Every finding on record at Capital Nursing and Rehabilitation Center

Based on record review, and staff and Consultant Pharmacist interviews, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving an antipsychotic medication, which is used for medication monitoring of side effects of antipsychotic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #82).The findings included:Resident #82 was admitted to the facility on [DATE] with diagnoses which included vascular dementia without behavioral disturbances.The Mental Health and Antipsychotic Review (which included the AIMS assessment) completed on 12/26/24 revealed Resident #82 had no negative findings related to the use of antipsychotic medication and was categorized as low risk for movement disorders.The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #82 had severe cognitive impairment and was coded for the use of antipsychotic medication.The care plan last reviewed on 6/27/25 revealed Resident #82 received antipsychotic medications with risk for adverse side effects with interventions which included performing an AIMS every 6 months.A current physician order dated 8/05/25 quetiapine fumarate 50 mg tablet; give 1 tablet by mouth every morning and at bedtime for dementia with psychosis. Further review of the physician orders indicated the resident was restarted on quetiapine fumarate on 5/09/25 after discontinuation of the medication in January 2025.A review of Resident #82's medical record on 8/05/25 revealed the facility had not completed an AIMS for the antipsychotic medication when the order was initiated on 5/09/25 and had not completed an AIMS to date.Review of the Consultant Pharmacist's Medication Regimen Review report dated 8/05/25 revealed the facility was notified that a Mental Health and Antipsychotic Review (formally the AIMS assessment) has been completed every 6 months since the patient was on the following therapy: quetiapine.A telephone interview was conducted on 8/06/25 at 4:49 pm with the Consultant Pharmacist who revealed that when a resident was prescribed an antipsychotic medication an AIMS assessment was required upon starting the medication for a baseline assessment and every 6 months thereafter for monitoring. The Consultant Pharmacist stated the facility was responsible for completing the AIMS assessment, but she stated she would notify the facility from the medication regimen reviews when she identified that the AIMS assessment was not completed. The Consultant Pharmacist stated that she did review Resident #82's medical record during the monthly pharmacy review and she did notify the Director of Nursing (DON) and Administrator on 8/05/25 to make sure an AIMS was completed for Resident #82's quetiapine.An interview was conducted on 8/07/25 at 11:35 am with the DON who revealed the previous AIMS assessment had been changed to the new Mental Health and Antipsychotic Review and she believed that due to that change, the AIMS assessment did not trigger to be completed for Resident #82's quetiapine order and it was missed.During an interview with the Administrator of 8/07/25 at 12:02 pm he revealed that due to the new Mental Health and Antipsychotic Review being implemented recently it may have caused Resident #82's AIMS assessment not to be triggered when it was due.

Based on observation, record review, and resident and staff interviews, the facility failed to consistently complete a thorough weekly pressure ulcer assessment that included the type of injury (pressure versus non pressure), pressure ulcer stage, a description of the pressure ulcer characteristics, presence of pain, and description of dressing or treatment for 1 of 2 residents observed for pressure ulcers (Resident #3). The findings included:Resident #3 was admitted to the facility on [DATE] with diagnoses which included functional quadriplegia and cerebral palsy. The Weekly Pressure Ulcer Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had one unhealed pressure ulcer to the sacrum, not staged, with measurements of 1 centimeter (cm) x 1 cm x 0.1 cm (length x width x depth). The wound bed was noted to have 100% granulation (new tissue that forms on the wound during healing process) tissue, with no odor. Resident #3 had a physician order in place dated 5/08/25 to apply zinc to the right buttock every day and evening shift for wound care. The Treatment Administration Record (TAR) May 2025 through August 2025 was reviewed and revealed Resident #3's treatment order to apply zinc to the right buttock every day and evening shift was completed as ordered. Resident #3 had a care plan last reviewed on 5/11/25 for risk for pressure ulcer development, current pressure ulcer to right buttock and risk for development of additional pressure ulcers. The care plan had interventions which included administer treatments as ordered and monitor for effectiveness, low air loss mattress, and to consult wound physician as needed and/or ordered.The Weekly Pressure Ulcer Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had one unhealed pressure ulcer to the sacrum; the wound was not staged. The wound measurements were 1 cm x 1 cm x 0.1 cm. The wound bed was noted to have 100% granulation tissue, light exudate (fluid that leaks out of blood vessels), with redness noted and no odor. The assessment also noted that the area was macerated (skin that softens and breaks down due to prolonged exposure to moisture) with bright red excoriation (break in the skin's surface) noted. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #3 was cognitively intact, was dependent of staff for activities of daily living (ADLs), and had an indwelling urinary catheter and colostomy related to bowel and bladder management. Resident #3 was coded for a pressure ulcer Stage 3 which was noted as present on admission or readmission. Resident # 3 was coded for pressure reducing device for the bed, pressure reducing device for the chair, and pressure ulcer care.The Weekly Pressure Ulcer Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had one unhealed pressure ulcer to the left and right buttock, Stage 3 with measurements of 1 cm x 1 cm x 0.1 cm. The wound bed was noted to have 100% granulation tissue, with surrounding tissue noted for redness. The assessment further noted the area was macerated with bright red excoriation noted. The Weekly Pressure Ulcer Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had one unhealed wound to the sacrum, pressure. The stage was noted as N/A (non-applicable), with measurements of 1.5 cm x 1.8 cm x 0.2 cm. The pressure ulcer was noted to have 50% granulation tissue and redness noted. Intact area of pressure due to damage of underlying soft tissue from moisture and pressure. The wound was noted as not painful, but firm as compared to adjacent tissue.The Weekly Pressure Ulcer Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had one unhealed wound to the right buttock, the stage was noted as pressure/denuded (skin injury where the outermost layer of skin is lost) with measurements of 1.5 cm x 1.8 cm x 0.2 cm. The wound bed was noted to have 100% granulation tissue. Intact area of pressure due to damage of underlying soft tissue from moisture and pressure. The pressure ulcer was reported as not painful, but firm as compared to adjacent tissue with a treatment of zinc daily post every brief change and bath for all shifts.The Weekly Pressure Ulcer Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had one unhealed pressure ulcer to the right buttock with measurements of 1.5 cm x 1.8 cm x 0.2 cm, the Stage was noted as N/A pressure/denuded. Intact area of pressure due to damage of underlying soft tissue from moisture and pressure. The pressure ulcer was reported as not painful, but firm as compared to adjacent tissue. The wound bed was noted to have 100% granulation tissue with a treatment of zinc daily post every brief change and bath for all shifts. The Weekly Pressure Ulcer Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had one unhealed pressure ulcer to the right buttock with measurements of 1.5 cm x 1.8 cm x 0.1 cm. The Stage was noted as N/A pressure/denuded. Intact area of pressure due to damage of underlying soft tissue from moisture and pressure. The pressure ulcer was reported as not painful, but firm as compared to adjacent tissue with a treatment of zinc daily post every brief change and bath for all shifts.The Weekly Wound Non-Pressure Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had a denuded area to right buttock. No further information was noted.The Weekly Wound Non-Pressure Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had a denuded area to right buttock. No further information was noted.The Weekly Wound Non-Pressure Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had a wound to the left and right buttock. No further information was noted related to the wound. The Weekly Wound Non-Pressure Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had a wound to the left and right buttock. No further information was noted. The Weekly Wound Non-Pressure Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had a wound to the left and right buttocks which measured 2.5 cm x 3 cm with no further information noted.The Weekly Wound Non-Pressure Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had a wound to the right buttock which measured 2.5 cm x 3 cm with no further information noted related to the wound. The Weekly Wound Non-Pressure Review assessment dated [DATE], completed by the Wound Treatment Nurse, revealed Resident #3 had a wound to the left buttock with no further information noted.An observation of Resident #3's right buttock pressure ulcer was conducted on 8/07/25 at 10:06 am. Resident #3 was noted to have one oblong shaped pressure ulcer to the right buttock which measured 3 cm x 2 cm with no depth noted. The wound was noted to have no drainage or odor present. The wound bed was red in color without slough (layer of dead tissue that impedes healing) or eschar (a dead layer of tissue that can prevent healing and increase risk of infection) present. Resident #3 had no other pressure ulcers at the time of the observation.An interview and observation was conducted with Resident #3 on 8/04/25 at 10:24 am who was observed sitting upright in bed watching television with an air mattress in place. Resident #3 revealed they had a pressure ulcer to her right backside, denied any pain from the pressure ulcer, and reported that the facility completed the treatment every day. Resident #3 stated there were no concerns regarding the care provided by the facility.Interviews were conducted with the Wound Treatment Nurse on 8/05/25 at 3:13 pm and 8/07/25 at 10:35 am. The Wound Treatment Nurse stated he had been responsible for the facility wound program for just over 2 years. He stated Resident #3 had one chronic Stage 3 pressure ulcer to her right buttock and that he documented the left buttock wound in error. The Wound Treatment Nurse reported a weekly assessment was completed for pressure ulcers and was documented in the medical record. He stated he had merged Resident #3's pressure ulcer information into the non-pressure wound assessment with a surgical wound that Resident #3 had, but he stated the pressure ulcer information should have been documented in the Weekly Pressure Ulcer Review. The Wound Treatment Nurse stated he would check the measurements of the pressure ulcer if he observed a change when doing wound care. The Wound Treatment Nurse stated was not getting and documenting all the information about the wounds, like size and the stage. The Wound Treatment Nurse stated the MDS Nurse had just recently educated him about the importance of the documentation of pressure ulcers.An interview was conducted on 8/07/25 at 11:38 am with the Director of Nursing (DON) who revealed when a resident had a pressure ulcer, a weekly pressure ulcer review assessment was to be completed. She stated the information that was required to be documented included description, staging, measurements, location, and any other pertinent information about the pressure ulcer. The DON stated the facility had a weekly meeting to discuss facility pressure ulcers and would look at the assessments to see if they were completed but she stated she did not open each assessment and make sure all the required information was documented. The DON was unable to say why the Wound Treatment Nurse did not complete a thorough wound assessment and document the required information regarding Resident #3's Stage 3 pressure ulcer.The Administrator and Corporate Representative were interviewed on 8/07/25 at 12:04 pm. The Corporate Clinical Specialist stated the Weekly Pressure Ulcer Review should have been reviewed at the weekly meeting to ensure that the Wound Treatment Nurse documented accurate and complete information regarding Resident #3's pressure ulcer.

Based on record review, and staff and Consultant Pharmacist interviews, the facility failed to ensure a physician order for an as needed (PRN) psychotropic medication was time limited in duration for 1 of 5 residents reviewed for unnecessary medications (Resident #90).The findings included:Resident #90 was admitted to the facility on [DATE] with diagnoses which included anxiety disorder.The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #90 was cognitively intact and was coded for use of an antianxiety medication.Resident #90 had an active physician order dated 7/19/25 for lorazepam oral tablet 0.5 milligram (mg). Give 0.5 mg by mouth two times a day for anxiety; give after breakfast AND give 0.5 mg tablet by mouth every 12 hours as needed (PRN) for anxiety. The order did not have a stop date.The care plan last reviewed on 7/28/25 revealed Resident #90 used anti-anxiety medication and was at risk for adverse side effects with an intervention for the Consulting Pharmacist to review the psychotropic medications quarterly and PRN for possible changes or reductions.The Medication Administration Record (MAR) for July 2025 revealed Resident #90 received the PRN lorazepam on 7/19/25 at 5:04 pm and no further PRN doses were administered to Resident #90 for the remainder of the month.The MAR for August 2025 revealed Resident #90 was not administered the PRN lorazepam.The Consultant Pharmacist's Medication Regimen Review report dated 8/04/25 revealed the facility received notification that Resident #90 was prescribed lorazepam 0.5 mg every 12 hours PRN for anxiety. The Consultant Pharmacist further noted that the order must have a stop date for re-assessment and requested the facility to clarify the order with a specific time/re-assessment date or discontinue.A telephone interview was conducted with the Consultant Pharmacist on 8/06/25 at 4:49 pm who revealed Resident #90's monthly medication review was conducted on 8/04/25. The Consultant Pharmacist reported she sent an email to the Director of Nursing (DON) when the review was completed and requested a stop date for Resident #90's PRN lorazepam but she was not sure if the DON had completed the request at this time.The DON was interviewed on 8/07/25 at 11:30 am and revealed medication orders were reviewed in the daily clinical meeting with the order listing report to review what medications were ordered and the stop dates would have been added during the meeting if missing. The DON stated the stop date was just missed for Resident #90's PRN lorazepam.An interview was conducted with the Administrator on 8/07/25 at 11:59 am who revealed medication orders were normally discussed in the morning clinical meeting. The Administrator stated Resident #90's PRN lorazepam order did not flag for not having a stop date by the way the order was written so it was missed.

Based on record review, observation, and staff interviews, the facility failed to accurately transcribe wound treatment orders for 1 of 2 residents reviewed for wound care (Resident #1).Findings included:Resident #1 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (stroke) and Type 2 Diabetes Mellitus.Resident #1's care plans included: I currently have a pressure ulcer to my sacrum and am at risk for development of additional pressure ulcers due to decreased ability to re-position andbowel/bladder incontinence, and immobility. This was initiated on 4/2/25 and most recently revised on 4/12/25. The Wound Physician assessed Resident #1 weekly; the dates included 5/6/25, 5/13/25, 5/20/25, 5/29/25, 6/5/25, 6/12/25, 6/19/25, 6/26/25, 7/3/25, 7/10/25, 7/17/25, 7/24/25, and 7/31/25. The Dressing Treatment Plan did not change and included: Primary Dressing alginate calcium with silver apply once daily and as needed. The Secondary Dressing included an island dressing with borders to cover the Primary Dressing. Resident #1's May 2025 Treatment Administration Record (TAR) noted orders: -Apply silver alginate, cover with dry dressing, every day shift. This was signed as administered 5/1/25 through 5/7/25 and 5/8/25 through 5/20/25. Noted as discontinued 5/21/25.-Apply calcium alginate, cover with dry dressing, every day shift. This was signed as administered 5/22/25 through 5/24/25 and 5/26/25 through 5/31/25.Resident #1's June 2025 TAR noted order: -Apply calcium alginate, cover with dry dressing, every day shift. This was noted as completed daily except for 6/9/25, 6/12/25 and 6/19/25. Resident #1's most recent quarterly Minimum Data Set assessment dated [DATE] indicated she had moderate cognitive impairment, dependent for all activities of daily living, had one stage 3 pressure ulcer, and had received pressure ulcer care.Resident #1's July 2025 Treatment Administration Record noted orders: -Apply calcium alginate, cover with dry dressing, every day shift. This was documented as administered every day. Resident #1's August 2025 Treatment Administration Record noted orders: -Apply calcium alginate, cover with dry dressing. every day shift, every Monday, Wednesday and Friday. One treatment was documented as completed on Monday 8/4/25.A wound care observation and interview was conducted on 8/5/25 at 9:10 AM with the Treatment Nurse. The sacral wound was cleaned with wound cleanser and gauze pads. A piece of alginate calcium with silver was applied to the wound and was covered with an island dressing. The wound appeared as a light pink area on the sacrum, approximately 2 centimeters (cm) long and 1 cm wide with no discernable depth. The Treatment Nurse explained Resident #1's wound had healed and then reopened. He stated she has been seen by the Wound Physician weekly since April when the wound reopened and was now nearly healed. An interview with the Treatment Nurse was conducted on 8/6/25 at 2:37 PM. When asked about the discrepancy in the treatment orders, the nurse explained it had been an oversight on his part to not transcribe the treatment orders correctly. He further explained that although he had transcribed the order incorrectly, the correct treatment had been provided to Resident #1. An interview with the Wound Physician was conducted on 8/7/25 at 12:30 PM via phone. He stated the person who had transcribed the order may have forgotten to add the silver detail. He stated the order should have been transcribed correctly but if the regular alginate calcium without silver had been used, it would not have been detrimental to the wound healing for Resident #1. He stated the silver added antimicrobial protection. He explained Resident #1 had multiple comorbidities and her sacral pressure ulcer was nearly healed. An interview with the Director of Nursing (DON) was conducted on 8/7/25 at 12:49 PM. She stated she would expect wound care orders to be transcribed correctly. During an interview with the Administrator on 8/7/25 at 1:36 PM he stated physician orders should be transcribed correctly.

Based on observations, record review, and resident, staff, family, and physician (MD) interviews, the facility failed to provide care in a safe manner when Resident #3, who was positioned onto her right side at the edge of her bed and was left unattended by MD #1 during wound care. Resident #3 fell from her bed and required transfer to the hospital for medical evaluation. This was for 1 of 3 residents (Resident #3) reviewed for accidents. Findings included: Resident #3 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (disruption in blood supply to the brain which causes tissue damage). A review of Resident #3's comprehensive care plan revealed a focus area dated as initiated on 3/18/21 of actual fall with risk for further falls related to poor balance and unsteady gait. An intervention was to anticipate Resident #3's needs as much as possible. A review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She had no functional limitation in range of motion of her upper or lower extremities. She was dependent for rolling left to right in bed, going from lying to sitting on the edge of the bed, and for transfers. She had no falls since her prior MDS assessment. Bed rails were not used as a restraint. A review of Resident #3's quarterly Interdisciplinary Team (IDT) risk assessment dated [DATE] revealed she was at low risk for falls. A review of Resident #3's quarterly Device and Bed Rail review dated 5/15/25 revealed she did not use bed rails. A review of a Fall report for Resident #3 dated 5/20/25 completed by Nurse #1 revealed on 5/20/25 at 11:51 AM Physician (MD) #1 was in Resident #3's room providing treatment to Resident #3. MD #1 stepped out of Resident #3's room to make Nurse #1 aware that Resident #3 was on the floor. Nurse #1 immediately entered Resident #3's room and observed Resident #3 lying on the floor on her right side in the fetal position. Resident #3 was assessed for injuries, no injuries were observed, and Resident #3 was sent to the emergency room for evaluation. Multiple attempts at telephone interview with Nurse #1 were unsuccessful. On 6/24/25 at 12:59 PM a telephone interview with MD #1 indicated she had been the facility's Wound Care physician for approximately 6 months at the time of Resident #3's fall on 5/20/25. She reported she could not recall if she had provided treatment to Resident #3 prior to 5/20/25 but it was normal for her and Nurse #2 to provide wound treatments together. She stated on 5/20/25, she had originally been there to assess an area on Resident #3's sacrum (base of spine) but observed an area on Resident #3's buttock that she felt needed an incision and drainage. MD #1 stated Resident #3 had been positioned on her right side closer to the edge of the bed than the middle of the bed facing Nurse #2. She reported she realized she needed additional supplies as the procedure had not been planned, asked Nurse #2 to go get them, and she stayed with Resident #3. MD #1 went on to say she herself had been positioned very closely physically to Resident #3 when Nurse #2 left the room and she felt that if Resident #3 had been unsteady or otherwise began to roll or fall she could have prevented this. MD #1 recalled she remembered a few other supplies she needed, and without assisting Resident #3 back onto her back she left Resident #3 unattended as she was and exited the room. She reported she was out of Resident #3's room for a few minutes, and when she went back into the room she saw Resident #3 was on the floor beside her bed. She stated she had not thought of the safety implications of leaving Resident #3 unattended positioned on her side at the edge of her bed before Resident #3's fall on 5/20/25, but she did now. MD #1 reported she no longer provided wound care at the facility. On 6/25/25 at 9:28 AM an interview with Nurse #2 indicated he was the facility's treatment nurse. He reported he was familiar with Resident #3 and had been involved in her fall incident on 5/20/25. He stated that morning, he accompanied MD #1 into Resident #3's room to assess Resident #3's sacral area. He went on to say he did not recall which side of the bed he had been on, and which side of the bed MD #1 had been on, but Resident #3 had been turned onto her right side positioned closer to the edge of the bed than in the middle, with the bed elevated approximately 18 inches from the floor during her treatment. Nurse #2 stated Resident #3 did not have bed rails. He reported MD #1 observed an area on Resident #3's buttock that she wanted to do a treatment on that was new, and he had not had the supplies at the bedside that MD #1 needed. Nurse #2 went on to say MD #1 did not have access to his treatment cart, which was located outside the room and locked, so MD #1 asked him to go obtain the supplies needed. Nurse #2 stated MD #1 had remained with Resident #3 when he left the room to obtain the supplies. He reported a few seconds later, MD #1 also came out of the room into the hallway. He stated he had not thought anything of it at the time, as he felt confident that MD #1 would have ensured Resident #3 was in a safe position before she left her unattended. Nurse #2 reported it was standard practice not to leave a resident you were working with in a vulnerable position, and if you needed to leave the room, to ensure that the resident was positioned safely in the middle of the bed with the bed in the lowest position. He stated he saw MD #1 go back into Resident #3's room, and as MD #1 got past the privacy curtain she called out that Resident #3 was on the floor. Nurse #2 reported he had not heard Resident #3 make any sound and had not heard her fall. He stated when he rushed back into Resident #3's room, she was lying on the floor on right side of her bed and positioned on her left shoulder facing her bed. He stated he assessed her for any injuries, didn't find any, placed a pillow under her head and covered her with a blanket. Nurse #2 reported by that point Resident #3's Nurse #1 and Nurse Aide (NA) #1 were there and stayed with Resident #3 until the Emergency Medical Services (EMS) arrived. Nurse #2 stated he provided his statement to the Administrator, and everyone received education after the incident regarding ensuring you collected all supplies before entering a residents room, safe positioning of residents, and ensuring residents were in a safe position in the middle of the bed with the bed lowered before you left the room. On 6/24/25 at 2:41 PM an interview with Nurse Aide (NA) #1 indicated she was familiar with Resident #3 and cared for her regularly. She reported she had been caring for Resident #3 on 5/20/25 on the 7:00 AM to 3:00 PM shift. She indicated Resident #3 could use her upper body to help with turning herself in the bed, but she was not able to use her lower body at all to assist. She reported Resident #3 was not able to balance to sit by herself on the side of her bed and was dependent for all care and transfers. NA #1 stated she had just been coming back from her lunch break on 5/20/25 when she heard the overhead page for the fall and she immediately went to Resident #3's room. She reported she saw Resident #3 on the floor on the right side of her bed. She stated she had not seen any injuries, Resident #3 had not been complaining of anything, and had not said anything to her. She went on to say she had stayed with Resident #3 until the ambulance arrived to take her to the hospital. A review of Resident #3's hospital Discharge summary dated [DATE] revealed in part she presented to the hospital emergency room (ER) on 5/20/25 after an unwitnessed fall at the facility. Resident #3 was not on any anticoagulant (blood thinning) medication. Extensive imaging studies were performed to evaluate Resident #3 for any fractures and subdural hematoma (bleeding in the brain). All these imaging studies were negative. Resident #3 returned to the facility on 5/21/25. A review of the untimed post-fall investigation report for Resident #3 dated 5/23/25 completed by the facility's Director of Nursing (DON) revealed after Resident #3's fall on 5/20/25 statements were obtained from the staff involved, camera footage of the incident was reviewed, immediate in-service education was provided to MD #1 regarding not leaving a resident unattended when they were being prepared for wound care, Resident #3's room environment was assessed for any factors that may have contributed to the fall, the fall was reviewed by the Interdisciplinary Team (IDT) and Resident #3's care plan was updated to reflect immediate interventions with the participation of Resident #3's family member. On 6/25/25 at 8:58 AM an interview with the Director of Nursing (DON) indicated she participated in the investigation of Resident #3's fall on 5/20/25. She stated Physician (MD) #1 and Nurse #2 were in the room, Nurse #2 needed to leave the room to get additional supplies and left the Resident #3 under the supervision of MD #1. She reported MD #1 then left Resident #3 unattended positioned on her side at the edge of the bed, and when MD #1 went back into the room Resident #3 was on the floor. The DON stated statements were obtained, camera footage was reviewed, she provide immediate education regarding proper positioning and not leaving the resident unattended during care to MD #1. She reported she had been doing follow-up audits to ensure the corrective action the facility put into place after the incident remained effective. On 6/24/25 at 10:23 AM Resident #3 was observed in a recliner chair in the facility's dining room. An interview with Resident #3 at that time indicated she did recall falling once out of bed at the facility. She stated she was asleep, and next thing she knew she woke up on the floor. She reported she had not been injured and felt safe when care was being provided to her. On 6/24/25 at 1:14 PM a telephone interview with Resident #3's family member indicated she visited Resident #3 in the facility at least twice weekly. She reported on 5/20/25 in the morning a doctor had called her to get permission to lance (cut open) a boil (a painful pus filled lump) on Resident #3's bottom. She stated a little while later, the facility called to notify her Resident #3 had fallen out of her bed during wound care and was being taken to the hospital. Resident #3's family member stated when she got to the hospital, Resident #3 was shaking a little, but was not in any pain and she did not see any injuries. She reported the hospital had done a lot of tests and had not found any broken bones or other injuries. On 6/24/25 at 2:49 PM an interview with Physical Therapist (PT) #1 indicated she was familiar with Resident #3 and had provided therapy to her multiple times during Resident #3's stay in the facility. She reported prior to 5/20/25, Resident #3's most recent therapy course had been from 5/14/25 through 5/19/25. She stated Resident #3 had cognitive impairment, and poor balance and upper body strength. PT #1 indicated Resident #3 would not have had the cognition, balance or strength to keep herself from falling from the bed if she had been left unattended positioned onto her right side at the edge of the bed and had begun to roll for any reason. On 6/25/25 at 8:23 AM an interview with the Administrator indicated he participated in the investigation of Resident #3's fall from her bed on 5/20/25. He stated the investigation consisted of a review of video camera footage of the hall outside Resident #3's room at the time of the incident, obtaining statements from staff involved, root cause analysis of the incident, and corrective action which included immediate education of MD #1, and education all staff who provided care to residents including therapy staff, nurses, nurse aides, and all the facility's medical providers. The Administrator stated the conclusion of the investigation was that MD #1 and Nurse #2 were in Resident #3's room providing care, Nurse #2 exited the room to gather supplies leaving Resident #3 with MD #1, and then MD #1 left Resident #3 unattended in an unsafe position while she exited Resident #3's room. He reported that follow up audits were done to monitor the corrective action plan, and the incident was taken through the facility's Quality Assurance and Performance Improvement (QAPI) process to ensure continued effectiveness of the corrective action. He stated that regardless of a physician's background or experience a resident's safety was everyone's responsibility. The Administrator indicated MD #1 should have positioned Resident #3 back onto her back and ensured she was in a safe position before leaving the room or stayed with Resident #3 until Nurse #2 returned and then went to get any additional supplies. The facility provided the following corrective action plan with a completion date of 5/26/25. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 5/20/2025 resident #3 was assessed post incident by the assigned nurse for any potential injuries or alteration in skin integrity. The results included: no noted injuries or new skin integrity concerns. On 5/20/2025 the physician and responsible party were notified, and the resident was transferred via EMS to ER for further evaluation. 2. Address how the facility will identify other residents having the potential to be affected. On 5/21/2025 the Director of Nurses audited all falls for the last 14 days to assure that no fall from bed had occurred related to positioning of the resident during care. The results included: No concerns were identified. On 5/21/2025 the Director of Nurses audited all falls for the past 14 days to assure the post fall process was in compliance. The results included: No concerns identified with the post fall process to include: completion of nursing fall assessments, notification of the MD or responsible party, development of an incident report of the event and review of resident care plans and interventions. On 5/21/2025 the MDS coordinator audited falls for the last 14 days to assure that care plans were current for falls with fall interventions in place. The results included: No concerns identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 5/20/2025 the Director of Nurses educated the wound care provider post incident on: prevention of falls from a bed. On 5/20/2025 the Staff Development Coordinator began education of all licensed nurses and certified nursing assistants and facility providers - Full time, Part time and PRN on fall prevention and the post fall process. The education included: - What are the common causes of falls. - What is a fall. - Fall prevention strategies: to include: o It is important that in the event that you have to move away from resident you must reposition the resident back in a safe position and bed in lowest position prior to stepping away. - Identifying fall risk and potential negative effects to include pain post fall - General Fall Prevention Strategies. - What should I do if I see a resident fall or see a resident on the floor? - Nursing immediate actions: to include nurse assessment prior to moving a resident and if c/o pain or the potential for an injury- do not move the resident. Contact MD and send resident to ER for further evaluation. - Post fall and method for assisting a resident from the floor. - Post Fall Documentation and Ongoing Assessment - Completing the incident report and the fall assessment UDA's. - Fall investigation and development of Root Cause. The Director of Nursing will ensure that any of the above identified staff who does not complete the in-service training by 5/25/2025 will not be allowed to work until the training is completed. This training was incorporated into the general orientation program and will be discussed during all general orientation programs that are completed for identified staff. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The Director of Nurses/Staff Development Coordinator will monitor bed positioning safety weekly for 2 weeks and monthly for 3 months for compliance with the safe provision of care. Monitoring started on 5/20/2025. The monitoring will include direct observation of 4 staff (including providers) on various shifts, to include weekends, for appropriate resident bed positioning, resident bed mobility safety/provision of safe care by staff. Reports will be presented to the monthly Quality Assurance Committee by the Administrator or Director of Nursing to ensure corrective action is initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the monthly Quality Assurance Meeting. The Quality Assurance Meeting is attended by the Administrator, Director of Nurses, Minimum Data Set Coordinator, Therapy, Health Information Manager, and the Dietary Manager. On 6/25/25 at 11:10 AM the facility's corrective action was verified via a review of observations of staff repositioning residents including Resident #3 back into a safe position and returning the bed to lowest position prior to stepping away from the resident, the facility's initial audits and follow-up weekly audits, the in-service education records, staff, Physician and Nurse Practitioner interviews, and a review of the facility's audit tools and QAPI minutes. The facility's date of completion of 5/26/25 was verified.

Based on observation, staff and resident interviews, the facility failed to ensure the caulking around the base of the toilets (room [ROOM NUMBER], #211, #308, #310, and #408) was adhered and free of black/brown matter. The facility also failed to ensure a baseboard in the bathroom (room [ROOM NUMBER]) was free of black/brown matter for 5 of 9 bathrooms reviewed for clean and homelike living environment. The findings included: a.During a continuous observation and interview with Resident #1 on 9/16/24 from 9:20 AM until 9:23 AM, the bathroom in room [ROOM NUMBER] revealed the caulking around the base of the toilet was detached in some areas with black/brown matter underneath. Also, a baseboard adjacent to the toilet had areas of dried black/brown matter. room [ROOM NUMBER] was occupied by 2 residents, and Resident #1 was able to use the bathroom on their own or with supervision assistance by staff. Resident #1 stated that the bathroom often becomes flooded from the shower on the other side of the wall, which caused the black/brown matter on the baseboard. Resident #1 was coded as cognitively intact for the most recent Minimum Data Set (MDS) assessment dated [DATE]. An observation and interview with the Maintenance Director on 9/16/24 at 9:47 AM revealed that the caulking around the base of the toilet does not look that bad in room [ROOM NUMBER], but he thought it needed to be pulled up and replaced. He further stated that the brown spots on the baseboard were due to water damage and needed to be painted. During an interview with the Administrator on 9/16/24 at 11:03 AM, he revealed that Resident #1's family member spoke to him last week about the brown spots on the baseboard, and she was told that that area needed to be addressed. The Administrator stated that the whole baseboard needed to be replaced. b.On 9/16/24 at 9:26 AM, an observation of the bathroom in room [ROOM NUMBER] revealed black/brown matter around the base of the toilet with the caulking detached in some areas. room [ROOM NUMBER] was occupied by 1 resident. The resident of this room was not able to use the bathroom on her own. An observation and interview with the Maintenance Director on 9/16/24 at 9:50 AM revealed that he thought the bathroom in room [ROOM NUMBER] looked ugly and the caulking needed to be replaced. The Administrator was interviewed on 9/16/24 at 11:06 AM. He revealed that brown was not the natural color of caulking. As time goes on and during room rounds, the caulking would not be observed. He stated that caulking was an optional item in the bathrooms. c.During a continuous observation and interview with Resident #2 on 9/16/24 from 9:35 AM until 9:38 AM, the bathroom in room [ROOM NUMBER] revealed the caulking around the base of the toilet was detached in some areas with black/brown matter underneath. room [ROOM NUMBER] was occupied by 2 residents, and Resident #2 was able to use the bathroom with assistance by staff. Resident #2 stated that the base of the toilet looked rough, and it did bother her. Resident #2 was coded as cognitively intact for the most recent Minimum Data Set (MDS) assessment dated [DATE]. An observation and interview with the Maintenance Director on 9/16/24 at 9:52 AM revealed that he stated there was no caulking around the base of the toilet, and the black/brown substance was dirt. The Administrator was interviewed on 9/16/24 at 11:08 AM. He revealed that he was not aware Resident #2 did not like the appearance of the base of the toilet. d.On 9/16/24 at 10:40 AM, an observation of the bathroom in room [ROOM NUMBER] revealed multiple areas of a dried brown matter along the base of the toilet where the caulking was detached in some areas. room [ROOM NUMBER] was occupied by 1 resident, and she was able to use the bathroom on her own or with supervision assistance by staff. During a continuous observation and interview with the Maintenance Assistant on 9/16/24 from 10:45 AM until 10:46 AM, he stated the base of the toilet in room [ROOM NUMBER] looked horrible. The caulking needs to be stripped and replaced. e.On 9/16/24 at 10:41 AM, an observation of the bathroom in room [ROOM NUMBER] revealed multiple areas of a dried brown matter along the base of the toilet where the caulking was detached in some areas. room [ROOM NUMBER] was occupied by 2 residents, and it was uncertain of their assistance with toileting. During a continuous observation and interview with the Maintenance Assistant on 9/16/24 from 10:47 AM until 10:48 AM, he stated The same thing. The caulking needs to be stripped and replaced around the base of the toilet in room [ROOM NUMBER]. The Maintenance Director was interviewed on 9/16/24 at 9:43 AM. He revealed that the bathrooms were not being renovated. Room rounds were made whenever he was in a resident's room to observe if the toilet was running, or the sink was leaking. The Maintenance Director stated that the caulking was only for appearance purposes, and it did not seal or prevent water leakage. Any staff member could notify him if they saw issues with the caulking around the base of the toilets; however, the Housekeeping Director or maintenance staff could replace the caulking. During an interview with the Administrator on 9/16/24 at 11:10 AM, he revealed that the rooms needed to be more thoroughly observed, including the caulking around the toilet base. Any rooms with the caulking issue needed to be replaced.

Based on record review and staff interviews, the facility failed to document wound treatment orders for 1 of 4 residents reviewed for medical record accuracy (Resident #251). The findings included: Resident #251 was admitted to the facility on [DATE] with a diagnosis of cellulitis (infection) of the right lower extremity. The nursing admission review note completed on 6/28/24 by Nurse #5 revealed Resident #251 was admitted to the facility on [DATE] with right lower extremity cellulitis and had two open areas to the right lower leg. The weekly skin assessment dated [DATE] completed by Nurse #5 revealed Resident #251 had an open area to the right lower leg. Nurse #5 noted that treatment was in place for the right lower leg open areas. An attempt to interview Nurse #5 via telephone on 7/17/24 at 9:30 am was unsuccessful. Review of the Treatment Administration Record (TAR) for June 2024 revealed no documentation that treatments were ordered or completed for Resident #251's right lower extremity wound. Nurse Practitioner (NP) #2 visit note dated 7/01/24 at 3:23 pm revealed Resident #251 had a right lower extremity dressing in place for the right leg cellulitis. During a telephone interview on 7/17/24 at 4:08 pm with NP #2 she revealed she was unable to recall about Resident #251's right lower extremity cellulitis, but she stated if she documented in the visit note that a dressing was in place that would have been what she observed. The weekly skin assessment dated [DATE] by Nurse #4 revealed Resident #251 had an open area to the right lower leg. Nurse #4 reported treatment was in place Resident #251's right lower extremity. An interview was conducted on 7/16/24 at 2:24 pm with the Wound Treatment Nurse who revealed Resident #251 had a wound to the right lower leg that he evaluated and completed an in-depth assessment on 6/29/24, and he determined the wound was a pressure ulcer. He stated he completed Resident #251's right lower leg treatment on 6/29/24 when he evaluated the wound, but he did not enter the order because he knew he would be taking care of it himself since it was every 2 days. The Wound Treatment Nurse stated he typically at times would take every other day treatments on personally and he would not always enter wound treatment orders for something he knew he was handling. A physician order dated 6/29/24 and created on 7/02/24 at 3:10 pm by the Wound Treatment Nurse indicated to cleanse open areas on lower right leg with wound cleanser or normal saline, pat dry. Apply layer of xeroform and cover with bandage one time a day every 2 days. A physician order was created on 7/02/24 by the Wound Treatment Nurse, with a start date of 7/03/24, to cleanse open areas on lower right leg with wound cleanser or normal saline, pat dry. Apply a thin layer of medihoney gel and cover with dry dressing one time a day every 2 days. Review of the TAR record for July 2024 revealed no treatments to the right lower extremity were documented as completed. A follow-up interview was conducted on 7/18/24 at 10:46 am with the Wound Treatment Nurse who stated Resident #251's right leg treatment would have been due to be changed on 7/01/24 but he completed the dressing change on 7/02/24. The Wound Treatment Nurse confirmed he did not document the treatment was completed and he did not enter any wound treatment orders for Resident #251. An interview was conducted with the Director of Nursing (DON) on 7/18/24 at 11:29 am who revealed the Wound Treatment Nurse should have entered any treatment orders that were required for Resident #251 so that any nursing staff were able to complete the treatment as scheduled. The DON stated she met with the Wound Treatment Nurse on 7/17/24 and provided education regarding entering all wound treatment orders when they were obtained. During an interview on 7/18/24 at 11:47 am with the Administrator he revealed that all treatment orders were to be obtained by the provider and entered into the record as a physician order.

Based on record review, and staff interviews, the facility failed to revise the care plan in the areas of behaviors (Resident #13) and hospice services (Resident #14) for 2 of 21 residents reviewed for care plan revision. The findings included: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, dementia, delusional disorder, and iron deficiency anemia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #13 had adequate vision without corrective lenses, had severe cognitive impairment, and required supervision for eating. Resident #13 was not coded for behaviors. The care plan last revised on 3/20/24 revealed no care plan for Resident #13's behavior related to the ingestion of non-edible substances and to keep bath items out of Resident #13's reach. The nursing progress note dated 4/04/24 at 12:01 am by Nurse #1 revealed Resident #13's vital signs were obtained, and Nurse Practitioner #1 was notified of Resident #13's incident. Nurse #1 called Poison Control and was notified by Poison Control that the cleanser was nontoxic and possible side effects included nausea and vomiting. Nurse #1 noted that all bathing items were removed from Resident #13's room. A telephone interview on 7/16/24 at 12:50 pm with Nurse #1 revealed she was notified by NA #1 that Resident #13 had the open bottle of liquid perineal and skin cleanser and she drank some of the liquid. Nurse #1 stated she removed all bath items from Resident #13's room and she notified the Nurse Practitioner and the Director of Nursing of the incident. An interview with MDS Nurse #2 on 7/18/24 at 11:06 am revealed she was present at the meeting when Resident #13's incident was reviewed but somehow just missed updating the care plan. MDS Nurse #2 stated she updated Resident #13's care plan on 7/17/24 to reflect to remove all bathing items from Resident #13's reach. An interview was conducted on 7/18/23 at 11:13 am with the Director of Nursing (DON) who revealed the MDS Nurse was required to update Resident #13's care plan when the incident was discussed in the clinical meeting. During an interview on 7/17/24 at 3:32 pm with the Administrator he revealed the MDS Nurse was responsible to update Resident #13's care plan to reflect to not leave bath items within reach of Resident #13 as discussed in the clinical meeting after the incident. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and dementia. Resident #14 had an active physician order dated 6/11/24 for hospice services. The Minimum Data Set (MDS) significant change assessment dated [DATE] revealed Resident #14 was coded for hospice services. Review of Resident #14's active care plan revealed no care plan for hospice services. An interview was conducted on 7/16/24 at 11:20 am with Nurse #3 who revealed Resident #14 was on hospice services. Nurse #3 stated the MDS Nurse was responsible to update Resident #14's care plan for hospice services. An interview was conducted on 7/16/24 at 3:35 pm with MDS Nurse #2 who revealed she was responsible for updating Resident #14's care plan when she admitted to hospice services. MDS Nurse #2 stated she was aware of Resident #14's hospice admission, but she just missed updating the care plan. During an interview on 7/18/24 at 11:26 am with the Director of Nursing (DON) she revealed hospice admissions were discussed in the daily clinical meetings and she stated the MDS Nurse was present at the meetings. The DON stated the MDS Nurse was responsible for updating Resident #14's care plan for hospice services. An interview was conducted with the Administrator on 7/18/24 at 11:46 am who revealed the MDS Nurse was responsible to update Resident #14's care plan to reflect hospice services.

Based on record review, staff interviews, Wound Provider interview, Nurse Practitioner interview, and Medical Director interview, the facility failed to obtain a treatment order prior to treating a wound for 1 of 4 residents reviewed for professional standards of practice (Resident #251). The findings included: Review of the hospital medication administration record dated 6/28/24 revealed Resident #251 received honey 80% gel treatment to the right lower extremity prior to discharge to the facility. Review of the hospital discharge summary revealed Resident #251 was discharged to the facility on [DATE] with diagnoses which included cellulitis of the right lower extremity. The hospital discharge summary did not include wound treatment orders for the right lower extremity cellulitis. Resident #251 was admitted to the facility on [DATE] with diagnoses which included cellulitis (infection) of the right lower extremity and diabetes. The nursing admission review note completed on 6/28/24 by Nurse #5 revealed Resident #251 was admitted to the facility on [DATE] with right lower extremity cellulitis and had two open areas to the right lower leg. The weekly skin assessment dated [DATE] completed by Nurse #5 revealed Resident #251 had existing skin concerns upon admission which included an open area to the right lower leg. Nurse #5 noted that treatment was in place for the right lower leg open areas. An attempt to interview Nurse #5 via telephone on 7/17/24 at 9:30 am was unsuccessful. Resident #251's care plan initiated on 6/28/24 revealed a care plan for antibiotic therapy related to cellulitis with interventions which included administering medications as ordered. A weekly pressure ulcer report (a report the facility utilizes to document all wounds) dated 6/29/24 completed by the Wound Treatment Nurse noted Resident #251 had a wound to the right lower leg with measurements of 2 centimeter (cm) x 2 cm x 0.1 cm noted as a stage 2 (shallow open wound with red or pink wound bed) pressure ulcer with 50% eschar (dry, dead tissue within a wound) and 50% granulation tissue (new connective tissues that forms during the wound healing process). The Wound Treatment Nurse further noted the wound was dry with patches of necrotic tissue (dead or dying tissue). No treatment was noted by the Wound Treatment Nurse. Review of the Treatment Administration Record (TAR) for June 2024 revealed no documentation that treatments were ordered or completed for Resident #251's right lower extremity wound. Nurse Practitioner (NP) #2 visit note dated 7/01/24 at 3:23 pm revealed Resident #251 had a right lower extremity dressing in place for the right leg cellulitis. NP #2 further noted that Resident #251's antibiotics would continue for the right leg cellulitis. During a telephone interview on 7/17/24 at 4:08 pm with NP #2 she revealed she was unable to recall about Resident #251's right lower extremity cellulitis, but she stated if she documented in the visit note that a dressing was in place that would have been what she observed. The Medical Director visit note dated 7/02/24 at 9:17 am revealed Resident #251 had a right anterior (front) lower leg wound which was clean with granulation tissue. The Medical Director noted that Resident #251 would continue with the full course of antibiotics for the right lower leg cellulitis. The weekly skin assessment dated [DATE] by Nurse #4 revealed Resident #251 had existing skin concerns present upon admission which included an open area to the right lower leg. Nurse #4 reported treatment was in place. An interview was conducted with Nurse #4 who was assigned to Resident #251 on 7/02/24 revealed she recalled Resident #251 had a wound to her right lower leg, but she stated she did not know what the treatment was because she did not do the treatments. Nurse #4 stated the Wound Treatment Nurse did the treatments to Resident #251's right lower leg. An interview was conducted on 7/16/24 at 2:24 pm with the Wound Treatment Nurse who revealed he had been at the facility since February 2024, his normal work schedule was Monday through Friday, and he was responsible to complete resident wound care for during his shift. The Wound Treatment Nurse stated the normal process for new admissions was the medication cart nurse completed the initial assessment and if wounds were identified, he would then complete his assessment. He reported that the facility had a Wound Provider that did resident rounds at the facility every Monday. The Wound Treatment Nurse reported that he recalled Resident #251 had a wound to the right lower leg that he evaluated and completed an in-depth assessment on 6/29/24, and he determined the wound was a pressure ulcer. He stated he determined xeroform dressing every two days was the appropriate treatment for Resident #251's lower extremity pressure ulcers. The Wound Treatment Nurse stated that he chose the initial treatment based on his assessment of the wound, but he stated when the Wound Provider did the weekly facility wound rounds she would make changes to the treatment if needed. He stated he completed Resident #251's right lower leg treatment on 6/29/24 when he evaluated the wound, but he did not enter the order because he knew he would be taking care of it himself since it was every 2 days. The Wound Treatment Nurse stated he typically at times he would take every other day treatments on personally and he would not always enter wound treatment orders for something he knew he was handling. He stated he kept a list of residents that had wounds and if the treatment orders were not in the computer it was because he just knew when the treatments were due and did them. A follow-up interview was conducted on 7/18/24 at 10:46 am with the Wound Treatment Nurse who stated he now recalled the wound to Resident #251's right lower extremity was cellulitis and not a pressure ulcer. He stated he was not aware Resident #251 had a diagnosis of right lower leg cellulitis prior to his evaluation of the wound so he initially documented it as a pressure ulcer due to the eschar that was present. He stated he later reviewed Resident #251's record and saw the wound was cellulitis. The Wound Treatment Nurse stated he must have just forgotten to strike out the pressure ulcer report. The Wound Treatment Nurse stated he was confused when he was first interviewed, and he should have reviewed Resident #251's record before giving the information. A physician order dated 6/29/24 and created on 7/02/24 at 3:10 pm by the Wound Treatment Nurse indicated to cleanse open areas on lower right leg with wound cleanser or normal saline, pat dry. Apply layer of xeroform and cover with bandage one time a day every 2 days. A physician order was created on 7/02/24 by the Wound Treatment Nurse, with a start date of 7/03/24, to cleanse open areas on lower right leg with wound cleanser or normal saline, pat dry. Apply a thin layer of medihoney gel and cover with dry dressing one time a day every 2 days. Resident #251 was transferred to the hospital on 7/02/24. Review of the TAR record for July 2024 revealed no treatments to the right lower extremity were documented as completed. A telephone interview was conducted on 7/18/24 at 10:33 am with the Wound Provider who revealed she did not recall receiving a referral from the Wound Treatment Nurse to evaluate and treat Resident #251. The Wound Provider stated she was unable to comment on treatments because she did not evaluate Resident #251. A follow-up interview was conducted on 7/18/24 at 10:46 am with the Wound Treatment Nurse revealed he did not put in an order for a referral to the Wound Provider for Resident #251's lower extremity wound because he was going to ask the Wound Provider to look at the wound during the next rounds on 7/01/24 to see if his initial treatment order needed to be changed. The Wound Treatment Nurse stated he did not need an order to have the wound looked at by the Wound Provider if he just wanted her to look at them. He was unable to recall if the Wound Provider saw Resident #251. The Wound Treatment Nurse stated he basically takes the medication cart nurse with him a lot of times when he completed wound treatments, and he would communicate verbally with the medication cart nurse during the treatment changes. He stated it was typically the same nurses on the medication carts, so they knew about the treatments. The Wound Treatment Nurse stated since Resident #251's treatments orders were to be completed every two days, if he did the treatment on Saturday it would have been due on Monday. The Wound Treatment Nurse stated that if the treatment was not done the exact date it was scheduled one day was not going to hurt. The Wound Treatment Nurse confirmed he did not enter any wound treatment orders and he should not have completed treatments on Resident #251's right lower extremity without a physician order in place. A telephone interview was conducted on 7/18/24 at 10:42 am with the Medical Director who revealed Resident #251 had cellulitis to the right lower leg, and to his knowledge, was prescribed oral antibiotics for treatment. The Medical Director stated the first and most important course of treatment for Resident #251's right lower extremity cellulitis was antibiotics. The Medical Director stated he did not think topical treatment was required for Resident #251's right leg cellulitis and was not aware of an order for topical treatments on the hospital discharge record. An interview was conducted with the Director of Nursing (DON) on 7/18/24 at 11:29 am who revealed she did not meet Resident #251 until 7/02/24 and she did not observe her leg wound. The DON stated the Wound Treatment Nurse should have obtained and entered any treatment orders that were required for Resident #251 so that any nursing staff were able to complete the treatment as scheduled. The DON stated the Wound Treatment Nurse should not have completed treatments to Resident #251's lower extremity without a physician order in place. The DON stated she met with the Wound Treatment Nurse on 7/17/24 and provided education regarding entering all wound treatment orders when they were obtained. During an interview on 7/18/24 at 11:47 am with the Administrator he revealed that all treatment orders were to be obtained by the provider and entered into the record as a physician order. The Administrator stated he reviewed the hospital discharge summary and there was not an order for wound treatments for Resident #251 upon admission to the facility. The Administrator was unable to state how the Wound Treatment Nurse obtained the orders for Resident #251.

Based on record review, observations, staff interviews, and interview with the Wound Care Physician the facility failed to transcribe Physician treatment orders and failed to implement the Wound Care Doctors orders as ordered for one (Resident #38) of three residents reviewed for pressure ulcers. The findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses that included stroke with hemiplegia, chronic atrial fibrillation, diabetes mellitus, hypothyroidism, and epilepsy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was cognitively impaired and was receiving treatments for a pressure ulcer. Review of Resident #38's care plan revealed she had a pressure ulcer on her coccyx and was at risk for development of additional pressure ulcers due to decreased ability to re-position and incontinence. bowel/bladder incontinence. Interventions included Apply moisture barrier with each brief change and prn, and administration of treatments as ordered by the physician and monitor effectiveness of treatments. Review of the Physician orders for 7/05/24 revealed: Cleanse sacrum with wound cleanser, pat dry, apply collagen powder and dry dressing. One time a day every 2 day(s). Review of Wound Care Progress note dated 7/15/24 revealed: Primary Dressing(s) Santyl apply once daily for 30 days. Secondary Dressing(s) Foam with border (silicone-sacrum) apply once daily for 16 days. Review of Resident #38s July 2024 eMAR (electronic Medication Administration Record) revealed the following: Cleanse sacrum with wound cleanser, pat dry, apply collagen powder and dry dressing. One time a day every 2 day(s). Observation on 7/17/24 at 11:10 AM of Resident #38's wound dressing change by the Wound Treatment Nurse. Resident #38's wound bed was cleaned with saline and gauze, slough and granulation tissue present, no active bleeding or drainage. There was no odor. The Wound Treatment Nurse stated he measured the wound in centimeters 2.5 cm x 1.5 cm (centimeters). During the interview, the Wound Treatment Nurse stated the treatment is completed every other day and will be either zinc or Santyl depending on the wound observation. With slough being present today Santyl will be used and then covered with border gauze. Santyl was applied and border gauze placed over the sacral wound. In an interview on 7/17/24 at 2:02 PM the Director of Nursing indicated the Wound Treatment Nurse should follow the Physician order and if there was a change in the order to call the Medical Doctor to verify. In a phone interview on 7/18/24 at 10:19 AM the Wound Care Physician revealed she discussed the order changes with the Wound Treatment Nurse during their rounds, he reviews her notes and would put the orders in the computer. She indicated the Wound Treatment Nurse called her on Tuesday to ask about making the Santyl as needed for when slough was present, and she gave the permission to change the order to PRN (as needed). In an interview on 7/18/24 at 10:22 AM the Administrator revealed if the Wound Treatment Nurse had a conversation with the Wound Care Physician and the order was changed. Then the Wound Treatment Nurse should have documented the conversation and changed the order. The Administrator indicated the Wound Treatment Nurse should follow what the Medical Doctor ordered and if the order did not match, he should have clarified the order. In an interview on 7/18/24 at 10:59 AM the Wound Treatment Nurse indicated that he was responsible for entering the order for Resident #38's wound treatment change and the order should have been changed.

Based on record review, staff interviews, Nurse Practitioner interview, Medical Director interview, and Poison Control interview, the facility failed to provide a hazard free environment to prevent an avoidable accident when a resident with severe cognitive impairment (Resident #13) ingested an unknown amount of nontoxic liquid perineal and skin cleanser that was left within the resident's reach for 1 of 4 residents reviewed for supervision to prevent accidents (Resident #13). The findings included: Resident #13 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, dementia, delusional disorder, and iron deficiency anemia. Resident #13 had no known drug or food allergies. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #13 had adequate vision without corrective lenses, had severe cognitive impairment, and was not coded for behaviors. Resident #13 had no range of motion limitation for upper or lower extremities, required supervision or cueing for bed to chair transfers, and was independent with wheelchair mobility. Resident #13's care plan last revised 3/20/24 revealed a care plan for impaired cognitive function, dementia, or impaired thought processes related to dementia with an intervention to cue, reorient, and supervise as needed. Review of the facility incident report dated 4/03/24 at 9:21 pm completed by Nurse #1 revealed Resident #13 was observed by Nurse Aide (NA) #1 drinking the liquid perineal and skin cleanser, but she was unable to state how much of the liquid Resident #13 consumed. The incident report further reported Resident #13 stated she did not know why she drank it. The incident report noted that Resident #1 was sitting on the edge of the bed with the bed in low position and the bedside table within reach at the time of the incident. The nursing progress note dated 4/04/24 at 12:01 am by Nurse #1 revealed Resident #13's vital signs were obtained, and Nurse Practitioner #1 was notified of Resident #13's incident. Nurse #1 called Poison Control and was notified by Poison Control that the cleanser was nontoxic and possible side effects from ingestion included nausea and vomiting. Nurse #1 noted that all bathing items were removed from Resident #13's room. A telephone interview on 7/16/24 at 12:50 pm with Nurse #1 revealed she was notified on 4/03/24 by NA #1 that Resident #13 had an open bottle of liquid perineal and skin cleanser and drank some of the liquid. Nurse #1 stated the perineal and skin cleanser belonged to Resident #13's roommate and was used to clean the area around her stoma (an opening in the body) site. She stated she did not use the liquid cleanser for the roommate's stoma site that day, she did not see the bottle on Resident #13's tables, and she was not sure how Resident #13 got the bottle. Nurse #1 stated she had left multiple drinks and a snack in Resident #13's room earlier in the shift on her bedside table and Resident #13 may have thought the liquid perineal and skin cleanser was a drink because she was confused. An interview was conducted on 7/16/24 at 3:44 pm with NA #1 who revealed she passed by Resident #13's room on 4/30/24 and saw Resident #13 sitting on her bed holding the open bottle of liquid perineal and skin cleanser to her mouth. NA #1 stated she was not able to say how much of the liquid perineal and skin cleanser Resident #13 drank, but there was not much missing from the bottle. NA #1 stated she did not recall seeing the liquid perineal and skin cleanser in Resident #13's room prior and she was not sure where Resident #13 got the bottle from. NA #1 stated had not seen Resident #13 eat or drink non-food items in the past. Review of the nursing progress notes dated 4/03/24 through 4/08/24 revealed no documentation that Resident #13 reported or was observed to have any nausea or vomiting. A telephone interview was conducted on 7/17/24 at 12:07 pm with Nurse Practitioner (NP) #1 who revealed she was notified on 4/03/24 that Resident #13 was observed in the motion of drinking the liquid perineal and skin cleanser, but it was reported only a small amount of liquid was missing from the bottle. NP #1 stated that Resident #13 must have mistaken the bottle of liquid perineal and skin cleanser for one of her drinks that were left on her table by staff due to her cognitive impairment and drank it. NP #1 stated Resident #13 did not display any ill effects or symptoms of nausea or vomiting from the ingestion of the liquid perineal and skin cleanser. NP #1 stated she had not known Resident #13 to ingest any non-food items in the past. A telephone interview was conducted on 7/17/24 at 12:45 pm with Poison Control who confirmed the liquid perineal and skin cleanser was non-toxic and if large amounts of liquid were ingested gastrointestinal irritation, such as nausea and vomiting, may occur. Poison Control stated the guidance provided after ingestion of the liquid perineal and skin cleanser would include monitoring for nausea and vomiting and to increase fluid intake if nausea or vomiting occurred to prevent dehydration. A telephone interview was conducted with the Medical Director on 7/18/24 at 10:40 am who revealed Nurse #1 contacted Poison Control immediately when Resident #13 drank the liquid perineal and skin cleanser to determine if the product was toxic when ingested and to receive guidance for how to proceed. The Medical Director stated once the product was determined to be non-toxic Resident #13 was monitored and no signs or symptoms of gastrointestinal irritation were noted. The Medical Director stated he did not have cause for concern regarding Resident #13's ingestion of a small amount of the liquid perineal and skin cleanser. An interview was conducted on 7/18/24 at 11:13 am with the Director of Nursing (DON) who revealed she recalled being notified on 4/03/24 by Nurse #1 that Resident #13 drank some of the perineal and skin cleanser. The DON stated Resident #13 had not ingested any non-food items prior to this incident to her knowledge. During an interview on 7/18/24 at 11:40 am with the Administrator he revealed Resident #13's ingestion of the liquid perineal and skin cleanser was possible due to her cognitive status but was not expected because she had not shown a history of ingestion of non-food items.

Based on record review, observations and staff interviews, the facility failed to administer enteral feeding formula at the correct rate as ordered by the physician for 1 of 1 resident (Resident #4) reviewed for enteral feedings. Findings included: Resident #4 was admitted to the facility on [DATE]. Diagnoses included dysphagia (difficultly swallowing) and gastrostomy (opening of the stomach) for enteral feedings. The revised care plan dated 9/14/2022 indicated Resident #4 required enteral feedings to assist her in maintaining or improving her nutritional status. Interventions included administering enteral feeding formula as ordered by the physician. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #4 received enteral feedings for nutrition for greater than 51% of total calories. Dietary notes dated 2/9/2023 recorded Resident #4 was receiving an enteral feeding at 40 milliliters (mL) per hour (hr) and increased the enteral feeding to 50 mL/hr due to weight loss. Physician orders dated 2/9/2023 included an order for an enteral feeding continuously at 50 mL/hr. A review of the February 2023 Medication Administration Record (MAR) recorded Resident #4 started receiving enteral feedings continuously at 50 mL/hr on 2/9/2023 on the evening shift (3:00 p.m. to 11:00 p.m.). A review of the March 2023 MAR recorded Resident #4 continued to receive enteral feedings continuously at 50 mL/hr. On 3/6/2023 at 10:45 a.m., the enteral feeding was observed infusing continuously at 40 mL/hr via a pump. On 3/8/2023 at 8:42 a.m., the enteral feeding was observed infusing via pump at 40 mL/hr. The label on the enteral feeding bag read the enteral feeding was started at 12:35 a.m. on 3/8/23 at 40 mL/ hr. On 3/8/2023 at 11:10 a.m., Nurse #1 was observed placing the continuously enteral feeding on hold while administering a bolus of 200 mL water flush via gravity using a syringe. Nurse #1 was observed restarting the enteral feeding via pump at 40 mL/ hr. In an interview with Nurse #1 on 3/8/2023 at 11:20 a.m., she stated she needed to check the physicians order on the rate of the enteral feeding for Resident #4. After Nurse #1 checked the electronic MAR and the physician's orders, she stated the enteral feeding was ordered to infuse at 50 mL/hr. She explained Nurse #2 (the 11:00 p.m. to 7:00 a.m. nurse) started the new bag of enteral feeding and didn't know why the enteral feeding was at 40 mL/hr. Nurse #1 was observed increasing the enteral feeding to 50 mL/hr. In an interview with the Director of Nursing on 3/8/2023 at 11:45 a.m., she recalled Resident #4's weight loss was discussed in the interdisciplinary meetings, and the dietician increased the enteral feeding rate due to weight loss. She stated the enteral feeding should be infusing at 50 mL/hr as ordered by the physician. In a phone interview with Nurse #2 on 3/8/2023 at 5:28 a.m., she stated she worked the 11:00 p.m. to 7:00 a.m. shift on 3/7/2023 and changed Resident #4's enteral feeding bag. She explained the infusion rate for the enteral feeding was indicated on the Resident #4's MAR and was unsure what the MAR indicated as the rate of infusion for the enteral feeding. She said she thought the infusion rate was still at 40 mL/hr and had not adjusted the infusion rate of the enteral feeding to 50 mL/hr.

Based on record review and staff interview the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint survey of 7/1/21. The deficiency is in the area of Notification of Discharge (623). The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: F623: Based on record review, resident interview, and staff interviews the facility failed to provide written notice of discharge to the resident and the resident's representative for residents who were transferred to the hospital and notification to the ombudsman (Resident #48) and failed to provide written notice of discharge to the resident or the resident's representatives (Resident # 63 and Resident #30) for 3 of 3 residents reviewed for facility-initiated discharge. During the recertification and complaint survey of 7/1/21, the facility was cited for failing to notify the ombudsman of facility-initiated discharges to the hospital. An interview with the Administrator was conducted on 3/9/23 at 11:01 AM. The Administrator stated the facility had some turnover in staff which contributed to the repeated citation.

Based on record review, resident interview, and staff interviews the facility failed to provide written notice of discharge to the resident and the resident's representative for residents who were transferred to the hospital and notification to the ombudsman (Resident #48) and failed to provide written notice of discharge to the resident or the resident's representatives (Resident # 63 and Resident #30) for 3 of 3 residents reviewed for facility-initiated discharge. The findings included: 1. Resident #48 was admitted to the facility on [DATE]. Review of Resident #48' s records revealed she was sent to the hospital on 2/20/23. Review of Resident #48's medical record revealed no evidence that written notification of discharge was provided to the resident or resident representative for hospitalization on [DATE]. She returned to the facility on [DATE]. An interview was conducted with the Admissions Coordinator on 3/8/23 at 11:37 AM who reported the Health Information Management (HIM) Coordinator was responsible for sending a list monthly to the Ombudsman of discharged residents. She reviewed the list of discharged residents for February 2023 and stated Resident #48 was not on the list. The Admissions Coordinator stated she was unsure who was responsible for sending written notification to residents or resident's representatives when they were discharged to the hospital. During an interview with the Social Services Director on 3/8/23 at 1:05 PM she stated she was not aware that written notification needed to be provided for residents who discharged to the hospital. On 3/9/2023 at 1:27 p.m. in an interview with the Administrator, he said Resident #48 did not receive written notification for the reason of her discharge. He explained the person in the Health Information Management position (who left the position last week) was contacting the ombudsman and was not sending written letters to the responsible parties and the ombudsman. He stated the social worker was transitioning into her new role and was not aware of the requirement to send written notification to the ombudsman and the responsible parties. 2. Resident #63 was admitted to the facility on [DATE]. Review of Resident #63 ' s records revealed she was sent to the hospital on 7/9/22. Review of Resident #63's medical record revealed no evidence that written notification of discharge was not provided to the resident or resident representative for hospitalization on [DATE]. An interview was conducted with the Admissions Coordinator on 3/8/23 at 11:37 AM who reported the Health Information Management (HIM) Coordinator was responsible for sending a list monthly to the Ombudsman of discharged residents. The Admissions Coordinator stated she was unsure who was responsible for sending written notification to residents or resident's representatives when they were discharged to the hospital. During an interview with the Social Services Director on 3/8/23 at 1:05 PM she stated she was not aware that written notification needed to be provided for residents who discharged to the hospital. On 3/9/2023 at 1:27 p.m. in an interview with the Administrator, he said Resident #63 did not receive written notification for the reason of his discharge. He explained the person in the Health Information Management position (who left the position last week) was contacting the ombudsman and was not sending written letters to the responsible parties and the ombudsman. He stated the social worker was transitioning into her new role and was not aware of the requirement to send written notification to the ombudsman and the responsible parties. 41387 3. Resident #30 was admitted to the facility on [DATE]. Resident #30 was discharged from the facility and admitted to the hospital on 1/27/2023. Resident #30 returned to the facility on [DATE]. A review of Resident #30's medical record revealed Resident #30 acted as her own responsible party. A review of Resident #30's medical record revealed no written communication to Resident #30 related to the hospitalization on [DATE]. The 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #30 was cognitively intact. On 3/9/2023 at 8:31 a.m. in an interview with Resident #30, she stated she had not received a written letter notifying her the reason she was discharged to the hospital on 1/27/2023. On 3/9/2023 at 12:18 p.m. in an interview with the Social Services Director (who assumed the responsibility one week ago for notifying the ombudsman and the responsible party in writing for the reason for transfer/discharge to the hospital), she stated she didn't know if Resident #30 received a written notification for the reason of her discharge to the hospital. On 3/9/2023 at 1:27 p.m. in an interview with the Administrator, he said Resident #30 did not receive written notification for the reason of her discharge. He explained the person in the Health Information Management position (who left the position last week) was contacting the ombudsman and was not sending written letters to the responsible parties and the ombudsman. He stated the social worker was transitioning into her new role and was not aware of the requirement to send written notification to the ombudsman and the responsible parties.

Based on observation, record review and staff interview the facility failed to use the correct technique when providing peri-care for 1 of 2 residents observed to receive incontinence care (Resident #67) and failed to maintain a catheter drainage bag off of the floor for 1 of 3 residents observed with an indwelling urinary catheter (Resident #36). The findings included: 1. Resident #67 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 6/28/21 noted the resident had severe cognitive impairment, was not ambulatory and required total assistance with toileting and extensive assistance with personal hygiene. The MDS noted the resident was incontinent of bowel and bladder. The resident's active care plan noted the resident had an ADL (activities of daily living) self-care performance deficit related to dementia and required staff assistance with personal hygiene. On 9/1/21 at 10:38 AM Nursing Assistant (NA) #1 was observed to provide incontinence care for Resident #67. The resident was observed to be lying on her back and the NA used pre-moistened wipes to clean the resident's perineal area and cleaned from front to back. The NA then assisted the resident to turn onto the left side and proceeded to clean the resident's bottom from back to front, towards the urinary urethra and stool was observed on the wipe. The NA obtained a clean wipe and again cleaned the resident from back to front several times until no more stool observed on the wipes. On 9/1/21 at 10:40 AM the NA was asked how she was trained to wipe when providing incontinence care and the NA stated: I did it wrong. I'm sorry. On 9/1/21 at the completion of care the NA was asked how she was supposed to clean during incontinence care and the NA stated: Front to back. The NA was asked why she cleaned back to front and the NA stated: I made a mistake. The Director of Nursing stated in an interview when doing peri-care the staff should clean the resident front to back. 2.Resident #36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent Minimum Data Set assessment completed on 7/27/21 revealed the resident was mildly cognitively impaired. Resident #36 required extensive assistance with activities of daily living (ADLs) and had an indwelling catheter. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Check every day and change every 7 days and as needed. An observation of Resident #36 was conducted on 9/01/21 at 9:15 AM. Resident #36 was laying in the bed. The catheter bag was lying on the floor. An observation of Resident #36 was conducted on 9/01/21 at 9:48 AM with the Director of Nursing (DON). Resident #36 was laying in the bed. The catheter bag was lying on the floor. An interview was conducted with the Director of Nursing on 9/01/21 at 9:50 AM. She stated if the nurse aide was unsure about the placement of the catheter bag, she should have asked the nurse. The DON stated staff were expected to keep the catheter bag off the floor. An interview was conducted on 9/01/21 at 10:04 AM with NA #2. She stated she had raised the resident ' s bed at breakfast, and she was not aware the catheter bag was on the floor. She stated she had been educated to keep catheter bags off the floor and if she had seen the bag, she would have picked it up off the floor. An interview was conducted on 9/01/21 at 10:42 AM with the Administrator and informed of the resident ' s catheter bag was on the floor. The Administrator stated staff were expected to keep catheter bags off the floor.

Based on observation, record review and staff interview, facility staff failed to notify the treatment nurse to assess and apply a dressing to a stage 3 pressure ulcer for 1 of 1 resident observed with a pressure ulcer (Resident #67). The findings included: Resident #67 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident had severe cognitive impairment and required extensive assistance for bathing, personal hygiene and dressing and total assistance for toileting. The MDS noted the resident was frequently incontinent of bowel and bladder and had one unstageable pressure ulcer with slough or eschar that was present on admission to the facility. Slough refers to a yellow/white material in the wound bed and eschar is dead tissue that is typically tan, brown or black and may be crusty. The resident's active care plan dated 8/4/21 noted the resident had an unstageable pressure ulcer to the sacrum and was at risk for additional pressure ulcers due to decreased ability to reposition and incontinence. One of the interventions was to report a loose dressing to the treatment nurse. On 9/1/21 at 9:45 AM, Nursing Assistant (NA) #2 was observed to provide a bath and peri-care for the resident. The NA turned the resident onto her right side to bathe her back and a dressing over the sacral area was noted to be attached with tape on the left side of the resident's sacrum and was not attached to the rest of the wound and a very large open wound was observed on the sacrum. The dressing was mostly saturated with a serosanguineous drainage. Serosanguineous drainage is pale red or pink in color. When the bath was completed, the NA placed the unattached part of the dressing back over the wound and proceeded to place a clean incontinent brief on the resident, dressed the resident and placed the resident in a wheelchair. During the care, the NA stated she was told to get the resident bathed and dressed and in her chair that they were going to pick her up in 15 minutes. The NA stated she did not know where the resident was going. On 9/1/21 at 9:55 AM an interview was conducted with NA #2. The NA stated usually she would tell the wound nurse about the dressing but since they were rushing her, she just put the same dressing back over the wound. On 9/1/21 at 9:58 AM, Nurse #1 stated in an interview the resident was being discharged home today and her family was on the way to the facility to pick up the resident. The Director of Nursing (DON) was present during the interview and was made aware of the care observed and the DON directed the nurse to go in to assess and redress the wound. On 9/1/21 at 12:50 PM an interview was conducted with the resident's Responsible Party who stated the resident was not eligible for Medicaid and the family had located an assisted living facility who was able to meet her needs and that is where they took the resident upon discharge from the nursing home. On 9/1/21 at 10:02 AM the Director of Nursing stated in an interview that the expectation was for the NA to notify the nurse so the nurse could go in and assess the wound.

Based on observation and staff interviews the facility failed to maintain one of one dumpster in good condition that contained waste and was free of leaks. The findings included: During the initial tour on 6/28/21 at 10:15 AM the dumpster was observed with the dietary manager. The dumpster had a rusty hole on the right long side of the dumpster that dripped. A pool of sludge approximately 20 inches long and 2-4 inches wide with wet sludge. Four flies were observed hovering over the wet sludge. The front of the dumpster was observed with four feet of grease located between the front wheels. On 6/30/21 at 8:09 AM and on 7/1/21 at 8:34 AM the dumpster was observed to be in the same condition. During an observation with the dietary manager on 7/01/21 at 9:46 AM the dumpster was observed to have a pool of sludge approximately 20 inches long and 2-4 inches wide with wet sludge. Five flies were observed hovering over the wet sludge. The front of the dumpster was observed with four feet of grease between the front wheels and two flies were observed hovering. On 7/1/21 at 9:49 AM the dietary manager stated she did not realize the dumpster was leaking, she thought it looked like grease from the wheels. She indicated she would call the waste company and have the dumpster replaced right away. In an interview on 7/01/21 at 10:10 AM the Administrator agreed the dumpster should not leak and indicated staff had called for the dumpster to be replaced. On 7/01/21 at 10:13 AM the maintenance man stated once before he had called the dumpster company to report a leak, which was fixed. He indicated he had called the company and they would replace the dumpster.

Based on observations, record review and staff interviews, the facility failed to provide nail care for 5 of 6 dependent residents reviewed for Activities of Daily Living (ADL) (Residents #67, #13, #53, #28 and #36). Findings included: 1. Resident #67 had been admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #67's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she had severe cognitive impairment, was able to feed herself with supervision and required extensive to total care for all other ADLs. Resident #67's ADL Care Plan initiated on 4/10/2017 indicated she had an ADL self-care performance deficit related to dementia. The care plan goal was to improve [her] current level of function. Interventions included anticipate [her] needs and to check nail length and trim and clean as necessary. Report any changes to the nurse. Another care plan most recently updated on 5/03/2021 indicated [Resident #67] is resistive to care related to anxiety and occasionally verbally abusive. He care plan goal was for the resident to cooperate with care for 90 days. Interventions included if [Resident #67] resists with ADLs, reassure resident, leave and return 5-10 minutes later and try again. An observation on 6/28/2021 at 11:52 AM Resident #67 in bed, appeared clean, without odors, nails long with brown matter under the nails. An observation on 6/28/2021 at 3:33 PM Resident #67 wanting to get out of bed, appeared clean, without odors, nails long with brown matter under the nails. An observation on 6/29/2021 at 8:17 AM Resident #67 in bed, appeared clean, without odors, nails long with brown matter under the nails. An interview with Nurse Aide (NA) #2 was conducted on 6/30/21 at 1:19 PM. NA #2 stated Resident #67 required extensive to total care with ADLs. She explained NA #5 completed nail care for the residents once weekly. An interview with NA #5 was conducted on 6/30/2021 at 1:57 PM. She stated she sometimes had a specific assignment to assist with ADL and nail care. She explained it had been awhile since she had this assignment. An interview with Nurse #3 who regularly cared for Resident #67 was conducted on 6/30/2021 at 2:14 PM. The nurse stated Resident #67 required extensive to total care for her ADLs and nails should be cleaned and checked daily or at minimum on shower days. An interview was conducted with the Director of Nursing (DON) on 6/29/21 at 4:46 PM. The DON stated unless the resident was diabetic or on [MEDICATION(S)] or the family preferred the resident to go out of the facility for nail care, the NAs should be providing nail care daily and as needed. The DON explained the NAs should clean and check nails when showering or bathing the residents. 2. Resident #13 had been admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13's most recent comprehensive Minimum Data Set (MDS) dated [DATE] indicated she had memory problems and required extensive to total care with ADLs. Resident #13's ADL Care Plan initiated on 7/31/2017 indicated she had an ADL self-care deficit related to activity intolerance and shortness of breath. The care plan goal was to improve [her] current level of function. Interventions included to anticipate [her] needs, and [she] requires staff assistance with grooming and personal hygiene. An observation on 6/28/2021 at 3:43 PM Resident #13 in bed, appeared clean, without odors, nails long with brown matter under the nails. An observation on 6/29/2021 at 8:16 AM Resident #13 in bed, appeared clean, without odors, nails long with brown matter under the nails. An observation on 6/29/2021 at 3:39 PM Resident #13 in bed, appeared clean, without odors, nails long with brown matter under the nails. An interview with Nurse Aide (NA) #3 was conducted on 6/29/2021 at 3:39 PM. NA #3 stated Resident #13 required extensive to total care and was able to feed herself after set-up and encouragement. She explained NA #5 goes around and cuts the residents nails. An interview with NA #5 was conducted on 6/30/2021 at 1:57 PM. She stated she sometimes had a specific assignment to assist with ADL and nail care. She explained it had been awhile since she had this assignment. An interview with Nurse #3 who regularly cared for Resident #13 was conducted on 6/30/2021 at 2:14 PM. The nurse stated Resident #13 required extensive to total care for her ADLs and nails should be cleaned and checked daily or at minimum on shower days. An interview was conducted with the Director of Nursing (DON) on 6/29/21 at 4:46 PM. The DON stated unless the resident was diabetic or on [MEDICATION(S)] or the family preferred the resident to go out of the facility for nail care, the NAs should be providing nail care daily and as needed. The DON explained the NAs should clean and check nails when showering or bathing the residents. 3. Resident #53 had been admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #53's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated he had a memory problem and required extensive to total assistance with ADLs. Resident #53's ADL Care Plan initiated on 5/21/2020 indicated he had an ADL self-care deficit related to cerebral vascular accident and [CONDITION(S)]. The care plan goal was to receive staff assistance with all aspects of daily care to ensure all [his] needs are met. Interventions included to anticipate [his] needs. An observation on 6/28/2021 at 12:18 PM Resident #53 in bed, appeared clean and without odors, fingernails long. An observation on 6/28/2021 at 3:41 PM Resident #53 in bed, appeared clean and without odors, fingernails long. An observation on 6/29/2021 at 8:21 AM Resident #53 in bed, appeared clean and without odors, fingernails long. An interview with Nurse #2 was conducted on 6/29/2021 at 4:01 PM. Nurse #2 stated she checked on her residents for any possible needs when first arriving for her shift and each time she's in any resident room. She stated she had worked at this facility about one month and was not sure of the process for fingernails. On 6/29/2021 at 4:21 PM Resident #53 was observed with Nurse #2. Nurse #2 indicated Resident #53's nails were long and should be trimmed. An interview was conducted with the Director of Nursing (DON) on 6/29/21 at 4:46 PM. The DON stated unless the resident was diabetic or on [MEDICATION(S)] or the family preferred the resident to go out of the facility for nail care, the NAs should be providing nail care daily and as needed. The DON explained the NAs should clean and check nails when showering or bathing the residents. 3. Resident #28 was admitted to the facility 12/17/20. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #28 's most recent Comprehensive MDS dated [DATE] indicated he was cognately intact, was able to feed himself with supervision and required extensive assistance for all other ADLS. Resident #28's ADL Care Plan dated 1/28/21 revealed he had an ADL Self- Care Performance Deficit related to right foot amputation. The care plan goal was to receive staff assistance with all aspects of his daily care to ensure his daily needs were met. Interventions included anticipate his needs. An observation of Resident #28 was conducted on 6/28/21 at 2:53 PM. Resident # 28 was in bed, appeared clean, had no odors and fingernails had brown matter under the nails. An observation of Resident #28 was conducted on 6/29/21 at 10:26 AM. Resident #28 was in bed, appeared clean, had no odors, and fingernails had brown matter under the nails. An interview was conducted with NA #6 on 6/30/21 at 2:00 PM. She stated Resident #28 required extensive assistance with ADLS. Nurse #6 stated nail care was provided on a weekly basis and as needed. NA#6 stated she looked at resident nails when she assisted with ADL care. An interview was conducted with the Administrator on 7/1/21 at 1:38 PM and she was informed that residents had brown matter under fingernails. The Administrator stated she expected that staff provided nail care daily for residents. 4. Resident #36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #36's Admission MDS assessment dated [DATE] indicated she was cognitively intact, required set up help only with eating and extensive assistance with all other ADLS. Resident # 36's ADL Care Plan date 4/29/21 revealed she had an ADL Self Care Performance Deficit related to impaired balance, limited mobility and limited range of motion. Interventions included to anticipate her needs and she required staff assistance with grooming and personal hygiene. An observation of Resident #36 was conducted on 6/28/21 at 3:18 PM. Resident #36 was sitting up in the wheelchair at the bedside, appeared clean, had no odors and a brown colored substance beneath her fingernails. An observation of Resident #36 was conducted on 6/29/21 at 8:41 AM. Resident #36 was in bed, appeared clean, had no odors, and a brown colored substance under her fingernails. An interview was conducted with NA#7 on 6/29/21 at 4:34 PM. She stated that nail care was performed during Resident #36's AM care. NA #7 stated she assisted with nail care when it was assigned. An interview was conducted with the Administrator on 7/1/21 at 1:38 PM and she was informed that residents had brown matter under fingernails. The Administrator stated she expected that staff provided nail care daily for residents.

Based on record review and staff interview the facility failed to update residents' care plans to reflect the care required for 2 of 39 residents whose care plans were reviewed (Resident #19 and #21). The findings included: Resident #19 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 1a. The resident's current care plan revealed an entry dated 12/31/19 that noted the resident was to be transferred with minimal assist with pull to stand at parallel bar. The most recent Minimum Data Set (MDS) assessment dated [DATE] noted the resident had severe cognitive impairment and required total assistance of 2 persons for transfers. On 6/30/21 at 2:59 PM the MDS Nurse stated in an interview that she received a sheet from rehab as to how the resident was to be transferred for the entry dated 12/31/19. The Nurse further stated once she put an intervention in the care plan she did not go in and take it out even though the intervention no longer applied to the resident. The MDS Nurse continued and stated she did not know she had to be that specific in the care plan. On 7/1/21 at 9:00 AM Nurse #1 stated in an interview that Resident #19 was total assist with transfers and was transferred with a mechanical lift. On 7/1/21 at 9:28 AM an interview was conducted with the Rehab Director who stated when the resident was admitted in 2019 she had contractures of both knees and she had severe dementia. The Rehab Director further stated that after therapy the resident was evaluated on 3/10/20 to be transferred with a mechanical lift since the resident was unable to fully extend her legs. 1b. Review of the resident's current care plan revealed an entry dated 1/17/20 that the resident was to have TED (Thrombo-[CONDITION(S)] Deterrent) stockings and to apply in the morning and remove at bedtime. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/30/21 at 2:44 PM, Resident #19 was observed to receive incontinence care and did not have TED hose on her feet and legs. During the care, Nursing Assistant (NA) #1 stated she had never known the resident to wear TED hose. On 6/30/21 at 2:59 PM an interview was conducted with the MDS Nurse who stated the resident's TED stockings were discontinued on 3/9/20. The MDS Nurse stated when reviewing a resident's care plan she looked to make sure the category or focus area was there but did not look at the interventions and once she added an intervention she did not remove it even if the intervention no longer applied to the resident. The MDS Nurse stated she did not know she had to be that specific. 2. Resident #21 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's current care plan last reviewed on 6/23/21 did not specify how the resident was to be transferred. A Minimum Data Set (MDS) assessment dated [DATE] noted the resident was cognitively intact and required extensive assistance of one person for transfers. On 6/30/21 at 2:59 PM an interview was conducted with the MDS Nurse who stated she used a system created care plan for the resident care areas and did not update or change them. The MDS Nurse further stated when she looked at the care plan she made sure the category or focus area was there but did not look at the interventions and did not know she had to be that specific. On 7/1/21 at 10:40 AM, Resident #21 was observed to be transferred from the bed to a wheelchair with the use of a total mechanical lift. On 7/1/21 at 11:38 AM the Rehab Director stated in an interview that Resident #21 was re-evaluated after a hospitalization on [DATE], was dependent on staff for transfers and was to be transferred with a total mechanical lift. On 7/1/21 at 12:29 PM an interview was conducted with the Director of Nursing (DON) and the nurse consultant. The DON stated it was her expectation for the care plans to be individualized for the resident and reflect the resident's needs.

Based on record review and resident and staff interview the facility failed to develop an individualized care plan for 4 of 39 residents whose care plans were reviewed (Resident #19, #21, #40 and #43). The findings included: 1. Resident #19 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's active care plan had an entry that was dated 12/31/19 and noted the resident was at risk for pressure ulcers. One of the interventions listed was to observe the resident's skin upon return from [CONDITION(S)]. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 3/24/21 revealed the resident was cognitively impaired. The MDS did not indicate the resident received [CONDITION(S)]. On 6/30/21 at 12:06 PM the MDS Nurse stated in an interview that she used a system created care plan for resident care areas that had the intervention to observe the resident's skin upon return from [CONDITION(S)] and she did not change the interventions. On 7/1/21 at 12:29 an interview was conducted with the Director of Nursing (DON) and the nurse consultant. The DON stated it was her expectation for the care plans to be individualized for the resident and reflect their care needs. 2. Resident #21 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's current care plan revealed an entry dated 9/16/19 that the resident was at risk for pressure ulcers. One of the interventions was to observe the resident's skin for redness and open areas upon return from [CONDITION(S)]. The most recent Minimum Data Set (MDS) Assessment (Quarterly) dated 3/25/21 revealed the resident was cognitively intact and did not indicate the resident received [CONDITION(S)]. During a resident interview on 6/29/21 at 10:30 AM the resident stated she was not on [CONDITION(S)]. On 6/30/21 at 12:06 PM the MDS Nurse stated in an interview that she used a system created care plan that had the intervention to check the skin for redness and open areas upon return from [CONDITION(S)] and she did not change the interventions. On 7/1/21 at 12:29 an interview was conducted with the Director of Nursing (DON) and the nurse consultant. The DON stated it was her expectation for the care plans to be individualized for the resident and reflect their care needs. 3. Resident #40 was admitted to the facility on [DATE] [CONDITION(S)] (stroke) and dementia. The resident's current care plan noted an entry dated 2/5/21 that the resident was at risk for pressure ulcers. One of the interventions was to observe the resident's skin for redness and open areas upon return from [CONDITION(S)]. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The MDS did not indicate the resident received [CONDITION(S)]. On 6/30/21 at 12:06 PM the MDS Nurse stated in an interview that she used a system created care plan that had the intervention to check the skin for redness and open areas upon return from [CONDITION(S)] and she did not change the interventions. On 7/1/21 at 12:29 an interview was conducted with the Director of Nursing (DON) and the nurse consultant. The DON stated it was her expectation for the care plans to be individualized for the resident and reflect their care needs. 4. Resident #43 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The MDS did not indicate the resident received [CONDITION(S)]. The resident's current care plan revealed an entry dated 2/4/21 that noted the resident was at risk for pressure ulcers and to observe the skin for redness and open areas upon return from [CONDITION(S)]. On 6/30/21 at 12:06 PM the MDS Nurse stated in an interview that she used a system created care plan that had the intervention to check the skin for redness and open areas upon return from [CONDITION(S)] and she did not change the interventions. On 7/1/21 at 12:29 PM an interview was conducted with the Director of Nursing (DON) and the nurse consultant. The DON stated it was her expectation for the care plans to be individualized for the resident and the care plan to reflect the resident's needs. .

Based on medical record review, staff and family interview the facility failed to ensure the safety of a resident by positioning a resident too close to the edge of the bed when staff were attempting to change the sheets on the resident's bed for 1 of 1 (Resident #1) residents reviewed for accidents. Resident #1 fell from bed while a staff member attempted to change the sheets on the bed which resulted in the resident experiencing a broken femur. Findings included: Resident #1 was admitted to the facility on [DATE]. Medical record review revealed [DIAGNOSES REDACTED]. Review of Resident #1's care plan dated 2/8/19 revealed that the resident had an increased risk for fall related to a history of fall, impaired balance, generalized weakness, decreased mobility and an actual fall. The resident had a goal to minimize falls through current interventions for the next 90 days. Interventions included transfer with 3 person/maximum /total assistance with Hoyer lift, anticipate needs, keep furniture in locked position, a safe environment (working and reachable call light, bed in a low position when in bed, personal items within reach). Review of the minimum data set ((MDS) dated [DATE] revealed that the resident scored 9 on the brief interview of mental status indicating cognitive impairment. She was coded as needing extensive 1 person assistance with bed mobility and transfer. She was coded as having no limits in range of motion. Medical record review revealed a health status note dated 3/25/19, at 3:30 PM written by Nurse #1 which stated, Resident hit her left knee and lower leg on her bed while getting ADL (activities of daily living) care, x-ray of the left knee and lower leg requested by hospice. A health status note dated 3/25/19 at 11:03 PM stated, x-ray of left knee/leg completed, results not in yet. Steri-strips applied to right knee per hospice for skin tear. No complaints of pain, no signs/symptoms of distress. Will continue to monitor. Review of a statement written by the hospice Nursing Assistant (NA) dated 3/25/19 revealed the following. On 3/25/19 I was performing my CNA (certified nursing assistant) care on (Resident #1). I was cleaning her bottom and turned her over onto her right side, when I observed (Resident #1) legs going off of the bed. I quickly grabbed hold of her shirt to prevent her body from falling out of bed. I managed to keep the resident upper body up but her knees slid to floor. At that point the resident was on the floor sitting up on her knees. I still had her top half. I managed to pull her back onto the bed using the shirt. Interview with hospice NA on 4/24/19 at 6:29 PM revealed on 3/25/19 around 2:30 PM she was in Resident #1's room to give her care. The hospice NA reported that after she washed the resident up and dressed her and then she started to change the sheets on the resident's bed with the resident in the bed. She stated she had the clean sheet underneath the resident and the dirty sheet rolled up under the resident on the side she finished. She went to the other side of the bed to pull out the dirty sheets to remove them from the bed and get the clean sheet (pull the clean sheet over). The NA explained that as she was pulling the sheet she observed the resident's legs go over the side of the bed. She stated she grabbed Resident #1 to break her fall from the bed and lowered her to the floor. The resident was on the floor in a kneeling position on her knees. The NA reported that she still had a hold the residents' top part. She stated that she got her by both arms and pulled her under her arms back up into the bed. The resident was telling her to get her up. The NA stated after she got Resident #1 back into bed she informed Nurse #1 and Nurse #1 helped her pull the sheet out and pull the resident up in the bed. The hospice NA stated the resident complained of pain after she positioned her legs in bed. Review of the incident report prepared by Nurse #1 dated 3/25/19, 3:00 PM with a revision date of 4/8/19 at 9:05 PM included a staff statement from Nurse #1 dated 3/26/19 This nurse notified that the resident had hit her knee on the side of the bed while giving ADL care. Resident was assessed and order given for x-ray of the left knee left tibia, left fibula. The incident description on the report stated, This nurse notified by hospice CNA (certified nursing assistant) that the resident was in the process of sliding out of her bed when she caught her and pulled her back onto the bed. The immediate action taken section of the report stated, Resident was assessed no signs of swelling, no bleeding but resident had complaints of pain in her left knee, x-ray of the left knee, left tibia and left fibula ordered. Interview with Nurse #1 at 6:20 PM on 4/24/19 revealed on 3/25/19 the hospice nursing assistant came to the door of the resident's room and asked him to come to Resident #1's room. The NA told him that Resident #1 was coming off the bed, she pulled her back up and the resident hit her hip on the bed itself. Nurse #1 stated the resident was on the bed when he went into the room. He got orders to get an x-ray of the resident's hip. Nurse #1 stated he did not know that Resident #1 actually hit the floor. Per nurse #1 the incident occurred close to 3:00 PM. He stated he called for the x-ray and then went off shift. Review of the medical record revealed a mobile x-ray report dated 3/26/19 12:39 AM which stated, acute mildly displaced complete supracondylar [MEDICAL CONDITION] femur, moderate degree of osteopenia, moderate [MEDICAL CONDITION]. A Health status note dated 3/26/19 12:15 PM written by the DON stated, Informed by hall nurse that resident x-ray results noted with femur fracture. MD made aware of results and received order to send to emergency room . Hospice nurse also made aware of x-ray results. Health status note 3/26/19 3:56 PM stated, Resident out of facility, at hospital for evaluation of fracture in left femur. A Hospice note dated 4/17/19 written by the Hospice nurse stated, Hospice Note for 3/25/19, regarding patient fall: PRN nurse visit. HCA (Nursing Assistant) called to report that patient has had a fall, and was complaining of pain to left knee. While performing personal care HCA rolled patient over, however Patient went over too far and her knees hit the floor. HCA reported she was able to protect upper body by grabbing patient blouse. Upon assessment skin tear was noted to right knee. Site cleaned and steri-strips applied by skilled nurse. Swelling noted to left knee and a report of pain. Primary physician was notified by facility nurse who ordered x-ray. Safety education provided to HCA. Understanding verbalized. Skilled nurse ensured that pain medication was administered. Interview with hospice nurse at 6:40 PM on 4/24/19 revealed that she was not present at the time of the incident on 3/25/19. She reported that the hospice NA called her and said that she was providing personal care to Resident #1 with the resident in bed and the resident started rolling and rolled off the bed. The resident's knees hit the floor. She stated her understanding was the NA rolled the resident to one side of the bed then rolled her to the other side of the bed (as she was taking off the dirty sheet and putting on the clean sheet). She further stated that the resident was in a great deal of pain when she was at the facility. The nurse was giving her pain medication and the nurse called the MD for an order for [REDACTED]. Review of hospital records dated 3/26/19 revealed the following under chief complaint, Pt. (Patient) was apparently dropped last night by nursing staff while attempting to move her. X-ray performed at midnight last night, showed supracondylar [MEDICAL CONDITION]. The exam section of the hospital record stated, severe pain with any range of motion of the left lower extremity. Interview with a family member on 4/23/19 at 3:15 PM revealed that the nursing assistant from hospice dropped Resident #1 out of bed. The facility took x-rays right after the fall happened. The resident had fractured femur. The family member reported that she fell on (MONTH) 25 and was sent to the hospital on (MONTH) 26. Interview with the Director of Nurses (DON) at 7:03 PM on 4/24/19 revealed that they called the physician (MD) and made her aware of the x-ray results for Resident #1. The MD said they could send her out to the emergency room . Interview with the DON at 7:33 PM on 4/24/19 revealed that when she spoke with the MD; the MD asked if Resident #1 was stable and if she was in pain. She (DON) told the nurse to check on the resident; she told the MD the resident was stable and that she was scheduling transportation. The DON reported the MD did not state to send the resident out immediately. Review of a written statement by the MD stated, (Resident Name) has been a hospice resident for the past 2 years. Also has been bed bound and family requested no hospitalization s or extensive treatment/surgery. When x-ray was available and family informed they stated they wanted her sent out for evaluation. Resident was not considered surgery candidate related to bed bound status. The resident was placed in immobilizer and discharged to different facility per family request. Review of the facility's Investigation guide portion of the plan of correction revealed a Conclusions-Root Cause(s) section which stated, what do you believe to be the root causes(s) of this incident? The facility response stated, Resident had a fall that resulted in her knees sliding to the floor and her sitting on her knees. Resident's legs began to slide off edge of bed. Resident was receiving care from aide. Resident was positioned too close to edge of bed. The following is the facility's corrective action plan: Facility Review to Ensure Quality (Plan of Correction) dated 3/31/19. Facility compliance date of corrective action 4/8/19. Corrective Action for resident involved: On the evening shift of 3/25/19 the physician and responsible party were notified of the incident and an x-ray was ordered of the left leg and knee with the results of the x-ray received on 3/26/19. The physician was notified of the results and the resident was sent to the emergency room for further evaluation. The responsible party was notified. Incident report corrected for the fall that was indicated as an other incident. Identification of potentially affected resident and corrective actions taken: All current residents who have had an incident in the last 14 days were reviewed on 3/31/19 by the nurse consultant to ensure that incident reports had been appropriately categorized and that the post fall process had been followed. 100% of incidents in the last 14 days were identified with the post fall process in place and with appropriate categorization of the incident report. Systemic changes: Education On 3/31/19 the DON/ADON (Assistant /Director of Nursing) began education of all full time, part time, as needed licensed nurses and certified nurse's aides on the following topics: definition of a fall, post fall process completion and follow through, and bed positioning safety. The DON will ensure that any of the above identified staff who does not complete the in-service training by 4/7/19 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility orientation for the above identified staff. Quality Assurance Plan: The DON/ADON will monitor this issue using the post fall process quality assurance tool and bed positioning tool for monitoring. The monitoring will include review of three falls for compliance with the post fall process. In addition positioning of 4 residents by CNA's while in bed receiving care, will be observed to include each shift and weekends. This will be completed weekly times 2 weeks then monthly times 3 months or until resolved. Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action was initiated as appropriate. Compliance will be monitored and ongoing auditing program reviewed at the weekly QA meeting. The weekly QA meeting is attended by the Administrator, Director of Nursing, MDS Coordinator, ADON, Therapy, HIM and Dietary Manager. Review of the facility Plan of Correction on 4/24/19 revealed, Falls and Post Fall Process Nursing Education Packet dated 3/31/19, which included a sign in sheet with signature of licensed practical nurses (LPN's). The packet addressed: Common causes of falls How to prevent falls Basic responsibility General documentation guidelines to consider Falls management Review of the facility post fall process sheet revealed review of falls for 4 residents over two weeks. The facility quality assurance tool for bed position safety plan revealed the facility utilized this tool for 8 residents over 2 weeks on the 7-3 shift. The review sheet included the following areas: Resident initials Shift/Date Care being provided such as: dressing, bathing, incontinence care Was the resident appropriately positioned for the provision of safe care Was the bed in the appropriate position to provide safe care Did staff have all needed supplies ready/available at bedside to provide care Follow up actions The facility's date of compliance was validated as 4/8/19.

Based on observations, staff interviews and record reviews, the facility failed to prevent a fall with injury for 1 of 1 resident (Resident #2) in the survey sample with a tilt wheelchair that was not correctly tilted during a transfer. The findings include: Resident #2 was admitted with a [DIAGNOSES REDACTED]. The 2/20/12 physical therapy (PT) plan of care indicated the resident was admitted with severe dementia and wheelchair bound, and having progressing flexion contractures of both lower extremities. The PT treatment notes dated 2/18, 2/24 and 3/1/12 did not reference the specialized wheelchair. On 2/18/12 the PT documented that education was initiated with nursing/nursing assistant (NA) focusing on splint protocol. There was no documentation staff was trained on use of the wheelchair. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory problems and severe cognitive impairment. It further noted that resident # 2 was totally dependent and required the assistance of two staff for transferring and positioning. The MDS also indicated there was a functional limitation of range of motion in both lower extremities. The 6/4/12 Assessement of Risk for Falls identified resident #2 at high risk for falls due to severe cognitive impairment, immobility, maximum assistance for transfer, poor vision and inability to bear weight. Review of the care plan dated 6/4/12 indicated the resident was at risk for falls and included an approach to use a mechanical lift for all transfers. There was no identification of the resident ' s specialized wheelchair. A 6/22/12 incident report noted resident #2 was transferred from the bed to the wheelchair with a mechanical lift by a nurse and NA. When the resident was positioned in the wheelchair the resident slid and hit her head on the wheelchair pedal. The injury was described as a deep laceration measuring 3 centimeters (cm) long and 1 cm deep. A Physician ' s Assistant (PA) Progress Note dated 6/22/12 indicated resident #2 had a laceration on the back of head. It was described as having clean edges, mild edema and bleeding. The Physician ' s Assistant noted that the laceration required sutures. The procedure note indicated that seven sutures were placed by the PA. The procedure was performed in the facility. A screen was completed by PT on 7/2/12 due to the fall on 6/22/12. The screen indicated to tilt the resident # 2 ' s wheelchair 25 degrees. Review of the entire medical record revealed that the first indication the wheelchair was evaluated was on 7/2/12. An interview with nurse #1 on 7/3/12 at 11:20 AM revealed she was assisting the NA #1 with the mechanical lift transfer on 6/22/12. She stated that the resident was lowered into the chair. Nurse #1 was positioning her and the resident slipped from the chair and hit her head on the foot pedal. When questioned she further stated that the sling was positioned correctly under the resident, had no tears and the lift was working correctly. NA #1 was interviewed at 11:45 AM on 7/3/12 and stated that resident #2 was lowered to the wheelchair with the mechanical lift. Nurse #1 was positioning the resident in the chair prior to removing the sling when the resident slipped down. The NA #1 further stated that she wasn't sure how it occurred "It happened so fast." An interview with the physical therapist at 2:25 PM on 7/3/12 indicated he screened the resident following the fall and determined that the contributing factors were that the chair was probably not tilted, the footrests were on the chair and not enough room was allowed around the chair to accommodate the mechanical lift. A subsequent interview with nurse #1 at 2:35 PM on 7/3/12 revealed that she was trained by the physical therapist on use of the tilt wheelchair on 7/2/12. At 2:55 PM on 7/3/12 NA #1 stated that she did not know the wheelchair tilted and no one showed her how to use it as of the time of interview. On 7/3/12 at 3:22 PM nurse #1 stated that the wheelchair was in a straight sitting position during the 6/22/12 mechanical transfer. At 3:25 PM on 7/3/12 NA #1 stated the wheelchair was not tilted during the mechanical lift transfer on 6/22/12 and the back of the wheelchair was in a straight position. An interview with the director of nursing (DON) on 7/3/12 at 3:41 PM indicated she thought resident #2 ' s wheelchair chair wasn't locked and the chair moved backwards. She further stated that she questioned NA #1 and nurse #1. NA #1 told her that the wheelchair was locked. Nurse #1 could not recall if the wheelchair was locked at the time of the transfer. The DON made no mention of the resident ' s specialized wheelchair. At 3:45 PM on 7/3/12 the administrator revealed her expectation was that when a resident is admitted with a specialized wheelchair the staff would be trained on its proper use. She stated that she and The DON were just trained themselves on use of the tilt wheelchair on 7/2/12. The director of rehab was interviewed on 7/3/12 at 4:05 PM. She stated that all new residents are screened, physical therapy learns how to use a specialized wheelchair then train staff by demonstration and redemonstration. She further stated that tilt wheelchairs are usually set at 25 degrees. The director of rehab also indicated that the staff should have known how to use the tilt wheelchair because a previous resident had a similar chair. When questioned, the rehab director stated that the previous resident was at the facility at least a year ago.

Based on record review, facility staff interviews, nurse practioner, and physician interview the facility failed to monitor [MEDICATION NAME], ([MEDICATION NAME]) for 1 of 4 sampled residents, (Resident #48), receiving anticonvulsant therapy. Furthermore, the facility gave an extra dose of [MEDICATION NAME], ([MEDICATION NAME]), to a resident (Resident #40) who was not ordered to receive a stat dose of anticonvulsant therapy, for 1 of 4 sampled residents. This constituted Immediate Jeopardy from 10/04/2010 until on-site removal of Immediate Jeopardy on 01/21/2011. The deficiency continues out at a scope and severity of " D " , (isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy, whereby significant corrections are required), so in-servicing of all staff can be completed and the facility has incorporated their proposed monitoring system into their Quality Assurance Program. The findings include: 1. A review of the facility furnished " Lab (Laboratory) Frequency Guideline, dated November 2006 " revealed: a list of medications, laboratory tests, and frequency of laboratory tests. Included in the list was " [MEDICATION NAME] ([MEDICATION NAME]); [MEDICATION NAME] and [MEDICATION NAME] level every three months " . A review of Resident #48 ' s record revealed that he was admitted to the facility on [DATE], with cumulative [DIAGNOSES REDACTED]. A review of Resident #48 ' s most recent Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the Resident had problems with short and long term memories and moderately impaired cognitive skills for daily decision making with cues/supervision required. The Resident was identified as requiring extensive assistance from facility staff for Activities of Daily Living. A review of Resident #48 ' s Attending Physician order [REDACTED]. There was no change in the dosage or frequency of the medication through the months of October, November, December 2010, or January 2011. On 10/03/2010 Resident #48 ' s Physician wrote an order for [REDACTED]. A review of the Resident ' s record revealed a Laboratory Test Results Sheet dated 10/04/2010. The documentation on the sheet for the Patient ' s Name had Resident #48 ' s correct last name and an incorrect first name. The sheet documented Resident #48 ' s accurate birth date and account number. The sheet showed handwritten documentation in the upper left hand corner " called Lab & (and) verified name by BD (birth date) Acc. (account) # (number). " The incorrect first name had been marked through and the correct first name for Resident #48 had been hand written above it. The hand written documentation was signed by Nurse #1. The laboratory results sheet showed that the blood sample was received on 10/04/2010 at 7:58 AM. The sheet documented the Test Name: [MEDICATION NAME] ([MEDICATION NAME]) Result: 3.3 ug/ML (micrograms per milliliter) L (low) Reference Range: (normal values) 10.0-20.0 ug/ML. The sheet documented that the results were reported on 10/04/2010 2:53 PM. There was an additional hand written note on the laboratory results sheet located underneath the documented results. The hand written note showed " 12/04/10 8 PM (Resident ' s Attending Physician) made aware Give [MEDICATION NAME] 500 mg po now recheck [MEDICATION NAME] level on Wednesday (10/06/2010) noted " (Nurse #2 ' s signature). The sheet had the Resident ' s Physician ' s initials hand written underneath the hand written note by Nurse #2. The incorrect Resident #40 had the [MEDICATION NAME] dose given on 10/04/2010 and the blood draw preformed on 10/06/2010 that was intended for Resident #48. A review of Resident #48 ' s record revealed no documentation of a telephone order dated 10/04/2010 for the administration of [MEDICATION NAME] 500 mg or a repeat [MEDICATION NAME] Level the following Wednesday (10/06/2010). A review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the Resident ' s record revealed no Laboratory Results Sheet for a [MEDICATION NAME] Level dated 10/06/2010. A review of the Nurse ' s Notes for the Resident revealed no documentation of the administration of [MEDICATION NAME] 500 mg on 10/04/2010 or a blood draw for a repeat [MEDICATION NAME] Level on 10/06/2010. A review of the Pharmacist Chart Review Notes from 10/01/2010 through present showed no documentation of the extra dose of [MEDICATION NAME] (500 mg) or of the repeat [MEDICATION NAME] Level request by the Resident ' s Attending Physician. A review of the physician progress notes [REDACTED]. A review of the Resident ' s record revealed a Laboratory Result Sheet dated 01/20/2011. The sheet documented a blood chemistry test for [MEDICATION NAME] ([MEDICATION NAME]) level. The results were documented as L (low) at 5.9 ug/ML, (normal values at 10-20 ug/ML). There was a hand written note on the bottom right side of the sheet that documented " on [MEDICATION NAME] 150 mg BID (Name of Nurse Practioner) notified 01/20/2011 6:00 PM, increase ([MEDICATION NAME]) to 200 mg BID redraw in 1 week " . A review of Resident #48 ' s record revealed a hand written telephone order dated 01/20/2011 as follows: increase [MEDICATION NAME] to 200 mg BID and redraw [MEDICATION NAME] level in 1 week. On 01/20/2011 at 2:30 PM an interview was conducted with the facility ' s Director of Nursing (DON) and the Administrator. The DON and the Administrator stated that they had been made aware of the omission of the medication administration and the omission of the repeat blood test, today (01/20/2011) for Resident #48. The DON stated that when lab results come back from the lab the Charge Nurse or the Supervisor checks the results. The DON added that if the results were abnormal the Charge Nurse or the Supervisor was responsible for calling the appropriate Physician and writing any telephone orders that the Physician may give. The DON said that the night shift nursing staff was responsible for double checking all laboratory results and orders. On 01/21/2011 at 9:40 AM an interview was conducted with the Nurse Practioner that was assigned to Resident #48. The Nurse Practioner stated that she was familiar with the Resident and his care needs. She said that her expectation regarding orders for medication administration and laboratory test was that the nurse on duty would carry out the order as written. She said that there should be checks and balances in place to be sure that orders were carried out. The Nurse Practioner stated that she expected to be called for abnormal laboratory results. The Nurse Practioner stated that she and the Resident ' s Attending Physician had been made aware of the missed medication and lab test on 01/20/2011. The Nurse Practioner stated that the Resident ' s Attending Physician asked her to follow up on the incident. She said that a repeat [MEDICATION NAME] Level was drawn yesterday for Resident #48 and that she had seen the results and ordered an increase in the Resident ' s [MEDICATION NAME]. On 01/21/2011 at 10:27 AM an interview was conducted with Nurse #1. She stated that she was working 1st shift on 10/04/2010. The Nurse stated that by the time she got the laboratory result sheet and verified the Resident ' s identity it was the end of her shift and the second shift Nurse was in the facility. The Nurse stated that it was her usual routine to verbally tell the oncoming second shift Nurse of any abnormal lab values and any stat (immediate) orders for any residents assigned to her care. Nurse #1 also stated that she always left laboratory result sheets received during her shift on the medication cart for the second shift Nurse to review. Nurse # 1 said that she remembered leaving the laboratory result sheet on the medication cart for the on coming Nurse but did not recall if she verbally told the second shift Nurse about the abnormal laboratory value for the Resident. On 01/21/2011 at 11:00 AM an interview was conducted with the Resident ' s Attending Physician. The Physician indicated that she did not know of the omission of the [MEDICATION NAME] until 01/20/2011. The Physician also indicated that there were no ill effects for either resident. There were no documented adverse affects of the [MEDICATION NAME] for either resident. On 01/21/2011 at 3:17 PM an interview was conducted with Nurse #2. Nurse #2 was assigned to the unit where Resident #48 resided on 10/04/2010 for the second shift. Nurse #2 stated that she had no recollection of any stat medication orders or repeat blood draws orders received on 10/04/2010 for Resident #48. She stated that she did recall that on 10/04/2010 a different resident (Resident #40) had an order for [REDACTED].#40 ' s last name, she did not recall what name the laboratory sheet had written as the Resident ' s first name and did not recall seeing a note verifying the correct Resident (#48). 2. A review of Resident #40 ' s record revealed that he was admitted to the facility on [DATE], with cumulative [DIAGNOSES REDACTED]. A review of Resident #40 ' s most recent Quarterly Minimum Set (MDS) revealed that the Resident had problems with short and long term memories and moderately impaired cognitive skills for daily decision making with cues/supervision required. The Resident was identified as requiring extensive assistance from facility staff for Activities of Daily Living. A review of Resident #40 ' s Attending Physician order [REDACTED]. There was no change in the dosage or frequency of the [MEDICATION NAME] order for the months of October, November, December 2010 or January 2011. A review of the Resident #40 ' s record revealed that on 10/04/2010 at 8 PM Nurse #2 wrote a telephone order " Give [MEDICATION NAME] 500 mg po X (times) 1 now recheck [MEDICATION NAME] level on Wednesday " . This order was initialed by the Resident ' s Attending Physician. A review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the Nurse ' s Notes for the Resident #40 revealed " 10/04/2010 12 MN (midnight) alert and responsive, no acute distress total care provided with ADL ' s (activities of daily living). (Physician ' s name) made aware of abn (abnormal) [MEDICATION NAME] level. MD ordered to give [MEDICATION NAME] 500 mg po x 1 now then repeat [MEDICATION NAME] level on Wednesday " . This note was signed by Nurse #2. A review of the Resident ' s record revealed a Laboratory Result Sheet dated 10/06/2010 for a [MEDICATION NAME] Level. The results were within normal levels at 14.5 ug/ML (normal values 10-20 ug/ML). The Laboratory Result Sheet showed the Attending Physician ' s initials with no date and showed the Nurse Practioner ' s hand written initials with the date of 10/15/2010 beside the initials. A review of the physician progress notes [REDACTED]. On 01/20/2011 at 2:30 PM an interview was conducted with the facility ' s Director of Nursing (DON) and the Administrator. The DON and the Administrator stated that they had been made aware of the medication error and of the inappropriate blood draw on Resident #40 on 01/20/2010. The DON stated that when lab results come back from the lab the Charge Nurse or the Supervisor checks the results. The DON added that if the results were abnormal the Charge Nurse or the Supervisor was responsible for calling the appropriate Physician and writing any telephone orders that the Physician may give. The DON said that the night shift nursing staff was responsible for double checking all laboratory results and orders. On 01/21/2011 at 9:40 AM an interview was conducted with the Nurse Practioner that was assigned to Resident #40. The Nurse Practioner stated that she was not aware of the Resident receiving an unnecessary dose of [MEDICATION NAME] on 10/04/2010 and an unnecessary blood draw on 10/06/2010 until yesterday 01/20/2011. She said that her expectation regarding orders for medication administration and laboratory test was that the nurse on duty would carry out the order as written for the correct resident. She said that there should be checks and balances in place to be sure that orders were carried out. On 01/21/2011 at 10:27 AM an interview was conducted with Nurse #1. She stated that she was working 1st shift on 10/04/2010. The Nurse stated that by the time she got the laboratory result sheet and verified the Resident ' s identity it was the end of her shift and the second shift Nurse was in the facility. The Nurse stated that it was her usual routine to verbally tell the oncoming second shift Nurse of any abnormal lab values and any stat (immediate) orders for any residents assigned to her care. Nurse #1 also stated that she always left laboratory result sheets received during her shift on the medication cart for the second shift Nurse to review. Nurse # 1 said that she remembered leaving the laboratory result sheet on the medication cart for the on coming Nurse but did not recall if she verbally told the second shift Nurse about the abnormal laboratory value for the Resident. On 01/21/2011 at 11:00 AM an interview was conducted with the Resident ' s Attending Physician. The Physician indicated that she did not know of the omission of the [MEDICATION NAME] until 01/20/2011. The Physician also indicated that there were no ill effects for either resident. There were no documented adverse affects of the [MEDICATION NAME] for either resident. On 01/21/2011 at 3:17 PM an interview was conducted with Nurse #2. Nurse #2 was assigned to the unit where Resident #48 and Resident #40 resided on 10/04/2010 for the second shift. Nurse #2 stated that she had no recollection of any stat medication orders or repeat blood draws orders received on 10/04/2010 for Resident #48. She stated that she did recall that on 10/04/2010 Resident #40 had an order for [REDACTED].#40. She stated that she did recall that on 10/04/2010 a different resident (Resident #40) had an order for [REDACTED].#40 ' s last name, she did not recall what name the laboratory sheet had written as the Resident ' s first name and did not recall seeing a note verifying the correct Resident (#48). On 01/21/2011 at 8:41 AM the facility Administrator and the Director of Nursing were notified of the Immediate Jeopardy. An acceptable allegation of compliance was provided by the facility on 01/21/2011 at 6:45 PM. The credible allegation included: Credible Allegation of Compliance Resident # 1 had a [MEDICATION NAME] lab drawn on 10/04/10 and the results were 3.3. The nurse practitioner had reviewed the lab. Resident #1 and #2 have both had lab values; which was resident #1 had a lab drawn on 01/20/11, the result was 5.9. Resident #2 had a [MEDICATION NAME] level drawn on 10/06/10 and the result was 14.5. Neither resident has had any [MEDICAL CONDITION] activity. The resident that received the one time stat dose did not have s/s of [MEDICATION NAME] toxicity. The two residents in this sample are stable with no negative outcomes. The nurse management team reviewed these two resident ' s MAR ' s for accuracy on 01/21/11. All residents who receive [MEDICATION NAME] had a chart review completed on January 21, 2011 by the nurse management team to ensure that lab levels received from October 1, 2010 until January 21, 2011 were for the correct resident. This was accomplished by matching the resident name and birth date on the lab form. If the results showed a high or low level, the charts were reviewed to ensure that the physician orders [REDACTED]. Correction actions for any identified concerns were implemented as appropriate. All resident charts were also reviewed by the pharmacy consultant on January 21, 2011. She reviewed all residents who receive [MEDICATION NAME] and the other resident ' s charts. The chart was reviewed to ensure that lab results were for the appropriate resident. This was accomplished by comparing name and birth date. Then the chart was reviewed to verify that any order issued by the physician was documented in the correct chart and that the order was initiated for the correct resident. This could include verifying additional lab work or medication administration. Any problems that were noted will be communicated to the DON for follow-up by January 21, 2011 On January 14, 2011, the facility had implemented a 24 hour chart check process. The night shift nurses are responsible for checking every chart for any newly written order to ensure that the order was transcribed to the correct MAR/TAR or implemented as ordered. This process has allowed the facility to promptly identify concerns with initiating medication orders and allow them opportunity to implement timely corrective actions. The lab check was added to the 24 hour chart check. Additionally, all nurses (RN and LPNs) who currently work in the facility were in-serviced on January 21, 2011 by SDC on the current process for order implementation. Areas covered include: ensuring that labs results are for the correct resident by verifying the birthday and resident name and then making sure that orders are written in the correct resident ' s chart and implemented for the correct resident. They will also be educated on an addition to the process that includes reviewing lab results during the 24 hour chart check. They will also check all newly received lab results to ensure appropriate interventions are initiated for the correct resident. Any staff member who does not receive training on January 21, 2011 will not be allowed to work until in-service training has been completed. The pharmacy consultant was in-serviced on January 21, 2011 by the Pharmacy Education Specialist, Topics included: the expectation for monthly reviews which includes identifying medication errors and lab concerns, timely reporting to the DON. Additional interventions are noted in the QA section of this document. The Director of Nursing or Staff Development Coordinator will monitor this issue using the "Medication Error QA Tool". The monitoring will include conducting 10 chart reviews to ensure that the 24 hour chart check was completed, that the lab results were reviewed during this chart check, that new orders are implemented on the correct resident and written in the correct chart. This will be done daily (Monday thru Friday) for four weeks and then weekly times three months or until resolved by QOL/QA committee. Reports will be given to the weekly Quality of Life- QA committee and corrective action initiated as appropriate. Additionally, every month during the Quality of Life-QA committee, the director of nursing will report on the medication errors identified during that month. Analysis will be conducted to identify trends/patterns and root causes of errors in order to implement systemic corrective action to reduce the number of medication errors. Pharmacy Education Specialist will also conduct peer reviews on staff that are assigned by her consulting agency to this facility. This will include a peer review of 10 resident charts to ensure that medication errors, lab concerns and other monthly requirements are met. This will be completed at the next scheduled chart review and will be completed monthly after that for 3 months. Results will be reported to the Administrator for review at the QA committee meetings. At the end of the 3 months review the QA committee will be consulted to determine if additional reviews are necessary. Corrective actions will be initiated as appropriate. Lab reports are to be filed by Ward Clerk/Charge Nurse on the chart once addressed by the doctor. On January 21, 2011, the filing of all lab reports in the correct resident ' s charts will be up to date. To continue to address this issue, a review to ensure that the most recent labs are on the chart will be added to the QA monitor for this survey. It will be completed as outlined in the QA section of this document. The credible allegation was validated via interviews with 8 licensed nurses that were on duty on 01/21/2011 during the first and second shifts. Validation was also accomplished via review of the records of all residents who received [MEDICATION NAME] from 01/01/2010 through present. The charts were reviewed to ensure that labs ordered by Physicians were completed timely and the results filed on the correct chart, this was done by comparing the resident ' s name and birth date. The charts were also reviewed to ensure that the Physicians had reviewed the laboratory results this was done by observing the Physicians initials on the Laboratory Result Sheets. The charts were also reviewed to ensure that any medications ordered by the Physicians were administered to the correct resident; this was done by comparing the Physician orders [REDACTED].

Based on record review, facility staff interviews, nurse practioner interview, and physician interview the facility failed to follow physician orders [REDACTED]. The facility wrote an order for [REDACTED]. The deficiency continues out at a scope and severity of " D " , (isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy, whereby significant corrections are required), so in-servicing of all staff can be completed and the facility has incorporated their proposed monitoring system into their Quality Assurance Program. The findings include: 1. A review of Resident #48 ' s record revealed that he was admitted to the facility on [DATE], with cumulative [DIAGNOSES REDACTED]. A review of Resident #48 ' s most recent Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the Resident had problems with short and long term memories and moderately impaired cognitive skills for daily decision making with cues/supervision required. The Resident was identified as requiring extensive assistance from facility staff for Activities of Daily Living. A review of Resident #48 ' s Attending Physician order [REDACTED]. There was no change in the dosage or frequency of the [MEDICATION NAME] for the months of October, November, December 2010 or January 2011. On 10/03/2010 Resident #48 ' s Physician wrote an order for [REDACTED]. A review of the Resident ' s record revealed a Laboratory Test Results Sheet dated 10/04/2010. The documentation on the sheet for the Patient ' s Name had Resident #48 ' s correct last name and an incorrect first name. The sheet documented Resident #48 ' s accurate birth date and laboratory account number. The sheet showed handwritten documentation in the upper left hand corner " called Lab & (and) verified name by BD (birth date) Acc. (account) # (number). " The incorrect first name had been marked through and the correct first name for Resident #48 had been hand written above it. The hand written documentation was signed by Nurse #1. The laboratory results sheet showed that the blood sample was received on 10/04/2010 at 7:58 AM. The sheet documented the Test Name: [MEDICATION NAME] ([MEDICATION NAME]) Result: 3.3 ug/ML (micrograms per milliliter) L (low) Reference Range: (normal values) 10.0-20.0 ug/ML. The sheet documented that the results were reported on 10/04/2010 2:53 PM. There was an additional hand written note on the laboratory results sheet located underneath the documented results. The hand written note showed " 12/04/10 8 PM (Resident ' s Attending Physician) made aware Give [MEDICATION NAME] 500 mg po now recheck [MEDICATION NAME] level on Wednesday (10/06/2010) noted " (Nurse #2 ' s signature). The sheet had the Resident ' s Physician ' s initials hand written underneath the hand written note by Nurse #2. . A review of Resident #48 ' s record revealed no documentation of a telephone order dated 10/04/2010 for the administration of [MEDICATION NAME] 500 mg or a repeat [MEDICATION NAME] Level the following Wednesday (10/06/2010). A review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the Resident ' s record revealed no Laboratory Results Sheet for a [MEDICATION NAME] Level dated 10/06/2010. A review of the Nurse ' s Notes for the Resident revealed no documentation of the administration of [MEDICATION NAME] 500 mg on 10/04/2010 or a blood draw for a repeat [MEDICATION NAME] Level on 10/06/2010. A review of the physician progress notes [REDACTED]. On 01/20/2011 at 2:30 PM an interview was conducted with the facility ' s Director of Nursing (DON) and the Administrator. The DON and the Administrator stated that they had been made aware of the omission of the medication administration and the omission of the repeat blood test, today (01/20/2011). The DON stated that when lab results come back from the lab the Charge Nurse or the Supervisor checks the results. The DON added that if the results were abnormal the Charge Nurse or the Supervisor was responsible for calling the appropriate Physician and writing any telephone orders that the Physician may give. The DON said that the night shift nursing staff was responsible for double checking all laboratory results and orders. On 01/21/2011 at 9:40 AM an interview was conducted with the Nurse Practioner that was assigned to Resident #48. The Nurse Practioner stated that she was familiar with the Resident and his care needs. She said that her expectation regarding orders for medication administration and laboratory test was that the nurse on duty would carry out the order as written. She said that there should be checks and balances in place to be sure that orders were carried out. The Nurse Practioner stated that she expected to be called for abnormal laboratory results. The Nurse Practioner stated that she and the Resident ' s Attending Physician had been made aware of the missed medication and lab test on 01/20/2011. The Nurse Practioner stated that the Resident ' s Attending Physician asked her to follow up on the incident. She said that a repeat [MEDICATION NAME] Level was drawn yesterday for Resident #48 and that she had seen the results and ordered an increase in the Resident ' s [MEDICATION NAME]. On 01/21/2011 at 10:27 AM an interview was conducted with Nurse #1. She stated that she was working 1st shift on 10/04/2010. The Nurse said that she verified the Resident ' s identity with the laboratory and that the laboratory result sheet was for Resident # 48. The Nurse stated that she used the Resident ' s date of birth and his laboratory account number from the laboratory request form to verify his identity. The Nurse stated that by the time she got the laboratory result sheet and verified the Resident ' s identity it was the end of her shift and the second shift Nurse was in the facility. The Nurse stated that it was her usual routine to verbally tell the oncoming second shift Nurse of any abnormal lab values and any stat (immediate) orders for any residents assigned to her care. Nurse #1 also stated that she always leaves laboratory result sheets received during her shift on the medication cart for the second shift Nurse to review. Nurse # 1 said that she remembered leaving the laboratory result sheet on the medication cart for the on coming Nurse but did not recall if she verbally told the second shift Nurse about the abnormal laboratory value for the Resident. On 01/21/2011 at 11:00 AM an interview was conducted with the Resident ' s Attending Physician. The Physician indicated that she did not know of the omission of the [MEDICATION NAME] or the omission of the blood draw until 01/20/2011. The Physician also indicated that there were no ill effects for either resident. There were no documented adverse affects of the [MEDICATION NAME] for either resident. On 01/21/2011 at 3:17 PM an interview was conducted with Nurse #2. Nurse #2 was assigned to the unit where Resident #48 resided on 10/04/2010 for the second shift. Nurse #2 stated that she had no recollection of any stat medication orders or repeat blood draws orders received on 10/04/2010 for Resident #48. She stated that she did recall that on 10/04/2010 a different resident (Resident #40) had an order for [REDACTED].#40 ' s last name, she did not recall what name the laboratory sheet had written as the Resident ' s first name and did not recall seeing a note verifying the correct Resident (#48). 2. A review of Resident #40 ' s record revealed that he was admitted to the facility on [DATE], with cumulative [DIAGNOSES REDACTED]. A review of Resident #40 ' s Attending Physician order [REDACTED]. There was no change in the dosage or frequency of the [MEDICATION NAME] for the months of October, November, December 2010 or January 2011. A review of the Resident #40 ' s record revealed that on 10/04/2010 at 8 PM Nurse #2 wrote a telephone order " Give [MEDICATION NAME] 500 mg po X (times) 1 now recheck [MEDICATION NAME] level on Wednesday " . This order was initialed by the Resident ' s Attending Physician. A review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the Nurse ' s Notes for the Resident #40 revealed " 10/04/2010 12 MN (midnight) alert and responsive, no acute distress total care provided with ADL ' s (activities of daily living). (Physician ' s name) made aware of abn (abnormal) [MEDICATION NAME] level. MD ordered to give [MEDICATION NAME] 500 mg po x 1 now then repeat [MEDICATION NAME] level on Wednesday " . This note was signed by Nurse #2. A review of the Resident ' s record revealed a Laboratory Result Sheet dated 10/06/2010 for a [MEDICATION NAME] Level. The results were within normal levels at 14.5 ug/ML (normal values 10-20 ug/ML). The Laboratory Result Sheet showed the Attending Physician ' s initials with no date and showed the Nurse Practioner ' s hand written initials with the date of 10/15/2010 beside the initials. A review of the physician progress notes [REDACTED]. On 01/20/2011 at 2:30 PM an interview was conducted with the facility ' s Director of Nursing (DON) and the Administrator. The DON and the Administrator stated that they had been made aware of the medication error and of the inappropriate blood draw on Resident #40. The DON stated that when lab results come back from the lab the Charge Nurse or the Supervisor checks the results. The DON added that if the results were abnormal the Charge Nurse or the Supervisor was responsible for calling the appropriate Physician and writing any telephone orders that the Physician may give. The DON said that the night shift nursing staff was responsible for double checking all laboratory results and orders. On 01/21/2011 at 9:40 AM an interview was conducted with the Nurse Practioner that was assigned to Resident #40. The Nurse Practioner stated that she was not aware of the Resident receiving an unnecessary dose of [MEDICATION NAME] on 10/04/2010 and an unnecessary blood draw on 10/06/2010 until yesterday 01/20/2011. She said that her expectation regarding orders for medication administration and laboratory test was that the nurse on duty would carry out the order as written for the correct resident. She said that there should be checks and balances in place to be sure that orders were carried out. On 01/21/2011 at 10:27 AM an interview was conducted with Nurse #1. She stated that she was working 1st shift on 10/04/2010. The Nurse said that she verified the Resident ' s identity with the laboratory and that the laboratory result sheet was for Resident # 48. The Nurse stated that she used the Resident ' s date of birth and his laboratory account number from the laboratory request form to verify his identity. The Nurse stated that by the time she got the laboratory result sheet and verified the Resident ' s identity it was the end of her shift and the second shift Nurse was in the facility. The Nurse stated that it was her usual routine to verbally tell the oncoming second shift Nurse of any abnormal lab values and any stat (immediate) orders for any residents assigned to her care. Nurse #1 also stated that she always left laboratory result sheets received during her shift on the medication cart for the second shift Nurse to review. Nurse # 1 said that she remembered leaving the laboratory result sheet on the medication cart for the on coming Nurse but did not recall if she verbally told the second shift Nurse about the abnormal laboratory value for the Resident. On 01/21/2011 at 11:00 AM an interview was conducted with the Resident ' s Attending Physician. The Physician indicated that she did not know of the omission of the [MEDICATION NAME] until 01/20/2011. The Physician also indicated that there were no ill effects for either resident. There were no documented adverse affects of the [MEDICATION NAME] for either resident. On 01/21/2011 at 3:17 PM an interview was conducted with Nurse #2. Nurse #2 was assigned to the unit where Resident #48 and Resident #40 resided on 10/04/2010 for the second shift. Nurse #2 stated that she had no recollection of any stat medication orders or repeat blood draws orders received on 10/04/2010 for Resident #48. She stated that she did recall that on 10/04/2010 Resident #40 had an order for [REDACTED].#40. The Nurse stated that she looked at the Resident ' s name on the top of the laboratory slip, which was circled in red and that name was resident #40 ' s last name, she did not recall what name the laboratory sheet had written as the Resident ' s first name and did not recall seeing a note verifying the correct Resident (#48). On 01/21/2011 at 8:41 AM the facility Administrator and the Director of Nursing were notified of the Immediate Jeopardy. An acceptable allegation of compliance was provided by the facility on 01/21/2011 at 6:45 PM. The credible allegation included: Credible Allegation of Compliance Resident # 1 had a [MEDICATION NAME] lab drawn on 10/04/10 and the results were 3.3. The nurse practitioner had reviewed the lab. Resident #1 and #2 have both had lab values; which was resident #1 had a lab drawn on 01/20/11, the result was 5.9. Resident #2 had a [MEDICATION NAME] level drawn on 10/06/10 and the result was 14.5. Neither resident has had any [MEDICAL CONDITION] activity. The resident that received the one time stat dose did not have s/s of [MEDICATION NAME] toxicity. The two residents in this sample are stable with no negative outcomes. The nurse management team reviewed these two resident ' s MAR ' s for accuracy on 01/21/11. All residents who receive [MEDICATION NAME] had a chart review completed on January 21, 2011 by the nurse management team to ensure that lab levels received from October 1, 2010 until January 21, 2011 were for the correct resident. This was accomplished by matching the resident name and birth date on the lab form. If the results showed a high or low level, the charts were reviewed to ensure that the physician orders [REDACTED]. Correction actions for any identified concerns were implemented as appropriate. All resident charts were also reviewed by the pharmacy consultant on January 21, 2011. She reviewed all residents who receive [MEDICATION NAME] and the other resident ' s charts. The chart was reviewed to ensure that lab results were for the appropriate resident. This was accomplished by comparing name and birth date. Then the chart was reviewed to verify that any order issued by the physician was documented in the correct chart and that the order was initiated for the correct resident. This could include verifying additional lab work or medication administration. Any problems that were noted will be communicated to the DON for follow-up by January 21, 2011 On January 14, 2011, the facility had implemented a 24 hour chart check process. The night shift nurses are responsible for checking every chart for any newly written order to ensure that the order was transcribed to the correct MAR/TAR or implemented as ordered. This process has allowed the facility to promptly identify concerns with initiating medication orders and allow them opportunity to implement timely corrective actions. The lab check was added to the 24 hour chart check. Additionally, all nurses (RN and LPNs) who currently work in the facility were in-serviced on January 21, 2011 by SDC on the current process for order implementation. Areas covered include: ensuring that labs results are for the correct resident by verifying the birthday and resident name and then making sure that orders are written in the correct resident ' s chart and implemented for the correct resident. They will also be educated on an addition to the process that includes reviewing lab results during the 24 hour chart check. They will also check all newly received lab results to ensure appropriate interventions are initiated for the correct resident. Any staff member who does not receive training on January 21, 2011 will not be allowed to work until in-service training has been completed. The pharmacy consultant was in-serviced on January 21, 2011 by the Pharmacy Education Specialist, Topics included: the expectation for monthly reviews which includes identifying medication errors and lab concerns, timely reporting to the DON. Additional interventions are noted in the QA section of this document. The Director of Nursing or Staff Development Coordinator will monitor this issue using the "Medication Error QA Tool". The monitoring will include conducting 10 chart reviews to ensure that the 24 hour chart check was completed, that the lab results were reviewed during this chart check, that new orders are implemented on the correct resident and written in the correct chart. This will be done daily (Monday thru Friday) for four weeks and then weekly times three months or until resolved by QOL/QA committee. Reports will be given to the weekly Quality of Life- QA committee and corrective action initiated as appropriate. Additionally, every month during the Quality of Life-QA committee, the director of nursing will report on the medication errors identified during that month. Analysis will be conducted to identify trends/patterns and root causes of errors in order to implement systemic corrective action to reduce the number of medication errors. Pharmacy Education Specialist will also conduct peer reviews on staff that are assigned by her consulting agency to this facility. This will include a peer review of 10 resident charts to ensure that medication errors, lab concerns and other monthly requirements are met. This will be completed at the next scheduled chart review and will be completed monthly after that for 3 months. Results will be reported to the Administrator for review at the QA committee meetings. At the end of the 3 months review the QA committee will be consulted to determine if additional reviews are necessary. Corrective actions will be initiated as appropriate. Lab reports are to be filed by Ward Clerk/Charge Nurse on the chart once addressed by the doctor. On January 21, 2011, the filing of all lab reports in the correct resident ' s charts will be up to date. To continue to address this issue, a review to ensure that the most recent labs are on the chart will be added to the QA monitor for this survey. It will be completed as outlined in the QA section of this document. The credible allegation was validated via interviews with 8 licensed nurses that were on duty on 01/21/2011 during the first and second shifts. Validation was also accomplished via review of the records of all residents who received [MEDICATION NAME] from 01/01/2010 through present. The charts were reviewed to ensure that labs ordered by Physicians were completed timely and the results filed on the correct chart, this was done by comparing the resident ' s name and birth date. The charts were also reviewed to ensure that the Physicians had reviewed the laboratory results this was done by observing the Physicians initials on the Laboratory Result Sheets. The charts were also reviewed to ensure that any medications ordered by the Physicians were administered to the correct resident; this was done by comparing the Physician orders [REDACTED].

Based on record review, facility staff interviews, pharmacist review, nursing practioner interview and physician review the facility failed to identify and report irregularities to the attending physician and the director of nursing. The facility did not give a dose of Dilantin or obtain a Dilantin level for 1 of 4 sampled residents (Resident #48) as ordered by the physician. The facility wrote an order for [REDACTED]. This constituted Immediate Jeopardy from 10/04/2010 until on-site removal of Immediate Jeopardy on 01/21/2011. The deficiency continues out at a scope and severity of " D " , (isolated no actual harm with potential for more than minimal harm that is not immediate jeopardy, whereby significant corrections are required), so in-servicing of all staff can be completed and the facility has incorporated their proposed monitoring system into their Quality Assurance Program. The findings include: 1. A review of Resident #48 ' s record revealed that he was admitted to the facility on [DATE], with cumulative [DIAGNOSES REDACTED]. A review of Resident #48 ' s most recent Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the Resident had problems with short and long term memories and moderately impaired cognitive skills for daily decision making with cues/supervision required. The Resident was identified as requiring extensive assistance from facility staff for Activities of Daily Living. A review of Resident #48 ' s Attending Physician order [REDACTED]. There was no change in the dosage or frequency of the medication for the months of October, November, December 2010 or January 2011. On 10/03/2010 Resident #48 ' s Physician wrote an order for [REDACTED]. A review of the Resident ' s record revealed a Laboratory Test Results Sheet dated 10/04/2010. The documentation on the sheet for the Patient ' s Name had Resident #48 ' s correct last name and an incorrect first name. The sheet documented Resident #48 ' s accurate birth date and account number. The sheet showed handwritten documentation in the upper left hand corner " called Lab & (and) verified name by BD (birth date) Acc. (account) # (number). " The incorrect first name had been marked through and the correct first name for Resident #48 had been hand written above it. The hand written documentation was signed by Nurse #1. The laboratory results sheet showed that the blood sample was received on 10/04/2010 at 7:58 AM. The sheet documented the Test Name: Dilantin (Phenytoin) Result: 3.3 ug/ML (micrograms per milliliter) L (low) Reference Range: (normal values) 10.0-20.0 ug/ML. The sheet documented that the results were reported on 10/04/2010 2:53 PM. There was an additional hand written note on the laboratory results sheet located underneath the documented results. The hand written note showed " 12/04/10 8 PM (Resident ' s Attending Physician) made aware Give Dilantin 500 mg po now recheck Dilantin level on Wednesday (10/06/2010) noted " (Nurse #2 ' s signature). The sheet had the Resident ' s Physician ' s initials hand written underneath the hand written note by Nurse #2. A review of Resident #48 ' s record revealed no documentation of a telephone order dated 10/04/2010 for the administration of Dilantin 500 mg or a repeat Dilantin Level the following Wednesday (10/06/2010). A review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the Resident ' s record revealed no Laboratory Results Sheet for a Dilantin Level dated 10/06/2010. A review of the Nurse ' s Notes for the Resident revealed no documentation of the administration of Dilantin 500 mg on 10/04/2010 or a blood draw for a repeat Dilantin Level on 10/06/2010. A review of the Pharmacist Chart Review Notes from 10/01/2010 through present showed no documentation of the extra dose of Dilantin (500 mg) or of the repeat Dilantin Level request by the Resident ' s Attending Physician. On 01/20/2011 at 10:00 AM an interview was conducted with the facility ' s Pharmacist Consultant. The Pharmacist stated that she did not know where the order for the repeat lab draw came from and stated that she had not seen the order (for the Dilantin 500 mg and repeat Dilantin Level) before today (01/20/2010). The Pharmacist said that when she did resident monthly medication reviews she checked for new medication orders, new lab orders and lab results. The Pharmacist stated that when she was aware that a lab test was missing she told the nursing staff at the facility and she would make a note to that effect in her progress notes. The Pharmacist said that if there was not a mention of a missing lab test in her notes she was not aware of the test being ordered and not completed. On 01/20/2011 at 2:30 PM an interview was conducted with the facility ' s Director of Nursing (DON) and the Administrator. The DON and the Administrator stated that they had been made aware of the omission of the medication administration and the omission of the repeat blood test, today (01/20/2011) for Resident #48. On 01/21/2011 at 9:23 AM a second interview was conducted with the facility ' s Pharmacist Consultant, she stated that she reviewed each resident ' s medications on a monthly basis and that she also reviewed the resident ' s labs at the same time. She said that when she saw any medication irregularities or abnormal labs she would write it in her note and make recommendations to the DON. The Pharmacist stated that she had not seen the laboratory test for Resident #48 dated 10/04/2010 until yesterday (01/20/2011) when the surveyor showed it to her. The Pharmacist added that if she had seen the lab report with the telephone order on it from the doctor ordering a stat (immediate) dose of Dilantin and a repeat blood draw she would have noted it in her October Note. The Pharmacist said that all of her recommendations are written and sent to the DON and that if she saw something that was urgent she would verbally tell the DON. On 01/21/2011 at 9:40 AM an interview was conducted with the Nurse Practioner that was assigned to Resident #48. The Nurse Practioner stated that she was familiar with the Resident and his care needs. She said that her expectation regarding orders for medication administration and laboratory test was that the nurse on duty would carry out the order as written. She said that there should be checks and balances in place to be sure that orders were carried out. The Nurse Practioner stated that she expected to be called for abnormal laboratory results. The Nurse Practioner stated that she and the Resident ' s Attending Physician had been made aware of the missed medication and lab test on 01/20/2011. The Nurse Practioner stated that the Resident ' s Attending Physician asked her to follow up on the incident. She said that a repeat Dilantin Level was drawn yesterday for Resident #48 and that she had seen the results and ordered an increase in the Resident ' s Dilantin. On 01/21/2011 at 10:27 AM an interview was conducted with Nurse #1. She stated that she was working 1st shift on 10/04/2010. The Nurse said that she verified the Resident ' s identity with the laboratory and that the laboratory result sheet was for Resident # 48. The Nurse stated that she used the Resident ' s date of birth and his laboratory account number from the laboratory request form to verify his identity. The Nurse stated that by the time she got the laboratory result sheet and verified the Resident ' s identity it was the end of her shift and the second shift Nurse was in the facility. The Nurse stated that it was her usual routine to verbally tell the oncoming second shift Nurse of any abnormal lab values and any stat (immediate) orders for any residents assigned to her care. Nurse #1 also stated that she always left laboratory result sheets received during her shift on the medication cart for the second shift Nurse to review. Nurse # 1 said that she remembered leaving the laboratory result sheet on the medication cart for the on coming Nurse but did not recall if she verbally told the second shift Nurse about the abnormal laboratory value for the Resident. On 01/21/2011 at 11:00 AM an interview was conducted with the Resident ' s Attending Physician. The Physician indicated that she did not know of the omission of the Dilantin until 01/20/2011. The Physician also indicated that there were no ill effects for either resident. There were no documented adverse affects of the Dilantin for either resident. On 01/21/2011 at 3:17 PM an interview was conducted with Nurse #2. Nurse #2 was assigned to the unit where Resident #48 resided on 10/04/2010 for the second shift. Nurse #2 stated that she had no recollection of any stat medication orders or repeat blood draws orders received on 10/04/2010 for Resident #48. She stated that she did recall that on 10/04/2010 a different resident (Resident #40) had an order for [REDACTED].#40 ' s last name, she did not recall what name the laboratory sheet had written as the Resident ' s first name and did not recall seeing a note verifying the correct Resident (#48). 2. A review of Resident #40 ' s record revealed that he was admitted to the facility on [DATE], with cumulative [DIAGNOSES REDACTED]. A review of Resident #40 ' s most recent Quarterly Minimum Set (MDS) revealed that the Resident had problems with short and long term memories and moderately impaired cognitive skills for daily decision making with cues/supervision required. The Resident was identified as requiring extensive assistance from facility staff for Activities of Daily Living. A review of Resident #40 ' s Attending Physician order [REDACTED]. There was no change in the dosage or frequency of the medication through the months of October, November, December 2010, or January 2011. A review of the Resident #40 ' s record revealed that on 10/04/2010 at 8 PM Nurse #2 wrote a telephone order " Give Dilantin 500 mg po X (times) 1 now recheck Dilantin level on Wednesday " . This order was initialed by the Resident ' s Attending Physician. A review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the Nurse ' s Notes for the Resident #40 revealed " 10/04/2010 12 MN (midnight) alert and responsive, no acute distress total care provided with ADL ' s (activities of daily living). (Physician ' s name) made aware of abn (abnormal) Dilantin level. MD ordered to give Dilantin 500 mg po x 1 now then repeat Dilantin level on Wednesday " . This note was signed by Nurse #2. A review of the Resident ' s record revealed a Laboratory Result Sheet dated 10/06/2010 for a Dilantin Level. The results were within normal levels at 14.5 ug/ML (normal values 10-20 ug/ML). The Laboratory Result Sheet showed the Attending Physician ' s initials with no date and showed the Nurse Practioner ' s hand written initials with the date of 10/15/2010 beside the initials. A review of the Pharmacist Chart Review Notes from 10/21/2010 through present showed no documentation of the extra dose of Dilantin (500 mg) or of the repeat Dilantin Level on 10/06/2010. A review of the physician progress notes [REDACTED]. On 01/20/2011 at 10:00 AM an interview was conducted with the facility ' s Pharmacist Consultant. The Pharmacist stated that she did not know that Resident #40 received an extra dose of Dilantin and a blood draw that were meant for Resident #48 before today. The Pharmacist said that when she did resident monthly medication reviews she checked for new medication orders, new lab orders and lab results. The Pharmacist stated that when she was aware that a medication had been administered in error she told the nursing staff at the facility and she would make a note to that effect in her progress notes. The Pharmacist said that if there was not a mention of an unnecessary medication given to a resident or of a blood draw was done on the wrong resident in her notes then she was not aware of the incidents. On 01/20/2011 at 2:30 PM an interview was conducted with the facility ' s Director of Nursing (DON) and the Administrator. The DON and the Administrator stated that they had been made aware of the medication error and of the inappropriate blood draw on Resident #40 until today 01/20/2011. On 01/21/2011 at 9:23 AM a second interview was conducted with the facility ' s Pharmacist Consultant, she stated that she reviewed each resident ' s medications on a monthly basis and that she also reviewed the resident ' s labs at the same time. She said that when she saw any medication irregularities or abnormal labs she would write it in her note and make recommendations to the DON. The Pharmacist said that all of her recommendations are written and sent to the DON and that if she saw something that was urgent she would verbally tell the DON. On 01/21/2011 at 9:40 AM an interview was conducted with the Nurse Practioner that was assigned to Resident #40. The Nurse Practioner stated that she was not aware of the Resident receiving an unnecessary dose of Dilantin on 10/04/2010 and an unnecessary blood draw on 10/06/2010 until yesterday 01/20/2011. She said that her expectation regarding orders for medication administration and laboratory test was that the nurse on duty would carry out the order as written for the correct resident. She said that there should be checks and balances in place to be sure that orders were carried out. On 01/21/2011 at 10:27 AM an interview was conducted with Nurse #1. She stated that she was working 1st shift on 10/04/2010. The Nurse said that she verified the Resident ' s identity with the laboratory and that the laboratory result sheet was for Resident # 48. The Nurse stated that she used the Resident ' s date of birth and his laboratory account number from the laboratory request form to verify his identity. The Nurse stated that by the time she got the laboratory result sheet and verified the Resident ' s identity it was the end of her shift and the second shift Nurse was in the facility. The Nurse stated that it was her usual routine to verbally tell the oncoming second shift Nurse of any abnormal lab values and any stat (immediate) orders for any residents assigned to her care. Nurse #1 also stated that she always left laboratory result sheets received during her shift on the medication cart for the second shift Nurse to review. Nurse # 1 said that she remembered leaving the laboratory result sheet on the medication cart for the on coming Nurse but did not recall if she verbally told the second shift Nurse about the abnormal laboratory value for the Resident. On 01/21/2011 at 11:00 AM an interview was conducted with the Resident ' s Attending Physician. The Physician indicated that she did not know of the omission of the Dilantin until 01/20/2011. The Physician also indicated that there were no ill effects for either resident. There were no documented adverse affects of the Dilantin for either resident. On 01/21/2011 at 3:17 PM an interview was conducted with Nurse #2. Nurse #2 was assigned to the unit where Resident #48 and Resident #40 resided on 10/04/2010 for the second shift. Nurse #2 stated that she had no recollection of any stat medication orders or repeat blood draws orders received on 10/04/2010 for Resident #48. She stated that she did recall that on 10/04/2010 Resident #40 had an order for [REDACTED].#40. The Nurse stated that she looked at the Resident ' s name on the top of the laboratory slip, which was circled in red and that name was resident #40 ' s last name, she did not recall what name the laboratory sheet had written as the Resident ' s first name and did not recall seeing a note verifying the correct Resident (#48). On 01/21/2011 at 8:41 AM the facility Administrator and the Director of Nursing were notified of the Immediate Jeopardy. An acceptable allegation of compliance was provided by the facility on 01/21/2011 at 6:45 PM. The credible allegation included: Credible Allegation of Compliance Resident # 1 had a Dilantin lab drawn on 10/04/10 and the results were 3.3. The nurse practitioner had reviewed the lab. Resident #1 and #2 have both had lab values; which was resident #1 had a lab drawn on 01/20/11, the result was 5.9. Resident #2 had a dilantin level drawn on 10/06/10 and the result was 14.5. Neither resident has had any seizure activity. The resident that received the one time stat dose did not have s/s of Dilantin toxicity. The two residents in this sample are stable with no negative outcomes. The nurse management team reviewed these two resident ' s MAR ' s for accuracy on 01/21/11. All residents who receive Dilantin had a chart review completed on January 21, 2011 by the nurse management team to ensure that lab levels received from October 1, 2010 until January 21, 2011 were for the correct resident. This was accomplished by matching the resident name and birth date on the lab form. If the results showed a high or low level, the charts were reviewed to ensure that the physician orders [REDACTED]. Correction actions for any identified concerns were implemented as appropriate. All resident charts were also reviewed by the pharmacy consultant on January 21, 2011. She reviewed all residents who receive Dilantin and the other resident ' s charts. The chart was reviewed to ensure that lab results were for the appropriate resident. This was accomplished by comparing name and birth date. Then the chart was reviewed to verify that any order issued by the physician was documented in the correct chart and that the order was initiated for the correct resident. This could include verifying additional lab work or medication administration. Any problems that were noted will be communicated to the DON for follow-up by January 21, 2011 On January 14, 2011, the facility had implemented a 24 hour chart check process. The night shift nurses are responsible for checking every chart for any newly written order to ensure that the order was transcribed to the correct MAR/TAR or implemented as ordered. This process has allowed the facility to promptly identify concerns with initiating medication orders and allow them opportunity to implement timely corrective actions. The lab check was added to the 24 hour chart check. Additionally, all nurses (RN and LPNs) who currently work in the facility were in-serviced on January 21, 2011 by SDC on the current process for order implementation. Areas covered include: ensuring that labs results are for the correct resident by verifying the birthday and resident name and then making sure that orders are written in the correct resident ' s chart and implemented for the correct resident. They will also be educated on an addition to the process that includes reviewing lab results during the 24 hour chart check. They will also check all newly received lab results to ensure appropriate interventions are initiated for the correct resident. Any staff member who does not receive training on January 21, 2011 will not be allowed to work until in-service training has been completed. The pharmacy consultant was in-serviced on January 21, 2011 by the Pharmacy Education Specialist, Topics included: the expectation for monthly reviews which includes identifying medication errors and lab concerns, timely reporting to the DON. Additional interventions are noted in the QA section of this document. The Director of Nursing or Staff Development Coordinator will monitor this issue using the "Medication Error QA Tool". The monitoring will include conducting 10 chart reviews to ensure that the 24 hour chart check was completed, that the lab results were reviewed during this chart check, that new orders are implemented on the correct resident and written in the correct chart. This will be done daily (Monday thru Friday) for four weeks and then weekly times three months or until resolved by QOL/QA committee. Reports will be given to the weekly Quality of Life- QA committee and corrective action initiated as appropriate. Additionally, every month during the Quality of Life-QA committee, the director of nursing will report on the medication errors identified during that month. Analysis will be conducted to identify trends/patterns and root causes of errors in order to implement systemic corrective action to reduce the number of medication errors. Pharmacy Education Specialist will also conduct peer reviews on staff that are assigned by her consulting agency to this facility. This will include a peer review of 10 resident charts to ensure that medication errors, lab concerns and other monthly requirements are met. This will be completed at the next scheduled chart review and will be completed monthly after that for 3 months. Results will be reported to the Administrator for review at the QA committee meetings. At the end of the 3 months review the QA committee will be consulted to determine if additional reviews are necessary. Corrective actions will be initiated as appropriate. Lab reports are to be filed by Ward Clerk/Charge Nurse on the chart once addressed by the doctor. On January 21, 2011, the filing of all lab reports in the correct resident ' s charts will be up to date. To continue to address this issue, a review to ensure that the most recent labs are on the chart will be added to the QA monitor for this survey. It will be completed as outlined in the QA section of this document. The credible allegation was validated via interviews with 8 licensed nurses that were on duty on 01/21/2011 during the first and second shifts. Validation was also accomplished via review of the records of all residents who received Dilantin from 01/01/2010 through present. The charts were reviewed to ensure that labs ordered by Physicians were completed timely and the results filed on the correct chart, this was done by comparing the resident ' s name and birth date. The charts were also reviewed to ensure that the Physicians had reviewed the laboratory results this was done by observing the Physicians initials on the Laboratory Result Sheets. The charts were also reviewed to ensure that any medications ordered by the Physicians were administered to the correct resident; this was done by comparing the Physician orders [REDACTED].