Every finding on record at Cedars Healthcare Center

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare and serve food in a sanitary manner in the main kitchen, having the potential to affect multiple residents on 4 of 4 nursing units. The findings included: 1. The facility staff failed to let dishes air dry and were stacking dishes wet or wet nesting, which can cause bacteria growth. On 11/19/24, during the lunch meal, observations were conducted in the dining room of the meal service. The dietary aide (Other Employee #17) was at the tray line plating food without wearing a beard guard, although facial hair was visible. On 11/20/24 at 1:40 p.m., during a follow-up visit to the kitchen, the cook (Other Employee #14) was observed in the area by the stove, preparing food without wearing a hair net. The dietary aide (Other Employee #15) was observed preparing beverages and her hair net was only covering the ends of her hair in the back. When asked about hair nets, Other Employee #15 stated that they don't have any large enough to cover her hair and that she usually has to wear two. The food services district manager, who was also present, stated that Other Employee #15 could put two on as she normally does, and that he would have some larger ones sent to the facility. On 11/20/24 at approximately 1:45 p.m., following the surveyor's conversation with Other Employee #15 about the hair net, the cook exited the kitchen and upon return, while walking through the kitchen, was donning a hair net. When asked why the hair net was not worn prior to the surveyor entering the kitchen, the cook gave no response On 11/20/24 at approximately 1:48 p.m., the dietary district manager confirmed that all kitchen staff should wear hair nets and beard guards as appropriate when in the kitchen. On 11/20/24, during an end of day meeting, the facility administrator was made aware of the above concerns. On 11/21/24, at approximately 12:30 p.m., an observation was made in the dining room. The kitchen employee that was working the steam table was distributing food to plates, had visible facial hair but had no beard guard on. On 11/21/24 at 2:24 p.m., as the surveyor was walking past the kitchen, the door was open, and the surveyor observed the facility's social services director standing by the stove without a hair net on. On 11/21/24, in the afternoon, an interview was conducted with the social services director. When the surveyor discussed that the employee had been observed in the kitchen, the social services director stated she was dropping off some food that had been brought in. According to the facility policy titled, Staff Attire, it read in part, 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained . On 11/21/24, during the end of day meeting, the facility administrator was made aware of the additional observations of facility staff in food preparation areas without proper hair restraints. No further information was provided. 2. The facility staff failed to wash dishes in a manner to properly clean and sanitize the items. On 11/20/24 at approximately 1:45 p.m., a dietary aide was observed manually washing dishes in the three-compartment sink. The employee was only using 2 of the 3 sinks. He was washing the dishes in the wash sink and then immediately removing them and taking them to the sanitizer, then took the dishes and placed them on a drying rack. No rinse was provided for the dishes as the middle sink was empty. The surveyor attempted to interview the staff member, but he didn't speak English. The dietary services district manager was present and confirmed the above observations. The district manager was giving gestures to instruct the dietary aide to fill the middle sink and to rinse dishes before dipping into the sanitizer. The facility policy titled, Manual Warewashing was reviewed. The policy didn't address dishes being rinsed. On 11/20/24, in the afternoon, during a follow-up visit to the kitchen it was observed that following dishes being washed in the dish washer, they were being stacked wet, causing wet nesting. An interview was conducted with the dietary aide (Other Employee #15), who confirmed the observation and stated that not allowing dishes to air dry could cause bacteria growth. According to the facility policy titled, Warewashing, it read in part, .4. All dishware will be air dried and properly stored. On 11/20/24, during an end of day meeting, the facility administrator was made aware of the above findings. No additional information was provided.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for one resident (Resident #2- R2) in the survey sample of six residents. The findings include: For R2, the facility staff failed to accurately transcribe a physician order, resulting in multiple occurrences of medications being administered at the wrong dose. On 2/26/25 at 11:25 a.m., R2 was visited in her room. When asked about medications, R2 reported she had difficulty getting her medications timely. On 2/26/25 and 2/27/25, a clinical record review was conducted of R2's chart. According to a progress note dated 2/10/25, from a neurologist that R2 saw that day, the note read in part, . Assessment/Plan: . Her exam is most notable for mild symmetric bradykinesia, minimal rigidity, and a prominent postural/action tremor that attenuates at rest . I am inclined to agree that this is likely drug-induced tremor; unfortunately, she is unable to reduce/stop VPA [valproic acid]. Since the postural/action component is most bothersome, we will restart propranolol at a very low dose . Drug-induced tremor/parkinsonism, restart propranolol: 5 mg daily for 2 weeks, then 5 mg bid [twice a day] for 2 weeks, then 5mg tid [three times a day], can continue to up-titrate from there . Medication changes as of 2/10/2025, added: propranolol (Inderal) 10 mg tablet, take 0.5 tablets by mouth three times daily, follow titration schedule . According to the physician orders and medication administration record, the propranolol was transcribed at the facility on 2/10/25 as Propranolol HCL oral tablet 10 mg, give 0.5 tablet by mouth three times a day for HTN [hypertension]. The MAR indicated that R2 received three doses daily on 2/12/25 - 2/21/25, then again on 2/24/25 - 2/25/25, until the supply was depleted. On 2/27/25 at 11 a.m., the surveyor approached the nurse working the medication cart where R2 resides. The nurse identified themselves as the unit manager. When asked to see R2's propranolol medication, the nurse was unable to find it in the medication cart. On 2/27/25 at 11:10 a.m., review of R2's medication administration record revealed that the propranolol was signed as having been administered that morning. The surveyor then went back to the nurse/unit manager to inquire about the medication being documented as having been administered, when the medication was not available in the medication cart. The nurse reported that he had given the last dose that morning. When asked to see the empty medication card, the nurse was unable to provide evidence to the surveyor. On 2/27/25 at 12:02 p.m., a telephone call was placed to the pharmacy and an interview was conducted with the pharmacist. The pharmacist confirmed that on 2/10/25, R2's propranolol was sent to the facility. The pharmacist also confirmed that 45 tablets were dispensed for a 30-day supply. When asked to confirm the order, the pharmacist stated it was to be given three times daily. When asked to explain how 45 tablets could be a 30-day supply if three tablets are being given daily, the pharmacist then stated that she needed to talk to the pharmacy manager. Upon returning to the call, the pharmacist stated that the pharmacy had provided the full 10 mg tablets, instead of the half tablets as ordered, . which was an error on our part. We are to cut the tablets and send. The pharmacist then confirmed that the resident likely received the full tablet of 10 mg three times daily, which was twice the ordered amount, as the facility was reporting that they had no supply left. The pharmacist also stated that they would need to talk to the physician about this before they can fill it again. On 2/27/25 at 1 p.m., during an end of day/pre-exit meeting with the facility administrator, director of nursing and regional director of operations, the facility's director of nursing was shown the above documentation, agreed that the order had been entered incorrectly, and stated that R2's dose should have been titrated up. The discrepancy with regards to the pharmacy sending full tablets versus 1/2 tabs was also discussed, adding that the pharmacist stated that they would have to talk with the doctor before the pharmacy could fill that medication again. On 2/27/25 at approximately 2 p.m., the facility's director of nursing let the surveyor know they had found a card of the propranolol for R1. No additional information was provided.

Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration for four residents (Resident #4-R4, Resident #5-R5, Resident #1-R1, and Resident #20-R20) in a survey sample of 6 residents. The findings included: 1. For R1, the facility staff failed to have Gabapentin available for administration in accordance with physician orders. On 2/26/25 at 11:15 a.m., an interview was conducted with R1. During the interview, R1 said, This is my 3rd day without gabapentin. I think it has to do with agency nurses. They are just lazy and don't do like they should. According to the physician orders, it was noted that R1 had an order for Gabapentin Capsule 400 mg, give 2 capsules by mouth every 8 hours for neuropathy. On 2/25/25, it was documented that the order was put on hold. According to the medication administration record, R1 did not receive two doses of the scheduled Gabapentin on 2/24/25 and did not recieve any of the three doses on 2/25/25. The medication order was then placed on hold until the second scheduled dose on 2/26/25. On 2/27/25 at 9:30 a.m., an interview was conducted with the medical director and attending physician of R1. The physician was asked about medications and reported that the pharmacy delivers twice daily, and medications are given plus or minus within an hour of when scheduled. When asked about medications not being available, the physician said, It happens frequently. When asked about hold orders, the doctor stated that hold orders are happening if medications are not available to be given, .particularly narcotics when the pharmacy says they are waiting on a prescription. The doctor explained that he would send prescriptions electronically but frequently the pharmacy would say they don't receive it. The doctor also stated that the pharmacy would not fill for the entire quantity written on the prescription, which required more frequent reordering of the medication by facility staff, and added, We use a lot of agency staff that are unfamiliar with the residents. On 2/27/25 at 10:50 a.m., the surveyor asked the licensed practical nurse (LPN #2) to allow the surveyor to see R1's Gabapentin supply. The card of medication had a prescription label that noted it was filled 2/25/25 and received on 2/26/25, in a quantity of 30 capsules. The facility also had two additional cards with 30 capsules each, which, when totaled, would be about a 15-day supply. 2. For R2, the facility did not have the blood pressure medication propranolol available to administer as ordered by the physician. On 2/26/25 at 11:25 a.m., R2 was visited in her room. When asked about medications, R2 reported she had difficulty getting her medications timely. On 2/26/25 and 2/27/25, a clinical record review was conducted of R2's chart. According to the physician orders R2 had an order dated 2/10/25, that read, Propranolol HCL oral tablet 10 mg, give 0.5 tablet by mouth three times a day for HTN [hypertension]. According to the medication administration record for February 2025, R2 did not receive the Propranolol on the following occasions: two missed doses on 2/11/25, three missed doses on 2/22/25, and one missed dose each on 2/23/25 and 2/26/25. According to the nursing progress note entries, on 2/11/25, it was documented not available. On 2/16/25, the nurse documented, The resident's medication is out of stock at this time, reordered from pharmacy 2/16 will monitor for s/s [signs and symptoms] hypertension. On 2/22/25, it was documented, Awaiting meds from pharmacy. On 2/23/25, the nursing note read, on order. On 2/26/24, the documentation read, being delivered. On 2/27/25 at 11 a.m., the surveyor approached the nurse working the medication cart where R2 resides. The nurse identified themselves as the unit manager. When asked to see R2's propranolol medication, the nurse was unable to find it in the medication cart. On 2/27/25 at 12:02 p.m., a telephone call was placed to the pharmacy and an interview was conducted with the pharmacist. The pharmacist confirmed that on 2/10/25, R2's propranolol was sent to the facility. The pharmacist confirmed that 45 tablets were dispensed for a 30-day supply. When asked to confirm the order, the pharmacist stated it was to be given three times daily. When asked to explain how 45 tablets could be a 30-day supply if three tablets are being given daily, the pharmacist paused, then stated that she needed to talk to the pharmacy manager. Upon returning to the call, the pharmacist stated that the pharmacy had provided the full 10 mg tablets, instead of the half tablets as ordered, . which was an error on our part. We are to cut the tablets and send. The pharmacist then confirmed that the resident likely received the full tablet of 10 mg three times daily, which was twice the ordered amount, as the facility was reporting that they had no supply left. The pharmacist also stated that they would need to talk to the physician about this before they can fill it again. 3. For Resident #4 (R4), the facility did not have the respiratory medication Bevespi available to administer as ordered by the physician. On 2/26/25, a closed record review was conducted. According to the physician orders, R4 was ordered Bevespi inhaler, and two puffs were to be administered twice daily for COPD. According to the medication administration record (MAR), R4 did not receive the Bevespi from 12/27/24 through 12/31/24. According to the nursing progress note dated 12/30/24, it read, Awaiting medicine from pharmacy. Will contact pharmacy to follow-up. On 2/27/25 at 12:02 p.m., the surveyor contacted the facility's contracted pharmacy via telephone. An interview was conducted with a pharmacist, who reported that R4's Bevespi order was received by the pharmacy on 12/27/24 but was not dispensed until 1/1/25. The pharmacy manager confirmed that deliveries are made to the facility daily by the pharmacy. When questioned about the delay in R4's Bevespi being delivered, the pharmacist stated, it was not covered by insurance, so they were probably waiting to hear back from the facility about how to proceed. 4. For Resident #5 (R5), the facility did not have the respiratory medication Breo Ellipta available to administer as ordered by the physician. On 2/26/25 at approximately 1:30 p.m., R5 stopped the surveyor and asked the surveyor to step into his room. R5 stated he has not had his inhaler for several days and really needs it. R5 opened the top drawer of his bedside table and removed the silver packaging that the Breo comes in and showed the surveyor, again saying he needed it to breathe. R5 was observed to be receiving continuous oxygen per nasal cannula. On 2/26/25, a clinical record review was conducted of R5's chart. This review revealed that R5 had a diagnosis to include chronic obstructive pulmonary disease (COPD). According to the physician orders, R5's orders included, but were not limited to, O2 at 2 LPM [liters per minute] via NC [nasal cannula] continuously for COPD and Breo Ellipta Inhalation Aerosol Powder breath activated 200-25 MCG/ACT. According to the medication administration record (MAR), R5 was noted as not receiving the daily Breo inhaler on 2/18/25, 2/20/25, 2/22/25, 2/23/25, 2/24/25, 2/25/25, and 2/26/25. According to R5's nursing progress notes, an entry dated 2/18/25 read, On order, RP [responsible party] notified. R5's nursing note dated 2/20/25 read, in route from pharmacy. R5's nursing note entry dated 2/22/25 read, on hold. On 2/23/25, the nurse documented, too soon to order on hold. On 2/26/25 at approximately 4:30 p.m., the surveyor approached the nurse and asked about R5's Breo and requested to see if it was in the medication cart. The nurse, RN #1 stated it was not available, that she had notified the unit manager, and called the pharmacy, who had reported it would be out on the next run. On 2/26/25 at 4:35 p.m., the surveyor conducted an interview with the assistant director of nursing/unit manager (Administrative Staff #2- AS#2). When asked about R5's Breo, AS#2 said, He needs a new one, the pharmacy said it was too soon, so I told them to fill it anyway. On 2/27/25 at 9:30 a.m., an interview was conducted with the medical director, the attending physician for R5. When asked about medications, the physician reported that the pharmacy delivers twice daily, and that medications are given plus or minus an hour of when scheduled. When asked about medications not being available for administration, the physician said, It happens frequently. The physician went on to state that R5 . really needs it [referring to the Breo] because he has COPD and is on oxygen. On 2/27/25 at 12:02 p.m., a phone conversation was held with the pharmacist at the facility's contracted pharmacy. The pharmacist reported that R5's Breo Ellipta was most recently filled on 1/30/25, which included 30 inhalations. The pharmacist further reported that it was delivered on 2/26/25 at 9:25 p.m., to the facility. On 2/27/25 at approximately 12:15 p.m., R5 reported that he still had not received his Breo and said, This place ain't worth a damn! On 2/26/25 at 2:22 p.m., an interview was conducted with a registered nurse (RN #1). When asked what the process is when a medication is not available, RN #1 said, We call the pharmacy to see if they have it in the Omnicell [emergency supply of medications]. If not available, we can ask the pharmacy to send it STAT [urgently]. We have to write a note that it is not available. On 2/26/25 at 4:29 p.m., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON was asked to explain the process staff are to take when a medication is not available for administration. The ADON stated that staff can see if the medication is in the Omnicell, get an order from the doctor to hold the medication, contact the pharmacy to see when it is coming, identify what the issue is that they haven't received it, and let the responsible party know. On 2/27/25 at approximately 9:30 a.m., an interview was conducted with the medical director, who is also the attending physician for many of the residents. When asked about his expectations with regards to medication orders, the physician stated that he expects residents to receive their medications as ordered. The medical director went on to report that the pharmacy delivers to the facility twice daily. When notified of the above findings of residents not receiving medications as ordered, the physician said, It happens frequently We use a lot of agency staff who are unfamiliar with the residents. According to the facility policy titled, Medication Administration was reviewed. The policy read in part, . The purpose of this policy is to provide guidance for the process for providing monitoring that all medications are received and administered in a timely manner . The facility policy titled, Missed Medication/Medication Error was received and reviewed. The policy read in part, Medication error/incident: any physician/provider prescribed medication that is not administered to the resident as prescribed regardless of the category or the reason for not providing the medication . II. For any medication(s) not available during a routine medication pass: 1. The charge nurse will check the E-kit to attempt to offer medication in a timely manner. 2. If medication is taken from the E-kit, the pharmacy will be notified so the E-kit can be exchanged . 3. In the event the medication is not available from the E-kit or the Emergency Pharmacy, the charge nurse will notify the physician immediately and receive guidance on how to proceed . On 2/27/25 at 1 p.m., during an end of day/pre-exit meeting, the facility administrator, director of nursing and regional director of operations, was made aware of the above findings. No additional information was provided.

Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of practice with regards to medication administration for three residents (Resident #2- R2, Resident #4-R4, and Resident #5 -R5), in a survey sample of six residents. The findings included: 1. For Resident #2, the facility staff failed to administer medications timely. On 2/26/25 at 11:25 a.m., an interview was conducted with R2 in her room. R2 reported, I haven't gotten my morning medications yet. When asked what time they are scheduled, R2 reported, 8 a.m. When asked how often this happens, R2 said, A lot. When asked if she knows why, R2 said, No, I don't know why. The resident stated that she has told the head nurse and nurses, but it doesn't get any better. On 2/26/25, a clinical record review was conducted. According to R2's physician orders and medication administration record, four medications, including propanolol for hypertension and carbidopa-levodopa for Parkinson's, were scheduled at 7 a.m., gabapentin for nerve pain was scheduled 8 a.m., and 10-12 other medications were scheduled for 9 a.m. administration. According to the Medication Audit Report, R2 received her scheduled 8 a.m., dose of gabapentin on 2/26/25 at 11:39 a.m., with five other 9 a.m. scheduled medications. This same report noted that on 2/19/25, R2 had propranolol and carbidopa-levodopa scheduled for 7 a.m. and gabapentin scheduled for 8 a.m. that were not administered until 10:11 a.m., along with 12 other 9 a.m. medications. On 2/21/25, this report documented that the 7 a.m. doses of propanolol and carbidopa-levodopa were not administered until 9:22 a.m. On 2/22/25, R2's medications scheduled for 7 a.m., including the carbidopa-levodopa were given at 10:43 a.m., while the propranolol HCL tablet, which was also scheduled for 7a.m., was not administered until 5 p.m. It was also documented that the 12 noon dose of oxycodone for pain was not given to R2 until 2:59 p.m., along with 3 other meds also scheduled for noon. On 2/23/25, the report showed that the 6 p.m. dose of oxycodone for pain was not given to R2 until 11:28 p.m., along with the 5 p.m. dose of propanolol and 8 other medications scheduled between 7 p.m. and 9 p.m. On 2/24/25, the 6 a.m. doses of oxycodone for pain, levothyroxine for hypothyroidism, and alpralozam for anxiety were all documented as being given to R2 at 8:44 a.m. 2. For Resident #4 (R4), the facility staff failed to administer medications timely. On 2/26/25, a closed record review was conducted. According to R4's physician orders, she was ordered to receive albuterol nebulizers three times a day for COPD. R4 also had physician orders for Bevespi inhaler, and two puffs were to be administered twice daily for COPD. According to the Medication Admin Audit Report R4 had multiple instances where medications were not administered within an hour of the scheduled time. On numerous occasions, 12/28/24, 12/29/24, 12/30/24, 12/31/24 and 1/1/25, R4's medications scheduled for administration at 7 a.m., were not administered until after 10 a.m. On 1/2/25, medications scheduled to be administered at 5 p.m. were documented as having been administered at 9:30 p.m. On 1/3/25, medications ordered to be administered at 1 p.m., were documented as having been administered at 5:04 p.m. According to the Medication Admin Audit Report on 1/3/25, R4 was not given the scheduled 7 a.m. albuterol nebulizer treatment until 6:37 p.m. As a result, a prn as needed dose/administration of a nebulizer treatment had to be administered at 9:40 a.m. The administration was not documented until 6:40 p.m. 3. For Resident #5 (R5) the facility failed to follow professional standards of nurse practice with regards to the timely administration of Breo Ellipta Inhaler. On 2/26/25 at approximately 1:30 p.m., R5 stopped the surveyor and asked the surveyor to step into his room. R5 said, I have not had my inhaler for several days and I really need it. R5 opened the top drawer of his bedside table and removed the silver packaging that the Breo comes in and showed the surveyor, again saying that he needed it to breathe. R5 was observed to be on continuous oxygen per nasal cannula. On 2/26/25, a clinical record review was conducted of R5's chart. This review revealed that R5 had a diagnosis to include chronic obstructive pulmonary disease (COPD). According to the physician orders, R5's orders included, but were not limited to, Breo Ellipta Inhalation Aerosol Powder breath activated 200-25 MCG/ACT. On 2/27/25 at approximately 11:00 a.m., R5 reported he still had not received his Breo and said, This place ain't worth a damn! According to R5's medication administration record, R5 was to receive the Breo in the morning at 7:00 am, but as of 11:20 a.m., the Breo was still not documented as having been administered. Further review revealed that the Breo was documented as not being administered on 2/18/25, 2/20/25, 2/22/25, 2/23/25, 2/24/25, 2/25/25, and 2/26/25. R5's clinical record did not indicate that the physician had been notified of these omitted doses of this medication used to improve breathing. On 2/26/25 at 2:22 p.m., an interview was conducted with a registered nurse (RN #1). When asked about the discrepancies with administering medications, RN #1 stated that medications are to be given within an hour of the scheduled time. When asked why, RN #1 stated . to maintain therapeutic levels in the resident. On 2/27/25 at approximately 9:30 a.m., an interview was conducted with the medical director, who is the attending physician of many of the residents. When asked about medication administration and timing of medications, the medical director said, They are on a liberalized med pass here. When asked what he meant by that, the medical director said, Plus or minus an hour of the scheduled time. When asked why is this important, he indicated to maintain therapeutic levels of certain medications. On 2/27/25 at 10:50 a.m., an interview was conducted with licensed practical nurse #2 (LPN #2). LPN #2 was asked about the timing of medication administration. LPN #2 stated, We can give an hour before or after. When asked why that is, LPN #2 said, To give you grace since we have 30 patients, and to give you some time to get to them. On 2/27/25 at 1 p.m., during an end of day/pre-exit meeting with the facility administrator, director of nursing, and regional director of operations, the facility director of nursing stated that medications are given when ordered, 1 hour before or after the ordered time. They were made aware of the above findings. According to the facility's policy titled, Medication Administration, it read in part, . The purpose of this policy is to provide guidance for the process for providing monitoring that all medications are received and administered in a timely manner .II. Safety Precautions: a. Observe the 'five rights' for administration. i. the right resident, ii. the right time, iii. the right medicine, iv. the right dose, v. the right method of administration . According to Lippincott's Manual of Nursing Practice, Eighth Edition, on page 18 it read in part, Common Legal Claims for Departures from Standards of Care . Failure to administer medications properly and in a timely fashion, or to report and administer omitted doses appropriately . No additional information was provided.

Based on observation, resident and staff interviews, clinical record review, and facility documentation review, the facility staff failed to ensure medications were available for administration for six residents (Resident #80-R80, Resident #69-R69, Resident #70-R70, Resident #20-R20, Resident #40-R40, and Resident #93-R93) in a survey sample of 30 residents. The facility staff also failed to ensure medications were available during medication administration on two units (200 unit and 400 unit) out of four units. The findings included: 1. For R69, the facility staff failed to ensure medications were available for administration as ordered by the physician for pain control. On 11/20/24 at 9:30 a.m., during an interview with R69, the resident reported she had a fall and broke her right foot. R69 was observed to have a cast on her right lower leg. R69 reported that she had several occurrences of running out of her pain medication oxycodone. On 11/20/24, a clinical record review was conducted. According to the medication administration record (MAR), R69 had orders for Percocet 5-325 mg (Oxycodone w/ Acetaminophen) to be given every 6 hours for pain, totalling 4 administrations per day. It was noted on the MAR that R69 did not receive the doses on 11/1/24 as ordered. According to R69's nursing note dated 11/1/24, the entries read in part, Per pharmacy medication will be delivered in am. Awaiting delivery resident made aware-stated That ok, I'll wait I got my Oxy. Thank you, [NAME], [sic] and Medication per pharmacy to be delivered in am. 2. For Resident #80 (R80), the facility staff failed to ensure pharmacy services were adequate to ensure medications were available for administration as ordered by the physician. On 11/19/24 at 11:18 a.m., R80 was visited and interviewed in his room. During the interview, R80 reported that he had cancer and has continuous, unrelieved pain, despite being on methadone for pain management. On 11/19/24-11/20/24, a clinical record review was conducted. According to the physician orders, R80 had a current and active order that read, Methadone HCl Oral Tablet 5 MG (Methadone HCl) Give 7.5 mg by mouth two times a day for Pain Give 3 half tabs to equal 7.5mg. According to the medication administration record (MAR), R80 was not given the Methadone as ordered on 11/2/24, and 11/3/24. According to R80's nursing notes, an entry dated 11/2/24, read, on hold MD [medical doctor] aware, waiting for it to come from pharmacy. Another nursing note entry dated 11/3/24, read in part, awaiting pharmacy delivery, MD/RP [medical doctor/responsible party] aware. On 11/8/24 and 11/12/24, documentation reflects that R80 only received one dose of Methadone. On 11/13/24, R80 didn't receive either of the two ordered doses and on 11/14/24, only the evening dose was administered. On 11/20/24, in the afternoon, an interview was conducted with R80. R80 confirmed that at times he doesn't receive his Methadone for pain. R80 reported he experienced pain all the time, due to the cancer and couldn't say that it the pain is any worse when he goes without the Methadone. 3. For Resident #70 (R70), the facility staff failed to maintain a system to account for controlled drugs to accurately reflect the quantity of Suboxone available and failed to ensure the medication was available to be administered to the resident. On 11/19/24 at 10:58 a.m., an interview was conducted with R70. During the interview, R70 reported he doesn't always get his medication. On 11/19/24-11/20/24, a clinical record review was conducted. This review revealed that R70 had an active physician's order that read, Suboxone Sublingual Film 4-1 MG (Buprenorphine HCl-Naloxone HCl Dihydrate) Give 1 film sublingually two times a day for Opioid dependence. According to the medication administration record, R70 did not receive either of the scheduled doses on 11/7/24. According to R70's nursing notes, entries were made with regards to the Suboxone that read, waiting for script and hold on order. On 11/20/24 at 3:56 p.m., an interview was conducted with licensed practical nurse #4 (LPN #4) and registered nurse #1 (RN #1). Both nurses explained that if they are administering medications and a medication is not available, they would search for the medication, then would look in the Pixis (an on-site back-up supply of medications), and if still not, available they would call the doctor to notify them that the dose may be missed or delayed and ask what they wanted the nurse to do. Following the above interview with LPN #4 and RN #1, the surveyor asked to see R70's Suboxone. LPN #4 opened the medication cart and retrieved a clear bag which contained 5 individually wrapped packages of Suboxone film. Upon review of the Controlled Drug Administration Record Tablet, it was noted that 6 doses should be remaining. RN #1 spoke up and stated that she had not signed off on the dose given to R70 that morning. RN #1 stated that she should have recorded it at the time of administration. According to the facility policy titled, Medication Administration, it read in part, VI. Narcotic. a. Sign out narcotic controlled substance from narcotic count card when removed . On 11/20/24 at 4:16 p.m., an interview was conducted with the Director of Nursing (DON). When notified of multiple findings where residents are not being administered their medications, the DON stated that many times there is an insurance issue that prevents the pharmacy from sending the medications. On 11/20/24 at 4:40 p.m., an interview was conducted with the facility's medical director (MD), who was also the attending physician for R69, R80 and R70. When the MD was made aware that the surveyor saw numerous findings when R80 and R70 were not administered medications as ordered, the MD said, The pharmacy won't send the amount I write for them. [Pharmacy name redacted] has been difficult to work with lately. I send prescriptions via e-script [electronically] and they will say they didn't get it. It takes multiple calls, then there are a few days delay in getting them delivered to the facility. On 11/20/24, during an end of day meeting, the facility administrator was made aware of the above findings. No additional information was provided. 21875 4. The medication methadone was not available for administration to Resident #20 as ordered by the physician. Resident #20 (R20) was admitted to the facility with diagnoses that included diabetes, peripheral vascular disease, neuropathy, congestive heart failure, hypertension and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R20 as cognitively intact. R20's clinical record documented a physician's order dated 11/1/24 for methadone 10 milligrams with instructions to give one tablet twice per day for pain management. R20's medication administration record documented the methadone was not administered on 11/15/24, 11/16/24 and 11/17/24 (morning dose). Nursing notes on 11/15/24, 11/16/24 and 11/17/24 documented the methadone was not available in the medication cart and as pending delivery from the pharmacy. A nursing note dated 11/16/24 documented R20's methadone was reordered on 11/12/24. On 11/20/24 at 3:12 p.m., the licensed practical nurse unit manager (LPN #3) caring for R20 was interviewed about the missed methadone doses. LPN #3 stated the scripts were sent to the pharmacy prior to running out but the pharmacy was not timely with deliveries. LPN #3 stated the pharmacy reported the medications were to be delivered but did not show up. LPN #3 stated the pharmacy at times will report that they do not have the needed scripts when the scripts have already been sent. LPN #3 stated methadone was not kept in the backup supply. LPN #3 stated there had been ongoing issues with the pharmacy regarding timely deliveries. On 11/20/24 at 3:33 p.m., R20 was interviewed about the missed doses of methadone. R20 stated she was recently made aware that the methadone had not been received from the pharmacy. On 11/20/24 at 4:16 p.m., the director of nursing (DON) was interviewed about medications not available from the pharmacy. When asked if she was aware that nurses reported ongoing issues with getting medicines delivered timely, the DON had no response. The DON stated nurses were able to reorder medications from the refill screen in the computerized health record. This finding was reviewed with administrator and regional consultants during a meeting on 11/21/24 at 5:00 p.m. with no further information presented prior to the end of the survey. 5. Calmoseptine ointment 0.44-20.6% ointment was not available for administration to Resident #40 as ordered by the physician. Resident #40 (R40) was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), dementia, diabetes, cellulitis, depression, coronary artery disease and anemia. The minimum data set (MDS) dated [DATE] assessed R40 with severely impaired cognitive skills. R40's clinical record documented a physician's order dated 10/29/24 for Calmoseptine external ointment 0.44-20.6 % (menthol-zinc oxide) with instructions to apply to bilateral buttocks every shift for folliculitis. R40's medication administration record documented the Calmoseptine ointment was not applied on 11/15/24, 11/16/24 or 11/17/24. Nursing notes on 11/15/24, 11/16/24 and 11/17/24 documented the Calmoseptine ointment was on order from the pharmacy and not available for administration. On 11/20/24 at 3:11 p.m., the licensed practical nurse unit manager (LPN #3) was interviewed about the Calmoseptine ointment administration. LPN #3 stated the Calmoseptine ointment was not ordered from the pharmacy but was an in-house stocked item. LPN #3 stated she was not sure why the Calmoseptine ointment was not available. On 11/21/24 at 10:05 a.m., the supply clerk (other staff #4) was interviewed about R40's Calmoseptine ointment. The supply clerk stated nursing usually informed her of needed ointments/creams. The supply clerk stated, Calmoseptine is not something I've ordered. The supply clerk stated she had received no request from nursing or hospice for the Calmoseptine ointment. The supply clerk stated the Calmoseptine ointment was not kept in stock but could be ordered if needed. This finding was reviewed with administrator and regional consultants during a meeting on 11/21/24 at 5:00 p.m. with no further information presented prior to the end of the survey. 6. The medications Pataday 0.2% eye drops and Azelastine 0.05% eye drops were not available for administration to Resident #93 as ordered by the physician. Resident #93 (R93) was admitted to the facility with diagnoses that included spinal stenosis, bradycardia, sick sinus syndrome, hypertension, neurogenic bladder, depression and insomnia. The minimum data set (MDS) dated [DATE] assessed as cognitively intact. On 11/19/24 at 11:44 a.m., R93 was interviewed about quality of care in the facility. R93 stated during this interview that he had not received eye drops as ordered by the physician. R93 stated the eye doctor had ordered two medications for his eyes due to itching/redness. R93 stated he had missed several doses of the drops, and he was told they ran out and were not available for some reason. R93 denied any problems from missing the drops but stated he wanted his medications administered as ordered by the physician. R93's clinical record documented the following physician orders for eye drops, listed with the order date. 7/6/24 - Azelastine HCL ophthalmic solution 0.05% drops with instructions to instill one drop in both eyes two times per day for allergic conjunctivitis. 11/12/24 - Pataday ophthalmic solution 0.2% with instructions to instill one drop in both eyes each day for itch/redness relief. R93's medication administration record (MAR) documented the Pataday drops were not administered on 11/2/24, 11/3/24, 11/4/24 and 11/11/24. Nursing notes on these dates documented the medication was on order from the pharmacy and not available for administration. R93's MAR documented the Azelastine drops were not administered on 11/14/24, 11/15/24 and 11/17/24. Nursing notes on these dates documented the last dose was given on the morning of 11/14/24. Notes documented the medication was order from the pharmacy and not available for administration starting on the evening of 11/14/24. On 11/20/24 at 3:05 p.m., the licensed practical nurse unit manager (LPN #3) was interviewed about R93's missed eye medications. LPN #3 stated R93's missed eye drop doses were because the medication was not available in the cart. LPN #3 stated that nurses were required to reorder medications when approximately eight doses were left so that medications could be delivered prior to running out. LPN #3 stated there had been trouble with the pharmacy delivering medications timely even when ordered on time. On 11/20/24 at 4:16 p.m., the director of nursing (DON) was interviewed about medications not available from the pharmacy. When asked if she was aware that nurses reported ongoing issues with getting medicines delivered timely, the DON had no response. The DON stated nurses were able to reorder medications from the refill screen in the computerized health record. This finding was reviewed with administrator and regional consultants during a meeting on 11/21/24 at 5:00 p.m. with no further information presented prior to the end of the survey. 7. Gentamicin eye drops were not available for administration to Resident #274 during a medication pass observation. A medication pass observation was conducted on 11/20/24 at 8:07 a.m. with registered nurse (RN #1) observed administering medications to Resident #274 (R274). R274 was administered all scheduled medications except gentamicin eye drops. RN #1 searched the medication cart and did not locate the drops. RN #1 stated the gentamicin eye drops were not available and that she would contact the pharmacy. R274's clinical record documented a physician's order dated 11/14/24 for gentamicin sulfate ophthalmic solution 0.3% with instructions to instill one drop in the left eye two times per day for 6 months. R274's medication administration record documented the drops were scheduled for administration each morning and evening. On 11/20/24 at 3:14 p.m., the licensed practical nurse unit manager (LPN #3) was interviewed about R274's unavailable gentamicin drops. LPN #3 stated the eye drops should not have run out. LPN #3 stated nurses were supposed to reorder the medications prior to exhausting the current supply. LPN #3 stated the gentamicin drops were not kept in the backup supply. On 11/20/24 at 3:55 p.m., RN #1 was interviewed about the status of R274's gentamicin drops. RN #1 stated the gentamicin drops were reordered from the pharmacy and that R274 was not administered the morning dose of the medication. The facility's policy titled Missed Medication/Medication Error (undated) documented, .The purpose of this policy is to provide guidance for the process for providing monitoring that all medications are received and administered in a timely manner .For any medication(s) not available during a routine medication pass .The Charge Nurse will check the E-kit [backup supply] to attempt to offer medication in a timely manner .In the event the medication is not available from the E-kit or the Emergency Pharmacy, the Charge Nurse will notify the Physician immediately .The Charge Nurse will notify the pharmacy and attempt to obtain the medication .The DON/designee is responsible for monitoring undocumented medications to assure residents are receiving their medications as ordered . This finding was reviewed with administrator and regional consultants during a meeting on 11/21/24 at 5:00 p.m. with no further information presented prior to the end of the survey. 28106 Resident #15's (R15) Lactulose (given for constipation) was not available for distribution during a medication pass and pour review. The Findings Include: On 11/20/24 at 8:00 a.m. during a medication pass and pour, license practical nurse (LPN #1) began to pull medications from the medication cart for R15 based on physician orders. LPN #1 was unable to locate physician ordered Lactulose in the medication cart. LPN #1 then went to the medication room to look for the Lactulose and returned verbalized that the pharmacy had not sent it to the facility. LPN #1 verbalized that sometimes R15 refuses the Laculose and proceeded to gather other medications and went into R15's room. LPN #1 did not offer R15 the Lactulose. LPN #1 was asked when do nurses usually reorder medications to ensure medications are available. LPN #1 verbalized orders are usually placed two to three days ahead of time saying she had sent the pharmacy a reorder for the Laculose on Monday (11/18/24). When asked to see the reorder, LPN #1 reviewed the reorder on the computer and verbalized the computer did not evidence a reorder was completed. Review of physicians orders indicated an order dated 10/23/24 for Lactulose Solution give 20 grams once a day for constipation. On 11/20/24 at 4:37 p.m. the above finding was presented to the administrator and other corporate staff. A facility policy titled Ordering and receiving Non-controlled Medications was obtained and read in part: Reorder medications based on the estimated refill date on the pharmacy Rx label, or at least three days in advance, to ensure adequate supply is on hand. No other information was presented prior to exit conference on 11/22/24.

Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to follow physician orders for seven of thirty residents in the survey sample (Residents #20, #40, #70, #77, #80, #93 and #323). The findings include: 1. Resident #20 was not administered the medication methadone as ordered by the physician. According to the clinical record, Resident #20 (R20) was admitted to the facility with diagnoses that included diabetes, peripheral vascular disease, neuropathy, congestive heart failure, hypertension, and gastroesophageal reflux disease. The minimum data set (MDS) dated [DATE] assessed R20 as cognitively intact. R20's clinical record documented a physician's order dated 11/1/24 for methadone 10 milligrams with instructions to give one tablet twice per day for pain management. R20's medication administration record documented the methadone was not administered as ordered on 11/15/24, 11/16/24, and 11/17/24 (morning dose). Nursing notes on 11/15/24, 11/16/24, and 11/17/24 documented that the methadone was not available in the medication cart and was pending delivery from the pharmacy. A nursing note dated 11/16/24 documented R20's methadone was reordered on 11/12/24. On 11/20/24 at 3:12 p.m., the licensed practical nurse unit manager (LPN #3) caring for R20 was interviewed about the missed methadone doses. LPN #3 stated the scripts were sent to the pharmacy prior to running out but the pharmacy was not timely with deliveries. LPN #3 stated the pharmacy reported the medications were to be delivered but did not show up. LPN #3 stated the pharmacy at times will report that they do not have the needed scripts when the scripts have already been sent. LPN #3 stated methadone was not kept in the backup supply. LPN #3 stated there had been ongoing issues with the pharmacy regarding timely deliveries. On 11/20/24 at 3:33 p.m., R20 was interviewed about the missed doses of methadone. R20 stated she was recently made aware that the methadone had not been received from the pharmacy. R20 denied any pain concerns from the missed doses. R20 stated, I'm on a bunch of stuff and again stated she had no issues with pain control. On 11/20/24 at 4:16 p.m., the director of nursing (DON) was interviewed about medications not available from the pharmacy. When asked if she was aware that nurses reported ongoing issues with getting medicines delivered timely, the DON had no response. The DON stated nurses were able to reorder medications from the refill screen in the computerized health record. This finding was reviewed with administrator and regional consultants during a meeting on 11/21/24 at 5:00 p.m., with no further information presented prior to the end of the survey. 2. Resident #40 was not administered Calmoseptine ointment as ordered by the physician. According to the clinical record, Resident #40 (R40) was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), dementia, diabetes, cellulitis, depression, coronary artery disease, and anemia. The minimum data set (MDS) dated [DATE] assessed R40 with severely impaired cognitive skills. R40's clinical record documented a physician's order dated 10/29/24 for Calmoseptine external ointment 0.44-20.6 % (menthol-zinc oxide) with instructions to apply to bilateral buttocks every shift for folliculitis. R40's medication administration record documented the Calmoseptine ointment was not applied on 11/15/24, 11/16/24 or 11/17/24. Nursing notes on 11/15/24, 11/16/24 and 11/17/24 documented the Calmoseptine ointment was on order from the pharmacy and not available for administration. On 11/20/24 at 3:11 p.m., the licensed practical nurse unit manager (LPN #3) was interviewed about the Calmoseptine ointment administration. LPN #3 stated the Calmoseptine ointment was not ordered from the pharmacy but was an in-house stocked item. LPN #3 stated she was not sure why the Calmoseptine ointment was not available. On 11/21/24 at 10:05 a.m., the supply clerk (other staff #4) was interviewed about R40's Calmoseptine ointment. The supply clerk stated nursing usually informed her of needed ointments/creams. The supply clerk stated, Calmoseptine is not something I've ordered. The supply clerk stated she had received no request from nursing or hospice for the Calmoseptine ointment. The supply clerk stated the Calmoseptine ointment was not kept in stock but could be ordered if needed. This finding was reviewed with administrator and regional consultants during a meeting on 11/21/24 at 5:00 p.m., with no further information presented prior to the end of the survey. 3. Resident #93 was not administered Pataday 0.2% eye drops and Azelastine 0.05% eye drops as ordered by the physician. According to the clinical record, Resident #93 (R93) was admitted to the facility with diagnoses that included spinal stenosis, bradycardia, sick sinus syndrome, hypertension, neurogenic bladder, depression, and insomnia. The minimum data set (MDS) dated [DATE] assessed as cognitively intact. On 11/19/24 at 11:44 a.m., R93 was interviewed about quality of care in the facility. R93 stated during this interview that he had not received eye drops as ordered by the physician. R93 stated the eye doctor had ordered two medications for his eyes due to itching/redness. R93 stated he had missed several doses of the drops, and he was told they ran out and were not available for some reason. R93 denied any problems from missing the drops but stated he wanted his medications administered as ordered. R93's clinical record documented the following physician orders for eye drops, listed with the order date. 7/6/24 - Azelastine HCL ophthalmic solution 0.05% drops with instructions to instill one drop in both eyes two times per day for allergic conjunctivitis. 11/12/24 - Pataday ophthalmic solution 0.2% with instructions to instill one drop in both eyes each day for itch/redness relief. R93's medication administration record (MAR) documented the Pataday drops were not administered on 11/2/24, 11/3/24, 11/4/24 and 11/11/24. Nursing notes on these dates documented the medication was on order from the pharmacy and not available for administration. R93's MAR documented the Azelastine drops were not administered on 11/14/24, 11/15/24 and 11/17/24. Nursing notes on these dates documented the last dose was given on the morning of 11/14/24. Notes documented the medication was ordered from the pharmacy and not available for administration starting on the evening of 11/14/24. On 11/20/24 at 3:05 p.m., the licensed practical nurse unit manager (LPN #3) was interviewed about R93's missed eye medications. LPN #3 stated R93's missed eye drop doses were because the medications were not available in the cart. LPN #3 stated that nurses were required to reorder medications when approximately eight doses were left so that medications could be delivered prior to running out. LPN #3 stated there had been trouble with the pharmacy delivering medications timely even when ordered on time. On 11/20/24 at 4:16 p.m., the director of nursing (DON) was interviewed about medications not available from the pharmacy. When asked if she was aware that nurses reported ongoing issues with getting medicines delivered timely, the DON had no response. The DON stated nurses were able to reorder medications from the refill screen in the computerized health record. The facility's policy titled Missed Medication/Medication Error (undated) documented, .The purpose of this policy is to provide guidance for the process for providing monitoring that all medications are received and administered in a timely manner .For any medication(s) not available during a routine medication pass .The Charge Nurse will check the E-kit [backup supply] to attempt to offer medication in a timely manner .In the event the medication is not available from the E-kit or the Emergency Pharmacy, the Charge Nurse will notify the Physician immediately .The Charge Nurse will notify the pharmacy and attempt to obtain the medication .The DON/designee is responsible for monitoring undocumented medications to assure residents are receiving their medications as ordered . This finding was reviewed with administrator and regional consultants during a meeting on 11/21/24 at 5:00 p.m., with no further information presented prior to the end of the survey. 41449 4. For Resident #80 (R80), who was on methadone for pain, the facility staff failed to administer the medication in accordance with physician orders. On 11/19/24 at 11:18 a.m., R80 was visited and interviewed in his room. During the interview R80 reported that he had cancer and suffers with continuous, unrelieved pain, despite being on pain medication. On 11/19/24-11/20/24, a clinical record review was conducted. According to the physician orders, R80 had a current and active order that read, Methadone HCl Oral Tablet 5 MG (Methadone HCl) Give 7.5 mg by mouth two times a day for Pain Give 3 half tabs to equal 7.5mg. According to the medication administration record (MAR), R80 was not given the Methadone as ordered on 11/2/24, and 11/3/24. According to the nursing notes, an entry dated 11/2/24, read, On hold MD [medical doctor] aware, waiting for it to come from pharmacy. A nursing note entry dated 11/3/24, read, awaiting pharmacy delivery, MD/RP [medical doctor/responsible party] aware. Documentation indicated that on 11/8/24 and 11/12/24, R80 only received one dose. On 11/13/24, R80 didn't receive either of the two ordered doses and on 11/14/24, only the evening dose was administered. On 11/20/24, in the afternoon, an interview was conducted with R80. R80 confirmed that at times he doesn't receive his Methadone for pain. R80 reported he has pain all the time due to the cancer and can't say that his pain is any worse when he goes without the Methadone. On 11/20/24, during an end of day meeting, the facility leadership was made aware of the above findings. No additional information was provided. 5. For Resident #70 (R70), the facility staff failed to administer Suboxone as ordered by the physician. On 11/19/24 at 10:58 a.m., an interview was conducted with R70. During the interview, R70 reported he doesn't always get his medication. On 11/19/24-11/20/24, a clinical record review was conducted. This review revealed that R70 had an active physician's order that read, Suboxone Sublingual Film 4-1 MG (Buprenorphine HCl-Naloxone HCl Dihydrate) Give 1 film sublingually two times a day for Opioid dependence. The medication administration record documented that R70 did not receive either of the scheduled doses on 11/7/24. R70's nursing note entries were made with regards to the Suboxone that read, waiting for script and hold on order. On 11/20/24 at 3:56 p.m., an interview was conducted with licensed practical nurse #4 (LPN #4) and registered nurse #1 (RN #1). Both nurses explained that if they are administering medications and a medication is not available, they would search for the medication, then would look in the Pixis [an on-site back-up supply of medications], and if still not available, they would call the doctor to notify them that the dose may be missed or delayed, and ask what they wanted the nurse to do. On 11/20/24 at 4:16 p.m., an interview was conducted with the Director of Nursing (DON). When notified of finding multiple instances where residents are not being administered their medications, the DON said that many times there is an insurance issue that prevents the pharmacy from sending the medications. On 11/20/24 at 4:40 p.m., an interview was conducted with the facility's medical director (MD), who was also the attending physician for both R80 and R70. When the MD was made aware that numerous instances were documented when R80 and R70 were not administered medications as ordered, the MD stated, The pharmacy won't send the amount I write for them. [Pharmacy name redacted] has been difficult to work with lately. I send prescriptions via e-script [electronically] and they will say they didn't get it, and it takes multiple calls. Then there are a few days delay in getting them delivered to the facility. A review of the facility policy titled, Missed Medication/Medication Error, was conducted. The policy read in part, Medication error/incident: any physician/provider prescribed medication that is not administered to the resident as prescribed regardless of the category or the reason for not providing the medication . It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of residents. The purpose of this policy is to provide guidance for the process for providing monitoring that all medications are received and administered in a timely manner .II. For any medication(s) not available during a routine medication pass: 1. The charge nurse will check the E-kit [emergency kit/ on-site back-up supply of medications] to attempt to offer medication in a timely manner. 2. If medication is taken from the E-kit, the pharmacy will be notified so the E-Kit can be exchanged. 3. In the event the medication is not available from the E-kit or Emergency Pharmacy, the charge nurse will notify the physician immediately and receive guidance on how to proceed. The physician may give orders to HOLD the medication or an order to change the medication to something that is currently available. 4. The charge nurse will notify the pharmacy and attempt to obtain the medication. 5. The charge nurse will notify the DON of any medication that is not available . On 11/20/24, during an end of day meeting, the facility administrator was made aware of the above findings. No additional information was provided. 49456 6. The facility staff failed to administer R77's pain medication as ordered. On 11/20/24 9:16 a.m., an interview was conducted with R77. R77 said, The staff don't order my pain meds, and I am out for days. Then I just get Tylenol and that does not help. I am without my pain medication, and I have been out since this weekend. On 11/20/24 a clinical record review was conducted. R77 had an order that read, Oxycodone HCI 5 mg tablet give 7.5 mg by mouth every 4 hours for pain. The medication administration record shows that R77 was taking the medication several times daily and had not received any of the pain medication since Saturday 11/16/24. According to the medication administration record, the nursing staff noted that Tylenol was effective following administration. There was no indication that R77's pain was increased or that an alternate pain medication was provided when the Oxycodone was not available. On 11/20/24 at 4:00 p.m., an interview was conducted with a licensed practical nurse, LPN5. LPN5 stated that R77's pain medication . came in today. When questioned further, LPN5 said, [R77's name redacted] was without her pain medication for 3-4 days, but it was ordered. We have problems with getting medications here timely from the pharmacy. On 11/22/24 at 11:00 a.m. an interview was conducted with OS18, who was a pharmacist at the facility's contracted pharmacy. When asked about the unavailable mediations, OS18 stated that R77's prescription was received on 11/19/24 at 6:45 p.m. at the pharmacy and that the pharmacy delivered the medication to the facility on [DATE] at 9:46 a.m. On 11/21/24 11:33 a.m., an interview was conducted with the director of nursing (DON). The DON stated that the nurse should go to the E-Kit, which is the facility's stock of medications and get the medication needed. The DON said that if the medication was not available, then the nurse should contact the doctor to obtain a prescription and send it to the pharmacy to have the medication filled. The DON stated that she expected that follow up on medication ordered from the pharmacy was to be ongoing and should be done until the medication has arrived at the facility. On 11/22/24, an end of day meeting was conducted with the administrator and corporate staff about the above findings. No additional information was provided. 7. The facility staff failed to have R323's pain medication available. On 11/19/24 at 4:20 p.m., R323 was observed sitting on the side of her bed. R323 appeared to be anxious, observed to have both hands shaking and shifting weight from side to side. R323 was observed requesting Imodium and Tylenol at 4:30 pm and inquired about her Methadone and Gabapentin medication, which she stated had been missed that morning due to being unavailable. On 11/19/24 4:31 p.m., an interview was conducted with R323. R323 stated that she had not received her pain medications because they are not available. R323 said, I arrived yesterday around 1:30 p.m. and have missed all doses of my medication except for Tylenol. I have not had my Methadone or Gabapentin at all. It was also observed that the nurse returned and administered the Tylenol and Imodium at 5:00p.m. The nurse told R323 that the doctor had sent in a prescription to the pharmacy and the other medications would come in that night. On 11/20/24 at 4:00 p.m., an interview was conducted with LPN5. When asked about R323's pain medications, LPN5 stated, while showing the med drawer, that R323's Methadone and Gabapentin was not at the facility. LPN5 stated that R323 had received one dose of Methadone at the facility and that R323 would go out to the clinic on Friday to get more pain medication. On 11/21/24 11:33 a.m., an interview was conducted with the director of nursing (DON) regarding R323's unavailable medications. The DON stated that Methadone was not available in the E-Kit but Gabapentin should have been available. On 11/22/24 at 11:00 a.m. an interview was conducted with OS18, who was a pharmacist at the facility's contracted pharmacy. OS18 stated that the prescription for the Methadone was sent to the pharmacy on 11/20/24 but did not have an appropriate diagnosis for the medication. OS18 stated that R323's medication order was pending due to an attempted contact with the facility about the prescription, that had not been addressed by the facility. OS18 stated that the pharmacy records did not indicate that the facility had tried to follow up with the pharmacy regarding the issue with the pain medication. On 11/22/24 9:52 a.m., an interview was conducted with the medical director. The medical director said, I put an e-script in for [R323's] narcotics on the 19th at 7am and was notified yesterday on the 21st of a missed diagnosis on the script and needing a new script. I wasn't aware of any missed dose of Methadone until yesterday. No one notified me of needing to contact pharmacy until yesterday, or that they needed a new script for the methadone. On 11/22/24 a clinical record review was conducted. R323's physician order read, Methadone HCI solution 5mg/5ml give 130 ml by mouth once daily for chronic pain. Gabapentin oral capsule 100 mg give one capsule three times daily for peripheral vascular disease. R323's medication administration record showed that the Methadone was not given on the 19th and that the first dose of Gabapentin R323 received was on 11/21/24 at 9:24 a.m. On 11/22/24 a facility documentation was reviewed. The policy titled, Missed Medications/Medication Error, read in part, .The purpose of this policy is to provide guidance for the process for providing monitoring that all medications are received and administered in a timely manner. In the event the medication is not received in the next pharmacy delivery, the charge nurse will contact the pharmacy to attempt to resolve. The charge nurse will check the E-Kit to attempt to offer medication as prescribed. On 11/22/24, an end of day meeting was conducted with the administrator and corporate staff about the above findings. No additional information was provided.

Based on observation, staff interview and facility document review, the facility failed to properly store medications on two of four units (200-unit, 300-unit). The findings include: On the 200-unit and 300-unit, it was observed that unopened insulin and eye drops were stored at room temperature when refrigeration was required. In the medication refrigerator on the 300-unit, the controlled medication lorazepam was not stored in a separately locked, permanently affixed compartment. On 11/20/24 at 1:57 p.m., accompanied by the licensed practical nurse unit manager (LPN #3), a 300-unit medication cart was inspected. Stored in the cart at room temperature was an unopened vial of Humalog insulin for a current resident. The label on the insulin directed to refrigerate until opened. On 11/20/24 at 2:05 p.m., accompanied by LPN #3, the medication room on the 300-unit was inspected. Stored in the medication refrigerator was a 30 ml (milliliter) bottle of liquid lorazepam. The lorazepam was stored along with other medications in a tray on the refrigerator shelf. There was no separate, permanently affixed compartment or lock box inside the refrigerator for storage of controlled medications. LPN #3 was interviewed at this time about the insulin and lorazepam storage. LPN #3 stated that she did not know why the unopened insulin was stored on the medication cart. When asked about why the narcotic was not secured, LPN #3 stated that there was no separate lock box for controlled medications in the refrigerator. On 11/20/24 at 2:10 p.m., accompanied by registered nurse (RN) #1, a medication cart on the 200-unit was inspected. Two unopened bottles of Xalatan eye drops (2.5 ml each) for current residents were stored in the cart. The Xalatan drops were labeled from the pharmacy with instructions to refrigerate until opened. There was three Promethegan suppositories for a current resident stored in the medication cart. These suppositories were labeled to store under refrigeration. RN #1 was interviewed at this time about the medications stored at room temperature that were labeled to be refrigerated. RN #1 checked the two bottles of eye drops and verified that they had not been opened. RN #1 stated that she did not know why the drops and suppositories had been placed on the medication cart and not in the refrigerator. On 11/20/24 at 3:00 p.m., the director of nursing (DON) was interviewed about the improperly stored medications. The DON stated medications were supposed to be refrigerated as labeled. The DON stated someone must have placed the medications on the cart instead of the refrigerator. The facility's policy titled Storage of Medications (revised 8/2024) documented, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier .All medications are maintained within the temperature ranges noticed in the United States Pharmacopoeia (USP) and by the Centers for Disease Control (CDC) .Medications requiring refrigeration are kept in a refrigerator at temperatures between 36 [degrees] F .and 46 [degrees] F .Controlled substances that require refrigeration are stored within a locked box within the refrigerator that is attached to the inside of the refrigerator . These findings were reviewed with administrator and regional consultants, during a meeting on 11/21/24 at 5:00 p.m., with no further information presented prior to the end of the survey.

Based on observation, staff interview, and facility documentation review, the facility staff failed to store, prepare, and serve food in a sanitary manner in the main kitchen and in the dining room. The findings included: 1. The facility staff failed to wear hair restraints (hair nets and beard guards) while preparing and distributing food, to prevent the contamination of food items. On 11/19/24, during lunch, meal service observations were conducted in the dining room. The dietary aide (Other Employee #17) was observed at the tray line, plating food without wearing a beard guard and visible facial hair. On 11/20/24 at 1:40 p.m., during a follow-up visit to the kitchen, the cook (Other Employee #14) was observed by the stove, preparing food without wearing a hair net. The dietary aide (Other Employee #15) was observed preparing beverages, with her hair net was only covering the ends of her hair in the back. When asked about hair nets, Other Employee #15 stated that they don't have any large enough to cover her hair and that she usually has to wear two. The food services district manager was present and stated that OS #15 could put two on as she normally does, and that he would have some larger ones sent to the facility. On 11/20/24 at approximately 1:45 p.m., following the surveyor's conversation with Other Employee #15 about the lack of hair net, OS #14 exited the kitchen and upon return, while walking through the kitchen, was observed putting on a hair net. When asked why he didn't have one on prior to the surveyor entering the kitchen, no response was given. On 11/20/24 at approximately 1:48 p.m., the dietary district manager confirmed that all kitchen staff should wear hair nets and beard guards as appropriate when in the kitchen. On 11/20/24, during an end of day meeting, the facility administrator was made aware of the above concerns. On 11/21/24, at approximately 12:30 p.m., an observation was made in the dining room. The kitchen employee that was working the steam table was distributing food to plates, had visible facial hair but had no beard guard on. On 11/21/24 at 2:24 p.m., walking past the open kitchen door, the surveyor observed the facility's social services director standing by the stove, without a hair net on. On 11/21/24, in the afternoon, an interview was conducted with the social services director. When the surveyor discussed the earlier observation of the employee in the kitchen, the social services director stated that she was dropping off some food that had been brought in. According to the facility policy titled, Staff Attire, it read in part, 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained . On 11/21/24, during the end of day meeting, the facility administrator was made aware of the additional observations of facility staff in food preparation areas without proper hair restraints. No further information was provided. 2. The facility staff failed to wash dishes in a manner to prevent contamination of food. On 11/20/24 at approximately 1:45 p.m., a dietary aide was observed manually washing dishes in the three-compartment sink. The employee was only using 2 of the 3 sinks., washing the dishes in the wash sink, then immediately removing them, and taking them to the sanitizer, before placing them on a drying rack. No rinse was provided for the dishes as the middle sink was empty. The surveyor attempted to interview the staff member, but he didn't speak English. The dietary services district manager was present and confirmed the above observations. The district manager was then observed giving gestures to instruct the dietary aide to fill the middle sink and to rinse dishes before dipping into the sanitizer. The facility policy titled, Manual Warewashing was reviewed. The policy didn't address dishes being rinsed. On 11/20/24, in the afternoon, during a follow-up visit to the kitchen, it was observed that after dishes had been washed in the dish washer, they were being stacked wet or wet nesting. An interview was conducted with the dietary aide (Other Employee #15), who confirmed the observation, and stated that not allowing dishes to air dry could cause bacteria growth. According to the facility policy titled, Warewashing, the process guidance read in part, .4. All dishware will be air dried and properly stored. On 11/20/24, during an end of day meeting, the facility administrator was made aware of the above findings. No additional information was provided.

Based on staff interview, facility document review and clinical record review, the facility staff failed to educate about and offer pneumococcal immunizations according to the facility's infection control policy for three of five residents reviewed (Residents #20, #93, and #94). The pneumococcal immunization status was not documented and/or up to date in the clinical record for five of five residents reviewed (Residents #20, #53, #84, #93, and #94). The findings include: On 11/21/24 at 11:45 a.m., accompanied by the regional infection preventionist (RN #2), five residents were reviewed for immunizations, as part of the infection control survey task. Clinical records for Residents #20, #93 and #94 documented no education or offering of the pneumococcal vaccine and their records documented no status/history of pneumococcal immunizations. Resident #84's clinical record did not include the resident's pneumococcal immunization status. Resident #53's record documented the administration of pneumococcal 23 immunization on 1/3/18, prior to age 65. The regional infection preventionist stated that she would investigate the missing information. On 11/21/24 at 2:09 p.m., the infection preventionist stated that she did not find any documentation regarding pneumococcal immunization status for Residents #20, #93, or #94. The regional infection preventionist stated she found no documentation that Residents #20, #93 or #94 had been educated about or offered the pneumococcal vaccine. On 11/21/24 at 4:11 p.m., the regional infection preventionist stated records for Residents #53 and #84 had not been updated with the most recent pneumococcal vaccine status. The regional infection preventionist presented vaccine records indicating Resident #53 had received an additional pneumococcal vaccine (Prevnar 13) on 9/13/18 and Resident #84 had the pneumococcal 23 vaccine on 10/20/21. The regional infection preventionist stated the clinical records for Residents #53 and #84 should have been updated to include vaccines doses administered and that immunization history was supposed to be obtained upon admission. The facility's policy titled Resident Pneumococcal Vaccines (undated) documented, . Residents in the facility will be offered education regarding the pneumococcal vaccine . Residents in the facility will be offered the pneumococcal vaccine unless medically contraindicated or the resident has already been immunized according to the schedule . The resident and/or responsible party will be provided the CDC vaccination education regarding pneumococcal pneumonia and pneumococcal vaccine . This information includes .risks and benefits of receiving the vaccine, and what can be expected as a result of receiving the vaccine and potential side effects . Document administration in the EMR [electronic medical record], on the MAR [medication administration record], and in the immunization tab . These findings were reviewed with administrator and regional consultants during a meeting on 11/21/24 at 5:00 p.m. with no further information presented prior to the end of the survey.

Based on staff interview and facility documentation review, the facility staff failed to implement their abuse policy with regards to the pre-screening of employees for 24 employees in a survey sample of 26 employee records reviewed. The findings included: On 11/19/24, a random sample of 26 employees was selected for review of evidence of pre-screening in accordance with state licensure survey activity and compliance with the facility's abuse policy. On 11/21/24, a meeting was held with the human resources director to review the sampled employees' files, and the following was noted: 1. For fourteen employees, the facility staff obtained a criminal background check from the Virginia State Police, beyond 30 days from hire. For Staff #1, #5, #6, #7, #8, #9, #13, #15, #16, #17, #18, #19, #20, and #22, the facility staff obtained a criminal background check from the Virginia State Police on 10/8/24 and 10/9/24, following an audit of employee files. Some of the employees were hired as much as 1 year and 8 months prior to the criminal background being obtained. On 11/21/24 at approximately 9:15 a.m., an interview was conducted with the Human Resource Manager (HRM). The HRM explained that A criminal background check [CBC] is obtained when we send their offer letter. We receive the CBC before they come through orientation. If they change their hire date and it is beyond 30 days, we have to run it again. When asked why a CBC is obtained, the HRM stated, To make sure they don't' have barrier crimes. We can't have anyone with barrier crimes, we have to protect our residents and ourselves. On 11/21/24, during the interview, the HRM explained that she had conducted an audit of all employee files and said, I pretty much re-ran everybody's criminal background, because when I was doing an audit and if I didn't find one, I re-ran them. We QAPI'ed [quality assurance and performance improvement] it. The HRM was asked to provide a copy of her audit. Review of the audit provided revealed that the HRM had identified each of the 14 staff noted above and obtained a criminal background check at that time. 2. For nine employees (Staff #3, #10, #11, #14, #21, #23, #24, #25, and #26), the facility staff failed to obtain a criminal background check. For Staff #3, who was hired 1/17/23, the facility staff did not have a criminal background check on file from the Virginia State Police (VSP). For Staff #10, who was the human resources manager and hired 8/21/23, the facility had no evidence that a criminal background check had been obtained from the VSP. For Staff #11, who was a physical therapist and was hired 11/21/23, the facility staff had no evidence of a criminal background check being obtained. For Staff #14, who was the director of nursing and was hired 4/3/24, the facility staff had no evidence that a criminal background check from the VSP was obtained. For Staff #21, who was hired as a nurse aide in training on 8/26/24, the facility had no evidence of a criminal background check (CBC) being obtained from VSP. For Staff #23, who was hired as a physical therapist on 9/23/24, the facility had no CBC from VSP on file. For Staff #24 and Staff #25, who were both registered nurses and hired in October 2024, the facility staff failed to have a CBC from VSP on file. For Staff #26, who was an agency CNA and was subject of an abuse investigation, the facility had no evidence of a CBC from VSP being obtained. It was noted that 7 of the 9 employees with no CBC had also been identified during the HRM's audit of employee files as not having a CBC on file. At the time of survey, there was still no CBC available/on file. Staff #24 and #25, were hired after the HRM's audit and were both beyond 30 days of hire at the time of survey. They had no criminal background check on file. Therefore, past non-compliance was not achieved. 3. For five employees (Staff #2, #8, #9, #17, and #20), the facility staff failed to verify the employee's professional license prior to allowing the staff member to work with residents. For Staff #2, who was a certified nursing assistant (CNA), the license verification indicated that the employee had additional public information noted against their license. The facility had no evidence that they had looked at the additional information to determine if Staff #2 was eligible for employment with the facility and what the adverse actions were. For Staff #8, who was hired 6/12/23, as a licensed practical nurse (LPN), the facility did not verify that the employee held a current and unencumbered license to practice until 8/7/23. According to the license look-up verification conducted on 8/7/23, Staff #8 had additional public information against their nursing license. The facility staff had no evidence that they had reviewed this information to determine if the nurse had any disciplinary action against their license that could have been a factor in their ability to work in a nursing home. For Staff #9, who was a CNA hired 7/6/23, the facility staff failed to verify that the employee held a current certification to practice as a nurse aide until 8/3/23. For Staff #17, who was the facility administrator, the facility had no evidence that they verified that the employee held a current, active, and unencumbered license to practice as a nursing home administrator with the department of health professions. The facility only had a copy of the license on file for Staff #17, which only indicated that the employee held the license as some point. For Staff #20, who was hired as a CNA on 1/18/24, the facility staff failed to verify the employee held a current, active, and unencumbered certificate with the board of nursing until 3/12/24. On 11/21/24, in the morning, an interview was conducted with the HRM. The HRM stated, A license look-up is to make sure their license is active, and they don't have anything pending on their record, to prevent them from giving care to our residents. When asked, when the license look-up is conducted, the HRM stated, We look it up when we do the interview. When asked, what if they have information on their license? The HRM stated, I print it off and give it to the ED or DON [executive director/administrator or director of nursing], they review, and I reach out to my regional. They sign off on it to say if we can hire. We don't want someone in the building if they can cause harm to the residents. We want to know if they are safe to work with residents. According to the facility policy titled, Abuse, Neglect, and Exploitation Policy- Virginia, it read in part, . I. Screening: 1. Employees seeking hire will complete an application including three (3) personal references as well as a work history of the last three (3) positions held, if applicable. a. Following the personal interview and upon recommendation from the interviewer, a background check will be performed . 2. A criminal background check will be completed to meet state requirements . 4. Licensure/registry check will also be performed, as applicable, after the interview to verify a. The Nurse Aide Registry b. State Board of Nursing, c. Other professional registries. 5. This facility will not employ individuals who have had a disciplinary action taken against their professional license by a state licensure body as a result of a finding of abuse, neglect, mistreatment of residents or misappropriate of their property . On 11/21/24 at 2:50 p.m., the HRM was given a detailed listing of the above findings include the employees' names and items noted above. On 11/21/24, during an end of day meeting, the facility administrator was made aware of the above findings. No additional information was provided.

Based on staff interviews, resident interviews, clinical record review, and facility documentation review, the facility staff failed to report allegations of abuse for three residents, Resident #11 (R11), Resident #55 (R55) and Resident #120 (R120) out of a survey sample of 30 residents. The findings included: 1. For Resident #120 - R120, who reported an allegation of rape, the facility reported the initial allegation to the state survey agency but failed to submit a follow-up report with the investigation findings. On 11/20/24, the surveyor reviewed the facility documentation and electronic health record of R120, which noted the resident was no longer a resident of the facility and therefore was not available for interview. On 11/20/24, in the afternoon, the facility administrator was asked to provide any information they had with regards to R120. On 11/20/24, in the afternoon, the facility provided a one-page document that was dated 9/26/24. It read in part, [City name redacted] Police Detective [name redacted] reported to a facility that [R120's name redacted] stated she was raped while she was a resident at the facility. The investigation started immediately. All residents were assessed for injury and harm; none were noted or reported. Per the detective, no identifying information was given by the resident. The form was signed by the director of nursing (DON). The facility administrator stated that no follow-up report was sent because they determined that according to hospital records that R120's allegation was against the hospital and not the facility. The administrator also stated that they would be providing education to the DON. On 11/20/24, the DON was interviewed that afternoon. When questioned about reporting of R120's allegations, the DON stated that the facility doctor had access to the hospital electronic records and noted that the allegation was against the hospital and not this nursing facility. The DON stated that she didn't feel a follow-up report was warranted. However, the DON confirmed that she had filed the initial report, and this information had been determined as part of their investigation process. On 11/20/24, the facility also provided the survey team with copies of R120's hospital records that read in part, .Of note, patient called a nursing hotline while in the ED [emergency department] and endorsed she was being neglected and sexually assaulted under the ED's care . On 11/22/24 at 10:20 a.m., a follow-up interview was conducted with the facility administrator, who stated he was the abuse coordinator of the facility. When asked about R120's allegation, and evidence of the investigation that included the residents being assessed as indicated in the form reported to the state survey agency on 9/26/24. The administrator confirmed that they didn't have any evidence of an investigation nor that the investigation results had been reported. When questioned further, the facility administrator confirmed that all allegations of abuse should be reported immediately but no more than two hours if there is bodily harm and all other incidents within 24 hours. The administrator explained that an investigation is started and . once the investigation is concluded, we report with a final report within five days. When asked what was done regarding R120's allegation, the administrator said, We reached out to the hospital for more information, and they said the allegation was against [hospital name redacted] emergency department. The administrator was asked why the DON was handling the allegation involving R120, since the administrator was the facility's abuse coordinator. The Administrator stated, At that time I had not commandeered that process yet and was I will still in training. The administrator stated that they provided the DON with a teachable moment and a copy was provided to the survey team. The document was dated 11/20/24, and read, DON submitted an FRI [facility reported incident] without completing an investigation or 5-day final. Moving forward DON will follow risk escalation process and involve the ED [executive director] in all FRI's. On 11/21/24, a review of the facility's abuse policy was conducted. The policy read in part, . V. Reporting of Incidents and Facility Response: . 3. The results of the facility's investigation must be reported to the survey agency, the ED/Designee [executive director] and other officials in accordance with state law, within five working days of the incident . On 11/21/24 and 11/22/24, during an end of day meeting, the facility administrator was made aware of the above findings. No additional information was provided. 49456 2. The facility staff failed to notify all required agencies of an allegation of abuse that involved R11 and certified nursing assistant, CNA#3. On 11/21/24 a review of facility documentation was conducted, which includent the incident summary and the facility synopsis of an allegation of abuse that involved R11 and CNA#3. No documentation was found that showed that the Virginia Department of Health professions (DHP) was notified of the determination of abuse that involved a certified nursing assistant, identified as CNA3. While the incident summary was completed on 9/15/24. the facility fax confirmation read, no answer, for the DHP on 9/16/24 and 9/19/24, On 11/21/24 at 2:00 p.m., an interview was conducted with the administrator. The Administrator said, Sometimes the fax numbers are busy, and we have to keep faxing. The Administrator was not able to show that the incident had been successfully faxed to fulfill the required abuse reporting. On 11/22/24 a review of facility documentation was completed. CNA#3's employee file was reviewed and there was no sworn statement or criminal background check in her file. 3. The facility staff failed to notify all required agencies of an allegation of abuse for R55. On 11/21/24 a review of facility documentation was completed, which included a facility incident dated 9/13/24. The facility documentation showed that the required agencies were not notified of this allegation of resident to resident abuse of R55 until two days after the allegation was made. The administrator only had one faxed confirmation to all agencies in the facility summary and it was dated 9/15/24. On 11/21/24 at 2:15 p.m., an interview was conducted with the administrator. When asked about the reporting timelines for abuse, the administrator said, We have 2 hours to report allegations of abuse, and the investigation is supposed to begin immediately. When shown the documentation of this abuse allegation, the administrator stated that he did not know why this was reported on 9/15/24 instead of 9/13/24, which was when the incident summary was completed. On 11/21/24 and 11/22/24, during an end of day meeting, the facility administrator was made aware of these findings noted above. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide credible evidence of an investigation being conducted following an allegation of sexual abuse for one resident (Resident #120-R120) in a survey sample of 30 residents. The findings included: For Resident #120- R120, who made an allegation of being raped, the facility staff failed to have credible evidence of an investigation being conducted. On 11/20/24, the surveyor reviewed the facility documentation and electronic health record of R120, which noted that R120 discharged from the facility on 9/20/24. According to progress notes dated 9/20/24, which read in part, .Patient had a recent ECO [emergency custody order] for similar symptoms, primarily mania. Due to her current mental status, she likely does not have capacity to make appropriate medical decisions for herself. Because of patient's severe psychiatric symptoms, her interfering with staffs' ability to provide care to herself and others, and her creation of a hostile environment, she would be best served by hospitalization with an ECO for further evaluation . On 11/20/24, in the afternoon, the facility administrator was asked to provide any information they had with regards R120's allegation of rape. On 11/20/24, in the afternoon, the facility provided a one-page document that was dated 9/26/24. It read in part, [City name redacted] Police Detective [name redacted] reported to a facility that [R120's name redacted] stated she was raped while she was a resident at the facility. The investigation started immediately. All residents were assessed for injury and harm; none were noted or reported. Per the detective, no identifying information was given by the resident. The form was signed by the director of nursing (DON). The facility administrator stated that he had no additional information to provide and stated that he would be providing education to the DON. On 11/20/24, in the afternoon, the DON was interviewed. The DON stated that an investigator with the police department had called her and reported that R120 alleged she was raped. The DON stated that because R120 was a resident of the facility when sent to the hospital, the detective was informing the facility. The DON stated the facility doctor had access to the hospital electronic records and noted that the allegation was against the hospital and not this nursing facility, so she didn't feel any further action was needed. On 11/20/24, the facility provided the survey team with copies of R120's hospital records that read in part, .Of note, patient called a nursing hotline while in the ED [emergency department] and endorsed she was being neglected and sexually assaulted under the ED's care . On 11/22/24 at 10:20 a.m., a follow-up interview was conducted with the facility administrator, he confirmed he was the abuse coordinator of the facility. When asked about R120's allegation, and the initial report of the allegation indicating that, The investigation started immediately. All residents were assessed for injury and harm, none were noted or reported . The surveyor asked for the evidence of the investigation and resident assessments/interviews. The administrator confirmed that they didn't have any evidence of an investigation nor that the investigation results were reported. The administrator was asked why the DON was handling the allegation involving R120, since the administrator was the facility's abuse coordinator. The Administrator stated, At that time I had not commandeered that process yet and was I will still in training. The administrator stated that they provided the DON with a teachable moment and a copy was provided to the survey team. The document was dated 11/20/24, and read, DON submitted an FRI [facility reported incident] without completing an investigation or 5-day final. Moving forward DON will follow risk escalation process and involve the ED [executive director] in all FRI's. On 11/22/24, a review of the facility's abuse policy was conducted. The policy read in part, . V. Investigation of Incidents: 1. In the event a situation is identified as abuse, neglect or misappropriation, an investigation by the executive leadership will immediately follow. a. The Director of Nursing (DON) and Executive Director (ED) receives reports of resident incidents. The Executive Director determine when an investigation is required and directs the investigation . No additional information was provided.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide respiratory care for three residents, Resident #77 (R77), Resident #83 (R83), and Resident #5 (R5) out of a survey sample of 30 residents. The findings included: 1. The facility staff failed to administer oxygen to R77, according to the physician's order. On 11/20/24 at 9:20 a.m., an interview was conducted with R77. R77 said, Staff says all concentrators are broken and sometimes at night I am short of breath. At this time, it was observed that R77's oxygen concentrator setting was on 2.5 liters per minute. On 11/20/24 at 11:00 a.m., a review of R77's clinical record was conducted. The clinical record revealed that R77's physician's order was for oxygen therapy at 5 liters per min via tracheostomy mask every shift for hypercarbia. On 11/20/24 12:22 p.m., an interview was conducted with a licensed practical nurse, LPN5. LPN5 read the physician's order for R77's oxygen and stated that the setting should be at 5 liters per minute. Accompanying the surveyor to R77's room, LPN5 observed that the oxygen concentrator and stated that it was set on 2.5 liters per minute. LPN5 said, [R77] needs a concentrator that will do the 5 liters per minute. On 11/21/24 at 9:00 a.m., an observation was made of a new oxygen concentrator in R77's room. The oxygen concentrator was set at 2 liters per minute. LPN5 came in the room and observed the oxygen concentrator setting. On 11/21/24 at 9:00 a.m., an observation was made of a new oxygen concentrator in R77's room. The oxygen concentrator was set at 2 liters per minute. LPN5 came in the room and observed the oxygen concentrator setting and tried to adjust to the correct setting, but it would not go to 5 liters. LPN5 stated that the oxygen concentrator was not working and will get R77 another concentrator that would go up to 5 liters. On 11/22/24 at 10:15 a.m., an interview was conducted with the corporate executive administrator (ED). The ED stated that R77 has a rental oxygen concentrator, and that the oxygen setting is on 5 liters per minute. The surveyor observed that R77's oxygen concentrator was set on 5 liters per minute. 2. The facility staff failed to administer oxygen to R83, according to the physician's order. On 11/20/24 at 9:41 a.m., an observation was made of R83's oxygen concentrator setting. R83's oxygen concentrator was set at 5 liters per minute. 11/20/24 a clinical record was conducted. R83's physician's order reads,O2 [oxygen] at 2LPM [liters per minute] via NC [nasal canula] continuous, and was written on 9/16/24. On 11/20/24 at 9:45 a.m., an interview was conducted with LPN5. LPN5 stated that R83's order for oxygen is 2 liters per minute by nasal canula. Accompanying the surveyor to R83's room, LPN5 observed that the oxygen concentrator was set on 5 liters per minute and corrected the setting to 2 liters per minute. LPN5 said, I do not know why it was set on the wrong setting. On 11/20/24 at 4:30 p.m., an end of day meeting was conducted with the administrator and corporate staff, with the above concerns were discussed. No additional information was provided. 28106 3. The facility failed to administer oxygen to R5 based on the physician's order. According to the clinical record, diagnoses for R5 included; Incontinence of bowel and bladder, chronic congestive heart failure, and chronic atrial fibrillation. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 9/27/24, which assessed R5 with a cognitive score of 14 out of 15, indicating cognitively intact. On 11/19/24 at 11:41 a.m., during an interview, R5 was observed receiving oxygen at 2 liters per minute (O2 at 2 LPM). R5 verbalized not having any difficulty with getting oxygen. Review of R5's clinical record revealed a physician order that documented an order placed on 7/3/24 for oxygen at 5 liters/minute continuous via nasal cannula for every shift. R5's oxygen rate was observed two other times on 11/20/24 at 12:30 p.m. set at 3.5 LPM and again at 1:40 p.m. set at 3.5 LPM. At this time license practical nurse (LPN #1), assigned to R5, was asked to check R5's oxygen saturation (O2 SAT) level. The O2 SAT result was observed at 96 percent, indicating R5's oxygen level was within normal range. LPN #1 also observed the oxygen setting, verbalizing that the setting looked to be between 3.5 LPM and 4.0 LPM. LPN #1 then reviewed the order and indicated that the oxygen level was not correctly set. On 11/20/24 at 4:37 p.m., the above finding was presented to the administrator and other corporate staff. No other information was presented prior to exit conference on 11/22/24.

Based on observation, staff interview and clinical record review, the facility staff failed to ensure a medication error rate of less than 5 percent. Medication pass observations resulted in two errors out of thirty opportunities for an error rate of 6.67%. The findings include: 1. R274 was not administered a dose of gentamicin eye drops as ordered by the physician. A medication pass observation was conducted on 11/20/24 at 8:07 a.m. with registered nurse (RN #1) observed administering medications to Resident #274 (R274). R274 was administered all scheduled medications except gentamicin eye drops. RN #1 searched the medication cart and did not locate the drops. RN #1 stated the gentamicin eye drops were not available and that she would contact the pharmacy. R274's clinical record documented a physician's order dated 11/14/24 for gentamicin sulfate ophthalmic solution 0.3% with instructions to instill one drop in the left eye two times per day for 6 months. R274's medication administration record documented the drops were scheduled for administration each morning and evening. On 11/20/24 at 3:55 p.m., RN #1 was interviewed about the status of R274's gentamicin drops. RN #1 stated the gentamicin drops were reordered from the pharmacy today (11/20/24) and that R274 was not administered the morning dose of the medication. This finding was reviewed with administrator and regional consultants during a meeting on 11/21/24 at 5:00 p.m. with no further information presented prior to the end of the survey. 28106 Resident #15's (R15) Lactulose (given for constipation) was not available for distribution during a medication pass and pour review resulting in a total medication error rate of 6.67 percent. The Findings Include: On 11/20/24 at 8:00 a.m. during a medication pass and pour, license practical nurse (LPN #1) began to pull medications from the medication cart for R15 based on physician orders. LPN #1 was unable to locate physician ordered Lactulose in the medication cart. LPN #1 then went to the medication room to look for the Lactulose and returned verbalized that the pharmacy had not sent it to the facility. LPN #1 verbalized that sometimes R15 refuses the Laculose and proceeded to gather other medications and went into R15's room. LPN #1 did not offer R15 the Lactulose. LPN #1 was asked when do nurses usually reorder medications to ensure medications are available. LPN #1 verbalized orders are usually placed two to three days ahead of time saying she had sent the pharmacy a reorder for the Laculose on Monday (11/18/24). When asked to see the reorder, LPN #1 reviewed the reorder on the computer and verbalized the computer did not evidence a reorder was completed. Review of physicians orders indicated an order dated 10/23/24 for Lactulose Solution give 20 grams once a day for constipation. On 11/20/24 at 4:37 p.m. the above finding was presented to the administrator and other corporate staff. A facility policy titled Ordering and receiving Non-controlled Medications was obtained and read in part: Reorder medications based on the estimated refill date on the pharmacy Rx label, or at least three days in advance, to ensure adequate supply is on hand. A facility policy titled Missed Medication/Medication Error was obtained and defined a medication error/incident as: any physician/provider prescribed medication that is not administered to the resident as prescribed regardless of the category or the reason for not providing the medication. No other information was presented prior to exit conference on 11/22/24.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide routine dental services to two residents (Resident #80-R80 and Resident #4-R4) in a survey sample of 30 residents. The findings included: 1. For R80, the facility staff failed to provide dental services following a recommendation for extractions. On [DATE] at 11:24 a.m., an interview was conducted with R80. R80 stated he is unable to eat because of his teeth and cancer and relies solely on nutritional drinks. When asked about his dental status, R80 said that he had gone to a dental clinic but was unable to be seen due to having expired identification. On [DATE], a clinical record review of R80's chart was conducted. According to a physician progress note dated [DATE], R80 was s/p [status post] antineoplastic chemotherapy and had a history of synovial sarcoma who had complications of dysphagia related to the pharyngeal/cervical mass . According to R80's dental services note dated [DATE], R80 was seen and the note read in part, Recommend extractions of all remaining teeth and retained roots in order to fabricate upper and lower denture to aide in mastication . Action required by Nursing Home Staff: Refer to oral surgeon if pain or swelling develops; refer to OS [oral surgeon] for extractions of all remaining teeth and retained root tips in order to prepare for fabrication of Upper and Lower Full Dentures; Refer to oral surgeon to evaluate upper left lesion. Within the clinical record, there was no evidence of any oral surgeon consultations or that the facility had attempted to make any arrangements for further dental services/follow-up, since the dental recommendations on [DATE]. On [DATE] at 10:16 a.m., an interview was conducted with the facility social workers (SW). Both social workers stated they had no knowledge of R80 being refused dental care due to an expired identification. The SW reported that they have a dentist that comes on-site to the facility quarterly. When made aware of the recommendations for extractions and dentures in [DATE], the SW's were both asked to provide any evidence of any follow-up, since . On [DATE], in the afternoon, the facility staff provided the survey team with evidence of residents that were seen during follow-up visits by the dentist. There was no indication that R80 was seen by the in-house dentist or by an oral surgeon, following the dental service on [DATE]. The facility did provide a progress note dated [DATE], indicating an appointment had been made for R80 to see a dentist outside of the facility on [DATE]. No other information was provided prior to exit. 2. For R4, who reported difficulty eating due to not having upper teeth, the facility failed to arrange for routine dental services. On [DATE] at 2:20 p.m., during an interview with R4, the resident reported he has difficulty eating due to not having any upper teeth. R4 reported that his top teeth were pulled while at another facility and that they had said they were going to replace them but didn't. R4 went on to say that he told the doctor at this facility that he needed to see a dentist. On [DATE] at 10:16 a.m., an interview was conducted with the two facility social workers (SW). The SW assistant said, I was informed recently from a unit manager that [R4's name redacted] requested he needed to be seen by a dentist, so I put him on the list with our dentist. He is not going to be able to be seen on the 25th of November, because it was too soon. When asked why R4 had not previously been seen, since according to the census tab of his clinical record R4 had been admitted to the facility [DATE]. The SW assistant stated, They [the resident] should be asked if they would like to see the dentist and should be put on the list. It doesn't look like he was seen before. According to the facility provided documents of residents that were seen on the dentist's visits to the facility, R4 had never been seen for dental services. On [DATE] at 10:59 a.m., R4 was visited again. R4 again stated that he has difficulty chewing foods because, I don't have anything to chew with. When asked if he would like a different consistency of foods, such as ground meats, R4 declined and said that he would continue to manage. R4 again stated, I have told the doctor I want to see a dentist. These teeth [pointing to his bottom teeth] need cleaning and I want to see about getting upper dentures. On the afternoon of [DATE], the social workers provided the surveyor with a list of residents scheduled to be seen by the dentist on [DATE], noting that R4 had been added to the list. On [DATE], during an end of day meeting, the facility administrator and corporate staff were made aware of the above findings. The facility policy regarding dental services was requested, but not received prior to conclusion of the survey. No additional information was provided.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a therapeutic diet and correctly provide foods per the meal ticket for one of thirty residents in the survey samplec, (Residents #103). Resident #103 (R103) was not provided foods per meal ticket for lunch. The findings include: According to the clinical record, diagnoses for R103 included severe protein calorie malnutrition, dementia, and iron deficiency anemia. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 10/31/24. R103 was assessed with a cognitive score of 12 out of 15, indicating intact cognition. An annual MDS, dated [DATE], Section K documented that R103 had un-prescribed weight loss. On 11/19/24 at 12:45 p.m., R103 lunch meal was observed, R103's meal ticket was verified against the meal served. The meal ticket indicated R103 was to receive a regular advanced dysphagia diet, with an added half cup of fortified pudding parfait and a bowl of pureed meat with gravy. Compared against the meal ticket, the fortified pudding and bowl of pureed meat with gravy were missing from the tray. At this time, registered nurse (RN #1), assigned to R103, also observed the meal ticket, reviewed R103's meal, verified that not all the listed food items had been served, and verbalized she would let the kitchen know. On 11/19/24 at 1:15 p.m., the dietary manager (other staff, OS #1) was interviewed regarding the missing food items from R103's tray. OS #1 verbalized that the food was available but had not been added to the meal tray. Review of R103's clinical record included a dietary progress note, dated 8/2/24, that indicated R103 had a history of weight loss, no longer wanted magic cups or house shakes, and noted that fortified pudding parfait had been recommended with two meals. R103's diet orders indicated that an order was placed on 8/2/24 to include fortified pudding parfait to lunch and dinner. On 11/20/24 at 4:37 p.m., the above finding was presented to the administrator and director of nursing during an end of day staff meeting. No other information was presented prior to exit conference on 11/22/24.

Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to honor food preferences for one of thirty residents in the survey sample (Resident #93). The findings include: Resident #93 was not provided a fruit salad as listed on the meal ticket and according to assessed food preferences. According to the clincal record, Resident #93 (R93) was admitted to the facility with diagnoses that included spinal stenosis, bradycardia, sick sinus syndrome, hypertension, neurogenic bladder, depression and insomnia. The minimum data set (MDS) dated [DATE] assessed R93 as cognitively intact. On 11/19/24 at 11:38 a.m., R93 was interviewed about quality of life/care in the facility. R93 stated that he was supposed to get a fruit salad each day for lunch and that he never gets the fruit. R93's clinical record documented the resident was prescribed a regular diet. A food preference assessment dated [DATE] listed that R93 liked/preferred fresh fruit. On 11/20/24 at 12:32 p.m., R93's served meal was observed during lunch. R93's meal ticket listed a fresh fruit plate, in addition to roast pork sandwich, green beans, mashed potatoes, and lemon cake. R93 was served all the items listed on the meal ticket except the fresh fruit plate. R93 stated again at this time that he was never served the fresh fruit plate, even though it was listed on the ticket. On 11/20/24 at 4:00 p.m., the dietary manager (other staff #1) was interviewed about R93 not being served fresh fruit as listed on the meal ticket. The dietary manager stated he did not realize the fresh fruit had not been served to R93. The dietary manger stated fruit plates were prepared and available each day. The dietary manager stated kitchen staff were supposed to serve foods according to the meal ticket. The dietary manager stated a previous manager assessed R93's preferences and had added the fresh fruit to the meal ticket based upon preference. R93's plan of care (revised 6/21/24) listed the resident was at risk of nutrition problems related to dependency on staff for eating and history of weight changes. Care plan interventions to maintain proper nutrition and prevent significant weight loss included the provision of diet as ordered and identification of resident food/beverage preferences. This finding was reviewed with administrator and regional consultants during a meeting on 11/21/24 at 5:00 p.m., with no further information presented prior to the end of the survey.

Based on staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for one of thirty residents in the survey sample (Resident #94). The findings include: Resident #94's clinical record included documented hospice notes for three other residents (Residents #10, #26 and #101). According to the clinical record, Resident #94 (R94) was admitted to the facility with diagnoses that included diabetes, adult failure-to-thrive, protein-calorie malnutrition, chronic kidney disease, anxiety, and depression. The minimum data set (MDS) dated [DATE] assessed R94 with having short and long-term memory problems and severely impaired cognitive skills. Review of R94's clinical record revealed documentation regarding hospice care/services. Included in R94's clinical record were hospice notes/documentation for three other current residents in the facility, who were also receiving hospice services. The other residents' notes scanned into R94's clinical record were as follows: Resident #10 - hospice notes dated 10/11/24, 10/16/24, 10/17/24, 10/21/24, and 10/24/24. Resident #26 - hospice notes dated 10/24/24 and 10/25/24. Resident #101 - hospice notes dated 10/16/24, 10/17/24, and 10/21/24. On 11/20/24 at 3:22 p.m., the medical records clerk (other staff #3) was interviewed about the co-mingled and mis-filed hospice notes. The medical records clerk stated hospice sent notes to the facility on paper. The medical records clerk stated that she scanned the documentation upon receipt and uploaded the notes to the clinical record. The medical records clerk stated, I must have uploaded incorrectly. I scanned [notes] together and put into his [R94's] record by mistake. This finding was reviewed with administrator and regional consultants during a meeting on 11/21/24 at 5:00 p.m., with no further information presented prior to the end of the survey.

Based on staff interview and clinical record review, the facility failed to develop a care plan for one of thirty one residents. Resident #5 (R5) did not have a complete care plan developed for incontinence. The Findings Included Review of R5's clinical record noted diagnoses for R5 included incontinence of bowel and bladder, chronic congestive heart failure, and chronic atrial fibrillation. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 9/27/24, which assessed R5 with a cognitive score of 14 out of 15, indicating cognitively intact. On 11/19/24 at 11:41 a.m. during an interview, R5 verbalized having incontinent episodes and that the staff did a good job at keeping her clean and dry. Review of R5's MDS dated [DATE], Section H - Bowel and Bladder, documented that R5 was Always Incontinent of bowel and bladder. Review of R5's care plan did not indicate a care plan had been developed for incontinence. On 11/21/24 at 11:54 a.m., license practical nurse (LPN #2, MDS coordinator) was interviewed. After reviewing the MDS and the care plan, LPN #2 verbalized that the nurse should have created a care plan regarding incontinence based on the assessment when first being admitted to the facility, which should have been updated into the care plan. On 11/21/24 at 4:54 p.m., the above finding was presented to the administrator during an end of day staff meeting. No other information was presented prior to exit conference on 11/22/24.

Based on observation, staff interview, and facility document review, the facility staff failed to follow infection control practices during medication pass and pour observation on one of two units. The findings include: License practical nurse (LPN #1) was observed handling medications with cross contaminated gloved hands, during medication pass on unit 400. on 11/20/24 at 8:00 a.m., during a medication pass for Resident #15 (R15), LPN #1 (LPN1)was observed sanitizing her hands and applying gloves. Then LPN1 began using the computer to view information, before reaching into the medication cart draw to pull out needed medications (consisting of bulk bottled medications and medication card packs). LPN1 started popping medications into her hand, reaching into bulk bottled medications with her fingers, and placing the medications into the medication cup, before distributing the medications to R15. After giving medications to R15, LPN #1 then pushed the medication cart to R42's room, sanitized her hands, applied gloves, and again used the computer, placed hands on the table top of the medication cart, reached into the medication draws, popped pills into her hands, and reached into medication bottles using her fingers, before placing medications into the medication cup and distributing the medications to R42. The above finding was presented to LPN #1 at the end of the medication pass observation. LPN #1 verbalized that sometimes it is hard to get the medications out of the bottles when there are just a few left. On 11/20/24 at 4:37 p.m., the above finding was presented to the director of nursing (DON) and administrator. The DON verbalized that the nurses should not be handling medications in that manner. Upon review, the facility's policy titled Medication Administration read in part: K. Use Standard Precautions for medication administration. No other information was presented prior to exit conference on 11/22/24.

Based on staff interview, clinical record review, facility document review and complaint investigation, the facility staff failed, for one of three residents in the survey sample (Resident #2), to provide a safe transfer with a mechanical lift resulting in a leg fracture and failed to prevent a fall during provision of personal care resulting in a femur fracture and scalp laceration. The findings include: Resident #2 was admitted to the facility with diagnoses that included [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], post traumatic seizures, [CONDITION(S)], anxiety and depression. The minimum data set (MDS - cms assessment tool) dated 8/24/22 assessed Resident #2 as cognitively intact for decision making skills and as requiring total dependence of one person for bed mobility and bathing, with the extensive assistance of two people for transfers. a) Safe Positioning of Resident #2's legs was not maintained during a transfer with a mechanical lift. The resident's right leg hit against the lift frame during the transfer, resulting in a fracture of the right lower leg (harm). Resident #2's clinical record documented a nursing note dated 4/22/22 stating, .resident with c/o [complaint of] pain to RLE [right lower extremity]. this nurse assessed and noted a hematoma below right knee. pt [patient] stated that her leg hit the bar of the lift during transfer .this nurse observed swelling to right ankle .new orders for xray. (sic) A nurse practitioner (NP) documented on 4/23/22, Patient bumped R [right] leg in transferring out of lift and developed small hematoma behind R knee. Ice applied already with recommendation for light compression. A NP note dated 4/24/22 documented, .Patient now c/o pain in the RLE post crush injury. Xray unavailable to be performed until tomorrow and patient is requesting transfer to ED [emergency department] for imaging and evaluation . A nursing note dated 4/24/22 documented, Patient was sent to ER [emergency room ] on 4/24/22 .An incident occurred on 4/22/22 at bedtime, during a transfer via hoyer lift. The patients leg hit the bar on the hoyer maachine [machine], causing the patient to be in pain. Through out the night the leg started to slightly swell and was warm to the touch .no one available to do X-ray until Monday morning. The patient tried to hold off, but is very sure the leg is broken so she requested this nurse send her to the emergency room . (sic) The clinical record documented Resident #2 was transported to the emergency roiagnom on [DATE] at 11:40 a.m. The emergency department report dated 4/24/22 documented, Patient presents with an injury to the right lower extremity. [MEDICATION(S)] trauma that occurred 2 days ago. She is functionally quadriplegic. Tenderness along the proximal tibia and fibula without obvious deformity. Mild soft tissue swelling present .Patient's x-rays show evidence of a nondisplaced fracture of the tibia and fibula . The resident returned to the nursing facility with the right leg immobilized in a splint and orders for orthopedic follow-up. Staff witness statements and the facility's investigation of the 4/22/22 incident documented staff failed to maintain positioning of the resident's legs/feet during the mechanical lift transfer resulting in the right leg trauma/fracture. The facility's incident report dated 4/22/22 documented certified nurses' aide (CNA) #3 and #6 were transferring Resident #2 from her wheelchair to bed using the Hoyer lift when the injury occurred. A written statement from CNA #6 dated 4/22/22 documented, .[CNA #3] and I were transfering [Resident #2] to bed with a howler [Hoyer] lift that her legs swung accidentally and hit the bar resulting to some injuries on her right leg. (sic) A statement obtained from CNA #3 on 4/25/22 documented, Went in room to help [CNA #6] get [Resident #2] to bed. We had to put hoyer pad under her. We got pad under her [CNA #6] was controlling lift. She started lifting her up but I noticed her foot was caught under her footrest on the wc [wheelchair]. I told [CNA #6] to move forward but she started backing up. I told her to stop. I was then able to get her foot from under the footrest and we put her to bed . (sic) The incident report documented a statement from Resident #2 dated 4/26/22 as, .stated she [Resident #2] was being transferred from chair to bed by mechanical lift. The aides were putting her into bed when she started leaning forward in the sling. The Aide [CNA #3] was trying to adjust her in the sling when she hit her leg on the metal part of the lift. She [Resident #2] stated she started having pain and swelling in the area. The incident form documented an interview/statement from CNA #6 dated 4/26/22 stating, I was transferring [Resident #2] back to bed with [CNA #3]. I was operating the lift and [CNA #3] was assisting in turning the resident in the sling. The resident was leaning forward, [CNA #3] was holding her shoulders to prevent her from leaning. I was lifting her up, I starting backing up away from the chair the resident said 'my leg' and I stopped operating the lift. The resident said she hit her leg on the support beam of the mechanical lift. We moved her legs to the side and continued to transfer her into the bed. Once in the bed she said her R leg was painful. I told the nurse . (sic) The incident form documented an interview/statement from licensed practical nurse (LPN) #6 dated 4/28/22. LPN #6's statement documented, I was the nurse working on Friday 4/22/22 with the resident. I was working with the resident and she complain in R ankle, I noted some swelling below her knee. I asked the CNA about the incident, the CNA stated that the resident was leaning forward in the lift and her leg hit the lift during the transfer .The resident complained of pain and was medicated . (sic) On 10/11/22 at 7:30 p.m., CNA #3 was interviewed by telephone about Resident #2's incident on 4/22/22. CNA #3 stated she and CNA #6 were transferring the resident from her wheelchair to bed with the Hoyer lift. CNA #3 stated CNA #6 operated the lift remote and when raised from the chair, Resident #2 started leaning forward in the sling. CNA #3 stated she pulled back on the resident's shoulders to keep her from falling when the resident's leg hit against a metal bar on the lift. CNA #3 stated when Resident #2 starting going forward in the sling, they were unable to guide the resident's legs. CNA #3 stated while she was holding on the shoulders, CNA #6 tried to get to the legs to guide them but she did not get to them in time. CNA #3 stated Resident #2 was total care and was unable to independently move her arms and legs. Concerning the resident's positioning during the transfer, CNA #3 stated, I was concentrating on keeping her from falling in the floor and did not see her feet. CNA #6 was not available for interview as she no longer worked at the facility. Resident #2's plan of care for activities of daily living (revised 2/4/22) documented the resident had self-care impairments due to [CONDITION(S)] and was dependent on staff for all aspects of care . Interventions to maintain physical functioning included use of a Hoyer lift for transfers with two person assistance, total assistance for bed mobility and may leave hoyer pad in place under resident when sitting . On 10/12/22 at 8:40 a.m., the administrator, director of nursing (DON) and mobile DON (administration staff #3) were interviewed about Resident #2's transfer with fracture of 4/22/22. The administrator, DON and mobile DON stated they were not employed at the facility in April 2022. The mobile DON stated the information about the incident was documented on the incident/investigation form and in statements and interviews with staff. The DON stated the resident required two-person assistance for transfers with a mechanical lift and was totally dependent on staff for care needs. The mobile DON stated from review of the incident form, Resident #2's leg hit against a bar on the lift during a transfer when the resident leaned in the sling. The mechanical lift manufacturer's instruction manual (part no. 87) documented on page 9 under safety warnings, .Adjustments for safety and comfort should be made before moving the patient . Page 27 of this manual documented when the patient is lifted, the patient is raised to a sitting position with the patient's head supported by the sling and/or an assistant. Page 28 of this manual illustrated transfer of the patient with one person operating the lift and the other person guiding the resident's feet/legs while the head is supported by the sling. The facility's training checklist titled Mechanical Lift Application and Use (referenced/adapted from FDA patient lift safety guide (2018), safe patient handling Perry & Potter 9th edition) included in steps to ensure safety during a transfer to lift the person two inches off the surface and then check that the person was secure and comfortable. b) Resident #2 fell from bed during the provision of a bed bath. The resident was hospitalized and diagnosed with a displaced fracture of the right femur and a scalp laceration as a result of the fall (harm). Review of Resident #2's clinical record documented a nursing note dated 4/17/22 stating, .called to residents room by staff member stating she had fallen off of bed while she was providing care to the resident .observed resident lying on floor on her back. resident stated she had pain in left scapula bilateral legs and head. residents head was noted to be bleeding from left side. writer attempted to assess the area to head but resident stated it was to [too] much pain for her to tolerate .able to apply pressure dressing to head to attempt to stop the bleeding .transported to .hospital to be evaluated. (sic) The emergency room history and physical dated 9/17/22 documented, .bed-bound .presenting to ED [emergency department] for evaluation of leg pain after being dropped from bed during efforts to have her back washed .In the ED a right proximal femur fracture was identified with imaging . The resident was also diagnosed with a 4 centimeter scalp laceration that was closed with staples. The resident was admitted to the hospital and had surgery for repair of the displaced femur. The hospital discharge summary dated 9/21/22 documented that Resident #2 had acute blood loss during the surgery with post-operative [CONDITION(S)]. On 9/21/22 the resident was transitioned to comfort care and transferred to a hospice care unit. The facility's investigation of Resident #2's fall documented a statement from CNA #2 who was caring for Resident #2 at the time of the fall. CNA #2's statement dated 9/19/22 documented, I was washing her to give her a full bed bath. I turned her on her right side to wash her back. I turned to get a wash cloth + towel and I heard 'I'm falling. I'm about to fall.' I tried to catch her but it was too late. She landed on her back with her right knee pulled up. She asked me to put a pillow under her head and leg, which I did. I then covered her up and went to go get the nurse . A statement from licensed practical nurse (LPN) #3 who was working when Resident #2 fell dated 9/23/22 documented, .[CNA #2] called me and said that [Resident #2] fell . When I entered the room [Resident #2] was on her back, her head was bleeding .I asked her how did she fall and she said she was over too far . The facility reported incident investigation sent to the state agency dated 9/23/22 documented, On 9/17/22, certified nurses' aide [CNA #2] was providing ADL [activities of daily living] to [Resident #2]. In the course of providing care, aide rolled resident onto her side, away from her. CNA [#2] proceeded to run around to gather additional items to perform care. While [CNA #2's] back was turned, resident fell off of the bed .As a result of the fall, resident fractured femur .CNA's statement reflects that she turned her back to the resident during patient care and that there were not two staff members providing care to resident .CNA has been terminated due to providing improper care. Resident #2's plan of care (revised 7/11/22) documented the resident was at risk of falls due inability to support/control movement due to paralysis/[CONDITION(S)] and was dependent on staff for all aspects of care. Interventions to maintain activities of daily living included .total asst [assistance] bed mobility . On 10/11/22 at 11:40 a.m., LPN #1 that routinely cared for Resident #2 was interviewed. LPN #2 stated the resident required total care and was unable to use her arms and legs due to paralysis. LPN #2 stated two people were required to provide ADL care because the resident was totally dependent. On 10/11/22 at 11:55 a.m., CNA #1 that routinely cared for Resident #2 was interviewed. CNA #1 stated the resident was able to only move her head and it was always best to have two people when bathing the resident. On 10/11/22 at 12:00 p.m., the unit manager (LPN #2) was interviewed about Resident #2's fall from bed. LPN #2 stated Resident #2 fell from bed after CNA #2 turned her in bed during a bath. LPN #2 stated one CNA was providing care during the bath when the resident rolled from the bed into the floor. LPN #2 stated two people were recommended to provide ADL care and bed mobility for Resident #2 due to her paralysis. On 10/11/22 at 12:26 p.m., LPN #3 caring for Resident #2 on 9/17/22 was interviewed. LPN #3 stated on the evening of 9/17/22 that CNA #2 called her and reported Resident #2 fell from the bed. LPN #3 stated she found the resident in the floor on her back with bleeding noted from her head. LPN #3 stated Resident #2 said she was over too far in the bed when she fell . LPN #3 stated she applied a dressing to the resident's head to control bleeding and the resident stated her arm and legs hurt. LPN #3 stated CNA #2 was giving the resident a bed bath when the resident rolled off the bed. LPN #3 stated at times one CNA provided ADL care for Resident #2 but many times two staff people assisted with Resident #2. LPN #3 stated the resident had been turned away from the CNA and with the CNA at the resident's back was unable to stop or break the fall. On 10/11/22 at 4:20 p.m., CNA #2 who was caring for Resident #2 at the time of the fall was interviewed. CNA #2 stated she had cared for Resident #2 for years and was familiar with the resident's routine. CNA #2 stated she usually performed Resident #2's bed bath without assistance of another staff person. CNA #2 stated she turned the resident on her side and then turned away from the resident to get a wash cloth. CNA #2 stated Resident #2 then said, I'm too close. I'm falling. CNA #2 stated as the resident rolled, she was unable to grab or hold the resident in bed. CNA #2 stated the resident was alert after falling but was bleeding from the head and expressed pain. CNA #2 stated she notified the nurse immediately of the fall. CNA #2 stated she had never been told that Resident #2 required two-person assistance for a bed bath. On 10/12/22 at 8:40 a.m., the administrator, director of nursing (DON) and mobile DON were interviewed about Resident #2's fall/fracture of 9/17/22. The administrator and DON were not working in the facility at the time of the incident. The mobile DON stated CNA #2 turned her back on Resident #2 during a bed bath to get supplies and the resident fell to the floor with the bed in high position. The mobile DON stated CNA #2 was unable to stop or hold the resident. The mobile DON stated Resident #2 required total care and dependence on staff for all ADL needs. When asked about the expectation for turning residents, the DON stated CNA #2 should have turned the resident toward her instead of away from her since she was providing assistance with one person. The mobile DON stated their investigation concluded that CNA #2 did not follow proper procedure for the bed bath. The mobile DON stated the improper procedures that contributed to the fall included positioning the resident too close to the edge of the bed, not having two-person assistance and turning away from the resident to get supplies with the resident unsecured. The facility's training checklist titled Positioning in Bed Assistance (referenced/adapted from Lippincott Manual of Nursing Practice (2019), Lippincott nursing procedures (2018), Perry & Potter 9th edition) included in steps for lateral positioning of a resident in bed, .roll the person onto their side towards you .Place a pillow under the neck and head and behind the neck . These findings were reviewed with the administrator, DON and mobile DON on 10/11/22 at 6:00 p.m. and on 10/12/22 at 8:40 a.m. No additional information was provided. This was a complaint deficiency.

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to follow professional standards of care for one of 31 residents in the survey sample. Resident #135's daily dosage of the anti-[MEDICAL CONDITION] medication [MEDICATION NAME] ([MEDICATION NAME]) was increased in error when it should have been decreased. Nursing failed to clarify or question the erroneous dosage prior to administering the medication. The increased dosage caused Resident #135's [MEDICATION NAME] level to exceed therapeutic levels resulting in slurred speech, headache, chest pain and a decline in muscle coordination. The resident was diagnosed with [REDACTED]. The findings include: Resident #135 was admitted to the facility on [DATE] with a re-admission on 4/20/17. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #135 as cognitively intact. Resident #135's clinical record documented a physician's orders [REDACTED]. A lab test report dated 4/3/17 documented the resident's [MEDICATION NAME] level was high with a reading of 22.8 ug/mL (micrograms per milliliter) with a reference range of 10.0 to 20.0 ug/mL. The nurse practitioner (NP) was notified and entered an order on 4/4/17 to change the resident's [MEDICATION NAME] dosage from 400 mg per day to 350 mg twice per day with a repeat [MEDICATION NAME] level check in four weeks. The clinical record documented the order was entered as written with the resident administered 350 mg of [MEDICATION NAME] twice per day starting on 4/4/17. The record documented no questioning or clarification of the order that actually increased the resident's daily [MEDICATION NAME] dose instead of decreasing the dose. Following the [MEDICATION NAME] dose change on 4/4/17, nursing notes documented the resident was assessed with [REDACTED]. The record documented the NP was notified and entered an order on 4/12/17 to send the resident to emergency room for evaluation. A note dated 4/12/17 at 12:31 p.m. documented the resident stated she was not short of breath, only felt weak and did not want to go the to the emergency room . The NP ordered additional lab work, a chest x-ray and an EKG. The NP evaluated Resident #135 on 4/13/18, assessed the resident with cough and nasal congestion and ordered [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] for treatment of [REDACTED]. There was no re-check of the resident's [MEDICATION NAME] level. A nursing note dated 4/14/17 documented the resident complained of feeling lethargic and was unable to hold her eating utensils during dinner. A note dated 4/15/17 documented, Resident presents with slurred speech, lethargy and severe throbbing headache. A physician's orders [REDACTED]. The emergency room report dated 4/15/17 documented, [MEDICATION NAME] ([MEDICATION NAME]) toxicity: Presented with slurred speech, AMS (altered mental status), [DIAGNOSES REDACTED] (involuntary eye movement) .in the setting of increasing in [MEDICATION NAME] dose at her SNF (skilled nursing facility) (increased from 400 mg daily to 350 mg BID (twice per day) in setting of already elevated level for unclear reasons). Also has been on [MEDICATION NAME] since 4/14 (2017) which could increase serum [MEDICATION NAME] level. [MEDICATION NAME] level was high at 54.2. (sic) The resident was hospitalized for [REDACTED]. The resident was re-admitted to the facility on [DATE]. A facility reported incident form to the state agency dated 4/17/17 documented Resident #135 was diagnosed with [REDACTED]. The facility's investigation documented the resident had a slightly elevated [MEDICATION NAME] level of 22.8 (normal range of 10 to 20 ug/ml) on 4/4/17. The nurse practitioner (NP) was notified and entered a physician's orders [REDACTED]. The investigation stated, The NP thought that she was decreasing the dose but mistakenly increased the dose to twice a day. The facility investigation stated, .The MD (physician) wrote order to change [MEDICATION NAME] dose to 350 mg BID (twice per day). The original order was for 400 mg QD (each day) so medication was increased as opposed to decreased .At hospital was noted with a [MEDICATION NAME] level of 54.8 . On 6/20/18 at 11:09 a.m., the director of nursing (DON) was interviewed about the [MEDICATION NAME] error with Resident #135 resulting in toxicity. The DON stated the resident's routine [MEDICATION NAME] level checked on 4/3/17 indicated the level was high and above the therapeutic range. The DON stated the NP wrote the order wrong and increased the resident's dose instead of lowering the dose. The DON stated the nurses entered the order as written and administered the [MEDICATION NAME] as ordered. The DON stated nursing did not question why the dosage was increased even though the resident's [MEDICATION NAME] level was already high. The DON stated their investigation did not reveal a transcription error but that the NP ordered the wrong dosage and the dosage error was not caught or questioned until after the resident had symptoms and went to the emergency room . The NP that wrote the order for the increased [MEDICATION NAME] dosage was not available for interview, as she no longer worked at the facility. The Nursing (YEAR) Drug Handbook on page 1171 describes [MEDICATION NAME] ([MEDICATION NAME]) as an anticonvulsant used to control [MEDICAL CONDITION]. Page 1174 of this reference lists signs and symptoms of overdose as decreased muscle coordination, [DIAGNOSES REDACTED], lethargy and slurred speech. Nursing considerations listed on page 1174 include, Monitor drug level. Therapeutic level of total [MEDICATION NAME] is 10 to 20 mcg/mL (micrograms/milliliter) . (1) The facility's policy titled Medication Ordering & Prescribing: New Orders (2017) stated, Nurse will review medication order for completeness as to: name of the medication, strength, dose, route of administration, frequency, stop date if applicable, and indication for use if ordered PRN or as needed and diagnosis. The Lippincott Manual of Nursing Practice 10th edition states on pages 16 and 17 concerning standards of care, Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to .follow appropriate nursing measures, communicate information about the patient .follow physician's orders [REDACTED]. (2) The DON presented a plan of correction to address the [MEDICATION NAME] medication error that was implemented with a correction date of 5/19/17. The corrective plan included the following: 1. Resident #135 was sent to the emergency room , [MEDICATION NAME] was held until the level returned to therapeutic range, dose adjusted to maintain therapeutic level. 2. Audit of 100% of all residents in the facility on anti-[MEDICAL CONDITION] medications, labs were obtained with therapeutic levels and dosages verified. 3. Education to 100% of licensed nurses regarding medication orders, dosages and therapeutic lab levels. Education provided to nurses on 4/17/17 included steps to take when lab results were received related to [MEDICAL CONDITION] medications. This education documented, .review with MD (physician) - ensure the correct, current dose of med (medication) is given to MD. After new orders are obtained, (check) the new orders & compare to previous orders. Enter order correctly into (computer) and d/c (discontinue) all other/previous orders. 4. Audit of all new [MEDICAL CONDITION] medication orders, order changes and lab testing three times per week for 4 weeks and then monthly for 3 months. During the current survey, a list of any medication errors since 5/19/17 was requested. There were no further medication errors on record in the facility since the incident with Resident #135 in (MONTH) (YEAR). There were no significant medication errors cited during the current survey. These findings were reviewed with the administrator and director of nursing during a meeting on 6/21/18 at 8:15 a.m. This deficiency was cited as past non-compliance. This was a complaint deficiency. (1) Rader, Janet, Dorothy Terry and Leigh Ann Trujillo. Nursing (YEAR) Drug Handbook. Philadelphia: Wolters Kluwer, (YEAR). (2) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014.

Based on staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to ensure one of 31 residents in the survey sample was free from a significant medication error. Resident #135's daily dosage of the anti-[MEDICAL CONDITION] medication [MEDICATION NAME] ([MEDICATION NAME]) was increased in error when it should have been decreased. The increased dosage caused the resident's [MEDICATION NAME] level to exceed therapeutic levels resulting in slurred speech, headache, chest pain and a decline in physical function. The resident was hospitalized for [REDACTED]. The findings include: Resident #135 was admitted to the facility on [DATE] with a re-admission on 4/20/17. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #135 as cognitively intact. Resident #135's clinical record documented a physician's orders [REDACTED]. A lab test report dated 4/3/17 documented the resident's [MEDICATION NAME] level was high with reading of 22.8 ug/mL (micrograms per milliliter) with a reference range of 10.0 to 20.0 ug/mL. The nurse practitioner (NP) was notified and entered an order on 4/4/17 to change the resident's [MEDICATION NAME] dosage from 400 mg per day to 350 mg twice per day with a repeat [MEDICATION NAME] level check in four weeks. The clinical record documented the order was entered as written with the resident administered 350 mg of [MEDICATION NAME] twice per day starting on 4/4/17. The record documented no questioning or clarification of the order that actually increased the resident's daily [MEDICATION NAME] dose instead of decreasing the dose. Following the [MEDICATION NAME] dose change on 4/4/17, nursing notes documented the resident was assessed with [REDACTED]. The record documented the NP was notified and entered an order on 4/12/17 to send the resident to emergency room for evaluation. A note dated 4/12/17 at 12:31 p.m. documented the resident stated she was not short of breath, only felt weak and did not want to go the to the emergency room . The NP ordered additional lab work, a chest x-ray and an EKG. The NP evaluated Resident #135 on 4/13/18, assessed the resident with cough and nasal congestion and ordered [MEDICATION NAME] (antibiotic) and [MEDICATION NAME] for treatment of [REDACTED]. There was no re-check of the resident's [MEDICATION NAME] level. A nursing note dated 4/14/17 documented the resident complained of feeling lethargic and was unable to hold her eating utensils during dinner. A note dated 4/15/17 documented, Resident presents with slurred speech, lethargy and severe throbbing headache. A physician's orders [REDACTED]. The emergency room report dated 4/15/17 documented, [MEDICATION NAME] ([MEDICATION NAME]) toxicity: Presented with slurred speech, AMS (altered mental status), [DIAGNOSES REDACTED] (involuntary eye movement) .in the setting of increasing in [MEDICATION NAME] dose at her SNF (skilled nursing facility) (increased from 400 mg daily to 350 mg BID (twice per day) in setting of already elevated level for unclear reasons). Also has been on [MEDICATION NAME] since 4/14 (2017) which could increase serum [MEDICATION NAME] level. [MEDICATION NAME] level was high at 54.2. (sic) The resident was hospitalized for [REDACTED]. The resident was re-admitted to the facility on [DATE]. A facility reported incident form to the state agency dated 4/17/17 documented Resident #135 was diagnosed with [REDACTED]. The facility's investigation documented the resident had a slightly elevated [MEDICATION NAME] level of 22.8 (normal range of 10 to 20 ug/ml) on 4/4/17. The nurse practitioner (NP) was notified and entered an order changing the resident's [MEDICATION NAME] dose from 400 mg once per day to 350 mg twice per day. The investigation stated, The NP thought that she was decreasing the dose but mistakenly increased the dose to twice a day. The facility investigation stated, .The MD (physician) wrote order to change [MEDICATION NAME] dose to 350 mg BID (twice per day). The original order was for 400 mg QD (each day) so medication was increased as opposed to decreased .At hospital was noted with a [MEDICATION NAME] level of 54.8 . On 6/20/18 at 11:09 a.m., the director of nursing (DON) was interviewed about the [MEDICATION NAME] error with Resident #135 resulting in toxicity. The DON stated the resident's routine [MEDICATION NAME] level checked on 4/3/17 indicated the level was high and above the therapeutic range. The DON stated the NP wrote the order wrong and increased the resident's dose instead of lowering the dose. The DON stated the nurses entered the order as written and administered the [MEDICATION NAME] as ordered. The DON stated nursing did not question why the dosage was increased even though the resident's [MEDICATION NAME] level was already high. The DON stated their investigation did not reveal a transcription error but that the NP ordered the wrong dosage and the dosage error was not caught or questioned until after the resident had symptoms and went to the emergency room . The NP that wrote the order for the increased [MEDICATION NAME] dosage was not available for interview, as she no longer worked at the facility. The DON presented a plan of correction to address the [MEDICATION NAME] medication error that was implemented with a correction date of 5/19/17. The corrective plan included the following: 1. Resident #135 was sent to the emergency room , [MEDICATION NAME] was held until the level returned to therapeutic range, dose adjusted to maintain therapeutic level. 2. Audit of 100% of all residents in the facility on anti-[MEDICAL CONDITION] medications, labs were obtained with therapeutic levels and dosages verified. 3. Education to 100% of licensed nurses regarding medication orders, dosages and therapeutic lab levels. 4. Audit of all new [MEDICAL CONDITION] medication orders, order changes and lab testing three times per week for 4 weeks and then monthly for 3 months. During the current survey, a list of any medication errors since 5/19/17 was requested. There were no further medication errors on record in the facility since the incident with Resident #135 in (MONTH) (YEAR). There were no significant medication errors cited during the current survey. These findings were reviewed with the administrator and director of nursing during a meeting on 6/21/18 at 8:15 a.m. The Nursing (YEAR) Drug Handbook on page 1171 describes [MEDICATION NAME] ([MEDICATION NAME]) as an anticonvulsant used to control [MEDICAL CONDITION]. Page 1174 of this reference lists signs and symptoms of overdose as decreased muscle coordination, [DIAGNOSES REDACTED], lethargy and slurred speech. Nursing considerations listed on page 1174 include, Monitor drug level. Therapeutic level of total [MEDICATION NAME] is 10 to 20 mcg/mL (micrograms/milliliter) . (1) This deficiency was cited as past non-compliance. This was a complaint deficiency. (1) Rader, Janet, Dorothy Terry and Leigh Ann Trujillo. Nursing (YEAR) Drug Handbook. Philadelphia: Wolters Kluwer, (YEAR).

Based on staff interview and clinical record review, the facility staff failed to ensure safety interventions were in place and failed to ensure supervision for the prevention of falls for two of 25 residents in the survey sample, Resident # 3 and Resident # 16. As a result, Resident # 3 fell and incurred actual harm. 1. The facility staff failed to implement any new safety interventions and/or appropriate supervision for the prevention of falls for Resident # 3; A) Resident # 3 was having hallucinations and/or delusion and the facility failed to address the resident's recurrent attempts to get up unassisted. As a result, Resident # 3 on 11/30/2015, had a fall sustaining a subcapital fracture of the right hip with ORIF (open reduction with internal fixation.) B) during the survey Resident # 3 safety interventions were not observed. 2. The facility staff failed to ensure supervision and assistive devices during ambulation as required in the plan of care for fall prevention for Resident #16. Findings include: Resident # 3 was admitted to the facility on [DATE], with the most current readmission on 02/18/16. [DIAGNOSES REDACTED]. The most current full MDS (minimum data set) was a significant change assessment dated [DATE], which assessed the resident as having short and long term memory impairment with severe impairment in daily decision making skills. The resident triggered in the CAAS (care area assessment summary) section of this MDS for falls. During clinical record review, Resident # 3's nursing progress notes were reviewed for the month of November 2015. The following was revealed: 11/01/15- .agitated with delusions & hallucinations .trying to get out of bed several times. Yelling & calling out to people who aren't there .1:1 comfort & reassurance provided. Redirection & distraction attempted. Toileted. Repositioned. Assessed for pain .Effective though behavior reoccurred repeatedly, requiring additional interventions . 11/12/15- .Delusions & hallucinations noted x 2 (two times) during noc (night) .Trying to get out of bed & calling out to people who aren't there .1:1 comfort & reassurance provided. Redirection & distraction attempted. Needs met .Effective . 11/13/15- .Agitated with delusions & hallucinations noted .Trying to get out of bed several times. Yelling & calling out to people who aren't there .1:1 comfort & reassurance provided. Redirection & distraction attempted .Effective though behavior reoccurred, requiring additional interventions . 11/18/15-(7:11 a.m.) .Agitated with delusions & hallucinations noted .Trying to get out of w/c (wheelchair) numerous times. Yelling & calling out to people who aren't there .1:1 comfort & reassurance provided. Redirection & distraction attempted. Toileted. Provided snack .Ineffective . 11/18/15-(9:14 p.m.) .Resident very agitated with delusions & hallucinations .Had c/o (complained of) pain of her legs (sic) and wanted to use the toilet and when she was taken she refused when she got there. She was also looking for her purse and insisted that the purse we gave her was not hers .1:1, meds for pain and blood sugar 411 and coverage was given and also her lantus (insulin) .When all was done she calmed down . 11/19/15- .has slept most of the day, since she was up most of the night . 11/27/15- .Hallucinations & delusions during noc (night) shift .Trying to get out of bed & later out of w/c (wheelchair), repeatedly talking to & referring to people who are not there .1:1 comfort & reassurance provided by multiple staff members. Needs met. Attempted to reorient. Toileted. Provided snack .Ineffective though resting quietly in w/c at nurse's station at this time . The nursing notes further documented that a UA C&S (urinalysis/culture and sensitivity) specimen was attempted to be obtained on 11/28/15 without success. The specimen was obtained on 11/29/15. 11/30/15-(2:02 a.m.) .Res (resident) attempted to walk without assist from bed and fell at 0100 (1:00 a.m.) .Res has full ROM (range of motion) at this time. c/o some right leg soreness however no warmth, redness, or swelling with increased agitation. U/A obtained on 11/29 per doctors orders for U/A C&S to see if resident has a UTI .no new orders . 11/30/15-(4:09 a.m.) .c/o (complained of) worsening pain. Dr. notified. new order to send out for eval . Resident # 3 was sent to theER on [DATE], as documented above and was admitted for a fall with fracture. The resident's discharge summary dated 12/03/15 documented: .discharged [DATE] .falls .subcapital fracture of right hip, UTI .discharge to skilled nursing facility (name of nursing facility) .Needs staples removed on 12/14/15 .mechanical ground level fall/slip and fall. Per nurse .found 1/2 way acorss (sic) her room .unable to provide history due to her dementia .endorses right hip pain .talking nonsensically about a little boy .likely hallucinating .Per her nurse .she is at her baseline and over the past month the hallucinations have been more pronounced .pain in her legs .S/P (status [REDACTED].dementia: this is likely her baseline. She does sundown and is at high risk for delirium in the hospital .no evidence of complication status [REDACTED]. Resident # 3 was observed on 03/29/16 at approximately 3:00 p.m., laying in bed, on top of her blankets. The bed had 2 (1/2) side rails in the up position. The resident's w/c was at the bottom of the resident's bed. No fall mats were observed on either side of the bed, and no bed or chair alarms were observed. Resident # 3's CCP (comprehensive care plan) was then reviewed and documented the following: .At risk for falls related to: Use of medication, new environment---fall hx (history). Fall 08/04/15. Fall 11/29/15. sent out to E.R. (emergency room ), 1-6-16 fall Date initiated: 01/27/14 .Assess for pain, Assess that wheel chair is of appropriate size; assess need for footrests; assess for need to have wheel chair locked/unlocked for safety, anti tippers, bed low position, call light or personal items available and in easy reach or provide reacher, .footwear to prevent slipping, observe for side effects of medications, orientation to new room and roommate . All of the above interventions were documented with a Date initiated as 09/30/13, with a revision date of 10/08/13. The resident's CCP further documented in the fall section: .Neuro checks as ordered (01/26/15) .If awake, place in a highly visible area-offer food and drink (04/22/15) .offer to lay res (resident) down for rest periods (01/07/15) . Resident # 3's nursing notes were then further reviewed for August 2015 and revealed the following: 08/02/15- .Uncooperative with delusion noted during first part of noc (night) .up in w/c (wheelchair) calling out to people who are not there & trying repeatedly to get up unassisted .1:1 comfort & reassurance provided. Redirection, reorientation & distraction attempted .Eventually effective . 08/04/15-Late Entry: Resident was observed on the floor in room .hx falls uti, generalize pain (sic), gout .NO c/o pain fall from fall (sic), no apparent injuries . 08/12/15- .reviewed in behavior meeting. Resident attempting to get out of bed, hallucinating, upset. Resident was provided with interventions that were effective for a short time. POC (plan of care) reviewed . The resident's CCP was reviewed again and documented: .Potential for drug related complications related to: Hx (history of) hallucinations Dated initiated 03/21/14 Will be free of psychotropic drug related complications .Assess pain, Monitor side effects and report to physician: Antidepressant-Sedation, drowsiness, dry mouth, blurred vision, .Monitor and report side effects to physician: Antipsychotic medication-sedation .Monthly pharmacy review .Provide medications as ordered by physician and evaluate for effectiveness . All of the above interventions were initiated on 03/21/14. Additionally an intervention was included in this section to: offer toileting and provide one on one as indicated, both of these interventions were initiated on 05/18/15. No new interventions were initiated after the fall on August 4, 2015. No new interventions were initiated after the fall with fracture on 11/20/15. The interventions under 'behaviors' were documented as: .Assist resident in getting out of bed if she is requesting to get up (07/28/15) .Do not seat me around others who disturb me (12/04/14) .Let my physician know if my behaviors are interfering with my daily living (12/04/14) . Additional interventions were listed, but were not initiated until 03/01/16-therefore do not apply to fall concerns for August 2015, November 2015 (fall with injury) and January 2016. Resident # 3's current POS (physician's orders [REDACTED].# 3 was prescribed one antidepressant, but was not currently on any type of antipsychotic as indicated in the resident's CCP. Resident # 3's nursing notes were then reviewed for January 2016 and revealed the following: 01/03/16-(6:13 p.m.) .alert to name, remains up in w/c sleeping on and off . 01/06/16-(3:24 p.m.) .fall from w/c .A&O (alert and oriented) to name, up in w/c most of shift, noted @ (at) approx 1445 (2:45 p.m.) falling from w/c to floor on her lt (left) side, c/o lt knee (sic), .flex except lt knee, pt c/o to middle (sic) of knee .pt was assisted up in back in w/c (sic), medicated .remains up in w/c .pt stated I fell asleep .offered to assist to put to bed, but refused . 01/07/16- .F/u (follow-up) fall assessment revealed no visible signs of injuries. Positive ROM (range of motion) .neuro checks .oriented to self only with periodic confusion . 01/08/16- .delusions & hallucinations noted .in bed resting quietly then calling out & talking to people who aren't there .1:1 comfort & reassurance provided. Redirected. Needs met .Effective . 01/13/16- .alert to name, up in w/c most of evening sleeping . 01/14/16- .Alert to self with random episodes of confusion noted . 01/28/16- .Hallucinations & delusions .Resting quietly in bed then calling out to people who weren't there .1:1 comfort & reassurance provided. Redirection & distraction attempted .Eventually effective . On 03/30/16 at approximately 2:00 p.m., the DON (director of nursing) and the administrator were made aware of concerns regarding Resident # 3's fall with injury on November 30, 2015 and an investigation was requested. The Verification of Investigation form for Resident # 3 dated 11/30/15 was presented and reviewed. The form documented: .11/30/15 0100 (1:00 a.m.) .Resident got out of bed without assist and walked several steps to go get the baby .full range of motion immediately after fall .denied pain and stood/transferred without difficulty. Around 4am resident started complaining of severe pelvic and right upper leg pain with facial grimaces and moaning .I was going to get the baby .assisted resident to stand and transfer to wheelchair and resident brought to nurses station .This writer feels as if the fall was related to hallucinations .Care plan reviewed-yes, Care plan revised-yes . A Post Fall Analysis/Plan was also presented and reviewed and documented: .lost balance .ambulating .impaired safety awareness/judgement Adaptive equipment at time of fall: None .Prior to the fall resident was up in w/c at nurses station attempting to get out of chair and go get the babies, visualizing (and trying to clean) wet spots on the floor, and calling staff by other names .Specify Recommendations/Interventions taken to prevent reoccurrence: Fall mat on floor and/or personal alarm. Gripper socks . Resident # 3 was observed multiple times during the survey process on 03/29/16 through 03/31/15, the safety interventions above were not observed. On 03/30/16 at approximately 4:30 p.m., the DON and administrator were informed of the concerns regarding Resident #3 having a history of falls, having a history of hallucinations with delusions without any additional interventions being implemented. The DON and administrator were made aware that Resident # 3 had been observed multiple times during the survey process and no safety interventions were observed. The facility staff were informed that according to the resident's clinical record, the resident had hallucinations with a fall in August, and no new interventions were implemented, the resident had multiple hallucinations during the month of November leading up to actual fall on 11/30/15, with no new interventions at all. The resident again, had hallucination in January and had another fall, with no new interventions in place. No interventions were put in place to address the resident's hallucinations with delusions in August 2015, no interventions were put in place after the fall in August. The resident had a history of [REDACTED]. The resident again fell in January of 2016, and still no interventions were initiated for the prevention of falls. Physician's progress notes from August 2015 to present were requested, in addition to any psychiatric evaluations and all fall risk assessments since the last survey for Resident # 3. Physician's progress notes were presented for Resident # 3 for Jan. 2015, Sept. 2015, Nov. 2015, Dec. 2015, Jan. 2016, Feb. 2016 and March 2016. None of the physician progress notes [REDACTED]. The DON reported on 03/31/16 that no psychiatric evaluations/consultations for Resident # 3 could be located and further voiced they were not done. Three (3) fall risk assessments were presented for Resident # 3. One assessment dated [DATE] documented that Resident # 3 had a fall risk score of 9. The fall risk assessment documented that a total score of 10 or above deems the resident at risk. This fall risk assessment was not completed in it's entirety, three sections (vision status, gait balance, and predisposing diseases) were not filled out, therefore this assessment score was documented incorrectly. The second fall risk assessment dated [DATE] was only partially completed. The assessment was started and had a score of 14 showing, but was not added up and put in the total score slot. This assessment had three sections not completed (systolic blood pressure, medications, and predisposing diseases) , therefore this assessment was also incorrect. The third fall risk assessment dated [DATE], was completely filled out and gave the resident a fall risk score of 19. The DON was asked how often fall risk assessments are completed, the DON relied, quarterly and further voiced that fall risk assessments for Resident # 3 were not done or could not be located for June and September 2015. Again the survey team met with the administrator and DON and voiced concerns regarding Resident # 3's history of hallucinations with delusions, a history of falls that the facility staff were aware of and no new interventions were implemented for the preventions of falls. The DON voiced that other interventions were on the care plan listed under 'behaviors', which were listed above; other interventions under behaviors were not initiated and/or implemented until 03/01/16. No further information or documentation was presented prior to the exit conference to evidence that the facility staff ensured Resident # 3 had adequate supervision and/or assistive devices/interventions for the prevention of falls, which resulted in the resident falling and incurring actual harm. 2. Facility staff failed to provide supervision and a gait belt during ambulation as required in the plan of care for fall prevention for Resident #16. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #16 with short and long-term memory problems and severely impaired cognitive skills. This MDS assessed the resident with moderately impaired vision and to require the extensive assistance of two people for ambulation. On 3/30/16 at 9:10 a.m. Resident #16 was observed ambulating in the hallway near the elevator assisted by an individual identified by staff as the resident's responsible party (RP). The RP was facing Resident #16 and walking backwards while holding the resident's hands directing the resident along with their arms extended. The resident stopped suddenly and shuffled her feet. The RP stopped pulling the resident at this point and stood in front of the resident then hugged her. Facing the resident and walking backwards, the RP proceeded to walk the resident while holding her hands with their arms extended. The RP directed the resident into the main dining room. The floor in the main dining room was wet at the time as housekeeping employees were mopping the floor. Yellow wet floor signs were posted at the entrances to the dining room. While standing on the wet floor, the social services assistant approached Resident #16 and the RP. The resident and RP stood momentarily on the wet floor near the middle of the room and then proceeded to walk on the wet floor toward the front entrance to the dining room. Just before reaching the door, the social services assistant brought a wheelchair for the resident. Resident #16 was seated in the wheelchair, pushed through the front entrance doorway and into the hallway near unit 1. Once in the hallway the RP grabbed the resident's hands and pulled the resident by her arms to a standing position and stated they were going to walk some more. Facing the resident and walking backwards, the RP held the resident's hands with their arms extended and walked the resident down the hallway on unit 1. The resident stopped suddenly at times when walking, leaning up on the tips of her toes and had a shuffled gait. There was no supervision of the resident by a staff member during this observation other than when the social services assistant brought in the wheelchair. There was no gait belt, walker or any other assistive device in use when the resident was ambulated by the RP. Resident #16's clinical record documented a recent decline in mobility and ambulation. The record documented the resident fell in the shower room on 1/26/16. Nursing notes from January 2016 through 3/29/16 documented the following concerning the resident's ability to ambulate. 1/26/16 - Resident lowered to floor in shower room by staff .Resident observed at times shuffling feet when staff and RP attempting to ambulate with her. Resident observed making sudden stops during ambulation leaning forward on tip of toes, resident also with history of leaning backward when standing still. Resident lowered to floor by cna (certified nurses' aide) from standing position resident began leaning backward, cna assisted resident to floor. 1/26/16 - Spoke with RP concerning residents decline in mobility RP stated i know she leans and make those abrupt stops when walking .may need to make some adjustments to how we move her and possible may need to use the sit to stand lift for toileting . (sic) 2/23/16 - Resident continues with great difficulty ambulating. Staff attempt to ambulate resident to and from dining room resident observed shuffling feet stopping during ambulation and leaning forward on tip of toes. Staff required to assist resident to meals in wheelchair . 3/4/16 - Resident has a friend who is very supportive and comes to visit often. They walk in the hallway together and have to take frequent rests as resident becomes tired . The resident's plan of care (print date 3/30/16) stated the resident was at risk of falls due to medications, Alzheimer's dementia and history of falls. The care plan stated the resident's RP does not use gait belt. The care plan documented the resident fell on [DATE] when out of the facility with the RP and listed the most recent fall occurred on 1/26/16 when the resident was lowered to the floor by staff in the shower room. Interventions for fall/injury prevention included, Ambulate with assist of 1 and with use of gait belt .Allow rest periods as needed while ambulating .May use wheelchair to assist with mobility . The care plan also listed the resident had impaired vision due to a history of cataracts and impaired communication due to dementia. On 3/30/16 at 9:15 a.m. the social services assistant that brought the wheelchair into the dining room for Resident #16 was interviewed. The social services assistant stated the dining room was closed for cleaning when the RP directed Resident #16 into the room. The social services assistant stated she told the RP not to walk on the wet floor but the RP went in anyway with the resident. The social services assistant stated the housekeepers also told the RP not to walk onto the wet floor. The social services assistant stated the RP told her they would find dry spots to walk on in the room. The social services assistant stated the RP comes daily and walks with the resident. The social services assistant stated it was not safe for anyone to be walking on the wet floor in the dining room. The social services assistant stated, She (RP) does what she wants. On 3/30/16 at 9:30 a.m. the licensed practical nurse (LPN #4) caring for Resident #16 was interviewed about Resident #16's observed unsteady gait and walking unsupervised by staff with the RP. LPN #4 stated the nurses and aides used a gait belt and/or wheelchair when ambulating or transporting Resident #16. LPN #4 stated the RP comes daily and walks the resident. LPN #4 stated she had previously seen the RP walk the resident facing her, walking backwards, holding her hands and arms extended. LPN #4 stated, I've seen her (RP) walk her (Resident #16) like that before. When asked if the RP had been educated about how to safely ambulate the resident, LPN #4 stated she did not know. On 3/30/16 at 9:40 a.m. the director of nursing (DON) was interviewed about the resident ambulating with the RP on the wet floor without staff supervision or a gait belt. The DON stated the RP should not be walking the resident in an unsafe manner and the resident should be ambulated following the care plan interventions for fall prevention. These findings were reviewed with the administrator and director of nursing during a review meeting on 3/30/16 at 4:40 p.m.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure two of 24 residents were free from significant medication errors. Resident #5, with a diagnosed [MEDICAL CONDITION] disorder, was harmed when facility staff failed to administer the anticonvulsant medication [MEDICATION NAME] as ordered by the physician. Facility staff failed to enter and follow a verbal order from the physician to restart the resident's daily dose of [MEDICATION NAME] to maintain therapeutic levels of the medication. After two days without [MEDICATION NAME], Resident #5 experienced a grand mal [MEDICAL CONDITION] as a result of low [MEDICATION NAME] levels and required hospitalization for treatment. Resident #4 was administered the antipsychotic medication [MEDICATION NAME] for 5 months after the physician had ordered the medication to be discontinued. The findings include: 1. Resident #5, with a diagnosed [MEDICAL CONDITION] disorder, was harmed when facility staff failed to administer the anticonvulsant medication [MEDICATION NAME] as ordered by the physician. Facility staff failed to enter and follow a verbal order from the physician to restart the resident's daily dose of [MEDICATION NAME] to maintain therapeutic levels of the medication. After two days without [MEDICATION NAME], Resident #5 experienced a grand mal [MEDICAL CONDITION] as a result of low [MEDICATION NAME] levels and required hospitalization for treatment. Resident #5 was admitted to the facility on [DATE] with a re-admission on 1/12/15. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #5 with severely impaired cognitive skills. A facility reported incident form dated 7/15/14 documented, Resident had elevated [MEDICATION NAME] level for the past week. His labs were being monitored and there was orders to hold his medication. On 7/12/14 residents [MEDICATION NAME] level was to resume. The nurse failed to transcribe the order into the eMAR (electronic medication administration record) system and resident did not receive his medication on 7/12/14 and 7/13/14. The resident began to have [MEDICAL CONDITION] activity on 7/14/14 and was sent to the ER (emergency room ) for evaluation. (sic) Resident #5's clinical record was reviewed on 3/25/15. The record documented a physician's orders [REDACTED]. The resident was also prescribed daily doses of the anticonvulsants [MEDICATION NAME] (40 mg twice per day every 2 days alternating with 40 mg three times per day every 2 days and [MEDICATION NAME] (500 mg two times per day). The record documented a physician's orders [REDACTED]. Resident #5's lab results dated 7/3/14 documented the resident had a high [MEDICATION NAME] level. The report documented a 7/3/14 reading of 39.4 mcg/mL (micrograms per milliliter) with the normal reference range listed as 10.0 to 20.0 mcg/mL. A physician's orders [REDACTED]. The order listed the hold dates from 7/3/14 until 7/8/14. Additional lab tests were ordered/completed monitoring the resident's [MEDICATION NAME] level while the medication was held. Lab results documented the following [MEDICATION NAME] levels: 7/5/14 at 33.5 mcg/mL; 7/7/14 at 41 mcg/mL; 7/8/14 at 33.7 mcg/mL; 7/9/14 at 28.6 mcg/mL. Nursing notes documented the following: 7/3/14 - Abnormal Lab [MEDICATION NAME] level.critical [MEDICATION NAME] level 39.4.Notified GNP (nurse practitioner).Hold [MEDICATION NAME] level until lab result back. 7/5/14 - .results of [MEDICATION NAME] level drawn on 7/4/14 = 33.5. (Physician) notified. NO (new order): continue to HOLD [MEDICATION NAME] for now. 7/7/14 - .lab called with critical lab value 41.Hold [MEDICATION NAME] level until lab result back. 7/9/14 - [MEDICATION NAME] level on 7/8/14 was 33.7. (nurse practitioner) notified. Continue to hold [MEDICATION NAME]. Recheck [MEDICATION NAME] am on 7/9/14. 7/10/14 - NP.called and requsted (requested) that (physician) be notified of [MEDICATION NAME] levels results 28.6.Hold med for 24 hrs (hours) and continue current dosage. The physician's orders [REDACTED]. The resident's MAR for July 2014 documented the resident's [MEDICATION NAME] was not restarted and continued to be held on 7/12/14 and 7/13/14. A lab report dated 7/14/14 listed the resident's [MEDICATION NAME] level was below the therapeutic range at 6.5 mcg/mL. A nursing note dated 7/14/14 at 5:00 a.m. documented the resident was assessed with [REDACTED]. Slow to respond to verbal and tactile stimuli. VS (vital signs of temperature, pulse, respirations, blood pressure, oxygen saturation) 96.4, 103, 22, 178/100, 93% RA (room air). Resident observed to have drool to sides of mouth. Resident with [MEDICAL CONDITION] activity occurring at 5:35 am and [MEDICATION NAME] 2 mins (minutes) with slapping and full body convulsions.On call doctor paged.new orders for STAT [MEDICATION NAME] level ans (and) give 200 mg of [MEDICATION NAME] X 1 (one time) now. A note dated 7/14/14 at 1:15 p.m. stated the resident again had [MEDICAL CONDITION] activity and was sent to the hospital for treatment. This note stated, Resident observed with [MEDICAL CONDITION] activity and slow to respond to sternal rub.NP observed with [MEDICAL CONDITION] activity.Resident is lethargic.Patient send 911 to ED (emergency department) now. (sic) A nurse practitioner note dated 7/14/14 documented, Pt (patient) unresponsive, seizing as I walk in room - labored breathing.very tonic (contraction of muscles) appearing.HR (heart rate approximately) [MEDICAL CONDITION] D/O (disorder) w/ (with) [MEDICATION NAME] level (around) 6 ??.To ED (emergency department) now. Resident #5's emergency room report dated 7/14/14 documented, Discuss with (physician). The patient had his [MEDICATION NAME] held all weekend, which was an error. He told the nursing home to hold the [MEDICATION NAME] only for 2 doses. Patient apparently will have a prolonged post ictal (recovery after epileptic [MEDICAL CONDITION]). Often last days post [MEDICAL CONDITION] per (physician). Resident #5's hospital discharge summary report dated 7/16/14 documented the resident was admitted and treated for [REDACTED]. The discharge report dated 7/16/14 documented, .Altered mental status s/p (status [REDACTED]. Patient was loaded with [MEDICATION NAME] in the ER (emergency room ) and was given [MEDICATION NAME]. He became minimally responsive, in a post-ictal state, for several hours after admission, but woke up by hospital day 2. He was transitioned to IV (intravenous) antiepileptics on admission, but when the patient awoke, he was very agitated and pulled out his IVs. Transitioned back to home regimen of antiepilipetics (antiepileptics).per neurology recommendations. [MEDICATION NAME] level was 23.7 on the day of discharge and no further [MEDICAL CONDITION] activity was witnessed. The cause of his [MEDICAL CONDITION] was thought to be suptherapeutic (subtherapeutic) [MEDICATION NAME] level in addition [MEDICAL CONDITION]. (sic) The resident returned to the facility on [DATE]. The facility's investigation findings listed Resident #5 was not administered [MEDICATION NAME] on 7/12/14 and 7/13/14 because the nurse failed to transcribe/follow a verbal physician's orders [REDACTED]. The facility's medication error report form dated 7/14/14 stated, Residents dilatin ([MEDICATION NAME]) level had been running high and on hold. Lab work obtained physician gave order to restart medication and follow up with labs. the order to restart was not entered into the system as ordered. Therefore the resident did not receive his [MEDICATION NAME] on 7/12/14 and 7/13/14. A written statement from the licensed practical nurse (LPN #9) that received the verbal order on 7/10/14 documented, I worked on Unit 3 on Thursday (7/10/14) evening. I do remember talking to (physician) about (Resident #5's) [MEDICATION NAME] levels and received new orders. I thought I put the order in the system because I always try to input the order then follow up with my documentation. The documentation I completed does reflect the order I received. (sic) On 3/25/15 at 3:00 p.m. the director of nursing (DON) was interviewed about Resident #5's [MEDICAL CONDITION] in July 2014 due to low [MEDICATION NAME] levels. The DON stated the resident's [MEDICATION NAME] levels were high and the physician had ordered the medication held. The DON stated on 7/10/14 the physician verbally gave an order to LPN #9 to restart the [MEDICATION NAME] on 7/12/14. The DON stated she confirmed with the physician that the order was given but the order was never transcribed or entered into the electronic medication administration system or paper record. The DON stated LPN #9 was training another nurse when the order was received on 7/10/14 and never transcribed the order. In addition, the DON stated the nurse failed to list the medication restart on the 24 hour report. The DON stated the 24 hour report was documentation used to communicate with nursing staff from shift to shift. The DON stated, The weekend nurses didn't know to restart (the [MEDICATION NAME]). The whole system failed. The DON stated the resident developed a [MEDICAL CONDITION] two days after the [MEDICATION NAME] was supposed to be restarted and the [MEDICATION NAME] level dropped. LPN #9 that received the verbal order from the physician on 7/10/14 to restart the resident's [MEDICATION NAME] no longer worked at the facility. The facility's procedure #C1125 (effective 1/29/14) titled Physician Telephone Orders stated, Licensed Nurse will document all physician's verbal and telephone orders into Point Click Care (facility's electronic clinical record system).The Licensed Nurse accepting the order.should include the date, time, physician's orders [REDACTED]. Drug Information Handbook for Nursing 13th Edition on page 961 describes [MEDICATION NAME] ([MEDICATION NAME]) as an anticonvulsant medication used for, Management of generalized tonic-clonic (grand mal), complex partial [MEDICAL CONDITION] This reference on page 963 documents nursing actions with use of [MEDICATION NAME] as, When oral [MEDICATION NAME] is discontinued, dose should be tapered gradually; abrupt discontinuance can cause [DIAGNOSES REDACTED]. Page 1327 of this reference lists therapeutic levels for [MEDICATION NAME] as 10 to 20 mcg/mL. (1) The Lippincott Manual of Nursing Practice 10th Edition on pages 557 states concerning management of [MEDICAL CONDITION], Nonadherence to medication regimen as well as toxicity of anti-epileptic medications can increase [MEDICAL CONDITION] frequency. Page 562 of this reference documents, Sudden unexpected death in [MEDICAL CONDITION] can be reduced by decreasing the number of [MEDICAL CONDITION] that a patient experiences and taking medications, as prescribed. (2) The National Institutes of Health Medline Plus health information defines [MEDICAL CONDITION] as .a brain disorder in which a person has repeated [MEDICAL CONDITION] over time. [MEDICAL CONDITION] are episodes of disturbed brain activity that cause changes in attention or [MEDICAL CONDITION] occurs when permanent changes in the brain cause it to be too excitable or irritable. As a result, the brain sends out abnormal signals. This leads to repeated, unpredictable [MEDICAL CONDITION] This reference defines a grand mal [MEDICAL CONDITION] as a generalized tonic-clonic [MEDICAL CONDITION] that involves the entire body, including aura, rigid muscles, and loss of alertness. This references documents regarding treatments for [MEDICAL CONDITION], Medication to prevent [MEDICAL CONDITION], called anticonvulsants, may reduce the number of future [MEDICAL CONDITION] take your medication on time and as directed. Missing a dose can cause you to have a [MEDICAL CONDITION] This reference lists possible complications from [MEDICAL CONDITION] include, .breathing in food or saliva into the lungs, during a [MEDICAL CONDITION], which can cause aspiration pneumonia.injury from falls, bumps, self-inflicted bites.permanent brain damage (stroke or other damage). (3) These findings were reviewed with the administrator, director of nursing and corporate consultant during a review meeting on 3/25/15 at 5:30 p.m. (1) Turkoski, Beatrice B., Brenda R. Lance and Elizabeth A. Tomsik. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2011. (2) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. (3) [MEDICAL CONDITION] - overview. MedlinePlus Medical Encyclopedia. 2/10/14. U.S. National Library of Medicine National Institutes of Health. 3/30/15. <http://www.nlm.nih.gov/medlineplus/ency/article/ 4.htm> 2. Resident #4 was administered the antipsychotic medication, [MEDICATION NAME] for five months after the physician ordered the medication to be discontinued. Resident #4 was admitted post psychiatric discharge on 10/07/2014. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/14/2015. Resident #4 was assessed as being impaired with both long and short term memory, as well as being severely impaired with daily decision making skills. The clinical record was reviewed on 03/24/2015 at approximately 3:30 p.m. The POS (physician's orders [REDACTED]. Medications ordered for Resident #4 included but were not limited to: [MEDICATION NAME] 15 mg (milligrams) TID (three times per day), [MEDICATION NAME] 2 mg at bedtime, [MEDICATION NAME] 150 mg at bedtime, [MEDICATION NAME] 200 mg by mouth once per day, [MEDICATION NAME] 250 mg in the evening, [MEDICATION NAME] 250 mg once per day, and [MEDICATION NAME] 15 mg at bedtime. The MAR (medication administration record) was reviewed, all medications were documented as given as ordered. On 03/25/2015 the NP (nurse practitioner) came to the conference room to speak with this surveyor regarding Resident #4. During the conversation the NP was asked about the [MEDICATION NAME] that Resident #4 receives at night. She stated, No, that was discontinued in October. The NP was shown the MAR (medication administration record) that documented Resident #4 receiving 2 mg of [MEDICATION NAME] every night. She stated, I didn't know that, I thought it had been discontinued.I will have them discontinue it today. The clinical record was in the conference room at the time. A handwritten physician order [REDACTED]. The order read: d/c (discontinue prn (as needed) [MEDICATION NAME]) (& scheduled if ordered). The order was signed by the attending physician. New orders written by the NP were reviewed on 03/25/2015 following the interview. The NP wrote the following orders: Increase [MEDICATION NAME] to 15 mg PO (by mouth) TID (three times per day) and 15 mg PO qhs (bedtime) for anxiety, decrease [MEDICATION NAME] to 100 mg PO q AM (every morning), 100 mg Po q (every) lunch, 100 mg PO q dinner 100 mg po q hs for agitation. D/C (discontinue) [MEDICATION NAME] tablets, D/C IM (intramuscularly) [MEDICATION NAME] injection, [MEDICATION NAME] oral concentration .25-.5 ml (milliliters) TID PRN (as needed) anxiety, D/C [MEDICATION NAME] scheduled see 10/14 MD order. During an end of the day meeting on 03/25/2015 at approximately 5:20 p.m. the above information was shared with the administrator. On 03/26/2016 this surveyor spoke with the pharmacist (other staff #5) who came to the facility to do monthly medication reviews. She was asked what she looked at when she came to the facility. She stated, I look at antipsych drugs, antianxiety meds, I talk to the staff about residents with behaviors, [MEDICAL CONDITION], falls, anything related to their medications.I look at the orders. She was asked if she had seen the order to discontinue Resident #4's [MEDICATION NAME] in October. She stated, Yes, I saw that. I asked the DON (director of nursing) for clarification on that.the order was to discontinue the PRN [MEDICATION NAME] and the scheduled and the scheduled was not discontinued.I sent letters to the DON about that, she gives them to the unit managers.I talked to (Name of Unit Manager on unit 3) and told her we needed to clarify.she recently told me that we are keeping the [MEDICATION NAME]. The Pharmacist was asked why her questions regarding the [MEDICATION NAME] were not written on the Clinical Pharmacist Medication Regimen Review Summary located in the clinical record. She stated, The nurses told me she had difficult behaviors, since the [MEDICATION NAME] was never discontinued and it showed back up on the POS (physician order [REDACTED]. Resident #4 continued to receive [MEDICATION NAME] 2 mg every evening at bedtime from October 14, 2014 through the bedtime dose on 03/25/2015 for a total of 161 doses. On 03/26/2015 at 6:20 p.m., the above information was shared with the administrator and the DON (director of nursing). No further information was obtained prior to the exit conference on 03/26/2015.

Based on clinical record review and staff interview, the facility staff failed, for one of 24 residents in the survey sample (Resident # 13), to provide treatment and services to prevent the development of a pressure sore. Resident # 13 was found with an unstageable pressure sore, which resulted in harm to the resident. The facility also failed to perform skin assessments for seven of 24 residents in the survey sample (Residents # 1, 5, 6, 8, 10, 11, and 16). Resident #5, assessed as a moderate risk for pressure sore development, did not have weekly skin assessments performed by nursing from November 2014 through week ending 3/21/15 as required in his plan of care. Resident #8, assessed as being at risk for skin breakdown, did not have weekly skin assessments performed by nursing as required in her plan of care. Resident #1's skin assessment were not performed weekly as ordered. Resident #10 did not have weekly skin assessments completed by the licensed nursing staff. The facility staff failed to perform weekly skin assessments for Resident #6. The facility staff failed to perform weekly skin assessments for Resident #11. The facility staff failed to perform weekly skin assessments for Resident #16 The findings include: 1. Resident # 13 was found with an unstageable pressure sore, covered with eschar, which resulted in harm to the resident. Resident # 13 in the survey sample, a [AGE] year-old female, was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. According to a Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/8/14, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 6 out of 15. Under Section M (Skin Conditions), at Item M0150 - Risk of Pressure Ulcers, the question Is this resident at risk of developing pressure ulcers? was answered Yes. At Item 0210 - Unhealed Pressure Ulcer(s), the question Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? was answered No. Resident # 13 also had a Quarterly MDS with an ARD of 2/6/15. Under Section C (Cognitive Patterns) the resident was assessed as having short and long term memory problems with modified independence for daily decision making skills. Under Section M (Skin Conditions), at Item M0150 - Risk of Pressure Ulcers, the question Is this resident at risk of developing pressure ulcers? was answered Yes. At Item 0210 - Unhealed Pressure Ulcer(s), the question Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? was answered Yes. At Item M0300 - Current Number of Unhealed Pressure Ulcers at Each Stage, under Part F - Unstageable - Slough or eschar, the question Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar, was answered with the number 1, indicating the resident had one unstageable pressure ulcer. (NOTE: Eschar is defined as Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. Ref. CMS's RAI Version 3.0 Manual, Chapter 3, Page M-15.) Review of the Progress (Nurses) Notes in the resident's electronic clinical record revealed the following entries: 12/18/14 - 1:34 p.m. Wound Note: Resident observed with LLE (left lower extremity) free open areas. 1/3/15 - 11:26 a.m. Lt (Left) heel scab.min (minimum) blood noted lt heel, scab off. No redness, no swelling, area cleanses with Normal Saline and dry dressing. MD (name) gave new order, skin prep q (every) shift and apply bunny boots while in bed. 1/10/15 - 8:16 a.m. Wound Note: Resident continues with 2.5 (centimeters) x 2.5 intact black eschar on L (left) heel.Continue with skin prep and heel boots. 1/15/15 - 2:17 p.m. Wound Note: Resident continues with 2.5 x 2.5 cm (centimeters) black eschar on L heel, intact with no drainage, no redness, sore to touch, continue with skin prep and heel boots. 1/23/15 - 3:28 p.m. Wound Note: Resident continues with unstaged ulcer L heel, 2.5 x 2.5 cm, black eschar intact, no drainage, no redness, continue with skin prep and heel boots. 2/6/15 - 4:38 p.m. Wound Note: Firm intact black eschar area on L heel has come off. Observed with white slough on L heel measures 2 x 1.7 cm. No redness, no drainage. New order for Santyl qd (daily) to debride area, continues with heel boots to off load heels. (NOTE: Slough is defined as Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. Ref. CMS's RAI Version 3.0 Manual, Chapter 3, Page M-15.) Resident # 13's paper clinical record included two Wound Evaluation Flow Sheets dated 11/5/14 and 11/25/14. The 11/5/14 Flow Sheet dealt with a skin tear to the left lower extremity that was noted as healed on 11/17/14. The 11/25/14 Flow Sheet concerned a skin abrasion to the left lower extremity that was healed on 12/17/14. There were no other Wound Evaluation Flow Sheets or any skin evaluation sheets in the resident's paper clinical record or electronic clinical record. At 9:45 a.m. on 3/26/15, LPN # 1 (Licensed Practical Nurse), the Wound Care Nurse, was interviewed about the eschar area on Resident # 13's left heel. Asked how he is alerted to the presence of pressure areas, LPN # 1 said he relies on nursing, and sometimes the CNA's to tell him. At the request of the surveyor, LPN # 1 reviewed his wound care records, but was unable to find any skin assessment sheets related to the left heel. Speaking to the area on the left heel, LPN # 1 said, It had eschar on the heel when I first saw it on 1/3/15. At approximately 5:30 p.m. on 3/25/15, during a meeting with the administrative staff, including the Administrator and the Director of Nursing (DON), the identification of an eschar area on Resident # 13's left heel was discussed. The DON was asked if there was any documentation that would help explain the source of the eschar area on Resident # 13's left heel. At about 1:30 p.m. on 3/26/15, the DON presented the surveyor with copies of two Wound Evaluation Flow Sheets dated 1/3/15. The first entry, dated 1/5/15, described an unstageable pressure area measuring 2.5 x 2.5, that was painful, with necrotic tissue, that was first observed on 1/3/15. At 3:45 p.m. on 3/26/15, LPN # 1 was interviewed again regarding the area of eschar on Resident # 13's left heel. When LPN # 1 was shown the Wound Evaluation Flow Sheets provided by the DON, he indicated he was not aware of them. Asked again how he became aware of the eschar area on Resident # 13's left heel, LPN # 1 said, I first became aware of the heel eschar by the Nurses Note of 1/3/15. 2. Resident #5, assessed as a moderate risk for pressure sore development, did not have weekly skin assessments performed by nursing from November 2014 through week ending 3/21/15 as required in his plan of care. Resident #5 was admitted to the facility on [DATE] with a re-admission on 1/12/15. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #5 with severely impaired cognitive skills. Resident #5's clinical record was reviewed on 3/25/15. The record documented on 1/12/15 the resident was assessed as a moderate risk for pressure sore development as documented with a score of 13 on the Braden scale for predicting pressure sore risk. The record documented no weekly nursing assessments of the resident's skin from December 2014 through week ending 3/21/15. Sheets to record the weekly assessments during these weeks were in the record but blank. The resident's current plan of care (revised 2/10/15) listed the resident was at risk of skin impairment due to incontinence, [MEDICAL CONDITION]/intellectual disability, impaired mobility and refusal of care at times. Included among interventions to prevent skin breakdown was, Inspect skin with care. Report reddened areas, rashes, bruising, or open areas to charge nurse. On 3/25/15 at 7:50 a.m. the registered nurse (RN #2) unit manager was interviewed about missing skin assessments for Resident #5. RN #2 stated she did not know why the assessments were not done as required. RN #2 stated charge nurses were assigned to perform skin assessments weekly according to a schedule in the skin assessment book. RN #2 stated charge nurses were supposed to perform skin assessments weekly and document their findings on the skin assessment sheets. On 3/25/15 at 4:10 p.m. with the resident's permission, licensed practical nurse (LPN) #1 was observed performing a skin inspection with Resident #5. No pressure sores or open areas were observed on the resident's skin. Red, blanchable areas were noted by LPN #1 on the resident's face, inside of both knees, between toes and on the right heel. LPN #1 was interviewed at this time about weekly skin assessments. LPN #1 stated floor nurses were supposed to perform skin assessments weekly and report to him any areas requiring treatment. The facility's skin care protocol (undated) titled Skin Integrity Guideline documented on page 2, Licensed nurse will be responsible for performing a skin evaluation/observation weekly.The following elements are in place to demonstrate satisfactory compliance with guideline:.Weekly skin checks are in place. These findings were reviewed with the administrator and director of nursing (DON) during a review meeting on 3/26/15 at 11:45 a.m. The DON was interviewed about weekly skin assessments performed by nurses at this time. The DON stated the nurses were supposed to perform a weekly skin assessment on all residents and document the findings. When asked why the assessments were not always being done, the DON stated nurses signed off the bath sheets completed by the certified nurses' aides indicating any redness, rashes, cuts or open areas observed during showers and/or baths. The DON stated she did not know if nurses thought signing the aide sheets was a substitute for the nursing assessment. The DON stated the bath sheets completed by the aides were not part of the clinical record. The DON stated, The nursing skin assessments are not being done consistently. 3. Resident #8, assessed as being at risk for skin breakdown, did not have weekly skin assessments performed by nursing as required in her plan of care. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #9 with severely impaired cognitive skills. Resident #8's clinical record was reviewed on 3/25/15. The record documented the resident was assessed upon admission to the facility on [DATE] to be at risk for pressure sore development as documented with a score of 17 on a Braden scale for predicting pressure sore risk. The clinical record documented no nursing assessments of Resident #8's skin for week ending 12/20/14 or for any weeks during January 2015. Weekly skin assessments sheets marked with Resident #8's name and room number were blank for week ending 12/20/14 and January 2015. Skin assessments for week ending 12/20/14 and January 2015 were not documented in nursing notes or any other part of the clinical record. The resident's current care plan (revised 2/27/15) listed the resident had the potential for altered skin integrity related to immobility, chronic liver disease and redness noted on her buttocks from moisture on 11/20/14. Included among interventions to maintain the resident's skin integrity was, Conduct weekly skin inspection.Monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor.Skin assessment to be completed per Living Center policy. On 3/25/15 at 7:50 a.m. the registered nurse (RN #2) unit manager was interviewed about missing skin assessments. RN #2 stated she did not know why the assessments were not done as required. RN #2 stated charge nurses were assigned to perform skin assessments weekly according to a schedule in the skin assessment book. RN #2 stated charge nurses were supposed to perform skin assessments weekly and document their findings on the skin assessment sheets. The facility's skin care protocol (undated) titled Skin Integrity Guideline documented on page 2, Licensed nurse will be responsible for performing a skin evaluation/observation weekly.The following elements are in place to demonstrate satisfactory compliance with guideline:.Weekly skin checks are in place. These findings were reviewed with the administrator and director of nursing (DON) during a review meeting on 3/26/15 at 11:45 a.m. The DON was interviewed about weekly skin assessments performed by nurses at this time. The DON stated the nurses were supposed to perform a weekly skin assessment on all residents and document the findings. When asked why the assessments were not always being done, the DON stated nurses signed off the bath sheets completed by the certified nurses' aides indicating any redness, rashes, cuts or open areas observed during showers and/or baths. The DON stated she did not know if nurses thought signing the aide sheets was a substitute for the nursing assessment. The DON stated the bath sheets completed by the aides were not part of the clinical record. The DON stated, The nursing skin assessments are not being done consistently. 4. Resident #1's skin assessment were not performed weekly as ordered. Resident #1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/28/15 was a 30 day assessment. The resident was assessed as a 15 for cognitive skills. On 3/26/15 at approximately 7:45 a.m., Resident #1's care plan (CP), initiated on 8/24/11, was reviewed to include the following: Focus.At risk for altered skin integrity related to: history of [MEDICAL CONDITION] to both legs, hx of buttock reddened, risk of decline due to diabetes, [MEDICAL CONDITION]: Conduct weekly skin inspection. On 3/26/15 at approximately 8:00 a.m., a Braden Scale for Predicting Pressure Sore Risk was reviewed the resident was assessed as a 16 At risk with a score of 15-18 for pressure sores. The clinical record was reviewed for documentation of the weekly skin assessment. The assessments were not located in the clinical record. On 3/26/15 at approximately 8:05 a.m., the unit manager, who was a registered nurse and will be identified as RN #3 was interviewed regarding the location of the weekly skin assessments. RN #3 stated, I have them in a book in my office. I will go and get them for you. RN #3 went to her office and returned with the skin assessment sheets for Resident #1. The skin assessment were dated 1/21/5, 1/27/15, 2/4/15 and 2/11/15. RN #3 was interviewed and asked about the location of the remainder of the skin assessments. RN #3 did not answer. On 3/26/15 at approximately 11:52 a.m. during a meeting with the administrator and the director of nursing, the survey team was discussing the skin assessments and the location. The DON stated that the skin assessments were not being done timely and the staff was gong to be educated. The DON also stated that the CNA, certified nursing assistant, and the nurse was supposed to inspect the residents skin weekly on bath days and document the findings on the skin sheet. The DON further states that she was aware that this was not being done consistently. The DON was interviewed and asked if Resident #1 had any other skin assessments available for review. The DON stated that she would check. On 3/26/15 at approximately 3:00 p.m. the DON presented to this Surveyor copies of the Resident skin assessments were done sporadically and not done weekly as stated by the DON on 3/26/15 at 11:52 a.m. Resident #1 did have an area on her left heel that was due to her [MEDICAL CONDITION] and the area was found readmission on 12/31/14, with assessments performed weekly by the wound nurse. 5. Resident #10 did not have weekly skin assessments completed by the licensed nursing staff. Resident #10 was originally admitted to the facility on [DATE]. His original [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/17/2014. Resident #10 was assessed as having a cognitive summary score of 15, indicating he was cognitively intact. Resident #10 was assessed on his MDS as being at risk for the development of pressure ulcers. The clinical record was reviewed on 03/25/2015. Weekly skin assessments were not present on the clinical record. There were no skin assessments for March 2015, one assessment was present for February 2015 (2/24/2015), and none for January 2015. The unit manager, RN (registered nurse) #2 was asked if the assessments were kept somewhere other than the clinical record. She stated, They are looking for the bath sheets to show to you all. The bath sheets were presented on 03/25/2015. The top of the sheet contained the following: The following assessment is to be completed on all residents receiving a bath. The charge nurse will co-sign and verify each assessment for accuracy and completion. All wounds and findings are to be addressed immediately by the charge nurse and forwarded to the unit manager (or supervisor) and treatment nurse with follow up of a physician or nurse practitioner. The sheet contained a table with three areas, Assessment; Yes/Comments; No. Under the assessment column were the following areas: Reddened area?; Rashes?; Bruises?; Open Lesion, cuts, lacerations or skin tears?; Open Ulcers (treated or new)?; Dry or flaky skin?; Fingernails clean and short?; Facial hair removed?; Toenails inspected? Is podiatrist needed? The bottom of the page had an area that contained the following information: Date, Resident's name, CNA (certified nursing assistant) name, Charge Nurse .signing ensures that the above assessment is correct and the appropriate interventions have been taken). Review of the bath sheets showed that not all bath sheets were signed by nursing staff. The facility policy for skin assessments was requested. The policy Skin Integrity Guideline stated, Licensed nurse will be responsible for performing a skin evaluation/observation weekly.licensed nurse to document weekly on wounds using the Wound Evaluation Flow Sheet.The following elements are in place to demonstrate satisfactory compliance with guideline: .weekly skin checks are in place. The DON (director of nursing) and the administrator were notified of the above information during an end of the day meeting on 03/26/2015. No further information was obtained prior to the exit conference on 03/26/2015. 6. The facility staff failed to perform weekly skin assessments for Resident #6. Resident #6 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), a quarterly with an assessment reference date (ARD) of 1/16/15 showed the resident with a brief interview for mental status (BIMS) score of 15 out of 15, meaning the resident is cognitively intact. The clinical record was reviewed on 3/24/15 and 3/25/15. The current care plan documented Focus - Pressure ulcer - at risk due to: Assistance required in bed mobility, res (resident) determines when she is and how she is to be repositioned and turned, as well as setting the schedule with an initiation date of 5/10/13 and a target date of 4/29/15. Documented under Interventions included, but not limited to, conduct weekly skin inspections. Documented Focus - Gastrointestinal distress due to emesis and loose stools with an initiation date of 2/17/15 and a target date of 4/29/15 documented the Intervention including, but not limited to, Assessment of skin condition weekly by licensed nurse. Assessment of skin condition around perineal area as needed if diarrhea present. The weekly skin assessment sheet documentation showed missing assessments between the dates of 6/23/14 and 7/7/14, 12/15/14 and 12/30/14, 1/12/15 and 1/26/15, 1/26/15 and 2/9/15, 2/9/15 and 2/23/15, and 3/2/15 and 3/26/15. The documentation on top of the skin assessment record showed Mon (Monday) 11-7 (shift). The skin assessments in the paper clinical record during the review dates went from 3/3/14 to 9/22/14. On 3/26/15 at 7:55 a.m., registered nurse (RN) #3 was asked to see the skin assessment book. RN #3 advised this surveyor that it was in her room and that she would get it. This surveyor then asked about the assessments. RN #3 stated the nurse does the weekly skin assessments and then documents it on the assessment sheet. When the sheet is completed, the nurse puts it in the clinical record. This surveyor also asked for all of Resident #6's weekly skin assessment sheets. On 3/26/15 at 8:15 a.m., the wound care nurse was asked how he is made aware of any skin issues with the residents. The wound care nurse stated the staff let me know, sometimes the residents or family members will too. When asked if he reviews the weekly skin assessment sheets to see if there are any skin problems with the residents, the wound nurse stated No, just go by what I am told. On 3/26/15 at 11:42 a.m., the administrative team was made aware of the findings during a meeting with the survey team. The director of nursing services was asked about the weekly skin assessments and the weekly skin assessment sheets. The director of nursing services mentioned that the nurses are triggered by the electronic treatment assessment record (eTAR) when to perform the weekly skin assessment sheets. This surveyor advised the director of nurses that there is no documentation on Resident #6's eTAR or eMAR (electronic medication administration record. This surveyor asked for the facility's policy on skin assessments. On 3/26/15 at 6:40 p.m., this surveyor received the facility's policy titled Skin Integrity Guideline which documented under the section General Guideline: Living Center develops a routine schedule to review patients/residents with wounds or at risk on a weekly basis and will document findings. DNS (director of nursing services) or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis. Documented under the section Documentation of Weekly Skin Evaluation/Observations: Licensed nurse will be responsible for performing a skin evaluation/observation weekly. The nursing order for weekly skin observations on all residents will be entered and printed out on the Treatment Administration Record or Medication Administration Record. No other information was provided to this surveyor prior to the exit conference on 3/26/15. 7. The facility staff failed to perform weekly skin assessments for Resident #11. Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), a quarterly with an assessment reference date (ARD) of 1/24/15 showed the resident with a brief interview for mental status (BIMS) score of 15 out of 15, meaning the resident is cognitively intact. The clinical record was reviewed on 3/25/15. The current care plan documented Focus - Pressure ulcer actual or at risk due to: Requires assist with bed mobility and dependant on staff with ADLs (activities of daily living). Resident is noncompliant with preventative devices and allowing staff to provide treatments at times (sic) with an initiation date of 2/23/15 and a target date of 5/7/15. The interventions include, but are not limited to, Conduct weekly skin inspections. Skin assessment to be completed per Living Center Policy. The weekly skin assessment sheet documentation showed missing assessments between the dates of 6/11/14 and 7/2/14, 7/2/14 and 8/20/14, 8/27/14 and 9/10/14, 11/19/14 and 12/24/14, and 12/24/14 and 1/7/15. There were no assessments for the month of 4/14. The last assessment was performed on 2/25/15. On 3/26/15 at 7:55 a.m., registered nurse (RN) #3 was asked to see the skin assessment book. RN #3 advised this surveyor that it was in her room and that she would get it. This surveyor then asked about the assessments. RN #3 stated the nurse does the weekly skin assessments and then documents it on the assessment sheet. When the sheet is completed, the nurse puts it in the clinical record. This surveyor also asked for all of Resident #11's weekly skin assessment sheets. On 3/26/15 at 8:15 a.m., the wound care nurse was asked how he is made aware of any skin issues with the residents. The wound care nurse stated the staff let me know, sometimes the residents or family members will too. When asked if he reviews the weekly skin assessment sheets to see if there are any skin problems with the residents, the wound nurse stated No, just go by what I am told. On 3/26/15 at 11:42 a.m., the administrative team was made aware of the findings during a meeting with the survey team. The director of nursing services was asked about the weekly skin assessments and the weekly skin assessment sheets. The director of nursing services mentioned that the nurses are triggered by the electronic treatment assessment record (eTAR) when to perform the weekly skin assessment sheets. This surveyor advised the director of nurses that there is no documentation on Resident #11's eTAR or eMAR (electronic medication administration record. This surveyor asked for the facility's policy on skin assessments. On 3/26/15 at 6:40 p.m., this surveyor received the facility's policy titled Skin Integrity Guideline which documented under the section General Guideline: Living Center develops a routine schedule to review patients/residents with wounds or at risk on a weekly basis and will document findings. DNS (director of nursing services) or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis. Documented under the section Documentation of Weekly Skin Evaluation/Observations: Licensed nurse will be responsible for performing a skin evaluation/observation weekly. The nursing order for weekly skin observations on all residents will be entered and printed out on the Treatment Administration Record or Medication Administration Record. No other information was provided to this surveyor prior to the exit conference on 3/26/15. 8. The facility staff failed to perform weekly skin assessments for Resident #16. Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), an annual with an assessment reference date (ARD) of 3/4/15 showed the resident with a brief interview for mental status (BIMS) score of 9 out of 15, meaning the resident is moderately cognitively impaired. On 3/26/15 at 7:55 a.m., registered nurse (RN) #3 was weekly skin assessments. RN #3 stated the nurse does the weekly skin assessments and then documents it on the assessment sheet. When the sheet is completed, the nurse puts it in the clinical record. On 3/26/15 at 8:15 a.m., the wound care nurse was asked how he is made aware of any skin issues with the residents. The wound care nurse stated the staff let me know, sometimes the residents or family members will too. When asked if he reviews the weekly skin assessment sheets to see if there are any skin problems with the residents, the wound nurse stated No, just go by what I am told. On 3/26/15 at 11:42 a.m., the director of nursing services was asked about the weekly skin assessments and the weekly skin assessment sheets. The director of nursing services mentioned that the nurses are triggered by the electronic treatment assessment record (eTAR) when to perform the weekly skin assessment sheets. This surveyor advised the director of nurses that there is no documentation on Resident #11's eTAR or eMAR (electronic medication administration record. This surveyor asked for the facility's policy on skin assessments. The clinical record was reviewed on 3/26/15. The current care plan documented under Focus - Pressure ulcer actual or at risk due to: Assistance required in bed mobility, Bowel and bladder incontinence with an initiation date of 3/21/12 and a target date of 6/16/15. The interventions include, but not limited to, Skin assessment to be completed per Living Center Policy. The weekly skin assessment sheet documentation showed missing skin assessments between the dates of 4/16/14 and 4/23/14, 4/23/14 and 5/7/14, 5/14/14 and 5/28/14, 5/28/14 and 6/11/14, 6/18/14 and 7/9/14, 7/23/14 and 8/6/14, 8/6/14 and 8/20/14, 9/3/14 and 9/17/14, 9/17/14 and 10/1/14, 10/1/14 and 10/15/14, and 11/26/14 and 12/10/14. The rest of month 12/14 and all of the months 1/15 and 2/15 weekly skin assessment sheets were blank. No assessment sheet was available for the month of 3/15. On 3/26/15 at 6:40 p.m., this surveyor received the facility's policy titled Skin Integrity Guideline which documented under the section General Guideline: Living Center develops a routine schedule to review patients/residents with wounds or at risk on a weekly basis and will document findings. DNS (director of nursing services) or designee will be responsible to implement and monitor the skin integrity program. Wound status is monitored on a weekly basis. Documented under the section Documentation of Weekly Skin Evaluation/Observations: Licensed nurse will be responsible for performing a skin evaluation/observation weekly. The nursing order for weekly skin observations on all residents will be entered and printed out on the Treatment Administration Record or Medication Administration Record. On 3/26/15 at 7:05 p.m., the administrative team was made aware of the findings during a meeting with the survey team. No other information was provided to this surveyor prior to the exit conference on 3/26/15.

Based on observations, investigation of a Facility Reported Incident, clinical record review, and staff interview, the facility staff failed, for two of 24 residents in the survey sample (Residents # 9 and 11), to provide adequate supervision to ensure resident safety from accidents, and failed to provide environmental safeguards to ensure resident safety. Resident # 9 suffered a fall during improperly supervised bathing which resulted in harm to the resident when she sustained a fractured pelvis. The facility staff failed to ensure Resident #11 smoke in the designated smoking area of the facility, and to ensure the resident did not maintain possession of smoking materials on his person for safety Observations in the main dining room found the room was being mopped while residents were still using the dining room, including residents who were walking and using their wheelchairs on the wet floors. On the 200 and 400 units, dirty utility rooms and a storage room were unlocked and accessible to residents. The findings include: 1. Resident # 9 suffered a fall during improperly supervised bathing which resulted in harm to the resident when she sustained a fractured pelvis. Resident # 9 in the survey sample, an [AGE] year-old female, was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. According to a Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/14, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 9 out of 15. Under Section G (Functional Status), the resident was assessed as totally dependent with one person physical assist for hygiene, bathing, and locomotion on and off the nursing unit; as needing extensive assistance with one person physical assist for dressing and eating; as needing limited assistance with one person physical assist for transfer; and as not walking in her room or in the unit corridor during the assessment lookback period. Review of the Progress (Nurses) Notes in the resident's electronic medical record revealed the following entries: 6/13/14 - 10:55 p.m. Resident fell to the shower room floor, bumping head and skin tear to left hip. 6/14/14 - 1:09 a.m. Resident observed to have swelling with pain and bruising at left hip. Resident unable to perform active or passive range of motion.New order given to send resident to (name of hospital) ER (emergency room ) for evaluation of left hip pain and swelling. 6/14/14 - 11:21 a.m. Pt (Patient/resident) admitted to (name of hospital) for pelvic fracture left side. On 6/16/14, the facility submitted a Facility Reported Incident (FRI) form via Fax to the State Agency (Office of Licensure and Certification) to report an incident that occurred on 6/13/14. The incident was described on the form as follows: On 6/13/14 resident was in the shower room with a CNA (Certified Nursing Assistant) slipped while transferring from a seated to standing position had a fall which resulted in a fracture to the pelvis. On 6/19/14, the facility submitted a Summary of Self-Reported Investigation via Fax to the State Agency. The Summary noted the following, (Name), CNA was with (name of Resident # 9) in the shower and confirmed that she assisted her up from the w/c (wheelchair) to proceed with her shower. The aide instructed the resident to hold onto the transfer bar. During this process the resident slipped and both the resident and CNA fell to the floor. Review of the facility's investigation report noted the following, Resident shower (should) have been transferred from w/c to shower chair before going to shower room, resident should have had 2 CNA's experienced to transfer resident, resident should have shoes on while transferring. At 3:00 p.m. on 3/26/15, the Director of Nursing (DON) was interviewed regarding the resident's fall in the shower. Asked how long the CNA who was in the shower with the resident had worked for the facility, the DON said, It was her 2nd or 3rd day. She (the CNA) should not have been working alone. The DON went on to say that the CNA was in training and had a more experienced staff member assigned to her during orientation. According to the DON, the other staff member left the shower room to provide care to another resident and left the CNA alone with Resident # 9. The DON said the CNA explained that the resident had assured her she could stand up by herself. The CNA, not knowing any different, allowed the resident to stand, and that was when she fell . Asked if there was a written policy regarding a new employee working with an experienced staff member, the DON said there was not, but that it was a facility standard of practice. 2a) Floors were mopped and wet in the main dining room while residents were using the area. Residents were observed in wheelchairs and/or walking on the wet floors. On 3/24/15 at 1:15 p.m. during the initial tour of the facility a resident was observed standing on the wet floor in the dining area while two housekeeping employees were mopping the area. Another resident sitting in a wheelchair was on the wet floor being mopped by housekeeping. On 3/26/15 at 1:30 p.m. four residents were observed at a table in the dining room playing cards. The floor around the residents was wet. Another resident was in the corner of the room in a wheelchair. The floor around her wheelchair was wet. Three other residents were in wheelchairs in the dining room on the wet floor. Two members of the housekeeping staff were mopping the floor around the residents in the room during this observation. On 3/26/15 at 4:05 p.m. the interim housekeeping manager was interviewed about the dining room floor being wet while residents were using the area. The housekeeping manager stated, We've had an issue with getting residents removed (from dining area). The housekeeping manager stated when all the food was removed and residents were no longer eating the housekeeping staff members were allowed to mop the floor. The housekeeping manager stated housekeeping employees have been instructed to not remove residents from the dining area so to get the floor mopped they have to work around them. The housekeeping manager stated some residents go outside to smoke after meals and then they come back into dining room walking/rolling on the wet floor. The housekeeping manager stated they had made some changes but getting residents out of the room for cleaning was still an issue. On 3/26/15 at 5:15 p.m. a housekeeping employee was interviewed about mopping the dining room floors after meals. The housekeeper stated she routinely worked from 10:00 a.m. to 6:30 p.m. The housekeeper stated sometimes residents stayed in the dining room after meals until after 6:00 p.m. The housekeeper stated, You either have to wait or work around them. The housekeeper stated she was supposed to clean the floor before she got off work at 6:30 p.m. so she mopped the area while residents were still in the room. These findings were reviewed with the administrator and director of nursing (DON) during a review meeting on 3/26/15 at 6:20 p.m. The DON stated at this time that some residents did not always want to leave the dining area immediately after meals and like to stay there to socialize. The DON stated, I know it's not the safest but residents want to use the area. 2b) Dirty utility rooms and a storage room were unlocked and accessible to residents on the 200 and 400 halls. On 3/26/15 at 3:20 p.m. an environmental inspection of the facility was conducted. The dirty utility room on 400 hall was unlocked and accessible to residents. The key to the door was in the door knob. The room contained soiled linens containers and several red bags of soiled items. On 3/26/15 at 3::30 p.m. the storage closet beside room 211 and the dirty utility room on the 200 hall were found unlocked. The key was in the door knob of the dirty utility room. The unlocked storage closet contained cartons of tube feeding formula, cans of nutritional supplements in addition to new nebulizer tube kits. The unlocked soiled utility room had dirty linen containers, a portable oxygen tank in a cart, suction equipment and supplies. On 3/26/15 at 3:40 p.m. the maintenance director came to the unlocked storage room beside room 211 and stated, This should be locked. On 3/26/15 at 3:42 p.m. a certified nurses' aide (CNA #11) working on the 200 hall was interviewed about the unlocked dirty utility room. CNA #11 stated the room was supposed to be locked and the key was supposed to be kept on a nail near the top of the door so residents could not enter the room. On 3/26/15 at 3:50 p.m. the licensed practical nurse (LPN #4) unit manager was interviewed about the unlocked dirty utility room on the 400 hall. LPN #4 stated the room was supposed to be locked and the key kept on a nail near the top of the door. These findings were reviewed with the administrator and director of nursing during a review meeting on 3/26/15 at 6:20 p.m. 3. The facility staff failed to ensure Resident #11 smoke in the designated smoking area of the facility, and to ensure the resident did not maintain possession of smoking materials on his person for safety. Resident #11 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS), a quarterly with an assessment reference date (ARD) of 1/24/15 showed the resident with a brief interview for mental status (BIMS) score of 15 out of 15, meaning the resident is cognitively intact. The clinical record was reviewed on 3/25/15. The current care plan documented under Focus - At risk for smoking related injury related to: limited mobility, non-compliant with smoking policy at times r/t keeping smoking supplies on person with an initiation date of 2/23/15 and a target date of 5/7/15. The interventions included, but are not limited to, Assist to and from Designated Smoking area; Assure smoking material is extinguished prior to patient leaving smoking area; Patient not to have cigarettes or smoking material on person; Storage of smoking materials per Living Center policy (sic). Focus - I make independent activity choices (sic) with an initiated date of 2/23/15 and a target date of 5/7/15. The interventions included, but are not limited to, encourage me to participate in supervised smoke breaks on grounds of facility for my own safety. On 3/25/15 at 6:45 p.m., Resident #11 was observed alone in the driveway of the building complex, next to the facility but off of the facility's property smoking. On 3/26/15 at 8:50 a.m., registered nurse (RN) #3 was asked about Resident #11's smoking habits, safe smoking assessment tool, and who maintains possession of his smoking materials; and also made aware of the 3/25/15 observation. RN #3 stated the resident keeps his smoking items on him and does smoke in the driveway of the facility next door. When asked if this is allowed and if there is a safe smoking assessment that has been performed on the resident. RN #3 stated This is what he does, he doesn't want anyone to have his smoking supplies and doesn't want to smoke in the designated area. There is a safe smoking assessment, I will get you a copy. On 3/26/15 at 2:27 p.m., the director of nursing services was asked about Resident #11's safe smoking assessment. She stated it is on the quarterly nursing assessment. Any nurse can do it. I will get you a copy. This surveyor also asked for the facility's policy on smoking. On 3/26/15 at 3:00 p.m., this surveyor was provided with the resident's safe smoking assessment and the facility's policy titled (Facility Name) Smoking Policy. The resident's safe smoking assessment documented that he was able to physically hold the smoking device while smoking, remains alert during the course of smoking, acknowledges understanding of the policy related to storage of smoking materials, and is able to communicate that they understand that smoking materials are for their (the resident's) own use only and that they may smoke only in designated smoking areas at designated times. The resident's name was not on the form and the assessment was dated 10/18, with no year attached to it. The policy documented Purpose: To ensure the safety of residents who wish to smoke. Documented under the section Policy: To ensure the safety of all residents, it is the policy of this facility to place all resident's smoking materials in a secured box at the Unit 1 nurses' station. Residents may not keep smoking materials on their person or in their rooms. Resident's in violation of said policy will have privileges re-evaluated. It is the policy of this facility to ensure that all residents are monitored while smoking (sic). Documented under the section Assessment: Supervised smoking will be allowed in the designated area only under direct supervision at the following times: 9:00 a.m., 1:30 p.m., 4:00 p.m., 8:00 p.m. Documented under the section Designated Area: Smoking will only be permitted in designated areas of the building. Currently the only area designated for resident smoking is in the courtyard off of the dining room. Smoking area will be equipped with a NFPA approved fire extinguisher (sic). Documented under the section Consequences for noncompliance: Therefore, any resident who does not comply with the facility's rules regarding smoking, may be asked to restrict or forfeit smoking privileges (sic). Underneath this section there was a line that states under it Signature and Date. On 3/26/15 at 5:55 p.m., RN #3 was asked if this is something that all of the residents that smoke are to sign, she stated yes. This surveyor asked for Resident #11's signed smoking policy. On 3/26/15 at 7:05 p.m., the administrative team was made aware of the findings during a meeting with the survey team. No other information was provided to this surveyor prior to the exit conference on 3/26/15.

Based on staff interview, clinical record review and facility document review, the facility staff failed to offer and administer the influenza vaccination to an eligible resident, who consented for the vaccination for the prevention of influenza, and subsequently the resident developed Influenza Type A and was hospitalized for [REDACTED]. Resident #14 was not offered and administered the influenza vaccine after consenting to receive the vaccine and subsequently developed Influenza Type A and was hospitalized for [REDACTED]. The findings include: Resident #14 was originally admitted to the facility on [DATE] and readmitted on [DATE], with but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) was a quarterly with an Assessment Reference Date (ARD) of 1/2/15; the recent quarterly assessment was in progress and not completed during the course of the survey. Section G 0400Functional Limitations in Range of Motion was as follows: Impairment on one side upper and lower extremities (shoulder, elbow, wrist, hand, hip, knee, ankle and foot). Resident #14's impairments were on the right side. Section O0250 Influenza Vaccine was reviewed to include the following: A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? 1, Yes Continue to O0250B, Date Influenza vaccine received. B. Date Influenza vaccine received 10-18-2013. On 3/25/15 at approximately 4:15 p.m., Resident #14's Immunization's Report for the Influenza vaccination was reviewed clinical record to include the following: NOS Flu vacc Consented (RN registered nurse named) 10/18/10, Flulaval vacc Consented Right Deltoid (RN named) 10/28/11, Flulaval vacc Consented Left Deltoid (LPN, Licensed practical nurse named) 10/26/12 and Flulaval vacc Consented Right Deltoid (LPN named) 10/18/13. The Immunization report did not evidence a Flulaval (flu) vaccine for the 2014 flu season. On 3/25/15 at approximately 4:17 p.m.,Resident #12's clinical record was reviewed to include the following Nursing Note: 12/16/14 10:29 a.m. Message left for RP (responsible person/party) brother (named) in reference to consent for the flu shot. Awaiting return call. 12/17/14 16:00 (4:00 p.m.) Resident's RP/Brother (named) phoned and notified of resident starting the medication [MEDICATION NAME] 75 mg (milligrams) once daily x (times) 14 days as an preventive measure against the [MEDICAL CONDITION]. Further review of the clinical record evidenced a General Medicine Discharge Summary to include the following: admitted : 12/18/14 discharged : 12/20/14.admitting [DIAGNOSES REDACTED]. Principal [DIAGNOSES REDACTED]. Vitals were checked-T 102.5, pulse 116.Hospital Course: Influenza A: (Resident named had a positive PCR (Polymerase Chain Reaction-test used to test for [MEDICAL CONDITION] influenza and the type) for influenza A. On 3/25/15 at approximately 4:20 p.m., the unit manager, who was a registered nurse and will be identified as RN #2 was interviewed regarding the Resident's immunization status. RN #2 stated, We contacted the brother on 12/6 at 10:29 and left a message and he did not return our call. (Resident named) started experiencing signs and symptoms after we called the brother. We also sent a letter to the brother and he did not return it. RN #2 was interviewed and asked when did the facility start administering influenza vaccinations to the residents. RN #2 stated, We start sending out the letters in September/October that gives them, the families, a month to a month and a half to respond and then we start with the vaccines in December. So see by the time we got (Resident named) brother he already had started experiencing signs and symptoms and it was too late. RN # 2 was asked the reason the flu vaccine was administered so late in the year if received in September or October. RN #2 stated, I don't know. RN #2 was made aware that Resident #14's previous flu vaccinations were administered in the month of October. RN #2 referred this Surveyor to the nursing note dated 12/16 and 12/17/14, which was leading to when the resident developed influenza. A copy of the resident's consent for the Influenza vaccine was requested. On 3/25/15 at approximately 4:30 p.m., the director of nursing (DON) was interviewed regarding the resident not receiving the flu vaccine for the current flu season and subsequently developing the flu and being admitted to the hospital for treatment. The DON stated, Let me pull my stuff. On 3/25/15 at approximately 5:45 p.m., the administrator and the regional consultant were made aware of the above findings. During the end of the day meeting this Surveyor asked for clarification of the consent form and how the facility kept record of resident's requesting the vaccine. The regional consultant stated, The consent form is filled out and mailed to the family; the family sign and return the form to the facility. The regional consultant was asked if the facility kept a copy of the form that was mailed to the family. The regional consultant stated, We should. A copy was requested of Resident #14's consent form, that was mailed to his RP, consenting for the flu vaccine and a copy of the facility's Influenza policy was requested. On 3/26/15 at approximately 10:00 a.m., Resident #14's consent form was received and reviewed to include the following: Immunization Consent or Declination: The Center has provided me with information regarding the risks and benefits of the Influenza and Pneumococcal immunization vaccines. I have been given the Centers for Disease Control Vaccine Information Statements, which have allowed me to be educated as to these risks and benefits. I have been given the opportunity to ask questions and discuss any concerns that I may have. I am making an informed decision regarding the immunizations. I hereby consent (Resident named), a resident at this center to receive the following immunization vaccine(s): Influenza (at admission and annually thereafter).The resident's RP's signature was documented at the bottom of the page consenting for the vaccine to be administered annually as checked. The facility's Influenza/Pneumococcal Immunization Guideline was reviewed to include the following: Center will offer and encourage that each resident receive immunization against influenza annually, as well as a lifetime immunization against Pneumococcal disease. This immunization will be administered unless it is medically contraindicated, the resident has already been immunized or the resident and/or responsible party refuses the immunization to be administered. Influenza Immunization: The center will administer the influenza vaccine each fall when the vaccine is available to the living center and will continue to be administered throughout the influenza season (October 1 through March 31). Monitoring compliance: Influenza vaccines are administered annually with evidence of consent and education. According to the Drug Information Handbook for Nursing page 917-[MEDICATION NAME]-Oseltamivir-Use: treatment of [REDACTED].>1 year of age and adults who have been symptomatic for more than 2 days.(1). No further information was provided during the course of the survey regarding the reason Resident #14 did not receive the Influenza vaccine. (1). Turkoski, Beatrice B., Brenda R. Lance and Mark F. Bonfiglio. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2007.