Every finding on record at Carlton Shores Healthcare and Rehabilitation Cente

Based on observations, interviews, and record review, the facility failed to ensure that all essential equipment in the kitchen was maintained in safe operating condition. The facility's dish machine did not reach 120 degrees F during the rinse cycle, the walk-in freezer had a large accumulation of ice on the floor, on storage racks, and on food boxes, the kitchen ice machine was not working, and the freezer fan was not running. The findings include: On 4/01/2024 at 12:51 pm, Dietary Aide C was asked to test the dish machine. She stated she was not really good at it. She stated Dietary Aide B usually performed this task. She then turned the dish machine on. At this time, none of the temperature gauges moved. She stated most of the time they tested the machine after lunch. She was not able to answer any questions regarding the dish machine. Signage was affixed to the wall behind the dish machine with operating instructions for the dish machine. Also, there was a label affixed to the machine advising that the minimum rinse temperature was 120 degrees. On 4/01/2024 at 1:03 pm, the certified dietary manager (CDM) returned to the kitchen. She was advised of the observation of the dish machine and that gauges weren't moving when the machine was turned on. She was asked to explain the process the facility used when the dish machine was inoperable. She stated Dietary Aide B repeated the process until the machine reached the appropriate temperature. She asked Cook D to test the dish machine. When he turned on the machine, neither of the gauges moved. The CDM stated, Yeah, it's off., adding that she would call Maintenance regarding the issue. The final rinse temperature gauge read 110 degrees Fahrenheit (F). On 4/01/2024 at 2:22 pm, the CDM advised that the gauges on the dish machine were set. She stated the only time they moved was if the temperature was less than 110 degrees F, as it was a low temperature machine. She advised that the dish machine was not broken as she previously stated. On 4/02/2024 at 11:21 am, the dish machine was re-tested . The Administrator, CDM, and Regional Dietary Manager were present. Again, neither of the gauges moved. The Administrator stated he received an email from the service company which stated the only gauge that should move was the final rinse. At this time, the Administrator, CDM, and the Regional CDM all confirmed that gauge did not move nor did any of the others. The CDM and Regional CDM stated the gauge would not move unless the water temperature dropped below 100 degrees F. They stated at that time that the gauge would slowly rise as the temperature increased. The Administrator advised them that was contrary to what the email from the service provider stated. He re-read the email aloud, emphasizing the final rinse temperature gauge was supposed to move. The Administrator then tapped on the final rinse temperature gauge with his finger. Again, the gauge did not move. The Regional CDM stated he would have to clarify this. The CDM advised the Administrator that the dish machine was low-temperature and therefore, the water temperature could not go too high as it would kill the chemicals. The Administrator confirmed clarity was needed, as this was contrary to the email he received from the service provider, and he needed to know whether there was a maintenance issue with the machine. Clarification was not provided during the survey. On 4/02/2024 at 11:34 am, a sign on the ice machine in the kitchen read: Out of Order. On 4/02/2024 at 12:17 pm, the CDM and Regional CDM were observed in the dish room manipulating the dish machine. At 1:48 pm, the CDM advised that they had drained the entire dish machine, and the gauges were now moving as they should. On 4/02/2024 at 2:24 pm, the CDM requested that the surveyor accompany her to the kitchen to re-test the dish machine. She stated after the machine was drained, the final rinse temperature registered at 89 degrees. She stated the gauges moved up. An observation of the machine revealed that the final rinse temperature gauge was still at 110 degrees F. She re-tested the machine two more times. Each time, the dial on the final rinse temperature gauge did not rise above 112 degrees F. At this time, the CDM's attention was directed to the signage and label affixed to the machine advising that the minimum rinse temp was 120 degrees F. Upon seeing this she replied, Oh, I'll let them know. (Photographic evidence obtained) According to Cleaner Solutions Custom Chemical Programs at www.cleanersolutions.net (dated 2/9/2024 and accessed on 4/18/24 at 4:40 pm): Low temperature commercial dishwashers have wash and rinse cycles that run between 120 and 150 degrees Fahrenheit. This temperature range does not achieve sanitation alone so the low-temp dish machines require chemical sanitizers. Although you are utilizing chemicals for sanitation, the water temperature has a large effect on cleaning results. Here are several things you need to know about your low-temp dish machine: * The Source of the Hot Water: Low-temp dishwasher machines do not heat the water, they use the water from your hot water heater. In order to get the correct water temperature in the dish machine, you ' ll need to adjust the temperature on the water heater. * National Sanitary Foundation Requirements: For low-temp dish machines the National Sanitary Foundation (NSF) requires a minimum of 120 F for automatic dishwasher machine applications. Therefore, this is the bare minimum and a temperature less than 120 F will result in a health department violation. During an observation of the walk-in freezer on 4/1/2024 at 12:37 pm, the fan/fan blades located near the top of the freezer were not moving. Icicles were observed hanging from the metal food racks. Mounds of ice were observed on the walls, floor, and boxes of food on the shelves inside of the freezer. (Photographic evidence obtained) During a kitchen observation on 4/02/2024 at 2:45 pm, the blades of the fan in the freezer were now moving. Icicles remained on the metal racks. Mounds of ice remained on the floor, wall, and on boxes of food on the metal shelves/racks. A large garbage can containing ice was stored in the freezer. The CDM was advised of the observation. She stated the freezer was being defrosted and repairs were being made to the broken ice machine located in the kitchen. She was shown the icicles on the shelves and mounds of ice on the floor. She stated she was aware of this. She stated the refrigeration company had been in the facility the morning of 4/1/2024 to service the machine however, she could not provide any documentation to support this. The documentation was requested from the Administrator on 4/2/2024 at 2:53 pm. (Photographic evidence obtained) On 4/02/2024 at 4:05 pm, the Administrator advised that the service provider for the dish machine had been contacted by telephone. They were not able to provide a definitive diagnosis for the dish machine rinse cycle not reaching 120 degrees F and the gauges not moving. He stated the meals would be served on Styrofoam until they could perform a proper diagnostic. He did not have a scheduled date of service for this. At this time, he also advised that he was unable to locate the invoice for the walk-in freezer repairs. .

Based on observations, interviews and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the resident's choices, by failing to provide one (Resident #56) of one resident admitted to the facility with the need for hemodialysis (HD) with a meal prior to [CONDITION(S)] and/or a meal/snack to take with him to the [CONDITION(S)] center onm his [CONDITION(S)] days. The findings include: A review of Resident #56's medical record revealed an admission on 11/19/2021 and a documented readmission on 2/23/2022. Resident #56's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/23/2022, a Mini Nutritional Assessment resulted in a score of 10, indicating At risk for Malnutrition. A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. A review of the active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plan revealed Resident #56 had the following documented focus areas: 1. Potential Fluid Imbalance related to Kidney Failure/End-Stage [CONDITION(S)] with Hemodialysis (Goal indicated resident would comply with diet and/or fluid restrictions daily through next review date). 2. Diabetes Mellitus with documented goal to be free of symptoms of [CONDITION(S)]. (Documented intervention indicated provided dietary consult for nutritional monitoring, discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen). 3. Nutritional Problem/Potential Nutritional Problem related to therapeutic diet restrictions, chronic kidney disease, Stage 5. Resident will maintain adequate nutritional status as evidenced by no significant weight change, no signs or symptoms of malnutrition through review date. There were no care plans indicating the resident should have an early breakfast or a meal/snack to take to the [CONDITION(S)] center with him on his [CONDITION(S)] days. On 4/25/2022 at 1:52 PM, an interview was conducted with Resident #56 and his wife. He was observed quickly eating potato chips. He stated he returned from [CONDITION(S)] and for the last two weeks the facility had not prepared him breakfast or sent him to [CONDITION(S)] with a meal/snack. He stated he went to [CONDITION(S)] on Mondays, Wednesdays and Fridays, and about two weeks ago, the facility staff no longer provided him with his yellow bagged snack/lunch. He said his chair time was at 7:20 AM, he got up around 5:30 AM, and went to wait for the bus at 6:45 AM. He said, I returned around 1:00 PM after [CONDITION(S)]. Resident #56 was interviewed again on 4/26/2022 at 9:27 AM. He confirmed that he went to [CONDITION(S)] for the last two weeks with no meal/snack. He said the facility did not provide breakfast in the facility, and no meal or snack was sent with him for the last two weeks. The staff were supposed to put a sandwich in a yellow bag, and drop it in the bag on the back of the wheelchair (he pointed to bag hanging on the back of his wheelchair). They have not done this for the last two weeks. He confirmed he did not refuse the lunch bag or snacks. He said the bus left at 6:00 AM, so he had to be at the front porch at 5:45 AM, and he returned around 12:00 PM to 1:00 PM from [CONDITION(S)]. An off-hours facility site visit was made on 4/27/2022 at 5:45 AM. An observation was made of Resident #56 at 5:45 AM in the hall near his room. He stated he was ready to go out to the bus stop. He was asked if the facility provided him with a snack, breakfast or a bagged lunch. He said no. Resident #56 said, I saved a deli sandwich (ham) from yesterday and I ate that at 4:00 AM. He said, Now it has been about three weeks since the facility provided me with the yellow bag that had a snack in it. Resident #56 stated the yellow bag was supposed to be put in the refrigerator in the snack room so the certified nursing assistant (CNA) could retrieve the bag and place it in his [CONDITION(S)] bag in the morning. An observation was made of CNA C on 4/27/2022 at 5:48 AM. She pushed Resident #56 in his wheelchair out to the front area with no snack or lunch. An observation was made on 4/28/2022 at 5:49 AM of the orthopedic unit nutrition room. A refrigerator was observed in that room. The refrigerator was opened and no yellow snack bag, sandwich or breakfast meal could be located for Resident #56 to take to [CONDITION(S)] with him. (Photographic evidence obtained) An interview was conducted with CNA C on 4/27/2022 at 5:52 AM. She was observed walking toward the kitchen and stated Resident #56 did not always get his snack bag or lunch, but she was going to the kitchen to retrieve it. She said she did not work every day and could only speak for the days she worked. She confirmed that for some time now, the dietary services staff had not shown up on time and did not make the resident's sandwich. The door may be locked and we cannot find snacks or sandwiches to give to residents. CNA C stated she told several people. The transportation staff member (CNA J/Transport) knew and she told dietary staff, but they were constantly changing so she could not recall who she told. She stated a couple of times she had to send Resident #56 to [CONDITION(S)] without even a snack. On 4/27/2022 at 5:55 AM, an observation was made of Cook D rushing around in the kitchen because CNA C reported to the kitchen to get a snack made for Resident #56 to take with him to [CONDITION(S)]. The snack was not ready. Cook D confirmed that Resident #56 did not have any snacks or lunch prepared for the day. She stated it was the job of the evening dietary aid to prepare the snacks and meals for [CONDITION(S)] residents. Because we have been so short-staffed and everyone is new, it is possible the evening aids do not even know about making the resident snacks and lunch who need them the next morning. Cook D pointed to the [CONDITION(S)] resident list on the wall in the kitchen and stated, We were provided with the list of residents on [CONDITION(S)]. It is just that in the evening there may be only one aide so they forget to make the snack bags. (Copy obtained) On 4/27/2022 at 5:58 AM, CNA C was observed as she rushed out to the front of the building to the bus taking Resident #56 to [CONDITION(S)]. The bus driver had finished strapping Resident #56 in. Resident #56 was interviewed at this time and stated, It has been three weeks now since I received that bag. He thanked CNA C, and stated he would have the bus driver drop the yellow meal bag in his [CONDITION(S)] bag. On 4/27/2022 at 9:23 AM, an interview was conducted with the interim Regional Director of Culinary Services who stated the Certified Dietary Manager (CDM) quit on 4/27/2022. He provided the procedure outline showing how to provide residents who needed to leave the facility with a nutritious snack to meet their dietary needs. A copy of the outline was requested. On 4/27/2022 at 9:35 AM, an interview was conducted with CNA J/Transportation. She confirmed that she arranged transport for three buildings. She stated she was aware of some problems with Resident #56 getting his [CONDITION(S)] trip snack/lunch, but thought it had been taken care of. CNA J confirmed that a [CONDITION(S)] list was sent to the kitchen and the dietary staff were expected to prepare the meals the day before [CONDITION(S)] because Resident #56's chair time was early. On 4/27/2022 at 10:20 AM, an interview was conducted with the interim Dietary Manager. He stated there was no process for preparing the [CONDITION(S)] meals. Staff were expected to make the meal. There was no defined procedure for getting the meal to the resident. Shortly after the interview with the interim Dietary Manager on 4/27/2022 at 10:24 AM, he provided the policy for Contracted Organization Hospitality Services Bagged Meals, which revealed that individuals who required a meal away from the facility would be provided with a bagged meal. This included those attending medical appointments, [CONDITION(S)], extended trips for treatments, or for other purposes. (copy obtained) None of the staff interviews supported knowledge of this policy. An interview was conducted with the Chief Clinical Officer (CCO) and the Regional Director of Regulatory Compliance (DRC) regarding how resident [CONDITION(S)] orders were entered. They confirmed by review of Resident #56's medical record at 1:53 PM on 4/27/2022, that no task or specific care plan was generated by the diet slip order entered for Resident #56. They stated they would load up a care plan and task so the CNA would be updated to send a meal with the resident. On 4/27/2022 at 2:00 PM, an interview was conducted with the Director of Nursing (DON), CCO and DRC. They indicated there was no identified procedure that ensured Resident #56 received his meals over the last two weeks. A review of Resident #56's medical record confirmed there was no diet order instructing staff that a meal must be provided prior to [CONDITION(S)]. There was no instruction to provide a snack/or bagged lunch to take to [CONDITION(S)] in Resident #56's Care Plan or CNA task list. They stated Resident #56 refused to take the meals at times and wanted to provide nursing notes that documented Resident #56's refusal. Only one note within the past 3 -4 weeks was identified with a refusal to accept a dietary snack because the resident felt nauseated. No other note or refusal of the meal/snack bag was located in the medical record over the last two weeks. An interview was conducted on 4/27/2022 at 2:20 PM with the COO and DRC. They provided a document dated 4/27/2022 at 2:15 PM. It read: Spoke with a staff member at the [CONDITION(S)] center and the staff member stated, On the days that [Resident #56] brings lunch, she has herself removed it and given him his sandwich and he ate it. The resident is not allowed to have food or drink on the floor while receiving [CONDITION(S)]. On 4/28/2022 at 8:00 AM, a telephone interview was conducted with the [CONDITION(S)] center staff member whose name was provided by the nursing facility on 04/27/2022 at 2:15 PM. The staff member knew Resident #56 and stated he was not permitted to eat while on the [CONDITION(S)] machine. Once off the machine, we take the resident back to the lobby. If he had a sandwich he asked the nurse who retrieved it from his bag. She confirmed she would also help him get the sandwich out of the bag. She was asked whether she had provided him with a snack/sandwich in the last three weeks and she said no. On 4/28/2022 at 8:51 AM, an interview was conducted by telephone with the [CONDITION(S)] center Registered Dietician (RD). She confirmed she saw Resident #56 yesterday (4/27/2022) and he had a sandwich. She confirmed she personally spoke to the facility in the past about Resident #56 needing breakfast before he came to [CONDITION(S)]. She confirmed she called and left messages and even spoke with the food supervisor who was no longer at the facility. The RD stated Resident #56 should not have to save a deli sandwich from the night before to eat because he was going to [CONDITION(S)] with no food. The RD confirmed Resident #56 was permitted to bring food, he just could not eat the food while in the [CONDITION(S)] treatment area. She stated Resident #56 showed her his lunch bag when she saw him yesterday at the [CONDITION(S)] center. An interview was conducted with the CCO on 4/28/2022 at 10:03 AM to discuss two newly introduced documents for Resident #56. One document was a care plan section and Kardex report that was updated on 4/27/2022. The care plan read, Offer/Provide resident (#56) with bagged breakfast on [CONDITION(S)] days (Monday, Wednesday and Friday leaves at 5:30 AM usually.) The Kardex read, Offer/Provide Resident with a bagged breakfast on [CONDITION(S)] days (Monday, Wednesday and Friday leaves at 5:30 AM usually.) The CCO confirmed the care plan was updated after it was brought to her attention during the survey. She stated they corrected it after a meeting on 4/27/2022. An interview was conducted with Licensed Practical Nurse (LPN) I/Unit Manager, on 4/28/2022 at 1:43 PM. She indicated there was supposed to be a diet slip that provided special instructions. Once the order was entered all of the staff should know that Resident #56 needed a meal prepared for the days he went to [CONDITION(S)]. A review of the medical record was completed with LPN I, and she confirmed there was only one diet order entered with no special instructions for the current admission. The diet slip was dated 12/17/2021 and was entered by a staff member that was no longer employed at the facility. When that order was put in, the staff member should have initiated the appropriate tasks and information provided for Resident #56, who was supposed to receive a meal on [CONDITION(S)] days to take with him to the center. A review of the facility's policy, standards and guidelines, indicated this facility would provide the necessary care and services to those residents receiving hemodialysis while they were a resident at the facility. Line 11 revealed that if the resident required a meal to be sent with them to the [CONDITION(S)] center, one would be provided by the facility. Date last revised was 03/01/2021. A review of the facility's policy provided by the interim Dietary Manager on 4/27/2022 at 10:24 AM, indicated a procedure was in place to provide individuals requiring a meal away from the facility would be provided with a bagged meal. This included those attending medical appointments, [CONDITION(S)], extended trips for treatments or for other purposes. .

Based on observation, interviews with staff, and reviews of the facility's Medication Destruction Policy and the Omnicare Med Pass Checklist, the facility failed to ensure its medication error rate was not 5% or greater (rate 6.67%) for two (Residents in rooms 110B and 304) of seven residents observed during medication administration. The findings include: A medication administration observation was conducted with Registered Nurse (RN) K on 4/26/22 at 4:00 p.m. for the resident in room [ROOM NUMBER] B. RN K reviewed the Medication Administration Record (MAR) and pulled [MEDICATION(S)] 10 milligrams (mg) for blood pressure and [MEDICATION(S)] 10-325 mg for pain from the medication cart. After approaching the resident in room [ROOM NUMBER] B and taking the resident's blood pressure (93/60), RN K decided not to administer the [MEDICATION(S)] and instead, call the physician. The resident took the [MEDICATION(S)]. RN K took the medication cup with the [MEDICATION(S)], discarded it in the trash can in the resident's room, and proceeded to walk out of the room. She was called back and asked what was done with medications not taken by the residents. She replied, I could dispose of it in the Sharps container or use the dissolver on the medication cart. She was asked to retrieve the pill from the resident's trash can and dispose of it properly. She removed the pill from the trash can and discarded it in the Sharps container on the wall in the resident's room. On 4/29/22 at 4:35 p.m. the Director of Nursing (DON) stated she was providing education to RN K and other nurses about the appropriate disposal of medications not taken by residents. She confirmed the [MEDICATION(S)] should not have been thrown in the resident's trash can; there was a dissolver on the cart for that purpose. A medication administration observation was conducted with RN G on 4/27/22 at 8:29 a.m., who was collecting medications for the resident in room [ROOM NUMBER]. RN G reviewed the MAR and pulled Alpha Lipolic Acid 600 mg, Carvediolol 6.25 mg, [MEDICATION(S)] 4 mg (which fell on the mouse pad on the medication cart and the nurse then used a corner of the medication card to pick it up and put it in the medication cup), Glipidzide 2.5 mg, MultiVitamin with minerals, [MEDICATION(S)] 75 mg, [MEDICATION(S)] 50 mg, Losartan 100 mg, Vitamin D 5000 international units (IU), and Tylenol 650 mg into the medication cup. RN G confirmed placing the dropped pill ([MEDICATION(S)]) in the medication cup and not disposing of it. He took the medication cup to resident's room with the dropped, contaminated [MEDICATION(S)] in the cup and gave it to the resident. An interview was conducted with the Chief Clinical Officer (CCO)/RN on 4/28/22 at 10:02 a.m. concerning the disposal of medication not taken, and dropped pills being placed in medication cups for administration to residents. The CCO stated if a pill was dropped on the medication cart surface, it should be destroyed in the chemical dissolution drug disposal container on the cart, and pills not taken should be destroyed in the same container. A pill dropped on the cart should not be given to a resident. A review of the Medication Destruction Policy (dated 1/15/21) revealed the disposal of all medications should be in accordance with state and federal guidelines for the safe disposition of controlled substances which renders such medications undesirable and unusable. The Omnicare Med Pass Checklist was reviewed, which noted under infection control: medications are dispensed without touching; gloves used when handling medications.

Based on observations, interviews and document review, the facility failed to ensure the appropriate labeling/storage of medications for four (Residents #48, #55, #77 and #206) of seven residents sampled. Pre-pouring medication placed each resident at risk for a medication administration error by risk of provided the incorrect medications. The findings include: On 4/27/2022 at 5:11 AM, an observation was made of Licensed Practical Nurse (LPN) A's medication cart. Three unlabeled medication cups were observed with an assortment of tablets of different shapes, sizes and colors inside. An interview was conducted with LPN A at the time of observation and she stated the medications were pulled for Residents #48, #55, #77 and #206. She confirmed the three medication cups had four different resident medications that included two pain pills in the same cup. LPN A stated the blue [MEDICATION(S)] (narcotic pain medication) was for Resident #55 and the other tablet was for Resident #48. Both were controlled substances. (Photographic evidence obtained) On 4/27/2022 at 5:28 AM, LPN A was asked what she was going to do with all of the pre-poured medication. She stated, give the medications. On 4/27/2022 at 1:00 PM, an interview was conducted with the Chief Clinical Officer (CCO) who stated pre-poured medication was not allowed. An interview was conducted with the CCO and the Director of Quality on 4/28/2022 at 3:00 PM. They both stated pre-poured medication was not permitted. A review of Resident #48's medical record revealed he had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. A review of Resident #48's care plan revealed a focus area for pain medication therapy. An intervention read, Administer analgesic medications as ordered by Physician. A review of Resident #48's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #55's medical record revealed she also had a BIMS score of 15. Her care plan revealed she had a focus area for pain medication which included the intervention Administer medications as ordered by physician. The MAR for Resident #55, dated 4/27/2022, revealed the initials for LPN A next to the administration of [MEDICATION(S)] tablet 5-325 mg at 4:00 AM on 4/27/2022. The blue tablet was confirmed in the unmarked medication cup at 5:11 AM along with a white oblong tablet for Resident #48 that was described by LPN A as [MEDICATION(S)]. A review of Resident #77's medical record revealed he had a BIMS score of 14, indicating intact cognition. The care plan for Resident #77 indicated he received [CONDITION(S)] replacement therapy. A review of the MAR for Resident #77 revealed that LPN A documented the administration of [MEDICATION(S)] tablet 100 mg on 4/27/2022 at 6:00 AM. A review of Resident #206's medical record revealed that she had a BIMS score of 15, indicating intact cognition. The care plan for Resident #206 indicated she was on antidepressant medication and anticoagulant therapy. A review of the facility's Omnicare Medication Pass Checklist used for nursing services revealed under Medication Cart Security, line 3, Medications are not pre-poured or pre-documented.

Based on record reviews, interviews, and a review of the hospice agency contract, the facility failed to maintain a hospice plan of care, hospice visits and documentation of care in the resident record for one (Resident #75) of four residents reviewed for hospice services/coordination of care, from a total sample of 43 residents. The findings include: An interview was conducted with Resident #75's daughter on 4/25/22 at 12:41 p.m. She reported her mother was receiving hospice care and the caregiver came to visit on Mondays, Wednesdays, and Fridays, but was not bathing the resident if she was already dressed. A call had been placed to the hospice agency and they were notified of the concern. Resident #75 was lying in bed covered up with blankets and had mats on the floor beside her bed. Lunch was on the bedside table and her daughter was going to assist her with lunch. A medical record review was conducted for Resident #75 which noted an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's recertification for hospice, dated 3/1/22, noted the primary hospice diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan for the facility was reviewed, which noted the resident was diagnosed with a terminal condition and was presently under hospice care for an end-stage diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospice contract was re-signed on 2/11/22. An interview was conducted with the Registered Nurse (RN)/Unit Manager for the Cardiac and Sub-acute Unit on 4/27/22 at 4:30 p.m. concerning a request for the plan of care, physician's recertification, documented visits and care from hospice. The Unit Manager reported faxing, and emailing for the last several hours trying to receive the documents requested, but had not received them as of this time. The documents were requested at 2:00 p.m. on 4/27/22. An interview was conducted with the Director of Regulatory Compliance (DRC-RN) at 8:45 a.m. on 4/28/22 after receiving the hospice documentation requested. The DRC-RN reported having to call the hospice provider again late yesterday afternoon to receive the information. He reported the information was not on site. An interview was conducted with Certified Nurses Assistant (CNA) O at 9:30 a.m. on 4/28/22. She reported Resident #75 required total care with bathing. The hospice CNA came in on Mondays, Wednesdays and Fridays and provided the resident's showers. If the hospice CNA did not show up, the facility CNAs gave the resident her shower. When asked if she spoke to the hospice nurse or staff about the resident, she reported no. An interview was conducted with the Social Services Director (SSD) and the Director of Nursing (DON), RN, on 4/28/22 at 1:25 p.m. The DON reported she was the contact person for hospice services and one of the other hospice agencies popped into her office and gave updates on their residents and asked whether anything else was needed. The DON confirmed the assigned hospice agency was contacted several times yesterday asking for information, and the Director of Regulatory Compliance also called them yesterday afternoon, before the facility finally received the information. There had been a discussion with the Chief Compliance Officer and the Director of Regulatory Compliance about a plan to follow up with hospice about visits and maintaining a current plan of care on site. She reported the team was also looking at discussions with each hospice nurse to keep up with their plan and orders and keeping documentation on site. The SSD reported an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Licensed Practical Nurse (LPN) L at 1:38 p.m. on 4/28/22. She confirmed that Resident #75 received hospice services and the nurse came in to visit the resident today. LPN L reported that the nurse asked if the resident needed any prescription refills and she replied no. When asked whether she spoke with the hospice nurse before she left, LPN L replied no. A review of the contract for hospice services for the facility revealed on page 6 under medical records documentation: Hospice will retain responsibility for ensuring requirements related to hospice medical records are met. Facility shall allow access to appropriate medical records and permit the inclusion of hospice care plans and other appropriate documentation in Hospice Patient's Facility Medical Record. Hospice shall coordinate with Facility to ensure documentation of services is completed.

Based on interviews, record reviews and policy and procedure review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #2) of 5 sampled residents reviewed for abuse. The findings include: A review of the medical record for Resident #2's revealed an admitted [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 1/13/22 at 3:08 PM, an interview was conducted with Resident #2 in her room. She stated that she was attacked by another resident on Thanksgiving Day and did not feel safe. She expressed that no one was listening to her. A record review of Resident #2's most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed she had a brief mental status (BIMS) score of 15 out of 15 points, indicating intact cognition. A telephone interview was conducted with Employee C, Social Worker (SW) on 1/13/22 at 4:50 PM. The SW confirmed that he and Employee A, Certified Nursing Assistant (CNA)/Social Services Assistant (SSA) met with Resident #2, who told them, she was hit by Resident #5 on Thanksgiving Day. The SW stated, he reported the allegation to the previous Director of Nursing (DON), who is no longer working at the facility. The SW was unable to describe what happened from there, except that the previous DON met with the Administrator at the time and created a file for the allegation. When the SW was asked if Resident #5 was moved to another unit, he said, Yes, Resident 2 did not want Resident #5 around her. On 1/13/22 at 6:19 PM, an interview was conducted with Employee A, CNA/SSA. She explained that she was familiar with Resident #2, and that Resident #2 did not want Resident #5 around her. She went on to say that Employee B, RN/Clinical Education, and the previous DON completed an investigation concerning the allegation of Resident #5 hitting Resident #2. Employee A stated that Resident #5 was moved to another unit because of the allegation. A review of Resident #2's incident report on the eINTERACT form dated 12/23/21, revealed she had a bruise to her right arm located below the deltoid. She was transferred to the local hospital for evaluation. On 1/13/22 at 7:15 PM, an interview was conducted with the Administrator. She confirmed that the allegation of resident-on-resident violence by Resident #2 should have been reported as required. The Administrator confirmed, she could not locate an investigation or detailed report related to Resident #2's allegation about Thanksgiving or the bruise on Resident #2's arm. The administrator was unable to provide a copy of the federal report related to the allegation of abuse. On 1/14/22 at 12:30 PM, a telephone interview was conducted with Physician A. The physician confirmed that Resident #2's allegation of abuse should have been reported to him. He was not aware or did not recall the incident being reported. A review of the social service progress notes for Resident #2 revealed an entry dated 12/30/21 at 11:21 AM, indicated the resident had concerns regarding Resident #5. (Copy obtained) A review of the progress notes for Resident #2 revealed an entry dated 1/10/22 at 12:13 PM (late entry note), indicated that Resident #2 had a referral for emotional and/or behavioral symptoms and concerns that prompted the referral for a full evaluation. Consult to evaluate for psychological services and assess delusions & paranoia (perseverates on another resident grabbing her arm & she states he bruised her arm; he has been moved to another unit, but she still perseverates on this). Experiencing psychological stress (Anxiety) that impacts social emotional functioning. The facility adjusted BIMS on this review indicated 13 (13-15 indicated intact cognition). Under diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I am not safe physically & my stuff. A review of the facility's Abuse, Neglect, Exploitation reference read, The facility must ensure that ALL allegations of abuse, neglect, injuries of unknown origin, and exploitation/misappropriation of resident property are reported immediately to the administrator of the facility, the Agency for Health Care Administration, the Department of Children and Families, the Florida Abuse Hotline and to other officials in accordance with state and federal law. The document revealed that Federal regulation requires a facility to have evidence that all allegations of abuse, neglect, injuries of unknown source, and exploitation/misappropriation are thoroughly investigated. (Copy obtained)

Based on interviews, record reviews and policy and procedure review, the facility failed to provide evidence that one allegation of abuse was fully investigated for 1 (Resident #2) of 5 sampled residents reviewed for abuse. Failure to thoroughly investigate an allegation of abuse can lead to unreported concerns of abuse and increased threat to the individual. The findings include: A review of the medical record for Resident #2's revealed an admitted [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 1/13/22 at 3:08 PM, an interview was conducted with Resident #2 in her room. She stated that she was attacked by another resident on Thanksgiving Day and did not feel safe. She expressed that no one was listening to her. A record review of Resident #2's most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed she had a brief mental status (BIMS) score of 15 out of 15 points, indicating intact cognition. A telephone interview was conducted with Employee C, Social Worker (SW) on 1/13/22 at 4:50 PM. The SW confirmed that he and Employee A, Certified Nursing Assistant (CNA)/Social Services Assistant (SSA) met with Resident #2, who told them, she was hit by Resident #5 on Thanksgiving Day. The SW stated, he reported the allegation to the previous Director of Nursing (DON), who is no longer working at the facility. The SW was unable to describe what happened from there, except that the previous DON met with the Administrator at the time and created a file for the allegation. When the SW was asked if Resident #5 was moved to another unit, he said, Yes, Resident 2 did not want Resident #5 around her. On 1/13/22 at 6:19 PM, an interview was conducted with Employee A, CNA/SSA. She explained that she was familiar with Resident #2, and that Resident #2 did not want Resident #5 around her. She went on to say that Employee B, RN/Clinical Education, and the previous DON completed an investigation concerning the allegation of Resident #5 hitting Resident #2. Employee A stated that Resident #5 was moved to another unit because of the allegation. A review of Resident #2's incident report on the eINTERACT form dated 12/23/21, revealed she had a bruise to her right arm located below the deltoid. She was transferred to the local hospital for evaluation. On 1/13/22 at 7:15 PM, an interview was conducted with the Administrator. She confirmed that the allegation of resident-on-resident violence by Resident #2 should have been reported as required. The Administrator confirmed, she could not locate an investigation or detailed report related to Resident #2's allegation about Thanksgiving or the bruise on Resident #2's arm. The administrator was unable to provide a copy of the federal report related to the allegation of abuse. On 1/14/22 at 12:30 PM, a telephone interview was conducted with Physician A. The physician confirmed that Resident #2's allegation of abuse should have been reported to him. He was not aware or did not recall the incident being reported. A review of the social service progress notes for Resident #2 revealed an entry dated 12/30/21 at 11:21 AM, indicated the resident had concerns regarding Resident #5. (Copy obtained) A review of the progress notes for Resident #2 revealed an entry dated 1/10/22 at 12:13 PM (late entry note), indicated that Resident #2 had a referral for emotional and/or behavioral symptoms and concerns that prompted the referral for a full evaluation. Consult to evaluate for psychological services and assess delusions & paranoia (perseverates on another resident grabbing her arm & she states he bruised her arm; he has been moved to another unit, but she still perseverates on this). Experiencing psychological stress (Anxiety) that impacts social emotional functioning. The facility adjusted BIMS on this review indicated 13 (13-15 indicated intact cognition). Under diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I am not safe physically & my stuff. A review of the facility's Abuse, Neglect, Exploitation reference read, The facility must ensure that ALL allegations of abuse, neglect, injuries of unknown origin, and exploitation/misappropriation of resident property are reported immediately to the administrator of the facility, the Agency for Health Care Administration, the Department of Children and Families, the Florida Abuse Hotline and to other officials in accordance with state and federal law. The document revealed that Federal regulation requires a facility to have evidence that all allegations of abuse, neglect, injuries of unknown source, and exploitation/misappropriation are thoroughly investigated. (Copy obtained) On 01/14/22 at 4:44 PM, an email was received from the Administrator, which was sent to her from Employee D, Director of Nursing (DON) (no longer working at the facility) on 01/14/22 at 1:43 PM. The email read, November 25, 2021, On this day the kitchen was preparing a thanksgiving lunch for residents. I went back to cardiac unit to check on those going to the dining area. Resident #2 was coming out of her room. I greeted her and asked if she would like assistance to the dining room. She agreed and I pushed her in her wheelchair to the dining room. At no time did she have contact with any other resident on her way to the dining room. Signed by Employee D, DON The facility was unable to provide any additional evidence that Resident #2's allegation of abuse on Thanksgiving Day was thoroughly investigated.

Based on record review, interviews and policy and procedure review, the facility failed to ensure residents were seen by a physician at least every 60 days for 1 (Resident #2) of 5 sampled residents for physician visits. Not routinely assessing and identifying health concerns has the potential to lead to negative outcomes. The findings include: A review of Resident #2's medical record revealed an admitted [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 1/13/22 at 3:08 PM, an interview was conducted with Resident #2 in her room. She stated that she was not being seen by a physician. When she was asked if she had seen a physician in December or January 2022, she stated, No I haven't. A record review of Resident #2's most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed she had a brief mental status (BIMS) score of 15 out of 15 points, indicating intact cognition. A review of the social service progress note for Resident #2 revealed an entry dated 12/30/21 at 11:21 AM, which indicated the resident had not seen her attending physician and would like to know when he will be in to see her. (Copy obtained) A review of Resident #2's physician's visit documentation provided by the facility revealed she was seen on 3/10/21, 5/10/21, 9/09/21, 9/27/21, and 10/05/21. There were no documented physician visits in June 2021, July 2021, August 2021, December 2021, or January 2022. On 1/13/22 at 3:15 PM, an interview was conducted with the facility Nurse Consultant (via telephone) and Administrator regarding Resident #2's physician visits. They could not explain why Resident #2 did not have documented physician visits every 60 days as required. On 1/13/22 at 6:32 PM, a telephone interview was conducted with Employee F, Billing. She confirmed that all physician billing is completed through the physician notes. She stated that based on physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) An interview was conducted with Employee G, Medical Records on 1/13/22 at 6:40 PM. She confirmed that she spoke with Employee E, Nurse Practitioner (NP) who works with Physician A. The NP told her that she only rounded on Resident #2 every 90-days because that is all Medicare would reimburse for. (Copy of statement from Employee G was provided) On 1/14/22 at 12:30 PM, a telephone interview was conducted with Physician A. Physician A stated that Resident #2 was visited on 1/8/21, 1/11/21, 3/10/21, 5/10/21, 9/09/21, 9/27/21 and 10/05/21. Physician A confirmed that Resident #2 received a physician visit on 5/10/21, but wasn't seen again until 9/09/21, which represented a timeframe greater than 60 days. On 1/14/22, the facility provided documentation showing Resident #2 received a physician visit on 1/14/22. A review of the facility's Standards and Guidelines: SG Physician's Initial Comprehensive Visit, with 1/1/21 date implemented revealed: It will be the standard of this facility that each resident shall be under the care of a licensed physician that will provide an initial comprehensive visit and routine physician visits according to state and federal law. 42 C.F.R. 483.40 (c) (4) and (e) state: the physician MAY NOT delegate the initial comprehensive visit in a SNF. (Copy obtained) .

Based on observation, interviews and record review, the facility failed to honor resident's choice for showers for one (Resident #5) of five residents reviewed for personal care choices. The findings include: A clinical record review for Resident #5 revealed he was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident #5 on 10/20/21 at 11:46 AM, he stated that he missed his shower on 10/19/21. He asked a certified nursing assistant (CNA) if he could get a shower later in the day. She said, she would return to give him one, but the CNA never came back, and he never got a shower on that day. On 10/20/21 at 4:26 PM, Resident #5 stated that he requested a shower again today, but staff did not give him one. When he was asked if he refused any showers, he replied, No I have not. On 10/21/21 at 8:13 AM, Resident #5 was asked if he received a shower yesterday. He said, No, I asked at least two people for a shower yesterday and I still didn't get one. A review of the admission minimum data set (MDS) assessment dated [DATE] revealed that Resident #5 had a brief interview for mental status (BIMS) score of 14, indicating cognitively intact. The resident required extensive assistance with personal hygiene and toilet use; and required one-person physical assist in part of his bathing activity. A review of the resident's care plan indicated he had an activity of daily living (ADL) self-care performance deficit related to fatigue, impaired balance, limited mobility, limited range of motion, musculoskeletal impairment, and weakness. Intervention included extensive assistance of two staff members for bathing; and resident usually prefers a shower; however, some days choses to have a bed bath. During an interview with Employee C, Licensed Practical Nurse (LPN) on 10/21/21 at 8:20 AM, she confirmed that she spoke with Resident #5 on 10/20/21 about getting a shower. She acknowledged that she, dropped the ball' and did not follow through with getting him a shower. A review of Resident #5's shower schedule revealed the following days and time: Tuesday, Thursday and Saturday from 7 AM to 3 PM. (Copy obtained) A review of the facility's shower documentation for Resident #5 revealed the intervention/task for bathing/showers was not documented as given on the following days: 10/07 (Thursday), 10/12 (Tuesday), 10/14 (Thursday), and 10/16 (Saturday). On 10/19/21 staff documented at 6:59 PM bathing/showers with N/A. It was also documented on 10/19/21 for the same bathing/showering section at 3:37 AM with N/A. (Copy obtained) An interview was conducted with the Assistant Director of Nursing (ADON) on 10/21/21 at 1:44 PM. The ADON stated that, if a resident asked for a shower, it should be completed as soon as practical and should not take a day and a half to be provided. During a follow up interview with Resident #5 on 10/21/21 at 12:03 PM, he confirmed he was in the process of getting a shower. An interview was conducted with Employee F, LPN on 10/21/21 at 3:54 PM related to a progress note dated 10/21/21 at 8:54 AM. She confirmed that her note referred to Resident #5's shower request on 10/19/21 after he missed his shower. She confirmed Resident #5 talked to the supervisor and that he was supposed to get a shower. A review of the facility's Resident Rights, Dignity, and Visitation Rights policy implemented on 1/1/21, revealed the following 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 4. The facility will promote care for residents in a manner and in an environment that maintains or enhances dignity and respect in recognition of his or her individually, preferences, activities, preferences, activities, pursuits, goals and desires. 6.(iv) The right to receive the services and/or items included in the care plan. (Copy obtained)

Based on record review and staff interviews, the facility failed to act as a fiduciary of the resident's funds and ensure the resident's monies were refunded to the appropriate resident for one (Resident #2) of two residents reviewed for refunds, out of a sample of five residents reviewed for accounting management. The findings include: A record review for Resident #2 revealed he had an initial admitted [DATE] and an initial discharge date of [DATE]. Resident #2 was listed as his own responsible party. Friend #1 was listed as his emergency contact. A review of the facility accounting notes revealed Resident #2 was owed a refund amount of $1,236.74. Further record review for Resident #2 revealed a document dated 9/14/21, which referred to a concern dated back to 6/16/21 which read, issued a refund check from the facility to another facility on behalf of Resident #2. The check was written to another person who was not Resident #2 and was not a documented Power of Attorney (POA) for Resident #2. An interview was conducted with the facility Business Office Manager (BOM) on 10/21/21 at 12:24 PM. He stated that the billing company issued a check to Resident #2's documented emergency contact by mistake. They were not supposed to do that. A telephone interview was conducted with Employee G, Accounting Representative on 10/21/21 at 1:02 PM. Employee G confirmed the accounting department put the wrong name on the refund check that was intended for Resident #2 and could not explain how that happened. The facility had not corrected the problem as of 10/21/21 but stated they would issue a new check to Resident #2 once they located his address. A review of the Resident Refund Information form for Resident #2 provided by the BOM on 10/21/21 at 12:24 PM revealed, Resident #2 as Resident Name, the amount of check $1236.74 and the name on check as Friend #1. (Copy obtained) A copy of the check provided on 10/21/21 at 12:24 PM revealed the amount of the check $1236.74 and pay to the order of Friend #1. The check was endorsed as cashed. (Copy obtained)

Based on observation, interview and record review, the facility failed to ensure medications remained in properly labeled containers until the time of administration for four (Residents #6, #7, #8 and #9) of four residents sampled for medication administration. This placed the residents at risk for medication administration error related to unsafe medication administration. The findings include: On 10/21/21 at 8:25 AM a medication cart was observed in the facility hallway unattended with the top drawer unlocked. After opening the top drawer, 4 medication cups were observed (two with crushed medications and two with tablet/capsules). The medication cups were marked 9 A, 9 B, 10 A and 10 B. Shortly thereafter, Employee B, Licensed Practical Nurse (LPN) came around the corner. She identified the four medication cups and confirmed immediately that she was not supposed to have four resident medications poured at the same time. (Photographic evidence obtained) An interview was conducted with Employee D, LPN on 10/21/21 at 8:31 AM. The LPN confirmed that staff should never have more than one resident medication pulled to administer at the same time. An interview was conducted with the Regional Nurse Consultant and Assistant Director of Nursing on 10/21/21 at 1:36 PM. Each confirmed that facility staff should never have more than one resident medication prepared to administer at the same time. A review of resident minimum data set (MDS) assessments with brief interview for mental status (BIMS) revealed the following: Resident #6- most recent quarterly MDS, dated [DATE], indicated a documented BIMS score of 15, indicating cognitively intact. Resident #7- most recent quarterly MDS, dated [DATE], indicated a documented BIMS score of 12, indicating moderate cognitive impairment. Resident #8- most recent quarterly MDS, dated [DATE], indicated a documented BIMS score of 03, indicating severe cognitive impairment. Resident #9-most recent quarterly MDS, dated [DATE], indicated a documented BIMS score of 10, indicating moderately impaired cognition. A review of the Med Pass Checklist provided by the facility revealed, Medications are not pre-poured or pre-documented. (Copy obtained)

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for for two (Residents #22 and #93) of 41 sampled residents. Resident #22's medications were administered more than two hours after the time they were ordered and were documented as having been administered at the time they were ordered, prior to the resident having received the medication. This could lead to omission in medication therapy. Resident #93's wound dressing change, which was ordered daily, was not completed daily as ordered. This placed Resident #93 at a greater risk for a wound infection. The findings include: 1. Resident #22 was admitted on [DATE] with [DIAGNOSES REDACTED]. She relied on staff for medication regimen management as ordered by her physician. On 10/15/20 at 9:00 AM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN), regarding the need to observe medication administration. LPN A stated all of the 9:00 AM medications had been administered and no additional medications were due until noon. LPN A's computer screen assignment was requested and reflected that all residents assigned to LPN A had a green radio button. LPN A stated the green radio button represented that the required task (medication administration) had been completed. Medication administration was documented as having been completed for Resident #22 at 9:00 AM. An interview was conducted with Resident #22 on 10/15/20 at 9:45 AM. She confirmed that she had not received her morning medications and recited some medications which included her sugar medications, vitamin, and some others. An interview was conducted with LPN A on 10/15/20 at 9:59 AM, and she confirmed that Resident #22 was alert and oriented to person, place and time. LPN A reviewed the Minimum Data Set (MDS) assessment's Brief Interview for Mental Status (BIMS) score, which was documented at 15, indicating that Resident #22 was cognitively intact. A second interview was conducted with Resident #22 on 10/15/20 at 10:01 AM, to confirm that the resident stated she had not received her morning medications. On 10/15/20 at 10:16 AM all 8:00 AM medications were confirmed documented for Resident #22 on 10/15/20. This was represented by a green radio button on the administration computer LPN A, who confirmed that indicated the medications were administered. A review of the electronic Medication Administration Record [REDACTED]. A medication administration observation was conducted with LPN A for Resident #22 on 10/15/20 at 10:11 AM. The following medications were observed pulled and administered to Resident #22 at 10:32 AM: 1 Tablet Aspirin 81 mg (milligrams), ordered for 8:00 AM administration daily, one tablet one time a day. 1 Tablet [MEDICATION NAME] 325 mg, ordered for 8:00 AM, 1 tablet by mouth one time a day for supplementation. 1 Tablet [MEDICATION NAME] 5 mg, ordered one tablet by mouth one time a day at 8:00 AM. 1 Tablet [MEDICATION NAME] 24 hours 90 mg, ordered one tablet by mouth one time a day at 8:00 AM. 1 Tablet Actos 30 mg, Ploglitazone ordered for 8:00 AM, one time a day related to diabetes mellitus. 1 Tablet [MEDICATION NAME] 10 mg, ordered for 8:00 AM one tablet by mouth daily for type 2 diabetes. The October 2020 Medication Administration Record [REDACTED]. A review of the medication administration audit report for Resident #22 on 10/15/20 indicated that LPN A administered the following: 1 Tablet Aspirin 81 mg ordered for 8:00 AM was administered on 10/15/20 at 8:07 AM. 1 Tablet [MEDICATION NAME] 325 mg ordered for 8:00 AM, 1 tablet by mouth one time a day for supplementation was administered on 10/15/20 at 8:07 AM. 1 Tablet [MEDICATION NAME] 5 mg ordered one tablet by mouth one time a day was administered on 10/15/20 at 8:07 AM. 1 Tablet [MEDICATION NAME] 24 hours 90 mg ordered one tablet by mouth one time a day was administered on 10/15/20 at 8:07 AM. 1 Tablet Actos 30 mg, Ploglitazone ordered for 8:00 AM one time a day related to diabetes mellitus was administered on 10/15/20 at 8:07 AM. 1 Tablet [MEDICATION NAME] 10 mg was administered on 10/15/20 at 8:07 AM. (Photographic and documented evidence obtained of MAR, computer documentation) An interview was conducted with the Director of Nursing (DON) on 10/15/20 at 12:09 PM. She confirmed that staff should not document medication administration until after the medication is administered. She also confirmed the green radio buttons on a nursing medication administration screen indicated that the medication had been administered. (Photographic evidence obtained) Resident #22's care plan was reviewed and revealed the resident had a potential for hyper/[DIAGNOSES REDACTED] related to diabetes mellitus and altered cardiovascular status related to hypertension. The intervention documented was to ensure that medication was administered as ordered by the doctor. A review of the facility's policy and procedure for Medication Administration was conducted and documented on line 14, When medications are administered, the individual administering the medications must record in the resident's medical record/MAR. 2. A review of the clinical record revealed that Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #93 was documented as cognitively impaired and relied on staff for care and services. On 10/12/20 at 1:36 PM, an observation was made of Resident #93's right leg and the three bandages were observed to be dated 10/12/20. On 10/15/20 at 2:47 PM, an observation was made of the right leg wound dressing with Certified Nursing Asistant (CNA) B who confirmed the date on the dressing was 10/13/20. An interview was conducted with LPN E on 10/15/20 at 2:53 PM. The treatment administration record (TAR) was reviewed and indicated that the wound dressing was ordered to be changed daily. LPN C's initials indicated that LPN C changed the dressing on the evening shift dated 10/14/20, however the dressing change was documented with a 10/13/20 due date. Employee LPN D was interviewed on 10/15/20 at 3:00 PM and confirmed that the right shin dressing on Resident #93 was not changed and the date indicated no dressing change occurred as had been ordered. A review of the resident's care plan revealed: The resident has a skin tear to her right lower leg. Anterior. (front) Date initiated 10/12/20. If skin tear occurs, treat per facility protocol/physician orders-see initiated 10/12/20. A review of the physician's orders [REDACTED]. LPN A created the note, which read: Clean skin tears on lower leg with normal saline then apply Xeroform with dry dressing every evening shift. The start date was 10/11/20 at 15:00 hours (3:00 PM).

Based on medical record review, staff interviews and a review of the facility's policy entitled Standards and Guidelines for Medication Administration, the facility failed to ensure residents were free of significant medication errors for one (Resident #11) of one resident reviewed for [MEDICAL TREATMENT], from of a total sample of 41 residents reviewed. Resident #11 received an antihypertensive medication ([MEDICATION NAME]) outside of parameters when he exhibited low blood pressures, and Sevelamar and [MEDICATION NAME] ([MEDICATION NAME] binders) were ordered three times a day, but were not being administered. The findings include: A record review was conducted for Resident #11, revealing an admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the October 2020 Medication Administration Record (MAR) revealed [MEDICATION NAME] 25 milligrams (mg) was ordered to be given in the evening every day with the following parameter: If systolic blood pressure (BP) was over 170. The order was dated 4/9/2020, and the medication was scheduled at 7:00 PM. Another order for [MEDICATION NAME] 25 mg was ordered to be given every Tuesday, Thursday, Saturday and Sunday on non-[MEDICAL TREATMENT] days. This order was dated 9/9/2020, and the medication was scheduled at 9:00 AM. A physician's orders [REDACTED]. Resident #11 leaves the building on Mondays, Wednesdays and Fridays for [MEDICAL TREATMENT] treatments. At this time, during the Covid pandemic, the resident was not able to take food with him to the [MEDICAL TREATMENT] center, so the orders for Sevelamer HCL and [MEDICATION NAME] should have been clarified with the physician or changed. A review of the MAR from April through October 2020, revealed the [MEDICATION NAME] was given multiple days with systolic blood pressures below 170. (Photographic evidence obtained) A review of the MAR for August through September noted the Sevelamer HCL and [MEDICATION NAME] were not given on days the resident went out to [MEDICAL TREATMENT] at lunch time. A review of the nursing notes and a chart review did not indicate that the physician had been notified that the resident was receiving the [MEDICATION NAME] with blood pressures that were not within the parameters, or that Sevelamer and [MEDICATION NAME] were not being given three times a day as ordered. A physician's orders [REDACTED]. A review of the blood pressures documented in the electronic medical record under vital signs revealed there were multiple days the systolic blood pressure was below 100 and the diastolic blood pressure was below 60. (Photographic evidence obtained) An interview was conducted with Resident #11 on 10/13/2020 at 4:19 PM. He reported that food was not allowed to be taken into the [MEDICAL TREATMENT] center, so a lunch was not given to him on the days he went to [MEDICAL TREATMENT]. An interview was conducted with the Registered Nurse (RN)/Assistant Director of Nursing (ADON) on 10/14/2020 at 3:00 PM. She was asked about the scheduled [MEDICATION NAME] given daily with a parameter instructing that the medication was not to be given unless the systolic BP was above 170, and Sevelamer and [MEDICATION NAME] were not being given as ordered because the resident did not take food with him on [MEDICAL TREATMENT] days. She reviewed the current MAR showing the [MEDICATION NAME] with parameters, and the Sevelamer and [MEDICATION NAME] ordered to be given three times a day, and reported she would call the physician for clarification. A medical record review was conducted on 10/15/2020, revealing an Event Note for medication variance. The Event Note read: Spoke with MD (physician) regarding [MEDICATION NAME] 25 mg, give 1 tablet by mouth one time daily, hold if systolic BP is below 170, order written on 4/9/2020. Received the following clarification orders: Okay to give this medication between the dates of 4/9 and 10/14/2020 outside of parameters. Discontinue [MEDICATION NAME] 25 mg, give 1 by mouth daily, hold if systolic BP below 170. The physician's orders [REDACTED]. An interview was conducted with the ADON on 10/15/2020 at 10:52 AM regarding Resident #11's medications. She reported a clarification order was received from the physician stating it was okay to give the medication [MEDICATION NAME] outside of the parameters 4/9-10/14/2020. The [MEDICATION NAME] 25 mg was discontinued with the parameter, and the [MEDICATION NAME] 25 mg given every Tuesday, Thursday, Saturday and Sunday would remain on non-[MEDICAL TREATMENT] days. She reported the resident was notified of the medication change and verbalized understanding. She confirmed the Sevelamer and Sucroferic were addressed also. The physician for Resident #11 was called via phone on 10/15/2020 at 3:48 PM to discuss the [MEDICATION NAME] being given outside of the parameters. A message was left and he returned the call at 4:00 PM. He reported he was not contacted about the resident having low BPs and the [MEDICATION NAME] being administered outside of the parameters. He stated, The [MEDICATION NAME] should not have been administered unless the blood pressure systolic was over 170. The physician also discussed the order for [MEDICATION NAME] 10 mg, which was ordered for [MEDICAL CONDITION] and to be administered on days the resident went to [MEDICAL TREATMENT]. He reported when fluid built up in a patient on [MEDICAL TREATMENT], it could cause high blood pressure, and when the fluid was taken off, the blood pressure could drop. The physician also reported he had two partners, and one of them must have been called last night if the orders were changed now. A review of the Standards and Guidelines for Medication Administration, revised 11/1/16, noted the standard of this facility was to administer medications in a timely manner and as prescribed by the physician. According to the Mayo Clinic at https://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-oral-route/side-effects/drg- 141?p=1 (Accessed 10/15/2020 at 4:30 PM): Take this medicine only as directed by your doctor. Do not take more of it, do not take it more often, and do not take it for a longer time than your doctor ordered. According to Medline Plus at https://medlineplus.gov/druginfo/meds/a 4.html#precautions (Accessed 10/15/20 at 4:40 PM): Take [MEDICATION NAME] exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. According to News Medical Life Sciences at https://www.news-medical.net/drugs/[MEDICATION NAME].aspx (Accessed 10/16/20 at 9:30 AM): [MEDICATION NAME] is used to treat [MEDICATION NAME], a condition caused by too much dietaryphosphorus being retained in your body due to a diseased kidney. [MEDICATION NAME] helps to remove excess phosphorus that has built up in your body by bindingthe phosphorus that is in the food that you eat. Your doctor may adjust your dosage during treatment dependingon your blood test results. The average daily dose of [MEDICATION NAME] is 3 [MEDICATION NAME] 800 mg tablets per meal. Follow all directions given to you by your treating doctor and pharmacist carefully. [MEDICATION NAME] helps lower your dietary [MEDICATION NAME]. It does not cure your condition. Therefore,you must continue to take it as directed by your treating doctor if you expect tolower your [MEDICATION NAME] level and keep it down. If you stop taking [MEDICATION NAME], your [MEDICATION NAME] levels may rise again. It is important to keep taking your medicine even if you feel well. Do not stop taking [MEDICATION NAME]. Your treating doctor may need to change the dose of your other medicines if you stop [MEDICATION NAME], so you should only stop when your treating doctor tells you to. It is important to try to take [MEDICATION NAME] as prescribed by your treating doctor. According to Drugs.com at https://www.drugs.com/cdi/velphoro.html (Accessed 10/16/20 at 9:50 AM): Velphoro ([MEDICATION NAME]) is a [MEDICATION NAME] binder that helps prevent [DIAGNOSES REDACTED] (low levels of calcium in the blood) caused by elevated phosphorus. Velphoro is used to control phosphorus levels in people with [MEDICAL CONDITION] who are on [MEDICAL TREATMENT]. Take Velphoro exactly as prescribed by your doctor. Follow all directions on your prescription label. Your doctor may occasionally change your dose. Do not use this medicine in larger or smaller amounts or for longer than recommended. Monitor serum phosphorus levels and titrate the dose of Velphoro in decrements or increments of 500 mg (1 tablet) per day as needed until an acceptable serum phosphorus level is reached, with regular monitoring afterwards. Titrate as often as weekly. Velphoro must be administered with meals. To maximize the dietary [MEDICATION NAME] binding, distribute the total daily dose among meals. [MEDICATION NAME] binders are used to decrease the absorption of [MEDICATION NAME] from food in the digestive tract. They are used when there is an abnormally high blood [MEDICATION NAME] level ([MEDICATION NAME]) which can be caused by impaired renal [MEDICATION NAME] excretion or increased extracellular fluid [MEDICATION NAME] loads. [MEDICATION NAME] binders react with [MEDICATION NAME] to form an insoluble compound, making it unable to be absorbed from the gastrointestinal tract. When taken regularly with meals, [MEDICATION NAME] binders lower the concentration of [MEDICATION NAME] in serum. According to Merck Manuals at https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/electrolyte-disorders/[MEDICATION NAME] (Accessed on 10/16/20 at 10:15 AM): [MEDICATION NAME] is a serum [MEDICATION NAME] concentration > 4.5 mg/dL (> 1.46 mmol/L). Causes include [MEDICAL CONDITIONS], and metabolic or respiratory acidosis. Clinical features may be due to accompanying [DIAGNOSES REDACTED] and include tetany. [DIAGNOSES REDACTED]. Treatment includes restriction of [MEDICATION NAME] intake and administration of [MEDICATION NAME]-binding antacids, such as calcium [MEDICATION NAME]. [MEDICATION NAME] plays a critical role in the development of secondary [MEDICAL CONDITION] and renal osteodystrophy in patients with advanced [MEDICAL CONDITION] as well as in patients on [MEDICAL TREATMENT]. [MEDICATION NAME] can lead to calcium precipitation into soft tissues, especially when the serum calcium × [MEDICATION NAME] product is chronically > 55 mg2/dL2 (4.4 mmol2/L2) in patients with [MEDICAL CONDITION]. Soft-tissue calcification in the skin is one cause of excessive pruritis in patients with [MEDICAL CONDITION] who are on chronic [MEDICAL TREATMENT]. Vascular calcification also occurs in [MEDICAL TREATMENT] patients with a chronically elevated calcium × [MEDICATION NAME] product; this vascular calcification is a major risk factor for cardiovascular morbidity including stroke, [MEDICAL CONDITION] infarction, and claudication. .

Based on observations and interviews, the facility failed to provide a call bell in reach for four (Residents #2, #3, #4, and #6) of seven residents reviewed, out of a total census of 106 residents. The findings include: On 12/12/18 at 9:22 AM, a tour of the facility commenced. Residents #2, #3, #4, and #6 were all observed in their beds, however none of the residents had a call light within their reach. (Photographic evidence obtained) On 12/12/18 at 9:25 AM, an interview was conducted with Resident #2 regarding the call light being out of reach, and the resident stated, It depends on who is working, where they put it. It ends up out of my reach a lot. On 12/12/18 at 9:28 AM, Employee A, Certified Nursing Assistant (CNA), entered Resident #2's room and verified that the call light was out of the resident's reach. On 12/12/18 at 9:31 AM, Resident #3 was observed in bed with the bed in the highest position; the call light was out of reach, and one floor mat was propped up against the wall. (Photographic evidence obtained) On 12/12/18 at 9:32 AM, an interview was conducted with Employee A, CNA, regarding the call light being out of Resident #3's reach, the bed in the highest position, and the floor mat propped up against the wall. She confirmed the light should have been within reach and she retrieved it for the resident. She stated the bed was in the highest position and the mat was up because the resident had just finished breakfast, however there was no breakfast tray in the room and/or in the hallway. She stated that the bed should have been lowered and the mat placed back down on the floor before the resident was left unattended. On 12/12/18 at 9:34 AM, an observation of Resident #4 revealed the call light was out of reach. Employee A, CNA, confirmed the call light was out of reach. She placed the call light within the resident's reach, and the resident was able to use it. Resident #4 had been lying in bed yelling for help previously. On 12/12/18 at 9:54 AM, Resident #6 was observed lying in bed. The call light was under the bed. (Photographic evidence obtained) On 12/12/18 at 9:58 AM, an interview was conducted with Employee C, CNA, regarding Resident #6's call light being under the bed. She confirmed the call light was under the bed, removed it and placed it within the resident's reach. She was asked whether Resident #6 could utilize the call light to call for help, and she replied, Yes, she can.

Based on interviews and record reviews, the facility failed to provide sufficient staffing to provide nursing and related services to ensure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. This impacted Residents #39, #13, #70, #78, #85, #193, #194, #195, #196, #197, #198, #199, #42, #45, #142 and #11. The findings include: 1. A medical record review was conducted for Resident #39, which revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score of 14 out of a possible 15 points, indicating the resident was cognitively intact. An interview was conducted with Resident #39 on 11/26/18 at 1:50 PM. He reported his problem was that when he used the call light at night, it could take up to a half hour for staff to respond. He reported this wait time had occurred off and on since admission. He reported that over the weekend following Thanksgiving his night shift certified nursing assistant (CNA) responded to the call light, looked in the room and walked away leaving him wet in bed. He reported during an interview on 11/27/18 at 11:40 AM, that a wound opened up in the crevice of his buttocks which the facility did not address until it was brought to the attention of Employee C, Registered Nurse on 11/29/18 at 9:12 AM and Employee D, RN/Charge Nurse on 11/29/2018 at 10:32 AM. During the medication pass observation on 11/28/18 at 8:23 AM, an interview was conducted with Employee H, Licensed Practical Nurse (LPN). She confirmed she was taking care of 36 residents today. There were two carts available and some days they did have two nursing staff assigned. Employee H also confirmed that when there was one nurse on the long-term care unit with up to 38 residents to care for, it was impossible to administer all of their medications timely. An interview was conducted with Employee W, RN/Charge Nurse on 11/28/18 at 8:31 AM. She was asked about staffing and she stated she ran two units, and when a nurse needed assistance she would help, but sometimes she was on the other side of the facility. Employee W also confirmed that on the long-term care unit, With one nurse you cannot get the medications that are scheduled at 8:00 AM administered on time; especially with interruptions. Employee H confirmed the charge nurse's statement and added, There is not enough time, like this, referring to having only one nurse on the long-term care unit. An interview was conducted with Employee O, LPN, on 11/30/18 at 9:54 AM. She was observed outside of room [ROOM NUMBER], and she stated that she was far behind on passing the 9:00 AM scheduled medications, because they pulled her over to the acute care unit. At 10:03 AM, she stated she was at the facility at 7:30 AM, however, she was reassigned to the cardiac unit by the Director of Nursing. She confirmed that she clocked in at 6:45 AM. She reported that she had to count the medication cart and conduct nurse to nurse report. She stated someone else was supposed to be on this cart, but was also moved to another location. This happened once in a while. She confirmed she had not provided medications to the rest of the Cardiac Unit residents. She provided a report titled, Shift Change Huddle Report which indicated that the following residents had not received their 9:00 AM scheduled medications: [REDACTED]#196, Resident #197, Resident #198 and Resident #199. An interview was conducted with the DON on 11/30/18 at 10:10 AM. She confirmed that she had a couple of nurse aids call off. The nurse that was on the Cardiac Unit volunteered to be the nurse aid on the long-term care unit. She reported that one nurse was a no-call, no show. She also stated that three nurse aids called out for today, but only one nurse aid position remained unfilled at this time. She stated the floors/units were manned appropriately. She further stated she was going to call all of the primary care physicians and obtain one-time late dose MEDICATION ORDERS FOR [REDACTED] During an interview with the Regional Nurse on 11/30/18 at 10:24 AMm the Regional Nurse stated that the Director of Labor and Operations and the Regional Nurse were out on the floor checking to see who was behind with administration of medication. A review of the Medication Administration Records (MARs) for the following residents, demonstrated that each resident had not received their medications timely: Resident # 13, Resident # 39, Resident #70, Resident #78, Resident # 85, Resident # 193, Resident # 194, Resident # 195, Resident # 196, Resident # 197, Resident # 198 and Resident # 199. This corresponded with the 11/30/18 interview with Employee O, LPN, at 9:54 AM, who confirmed that she was far behind with her 9:00 AM medication pass. The following order summary for each resident documented, Physician is in agreement to continue with medication pass until completion for morning medication pass on 11/30/18. Medication Administration Records were printed on 11/30/18 at 10:06 AM reflecting that each of the above-noted residents' medications were not administered timely. Additionally, for each of the above-noted residents, a note was documented in the electronic medication record effective date of 11/30/18 at 10:29 AM. It read, Call placed to medical director and report given that patient's morning medications will potentially be administered outside of parameters. MD (physician) order received to pass medications until completion. Notes were entered by the Director of Nursing. On 11/30/18 at 11:01 AM, the Director of Nursing provided a list of the same residents as noted above with the following orders initiated by the facility once it was identified that these medications were not going to be administered timely: Physician is in agreement to continue with medication pass until completion for morning medication pass on 11/30/18 for one day. An interview and review of selected residents on the long-term care unit for medication pass was conducted with the facility Administrator on 11/30/18 at 11:35 AM. He was able to isolate only medications on the Medication Audit Report for the facility. Two days were selected for review including 11/27/18 and 11/28/18, which was also the date of the interview with Employee H, RN and Employee W, RN/Charge Nurse confirming that having only one nurse on the long-term care unit made it, impossible to administer all of their residents' medications timely. The review for the date of 11/28/18 yielded (10) late medication administrations for four residents of 40 residents who were included in the sample; Resident #42 for 9:00 AM scheduled medications, Resident #45 for 8:00 AM scheduled medications, Resident #142 for 9:00 AM medications and Resident #11 for 9:00 AM scheduled medications. 2. On 11/30/18 at 1:27 PM, an interview was conducted with the Director of Nursing regarding the staffing and assignment for Employee L, Certified Nursing Assistant (CNA), on 11/19/18 during the 11P - 7A shift. She reviewed the assignment sheet and census, and confirmed that the CNA was assigned the entire unit of twenty-five (25) residents. She confirmed she was aware that one aide was not allowed to have more than twenty (20) residents assigned to them at one time. .

Based on observations and interviews, the facility failed to follow infection control procedures with storage of insulin medication and insulin syringes as well as appropriate use of gloves during insulin administration for one resident (#52) of a total of 57 sampled residents, and failed to appropriately handle residents' personal laundry. This potentially impacted all 103 residents residing in the facility. The findings include: 1. On 11/26/18 at 11:27 AM, an observation was made of Employee A, Licensed Practical Nurse (LPN), performing blood glucose testing for Resident #52. Employee A was in the resident's room with a glucometer and a vial of insulin on the bedside table when entrance was made into the room. The nurse was observed with the lancet in her hand and holding an alcohol wipe with no gloves on. She then obtained two paper towels from the resident's bathroom and a pair of gloves. She placed the glucometer on a paper towel, however the resident's insulin vial remained on the table without a barrier. She donned the gloves and obtained the blood sugar reading. She picked up the insulin vial and placed it in her scrub (uniform) pocket. She then placed the glucometer in her pocket, picked up the paper towels and threw them in the garbage can. She told the resident that his blood sugar reading was 147, and that he did not require any coverage. She then returned to the cart and pulled the glucometer out of her pocket. She stated, I don't know what the state protocol is. Do I wash my hands before or after I clean this? She was encouraged to follow the facility's protocol and do what she would normally do. The nurse pulled a clean glove out of the box of gloves on her cart and placed it on top of the cart. She laid the glucometer on the glove, and went to wash her hands. She returned to the cart and obtained a bleach wipe from the purple-top container in the bottom drawer. She wiped the glucometer for four seconds, and placed it in the bottom drawer of her medication cart. (Photographic evidence obtained) She then removed the vial of insulin from her pocket along with the insulin syringe and placed them back in the top drawer of her medication cart. She stated, I can't remember what his result was now. Can I touch the machine to find out before it is dried? She was again reminded to follow facility protocol and do whatever she would normally do. She then reached in the bottom drawer of the medication cart and retrieved the result from the glucometer before closing the drawer. On 11/26/18 at 11:30 AM, an interview was conducted with Employee A regarding her practice of keeping items like the glucometer, insulin vial and insulin syringe in her uniform pocket. She stated, Yes, I usually carry them in my pocket. She was asked about cleaning the glucometer and she stated, I wipe the glucometer off to clean it, and get it wet, then I place it in the drawer to dry. On 11/29/18 at 5:27 PM, an interview was conducted with the Director of Nursing (DON) regarding the reasons for the facility's initiation of education on glucometer cleaning on 11/27/18. She stated the education was initiated due to Employee A's informing her that she thought she had done something wrong when cleaning her glucometer. Photographic evidence was produced showing that Employee A's glucometer had been placed in the bottom drawer of the medication cart without a barrier after cleaning it. The DON confirmed the nurse should have placed it on a barrier after cleaning it. She was then asked whether nursing staff should carry glucometers, insulin vials or insulin syringes in their uniform pockets, and she stated, No, they should not even take the insulin in the room with them. They should be drawing it up at the cart. 2. On 11/26/18 at 3:07 PM, an observation was made on the cardiac unit (200 hallway) which revealed a staff member pushing a rolling cart with multiple articles of hanging clothing and folded laundry in the bottom of the cart. There was no cover on the clean linens to protect them. On 11/29/18 at 2:47 PM, the clean linen carts were observed, and they were open and did not have covers over them for transporting the clean clothes to the residents' rooms. On 11/29/18 at 3:02 PM, an interview was conducted with Employee T, Laundry Assistant, regarding the cart that was used to transport residents' personal laundry to their rooms. She confirmed that open carts were used, and that they were not covered. On 11/29/18 at 3:12 PM, an interview was conducted with Employee U, Laundry Supervisor, regarding the carts utilized to deliver residents' personal laundry to their rooms. He confirmed that open carts were used, because they were the only ones the facility had. He stated they were not covered during transport.

Based on observation and interview, the facility failed to treat one (Resident #57) of one residents reviewed with dignity and respect, out of a total of 57 sampled residents. The findings include: A record review was conducted for Resident #57 which revealed a [AGE] year-old female admitted to the facility with [DIAGNOSES REDACTED]. On 11/26/18 at 11:11 AM, Resident #57 was observed wearing a black t-shirt with bright yellow writing on the front. Written in bright yellow was the resident's first and last name and her room number. An interview was conducted with the resident at the time of the observation and she stated, They wrote my name on here when my shirt was in the laundry. I don't like it. I am fixing to go to the bank, and everyone there does not need to know my name and room number. It is embarrassing. I would not be wearing it, but I did not have anything else clean. On 11/29/18 at 3:04 PM, an interview was conducted with Employee T, Laundry Assistant, regarding labeling of residents' personal laundry. She stated, We are supposed to label it inside the shirt, on the back, or on their tag. She was asked whether there was ever a reason to label the front of residents' clothing where it is visible, and she stated, No, we are not supposed to put it anywhere it can be seen by others.

Based on observation, interview and facility document review, the facility failed to ensure that one (Resident #53) of one resident sampled for smoking received services with a reasonable accommodation of needs related to automated access via wheelchair to the Long Term Care smoking patio. The findings include: An observation was made on 11/28/18 at 1:01 PM of Resident #53 struggling to use the automated access door to enter the long-term care patio (smoking patio). The door closed on him as he tried to push it open and move through the doorway as the door banged into him and the wheelchair he was using. This occurred three times as he struggled to get out onto the smoking porch. An interview was conducted with Resident #53 on 11/28/18 at 1:04 PM after several attempts were made to activate the automated door without success. During the interview, Resident #53 was observed with a left arm contracture. When asked whether he had been struggling with the door for a week or less, he shook his head no and gestured with his thumbs in an upward direction indicating that it had been longer than a week. He was then asked whether it had been about a month, and nodded and stated yes and more than a month. There was only one automated entrance to this smoking patio. An interview was conducted with Employee W, Registered Nurse (RN) and Unit Manager (UM) of the Long Term Care Unit on 11/28/18 at 1:08 PM. When she was asked about the non-functioning, automated access door she stated, I did not even know that the door was not working. She confirmed that she would contact maintenance about this right away. On 11/29/18 at 9:22 AM, the long-term care smoking patio door marked for handicap accessible use was tested and did not not operate. (Photographic evidence of the door and handicap markings obtained) On 11/29/18 at 10:14 AM, Resident #53 was observed attempting to come back inside the building from the long-term care smoking patio. He was struggling to get back in. When asked whether he needed assistance he stated, No, I am getting used to this. An interview was conducted with Employee V, Plant Operations Director, on 11/29/18 at 3:50 PM. He confirmed the door had been broken since at least (MONTH) 11, (YEAR). He stated he had forgotten to submit the request for repairs into the corporate Purchasing Tracking System. Employee V further stated he did submit the financial request into the Purchasing Tracking System on 11/28/2018, after the survey team addressed the concern with facility staff. A review of the following documents was conducted with Employee V, Plant Operations Director: 1. One locksmith assessment dated [DATE]. The assessment documented the following, Installing a new automatic low voltage door operator in the Long Term Care Unit to courtyard. 2. A new purchase order request documented the date 11/28/2018 invoice # and Employee V confirmed that he forgot to enter this, as there were only two staff in the maintenance department, and we just get busy. An interview was conducted with Resident #53 on 11/30/2018 at 8:39 AM. He reported that regarding the automated door to the smoking patio, the Administrator told him today that the motor burned up. On 11/30/18 at 10:06 AM, an observation was made of Resident #53 struggling to enter the smoking patio directly in front of his room. A review of Resident #53's Smoking care plan revealed, Resident will smoke safely at designated area(s) through next review initiated on 10/03/2017. A review of the [DIAGNOSES REDACTED].#53 revealed, Personal history of [MEDICAL CONDITION] (TIA), cerebral infarction without residual deficits, difficulty in walking, [MEDICAL CONDITION], lack of coordination, low back pain, and nicotine dependence. A review of the (MONTH) 10, (YEAR) Minimum Data Set (MDS) assessment revealed that he had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating no cognitive impairment. A review of the following documents was conducted with Employee V, Plant Operations Director: 1. One locksmith assessment dated [DATE]. The assessment documented the following, Installing a new automatic low voltage door operator in the Long Term Care Unit to courtyard. 2. A new purchase order request documented the date 11/28/2018 invoice # and Employee V confirmed that he forgot to enter this as there are only two staff in the facility department, and we just get busy he said.

Based on observations and interviews, the facility failed to provide a clean environment for one (Resident #10) of one resident reviewed for clean linens, out of a total sample of fifty-seven residents. The findings include: On 11/28/18 at 9:50 AM, an observation was made of Employee AA, Certified Nursing Assistant (CNA) and Employee BB, CNA, placing Resident #10 back in her bed after her shower using a Hoyer lift. Employee AA started to lift the resident up and Resident #10 stated, Don't put me back in bed on those dirty sheets. Observation of the bed linens revealed that they were visibly soiled. (Photographic evidence obtained) Employee AA asked Employee BB to get clean sheets for the bed. During an interview at the time of the observation with the Unit Manager, who was present, she confirmed that the sheets should have been changed due to them being visibly soiled, and because the facility's practice was to change them whenever they showered a resident. On 11/29/18 at 1:37 PM, an interview was conducted with Employee BB, CNA, regarding bed linens and when they should be changed. She confirmed the linens were supposed to be changed when the residents were showered, or when they requested that they be changed.

Based on observations, resident record review and staff interview, the facility failed to implement the comprehensive person-centered plan by failing to provide prescribed treatments and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #48) of four sampled residents reviewed for skin conditions, out of a total of 57 residents in the sample. The findings include: During an observation of Resident #48 on 11/27/18 at 10:03 AM, he produced his right forearm where two circular and scabbed abrasions were observed close to the elbow. He reported he sustained the injury during a transfer. In an interview with Employee EE, Certified Nursing Assistant (CNA), on 11/28/18 at 1:55 PM, she was asked about the scabbed areas on Resident #48's arm. She stated this resident ran his wheelchair into objects frequently, which was how he injured himself. She stated Resident #48 was very independent and could tell you exactly what he wanted. Employee H, Licensed Practical Nurse (LPN), was interviewed on 11/28/18 at 2:19 PM. She stated Resident #48 was alert and oriented. She had no awareness of the injuries on the resident's arm, and stated that she would have to look. Employee H explained this resident banged his wheelchair into objects like a bull in a china cabinet, and staff had to clear space for him. In an interview with Employee CC, CNA, on 11/29/18 at 3:59 PM, she was asked about the scabbed areas on Resident #48's arm. She stated they were likely a result of his banging into things while in his electric wheelchair. Resident #48 was observed again on 11/29/18 at 4:28 PM. One of the abraded/scabbed areas was visible from under the hem of his short-sleeved shirt. The sleeve covered the remainder of the observed wounds. A clinical record review for Resident #48 revealed a quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/4/18. Resident #48 had the ability understand others and to make himself understood. He had a brief interview for mental status (BIMS) score of 14, indicating he had intact cognitive skills for daily decision making. Resident #48 required supervision for activities of daily living. He had an upper extremity impairment on one side, and used a walker and wheelchair as mobility aides. His [DIAGNOSES REDACTED]. There had been no falls since the last assessment. Resident #48 was care planned on 10/26/18 for scabs to his bilateral knees. The goal was for the disruption of skin surfaces to remain free from infection. Approaches included: monitor the location, size, and treatment of [REDACTED]. While it did not mention the abraded arm, the approaches also included: Avoid scratching, keep skin clean and dry, and use lotion on dry skin. Resident #48 had weekly skin assessments completed by five different licensed nurses (Employees Y, Q, X, O and Z) between (MONTH) 27, (YEAR) and (MONTH) 28, (YEAR). None of the assessments captured the abrasions on Resident #48's arms. They did note the following: 10/27/18- No skin issues (signed by Employee Y, LPN). 11/3/18- No new areas noted at this time (signed by Employee Q, LPN). 11/10/18- No areas of skin impairment (signed by Employee X, Registered Nurse). 11/17/18- No new areas noted at this time (signed by Employee Q, LPN). 11/24/18- No new skin issues at this time (signed by Employee O, LPN). (Photographic evidence obtained) Resident #48 had a physician's order dated 7/26/16 to apply stock moisturizer to his whole body, excluding skin folds and webbed spaces, every day and evening shift for dry skin. Review of the treatment administration record (TAR) for (MONTH) (YEAR) found the lotion was signed as having been applied to Resident #48's whole body twice daily (day and evening shift) in (MONTH) (YEAR) by ten (10) different licensed nurses. Five (5) of the nurses had authored and signed the above referenced skin checks; Employee Q, LPN, Employee X, RN, Employee O, LPN, and Employee Z, LPN. The remaining five nurses signing that lotion was applied to all skin surfaces included Employee H, LPN, Employee L, LPN, Employee N, LPN, Employee R, LPN, Employee Y, LPN, and Employee P, LPN. The electronic nursing progress and wound notes for Resident #48 revealed none of the ten nurses referenced the abraded areas on Resident #48's right elbow. There were no physician's orders for treatment, or to promote healing of the affected area. Resident #48 was interviewed on 11/30/18 at 9:51 AM in his room. He pulled his shirt sleeve up to reveal a total of three abrasions on his right arm. When asked whether he received head to toe lotion application twice daily, Resident #48 stated nobody had applied lotion to his body. He said he would like the nurses to apply lotion to his skin, insisting he would absolutely permit that. Observation of both arms found them dry and flaky. An interview was conducted with Employee W, Unit Manager, on 11/30/18 at 9:56 AM. She reviewed the electronic clinical records for this resident, and confirmed none of the nurses captured any skin issues. She observed a photograph of Resident #48's right arm abrasions and stated the areas looked old; like they had been there for some time. Employee W reviewed the TAR for the lotion application. She stated if the nurses were applying and signing off the lotion, as per the plan of care, they could not have missed the abrasions.

Based on record reviews and staff interviews, the facility failed to meet the professional standards of quality care evidenced by failure to administer prescribed medication for a for 1 resident (Resident #1), out of 6 sampled residents. This resulted in harm when Resident #1 did not receive prescribed [MEDICATION NAME] dosing for 2 days to reduce a pituitary tumor and treat [DIAGNOSES REDACTED] (not enough [MEDICATION NAME] hormone produced by the adrenal glands in the body, with resultant metabolic effects including low blood pressure and high blood potassium). Resident #1 experienced nausea and vomiting which prohibited her from eating, and a sudden decline in mental and functional status requiring rehospitalization . The findings include: The Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. According to the Florida Nurse Practice Act, Chapter 464.003: (3)(a) Practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (e) Nursing diagnosis means the observation and evaluation of physical or mental conditions, behaviors, signs and symptoms of illness, and reactions to treatment and the determination as to whether such conditions, signs, symptoms, and reactions represent a deviation from normal. (f) Nursing treatment means the establishment and implementation of a nursing regimen for the care and comfort of individuals, the prevention of illness, and the education, restoration, and maintenance of health. The practice of practical nursing is defined as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or informed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician. Record review for Resident #1 showed that she was admitted to the facility on the evening of 9/28/15 for rehabilitation with a newly diagnosed pituitary tumor and [DIAGNOSES REDACTED]. Review of admission nurse's notes dated 9/28/15 revealed that the resident was able to walk with or without the use of a walker. Review of admission orders [REDACTED]. A review of the September, 2015 Medication Administration Record (MAR) for Resident #1 revealed the AM dose of [MEDICATION NAME] was not signed out as given on 9/29/2015 or 9/30/2015. No explanation or exception note was given on the MAR or in the nurses' narrative notes for the omitted [MEDICATION NAME] doses. An interview was conducted with Employee B, Registered Nurse (RN), on 10/22/015 at 12:30 PM. She reviewed Resident #1's record and confirmed that the resident did not receive her scheduled [MEDICATION NAME] 12.5 mg with breakfast on 9/29/2015 or 9/30/2015. Employee B stated that staff did not give the AM doses due to it didn ' t look right the way it was written. She said Employee H (the admitting RN) was confused when he entered the order in the electronic record, and he called pharmacy for assistance. She said Employee H entered the order the way the pharmacy told him to (it was entered as 1.25mg with breakfast). Employee B said the morning nurse saw the discrepancy in the AM [MEDICATION NAME] dose ordered compared to the dose entered in the electronic record, and she wanted to get clarification. Employee B did not have an explanation for why the medication order was never clarified, and the AM doses of [MEDICATION NAME] were not given on 9/29/15 and 9/30/15. She said there was no documentation to let her know whether a Unit Manager or Supervisor was notified of the concern. An interview was conducted with Employee H on 10/26/2015 at 3:45 PM. When asked about Resident #1's [MEDICATION NAME] order, he stated, I knew there was going to be a problem with this order. I put it in the computer and it said it wasn't formulary. I called the pharmacy and made them aware. Employee H confirmed that he did not obtain any clarification from the physician on the medication order. An interview was conducted with Employee C, Licensed Practical Nurse (LPN), on 10/22/0215 at 2:50 PM. She confirmed that she did not initial the MAR for administration of Resident #1's morning doses of [MEDICATION NAME] 12.5mg on 9/29/2015 or 9/30/2015. She stated that since there were so many orders for the resident's [MEDICATION NAME], she looked to see that they were entered correctly into the electronic record. She said, I think I got the clarification. I can't remember if she got the medication. I'm sure she did. I just didn't sign it. Employee C recalled that the resident started complaining of nausea on 9/30/15. Employee C said the resident's family was concerned due to this was the way the resident was feeling before she went to the hospital. An interview was conducted on 10/22/15 at 3:15 PM with the Occupational Therapist (OT). She said that on 9/30/15 Resident #1 was able to walk to the gym in the morning for her therapy session, but at the end of the session the resident started feeling nauseous. She said the resident returned to her room and made a big decline. Review of the OT's notes for 9/30/15 revealed that Resident #1 was alert in the AM and followed 100% of commands. During the PM session on 9/30/15 the resident was lethargic and able to follow only 15% of verbal and tactile commands. Nausea was present and the resident presented with constant bilateral upper extremity movements. The resident had a change in mentation, and required maximal assistance to take off her bra and long sleeved shirt, with maximal verbal, tactile, and visual cues. The family reported the resident was unable to eat due to nausea and vomiting. Review of nurse's notes dated 9/30/15 revealed that at 12:30 PM Resident #1's private caregiver came to the nursing station and stated the resident was demonstrating symptoms that she had prior to her hospitalization . The resident was unable to answer direct questions. The resident vomited when she tried to eat. An interview was conducted on 10/22/15 at 1:34 PM with Employee A, Advanced Registered Nurse Practitioner. She stated that the facility asked her to see Resident #1 on 9/30/15 due to nausea and vomiting. She recalled that the resident's family was very concerned about whether the resident received the correct dosage of medication, since she was declining so quickly. Employee A stated, I don't think she got the right dosage or she wasn't getting enough, so we got an order to give her more stat (now). Employee A said she went over the resident's medications with her facility physician, and we realized that the dosage for her morning [MEDICATION NAME] was wrong. Employee A said, When we discovered she wasn't getting the right dose of [MEDICATION NAME], the staff said the order was kind of confusing. Employee A said the resident's Endocrinologist asked the facility to administer an intravenous dose of cortisone to the resident, but because the facility couldn't provide the dosage, he instructed staff to send the resident to the hospital. Nurse's note at 6:45 PM stated a decrease in consciousness was noted. The resident vomited after a stat dose of [MEDICATION NAME]. The resident was unable to walk, became incontinent, and was now vomiting brown colored emesis. The resident was transported to the hospital at 6:30 PM. An interview was conducted with Employee J, Pharmacy Technician, on 10/22/015 at 1:10 PM. He stated that the pharmacy did not receive the order for Resident #1's [MEDICATION NAME] 12.5 mg AM dosage until 9/30/2015. Employee J said the prescribed [MEDICATION NAME] 12.5 mg for Resident #1 was sent to the facility on [DATE], after the resident had been transferred to the hospital. An interview was conducted on 10/22/15 at 3:42 PM with Employee F, Resident #1's physician at the facility. He stated that Resident #1 was hosptalized on [DATE] with the [DIAGNOSES REDACTED]. He said, The amount of medicine she was getting wasn't enough, and she needed a lot more. An interview was conducted on 10/22/2015 at 8:30 PM with Employee G, Resident #1's Endocrinologist. He stated that the resident was rehosptalized on [DATE] due to the facility dropped the ball. He stated, If she had gotten the right medication and they had followed the schedule for this medication, the patient wouldn't have needed to go back to the hospital. He said the type of tumor the resident has lays on the optic nerve, and the location causes the nausea and vomiting she experienced. He said the condition is 100% treatable with the correct dosage of medication. When asked if he was informed that Resident #1 did not get the [MEDICATION NAME] as prescribed, he said, We were skeptical of that since she declined so quickly, and came around quickly when she started getting the medication. In a phone interview on 10/27/2015 at 11:40 AM with Employee I, Consultant Pharmacist, he confirmed that the facility did not make him aware on his visit to the facility on [DATE] of the medication error that occurred for Resident #1. According to the U.S. National Library of Medicine at www.nlm.nih.gov <http://www.nlm.nih.gov>, symptoms of adrenal crisis can include any of the following: confusion or coma, fatigue, high fever, low blood pressure, nausea, and vomiting. The treatment for [REDACTED]. Expand Section adrenal crisis is an immediate injection of [MEDICATION NAME] through a vein or muscle. You will need to go to the hospital for treatment and monitoring. Expand Section Shock may occur if treatment is not provided early, and it can be life-threatening. Possible complications include coma, [MEDICAL CONDITION], and low blood sugar. Call your health care provider if you have Addison disease and are unable to take your glucocorticoid medicine for any reason. Expand Section A review of the facility's policy General Dose Preparation and Medication Administration, dated 1/1/2013 showed, The facility staff should verify the medication name and dose are correct. Verify each time a medication is administered that it is the correct medication, at the correct dose and the correct route, at the correct rate, and the correct time for the correct resident. Confirm that the MAR reflects the most recent medication order.

Based on record reviews and staff interviews, the facility failed to ensure residents were free from significant medication errors for 1 resident (Resident #1), out of 6 sampled residents. This resulted in harm when Resident #1 did not receive prescribed [MEDICATION NAME] dosing for 2 days to reduce a pituitary tumor and treat [DIAGNOSES REDACTED] (not enough [MEDICATION NAME] hormone produced in the adrenal glands in the body, with resultant metabolic effects including low blood pressure and high blood potassium). Resident #1 experienced nausea and vomiting which prohibited her from eating, and a sudden decline in mental and functional status requiring rehospitalization . The findings include: Record review for Resident #1 showed that she was admitted to the facility on the evening of 9/28/15 for rehabilitation with a newly diagnosed pituitary tumor and [DIAGNOSES REDACTED]. Review of admission nurse's notes dated 9/28/15 revealed that the resident was able to walk with or without the use of a walker. Review of admission orders [REDACTED]. A review of the September, 2015 Medication Administration Record (MAR) for Resident #1 revealed the AM dose of [MEDICATION NAME] was not signed out as given on 9/29/2015 or 9/30/2015. No explanation or exception note was given on the MAR or in the nurses' narrative notes for the omitted [MEDICATION NAME] doses. An interview was conducted with Employee B, Registered Nurse (RN), on 10/22/015 at 12:30 PM. She reviewed Resident #1's record and confirmed that the resident did not receive her scheduled [MEDICATION NAME] 12.5 mg with breakfast on 9/29/2015 or 9/30/2015. Employee B stated that staff did not give the AM doses due to it didn't look right the way it was written. She said Employee H (the admitting RN) was confused when he entered the order in the electronic record, and he called pharmacy for assistance. She said Employee H entered the order the way the pharmacy told him to (it was entered as 1.25mg with breakfast). Employee B said the morning nurse saw the discrepancy in the AM [MEDICATION NAME] dose ordered compared to the dose entered in the electronic record, and she wanted to get clarification. Employee B did not have an explanation for why the medication order was never clarified, and the AM doses of [MEDICATION NAME] were not given on 9/29/15 and 9/30/15. She said there was no documentation to let her know whether a Unit Manager or Supervisor was notified of the concern. An interview was conducted with Employee H on 10/26/2015 at 3:45 PM. When asked about Resident #1's [MEDICATION NAME] order, he stated, I knew there was going to be a problem with this order. I put it in the computer and it said it wasn't formulary. I called the pharmacy and made them aware. Employee H confirmed that he did not obtain any clarification from the physician on the medication order. An interview was conducted with Employee C, Licensed Practical Nurse (LPN), on 10/22/0215 at 2:50 PM. She confirmed that she did not initial the MAR for administration of Resident #1's morning dose of [MEDICATION NAME] 12.5mg on 9/29/2015 or 9/30/2015. She stated that since there were so many orders for the resident's [MEDICATION NAME], she looked to see that they were entered correctly into the electronic record. She said, I think I got the clarification. I can't remember if she got the medication. I'm sure she did. I just didn't sign it. Employee C recalled that the resident started complaining of nausea on 9/30/15. Employee C said the resident's family was concerned due to this was the way the resident was feeling before she went to the hospital. An interview was conducted on 10/22/15 at 3:15 PM with the Occupational Therapist (OT). She said that on 9/30/15 Resident #1 was able to walk to the gym in the morning for her therapy session, but at the end of the session the resident started feeling nauseous. She said the resident returned to her room and made a big decline. Review of the OT's notes for 9/30/15 revealed that Resident #1 was alert in the AM and followed 100% of commands. During the PM session on 9/30/15 the resident was lethargic and able to follow only 15% of verbal and tactile commands. Nausea was present and the resident presented with constant bilateral upper extremity movements. The resident had a change in mentation, and required maximal assistance to take off her bra and long sleeved shirt, with maximal verbal, tactile, and visual cues. The family reported the resident was unable to eat due to nausea and vomiting. Review of nurse's notes dated 9/30/15 revealed that at 12:30 PM Resident #1's private caregiver came to the nursing station and stated the resident was demonstrating symptoms that she had prior to her hospitalization . The resident was unable to answer direct questions. The resident vomited when she tried to eat. An interview was conducted on 10/22/15 at 1:34 PM with Employee A, Advanced Registered Nurse Practitioner. She stated that the facility asked her to see Resident #1 on 9/30/15 due to nausea and vomiting. She recalled that the resident's family was very concerned about whether the resident received the correct dosage of medication, since she was declining so quickly. Employee A stated, I don't think she got the right dosage or she wasn't getting enough, so we got an order to give her more stat (now). Employee A said she went over the resident's medications with her facility physician, and we realized that the dosage for her morning [MEDICATION NAME] was wrong. Employee A said, When we discovered she wasn't getting the right dose of [MEDICATION NAME], the staff said the order was kind of confusing. Employee A said the resident's Endocrinologist asked the facility to administer an intravenous dose of cortisone to the resident, but because the facility couldn't provide the dosage, he instructed staff to send the resident to the hospital. Nurse's note at 6:45 PM stated a decrease in consciousness was noted. The resident vomited after a stat dose of [MEDICATION NAME]. The resident was unable to walk, became incontinent, and was now vomiting brown colored emesis. The resident was transported to the hospital at 6:30 PM. An interview was conducted with Employee J, Pharmacy Technician, on 10/22/015 at 1:10 PM. He stated that the pharmacy did not receive the order for Resident #1's [MEDICATION NAME] 12.5 mg AM dosage until 9/30/2015. Employee J said the prescribed [MEDICATION NAME] 12.5 mg for Resident #1 was sent to the facility on [DATE], after the resident had been transferred to the hospital. An interview was conducted on 10/22/15 at 3:42 PM with Employee F, Resident #1's physician at the facility. He stated that Resident #1 was hosptalized on [DATE] with the [DIAGNOSES REDACTED]. He said, The amount of medicine she was getting wasn ' t enough, and she needed a lot more. An interview was conducted on 10/22/2015 at 8:30 PM with Employee G, Resident #1's Endocrinologist. He stated that the resident was rehosptalized on [DATE] due to the facility dropped the ball. He stated, If she had gotten the right medication and they had followed the schedule for this medication, the patient wouldn't have needed to go back to the hospital. He said the type of tumor the resident has lays on the optic nerve, and the location causes the nausea and vomiting she experienced. He said the condition is 100% treatable with the correct dosage of medication. When asked if he was informed that Resident #1 did not get the [MEDICATION NAME] as prescribed, he said, We were skeptical of that since she declined so quickly, and came around quickly when she started getting the medication. In a phone interview on 10/27/2015 at 11:40 AM with Employee I, Consultant Pharmacist, he confirmed that the facility did not make him aware on his visit to the facility on [DATE] of the medication error that occurred for Resident #1. According to the U.S. National Library of Medicine at www.nlm.nih.gov <http://www.nlm.nih.gov>, symptoms of adrenal crisis can include any of the following: confusion or coma, fatigue, high fever, low blood pressure, nausea, and vomiting. The treatment for [REDACTED]. Expand Section adrenal crisis is an immediate injection of [MEDICATION NAME] through a vein or muscle. You will need to go to the hospital for treatment and monitoring. Expand Section Shock may occur if treatment is not provided early, and it can be life-threatening. Possible complications include coma, [MEDICAL CONDITION], and low blood sugar. Call your health care provider if you have Addison disease and are unable to take your glucocorticoid medicine for any reason. Expand Section A review of the facility's policy General Dose Preparation and Medication Administration dated 1/1/2013 showed, The facility staff should verify the medication name and dose are correct. Verify each time a medication is administered that it is the correct medication, at the correct dose and the correct route, at the correct rate, and the correct time for the correct resident. Confirm that the MAR reflects the most recent medication order.