergency department for evaluation. Resident #41 returned from the hospital on 9/6/22. The Social Worker was unable to provide documentation or records providing evidence of communication of the residents discharged to the hospital to the ombudsman. During an interview with the administrator on 11/17/22 at 2:30pm she stated that the social work staff were responsible for issuing the notices of discharge to the Ombudsman. The administrator stated that this has not been done for over a year.

Based on record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey dated 03/17/21. This was discovered for one deficiency cited in the areas of discharge. A discharge deficiency was cited again on the recertification and complaint survey dated 11/18/22. The repeated citations during the two surveys of record shows a pattern of the facility's inability to sustain an effective QAA program Findings included: This tag is cross referenced to: F623: Based on record review and staff interviews the facility failed to provide written notice of discharge to the ombudsman for 1 of 2 residents reviewed for hospital discharge (Resident #41). During the recertification and complaint survey dated 03/17/21 the facility failed to notify the resident's responsible party of the resident's discharge in writing for 1 of 3 residents reviewed for discharge who were discharged from the facility to home. An interview with the Administrator was conducted on 11/18/22 at 4:35 pm. She revealed that her expectation was for the team to work together to sustain an effective Quality Assurance Performance Improvement Committee to ensure the facility does not repeat a previous deficient practice. The Administrator indicated her goal for the facility was to not receive any more repeat tags.

Based on observation, record review and staff interview, the facility failed to store an inhalation drug vial according to the manufacturer's specification. The facility failed to label medications and biologicals with an opened date in 4 of 6 medication carts observed. (100 medication cart, 400, 500, and 600 medication cart. Findings included: Review of the manufacturer's specification for Humalog (fast-acting mealtime insulin) and Admelog (short-acting insulin) revealed to discard 28 days after opening. The manufacturer ' s instructions for [MEDICATION NAME] 0.55 milligram (mg) and [MEDICATION NAME] (drugs used to help control the symptoms of asthma and other lung disease) 3 milliliter (ml) vial indicated the medications should always remain stored in the protective foil pouch and once removed must be used within one week. Review of the Prostat (a protein supplement) bottle instructions read to discard 3 months after opening. 1. Observation on 3/10/21 at 8:00 AM during the medication pass revealed the 100-unit medication cart had a Humalog multi-vial already open and undated. Nurse #3 attempted to use the multi-vial until an inquiry was made about the opened and undated vial. Nurse #3 stated she did not know when the medication was open. 2. Observation on 3/11/21 at 8:19 AM revealed: 100 medication cart a. Prostat sugar free 30 fluid ounce bottle was open and undated. b. Saline eye drops were open and undated. c. Admelog 3 ml vial was open and undated. d. Clear laxative fiber powder 17.9 grams container was opened and undated. e. Cinnamon 500 milligrams (mg) plus [MEDICATION NAME] bottle was opened and undated. 3. Observation on 3/11/21 at 8:37 AM through 9:15 AM on the Magnolia Unit with Nurse #6 revealed: 600 medication cart a. Admelog 3 ml vial was open and undated. b. Clear Laxative container was open and undated. c. Oyster shell with Calcium 500 mg plus Vit D was opened and undated. 400 medication cart a. Prostat sugar free 30 fluid ounce was open and undated. 500 medication cart a. Three (3) vials of [MEDICATION NAME] 0.55 mg and [MEDICATION NAME] were stored outside of the package and undated. b. Vitamin C 500 mg bottle was opened and undated. c. COQ-10 100 mg bottle was opened and undated. Interview on 3/11/21 at 8:50 AM with Nurse #6 stated staff should date medications when opened. Interview on 3/11/21 at 1:27 PM, with the Director of Nurses stated he did not know the rationale for why the staff did not date medications and solutions when opened. He stated staff should date the medication when opened.

Based on record reviews, family interview, Nurse Practitioner, Responsible Party, and staff interview the facility failed to provide information on resident COVID status per the Responsible Party's request prior to the resident's discharge home. The facility additionally failed to follow-up on a Responsible Party's request to speak to the resident's provider regarding the addition of an antidepressant to his medication regimen. This was evident for 2 of 3 residents reviewed for right to be informed and make treatment decisions (Resident #311 and Resident #75). The findings included: 1. Resident #311 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #311's admission Minimum Date Set (MDS) dated [DATE] revealed Resident #311's cognition was severely impaired, and he was unable to make his needs known to staff. Resident #311 required extensive assistance to total dependence on staff for all his activities of daily living (ADL's). Resident #311 was always incontinent of urinary and bowel. Review of a nursing progress note dated 08/28/20 at 11:24 am revealed a discharge care plan meeting was held with Resident #311's family via telephone conference. The resident was set to discharge home with home health on 8/31/2020 and would require 24/7 assistance at home. Nothing in the note discussed the health condition and or Resident #311's status as it related to COVID-19. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the discharge summary written by the Nurse Practitioner (NP) dated 09/01/20 revealed Resident #311 was seen today for discharge. The resident was admitted to the facility after hospitalization from [DATE] through 08/12/20 after presenting with malaise post-fall. COVID-19 test was positive in emergency room . The discharge summary note stated the PT note indicated the resident needed moderate assist with transfer to wheelchair and he was able to self-propel in the wheelchair. PT was unsuccessful in being able to advance the patient's ambulation. The resident would need to continue to work with PT and OT at discharge. Resident #311 was medically stable for discharge at this time with appropriate support system arranged for him at home with family. During an interview with Family member (FM) on 03/09/21 at 8:30 am she indicated Resident #311 was discharged home on 09/01/20 and no one discussed Resident #311's condition related to any signs/symptoms of COVID-19. The FM indicated Nurse #11 told the family he was still on the COVID-19 positive unit, however Nurse #11 indicated she had no knowledge if Resident #311 had been retested for the virus. The FM also indicated she asked the Social Worker (SW) #1 on Monday about Resident #311's COVID status. She added no one at the facility would give her any information about Resident #311's status as it related to COVID-19. The FM also indicated that during Resident #311's stay at the facility the only calls she received from the facility was the night Resident #311 had a fall and on 08/28/20 to discharge Resident #311. The FM indicated that she called the SW and the Nurses on the unit, but no one would answer her questions about Resident #311 COVID-19 status. During an interview with SW #1 on 03/10/21 at 9:00 am she denied the family of Resident #311 had inquired about his status related to COVID-19. The SW indicated the facility communicated with all the residents and/or resident's responsible party about the resident's status as it related to COVID-19. She explained the facility used robocall and individual phone calls to communicate with the families regarding COVID-19 status. During an interview with the Administrator on 03/10/21 at 9:30 am he indicated he had no knowledge of Resident #311's family not receiving any information from the facility regarding the status of the resident's COVID-19 status upon discharge. The Administrator stated he was aware Resident #311 was discharged home from the positive COVID-19 unit. An interview was conducted with Nursing Assistant (NA) #21 on 03/14/21 at 2pm, she stated she had worked with Resident #311 on the COVID-19 hall during his stay at the facility. NA #21 stated the resident needed assistance with all his ADL's during his stay at the facility. She stated she was his NA the day he was discharged from the facility. NA #21 indicated the FM asked about Resident #311's condition and status due to being positive for COVID-19. NA #21 indicated Resident #311 was on the COVID-19 unit and she had to use full Personal Protective equipment (PPE) during care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Nurse #11 on 03/14/21 at 3:00 pm, indicated she worked on the unit with Resident #311 and discharged him. Nurse #11 stated she remembered this discharge because the family was upset about having to wait while they got the resident ready and out to their car. Nurse #11 indicated she was the only nurse on the COVID-19 unit that day and she had to complete her medication pass before completing the discharge for Resident #311. Nurse #11 indicated once we were outside with the family, she had no problem with the family. She stated she apologized to them for the wait and instructed the family on Resident #311's medication and what appointments he had if any. Nurse #11 indicated to the family she did not have or provide any information to the FM concerning Resident #311's COVID-19 status when he was discharged . 2, Resident #75 was admitted to the facility on [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly minimum data set (MDS) dated [DATE] for Resident #75 identified his cognition was moderately impaired, had not experienced any behaviors during the look-back period and received an anti-anxiety medication for 7 days during the look back period. A care plan with a revision date of 3/10/21 for Resident #75 stated he was at risk for adverse consequences related to receiving [CONDITION(S)] medication related to anxiety. Review of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . A phone interview was conducted on 3/9/21 at 10:49 am with Resident #75 ' s responsible party (RP). She stated the family had a care plan meeting over the phone with the facility on 2/22/21 and were informed the resident had been started on an antidepressant medication. The RP explained they had requested the facility to provide them with the contact information for the provider who had ordered the antidepressant so they could speak to them about the addition of the medication. She stated the facility refused to give them the providers contact information. Review of a progress note for Resident #75 dated 2/22/21 written by Social Worker (SW) #1 stated in part a care plan meeting was held via phone with the resident ' s family. The residents plan of care, medications, code status were reviewed, and questions / concerns were addressed. Review of a care plan conference summary dated 2/22/21 completed by SW #1 stated in part medications were reviewed with Resident #75 ' s family and they would like to speak with psych services. An interview on 3/11/21 at 12:15 pm with SW #1 revealed the facility had recently had a care plan meeting with Resident #75 ' s family over the phone. She stated she did not recall the family requesting any specific information regarding the addition of an antidepressant or that they requested the providers contact information. SW #1 stated the resident did have some behaviors of hollering out, but she did not feel they had worsened recently. She added she did not know why the resident had been started on the antidepressant, but she would find out. SW #1 also stated she did not think the resident was being seen by psych services. A follow-up interview on 3/11/21 at 2:20 pm with SW #1 revealed the resident had been seen by the psych Nurse Practitioner (NP) and they had ordered the antidepressant for Resident #75. A phone interview was conducted with the psych NP on 3/15/21 at 10:30 am. She stated she was familiar with Resident #75 and had been providing psych services for him. She explained the staff had reported the resident had low mood and outburst type behaviors and she had started the resident on an antidepressant several weeks ago. The NP stated she had not been notified by the facility that Resident #75 ' s family wanted to speak to her about his medications and she would follow-up on this. An interview on 3/16/21 at 10:50 am with the Administrator revealed he was not aware Resident #75 ' s family had requested the contact information for the psych NP to discuss his medications. He stated he expected the SW would have provided this to the family or would have notified the ps

Based on record review, family, and staff interviews, the facility failed to notify the resident's responsible party of the resident's discharge in writing for 1 of 3 residents reviewed for discharge (Resident #311) who were discharged from the facility to home. The findings included: Resident #311 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #311's admission Minimum Date Set ((MDS) dated [DATE] revealed the resident's cognition was severely impaired, and he was unable to make his needs known to staff. Resident #311 required extensive assistance to total dependence on staff for all his activities of daily living (ADL's). Resident #311 was always incontinent of bowel and bladder. Section Q (return to community) was not selected and indicated that neither resident nor family participated in the assessment. The MDS indicated the resident was to remain in the facility; answered yes for the discharge plan and that no referrals were needed. A review of Resident #311's care plan dated 08/16/20 revealed there was no discharge care plan for the resident. Review of a progress note, written by the Social Worker (SW) dated 08/28/20 at 11:24 am revealed a discharge care plan meeting was held with Resident #311's family via telephone conference. The resident was set to discharge home with home health on 8/31/2020 and would require 24/7 assistance at home. The resident was still having concerns with chewing and staying alert while eating. The resident required maximum 2-person assist with ADL care and would be sent home with home health, physical therapy (PT), occupational therapy (OT), speech therapy (ST), a home health aide (HHA) and durable medical equipment (DME) will be updated by therapy. Review of a physician's orders [REDACTED].#311 was to be discharged home with home health services including PT, OT, ST, and home health aide. A review of the discharge summary written by the Nurse Practitioner (NP) dated 09/01/20 revealed Resident #311 was seen today for discharge. The resident was admitted to the facility after hospitalized from [DATE] through 08/12/20 after presenting with malaise post-fall. COVID-19 test was positive in emergency room . The discharge summary note stated the PT note indicated the resident needed moderate assist with transfer to wheelchair and he was able to self-propel in the wheelchair. PT was unsuccessful in being able to advance the patient's ambulation. The resident would need to continue to work with PT and OT at discharge. Resident #311 was medically stable for discharge at this time with appropriate support system arranged for him at home with family. A review of the discharge summary from PT dated 09/01/20 indicated that Resident #311 was not able to be complete therapy and recommend 24-hour care at home with home health and support family/caregiver. A review of the discharge summary from OT dated 09/01/20 indicated that Resident #311 would be discharged home with family. Resident #311 still needed max assistance with all his ADL's. OT was recommended at discharge with home health services. Review of a progress note, written by the SW dated 09/03/20 (identified as a late entry) stated in part. Resident #311's discharge care plan meeting was held on 8/28/20 with the resident's family and discharge was set for 8/31/20. The family was given discharge options during this time, After the meeting the resident was set up with DME including a wheelchair, bedside commode, and hospital bed. The family was also informed the resident would require a medical transport home and this information was provided as well. The SW informed the family all discharge information would be available on day of discharge. The SW called family back to find out what day to set for discharge and informed the family again that co pays would begin. The family stated she still had not scheduled transportation and wasn't sure if family could pick him up on 9/1/20. The SW informed the family the facility business office would possibly call to collect 30 days of copayment upfront or family could provide the Medicaid information to business office. The family had previously stated the resident had Medicaid. The family called back to provide the Medicaid number, but did not set a discharge date . The family indicated they would call back to let us know about discharge plans. Admissions and SW informed the family on 8/31/20 and 9/1/20 that administrative staff leave the facility at 5:00 pm. The family stated the resident's primary care physician informed her the resident could stay at our facility for 2 months and would not have co pays. The family had been informed at their 72-hour meeting, discharge care plan and day of set discharge of co pays which she took note of. During an interview with a family member (FM) on 03/10/21 at 10:00 am they indicated Resident #311 was discharged home on[DATE] and was supposed to have home health services including home health aides, physical, speech and occupational therapy. During this interview the FM revealed the facility did not give her a discharge letter nor did the FM understand why Resident #311 was being discharged . She also indicated the doctor at the hospital told her Resident #311 would be in the facility for at least 2 months for rehab and short-term services, but the resident was only in the facility from 08/12/20 to 09/01/20. The FM stated the facility informed her if she didn't come and get Resident #311 that APS would be called. The FM indicated she had made several calls to the facility to check on the resident and no one would answer the phone. She added she got two phone calls from the facility during his stay: one about a fall on 8/28/20 and about the resident's discharge. The FM indicated the SW informed her of a copayment of $200 beginning on 08/28/20 if she did not come and get him. The FM stated she had told the facility they had no means of providing care and treatment for [REDACTED]. The FM indicated she had no knowledge of the letter and if we had knowledge of that information, we would have appealed that decision. The FM indicated the SW did not read any letter to her over the phone just told her that Resident #311 needed to be discharged today. The FM stated Resident #311 was very weak at discharge and two people had to help the family place him in the car. During an interview with the Business Office Manager (BOM) on 03/12/21 at 3:00pm the BOM indicated Resident #311's family did not receive any letter from the facility because he was discharged before his insurance coverage was completed. According to the BOM no letter was completed at the facility for Resident #311's family as the resident had a few more days of coverage left before his letter would be issued. An interview was conducted with the Administrator on 03/16/21 at 10:30 am who indicated it was the SW's responsible to plan for Resident #311's safe discharge and follow all the federal guidelines for this process. The Administrator indicated he was not aware of the family not receiving the letter and the SW not completing the referral to Home Health until after Resident #311 was discharged . The Administrator stated it was his expectation that referrals be made to Home Health services before any resident was discharged . BOM indicated he had few more days left.

Based on record review, staff interview and physician interview, the facility failed to develop a base line care plan for a resident who had multiple pressure ulcers for 1 of 3 residents (Resident #214) reviewed for pressure ulcers. Findings included: Resident #214 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #214's care plan dated 7-21-20 did not contain goals or interventions for the resident's pressure ulcer. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #214 was moderately cognitively impaired and was coded for four unstageable pressure ulcers. The MDS nurse#4 was interviewed on 3-10-21 at 1:26pm. The MDS nurse confirmed Resident #214 had multiple pressure ulcers upon admission to the facility. She stated she had missed the information on the hospital discharge summary and the facility admission documentation, so she did not add pressure ulcer treatments to Resident #214's base line care plan. During an interview with the facility's medical director on 3-11-21 at 8:15am, the medical director discussed the importance of having a treatment plan for residents and she stated it was improper for the facility not to have a plan of care developed for a residents wounds upon admission. An interview with the Director of Nursing (DON) occurred on 3-11-21 at 2:15pm. The DON stated he could not discuss why a baseline care plan was not developed for Resident #214's pressure ulcers but stated he expected the residents to be care planned according to the resident needs.

Based on record review and staff interviews the facility failed to develop an individualized and person-centered care plan that address Resident discharge for 1 of 3 residents (Resident #311) reviewed for discharged . Findings included: Resident #311 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #311's admission Minimum Date Set ((MDS) dated [DATE] revealed Resident #311's cognition was severely impaired, and he was unable to make his needs known to staff. Review of the Participation in Assessment section was not selected and indicated that neither resident nor family participated in the assessment. The MDS further indicated the resident was to remain in the facility. A review of Resident #311's care plan dated 08/16/20 did not include a discharge care plan. During an interview with the MDS Nurse on 03/15/21 at 11:00 am, the MDS Nurse stated that the Social Worker was responsible for developing the discharge care plan. During an interview with the Social Worker (SW) on 03/16/21 at 10:00 am, the SW indicated that Resident #311 was assigned to the former Social Worker, and believed it was an oversight. During an interview with the Administrator on 03/16/21 at 10:30 am, he indicated that it was his expectation for staff to develop a discharge care plan timely.

Based on record reviews, interviews with family, facility-staff, Nurse Practitioner, Physician and home health agency staff the facility failed to provide discharge planning process for discharge goals, needs and caregiver support for 1 of 3 residents (Resident #311) reviewed for discharge. The findings included: Resident #311 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #311's admission Minimum Date Set (MDS) dated [DATE] revealed Resident #1's cognition was severely impaired, and he was unable to make his needs known to staff. Resident #311 required extensive assistance to total dependence on staff for all his activities of daily living (ADL's). Resident #311 was always incontinent of urinary and bowel. Section Q (return to community) was not selected and indicated that neither resident nor family participated in the assessment. The MDS indicated the resident was to remain in the facility; answered yes for the discharge plan and that no referrals were needed. A review of Resident #311's care plan dated [DATE] revealed there was no discharge care plan for the resident. Review of a progress note, written by the Social Worker (SW) dated [DATE] at 11:24 am revealed a discharge care plan meeting was held with Resident #311's family via telephone conference. The resident was set to discharge home with home health on [DATE] and would require ,d+[DATE] assistance at home. The resident was still having concerns with chewing and staying alert while eating. The resident required maximum 2-person assist with ADL care and would be sent home with home health, physical therapy (PT), occupational therapy (OT), speech therapy (ST), a home health aide (HHA) and durable medical equipment (DME) will be updated by therapy. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #311 to be discharged home with home health services including PT, OT, ST, and home health aide. A review of the discharge summary written by the Nurse Practitioner (NP) dated [DATE] revealed Resident #311 was seen today for discharge. The resident was admitted to the facility after hospitalization from [DATE] through [DATE] after presenting with malaise post-fall. COVID-19 test was positive in emergency room . The discharge summary note stated the PT note indicated the resident needed moderate assist with transfer to wheelchair and he was able to self-propel in the wheelchair. PT was unsuccessful in being able to advance the patient's ambulation. The resident would need to continue to work with PT and OT at discharge. Resident #311 was medically stable for discharge at this time with appropriate support system arranged for him at home with family. A review of the discharge summary from PT dated [DATE] indicated that Resident #311 was not able to be complete therapy and recommend 24-hour care at home with home health and support family/caregiver. A review of the discharge summary from OT dated [DATE] indicated that Resident #311 would be discharged home with family. Resident #311 still needed max assistance with all his ADL's. OT was recommended at discharge with home health services. Review of a progress note, written by the SW dated [DATE] (identified as a late entry) stated in part. Resident #311's discharge care plan meeting was held on [DATE] with the resident's family and discharge was set for [DATE]. The family was given discharge options during this time. After the meeting the resident was set up with DME including a wheelchair, bedside commode, and hospital bed. The family was also informed that resident would require a medical transport, home and this information was provided as well. The SW informed the family all discharge information would be available on day of discharge. On [DATE] the family called the facility and stated they would like to pick up the resident due to medical equipment not being delivered due to rain. The SW confirmed with the medical supply company that equipment was delivered to the family on [DATE] and the wheelchair was delivered to facility on [DATE]. The writer called family back to find out what day to set for discharge and informed the family again that co pays would begin. The family stated she still had not scheduled transportation and wasn't sure if family could pick him up on [DATE]. The SW informed the family the facility business office would possibly call to collect 30 days of copayment upfront or family could provide the Medicaid information to business office. The family had previously stated the resident had Medicaid. The family called back to provide the Medicaid number, but did not set a discharge date . The family indicated they would call back to let us know about discharge plans. Admissions and SW informed the family on [DATE] and [DATE] that administrative staff leave the facility at 5:00 pm and she planned to call us before then to confirm discharge plans. No plans were confirmed by end of the day. SW received a call about 7:00 pm on [DATE] that the family was at the facility to pick up resident. The family stated the resident primary care physician informed her the resident could stay at our facility for 2 months and would not have co pays. The family had been informed at their 72-hour meeting, discharge care plan and day of set discharge of co pays which she took note of. The nurse was able to discharge resident and went over all the discharge paperwork and medications. The nurse also helped place the resident inside the family's van. Writer sent in residents' information to the home health company and reached out to his primary care physician to inform him of discharge and to reach out to family to follow up and continue therapy. The home health company reached out to family with no response. Home health will continue to attempt. Resident has appointment with primary care physician on [DATE] at 8:00AM. During an interview with the SW on [DATE] at 10:30 am, She stated the family was told about the appeal process on [DATE] and wanted to discharge Resident #311. She added she had read the letter to the family over the phone during the discharge meeting and the family got upset and indicated they did not want to appeal. The SW indicated she contacted the equipment agency and home health service company for Resident #311 and doctor had also completed the discharge paperwork for Resident #311. A follow up interview with the SW on [DATE] at 1:30 pm revealed she was unsure what day she made the referral for home health services for Resident #311. She was asked to provide the referral that she faxed to the home health agency. The SW provided the referral information and the date of the referral was [DATE]; the day after the resident was discharged home. During an interview with a family member (FM) on [DATE] at 10:00 am they indicated Resident #311 was discharged home on [DATE] and was supposed to have home health services including home health aides, physical, speech and occupational therapy. The FM revealed the facility informed them the home health company would contact them within 24 to 48 hours. The FM indicated no one came out to the home until [DATE] and Resident #311 never received any home health services only an evaluation. She also indicated the doctor at the hospital indicated that Resident #311 would be in the facility for at least 2 months for rehab and short-term services, but the resident was only in the facility from [DATE] to [DATE]. The FM stated the facility informed her if she didn't come and get Resident #311 that APS would be called. The FM indicated she had made several calls to the facility to check on the resident and no one would answer the phone. She added she got two phone calls from the facility during his stay: one about a fall on [DATE] and about the resident's discharge. The FM indicated the SW informed her of a copayment of $200 beginning on [DATE] if she did not come and get him. The FM stated that she had told the facility they had no means of providing care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The FM indicated she had no knowledge of the letter and if we had knowledge of that information, we would have appealed that decision. FM indicated that the SW did not read any letter to her over the phone just told her that Resident #311 needed to be discharged today. The FM stated Resident #311 was very weak at discharge and two people had to help family place him in the car. Family member indicated that we are not able to provide the care that Resident #311 needed at this time. A follow up interview with the FM on [DATE] at 9:00 am revealed Resident #311 never got any help from the home health services and indicated the facility did not have everything in place when Resident #311 was discharged home. Home health services were not in place and the FM explained the Home Health PT came and assessed the resident on [DATE] but that was the only time any home health visit was received. The FM indicated the facility knew that Resident #311 needed 24-hour care and that family could not provide this. An interview was conducted with the PT at 11:00 am who indicated the family requested for Resident #311 to be discharged home during the week on [DATE], PT stated that the SW indicated them of the family request. The PT indicated Resident #311 needed maximum assistance with all his ADL's and would need to have physical therapy in place at discharge. The PT revealed it would be the facility's responsibility to set up physical therapy services before Resident #311 was discharged and the facility SW would be the person to set up those services for the resident. The PT added Resident #311 was discharged home before his goals were met. An interview was conducted with the OT on [DATE] at 11:15 am, who indicated that Resident #311 needed maximum assistance with his occupational goals. The OT stated Resident #311 needed engagement to continue body movement for improved strength and range of motion. Resident #311 required 2-person maximum assist with his ADL's and 24-care care. The OT also indicated it was the facility's responsibility to set this service up for Resident #311 before discharging he home. Resident #311 was discharged before any of his goals were met. An interview with the Physician for Resident #311 on [DATE] at 9:30 am revealed she remembered Resident #311 during his admission, and he was admitted with COVID-19. She indicated the nurse practitioner conducted the discharge for Resident #311. She stated she expected the facility would follow up with any recommendation for therapies and services the resident needed before being discharged home. An interview was conducted with the Home Health Agency representative on [DATE] at 10:30 am. The representative stated they received a referral from the facility on [DATE] for Resident #311. The representative explained no home health services (PT, OT, ST, or home health aide) were provided to the resident after he was discharged home because he expired on [DATE]. Interview with the NP on [DATE] at 1:15 pm NP revealed she observed Resident #311 on his day of discharge, and he was up in his wheelchair in his room. She stated the resident was able to answer simple questions. The NP explained her discharge summary was based on other information noted in Resident #311's chart and the notes from PT and OT. The NP indicated she requested Resident #311 be discharged with home health aides, based on what the NAs charted, PT and OT goals and interventions they had put in place for Resident #311. She added the resident needed maximum assistance with all his ADL's. The NP also indicated that it was mainly the SW's job to set up the recommended home health services and medical transport when a resident was discharged . NP indicated she have expected the services that Resident #311 was ordered to be in place once he got home. An interview was conducted with the Administrator on [DATE] at 10:30 am, Administrator indicated that it was the Social Worker responsible to plan for Resident #311 a safe discharge process and follow all the federal guideline for this process. Administrator indicated that he was not aware of the family not receiving the letter and the SW not completing the referral to Home Health until after Resident #311 was discharge he indicated the expectation was that referrals be made to Home Health services before any resident was discharged .

Based on observations, record review, medical doctor, family and staff interviews the facility failed to protect 1 of 3 residents (Resident #11) from two injuries of unknown origin. The first injury resulted in a laceration to the right side of her head, an abrasion to her right check and bruises to her right shoulder and right knee. The second injury resulted in a laceration to the top left side of her head that required transfer to the emergency room (ER) and 4 staples to the [MEDICAL CONDITION]. Findings included: 1a. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's physician order [REDACTED]. Review of an Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 was rarely understood. Resident #11 needed extensive assistance of one person with bed mobility, eating, and personal hygiene. Resident #11 was totally dependent on one person's assistance for dressing, toileting and bathing. Resident #11 was always incontinent of bowel and bladder and no behavioral symptoms were identified on this MDS. Resident #11's care plan dated 4/23/2019 identified a problem with activities of daily living. Interventions included to provide assistance with activities of daily living, mobility and transfers as needed, to be careful not to overwhelm the resident and provide privacy and converse with the resident while giving care. During an interview with a family member (FM) for Resident #11 on 12/1/19 at 2pm, she revealed the resident had been in the facility since (YEAR). The FM indicated several months ago the resident received several injuries of unknown origin that she could not inflict herself. The FM revealed the resident had some bruises on her body and a laceration on her forehead. She added the injury on her forehead required treatment at the ER and staples to close the incision. The FM had concerns about how these injuries happened as the resident was not able to move and was nonverbal. Review of a nursing resident progress note, written by Nurse #7, dated 6/6/2019 at 11:12pm revealed a Nursing Assistant (NA) #20 called (Nurse #7) to Resident #11's room because she had an area on the right side of her face. This writer noted the resident had a small red open area to the right temple and a red area to her right upper cheek with a small indentation in center. The NA stated she did not notice it earlier when she fed the resident supper. NA #20 stated the resident was positioned on her back and the resident was currently lying on her left side. The resident's legs and arms were contracted. Nurse #7 documented in the progress note that Med Aide (MA) #21 noted, when she went in at 6:50pm to give Resident #11 her medications, her right hand was balled up beside the area and the hand was pressed against her face. Fingernails were at normal length but difficult to cut due to contracture on the hand. The nurse supervisor was called to assess the resident. The family was contacted and made aware. The nurse supervisor assessed the resident and the Director of Nursing (DON) was made aware and will continue to monitor the resident. The summary of investigation for injury of unknown origin for Resident #11 dated 6/13/2019 read Resident was assessed by the treatment nurse and RN supervisor when they were made aware of the injury. The DON assessed the resident upon report of incident. Family and Nurse Practitioner were notified immediately. The NA that took care of the resident and the MA that provided medication during the evening shift when the injury occurred were both questioned and statements were included. The LPN care coordinator, who first found the injury also was questioned and the statement was included. The NA that cared for the resident when the injury was found denied anything happened while she cared for the resident, but the injury occurred while she was on duty and providing care to the resident. The aide was suspended and then terminated on 6/11/2019. Family was informed of the outcome of the investigation. During an interview with Nurse #7 on 12/3/19 at 10am, she revealed she was the nurse on duty on 6/6/2019. She indicated she was called to the room by NA #20 who was assigned to Resident #11 that evening. Nurse #7 revealed she walked in the room and saw that Resident #11 had bruises and laceration on her right side. Nurse #7 stated that NA #20 raised her hands in the air and stated, 'I did not touch her' in a defensive tone. Nurse #7 revealed the resident was observed to have had a small red open area to the right temple. Right below the upper cheek was a red area with small indentation in the center. Nurse #7 also stated the resident had a bruise on her shoulder, hip and knee. Nurse #7 indicated she asked NA #20 if the resident had fallen and the NA stated no. Nurse #7 revealed this resident was not able to inflict on herself the injuries observed. She added she had been working with the resident for several years and the resident was not able to make her needs known to staff. Nurse #7 revealed Resident #11's hands were contracted and would not have been able to do injury to herself. Nurse #7 indicated she believed NA #20 caused Resident #11 to fall off the bed, put her back in bed and then called the nurse to the room. Nurse #7 indicated she called the director of nursing (DON) and Administrator with this information. She added due to this incident NA #20 was terminated because of this injury. NA #20 and MA #21 were called several times during this investigation and did not return the calls. An interview with NA #12 on 12/3/19 at 11am revealed she had only worked with Resident #11 a few times and to her knowledge this resident would not be able to inflict any of the injuries to herself. Review of a note from medical doctor (MD) dated 6/11/2019 at 11:24pm indicated the resident was seen on 6/11/19. On evaluation, the resident did not exhibit any sign or symptoms of pain. An abrasion was noted to the right side of her forehead and below her lower right eyelid. Unable to obtain any history from the resident due to her non-verbal status and Alzheimer Dementia. During an interview with the DON on 12/4/19 at 1pm she revealed during this investigation she was able to get statements from staff and all alert residents were interviewed. She stated no issues with abuse or mistreatment by staff were identified. The DON revealed the facility followed the state guidelines for reporting and investigation of injuries of unknown origin. DON indicated that she felt that NA #20 may have caused Resident #11 to fall off the bed and then placed her back in the bed and then called Nurse #7. However, the DON asked NA #20 the question and NA #20 denied it. DON also revealed that NA #20 was termination because she was the one that provided care for Resident #11 on 6/6/2019. 1.b Review of a quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #11 had moderately impaired cognition, required one-person assistance with bed mobility, transfers and locomotion, and required extensive one-person assistance with dressing, toileting and personal hygiene. Resident #11 was incontinent of bowel and bladder and no behavioral symptoms were identified on this MDS. A Review of Resident #11's nursing resident progress note, written by Nurse #7 and dated 9/28/19, indicated NA #11 came and informed this writer he noted the resident had some blood on her pillow. I noted the resident had some blood on her hair on top left side. I removed pony tail holder from her hair to further assess area. Noted that resident had a small gash to top left side of head. Called supervisor in to assess area. Supervisor assessed and called the on-call clinician for orders. New order received to send to ER for evaluation. Family called and made aware. Supervisor also called family and told them that 911 was called and resident was going to hospital. Resident left at 6:35pm. Review of the hospital record dated 9/29/2019 for Resident #11 revealed she was transferred from nursing facility for evaluation of a [MEDICAL CONDITION]. The resident was found at approximately 6:15 pm this evening with blood on her pillow and staff noticed a laceration to the left side of her head. The staff were unsure how the laceration occurred. The ER physician spoke with the facility nurse supervisor who stated the resident was not mobile and required assistance from staff to be transferred and there were no reported falls. The nurse supervisor stated the resident was last seen at about 4:30 or 5:00 pm when she was transferred from a chair into the bed. At that time, she had no evidence of laceration. The resident's family was at bedside, denied any blood thinner use and reported the resident was at her mental baseline. Physical exam revealed a 3-centimeter (cm) laceration to her head and received 4 staples to the [MEDICAL CONDITION]. The resident tolerated the procedure well and no other obvious injuries were noted on physical exam. A cat scan (CT) of the head was ordered and did not reveal any evidence of brain bleed. The resident was stable for discharge. A review of nursing resident progress note dated 9/29/19 at 1:03am stated the resident arrived back to the facility with a [DIAGNOSES REDACTED]. Resident was noted with staples to the left side of her head with instructions to apply [MEDICATION NAME] and [MEDICATION NAME] twice daily to area and staples to be removed in 5 to 7 days. Resident was provided care and placed comfortably in bed. Review of a physician progress notes [REDACTED]. The resident was sent to the ER for a scalp laceration; it was unclear how this happened. The resident's family expressed a concern that the resident may be in pain. The resident was seen yesterday by a team member who treated the resident with [MEDICATION NAME] 25 mg twice daily. She did receive [MEDICATION NAME] this morning, but she is non-verbal and difficult to evaluate. The staff reported no changes in the resident's baseline. The Hospice nurse had noticed a vague change yesterday that could have been pain. Resident appears to be tolerating the low dose of [MEDICATION NAME]. A review of the Report of Investigation of Resident #11 dated 10/4/2019 stated Resident #11 was admitted to facility on 3/22/2016 with admitting [DIAGNOSES REDACTED]. On 9/28/2019 Resident #11 was identified for an injury of unknown origin. Small traces of blood were noted on the resident's pillow while the NA was feeding her. Nursing supervisor assessed and found the resident lying in bed with small amount of blood in her hair. A small laceration was found on the top left side of the resident's head. Nursing supervisor cleaned the area with gauze and applied pressure. The nursing supervisor then notified the DON who instructed staff to transfer the resident to the ER for further evaluation. Prior to the resident being transferred to the ER, the DON and RN discussed the incident to identify what could have caused this injury of unknown source. The resident was unable to communicate and therefore was unable to indicate how this injury occurred. The DON walked through a comprehensive timeline of events and was unable to conclude at that time what could have caused this injury. The nursing supervisor contacted the family and the Administrator and 24 hour reportable was faxed. The facility began an immediate investigation. The NA that was responsible for taking care of the resident was removed from her assignment immediately. Resident #11 returned to the facility at 1:03 am. The resident returned with four staples in her head and new order to apply [MEDICATION NAME] and [MEDICATION NAME] twice a day and removal of staples in 5 to 7 days. The resident was placed comfortably in bed and vital signs were obtained. A Review of a form called, Summary of notification on Resident #11 injury of unknown origin, completed by the DON revealed, on 9/28/19 the RN supervisor called the DON to make her aware of a laceration on the top left side of Resident #11's head. The nurse reported that NA and Med Aide noticed a scant of blood on the resident's pillow. They notified the charge nurse to check the resident and when she did, she called the RN supervisor to see the resident immediately. After the RN supervisor checked the resident, she called the DON to notify her of the injury. The DON instructed the RN to notify the MD on call and call the responsible party (RP). Then the DON went through the resident's day to identify anything that may have caused the injury. The DON asked the RN multiple questions about the resident's activities throughout the day to see if something may have occurred. The DON also asked the RN to interview all the NAs that cared for the resident throughout the day. The DON instructed the RN to examine the bed, around the room, the Geri-chair, and the resident's fingernails to see if there was any additional blood on these items. RN also informed the DON the resident was out of bed in a geri-chair most of the day, and the shift NA reported combing the resident' hair and putting it in a bun on top of her head and there was no injury on her head at that time. The evening NA reported he was feeding the resident when the med aide MA#10 came in and saw the blood on the pillow but did not see any injuries. RN was then instructed to send the resident to the ER for care and treatment of [REDACTED]. The DON also instructed the RN to begin the 24-hour abuse investigation and fax to the registry as soon as possible to comply with the 2-hour requirement. The DON then notified the administrator of the reportable injury and instructed him of what was done. It was also noted that Resident #11's roommate was unable to communicate event in question due to her dementia and cognitive status. The facility did move the roommate of Resident #11 to another room while the investigation was on-going. It was stated based upon resident and staff interviews as well as there were no staff members identified or accused, the facility was unable to substantiate that abuse to Resident #11 occurred. The facility did recognize that an injury did occur but was unable to ascertain how Resident #11 received it. Due to Resident #11's dementia and Alzheimer's, she was unable to communicate how she sustained the laceration. Upon review of facility fall logs Resident #11 did not have any reported falls that could have caused this injury. A review of form called Report of Investigation dated 10/4/2019 revealed on 9/30/19 the facility began to interview alert and oriented residents to identify if they saw any abuse or mistreatment of [REDACTED]. There were no negative responses to indicate that they were abused, saw any abuse or knew of any abuse. The Facility Social Workers and other personnel were responsible for completing this task. The Administrator and Nurse Consultant began to interview staff. Floor staff, Dietary staff, Housekeeping and Therapy Staff were all interviewed and questioned to identify if they had any knowledge of how Resident #11 received this injury of unknown source, if they knew how could it have happened and if they knew how to report abuse and injury of unknown origin. There were no negative results or conclusive comments that indicated anyone had any knowledge of the event in question. No staff members interviewed knew anything about the injury or saw anyone abuse Resident #11. The Staff Development Coordinator initiated abuse education and reporting standards to also include injury of unknown origin on 9/30/19 and was completed on 10/3/19. All staff members were given this education. During an interview with Nurse #7 on 12/3/19 at 9:45 am she revealed she was also working the evening of 9/28/19. Nurse #7 revealed she called Nurse #8 to come and assess the resident. Nurse #7 indicated that she and other staff member looked in Resident #11's room for any items that would have caused this injury to her head. Nurse #7 did recall the resident's roommate was not in the room during the time the NA was feeding this resident. Then the med aide came in to give Resident #11 her medication and that was when they saw the blood on her pillow. Nurse #7 indicated she pulled the resident's hair back and noted a small gash/laceration with bright red blood around the area. She stated she called Nurse #8 who spoke with both NA #11 and MA #10 and then called the DON and Administrator. Nurse #7 stated EMS was called, and the resident went to the ER. Nurse #7 revealed that Resident #11 and her roommate had been together for close to two years. Nurse #7 also revealed this was the second injury of unknown origin and Resident #11 did not have the ability to inflict the injuries to herself. She added the resident could not reach out to her head, face or any part of her body. An observation of Resident #11 on 12/3/19 at 10:30 am revealed the resident was in bed facing the window in her room. Resident #11 was not able to answer any questions. Resident #11 was observed being transferred from the bed to a chair on 12/3/19 at 10:45am. The resident was transferred using a mechanical lift and no sharp objects were observed on or around the lift. During an interview with NA #10 on 12/4/19 at 11am, she revealed she did not recall having Resident #11 on 9/28/19 but she observed her during the day and the resident was up in her Geri-chair and no concerns were observed. NA #10 stated she had Resident #11 the day before that incident and provided care as normal. NA #10 indicated she would give Resident #11 a bath and get her up in her Geri-chair with a lift and a second staff person and assist the resident with eating. NA #10 revealed that Resident #11 required total care and she could not do anything for herself. NA #10 also indicated that hospice was present some days to help her with Resident #11. NA #10 stated she would position the resident with pillows in her chair and bed to help her be safe during the day. The NA who was assigned to Resident #11 during the morning shift on 9/28/2019 was called, but he never returned the calls. The Administrator was requested during the survey to contact him as well and no returned calls were received. During an interview with NA #11 on 12/4/19 at 11:45am, he revealed he was assigned to Resident #11 on 9/28/2019 during the 3pm to 11pm shift. NA #11 stated he believed he was late that day and when he got to work Resident #11 was already in bed. NA #11 remembered going to Resident #11's room to assist her with eating. NA #11 also stated that Resident #11's hands were contracted, and she would not be able to scratch or put an incision on her head. NA #11 revealed that other staff reported the resident had fallen off the bed, but when you positioned her right she would stay in place. NA #11 indicated he did not know how the incident happened to the resident. NA #11 added the MA was the one who identified that there was blood on the pillow and in her scalp and they reported this information to the Nurse. During an interview with MA #10 on 12/4/19 at 1pm, she revealed she was working with Resident #11. MA #10 stated she arrived in Resident #11's room and NA #11 was assisting the resident with her dinner. MA #10 explained she noticed a substance on the pillow that appeared to be dried blood. She added a substance in Resident #11's hair appeared to be blood and was dry and some was fresh. MA #10 indicated she called the charge nurse who came in the room and observed the blood and she requested the nurse supervisor to come and assess the resident. An interview with the Medical Doctor (MD) on 12/5/19 at 11am revealed she had examined Resident #11 after both injuries of unknown origin. The MD stated due to the resident's health condition she was not able to tell the staff what happened. The MD indicated she believed the facility investigated the incident but had not been able to determine what caused the laceration to her head. The MD explained that due to her history and diagnoses, the resident would not be able to inflict the injuries to herself because of contracture to both hands. The injuries would be very difficult to self-inflict. The MD added the resident's family and hospice had concerns the resident was in pain after this last incident and [MEDICATION NAME] 25 mg BID was now given for pain. During an interview with Nurse #8 via phone on 12/11/19 at 10:46am, Nurse #8 revealed she only worked at the facility on the weekend and she was the Nurse that assessed the resident before she was sent to the ER. Nurse #8 explained she was called to the room by the charge nurse on that side of the facility to assess a resident who had a head injury. Nurse #8 stated she arrived at Resident #11's room and observed blood on the pillow and some blood coming from the left top side of her scalp. She added the resident's hair was matted to her scalp with a substance that appeared to be dry blood. Nurse #8 stated she applied pressure to the site and then called the DON, MD on call and the residents' family. During an interview with DON, Administrator and Corporate Nurse on 12/4/19 at 1:30pm, the Administrator indicated the facility followed the regulation for abuse with reporting and investigation of any allegation, injury of unknown origin for Resident #11. He added we educated all staff, interviewed all alert residents and corporate staff assisted with the investigation. The DON stated the staff who had the resident during the incident of 6/6/19 were terminated. During the investigation of the 9/28/19 incident, no staff indicated harm to Resident #11. The Administrator stated that the facility following the regulation and through investigation of the incidents. He added based on resident and staff interviews as well as no staff member was identified or accused, the facility was unable to substantiate that abuse had occurred to Resident #11. He stated the facility did recognize that two injuries did occur, but they were unable to ascertain how Resident #11 received them and because of her dementia she was unable to communicate how these injuries occurred.

Based on record review, staff, physician and pharmacist interviews the facility failed to administer a topical compound medication of [MEDICATION NAME] and [MEDICATION NAME] (ABH) according to the physician ordered dose and route for one of four sampled residents. (Resident #1) Resident #1 received [MEDICATION NAME] 10 milligrams (mg), [MEDICATION NAME] 250 mg and [MEDICATION NAME] 10 mg orally instead of the physician ordered dose of [MEDICATION NAME] 1 mg, [MEDICATION NAME] 25 mg and [MEDICATION NAME] 1 mg topically. : Resident #1 was found to be lethargic and unresponsive on [DATE]. Resident #1 was transported to a local emergency room and admitted to the hospital with [REDACTED]. The findings included: Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 14- day Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 had severe impairment with short and long- term memory, required extensive assistance of one staff for eating, was total assistance with toileting, and extensive assistance of two staff for bed mobility and transfers. This MDS indicated he had no behaviors and no complaints of pain. Review of the primary physician ' s progress notes dated [DATE] indicated he had Alzheimer ' s dementia with behavioral disturbance. Recommendations were to provide supportive care, get palliative care consult, continue [MEDICATION NAME] (a medication used to treat Alzheimer ' s disease) for now and [MEDICATION NAME] (an antipsychotic medication) at bedtime. The psych consult progress notes dated [DATE] indicated Resident #1 had a [DIAGNOSES REDACTED]. The recommendations: included in part, multiple medical issues and [MEDICAL CONDITION] exhibiting labile/irritable mood, distress with anxiety and paranoia impairing function, care and safety . The telephone order, written by the psych nurse practitioner, dated [DATE], included ABH gel (1:25:1mg) milliliter (m) topically 1 ml twice a day for anxiety and paranoia. ABH gel is a topical compounded medication of [MEDICATION NAME] (an antianxiety medication), [MEDICATION NAME] (an [MEDICATION NAME]) and [MEDICATION NAME] (an antipsychotic medication). Review of the Medication Administration Record [REDACTED]. The instructions on the MAR indicated [REDACTED]. The times of administration were at 8 AM and 8 PM. The 8 PM dose on [DATE] was held due to lethargy per nursing documentation on the MAR. Resident #1 also received [MEDICATION NAME] 50 mg every night at 9:00 PM. Review of the (MONTH) MAR indicated [REDACTED]. Further review revealed a Finger Stick Blood Sugar (FSBS) was obtained at 12:00 PM and was 112 and no Insulin was required to be administered per the sliding scale orders. Other medications administered after the morning medication pass included Tylenol (an [MEDICATION NAME]) 325 mg 2 tabs, [MEDICATION NAME] (a diuretic) 40 mg 1 tab, [MEDICATION NAME] (an antibiotic) 500 mg 1 tab and [MEDICATION NAME] (a drug to treat reflux) 40 mg 1 tab. Review of the Medication Error Report dated [DATE] revealed Nurse #1 administered the entire contents (10ML) of the ABH orally to Resident #1 at 10:00 AM. The report indicated the error was found during the first to second shift narcotic count. The Assistant Director of Nursing (ADON), Director of Nursing (DON) were notified of the error. The on-call physician was notified by Nurse #1 at 3:45 PM of the error. Resident #1 was assessed and found to be lethargic with poor response to verbal or physical stimuli. The on-call physician gave orders to send the resident to the local emergency room for evaluation. Per the written statement of events dated [DATE] by Nurse #1, vital signs were obtained at 4:00 PM on [DATE] and were as follows: blood pressure ,[DATE], pulse 63, respirations 18 and oxygen saturation 93% on 2 liters/min of oxygen. Per the Emergency Management Service ' s (EMS) report log dated [DATE] they arrived at 4:15 PM and left for the hospital at 4:20 PM. The vital signs by EMS at 4:20 PM were Blood Pressure ,[DATE], pulse 70 and respirations 18. EMS documented Resident #1 would respond to painful stimuli only. EMS arrived at the hospital at 4:43 PM on [DATE]. Review of the hospital admission documentation, Resident #1 was seen at (name of hospital) in the emergency room . On arrival to the emergency department, per the physician ' s admission note on [DATE] at 5:15 PM, Resident #1 responded briefly to sternal rub and would shake his head for yes/no. The Poison Control Center was called on [DATE] at 5:30 PM and recommended to provide supportive care and assess the resident. According to the hospital admission documentation records, Resident #1 remained in the hospital acute on chronic [MEDICAL CONDITION] and left side pleural effusion, [MEDICAL CONDITION] and questionable aspiration pneumonia. The white blood count (WBC) was elevated above normal indicating an infection was present. Further review of the hospital emergency room physician notes revealed the plan and assessment included: 1. Accidental overdose, Poison Control had advised monitoring and supportive care, Patient was protecting his airway on admission, but in some respiratory distress with increased O2 (oxygen) requirement. Plan to continue telemetry monitoring with supportive care. 2. Acute on chronic hypoxic [MEDICAL CONDITION], Patient required 2 Lpm (liters per minute) supplemental O2 at baseline. He is in respiratory distress on admission requiring 4 Lpm via nasal cannula in emergency department (ED). Chest X-ray with moderate to large left sided effusion, rhonchi bilaterally on auscultation and concern for aspiration clinically. He also has chronic [MEDICAL CONDITIONS] with preserved EF (Ejection Fraction) and was given 40 mg IV (intravenous) [MEDICATION NAME] 1 time in the ER. Suspect the effusion and possible aspiration to be responsible for the acute [MEDICAL CONDITION]. 3. Pleural effusion, left, moderate to large left pleural effusion noted on admission chest X-ray and patient has increased supplemental O2 requirement and is in mild distress. Resident #1 had 7 additional areas of concern and treatment management. These areas were Chronic diastolic [MEDICAL CONDITION], Chronic [MEDICAL CONDITIONS], OSA (Obstructive Sleep Apnea), [MEDICAL CONDITION], Insulin Dependent Diabetes, Chronic wounds, and agitation. Per interview with the DON on [DATE] at 10:00 AM, Nurse #1 informed her of the medication error and assessed Resident #1. The resident was lethargic and difficult to arouse. Interview with the pharmacist at the facility contracted pharmacy on [DATE] at 2:12 PM revealed the compound of the medications was made with the medication tablet(s) and compounded in a gel. The medications would be absorbed, but at a slower rate than if administered topically. He explained it would be absorbed slower, delayed and at a reduced amount when given orally. The pharmacist explained the packaging had a red sticker with a label that informed the nurses the gel was for external use only. Interview with Nurse #1 on [DATE] at 1:16 PM revealed on [DATE], this was her third day of orientation as the floor nurse. She did the medication pass on Resident #1 ' s hall independently. She explained she had not worked on his hall, and the residents were new to her. During the med pass, Nurse #1 obtained the prefilled syringe containing the ABH gel from the medication refrigerator. She explained she did not see a route for the medication on the MAR. The instructions were to apply 1 ml of the ABH gel. Nurse #1 explained she had not given this medication topically before, but had given it orally. She did not realize it was 10ml and not 1 ml. Nurse #1 gave the entire contents (10 ml) orally to Resident #1. During her shift, Nurse #1 explained she did a blood sugar check at 12 noon, and gave afternoon medications to him around 1:30 PM. At each visit with the resident, he was alert, verbal and sitting up. During the narcotic count at the end of the shift, the second shift nurse asked why the count was not correct. It was at that time, Nurse #1 realized she had given 10 ml and not 1 ml. Nurse #1 explained she informed the Assistant Director of Nursing and called the on- call physician. Interview with Nurse #2 on [DATE] at 3:30 PM revealed she usually worked on Resident #1 ' s hall. Nurse #2 detailed the events of [DATE] as follows: She came to work at 3:00 PM, Nurse #1 gave her shift report and then the narcotics were counted. During the narcotic count, she realized the ABH gel count was not correct. At that time, she explained to Nurse #1 the dose was 1 ml and the syringe was a 10 ml, multi-dose syringe. Nurse #2 went to Resident #1 ' s room to do an assessment. Upon entering his room, he was lethargic, in a deep sleep and not waking up when his named was called or she shook him. The estimated time of the assessment was around 3:30 PM. Nurse #1 notified the ADON and the on call physician. Nurse #2 prepared the paper work to send the resident by EMS to the emergency room . Nurse #2 explained her method of administration of the ABH gel included putting 1 ml of the gel in a medication cup, locking the multi-dose syringe up and taking the medication cup to the room to apply it to his skin. Interview with the primary physician on [DATE] at 10:35 AM revealed she was made aware of the medication error on [DATE]. The on call physician was notified and gave orders to send to the emergency room . During the interview she explained she would not be able to say the overdose led to his death. She would need to read the hospital records to see the course that was taken at the hospital. From his records up to the day of discharge, he had an infection that was not responding (wound) and he may have developed an acquired infection on top of his existing infection. With multiple antibiotic usage, his immune system was compromised. With additional testing that may have been completed at the hospital, the records would give a better indication of his prognosis. The ABH gel would not have the same effect orally as topically, due to the compound was made to be absorbed topically. It would have some effect, but the total effect would be unknown. The resident was referred to palliative care at the facility and was seen on [DATE]. The palliative care notes indicated his wounds would become worse, even with antibiotic treatment. The resident had vascular problems which also hindered the healing process. When asked what would supportive care and monitoring mean to her, she explained it would be supportive for respiratory, cardiovascular and neurological. The resident would be assessed for respiratory depression, low blood pressure and neurological changes. On [DATE] at 11:09 AM the medical examiner was interviewed via telephone regarding Resident #1. The resident had expired on [DATE] at the hospital. She said the death happened after 14 days of the drug overdose. She said Resident #1 ' s case was referred to the medical examiner office because it was a drug overdose and it might be the policy of the hospital to refer the case to the medical examiner if there is a drug overdose. She said the investigation just started since they got the referral 4 days ago and they do not have results of the toxicology. But in her opinion, it is going to be difficult to prove that the drug overdose had contributed to the death because of the lapse of time between the overdose and the date of death . The medical examiner will do a toxicology test (which she is not expecting that there will conclusive results), they will do an autopsy and they will read the resident ' s medical records, then they will make a decision. The policy for Administering Medications dated ,[DATE] included in part: 3. Medications must be administered in accordance with the orders, including any required time frame. 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 26. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. 27. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned. Interview with the Administrator and the DON on [DATE] at 10:00 AM revealed a plan of correction was instituted on [DATE] after Resident #1 was transported to the hospital. In-service regarding the 6 rights of medication administration was given to Nurse #1, a statement of the events surrounding the medication error was provided and an investigation was initiated using root cause analysis. Nurse #1 was suspended pending outcome of the facility investigation. They explained Nurse #1 had the support of the charge nurse for her hall, the ADON and supervisor were also available. During the interview, the DON explained the packaging of the ABH gel had a red sticker with instructions the medication was for external use only. In-services for all nurses and medication aides began on [DATE] and was completed on [DATE]. Assessments of all residents was completed on [DATE] by the nursing administration that received [MEDICATION NAME] or ABH gel medications. There were no negative findings. There were 3 residents (Residents 4, 5 and 6) who had orders for that type of medication. Pharmacy was informed the labels for gel compounds would require the word topical on the label and to send single use syringes instead of multi-dose syringes. The narcotic storage unit was checked for the new labels for Residents #4, 5 and 6. The syringes were single dose with the label using the word topical provided by the pharmacy. Red stickers indicating the medication was For External Use Only was present on the packaging. Audits were present beginning [DATE] of new medication orders and continued a weekly basis. The facility obtained compliance as of [DATE]. The facility plan of correction was as follows: Preparation and or execution of this plan does not constitute admission or agreement by the Provider of the truth of facts alleged or conclusion set forth on the statement of deficiencies. The plan is prepared and executed solely because it is required by the provisions of State and Federal law. Resident was admitted to the facility [DATE] with dx that included Left foot diabetic ulcer [MEDICAL CONDITION], muscle weakness, [MEDICAL CONDITION], anxiety and paranoia. Resident had a fall [DATE] resulting in a fracture to his right shoulder, Resident was readmitted [DATE] and continued to receive therapy services. Resident physician orders [REDACTED]. On [DATE] at 3:30 pm nurse reported administering 10ml of ABH gel to resident by mouth. The resident was assessed by attending nursing staff and was noted to have decreased level of consciousness. The physician was notified regarding the error and current resident assessment and gave new orders to send the resident to ER for further evaluation. Resident RP notified. The resident left the facility via EMS at 4:05 pm. Resident was admitted to the hospital on [DATE]. The medical examiner contacted administrator on [DATE] indicating that the resident had expired on or about [DATE]. The administrator sent the medical examiner additional information from the resident medical records as requested. As of [DATE] the cause of the resident ' s death is still pending. The nurse was immediately interviewed regarding the medication error. The nurse stated that she thought the syringe provided for the resident was a 1ml syringe. The root cause of the medication error was determined to be failure of the nurse to adhere to the six rights of medication administration. The nurse administering the medications was on her third day of a five-day orientation plan. The medication label did include a warning that stated for external use only. The instructions on the medication label stated to apply, however the instructions on the medication label did not specify the route of administration. The nurse administering incorrect dose of ABH gel was educated [DATE] by the director of nursing regarding the six rights of medication administration to include: 1) verification the correct medication is being administered 2) Verification of the dosage being administered 3) Verification the correct resident is receiving the medication 4) Verification the medication is being administered at the correct time and 5) verification the medication is being administered the correct route, and 6) Verification the medication administration is correctly documented. Education was also specific to include instructions for the nurse not to administer the medication if any of the six routes are not included in the administration instructions and to seek further clarification from pharmacy, nurse supervisor or physician. Nurse completing the medication error was suspended pending investigation on [DATE]. Nurse completing the medication error never returned to the facility to determine any subsequent personnel action. Beginning [DATE] and ending [DATE], the staff development nurse, DON or RN supervisor educated 100% nurses and medication aides regarding the six rights of medication administration. This education included; 1) verification the correct medication is being administered 2) Verification of the dosage being administered 3) Verification the correct resident is receiving the medication 4) Verification the medication is being administered at the correct time and 5) verification the medication is being administered the correct route, and 6) Verification the medication administration is correctly documented. Education was also specific to include instructions for the nurse not to administer the medication if any of the six routes (rights) are not included in the administration instructions and to seek further clarification from pharmacy, nurse supervisor or physician. On [DATE] the director of nursing clarified physician order [REDACTED].>ABH ([MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME]) GEL (1:25:1 MG/ML) APPLY 1ML BID FOR ANXIETY/PARANOIA to ABH ([MEDICATION NAME]/ [MEDICATION NAME]/ [MEDICATION NAME]) Gel (1:25:1 MG/ML) Apply 1ml BID topically to bilateral arms alternating sites for anxiety/ paranoia. On [DATE], the director of nursing services, SDC, and ADON conducted 100% audit of all orders for medications applied topically to ensure the route is indicated in the physician order [REDACTED]. Starting on [DATE] the pharmacy repackaged all [MEDICATION NAME] gel and ABH gel, to 1ml unit dosing. The facility has no other multi dose medications that are provided by the pharmacy in a syringe. Any staff not in-serviced by (MONTH) 30, (YEAR) did not work until in-servicing was completed by Director of Nursing, Staff Development Coordinator/Assistant Director of Nursing, RN Nurse Manager, with inservicing 100% complete on [DATE]. All New admission orders [REDACTED]. All new orders for the previous day are verified by the Nurse Administration Team including the Director of Nursing, Staff Development Coordinator/Assistant Director of Nursing, Treatment Nurse, and RN Nurse Managers in the morning clinical quality meeting which is held five times weekly. New orders received on Friday, Saturday and Sunday are reviewed for accuracy by the Nurse Administration Team including the Director of Nursing, Staff Development Coordinator/Assistant Director of Nursing, Treatment Nurse, and RN Nurse Managers each Monday. On (MONTH) 30, (YEAR), all residents receiving prescription [MEDICATION NAME] or ABH gel were assessed by the Director of Nursing, Staff Development Coordinator, Assistant Director of Nursing, and Unit RN Manager for level of consciousness with no abnormal findings. The Administrator, Staff Development Coordinator/Assistant Director of Nursing, Regional Clinical Manager, and IDT Team updated a Facility Self-Assessment Tool and a QAPI Self-Assessment Tool on (MONTH) 30, (YEAR) to ensure the facility had resources and systems in place to efficiently attain the highest practicable physical, mental, and psychosocial well-being of each resident. Administration has been integrally involved in developing the policies and procedures described above with respect to this incident. Administration has reinforced to all staff the expectation of adherence to all policies and procedures described above. Administration is actively committed to creating and maintaining a culture of compliance within the facility, including but not limited to being free of significant medication errors. It has been reinforced to all staff that any incidents of actual or suspected medication errors be reported directly to the administrator, Director of Nursing, or Assistant Director of nursing immediately. Staff development coordinator will conduct medication pass audits five times weekly starting [DATE] for twelve weeks. Findings of these audits will be presented in the Quality Assurance Performance Improvement Meeting for a minimum of three consecutive meetings and ongoing as indicated. The Regional Clinical Manager will review the daily clinical meeting documentation and review of order transcription verification weekly for four weeks, monthly for three months and ongoing as indicated. Findings of these audits will be presented in the Quality Assurance Performance Improvement Meeting for a minimum of three consecutive meetings and ongoing as indicated. Validation of the allegation of compliance was conducted on [DATE] at 3:00PM. Residents # 4, 5 and 6 were added to the sample for record review. Record review revealed orders for gel compound medications included the word topical. Review of the in-service training revealed staff were in serviced on the 6 rights of medication administration, with instructions on how to handle situations if any of the 6 rights were missing. Interviews of staff working ,[DATE] and ,[DATE] shifts revealed they had received the in-service training, knew the 6 rights of medication administration and what to do if any of the 6 rights were missing. There were no new hires for licensed nurses since [DATE]. Review of the audits for medication orders was found to be completed and on-going. Review of the medication pass audits were completed and on-going.