Every finding on record at Casa Arena Healthcare LLC

Based on observation and interview, the facility failed to secure medications in a medication cart for 58 residents on the 600 Unit (residents were identified by the census list provided by the Director of Nursing (DON) on 05/07/26). This deficient practice could likely result in residents obtaining medication not prescribed to them resulting in adverse side effects. The findings are:A. On 05/08/26 at 12:46 PM, during an observation of the 600 unit, revealed an unlocked medication cart. Staff were not present. B. On 05/08/26 at 12:47 PM, during an interview, CNA #8 stated the medication cart was unlocked on the 600 unit. C. On 05/08/26 at 1:04 PM, during an interview, the DON stated the medication carts should be locked when not in direct care of staff.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #18) of 3 (R #17, R #18, and R #27) residents reviewed accuracy of documentation when staff failed to: 1. Document R #18's enteral feedings (tube feeding, delivers liquid nutrition directly into the stomach or small intestine via a tube for individuals unable to meet nutritional needs orally, despite having a functional gastrointestinal tract.) 2. Document R #18's residual volume (the amount of formula and gastric juice remaining in the stomach, often checked to assess tube feeding tolerance).3. Document R #18's enteral flushes (water administered through enteral tube). These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are:A. Record review of R #18's admission Record, no date, revealed the following:1. R #18 was admitted to the facility on [DATE].2. R #18 had the following diagnoses: a. Dysphagia oropharyngeal phase (difficulty initiating a swallow, moving food from the mouth to the throat, and into the esophagus). b. Gastrostomy (indicates the presence of a functioning feeding tube (G-tube) inserted through the abdomen into the stomach for long-term nutritional support or gastric decompression). B. Record review of R #18's physician's orders revealed the following: 1. An order dated 12/02/25 and discontinued on 12/31/25, for enteral feeding with Jevity 1.5 (a balanced liquid nutrition for long- or short-term tube feeding), one (1) carton every four (4) hours. 2. An order dated 01/03/26 and discontinued on 01/06/26, for enteral feeding with Jevity 1.2 at a rate of 70 milliliters (mL, unit for measuring liquids) per hour, and 150 mL of water every six (6) hours. 3. An order dated 01/03/26 and discontinued on 03/04/26, to flush enteral tube with 30 mL's water before and after medication administration and 5-10 mL's water between each medication. 4. An order dated 01/03/26 and discontinued on 02/26/26, to check residual before med administration. If residual volume is greater than 60 mL, hold feeding and notify physician. 5. An order dated 11/24/26 and discontinued on 03/04/26, revealed an order for phenobarbital (medication used to treat seizures) 64.8 mg, give two (2) tablets via PEG-Tube once a day for seizures. 6. An order dated 01/03/26 and discontinued on 02/06/26, for docusate sodium (an over-the-counter stool softener used to treat occasional constipation) 100 mg, give one tablet via PEG-Tube two times a day for constipation. C. Record review of R #18's MAR, dated December 2025, revealed staff did not document administering R #18's bolus feedings on following dates and times:1. On 12/02/25 at 8:00 PM.2. Between 12/03/25 to 12/09/25 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, or 8:00 PM.3. On 12/10/25 at 12:00 AM, 4:00 AM, 4:00 PM, or 8:00 PM.4. On 12/11/25 at 12:00 AM, 4:00 AM, 4:00 PM, or 8:00 PM.5. On 12/12/25 at 12:00 AM, 4:00 AM, 4:00 PM, or 8:00 PM.6. On 12/13/25 at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, or 8:00 PM.7. On 12/14/25 at 12:00 AM, 4:00 AM, 4:00 PM, or 8:00 PM.8. On 12/15/25 at 12:00 AM, 4:00 AM.9. On 12/24/25 at 8:00 PM. D. Record review of R #18's MAR, dated January 2026, revealed the following:1. On 01/04/26 for the 6AM-6PM shift, staff did not document administration of R #18's Jevity at 70 mL per hour and 150 mL of water every six (6) hours.2. On 01/04/26 staff documented administering R #18's 9:00 AM dose of Phenobarbital and Docusate Sodium.3. On 01/04/26 for the 6AM-6PM shift, staff did not document flushing R #30's enteral tube with 30 mL of water before and after medication administration and 5-10 mL of water between each medication.4. On 01/04/26 for the 6AM-6PM shift, staff did not document that R #18's residual volume was checked before medication administration and staff did not document the amount of residual volume R #18 had.5. On 01/05/26 for the 6AM-6PM shift, staff did not document administration of R #18's Jevity at 70 mL per hour and 150 mL of water every six (6) hours.6. On 01/05/26 staff documented administering R #18's 9:00 AM dose of Phenobarbital and Docusate Sodium.7. On 01/05/26 for the 6AM-6PM shift, staff did not document flushing R #30's enteral tube with 30 mL of water before and after medication administration and 5-10 mL of water between each medication.8. On 01/05/26 for the 6AM-6PM shift, staff did not document that R #18's residual volume was checked before medication administration and staff did not document R #18's residual volume. E. On 03/10/26 at 12:03 PM, during an interview, LPN #16 stated the following: 1. R #18 was able to tell staff when he was hungry and make his needs known. 2. She administered R #18's feedings as ordered. F. On 3/12/26 at 9:25 AM, during an interview, LPN #24 stated the following: 1. He administered R #18's enteral feedings as ordered. 2. He followed all physicians' orders. 3. He checked R #18's residual volume as ordered and would notify the provider if R #18 had too much residual volume. G. On 03/13/26 at 12:18 PM, during an interview, the DON confirmed the following: 1. Staff did not document multiple bolus feedings for R #18's between 12/02/26 and 12/24/25. 2. Staff did not document administering R #18's continuous feedings on the mornings of 01/04/26 or 01/05/26. 3. Staff did not document checking R #18's residual volume on the mornings of 01/04/26 or 01/05/26. 4. Staff did not document administering water flushes to R #18 on the mornings of 01/04/26 or 01/05/26. 5. Staff were expected to follow all orders and document in the medical record.

Based on record review and interview, the facility failed to report allegations of misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) to the State Agency within 24 hours of an allegation for 1 (R #17) of 4 (R #16, R #17, R #27, and R #29) residents reviewed for misappropriation of property, when staff failed to report allegations of missing money for R #17. If the facility fails to report allegations of misappropriation of resident property to the state agency within 24 hours of the allegation, then corrective action may not be taken, and residents may suffer increased anxiety and fear that their belongings are not being protected. The findings are:A. Record review of R #17's admission Record, no date, revealed the following: 1. R #17 was admitted to the facility on [DATE]. 2. R #17 had a diagnosis of cognitive communication deficit (difficulty with verbal or non-verbal communication caused by underlying cognitive deficits, rather than primary speech or language impairments). B. Record review of the Grievance Log, dated March 2026, revealed that on 03/03/26 R #17 reported she was missing money. C. Record review of R #17's grievance form, dated 03/03/26, revealed the following: 1. R #17 reported that she was missing $44. 2. On 03/05/26, staff documented that R #17 stated that she was not missing any money. D. On 03/11/26 at 1:18 PM, during an interview, R #17 stated the following: 1. She was missing $44 from her purse.2. The money went missing about a week or two (2) before 03/11/26. 3. She told a staff member in the business office that she was missing money (she was unsure of staff name or title or the date she notified staff). E. Record review of the State Agency Incident Management System, no date, revealed staff did not report R #17's missing money to the State Agency. F. On 03/12/26 at 10:54 AM, during an interview, the Administrator stated the following: 1. She confirmed that she did not report R #17's grievance about missing $44 to the State Agency, because R #17 did not state that she thought someone stole her money. 2. The Administrator only reports missing money or property to the State Agency if the resident alleges theft or if the resident reports that they saw someone going through their belongings.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) for 1 (R #17) of 4 (R #16, R #17, R #27, and R #29) residents reviewed for misappropriation of property. If the facility does not adequately investigate allegations of misappropriation of resident property, then corrective action may not be implemented to protect other residents which could cause residents to suffer increased anxiety and fear that their belongings are not being protected. The findings are:A. Record review of R #17's admission Record, no date, revealed the following: 1. R #17 was admitted to the facility on [DATE]. 2. R #17 had a diagnosis of cognitive communication deficit (difficulty with verbal or non-verbal communication caused by underlying cognitive deficits, rather than primary speech or language impairments). B. Record review of the Grievance Log, dated March 2026, revealed that R #17 reported that she was missing money. C. Record review of R #17's grievance form, dated 03/03/26, revealed the following: 1. R #17 reported that she was missing $44. 2. On 03/05/26, staff documented that R #17 stated that she was not missing any money. D. On 03/11/26 at 1:18 PM, during an interview, R #17 stated the following: 1. She was missing $44. 2. Her money went missing about a week or two (2) before 03/11/26. 3. She told a staff member in the business office that she was missing money (she was unsure of staff name or title or the date she notified staff). 4. Her money was in a pink bag in her purse when it went missing. 5. She was planning to buy pants with the money. 6. She could not remember if staff talked to her after she reported that her money was missing. 7. She forgets things frequently. E. On 03/11/26 at 1:25 PM, during an interview, the Social Services Clerk (SSC) stated the following: 1. The Business Office Manager (BOM) told her that R #17 was missing money on 03/03/26. 2. She completed the grievance form for R #17 on 03/03/26. 3. She helped R #17 look through her drawers for the missing money on 03/03/26. 4. On 03/05/26 she met with R #17 again and R #17 told her the following: a. She was not missing any money. b. She might have given the money to her kids. 6. She did not call R #17's kids to ask if R #17 had given them money. 7. She did not report R #17's missing money to the police. F. On 03/11/26 at 1:40 PM, during an interview, the BOM stated the following:1. R #17 had withdrawn $100 on 02/27/26.2. When R #17 withdrew the $100 on 02/27/26, she told the BOM that she planned to have her daughter buy clothes for her.3. During a morning meeting on 03/03/26, a staff member reported that R #17 was missing money.4. R #17 frequently buys snacks from the facility vending machines.5. She was unsure if anyone contacted R #17's kids to ask if R #17 gave them any money.6. R #17's Daughter was her Power of Attorney (POA, is a legal document enabling a trusted person (agent/attorney-in-fact) to act on your behalf regarding financial, legal, or medical matters). G. On 03/12/26 at 9:37 AM, during an interview, R #17's Daughter stated the following: 1. R #17 called her on 03/01/26 and told her that she was missing $44 from her purse. 2. R #17 did not give her any money. 3. Sometimes R #17 would give the activities staff money to buy things for R #17. 4. R #17 gets very confused and sometimes forgets. 5. Facility staff did not notify her that R #17 reported missing money or ask if R #17 gave her money. H. Record review of the Administrator's investigation note, dated 03/03/26, revealed the following:1. She spoke with R #17 regarding missing $44. 2. R #17 told the Administrator that she wasn't missing any money. 3. R #17 told the Administrator that she gives her money to her kids. 4. R #17 did not state that her money was stollen. 5. The BOM confirmed that R #17 withdrew $100 from her account on 02/27/26. 6. R #17 told the administrator that she buys things from the vending machines. I. Record review of the SSC's investigation notes revealed the following: 1. Note dated 03/03/26: a. R #17 told the SSC that she was not missing any money. b. R #17 gave SSC permission to look through her drawers for her missing money. c. R #17 told the SSC that she may have given the money to her kids for clothes. 2. On 03/05/26, R #17 told the SSC that she was not missing any money. J. On 03/12/26 at 12:58 PM, during an interview, the Administrator confirmed the following: 1. On 03/03/26 during a morning meeting, a nurse (did not specify which nurse) reported that R #17 was missing $44. 2. She did not know which staff member R #17 reported that she was missing money. 3. She was not sure how long R #17's money had been missing.4. She did not interview nursing staff or CNA's to see if they witnessed anything regarding R #17's missing money. 5. She did not review cameras to see if anyone took R #17's money. 6. She did not call R #17's kids to see if R #17 gave them money. 7. She did not interview the activities staff to see if R #17 gave them money to buy her something. 8. After R #17 told her and the SSC that she was not missing any money on 03/03/26, she did not investigate further.

Based on record review and interview, the facility failed to ensure care plans were revised for 1 (R #24) of 5 (R #24, R #25, R #26, R #27 and R #28) residents when staff failed to revise R #24's care plan with the most current resident information regarding care preferences. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: A. Record review of R #24's admission Record, no date revealed the following: 1. An admission date of 12/24/19. 2. R #24 diagnoses of unspecified dementia, unspecified severity, with other behavioral disturbances (a type or severity of dementia that is not clearly determined, and the patient exhibits behavioral disturbances such as agitation, aggression, psychosis, mood changes, and sleep disturbances). B. Record review of R #24's 5-day complaint narrative note (the facility's incident follow up report to the State Agency) dated 12/17/25 revealed the following: 1. R #24 reported to staff that a male staff member attempted to kiss her forehead. 2. Facility corrective action was to implement that only female staff provide care to R #24. C. Record review of R #24's care plan revision dated 03/03/26 revealed staff did not revise the care plan to include only females to provide care for R #24. D. On 03/12/26 at 12:32 PM, during an interview, the DON confirmed R #24's care plan was not revised with the intervention that only female staff will provide care for R #24. DON stated that R #24's care plan should have been revised with this intervention.

Based on record review, and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #9) of 4 (R #8, R #9, R #10, and R #11) residents reviewed for documentation accuracy when staff failed to document R #9's skin impairment (the skin's normal structure and function are compromised). This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: A. Record review of R #9's skin assessment dated [DATE], revealed R #9 had an open area on her coccyx (tailbone). B. Record review of R #9's nursing progress note, dated 12/18/25, revealed the medical provider was notified of the open area. The facility would follow up with the wound care nurse (WCN) for treatment of R #9's open area on the coccyx. C. Record review of R #9's medical record no date, revealed the WCN did not document her assessments of R #9. D. On 12/23/25 at 9:48 AM, during an interview, LPN #8 stated that during a skin assessment there was an impairment on R #9's coccyx. LPN #8 stated that the medical provider was notified. The WCN was treating the area. E. On 12/23/25 at 10:22 AM, during an interview, the WCN stated that when she assessed the wound on R #9's coccyx, that the wound was not open. The WCN nurse stated that she saw some moister to the area and that she was going to order some ointment and for it to be covered. The WCN stated that she would be assessing the wound daily. The WCN confirmed that she did not document her assessments and treatments in R #9's medical record. F. On 12/23/25 at 10:33 AM, during an interview, the DON stated that the WCN should be documenting R #9's wound assessments and treatments in the resident's medical record. The DON confirmed that the WCN did not document her observations, assessments, and treatments of R #9's coccyx in the resident's medical record.

Based on observation and interview, the facility failed to provide a comfortable and homelike environment for 1(R #8) of 1 (R #8) resident when staff failed to keep R #8's bathroom clean of urine around the toilet. This deficient practice could likely cause the residents to feel like they are not living in a comfortable home-like environment and like they are not valued. The findings are:A. On 07/14/25 at 11:06 AM, during an observation of R #8's bathroom, a strong smell of urine. The floor around the toilet had a wet spot and the floor appeared to be stained with a darker color than the rest of the floor. There was dark build up around the toilet seal on the floor. B. On 07/14/25 at 11:08 AM, during an interview, LPN #8 confirmed the urine on the floor of R #8's bathroom floor and the odor. LPN #8 stated R #8 does go to the bathroom on his own. LPN #8 stated she did not think the toilet was leaking. C. On 07/17/25 at 11:06 AM, during an interview, the Administrator said her expectation is the bathroom be cleaned and staff be made aware of the urine on the floor.

Based on record review and interview, the facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for 1 (R #1) of 9 (R #1, R #3, R #4, R #5, R #8, R #9, R #10, R #25, and R #26) residents reviewed for MDS assessment timing. This deficient practice could likely result in residents' care not being met. The findings are: A. Record review of R #1's admission Record (no date) revealed an admission date of 04/09/25. B. Record review of R #1's admission MDS assessment dated [DATE] revealed the assessment was not completed by the RN until 04/26/25. C. On 07/14/25 at 3:29 PM, during an interview with the administrator and the director of clinical services, they confirmed R #1's admission MDS assessment was not completed by facility staff within 14 days of admission.

Based on record review and interview, the facility failed to complete and transmit (electronically sending encoded information) a Significant Change in Condition (SCIC; major decline or improvement in the patient's health status) MDS assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #2) of 3 (R #1, R #2 and R #3) residents reviewed for SCIC MDS assessment timing. This deficient practice could likely result in the residents not receiving the appropriate care and services they need related to changes in their condition. The findings are: A. Record review of R #2's Physician's Orders dated 06/03/25 revealed: admit to hospice.B. Record review of R #2's MDS assessments revealed a SCIC MDS assessment was not completed upon R #2's admission to hospice. C. On 07/14/25 at 3:45 PM, during an interview with the administrator and the director of clinical services, they confirmed staff did not complete the required SCIC MDS within 14 days of R #2's admission to hospice.

Based on observation and interview, the facility failed to post nurse staffing data on a daily basis for access by the public and all 102 residents (residents were identified by the census list provided by the Administrator on 07/10/25) included the following:1. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift to include: a. Registered Nurses. b. Licensed Practical Nurses. c. Certified Nurse Aides. This deficient practice could likely result in residents not knowing which staff is working. The findings are:A. On 07/10/25 at 1:42 PM, during an observation of the facility, revealed the nurse staffing data posted at the front entrance of the facility did not include the total number of actual nursing staff scheduled and actual hours worked by nursing staff for the day. B. On 07/10/25 at 1:43 PM, during an interview, the Front Desk Clerk (FDC) confirmed she is responsible for posting the nurse staffing data. The FDC confirmed the posted staffing data was not posted on 07/10/25 and should include the total number of staff scheduled for each shift and the number of hours that each nursing staff is scheduled to work. C. On 07/14/25 at 2:21PM, during an interview with the Administrator, she stated her expectation is that the nurse staffing data be posted at the front entrance of the facility by 10:00 AM daily.

Based on observation, record review, and interview, the facility failed to maintain appropriate staffing levels to meet the needs of the residents. This failure has the potential to affect all 98 residents (residents were identified by the resident census list provided by the Administrator on 06/01/25). This deficient practice could likely result in residents not receiving the care and service needed while in the facility. The findings are: A. On 06/02/25 at 9:14 AM during an interview with R #31 and her daughter. R #31's daughter stated that she comes in the mornings because the facility is short staffed, and staff don't give R #31 her dentures, and get R #31 situated for breakfast. R #31's daughter stated R #31's hair hasn't been washed since she entered the facility a few weeks ago. B. On 06/01/25 at 12:05 PM, during an interview, R #44 stated the following: 1. He preferred to eat food in his room. 2. When the facility is short staffed, they deliver meal trays late. 3. That morning (06/01/25), they were short staffed, it took an hour to get his breakfast and it was cold. C. On 06/02/25 at 8:42 AM during an interview, R #72 said it takes them a long time to answer the call light. R #72 said that she has asked for pain pills and that it takes staff a long time to bring them to her. R #72 said it is all shifts and sometimes it takes an hour. D. On 06/01/25 at 12:35 PM during an observation, revealed the following: 1. The medical records coordinator passed out the meal tray to R #253 for lunch. 2. The medical records coordinator entered R #253's room with meal tray and stated, I have your lunch. 3. R #253 asked to keep his food on meal tray, and the medical record coordinator stated, I'm not supposed to leave your food on the meal tray. R #253 insisted on keeping his meal tray. The medical records coordinator dropped the meal tray on R #253's bedside table. The medical records coordinator rushed out of R #253's room without further communication with R #253 and sighed heavily. 4. The medical records coordinator did not offer to set up R #253's lunch tray, and did not assist R #253 to open any containers or place the bedside table within R #253's reach. 5. R # 253 looked at this surveyor with a puzzled look on his face and stated, you saw that right? R #253 then attempted to reach for the bedside table but was unable to move it within his reach. E. On 06/01/25 at 1:30 PM during an interview, the medical records coordinator stated the facility was short staffed and she was assisting with passing meal trays. F. On 06/05/25 at 9:27 AM during an interview with R #253, he stated he figured the medical records coordinator was a new employee and probably shouldn't have been serving people their food. G. On 06/01/25 at 12:03 PM during an interview, R #254 said that the facility is short handed all the time, and he has to wait for assistance. R #254 said that he can't go to the bathroom on his own and that it takes staff a while to get to him. H. On 06/05/25 at 2:14 PM during an interview, R #254 said that he had an accident waiting for staff to help him go to the bathroom. R # 254 said he can't get his pants down on his own. I. On 06/05/25 at 10:32 AM during an interview, the DON said that she does the staffing. The DON said that there is one CNA and one nurse for each floor except for the 100 hall. The DON said that 2 nurses split the 100 hall. The DON said that when staff is available she will have 2 CNA's on the 200 and 600 hall. The DON said the following: - 600 hall have 17 residents and there are not any residents that need two person assist. -500 hall have 18 residents and there are 2 residents that need two person assist. -200 hall have 17 residents and there are 5 residents that need two person assist. -100 hall have 15 residents and there are 2 residents that need two person assist. - Secured hall 300 and 400 have 30 residents and there is one person that is a two person assist. The DON said that when a CNA needs help, that a CNA from another floor will assist and that the nurses help too. The DON said that her expectation is that all staff answer call lights and help if they can. The DON said that she thinks there is enough staff to take care of the residents' needs. The DON said that she has not heard any complaints about there not being enough staff. J. On 06/05/25 11:19 AM, during an interview, CNA #10 said that she picked up a shift today because they are shorthanded. CNA #10 said that there are not enough CNA's to help the residents. CNA #10 said that there is usually one per hall. CNA #10 said when they are showering residents, a CNA from another hall has to cover their hall. CNA #10 said that the residents have to wait for care. CNA #10 said when the surveyors are at the facility, everyone helps, but it isn't like that when surveyors aren't at the facility. CNA #10 said they have asked for more help but they don't get it. K. On 06/05/25 at 11:25 AM, during an interview, CNA #8 said that there is one CNA on each floor and it's not enough to take care of the residents' needs. CNA #8 said that she they have to shower, get residents up and dress, take residents to the bathroom, change residents, pass out trays, assist residents with meals, and help with any other needs the residents have. CNA #8 said that the resident care is delayed because there are not enough staff. CNA #8 said that she has to rush to get the resident's cared for. CNA #8 said that she doesn't have time to spend with the residents. CNA #8 said that residents have to wait to be changed. CNA #8 said that she is always hurrying. CNA #8 said that there are more staff now that the surveyors are here but usually it is just 1 CNA per floor and 1 nurse. L. On 06/05/25 at 2:51 PM, during an interview, RN #9 said that she doesn't believe there are enough CNA's. RN #9 said that CNA's are rushed and can't take time with the residents. RN #9 said that residents get frustrated because they have to wait. RN #9 said that there are four residents requiring the hoyer lift that are two persons assist and one sit to stand assist resident on the 200 hall. RN #9 said that there are two residents requiring hoyer lift and two persons assist on the 100 hall. RN #9 said that when a CNA has to leave her floor to assist another CNA, that leaves the floor without a CNA, and depending on what they are assisting with, it can be a while. RN #9 said that she will help, but it still isn't enough to give each resident the time they need with assistance. M. Record review of the facility's staffing assignment and time sheets for 05/31/25 with a census of 97 revealed the following: 1. 600 hall had 1 nurse and 1 CNA for both shifts. 2. 500 hall had 1 nurse and 1 CNA. The nurse assigned split the 100 hall on day shift. Night shift only had 1 nurse from 6:00 PM until 9:00 PM. 3. Secured unit 300 and 400 1 nurse and 2 CNA's for both shifts. 4. 200 hall had 1 nurse and 1 CNA. The nurse assigned split the 100 hall also. 5. 100 hall had 1 CNA and 2 nurses split the hall. Night shift only had 1 nurse from 6:00 PM until 9:00 PM. N. Record review of the facility's staffing assignment and time sheets for 06/01/25 with a census of 97 revealed the following: 1. 600 hall had 1 nurse and 1 CNA for both shifts. 2. 500 hall had 1 nurse and 1 CNA. The nurse assigned split the 100 hall on day shift. Night shift only had 1 nurse from 6:00 PM until 9:00 PM. 3. Secured units 300 and 400 had 1 nurse and 2 CNA's for both shifts. 4. 200 hall had 1 nurse and 1 CNA. The nurse assigned split the 100 hall also. 5. 100 hall had 1 CNA and 2 nurses split the hall. Night shift only had 1 nurse from 6:00 PM until 9:00 PM.

Based on record review and interview, the facility failed to submit direct care staffing information to the federal agency overseeing certification for long term care facilities for July 2024 through December 2024. This has the potential to affect all 98 residents in the facility, (residents were identified by the Resident Matrix provided by the Administrator on 06/01/25). This deficient practice could likely result in inaccurate direct care staffing information for residents/facility. The findings are: A. Record review of Payroll Base Journal (PBJ) Staffing Data Report (report from the data base of the federal agency overseeing certification for long term care facilities) dated Quarter #3 and #4 2024 (July 1 through December 31) revealed low weekend staffing. B. On 06/05/25 at 9:33 AM, during an interview, the Administrator revealed that contracted staff are not being captured on the PBJ report. The Administrator stated that contract staff don't clock in and out at the facility like staff do, and their agency keeps their time. The Administrator said that they are working with the corporate office to correct the reporting.

Recite from [DATE] Based on observation and interview, the facility failed to provide a comfortable and homelike environment for all 69 residents who do not reside in the secure unit (residents were identified by the census provided by the Administrator on [DATE]) when staff failed to: 1. Store a deceased resident's belongings out of common areas share by residents. 2. Repair the floor in front of R #31's restroom, and replace ceiling covers above R #31's bed. These deficient practices could likely cause residents to feel like they are not living in a comfortable home like environment and like they are not valued. The findings are: A. On [DATE] at 2:28 PM an observation of R #31's room revealed the floor in front of R #31's restroom door had a deep indention in the floor, and the ceiling above R #31's bed had 2 large brown stains. B. On [DATE] at 2:28 PM during an interview with the Maintenance director, he confirmed the floor in front of R #31's restroom door had a deep indention in the floor, and the ceiling above R #31's bed had two large brown stains. The Maintenance director stated he was not aware of this and there were no work orders regarding these issues, and he would get this fixed right away. C. On [DATE] at 1:35 PM during a phone interview with the state ombudsman, she stated that she had visited the facility the week of [DATE] through [DATE] and noticed there were several large black trash bags in the main hall of the facility. She stated that you can see it upon entering the building and the trash bags make the facility entrance look cluttered. D. On [DATE] at 9:40 AM during an observation of the main hall, ten large black trash bags, in an open area of the main hall of the facility. E. On [DATE] at 9:05 AM during an interview, the Administrator said that the bags contained the belongings of a resident that passed away and are waiting for family to pick them up. The Administrator said that they keep them there so that when family comes, they have access to them (the Administrator did not indicate how long they had been there).

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 4 (R #14, R #15, R #33 and R #63) of 7 (R #14, R #15, R #18, R #28, R #33, R #35 and R #63) residents reviewed for unnecessary medications, when staff failed to ensure: 1. A gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) was carried out for R #14 and R #63. 2. Psychotropic medications ordered to be given as needed (PRN) for R #15 and R #33 were not prescribed for longer than 14 days without documentation of the rationale to extend beyond 14 days in the resident's medical record including an indication for the duration of the PRN order. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: Gradual Dose Reduction R #14 A. Record review of R #14's admission record (no date) revealed the following: 1. R #14 was admitted to the facility on [DATE]. 2. R #14 has a diagnosis of other recurrent depressive disorders (mental health condition with symptoms characteristic of a depressive disorder such as persistent sadness that cause clinically significant distress but do not meet the full criteria for any other depressive disorder). B. Record review of R #14's physician's orders revealed an order dated 09/25/24 for Prozac (antidepressant medication primarily used to treat depression disorders) capsule 20 mg, give 1 capsule by mouth one time a day for depression. Start date: 09/16/24. C. Record review of R #14's Medication Administration Record (MAR; electronic form used by nursing staff to document when medication is given), dated 05/01/25 through 05/31/25, revealed R #14 received Prozac (fluoxetine) 20 mg every morning from 05/01/25 through 05/31/25. D. Record review of R #14's Medication Regimen Review (form provided to the facility with pharmacist recommendation) dated 03/14/25, revealed the following: 1. Gradual dose reduction request: Medication fluoxetine 20 mg once daily. 2. Residents who use psychotropic drugs must have GDR attempts unless clinically contraindicated, in an effort to discontinue these drugs. Do you feel a reduction could be attempted on the above medication at this time? 3. The form was electronically signed by the pharmacist. 4. The physician response section was blank, and the form was not signed by a physician. E. On 06/05/25 at 4:10 PM during a joint interview, the DON and the Regional Nurse Consultant (RNC) confirmed the following: 1. R #14 has not had a GDR for fluoxetine. 2. The medical director did not provide a rationale in R #14's medical record indicating the reason a GDR was not completed for R #14 as recommended by the pharmacist. R #63 F. Record review of R #63's admission record (no date) revealed the following: 1. R #63 was admitted to the facility on [DATE]. 2. R #63 diagnosis as follows: a. Unspecified dementia, moderate, with psychotic disturbance (diagnosis that encompasses a range of symptoms that lead to a decline in skills your brain uses to complete daily tasks, can cause abnormal thinking and perceptions but specific details regarding the condition are not clearly defined). b. Other recurrent depressive disorders. c. Unspecified dementia, unspecified severity, with other behavioral disturbances (confusion or mild cognitive impairment that cannot be clearly diagnosed and include consistent patterns of actions or responses that disrupt daily life . G. Record review of R #63's physician's orders, multiple dates, revealed the following: 1. Order dated 06/14/23 for divalproex sodium oral tablet delayed release (antiseizure medication commonly used to treat seizures, bipolar disorder and to prevent migraine headaches) 250 mg, give 1 tablet by mouth three times a day for behavioral disturbances in dementia. 2. Order dated 08/14/23 for buspirone (anti-anxiety commonly used to treat symptoms of anxiety, such as fear, tension, irritability, dizziness, pounding heartbeat, and other physical symptoms) oral tablet, give 7.5 mg by mouth two times a day for sexually inappropriate behaviors (behaviors such as sexual conversation, inappropriate touching or grabbing that occur when a person has lost the ability to inhibit behavior) ordered by [name of psychiatric service provider]. 3. Order dated 07/24/24 for sertraline tablet give 100 mg by mouth one time a day for depression. H. Record review of the Psychotropic Medication Utilization Report (pharmacist spreadsheet that includes information about the use of psychotropic, sedative, and hypnotic medications) dated 03/14/25 revealed the following: 1. R #63 had an order for divalproex three times a day since 06/14/23, and a GDR was declined in September 2024. 2. R #63 had an order for buspirone 7.5 mg two times a day since 08/14/23, and a GDR was declined in July 2024. 3. R #63 had an order for sertraline 100 mg one time a day since 07/24/24, and a GDR was declined in November 2024. I. Record review of R #63's MAR, dated 05/01/25 through 05/31/25, revealed the following: -divalproex 1. R #63 received divalproex 250 mg three times daily from 05/01/25 through 05/09/25 2. R #63 received divalproex 250 mg at 8 AM on 05/10/25. 3. R #63 received divalproex 250 mg at 7 PM on 05/10/25. 4. R #63 received divalproex 250 mg three times daily from 05/11/25 through 05/31/25 -buspirone 5. R #63 received buspirone 7.5 mg two times a day from 05/01/25 through 05/31/25 -sertraline 6. R #63 received sertraline 100 mg one time a day from 05/01/25 through 05/31/25. J. On 06/05/25 at 4:20 PM, during a joint interview, the DON and the Regional Nurse Consultant (RNC) confirmed the following: 1. R #63 has not had a GDR for divalproex, buspirone or sertraline. 2. R #63's physician did not provide a rationale in R #63's medical record, indicating the reason a GDR was not completed for R #63 as recommended by the pharmacist. PRN psychotropic medications R #15 K. Record review of R #15's admission record, no date revealed the following: 1. R #15 was admitted to the facility on [DATE]. 2. R #15 has diagnosis of anxiety. L. Record review of R #15's physician's orders dated 04/08/25 for Lorazepam (medication that can be used to treat anxiety) 0.5 mg 1 tab via PEG-Tube every 4 hours as needed for anxiety. M. Record review of R #15's MAR, dated 05/01/25 through 05/31/25, revealed on 05/09/25, R #15 received Lorazepam 0.5 mg PRN (as needed). N. Record review of the medication regimen review form, dated 04/09/25 revealed the following: 1. The recommendation to consider discontinuing the Lorazepam medication if R #15 still benefits from PRN use, R # 15 requires PRN psychotropic medication due to Hospice care. 2. Lorazepam medication anticipation of duration of use for R #15 was left blank. Physician marked agree with this recommendation. 3. Medical director signed the medication regimen review for on 04/20/25. O. On 06/05/25 at 2:22 PM, during an interview with DON, she stated Lorazepam PRN medication for R #15 should have an end date. DON confirmed that PRN medications should have an end date, and she will work on getting that done. R #33 P. Record review of R #33's admission record, no date revealed the following: 1. R #33 was admitted to the facility on [DATE]. 2. R #33 has diagnosis of seizures. Q. Record review of R #33's physician's orders dated 05/27/25 for Ativan (Lorazepam) injection solution 2 mg/ml every 4 hours as needed for seizures. R. Record review of R #33's medical record, no date, revealed the record did not have any documented rationale in the resident's medical record and the duration for the PRN order was not indicated. S. On 06/05/25 at 3:51 PM, during an interview, the DON said that there should be a rationale and end date for PRN Ativan for R #33.

Recite from 08/21/24 Based on record review and interview, the facility failed to ensure care plan revisions occurred for 2 (R #68 and R #86) of 6 (R #21, R #28, R #33, R #35, R #68, and R #86) residents when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #68 A. Record review of R #68's admission documents, no date, revealed he was admitted to the facility on [DATE]. B. Record review of R #68's physician's orders, multiple dates, revealed the following: 1. An order dated 05/27/25, to monitor right heel daily for redness. 2. An order dated 05/20/25 and discontinued on 05/27/25 for wound care to the right heel. 3. An order dated 03/19/25 and discontinued on 04/05/25 for strict isolation. Droplet/Contact precautions (intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment). 4. An order dated 05/04/25 and completed on 05/17/25 for Ertapenem Sodium Solution (antibiotic used to treat certain serious infections) 1 gram to be administered intravenously (through a vein) once a day for two weeks due to wound infection. C. Record review of R #68's care plan, revised 05/11/25, revealed the following: 1. R #68 was on antibiotic therapy for wound infection. 2. R #68 was on strict contact isolation. D. On 06/04/25 at 11:07 AM, during an interview, the wound care nurse confirmed the following: 1. R #68's wound was healed. 2. R #68 was no longer receiving antibiotic therapy for his wound infection. 3. R #68 was no longer on contact isolation precautions. E. On 06/05/25 at 4:51 PM, during an interview, the DON confirmed the following: 1. R #68's care plan included that he was on antibiotic therapy for a wound. 2. R #68's care plan included that he was on strict contact isolation. 3. R #68's care plan should have been revised when his antibiotic therapy was completed. 4. R #68's care plan should have been revised when he was removed from contact isolation. R#86 F. Record review of R #86'S admission documents, no date, revealed R #86 was admitted to the facility on [DATE]. G. Record review of R #86's physician's orders, multiple dates, revealed the following: 1. An order dated 01/26/25, staff to put on compression stocking in the morning for pitting edema (occurs when excess fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, a pit, or indentation, will remain). 2. An order dated 01/26/25, staff to remove compression stocking at bedtime. H. Record review of R 86's care plan dated 12/20/25 revealed that R #86's compression stockings and interventions were not documented. I. On 06/02/25 at 3:36 PM during an interview, the DON said that R #86's compression stockings and interventions should be care planned for to ensure that R #86 receives care as ordered by the provider.

Based on record review, and interview, the facility failed to ensure residents received necessary behavioral health care to meet their needs for 1 (R #63) of 2 (R #14 and R #63) residents reviewed for behavioral health concerns when staff failed to ensure consistent psychiatric services. This deficient practice could likely result in residents not receiving the behavioral or mental health care and assistance needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The findings are: A. Record review of R #63's admission record (no date) revealed the following: 1. R #63 was admitted to the facility on [DATE]. 2. R #63 diagnoses as follows: a. Unspecified dementia, moderate, with psychotic disturbance (diagnosis that encompasses a range of symptoms that lead to a decline in skills your brain uses to complete daily tasks, can cause abnormal thinking and perceptions but specific details regarding the condition are not clearly defined). b. Other recurrent depressive disorders. c. Unspecified dementia, unspecified severity, with other behavioral disturbance (confusion or mild cognitive impairment that cannot be clearly diagnosed and include consistent patterns of actions or responses that disrupt daily life). B. Record review of R #63's physician's orders revealed an order dated 07/07/23, refers to [name of psychiatric provider] for evaluation and treatment. C. Record review of R #63's Initial Psychotherapy (treatment for mental health issues by talking with a mental health provider) Assessment, dated 04/10/24 revealed the following: 1. Reason for referral: agitation, anger, anxiety, psychosis (loss of contact with reality that affects the mind and can cause delusions [strongly held false beliefs], hallucinations [seeing or hearing things that are not present], and other symptoms) aggressive behavior/verbal, sexually inappropriate behavior. 2. The purpose of psychotherapy is to alleviate emotional disturbance, improve function, and prevent deterioration. 3. Patient could benefit and has the capacity to participate in treatment. Patient is compliant. 4. Psychotherapy treatment plan: Goals for therapy include reducing symptoms of depression and preventing/reducing decline due to dementia. Psychotherapy is recommended one to four times per month. D. Record review of R #63's care plan, multiple dates, revealed the following: - Focus: R #63 is on psychotropic medication related to depression, dementia with psychotic disturbances and behavioral disturbances. - Approaches/Tasks: Psych consult as needed. - Focus: R #63 is exhibits difficulty with behavioral issues as evidenced by anger easily. - Approaches/Tasks: Refer to Psyche(sic) - Focus: R #63 has aggressive behavior - Approaches/Tasks: investigate/monitor need for psychological/psychiatric support. E. Record review of R #63's Electronic Health Record (EHR) revealed the R #63 was not seen for any further psychotherapy visits after 04/10/24 visit. F. On 06/0524 at 4:13 PM, during an interview with the administrator, she stated the following: 1. She is not sure why R #63 was no longer seen for psychotherapy. 2. The initial visit on 04/10/24 was the only visit R #63 received for psychotherapy.

Based on record review and interview the facility failed to ensure a resident diagnosed with dementia (group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells) received appropriate treatment and services to attain his highest mental and psychosocial well-being for 1 (R #33) of 1 (R #33) resident reviewed for dementia treatment and services when the facility failed to: 1. Ensure R #33's care and services are person centered and help maximize his dignity and autonomy. 2. Utilize individualized, non-pharmalogical (treatments or interventions that do not involve the use of medications or drugs) approaches to his care. This deficient practice could likely result in a lack of meaningful relationships, engagement in day-to-day activities and diminished quality of life. A. Record review of R #33's admission record, no date, revealed the following: 1. R #33 was admitted to the facility on [DATE]. 2. R #33 had a diagnosis of dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. B. Record review or R #33's care plan does not include R #33's dementia diagnosis or any care related dementia. C. Record review of R #33's orders revealed the following: 1. An order dated 05/27/25 for donepezil oral tablet 10 mg give 1 tablet via peg-tube (a feeding tube inserted through the abdominal wall directly into the stomach) at bedtime for dementia. 2. An order dated 05/27/25 for memantine oral tablet 10 mg give 1 tablet via peg-tube two times a day for dementia. 3. An order dated 05/30/25 for hydroxyzine 25 mg Give 1 capsule via peg-tube two times a day for agitation/anxiety. D. Record review of R #33's progress notes revealed the following: 1. On 03/18/25 at 12:28 pm R #33 was physically fighting to stand up from chair, throwing items, scratching, and pulling at staff. 2. On 03/18/25 at 1:16 pm R #33 tried to exit the facility, stripped all his clothes off and went into other rooms. R #33 was combative with staff when attempting to redirect. R #33 is a peg tube and NPO (nothing by mouth) and staff has been unable to feed him or provide any medications because R #22 will not allow staff to care for him and becomes combative. This nurse stated that staff will not be able to care for R #33. state he is in. This nurse notified residents nurse of the order to send to hospital 3. On 04/23/25 that multiple attempts were made by CNA and a nurse to assist R #33 into his wheelchair and encouraged him to attend activities. R #33 continuously refused. R #33 did not state reason for refusing. 4. On 05/15/25 R #33 was redirected multiple times by staff because R #33 was witnessed picking and scratching at his left cheek by this nurse. E. On 06/04/25 at 11:07 AM, during an interview, the Activities Director (AD) said that she has colored with R #33. The AD said that she takes R #33 to see the fish and will ask him if he remembers the fish. The AD said that she talks to R #33 and will ask him if he remembers her. The AD said that she has had the activity director training for dementia care and that she knows that there are memory care activities that can be done with residents with dementia but that she has not done memory games with R #33. The AD said that she did bring the memory cards out once, but R #33 was more receptive to coloring. D. On 06/04/25 at 3:06 PM, during an interview, the DON confirmed R #33's dementia diagnosis. The DON said that R #33 should be provided care that is needed to help with his memory and to maintain his health.

Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation for 3 (R #14, R #33 and R #63) of 7 (R #14, R #15, R #18, R #28, R #33, R #35, and R #63) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: R #14 A. Record review of R #14's admission record (no date) revealed the following: 1. R #14 was admitted to the facility on [DATE]. 2. R #14 had a diagnosis of other recurrent depressive disorders (mental health condition with symptoms characteristic of a depressive disorder such as persistent sadness that cause clinically significant distress but do not meet the full criteria for any other depressive disorder). B. Record review of R #14's physician's orders revealed an order dated 09/25/24 for Prozac (fluoxetine antidepressant medication primarily used to treat depression disorders) capsule 20 mg, give 1 capsule by mouth one time a day for depression. Start date: 09/16/24. C. Record review of R #14's Medication Regimen Review (form provided to the facility with pharmacist recommendation) dated 03/14/25, revealed the following: 1. Gradual dose reduction request: Medication fluoxetine (Prozac) 20 mg once daily. 2. Residents who use psychotropic drugs must have GDR attempts unless clinically contraindicated, in an effort to discontinue these drugs. Do you feel a reduction could be attempted on the above medication at this time? 3. The form was electronically signed by the pharmacist. 4. The physician response section was blank, and the form was not signed by a physician. D. Record review of R #14's Medication administration record (MAR; electronic form used by nursing staff to document when medication is given), dated 05/01/25 through 05/31/25, revealed R #14 received Prozac (fluoxetine) 20 mg every morning from 05/01/25 through 05/31/25. E. On 06/05/25 at 4:10 PM during a joint interview, the DON and the Regional Nurse Consultant (RNC) confirmed the following: 1. The pharmacist recommendation was not implemented by R #14's physician. 2. R #14's physician did not provide a rationale in R #14's medical record, indicating the reason a GDR was not completed for R #14. R #33 F. Record review of R #33's admission record (no date) revealed the following: 1. R #33 was admitted to the facility on [DATE]. 2. R #33 diagnoses as follows: a. Depression, Unspecified. b. Other seizures. c. Traumatic brain injury (TBI; an injury that disrupts the normal function of the brain, typically caused by a blow or impact to the head or body). G. Record review of R #33's physician's orders, multiple dates, revealed the following: 1. Order dated 03/17/25 for duloxetine oral capsule delayed release sprinkle 60 mg give one capsule via peg tube (a feeding tube inserted directly into the stomach through the abdominal wall) two times a day for depression. 2. Order dated 03/21/25 for phenobarbital oral tablet 64.8 mg in the morning and 97.2 mg at bedtime for seizures. 3. Order dated 03/19/25 for olanzapine oral tablet 5 mg give 1 tablet enterally at bedtime for TBI. 4. Order dated 03/21/25 for trazodone hci oral tablet 100 mg give 1 tablet via peg tube at bedtime for insomnia. 5. Order dated 03/17/25 for Keppra oral solution 100 mg give 7.5 ml via peg tube two times a day for seizures. H. Record review of R #33's progress note dated 03/26/25, revealed R #33 had a fall and was on the floor in front of his wheelchair. I. Record review of a medication regimen review dated 04/09/25, revealed the following: 1. R #33 had a recent fall and that R #33's medication can increase fall risk. 2. Would physician like to make any changes to medications? 3. Please offer clinical rationale. 4. Physician documented R #33 was stable on medication. J. Record review of R #33's medical record revealed the following: 1. The physician did not document that the medications listed on the pharmacy recommendation were reviewed. 2. The physician did not provide clinical rationale for continuing R #33's medication. R #63 K. Record review of R #63's admission record (no date) revealed the following: 1. R #63 was admitted to the facility on [DATE]. 2. R #63 diagnoses as follows: a. Unspecified dementia, moderate, with psychotic disturbance (diagnosis that encompasses a range of symptoms that lead to a decline in skills your brain uses to complete daily tasks, can cause abnormal thinking and perceptions but specific details regarding the condition are not clearly defined). b. Other recurrent depressive disorders. c. Unspecified dementia, unspecified severity, with other behavioral disturbance (confusion or mild cognitive impairment that cannot be clearly diagnosed and include consistent patterns of actions or responses that disrupt daily life. L. Record review of R #63's physician's orders, multiple dates, revealed the following: 1. Order dated 06/14/23 for divalproex sodium oral tablet delayed release (antiseizure medication commonly used to treat seizures, bipolar disorder and to prevent migraine headaches) 250 mg, give 1 tablet by mouth three times a day for behavioral disturbances in dementia. 2. Order dated 08/14/23 for buspirone (anti-anxiety commonly used to treat symptoms of anxiety, such as fear, tension, irritability, dizziness, pounding heartbeat, and other physical symptoms) oral tablet, give 7.5 mg by mouth two times a day for sexually inappropriate behaviors (behaviors such as sexual conversation, inappropriate touching or grabbing that occur when a person has lost the ability to inhibit behavior) ordered by [name of psychiatric service provider]. 3. Order dated 07/24/24 for sertraline tablet give 100 mg by mouth one time a day for depression. M. Record review of the Psychotropic Medication Utilization Report (pharmacist spreadsheet that includes information about the use of psychotropic, sedative, and hypnotic medications), dated 03/14/25, revealed the following: 1. R #63 had an order for divalproex three times a day since 06/14/23, and a GDR was declined in September 2024. 2. R #63 had an order for buspirone 7.5 mg two times a day since 08/14/23, and a GDR was declined in July 2024. 3. R #63 had an order for sertraline 100 mg one time a day since 07/24/24, and a GDR was declined in November 2024. N. Record review of R #63's MAR, dated 05/01/25 through 05/31/25, revealed the following: -divalproex 1. R #63 received divalproex 250 mg three times daily from 05/01/25 through 05/09/25. 2. R #63 received divalproex 250 mg at 8 AM on 05/10/25. 3. R #63 received divalproex 250 mg at 7 PM on 05/10/25. 4. R #63 received divalproex 250 mg three times daily from 05/11/25 through 05/31/25. -buspirone 5. R #63 received buspirone 7.5 mg two times a day from 05/01/25 through 05/31/25. -sertraline 6. R #63 received sertraline 100 mg one time a day from 05/01/25 through 05/31/25. O. On 06/05/25 at 4:20 PM, during a joint interview, the DON and the Regional Nurse Consultant (RNC) confirmed the following: 1. R #63 has not had a GDR for divalproex, buspirone or sertraline as recommended by pharmacist. 2. R #63's physician did not provide a rationale in R #63's medical record, indicating the reason a GDR was not completed for R #63 as recommended by the pharmacist.

Recite from 04/24/24 Based on observation and interview, the facility failed to store food under sanitary conditions for all 94 residents who eat food from the kitchen (residents were identified by the resident matrix provided by the administrator on (06/01/25) when staff failed label and date all items in the kitchen refrigerator. Failure to store food under safe and sanitary conditions could likely lead to foodborne illnesses in residents. The findings are: A. On 06/01/25 at 9:25 AM, an observation of the kitchen revealed the following: 1. The refrigerator had two trays with 10 lid-covered beverages, the lids were not dated. 2. The walk-in refrigerator had three trays with covered desserts on them. The desserts did not have a date to indicate when they were prepared. B. On 06/01/25 at 9:32 AM, during an interview, the Dietary Manager confirmed that the drinks and desserts should all be labeled with the date they were prepared.

Based on observation and interview, the facility failed to ensure residents were treated with respect and dignity for 2 (R #86 and R #253) of 3 (R #33, R #86 and R #253) residents when the facility failed to do the following: 1. Use a privacy bag for R #86's foley catheter bag (a urine drainage bag that collects urine from the bladder). 2. Treat R #253 with dignity when serving him lunch. The findings are: R #86 A. On 06/02/25 at 3:15 PM, during an observation of the 600 unit, R #86's catheter bag did not have a privacy bag (a discreet cover that conceals the urine drainage bag from view). B. On 06/02/25 at 3:18, during an interview, CNA #8 confirmed that there was not a privacy bag on R #86's catheter bag. C. On 06/02/25 at 3:42, during an interview, the DON said that catheters bags should have a privacy cover. R #253 D. Record review of R #253's administration record, no date revealed the following: 1. R #253 was admitted to the facility of 05/12/17. 2. R #253 diagnoses included the following: a. Muscle weakness (generalized). b. Hemiplegia, unspecified affecting the left non dominant side. c. Contracture of muscle (a type of scarring in your soft tissues that causes them to tighten and stiffen), unspecified upper arm. E. On 06/1/25 at 12:35 PM, during an observation of R #253's room revealed the following: 1. The medical records coordinator passed out the meal tray to R #253 for lunch. 2. The medical records coordinator entered R #253's room with a meal tray and stated, I have your lunch. 3. R #253 asked to keep his food on the meal tray, and the medical record coordinator stated, I'm not supposed to leave your food on the meal tray. R #253 insisted on keeping his meal tray. The medical records coordinator dropped the meal tray on R #253's bedside table. The medical records coordinator rushed out of R #253's room without further communication with R #253 and sighed heavily. 4. The medical records coordinator did not offer to set up R #253's lunch tray, and did not assist R #253 to open any containers or place the bedside table within R #253's reach. 5. R # 253 looked at this surveyor with a puzzled look on his face and stated, You saw that right? R #253 then attempted to reach for the bedside table but was unable to move it within his reach. F. On 06/01/25 at 12:40 PM, during an interview with LPN #28, she stated that she would get a CNA to assist R #253 immediately with his meal setup. LPN #28 stated that the medical records coordinator should not have treated R #253 in that manner. G. On 06/01/25 at 1:30 PM, during an interview with the medical records coordinator, stated the following: 1. The facility was short staffed, and she assisted with passing meal trays. 2. When she passes out meal trays she knocks on door and puts tray in front of the resident removing tray and overhead warmer containers. 3. If a resident prefers to keep food on meal tray the resident can keep it. 4. She has taken resident rights training. H. On 06/05/25 at 9:27 AM, during an interview with R #253, he stated he figured the medical records coordinator was a new employee, and probably shouldn't have been serving people their food, and said he felt indifferent about what happened. I. On 06/05/25 at 1:57 PM, during an interview with the administrator, she confirmed that she expects her staff to treat residents with dignity and respect, and her expectations would be that staff treat all residents with dignity and respect.

49313 Based on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #108) of 2 (R #78 and R #108) residents when they failed to: 1. Notify the provider about R #108's abnormal lab values (high potassium). 2. Notify the provider about potential drug-to-drug interactions for R #108. 3. Monitor potassium levels for R #108 who had elevated potassium blood levels, chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and an order for medications that can cause hyperkalemia (elevated potassium blood levels). 4. Notify the provider about R #108 experiencing nausea and vomiting. These deficient practices likely lead to R #108's death. The findings are: R #108 A. Record review of R #108's face sheet, revealed R #108 was admitted on [DATE]. B. Record review of R #108's admission MDS assessment dated [DATE], revealed R #108 had a diagnosis of Acute Kidney Failure. C. Record review of R #108's physician progress note dated [DATE], revealed R #108 had a diagnosis of chronic kidney disease, stage 3 (mild to moderate loss of kidney function). D. Record review of R #108's laboratory test results dated [DATE], revealed the following: 1. Elevated Potassium- 7.5 (normal levels 3XXX,d+[DATE].2) [too much potassium is very common if you have kidney disease or kidney failure]. 2. High Blood Urea Nitrogen (BUN)- 71 (normal levels ,d+[DATE] [high levels indicates kidneys are not working well, or can be due to dehydration or urinary tract obstruction] 3. High Creatinine- 3.5 (normal levels 0XXX,d+[DATE].3) [high levels may be due to kidney problems, such as kidney damage or failure, infection, reduced blood flow, or loss of body fluid]. 4. Low Glomerular Filtration Rate (GFR)- 12.73 (normal level 60 or higher) [low levels means the kidneys are not filtering blood as well as they should. If the number is below 15, it indicates kidney failure]. 5. Elevated potassium and BUN results called into [name of nurse at facility]. E. Record review of nursing progress notes not dated, revealed staff did not contact the provider to notify about R #108's laboratory test results with an elevated potassium and BUN received on [DATE]. F. Record review of nursing progress note dated [DATE] at 2:48 PM, revealed the following: 1. R #108 was seen by the Medical Director (MD) on [DATE]. 2. Laboratory results from [DATE] was reviewed by MD. 3. Additional laboratory tests ordered. 4. Referral for nephrologist (kidney doctor). 5. R #108 encouraged to increase fluids due to lab results and poor kidney function. G. Record review of R #108's laboratory results, dated [DATE], revealed the following: 1. Elevated potassium-7.1, 2. High BUN- 73, 3. High Creatinine- 3.46, 4. Low GFR non-African American- 12.90 5. Elevated potassium and BUN results were called to [name of staff at MD office] on [DATE] at 5:01 PM [after R #108 was seen by provider on [DATE]]. H. Record review of R #108's physician's order [DATE] revealed Bactrim (an antibiotic used to treat ear infections, urinary tract infections, and other infections) was started on [DATE] for a diagnosis of UTI. I. Record review of nursing progress note from ADON #1 dated [DATE], revealed the following: 1. The electronic medical record (EMR) system triggered a drug protocol alert for a drug-to-drug interaction between Bactrim and spironolactone (a potassium-sparing diuretic that can treat high blood pressure, fluid retention (edema), and high levels of the hormone aldosterone. It prevents potassium levels from getting too low). 2. The EMR system indicated, coadministration of Spironolactone oral tablet 25 mg and Bactrim DS oral tablet ,d+[DATE] mg may increase the risk of hyperkalemia (High potassium levels in your blood. While mild hyperkalemia is usually asymptomatic, high potassium levels may cause life-threatening cardiac arrhythmias, muscle weakness, or paralysis). J. Record review of R #108's [DATE] Medication Administration Record revealed the following: 1. R #108 received Spironolactone every morning between [DATE] and [DATE]. 2. R #108 received Bactrim on: a. [DATE] in the evening b. [DATE] in the morning c. [DATE] in the evening d. [DATE] in the morning e. [DATE] in the evening f. [DATE] in the morning g. [DATE] in the evening h. [DATE] in the morning i. [DATE] in the evening j. [DATE] in the morning k. [DATE] in the evening K. Record review of nursing progress notes dated [DATE] at 3:54 PM, revealed the following: 1. R #108 ate 50% or less of two or more meals due to being nauseated and not wanting to eat (nausea and vomiting are symptoms of hyperkalemia). 2. R #108 had reported vomiting and was given Zofran (used to prevent nausea and vomiting) per standing order (means a written medical protocol in which a medical director determines in advance the medical criteria that allows nurses (LPNs and RNs) to fulfill routine requests for refills and physician orders without having to wait for a physician's approval). L. Record review of R #108's physician's orders dated [DATE], revealed an order for Zofran 4 mg, every 6 hours as needed for nausea. M. Record review of facility standing orders, no date, revealed for nausea and vomiting, give Zofran 4 mg, 1 tablet by mouth every 4 hours as needed, and/or Phenergan (medication used to treat nausea and vomiting) 12.5 mg 1 tablet by mouth as needed, and increase fluid intake to make sure they don't get dehydrated. N. Record review of nursing progress note dated [DATE] at 4:03 PM, revealed the electronic medical record system triggered a drug protocol alert for a drug-to-drug interaction between: 1. Zofran and Desvenlafaxine (medication used to treat depression), indicating a potential for additive serotonergic effects (too much serotonin in the blood that causes signs and symptoms that can range from mild (shivering and diarrhea) to severe (muscle rigidity, fever and seizures) which may increase the risk of developing serotonin syndrome (caused by medications that build up high levels of serotonin in the body. Severe serotonin syndrome can cause death if not treated). 2. Zofran and Trazadone (medication used to treat depression), indicating a potential for additive serotonergic effects, which may increase the risk of developing serotonin syndrome. O. Record review of the medical record revealed the following: 1. Staff did not notify the provider about R #108 having nausea and vomiting. 2. Staff did not notify the provider about the potential drug interaction between Zofran, Desvenlafaxine, and Trazadone. P. Record review of a nursing progress note dated [DATE] at 7:12 PM, revealed: 1. R #108 had reported nausea and vomiting at lunch time. 2. Nurse placed a standing order for Zofran 4 mg, sublingual (under the tongue). 3. CNA obtained vital signs from R #108 around 3:00 PM, that were within normal limits (WNL) [no vital signs provided]. 4. Around 4:00 PM, R #108 was offered another Zofran, which she refused. 5. CNA took R #108 her dinner tray and she was sitting on the side of the bed. 6. CNA went to remove R #108's dinner tray and R #108 was unresponsive. Insert times 7. Nurse assessed R #108 and there were no signs of life. Post mortem assessment was performed and R #108 was pronounced deceased . Q. Record review of R #108's EMR revealed, staff did not complete a vital sign assessment for R #108 on [DATE]. R. On [DATE] at 11:43 AM, during an interview with ADON #1, she stated the following: 1. She was unsure if the EMR system notified staff about a contraindication (drug-drug interactions) between medications. 2. She has not seen any alerts about a contraindication (drug-drug interactions) between medications. 3. Pharmacy will call the nurses' station if there is a contraindication between medications. S. On [DATE] at 11:47 AM, during an interview with RN #21, she stated the following: 1. If there is a contraindication between medications a box pops up on the computer screen that you must acknowledge prior to processing and completing the order. 2. If she [nurse] determines that it is not a significant contraindication she will acknowledge without contacting the provider (RN #21 did not specify what constituted a significant contraindication). 3. If it is a significant contraindication she [nurse] will contact the provider. 4. She documents in medical record any time she contacts the provider. T. On [DATE] at 12:59 PM, during an interview with LPN #21, she stated the following: 1. If there is a contraindication between medications a box pops up that you must acknowledge prior to processing and completing the order. 2. She [nurse] will usually notify the provider about a contraindication. 3. She would document contact with provider if she remembers [to write a note]. U. On [DATE] at 11:52 AM, during an interview with the DON, she confirmed the following: 1. When an order is first created, if there is a contraindication between medications, it will notify the staff member that there is a contraindication alert (via a window on the computer screen) that must be acknowledged prior to completing the order. 2. The EMR system will not allow you to sign the order unless it is acknowledged. 3. Nurses are expected to notify the physician for all alerts. 4. Nurses shouldn't acknowledge the order until the MD approves it. 5. She would not expect the nurse to document their discussion with the provider. V. On [DATE] at 9:43 AM, during an interview with the Medical Director, she revealed the following: 1. Staff are expected to notify the provider about any potential drug interactions. 2. Staff are expected to document any communication with the provider in the medical record. 3. Staff should have notified the provider about the drug interaction notification between Spironolactone and Bactrim. 4. She does not remember being notified about R #108 the potential drug interaction between Bactrim and Spironolactone. 5. If she had been notified about the interaction between Bactrim and Spironolactone, she would have either discontinued Spironolactone or ordered a different antibiotic to treat R #108's UTI. 6. She usually would hold Spironolactone while a resident is on Bactrim if they have chronic kidney disease or their GFR is not good. 7. Spironolactone has the potential to increase potassium in the blood, combined with Bactrim, it can cause a worsening of kidney disease and could cause elevated potassium. 8. Nausea could be a symptom of elevated potassium. 9. She would have expected staff to assess vital signs when R #108 reported nausea. 10. Staff should have notified the provider about the drug interaction notification between Zofran, Desvenlafaxine, and Trazadone. 11. She does not remember being notified about R #108 having nausea or about the potential drug interactions identified by the electronic medical record. 12. Elevated potassium could cause death. 13. She was unsure what R #108's potassium level was after [DATE]. The above findings resulted in an Immediate Jeopardy that was called on [DATE] at 12:44 PM. The facility was verified to have fully implemented this approved plan on [DATE] at 11:44 AM. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted on [DATE]. Plan of Removal Facility will review the last 30 days of labs for all current residents. If abnormal lab is discovered, facility will check to see if MD/provider was notified. If not, we will notify MD/ Provider and follow any orders given. An identification audit will be completed by the DON/designee. The identification audit will be reported to MD/provider for further interventions based on findings. The DON/ designee will communicate orders given by MD/provider for implementation. This will be completed by end of day on [DATE]. Facility will look at current resident charts for current drug to drug interactions on spironolactone and residents with chronic kidney disease. The DON/designee will check to see if MD/provider was notified. If not, MD/provider will be notified and follow any orders given. An identification audit will be completed by the DON/designee. The identification audit will be reported to MD/provider for further interventions based on findings. The DON/designee will communicate orders given by MD/provider for implementation. This will be completed by end of day on [DATE]. Facility will educate current nursing staff regarding the process for reviewing labs which is: When new lab results are returned to the center, the nurse will review the lab results to determine if any abnormal lab results are present. The nurse will then notify the MD/provider of the abnormal lab result, follow orders given and document the notification in the medical record. -Education also to include what to do for drug-to-drug interaction notification in PCC. When the nurse is entering new resident orders into PCC and a notification comes up for a drug-to-drug interaction the nurse is to notify the MD/provider of the interaction, follow orders given and document the notification in PCC. -DON/designee will complete the education for staff on shift today, [DATE]. Staff not present will receive education before start of their shift.

41755 49313 Based on record review and interview, the facility failed to ensure that nursing staff demonstrated competency in skills and techniques necessary to safely administer medications to residents for 4 (RN #1, RN #33, LPN #31, and LPN #32) of 6 (RN #1, RN #31, RN #33, LPN #31, LPN #32, and CMA #31) employees sampled for training. This deficient practice likely resulted in R #1 receiving another residents medication, resulting in R #1 being admitted to the hospital on 06/02/23 for accidental overdose and hypotension (low blood pressure). The findings are: A. Record review of the facility Medication Administration Nursing Manual Policy and Procedure undated revealed IV. Nursing Staff will keep in mind the seven 'rights' of medication when administering medication: A. The right medication, B. The right amount, C. The right resident, D. The right time, E. The right route, F. Right indication, G. Right outcome. B. Record review of the facility's Complaint Narrative Investigation Follow-up Report (5 day), no date, revealed the following: This incident is to report a medication error. On 06/02/23, a new traveling nurse (LPN #31) was shadowing (follow and observe closely) a more experienced charge nurse (RN #31). The new traveling nurse told the charge nurse that she believed she was prepared to pass meds on her own so she was given permission. Shortly after, the new nurse informed the charge nurse that she had accidentally given patient (R #1) her roommates medications. C. On 10/16/23 at 2:15 PM, during a phone interview, R #1's daughter stated the following: 1. She received a phone call from the nurse at the facility on 06/02/23 at 10:00 PM stating R #1 received another resident's medications along with her own and was being sent to the hospital. 2. R #1 was hospitalized for six to seven days. Three of those days were in the ICU (Intensive Care Unit). D. Record review of R #1's hospital records revealed: 1. R #1 was triaged (evaluated) at the emergency roiagnom on [DATE] at 9:07 PM. 2. History of present illness: The patient presents with altered mental status. Accidentally given Seroquel (quetiapine fumarate) 200 mg (milligrams) at the nursing home. Brought by EMS (Emergency Medical Services) lethargic (lack of energy), hypotensive (low blood pressure), H/O (history of) Sz (seizures), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and Pt (patient) is a DNR (Do Not Resuscitate). The course/duration of symptoms is constant. The character of symptoms is decreased responsiveness. The degree at onset was moderate. The degree at present is moderate. Baseline status: confused. 3. At 9:25 PM, R #1's blood pressure was 63/48 (normal blood pressure is 120/80 mmHg) mmHg (millimeters of Mercury). 4. At 9:30 PM, R #1's blood pressure was 95/56 mmHg. 5. Assessment/Plan: Hypotension-[AGE] year-old with known history of dementia from a nursing home presents with hypotension presumably secondary to medication reaction to the accidental administration 300 mg Seroquel. She initially responded to low blood pressure with IV (intravenous) fluids and now has recurrent bradycardia associated with hypotension which is getting fluid bolus and repeat EKG. Altered mental status- She does have a baseline dementia which is exacerbated by hypotension and medication administration that was by mistake. 6. On 06/07/23, R #1 was discharged to another long term care facility in the area with diagnoses: Hypotension- suspect secondary to medication, resolved. Altered mental status- Secondary to toxic metabolic encephalopathy secondary to medication and hypotension-resolved. E. On 10/18/23 at 12:41 PM, a phone interview, the physician stated the following: 1. The facility used a lot of contract nurses. 2. The contract nurses did not know the residents. 3. Contract nurses not knowing the residents was the reason R #1 received another resident's medication. F. On 10/23/23 at 11:30 AM, a phone interview with RN #31 revealed: 1. LPN #31 started her first shift on 06/01/23 and shadowed RN #31. 2. On 06/02/23, LPN #31 said she was comfortable to administer medications to the residents. RN #31 allowed her to work independently. RN #31 told LPN #31 she was available if she needed anything. 3. She [RN #31] did not receive any training regarding orienting or completing competency checks on any new employees. G. On 10/23/23 at 11:50 AM, a phone interview with LPN #31 stated the following: 1. She started working at the facility on 06/01/23 and shadowed RN #31 for that day. 2. On 06/02/23 [the following day], RN #31 told her to administer medications to the residents. LPN #31 stated, she told RN #31 that she was not comfortable [contrary to RN #31's interview], and RN #31 told her that she would be available if she had any questions. 3. LPN #3 never acknowledged the reason for the medication error [not verifying resident identity before administering medication]. H. Record review of LPN #31 competency assessment was dated 06/05/23 [after the medication error.] Findings related to competency: I. On 10/18/23 at 1:50 PM, an interview, LPN #32 stated the following: 1. He worked at the facility since July 2023. 2. He shadowed another nurse and then had them shadow him for three or four days. 3. After the 3-4 days of shadowing he was able to administer medications independently. 4. He did not complete any competencies or trainings. J. On 10/18/23 at 1:49 PM, an interview, RN #1 stated the following: 1. She worked at the facility on 08/02/23. 2. She did not receive any onboarding training (process by which new employees acquire the skills, knowledge and behaviors to become effective contributors to an organization) 3. RN #1 denied receiving any training or competencies (measurement of the skills, judgment, knowledge and attributes of a particular job required to perform a role effectively) related to the administration of medications. K. On 10/18/23 at 2:24 PM, during an interview, RN #33 stated the following: 1. She started working in July 2023, 2. She shadowed another nurse for five shifts, 3. She did on-line training, 4. She demonstrated basic competencies, for example, Doning and doffing (putting on and taking off) PPE (personal protective equipment) and hand hygiene. L. On 10/18/23 at 1:45 PM, during record review and an interview, the DON stated the following: 1. Training for travelers/contract staff and in-house staff was the same. 2. The expectation was that new staff orient on the floor with other trained nurses, by shadowing for 3-5 shifts before they do medication administration independently. 3. The facility considered new nursing staff to be competent to administer medications because of their (nurse) license and previous experience (outside the facility). 4. Training nurse would let Administration (Administrator/DON) know if the new staff member was ready or not to work independently . 5. The facility had route (oral, ear, eyes, inhalation, etc.) specific competencies (checklists that are used to evaluate an individuals knowledge/abilities) for medication administration. 6. The expectation was that competencies were completed when the new staff trained with the nurses. 7. Competency forms for employees were requested and provided by the DON to include: Record review of Medication Administration Licensed Nurse Competency Evaluation included Identifies resident by name and photograph and Clinical Competency Validation Oral Medication Administration identified verifies patient identification. DON was only able to produce competencies completed for (11) nurse staff dated 04/27/23. No other competencies were located and provided at the time of survey exit. The facility was unable to provide training documents or competency check off forms for RN #1, RN #33 and LPN #32. M. On 10/18/23 at 4:03 PM, during an interview, the Administrator confirmed they were unable to find the competencies for new staff hired after 04/27/23 [date of completion for previous plan of correction from recertifcation survey]. The above findings resulted in an Immediate Jeopardy that was called on 10/18/23 at 4:22 PM. The facility was verified to have fully implemented this approved plan on 10/18/23 at 7:30 PM. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted on 10/18/23. Plan of Removal This Plan of Removal is in response to the identification of Immediate Jeopardy communicated by the survey team on October 18, 2023, at [name of facility]. The Immediate Jeopardy finding was identified in the following area: failure to provide current nurse and CMA staff with onboarding regarding and competency for medication administration to residents. The Facility respectfully submits this Plan of Removal (POR) pursuant to Federal and State regulatory requirements. Submission of this Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiency. Identification Resident receiving wrong medications does not reside at the center. Resident on 06/02/23 after the medication error occurred was sent to the emergency room for further evaluation and higher level of care. Corrective Action The DON/designee reviewed the last 30 days of incident reports with no med errors occurring during this period of time. HR/designee identified a list of new hires still employed and worked with DON/designee to determine those lacking onboarding education and competency for medication administration. Nurses without onboarding education and competency received education and competency beginning 10/18/23. Nurses and CMAs as they return to work will have the education and competency completed prior to beginning med pass. Systematic Measures DON/designee began completing re-education and competencies for medication administration with current nursing and CMA staff beginning on 10/18/23 to ensure all staff continue to be competent to administer medications to the residents. Newly hired nursing staff received education and competency for medication administration also. The DON, Administration, and HR received re-education on 10/18/23 regarding new nursing and CMA employees are to receive both general and clinical orientation prior to accepting a solo assignment. The re-education was completed by Director of Clinical Services. Nursing staff that have not had clinical orientation will be given the orientation materials and reviewed with the DON/designee. Quality Assurance and Monitoring The HR/designee will complete a weekly audit of newly hired nursing employees to ensure both general and clinical orientation has been completed. Nurses not completing clinical orientation will not be given solo assignment until orientation materials and competencies have been completed and returned. DON/ADONs/designee will ensure orientation is complete prior to first solo assignment. An Ad Hoc QAPI Meeting will be held on 10/19/23 to approve above plan.

Based on record review and interview, the facility failed to ensure residents are free of any significant medication errors for 1 (R #1) of 6 (R #1, R #2, R #3, R #4, R #5, and R #6) residents reviewed for neglect, when they failed to administer medication to the correct resident. This deficient practice likely resulted in R #1 experiencing adverse (unwanted, harmful, or abnormal result) side effects and admission to the hospital. The findings are: A. On 10/16/23 at 2:15 PM, during a phone interview, R #1's daughter stated the following: 1. She received a phone call from the nurse at the facility on 06/02/23 at 10:00 PM stating R #1 received another resident's medications along with her own and was being sent to the hospital. 2. R #1 was hospitalized for six to seven days. Three of those days were in the ICU (Intensive Care Unit). B. Record review of R #1's Progress Notes, written by RN #31, revealed: 1. On 06/02/23 at 8:30 PM, R #1 received another resident's medications, which were sucralfate (medication used to treat duodenal ulcers) 1GM (gram, unit of measure), melatonin (supplement given to regulate sleep) 3 mg (milligrams), quetiapine fumarate (medication used to treat certain mental/mood conditions such as schizophrenia, bipolar disorder, sudden episodes of mania or depression) 200 mg, atorvastatin (medication used to slow the production of cholesterol in the body) 10 mg, gabapentin (medication used to treat seizures and nerve pain) 300 mg, lactulose (medication that is a laxative and ammonia reducer used to treat constipation. It can also treat liver disease) 15 ml (milliter), protonix (medication used to treat certain stomach and esophagus problems such as acid reflux) 40 mg, and ropinirole (medication used to treat Parkinson's disease and restless legs syndrome) 0.5 mg. 2. R #1 was sent to the local emergency room for evaluation. C. Record review of R #1's hospital records revealed: 1. R #1 was triaged (evaluated) at the emergency roiagnom on [DATE] at 9:07 PM. 2. History of present illness: The patient presents with altered mental status. Accidentally given Seroquel (quetiapine fumarate) 200 mg at the nursing home. Brought by EMS (Emergency Medical Services) lethargic (lack of energy), hypotensive (low blood pressure), H/O (history of) Sz (seizures), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and Pt (patient) is a DNR (Do not resuscitate). The course/duration of symptoms is constant. The character of symptoms is decreased responsiveness. The degree at onset was moderate. The degree at present is moderate. Baseline status: confused. 3. At 9:25 PM, R #1's blood pressure was 63/48 (normal blood pressure is 120/80 mmHg) mmHg (millimeters of Mercury). 4. At 9:30 PM, R #1's blood pressure was 95/56 mmHg. 5. Assessment/Plan: Hypotension-[AGE] year-old with known history of dementia from a nursing home presents with hypotension presumably secondary to medication reaction to the accidental administration 300 mg Seroquel. She initially responded to low blood pressure with IV (intravenous) fluids and now has recurrent bradycardia associated with hypotension which is getting fluid bolus and repeat EKG. Altered mental status- She does have a baseline dementia which is exacerbated by hypotension and medication administration that was by mistake. 6. On 06/07/23, R #1 was discharged to another long term care facility in the area with diagnoses: Hypotension- suspect secondary to medication, resolved. Altered mental status- Secondary to toxic metabolic encephalopathy secondary to medication and hypotension-resolved. Diabetes (chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces.) -Reasonably controlled, continue current management. Atrial fibrillation (an irregular and often very rapid heart rhythm) with RVR (rapid contractions of the atria make the ventricles beat too quickly)- Rate reasonably controlled. Hypothyroid (thyroid gland doesn't make enough thyroid hormones to meet your body's needs) - Replacement. Dementia- Patient with psychotic features. D. On 10/18/23 at 12:41 PM, during a phone interview with the physician/Medical Director: 1. She stated, Quetiapine 200 mg is for psychosis and would be a large dose and could make her sleepy or affect her mentation [mental status]. 2. She stated, 200 mg of quetiapine and 300 mg of Gabapentin would knock her down. Combined together would have sedative affect. 3. She stated, Ropinerol could cause low blood pressure. 4. She stated, These medications combined could have caused her to be lethargic and low blood pressure as the emergency room documents state. E. On 10/23/23 at 11:30 AM, during a phone interview, RN #31 stated the following: 1. LPN #31 started her first shift on 06/01/23 and shadowed (follow and observe closely) RN #31. 2. On 06/02/23, LPN #31 said she was comfortable to administer medications to the residents. R #31 allowed her to work independently. RN #31 told LPN #31 she was available if she needed anything. 3. On 06/02/23, LPN #31 notified her that she (LPN #31) had given R #1 medications which belonged to another resident that was located at the other end of the hallway. 4. RN #31 told LPN #31 to monitor R #1. 5. RN #31 went through the other resident's medications with LPN #31 to confirm which medications R #1 received. 6. RN #31 called the DON, Administrator, doctor, administrator on call, and R #1's daughter. 7. RN #31 did not receive any training regarding orienting or completing competency checks on new employees. 8. The facility's corporate recommended R #1 be sent to the emergency room . 9. No concerns were identified during monitoring. 10. Ambulance arrived and took R #1 to the hospital. F. On 10/23/23 at 11:50 AM, during a phone interview, LPN #31 stated the following: 1. LPN #31 started working at the facility on 06/01/23 and shadowed RN #31 for that day. 2. On 06/02/23, RN #31 told her to administer medications to the residents. LPN #31 stated she told RN #31 that she was not comfortable [contradicting RN #31's statement] yet to pass mediations after one day, and RN #31 told her that she would be available if she (LPN #31) had any questions. 3. LPN #31 described that several nurses came to LPN #31's cart. The other nurses were using her computer and getting medications out of her cart. LPN #31 stated, I had never experienced this type of disorganization. 4. LPN #31 stated that when she realized that she had given R #1 medications that were ordered for another resident down the hall, she immediately notified RN #31. LPN #31 did not acknowledge the reason she gave the medication to the wrong resident [did not verify resident identity before administration]. 5. She monitored the resident until the ambulance arrived. 6. R #1 became sleepy, and LPN #31 roused her. G. Record review of the facility's Complaint Narrative Investigation Follow-up Report (5 day), no date, revealed: 1. This incident is to report a medication error. On 06/02/23, a new traveling nurse (LPN #31) was shadowing a more experienced charge nurse (RN #31). The new traveler told the charge nurse that she believed she was prepared to pass meds on her own so she was given permission. Shortly after, the new nurse informed the charge nurse that she had accidentally given patient (R #1) her roommate's medications. 2. The investigation concluded that the new traveling nurse did pass R #1 medications ordered for her roommate. Therefore the allegation of neglect is substantiated.

Based on record review and interview, the following was discovered: 1. Record review of a fax communication dated 09/13/16 from the facility's DON to R #10's physician revealed Received last dose of [MEDICATION NAME] (blood thinner) (sic) sq (subcutaneous) yesterday still c (with) limited mobility & (and) ROM (range of motion) - do you want something [MEDICATION NAME] (preventative) as he had [MEDICAL CONDITION] 8/13? (sic) The response from the physician was Xarelto (blood thinner used to treat and prevent blood clots) 20 mg (milligrams), 1 po (oral) qd (each day) x (times) 4 mths (months). 2. Record review of a Physician/Prescriber order dated 09/12/16 revealed Xarelto 20 milligrams per day with food. Review of a Physician/Prescriber order dated 09/19/16 revealed Xarelto (blood thinner used to treat and prevent blood clots) 20 milligrams per day. 3. Record review of a Medications Flow Sheet dated 09/01/16 to 09/30/16 for R #10 revealed he did not receive the prescribed Xarelto 20 mg on 09/28/16, 09/29/16 and 09/30/16. Review of a Medications Flow Sheet dated 10/01/16 to 10/31/16 for R #10 revealed he did not receive the prescribed Xarelto 20 mg on 10/01/16, 10/02/16, 10/03/16 and 10/04/16. Review of a Medications Flow Sheet dated 11/01/16 to 11/30/16 for R #10 revealed he did not receive the prescribed Xarelto 20 mg on 11/0516, 11/06/16 and 11/07/16. 4. Record review of a Final Report from a out of state hospital dated 08/13/16 revealed R #10 had an Acute (severe, critical) extensive [MEDICAL CONDITION] of the right femoral vein (located in the upper thigh and pelvic region) up to the right popliteal (back of the knee) vein. Record review of hospital report for Doppler study dated 10/05/16 revealed R #10 had a blood clot in his right femoral vein. 5. On 11/07/16 at 2:00 pm, during an interview, the DON stated, The Xarelto was unavailable from the pharmacy. We called (name of pharmacy) continually. (Name of R #10) did miss 7 days of his Xarelto from September 28th to October 4th. He complained of pain in his right leg. He does have a history of [MEDICAL CONDITION]. I cannot find any documentation of the missed medication in the nurses notes. I was made aware of the misses Xarelto on day 7 and (Name of Physician was notified). When asked if the missed medication contributed to R #10 having another [MEDICAL CONDITION], she replied, In my clinical opinion, it did. 6. On 11/07/16 at 2:15 pm, during an interview, the Unit Manager was asked about the missing Xarelto on 11/05/16, 11/06/16 and 11/07/16. He stated the medication was not given and there was no documentation for notification of the physician. When asked if he should have notified the physician, he stated, Yes. This resulted in an Immediate Jeopardy being called on 11/07/16 at 3:00 pm. The Administrator and Director of Nursing were notified at this time. A Plan of Removal was received on 11/08/16 at 10:30 am but was rejected. A second Plan of Removal was presented on 11/08/16 at 12:05 pm and was accepted. The Plan of Removal included: The following issue was identified by the surveyor during a complaint survey at (name of facility). The Immediate Jeopardy was called related to missed doses of medication. Resident is receiving Xarelto as ordered by the physician. Licensed nurses and Certified Medication Technicians were re-educated on the process for medication availability to include the addition of licensed nurse validation of proper administration. This re-education was completed by 11/07/16. Any licensed nurse or Certified Medication Technician not receiving this information will receive prior to next scheduled shift. The process for medications when not available for administration is as follows: 1. Check the E-kit (emergency kit) inventory list to see if the medication needed is in the E-Kit and obtain and administer if it is included and then follow the re-order process. 2. Call the pharmacy and ask for the medication to be delivered stat, or the after-hours local pharmacy number and ask for the med to be delivered stat. If the med delivery will result in a late medication administration, the Doctor must be notified and an order written [REDACTED]. 3. If the pharmacy is unable to deliver and the med is not in the E-Kit, the Director of Nursing must be notified immediately. 4. Complete an assessment on the resident to include vitals. 5. The physician must be notified. 6. The responsible party must be notified. Each licensed nurse or Certified Medication Technician administering an anti-coagulant (drugs that work to prevent blood clots) will have another licensed nurse validate that the anti-coagulant medication was administered per the physician's orders [REDACTED]. Any identified issue will be reported to the nursing manager immediately for follow up as indicated. Medication Administration Records of residents with orders for anti-coagulant medication were audited to validate that ordered anti-coagulant medications were administered per order. A complete MAR (Medication Administration Reocrd)/Cart audit was done to validate that other ordered medications were available. Members of Nursing Management will validate that anti-coagulant medications are available and administered daily on residents identified with physician ordered anti-coagulants for four weeks then on random residents weekly for eight weeks. The Unit Manager was aware of the missed doses as of 11/07/16 and notified the pharmacy immediately for a STAT dose of Xarelto and notified the physician. The Xarelto was given when it was received on 11/07/16 per physician order. The resident is his own person and was notified. The resident had no negative outcome. The Unit manager did not follow process of notification of the Director of Nursing and was suspended pending investigation. The coorportation pharmacy consultant spoke with facility pharmacy regarding their delivery process and requested a root cause analyses for the discrepancies of medication delivery. Communication will continue with the pharmacy regarding discrepancies of medication delivery. The pharmacy will add Xarelto to the emergency drug kit at (Name of Facility). A house stock of Xarelto is available until the EDK (emergency drug kit) is delivered today. The new EDK content list has been developed which includes Xarelto. The licensed agency nurse that worked on 11/05/16 and 11/06/16 was reported to his agency for appropriate action and will not be scheduled to work at the facility. Medication Incident reports will be reviewed monthly for trends by the Director of Nursing /designee. Any trend identified will be presented to the Quality Assurance Performance Improvement committee for further recommendations for a period of 6 months. Any discrepancies will be addressed at time of discovery. Facility Administrator will be responsible for the overall implementation and validation of this plan of removal. Facility Medical Director will be informed of this plan and given progress updates. After the plan was noted to be implemented on 11/08/16 at 1:55 pm, the IJ was lifted. The scope and severity was decreased form a Level 4, K to a Level 3 G. Based on record review and interview, the facility failed to administer medications as ordered by the physician for 3 (R #10, #11, #12) of 4 (R #2, #10, #11, #12) sampled residents for medication errors. This resulted in R#10 returning to the hospital with a [MEDICAL CONDITION] ([MEDICAL CONDITION] - blood clot in a vein) and R# 11 complaining of increased pain. This failed practice could likely result in any resident of the facility not getting prescribed medications to maintain their current level of health therefore putting all residents at risk for developing new health issues, increased pain, abnormal lab values and possibly death. The findings are: R#10 A. Record review of the Resident Face Sheet for R #10 revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. B. Record review of a fax communication dated 09/13/16 from the facility's DON to R #10's physician revealed, Received last dose of [MEDICATION NAME] (sic) sq (subcutaneous) yesterday still c (with) limited mobility & (and) ROM (range of motion) - do you want something [MEDICATION NAME] (preventative) as he had [MEDICAL CONDITION] 8/13? The response from the physician was, Xarelto (blood thinner used to treat and prevent blood clots) 20 mg 1 po (oral) qd (each day) x (times) 4 mths (months). Record review of a Final Report from a out of state hospital dated 08/13/16 revealed R #10 had an Acute (severe, critical) extensive [MEDICAL CONDITION] of the right femoral vein (located in the upper thigh and pelvic region) up to the right popliteal (back of the knee) vein. C. Record review of a Physician/Prescriber order dated 09/12/16 revealed Xarelto 20 milligrams per day with food. D. Record review of a Medications Flow Sheet dated 09/01/16 to 09/30/16 for R #10 revealed he did not receive the prescribed Xarelto 20 mg on 09/28/16, 09/29/16 and 09/30/16. Review of a Medications Flow Sheet dated 10/01/16 to 10/31/16 for R #10 revealed he did not receive the prescribed Xarelto 20 mg on 10/01/16, 10/02/16, 10/03/16 and 10/04/16. Review of a Medications Flow Sheet dated 11/01/16 to 11/30/16 for R #10 revealed he did not receive the prescribed Xarelto 20 mg on 11/05/16, 11/06/16 and 11/07/16. E. Record review of Nurse's Notes dated 09/28/16 to 10/04/16 did not reveal any entry for missed Xarelto. The nurses notes did not reveal any entry for notification of physician regarding missed Xarelto. F. Review of Nurses's Notes dated 10/04/16 revealed (Name of Physician) notified of slight swelling to bil ((bilateral) (both)) ankles. 0 (no) [MEDICAL CONDITION] (swelling of body tissues due to fluid accumulation) 0 (no) redness or warmth noted to lower extremities .Pt (patient) to be sent out in AM (morning) for venous Doppler (test to determine presence of blood clot) bil lower extremities STAT (urgent) . Review of Nurse's Notes dated 10/05/16 revealed (Name of Physician) notified ultrasound of lower extremities showed positive for [MEDICAL CONDITION] femoral vein (large vein in the groin) right lower extremity . G. Record review of hospital report for Doppler study dated 10/05/16 revealed R #10 had a blood clot in his right femoral vein. H. On 11/07/16 at 1:30 pm, during an interview with R #10, he stated I missed 7 days of my Xarelto and that's probably why I had a [MEDICAL CONDITION]. I've also missed some Xarelto recently. I. On 11/07/16 at 2:00 pm, during an interview, the DON stated, The Xarelto was unavailable from the pharmacy. We called (name of pharmacy) continually. (Name of R #10) did miss 7 days of his Xarelto from September 28th to October 4th. He complained of pain in his right leg. He does have a history of [MEDICAL CONDITION]. I cannot find any documentation of the missed medication in the nurses notes. I was made aware of the missed Xarelto on day 7 and (Name of Physician was notified). When asked if the missed medication contributed to R #10 having another [MEDICAL CONDITION], she replied In my clinical opinion, it did. J. On 11/07/16 at 2:15 pm, during an interview, the Unit Manager was asked about the missing Xarelto on 11/05/16, 11/06/16 and 11/07/16. He stated the medication was not given and there was no documentation for notification of the physician. When asked if he should have notified the physician, he stated Yes. R #11 K. Record review of a Resident Face Sheet revealed R #11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. L. Record review of the discharge orders for the local hospital dated 09/23/16 revealed an order for [REDACTED]. M. Record review of a Medications Sheet dated 09/2016 revealed R #11 did not receive her [MEDICATION NAME] on 09/25/16 or 09/28/16. N. Record review of a Physician/Prescriber order dated 09/28/16 revealed [MEDICATION NAME] 50 mcg/hr [MEDICATION NAME] film extended release 1 patch q 72 hrs. O. On 11/08/16 at 2:00 pm, during an interview, the DON stated, I am aware the [MEDICATION NAME]es were missed. I can't explain why. P. On 11/09/16 at 3:15 during an interview with R #11's spouse, he stated She did miss some patches, I think it was two. She did complain of more pain when the patches were missed. They (the facility) needed a prescription for the patches and they didn't have one. She's getting the patches now. R #12 Q. Record review of facility Resident Face Sheet revealed R #12 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R. Record review of Physician order [REDACTED]. The order start date was 09/20/16. S. Record review of the Medications Flowsheet dated 09/01/16 to 09/30/16 revealed an entry for [MEDICATION NAME] Patch 100 mcg/hr 1 patch every 72 hours. Further review revealed R #12 did not receive her [MEDICATION NAME] on 09/24/16, 09/27/16 and 09/30/16. Record review of the Medications Flowsheet dated 10/01/16 to 10/31/16 revealed the resident did not receive her [MEDICATION NAME] on 10/11/16 and 10/14/16. T. On 11/08/16 at 12:00 pm, during an interview with the DON regarding the missed [MEDICATION NAME]es for R #12, she stated, I was not aware of the missed patches in September. The nurse who missed the patches in October was re-educated. The nurse was not available for interview. The DON was asked to provide a Policy and Procedure for medication management including the process of notifying the physician and the family. She stated there was not one. She was then asked for a Policy and Procedure for reporting missed medications within the facility; from the nurse to the DON or the Administrator. She stated she was not aware of one.

Based on observation, interviews and record review, the facility failed to provide proper infection control protocols for 1 (R #5) of 1 (R#5) residents randomly observed, when they failed to place a sign on R #5 door instructing them to see the nurse before entering R #5's room due to isolation precautions. Also, the facility failed to provide proper infection control protocols for 1 (R #8) of 4 (R #2, R #6, R #7, and R #8) residents sampled for incontinence care and UTIs, when they failed to provide proper incontinence care for R #8. This deficient practice could likely result in the spread of infection to other residents in the facility, as well as resulting in R #8's UTI, causing illness, discomfort, or death. The finding are: R #8 F. Record review of facility Resident Face Sheet revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. G. On 11/09/16 at 12:10 pm, CNA #1 was asked to perform perineal care for R #8. The following was observed: 1) The resident was lying in bed on her back. 2) The resident has a indwelling foley catheter. 3) The CNA washed her hands and put on a pair of gloves. The CNA wiped the top of the mons pubis (rounded mass of fatty tissue found over the pubic bone). 4) The CNA wiped the ceases of the thigh on both sides and obtained a clean wipe. 5) The CNA wiped down the center of the vaginal area 1 time. 6) The CNA wiped the catheter tubing from the outside of the pubic area downward approximately 3 inches. She obtained a clean wipe. 7) The CNA wiped the ceases at the thighs and obtained a clean wipe. 8) The CNA wiped down the center of the pubic area, wiped the legs, wiped the center of the pubic area. 9) The CNA turned the resident on her left side and cleaned the rectal area. The CNA was observed to wipe the rectal area up toward the Stage IV pressure ulcer and under the existing dressing. H. On 11/09/16 at 1:30 pm during an interview, the Staff Development Coordinator stated the CNA should have opened the vaginal area and cleaned the labia (the inner and outer folds of the vulva, at either side of the vagina) and vaginal opening. She stated the CNA she should have cleaned further down the catheter tubing. She stated the CNA should not have wiped the rectal up toward the pressure ulcer. She stated the CNA should have wiped to the side of the pressure ulcer. When asked if the CNA had provided correct perineal care per the facility procedures, she stated No, she failed. I. On 11/10/16 at 11:50 PM during an interview, the DON was asked if the CNA's failure to provide correct perineal care contributed to the resident having a UTI. She replied Yes. She was also asked if the incorrect wiping of the rectal area could contribute to the Stage IV worsening. She replied Yes. There is a possibility for cross-contamination. R #5 A. On 11/03/16 at 10:40 am, an observation of 600 hallway revealed therapy staff donning personal protective equipment (PPE) to enter R #5's room. No sign was on the outside of the room to indicate the need to see the nurse or with instructions to don PPE. The bin containing the PPE was on the inside of R #5's doorway against the wall. The room next door, R #11's room, had a hand written sign that instructed visitors to see the nurse before entering. B. Record review of the physician's orders [REDACTED]. MRSA (Methicillin-resistant Staphylococcus aureus infection is caused by a type of staph bacteria that's become resistant to many antibiotics). C. On 11/03/16 at 10:45 am, during an interview, the Administrator confirmed that R #5 did not have any sign to prevent people from going in before donning their PPE. The Administrator stated that they did not have a sign to put up for R #5 and confirmed that the facility could have had a hand written sign to warn visitors like R #11's room. D. On 11/03/16 at 11:35 am, during an interview, the DON confirmed that R #5 should have had a sign warning visitors. The DON also confirmed that the facility's policy stated there should be a sign outside the residents room for residents on isolation precautions. E. Record review of the Infection Prevention and Control Policies and Procedures revised date September 2011 revealed Signs . C) For all other transmission-based Isolation (contact, droplet, airborne) a sign stating Please stop at the nurses station before entering is sufficient.

Based on record review and interview, the facility failed to notify the physician of medication errors for 3 (R #10, R# 11, R#12) of 4 (R #2, R #10, R #11, R #12) sampled residents for medication errors. This deficient practice could result in the residents of the facility not receiving appropriate doses of medications resulting in inappropriate treatment of [REDACTED]. The findings are: R#10 A. Record review of the Resident Face Sheet for R #10 revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. B. Record review of a Final Report from an out of state hospital dated 08/13/16 revealed R #10 had an Acute (severe, critical) extensive [MEDICAL CONDITION] of the right femoral vein (located in the upper thigh and pelvic region) up to the right popliteal (back of the knee) vein. C. Record review of a fax communication dated 09/13/16 from the facility's DON to R #10's physician revealed, Received last dose of [MEDICATION NAME] (blood thinner) (sic) sq (subcutaneous) yesterday still c (with) limited mobility & (and) ROM (range of motion) - do you want something [MEDICATION NAME] (preventative) as he had [MEDICAL CONDITION] 8/13? The response from the physician was, Xarelto (blood thinner used to treat and prevent blood clots) 20 mg 1 po (oral) qd (each day) x (times) 4 mths (months). D. Record review of a Physician/Prescriber order dated 09/12/16 revealed Xarelto 20 mg (milligrams) per day with food. E. Record review of a Medications Flow Sheet dated 09/01/16 to 09/30/16 for R #10 revealed he did not receive the prescribed Xarelto 20 mg on 09/28/16, 09/29/16 and 09/30/16. Review of a Medications Flow Sheet dated 10/01/16 to 10/31/16 for R #10 revealed he did not receive the prescribed Xarelto 20 mg on 10/01/16, 10/02/16, 10/03/16 and 10/04/16. Review of a Medications Flow Sheet dated 11/01/16 to 11/30/16 for R #10 revealed he did not receive the prescribed Xarelto 20 mg on 11/05/16, 11/06/16 and 11/07/16. F. Record review of Nurse's Notes dated 09/28/16 to 10/04/16 did not reveal any entry for missed Xarelto. The nurses notes did not reveal any entry for notification of physician regarding missed Xarelto. G. Review of Nurses's Notes dated 10/04/16 revealed (Name of Physician) notified of slight swelling to bil ((bilateral) (both)) ankles. 0 (no) [MEDICAL CONDITION] (swelling of body tissues due to fluid accumulation) 0 (no) redness or warmth noted to lower extremities .Pt (patient) to be sent out in AM (morning) for venous Doppler (test to determine presence of blood clot) bil lower extremities STAT (urgent) . Review of Nurse's Notes dated 10/05/16 revealed (Name of Physician) notified ultrasound of lower extremities showed positive for [MEDICAL CONDITION] femoral vein (large vein in the groin) right lower extremity . H. Record review of hospital report for Doppler study dated 10/05/16 revealed R #10 had a blood clot in his right femoral vein. I. On 11/07/16 at 1:30 pm, during an interview with R #10, he stated I missed 7 days of my Xarelto and that's probably why I had a [MEDICAL CONDITION]. I've also missed some Xarelto recently. J. On 11/07/16 at 2:00 pm, during an interview, the DON stated, The Xarelto was unavailable from the pharmacy. We called (name of pharmacy) continually. (Name of R #10) did miss 7 days of his Xarelto from September 28th to October 4th. He complained of pain in his right leg. He does have a history of [MEDICAL CONDITION]. I cannot find any documentation of the missed medication in the nurses notes. I was made aware of the missed Xarelto on day 7 and (Name of Physician was notified). When asked if the missed medication contributed to R #10 having another [MEDICAL CONDITION], she replied In my clinical opinion, it did. K. On 11/07/16 at 2:15 pm, during an interview, the Unit Manager was asked about the missing Xarelto on 11/05/16, 11/06/16 and 11/07/16. He stated the medication was not given and there was no documentation for notification of the physician. When asked if he should have notified the physician, he stated Yes. R #11 L. Record review of a Resident Face Sheet revealed R #11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. M. Record review of the discharge orders for the local hospital dated 09/23/16 revealed an order for [REDACTED]. N. Record review of a Medications Sheet dated 09/2016 revealed R #11 did not receive her [MEDICATION NAME] on 09/25/16 or 09/28/16. O. Record review of a Physician/Prescriber order dated 09/28/16 revealed [MEDICATION NAME] 50 mcg/hr [MEDICATION NAME] film extended release 1 patch q 72 hrs. P. On 11/08/16 at 2:00 pm, during an interview, the DON stated, I am aware the [MEDICATION NAME]es were missed. I can't explain why. Q. On 11/09/16 at 3:15 pm during an interview with R #11's spouse, he stated She did miss some patches, I think it was two. She did complain of more pain when the patches were missed. They (the facility) needed a prescription for the patches and they didn't have one. She's getting the patches now. R #12 R. Record review of facility Resident Face Sheet revealed R #12 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. S. Record review of Physician order [REDACTED]. The order start date was 09/20/16. T. Record review of the Medications Flowsheet dated 09/01/16 to 09/30/16 revealed an entry for [MEDICATION NAME] Patch 100 mcg/hr 1 patch every 72 hours. Further review revealed R #12 did not receive her [MEDICATION NAME] on 09/24/16, 09/27/16 and 09/30/16. Record review of the Medications Flowsheet dated 10/01/16 to 10/31/16 revealed the resident did not receive her [MEDICATION NAME] on 10/11/16 and 10/14/16. U. On 11/08/16 at 12:00 pm, during an interview with the DON regarding the missed [MEDICATION NAME]es for R #12, she stated, I was not aware of the missed patches in September. The nurse who missed the patches in October was re-educated. The nurse was not available for interview. The DON was asked to provide a Policy and Procedure for medication management including the process of notifying the physician and the family. She stated there was not one. She was then asked for a Policy and Procedure for reporting missed medications within the facility; from the nurse to the DON or the Administrator. She stated she was not aware of one.

Based on record review, observation, and interview, the facility failed to 1)provide perineal care (washing the genitals and anal area) in accordance with the facility Policy and Procedure for Perineal Care/Incontinence Care for 3 (R #6, #7, and #8) for 3 (R #6, #7, and #8) residents requiring incontinence (loss of bladder control) care and 2) failed to administer medications as ordered by the physician for 2 (R #11, #12) of 4 (R #2, #10, #11, #12) sampled resident for medication errors. This resulted in R#10 returning to the hospital with a [MEDICAL CONDITION] ([MEDICAL CONDITION] - blood clot in a vein) and R# 11 complaining of increased pain. This failed practice could possible result in the resident not being thoroughly cleaned and developing urinary tract infections and could result in any resident of the facility not getting prescribed medications to maintain their current level of health, therefore putting all residents at risk for developing new health issues, increased pain, abnormal lab values and possibly death. The findings are: R #6 A. Record review of facility Physician order [REDACTED].#6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. B. Record review of the Care Plan dated 08/09/16 for R #6 revealed he is incontinent of bowel and bladder and requires assistance with toileting. The Care Plan also revealed the resident requires assistance with ADL's (activities of daily living) and requires extensive assistance of 2 two staff for toileting. C. Record review of a Minimum Data Set ((MDS) dated [DATE] revealed in Section H. Bladder and Bowel; H0300 Urinary Continence: Always Incontinent (no episodes of continent voiding). D. On 11/09/16 at 11:10 am, CNA #2 was asked by this surveyor to perform perineal care for R #6. The following was observed: 1) The resident was lying in bed on his back. The CNA put on a pair of gloves, removed the residents blanket, put a liner in the trash can. 2) The CNA removed the soiled Depend (adult incontinence brief) and tucked the top in between the residents legs. The resident had an extra-large bowel movement. She cleaned the creases of the thighs with a wipe. She wiped down the shaft of the penis 5 times with the same wipe. The CNA again wiped the creases at the thigh wiping down toward the rectum. When the CNA wiped the right side in a downward motion, she got feces on the wipe. The CNA folded the wipe and wiped the left side crease. The CNA wiped the testicles with the same wipe 3 times. 3) The CNA had got feces on the resident's right thigh which she wiped off with the same wipe she had folded over. 4) The CNA turned the resident onto his left side. She obtained a wipe and cleaned the rectum 2 times. She cleaned the right buttock. 5) The CNA pulled the soiled Depend from under the resident and got feces on the bed sheet. She cleaned the rectum 4 more times. She changed her gloves. 6) She cleaned the rectal area 4 more times with a folded wipe and put a clean Depend under the resident. She put barrier cream on the residents rectum, turned him onto his back and applied barrier cream to his genitals. She closed the Depend on the right side, changed her gloves and closed the Depend on the left side. She changed the bed sheet. She then covered the resident with the blanket and removed her gloves. R #7 E. Record review of a facility Resident Face Sheet revealed R #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. F. Record review of a Care Plan dated 07/28/16 for R #7 revealed he is incontinent of urine with a [DIAGNOSES REDACTED]. The care plan revealed the resident requires assistance after each incontinent episode. G. Record review of a MDS dated [DATE] revealed in Section H: Bladder and Bowel; H0300: Urinary Continence that the resident is always incontinent. H. On 11/09/16 at 12:20 pm, CNA #1 was asked to perform this surveyor to perform perineal care. for R #7. The following was observed: 1) The CNA put on a pair of gloves and removed the residents pants. 2) The resident was turned onto his right side. The resident had a small bowel movement. The CNA cleaned the residents rectum multiple times until clean. She put a clean Depend under the resident had he was turned onto his back. 3) The CNA obtained a clean wipe. The CNA cleaned the outside creases at the thigh one time on each side. The CNA cleaned the penis by grasping at the top and wiping down 2 times. 4) The clean Depend was fastened and the residents was covered with a blanket. I. Record review of facility Resident Face Sheet for R #8 revealed she was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted with an indwelling foley catheter because of a Stage IV pressure ulcer. J. Record review of a Minimum Data Set ((MDS) dated [DATE] revealed in Section H: Bladder and Bowel; H0100 Appliances: Indwelling catheter. K. Record review of a laboratory report from the local hospital dated 11/02/16 revealed the resident has a urinary tract infection. The bacteria was Escherichia coli (a type of bacteria normally found in intestines). L. Record review of a Physician order [REDACTED]. M. On 11/09/16 at 12:10 pm, CNA #1 was asked by this surveyor to perform perineal care for R #8. The following was observed: 1) The resident was lying in bed on her back. 2) The resident has a indwelling foley catheter. 3) The CNA washed her hands and put on a pair of gloves. The CNA wiped the top of the mons pubis (rounded mass of fatty tissue found over the pubic bone). 4) The CNA wiped the ceases of the thigh on both sides and obtained a clean wipe. 5) The CNA wiped down the center of the vaginal area 1 time. 6) The CNA wiped the catheter tubing from the outside of the pubic area downward approximately 3 inches. She obtained a clean wipe. 7) The CNA wiped the ceases at the thighs and obtained a clean wipe. 8) The CNA wiped down the center of the pubic area, wiped the legs, wiped the center of the pubic area. 9) The CNA turned the resident on her left side and cleaned the rectal area. The CNA was observed to wipe the rectal area up toward the Stage IV sacral wound. 10) The CNA left the room to get a clean draw sheet from the linen cart while wearing the same gloves. She returned and put the clean draw sheet under the resident. N. On 11/09/16 at 12:30 pm during an interview, the Staff Development Coordinator was asked if CNA #1 and CNA #2 had provided perineal care in accordance with the facility policy and procedures. She stated No, they failed. O. On 11/09/16 at 1:00 pm during an interview, the DON was asked if CNA #1 and CNA #2 had performed Perineal Care in accordance with the facility policy and procedures. She stated No, they failed. When asked the potential outcomes for the residents, she stated, For R #6 and #7, there is a potential for them to develop an UTI. P. On 11/09/16 at 2:30 pm during an interview with CNA #1, she stated I forgot to change my gloves. That's what I did wrong. CNA #2 was not available for interview. Q. Record review of the facility Staff Education/Orientation Policies and Procedures. Discipline: Nursing. Competency: Peri-Care dated 10/27/16 revealed the following: 1) Performance Criteria 4. Washes hands, applies disposable gloves . 2) Female: 9. Cleanse upper thighs. 10. Cleanses labia majora (the larger outer folds of the vulva) carefully among folds. 12. Separates labia with hand to expose urethral meatus (opening where urine is discharged from the body). 13. Cleans in one direction, clean to dirty. 17. Ask resident to lower legs and assume side lying position. Assist as necessary. 18. Cleanses area first by wiping fecal matter .19. Discard soiled gloves, wash hands and don clean gloves. 20. Cleanses by wiping from vagina toward anus with one stroke. uses clean area of cloth for each stroke. 21. Discard soiled gloves, wash hands and don clean gloves. Male: 27. Gently raises penis and places towel underneath. If uncircumcised, retracts foreskin. 28. Disposes of soiled gloves, washes hands and dons clean gloves. 29. Washes tip of penis at urethral meatus first, using circular motion from meatus outward. 31. Cleanses shaft of penis with gentle but firm downward [MEDICAL CONDITION]. R #11 R. Record review of a Resident Face Sheet revealed R #11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. S. Record review of the discharge orders for the local hospital dated 09/23/16 revealed an order for [REDACTED]. T. Record review of a Medications Sheet dated 09/2016 revealed R #11 did not receive her [MEDICATION NAME] on 09/25/16 or 09/28/16. U. Record review of a Physician/Prescriber order dated 09/28/16 revealed [MEDICATION NAME] 50 mcg/hr [MEDICATION NAME] film extended release 1 patch q 72 hrs. V. On 11/08/16 at 2:00 pm, during an interview, the DON stated, I am aware the [MEDICATION NAME]es were missed. I can't explain why. W. On 11/09/16 at 3:15 during an interview with R #11's spouse, he stated She did miss some patches, I think it was 2. She did complain of more pain when the patches were missed. They (the facility) needed a prescription for the patches and they didn't have one. She's getting the patches now. R #12 X. Record review of facility Resident Face Sheet revealed R #12 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Y. Record review of Physician order [REDACTED]. The order start date was 09/20/16. Z. Record review of the Medications Flowsheet dated 09/01/16 to 09/30/16 revealed an entry for [MEDICATION NAME] Patch 100 mcg/hr 1 patch every 72 hours. Further review revealed R #12 did not receive her [MEDICATION NAME] on 09/24/16, 09/27/16 and 09/30/16. Record review of the Medications Flowsheet dated 10/01/16 to 10/31/16 revealed the resident did not receive her [MEDICATION NAME] on 10/11/16 and 10/14/16. AA. On 11/08/16 at 12:00 pm, during an interview with the DON regarding the missed [MEDICATION NAME]es for R #12, she stated, I was not aware of the missed patches in September. The nurse who missed the patches in October was re-educated. The nurse was not available for interview. The DON was asked to provide a Policy and Procedure for medication management including the process of notifying the physician and the family. She stated there was not one. She was then asked for a Policy and Procedure for reporting missed medications within the facility; from the nurse to the DON or the Administrator. She stated she was not aware of one.

Based on record review, observation, and interview, the facility failed to ensure correct perineal care (washing the genitals and anal area) was provided for a resident resulting in a urinary tract infection [MEDICAL CONDITION] for 1 (R #8) of 1 (R #8) sampled residents. This deficient practice resulted in a resident with an indwelling foley catheter (a flexible tube passed through the urethra and into the bladder to drain urine) failed to prevent a urinary tract infection from developing. The findings are: A. Record review of facility Resident Face Sheet revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident was admitted with an indwelling foley catheter because of a Stage IV pressure ulcer to her sacrum (a triangular bone in the lower back). B. Record review of a Minimum Data Set ((MDS) dated [DATE] revealed in Section H: Bladder and Bowel; H0100 Appliances: Indwelling catheter. C. Record review of a laboratory report from the local hospital dated 11/02/16 revealed the resident has a urinary tract infection. The bacteria was Escherichia coli (a type of bacteria normally found in intestines). D. Record review of a Physician order [REDACTED]. E. On 11/09/16 at 12:10 pm, CNA #1 was asked to perform perineal care for R #8. The following was observed: 1) The resident was lying in bed on her back. 2) The resident has a indwelling foley catheter. 3) The CNA washed her hands and put on a pair of gloves. The CNA wiped the top of the mons pubis (rounded mass of fatty tissue found over the pubic bone). 4) The CNA wiped the ceases of the thigh on both sides and obtained a clean wipe. 5) The CNA wiped down the center of the vaginal area 1 time. 6) The CNA wiped the catheter tubing from the outside of the pubic area downward approximately 3 inches. She obtained a clean wipe. 7) The CNA wiped the ceases at the thighs and obtained a clean wipe. 8) The CNA wiped down the center of the pubic area, wiped the legs, wiped the center of the pubic area. 9) The CNA turned the resident on her left side and cleaned the rectal area. F. On 11/09/16 at 1:30 pm, during an interview, the Staff Development Coordinator stated the CNA should have opened the vaginal area and cleaned the labia (the inner and outer folds of the vulva, at either side of the vagina) and vaginal opening. She stated the CNA she should have cleaned further down the catheter tubing. When asked if the CNA had provided correct perineal care per the facility procedures, she stated No, she failed. G. On 11/09/16 at 2:30 pm, during an interview with CNA #1, she was asked if she thought she had done the perineal care for R #8 according to the facility guidelines. She stated, I didn't change my gloves enough. H. On 11/10/16 at 11:50 PM during an interview, the DON was asked if the CNA's failure to provide correct perineal care contributed to the resident having a UTI. She replied, Yes.

Recite from survey dated 11/14/16. This survey was conducted as revisit for 2 complaint surveys conducted on 10/03/16 and 11/14/16 tag 333 was cited on both surveys. The 11/14/16 survey resulted in and Immediate Jeopardy (IJ) because R #1 did not receive several doses of Xarelto (blood thinning medication to prevent blood clots) and was hospitalized with a [MEDICAL CONDITIONS], as a result of the missed medication. Based on interview and record review it was determined that: 1) R #1 had missed a dose of Xarelto on 12/12/16. 2) Facility administration were not aware of the missed medication. 3) Communication was not taking place from the nursing staff to administration about medication errors. 4) Several other residents had missed medications, medication not available, or other medication errors. 5) The facility was unable to follow the Plan of Removal for the IJ on 11/14/16. This resulted in an Immediate Jeopardy with a starting date of 12/12/16 (when the Plan of Removal failed (See #1 above.)). The facility was notified on 12/16/16 at 12:00 pm. A plan of removal was received on 12/16/16 and rejected on 12/19/16. A second Plan of Removal was received and approved on 12/20/16 at 9:50 am. Based on record review and interview, the facility failed to notify the physician of missed medications for 25 of all 94 residents in the facility (Residents were identified by the list provided by the Administrator on 12/14/16), who were sampled for medication errors. This deficient practice could result in residents not receiving prescribed medications and/or treatments resulting in ineffective medications, worsening conditions and death. The findings are: R #1 A. Record review of Physician Order Report dated 11/01/16 to 11/30/16 revealed a prescription dated 10/22/16 for Xarelto tablet 20 milligram (mg); amt (amount); 1 tab; oral; once a day; 0800 (8:00 am). B. Record review of the Medications Flowsheet dated 12/01/16 to 12/31/16 for R #1 revealed no entry for medication administration on 12/12/16. The area for the nurse to initial after giving the medications at 8:00 am were blank. R #2 C. Record review of the MAR for November 2016 for R #2 revealed an order for [REDACTED]. D. On 12/14/16 at 3:28 pm, during an interview the DON stated, It was missed (the medication). We were not made aware of that incident. The DON also confirmed that R #2 went without the [MEDICATION NAME] Patch for 72 hours until his next scheduled patch. R #9 E. Record review of a Resident Face sheet revealed R #9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. F. Record review of a Pharmacy Consultation Report dated 12/07/16 revealed a recommendation to decrease [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) to 7.5 milligrams (mg) at bedtime. The resident had been receiving 15 mg at bedtime. G. Record review of a pharmacy report for refill medications revealed [MEDICATION NAME] 7.5 mg arrived at the facility on 12/16/16 in the morning. H. Record review of the Medications Flowsheet dated 12/01/16 to 12/31/16 revealed an entry for [MEDICATION NAME] 7.5 mg 1 tab PO (oral) QHS (at bedtime). Start when arrives. Review of the flowsheet revealed the resident did not receive the prescribed [MEDICATION NAME] on 12/16/16, 12/17/16 and 12/18/16. I. On 12/19/16 at 11:05 am, during an interview with Unit Manager #1 and LPN (Licensed Practical Nurse) #2, they stated there was no documentation of the Nurse Practioner (NP) being notified of the need for a hand-written prescription for the [MEDICATION NAME]. J. On 12/19/16 at 11:30 am, observation of the medication card for [MEDICATION NAME] 7.5 mg 1 tab QHS revealed the card to have a 30 day supply. K. On 12/19/16 at 11:32 am, during an interview with the DON, she stated, The medication should have been given starting 12/16/16 at 1900 (7:00 pm). The nurse should have called the NP and asked for a hand-written prescription. The negative outcome for the resident would be lack of sleep. Random Sample of Residents MAR's on 12/19/16 L. 1) R #3: a. Record review of the MAR for December 2016 for R #3 revealed an order for [REDACTED]. b. Record review of R#3 medication Pass document dated December 2016 confirmed a missed accucheck (blood sugar) and missed medication Novalog sliding scale (amount of medication administered depending on the blood sugar level) on December 18, 2016. c. On 12/19/16, during interview the DON, confirmed that the accucheck had not been done and the Novalog medication was not administered on 12/12/16. 2) R #8: a. Record review of R #8 MAR indicated [REDACTED]. b. On 12/19/16, during interview, the DON confirmed that the ordered medication had been missed for R #8. 3) R #10: [MEDICATION NAME] Insulin per sliding scale (amount of medication administered depending on the blood sugar level) not given 12/05/16 at 5:00 pm and 12/08/16 at 11:00 am and 5:00 pm. 4) R #11: [MEDICATION NAME] per sliding scale documented on 12/03/16 and 12/07/16. [MEDICATION NAME] Insulin [MEDICATION NAME] 12 units not given on 12/08/16 at 11:00 am. a.[MEDICATION NAME](blood pressure medication) 60 mg every day vital signs not documented on 12/02/16, 12/03/16, 12/14/16, 12/17/16 and 12/18/16. b. [MEDICATION NAME] (blood pressure medication) 5 mg at bedtime vital signs not documented on 12/15/16, 12/17/16 and 12/18/16. 5) R #12: [MEDICATION NAME] (anti-anxiety) 20 mg daily at 8:00 am not given on 12/07/16 and 12/08/16. [MEDICATION NAME] ([MEDICAL CONDITION] medication) 75 mcg (microgram) daily not given on 12/06/16. 6) R #13: [MEDICATION NAME] (blood pressure medication) 50 mg twice a day; blood pressure not documented on 12/05/16 to 12/09/16 and 12/11/16 and 12/12/16. 7) R #14: Vitamin D2 capsule 50,000 units once a day on every Sunday, not given on 12/18/16. 8) R #15: Klonopin (anti-anxiety medication) 0.25 mg daily at 8:00 am, not given on 12/18/16. No documentation of refusal. 9) R #16: [MEDICATION NAME] (kidney disease medication) 30 mg twice a day was not given at 7:00 pm on 12/18/16. 10) R #17: Donepezil (dementia medication) 10 mg twice a day, not given 12/18/16 at 7:00 pm. 11) R #18: Donepezil (dementia medication) 5 mg once a day not given on 12/18/16. Multivitamin with minerals 1 tab in the morning not given on 12/18/16 at 8:00 am. [MEDICATION NAME] (medication for tremors) 20 mg 1 tab in the morning not given on 12/18/16 at 8:00 am. 12) R # 19: [MEDICATION NAME] (blood pressure medication) 40 mg once a day not given on 12/18/16. [MEDICATION NAME] (for diarrhea) 2 tablespoons three times a day, not given 12/18/16 at 8:00 am and 2:00 pm. Review of entire MARs for all residents on 12/20/16 M. R #20: 1) Record Review of the MAR for R #20 dated 12/01/16 to 12/31/16 revealed the following: a. [MEDICATION NAME] (anti-reflux medication) 20 mg every morning not given on 12/20/16 at 6:00 am. b. During an interview with the Staff Development Coordinator at 9:45 am, she stated, This is a missed medication. The 10 to 6 (10:00 to 6:00 am shift) nurse should have given this medication. 2) R #21: Record review of the MAR for December 2016 for R #21 revealed an order for [REDACTED]. Documentation revealed [MEDICATION NAME] not available from pharmacy MD notified. 3) R #22: Record review of the MAR for December 2016 for R #22 revealed an order for [REDACTED]. 4) R #23: Record review of the MAR for December 2016 for R #23 revealed an order for [REDACTED]. an order for [REDACTED]. 5) R #24: Record review of the MAR for December 2016 for R #24 revealed an order for [REDACTED]. No explanation documentation on either date. Order for [MEDICATION NAME] ([MEDICAL CONDITION]) daily. On 12/12/16 at 8:00 am and 8:00 pm it was documented as not given. Documentation for 12/12/16 8:00 am dose [MEDICATION NAME] 200mg not available ordered will deliver (sic) . Order for [MEDICATION NAME] (blood pressure medication) twice daily check blood pressure and pulse. The blood pressure and pulse was not documented for the 8:00 am dose on 12/01/16, 12/02/16, 12/04/16, 12/05/16, 12/08/16, and 12/09/16. The 8:00 pm dose was blank on 12/08/16 and 12/09/16. 6) R #25: Record review of the MAR for December 2016 for R #25 revealed an order for [REDACTED]. Documentation for 12/13/16 revealed Lubricant eye not available ordered . 7) R #26: Record review of the MAR for December 2016 for R #26 revealed an order for [REDACTED]. No explanation documentation. 8) R #27: Record review of the MAR for December 2016 for R #27 revealed an order for [REDACTED]. Documentation for 12/13/16 Phos-Nak (Potassium, sodium [MEDICATION NAME]) not available ordered will arrive tomorrow (sic). 9) R #28: Record review of the MAR for December 2016 for R #28 revealed an order for [REDACTED]. Documentation [MEDICATION NAME] cream n/a (not available) nurse informed. On 12/09/16 the 8:00 am and12:00 pm doses were documented as not given, the 7:00 pm was blank. No further explanation documentation. On 12/10/16 -12/19/16 for 8:00 am, 12:00 pm, and 7:00 pm were all blank. No explanation documentation. 10) R #29: Record review of the MAR for December 2016 for R #28 revealed an order for [REDACTED]. No explanation documentation. N. On 12/19/16 at 3:30 pm. during an interview, the DON confirmed that all of the medications were missed and the physicians were not notified of the missed medications. O. Record review of the facility policy on Significant Change dated 03/2006 revealed, Policy: 3. All significant changes in a patient's/resident's condition will be relayed to the patient's/resident's physican immediately.

Based on record review, interview, and observation, the facility failed to ensure that the residents were free of significant medication errors for 3 (R #2, R #5, and R #7) of 3 (R #2, R #5, and R #7) residents reviewed for medication errors. This deficient practice likely results in residents receiving ineffective amounts of medications having the potential to result in negative outcomes such as blood clots, depression, [MEDICAL CONDITION], and other symptoms that prevent their highest practicable well being. The findings are: R #2 A. Record review of a facility Resident Assessment Record revealed R #2 was admitted on [DATE] with a [DIAGNOSES REDACTED]. B. Record review of a facility PRN (as needed)/Medications Flowsheet dated 08/01/16 to 08/31/16 revealed an entry for [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]) 88 mg (milligram) PO (oral) 1 pill per day for 6 days then 1.5 pills on the 7th day give at 10 pm. Further review revealed R #2 did not receive any [MEDICATION NAME] on 08/16/16, 08/17/16, 08/21/16, 08/22/16, 08/23/16, 08/24/16, 08/26/16, 08/27/16, 08/28/16, 08/29/16, 08/30/16, and 08/31/16. C. Record review of physician's orders [REDACTED]. D. On 09/30/16 at 3:05 pm, during an interview, the DON stated, Agency nurses or new nurses didn't know it ([MEDICATION NAME]) was in a bottle and missed the med (medication). We addressed this with a big sign in the medication record. R #5 E. Record review of the facility Resident Face Sheet for R #5 revealed she was admitted on [DATE] with a [DIAGNOSES REDACTED]. F. Record review of the facility Medication Administration Record [REDACTED]. The record indicates the resident did not receive her [MEDICATION NAME] 08/05/16 through 08/10/16. G. On 09/30/16 at 11:30 am during an interview, the DON stated, I think the missed 6 doses of [MEDICATION NAME] is the medication error. The circled [MEDICATION NAME] on 08/05/16 and the dashes after mean the the dose was missed. From 08/05/16 to 08/10/16 she did not get [MEDICATION NAME]. I would consider the missed [MEDICATION NAME] a significant medication error. R#7 H. Record review of the Medication Error Investigation Worksheet dated 7-1-16 to 7-9-16 for R #7 revealed: MARs (Medication Administration Review) were incorrect. 24 doses of [MEDICATION NAME] (medication used for [MEDICAL CONDITION]) ER (extended release) 500 mg not given. 8 doses of [MEDICATION NAME] (an antidepressant medication) 7.5 mg PO (by mouth) Q (every) HS (bedtime) not given. I. Record review of the Discharge Instructions, Medication list from the local hospital revealed: 1. [MEDICATION NAME] 7.5 mg po q HS 2. [MEDICATION NAME] ER 500 mg tab 1 po TID (three times a day) J. Record review of the MARs for 07/01/16 to reveal an x in the documentation spaces from 07/01/16 to 07/08/16 for the following medications: [REDACTED] 1. [MEDICATION NAME] 7.5 mg po q hs 2. [MEDICATION NAME] ER 500 mg po TID K. On 09/30/16 at 2:50 pm, during an interview, the DON stated, I have not reported the medication error to the state. I was not aware of the need to report this. The medications were missed in transcription and not carried to the new MARs. L. Record review of a facility Administrative Policies and Procedures dated 03/2006 revealed the following: Subject: Accident/Incident Reporting - Patient/Resident. Policy: The facility's Leadership will follow the established guidelines for the reporting of accidents and incidents. In the event of a state reportable incident, the facility's Leadership will notify the state regulatory agency according to applicable law and regulation. Procedures: 4. Information related to accidents and incidents is documented on the appropriate worksheet: FORM #'s FFER001 Incident/ Accident and #FFER004 Medication error.

Recited from 11/14/16 survey. R #1 had an open wound to his spine that was be treated at the facility. A wound culture was sent out on 12/01/16, and the results were ready on 12/04/16. The Wound Care Nurse did not follow up with the results until 12/14/16, when surveyors asked her about it. Based on interview and record review the the following was discovered: 1) The results of the culture showed that R #1 had an infection of his wound. 2) The Wound Care Nurse did not follow up with the results of the wound culture. 3) Observations of wound care showed the Wound Care Nurse failed to follow proper infection control techniques during wound treatment. 4) The facility Administration did not have a competency performed by the Wound Care Nurse demonstrating her ability and knowledge, against facility policy. 5) There was a lack of communication from the laboratory services and the facility. This resulted in an Immediate Jeopardy being called on 12/15/16 at 3:55 pm. Plan of removal submitted and rejected on12/16/16 at 12:00 pm. A second Plan of Removal was submitted and approved on 12/16/16 at 12:55 pm. Based on observation, interviews and record review, the facility failed to provide proper infection control protocols for 3 (R #1, #3, #4) of 3 (R #1, #3, #4) residents sampled for wound care. Also, the facility failed to provide proper infection control protocols for 3 (R #5, #6, #7) of 3 (R #5, #6, #7) residents sampled for incontinence care and UTIs, when they failed to provide proper incontinence care. This deficient practice could likely result in the development of infection in wounds, as well as resulting in UTIs, causing illness, discomfort, or death. The findings are: Wound Care R #1 A. Record review of the Resident Face Sheet for R #1 revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. B. Record review of a Nursing Data Collection Tool dated 09/09/16 revealed in Section 8: Skin Condition that the resident has a surgical wound middle of his back. C. Record review of a laboratory wound culture report dated 12/01/16 revealed the resident had Escherichia coli (bacteria found in the lower intestine) in the mid back wound. Final results of the wound culture revealed the resident also had ESBL (organisms that are resistant to multiple antibiotics) in the wound. D. Record review of Physician order dated 12/03/16 revealed, Medial (situated in the middle) mid back - cleanse c (with) wound cleanser, pack c [MEDICATION NAME] (gauze packing strips used for sterile drainage of open and/or infected wounds) packing strip, cover coptilock (absorbent dressing), secure c tape q (each) day. E. On 12/14/16 at 10:50 am, the Wound Care Nurse (WCN) was asked to explain the wound culture report. She stated, I did the culture on 12/01/16. (Name of physician) told me to do it. I did not check to see if there was a written order for the culture. I did not follow up on the lab report. Today was the first day I have seen the report. I was not aware of the E-Coli (Escherichia coli bacteria). When asked about the consequences to the resident for not following up on the report, she stated, The infection could spread and he could go septic (a life-threatening complication of an infection). F. On 12/14/16 at 11:10 am during an interview with the DON, she stated, I was not aware of the wound culture for R #1 or that (name of physician) was not notified of the results. The wound infection is fecal matter. Cross-contamination. He is not currently taking antibiotics for this. G. On 12/14/16 at 1:45 pm, the WCN was asked to do a dressing change for R #1. The following was observed: The nurse gathered her supplies from the wound care cart in the hallway and placed them on the residents bedside table. She washed her hands and put on gloves. She put a clean trash bag on the foot of the resident's bed, changed her gloves, put a chux (disposable underpad) under the resident, removed the soiled dressing, removed the packing from the wound and then changed her gloves. The WCN was asked to describe the wound. She stated, There is granulation (new tissue), the spine is exposed, surrounding skin is red, there was serosanguineous (fluid leaving a wound that is serosanguineous is yellowish with small amounts of blood) drainage on the old dressing. The WCN cleaned the wound with wound cleanser. She stated, There is no slough (tissue that consists of pus), no eschar (falling away of dead skin), no odor. The WCN changed her gloves. She measured the wound then changed her gloves. She opened the jar of [MEDICATION NAME] gauze, removed a section of gauze with her finger, reached into her pocket and removed a pair of scissors and cut a section of gauze. The WCN packed the wound with her fingers. She changed her gloves, covered the area with Optilock dressing and secured with tape. When putting the lid back on the jar of [MEDICATION NAME] gauze, she dropped the lid on the floor, picked it up and put it on the jar. H. On 12/14/16 at 2:05 pm, during an interview with the WCN, she was asked about her technique during the dressing change. She stated, I did not clean my scissors, I just pulled them out of my pocket. She was asked if that was all, and she stated, Yes. I. On 12/14/16 at 3:00 pm, during an interview with the DON, she was asked about the WCN's technique during the dressing change. She stated, She should have cleaned the bedside table before putting her supplies on it. She should have used tweezers to remove the packing from the wound. The outside of the jar is contaminated so she should have opened the jar then changed her gloves to get the packing out. She should have cleaned her scissors before cutting the gauze. The DON was asked about the negative outcome to the resident. She stated, Possible, the dressing change could potentially cause more contamination to the wound. The WCN failed, possibly because of poor technique. The DON was asked to provide a competency for the WCN for proving wound care. J. On 12/15/16 at 12:45 pm, during a follow up interview with the DON, she stated, The wound was dehisced (to gape or burst open) upon admission. I am not aware of any previous cultures done before he arrived here. The culture was done on 12/01/16, completed on 12/04/16 but we didn't follow up. I was not aware of the culture until 12/14/16. (Name of physician) was not aware of the results until 12/14/16. K. On 12/15/16 at 3:30 pm, the DON was asked about the competency for the WCN. She stated, There is no competency for the nurse for wound care. There was no competency done when she was hired. R #3 L. On 12/14/16 at 2:19 pm, during observation of wound care for R #3 revealed WCN and RN #2 came into the R #3's room. WCN washed her hands in the bathroom sink, while RN #2 cleared off the bedside tray table of R #3 belongings. The bedside tray table was visibly dirty, RN #2 did not wipe down the bedside tray table with cleanser, RN #2 also did not wash her hands. WCN got her supplies ready placed them on the bedside tray table. WCN got out her trauma shears and proceeded to cut off R #3 bandage on his right ankle. RN #2 was holding R #3 leg up in the air to assist WCN. After bandage was removed, WCN cleansed the wound changing her gloves as she went. No hand washing or sanitize was done between glove changes. WCN had to excuse herself and left to the bathroom to sneeze and wash her hands. RN #2 placed R #3's exposed wound on the chuxs pad that was placed on the bed to catch all the liquids and particulates from the wound cleansing and change. When WCN returned, she got new gloves and proceeded to wrap the wound with the bandage. WCN did not reclean the wound. After completing the right ankle WCN proceeded to change R #3's wound on his left big toe. WCN removed the bandage and cleansed the wound changing her gloves as she went. WCN again did not wash or sanitize her hands between glove changes. WCN got a bandage from a sterile package. WCN proceeded to cut the sterile bandage with the trauma shears she had removed R #3's right ankle bandage. WCN did not clean the trauma shears with any cleanser. WCN placed the bandage on R #3 left big toe and wrapped it up. WCN removed her gloves and gathered all the trash in the chux pad and threw it away. WCN then grabbed the trauma shears, 4 x 4 package, and wound cleanser without gloves. The wound cleanser was thrown away, the trauma sheers and 4 x4 package was taken with her. WCN open R #3's door and placed the items on the wound cart and then sanitized her hands. M. On 12/14/16 at 2:58 pm, during an interview with WCN, she stated that she was not aware she needed to wash her hands between glove changes, or at the end. WCN was not aware that RN #2 had placed R #3's right foot down on the dirty chux after she had cleaned the wound. When asked about the sterile bandage that she had used to cut with the uncleansed trauma shears, WCN stated, Oh S@$* (profanity), I forgot to clean them (trauma shears). N. On 12/16/16 at 1:20 pm, during an interview, the DON was asked if the WCN and RN #2 would have passed proper infection control practices given the description of the wound care treatment preformed for R #3, the DON stated that WCN Failed. R #4 O. Record review of the Resident Face Sheet for R #4 revealed she was admitted to the facility on [DATE]. P. Record review of a Physician Order dated 11/28/16 revealed Clean c (with) wound wash, mix remedy orange top (topical) & (and) collagen (aids with cell growth) q day & PRN (as needed). Diagnosis: [REDACTED]. Q. On 12/14/16 at 1:20 pm, the WCN was asked to perform wound care on R #4. The following was observed: The nurse gathered her supplies from the treatment cart in the hallway and put them on the residents bedside table. The nurse washed her hands and put on gloves. She forgot a tongue depressor to stir the cream with and went to the hallway and got one from the cart. She changed gloves and mixed the cream. She removed the Depend from the resident and rolled her to her right side. The nurse removed her gloves, got a clean Depend from a dresser drawer, put on gloves and pushed the resident further to her right side. She measured the wound, changed her gloves, cleaned the area with wound cleanser, changed her gloves, stirred the ointment, applied it to the wound, changed her gloves and put the clean Depend on the resident. R. On 12/14/16 at 3:00 pm, during an interview with the DON, she was asked about the WCN's technique during wound care. She stated, She should have washed her hands before each time before putting on clean gloves. She should have cleaned the bedside table before putting her supplies on it. The possible negative outcomes would be infection or cross-contamination. S. Record review of the facility Policy and Procedure for Wound Care dated 06/01/15 revealed: Policy: A dressing change will follow specific manufacture ' s guidelines and general infection control principles. Procedures: NOTE: Wash hands before and after donning glove) . Perineal Care T. Record review of the Resident Face Sheet for R #5 revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. U. Record review of a Minimum Data Set ((MDS) dated [DATE] revealed in Section H that the resident is always continent of bowel. V. Record review of the Care Plan dated 11/03/16 revealed Problem: Resident is occasionally incontinent of B&B (bowel and bladder). Approach: Provide incontinence care after each incontinent episode. W. On 12/15/16 at 9:30 am, Certified Nursing Assistant (CNA) #1 was asked to perform perineal care for R #5. Upon entering the resident's room, she was sitting on the toilet in the bathroom. The resident was observed to be wearing a Depend (adult diaper) and had diarrhea in the Depend, down her legs and on her clothing. The CNA washed her hands, put on gloves, and wiped the back of R #5's legs. She assisted the resident to stand and wiped the resident from behind starting at the top of the vaginal area to the anal area. The CNA assisted the resident to sit in her wheelchair and removed the residents soiled pants, socks and shoes. The CNA wheeled the resident to her bed and assisted her to lie down. The CNA changed her gloves. The resident was lying on her back and the CNA wiped the outside of the legs, wiped the creases of the legs, wiped down the center of the vaginal area one time. She did not open the vaginal area and clean the labia or the vaginal opening. The resident was turned onto her left side and the CNA wiped the rectum twice, wiped the buttocks, wiped the rectum, wiped the calf of the right leg. The CNA then put a clean Depend on the resident and removed her gloves. X. On 12/15/16, during an interview with the Director of Nursing (DON), she was asked if the CNA had performed perineal care correctly. She replied, She failed. She should have opened the labia and cleaned. She should have washed her hands between every glove change. Y. Record review of a Staff Education/Orientation Policies and Procedures dated 11/11/16 for CNA #1 revealed the CNA had met the facility goals for perineal care. Z. Record review of the Resident Face Sheet for R#6 revealed he was admitted on [DATE] with a [DIAGNOSES REDACTED]. AA. Record review of a MDS dated [DATE] for R #6 revealed in Section H that the resident is frequently incontinent of urine and bowel. BB. Record review of the Care Plan dated 12/13/16 for R #6 revealed Problem: Resident is frequently incontinent of B&B. Approach: Provide incontinence care after each incontinent episode. CC. On 12/15/16 at 1:45 pm CNA #2 was asked to perform perineal care for R #6. Upon entering the room, the resident was observed to be laying on his back in bed. The CNA washed her hands, put on gloves and removed the resident's pants. The CNA wiped the inside of the resident's legs, wiped the tip of the penis, wiped the shaft of the penis, wiped the scrotum and turned the resident onto his right side. The CNA wipe the rectum. There was a small amount of feces on the wipe. The CNA started to put a clean Depend on the resident. She was stopped and asked to wipe the resident's rectum once more. The wipe had feces on it. The CNA wiped the rectum four more times until the rectum was clean. She rolled the resident onto his back and put the clean Depend on him. She removed her gloves and pulled up his pants. DD. On 12/15/16 at 2:00 pm, during an interview with the DON, she was asked if the CNA had performed perineal care correctly. She replied, She failed. She should have cleaned the resident until there was no more feces. She should have washed her hands and changed her gloves before putting on the clean Depend. The DON was asked to provide a competency training for the CNA for providing perineal care prior to 12/15/16. It was not provided. EE. Record review of a Resident Face Sheet for R #7 revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. FF. Record review of a MDS dated [DATE] revealed in Section H that the resident is frequently incontinent of urine and bowel. GG. Record review of a Care Plan dated 12/01/16 revealed Problem: Resident experiences bladder incontinence. Approach: provide incontinence care after each incontinent episode. HH. On 12/15/16 at 10:45 am, CNA #3 was asked to provide perineal care for R #7. Upon entering the room, the resident was observed to be lying in bed on his back. The CNA washed her hands, put on gloves, raised the residents bed and removed the soiled Depend. The CNA wiped the outside creases of the perineal area, wiped the scrotum, wiped the shaft of the penis and wiped the head of the penis. She turned the resident onto his left side. The CNA wiped the bottom of the scrotum. She put a clean Depend on the resident and put his pants and socks back on. She disposed of the trash and washed her hands. II. On 12/15/16, at 11:00 am, the Staff Development Coordinator was asked to provide a competency for perineal care for CNA #3. The Staff Development Coordinator stated there was no competency since 2014 for CNA #3. JJ. On 12/15/16 at 11:20 am, during an interview with the DON, she was asked if the CNA #3 had performed perineal care correctly. She replied, She failed. She should have changed her gloves before putting on the clean Depend. Hands should be washed every time there is a glove change for all of the CNA's. The DON was asked if competencies for every CNA was part of the Plan of Correction. She stated Yes.

Based on record review and interviews, the following was discovered: 1. Resident #1 had 4 falls starting on [DATE] with three of the falls with injuries and the injuries progressively became worse. The last fall with injury that was documented occurred on the early morning of [DATE] that caused a bilateral parenchymal hemorrhage in the fontal lobes on both sides and in the left temporal and parietal lobes. There is a 2.8 cm x 1.2 cm right frontal lobe parenchymal hematoma. There is a 3 cm x 1.9 cm left frontal lobe hematoma. Mostly likely related to traumatic hemorrhagic contusions. In addition, there is a subarachnoid hemorrhage in the sylvian fissure, right cerebral peduncle, and in the frontal lobe sulci bilaterally. Later on [DATE], he returned to the facility in a comatose state and died on [DATE]. 2. The facility did not complete the fall risk assessment after the falls on [DATE], [DATE], and [DATE]. The staff verbalized that they noted a decline in the residents ability to transfer himself. They also stated that he seemed more lethargic after his fall on [DATE]. 3. The facility did not re-evaluate the residents care plan for assistance while transferring, but instead continued to encourage the resident to utilize his call-light. This resulted in Immediate Jeopardy being called on [DATE] at 2:35 pm. The Administrator and DON were notified at this time. A Plan of Removal was received and approved on [DATE] at 5:00 pm. After the plan was noted to be implemented, the scope and severity was decreased from a Level 4, K, to a Level 3 G. The Plan of Removal included: 1. Incidents involving a fall will be reviewed at the morning meeting. Fall risk assessment will be completed and the care plan will be reviewed and revised on the care plan. Any new interventions will be written on the care plan and any interventions that are not useful will be eliminated. 2. Root cause analysis will be completed for each fall to determine the reason for the fall and the care plan will be revised accordingly. 3. Nursing staff were re-educated on interventions, fall precautions, and appropriate documentation. 4. Residents with fall precautions and/or at-risk for falls will be addressed at weekly QOC and at monthly QAPI meetings. Based on record review and interview, the facility failed to complete an assessment that fully reflected the resident's physical strength and ability after each fall for 1 (R #1) of 5 (R #1 - 5) sampled residents for falls. The resident had a series of four falls in 11 days. During the last one, the resident fell face first and had a brain bleed. This deficient practice likely led to significant injury that lead to death. The findings are: A. Record review of R #1's Nursing assessment dated [DATE] revealed the resident had the following Diagnoses: [REDACTED]. B. Record review of R #1's Nurses' Notes revealed the following entries: 1. Dated [DATE] - fall while doing a self-transfer and had minor injuries. 2. Dated [DATE] - slipped and fell while using cane between bed and bathroom and had a facial laceration that required two stitches. 3. Dated [DATE] - R #1 was found after a fall sitting on the floor next to the window and had no injuries. 4. Dated [DATE] - at 2:15 am, R #1 was found at foot of his bed, face down, bleeding and unconscious. Bleeding profusely from nose and mouth. Right eye swollen shut. Twitching noted in L (left) foot. 5. Dated [DATE] - Resident returned from (name of local hospital) via (name of local ambulance) in a coma (sic) state. 6. Dated [DATE] - R #1 was found deceased at 6:45 pm. C. Record review of the Fall Risk Evaluation revealed only one entry for [DATE]. This was dated [DATE]. As scored on the evaluation, the resident was at risk for falls. D. Record review of the Therapy Screening form dated [DATE] revealed signatures of the Physical Therapist and the Certified Occupational Therapy Assistant dated [DATE]. No therapy assessment was found. E. On [DATE] at 4:00 pm, during an interview, CNA #2 stated that R #1 had gotten up multiple times during the evening of [DATE] and was both more unsteady than usual and more drowsy than usual. When asked, CNA #2 stated that the nurses were aware of his state. F. On [DATE] at 10:15 am, during an interview, CNA #3 stated R #1 had a decline in his activities of daily living (ADLs) starting about 2 weeks before his final fall. She stated that he would use the call light if he needed something, but not for transfers. She stated that he knew that he was to let them know when he was going to transfer himself, but usually did not. CNA #3 stated that he was getting up often on the evening of the [DATE] because he was asking for pain medication. When asked, CNA #3 stated that the nurses were aware of his state. G. On [DATE] at 10:45 am, during an interview, LPN #2 stated that the resident had fallen on [DATE] and had needed stitches to his upper lip. This was causing him pain and he had gotten up multiple times the evening of [DATE] to request medication. The facility was waiting on the pharmacy to deliver the narcotic pain medications for the resident. H. On [DATE] at 11:30 am, during an interview, the DON confirmed the fall risks assessments were not completed on [DATE], [DATE], and after his final fall on [DATE]. She further confirmed that no therapy evaluations could be found in the clinical record.

Based on record review and interviews, the following was discovered: 1. Resident #1 had 4 falls starting on [DATE] with three of the falls with injuries and the injuries progressively became worse. The last fall with injury that was documented occurred on the early morning of [DATE] that caused a bilateral parenchymal hemorrhage in the fontal lobes on both sides and in the left temporal and parietal lobes. There is a 2.8 cm x 1.2 cm right frontal lobe parenchymal hematoma. There is a 3 cm x 1.9 cm left frontal lobe hematoma. Mostly likely related to traumatic hemorrhagic contusions. In addition, there is a subarachnoid hemorrhage in the sylvian fissure, right cerebral peduncle, and in the frontal lobe sulci bilaterally. Later on [DATE], he returned to the facility in a comatose state and died on [DATE]. 2. The facility did not complete the fall risk assessment after the falls on [DATE], [DATE], and [DATE]. The staff verbalized that they noted a decline in the residents ability to transfer himself. They also stated that he seemed more lethargic after his fall on [DATE]. 3. The facility did not re-evaluate the residents care plan for assistance while transferring, but instead continued to encourage the resident to utilize his call-light. This resulted in Immediate Jeopardy being called on [DATE] at 2:35 pm. The Administrator and DON were notified at this time. A Plan of Removal was received and approved on [DATE] at 5:00 pm. After the plan was noted to be implemented, the scope and severity was decreased from a Level 4, K, to a Level 3 G. The Plan of Removal included: 1. Incidents involving a fall will be reviewed at the morning meeting. Fall risk assessment will be completed and the care plan will be reviewed and revised on the care plan. Any new interventions will be written on the care plan and any interventions that are not useful will be eliminated. 2. Root cause analysis will be completed for each fall to determine the reason for the fall and the care plan will be revised accordingly. 3. Nursing staff were re-educated on interventions, fall precautions, and appropriate documentation. 4. Residents with fall precautions and/or at-risk for falls will be addressed at weekly QOC and at monthly QAPI meetings. Based on record review and interview, the facility failed to re-evaluate the effectiveness of each intervention on the care plan after each fall for 1 (R #1) of 5 (R #1 - 5) sampled residents for falls. The resident had a series of four falls in 11 days. During the last one, the resident fell face first and had a brain bleed. This deficient practice likely led to significant injury that lead to death. The findings are: A. Record review of R #1's Nursing assessment dated [DATE] revealed the resident had the following Diagnoses: [REDACTED]. B. Record review of R #1's Nurses' Notes revealed the following entries: 1. Dated [DATE] - fall while doing a self-transfer and had minor injuries. 2. Dated [DATE] - slipped and fell while using cane between bed and bathroom and had a facial laceration that required two stitches. 3. Dated [DATE] - R #1 was found after a fall sitting on the floor next to the window and had no injuries. 4. Dated [DATE] - at 2:15 am, R #1 was found at foot of his bed, face down, bleeding and unconscious. Bleeding profusely from nose and mouth. Right eye swollen shut. Twitching noted in L (left) foot. 5. Dated [DATE] - Resident returned from (local hospital) via (ambulance) in a coma (sic) state. 6. Dated [DATE] - R #1 was found deceased at 6:45 pm. C. Record review of the Care Plan for R #1 revealed an intervention of Keep call light in reach at all times. Further review revealed the dates in [DATE] when the resident fell , but no new interventions and no previous interventions marked out. No notes regarding any meetings about the update after each fall were found. D. On [DATE] at 10:00 am, during an interview, CNA #1 stated R #1 was supposed to use the call-light when he was going to transfer himself and the staff encouraged him to use it. The staff only needed to be there for supervision and if he started to fall. E. On [DATE] at 4:00 pm, during an interview, CNA #2 stated R #1 was supposed to use the call-light when he was going to transfer himself and the staff encouraged him to use it. The staff only needed to be there for supervision and if he started to fall. When asked, she was not aware of any new interventions for R #1. F. On [DATE] at 10:15 am, during an interview, CNA #3 stated R #1 was supposed to use the call-light when he was going to transfer himself and the staff encouraged him to use it. The staff only needed to be there for supervision and if he started to fall. When asked, she was not aware of any new interventions for R #1. G. On [DATE] at 11:30 am, during an interview, the DON confirmed the falls were noted on the care plan and that there were no new interventions and no older interventions eliminated.

Based on record review and interviews, the following was discovered: 1. Resident #1 had 4 falls starting on [DATE] with three of the falls with injuries and the injuries progressively became worse. The last fall with injury that was documented occurred on the early morning of [DATE] that caused a bilateral parenchymal hemorrhage in the fontal lobes on both sides and in the left temporal and parietal lobes. There is a 2.8 cm x 1.2 cm right frontal lobe parenchymal hematoma. There is a 3 cm x 1.9 cm left frontal lobe hematoma. Mostly likely related to traumatic hemorrhagic contusions. In addition, there is a subarachnoid hemorrhage in the sylvian fissure, right cerebral peduncle, and in the frontal lobe sulci bilaterally. Later on [DATE], he returned to the facility in a comatose state and died on [DATE]. 2. The facility did not complete the fall risk assessment after the falls on [DATE], [DATE], and [DATE]. The staff verbalized that they noted a decline in the residents ability to transfer himself. They also stated that he seemed more lethargic after his fall on [DATE]. 3. The facility did not re-evaluate the residents care plan for assistance while transferring, but instead continued to encourage the resident to utilize his call-light. This resulted in Immediate Jeopardy being called on [DATE] at 2:35 pm. The Administrator and DON were notified at this time. A Plan of Removal was received and approved on [DATE] at 5:00 pm. After the plan was noted to be implemented, the scope and severity was decreased from a Level 4, K, to a Level 3 G. The Plan of Removal included: 1. Incidents involving a fall will be reviewed at the morning meeting. Fall risk assessment will be completed and the care plan will be reviewed and revised on the care plan. Any new interventions will be written on the care plan and any interventions that are not useful will be eliminated. 2. Root cause analysis will be completed for each fall to determine the reason for the fall and the care plan will be revised accordingly. 3. Nursing staff were re-educated on interventions, fall precautions, and appropriate documentation. 4. Residents with fall precautions and/or at-risk for falls will be addressed at weekly QOC and at monthly QAPI meetings. Based on record review and interview, the facility failed to supervise a resident and keep the resident free from falls for 1 (R #1) of 5 (R #1 through 5) sampled resident for falls. This failed practice could have led to the death after the fall on [DATE]. The findings are: A. Record review of R #1's Nursing assessment dated [DATE] revealed the resident had the following Diagnoses: [REDACTED]. B. Record review of R #1's Nurses' Notes revealed the following entries: 1. Dated [DATE] - fall while doing a self-transfer and had minor injuries. 2. Dated [DATE] - slipped and fell while using cane between bed and bathroom and had a facial laceration that required two stitches. 3. Dated [DATE] - R #1 was found after a fall sitting on the floor next to the window and had no injuries. 4. Dated [DATE] - at 2:15 am, R #1 was found at foot of his bed, face down, bleeding and unconscious. Bleeding profusely from nose and mouth. Right eye swollen shut. Twitching noted in L (left) foot. 5. Dated [DATE] - Resident returned from (name of local hospital) via (name of local ambulance) in a coma (sic) state. 6. Dated [DATE] - R #1 was found deceased at 6:45 pm. C. Record review of the Fall Risk Evaluation revealed only one entry for [DATE]. This was dated [DATE]. As scored on the evaluation, the resident was at risk for falls. D. Record review of the Therapy Screening form dated [DATE] revealed signatures of the Physical Therapist and the Certified Occupational Therapy Assistant dated [DATE]. No therapy assessment was found. E. Record review of the Care Plan for R #1 revealed an intervention of Keep call light in reach at all times. Further review revealed the dates in [DATE] when the resident fell , but no new interventions and no previous interventions marked out. No notes regarding any meetings about the update after each fall were found. F. On [DATE] at 10:00 am, during an interview, CNA #1 stated R #1 was supposed to use the call-light when he was going to transfer himself. The staff only needed to be there for supervision and if he started to fall. G. On [DATE] at 4:00 pm, during an interview, CNA #2 stated that R #1 had gotten up multiple times during the evening of [DATE] and was both more unsteady than usual and more drowsy than usual. When asked, CNA #2 stated that the nurses were aware of his state because they had given him Flexaril (medication to relax the muscles) earlier that evening. CNA #2 stated R #1 was supposed to use the call-light when he was going to transfer himself. The staff only needed to be there for supervision and if he started to fall. When asked, she was not aware of any new interventions for R #1. H. On [DATE] at 10:15 am, during an interview, CNA #3 stated R #1 had a decline in his activities of daily living (ADLs) starting about 2 weeks before his final fall. She stated that he would use the call light if he needed something, but not for transfers. She stated that he knew that he was to let them know when he was going to transfer himself, but usually did not. CNA #3 stated that he was getting up often on the evening of the [DATE] because he was asking for pain medication. When asked, CNA #3 stated that the nurses were aware of his state because they had given him Flexaril (medication to relax the muscles) earlier that evening. CNA #3 stated R #1 was supposed to use the call-light when he was going to transfer himself. The staff only needed to be there for supervision and if he started to fall. When asked, she was not aware of any new interventions for R #1. I. On [DATE] at 10:45 am, during an interview, LPN #2 stated that the resident had fallen on [DATE] and had needed stitches to his upper lip. This was causing him pain and he had gotten up multiple times the evening of [DATE] to request pain medication. The facility was waiting on the pharmacy to deliver the narcotic pain medications for the resident. J. Record review of the facility's investigation revealed LPN #3 statement read that R #1 had requested pain medication multiple times since his fall on [DATE]. This also happened on the evening of [DATE]; R #1 had gotten up and come down to the nurse's station for pain medication multiple times. K. On [DATE] at 11:30 am, during an interview, the DON confirmed the fall risks assessments were not completed on [DATE], [DATE], and after the last fall on [DATE]. She further confirmed that no therapy evaluations could be found in the clinical record. The DON confirmed the falls were noted on the care plan and that there were no new interventions and no older interventions were eliminated.

Based on observation, record review and interview, the facility failed to follow the written care plan for 2 (R#2, R#3) of 3 (R#2, R#3, R#4) sampled residents for turning and repositioning who developed pressure ulcers resulting in facility acquired pressure ulcers. This failed practice has resulted in residents developing pressure ulcers because the facility did not turn and reposition these residents. The findings are: Resident #2 A. Record review of the Resident Admission Record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. B. Record review of a hand written timeline by the Director of Nursing revealed the resident was admitted on [DATE]. The resident had a Stage II pressure ulcer noted on his coccyx (tailbone) on 11/01/13, 07/28/14, 01/27/15, 04/10/15 and 07/27/15. C. Record review of a Comprehensive Care Plan dated 04/22/14 for R #2 revealed Problem: Resident is at risk for skin breakdown is incontinent of B&B (bowel and bladder). Goal: Resident's skin will remain intact. Approach: Conduct daily skin check (weekly, daily, etc). Pay particular attention to the bony prominence's (sic); Turn and reposition prn (as needed). The care plan had a hand written entry dated 04/10/15; open area to Rt. (right) buttocks. The care plan has a hand written entry dated 07/27/15; pressure ulcer re (regarding) opened to coccyx area, Rsd (resident) remains on back when in bed. D. On 09/01/15 observations of the R #2 in bed at 11:30 am, 2:10 pm and at 3:30 pm revealed the resident was laying on his back. Observations on 09/02/15 at 9:35 am and at 10:45 am revealed the resident in bed laying on his back in bed. Observations on 09/03/15 at 1:30 pm and 3:45 pm revealed the resident in bed laying on his back in bed. E. On 09/03/15 at 1:40 pm during an interview with CNA (Certified Nursing Assistant) #1, she stated He is not on a turning schedule. F. On 09/03/15 at 3:45 pm during an interview with CNA #2, she stated I had not been turning him before today. I think we are supposed to turn and reposition every 30 minutes. G. On 09/03/15 at 4:10 pm during an interview with CNA #3, she stated I did not reposition him. I did not know I was supposed to. H. On 09/03/15 at 4:00 pm during an interview with LPN (Licensed Practical Nurse) #5, she stated I monitor for the CNA's turning and repositioning of the residents. I ask them if they have done it. The resident has a reoccurring (sic) pressure ulcer on his coccyx. When asked if she checked on the resident to see if he had been turned, she confirmed she did not. I. On 09/03/15 at 10:30 am during an interview with the Director of Nursing (DON), she stated, Everyone in our facility who need assistance to get in and out of bed are on a turning schedule. They should be turned every 2 hours. This resident needs to be turned and repositioned every 2 hours while he is in bed. There's not any place where we document where it's been done. We rely on the nurses to check. Resident #3 J. Record review of the Resident Admission Record for R #3 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. K. Record review of the admission Nursing Data Collection Tool dated 01/23/15 revealed in Section 8 under Skin Condition that the resident was admitted without wounds. L. Record review of a Comprehensive Care Plan 03/05/15 for R #3 revealed Problem: Resident has a Stage II to coccyx, (3) unstageables (unable to determine the stage of the pressure ulcer) to left foot. Resident is at risk for skin breakdown. There was a hand written entry at the bottom of the page 7/19/15; St (stage) II to left ankle. St II to left foot. Red area left shin. Goal: Resident's ulcer will heal without complications. Approach: Conduct a skin check (e.g. weekly, daily, etc); Keep bony prominence's from direct contact with another with: (pillows, foam wedges, etc.); turn and reposition prn. Review of Interim Plan of Care dated 01/27/15 revealed Booties Bilat (bilateral) Feet. M. Record review of Physician order [REDACTED]. Review of Physician order [REDACTED]. N. On 09/02/15 at 10:20 am during observation of wound care the resident was laying on her back, there was no pillow under her left foot and no booties on her feet. O. On 09/02/15 at 2:45 during an interview with the Wound Care nurse, she state She should have something, a sheet or pillow between her legs. There should be a pillow to float her ankle. P. On 09/02/15 at 3:50 pm during an interview with CNA #2 she stated, I did not know about turning her. I have never seen a bootie on her feet. Q. On 09/02/15 at 4:55 pm during an interview with RN (Registered Nurse) #1, she stated I noticed the wound on her left foot and left skin about 2 weeks ago. They were necrotic (dead cells). R. On 09/04/15 at 11:30 am during an interview with R #3, she stated They don't put any booties on me. They don't move me in bed. Observation at the time of this interview revealed no booties on her feet and no pillow or folded sheet between her legs. S. On 09/02/15 at 10:30 am during an interview with the DON, she stated The ulcer on her ankle was in-house acquired on 04/08/15. The Stage II on her shin was in-house acquired on 07/14/15. She is on an air mattress and she should have something between her legs. If the resident's booties are not on her, they should be. They are there to prevent pressure on her foot.

Based on record review, observation, and interview, the facility failed to prevent the develpment of pressure ulcers for 2 (R #2 and #3) of 3 (R#2, #3, and #4) sampled residents for pressure ulcers by failing to: 1) not turn and reposition R #2 and therefore a recurring Stage II pressure ulcer on the coccyx (tailbone) developed, and 2) not provide consistent pressure relieving interventions for R #3 therefore a Stage III pressure ulcer on resident's left foot and a Stage II pressure ulcer on the resident's left shin developed. The findings are: Resident #2 A. Record review of the Resident Admission Record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. B. Record review of a hand written timeline by the Director of Nursing (DON) revealed the resident was admitted on [DATE] without pressure ulcers. The resident had a Stage II pressure ulcer noted on his coccyx (tailbone) on 11/01/13, 07/28/14, 01/27/15, 04/10/15 and 07/27/15. C. Record review of a Braden Scale for Predicting Pressure Sore risk dated 01/21/05 revealed a score of 16 indicating at risk. A Braden Scale dated 04/18/15 revealed a score of 16 indicating at risk. A Braden Scale dated 07/16/15 revealed a score of 14 indicating moderate risk for developing a pressure ulcer. D. Record review of a Comprehensive Care Plan dated 04/22/14 for R #2 revealed Problem: Resident is at risk for skin breakdown is incontinent of B&B (bowel and bladder). Goal: Resident's skin will remain intact. Approach: Conduct daily skin check (weekly, daily, etc). Pay particular attention to the bony prominence's (sic); Turn and reposition prn (as needed). The care plan has a hand written entry dated 04/10/15; open area to Rt. (right) buttocks. The care plan has a hand written entry dated 07/27/15; pressure ulcer re (regarding) opened to coccyx area, Rsd (resident) remains on back when in bed. E. On 09/01/15 observations of the resident in bed at 11:30 am, 2:10 pm, and at 3:30 pm revealed the resident was laying on his back. Observations on 09/02/15 at 9:35 am and at 10:45 am revealed the resident in bed laying on his back in bed. Observations on 09/03/15 at 1:30 pm and 3:45 pm revealed the resident in bed laying on his back in bed. F. On 09/03/15 at 1:40 pm during an interview with CNA (Certified Nursing Assistant) #1, she stated, He is not on a turning schedule. G. On 09/03/15 at 3:45 pm during an interview with CNA #2, she stated, I had not been turning him before today. I think we are supposed to turn and reposition every 30 minutes. H. On 09/03/15 at 4:10 pm during an interview with CNA #3, she stated I did not reposition him. I did not know I was supposed to. I. On 09/03/15 during interviews with CNA #4, CNA #5, CNA #6 and CNA #7 all stated they turned and repositioned R #2 and R #3 per the facility policy. When asked what the facility policy states, they all stated that residents requiring assistance with turning and repositioning should be turned and repositioned every two hours. J. On 09/03/15 at 4:00 pm during an interview with LPN (Licensed Practical Nurse) #5, she stated I monitor for the CNA's turning a repositioning of the residents. I ask them if they have done it. The resident has a reoccurring pressure ulcer on his coccyx. When asked if she checked on the resident to see if he had been turned, she confirmed she did not. K. On 09/03/15 at 10:30 am during an interview, the DON stated, Everyone in our facility who need assistance to get in and out of bed are on a turning schedule. They should be turned every 2 hours. This resident needs to be turned and repositioned every 2 hours while he is in bed. There's not any place where we document where it's been done. We rely on the nurses to check. Resident #3 L. Record review of the Resident Admission Record 01/23/15 for R#3 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. M. Record review of the admission Nursing Data Collection Tool dated 01/23/15 revealed in Section 8 under Skin Condition that the resident was admitted without wounds. N. Record review of a Nursing Data Collection Tool dated 07/19/15 revealed in Section 8 under Skin Condition that the resident has wounds present. O. Record review of the Braden Scale for Predicting Pressure Ulcer Risk dated 01/23/15, 02/02/15, 02/12/15 and 02/19/15 revealed a score of 12, indicating a high risk. P. Record review of a Comprehensive Care Plan for R #3 dated 04/29/14 revealed Problem: Resident has a Stage II to coccyx, (3) unstageables (unable to determine the stage of the pressure ulcer) to left foot. Resident is at risk for skin breakdown. There is a hand written entry at the bottom of the page 7/19/15 St (stage) II to left ankle. St II to left foot. Red area left shin. Goal: Resident's ulcer will heal without complications. Approach: Conduct a skin check (e.g. weekly, daily, etc); Keep bony prominence's (sic) from direct contact with another with: (pillows, foam wedges, etc.); turn and reposition prn. Review of Interim Plan of Care dated 01/27/15 revealed Booties Bilat (bilateral) Feet. Q. Record review of Physician order [REDACTED]. Review of Physician order [REDACTED]. R. On 09/02/15 at 10:20 am during observation of wound care the resident was laying on her back, there was no pillow under her left foot and no booties on her feet. S. On 09/02/15 at 2:45 during an interview with the Wound Care nurse, she stated She should have something, a sheet or pillow between her legs. There should be a pillow to float her ankle. T. On 09/02/15 at 3:50 pm during an interview with CNA #2 she stated, I did not know about turning her. I have never seen a bootie on her feet. U. On 09/02/15 at 4:55 pm during an interview with RN (Registered Nurse) #1, she stated I noticed the wound on her left foot and left skin about 2 weeks ago. They were necrotic (dead cells). V. On 09/04/15 at 11:30 am during an interview with R #3, she stated They don't put any booties on me. They don't move me in bed. Observation at the time of this interview revealed no booties on her feet and no pillow or folded sheet between her legs. W. On 09/02/15 at 10:30 am during an interview with the Director of Nursing, she stated The ulcer on her ankle was in-house acquired on 04/08/15. The Stage II on her shin was in-house acquired on 07/14/15. She is on an air mattress and she should have something between her legs. If the resident's booties are not on her, they should be. They are there to prevent pressure on her foot.

Based on record review and interview, the facility failed to follow the written care plan for 1(R #1) of 5 (R #1, #2, #3, #4, and #5) sampled residents on [MEDICATION NAME] ([MEDICATION NAME], a blood thinning medication) by not monitoring her Anticoagulant medication levels through laboratory tests. This deficient practice resulted in Resident #1 having a critical level of blood thinning medication which prevented her blood from clotting effectively after a fall which likely resulted in severe blood loss and death. The findings are: A. Record review of the Physician order [REDACTED].#1 was taking [MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg (milligrams) daily. B. Record review of the care plan dated 11/25/14 revealed "Resident requires anticoagulant therapy (anticoagulant medications is administered to a patient to slow the rate at which the patient's blood clots.)" The goal of the care plan is "Resident will have no active bleeding." The approach indicates the "licensed nurse is to coordinate lab work. The licensed nurse and physician are to monitor lab work as ordered." C. Record review of a "Laboratory Requisition Form" dated 11/25/14 and signed by Physician #1 revealed an order for [REDACTED]. D. Record review of the medical record did not reveal that any laboratory test for PT/INR were ordered by the facility for R #1. E. Record review of the hospital discharge summary for R#1 dated 01/12/15 revealed the date of death was 01/12/15. Final [DIAGNOSES REDACTED]. Primary cause of death is [MEDICAL CONDITION] (bleeding within the skull). 2. Contributing cause is fall and anticoagulation with [MEDICATION NAME]." F. On 03/17/15 at 2:15 pm during an interview with the Director of Nursing she stated, "I could not find an order for [REDACTED]. I could not find any orders in the chart. We did not do any labs while she was here."

Based on record review and interview, the facility failed to monitor laboratory values for 1 (R #1) of 5 (R #1, #2, #3, #4, and #5) residents on [MEDICATION NAME] ([MEDICATION NAME]; anticoagulant medication). This deficient practice resulted in Resident #1 having a critical level of blood thinning medication which prevented her blood from clotting effectively after a fall which likely resulted in severe blood loss and death. The findings are: A. Record review of a facility Nursing Policies and Procedures dated 03/27/13 revealed the following: 1. " Subject : Anticoagulation Monitoring Program" 2. " Policy: Administration of anticoagulants to patients/residents is based on a defined management program to individualize the care provided to each patient/resident....."[MEDICATION NAME] includes a boxed warning. [MEDICATION NAME] can increase the risk of major or fatal bleeding, perform monitoring of INR in all treated patient/residents...." 3. " Procedures: [MEDICATION NAME] 1) Upon admission or transition of care, [MEDICATION NAME] orders will be reconciled per facility policy for medication reconciliation. 2) Upon admission, a baseline International Normalized Ration ("INR") must be drawn unless there is documentation of the most recent INR from the transferring facility. 4) The target INR will be stated with any admission order or any initiation of [MEDICATION NAME] therapy. A.) If target INR is not specified with the order, the nurse will clarify the order. 8. INR's ordered to be drawn per physician's orders [REDACTED]." B. Record review of the medical record for Resident #1 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. C. Record review of a Laboratory Flowsheet from the local hospital taken prior to the resident's admission to the facility revealed R #1's PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) laboratory value on 11/24/15 of 47.7 (seconds)/4.2; and on 11/25/15 of 52.5/4.6. The laboratory values for INR on 11/24/15 and 11/25/15 are high values. Normal values for PT is a time of between 10 and 14 seconds and an INR value of 2.0 to 4.0 is the normal clotting time for a person taking anticoagulant medication. D. Record review of a Medication List for discharge meds (medications) from the local hospital revealed "[MEDICATION NAME] ([MEDICATION NAME]) 2.5 mg oral tablet. " E. Record review of a "Laboratory Requisition Form" dated 11/25/14 and signed by Physician #1 revealed an order for [REDACTED]. F. Record review of the Physician order [REDACTED].#1 on 01/05/15 revealed a prescription dated 11/26/14 for [MEDICATION NAME] tablet 2.5 mg once a day. G. Record review of a Medications Administration Record (MAR) dated 11/27/15 to 1/11/15 revealed [MEDICATION NAME] 2.5 mg was administered daily. H. Record review of R #1's medical record revealed no record of laboratory values being done while Resident #1 was at the facility. I. On 03/17/15 at 1:10 pm during an interview with Registered Nurse (RN) #2 she stated, "I am not sure of the protocol for labs. I think it should be every 2 weeks. The nursing staff is responsible for checking for lab orders." J. On 03/17/15 at 2:00 pm during an interview with the Unit Manager for the 200 hall she stated, " I am responsible for checking for lab orders. I don't know why her's (R #1) were not done." K. On 03/17/15 at 2:15 pm during an interview with the Director of Nursing she stated, "I could not find an order for [REDACTED]. I could not find any orders in the chart. We did not do any labs while she was here." L. On 03/17/15 at 12:35 pm during an interview with RN #1, she stated, "The CNA (Certified Nursing Assistant) (CNA #2) came to get me for help in the ALC (Alternate Level of Care) unit. When I got there she (R#1) was sitting on her bed. The CNA was holding pressure on the laceration on the back of her head. I'm not sure but I think it was on the left side of her head. She had a prior laceration on the back of her head in December. She was in bed, her pillow was bloody. We had a hard time stanching the flow of blood. She was on [MEDICATION NAME]. She worried me." When asked about an order for [REDACTED]. M. Record review of the hospital discharge summary for Resident #1 dated 01/12/15 revealed the date of death was 01/12/15. Final [DIAGNOSES REDACTED]. Primary cause of of death is [MEDICAL CONDITION] (bleeding within the skull). 2. Contributing cause is fall and anticoagulation with [MEDICATION NAME]." N. Record review of a Laboratory Flowsheet from the local hospital dated 01/11/15 revealed R #1's PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) laboratory value was 170.0 (seconds)/10.0. This is a critical value. Normal values for PT is a time of between 10 and 14 seconds and an INR value of 2.0 to 4.0 is the normal clotting time for a person taking anticoagulant medication.

Based on record review and interview, the facility failed to obtain laboratory tests to monitor [MEDICATION NAME] ([MEDICATION NAME], a blood thinning medication) levels for 1 (R #1) of 5 (R #1, #2, #3, #4, and #5) residents on [MEDICATION NAME]. This deficient practice resulted in Resident #1 having a critical level of blood thinning medication which prevented her blood from clotting effectively after a fall which likely resulted in severe blood loss and death. The findings are: A. Record review of a facility Nursing Policies and Procedures dated 03/27/13 revealed the following: 1. " Subject : Anticoagulation Monitoring Program" 2. " Policy: Administration of anticoagulants to patients/residents is based on a defined management program to individualize the care provided to each patient/resident....."[MEDICATION NAME] includes a boxed warning. [MEDICATION NAME] can increase the risk of major or fatal bleeding, perform monitoring of INR in all treated patient/residents...." 3. " Procedures: [MEDICATION NAME] 1) Upon admission or transition of care, [MEDICATION NAME] orders will be reconciled per facility policy for medication reconciliation. 2) Upon admission, a baseline International Normalized Ration ("INR") must be drawn unless there is documentation of the most recent INR from the transferring facility. 4) The target INR will be stated with any admission order or any initiation of [MEDICATION NAME] therapy. A.) If target INR is not specified with the order, the nurse will clarify the order. 8. INR's ordered to be drawn per physician's orders [REDACTED]." B. Record review of the Physician order [REDACTED]. C. Record review the Physician order [REDACTED].#1 was taking [MEDICATION NAME] 2.5 mg (milligrams) daily. D. Record review of a "Laboratory Requisition Form" dated 11/25/14 and signed by Physician #1 revealed an order for [REDACTED]. E. Record review of a Laboratory Flowsheet revealed R#1 had PT/INR testing done only when at the local hospital emergency roiagnom on [DATE], 11/25/14 and 01/11/15, prior to admission to the facility and after the resident fell , resulting in injury. F. Record review of the medical record did not reveal that any laboratory test for PT/INR were ordered by the facility for R #1. G. Record review of the hospital discharge summary for Resident #1 dated 01/12/15 revealed the date of death was 01/12/15. Final [DIAGNOSES REDACTED]. Primary cause of of death is [MEDICAL CONDITION] (bleeding within the skull). 2. Contributing cause is fall and anticoagulation with [MEDICATION NAME]." H. On 03/17/15 at 2:00 pm during an interview with the Unit Manager for the 200 hall she stated, "I am responsible for checking for lab orders. I don't know why hers were not done." I. On 03/17/15 at 2:15 pm during an interview with the Director of Nursing she stated, "I could not find an order for [REDACTED]. I could not find any orders in the chart. She did not have any lab tests done while here."

Based on record review, interview and observation the facility failed to monitor and evaluate the resident's response to pain medication for one (R #91) of one (R #91) residents sampled for pain management. This failure likely caused R #91 to remain in pain and not reach his highest practicable physical well being. The findings are: A. Review of the 06/14 physician orders [REDACTED]. The 06/14 physician orders [REDACTED]. B. Review of the facility monthly treatment and medication treatment flow sheets for Resident #91 indicated the following: 1. 02/2014 Resident #91 complained of 6+ pain on a scale of one to ten of 15 days. Review of the medication flow sheet dated 02/2014 indicated Resident #91 was given pain medication 24 of 28 days. Monitoring for effectiveness of the pain medication was documented on five occasions. 2. 03/2014 Resident #91 experienced pain of greater than six 24 days out of the month. He received pain medication 27 times and five occasions effectiveness of the pain medication was documented. 3. 04/2014 Resident #91 experienced 19 days of pain six or greater. The resident received pain medication 29 of 30 days. Effectiveness of the pain medication was documented 13 times. 4. 05/2014 Resident #91 experienced pain greater than six 19 of 31 days days. The resident received pain medication 26 days and effectiveness was documented 13 times. 5. 06/2014 Resident #91 experienced seven of 12 days of a level greater than 6. Pain medication was given nine times, three times were documented for effectiveness. C. Review of the facility's pain evaluation assessment form indicates the following scale and guidelines: 1. 0-No hurt 2. 2-Hurts a little bit 3. 4-Hurts a little more 5. 6- Hurts even more 6. 8-Hurts whole lot 7. 10-Hurts worst D. Review of the Consulting Psychiatric Certified Nursing Practitioner's progress notes dated 04/09/14 indicated Resident #91's sleep was disrupted secondary to pain. 1, Review of the consulting psychiatric Certified Nurse Practitioner's progress notes dated 05/21/14 indicated the resident was experiencing "bad headaches." E. Review of the Nurses Progress Notes for Resident #91 indicated the following: 1. 03/25/14 "complaining of pain 10/10." 2. 03/26/14- "complaining of pain in knees and bottom." 3. 03/27/14-"complaining of pain in knees and bottom." 4. 03/29/14-"this morning resident reported considerable pain." 5. 03/30/14- "resident in bed, declined breakfast, complaining of knee" pain. 6. 04/01/14-"complaint of pain in knees." 7. 04/02/14-"complain of pain in knee." 8. 04/05/14-"medicated with prn (as needed) pain medication due to complaints of generalized pain." 9. 04/06/14-"complaining of pain, prn pain meds given." 10. 04/07/14-"complaining of pain in knees and back." 11. 04/08/14-"complaining of pain, prn pain meds given." 12. 04/09/14-"pain medication given at 0800 (8:00 am)." 13. 04/10/14-"resident is in bed at this time, states his back is hurting, pain meds given." 14. 04/11/14-"resident states back hurts, prn pain meds given." 15. 04/12/14-"complaint of pain in butt and back, prn pain meds given." 16. 04/13/14-"resident states pain in back and knees, prn pain meds given. 17. 04/14/14-"complaining of pain in back and knees." 18. 04/16/14-"resident was given a pain medication on the morning med pass." F. Review of the quarterly Minimum Data Set (MDS) for Resident #91 dated 04/20/14 in the section titled Pain Assessment Interview portion of the assessment indicated the resident answered yes to the question of "have you had pain or hurting at any time in the last five days?" The assessment also indicated the resident answered he frequently experienced this pain or hurting over the last five days. The pain intensity numeric rating scale does not have a two digit response as required by the MDS. In place of numbers is a "dash symbol." G. Review of Resident #91's care plan dated 03/13/14 indicated a problem of the resident having complaints of pain. The goal is documented as "the resident will verbalize relief of pain." One of the approaches is documented as "evaluate effectiveness of pain management interventions. Adjust if ineffective." There is no documentation to indicate the care plan was revised to address Resident #91's continuing pain and the ineffectiveness of the prn pain medication that was given to him. H. Review of the consultant psychiatric certified nurse practitioner (CNP) progress notes dated 05/21/14 indicated the CP's plan for resident #91 was to increase the dosage of [MEDICATION NAME] from 50 milligrams (mg) daily to 100 mg daily. The CNP also ordered [MEDICATION NAME] 100 mg at time of sleep and Triliptal 300 mg for mood stabilization. Review of the physician orders [REDACTED]. I. On 06/10/14 at 12:25 pm, during an interview R#91 stated, "I am in pain all the time. They give me one little pill. They don't understand, my head hurts, my ribs hurt, my hips hurt. I can't sleep at night. Whatever they give me doesn't work." J. On 06/12/14 at 11:30 am, during an interview the ADON (Assistant Director of Nursing) and RN #1 stated, "There are no telephone orders in the chart. We are going to get a hold of the nurse practitioner and have her write the orders. We are not sure what happened in this case. The nurse practitioner usually writes the telephone orders while she is here and gives them back to us. The progress notes from the nurse practitioner are just sent to medical records and filed." K. On 06/12/14 at 4:45 pm, during an interview the MDS coordinator stated, "The dash was the incorrect answer, if the resident could not answer, it should have been 99 not a dash. I don't remember what he, (Resident #91) told me about pain." The MDS coordinator also stated, "Because the dash was entered, the MDS allowed the assessment to continue without pain intensity response from the Resident." L. On 06/12/14 at 5:05 pm, during an interview the ADON, RN #1 and RN #3 stated, "It is a standard of practice that a nurse caring for a resident notify the physician of pain meds that are being given routinely and request something else". They stated Resident #91's physician "refuses to make a pain meds routine." They also stated they could not find any communication from the facility to the resident's physician indicating to the physician that Resident #91 was frequently in pain. M. On 06/13/14 at 10:30 am, during an interview Registered Nurse (RN) #1 stated "there are no more nurse's progress notes after 04/16/14. We only chart if there is something going on, antibiotic therapy, neurological checks, medication changes, etc. (Name of Resident #91) received pain medication after 04/16/14, it is documented in the MAR (medication administration record), not nursing progress notes.

Based on record review and interview the facility failed to prevent a significant weight loss for one (#91) of four (#'s 4 ,79 ,88 and 91) residents sampled for nutrition. This failure likely caused Resident #91 to lose 19 pounds since admission. The findings are: A. On 06/10/14 at 4:45 pm during an interview Resident #91 stated, "How is the food? Sometimes I eat, sometimes I don't. Lots of times I don't feel like going to the dining room because I hurt so bad. When they do bring food to my room, it is cold, but what's a person to do?" B. Review of the facility Data Collection/Evaluation/Nutritional dated 01/14/14 for Resident #91 indicated the resident was admitted [DATE] with an admission weight of 170 pounds. Review of the facility vital signs and weight record for Resident #91 indicated an admission weight of 169.9 pounds on 01/14/14. C. Review of the facility 6 month weight change report dated 06/05/14 indicated the following for Resident #91: 1. January 2014-no weight recorded 2. February 2014-150.8 lbs. 3. March 2014-158.0 lbs. 4. April 2014-151.4 lbs. 5. May 2014 150.2 lbs. 6. June 2014 151.7 lbs. D. Review of the initial care plan for Resident #91 dated 01/28/14 indicated the resident was at risk for weight loss due to dementia. One of the approaches listed on this care plan is "monitor/record weight. Notify MD (Medical Doctor), RD (Registered Dietician), and family of significant weight change." Documentation indicated the careplan was updated on 0 3/07/14 with "small portions vegetables." A statement dated 03/13/14 indicated "all meals on paper related to allergic to sour cream." A statement dated 04/21/14-"no green vegetables, will eat tomatoes." There was no documentation to indicate the facility recognized the 19 lbs or 11 percent weight loss from 01/14/14 through 06/10/14. E. Review of the Certified Nurse Practitioner's (CNP) psychiatric progress notes dated 05/21/14 indicates Resident #91 "appears somewhat sad, says his more depressed." The CNP also documents the resident is not sleeping well and his appetite is decreased. F. On 06/12/14 at 12:10 pm during an interview the facility dietary manager, the assistant Director of Nursing (ADON) Registered Nurse (RN) #1 and RN #2 stated Resident #91 was not put on the list for the consultant dietician to review because the Resident's weight loss was not triggered as "significant." They also stated Resident #91 was not discussed in quality of care meetings. They stated they were not sure why the Residents' admission weight of 170 pounds was not put on the weight change form. They stated, "By looking at him (Resident #91) you would not know he has lost weight."

Based on record review and interview, the facility failed to follow physician orders [REDACTED].#155) of 1 (#155) resident. The [MEDICATION NAME] had been increased from 10 milligrams (mg.) daily to 20 mg. daily on 06/02/11, but it was stopped from 06/11/11 through 06/16/11 when the facility ran out of the resident's medication. This deficient practice likely exacerbated Resident #155's depression and had the potential to result in impaired decision-making relating to the resident's [MEDICAL TREATMENT] treatments. The findings are: A. On 06/15/11 at 2:05 pm, during an interview, Resident #155 stated he had not gone to his scheduled [MEDICAL TREATMENT] that day because the van was 2 hours late coming to get him. He was crying frequently, stating that he wanted to quit [MEDICAL TREATMENT] and die, expressing frustration and stating he was "tired of living like this." B. Record review of the physician's orders [REDACTED]. to 20 mg. by mouth daily. C. Review of the Medications Flow sheet dated 06/01/11 to 06/30/11 revealed, "[MEDICATION NAME] 10 mg., oral, once a day, DX (diagnosis) Disorder, depressive." A handwritten note was entered stating, "order changed increase 20 mg QD (every day)." On 06/11/11 and 06/16/11 the area for the nurse's initials (to indicate the medication was given) was blank. From 06/12/11 through 06/15/11, the initials were circled, indicating the [MEDICATION NAME] was not given. D. On 06/16/11 at 10:50 am, Licensed Practical Nurse (LPN) #2 was asked if Resident #155 had been depressed. LPN #2 stated, "Yes, he has been very depressed and the doctor increased his medication but we have not had any the past few days to give him. When asked if the [MEDICATION NAME] 20 mg was being given daily as ordered, LPN #2 stated, "No, it is not being given every day. When the doctor changed the order, we should have marked out the old order and written a new one with the new dose. I can't say for sure what dose was being given every day, whether it was 10 mg or 20 mg. Some of the nurses did write 20 mg. We ran out of the [MEDICATION NAME] last Saturday (06/11/11) because we had to give 2 of the 10 mg pills ([MEDICATION NAME]) and the pharmacy did not send us the extra for the new dosage." When asked if it was possible to get the [MEDICATION NAME] from a local pharmacy, LPN #2 stated that she needed to call the pharmacy today to get some. E. On 06/16/11 at 4:10 pm, the Director of Nurses (DON) was asked if the [MEDICATION NAME] had been given as ordered by the physician. The DON stated, "No, it was not given as ordered. The blank and the circled initials indicate the medication was not given on those days. We can obtain medications locally but I was not made aware of not having the [MEDICATION NAME]. This is a medication error." Based on record review, observation and interview, the facility failed to follow the care plan by not providing personal hygiene for fingernail care for 1 (#104) of 2 (#104 and 172) residents reviewed for Activities of Daily Living (ADL) and personal hygiene who required assistance. Resident #104 was left with dirty and untrimmed fingernails which could affect the dignity of the resident. This deficient practice had the potential to result in Resident #104 receiving inadequate levels of hygiene assistance with potential embarrassment or loss of dignity resulting from poor personal appearance. The findings are: A. On 06/14/11 at 12:17 pm, observation of Resident #104 revealed that his finger nails on both hands were not clean. 1. Observation on 06/15/11 at 2:30 pm, Resident #104's fingernails were dirty. He was observed being taken to the shower 06/15/11 at 3:00 pm. 2. Observation on 06/16/11 at 10:00 am, revealed that Resident #104's fingernails were dirty and long. 3. Observation on 06/17/11 at 9:35 am, Resident #104's fingernails were long and dirty. Resident #104 was asked if he liked his fingernails long. He stated, "Not this long." He was asked if the nurse aides did his nail care and hand washing. He stated, "Sometimes." He was asked if he wanted his nails trimmed. The resident stated, "Yes." B. On 06/17/11 at 9:40 am, the Director of Nurses (DON) was and asked to observe Resident #104's fingernails. She agreed that his nails were dirty and needed to be trimmed. She was told he had his shower on Wednesday (06/15/11). She stated that he should have had his nails trimmed on his shower day, and his nails should be cleaned when dirty. C. Review of the resident's 04/17/11 Minimum Data Set Quarterly Assessment revealed that the resident requires extensive assistance from staff for personal hygiene care. Review of Resident #104's Care Plan dated 04/17/11 revealed that he required extensive assistance with ADL functioning and personal hygiene. Review of the Care Plan revealed an intervention for nail care instructing staff to, "Give nail care per schedule and prn (as needed)." D. On 06/17/11 at 5:15 pm, the DON was asked if the care plan had been followed for Resident #104's ADLs and nail care. She stated, "No."