Every finding on record at Creekside Terrace Rehabilitation

Based on observation, interview and record review the facility failed to ensure the residents' environment remained as free of accident hazards as possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #1) reviewed for accidents and hazards. The facility failed to prevent Resident #1 from eloping from the facility. Resident #1 eloped from the facility and was found by local PD on a nearby highway with a speed limit of 70 mph on a sunny day with outside temperatures ranging from 88 to 89 degrees on 06/06/2026 at about 3:30 pm to 4:40 pm. The noncompliance was identified as PNC. The IJ began on 06/06/2026 and ended on 06/07/2026. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, and hospitalization.Findings included: Review of Resident #1's face sheet printed 06/07/2026 revealed a [AGE] year-old male with admission date of 01/15/2026 and readmission date of 06/07/2026, diagnoses include unspecified Dementia (decline in mental abilities severe enough to interfere with daily life, with unknown underlying cause), Anxiety disorder (a group of treatable mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry in non-threatening situations), Psychotic disorder with delusions due to known physiological condition (a condition where false, fixed beliefs (delusions) are directly caused by a physical illness or neurological disorder rather than a primary mental illness). Review of Resident #1's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 06, severely impaired. No risk for elopement. Review of R#1's progress notes dated 04/21/2026 at 11:26 pm reflected Resident #1 had exit seeking behavior. Review of Resident #1's Care Plan initiated 4/22/2026 after the exit seeking behavior revealed Resident #1 had Behavioral Symptoms [R#1] wanders through out the facility, is a risk for 1. Elopement 2. exit seeking behavior 3. fall risk. Related to diagnosis of Dementia. Residents verbalize wanting to smoke. Resident #1's care plan also reflected Resident #1 had documented wandering in nurse's station and he was at risk for complications. It reflected Resident #1 required assistance with his ADLs 2/2 muscle weakness, lack of coordination, need for assistance with his ADLs, intake of anti-anxiety medication. Review of Resident #1's progress notes dated 04/21/2026 at 11:26 pm reflected: At 6pm this nurse was given report that the resident had had an episode of attempting to leave the facility. Resident was observed by this nurse wandering through the halls. After report this nurse went to speak to resident and resident stated, All I want to do is go outside and smoke a cigarette. Resident did not appear agitated and was calmly stating why he was attempting to go outside the facility. This nurse explained to resident that the facility was a non smoking campus. I also explained to him that we do not have cigarettes available. Resident stayed on his [NAME] to go outside to smoke without a tangible way to even carry this out, being he has no cigarette or lighter to smoke with even if he did go outside. This nurse stayed with the resident as he was wandering through the halls. Resident would wander to an exit door and look through the window. Resident did appear to attempt to press the code key pad at one point but was easily redirected. Resident was given fresh ice water per his request. This nurse asked resident if he would like a nicotine patch and resident refused. Per policy the DON was notified and the on call provider was called. New orders were received for CBC, CMP, UA, U/C&S and for Nicotine patch. Orders entered. Resident was closely monitored by this nurse. Resident went to his room and got ready for bed at 8:15pm and has been in his bed resting quietly with no complaints since then. Resident has fresh fluids and snacks and call light in reach. Review of Resident #1's progress notes from 04/22/2026 through 04/28/2026 reflected Resident #1 was being monitored for exit seeking behaviors and there were none noted. Review of Resident #1's hospital records dated 06/06/2026 reflected the following:Temperature of 102.7 degrees at 05:04 pm, chest x-ray (is a quick, painless imaging test that passes a small amount of electromagnetic radiation through your body) reflected no evidence of acute cardiopulmonary (refers to the body's interrelated heart (cardio) and lungs (pulmonary).) abnormality, no pleural effusion or pneumothorax (occurs when air leaks into the space between your lung and your chest wall), CT scan(is an advanced imaging test that combines a series of X-ray views taken from various angles to create detailed, cross-sectional slices of bones, organs, and soft tissues )of the head reflected no acute intercranial abnormality. Resident #1 was given IV lactated Ringers 1,000 mL bolus at 5:32 pm and 5:52 pm respectively. Review of Resident #1's Elopement assessments reflected an elopement assessment was completed for Resident #1 on 01/15/2026 upon admission and on 06/07/2026 after the incident. Reviewed of Resident #1's progress notes dated 06/07/2026 at 2:46 pm written by the Social Worker reflected: submitted MCU referral to [another facility]. RP updated on referral and LMSW will follow up with RP with any further updates in transfer process. RP in agreement and appreciates call. LMSW to continue to assist and support in transfer process. Review of Resident #1's progress notes dated 06/08/2026 at 11:00 am written by the Social Worker reflected: Resident was accepted to transfer to [another facility] memory Care Placement. Resident is scheduled to transfer today around 12:30 pm. RP was notified and agrees with transfer. No further questions or concerns were verbalized. LMSW to complete DC letter and DC planning. During an observation and interview on 06/07/2026 at 2:37 pm, Resident #1 was noted in his room, lying in bed with door open. CNA C was noted sitting next to Resident #1's door. Resident #1 denied leaving the facility, being found by the local PD or being transferred to the ER. During an interview on 06/07/2026 at 2:44 pm, CNA C stated she was assigned to do a 1:1 monitoring for Resident #1 at the beginning of her shift at 2:00 pm. CNA C stated she was in-serviced on elopement at the beginning of her shift. CNA C stated she was told to report immediately to the nurses once a resident is showing signs of elopement, like wanting to go home. CNA C stated, if a resident assigned to her could not be found, she would report to the charge nurse, they would start to search for the resident within the facility and then to the immediate surroundings. CNA C stated the Administrator, DON, ADON and all authorities would be notified. During an interview on 06/07/2026 at 2:55 pm, CNA D stated she was the CNA assigned to Resident #1 on 06/06/2026 when he eloped. CNA D stated she last saw Resident #1 at about 3:00pm and he was on the 100-hall with other residents. CNA D stated at about 4:40 pm, she took Resident #1's dinner tray and noticed he was not in his room. CNA D stated just about the time she was going to look for Resident #1 for him to eat, the nurse on the hall was coming from the front and told her what had happened. CNA D stated they immediately stopped what they were doing and started to account for all other residents in the facility. CNA D stated she gave verbal statement as to when last she saw Resident #1. CNA D stated the Maintenance Director in-serviced staff on abuse and neglect, elopement, fire safety, who to notify when a resident was missing and an elopement drill was conducted. CNA D stated usually Resident #1 was walking around the facility, so it was not out of the ordinary not seeing in his room at the time. CNA D stated Resident #1 was now on a 1:1 monitoring since he got back from the hospital. During an interview on 06/07/2026 at about 3:10 pm, CNA E stated she was in-serviced on abuse and neglect on 06/06/2026 by LVN F. CNA E stated she was also in-serviced today 06/07/2026 by the Maintenance Director on elopement, when a resident left the facility or was missing, what to do, and an elopement drill was conducted. CNA E stated they were told when a resident was missing to search every room, if the resident was not found, to look around the premises, contact the Administrator, DON and ADON. CNA E stated Resident #1 was assigned to her on 06/06/2026 during the morning shift and he did not show sign of elopement like pushing on the door or talking about wanting to go home. CNA E stated Resident #1 was on 1:1 monitoring due to the incident. During an interview on 06/07/2026 at about 3:35 pm, LVN G stated she was Resident #1's charge nurse, she worked at the facility PRN. LVN G stated her shift started by 12:00 pm and she was in-serviced by LVN F prior to her shift on elopement. LVN G stated she was also told Resident #1 was on a 1:1 monitoring due his elopement on 06/06/2026. LVN G stated, if a resident was missing, they had to look in every room in the facility, restrooms and call code white. If the resident is not found within the facility, look in the perimeter of the building, notify everyone. LVN G stated, risk of elopement included exit seeking behavior, wanting to get out, finding ways to escape, pushing the door. During an interview on 06/07/2026 at 3:45 pm, LVN H/wound care nurse stated she was not in the facility when Resident #1 eloped. LVN H stated she was made aware that the Maintenance Director was in the facility on 06/06/2026 checking all the exit doors and today 6/07/2026, he was here checking all the windows. LVN H stated she was in-serviced today 06/07/2026 by the ADON on how to prevent elopement, ensuring room rounds and checking on residents. LVN H stated if you cannot see a resident, try to locate them, if not, let the charge nurses, ADON, DON and Administrator know. Extend to the outside perimeter. LVN H stated risk for elopement, were constantly wandering, wanting to go outside, possible agitation. LVN H stated Resident #1 had been on 1:1 all day. He has not attempted to leave the facility, he walks around but going to activities, I have not seen him pressing on doors. During an interview on 06/07/2026 at 05:05 pm, the Maintenance Director stated he was informed that Resident #1 had gotten out of the facility. The Maintenance Director stated he immediately came to the facility to check all the exit doors to see if they were working properly and alarming, when he checked, all doors were functioning well. He stated all the exit doors had keypad and you have to have the code to get out of the facility. He also stated he usually checks all doors once a week, on Wednesdays and his last check before the incident was 06/03/2026. The Maintenance Director stated he initiated elopement in-service; he conducted elopement drilled with the 2-10 shift. The Maintenance Director stated he did another elopement drill on 06/07/2026 on the 6am to 2 pm shift. The Maintenance Director stated Resident #1's CNA on the morning of 06/07/2026 stated she felt breeze coming in Resident #1's room from the window, when she checked, the screen was pushed back. The Maintenance Director stated he checked all the windows and screens in the facility, all other windows were intact except for Resident #1's, his window screen was pushed back. The Maintenance Director stated he adjusted Resident #1's window and fixed the screen. During an interview on 06/07/2026 at 5:13 pm the DON stated Resident #1 had exit seeking behavior in April 2026, he was assessed, care plan was updated, he was monitored for few days and there were no more behaviors. The DON stated Resident #1 wanted to smoke a cigarette, that is why he wanted to go out but the facility was a non-smoking facility, so the provider ordered a Nicotine patch to help. The DON stated MDS Nurse A was the MOD on 06/06/2026, she received a call from the local PD that Resident #1 was found near a local church close to a major highway. The DON stated Resident #1 was found about 2 miles away from the facility and was at risk of being out in the street, risks of walking along a busy highway, injury and getting lost. The DON stated the facility put elopement mitigation in place right after they found out about the incident. The DON stated on the morning of 06/07/2026, Resident #1's CNA noticed that Resident #1's window screen was pushed back, and they think Resident #1 must have eloped through his room window because no one heard the doors alarm going off. The DON stated, after they got the information of window screen being pushed back, the Maintenance Director checked all windows and screens in the facility and they were intact. During an interview on 06/07/2026 at 5:30 pm the Administrator stated she found out about Resident #1's elopement on 6/6/2026 at about 4:45 pm. The ADM stated she got a call from the manager on duty/MDS Nurse A. The ADM stated MDS Nurse A told her that she had just gotten a call from the local PD that Resident #1 was found near a local church, not too far from a major highway, about 2 miles away from the facility. The ADM stated the local PD sent Resident #1 to the local hospital to rule out heat exhaustion. The Administrator stated Resident #1 was at risk of dehydration, it was hot, a vehicle could have hit him. The Administrator stated Resident #1 wandered but was easily redirect, he went to activities and meal service. The Administrator stated they learned Resident #1's window screen was pushed back on the morning of 06/07/2026 and the Maintenance Director came up to the facility to check all window screens in the building; they were all intact except for Resident #1's. The ADM stated the facility had an AD HOC (doing something for a specific, immediate purpose rather than planning it in advance), completed elopement assessment for Resident #1 and all other residents in the facility, all exit doors and windows were checked by the Maintenance direct to ensure they were intact and functioning, elopement drill completed on 06/06/2026 and 06/07/2026, staff were in-serviced/ re-educated on elopement, Abuse and Neglect and staff would continue to be in-service before the start shift, Resident was placed on 1:1 monitoring and would continue until his placement to a MCU facility. During an interview on 06/07/2026 at 5:44 pm, MDS Nurse A stated she was the MOD on 06/06/2026 and she got a call at about 4:40 pm from the local PD wanting to confirm Resident #1 was a Resident at the facility. The MDS Nurse A stated the Local PD stated Resident #1 was found near a local church close to a major highway and was being sent to the local ER for evaluation for heat exhaustion. The MDS Nurse A stated right after the call, she reported to the Administrator, went to the nurse's station to notify Resident #1's charge nurse. MDS Nurse A stated the Administrator had instructed her to ensure all residents were accounted for, she initiated a count of all residents, and all residents were present except Resident #1. MDS Nurse A stated she checked all exit doors to make sure they were working because she did not hear any alarm go off, all doors were working after she checked. The MDS Nurse stated she was sitting at the receptionist desk in the front, she did not see Resident #1 exit through the front door and the alarm to the other exit doors did not alarm. During an interview on 06/08/2026 at 12:23 pm the Social Worker stated she was in-serviced by the Maintenance Director on 06/08/2026 on elopement and there was an elopement drill as well. The Social Worker they talked about what to do when a resident left the facility, who to contact, what were the signs of elopement risk. The Social Worker said she got a referral for Resident #1 to be transferred to a facility with MCU, she sent the referral and the facility was waiting for pick up later today 6/08/2026. The Social Worker stated she spoke with Resident #1's family regarding the referral and the transfer and they were ok with it. During an interview on 06/08/2026 from 09:58 am to 12:23 pm, MDS Nurse B, LVN I, RN J, CNA K, CNA L, CNA M and CNA N all stated they were in-serviced prior to their shift on abuse and neglect, elopement risks, what to do when a resident left the facility, who to report to and the steps to take. The facility immediately implemented the following actions to immediately address Resident #l's elopement incident on 06/06/2026:Elopement Mitigation Plan initiated 6/6/2026 PD sent Resident #1 to the local hospital.MD notified on 6/6/2026Elopement assessment for Resident #1 completed on 6/6/2026 at about 4:40 pm.Doors and alarm checks on 6/6/26 at 6:20 pm.In-services initiated by DON/ Maintenance Director 06/06/2026 on elopementAll residents in the facility elopement assessment completed from 06/06/2026 through 06/07/2026Elopement Drill completed by the Maintenance Director on 6/06/2026 and 06/07/2026Skin assessment completed for Resident #1 on 6/7/2026 when he got back from the hospital, superficial skin tear noted to both hands.Resident #1 was placed on 1:1 monitoring until he got placed at an MCU facility.All window screens in the facility checked by Maintenance Director on 06/07/2026AD HOC meeting with IDT team completed on 06/07/2026Progress notes and care plan dated 6/7/2026 reflected referred to MCU facility Record review of facility's Elopement Mitigation plan reflected: Date of event: 06/06/2026---What corrective action(s) will be accomplished for those residents found to have been affected by the alleged deficient practice: Resident was transferred to the hospital by police department and currently receiving care at the hospital.Upon return, resident elopement risk evaluation will be repeated and appropriate interventions implemented with care plan & profile updates.MD/RP notified. Each exit door was assessed by the Maintenance Director on 6/6/26 to validate doors were working properly. An elopement drill was completed on 6/6/26 by the Maintenance Director --- How other residents who have the potential to be affected by the alleged deficient practice are identified: Residents at risk of elopement have the potential to be affected.Elopement risk evaluations done in the past 90 days on current residents in facility will be reviewed by nursing managers for accuracy. Residents identified at risk will be reviewed for appropriate interventions with care plans and profiles updated. ---How the corrective action will be monitored to ensure the deficient practice will not recur: Licensed nurses will be re-educated on the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified. Facility staff will be reeducated on identification of exit seeking behaviors and implementing interventions immediately.This education will be completed on 6/7/26.Any member of target audience not receiving this by this date will receive prior to next scheduled shift New admissions will be reviewed in morning meeting daily Monday thru Friday as part of the clinical morning meeting process. Elopement risks assessments will be reviewed for accuracy and interventions validated if indicated. Quarterly assessments will be reviewed as part of the MDS/Care planning process The Director of Nursing will randomly audit a minimum of 5 elopement assessments weekly for 4 weeks then monthly for 2 additional months to validate accuracy The maintenance director will inspect facility doors 3 times weekly for 4 weeks then weekly for 2 additional months The administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with maintenance director to validate that doors are functioning properly ---What quality assurance program will be put into place: Ad hoc QAPI held on 6/7/26 Medical Director was notified of the incident and plan for improvement on 6/6/26This process will be reviewed in QAPI for a minimum of 3 months Review of facility's in-service initiated 06/06/2026 provided by the DON reflected: Topics:Elopement, Elopement risk1. Staff must report any behaviors that indicate an increased risk for elopement such as; wandering, more confused, trying to go out the door, resident stating I want to go home. Etc. This must be reported immediately to the charge nurse and resident must not be left unattended until the nurse is aware.2. Charge nurses must report any increased signs of elopement risk to DON for further guidance and intervention.3. Staff do not assist residents outside.4. When residents leave on pass, they must sign out and this must be communicated to oncoming shifts5. Wandering and elopement assessments/Care plan should be updated quarterly and when elopement risks are identified. Please see below for steps to take in the event a resident is missing to include.Notify ADMIN/DONNotify employees of missing resident on the overhead paging systemObtain missing resident profile from elopement book Searching the facility and facility grounds within 30 minutes.If the search fails after 30 minutes the DON/ADMIN will notify appropriate agenciesAfter 30 min the search will continue and extend 2 miles around the facility-DON/ADMIN will coordinateIf resident is found, nurse must complete assessment immediately to include head to toe assessment, VS, skin, hydration and pain. RP/Provider notification RVP & CSD notification. Record review of facility's elopement drill reflected a drill was conducted on 06/06/2026 at 6:35 pm during the 2pm to 10 pm shift and 06/07/2026 at 09:08 am during the 6:00 am to 2:pm shift Review of facility's document titled Equipment and Utilities Management Program dated 06/06/2026 reflected that all nine (9) exit doors were checked on 06/06/2026 at 06:20 pm.Review of facility's document titled Screens in the facility dated 06/07/2026 reflected all window screens in the facility were checked. Record review of investigation document reflected an Ad hoc was held on 06/07/2026 --ADHOC Meeting held with IDT Team on 6/7/2026 to discuss incident regarding Resident#1's Elopement on 6/6/2026 and mitigation plan, investigation and interventions, presented by the Administrator and the DON. Reviewed of facility's elopement policy reflected: The Facility will assess all patients/residents for elopement potential.1. All patients/residents are assessed on admission by a licensed nurse for elopement risk utilizing an elopement risk assessment form. 2. All patients/residents are re-assessed for elopement potential by the MDS Nurse/Social Service or designee periodically throughout a patient's/resident's stay and with a significant change. The noncompliance was identified as PNC. The IJ began on 06/06/2026 and ended on 06/07/2026. The facility had corrected the noncompliance before the survey began.

Based on interviews and records review the facility failed to ensure each resident Quarterly Review Assessment A was completed not less frequently than once every 3 months for one (Resident #1) three residents review for assessment in that:The facility failed to complete Resident #1's quarterly MDS assessment and elopement assessment for more than 3 months. This deficient practice placed Residents at risk for not getting right interventions, risk for harm and hospitalizationFindings included:Review of Resident #1's face sheet printed 06/07/2026 revealed a [AGE] year-old male with admission date of 01/15/2026 and readmission date of 06/07/2026, diagnoses include unspecified Dementia (decline in mental abilities severe enough to interfere with daily life, with unknown underlying cause), Anxiety disorder (a group of treatable mental health conditions characterized by persistent, excessive, and uncontrollable fear or worry in non-threatening situations), Psychotic disorder with delusions due to known physiological condition (a condition where false, fixed beliefs (delusions) are directly caused by a physical illness or neurological disorder rather than a primary mental illness). Review of Resident #1's quarterly minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 06, severely impaired. No risk for elopement. There were no other MDS assessments completed for Resident #1 after 02/18/2026 which was over 3 months since the last assessment. Review of R#1's progress notes dated 04/21/2026 at 11:26 pm reflected Resident #1 had exit seeking behavior. Review of Resident #1's Care Plan initiated 4/22/2026 revealed Resident #1 had Behavioral Symptoms [Resident#1] wanders through out the facility, is a risk for 1. Elopement 2. exit seeking behavior 3. fall risk. Related to diagnosis of Dementia. Resident verbalizes wanting to smoke. Resident #1's care plan also reflected Resident #1 had documented wandering in nurse's station and he was at risk for complications. It reflected Resident #1 required assistance with his ADLs 2/2 muscle weakness, lack of coordination, need for assistance with his ADLs, intake of anti-anxiety medication. Review of Resident #1's Elopement assessments reflected an elopement assessment was completed for Resident #1 on 01/15/2026 upon admission and on 06/07/2026 after the incident. The was no elopement assessment completed for Resident # 1 on 04/21/2026 when he had exit seeking behavior. There was no quarterly elopement assessment completed for Resident #1 after the initial assessment post admission. During an interview on 06/07/2026 at 5:13 pm the DON stated if there was a quarterly MDS done in 2/18/2026 for Resident #1, he should have had the next assessment done in May 2026 along with elopement assessment. The DON stated MDS assessments and elopement assessments were done quarterly and as needed when there were changes. The DON stated the staff were supposed to complete an elopement assessment for Resident #1 in April of 2026 when he had an exit seeking behavior. During an interview on 06/07/2026 at 5:30 pm the Administrator stated elopement risk assessment was done on admission and quarterly. The Administrator stated it was important to do quarterly assessment to identify any other risk. The Administrator stated when Resident #1 had exit seeking behavior sometimes in April 2026, the facility should have completed elopement assessment. During an interview on 06/07/2026 at 5:44 pm, MDS Nurse A stated MDS assessments were done upon admission and quarterly. MDS Nurse A stated Resident #1's last quarterly MDS assessment was done 2/18/2026, there should have been another quarterly MDS assessment completed on 05/18/2026. MDS Nurse A stated MDS Nurse B was responsible to complete Resident #1's quarterly MDS assessments. During an interview on 06/08/2026 at 09:58 am, MDS Nurse B stated she was responsible to complete Resident #1's MDS assessments. MDS Nurse B stated MDS assessments were done every 92 days to be in compliance. MDS Nurse B stated if Resident #1's last MDS assessment was completed on 02/18/2026, there should have been another assessment on 05/18/2026. MDS Nurse B stated that was a missed assessment and it would be completed by the end of the day. MDS Nurse B stated the floor nurses were responsible for completing elopement assessments. MDS Nurse B stated elopement assessment should be done if a resident had risk or history of elopement. MDS Nurse B stated the elopement assessment would indicate that the residents needed more observation and to bring awareness to the staff. MDS Nurse B stated elopement assessment should be done with every MDS assessment and as needed. Review of facility's policy titled NURSING POLICIES AND PROCEDURES- MINIMUM DATA SET (MDS) with revision date of 09/28/2023 reflected:Policy:A licensed nurse will conduct or coordinate each assessment with the interdisciplinary team. An MOS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified. The comprehensive assessment is completed initially and periodically.Quarterly and Significant Change assessments are completed as required, following the RAI specific guidelines. State-specific versions of such assessments are completed within the required timeframes according to applicable law and regulations. The Facility uses the RAI specified by CMS {which includes the MOS, utilization guidelines and the CAAs) to assess each resident and develop a comprehensive care plan. The facility is responsible for addressing all the needs and strengths of each resident. Each staff member will note their liability for the accuracy of the data recorded by signing {electronically) their name and identifying the MOS sections and questions to which they provided responses. A registered nurse (RN) must sign and certify that the assessment is completed. Procedures:Each assessment must represent an accurate picture of the resident's status during the observation period of the MOS. When the MOS is completed, onlythose occurrences during the observation period will be captured on the assessment. If it did not occur during the observation period, it is not coded on the MOS.A quarterly review assessment is completed using the standardized Quarterly review assessment tool specified by the State and approved by CMS no less than once every 3 months between comprehensive assessments. The quarterly MOS does not require the completion of CAAs, however the resident's care plan must be reviewed and revised by the interdisciplinary team after each assessment.

Based on observations, interviews, and record reviews, the facility failed to store food in accordance with professional standards for foodservice safety in 1 of 1 kitchen reviewed food and nutrition services. The facility failed to ensure food safety on 03/24/2026 by not consistently monitoring and discarding expired food, not sanitizing the food thermometer between each food item, not storing food items that were not labeled and/or dated, and keeping racks where the serving utensils and dishes were stored dirty. Have knives that was chipped and not in good condition. These failures could place residents who received meals from the main kitchen at risk for foodborne illness. Findings included: Observation on 03/24/2026 at 8:45 AM of the walk-in cooler reflected the following:- Unknown food item in a metal container covered with plastic wrap, dated 3-23-2026 with no use by date. - Unknown food item in a container covered with a lid, that had one date of 3-22-2026. - Scrambled Eggs in a Ziplock bag, dated 3-23-2026 and no use-by date. - Unknown red sauce in a metal container covered with Saran Wrap dated 3-24-2026.- An unsealed package of raw hot dogs in a clear container that was not sealed and not date on the container. - Ham wrapped in plastic wrap dated 3-23-2026 and no use-by date. - Hotdog Buns with an open date of 3-12-2026 and no use-by date. - Hamburger Buns with an open date of 3-22-2026 on the package and no use-by date. - Salsa in a clear container covered with plastic wrap dated 3-11-2026 and no use-by date. Observation on 03/24/2026 at 8:55 AM of the walk-in freezer reflected the following:- Opened Whole Kernel Corn dated 1-29-2026 with no use-by date. - Opened pancakes dated 3-05-2026 and no use-by date. Observation on 03/24/2026 at 9:05 AM of the kitchen reflected the following:- 2 loaves of wheat bread undated. - Utensil container with forks and spoons with pieces of paper inside the container. - A [NAME] bin containing thickener undated. - A [NAME] bin containing flour undated. - A [NAME] bin containing Sugar undated. Utinsil holder containing forks had paper trash in the container. - A [NAME] bin containing oatmeal undated. - A knife hanging on the wall on a magnet had a chip in the blade. Build up of old juice on the juice machine. Observation on 03/24/2026 at 9:10 AM of the Pantry reflected the following:- A clear tub filled with mini water bottles undated. - An open package of grits not sealed. - An open package of oatmeal not sealed. Observation on 03/24/2026 at 11:15 AM of food temperatures. CK took the food temperatures at 11:15 AM. CK took the food temperatures again at 12:15 PM. CK took the food temperatures and did not clean the thermometer completely before taking temperature of another food item. An interview on 03/26/26 at 11:04 AM with the DM revealed. The DM stated food placed in top zip storage bags and containers should be labeled with the contents, date, and use-by date. The DM said the cooks and dietary aides are responsible for labeling and dating items. The DM stated that she and the CK were responsible for checking the dates on food items in the kitchen. The DM stated that food in the kitchen should be checked daily. The DM stated they use the first-in, first-out method, where the new items are at the back, and old items are at the front, so the old items are used first. The DM stated that residents could get sick if they were served expired food. The DM stated she completed in-service training on labeling and dating food items in the kitchen on 3-24-2026. The DM stated that the DAs are responsible for cleaning the juice machine and the kitchen utensil holders. The DM stated there should be no leftover juice in the juice machine or paper in the utensil containers. The DM stated these should be cleaned daily. The DM stated that food item temperatures should be measured 30 minutes before serving food to residents . The DM stated the thermometer should be wiped clean before reusing. The DM stated that if a knife has a chip on the blade, it should be discarded. The DM stated that if residents are served food from the dirty juice container or utensils from a dirty container, they could get sick. The DM stated that she has had in-service training on cleaning the kitchen, and the last time was on 3-24-2026 03/26/2026 10:44 AM CK The CK stated she did not know she was supposed to write the name of the container's contents. The CK stated that she put the date on the items she put in the cooler. The CK stated those items were only to be in the cooler for three days. The CK stated food items placed in containers or Ziplock bags should not have been kept in the cooler for more than three days. The CK stated that she threw the food item away after three days. The CK stated that it was everyone's responsibility to label and date food items in the kitchen. The CK stated the cooler should have been checked every other day, but it was not checked on some days. The CK stated that date checks should have been conducted regularly. The CK stated all food in the kitchen should have been sealed. The CK stated that the food temperature should have been taken 15 minutes before it was served. The CK stated that residents could have become ill if they had been served out-of-date food. The CK stated that she would now write the name and use-by date on the container. The CK stated that the aides cleaned the juice dispenser and the utensil container daily. The CK stated there was an in-service on 3-24-2026 for cleaning, labeling, and dating food items, and temping food. 03/26/2026 10:31 AM DA-A The DA-A stated that she includes the item name, the date it was placed in the bag, and the use-by date on the label. DA A stated the DM was responsible for making rounds and checking dates. DA-A stated to prevent out-of-date items, she would place the older items at the front. DA-A stated residents could have gotten sick if proper procedures had not been followed. DA A stated there was an in-service last Monday regarding cleaning and labeling food items. DA-A said the juice machine was cleaned daily and that they used a check-off list. The DA A stated that there was a check-off list that they checked when a task was complete. The DA-A stated that the dietary aides were supposed to clean the juice machine and the utensil holders. The DA-A stated that they had an in-service training on 3-25-2026 that covered cleaning, labeling, and dating. 03/26/2026 10:20 AM, DA-B 1 monthThe DA-B stated that when a food item was placed in a Ziploc bag or a container, the label should have included the contents, the date it was put in, and the use-by date. The DA-B stated it was everybody's responsibility to label and date food items in the kitchen. The DA-B stated that out-of-date items should have been discarded. The DA-B stated that it was the dietary aide's responsibility to clean the juice machine and the utensil holders in the kitchen. The DA-B stated that she did not realize there had been buildup on the juice machine. The DA-B stated that she did not notice any trash in the utensil container. The DA-B stated that she had received in-service training on labeling, dating, and cleaning in the kitchen on 3/25/2026. The DA-B stated residents could have gotten a foodborne illness if they had consumed out-of-date food. The DA-B stated that residents could also have gotten sick if the juice machine and the utensil container had not been clean. Record review: Record review of the facility's Food Storage Policy dated 10/15/2025 reflected: Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents, the date it was transferred to the new container, and the discard date. It is recommended that food stored in bins (e.g. flour or sugar) be removed from its original packaging. Refrigerated, ready-to-eat Time/Temperature Control for Safety Foods are properly covered, labeled, dated with a use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. opened shall be considered day 1 immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or the day the original container is The day opened shall be considered day 1. Follow USDA guidelines for food storage. Tightly reseal opened packages to prevent contamination or place food in covered containers. Make certain the thermometer is clean and has been sanitized. The thermometer must be cleaned and sanitized between each product that is tested.

Based on observations, interviews and record review, the facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting for 1of 1 resident (Resident #1) reviewed for PASARR nursing facility specialized services. The facility failed to submit a Nursing Facility Specialized Service (NFSS) request by the specific deadline for Resident #1 for a customized manual wheelchair. This failure could place residents at risk of not receiving or benefiting from specialized equipment and services required and could affect her quality of life. Findings included:Record review of Resident #1's Face Sheet dated 11/17/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Cerebral Palsy (neurological disorder affecting movement, posture, balance and muscle coordination), Unspecified lack of coordination (clumsy movements, difficulty with balance and poor muscle control impacting walking, speaking and fine motor skills), and muscle weakness (lack of strength in muscles). Record review of the MDS assessment dated [DATE] reflected that Resident #1's BIMS score was 14, indicating intact cognition, and her functional abilities required the use of a wheelchair for mobility. Record review of Resident #1's Care Plan dated 11/18/2025 reflected Resident #1 was PASARR positive due to diagnoses of cerebral palsy and intellectual disability.In an interview and observation on 12/12/2025 at 15:59pm of Resident #1, she was observed sitting in her room in a wheelchair, however not the customized wheelchair that she required. Resident #1 stated she had been in the facility for 7 months and had not received her new wheelchair yet but stated she was advised that it had been ordered. In an interview with the Administrator on 12/12/2025 at 3:08PM she confirmed that the request for the medical equipment should have been submitted by the 20th day after the Interdisciplinary Team meeting in which Resident #1's needs were identified. Per the Administrator the MDS nurse is responsible for ensuring that all documents required are sent in timely for services. this could affect her quality of life. In an interview with the MDS Coordinator on 12/12/2025 at 4:31PM she confirmed that the request for the medical equipment should have been submitted by the 20th day after the Interdisciplinary Team meeting in which Resident #1's needs were identified. She stated the request for customized manual wheelchair was submitted on 12/12/2025. The MDS nurse is responsible for ensuring that all documents required are sent in timely for services. This could affect the resident's ability to move around freely; this could also affect her quality of life without having the customized wheelchair. Record review of Resident #1's IDT meeting documentation reflected the IDT meeting was held on 8/6/202 and a customized manual wheelchair was recommended for Resident#1., The MDS nurse is responsible for ensuring that all documents required are sent in timely for services. This could affect the resident's ability to move around freely, this could affect her quality of life without having the correct wheelchair.

Resident #24 FTag Initiation Resident #47 FTag Initiation Resident #48 FTag Initiation 01/09/25 08:07 AM RESIDENT'S ROOM OBSERVED W/ DIRTY WALLS, SCUFFED SHEETROCK, DIRTY AIR FILTERS; PICS TAKEN Resident #84 FTag Initiation

FACILITY Kitchen 01/07/25 10:09 AM During the initial walk through of the kitchen, everything was clean. The freezer had no open food or containers. Everything was boxed up and no open packages. The refrigerator had lunch bags that were correctly dated with made and used by dates. The pantry items were package up properly. No open bags were found opened. The perishable items were all either ziplocked or wrapped up properly with dates of when it was open. The ice machine was clean and no mold or any substance in the cooler. The overall environment of the kitchen was clean. Regular diet the resident had Chicken (180) taco (with lettuce and tomato), refired beans (170). Mechanical diet: Enchilada ground casserole (170) and refried beans (172). Puree casserole (174), puree beans (172). On 1/7/2025, the menu was supposed to be beef ravioli, lima beans, garlic toast, cream pie. The meal prepared was chicken tacos, refried beans with a cup of fruit. On 1/8/2025, the menu was supposed to be cheese pizza, tossed salad, breadstick, cinnamon baked apples. Pizza was served (pepperoni not cheese), and it was not fully baked, there was no breadstick nor cinnamon baked apples. It was a tasteless cup of fruit.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections in 1 of 1 dining room observed for infection control in that: LVN A failed to practice proper hand hygiene between residents while distributing food in the dining room. This failure placed residents at risk of cross contamination and the spread of infection. Findings included: During observation of dining services and food distribution to residents in the dining room on 1/7/2025 from 11:40AM to 12:30PM revealed: LVN A removed a used and contaminated cup of water from a resident's dining table and disposed of the cup of water. LVN A failed to wash or sanitize his hands before obtaining and distributing a cup of lemonade to another resident. LVN A grabbed both handles of a resident's wheelchair and rolled the resident to a dining table for meal service but failed to wash or sanitize his hands before and after. LVN A poured a resident coffee from a communal coffee pot but failed to wash and sanitize his hands before placing a plastic lid on top of the coffee cup and placing the coffee cup in front of the resident for consumption. LVN A touched the top of a cup of iced tea on a tray waiting to be served but failed to wash or sanitize his hands before. LVN A distributed a cup of iced tea to a resident but failed to wash or sanitize his hands prior to distribution. LVN A handled and opened a resident's personal plastic storage bag of what appeared to be sugar or a sugar substitute, removed the plastic lid on top of the resident's coffee cup with his bare hands, and poured the substance into the resident's coffee cup. LVN A failed to wash or sanitize his hands before the preparation and service. LVN A placed a consumed and contaminated plate of food on a tray on a rolling cart. LVN failed to wash or sanitize his hands after. LVN A used his bare hands to push open the swinging doors of the kitchen to obtain a frozen dessert cup for a resident. LVN A distributed the frozen dessert cup to the resident. LVN A failed to wash or sanitize his hands before and after distribution. LVN A placed contaminated food service items (plate, cup, utensils) on a tray and placed the tray on a food cart. LVN A failed to wash or sanitize his hands after. LVN A used his bare hands to push open the swinging doors of the kitchen to obtain a salad and salad dressing for a resident. LVN A failed to wash or sanitize his hands before and after. LVN A opened a drawer and obtained mayonnaise. LVN A failed to wash or sanitize his hands before and after. LVN A distributed the salad, salad dressing, and mayonnaise to the resident. LVN A failed to wash or sanitize his hands before. During an interview on 1/7/2025 at 12:12PM, LVN A stated that he is a charge nurse. LVN A stated that he assists with dining service and was familiar with the dining service times and process, including seating, set-up, and distribution. During an interview on 1/9/2025 at 2:21PM, the MS stated that he was responsible for ordering hand sanitizer for the facility. He stated that there has never been a shortage of hand sanitizer in the facility, and they have never run out. Staff were observed using a hand sanitizer dispenser in the dining room along with the sink and soap and personal hand sanitizers they kept on their person. There was also a bottle of hand sanitizer observed on the half wall in the dining room that was being utilized by staff periodically. During an interview on 1/9/2025 at 2:29PM, the ADON acknowledged the facility has a hand hygiene policy that she is familiar with and educated on. The ADON provided proper and extensive examples on hand hygiene procedures to demonstrate her competency. Regarding hand washing and dining service, the ADON stated that staff are required to wash their hands prior to passing dining trays and drinks. Thereafter, staff should practice hand hygiene in between tray and drink passes by washing their hands or using hand sanitizer. The ADON stated hand hygiene is very important to prevent the spread of infection. The ADON stated that staff should wash their hands or use hand sanitizer in between contact with each resident or each resident's equipment, even if there has been no known skin to skin contact or bodily fluid contact. She said staff are trained on this procedure and regularly receive in-service education on this topic. During an interview on 1/9/2025 at 2:40PM, the ADM stated that the facility's policy and procedures regarding hand hygiene is contained in their Infection Prevention and Control Plan policy and procedures. The ADM stated that the facility's DON conducts staff education and competency evaluations regarding hand hygiene . The ADM stated that her expectation regarding hand hygiene, specifically during dining service, is for staff to sanitize or wash their hands in between each tray pass and that cups should not be grabbed around the rim, even if they are covered. She stated that staff should wash or sanitize their hands in between contact with residents or resident equipment, even if there is no known skin to skin contact or bodily fluid contact. The ADM stated hand hygiene is important to prevent the spread of infection. The ADM stated that in-service education on this topic is regularly provided to staff, as well as annual competency evaluations. During an interview on 1/9/2025 at 3:00PM, the DON stated that all staff are expected to practice proper hand hygiene. The DON stated that staff should wash or sanitize their hands thoroughly using the proper technique after any resident contact. The DON stated that all nursing staff undergo proficiency and competency checkoff's every year . Record review of the facility's Infection Prevention and Control Policies and Procedures, dated May 15, 2023 (complete revision), regarding Infection Prevention and Control Program and Plan, states the facility's procedures include in part: 1. Operational Direction: C. 8). The facility will implement the Infection Prevention and Control Facility of Excellence Program and maintain the associated standards . 6. Staff Development: D. Quarterly infection control education to all staff with validation of core competencies completed (e.g., handwashing, donning/doffing PPE, and equipment cleaning) . E. Staff is provided with information and training on: 1.) Infection Prevention and control information and plans 2.) Federal, state, and local regulations impacting the facility infection prevention and control requirements, and employee protection, including the Bloodborne Pathogen Standard, Tuberculosis and required OSHA education/training. This training is provided in accordance with regulatory requirements: a) At the time of hire. b) At least every 12 months. c) When job activities change . d) Updated education and training when policies and procedures are revised or when there is special circumstance . 3.) Hand hygiene, including hand washing and alcohol-based hand rub (ABHR) . 6.) Proper handling of linens, wastes, equipment, and supplies. 10.) Cleaning, disinfecting and sanitation procedures . 8. Department Responsibilities A. All department managers are oriented to infection control and prevention policies and procedures that relate to their department. B. Department Managers take responsibility for implementing such standards, and to verify staff understand and take an active role in infection prevention and control . Record review of the facility's Staff Education/Orientation Policies and Procedures, dated January 12, 2024 (complete revision) states the facility policy regarding orientation is: The facility will provide orientation and training that is integral to fulfilling the organization's mission thus creating a culture that fosters self-development and continued learning. The facility procedures regarding orientation states: 1. Day 1: All new employees receive the general facility orientation program on day one of employment and it is completed with the designated member of the facility staff . The facility's day one General Orientation Checklist includes the following topics in part: COVID Related Training which includes but is not limited to handwashing. Infection Control which includes but is not limited to universal precautions, handwashing and hand hygiene, equipment cleaning and disinfecting, and Infection Prevention Pledge. Environment, Safety & Health. Record review of the facility's Staff Education/Orientation Policies and Procedures regarding Nursing Policies and Procedures hand hygiene competency dated 2018 (Complete Revision: 7/1/2013; Email Revision: 8/31/2018) shows that nursing department staff must meet competency and performance criteria for hand hygiene and alcohol-based hand rub (ABHR). Record review of the facility's Inservice Attendance Records show the following topics covered in part for the last 90 days: 9/17/2024-Staff: Nursing, Topics: Infection Control, including Perform hand hygiene following facility policy; before and after patient care, meal service, when hands are visibly soiled. 9/17/2024, 9/24/2024-Staff: Nursing, Topics: Dining Room & Meal Service, which states in part, Please follow the below guidance during meal service and in dining room to honor resident rights and practice good infection control processes .Staff must perform hand hygiene when serving meal trays. Staff must use hand sanitizer between tray passes up to 3 times. After third use of hand sanitizer staff must wash their hands. 10/21/2024-Staff: All Staff, Topics: Norovirus Dietary, which states in part, Please note that we have several residents with GI symptoms to include nausea, vomiting, and diarrhea. Please see below for information about Norovirus, how to care for symptomatic residents and preventative measures .Preventing Norovirus: Frequent hand hygiene. Always perform hand hygiene before and after care and before and after serving meals. LVN A did not attend the above in-service sessions as evidenced by the lack of his printed and/or signature on the attendance records. 50360

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 9 of 9 A/C units/filters inspected in that: The facility failed to ensure air conditioner filters and vents were safe and sanitary. This deficient practice could place residents at risk of respiratory and other illness and cause significantly restricted airflow and reduced efficiency of the heating and cooling system. Being in an environment that is not safe and/or sanitary. The findings included: An observation on 1/9/2025 at 9:34 AM in facility conference room revealed an A/C grate on the wall, near the door had a thick layer of dust and dirt which had accumulated on its surface. The filter had a grayish, brown coating. An observation on 1/9/2025 at 9:58 AM in resident room [ROOM NUMBER] revealed an A/C filter had a thick layer of dust and dirt which had accumulated on its surface. The filter had a grayish, brown coating. The vents on top of the unit had a layer of dust and debris. The left and right corners underneath the vents, contained a fuzzy, white substance and many particles which were food. An observation on 1/9/2025 at 10:16 AM in resident room [ROOM NUMBER] revealed an A/C filter had a thick layer of dust and dirt which had accumulated on its surface. The filter had a grayish, brown coating. The holes in the grate were completely covered with dust and dirt. No light was visible through the filter. When the air filter was lifted from the compartment, a clump of dust, dirt and debris fell on to the floor. An observation on 1/9/2025 at 10:23 AM in resident room [ROOM NUMBER] revealed an A/C filter had a thick layer of dust and dirt which had accumulated on its surface. The filter had a grayish, brown coating. The holes in the grate were completely covered with dust and dirt. No light was visible through the filter. When the air filter was lifted from the compartment, a clump of dust, dirt and debris fell on to the floor. An observation on 1/9/2025 at 10:29 AM in resident room [ROOM NUMBER] revealed an A/C filter had a thick layer of dust and dirt which had accumulated on its surface. The filter had a grayish, brown coating. An observation on 1/9/2025 at 10:35 AM in resident room [ROOM NUMBER] revealed an A/C filter had a thick layer of dust and dirt which had accumulated on its surface. The filter had a grayish, brown coating. The holes in the grate were completely covered with dust and dirt. No light was visible through the filter. When the air filter was lifted from the compartment, a clump of dust, dirt and debris fell on to the floor. An observation on 1/9/2025 at 10:35 AM in resident room [ROOM NUMBER] revealed an A/C filter had a thick layer of dust and dirt which had accumulated on its surface. The filter had a grayish, brown coating. An observation on 1/9/2025 at 10:35 AM in resident room [ROOM NUMBER] revealed an A/C filter had a thick layer of dust and dirt which had accumulated on its surface. The filter had a grayish, brown coating. When the air filter was lifted from the compartment, a clump of dust, dirt and debris fell on to the floor. An observation on 1/9/2025 at 10:35 AM in resident room [ROOM NUMBER] revealed an A/C filter had a thick layer of dust and dirt which had accumulated on its surface. The filter had a grayish, brown coating. In an interview on 1/9/2025 at 3:07 PM with M S, they said they were responsible to develop the schedule for and to complete the routine maintenance. They identified negative outcomes for residents and poorly functioning A/C units, and they could get sick. They said the filters were cleaned and changed each month . They said, I am a one-man department. It is just me. I do the best I can. They said they were informed about the condition of the A/C filters, and it did not meet their expectations. In an interview on 1/9/2025 at 3:13 PM with DON, they said the maintenance department was responsible for completing the routine maintenance on the A/C units. They said the ADM was responsible to ensure the routine maintenance was completed. They identified risk for residents as serious respiratory issues, difficulty breathing, Pneumonia, and other illness. They said the condition of the A/C units did not meet their expectations. In an interview on 1/9/2025 at 3:26 PM with ADM, they said the maintenance department was responsible for scheduling and completing the routine maintenance on the A/C units. They said the ADM and DON were responsible to ensure the routine maintenance was completed. They identified risk for residents as respiratory illness. When asked if the condition of the A/C units met their expectations, the response was, No. A Record Review of the facility's Maintenance/Housekeeping, Policies and Procedures, Wall A/C Unit Filter Inspection - Patient/Resident Areas (Monthly) forms, Revision date 7/26/2017. There were four forms, one for each hallway. The forms were divided into three columns; Room#/Location, Insp. Int., and Date. The first column, Room#/Location, is blank on all four forms. There was no indication of the specific rooms inspected monthly. A Record Review of the facility's Position Description for Maintenance Director, dated 09/08/2009 reflected: Summary Description: The Maintenance director is responsible for directing the overall operation of the requirements and as directed by the Administrator or designee, to ensure that a successful maintenance program is maintained at all times. (May be used along or along with Maintenance Assistant and/or transportation job description.) .4. Ensures the plant and equipment are properly maintained for patient/resident safety, comfort, and convenience. .8. Inspects the facility, on a regular basis, to ensure that the grounds, facility, and equipment are maintained in accordance with established policies and procedures and all hazardous areas are properly identified. .10. Establishes an effective preventive maintenance program of cleaning, painting, maintaining facility equipment, etc., as necessary/approved. .12. Maintains the heating and cooling units/systems in proper working condition, as specified by the manufacturer. Prior to the onset of seasonal changes, inspects the systems for loose wires, broken lines, leaks, etc., and pre-start unit/system to ensure proper working order. 50042

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 3 residents (Resident #92) reviewed for PASARR Level I screenings. 1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #92. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (post-traumatic stress disorder PTSD with an onset date of 11/08/2024) was present upon Resident #92's admitted on 11/11/24. The facility did not complete a 1012 form to update the PASARR Level 1 with the new diagnosis until surveyor intervention on 01/08/2025. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #92's face sheet, dated 01/08/25, reflected he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included Post-Traumatic Stress Disorder (a condition of persistent mental and emotional stress occurring as a result of injury or severe psychological shock, typically involving disturbance of sleep and constant vivid recall of the experience, with dulled responses to others and to the outside world.) with an onset date of 11/08/2024 and Vascular Dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a group of symptoms that affect memory, thinking, and behavior caused by brain damage from reduced blood flow) with an onsite date of 11/09/2024). Record review of Resident #92's quarterly MDS assessment, dated 11/12/24, reflected he had a BIMS score of 12, which indicated intact cognition. Resident #92 also took an antipsychotic medication during the assessment window. The MDS assessment reflected Resident #92 required partial/moderate assistance with eating, required substantial/maximal assistance for toileting, showering, and required assistance with personal hygiene. Record review of Resident #92's PASARR Level 1 Screening, dated 11/08/2024, reflected that in Section C Mental Illness was marked as no, which indicated Resident #92 did not have a mental illness. Record review of Resident #92's care plan dated 12/16/24 reflected Resident #92 had a diagnosis of post-traumatic stress disorder and was at risk for side effects to antidepressant medications. Goal: Resident will be prescribed the lowest effective dose of medication. Interventions included Assess resident's functional status prior to initiation of drug use to serve as a baseline. Monitor and report signs of sedation, hypotension, or anticholinergic symptoms. Refer to psychological services as indicated. In an interview on 01/08/2025 at 12:29 PM, Resident #92 stated was doing fine, and staff treated him great. He stated she used her call light if he needed help and staff got to her quickly when he called. He stated he felt safe in the facility, and he had no concerns. In an interview on 01/10/2025 at 03:45 PM, the MDS Coordinator A who stated the PASARR's are done by MDS Coordinator B. She stated she helps her when she is on vacation. She stated if they are PASARR positive, they have services they can miss out on that can be beneficial for their well-being. She stated her expectations is to make sure the PASARR's are completed accurately and done timely. In an interview on 01/10/2025 at 03:45 PM, MDS Coordinator B stated the MDS assessment for Resident #92, was completed incorrectly by the hospital when Resident #92 admitted . She stated there should have been a Y for yes placed in the PASARR Level 1 Screening where the form asks if the resident has evidence or an indicator of a mental illness. She stated the PASSAR II is done if there is a yes on the PASARR evaluation. She stated she was responsible to complete the PASARR's. She stated someone was looking for the PASARR policy and that sparked them to check. She stated they just did Resident #92 PASARR evaluation II on 1/9/2025 because of his PTSD which she learned on 01/09/2025. An in-service and audit on all PTSDs in the building and created 1012. She stated if a PASARR screening was not completed correctly, residents may not receive the services there were entitled to. In an interview on 01/10/2025 at 03:30PM the DON stated the MDS nurses are responsible for making sure PASARR's are done. She stated if it is not completed accurately, it could prevent residents from receiving services. She stated her expectation is that PASARR's will be completed timely. In an interview on 01/10/2025 at 03:10 PM ADM stated that usually the hospital completes the PL1 prior to residents' admission, but if it's not done by the hospital then the facility's MDS Nurses will complete them. She stated if PL1 are not completed, the facility would be out of compliance and the residents would not get the services they need. Record review of the facility's policy dated 06/09/2023, Preadmission Screening and Resident Review (PASARR) stated: Federal requirements to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR required that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) the services they need in those settings. General Guidelines for PASARR: 4. PASARR requires that: Individual seeking admission to a Medicaid Certified nursing facility (NF) receives a PASARR Level I Screen for intellectual disability (ID) or development disability (DD) or mental illness (MD) before or upon admission. 5. If the PASARR Level I screen indicates the individual may have an ID, DD, or MI diagnosis, follow the state-specific process for completion of the Level II evaluation. 6. If the Level II evaluation confirms an ID, DD, or MD diagnosis, the Facility will collaborate with the community resources when special services are necessary or required. 7. If special services are required, the Facility will coordinate services per State policy and develop a care plan that addresses the specific needs.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1's weight was recorded daily as ordered from 11/22/24 through 12/02/24. This failure could place residents at risk of not receiving care to maintain optimum health and placing them at risk for decline in health. Findings included: Review of Resident #1's face undated face sheet reflected he was admitted on [DATE] and discharged on [DATE]. Review of Resident #1's admission MDS assessment, dated 11/22/24, Section A (Identification Information) reflected a [AGE] year-old male admitted to the facility on [DATE]. Section I (Active Diagnoses) reflected diagnoses including atrial fibrillation (an irregular heartbeat), heart failure, hypertension (high blood pressure), cirrhosis (severe liver damage), morbid obesity, and diabetes mellitus (a condition that affects the way the body processes blood sugar). Section C (Cognitive Patterns) reflected a BIMS score of 14 indicating intact cognition. Review of Resident #1's care plan initiated on 09/20/24 reflected in part, Resident #1 is at risk for nutritional and/or dehydration risk related to diabetes, congestive heart failure, and morbid obesity. Will maintain nutritional status as evidenced by no significant weight changes through next review. Interventions included, Monitor weights, skin report, and labs . Review of Resident #1's physicians orders dated 11/20/24 reflected, Daily weight once a day 6:00 AM to 11:00 AM. Review of Resident #1's recorded weights reflected 11/19/24 441.5 lbs., 11/20/24 440.5 lbs., and 11/21/24 440 lbs. There were no weights recorded for 11/22/24 through 12/02/24 (11 days). During an interview on 12/04/24 at 12:05 PM, the NP stated it was important to monitor Resident #1's weight because of his heart conditions , chronic edema, and morbid obesity. She stated weight changes could indicate a change in status. During an interview on 12/04/24 at 3:52 PM, with LVN A, she stated the restorative aide was responsible for weighing residents. She stated weights were monitored to help assess changes in fluid balance or nutritional status. She stated Resident #1 had an order for daily weights, but she saw only three weights recorded in the record. She stated she did not weigh the resident and did not know if the resident had refused to be weighed. During an interview on 12/04/24 at 3:57 PM the ADON, stated the restorative aide was responsible for daily and weekly weights but anyone could weigh the residents. There were other staff who were responsible for weights when the restorative aide was not in the building. She stated the weights were included on a weekly report that went to the management team and the weights were reviewed at a meeting. She stated changes in weight could indicate fluid imbalance or CHF. During an interview on 12/04/24 at 4:34 PM, the DON stated the restorative aide was responsible to take and record the weights, but all nursing staff could have taken a weight. She stated the restorative aide was out of the facility, but she had left a message and requested a return call. She stated she found some papers on the restorative aide's desk which included a weight for Resident #1 on 11/26/24. The DON stated the weight was not recorded in Resident #1's electronic medical record. The DON stated it was her expectation that physician orders be followed. During an interview on 12/04/24 at 4:38 PM, the ADM stated it was her expectation that physician orders be followed. Review of the facility policy, Weighing the Resident, revised 02/26/24, reflected in part, Record all weights per facility protocol. The policy did not address daily weights. Review of the facility policy, Physician Orders, revised 05/05/23, reflected in part, 3. Upon admission, the Facility has physician orders for the resident's immediate care to include but not limited to: C. Routine care orders to maintain or improve the resident's functional abilities .

Based on observation, interview, and record review, the facility failed to treat each resident with dignity and respect and care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #1) of six residents reviewed for dignity. The facility failed to ensure MA A treated Resident #1 with dignity and respect when she spoke to the resident in a rude manner in front of others . This failure could place residents at the risk for psychosocial harm due to diminished self-esteem and quality of life. The findings were: Record review of Resident #1's face sheet, dated 08/07/24, reflected a [AGE] year-old-male who was admitted to the facility on [DATE]. His diagnoses included Severe protein-calorie malnutrition, Mood disorder, BMI 19.9 or less (Low body weight), Nausea with vomiting, Muscle weakness, Abnormalities of gait and mobility, Hypertension and chronic kidney disease . Record review of Resident #1's quarterly MDS assessment, dated 07/30/24. reflected a BIMS of 15, which indicated his cognition was intact. Record review of Resident #1's quarterly Care Plan, dated 07/30/24, reflected Resident #1 made verbal expressions of distress related to feeling depressed (Sad), fearful (not feeling safe), and anxiety (over needs and care) . The relevant interventions were: 1. Establish a trusting relationship with the resident and family. 2. Maintain a calm environment and approach to the resident. 3.Convey an attitude of acceptance toward the resident. 4.Acknowledge to the resident that the current situation must be difficult. 5.Allow resident to make decisions, to set realistic goals, and to participate in self-care. Record review of the incident report by the facility, dated 08/02/24, reflected on 08/02/24 at 6:15 PM, Resident #1 reported a rude interaction during meal services and was witnessed by MA B and CNA C. Resident #1 stated he was standing at the dining door with his water pitcher when MA A approached and asked him what he wanted. He explained to her he wanted to make a change to his meal and refill his pitcher. MA A told him he had to make meal changes earlier if he wanted, not possible now and asked him to walk around the corner and fill up his pitcher instead of getting it from the kitchen. In an observation and interview on 08/07/24 at 12:10 PM revealed Resident #1 was lying in bed in his room. When the State Surveyor asked about the incident that happened in the dining room on 08/02/24 at 5:20 PM, he stated he was upset about how the staff member, MA A, talked to him in the dining room while other residents were present. He said he was at the dining room door waiting for dietary staff to come out so he could tell the changes he wanted in his meal and fill up the water pitcher. He continued, that time MA A approached and asked him why he was waiting there. He stated he explained to her the reason why he was there. He stated, at that time she rudely told him he had to get his meal changes in by 3:00 PM and asked him not to stand at the door, instead walk around the corner and fill up the water pitcher. He said he asked for her name and instead of telling her name, asked him to look at her name tag and read. He stated he felt humiliated in front of others and did not want to go to the dining hall anymore . He stated he reported this to the ADON and decided to move out of the facility as he believed the staff at the facility were not treating him with dignity and respect . He also stated he was afraid MA A would do something with his food from the kitchen, as retaliation for complaining. During an interview over the phone on 08/07/24 at 1:30 PM, MA A stated she worked as a med aide for more than [AGE] years and was working at the facility for about a year. She stated she would never do anything that would harm any resident. She stated on 08/02/24 in the evening she was helping Resident #1 however her actions were misinterpreted. MA A said she was on suspension after the incident until the facility investigation was completed, however she decided to resign as she felt the facility did not have a stable policy. She stated she was following the facility's policy that no meal changes were allowed after 3:00 PM, however after the incident the facility changed their stand and blamed her for her actions. She stated some people thought she was rude due to her English. She added, she was from a different ethnicity and had a think English accent. MA A said she used hearing aids and sometimes it was difficult to hear and understand what others said. During an interview, over the phone on 08/07/24 at 2:00 PM, CNA C stated he went to throw trash at the dumpster and when he walked in through the door, he heard the resident asking MA A's name. CNA C said he heard MA A stated she didn't need to tell her name to residents, instead he could look at her name badge and read if he wanted. CNA C said MA A was rude and argumentative with Resident #1. The resident appeared upset and walked off. CNA C stated he did not know what they were talking about before then or why the resident asked for her name. CNA C stated MA A did not use any abusive or derogatory words; however, she was unpolite in her conversation and not helpful in her actions. During an interview on 08/07/24 at 2:30 PM, MA B stated she was present in the dining room when the incident occurred and Resident #1 asked MA A something at the dining room door. MA B said the only thing she heard was MA A telling the resident where the water station in his hall was. She said, when Resident #1 asked if could go to the hall close to the dining hall for filling his water pitcher, MA A asked him to go to his hallway and fill the water. MA B stated MA A could be stubborn and sometimes got into arguments with the residents. During an interview on 08/07/24 at 3:00 PM with the ADON, she stated at about 6:00 PM Resident #1 approached her to report MA A was very unkind with him when he asked for help. She stated, Resident #1 was visibly upset about it. The ADON stated there was no such rule stated that residents must let the dietary team know any meal changes before 3:00 PM. She said residents could request for a meal change anytime they wanted, and residents were free to collect drinking water from any hall. She stated ideally the staff ensured regular supply of water in residents' rooms, however some residents occasionally liked to collect it personally as well. The ADON stated MA A was under suspension until the facility investigation on the incident was completed. During an interview on 08/07/24 at 3:00 pm, the ADM stated the incident was under investigation and MA A was suspended until the investigation was completed. She stated the expectation from all the staff was treating every individual at the facility with dignity, respect and empathy. She stated any violation to this would never be tolerated and the facility was committed to ensure this policy was implemented. Record review of the policy Social Services Policies and Procedures: Resident Rights revised on 06/09/2023, reflected: The Facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities . The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchens reviewed for food and nutrition services. 1. The facility failed to ensure all food items were covered, labeled, dated and discarded prior to their use-by date. 2. The facility failed to ensure CK N washed and sanitized the food processor between uses 3. The facility failed to ensure CK N wore gloves when handling ready-to-eat foods 4. The facility failed to ensure CK N washed her hands for 20 seconds after handling trash 5. The facility failed to ensure DA P removed his gloves and washed his hands after touching a contaminated object These failures could place residents at risk of foodborne illness. Findings included: An observation of the reach-in refrigerator on 11/28/2023 at 8:38 a.m. revealed a container of sliced cheddar cheese dated 11/21/2023 open to air and not sealed. There were also 12 2-oz. cups of salad dressing not labeled or dated. Observations of the walk-in refrigerator on 11/28/3034 from 8:40 a.m.-8:49 a.m. revealed the following: At 8:40 a.m., the walk-in refrigerator contained a container of chili dated 11/09/2023 with an illegible use-by date. At 8:43 a.m., the walk-in refrigerator contained a jug of pickles dated 7/20 and there were black, round, fuzzy spots on the lid, which was not tightly sealed. At 8:44 a.m., the walk-in refrigerator contained a jug of opened mayonnaise with a received date of 11/08/2023 and no opened date. At 8:45 a.m., the walk-in refrigerator contained a jug of coleslaw dressing dated 4/12/2023-the jug had black, round, fuzzy spots all over the lid and container. At 8:45 a.m., the walk-in refrigerator contained a jug of opened picante sauce with an opened date. At 8:46 a.m., the walk-in refrigerator contained an additional jug of picante sauce without and opened date. This container also had black-brown, round, fuzzy spots around the lid and container. At 8:47 a.m., the walk-in refrigerator contained a jug of opened Worcestershire sauce, covered with aluminum foil, and without an opened date. At 8:47 a.m., the walk-in refrigerator contained a plastic sealable bag of shredded cheddar cheese dated 11/23/2023. The bag was not sealed and was open to air. At 8:49 a.m., the walk-in refrigerator contained a raw round top roast dated 9/9. During an observation and interview on 11/28/2023 at 8:53 a.m., CK N stated she did not know if the round, black, fuzzy substance was mildew. CK N stated she was not sure what it could be but stated it could be oyster sauce or Worcestershire sauce. CK N stated she did not see anything that could have dripped. CK N stated she did not know when the round top was pulled from the freezer but said everything came in frozen. CK N stated all sealable bags should have been sealed shut and that was her first day back to work after being off for two days. CK N stated they kept leftovers for four days and said the chili needed to be taken out. Observed CK N remove, from the walk-in refrigerator, the items with the black unidentifiable substance-two jugs of picante sauce and one jug coleslaw sauce. An observation on 11/28/2023 at 10:11 a.m. revealed DA P was preparing toast in the kitchen. DA P touched his sweatshirt twice with gloved hands and continued to prepare toast without removing his gloves or washing his hands. During an interview on 11/28/2023 at 10:13 a.m., CK N stated she started as a dietary aide 4-5 months prior and was promoted to cook 2-3 months ago. Observations on 11/28/2023 from 10:25 a.m.-10:48 a.m. revealed CK N pureed ham, green beans, and pears consecutively without washing and sanitizing the food processor-she rinsed the food processor, blade, and lid under running water in the preparation sink in the kitchen. During an observation and interview on 11/28/2023 at 10:40 a.m., CK N was observed making pureed chicken-she pinched some chicken base with bare hands and dropped it into the food processor before blending it together. CK N stated she used the chicken base to add flavor. An observation on 11/28/2023 at 10:51 a.m. revealed CK N lifted the trash can lid up to throw away an empty can and then proceeded to pour the contents of the can into the food processor without washing her hands. During an interview on 11/29/2023 at 10:52 a.m., CK N stated she had not washed the food processor the day prior (11/28/2023) in between pureeing food items because the prep sink was right there and was easier. CK N stated she did not believe the food processor needed to be washed, rinsed and sanitized between pureeing each food item. During an interview on 11/29/2023 at 8:51 a.m., the RD stated the unlabeled salad dressing found in the reach-in refrigerator the day prior was ranch dressing and she thought dietary staff had just portioned it out prior to lunch. The RD stated the roast dated 9/9 had been frozen but since it had not been labeled with a pull date, they tossed it. During an interview on 11/29/2023 at 3:01 p.m., the RD stated yes everything should have a label and a date. The RD stated yes sealable bags needed to be sealed and everything should be covered, labeled, and dated. The RD stated yes items should be dated when opened and staff should follow best-if-used-by dates. The RD stated she expected staff to wash their hands and change gloves after touching part of their body during a food prep activity. The RD stated dietary staff should use a spoon when handling chicken base while preparing ready-to-eat items. The RD stated dietary staff should wash their hands for 20 seconds after handing a contaminated food item and before moving to a food prep activity. The RD stated staff should wash and sanitize the food processor in between pureeing different food items. The RD stated it was her first time seeing CK N cooking since the RD had been there. The RD stated she did not know how often staff cleaned food containers in the walk-in refrigerator, but she had never seen mildew and did not know what the black, circular, fuzzy spots on the condiment containers could be. The RD stated dietary staff were trained on food storage and sanitation by the Dietary Manager , who paired them with an experience employee for shadowing. The RD stated she trained staff in the form of in-services but not all staff had been trained by herself-she said CK N was new to her. The RD stated the Dietary Manager did some in-servicing as well. The RD stated the Dietary Manager monitored the kitchen for sanitation, but she was not sure how she monitored and handled her individual staff. The RD stated, we ask the Dietary Manager to check everything each day. The RD stated she monitored the kitchen by completing sanitation audits once a month. The RD stated if policies on food storage and sanitation were not followed, it could affect food quality and food safety. During an interview on 11/30/2023 at 4:30 p.m., the Administrator stated food should be covered and dated for whatever date they put it in the refrigerator. The Administrator stated leftovers should not be kept more than three days and the food processor should be washed between each use. The Administrator stated staff should wear gloves when handling ready to eat foods and if touching their body, staff should wash hands and change gloves. The Administrator stated she monitored the kitchen a lot and corrected things on the spot. The Administrator state she did a tray line audit every day she was in the facility and said she was constantly correcting dietary staff to wash their hands and not touch their body. The Administrator stated she did a sanitation audit once a week and when the RD was out for about six weeks, she did not find any audits from the dietitian who was covering. The Administrator stated the RD did a sanitation audit once a month and the Dietary Manager did the same things-she said the Dietary Manager should have completed a walk through every day. The Administrator stated dietary staff received skills check off for training and the Dietary Manager did side by side training with new staff for three days. The Administrator stated if kitchen sanitation policies were not followed, they could get sick or have foodborne illness. A record review of the facility's policy titled HAND HYGIENE/HAND WASHING dated6/20/2023 reflected the following: POLICY: Hand hygiene is the most important component for preventing the spread of infection. Proper hand washing technique will be used when hand washing is indicated. Employees keep their hands and exposed portions of arms clean. PROCEDURES: 1. Clean hands in a hand washing sink. Hands may not be cleaned in a sink used for food preparation or ware washing or in a service sink used for disposal of mop water. 2. Wash hands: C. Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves D. Before handling or eating food J. After contact with soiled or contaminated articles, such as, dirty dishes K. After contact with an object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds RAIONALE Warm water helps to lather soap and also is more comfortable, thus increasing the chance [that] hands will be washed for at least 20 seconds. A record review of the facility's policy titled FOOD SAFETY IN RECEIVING AND STORAGE dated 6/20/2023 reflected the following: POLICY: Food will be received and stored by methods to minimize contamination and bacterial growth. General Food Storage Guidelines 2. Store food in its original packaging if the packaging is clean, dry, and intact. 3. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents, the date it was transferred to the new container, and the discard date. It is recommended that food stored in bins (e.g. flour or sugar) be removed from its original packaging. 12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Follow USDA guidelines for food storage. 14. Refrigerated condiments and salad dressings are properly covered, labeled, and clearly marked to indicate a use by date two months from the date opened. A record review of the facility's policy titled MANUAL CLEANING AND SANITIZING WITH A THREE-COMPARTMENT SINK dated 6/20/2023 reflected the following: POLICY: Equipment and utensils will be cleaned and sanitized appropriately after use. A three-compartment sink is used for manual washing, rinsing, and sanitizing utensils, and equipment. A high concentration of sanitation solution may be potentially hazardous. PROCEDURES: 1. Fixed equipment, utensils, and equipment too large to be cleaned in sink compartments are washed manually with detergent and hot water, rinsed, air-dried, and sprayed with a sanitizing solution. 2. Pre-flush or pre-scrape equipment and utensils and when necessary, pre-soak to remove large food particles and soil. 3. Conduct manual washing, rinsing, and sanitizing in sink compartments in the following sequence: NOTE: All methods will coincide with manufacturer's recommendations and/or state/local requirements. A. Clean the sink before each use. 8. Flush, scrape, or soak items before washing. C. 1st Sink: Equipment and utensils are thoroughly washed in the first sink in a detergent solution of at least 11 0 F. Wash water is kept clean and changed frequently. D. 2nd Sink: Equipment and utensils are rinsed free of detergent and abrasive with clean, clear water E. 3rd Sink: Equipment and utensils are sanitized in the third compartment according to one of the following methods: Facility uses method # ____ NOTE: If only a 2-compartment sink is available, follow A, B , C as written, rinse under running water and sanitize as per E or per state/local requirements. Method: 1. Immersion for at least 30 seconds in clean hot water at 171 F or hotter. (To prevent burns, use a basket, a rack or tongs to lower and remove items form the water). 2. Chemical sanitization following manufacturer's instructions. If explicit instructions are not provided, the recommended concentrations are as follows: Immersion for at least 10 seconds in a clean solution containing 50-100 ppm (parts per million) of chlorine at 75 For hotter but not exceeding 120 F. 4. Immersion for 30 seconds in a clean solution containing at least 12.5 ppm to 25 ppm of iodine and with a pH not higher than 5.0 and at 75 For hotter but not to exceed 120 F. A record review of the facility's policy titled WAREWASHING USING DISHWASHING MACHINE dated 6/20/2023 reflected the following: POLICY: Utensils and dishes washed by a mechanical dishwasher will be clean and sanitized. A record review of the 2017 FDA Food Code reflected the following: 4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. 2-301.12 Cleaning Procedure. (A) Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under S 5-202.12 and Subpart 6-301. 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms

Based on observation, interview, and record review, the facility failed to ensure storage of medications used in the facility was in accordance with currently accepted professional principles and include the appropriate expiration dates 3 of 4 medication carts (100 hall nurse cart, 200 hall nurse cart, and 300/400 hall med aide cart) reviewed for pharmacy services. -1. The facility failed to date a multi-use product (eye drops and inhalers) when the products were first opened according to manufacturer and professional standards. -2. The facility failed to ensure an expired insulin pen was removed from the medication cart. These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. Findings Included: Observation on 11/29/23 at 8:51 AM revealed the 300/400 med aide cart had 2 bottles of latanoprost eye drops and 1 bottle of pilocarpine eye drops without open dates. Observation on 11/29/23 at 2:40 PM revealed the 100-hall nurse cart had a Fluticasone Propionate & Salmeterol inhaler without an open date. Observation on 11/29/23 at 2:42 PM revealed the 200-hall nurse cart had a Novolog insulin pen labeled Expires 28 days after opening, date opened 10/27/23, thus expired on 11/24/23. Observation on 11/29/23 at 2:42 PM revealed the 200-hall nurse cart with a Ventolin inhaler without an open date. During an interview on 11/29/23 at 8:53 AM, with MA G, she stated eye drop bottles should have been labeled with name and date when they were opened. During an interview on 11/29/23 at 3:45 PM., the DON stated multi-dose items should have been dated and expired medications should be removed from the medication carts. She stated the med aides and nurses were responsible for checking the expiration dates. The DON stated expired meds may not provide the desired effect. During an interview on 11/30/23 at 8:46 AM, the ADON stated the nurse or med aide labeled multi-dose items with the resident name and the date when opened. She stated insulin pens were good for 28 days once opened then needed to be discarded. During an interview on 11/30/23 at 9:35 AM, RN A stated multi-dose containers such as inhalers and insulin were dated when opened. She stated the person who opened the item was supposed to label it. If an opened undated multi-dose item was found in the med cart, it would be discarded. He stated insulin pens were good for 28 days once opened. RN A stated expired meds may not be effective. Review of the facility's policy titled Medication Management Program, revised 05/05/23 reflected in part: 7. H. Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose package with the date opened and follow guidelines for expiration dates. 15. Outdated medication is destroyed or returned to the pharmacy according to applicable state rules and regulations.

Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 19 residents (Resident #85, #90, #92, #297) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #85 and Resident #90's Comprehensive Care plan reflected a care plan for post-traumatic stress disorder. 2. The facility failed to ensure Resident #92's Comprehensive Care plan reflected Resident #92 utilized a wearable cardioverter defibrillator (a vest worn by the resident which detects and treats life-threatening rapid heart rhythms in residents at risk of sudden cardiac death). 3. The facility failed to ensure Resident #297's Comprehensive Care plan reflected his communication deficits and devices used for communication. This facility placed residents at risk for unmet needs. Findings include: Review of Resident #85's undated face sheet, printed 11/28/23, reflected a [AGE] year-old male, who was admitted to the facility on [DATE] with diagnoses of anxiety disorder, stroke (bleeding in the brain) that caused paralysis on the right side, and post-traumatic stress disorder. Review of Resident #85's Quarterly MDS assessment, dated 10/18/23, reflected that Resident #85 had a BIMS of 9, which indicated moderately impaired cognition. Review of the MDS did not reveal documentation regarding behaviors. Review of Resident #85's care plan, dated 09/25/23, reflected no care plan for post-traumatic stress disorder. Review of Resident #90's face sheet, undated, printed 11/28/23, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of acute respiratory failure (not enough oxygen getting to the body), depression, diabetes, and chronic kidney disease. Review of Resident #90's Admission MDS , dated 10/03/23, reflected Resident #90 had a BIMS of 14, which indicated intact cognition. Section I - Active Diagnoses of the MDS reflected that Resident #90 was marked as being diagnosed with post-traumatic stress disorder. Review of the MDS did not reveal documentation regarding behaviors. Review of Resident #90's care plan, dated 09/29/23, reflected no care plan for post-traumatic stress disorder. Review of Resident #92's 5-day MDS assessment, dated 10/31/23, reflected a [AGE] year-old male who was admitted on [DATE] with diagnoses of acute and subacute infective endocarditis (an infection of the inner lining and valves of the heart), presence of heart assistive device, essential hypertension (high blood pressure), heart failure, and bacteremia (bacteria present in the blood). The assessment reflected Resident #92 had a BIMS score of 14, which indicated intact cognition. Review of Resident #92's Care Plan, dated 10/29/23, reflected interventions for ADL assistance, dehydration risk, fall risk, and pain management. The care plan did not reflect the wearable cardioverter defibrillator. Review of Resident #92's physician's orders, dated 10/29/23, reflected Special Instructions: (Brand name) wearable cardioverter defibrillator instructions 1. Replace battery daily with fully charged battery and place other battery to charge 2. Never hit the response button 3. May remove vest for showering only but immediately place once dry 4. If Blue gel is observed on patient or 2 tone siren is alarming, do not touch the resident and call provider STAT. Observation and interview on 11/30/23 at 9:06 AM with Resident #92 revealed he was sitting up on the edge of the bed wearing a cardioverter defibrillator vest. A battery charger with an extra battery was observed on the nightstand. Resident #92 stated his implanted defibrillator had been removed due to an infection and he had to wear the vest until the infection resolved and the heart doctor thought it was safe to replace the internal device. He stated he wore the vest at all times except when he showered. He stated the nursing staff help him to change the battery daily. Review of Resident #297's MDS assessment, dated 11/10/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Section C of his MDS reflected that he had a BIMS of 14, which indicated intact cognition. Section B - Hearing, Speech, and Vision reflected that Resident #297 was Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. Review of Resident #297's care plan, dated 11/6/23, reflected that he had a primary diagnosis of ALS (a progressive disease that affects nerve cells in the brain and spinal cord) and other diagnosis' including cognitive communication deficit, dysphagia and an age-related physical debility. The care plan did not reveal evidence of documentation regarding his communication deficit or communication devices he used to communicate. Review of Resident #297's Inventory Sheet, signed 11/4/2023, reflected ARTICLES RETAINED BY PATIENT .Tablet + Charger, Phone + Charger. During an observation and attempted interview on 11/28/23 at around 9:00 AM, Resident #297 was observed in his room, in bed. Resident #297 waved, then began to point behind him. A tablet-like device and cell phone were observed on a small dresser behind him; another tablet-like device was attached to the right side of his bed. Resident #297 was asked if he would like his phone and he nodded, Yes. A nearby CMA was alerted, who sanitized his hands, knocked and entered the room. The CMA grabbed Resident #297's phone and realized it needed to be charged. Resident #297 nodded, Yes, agreeing to continue the interview at another time. A follow-up interview was attempted on 11/30/23 at 10:07 AM with Resident #297, however, he stated he did not want to answer any questions. During an interview on 11/29/23 at 9:53 AM CNA L stated she worked at the facility for about 7 months. She stated she was familiar with Resident #297, adding that he communicated using a tablet or a phone; she stated there was also a tablet attached to his bed that he used to communicate. She stated Resident #297 used gestures as well to communicate his needs, for example, by rubbing his stomach if he was not feeling well. During an interview on 11/29/23 at 10:26 AM, CNA M stated she worked at the facility for 4.5 years and was familiar with Resident #297. She stated Resident #297 used his tablet and other devices to communicate. She stated upon rounds every 2-hours or when she responded to his call light, Resident #297 would use these devices to communicate his needs. She stated he could also answer yes/no questions. She stated he was a new admission and had the devices upon admission. During an interview on 11/30/23 at 10:30 AM, the DON stated that failure to care plan for post-traumatic stress disorder could have led to increased symptoms and missing triggers for Resident #85 and Resident #90 which could resulted in the residents not achieving their highest functional level. She stated care plans were the responsibility of the MDS nurse who was relatively new to the position. During an interview on 11/30/23 at 10:30 AM, the NP and the DON stated that Residents #85 and #90 were also in the care of the VA and records were difficult to obtain and it could be a slow process, but the DON was going to reach out again. During an interview on 11/30/23 at 11:34 AM, LVN E stated the battery for Residents #92's defibrillator vest was changed each day. The used battery was placed on the charger and charged overnight. She stated he wore the vest all the time except while he showered. She stated, after he showered, he had to dry off completely before he replaced the vest. During an interview on 11/30/23 at 10:41 AM, RN A stated he worked at the facility for approximately 1 month. He stated he communicated with Resident #297 using yes/no questions. He stated at other times, he observed Resident #297 use a tablet to communicate or Resident #297 has texted or wrote his needs, questions or concerns in his phone. During an interview on 11/30/23 at 4:17 PM, MDS LVN B stated, she was responsible for MDS assessments and care plans for the short-term residents at the facility. She stated she had been getting help with MDS assessments from traveling nurses. She stated she recently found out the traveling nurses had not completed all the care plans. She stated the care plan was due seven days after the assessment was completed, no later than day 21. She stated a wearable cardioverter defibrillator should be on the care plan . She stated accurate care plans ensured residents received the needed care. During an interview on 11/30/23 at approximately 4:15 PM, MDS LVN C stated she oversaw completing MDS assessments and care plans for long-term residents at the facility. She stated if a resident had impaired communication and used devices to communicate, this should be documented in their care plan. She stated depending on what was assessed for the resident, the social worker or nurse could also put information in care plans. She stated if the information was not present in a care plan, it was likely that that care area did not get relayed to the right department. She stated despite floor nurses having knowledge of how Resident #297 communicated, this information should have been in his care plan. During an interview on 11/30/23 at approximately 3:55 PM, the DON stated she had not provided any in-services specific to the wearable cardioverter defibrillator. She stated the device should have been on the care plan but all the things you needed to look for were in the order. During the interview, the DON stated if a resident had communication deficits, or used communication devices, this would be reflected in the care plan. She stated putting this information into a care plan was the MDS nurse's responsibility. She stated upon admission, Resident #297 was accompanied by his tablet and phone. She stated Resident #297 primarily used these devices to communicate in addition to pointing, head-nodding, and making noises; she added that he is good at communicating. She stated CNAs could access resident information, including information on how the resident communicated by accessing their POC system. She stated nurses could access resident care plans where communication information should be reflected. During an interview on 11/30/23 at 4:45 PM, the Administrator stated during QAPI meetings they looked at CASPER reports and talked about the MDSs and anything that needed to be care planned. She stated she expected to see the wearable cardioverter defibrillator on the care plan. She stated if a problem was not identified, the resident would not get the needed care. She stated, Everything needed to be on the care plan. Review of facility policy, titled Care Plan Process, Person-Centered Care, last revised 5/5/2023, reflected the following: The facility will develop and implement a . comprehensive care plan for each resident that includes instructions needed to provide effective and person-centered care for the resident that meet professional quality of care . Person-centered care includes trying to understand what each resident is communicating . and understanding the resident's life before coming to reside in the nursing home . The person-centered care plan includes: A. Date B. Problem C. Resident goals for admission and desired outcomes D. Time frames for achievement E. Interventions, discipline specific services, and frequency F. Refusal of services and/or treatments 1. Evaluation of resident's decision-making capacity 2. Educational attempts 3. Attempts to find alternative means to address the identified risk/need G. Discharge plans 1. Resident's preferences and potential for future discharge 2. Resident's desire to return to the community and any referrals to local contact agencies and/or other appropriate entities, for this purpose. H. Resolution/Goal Analysis

Based on observation, interview, and record review, the facility failed to ensure menus were followed for 9 of 9 (Resident #8, Resident #18, Resident #24, Resident #29, Resident #46, Resident #52, Resident #60, Resident #73, Resident #91) residents reviewed for menus. 1. The facility failed to ensure CK N followed recipes when preparing pureed food items 2. The facility failed to ensure CK N served adequate portion sizes for residents on a pureed diet. These failures placed residents at risk of decreased intake, malnutrition, and weight loss. Findings included: A record review of Resident #8's face sheet dated 11/30/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (dementia), hypertension (high blood pressure), neuralgia (nerve pain), deficiency of other vitamins, unspecified severe protein-calorie malnutrition, stage 2 pressure ulcer of sacral region, cachexia (unintentional weight loss), and dysphagia (difficulty swallowing). A record review of Resident #8's MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderately impaired cognition. Resident #8's MDS assessment reflected she was on a mechanically altered diet. A record review of Resident #8's care plan last revised on 11/08/2023 reflected she was at risk for malnutrition. A record review of Resident #8's physician orders reflected an order dated 11/09/2023 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #8 had not had significant weight loss in the past six months. A record review of Resident #18's face sheet dated 11/30/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Parkinson's disease, muscle wasting and atrophy (muscle loss), abnormal weight loss, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and cerebral infarction (stroke). A record review of Resident #18's MDS assessment dated [DATE] reflected she was not assessed for BIMS due to rarely/never being understood. Resident #18's MDS assessment reflected she was on a mechanically altered diet. A record review of Resident #18's care plan last revised on 10/25/2023 reflected she was at risk for malnutrition. A record review of Resident #18's physician orders reflected an order dated 4/22/2023 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #18 had not had significant weight loss in the past six months. A record review of Resident #24's face sheet dated 11/30/2023 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of cerebral infarction (stroke), stage 2 pressure ulcer of right heel, dysphagia (difficulty swallowing), muscle wasting and atrophy (muscle loss), hypertension (high blood pressure), vitamin deficiency, and history of nutritional and metabolic disease. A record review of Resident #24's MDS assessment dated [DATE] reflected a BIMS score of 11, which indicated moderately impaired cognition. Resident #24's MDS assessment reflected she was on a mechanically altered diet. A record review of Resident #24's care plan last revised on 10/30/2032 reflected she was at risk for malnutrition and received hospice services for her terminal illness of dementia. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #24 had significant weight loss of 7.5% in 90 days. Resident #24 went from 135.2 lbs. on 8/01/2023 to 125 lbs. on 11/01/2023. A record review of Resident #29's face sheet dated 11/30/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of cerebral infarction (stroke), dysphagia (difficulty swallowing), muscle wasting and atrophy (muscles loss), hypertension (high blood pressure), and hyperlipidemia (high cholesterol). A record review of Resident #29's MDS assessment dated [DATE] reflected a BIMS score of 9, which indicated moderately impaired cognition. Resident #29's MDS assessment reflected he was on a mechanically altered diet. A record review of Resident #29's care plan last revised on 10/20/2023 reflected he was at risk for malnutrition. A record review of Resident #29's physician orders reflected an order dated 8/03/2023 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #29 had not had significant weight loss in the past six months. A record review of Resident #46's face sheet dated 11/30/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral infarction (stroke), hypertension (high blood pressure), hyperlipidemia (high cholesterol), nutritional deficiency, and dysphagia (difficulty swallowing). A record review of Resident #46's MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderately impaired cognition. Resident #46's MDS assessment reflected she was on a mechanically altered diet. A record review of Resident #46's care plan last revised on 10/10/2023 reflected she was at risk for malnutrition. A record review of Resident #46's physician orders reflected an order dated 8/20/2021 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #46 had not had significant weight loss in the past six months. A record review of Resident #52's face sheet dated 11/30/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of vascular dementia (dementia due to cerebral vascular disease), dysphagia (difficulty swallowing), hypertension (high blood pressure), anemia (deficiency of healthy red blood cells), hyperlipidemia (high cholesterol), and disorder of mineral metabolism. A record review of Resident #52's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. Resident #52's MDS assessment reflected he was on a mechanically altered diet. A record review of Resident #52's care plan last revised on 11/08/2023 reflected he was at risk for malnutrition and received hospice services for sequela (pathological condition resulting from a prior disease) of cerebral infarction. A record review of Resident #52's physician orders reflected an order dated 11/08/2023 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #52 had a severe weight loss of 9.4% in 90 days. Resident #52's weight went from 172 lbs. on 9/08/2023 to 155.7 lbs. on 11/01/2023. A record review of Resident #60's face sheet dated 11/30/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of dysphagia (difficulty swallowing), abnormal weight loss, hypertension (high blood pressure), hyperlipidemia (high cholesterol), unspecified dementia and repeated falls. A record review of Resident #60's MDS assessment dated [DATE] reflected a BIMS score of 7, which indicated moderately impaired cognition. Resident #60's MDS assessment reflected he was on a mechanically altered diet. A record review of Resident #60's MDS assessment dated [DATE] reflected he was not assessed for BIMS. A record review of Resident #60's care plan last revised on 10/31/2023 reflected he was at risk for malnutrition. A record review of Resident #60's physician orders reflected an order dated 10/05/2023 for a pureed diet. A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #60 had not had significant weight loss in the past six months. A record review of Resident #73's face sheet dated 11/30/2023 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of abnormal weight loss, Alzheimer's disease (type of dementia), hyperlipidemia (high cholesterol), and dysphagia (difficulty swallowing). A record review of Resident #73's MDS assessment dated [DATE] reflected a BIMS score of 7, which indicated moderately impaired cognition. Resident #73's MDS assessment reflected she was on a mechanically altered diet. A record review of Resident #73's care plan last revised on 11/28/2023 reflected she was at risk for malnutrition. A record review of Resident #73's physician orders reflected an order dated 8/16/2023 for a pureed diet A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #73 had not had significant weight loss in the past six months. A record review of Resident #91's face sheet dated 11/30/2023 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of gastric ulcer, dysphagia (difficulty swallowing), muscle wasting and atrophy (muscles loss), hypertension (high blood pressure), moderate protein0calorie malnutrition, hyperlipidemia (high cholesterol) and gastro-esophageal reflux disease (acid reflux). A record review of Resident #91's MDS assessment dated [DATE] reflected a BIMS score of 14, which indicated minimally impaired cognition. This assessment also reflected Resident #91 received artificial nutrition. Resident #91's MDS assessment reflected he was on a mechanically altered diet. A record review of Resident #91's care plan last revised on 11/01/2023 reflected he was at risk for malnutrition and received artificial nutrition (Delivery of a patient's nutritional support without requiring the patient to chew and swallow). A record review of Resident #91's physician orders reflected an order dated 11/13/2023 for a pureed diet. Resident #91's order dated 10/26/2023 reflected he received enteral feedings (intake of food via the gastrointestinal tract). A record review of the facility's Weight Variance Report dated 11/01/2022-11/28/2023 reflected Resident #91 had not had significant weight loss in the past six months. An observation on 11/28/2023 at 9:11 a.m. revealed Resident #18 was sitting in her bed. Resident #18 did not respond when spoken to by name. An observation on 11/28/2023 at 9:24 a.m. revealed Resident #52 was lying in bed. Resident #52 was non-interviewable. During an interview an observation on 11/28/2023 at 9:40 a.m., Resident #91 was observed lying in bed with his tube feeding connected. Resident #91 stated staff changed the dressing around his tube regularly. During an observation and interview on 11/28/2023 at 9:55 a.m., Resident #29 was observed sitting in his room and he said his breakfast was good. An observation on 11/28/2023 at 9:56 a.m. revealed Resident #60 was lying in his bed. Resident #60 was unable to be interviewed. During an observation and interview on 11/28/2023 at 11:29 a.m., Resident #46 was observed to be comfortable, and she stated she had no concerns. An observation on 11/28/2023 at 12:31 p.m. revealed Resident #73 was eating without assistance. Resident #73 was unable to be interviewed. During an observation and interview on 11/29/2023 at 8:57 a.m., Resident #24 was observed lying in bed. Resident #24 voiced no concerns but said she was a little hungry. During an observation and interview on 11/29/2023 at 10:03 a.m., Resident #8 was observed in the activity room. Resident #8 stated she stayed in the activity room most of the day. During an interview on 11/28/2023 at 10:13 a.m., CK N stated she started as a dietary aide 4-5 months prior and was promoted to cook 2-3 months ago. An observation of puree preparation on 11/28/2023 at 10:20 a.m. revealed CK N prepared pureed ham by adding six half cup measurements of mashed potatoes to the ham inside the food processor. During an interview on 11/28/2023 at 10:21 a.m., CK N stated she had added 1.5 lb. of ham to puree. CK O stated, you want it to look like pink mashed potatoes. During an interview on 11/28/2023 at 10:25 a.m., CK O stated adding mashed potatoes to the puree added flavor, nutrition, and it helps it puree. CK O stated, you just can't over do it with the mashed potatoes. During an interview on 11/28/2023 at 10:27 a.m., CK N stated that was her first time using mashed potatoes for puree. An observation on 11/28/23 at 10:29 a.m. revealed CK N added three half cups of mashed potatoes to the pureed green beans and blended it all together. CK N then added half a #10 can (12-13 cups) of green beans to the food processor plus six more half cup scoops of mashed potatoes-she then blended it all together and added some liquid from the green beans to the mix. During an observation and interview on 11/28/2023 at 10:33 a.m., CK O stated, we got to put the vegetable back in them. CK O then added 1/3 a can of green beans to the food processor and blended it again. CK N added two more scoops mashed potatoes. CK N stated, it tastes like green beans with mashed potatoes. An observation of tray line service on 11/28/2023 at 11:28 a.m. revealed CK N served pureed ham and pureed green beans using a blue #16 (2 oz./a quarter cup) scoop. An observation of puree preparation on 11/29/2023 at 10:40 a.m. revealed CK N pureed 7 6 oz. scoops of chicken with 4 scoops (unspecified in size) of mashed potatoes. During an interview and observation on 11/29/2023 at 10:45 a.m., CK N stated noodles was on the menu but residents on a pureed diet would receive mashed potatoes instead of noodles because noodles were harder to puree, and they wanted to make sure nobody chokes. An observation on 11/29/2023 at 11:54 a.m. revealed CK N served pureed greens and pureed chicken using a blue #16 (2 oz./a quarter cup). A record review of the facility's undated recipe titled Pineapple Glazed Ham reflected pureed ham was to be served using a #8 (4 oz./half cup) scoop. The recipe did not reflect mashed potatoes were to be added. A record review of the facility's undated recipe titled Italian Green Beans reflected pureed green beans were to be served using a #10 (3.2 oz./a third cup) scoop. The recipe did not reflect mashed potatoes were to be added. A record review of the facility's undated recipe titled Seasoned Greens reflected pureed greens were to be served using a #8 (4 oz./half cup) scoop. A record review of the facility's undated recipe titled Baked Chicken Thigh did not reflect mashed potatoes were to be added. A record review of the diet spreadsheet titled Fall Winter '23-'24 Diet Guide Sheet dated 11/28/2023 reflected baked chicken was to be served in 3 oz. portions. During an interview on 11/29/2023 at 2:50 p.m., the RD stated she was not sure whether there was a written policy on following menus. The RD stated she could not speak specifically as to how cooks were trained on following menus, preparing pureed food items, and identifying correct scoop sizes. The RD stated there were recipe books and the cooks knew where to find recipes based on the recipe number. The RD stated staff knew which scoop size to use because it was on the recipes and menus. The RD stated the Dietary Manager trained cooks on finding recipes and using scoop sizes, but she was not sure whether the Dietary Manager had done that with CK N. When asked if the recipes for pureed ham, pureed green beans and pureed chicken called for mashed potatoes, the RD stated she did not know but usually it's food thickener. The RD stated her suspicion was that CK N added mashed potatoes to those food items to thicken them. When asked if CK N had used recipes the day prior (11/28/2023) and that day (11/29/2023), the RD stated she did not look. The RD stated she was not sure how, but that the Dietary Manager monitored staff to ensure they followed recipes, menus, and used correct scoops. The RD stated whenever possible, residents on a pureed diet should receive the same food item as residents on a regular diet-she stated she did not think there was any reason why residents on a pureed diet would receive mashed potatoes instead of pureed noodles. The RD stated it was not too difficult to puree rice or noodles. The RD stated adding mashed potatoes to food items could dilute the source of protein with meat and would also make food taste like mashed potatoes. The RD stated if residents received a smaller portion than the menu indicated as well as food thinned out with mashed potatoes, it could cause residents' needs to not be met. The RD stated, yes it would cause weight loss. During an interview on 11/30/2023 at 4:07 p.m., the DON stated residents on a pureed diet were at risk of nutrition deficits depending on ratio of food amounts. The DON stated receiving smaller portions and less protein would cause nutritional deficits and weight loss for sure. The DON stated Resident #24 had declined over the last year and her disease process had contributed to her weight loss. The DON stated Resident #24's dementia had caused her to lose the ability to eat as much. The DON stated Resident #52 had been admitted with a recently downgraded diet and wanted things outside of a pureed diet. The DON stated he had a history of choking and was admitted to hospice after being admitted to the facility. The DON stated Resident #52 struggled with dysphagia and did not want to eat at times. During an interview on 11/30/2023 at 4:30 p.m., the Administrator state she was sure there was a policy in the nutrition manual on following menus, but she expected that dietary staff followed recipes. The Administrator stated there was a book in the kitchen where recipes were, cooks were shown where recipes were, and CK N should have been trained. The Administrator stated cooks were not supposed to use mashed potatoes to puree food, it loses its nutritional value, and could cause weight loss. The Administrator stated yes if residents were not getting enough to eat, it could relate to some of the same issues. A record review of the facility's policy titles FOOD PREPARATION dated 6/20/2023 reflected the following: POLICY: Food will be prepared and attractively served using methods that conserve nutritive value, flavor, and appearance. PROCEDURES: 1. The cook is responsible for food preparation. Menu items are prepared according to the production count sheet. When Meal Tracker software is used, production count sheets are calculated automatically from the tray tickets. 3. Use the Recipe manual with standardized, yield-adjusted recipes. 6. Prepare altered consistency foods such as puree, minced-moist, and bite- size foods to meet the patient's/resident's individual needs and satisfaction. The facility will use the International Dysphagia Diet Standardization Initiative (IDDSI) as the foundation for texture modified foods and thickened drinks provided to the residents.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6.82 % based on 3 errors out of 44 opportunities, which involved 3 of 4 residents (Resident #88, Resident #57 and Resident #351) reviewed for pharmacy services. 1. LVN E administered multivitamin with minerals instead of the ordered multivitamins with folic acid to Resident #88. 2. MA G administered calcium carbonate 500 mg instead of the ordered calcium carbonate-vitamin D3 500 mg-5 mcg to Resident #57. 3. MA G administered calcium carbonate 500 mg instead of the ordered calcium carbonate 600 mg to Resident #351. These failures could affect residents and put them at risk for not receiving the intended therapeutic benefit of their medication and or adverse outcomes. The findings included: Resident #88 Review of Resident #88's undated face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction (stroke), urinary tract infection, retention of urine, vitamin deficiency, dysphagia (difficulty swallowing food or fluids), type 2 diabetes mellitus (abnormal blood sugar levels), and gastrostomy status (presence of a tube into the stomach to provide nutrition). Review of Resident #88's 5-day MDS assessment dated [DATE] reflected he had no speech and rarely/never understands. He was assessed as being dependent for ADL care and had an indwelling urinary catheter. Review of Resident #88's physician order dated 11/07/23 reflected, Tab-A-Vite (multivitamin with folic acid) tablet; 400 mcg, amt:1; gastric tube once a day. Observation on 11/29/23 at 7:25 AM revealed, LVN E prepared for administration of medications to Resident #88. LVN E retrieved a multivitamin with minerals tablet and placed it in a medication cup. LVN E placed the other 8 medications into individual medication cups. LVN crushed each medication individually and returned the crushed medication to the cup. LVN E gathered all the med cups and entered Resident #57's room. LVN E administered the medications individually through the gastrostomy tube. Resident #57 Review of Resident #57's undated face sheet reflected a[AGE] year-old female admitted on [DATE] with diagnoses including mild intellectual disabilities, atherosclerotic heart disease (the arteries of the heart are thick and stiff), hypertension (high blood pressure), vitamin deficiency unspecified, hyperlipidemia (high levels of fat in the blood), acute kidney failure, and vascular dementia (dementia caused by impaired blood flow to the brain). Review of Resident #57's quarterly MDS dated [DATE] reflected a BIMS score of 14 indicting intact cognition. Review of Resident #57's physician order dated 07/08/23 reflected, Calcium carbonate-vitamin D3 tablet; 500 mg-5 mcg (200 unit); amt:1 tablet; oral once a day. Observation on 11/29/23 at 8:06 AM revealed, MA G prepared for administration of medications to Resident #57. MA G retrieved a Calcium Carbonate 500 mg chewable tablet and placed it in a medication cup. MA G prepared 10 other oral medications and a nasal spray then walked into Resident #57's room. MA G administered all the medications. Resident #351 Review of Resident #351's undated face sheet reflected an [AGE] year-old female admitted to the facility 11/17/23 with diagnoses including diabetes mellitus with hyperglycemia (abnormal blood sugar levels), hypertension (high blood pressure), atherosclerotic heart disease (the arteries of the heart are thick and stiff), fracture of superior rim of left pubis (the lower front part of the hip bone), fracture of unspecified parts of lumbosacral spine and pelvis, and vitamin deficiency unspecified. Review of Resident #351's admission MDS assessment dated [DATE] reflected a BIMS [NAME] of 13 indicating intact cognition. Review of Resident #351's physician order dated 11/17/23 reflected, Calcium carbonate; 600mg calcium (1,500mg); amt: 1 tablet; oral once a day. Observation on 11/29/23 at 8:24 AM revealed, MA G prepared for administration of medications to Resident #351. MA G retrieved a Calcium Carbonate 500 mg chewable tablet and placed it in a medication cup. MA G prepared and gathered 14 other oral medications, eye drops, and topical patches then walked into Resident #351's room. MA G administered all the medications. During an interview on 11/29/23 at 1:43 PM with LVN E, she confirmed the order for Resident #88 was for multivitamin with folic acid. After LVN E reviewed the ingredients on the bottle of multivitamins with minerals she confirmed folic acid was not listed in the ingredients. She stated she had just missed it when she administered the medication. She stated giving the wrong medication could prevent the resident from getting the desired effect. During an interview on 11/29/23 at 1:54 PM the DON stated she would notify the provider about the medication errors. She stated a potential adverse outcome to getting the wrong medication was, Not getting what they need. During an interview on 11/30/23 at 8:46 AM the ADON stated calcium carbonate and calcium carbonate with vitamin D were two different things. She stated an adverse outcome if a resident received the wrong medication could have been lack of desired effect. During an interview on 11/30/23 at 9:26 AM with MA G, she stated there were multiple kinds of calcium she pulled several bottles out of the med cart. MA G stated she talked with a nurse before about clarification of calcium orders. She stated that she had given both Resident #57 and Resident #351 calcium carbonate 500 mg during medication administration on 11/29/23. Review of the facility's policy titled Medication Management Program revised 05/05/23 reflected in part, Preparing for the Medication Pass 4. Authorized staff must understand: D. The 8 Rights for administering medication: 1. The Right Patient/Resident 2. The right Drug 3. The right Dose . Administering the Medication Pass 6. The authorized staff member reads the label on the medication three (3) times. A. Before removing the medication from the drawer. B. Before dispensing the medication. C. After dispensing the medication.

Based on observation, interview, and record review, the facility failed to adequately equip all residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 8 (Resident #56) residents reviewed for call light function. The facility failed to ensure Resident #56 had a functioning call light. This placed Resident #56 at risk of not having her needs met. Findings included: A record review of Resident #56's undated face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of fracture of unspecified part of neck of right femur, Parkinson's disease (problems with movement, balance and coordination), muscle wasting and atrophy (muscle loss), history of falling, weakness, unspecified abnormalities of gait and mobility and anxiety disorder. A record review of Resident #56's MDS assessment dated [DATE] reflected a BIMS score of 11, which indicated moderately impaired cognition. Resident #56's MDS assessment reflected she required substantial assistance with going from lying to sitting on the side of her bed. A record review of Resident #56's care plan last revised on 11/21/2023 reflected she required assistance with ADLs, was at risk for falls, and staff were to encourage her to use her call light for assistance. During an observation and interview on 11/28/2023 at 12:10 p.m., Resident #56 was observed lying in bed. Resident #56 stated the call light took a long time sometimes and it's been an ongoing issue with her call light not working. Resident #56 had a call light which also worked as a TV and bed control. Observed Resident #56 press her call light three times and it did not illuminate on her wall or outside her door. On the fourth try, Resident #56's call light turned on and LVN F walked in. LVN F stated she had not known Resident #56's call light to not work. LVN F then observed Resident #56 press the call light, LVN F observed it to not work, and so LVN F placed a new call button at Resident #56's bedside. During an observation and interview on 11/29/2023 at 9:30 a.m., Resident #56 stated she had tried using her call light that morning, and it did not work. Observed two call lights plugged in to Resident #56's wall and at her bedside-one was the TV remote call light and the other was a soft circular push device. Observed Resident #56 push her TV remote call light twice and the light did not illuminate on the wall or outside her room. Resident #56 then pressed the soft circular call light three times, and it came on the third time. During an interview on 11/29/2023 at 9:30 a.m., CNA J entered Resident #56's room and stated the squishy call light was easier for Resident #56 to press. CNA J stated Resident #56 had two call lights because she had been having a hard time with the TV call light. During an interview and observation on 11/30/2023 at 10:23 a.m., MA H entered Resident #56's room. Resident #56 was lying in bed, and she pressed her TV remote call light. MA H stated yes she could hear the call button click and no it did not illuminate on the wall or outside her door. MA H stated, that's strange and. Resident #56 then squeezed her circular call light and MA HA stated yes Resident #56 gave it a hard squeeze. MA H observed it had not illuminated the light on the wall nor outside Resident #56's door. MA H stated, I'll have to put that in our book. During an interview on 11/30/2023 at 10:46 a.m., the Maintenance Director stated he had worked at the facility for ten years. The Maintenance Director stated anyone that worked there could put in a maintenance request in the book. The Maintenance Director stated he checked the maintenance log every day. When asked who was responsible for ensuring call lights functioned, the Maintenance Director stated, if it's messed up, nursing will report it to him. The Maintenance Director stated checking for call light function was not part of his everyday monitoring. The Maintenance Director stated he fixed them when nursing identified it as an issue. The Maintenance Director stated someone from therapy had communicated to him verbally on Monday 11/27/2023 that Resident #56's call light did not work. During an observation and interview on 11/30/2023 at 11:23 a.m., Resident #56 was lying in bed. Resident #56 stated she had probably mentioned to staff that her call light did not work but she was not sure. During an interview on 11/30/2023 at 12:32 p.m., the Maintenance Director stated he only put maintenance requests in the book if he did not have time to address the issue right way. With Resident #56, he stated he checked her call light on Monday 11/27/2023 and it worked. The Maintenance Director stated he checked it Tuesday 11/28/2023 and Wednesday 11/29/2023, and it worked then as well. During an interview on 11/30/2023 at 3:48 p.m., the DON stated the facility's policy on call lights were that the needed to function 100% and that they press it, and it works. The DON stated there would be times when there were technical issues, but residents should always have a means to call for assistance. The DON stated once the issue was identified, it should have been rectified, or the resident should have been moved to a different room. The DON stated nursing did not monitor call lights for function and I assume it would be maintenance. The DON stated if staff or residents should report issues to maintenance. The DON stated there was a maintenance binder at each nurses' station where concerns should have been placed. The DON stated at the present point in time, Resident #56 had a touch pad call light and there were no issues. The DON stated she believed Resident #56 had trouble pressing the inflated circular call light. The DON stated if a resident's call light did not work, they would not get their need met. The DON stated she first became aware of Resident #56's call light not working on Tuesday 11/28/2023 when it was brought to her attention by an HHSC surveyor. The DON stated she could have put in an alternate call light system for Resident #56 and she had not done so yet since she observed Resident #56's call light to be working. During an interview on 11/30/2023 at 4:48 p.m., the Administrator stated she expected call lights to function and if something was mechanically wrong, she expected it to get fixed. The Administrator stated they usually did a room move until the call light issue was fixed. The Administrator stated monitoring for call light function should be part of the Maintenance Director's preventative maintenance. The Administrator stated the Maintenance Director did random checks of call lights and if staff noticed they were not working, they would report it to the Maintenance Director. The Administrator stated she liked for staff to put the maintenance concerns in the book but sometimes they would call or text the Maintenance Director. The Administrator stated, with an intermittently functioning call light, her needs wouldn't be met if she didn't have a call light. A record review of the facility's maintenance log dated 11/07/2023-11/29/2023 reflected no entry for Resident #56's call light. A record review of the facility's policy titled RESIDENT ROOM - ENVIRONMENTAL dated 11/01/2017 reflected the following: POLICY: The Facility provides the patient/resident with an environment that preserves dignity, privacy and contributes to a positive self-image. Resident rooms are designed and equipped for adequate nursing care comfort and privacy of residents. Promoting and preserving resident independence and self-sufficiency should be considered when arranging the resident living space. PROCEDURES: 8. The facility must be adequately equipped to allow residents to call for staff assistance at each resident bedside, bathing and toileting areas through a communication system which relays the call directly to a staff member or to a centralized staff work area. A. All portions of the system must be functioning, which means: 1) The system must be turned on, 2) The volume must remain at a level that can be heard, 3) The lights above the rooms must be working, 4) There must be staff at the nursing station or with- in hearing distance of the system. B. Adaptations should be considered as needed for resident's abilities.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for 1 of 7 residents (Resident #15) reviewed for accidents. The facility failed to ensure staff did not hand Resident #15 a cup of hot coffee and two sweetener packets while his hands were full or offered to assist him, leading to Resident #15 spilling the coffee on his leg (with no injury). This failure placed residents at risk of burns and embarrassment. Findings included: Review of the updated face sheet for Resident #15 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cellulitis (skin infection) of right lower limb, abnormalities of gait and mobility, muscle weakness, pain in right shoulder, lack of coordination, acquired absence of left leg above knee, age-related cognitive decline, dizziness and giddiness (feeling of being unbalanced or lightheaded), chronic pain, muscle wasting and atrophy, peripheral vascular disease (abnormal narrowing of arteries to the limbs which makes the healing of wounds in those areas more difficult), non-pressure chronic ulcer of unspecified part of left lower leg with necrosis of muscle, and cognitive communication deficit (communication problems stemming from cognitive impairment). Review of the quarterly MDS assessment for Resident #52 dated 11/14/23 reflected a BIMS score of 12, indicating a moderate cognitive impairment. The section titled Functional Abilities and Goals reflected he required set-up or clean-up assistance in the activity of eating, which was defined as the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Review of the care plan for Resident #15 dated 10/20/23 reflected the following: (Resident #52) requires assistance with ADL's r/t AKA. Will maintain a sense of dignity by being clean, dry, odor free and well groomed over next 90 days. EATING: Assist of set up. Review of nursing progress notes for Resident #1 reflected the following: 11/29/2023 08:30 AM by DON Charge Nurse reported that resident spilled coffee this morning on his lap. She advised she had assessed and no areas of concern was noted. This nurse and (Nurse Practitioner) assessed approximately 20 min after. Spill occurred to LLE, Resident had compression sleeve and pants on. Clothing removed and skin assessed, no open areas, redness or swelling noted. Resident denies pain. Provider advised resident to notify nursing if skin concerns or pain arise. 11/30/2023 03:21 PM by LVN D Resident denies pain to LLE where resident spilled coffee. Compression sleeve removed and skin assessed no signs of burn or irritation to area and is wnl for resident. Review of a skin assessment for Resident #52 dated 11/29/23 at 08:42 AM reflected the following: Resident assessed post coffee spill. No open areas, redness, or swelling. Observation n 11/29/23 at 08:05 AM revealed Resident #52, who had an above-knee amputation of his left leg, self-ambulated in his wheelchair to the meal cart from which staff were delivering meal trays to the hall where he lived. He asked for coffee and said he did not get any coffee. Resident #52 was holding five bagged newspapers with his left hand by the tops of their plastic bags, and the ADON poured a cup of coffee from a small urn into a plastic mug with no lid and handed it to him. He accepted the cup of coffee with his right hand and asked for two sugars. Resident #52 moved the mug of coffee into his left hand, which was still holding the newspaper bags, and CNA K handed him two packets of sweetener, which he accepted with his right hand and placed into his left hand. His left hand was still holding the newspaper bags and the mug of coffee, and he struggled to balance the items, but was able to hold them all in his left hand and ambulated his electric wheelchair with his right hand to the door of another resident's room. Resident #52 began to move his coffee into his right hand, some spilled from the mug onto his left leg, and he cried out, oh! During an interview at this time, Resident #52 stated, yes it hurt, it's hot coffee! The ADON stated to Resident #52 she would check his leg shortly. During an interview on 11/30/23 at 08:20 AM, Resident #52 stated he had no injury on his leg or anywhere else. He stated the coffee stung for one second when it spilled but it did not hurt for long and did not injure him. During an interview on 11/30/23 at 08:39 AM, the ADON stated Resident #52 wanted something to do so he volunteered to pass out newspapers to the residents who had subscriptions. The ADON stated Resident #52 liked his coffee, and the morning of 11/29/23 he came to the meal cart and asked for it. The ADON stated she poured the coffee and gave it to Resident #52. The ADON stated Resident #52 asked for sugar, and one of the aides handed him the sugar. The ADON stated, as Resident #52 was delivering a newspaper to another resident, he spilled a little coffee on his leg. The ADON stated Resident #52 wore a compression sleeve on his left leg after his amputation, and the coffee did not burn him through the sleeve. The ADON stated they had the Nurse Practitioner come look at him, and he had no burns no redness. The ADON stated she saw Resident #52 daily and thought the coffee spilled because of the way he had been holding he newspapers. She stated normally, he was still in bed at that hour and would have his coffee on his overbed table in bed. The ADON stated Resident #52 could have been burned by the coffee, had he not been wearing a compression sleeve. Observation on 11/30/23 at 12:28 PM revealed the RD took the temperature of coffee in the coffee urn on the meal cart for Resident #52's hall, and it measured at 163.1 degrees. The coffee cups on the cart were being served with lids. During an interview on 11/30/23 at 03:39 PM, the DON stated she had not done specific training on safety with hot liquids. The DON stated she was not sure what the temperature should have been of the coffee, but she thought it was lower than the temperature of coffee in a regular coffee pot at home. She stated the failure could have had a range of adverse effects; it could have caused embarrassment, burns, and possible scarring. During an interview on 11/30/23 at 04:48 PM, the Administrator stated she would say everyone was responsible for preventing accidents in the resident population. She stated coffee should have been served with a lid on it to prevent burns. The Administrator stated it did not mean the resident could not drop the coffee and get burned, but it helped with prevention. The Administrator stated she had been told Resident #52 had newspapers in his hand and asked for coffee. The Administrator stated she would have either taken the newspapers and held them while serving the resident coffee or brought the coffee to his room for him. The Administrator stated Resident #52 was very independent and did not like a lot of help, but someone should have made sure he had the help he needed. The Administrator stated a potential outcome was that Resident #52 could have been burned. She stated there had been no harm to Resident #52, but it could have caused a burn. Review of facility policy dated 11/01/17 and titled Accidents/Incidents reporting reflected the following: The facility's leadership will follow the established guidelines for the reporting of accidents and incidents. In the event of a state, reportable incident, the facilities leadership will notify the state regulatory agency, according to applicable law and regulation. . An accident is an unexpected, unintended event that can result in bodily injury.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents reviewed for quality of care (Resident #88). The facility failed to ensure Resident #88's catheter was secured to his body with a catheter secure device. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings Included: Review of Resident #88's undated face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction (stroke), urinary tract infection, retention of urine, vitamin deficiency, dysphagia (difficulty swallowing food or fluids), type 2 diabetes mellitus (abnormal blood sugar levels), and gastrostomy status (presence of a tube into the stomach to provide nutrition). Review of Resident #88's 5-day MDS assessment dated [DATE] reflected he had no speech and rarely/never understands. He was assessed as being dependent for ADL care and had an indwelling urinary catheter. Review of Resident #88's care plan initiated 10/20/23 reflected the problem Resident has catheter and is at risk for increased UTIs. Approaches included catheter care per order, change catheter, tubing and bag per order, keep tubing/bag below the bladder do not kink tubing, and monitor urine and report abnormals. The care plan did not reflect a catheter leg strap or stabilization device. Review of Resident #88's physician orders dated 10/23/23 reflected, indwelling catheter 16fr (the size of the catheter), 10 cc (the amount of saline in the balloon holding the catheter in the bladder) for sacral pressure wound, and catheter leg strap in place - to secure catheter and facilitated flow of urine. Observation on 11/29/23 at 9:31 AM revealed Resident #88 in room in bed. Resident #88 had a urinary catheter in place without a device to secure the catheter to his leg. Observation and interview on 11/29/23 at 1:43 PM revealed Resident #88 in room in bed. Observation with LVN E revealed the resident had no catheter secure device in place. LVN E stated the resident should have had a catheter secure device in place. She stated the resident had a device in place earlier when she checked. LVN E stated without a device in place, the catheter could be tugged or pulled out. During an interview on 11/30/23 at 3:57 PM, the DON stated a catheter securing device was used on residents with a physician's order. She stated it was the responsibility of the nurse to ensure the device was intact and properly positioned. Review of the facility's policy titled Catheter - Urinary Catheter, Cleaning and Maintenance reflected, [NAME] Nursing Procedures 9th Ed., pages 432-435. Review of [NAME] Nursing Procedures 9th Ed. Pages 432-435 reflected in part: Make sure the catheter is properly secured. Assess the securement device daily, and change it when clinically indicated and as recommended by the manufacturer.

Based on observation, interview, and record review, the facility failed to ensure the right to be free from misappropriation of proper for 1 of 5 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Belsomra, a medication to help with sleeping. This failure could place residents at risk for not receiving prescribed medications. Findings included: Review of Resident #1's undated face sheet reflected the resident was admitted [DATE]. Her diagnoses included chronic respiratory failure (inability of the lungs to get enough oxygen to the body), sepsis (an infection in the blood), cognitive communication deficit (communication problem related to cognition rather than language or speech), hypertension (high blood pressure), cerebral infarction (stroke), type 2 diabetes mellitus (a problem with how the body regulates blood sugar), anxiety (intense feelings of fear or terror), and depression (persistent feeling of sadness and loss of interest). Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMs score of 14 indicating intact cognition. She was documented as receiving a hypnotic during the 7-day look back period. Review of Resident #1's physician orders dated 7/11/23 reflected an active order for Belsomra 10mg oral at bedtime. Review of Resident #1's Medication Administration Record (MAR) dated 11/1/23 through 11/21/23 reflected the Belsomra had not been administered the night of 11/13/23 because the medication was unavailable. Review of the facility's investigation of the missing Belsomra medication reflected on 11/14/23 at 6:12 AM, the DON was notified by LVN A of a med discrepancy for Resident #1. LVN A stated the narcotic count sheet reflected 10 tablets but there were only 6 on the medication cart. LVN A told the DON that MA C had counted the medications and told RN B there was a discrepancy. LVN A told the DON, RN B had already left the building. Review of the controlled drug receipt/record/disposition form reflected RN B signed the form on 11/13/23 with the quantity received marked as 10. During an interview on 11/21/23 at 12:55 PM with LVN A, she stated she had worked at the facility going on two years. She stated she had recent in-service on controlled medications and diversion. She stated the controlled meds were counted every time the keys change hands. She stated on her halls the med aides worked from 6:00 AM until 2:00 PM and then from 4 PM until 8:00 PM so the meds were counted multiple times throughout her shift. She stated if there was a med discrepancy, the DON was notified immediately. She stated she nor the other nurse or med aide could leave the building. During an interview on 11/21/23 at 1:00 PM with the DON, she stated she received a phone call in the morning reporting the narcotic count was off with four pills missing. She was informed the off-going nurse (RN B) had already left the building. She stated she called him, and he was loud and cursing and, all over the place. She stated that during the second call to RN B, he first said he could not remember if the medication was sealed and bagged but later, he stated it was sealed but he took it out of the bag when he locked it in his medication cart. The DON stated RN B admitted he had put the medication cart keys in the drawer at the nurse's station. She stated she was not able to determine who took the medications but, by leaving the keys in the drawer, he allowed everyone access to the medication cart. She stated RN B was suspended pending the investigation then after conversations with cooperate and human resources, RN B was terminated. She stated the facility did not have cameras, so she was not able to see who took the medications. During an interview on 11/21/23 at 1:10 PM with MA D, she stated she had worked at the facility full time since 2018. She stated she had recent training on counting controlled medications. She stated she had to count at the start of her shift and again before leaving. She stated if there was a discrepancy in the count that was not easily resolved, the charge nurse or DON was notified immediately. She stated staff could not leave the facility until the discrepancy was resolved. She stated the keys were kept in her pocket throughout the shift, but if she left the floor, she gave the keys to the nurse. During a telephone interview on 11/21/23 at 1:48 PM with the police detective assigned to the case, he stated he had not yet been in contact with RN B. During an interview on 11/21/23 at 3:26 PM with the DON, she stated it did not meet her expectations that controlled medications would be missing. She stated the suspected staff member was out of the building and there were systems in place to prevent it from happening again. Observation and interview on 11/21/23 at 2:50 PM revealed Resident #1 awake in a wheelchair in her room. She stated she slept well most nights but occasionally had trouble falling asleep. She stated she did not remember if she had missed any doses of the sleep medication recently. A telephone message was left on 11/21/23 at 3:25 PM for RN B requesting a return call. A return call was not received before close of business 11/21/23. Review of the facility's policy regarding Loss or Theft of Medications, revised 4/1/22 reflected in part, Staff should immediately report any discrepancies or a suspected theft or loss of drugs from an onsite store to a supervisor/manager or the Director of Nursing for appropriate investigation for possible diversion. Review of the facility's policy regarding storage and reconciliation of controlled substances revised 4/1/22 reflected in part, 1. Only authorized staff, licensed nurses and pharmacy personnel will have access to controlled medications. 3. All controlled medications must be maintained in separately locked, permanently affixed compartments. The access key to controlled medications is not the same key which gives access to other medications. Duplicate keys to all medication storage areas, including those for controlled medications, are kept by the Director of Nursing. A. The authorized staff member will have the controlled substance key(s) in his/her possession at all times while on duty. 4A. At the end of every shift the nurse/authorized staff member reporting on duty and the nurse/authorized staff member reporting off duty meet at the designated medication cart or storage area to count all controlled substance drugs.

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #1) of 12 residents reviewed for medication errors. The facility failed to administer Resident #1's life-sustaining medication, [MEDICATION(S)] (anti-rejection medication), as ordered by the physician. Resident #1 missed 57 doses of [MEDICATION(S)] medication in a 105-day period. This failure likely contributed to Resident #1 developing multi-organ failure, which resulted in his death on [DATE]. This failure could place residents at risk for not receiving care and services to meet resident needs, which could lead to hospitalization and death. On [DATE] at 6:10 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: A record review of Resident #1's face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderately impaired cognition. A record review of Resident #1's care plan last revised on [DATE] reflected he was a heart transplant patient with an implanted cardiac defibrillator related to irregular heart rhythm. A review of Resident #1's care plan goal dated reflected he would not exhibit complications of heart transplant rejection, medication side effects, or signs of abnormal heart rhythm. A review of Resident #1's care plan approach reflected he was to be observed for signs of abnormal heart rhythm and monitored for immunosuppressive medication side effects including acute infection, kidney disease, loss of appetite, nausea, vomiting, and hand trembling. A record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE]-[DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE] (on hold) [DATE] [DATE]-[DATE] [DATE]-[DATE] (on hold) A record review of Resident #1's lab result dated [DATE] reflected his assay level (amount of drug in blood) of [MEDICATION(S)] (anti-rejection medication) was <1 ng/mL with a reference range of 5.,d+[DATE].0 ng/mL, which indicated an abnormally low level. Laboratory work was completed through the facility's laboratory services provider. There were no notes in Resident #1's chart which indicated the facility took action. In an interview on [DATE] at 9:20 a.m., Resident #1's Transplant Cardiologist stated Resident #1's low assay level of [MEDICATION(S)] (anti-rejection medication) was first communicated to him in [DATE]. In an interview on [DATE] at 3:28 p.m. Resident #1's family member stated Resident #1's low level of [MEDICATION(S)] (anti-rejection medication) was not communicated to her in [DATE]. A record review of Resident #1's progress note completed by ADON A dated [DATE] reflected Resident #1's family member called the facility, was upset, stated the facility was not giving the correct dose of anti-rejection, and stated this was evident by his [MEDICATION(S)] (anti-rejection medication) lab values. A record review of Resident #1's progress note authored by ADON A dated [DATE] 2:14 p.m. reflected he had complained of shortness of breath and stated to staff his heart did not feel right. The progress note reflected ADON A contacted Transplant Nurse 1, who then recommended Resident #1 be sent out to the hospital due to elevated pulse and shortness of breath. The progress note reflected Transplant Nurse 1 stated the following to ADON A: due to his heart showing signs of rejection according to his labs that it is best he go to the ER. A record review of Resident #1's lab results collected and analyzed at the hospital in which he was admitted on [DATE] reflected the following assay levels (amount of drug in blood) of [MEDICATION(S)] (anti-rejection medication): [DATE]: <2 ng/mL [DATE]: <2 ng/mL A review of the lab report reflected a reference range of 5.,d+[DATE].00 ng/mL, which indicated abnormally low levels. A record review of Resident #1's hospital note dated [DATE] reflected his reasons for admission to the ER included cardiogenic shock and acute rejection of heart transplant. A review of his history of present illness dated [DATE] reflected Resident #1 had last been seen by the Transplant Cardiologist on [DATE] and had not been getting [MEDICATION(S)] appropriately at the skilled nursing facility. A record review of Resident #1's hospital discharge summary dated [DATE] reflected the following: There was suspicion for acute rejection due to possible anti-rejection medication dosing issues and he was started on high dose steroids. A record review of Resident #1's discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's hospital note dated [DATE] reflected he passed away in the hospital on [DATE] at 4:02 a.m. During an interview on [DATE] at 5:16 p.m., Resident #1's family member stated she had brought up concerns that Resident #1 was not receiving the proper dose of [MEDICATION(S)] (anti-rejection medication) because his assay levels of the drug were low. Resident #1's family member could not recall who she had spoken with at the facility. Resident #1's family member stated the facility told her they did not have the medication in stock because she had not brought it in to the facility. Resident #1's family member stated that upon Resident #1's admission on [DATE], the facility told her Resident #1's medications were too expensive, and that Resident #1's family member would need to supply them. A record review of Resident #1's patient chart reflected no agreement between Resident #1's family member and the facility regarding the need for family to supply Resident #1's [MEDICATION(S)] (anti-rejection medication). During an interview on [DATE] at 1:01 p.m., ADON A stated it was not atypical for family to bring in high cost medications. ADON A stated she did not know if the facility was responsible for providing [MEDICATION(S)] (anti-rejection medication), or if it was the family's responsibility. ADON A stated high cost medications were usually approved in the business office upon the resident's admission. During an interview on [DATE] at 2:19 p.m., ADON A stated she was not sure whether [MEDICATION(S)] (anti-rejection medication) was a high cost medication. ADON A stated some high cost medications needed approval from facility before the pharmacy filled the prescription, but she stated Resident #1's medications did not need to be approved for the pharmacy to fill the medication. During an observation and interview on [DATE] at 1:10 p.m., the DON stated Resident #1's family member had brought in [MEDICATION(S)] (anti-rejection medication) on a few occasions, but she did not remember exactly when. Observation revealed three full bottles of [MEDICATION(S)] (anti-rejection medication) on the DON's desk, all with a filled date of [DATE]. A record review of the pharmacy cost of [MEDICATION(S)] (anti-rejection medication) reflected a 30-day supply cost approximately $27. During an interview on [DATE] at 3:21 p.m., the Transplant Nurse stated she received a phone call from ADON A the morning of [DATE], told ADON A to take Resident #1 to the ER that morning, and stated he did not show up to the hospital until hours, during the afternoon of [DATE]. A review of Resident #1's hospital records reflected a provider note authored by an emergency department physician on [DATE] at 1:49 p.m. A record review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Reasons and comments reflected the following: drug/item unavailable, waiting on rx to come in, pending medication arrival from pharmacy, and waiting on pharmacy to deliver. A review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; reordered [DATE] - other; na [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Resident unavailable; dr. appt [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Other; waiting on pharmacy to deliver [DATE] - Other; waiting on pharmacy to deliver [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Other; waiting on pharmacy to deliver [DATE] (on hold) [DATE] - Refused [DATE] - Other; waiting on pharmacy to deliver [DATE] - Other; waiting on pharmacy to deliver [DATE] - Drug/Item unavailable [DATE] - Other; waiting on pharmacy to deliver [DATE]-[DATE] (on hold) During an interview on [DATE] at 10:23 a.m., Medication Aide A stated the resupply button on her computer kiosk was supposed to notify the pharmacy that the facility needed a supply of medication. During an interview on [DATE] at 10:15 a.m., the DON stated that according to the pharmacy's records, the facility did not order [MEDICATION(S)] (anti-rejection medication) until [DATE]. A record review of Resident #1's MAR from March to April reflected Medication Aide A failed to administer [MEDICATION(S)] (anti-rejection medication) on 29 occasions. A review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1 on the following dates: [DATE] [DATE]-[DATE] [DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE] [DATE]-[DATE] [DATE] [DATE]-[DATE] [DATE]-[DATE] During an interview on [DATE] at 10:23 a.m., Medication Aide A stated she had a resupply button on her computer, and she pressed it every day. The facility was unable to provide documentation proving this to be true. Medication Aide A stated she left multiple notes for nurses saying pharmacy was not sending the [MEDICATION(S)] (anti-rejection medication). Medication Aide A stated those notes to nurses were written on sticky notes and they were not documented anywhere. Medication Aide A stated she notified her charge nurses and other PRN nurses two to three times . Medication Aide A stated she did not remember who all she notified, but she remembered notifying LPN A. Medication Aide A stated she would give sticky notes with lists of out-of-stock medications to her charge nurses and to other PRN nurses. Medication Aide A stated when nothing happened, that was when she notified the Rehab Nurse. Medication Aide A stated this was sometime in early March. Medication Aide A stated the Rehab Nurse stated to her she would take care of the issue. Medication Aide A stated she never informed the DON of this issue. Medication Aide A stated she had noticed a bottle of [MEDICATION(S)] (anti-rejection medication) in the facility, which she believed was brought in by Resident #1, so she started giving him that. Medication Aide A stated she did not know exactly when that was. Medication Aide A stated she knew [MEDICATION(S)] (anti-rejection medication) was for Resident #1's heart and stated if he did not receive it, it could cause him to start having problems with his heart. Medication Aide A stated ADON B started monitoring her medications about a month ago. Medication Aide A stated that back in March, ADON A was covering both the long-term care side and the rehab side of the facility, and ADON A had trouble covering all the residents. During an interview on [DATE] at 1:01 p.m., when asked specific questions regarding Resident #1's medication, ADON A stated, I don't know, I have 90 residents. During an interview on [DATE] at 5:26 p.m., the DON stated the only explanation as to why Resident #1's [MEDICATION(S)] (anti-rejection medication) was not given was that it was not ordered timely so that resulted in missed doses. The DON stated that through talking with the MAs , she found out they were not notifying the charge nurse. The DON did not specify which MAs she spoke with. The DON stated therefore, the nurses were not aware and were not notifying the pharmacy. During an interview on [DATE] at 10:15 a.m., the DON stated Resident #1 did not receive his anti-rejection medication due to protocols not being followed and a major breakdown in communication. The DON stated the facility received a 14-day supply of [MEDICATION(S)] (anti-rejection medication) from the pharmacy upon Resident #1's admission. The DON stated, after communicating with the facility's pharmacy, that the medication was not ordered from the pharmacy until [DATE]. When asked why the same couple of MAs were repeatedly documenting in Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated there were ways to get medications in house but that just was not followed due to lack of notification. When asked if missing that much medication could have contributed to Resident #1's death, the DON stated I can't answer that, I am not a doctor. I can't say for sure. It's an important medication. When asked what the risks were of residents with a heart transplant not receiving their anti-rejection medication, the DON stated the medication prevented the immune system from targeting and attacking the transplant organ. The DON stated if anti-rejection medication was missed, one would see shortness of breath, the heart giving out, [CONDITION(S)] (chest pain), and heart failure. The DON stated the process for administering out of stock medications included checking the emergency medication kit, pulling the medication from there if it was available, and then order the medication from the pharmacy. The DON stated if the medication was not in the emergency medication kit, the employee passing medications would need to immediately notify the charge nurse who would then call the pharmacy. The DON said the process for ordering medications included the MA notifying the nurse via word of mouth that medications were out of stock so the nurse could then contact the pharmacy to place an order. During an interview on [DATE] at 1:57 p.m., the DON stated when MAs pressed the resupply button on their computer kiosk, that it sent a message to the pharmacy for medication to be ordered. The DON stated all MAs received proficiency training on administering medications prior to hire and annually. During an interview on [DATE] at 2:19 p.m., ADON A stated she was never notified of any refills needed because it was never brought to her attention. ADON A stated herself or charge nurses could monitor compliance of medication administration by running daily reports of missed medications . ADON A stated MAs should notify their nurses when medications were out of stock. ADON A stated she was not aware of Resident #1's missed doses because she took over his care on [DATE], when Resident #1 moved from the rehab to the long-term care side. ADON A stated [MEDICATION(S)] was a vital medication and if a resident did not receive it, it would be very serious. ADON A stated not receiving the medication could cause the immune system to attack its organs and could lead to serious injuries and harm. ADON A stated she was not sure whether [MEDICATION(S)] (anti-rejection medication) was a high-cost medication. ADON A stated some high-cost medications needed approval from facility before the pharmacy filled the prescription, but she stated Resident #1's medications did not need to be approved for the pharmacy to fill the medication. During an interview on [DATE] at 3:21 pm, Transplant Nurse 1 stated Resident #1 was way below therapeutic assay levels of the drug, [MEDICATION(S)] (anti-rejection medication), on several occasions. Transplant Nurse 1 stated the therapeutic level of the drug was ,d+[DATE] ng/mL, and his levels were below 2 ng/mL several times. Transplant Nurse 1 stated from her understanding, Resident #1 was not receiving the correct dose of medication at the nursing facility. Transplant Nurse 1 stated there was no reason why the medication, [MEDICATION(S)], should be paused or stopped for any reason. Transplant Nurse 1 stated Resident #1 not getting [MEDICATION(S)] (anti-rejection medication) caused him to go into rejection, stating his heart did reject. Transplant Nurse 1 stated Resident #1's cause of death was multi-organ failure. During an interview on [DATE] at 11:26 a.m., Transplant Nurse 2 stated the therapeutic level of [MEDICATION(S)] (anti-rejection medication) was between ,d+[DATE] ng/mL. Transplant Nurse 2 stated the therapeutic level of the drug could be reached after 72 hours of taking the medication, but absorption played a factor as well. Transplant Nurse 2 stated, in her professional opinion, I absolutely feel like this contributed to his multi-organ failure-you need these therapeutic values to prevent your immune system from attacking your organs. Transplant Nurse 2 stated during the times when Resident #1's levels of [MEDICATION(S)] (anti-rejection medication) were low, he had some evidence of cellular damage in his heart-he had been showing signs of heart damage. Transplant Nurse 2 stated that absolutely, by not receiving [MEDICATION(S)] (anti-rejection medication) most of March and 28 days in April, that that could have contributed to Resident #1's death. During an interview on [DATE] at 9:20 a.m., Transplant Cardiologist stated he was very familiar with Resident #1 and had been seeing him even prior to Resident #1's transplant surgery in 2015. Transplant Cardiologist stated Resident #1 had some robust years after the transplant. Transplant Cardiologist stated that two years post-surgery, the therapeutic level of [MEDICATION(S)] (anti-rejection medication) was between ,d+[DATE] ng/mL. Transplant Cardiologist stated if a patient was on a stable dose, they would need their levels of [MEDICATION(S)] measured once a month, but in Resident #1's case, we wanted to measure his level more frequently. Transplant Cardiologist stated, they are supposed to draw the level once a week or once every two weeks. Transplant Cardiologist stated that missing doses could have contributed to Resident #1's death, stating Resident #1 was underdosed for a long period of time and that may have contributed to the severity of his anti-rejection. Transplant Cardiologist stated they did everything to treat Resident #1's antirejection until Resident #1 said no more due to poor quality of life-Resident #1 communicated he did not want any more aggressive therapy. Transplant Cardiologist stated Resident #1's family did not want an autopsy to be performed. A record review of the facility's policy titled Pharmacy Services Policies and Procedures dated [DATE] reflected the following: The facility must provide or obtain routine medications and biologicals to meet the needs of each resident. Nurses must monitor medication availability and reorder medications when there is a four to five day supply of medication remaining. A record review of the facility's procedure titled Medication Pass Preparation dated [DATE] reflected the following: The facility will ensure there is an adequate supply of floor stock medications available. The Administrator was notified on [DATE] at 6:10 p.m. that an Immediate Jeopardy situation had been identified due to the above failure. The Immediate Jeopardy template was provided to the Administrator. A Plan of Removal was submitted by the Administrator and accepted on [DATE] at 5:32 p.m., and included: Plan of Removal POR F760 Medication Error The identified resident no longer resides in the facility. Residents who receive medications have the potential to be affected. A review of the medication administration compliance report was completed by the Director of Nursing/designee to identify any medications not available. Any identified medications were re-ordered on [DATE] by the Director of Nursing or designee and those residents were assessed for any adverse effects and the physician was notified for further orders. Physician recommendations will be followed while waiting on medication arrival. A review of lab values for antirejection medications, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician that require a therapeutic level will be completed by the Director of Nursing/designee to validate that values are within the therapeutic range. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician will be notified immediately if any values are found to be out of therapeutic range. This will be completed by [DATE]. This will be accomplished by the Director of Nursing or her RN designee. Therapeutic medication laboratory values for antirejection medications, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician that require a therapeutic level will be reviewed daily Monday - Friday in the clinical morning meeting. Residents' therapeutic levels are found to be low or critical, the availability of the medication will be validated, and the physician will be notified immediately for further direction. This will be accomplished by the Director of Nursing or her RN or LVN designee. MAR to cart audit, validating that there is a medication available in the medication cart for each physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing Management will be re-educated on the following by the Clinical Consultant by [DATE] the following: o Reviewing Medication Administration compliance report Monday - Friday in clinical morning meeting to review and resolve any issues regarding missed I unavailable medications. The Clinical Consultant will be responsible for the re-education. o Addressing unavailable medications when licensed nurses and/or Certified Medication Aides report that medications are not available. This will be documented by the licensed nurse or Certified Medication Aide on the 24-hour report for review by nursing management. The Director of Nursing will then document the clinical morning meeting agenda for tracking until resolved. The Clinical Consultant will be responsible for the re-education. o When a complaint from a family is voiced, a grievance form will be completed for review by nursing management and the administrator for appropriate action. The grievance will be reviewed in standup each day until resolved. The social service director will track for resolution of grievances). The Clinical Consultant will be responsible for the re-education. Nurse Leadership hired after this date will complete this education presented in orientation by Clinical Consultant or designee. o The Clinical Consultant will be responsible for the re-education. Nurse Leadership hired after this date will complete this education presented in orientation by Clinical Consultant or designee. Licensed nurses and Certified Medication Aides will be re-educated on the medication management. The following process for medication management will be implemented beginning [DATE] if a medication is not available: 1. The Licensed Nurse upon identification of a needed medication will Check the F-Kit inventory kit list to see if the medication needed is in the F-Kit and obtain and administer if it is included and then follow the re-order process. 2. The Licensed Nurse will then call the pharmacy and ask for the medication to be delivered within 4 hours, or the after-hours pharmacy number and ask for the med to be delivered within 4 hours. If the med will be delivered and will result in a late medication administration, the Doctor MUST be notified upon discovery and order written to be given when arrives from the pharmacy. 3. The Director of Nursing/designee MUST be notified within the hour, but no later than the end of shift by the licensed nurse if the facility is unable to obtain an antirejection medication, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician that requires a therapeutic level for further direction 4. If a therapeutic laboratory value for an antirejection medication, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician to require a therapeutic level is noted to be low or critical, the medication availability will be validated, and the physician will be notified immediately upon discovery by the licensed nurse for further orders within one hour of discovery. 5. When a family member or resident voices concern regarding medications administration or availability, a grievance should be initiated at the time of the notice of the grievance; by staff receiving the grievance or family may complete the grievance form, and nursing management notified for resolution. The administrator/designee will validate the resolution of the grievance including family notification. 6. Medication re-ordering process to prevent medication unavailability concerns a. Medication aides and nurses will reorder medications when there is a four -to- five- day supply of medication remaining using the resupply button in Matrix to communicate with the pharmacy a refill is needed. This monitoring will be accomplished by the Director of Nursing or her RN designee. This re-education will be completed by [DATE]. Any licensed nurse or Certified Medication Aide not receiving by this date will receive prior to the next scheduled shift. This will be presented to agency personnel and in new hire orientation. Licensed nurses and certified medication aides will not be able to work or administer medication until they receive this training. This will be accomplished by the Director of Nursing or her RN designee. Medication compliance report to be reviewed daily Monday - Friday as part of the clinical morning meeting process beginning [DATE] in the clinical morning meeting. This will be an ongoing practice. Any concern will be addressed at the time of discovery. This will be accomplished by the Director of Nursing or her RN or LVN designee. Therapeutic medication laboratory values for antirejection medications, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, and others deemed by the physician that require other that require a therapeutic level will be reviewed daily Monday - Friday in the clinical morning meeting beginning [DATE] in the clinical morning meeting. This will be an ongoing practice. If any are found to be low or critical, the availability of the medication will be validated, and the physician will be immediately notified for further direction. This will be accomplished by the Director of Nursing or her RN designee. A MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This practice will start on [DATE]. Medical Director was notified of the Immediate Jeopardies and the contents of this plan on [DATE] by the Administrator. The Administrator and Director of Nursing will oversee the compliance of this Plan of Correction. An Ad Hoc Quality Assurance Performance Improvement Meeting was held on [DATE] and [DATE] The administrator will report all findings from audits to the Quality Assurance committee for 3 months for further recommendations, and then randomly thereafter. Any areas of concern will be addressed at the time of discovery. The facility was monitored for compliance of the Plan of Removal from [DATE] through [DATE]. During observations of medication pass on [DATE] from 2:00 p.m.-2:45 p.m., medications were observed to be passed to residents accurately and in accordance with their respective physician orders. Observations of the nursing floor on [DATE] from 2:45 p.m-3:00 p.m. revealed ADON A provided on-the-job training to medication aides and charge nurses on the new process of documenting and communicating out of stock medications. An observation on [DATE] at 3:00 p.m. revealed the facility was implementing their new policy of notifying appropriate medical parties regarding out-of-stock medications-observed ADON A call the nurse practitioner and pharmacy to communicate out of stock medications. Record reviews on [DATE] of the facility's 24-hour nurses shift report and nurses progress notes reflected out of stock medications were documented appropriately, per the facility's Plan of Removal. A record review on [DATE] of the facility's administration compliance report reflected no issues. A record review of the facility's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review on [DATE] reflected the facility ran a report on all residents taking ACE inhibitors, antibiotics, anticoagulants, anticonvu

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 resident (Resident #1) of 12 residents reviewed for pharmacy services. The facility failed to administer Resident #1's life-sustaining medication, [MEDICATION(S)] (anti-rejection medication), as ordered by the physician. Three bottles of the medication dated [DATE] were in the DON's office, however facility staff were documenting that the medication was not available and waiting for the pharmacy to deliver. Resident #1 missed 57 doses of [MEDICATION(S)] medication in a 105-day period. This failure likely contributed to Resident #1 developing multi-organ failure, which resulted in his death on [DATE]. This failure could place residents at risk for not receiving care and services to meet resident needs, which could lead to hospitalization and death. On [DATE] at 6:10 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: A record review of Resident #1's face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses of altered mental status, hypertension, immunodeficiency, type 2 diabetes, [CONDITION(S)] (high cholesterol), and history of heart transplant. A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderate cognitive impairment. A record review of Resident #1's hospital discharge paperwork dated [DATE] reflected he had a heart transplant in 2015. A record review of Resident #1's care plan last revised on [DATE] reflected he was a heart transplant patient with an implanted cardiac defibrillator related to irregular heart rhythm. A review of Resident #1's care plan goal dated reflected he would not exhibit complications of heart transplant rejection, medication side effects, or signs of abnormal heart rhythm. A review of Resident #1's care plan approach reflected he was to be observed for signs of abnormal heart rhythm and monitored for immunosuppressive medication side effects including acute infection, kidney disease, loss of appetite, nausea, vomiting, and hand trembling. A record review of Resident #1's physician orders reflected an order on [DATE] for 0.5 mg [MEDICATION(S)] (anti-rejection medication) to be taken once daily for aftercare following heart transplant. A record review of Resident #1's MAR reflected [MEDICATION(S)] (anti-rejection medication) was not administered 21 days in [DATE] days in [DATE], one day in [DATE], and seven days in [DATE]. [MEDICATION(S)] was not administered to Resident #1 on the following dates: [DATE]-[DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE] (on hold) [DATE] [DATE]-[DATE] [DATE]-[DATE] (on hold) A record review of Resident #1's lab result dated [DATE] reflected his assay level (amount of drug in blood) of [MEDICATION(S)] (anti-rejection medication) was <1 ng/mL with a reference range of 5.,d+[DATE].0 ng/mL, which indicated an abnormally low level. Laboratory work was completed through the facility's laboratory services provider. There were no notes in Resident #1's chart which indicated the facility took action. In an interview on [DATE] at 9:20 a.m., Resident #1's Transplant Cardiologist stated Resident #1's low assay level of [MEDICATION(S)] (anti-rejection medication) was first communicated to him in [DATE]. In an interview on [DATE] at 3:28 p.m. Resident #1's family member stated Resident #1's low level of [MEDICATION(S)] (anti-rejection medication) was not communicated to her in [DATE]. A record review of Resident #1's progress note completed by ADON A dated [DATE] reflected Resident #1's family member called the facility, was upset, stated the facility was not giving the correct dose of anti-rejection, and stated this was evident by his [MEDICATION(S)] (anti-rejection medication) lab values. A record review of Resident #1's progress note authored by ADON A dated [DATE] 2:14 p.m. reflected he had complained of shortness of breath and stated to staff his heart did not feel right. The progress note reflected ADON A contacted Transplant Nurse 1, who then recommended Resident #1 be sent out to the hospital due to elevated pulse and shortness of breath. The progress note reflected Transplant Nurse 1 stated the following to ADON A: due to his heart showing signs of rejection according to his labs that it is best he go to the ER. A record review of Resident #1's lab results collected and analyzed at the hospital in which he was admitted on [DATE] reflected the following assay levels (amount of drug in blood) of [MEDICATION(S)] (anti-rejection medication): [DATE]: <2 ng/mL [DATE]: <2 ng/mL A review of the lab report reflected a reference range of 5.,d+[DATE].00 ng/mL, which indicated abnormally low levels. A record review of Resident #1's hospital note dated [DATE] reflected his reasons for admission to the ER included cardiogenic shock and acute rejection of heart transplant. A review of his history of present illness dated [DATE] reflected Resident #1 had last been seen by the Transplant Cardiologist on [DATE] and had not been getting [MEDICATION(S)] appropriately at the skilled nursing facility. A record review of Resident #1's hospital discharge summary dated [DATE] reflected the following: There was suspicion for acute rejection due to possible anti-rejection medication dosing issues and he was started on high dose steroids. A record review of Resident #1's discharge diagnoses dated [DATE] reflected he had cardiogenic shock and acute rejection of cardiac transplant. A record review of Resident #1's hospital note dated [DATE] reflected he passed away in the hospital on [DATE] at 4:02 a.m. During an interview on [DATE] at 5:16 p.m., Resident #1's family member stated she had brought up concerns that Resident #1 was not receiving the proper dose of [MEDICATION(S)] (anti-rejection medication) because his assay levels of the drug were low. Resident #1's family member could not recall who she had spoken with at the facility. Resident #1's family member stated the facility told her they did not have the medication in stock because she had not brought it in to the facility. Resident #1's family member stated that upon Resident #1's admission on [DATE], the facility told her Resident #1's medications were too expensive, and that Resident #1's family member would need to supply them. A record review of Resident #1's patient chart reflected no agreement between Resident #1's family member and the facility regarding the need for family to supply Resident #1's [MEDICATION(S)] (anti-rejection medication). During an interview on [DATE] at 1:01 p.m., ADON A stated it was not atypical for family to bring in high cost medications. ADON A stated she did not know if the facility was responsible for providing [MEDICATION(S)] (anti-rejection medication), or if it was the family's responsibility. ADON A stated high cost medications were usually approved in the business office upon the resident's admission. During an interview on [DATE] at 2:19 p.m., ADON A stated she was not sure whether [MEDICATION(S)] (anti-rejection medication) was a high cost medication. ADON A stated some high cost medications needed approval from facility before the pharmacy filled the prescription, but she stated Resident #1's medications did not need to be approved for the pharmacy to fill the medication. During an observation and interview on [DATE] at 1:10 p.m., the DON stated Resident #1's family member had brought in [MEDICATION(S)] (anti-rejection medication) on a few occasions, but she did not remember exactly when . Observation revealed three full bottles of [MEDICATION(S)] (anti-rejection medication) on the DON's desk, all with a filled date of [DATE]. A record review of the pharmacy cost of [MEDICATION(S)] (anti-rejection medication) reflected a 30-day supply cost approximately $27. During an interview on [DATE] at 3:21 p.m., the Transplant Nurse stated she received a phone call from ADON A the morning of [DATE], told ADON A to take Resident #1 to the ER that morning, and stated he did not show up to the hospital until hours, during the afternoon of [DATE]. A review of Resident #1's hospital records reflected a provider note authored by an emergency department physician on [DATE] at 1:49 p.m. A record review of Resident #1's MAR reflected reasons and comments as to why [MEDICATION(S)] (anti-rejection medication) was not administered on a given day. Reasons and comments reflected the following: drug/item unavailable, waiting on rx to come in, pending medication arrival from pharmacy, and waiting on pharmacy to deliver. A review of Resident #1's MAR reflected [MEDICATION(S)] (anti-rejection medication) was on hold due to pending lab levels of the drug on [DATE] and [DATE] through [DATE]. A record review of Resident #1's MAR reflected [MEDICATION(S)] (anti-rejection medication) was not given on the following dates for the following reasons: [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; reordered [DATE] - other; na [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Resident unavailable; dr. appt [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Other; waiting on pharmacy to deliver [DATE] - Other; waiting on pharmacy to deliver [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Other; waiting on pharmacy to deliver [DATE] (on hold) [DATE] - Refused [DATE] - Other; waiting on pharmacy to deliver [DATE] - Other; waiting on pharmacy to deliver [DATE] - Drug/Item unavailable [DATE] - Other; waiting on pharmacy to deliver [DATE]-[DATE] (on hold) During an interview on [DATE] at 10:23 a.m., Medication Aide A stated the resupply button on her computer kiosk was supposed to notify the pharmacy that the facility needed a supply of medication. During an interview on [DATE] at 10:15 a.m., the DON stated that according to the pharmacy's records, the facility did not order [MEDICATION(S)] (anti-rejection medication) until [DATE]. A record review of Resident #1's MAR from March to April reflected Medication Aide A failed to administer [MEDICATION(S)] (anti-rejection medication) on 29 occasions. A review of Resident #1's MAR reflected Medication Aide A documented in Resident #1's MAR that she did not administer [MEDICATION(S)] (anti-rejection medication) to Resident #1 on the following dates: [DATE] [DATE]-[DATE] [DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE] [DATE]-[DATE] [DATE] [DATE]-[DATE] [DATE]-[DATE] During an interview on [DATE] at 10:23 a.m., Medication Aide A stated she had a resupply button on her computer, and she pressed it every day. The facility was unable to provide documentation proving this to be true. Medication Aide A stated she left multiple notes for nurses saying pharmacy was not sending the [MEDICATION(S)] (anti-rejection medication). Medication Aide A stated those notes to nurses were written on sticky notes and they were not documented anywhere. Medication Aide A stated she notified her charge nurses and other PRN nurses two to three times . Medication Aide A stated she did not remember who all she notified, but she remembered notifying LPN A. Medication Aide A stated she would give sticky notes with lists of out-of-stock medications to her charge nurses and to other PRN nurses. Medication Aide A stated when nothing happened, that was when she notified the Rehab Nurse. Medication Aide A stated this was sometime in early March. Medication Aide A stated the Rehab Nurse stated to her she would take care of the issue. Medication Aide A stated she never informed the DON of this issue. Medication Aide A stated she had noticed a bottle of [MEDICATION(S)] (anti-rejection medication) in the facility, which she believed was brought in by Resident #1, so she started giving him that. Medication Aide A stated she did not know exactly when that was. Medication Aide A stated she knew [MEDICATION(S)] (anti-rejection medication) was for Resident #1's heart and stated if he did not receive it, it could cause him to start having problems with his heart. Medication Aide A stated ADON B started monitoring her medications about a month ago. Medication Aide A stated that back in March, ADON A was covering both the long-term care side and the rehab side of the facility, and ADON A had trouble covering all the residents. During an interview on [DATE] at 1:01 p.m., when asked specific questions regarding Resident #1's medication, ADON A stated, I don't know, I have 90 residents. During an interview on [DATE] at 5:26 p.m., the DON stated the only explanation as to why Resident #1's [MEDICATION(S)] (anti-rejection medication) was not given was that it was not ordered timely so that resulted in missed doses. The DON stated that through talking with the MAs , she found out they were not notifying the charge nurse. The DON did not specify which MAs she spoke with. The DON stated therefore, the nurses were not aware and were not notifying the pharmacy. During an interview on [DATE] at 10:15 a.m., the DON stated Resident #1 did not receive his anti-rejection medication due to protocols not being followed and a major breakdown in communication. The DON stated the facility received a 14-day supply of [MEDICATION(S)] (anti-rejection medication) from the pharmacy upon Resident #1's admission. The DON stated, after communicating with the facility's pharmacy, that the medication was not ordered from the pharmacy until [DATE]. When asked why the same couple of MAs were repeatedly documenting in Resident #1's MAR that [MEDICATION(S)] (anti-rejection medication) was not administered due to waiting on rx to come in, she stated it was because MAs were not doing their job. The DON stated there were ways to get medications in house but that just was not followed due to lack of notification. When asked if missing that much medication could have contributed to Resident #1's death, the DON stated I can't answer that, I am not a doctor. I can't say for sure. It's an important medication. When asked what the risks were of residents with a heart transplant not receiving their anti-rejection medication, the DON stated the medication prevented the immune system from targeting and attacking the transplant organ. The DON stated if anti-rejection medication was missed, one would see shortness of breath, the heart giving out, [CONDITION(S)] (chest pain), and heart failure. The DON stated the process for administering out of stock medications included checking the emergency medication kit, pulling the medication from there if it was available, and then order the medication from the pharmacy. The DON stated if the medication was not in the emergency medication kit, the employee passing medications would need to immediately notify the charge nurse who would then call the pharmacy. The DON said the process for ordering medications included the MA notifying the nurse via word of mouth that medications were out of stock so the nurse could then contact the pharmacy to place an order. During an interview on [DATE] at 1:57 p.m., the DON stated when MAs pressed the resupply button on their computer kiosk, that it sent a message to the pharmacy for medication to be ordered. The DON stated all MAs received proficiency training on administering medications prior to hire and annually. During an interview on [DATE] at 2:19 p.m., ADON A stated she was never notified of any refills needed because it was never brought to her attention. ADON A stated herself or charge nurses could monitor compliance of medication administration by running daily reports of missed medications . ADON A stated MAs should notify their nurses when medications were out of stock. ADON A stated she was not aware of Resident #1's missed doses because she took over his care on [DATE], when Resident #1 moved from the rehab to the long-term care side. ADON A stated [MEDICATION(S)] was a vital medication and if a resident did not receive it, it would be very serious. ADON A stated not receiving the medication could cause the immune system to attack its organs and could lead to serious injuries and harm. ADON A stated she was not sure whether [MEDICATION(S)] (anti-rejection medication) was a high-cost medication. ADON A stated some high-cost medications needed approval from facility before the pharmacy filled the prescription, but she stated Resident #1's medications did not need to be approved for the pharmacy to fill the medication. During an interview on [DATE] at 11:26 a.m., Transplant Nurse 2 stated the therapeutic level of [MEDICATION(S)] (anti-rejection medication) was between ,d+[DATE] ng/mL. Transplant Nurse 2 stated the therapeutic level of the drug could be reached after 72 hours of taking the medication, but absorption played a factor as well. Transplant Nurse 2 stated, in her professional opinion, I absolutely feel like this contributed to his multi-organ failure-you need these therapeutic values to prevent your immune system from attacking your organs. Transplant Nurse 2 stated during the times when Resident #1's levels of [MEDICATION(S)] (anti-rejection medication) were low, he had some evidence of cellular damage in his heart-he had been showing signs of heart damage. Transplant Nurse 2 stated that absolutely, by not receiving [MEDICATION(S)] (anti-rejection medication) most of March and 28 days in April, that that could have contributed to Resident #1's death. During an interview on [DATE] at 9:20 a.m., Transplant Cardiologist stated he was very familiar with Resident #1 and had been seeing him even prior to Resident #1's transplant surgery in 2015. Transplant Cardiologist stated Resident #1 had some robust years after the transplant. Transplant Cardiologist stated that two years post-surgery, the therapeutic level of [MEDICATION(S)] (anti-rejection medication) was between ,d+[DATE] ng/mL. Transplant Cardiologist stated if a patient was on a stable dose, they would need their levels of [MEDICATION(S)] measured once a month, but in Resident #1's case, we wanted to measure his level more frequently. Transplant Cardiologist stated, they are supposed to draw the level once a week or once every two weeks. Transplant Cardiologist stated that missing doses could have contributed to Resident #1's death, stating Resident #1 was underdosed for a long period of time and that may have contributed to the severity of his anti-rejection. Transplant Cardiologist stated they did everything to treat Resident #1's antirejection until Resident #1 said no more due to poor quality of life-Resident #1 communicated he did not want any more aggressive therapy. Transplant Cardiologist stated Resident #1's family did not want an autopsy to be performed. A record review of the facility's policy titled Pharmacy Services Policies and Procedures dated [DATE] reflected the following: The facility must provide or obtain routine medications and biologicals to meet the needs of each resident. Nurses must monitor medication availability and reorder medications when there is a four to five day supply of medication remaining. A record review of the facility's procedure titled Medication Pass Preparation dated [DATE] reflected the following: The facility will ensure there is an adequate supply of floor stock medications available. The Administrator was notified on [DATE] at 6:10 p.m. that an Immediate Jeopardy situation had been identified due to the above failure. The Immediate Jeopardy template was provided to the Administrator. A Plan of Removal was submitted by the Administrator and accepted on [DATE] at 5:32 p.m., and included: Plan of Removal POR F755 Pharmacy Services The identified resident no longer resides in the facility. Residents who receive medications have the potential to be affected. The pharmacy consultant will review quarterly for the occurrence of unavailable medications and notify the Director of Nursing/designee. The Administrator/DON will be responsible to ensure that the pharmacy consultant completed this task at least quarterly. This will begin with the next pharmacy review. A review of the medication administration compliance report was completed by the Director of Nursing/designee to identify any medications not available. Any identified medications were re-ordered on [DATE] by the Director of Nursing or designee and those residents were assessed for any adverse effects and the physician was notified for further orders. Physician recommendations will be followed while waiting on medication arrival. A review of lab values for antirejection medications, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician that require a therapeutic level will be completed by the Director of Nursing/designee to validate that values are within the therapeutic range. A review of physician orders for labs related to these medications will be included. The physician will be notified immediately if any values are found to be out of therapeutic range. This will be completed by [DATE]. This will be accomplished by the Director of Nursing or her RN designee. Therapeutic medication laboratory values for antirejection medications, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician that require a therapeutic level will be reviewed daily Monday - Friday in the clinical morning meeting. Residents' therapeutic levels are found to be low or critical, the availability of the medication will be validated, and the physician will be notified immediately upon discovery for further direction. This will be accomplished by the Director of Nursing or her RN or LVN designee. MAR to cart audit, validating that there is a medication available in the medication cart for each physician's order will be completed by [DATE] to validate that there is a medication for any physician's order. This will be accomplished by the Director of Nursing or her RN designee. Nursing Management will be re-educated on the following by the Clinical Consultant by [DATE] the following: o Reviewing Medication Administration compliance report Monday - Friday in clinical morning meeting to review and resolve any issues regarding missed / unavailable medications. The Clinical Consultant will be responsible for the re-education. o Addressing unavailable medications when licensed nurses and/or Certified Medication Aides report that medications are not available. This will be documented by the licensed nurse or Certified Medication Aide on the 24-hour report for review by nursing management. The Director of Nursing will then document the clinical morning meeting agenda for tracking until resolved. The Clinical Consultant will be responsible for the reeducation. o When a complaint from a family is voiced, a grievance form will be completed for review by nursing management and the administrator for appropriate action. The grievance will be completed at the time of the complaint. The grievance will be reviewed in standup each day until resolved. The social service director will track for resolution of grievances). o The Clinical Consultant will be responsible for the re-education. Nurse Leadership hired after this date will complete this education presented in orientation by Clinical Consultant or designee. Licensed nurses and Certified Medication Aides will be re-educated on the medication management. The following process for medication management will be implemented beginning [DATE] if a medication is not available: (this will be an ongoing practice) 1. The Licensed Nurse upon identification of a needed medication would Check the E-Kit inventory kit list to see if the medication needed is in the E-Kit and obtain and administer if it is included and then follow the re-order process. 2. The Licensed Nurse will then call the pharmacy and ask for the medication to be delivered within 4 hours, or the after-hours pharmacy number and ask for the med to be delivered within 4 hours. If the med will be delivered and will result in a late medication administration, the Doctor MUST be notified immediately upon discovery and an order written to be given when arrives from the pharmacy. 3. The Director of Nursing/designee MUST be notified within the hour, but no later than the end of shift by the licensed nurse if the facility is unable to obtain an antirejection medication, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician that requires a therapeutic level for further direction 4. If a therapeutic laboratory value for an antirejection medication, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician that requires a therapeutic level is noted to be low or critical, the medication availability will be validated, and the physician will be notified immediately by the licensed nurse for further orders upon discovery. 5. When a family member or resident voices concern regarding medications administration or availability, a grievance should be initiated; by staff receiving the grievance or family may complete grievance form; nursing management notified for resolution. The administrator/designee validates the solution of the grievance including family notification. 6. Medication re-ordering process to prevent medication unavailability concerns a. Medication aides and nurses will reorder medications when there is a four -to- five- day supply of medication remaining using the resupply button in Matrix to communicate with the pharmacy a refill is needed. This will be accomplished by the Director of Nursing or her RN designee. This re-education will be completed by [DATE]. Any licensed nurse or Certified Medication Aide not receiving by this date will receive prior to the next scheduled shift. This will be presented to agency personnel and in new hire orientation. Licensed nurses and certified medication aides will not be able to work or administer medication until they receive this training. This will be accomplished by the Director of Nursing or her RN designee. Medication compliance report to be reviewed daily Monday - Friday as part of the clinical morning meeting process beginning [DATE] in the clinical morning meeting. Any concern will be addressed at the time of discovery. This will be accomplished by the Director of Nursing or her RN or LVN designee. Therapeutic medication laboratory values for antirejection medications, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician that require a therapeutic level will be reviewed daily Monday - Friday in the clinical morning meeting. If any are found to be low or critical, the availability of the medication will be validated, and the physician will be notified immediately upon discovery for further direction. This will be accomplished by the Director of Nursing or her RN designee. A MAR to Cart audit will be completed weekly for 4 weeks, or until substantial compliance is achieved to validate that medications are available for physician's orders. This will be accomplished by the Director of Nursing or designee Medical Director was notified of the Immediate Jeopardies and the contents of this plan on [DATE] by the Administrator. The Administrator and Director of Nursing will oversee the compliance of this Plan of Correction. An Ad Hoc Quality Assurance Performance Improvement Meeting was held on [DATE] and [DATE] The administrator will report all findings from audits to the Quality Assurance Committee for 3 months for further recommendations, and then randomly thereafter. Any areas of concern will be addressed at the time of discovery. The facility was monitored for compliance of the Plan of Removal from [DATE] through [DATE]. During observations of medication pass on [DATE] from 2:00 p.m.-2:45 p.m., medications were observed to be passed to residents accurately and in accordance with their respective physician orders. Observations of the nursing floor on [DATE] from 2:45 p.m-3:00 p.m. revealed ADON A provided on-the-job training to medication aides and charge nurses on the new process of documenting and communicating out of stock medications. An observation on [DATE] at 3:00 p.m. revealed the facility was implementing their new policy of notifying appropriate medical parties regarding out-of-stock medications-observed ADON A call the nurse practitioner and pharmacy to communicate out of stock medications. Record reviews on [DATE] of the facility's 24-hour nurses shift report and nurses progress notes reflected out of stock medications were documented appropriately, per the facility's Plan of Removal. A record review on [DATE] of the facility's administration compliance report reflected no issues. A record review of the facility's MAR to cart pharmacy audit reflected no issues. A record review on [DATE] reflected the facility ran a report on all residents taking ACE inhibitors, antibiotics, anticoagulants, anticonvulsants, hormones, or immunosuppressants-the facility determined and noted which residents required monitoring and for those who required monitoring, the type of monitoring, depending on the medication they were taking, was noted. A record review on [DATE] of in-service trainings reflected all licensed nurses and certified s were reeducated on medication management-topics included checking the emer

Based on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 12 residents reviewed for quality of care. The facility failed to administer Resident #1's life-sustaining medication, [MEDICATION(S)] (anti-rejection medication), as ordered by the physician. Resident #1 missed 57 doses of [MEDICATION(S)] medication in a 105-day period. This failure likely contributed to Resident #1 developing multi-organ failure, which resulted in his death on [DATE]. This failure could place residents at risk for not receiving care and services to meet resident needs, which could lead to hospitalization and death. On [DATE] at 6:10 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: A record review of Resident #1's face sheet reflected a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderately impaired cognition. A record review of Resident #1's hospital discharge paperwork dated [DATE] reflected he had a heart transplant in 2015. A record review of Resident #1's care plan last revised on [DATE] reflected he was a heart transplant patient with an implanted cardiac defibrillator related to irregular heart rhythm . A review of Resident #1's care plan goal dated reflected he would not exhibit complications of heart transplant rejection, medication side effects, or signs of abnormal heart rhythm. A review of Resident #1's care plan approach reflected he was to be observed for signs of abnormal heart rhythm and monitored for immunosuppressive medication side effects including acute infection, kidney disease, loss of appetite, nausea, vomiting, and hand trembling. A record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE]-[DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE] (on hold) [DATE] [DATE]-[DATE] [DATE]-[DATE] (on hold) A record review of Resident #1's lab result dated [DATE] reflected his assay level (amount of drug in blood) of [MEDICATION(S)] (anti-rejection medication) was <1 ng/mL with a reference range of 5.,d+[DATE].0 ng/mL, which indicated an abnormally low level. Laboratory work was completed through the facility's laboratory services provider. There were no notes in Resident #1's chart which indicated the facility took action. In an interview on [DATE] at 9:20 a.m., Resident #1's Transplant Cardiologist stated Resident #1's low assay level of [MEDICATION(S)] (anti-rejection medication) was first communicated to him in [DATE]. In an interview on [DATE] at 3:28 p.m. Resident #1's family member stated Resident #1's low level of [MEDICATION(S)] (anti-rejection medication) was not communicated to her in [DATE]. A record review of Resident #1's progress note completed by ADON A dated [DATE] reflected Resident #1's family member called the facility, was upset, stated the facility was not giving the correct dose of anti-rejection, and stated this was evident by his [MEDICATION(S)] (anti-rejection medication) lab values. A record review of Resident #1's progress note authored by ADON A dated [DATE] 2:14 p.m. reflected he had complained of shortness of breath and stated to staff his heart did not feel right. The progress note reflected ADON A contacted Transplant Nurse 1, who then recommended Resident #1 be sent out to the hospital due to elevated pulse and shortness of breath. The progress note reflected Transplant Nurse 1 stated the following to ADON A: due to his heart showing signs of rejection according to his labs that it is best he go to the ER. A record review of Resident #1's lab results collected and analyzed at the hospital in which he was admitted on [DATE] reflected the following assay levels (amount of drug in blood) of [MEDICATION(S)] (anti-rejection medication): [DATE]: <2 ng/mL [DATE]: <2 ng/mL A review of the lab report reflected a reference range of 5.,d+[DATE].00 ng/mL, which indicated abnormally low levels. A record review of Resident #1's hospital note dated [DATE] reflected his reasons for admission to the ER included cardiogenic shock and acute rejection of heart transplant. A review of his history of present illness dated [DATE] reflected Resident #1 had last been seen by the Transplant Cardiologist on [DATE] and had not been getting [MEDICATION(S)] appropriately at the skilled nursing facility. A record review of Resident #1's hospital discharge summary dated [DATE] reflected the following: There was suspicion for acute rejection due to possible anti-rejection medication dosing issues and he was started on high dose steroids. A record review of Resident #1's discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's hospital note dated [DATE] reflected he passed away in the hospital on [DATE] at 4:02 a.m. During an interview on [DATE] at 5:16 p.m., Resident #1's family member stated she had brought up concerns that Resident #1 was not receiving the proper dose of [MEDICATION(S)] (anti-rejection medication) because his assay levels of the drug were low. Resident #1's family member could not recall who she had spoken with at the facility. Resident #1's family member stated the facility told her they did not have the medication in stock because she had not brought it in to the facility. Resident #1's family member stated that upon Resident #1's admission on [DATE], the facility told her Resident #1's medications were too expensive, and that Resident #1's family member would need to supply them. A record review of Resident #1's patient chart reflected no agreement between Resident #1's family member and the facility regarding the need for family to supply Resident #1's [MEDICATION(S)] (anti-rejection medication). During an interview on [DATE] at 1:01 p.m., ADON A stated it was not atypical for family to bring in high-cost medications. ADON A stated she did not know if the facility was responsible for providing [MEDICATION(S)] (anti-rejection medication), or if it was the family's responsibility. ADON A stated high-cost medications were usually approved in the business office upon the resident's admission. When asked specific questions regarding Resident #1's medication, ADON A stated, I don't know, I have 90 residents. During an observation and interview on [DATE] at 1:10 p.m., the DON stated Resident #1's family member had brought in [MEDICATION(S)] (anti-rejection medication) on a few occasions, but she did not remember exactly when. Observation revealed three full bottles of [MEDICATION(S)] (anti-rejection medication) on the DON's desk, all with a filled date of [DATE]. A record review of the pharmacy cost of [MEDICATION(S)] (anti-rejection medication) reflected a 30-day supply cost approximately $27. During an interview on [DATE] at 3:21 p.m., the Transplant Nurse stated she received a phone call from ADON A the morning of [DATE]. She said she told ADON A to take Resident #1 to the ER that morning and stated he did not show up to the hospital until hours, during the afternoon of [DATE]. A review of Resident #1's hospital records reflected a provider note authored by an emergency department physician on [DATE] at 1:49 p.m. During an interview on [DATE] at 3:18 pm, the Medical Director of the nursing facility stated if Resident #1 had missed doses of [MEDICATION(S)] (anti-rejection medication), it could have been due to technical difficulties or staffing, stating it's hard to pin. The Medical Director stated [MEDICATION(S)] was an immunosuppressant drug given to patients with heart transplants. The Medical Director stated if a resident stopped taking it, immunity would go down, the body would become infected, opportunistic infections could occur, and the resident would become prone to heart failure. The Medical Director stated he did not see a direct correlation between missed doses and Resident #1's death, but he stated it depended on the sequence of events. The Medical Director stated, usually it's an immediate thing and stated missing doses would not cause a delayed reaction-any detrimental effect would occur within days of missing the dose. During an interview on [DATE] at 3:21 pm, Transplant Nurse 1 stated Resident #1 was way below therapeutic assay levels of the drug, [MEDICATION(S)] (anti-rejection medication), on several occasions. Transplant Nurse 1 stated the therapeutic level of the drug was ,d+[DATE] ng/mL, and his levels were below 2 ng/mL several times. Transplant Nurse 1 stated from her understanding, Resident #1 was not receiving the correct dose of medication at the nursing facility. Transplant Nurse 1 stated there was no reason why the medication, [MEDICATION(S)], should be paused or stopped for any reason. Transplant Nurse 1 stated Resident #1 not getting [MEDICATION(S)] (anti-rejection medication) caused him to go into rejection, stating his heart did reject. Transplant Nurse 1 stated Resident #1's cause of death was multi-organ failure. During an interview on [DATE] at 4:42 p.m., the Nurse Practitioner stated, I don't think he'd pass away from missing dosage. The Nurse Practitioner stated this was not her expertise and Resident #1's cardiologist would be the best person to talk to. The Nurse Practitioner stated, it would be hard to answer if he missed medication, if that would cause him to die. The Nurse Practitioner stated she was not sure what missing one dose, two doses, or a month of doses would do. The Nurse Practitioner stated if Resident #1 had not received the same dose of [MEDICATION(S)] (anti-rejection medication) at the nursing facility as he had while he was at home, that would not be the first time she had seen a situation like that. The Nurse Practitioner stated she could not imagine the [MEDICATION(S)] (anti-rejection medication) was not delivered to the facility due to a pharmacy issue. During an interview on [DATE] at 5:26 p.m., the DON stated the only explanation as to why Resident #1's [MEDICATION(S)] (anti-rejection medication) was not given was that it was not ordered timely so that resulted in missed doses. The DON stated that through talking with the MAs , she found out they were not notifying the charge nurse. The DON did not specify which MAs she spoke with. The DON stated therefore, the nurses were not aware and were not notifying the pharmacy. During an interview on [DATE] at 10:15 a.m., the DON stated that according to the pharmacy's records, the facility did not order [MEDICATION(S)] (anti-rejection medication) until [DATE]. The DON stated Resident #1 did not receive his anti-rejection medication due to protocols not being followed and a major breakdown in communication. The DON stated the facility received a 14-day supply of [MEDICATION(S)] (anti-rejection medication) from the pharmacy upon Resident #1's admission. The DON stated, after communicating with the facility's pharmacy, that the medication was not ordered from the pharmacy until [DATE]. When asked why the same couple of MAs were repeatedly documenting in Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated there were ways to get medications in house but that just was not followed due to lack of notification. When asked if missing that much medication could have contributed to Resident #1's death, the DON stated I can't answer that, I am not a doctor. I can't say for sure. It's an important medication. When asked what the risks were of residents with a heart transplant not receiving their anti-rejection medication, the DON stated the medication prevented the immune system from targeting and attacking the transplant organ. The DON stated if anti-rejection medication was missed, one would see shortness of breath, the heart giving out, [CONDITION(S)] (chest pain), and heart failure. The DON stated the process for administering out of stock medications included checking the emergency medication kit, pulling the medication from there if it was available, and then order the medication from the pharmacy. The DON stated if the medication was not in the emergency medication kit, the employee passing medications would need to immediately notify the charge nurse who would then call the pharmacy. The DON said the process for ordering medications included the MA notifying the nurse via word of mouth that medications were out of stock so the nurse could then contact the pharmacy to place an order. A record review of Resident #1's MAR from March to April reflected Medication Aide A failed to administer [MEDICATION(S)] (anti-rejection medication) on 29 occasions. A review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #1 on the following dates: [DATE] [DATE]-[DATE] [DATE] [DATE]-[DATE] [DATE]-[DATE] [DATE] [DATE]-[DATE] [DATE] [DATE]-[DATE] [DATE]-[DATE] A record review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Reasons and comments reflected the following: drug/item unavailable, waiting on rx to come in, pending medication arrival from pharmacy, and waiting on pharmacy to deliver. A review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; reordered [DATE] - other; na [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Resident unavailable; dr. appt [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable; pending medication arrival from pharmacy [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable; waiting on rx to come in [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Other; waiting on pharmacy to deliver [DATE] - Other; waiting on pharmacy to deliver [DATE] - Drug/Item unavailable [DATE] - Drug/Item unavailable [DATE] - Other; waiting on pharmacy to deliver [DATE] (on hold) [DATE] - Refused [DATE] - Other; waiting on pharmacy to deliver [DATE] - Other; waiting on pharmacy to deliver [DATE] - Drug/Item unavailable [DATE] - Other; waiting on pharmacy to deliver [DATE]-[DATE] (on hold) During an interview on [DATE] at 11:26 a.m., Transplant Nurse 2 stated the therapeutic level of [MEDICATION(S)] (anti-rejection medication) was between ,d+[DATE] ng/mL. Transplant Nurse 2 stated the therapeutic level of the drug could be reached after 72 hours of taking the medication, but absorption played a factor as well. Transplant Nurse 2 stated, in her professional opinion, I absolutely feel like this contributed to his multi-organ failure-you need these therapeutic values to prevent your immune system from attacking your organs. Transplant Nurse 2 stated during the times when Resident #1's levels of [MEDICATION(S)] (anti-rejection medication) were low, he had some evidence of cellular damage in his heart-he had been showing signs of heart damage. Transplant Nurse 2 stated that absolutely, by not receiving [MEDICATION(S)] (anti-rejection medication) most of March and 28 days in April, that that could have contributed to Resident #1's death. During an interview on [DATE] at 1:57 p.m., the DON stated when MAs pressed the resupply button on their computer kiosk, that it sent a message to the pharmacy for medication to be ordered. The DON stated all MAs received proficiency training on administering medications prior to hire and annually. During an interview on [DATE] at 2:19 p.m., ADON A stated she was never notified of any refills needed because it was never brought to her attention. ADON A stated herself or charge nurses could monitor compliance of medication administration by running daily reports of missed medications . ADON A stated MAs should notify their nurses when medications were out of stock. ADON A stated she was not aware of Resident #1's missed doses because she took over his care on [DATE], when Resident #1 moved from the rehab to the long-term care side. ADON A stated [MEDICATION(S)] was a vital medication and if a resident did not receive it, it would be very serious. ADON A stated not receiving the medication could cause the immune system to attack its organs and could lead to serious injuries and harm. ADON A stated she was not sure whether [MEDICATION(S)] (anti-rejection medication) was a high-cost medication. ADON A stated some high-cost medications needed approval from facility before the pharmacy filled the prescription, but she stated Resident #1's medications did not need to be approved for the pharmacy to fill the medication. During an interview on [DATE] at 9:20 a.m., Transplant Cardiologist stated he was very familiar with Resident #1 and had been seeing him even prior to Resident #1's transplant surgery in 2015. Transplant Cardiologist stated Resident #1 had some robust years after the transplant. Transplant Cardiologist stated that two years post-surgery, the therapeutic level of [MEDICATION(S)] (anti-rejection medication) was between ,d+[DATE] ng/mL. Transplant Cardiologist stated if a patient was on a stable dose, they would need their levels of [MEDICATION(S)] measured once a month, but in Resident #1's case, we wanted to measure his level more frequently. Transplant Cardiologist stated, they are supposed to draw the level once a week or once every two weeks. Transplant Cardiologist stated that missing doses could have contributed to Resident #1's death, stating Resident #1 was underdosed for a long period of time and that may have contributed to the severity of his anti-rejection. Transplant Cardiologist stated they did everything to treat Resident #1's antirejection until Resident #1 said no more due to poor quality of life-Resident #1 communicated he did not want any more aggressive therapy. Transplant Cardiologist stated Resident #1's family did not want an autopsy to be performed. A record review of the facility's policy titled Pharmacy Services Policies and Procedures dated [DATE] reflected the following: The facility must provide or obtain routine medications and biologicals to meet the needs of each resident. Nurses must monitor medication availability and reorder medications when there is a four-to-five-day supply of medication remaining. A record review of the facility's procedure titled Medication Pass Preparation dated [DATE] reflected the following: The facility will ensure there is an adequate supply of floor stock medications available. The Administrator was notified on [DATE] at 6:10 p.m. that an Immediate Jeopardy situation had been identified due to the above failure. The Immediate Jeopardy template was provided to the Administrator. A Plan of Removal was submitted by the Administrator and accepted on [DATE] at 5:32 p.m., and included: Plan of Removal POR F684 Quality of Care The identified resident no longer resides in the facility. Residents who receive medications have the potential to be affected. A review of the medication administration compliance report was completed by the Director of Nursing/designee to identify any medications not available. Any identified medications were re-ordered on [DATE] by the Director of Nursing or designee and those residents were assessed for any adverse effects and the physician was notified for further orders. Physician recommendations will be followed while waiting on medication arrival. A review of lab values for antirejection medications, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician that require a therapeutic level will be completed by the Director of Nursing/designee to validate that values are within the therapeutic range. A review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician will be notified immediately if any values are found to be out of therapeutic range. This will be completed by [DATE]. This will be accomplished by the Director of Nursing or her RN designee. Therapeutic medication laboratory values for antirejection medications, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician to require a therapeutic level will be reviewed daily Monday - Friday in the clinical morning meeting. This process will begin on [DATE]. This will be an ongoing practice. Residents' therapeutic levels are found to be low or critical, the availability of the medication will be validated, and the physician will be notified immediately upon discovery for further direction. This will be accomplished by the Director of Nursing or her RN or LVN designee. MAR to cart audit, validating that there is a medication available in the medication cart for each physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing Management will be re-educated on the following by the Clinical Consultant by [DATE] the following: o Reviewing Medication Administration compliance report Monday - Friday in clinical morning meeting to review and resolve any issues regarding missed / unavailable medications. The Clinical Consultant will be responsible for the re-education. o Addressing unavailable medications when licensed nurses and/or Certified Medication Aides report that medications are not available. This will be documented by the licensed nurse or Certified Medication Aide on the 24-hour report for review by nursing management. The Director of Nursing will then document the clinical morning meeting agenda for tracking until resolved. The Clinical Consultant will be responsible for the re education. o When a complaint from a family is voiced, a grievance form will be completed for review by nursing management and the administrator for appropriate action. The grievance will be reviewed in standup each day until resolved. The social service director will track for resolution of grievances). The Clinical Consultant will be responsible for the re education. Nurse Leadership hired after this date will complete this education presented in orientation by Clinical Consultant or designee. o The Clinical Consultant will be responsible for the re-education. Nurse Leadership hired after this date will complete this education presented in orientation by Clinical Consultant or designee. Licensed nurses and Certified Medication Aides will be re-educated on the medication management. The following process for medication management will be implemented beginning [DATE] if a medication is not available: 1. The Licensed Nurse upon identification of a needed medication will Check the E-Kit inventory kit list to see if the medication needed is in the E-Kit and obtain and administer if it is included and then follow the re-order process. 2. The Licensed Nurse will then call the pharmacy and ask for the medication to be delivered within 4 hours, or the after-hours pharmacy number and ask for the med to be delivered within 4 hours. If the med will be delivered and will result in a late medication administration, the Doctor MUST be notified immediately upon discovery and an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. The Director of Nursing/designee MUST be notified within the hour, but no later than the end of shift by the licensed nurse if the facility is unable to obtain an antirejection medication, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician that requires a therapeutic level for further direction. 4. If a therapeutic laboratory value for an antirejection medication, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician to require a therapeutic level is noted to be low or critical, the medication availability will be validated, and the physician will be notified immediately upon discovery by the licensed nurse for further orders upon discovery. 5. When a family member or resident voices a concern regarding medications administration or availability, a grievance should be initiated at the time of the voiced grievance; by staff receiving the grievance or family may complete a grievance form, and nursing management notified for resolution. The administrator/designee will validate the resolution of the grievance including family notification. 6. Medication re-ordering process to prevent medication unavailability concerns a. Medication aides and nurses will reorder medications when there is a four -to- five- day supply of medication remaining using the resupply button in Matrix to communicate with the pharmacy a refill is needed. This monitoring will be accomplished by the Director of Nursing or her RN designee. This re-education will be completed by [DATE]. Any licensed nurse or Certified Medication Aide not receiving by this date will receive prior to the next scheduled shift. This will be presented to agency personnel and in new hire orientation. Licensed nurses and certified medication aides will not be able to work or administer medication until they receive this training. This will be accomplished by the Director of Nursing or her RN designee. Medication compliance report to be reviewed daily Monday - Friday as part of the clinical morning meeting process beginning [DATE] in the clinical morning meeting. This will be an ongoing practice. Any concerns will be addressed at the time of discovery. This will be accomplished by the Director of Nursing or her RN or LVN designee. Therapeutic medication laboratory values for antirejection medications, anticonvulsants, anticoagulants, ace inhibitors, antipsychotics, barbiturates, [MEDICATION(S)] medications, or others deemed by the physician to require a therapeutic level will be reviewed daily Monday - Friday in the clinical morning meeting. If any are found to be low or critical, the availability of the medication will be validated, and the physician will be notified immediately upon discovery for further direction. This will be accomplished by the Director of Nursing or her RN designee. This will begin on [DATE]. A MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This practice will start on [DATE]. Medical Director was notified of the Immediate Jeopardies and the contents of this plan on [DATE] 2 by the Administrator. The Administrator and Director of Nursing will oversee the compliance of this Plan of Correction. An Ad Hoc Quality Assurance Performance Improvement Meeting was held on [DATE] and [DATE]. The administrator will report all findings from audits to the Quality Assurance Committee for 3 months for further recommendations, and then randomly thereafter. Any areas of concern will be addressed at the time of discovery. The facility was monitored for compliance of the Plan of Removal from [DATE] through [DATE]. During observations of medication pass on [DATE] from 2:00 p.m.-2:45 p.m., medications were observed to be passed to residents accurately and in accordance with their respective physician orders. Observations of the nursing floor on [DATE] from 2:45 p.m-3:00 p.m. revealed ADON A provided on-the-job training to medication aides and charge nurses on the new process of documenting and communicating out of stock medications. An observation on [DATE] at 3:00 p.m. revealed the facility was implementing their new policy of notifying appropriate medical parties regarding out-of-stock medications-observed ADON A call the nurse practitioner and pharmacy to communicate out of stock medications. Record reviews on [DATE] of the facility's 24-hour nurses shift report and nurses progress notes reflected out of stock medications were documented appropriately, per the facility's Plan of Removal. A record review on [DATE] of the facility's administration compliance report reflected no issues. A record review of the facility's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review on [DATE] reflected the facility ran a report on all residents taking ACE inhibitors, antibiotics, anticoagulants, anticonvulsants, hormones, or immunosuppressants-the facility determined and noted which residents required monitoring and for those who required monitoring, the type of monitoring, depending on the medication they were taking, was noted. A record review on [DATE] of in-service trainings reflected all licensed nurses and certified s were reeducated on medication management-topics included check

Based on observation, interview, and record review, the facility failed to ensure each resident's environment was free of hazards and received adequate supervision, for one (Resident #1) of five residents reviewed for accidents. The facility failed to ensure the resident's environment was free from hazards and properly supervise when Resident # 1's fingers where smashed by the LPN A while following behind her. Resident #1 's sustaining middle and ring finger fractures. This deficient practice could affect residents by placing them at risk of serious injury that could have otherwise been avoided. Findings included: Review of the Face Sheet for Resident #1 reflected a [AGE] year-old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the initial MDS for Resident #1 dated on 9/30/19, reflected a BIMS of 02 indicating severe impairment. Further review of the MDS section E reflected Resident #1 had not exhibited any type of behavior. The MDS revealed Resident #1 had not exhibited wandering behaviors. Further record review of the MDS section N revealed that the resident was receiving antidepressant and antipsychotic medications. Review of resident progress notes dated 10/02/19, 10/07/19, 10/08/19, and 10/15/19 reflected that Resident # 1 was constantly confused, tried to get out of bed and frequently attempted to remove her right leg brace. Review of the resident progress notes dated 10/27/19 reflected that at 7:30 p.m. Resident # 1 was trying to get out a bed without assistance. The resident was placed at the nurse's station and she began to ramble, pull things out of the drawers, and broke a tape dispenser. Resident #1 went unassisted to the 400 hall trying to pull a fire extinguisher box and the resident was redirected from the area. At the front area, the resident was trying to pull a picture frame off the wall. Review of the resident incident/accident investigation finding dated on 10/28/19, reflected that LPN A was entering another resident's room and that resident attempted to follow on 10/27/19 LPN A as she was shutting the door to the room. The resident stuck her right hand into the door as it closed, smashing her right middle and ring fingers. Review of the investigation regarding incident on October 27, 2019 on Resident #1 dated 10/28/19 reflected that on the evening of 10/27/19, the resident was with her husband who put her to bed around 7:00 p.m. then left. Further review reflected that Resident #1 usually gets up within the next hour after her husband leaves the facility and that the resident is more confused in the evening than in the daylight hours. After the incident, first aid was given to the resident along with a dressing to assist in the decrease of bleeding, and an x-ray was ordered for the morning. Further review reflected that in the morning the facility was still waiting for the x-ray. The resident was then sent to the emergency room for the x-ray and for evaluation and treatment and possible removal of remaining nail. Further review reflected that education was provided to staff to be alert and always check the resident placement in their surroundings. Review of the hospital medical records dated 10/28/19 reflected Resident #1 presented with injury to her right hand. Resident #1 was able to verbalize she was in pain and the pain was in her right middle and ring finger. Resident #1's nail on her middle finger was torn off. X-ray revealed fractures to both the middle and ring finger. Surgery was performed on Resident #1's right hand to repair the fractures. Review of the Care Plan for Resident #1 dated 10/28/19 reflected Resident #1 was taking [MEDICAL CONDITION] medication and interventions included protecting the resident from self harm or harm to others. Review of the Care Plan for Resident #1 dated 10/28/19 reflected interventions for risk for acute injury due to dementia which included monitor resident locations in the facility to ensure safe environment. Review of the administrator and director of nursing follow-up of the incident dated on 10/28/19, reflected that LPN A was educated that any time there is an incident that is out of the ordinary to call the DON and/or Administrator as well as the ADON. Review of the in-services dated on 10/28/19 on staff entering and exiting resident rooms reflected that staff were educated to visually look behind them and face the door being closed to ensure no one was in the doorway of the door they are closing. During an interview on 11/06/19 at 3:45 p.m., CNA A stated she had not received dementia training at this facility and added that she received training years ago at another facility. She stated that if the resident presents any change in behavior it should be reported to the nurses. During an interview on 11/06/19 at 3:55 p.m., CNA B stated that if she observed any resident with dementia and confusion, she redirects them and look for the adequate interventions in the resident's care plan. During an interview by phone on 11/06/19 at 4:52 p.m., LPN A stated that on the evening of 10/27/19 Resident #1 was agitated and her usual self. She stated that she thought that the resident might fall so she took the resident in her wheelchair to the nurse station as she had done that before. She stated that when she was going to provide care in another resident's room, she accidentally closed the door on Resident #1's hand. She stated that before the incident she administered PRN medication to the resident for agitation, but the medication didn't seem to work that night. She stated that the residents with [DIAGNOSES REDACTED].# 1 needed more supervision. She stated that she had to pass medications that evening and that the CNAs were busy with their own work. She stated that the facility has not provided her with any training for residents with dementia and that she relied on her own experiences from past jobs working with resident with Alzheimer's. She stated that the protocol when an incident occurs is to notify the physician, NP, DON, ADM, and FM. She said that the evening of the incident she notified the NP, but she didn't notify the DON or the ADM. She stated that the NP did not ask questions about the incident. She stated that she had to suggest the NP to give the order for an X-ray. She stated that she didn't provide any details about the injury to the NP. During an interview on 11/06/19 at 5:15 p.m., CNA C stated that she hadn't received training for residents with dementia but that she relies on her past experiences working with Alzheimer's residents. She stated that Resident #1 exhibited wandering behaviors when the family would leave the facility and especially during the evening. She stated that they were aware that the resident was constantly following the staff in her wheelchair. During an interview on 11/06/19 at 5:25 p.m., CNA D stated that Resident #1 would get up after her family left the facility and she acted like a different person. She stated the resident constantly wandered around and acted confused. She stated that when the resident presented behaviors, the staff brought her to the nurse station or pushed her wheelchair around the facility to keep an eye on her. During an interview on 11/06/19 at 5:25 p.m., DON stated that the resident came to the facility very confused and having problems adjusting to the facility. She stated that with time the resident's dementia got worse. She said that weeks before the incident, the resident disassembled her air condition. She stated the night of the incident when the resident was agitated, they should have assigned her one-on-one supervision. She said that the X-rays were ordered for the day of the incident but added that mobile X-ray doesn't come to the facility during the evening. She stated that the resident was sent to the hospital because she was notified by the staff that the resident continued to bleed through the night. She stated that LPN A should have notified her about the incident and that LPN A was aware that during that evening Resident #1 was following her. She stated that the facility's staff needs more training. During an interview on 11/06/19 at 7:25 p.m., ADM stated that it was not necessary for LPN A to contact the DON or the ADM since she contacted the NP and the FM. She stated that she expected LPN A to have provided all the details of the resident's incident to the NP. She stated that her expectations from the staff were to keep the residents safe. She stated that she expected the staff to be documenting changes in behaviors and/or interventions on the progress notes, care plan or the incident and accidents report. Review of facility Accident/Incident Reporting Policy dated November 1, 2017, read in part, All incident and accidents involving patients/residents are immediately reported to the departmental or unit supervisor or in his/her absence, the house supervisor. In addition, all serious incidents such as those outlined in guideline #10 are immediately reported to the Administrator and Director of Nursing.

Based on observation, interview, and record review, the facility failed to ensure that residents having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 2 of 7 residents reviewed for pressure sores (Resident #1 and Resident # 2). A. The facility failed to ensure Resident #2 was seen by the wound care physician for areas of redness as ordered on [DATE] and licensed nurses initiated treatments without physician orders or notification when they worsened and/or new areas developed. These areas of redness developed into three Stage IV pressure sores (full thickness loss of skin extending to the bone), one Stage III (full thickness loss of skin) and [MEDICAL CONDITION] of her left lower leg (a bacterial infection of the skin), and the facility had not identified them as of 05/27/15. Resident #2 was admitted to a local hospital on [DATE] for evaluation and was diagnosed with [REDACTED]. B. The facility failed to: complete weekly skin assessments; follow physician orders dated 03/03/15 to be seen by the podiatrist; and follow physician orders for daily targeted skin checks for skin breakdown behind the ears due to oxygen tubing dated 12/13/ 14 for Resident #1. Resident #1 developed two Stage II pressure sores on his buttocks, painful reddened areas behind his ears and a deep tissue injury on his left 2nd toe due to long untrimmed toenails that the facility had not identified until 05/27/15. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/27/15. While the IJ was removed on 06/02/15, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern. This deficient practice could place 69 residents, identified by the facility with moderate to high potential for skin breakdown, at risk for unidentified pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and medications, and pain. The Findings Include: A. Review of a face sheet for Resident #2 reflected she was a [AGE] year old female originally admitted to the facility on [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident #2 dated 03/14/15 reflected the following: -Severe cognitive impairment -Assistance of two persons for transfers and bed mobility -No pressure sores -Preventative measures for skin breakdown -pressure relieving mattress -Always incontinent of urine and bowel Review of a Skin Risk Assessment for Resident #2 dated 04/24/15 reflected a score of 12 indicating at high risk for skin breakdown. Review of physician orders for Resident #2 reflected the following: - 04/14/15 Apply duoderm dressing to left inner great toe and change every 3rd day - 04/14/15 Apply skin prep ( a skin conditioner cream) to left ankle and to right inner great toe each shift - 04/28/15- Wound care to evaluate feet and ankle Review of a care plan for Resident #2 dated 04/01/15 reflected the following: -Start date 10/16/14- Report any signs of skin breakdown (sore, red, tender, or broken area). -Conduct a systematic skin inspection weekly by the licensed nurse and daily by CNAs. Pay particular attention to the bony prominence. -Use barrier cream product to perineal area. -Provide incontinent care after each episode. (Note: there was no interim care plan interventions for the areas of skin breakdown on her feet and ankles originally noted on 04/14/15). Review of the facility ' s Wound Log/Skin Report dated 05/26/15 reflected no documentation of Resident #2's pressure sores. In an interview during initial tour on 05/26/15 at 1:05 pm, LVN G (charge nurse) stated she cared for Resident #2 on a frequent basis and she mainly stayed in bed except for showers, but lately had been requesting bed baths due to increased weakness. LVN G added she thought Resident #2 had a couple of skin tears on her legs, but no pressure sores. In an interview on 05/29/15 at 10:00 am, CNA U stated on 05/27/15 she was giving Resident #2 a bed bath around 9:00 am and noticed the dressings on her toes were wet with yellow and brown drainage and smelled bad , and her leg had no dressing and it looked black and smelled bad too. CNA U further stated she went to inform the charge nurse immediately, LVN G, who told her to put a pad under her (Resident #2) and would get to it later. CNA U stated she later (after lunch) saw LVN G in resident #2's room with the Wound Care Physician and he was scraping one of the wounds. During an interview on 05/27/15 at 1:45 pm, RN A (the corporate regional Clinical Services Director) was informed, by the surveyor, since 9:00 am, requests to observe care and a skin assessment for Resident #2 had been unanswered by staff. RN A stated she needed to inform the surveyor that Resident #2 had a new facility acquired Stage III pressure sore and was seen after lunch by the facility's contracted Wound Care Physician. During an observation on 05/27/15 at 2:00 pm of Resident #2 with LVN G (charge nurse) reflected she was in bed with the following skin conditions : a large open area on the left malleolus (ankle bone) approximately 8 cm in size with drainage and bleeding; the distal portion of the left foot a large area of necrotic tissue (dead tissue that appears black in color) approximately 3 cm x 4 cm and with a large area of red swollen skin/tissue extending from the foot to below the knee; the bony prominence below the left great toe had a large open area with necrotic tissue; right lateral portion of her right leg had an opened pressure sore extending through all layers of the skin, there was blood between her toes on her left foot. During an interview with LVN G (charge nurse) at the time of the observation on 05/27/15 of Resident #2's skin, she stated CNA U had reported to her earlier in the day she was concerned about Resident #2 ' s dressings because they were bleeding and needed changing. LVN G stated she removed the dressings on her left ankle and foot, which were reportedly dated 05/25/15, she did not know Resident #2 had the pressure sores she observed. LVN G stated she had only been assigned to do weekly skin assessments on her shift (6:00 am-2:00 pm) for Resident #2 and not dressing changes; and does not look under dressings as part of her assessment. LVN G went on to say the facility's treatment nurse was no longer employed as of approximately 2 weeks ago and prior to that she (the treatment nurse) had been doing dressing changes and treatments. LVN G added she thought the night shift nurses (10:00 pm-6:00 am) had been doing the treatments and dressing changes since the treatment nurse left. In a telephone interview on 05/28/15 at 10:39 pm, LVN K (night shift charge nurse) stated she had changed Resident #2's dressings a few times since the treatment nurse left and a couple of weeks ago she told LVN F that they were getting worse and needed new orders for a treatment change. LVN K stated she decided to start applying triple antibiotic ointment to the wounds and covering them with duoderm dressings because there wasn ' t an order for [REDACTED].#2, LVN K stated she thought it was her ankle and toes. LVN K added she couldn't remember if she contacted Resident #2's physician or put any information about Resident #2's pressure sores on the 24 hour report or informed the DON. When asked if the facility had protocols for nurses to follow for wound care (i.e. triple antibiotic ointment) she stated no, she was just trying to do something for the resident. Review of a nursing progress note for Resident #2 dated 05/19/15 documented by LVN I (a 10 pm-6 am shift charge nurse) reflected: noted 8.7 cm wound to the left ankle. Previous dressing was soiled with bloody discharge. Site cleansed, TAO (triple antibiotic ointment) applied and a dressing, and made request for wound care physician to see. In a telephone interview on 05/28/15 at 11:00 pm LVN I (night shift charge nurse) stated she thought the last time she cared for Resident #2 was a couple of weeks ago. LVN I recalled she had made a progress note that the treatment needed changing for Resident #2's left ankle and could have possibly made a note on the 24 hour report, but could not remember. LVN I stated she could not remember how or if she communicated that Resident #2 needed to see the wound care physician. LVN I added she applied triple antibiotic ointment and a duoderm dressing to Resident #2's left ankle without an order and stated she thought that was what all of the other nurses were doing. Review of the wound care physician ' s observations of Resident #2 on 05/27/15 dictated to and noted by LVN G dated 05/27/15 reflected the following: Left lateral (ankle) [MEDICAL CONDITION] smells infected. Stage IV measures 4.3 cm x 4.8 cm x .5. 30% yellow drainage and 70% necrotic; Left foot medial and distal infection. Stage IV with pus and 100% necrotic; 2.7 cm x 3.5 cm x .7 cm; right foot Stage IV 1.0 cm x 1.3 cm x ,4 cm. 30% and 70 % granulation ( the process of tissue replacing blood vessels); Right leg lateral Stage III. 1 cm x 1 cm x .5 cm. Recommend I.V. (intravenous) antibiotics. During a telephone interview on 05/28/15 at 8:25 pm LVN E (charge nurse) stated the last time she cared for Resident #2 was on 05/25/15 on the 2:00 pm-10:00 pm shift. LVN E stated she changed Resident #2's dressings and she observed brown drainage and some necrotic tissue on her left foot. LVN E went on to say she applied triple antibiotic ointment after cleaning the wound with wound cleanser and then applied a duoderm dressing. LVN E added she thought triple antibiotic cream and a duoderm was what the physician had ordered. LVN E confirmed that despite finding brown drainage and necrotic tissue she did not notify Resident #2's physician or the DON, and did not document in the progress notes or 24 hour report. LVN E could not recall the last time she did dressing changes for Resident #2 prior to 05/25/15. In a telephone interview on 06/02/15 at 1:14 pm, the facility's contracted Wound Care Physician stated the first time he saw Resident #2 for evaluation of her pressure sores was on 05/27/15 and he found them to be infected and really bad. He stated he recalled there were multiple Stage IV areas and a Stage III and his recommendation was for intravenous antibiotics: and he would not have prescribed triple antibiotic as a treatment for [REDACTED]. In an interview on 05/29/15 at 11:00 am CNA Y stated she typically works the 200 hall (where Resident #2 resided) and the last time she took care of Resident #2 was during the weekend of 05/23/15-05/24/15 and gave Resident #2 a shower on Saturday 05/23/15. CNA Y also stated that Resident #2 had two dressings on her feet and they got a little wet while she was showering her, so she informed LVN F, the 2 pm-10 pm charge nurse, they needed to be changed. CNA Y stated she did not know if the dressings were changed. In an interview on 05/28/15 at 2:39 pm, LVN F (charge nurse) stated she took care of Resident #2 on the 2:00 pm to 10:00 pm shift on Saturday and Sunday 05/23/15-05/24/15 and she did not do any dressing changes on Resident #2. LVN F stated she could not remember being informed by CNA Y that Resident #2's dressings were wet and needed to be changed. LVN F stated since the treatment nurse left in mid- May, 2015 the 10:00 pm - 6:00 am nurses had been doing the dressing changes and treatments because they had more time. When asked if any of the nurses from that shift had reported to her Resident #2's pressure sores were worsening she stated that she could recall a time when LVN K mentioned to her new orders were needed for a treatment change, but she did not know if LVN K contacted the physician for new orders. LVN F added that she had not contacted the physician after being informed by LVN K that a treatment change was needed or put the information on the facility 24 hour report. Review of the facility's 24 hour reports for the 200 Hall for the month of May, 2015 reflected no entries for Resident #2 regarding skin concerns or referrals for the wound care physician. In a telephone interview on 05/28/15 at 4:39 pm, the physician responsible for Resident #2's care in a local hospital stated when she and the emergency room team received Resident #2 on 05/27/15 they were heartbroken by her condition. The physician stated Resident #2's pressure sores appeared infected and in general were severe. The physician added Resident #2 was able to whisper to the emergency room staff she was hungry and hurting, but that was all. The physician went on to say Resident #2 was currently receiving intravenous antibiotics and a MRI completed on 05/28/15 indicated osteo[DIAGNOSES REDACTED], which would require six weeks of antibiotic therapy via a PICC line ( a Peripherally Inserted Central Catheter for long term therapies to avoid repeated intravenous punctures). The physician added in her professional opinion Resident #2's pressure sores and the [DIAGNOSES REDACTED]. In an interview on 05/28/15 at 4:39 pm, the Medical Director stated she received a phone call from the facility in the late afternoon on 05/27/15 regarding Resident #2. It was reported by facility staff Resident #2 had some pressure sores that smelled bad and the wound care physician had recommended intravenous antibiotics to treat them. The Medical Director stated she was going to start Resident #2 on oral antibiotics ([MEDICATION NAME]) and ordered a wound culture until Resident #2's primary care physician could be reached for orders. After reviewing the photos (taken by the surveyor) of Resident #2's pressure sores and the condition of her left leg, she stated osteo[DIAGNOSES REDACTED] was a probably [DIAGNOSES REDACTED]. But based on the information she received verbally from the facility the severity of Resident #2's condition was not reported clearly. In an interview on 05/31/15 at 11:00 am, RN A (the corporate Clinical Services Director) stated since the treatment nurse left employment on 05/15/15 no licensed staff was responsible for measuring and staging pressure sores. RN A added the DON was new to the position (for about 6 weeks) and would assume the responsibilities for staging and measuring pressure sores and ensuring skin assessment and treatments are completed, until a fulltime RN could be hired for the treatment nurse position. RN A stated the facility had not been following corporate guidelines for reviewing new physician orders and nursing/physician progress notes [REDACTED]. B. Review of a face sheet for Resident #1 reflected he was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident #1 dated 04/28/15 reflected the following: - a BIMS score of 14, indicating minimal cognitive impairment -Assistance of two persons for transfers and bed mobility -Incontinent of bowel and an indwelling urinary catheter in place for retention -Upper and Lower extremity impairment -One Stage II pressure sore -Preventative measures- pressure relieving mattress, ointments and non-surgical dressings Review of physician orders for Resident #1 reflected the following: -Focused Skin Assessment bilateral ear folds each shift dated 12/13/14 -Refer for podiatry services 03/03/15 Review of a care plan for Resident #1 dated 01/16/15 reflected: resident at risk for pressure ulcer related to open area to resident's right ear. Resident wears a nasal cannula- pressure from tubing. Goal: Resident ' s skin will remain intact. Approach: Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominence and ears where oxygen tubing rests. Keep clean and dry and minimize moisture. Review of a Pressure Sore Risk assessment for Resident #1 dated 04/22/15 reflected a score of 16 indicating at risk for pressure sores and skin breakdown. (Note: there were no physician orders for the open area in the right ear fold identified on the care plan dated 01/16/15). During an interview on 05/27/15 at 2:00 pm, LVN (charge nurse) stated that after reviewing the weekly skin assessments for Resident #1, the most recent skin assessment date was 05/12/15. LVN F stated the assignment for the weekly skin assessments for Resident #1 is scheduled for Tuesdays on the 6:00 am - 2:00 pm shift. LVN F stated the only explanation she had for the missed skin assessments for Resident #1 was due to work overload and time constraints and it was the hope the next shift would do them. LVN F also stated Resident #1 had no current skin issues, but had a healed spider bite on his left arm. During an observation on 05/27/15 at 2:10 pm of Resident #1's skin with the DON the following was identified: -Two linear open areas on the right buttock in close proximity presenting as Stage II (a partial thickness skin loss) each were approximately 3 centimeter in length and 1 cm in width. -Bilateral redness in the ear folds and Resident #1 expressed pain on the right ear fold -Excoriation of the right groin -Deep tissue injury on the inner aspect of the left foot 2nd toe due to pressure from a long toenail on the adjacent toe that curled inward (note: the DON assessed this as a deep tissue injury) -All toenails were long, thick and yellow During an interview with Resident #1 at the time of observed skin assessment on 05/27/15 he stated the area behind his right ear was painful (where the oxygen tubing rests) and he had never been seen by a podiatrist but he would like to be seen. In an interview on 05/27/15 at 2:30 pm, the DON stated she was not aware Resident #1 had not had a weekly skin assessment since 05/12/15. The DON added she was in the process of ensuring weekly skin assessment were done and would change the assignment days to correspond with residents shower days. Review of the facility ' s Wound Care Policies and Procedures - dated 12/2011 reflected the following: -Subject- Wound Documentation -Policy- Documentation of wounds will be performed consistently using approved forms. Procedures: 1. Documentation about the wound provided valuable information about wound progress or lack of progress. 2. On admission and/or discovery, the clinician initiates the wound documentation process. Subject- Evaluations of wounds will be performed on admission, weekly, and on discovery. Objective evaluation components include: Location, Measurements, appearance, Drainage, Odor, Presence of tunneling, Healing, Stage and date of onset if a pressure sore and pain. Resources: National Pressure Ulcer Advisor Panel (PUPA) The facility Administrator, Regional Clinical Services Director, and the DON were notified on 03/27/15 at 3:43 pm that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 05/27/15 at 5:40 pm. The final Plan of Removal was accepted by the survey team on 05/28/15 at 5:45 pm. The Plan of Removal reflected the following: Issues Identified: Failure to identify, communicate and perform an assessment for new and existing pressures ulcers including failure to complete weekly skin assessments, complete ordered treatments, and follow physician orders. 1. Resident #2 ' s physician and responsible party were notified and resident sent to hospital for further evaluation and treatment. Resident #1's physician and responsible party were notified and orders treatment orders were obtained from the physician. Resident # 1's care plan was updated to reflect his current condition. The resident ' s wounds were measured by the Director of Nursing and entered on to the facility wound log for evaluating and tracking. 2. Residents who are found to have a pressure ulcer will have physician and responsible party notification completed by the licensed nurse. The Director of Nursing/RN designee will complete a Skin Assessment, measure and stage the wound(s) and add the resident to the weekly wound log for tracking. A care plan will be formulated by the RN at this time. 3. All facility residents will have a full Skin Evaluation completed by licensed nursing staff by 05/29/15. The Director of Nursing/RN Designee will review the Skin Evaluations and formulate a plan of care based on the findings. Residents identified as high risk will have a Skin Evaluation completed by midnight 05/28/15. 4. Licensed nurses will be re-educated by the Director of Nursing/Clinical Services Director beginning on 05/27/15 and completed by 05/29/15 for all regular staff nurses. {PRN (as needed) will not be receive this education will not be allowed to perform wound care until the education is completed.} Staff Nurses: (Names of 17 licensed nursing staff to be educated were listed here). Education to include: a. Facility policy and procedures for completing weekly skin assessments b. Identification of pressure sores c. Timely notification to the physician, responsible party and Director of Nursing d. Communication of new pressure ulcers and treatments to the Director of Nursing, staff nurses and the facility wound nurse e. Following physician orders f. Nursing assessments for pressure ulcers g. Education of RNs on staging of wounds 5. Residents identified as having a Braden score of 18 or less will have a Skin Risk Analysis/Assessment completed by a RN and an at risk care plan will be formulated. Residents at risk will also have a daily skin check completed by the CNA ' s on the Point of Care (electronic data entry system).CNA ' s will receive re-education by the Director of Nursing/Designee on skin checks to begin 05/28/15 and completed by 05/30/15. 6.All facility residents will be assigned a day/shift for (weekly) skin assessment completion. This will be audited and completed by 05/29/15. New admissions will be assigned a day/shift for a Skin Assessment to be completed by the RN or LVN. Any skin abnormalities identified will be added to the 24 hour report and a progress note written. The Director of Nursing/RN Designee will review the 24 hour report in the morning clinical meeting for further assessment needs. 7. The Director of Nursing/RN Designee will complete a skin assessment on all new admissions and re-admissions and formulate a care plan. The weekend RN will be responsible for new admissions on the weekends and the Director of Nursing/RN Designee will stay after hours for new admissions and complete the assessment. 8. The Director of Nursing/Designee will review all skin assessments weekly for 60 days. Issues identified will be corrected immediately. Trends will be reviewed in the monthly Quality Assurance Performance Improvement meeting. 9. Full facility skin sweeps with assessments will be completely quarterly for 12 months and results reported in the monthly Quality Assurance and Performance Improvement meeting. The survey team monitored the current plan of removal as follows: Licensed staff were interviewed/questioned and their answers demonstrated them to be knowledgeable of the content of the training/in-services for the Plan of Removal regarding: documentation of skin assessments in the nursing progress notes per policy, documentation of changes in wounds or identification of new wounds in the progress notes and the 24 hour report to include notification of the physician and any new orders received; their responsibility of following up on CNA findings written in the CNA Communication Book located at each hall; reporting off to the CNAs at shift change any residents with changes in skin conditions and who require dressings/treatments; transcribing orders for referrals to the Wound Care Physician and ensuring they are completed and the resident is scheduled to be seen; treatment of [REDACTED]. CNAs were interviewed/questioned and their answers demonstrated them to be knowledgeable of the content of the training/in-services for the Plan of Removal regarding: Documentation of any resident skin concerns in the CNA Communication Book located on each hall as well as verbal notification to the charge nurse; if the charge nurse informed of a resident concern does not follow up then the CNA will inform the DON or administrator; documentation each shift in the electronic Point of Care system of any resident skin concerns; procedure when a resident's dressing is missing or in need of being changed; expectation that licensed staff will report to the any residents with skin treatments or changes. On 06/02/15 at 3:52 pm, the Administrator, Regional Clinical Services Director and the DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON provided a list of 69 residents at risk for pressure sores.

Based on interview and record review the facility failed to be administered in a manner that enabled it to use its resources in an effective and efficient manner in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 7 residents reviewed for pressure sores (Residents # 1 and #2). A. The DON failed to supervise and monitor licensed staff to ensure residents were receiving weekly skin assessments, treatments for pressure sores according to physician orders, and pressure sore measurements and staging, were completed on a weekly basis. B. The Administrator and DON failed to implement their wound care policies and procedures and implement processes for the content of the daily management meetings; and RN A (the Clinical Services Director failed to supervise the DON and ensure a designated person was assigned to provide wound care. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/27/15. While the IJ was removed on 06/02/15, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern. This deficient practice could place 69 residents identified by the facility with moderate to high potential for skin breakdown at risk for unidentified pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and medications, and pain. The Findings Include: A. 1) Review of a face sheet for Resident #2 reflected she was a [AGE] year old female originally admitted to the facility on [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident #2 dated 03/14/15 reflected the following: -Severe cognitive impairment -Assistance of two persons for transfers and bed mobility -No pressure sores -Preventative measures for skin breakdown -pressure relieving mattress -Always incontinent of urine and bowel Review of a Skin Risk Assessment for Resident #2 dated 04/24/15 reflected a score of 12 indicating at high risk for skin breakdown. Review of physician orders for Resident #2 reflected the following: - 04/14/15 Apply duoderm dressing to left inner great toe and change every 3rd day - 04/14/15 Apply skin prep ( a skin conditioner cream) to left ankle and to right inner great toe each shift - 04/28/15- Wound care to evaluate feet and ankle Review of a care plan for Resident #2 dated 04/01/15 reflected the following: -Start date 10/16/14- Report any signs of skin breakdown (sore, red, tender, or broken area). -Conduct a systematic skin inspection weekly by the licensed nurse and daily by CNAs. Pay particular attention to the bony prominence. -Use barrier cream product to perineal area. -Provide incontinent care after each episode. (Note: there was no interim care plan interventions for the areas of skin breakdown on her feet and ankles originally noted on 04/14/15). Review of the facility ' s Wound Log/Skin Report dated 05/26/15 reflected no documentation of Resident #2's pressure sores. In an interview during initial tour on 05/26/15 at 1:05 pm, LVN G (charge nurse) stated she cared for Resident #2 on a frequent basis and she mainly stayed in bed except for showers, but lately had been requesting bed baths due to increased weakness. LVN G added she thought Resident #2 had a couple of skin tears on her legs, but no pressure sores. In an interview on 05/29/15 at 10:00 am, CNA U stated on 05/27/15 she was giving Resident #2 a bed bath around 9:00 am and noticed the dressings on her toes were wet with yellow and brown drainage and smelled bad , and her leg had no dressing and it looked black and smelled bad too. CNA U further stated she went to inform the charge nurse immediately, LVN G, who told her to put a pad under her (Resident #2) and would get to it later. CNA U stated she later (after lunch) saw LVN G in resident #2's room with the Wound Care Physician and he was scraping one of the wounds. During an interview on 05/27/15 at 1:45 pm, RN A (the corporate regional Clinical Services Director) was informed, by the surveyor, since 9:00 am, requests to observe care and a skin assessment for Resident #2 had been unanswered by staff. RN A stated she needed to inform the surveyor that Resident #2 had a new facility acquired Stage III pressure sore and was seen after lunch by the facility's contracted Wound Care Physician. During an observation on 05/27/15 at 2:00 pm of Resident #2 with LVN G (charge nurse) reflected she was in bed with the following skin conditions : a large open area on the left malleolus (ankle bone) approximately 8 cm in size with drainage and bleeding; the distal portion of the left foot a large area of necrotic tissue (dead tissue that appears black in color) approximately 3 cm x 4 cm and with a large area of red swollen skin/tissue extending from the foot to below the knee; the bony prominence below the left great toe had a large open area with necrotic tissue; right lateral portion of her right leg had an opened pressure sore extending through all layers of the skin, there was blood between her toes on her left foot. During an interview with LVN G (charge nurse) at the time of the observation on 05/27/15 of Resident #2's skin, she stated CNA U had reported to her earlier in the day she was concerned about Resident #2 ' s dressings because they were bleeding and needed changing LVN G stated she removed the dressings on her left ankle and foot, which were reportedly dated 05/25/15, she did not know Resident #2 had the pressure sores she observed. LVN G stated she had only been assigned to do weekly skin assessments on her shift (6:00 am-2:00 pm) for Resident #2 and not dressing changes; and does not look under dressings as part of her assessment. LVN G went on to say the facility's treatment nurse was no longer employed as of approximately 2 weeks ago and prior to that she (the treatment nurse) had been doing dressing changes and treatments. LVN G added she thought the night shift nurses (10:00 pm-6:00 am) had been doing the treatments and dressing changes since the treatment nurse left. In a telephone interview on 05/28/15 at 10:39 pm, LVN K (night shift charge nurse) stated she had changed Resident #2's dressings a few times since the treatment nurse left and a couple of weeks ago she told LVN F that they were getting worse and needed new orders for a treatment change. LVN K stated she decided to start applying triple antibiotic ointment to the wounds and covering them with duoderm dressings because there wasn ' t an order for [REDACTED].#2, LVN K stated she thought it was her ankle and toes. LVN K added she couldn't remember if she contacted Resident #2's physician or put any information about Resident #2's pressure sores on the 24 hour report or informed the DON. When asked if the facility had protocols for nurses to follow for wound care (i.e. triple antibiotic ointment) she stated no, she was just trying to do something for the resident. Review of a nursing progress note for Resident #2 dated 05/19/15 documented by LVN I (a 10 pm-6 am shift charge nurse) reflected: noted 8.7 cm wound to the left ankle. Previous dressing was soiled with bloody discharge. Site cleansed, TAO (triple antibiotic ointment) applied and a dressing, and made request for wound care physician to see. In a telephone interview on 05/28/15 at 11:00 pm LVN I (night shift charge nurse) stated she thought the last time she cared for Resident #2 was a couple of weeks ago. LVN I recalled she had made a progress note that the treatment needed changing for Resident #2's left ankle and could have possibly made a note on the 24 hour report, but could not remember. LVN I stated she could not remember how or if she communicated that Resident #2 needed to see the wound care physician. LVN I added she applied triple antibiotic ointment and a duoderm dressing to Resident #2's left ankle without an order and stated she thought that was what all of the other nurses were doing. Review of the wound care physician ' s observations of Resident #2 on 05/27/15 dictated to and noted by LVN G dated 05/27/15 reflected the following: Left lateral (ankle) [MEDICAL CONDITION] smells infected. Stage IV measures 4.3 cm x 4.8 cm x .5. 30% yellow drainage and 70% necrotic; Left foot medial and distal infection. Stage IV with pus and 100% necrotic; 2.7 cm x 3.5 cm x .7 cm; right foot Stage IV 1.0 cm x 1.3 cm x ,4 cm. 30% and 70 % granulation ( the process of tissue replacing blood vessels); Right leg lateral Stage III. 1 cm x 1 cm x .5 cm. Recommend I.V. (intravenous) antibiotics. During a telephone interview on 05/28/15 at 8:25 pm LVN E (charge nurse) stated the last time she cared for Resident #2 was on 05/25/15 on the 2:00 pm-10:00 pm shift. LVN E stated she changed Resident #2's dressings and she observed brown drainage and some necrotic tissue on her left foot. LVN E went on to say she applied triple antibiotic ointment after cleaning the wound with wound cleanser and then applied a duoderm dressing. LVN E added she thought triple antibiotic cream and a duoderm was what the physician had ordered. LVN E confirmed that despite finding brown drainage and necrotic tissue she did not notify Resident #2's physician or the DON, and did not document in the progress notes or 24 hour report. LVN E could not recall the last time she did dressing changes for Resident #2 prior to 05/25/15. In a telephone interview on 06/02/15 at 1:14 pm, the facility's contracted Wound Care Physician stated the first time he saw Resident #2 for evaluation of her pressure sores was on 05/27/15 and he found them to be infected and really bad. He stated he recalled there were multiple Stage IV areas and a Stage III and his recommendation was for intravenous antibiotics: and he would not have prescribed triple antibiotic as a treatment for [REDACTED]. In an interview on 05/29/15 at 11:00 am CNA Y stated she typically works the 200 hall (where Resident #2 resided) and the last time she took care of Resident #2 was during the weekend of 05/23/15-05/24/15 and gave Resident #2 a shower on Saturday 05/23/15. CNA Y also stated that Resident #2 had two dressings on her feet and they got a little wet while she was showering her, so she informed LVN F, the 2 pm-10 pm charge nurse, they needed to be changed. CNA Y stated she did not know if the dressings were changed. In an interview on 05/28/15 at 2:39 pm, LVN F (charge nurse) stated she took care of Resident #2 on the 2:00 pm to 10:00 pm shift on Saturday and Sunday 05/23/15-05/24/15 and she did not do any dressing changes on Resident #2. LVN F stated she could not remember being informed by CNA Y that Resident #2's dressings were wet and needed to be changed. LVN F stated since the treatment nurse left in mid- May, 2015 the 10:00 pm - 6:00 am nurses had been doing the dressing changes and treatments because they had more time. When asked if any of the nurses from that shift had reported to her Resident #2's pressure sores were worsening she stated that she could recall a time when LVN K mentioned to her new orders were needed for a treatment change, but she did not know if LVN K contacted the physician for new orders. LVN F added that she had not contacted the physician after being informed by LVN K that a treatment change was needed or put the information on the facility 24 hour report. Review of the facility's 24 hour reports for the 200 Hall for the month of May, 2015 reflected no entries for Resident #2 regarding skin concerns or referrals for the wound care physician. In a telephone interview on 05/28/15 at 4:39 pm, the physician responsible for Resident #2's care in a local hospital stated when she and the emergency room team received Resident #2 on 05/27/15 they were heartbroken by her condition. The physician stated Resident #2's pressure sores appeared infected and in general were severe. The physician added Resident #2 was able to whisper to the emergency room staff she was hungry and hurting, but that was all. The physician went on to say Resident #2 was currently receiving intravenous antibiotics and a MRI completed on 05/28/15 indicated osteo[DIAGNOSES REDACTED], which would require six weeks of antibiotic therapy via a PICC line ( a Peripherally Inserted Central Catheter for long term therapies to avoid repeated intravenous punctures). The physician added in her professional opinion Resident #2's pressure sores and the [DIAGNOSES REDACTED]. In an interview on 05/28/15 at 4:39 pm, the Medical Director stated she received a phone call from the facility in the late afternoon on 05/27/15 regarding Resident #2. It was reported by facility staff Resident #2 had some pressure sores that smelled bad and the wound care physician had recommended intravenous antibiotics to treat them. The Medical Director stated she was going to start Resident #2 on oral antibiotics ([MEDICATION NAME]) and ordered a wound culture until Resident #2's primary care physician could be reached for orders. After reviewing the photos (taken by the surveyor) of Resident #2's pressure sores and the condition of her left leg, she stated osteo[DIAGNOSES REDACTED] was a probably [DIAGNOSES REDACTED]. But based on the information she received verbally from the facility the severity of Resident #2's condition was not reported clearly. In an interview on 05/31/15 at 11:00 am, RN A (the corporate Clinical Services Director) stated since the treatment nurse left employment on 05/15/15 no licensed staff was responsible for measuring and staging pressure sores. RN A added the DON was new to the position (for about 6 weeks) and would assume the responsibilities for staging and measuring pressure sores and ensuring skin assessment and treatments are completed, until a fulltime RN could be hired for the treatment nurse position. RN A stated the facility had not been following corporate guidelines for reviewing new physician orders and nursing/physician progress notes [REDACTED]. 2.) Review of a face sheet for Resident #1 reflected he was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident #1 dated 04/28/15 reflected the following: - a BIMS score of 14, indicating minimal cognitive impairment -Assistance of two persons for transfers and bed mobility -Incontinent of bowel and an indwelling urinary catheter in place for retention -Upper and Lower extremity impairment -One Stage II pressure sore -Preventative measures- pressure relieving mattress, ointments and non-surgical dressings Review of physician orders for Resident #1 reflected the following: -Focused Skin Assessment bilateral ear folds each shift dated 12/13/14 -Refer for podiatry services 03/03/15 Review of a care plan for Resident #1 dated 01/16/15 reflected: resident at risk for pressure ulcer related to open area to resident's right ear. Resident wears a nasal cannula- pressure from tubing. Goal: Resident ' s skin will remain intact. Approach: Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominence and ears where oxygen tubing rests. Keep clean and dry and minimize moisture. Review of a Pressure Sore Risk assessment for Resident #1 dated 04/22/15 reflected a score of 16 indicating at risk for pressure sores and skin breakdown. (Note: there were no physician orders for the open area in the right ear fold identified on the care plan dated 01/16/15). During an interview on 05/27/15 at 2:00 pm, LVN (charge nurse) stated that after reviewing the weekly skin assessments for Resident #1, the most recent skin assessment date was 05/12/15. LVN F stated the assignment for the weekly skin assessments for Resident #1 is scheduled for Tuesdays on the 6:00 am - 2:00 pm shift. LVN F stated the only explanation she had for the missed skin assessments for Resident #1 was due to work overload and time constraints and it was the hope the next shift would do them. LVN F also stated Resident #1 had no current skin issues, but had a healed spider bite on his left arm. During an observation on 05/27/15 at 2:10 pm of Resident #1's skin with the DON the following was identified: -Two linear open areas on the right buttock in close proximity presenting as Stage II (a partial thickness skin loss) each were approximately 3 centimeter in length and 1 cm in width. -Bilateral redness in the ear folds and Resident #1 expressed pain on the right ear fold -Excoriation of the right groin -Deep tissue injury on the inner aspect of the left foot 2nd toe due to pressure from a long toenail on the adjacent toe that curled inward (note: the DON assessed this as a deep tissue injury) -All toenails were long, thick and yellow During an interview with Resident #1 at the time of observed skin assessment on 05/27/15 he stated the area behind his right ear was painful (where the oxygen tubing rests) and he had never been seen by a podiatrist but he would like to be seen. In an interview on 05/27/15 at 2:30 pm, the DON stated she was not aware Resident #1 had not had a weekly skin assessment since 05/12/15. The DON added she was in the process of ensuring weekly skin assessment were done and would change the assignment days to correspond with residents shower days. B. In an interview on 05/31/15 at 11:00 am, RN A (the corporate Clinical Services Director) stated since the treatment nurse left employment on 05/15/15 no licensed staff was responsible for measuring and staging pressure sores. RN A added the DON was new to the position (for about 6 weeks) and would assume the responsibilities for staging and measuring pressure sores and ensuring skin assessments and treatments are completed; until a fulltime RN could be hired for the treatment nurse position. RN A stated the facility had not been following corporate guidelines for reviewing new physician orders and nursing/physician progress notes [REDACTED]. Interview on 6/2/15 at 2:05 PM the Administrator stated the facility did not have a treatment nurse when he started (approximately one month prior to 05/26/15 survey team entry) and they were working on hiring a treatment nurse. Record review of facility 24 hour nurses ' reports from 05/01/15 through 05/27/15 reflected no documentation regarding Resident #2 or Resident #1 changes in skin conditions. In an interview on 05/28/15 at 4:39 pm, the Medical Director stated she became the medical director in 09/2013 and since that time, she thought, there had been five DONs previously employed and numerous treatment nurses. The Medical Director stated she is the physician of record for 80 of the current 83 residents in the facility. The Medical Director went onto say she implemented a communication book for licensed staff to utilize for non-emergent matters, but otherwise she, the physician on call or the nurse practitioners were available 24 hours a day 7 days a week by phone. The Medical Director also stated she created a binder to keep all new written physician orders (prior to being added/transcribed into the electronic medical record) to help maintain continuity of the orders and it is specifically for her residents. Review of the physician orders binder revealed a physician order for [REDACTED]. In an interview with the DON on 05/28/15 at 5:30 pm, she stated no one was assigned to review the physician orders in the binder. Review of the facility's Wound Care Policies and Procedures - dated 12/2011 reflected the following: -Subject- Wound Documentation -Policy- Documentation of wounds will be performed consistently using approved forms. Procedures: 1. Documentation about the wound provided valuable information about wound progress or lack of progress. 2. On admission and/or discovery, the clinician initiates the wound documentation process. Subject- Evaluations of wounds will be performed on admission, weekly, and on discovery. Objective evaluation components include: Location, Measurements, appearance, Drainage, Odor, Presence of tunneling, Healing, Stage and date of onset if a pressure sore and pain. Resources: National Pressure Ulcer Advisor Panel (PUPA) The facility Administrator, Regional Clinical Services Director, and the DON were notified on 03/27/15 at 3:43 pm that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 05/27/15 at 5:40 pm. The final Plan of Removal was accepted by the survey team on 05/28/15 at 5:45 pm. The Plan of Removal reflected the following: Issues Identified: Failure to identify, communicate and perform an assessment for new and existing pressures ulcers including failure to complete weekly skin assessments, complete ordered treatments, and follow physician orders. 1. Resident #2's physician and responsible party were notified and resident sent to hospital for further evaluation and treatment. Resident #1's physician and responsible party were notified and orders treatment orders were obtained from the physician. Resident # 1's care plan was updated to reflect his current condition. The resident's wounds were measured by the Director of Nursing and entered on to the facility wound log for evaluating and tracking. 2. Residents who are found to have a pressure ulcer will have physician and responsible party notification completed by the licensed nurse. The Director of Nursing/RN designee will complete a Skin Assessment, measure and stage the wound(s) and add the resident to the weekly wound log for tracking. A care plan will be formulated by the RN at this time. 3. All facility residents will have a full Skin Evaluation completed by licensed nursing staff by 05/29/15. The Director of Nursing/RN Designee will review the Skin Evaluations and formulate a plan of care based on the findings. Residents identified as high risk will have a Skin Evaluation completed by midnight 05/28/15. 4. Licensed nurses will be re-educated by the Director of Nursing/Clinical Services Director beginning on 05/27/15 and completed by 05/29/15 for all regular staff nurses. {PRN (as needed) will not be receive this education will not be allowed to perform wound care until the education is completed.} Staff Nurses: (Names of 17 licensed nursing staff to be educated were listed here). Education to include: a. Facility policy and procedures for completing weekly skin assessments b. Identification of pressure sores c. Timely notification to the physician, responsible party and Director of Nursing d. Communication of new pressure ulcers and treatments to the Director of Nursing, staff nurses and the facility wound nurse e. Following physician orders f. Nursing assessments for pressure ulcers g. Education of RNs on staging of wounds 5. Residents identified as having a Braden score of 18 or less will have a Skin Risk Analysis/Assessment completed by a RN and an at risk care plan will be formulated. Residents at risk will also have a daily skin check completed by the CNA ' s on the Point of Care (electronic data entry system).CNA ' s will receive re-education by the Director of Nursing/Designee on skin checks to begin 05/28/15 and completed by 05/30/15. 6.All facility residents will be assigned a day/shift for (weekly) skin assessment completion. This will be audited and completed by 05/29/15. New admissions will be assigned a day/shift for a Skin Assessment to be completed by the RN or LVN. Any skin abnormalities identified will be added to the 24 hour report and a progress note written. The Director of Nursing/RN Designee will review the 24 hour report in the morning clinical meeting for further assessment needs. 7. The Director of Nursing/RN Designee will complete a skin assessment on all new admissions and re-admissions and formulate a care plan. The weekend RN will be responsible for new admissions on the weekends and the Director of Nursing/RN Designee will stay after hours for new admissions and complete the assessment. 8. The Director of Nursing/Designee will review all skin assessments weekly for 60 days. Issues identified will be corrected immediately. Trends will be reviewed in the monthly Quality Assurance Performance Improvement meeting. 9. Full facility skin sweeps with assessments will be completely quarterly for 12 months and results reported in the monthly Quality Assurance and Performance Improvement meeting. The survey team monitored the current plan of removal as follows: Licensed staff were interviewed and their answers demonstrated them to be knowledgeable of the content of the training/in-services for the Plan of Removal regarding: documentation of skin assessments in the nursing progress notes per policy, documentation of changes in wounds or identification of new wounds in the progress notes and the 24 hour report to include notification of the physician and any new orders received; their responsibility of following up on CNA findings written in the CNA Communication Book located at each hall; reporting off to the CNAs at shift change any residents with changes in skin conditions and who require dressings/treatments; transcribing orders for referrals to the Wound Care Physician and ensuring they are completed and the resident is scheduled to be seen; treatment of [REDACTED]. CNAs were interviewed/questioned and their answers demonstrated them to be knowledgeable of the content of the training/in-services for the Plan of Removal regarding: Documentation of any resident skin concerns in the CNA Communication Book located on each hall as well as verbal notification to the charge nurse; if the charge nurse informed of a resident concern does not follow up then the CNA will inform the DON or administrator; documentation each shift in the electronic Point of Care system of any resident skin concerns; procedure when a resident's dressing is missing or in need of being changed; expectation that licensed staff will report to the any residents with skin treatments or changes. On 06/02/15 at 3:52 pm, the Administrator, Regional Clinical Services Director and the DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immedate jeopardy with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON provided a list of 69 residents at risk for pressure sores.

Based on observation, interview, and record review, the facility failed to ensure services by the facility meet professional standards of quality for 2 of 7 residents reviewed for pressure sores (Resident #2). -LVN E, LVN K, and LVN I failed to obtain physician orders [REDACTED]. - LVN E, LVN F , LVN G. LVN K, and LVN I recognized and/or discussed amongst themselves Resident #2's pressure sores were worsening and failed to consult with the physician or notify the DON of the changes. Resident #2 developed three Stage IV pressure sores (full thickness loss of skin extending to the bone), one Stage III (full thickness loss of skin) and [MEDICAL CONDITION] of her left lower leg (a bacterial infection of the skin). Resident #2 was admitted to a local hospital on [DATE] for evaluation and was diagnosed with [REDACTED]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/27/15. While the IJ was removed on 06/02/15, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern. This deficient practice could place 69 residents identified by the facility with moderate to high potential for skin breakdown at risk for unidentified pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and medications, and pain. The Findings Include: Sec. 301.002. Texas Board of Nurse Examiners Licensed Vocational Nurse Scope of Practice (5) Vocational nursing means a directed scope of nursing practice, including the performance of an act that requires specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing. The term does not include acts of medical [DIAGNOSES REDACTED]. Vocational nursing involves: (A) collecting data and performing focused nursing assessments of the health status of an individual; (B) participating in the planning of the nursing care needs of an individual; (C) participating in the development and modification of the nursing care plan; (D) participating in health teaching and counseling to promote, attain, and maintain the optimum health level of an individual; (E) assisting in the evaluation of an individual ' s response to a nursing intervention and the identification of an individual ' s needs; and (F) engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse ' s experience, continuing education, and demonstrated competency. Review of a face sheet for Resident #2 reflected she was a [AGE] year old female originally admitted to the facility on [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident #2 dated 03/14/15 reflected the following: -Severe cognitive impairment -Assistance of two persons for transfers and bed mobility -No pressure sores -Preventative measures for skin breakdown -pressure relieving mattress -Always incontinent of urine and bowel Review of a Skin Risk Assessment for Resident #2 dated 04/24/15 reflected a score of 12 indicating at high risk for skin breakdown. Review of physician orders [REDACTED]. - 04/14/15 Apply duoderm dressing to left inner great toe and change every 3rd day - 04/14/15 Apply skin prep ( a skin conditioner cream) to left ankle and to right inner great toe each shift - 04/28/15- Wound care to evaluate feet and ankle Review of a care plan for Resident #2 dated 04/01/15 reflected the following: -Start date 10/16/14- Report any signs of skin breakdown (sore, red, tender, or broken area). -Conduct a systematic skin inspection weekly by the licensed nurse and daily by CNAs. Pay particular attention to the bony prominence. -Use barrier cream product to perineal area. -Provide incontinent care after each episode. (Note: there was no interim care plan interventions for the areas of skin breakdown on her feet and ankles originally noted on 04/14/15). Review of the facility ' s Wound Log/Skin Report dated 05/26/15 reflected no documentation of Resident #2's pressure sores. In an interview during initial tour on 05/26/15 at 1:05 pm, LVN G (charge nurse) stated she cared for Resident #2 on a frequent basis and she mainly stayed in bed except for showers, but lately had been requesting bed baths due to increase weakness. LVN G added she thought Resident #2 had a couple of skin tears on her legs, but no pressure sores. In an interview on 05/29/15 at 10:00 am, CNA U stated on 05/27/15 she was giving Resident #2 a bed bath around 9:00 am and noticed the dressings on her toes were wet with yellow and brown drainage and smelled bad , and her leg had no dressing and it looked black and smelled bad too. CNA U further stated she went to inform the charge nurse immediately, LVN G, who told her to put a pad under her (Resident #2) and would get to it later. CNA U stated she later (after lunch) saw LVN G in resident #2's room with the Wound Care Physician and he was scraping one of the wounds. During an interview on 05/27/15 at 1:45 pm, RN A (the corporate regional Clinical Services Director) was informed by the surveyor, since 9:00 am, requests to observe care and a skin assessment for Resident #2 had been unanswered by staff. RN A stated she needed to inform the surveyor that Resident #2 had a new facility acquired Stage III pressure sore and was seen after lunch by the facility's contracted Wound Care Physician. During an observation on 05/27/15 at 2:00 pm of Resident #2 with LVN G (charge nurse) reflected she was in bed with the following skin conditions : a large open area on the left malleolus (ankle bone) approximately 8 cm in size with drainage and bleeding; the distal portion of the left foot a large area of necrotic tissue (dead tissue that appears black in color) approximately 3 cm x 4 cm and with a large area of red swollen skin/tissue extending from the foot to below the knee; the bony prominence below the left great toe had a large open area with necrotic tissue; right lateral portion of her right leg had an opened pressure sore extending through all layers of the skin, there was blood between her toes on her left foot. During an interview with LVN G (charge nurse) at the time of the observation on 05/27/15 of Resident #2's skin, she stated CNA U had reported to her earlier in the day she was concerned about Resident #2's dressings because they were bleeding and needed changing LVN G stated she removed the dressings on her left ankle and foot, which were reportedly dated 05/25/15, she did not know Resident #2 had the pressure sores she observed. LVN G stated she had only been assigned to do weekly skin assessments on her shift (6:00 am-2:00 pm) for Resident #2 and not dressing changes; and does not look under dressings as part of her assessment. LVN G went on to say the facility's treatment nurse was no longer employed as of approximately 2 weeks ago and prior to that she (the treatment nurse) had been doing dressing changes and treatments. LVN G added she thought the night shift nurses (10:00 pm-6:00 am) had been doing the treatments and dressing changes since the treatment nurse left. In a telephone interview on 05/28/15 at 10:39 pm, LVN K (night shift charge nurse) stated she had changed Resident #2's dressings a few times since the treatment nurse left and a couple of weeks ago she told LVN F that they were getting worse and needed new orders for a treatment change. LVN K stated she decided to start applying triple antibiotic ointment to the wounds and covering them with duoderm dressings because there wasn ' t an order for [REDACTED].#2, LVN K stated she thought it was her ankle and toes. LVN K added she couldn't remember if she contacted Resident #2's physician or put any information about Resident #2's pressure sores on the 24 hour report or informed the DON. When asked if the facility had protocols for nurses to follow for wound care (i.e. triple antibiotic ointment) she stated no, she was just trying to do something for the resident. Review of a nursing progress note for Resident #2 dated 05/19/15 documented by LVN I (a 10 pm-6 am shift charge nurse) reflected: noted 8.7 cm wound to the left ankle. Previous dressing was soiled with bloody discharge. Site cleansed, TAO (triple antibiotic ointment) applied and a dressing, and made request for wound care physician to see. In a telephone interview on 05/28/15 at 11:00 pm LVN I (night shift charge nurse) stated she thought the last time she cared for Resident #2 was a couple of weeks ago. LVN I recalled she had made a progress note that the treatment needed changing for Resident #2's left ankle and could have possibly made a note on the 24 hour report, but could not remember. LVN I stated she could not remember how or if she communicated that Resident #2 needed to see the wound care physician. LVN I added she applied triple antibiotic ointment and a duoderm dressing to Resident #2's left ankle without an order and stated she thought that was what all of the other nurses were doing. Review of the wound care physician ' s observations of Resident #2 on 05/27/15 dictated to and noted by LVN G dated 05/27/15 reflected the following: Left lateral (ankle) [MEDICAL CONDITION] smells infected. Stage IV measures 4.3 cm x 4.8 cm x .5. 30% yellow drainage and 70% necrotic; Left foot medial and distal infection. Stage IV with pus and 100% necrotic; 2.7 cm x 3.5 cm x .7 cm; right foot Stage IV 1.0 cm x 1.3 cm x ,4 cm. 30% and 70 % granulation ( the process of tissue replacing blood vessels); Right leg lateral Stage III. 1 cm x 1 cm x .5 cm. Recommend I.V. (intravenous) antibiotics. During a telephone interview on 05/28/15 at 8:25 pm LVN E (charge nurse) stated the last time she cared for Resident #2 was on 05/25/15 on the 2:00 pm-10:00 pm shift. LVN E stated she changed Resident #2's dressings and she observed brown drainage and some necrotic tissue on her left foot. LVN E went on to say she applied triple antibiotic ointment after cleaning the wound with wound cleanser and then applied a duoderm dressing. LVN E added she thought triple antibiotic cream and a duoderm was what the physician had ordered. LVN E confirmed that despite finding brown drainage and necrotic tissue she did not notify Resident #2's physician or the DON, and did not document in the progress notes or 24 hour report. LVN E could not recall the last time she did dressing changes for Resident #2 prior to 05/25/15. In a telephone interview on 06/02/15 at 1:14 pm, the facility's contracted Wound Care Physician stated the first time he saw Resident #2 for evaluation of her pressure sores was on 05/27/15 and he found them to be infected and really bad. He stated he recalled there were multiple Stage IV areas and a Stage III and his recommendation was for intravenous antibiotics: and he would not have prescribed triple antibiotic as a treatment for [REDACTED]. In an interview on 05/29/15 at 11:00 am CNA Y stated she typically works the 200 hall (where Resident #2 resided) and the last time she took care of Resident #2 was during the weekend of 05/23/15-05/24/15 and gave Resident #2 a shower on Saturday 05/23/15. CNA Y also stated that Resident #2 had two dressings on her feet and they got a little wet while she was showering her, so she informed LVN F, the 2 pm-10 pm charge nurse, they needed to be changed. CNA Y stated she did not know if the dressings were changed. In an interview on 05/28/15 at 2:39 pm, LVN F (charge nurse) stated she took care of Resident #2 on the 2:00 pm to 10:00 pm shift on Saturday and Sunday 05/23/15-05/24/15 and she did not do any dressing changes on Resident #2. LVN F stated she could not remember being informed by CNA Y that Resident #2's dressings were wet and needed to be changed. LVN F stated since the treatment nurse left in mid- May, 2015 the 10:00 pm - 6:00 am nurses had been doing the dressing changes and treatments because they had more time. When asked if any of the nurses from that shift had reported to her Resident #2's pressure sores were worsening she stated that she could recall a time when LVN K mentioned to her new orders were needed for a treatment change, but she did not know if LVN K contacted the physician for new orders. LVN F added that she had not contacted the physician after being informed by LVN K that a treatment change was needed or put the information on the facility 24 hour report. Review of the facility's 24 hour reports for the 200 Hall for the month of May, 2015 reflected no entries for Resident #2 regarding skin concerns or referrals for the wound care physician. In a telephone interview on 05/28/15 at 4:39 pm, the physician responsible for Resident #2's care in a local hospital stated when she and the emergency room team received Resident #2 on 05/27/15 they were heartbroken by her condition. The physician stated Resident #2's pressure sores appeared infected and in general were severe. The physician added Resident #2 was able to whisper to the emergency room staff she was hungry and hurting, but that was all. The physician went on to say Resident #2 was currently receiving intravenous antibiotics and a MRI completed on 05/28/15 indicated osteo[DIAGNOSES REDACTED], which would require six weeks of antibiotic therapy via a PICC line ( a Peripherally Inserted Central Catheter for long term therapies to avoid repeated intravenous punctures). The physician added in her professional opinion Resident #2's pressure sores and the [DIAGNOSES REDACTED]. In an interview on 05/28/15 at 4:39 pm, the Medical Director stated she received a phone call from the facility in the late afternoon on 05/27/15 regarding Resident #2. It was reported by facility staff Resident #2 had some pressure sores that smelled bad and the wound care physician had recommended intravenous antibiotics to treat them. The Medical Director stated she was going to start Resident #2 on oral antibiotics ([MEDICATION NAME]) and ordered a wound culture until Resident #2's primary care physician could be reached for orders. After reviewing the photos (taken by the surveyor) of Resident #2's pressure sores and the condition of her left leg, she stated osteo[DIAGNOSES REDACTED] was a probably [DIAGNOSES REDACTED]. But based on the information she received verbally from the facility the severity of Resident #2's condition was not reported clearly. In an interview on 05/31/15 at 11:00 am, RN A (the corporate Clinical Services Director) stated since the treatment nurse left employment on 05/15/15 no licensed staff was responsible for measuring and staging pressure sores. RN A added the DON was new to the position (for about 6 weeks) and would assume the responsibilities for staging and measuring pressure sores and ensuring skin assessment and treatments are completed, until a fulltime RN could be hired for the treatment nurse position. RN A stated the facility had not been following corporate guidelines for reviewing new physician orders [REDACTED]. Review of the facility ' s Wound Care Policies and Procedures - dated 12/2011 reflected the following: -Subject- Wound Documentation -Policy- Documentation of wounds will be performed consistently using approved forms. Procedures: 1. Documentation about the wound provided valuable information about wound progress or lack of progress. 2. On admission and/or discovery, the clinician initiates the wound documentation process. Subject- Evaluations of wounds will be performed on admission, weekly, and on discovery. Objective evaluation components include: Location, Measurements, appearance, Drainage, Odor, Presence of tunneling, Healing, Stage and date of onset if a pressure sore and pain. Resources: National Pressure Ulcer Advisor Panel (PUPA) The facility Administrator, Regional Clinical Services Director, and the DON were notified on 03/27/15 at 3:43 pm that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 05/27/15 at 5:40 pm. The final Plan of Removal was accepted by the survey team on 05/28/15 at 5:45 pm. The Plan of Removal reflected the following: Issues Identified: Failure to identify, communicate and perform an assessment for new and existing pressures ulcers including failure to complete weekly skin assessments, complete ordered treatments, and follow physician orders. 1. Resident #2 's physician and responsible party were notified and resident sent to hospital for further evaluation and treatment. Resident #1's physician and responsible party were notified and orders treatment orders were obtained from the physician. Resident # 1's care plan was updated to reflect his current condition. The resident ' s wounds were measured by the Director of Nursing and entered on to the facility wound log for evaluating and tracking. 2. Residents who are found to have a pressure ulcer will have physician and responsible party notification completed by the licensed nurse. The Director of Nursing/RN designee will complete a Skin Assessment, measure and stage the wound(s) and add the resident to the weekly wound log for tracking. A care plan will be formulated by the RN at this time. 3. All facility residents will have a full Skin Evaluation completed by licensed nursing staff by 05/29/15. The Director of Nursing/RN Designee will review the Skin Evaluations and formulate a plan of care based on the findings. Residents identified as high risk will have a Skin Evaluation completed by midnight 05/28/15. 4. Licensed nurses will be re-educated by the Director of Nursing/Clinical Services Director beginning on 05/27/15 and completed by 05/29/15 for all regular staff nurses. {PRN (as needed) will not be receive this education will not be allowed to perform wound care until the education is completed.} Staff Nurses: (Names of 17 licensed nursing staff to be educated were listed here). Education to include: a. Facility policy and procedures for completing weekly skin assessments b. Identification of pressure sores c. Timely notification to the physician, responsible party and Director of Nursing d. Communication of new pressure ulcers and treatments to the Director of Nursing, staff nurses and the facility wound nurse e. Following physician orders f. Nursing assessments for pressure ulcers g. Education of RNs on staging of wounds 5. Residents identified as having a Braden score of 18 or less will have a Skin Risk Analysis/Assessment completed by a RN and an at risk care plan will be formulated. Residents at risk will also have a daily skin check completed by the CNA ' s on the Point of Care (electronic data entry system).CNA ' s will receive re-education by the Director of Nursing/Designee on skin checks to begin 05/28/15 and completed by 05/30/15. 6.All facility residents will be assigned a day/shift for (weekly) skin assessment completion. This will be audited and completed by 05/29/15. New admissions will be assigned a day/shift for a Skin Assessment to be completed by the RN or LVN. Any skin abnormalities identified will be added to the 24 hour report and a progress note written. The Director of Nursing/RN Designee will review the 24 hour report in the morning clinical meeting for further assessment needs. 7. The Director of Nursing/RN Designee will complete a skin assessment on all new admissions and re-admissions and formulate a care plan. The weekend RN will be responsible for new admissions on the weekends and the Director of Nursing/RN Designee will stay after hours for new admissions and complete the assessment. 8. The Director of Nursing/Designee will review all skin assessments weekly for 60 days. Issues identified will be corrected immediately. Trends will be reviewed in the monthly Quality Assurance Performance Improvement meeting. 9. Full facility skin sweeps with assessments will be completely quarterly for 12 months and results reported in the monthly Quality Assurance and Performance Improvement meeting. The survey team monitored the current plan of removal as follows: Licensed staff were interviewed/questioned and their answers demonstrated them to be knowledgeable of the content of the training/in-services for the Plan of Removal regarding: documentation of skin assessments in the nursing progress notes per policy, documentation of changes in wounds or identification of new wounds in the progress notes and the 24 hour report to include notification of the physician and any new orders received; their responsibility of following up on CNA findings written in the CNA Communication Book located at each hall; reporting off to the CNAs at shift change any residents with changes in skin conditions and who require dressings/treatments; transcribing orders for referrals to the Wound Care Physician and ensuring they are completed and the resident is scheduled to be seen; treatment of [REDACTED]. CNAs were interviewed/questioned and their answers demonstrated them to be knowledgeable of the content of the training/in-services for the Plan of Removal regarding: Documentation of any resident skin concerns in the CNA Communication Book located on each hall as well as verbal notification to the charge nurse; if the charge nurse informed of a resident concern does not follow up then the CNA will inform the DON or administrator; documentation each shift in the electronic Point of Care system of any resident skin concerns; procedure when a resident's dressing is missing or in need of being changed; expectation that licensed staff will report to the any residents with skin treatments or changes. On 06/02/15 at 3:52 pm, the Administrator, Regional Clinical Services Director and the DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON provided a list of 69 residents at risk for pressure sores.

Based on observation, interview, and record review, the facility failed to consult with the resident's physician and when there was a significant change in condition requiring physician intervention and/or a need to alter treatment for 2 of 7 residents reviewed for new and worsened pressure sores (Resident #1 and Resident # 2) when: A The facility failed to consult with Resident #2's physician when areas of skin redness worsened. These areas of redness developed into three Stage IV pressure sores (full thickness loss of skin extending to the bone), one Stage III (full thickness loss of skin) and [MEDICAL CONDITION] of her left lower leg (a bacterial infection of the skin), and the facility had not identified them as of 05/27/15 or consulted with the physician. Resident #2 was admitted to a local hospital on [DATE] for evaluation and was diagnosed with [REDACTED]. B. The facility failed to consult with Resident #1 physician when the resident developed two Stage II pressure sores on his buttocks, painful reddened areas behind his ears, a deep tissue injury on his left 2nd toe from long untrimmed toenails. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 05/27/15. While the IJ was removed on 06/02/15, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope identified as pattern. This deficient practice could place 69 residents identified by the facility with moderate to high potential for skin breakdown at risk for unidentified pressure sores, worsening of existing pressure sores, infections, unnecessary hospital stays, extensive treatments and medications, and pain. The Findings Include: A. Review of a face sheet for Resident #2 reflected she was a [AGE] year old female originally admitted to the facility on [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident #2 dated 03/14/15 reflected the following: -Severe cognitive impairment -Assistance of two persons for transfers and bed mobility -No pressure sores -Preventative measures for skin breakdown -pressure relieving mattress -Always incontinent of urine and bowel Review of a Skin Risk Assessment for Resident #2 dated 04/24/15 reflected a score of 12 indicating at high risk for skin breakdown. Review of physician orders for Resident #2 reflected the following: - 04/14/15 Apply duoderm dressing to left inner great toe and change every 3rd day - 04/14/15 Apply skin prep ( a skin conditioner cream) to left ankle and to right inner great toe each shift - 04/28/15- Wound care to evaluate feet and ankle Review of a care plan for Resident #2 dated 04/01/15 reflected the following: -Start date 10/16/14- Report any signs of skin breakdown (sore, red, tender, or broken area). -Conduct a systematic skin inspection weekly by the licensed nurse and daily by CNAs. Pay particular attention to the bony prominence. -Use barrier cream product to perineal area. -Provide incontinent care after each episode. (Note: there was no interim care plan interventions for the areas of skin breakdown on her feet and ankles originally noted on 04/14/15). Review of the facility ' s Wound Log/Skin Report dated 05/26/15 reflected no documentation of Resident #2's pressure sores. In an interview during initial tour on 05/26/15 at 1:05 pm, LVN G (charge nurse) stated she cared for Resident #2 on a frequent basis and she mainly stayed in bed except for showers, but lately had been requesting bed baths due to increase weakness. LVN G added she thought Resident #2 had a couple of skin tears on her legs, but no pressure sores. In an interview on 05/29/15 at 10:00 am, CNA U stated on 05/27/15 she was giving Resident #2 a bed bath around 9:00 am and noticed the dressings on her toes were wet with yellow and brown drainage and smelled bad , and her leg had no dressing and it looked black and smelled bad too. CNA U further stated she went to inform the charge nurse immediately, LVN G, who told her to put a pad under her (Resident #2) and would get to it later. CNA U stated she later (after lunch) saw LVN G in resident #2's room with the Wound Care Physician and he was scraping one of the wounds. During an interview on 05/27/15 at 1:45 pm, RN A (the corporate regional Clinical Services Director) was informed, by the surveyor, since 9:00 am, requests to observe care and a skin assessment for Resident #2 had been unanswered by staff. RN A stated she needed to inform the surveyor that Resident #2 had a new facility acquired Stage III pressure sore and was seen after lunch by the facility's contracted Wound Care Physician. During an observation on 05/27/15 at 2:00 pm of Resident #2 with LVN G (charge nurse) reflected she was in bed with the following skin conditions : a large open area on the left malleolus (ankle bone) approximately 8 cm in size with drainage and bleeding; the distal portion of the left foot a large area of necrotic tissue (dead tissue that appears black in color) approximately 3 cm x 4 cm and with a large area of red swollen skin/tissue extending from the foot to below the knee; the bony prominence below the left great toe had a large open area with necrotic tissue; right lateral portion of her right leg had an opened pressure sore extending through all layers of the skin, there was blood between her toes on her left foot. During an interview with LVN G (charge nurse) at the time of the observation on 05/27/15 of Resident #2's skin, she stated CNA U had reported to her earlier in the day she was concerned about Resident #2 ' s dressings because they were bleeding and needed changing LVN G stated she removed the dressings on her left ankle and foot, which were reportedly dated 05/25/15, she did not know Resident #2 had the pressure sores she observed. LVN G stated she had only been assigned to do weekly skin assessments on her shift (6:00 am-2:00 pm) for Resident #2 and not dressing changes; and does not look under dressings as part of her assessment. LVN G went on to say the facility's treatment nurse was no longer employed as of approximately 2 weeks ago and prior to that she (the treatment nurse) had been doing dressing changes and treatments. LVN G added she thought the night shift nurses (10:00 pm-6:00 am) had been doing the treatments and dressing changes since the treatment nurse left. In a telephone interview on 05/28/15 at 10:39 pm, LVN K (night shift charge nurse) stated she had changed Resident #2's dressings a few times since the treatment nurse left and a couple of weeks ago she told LVN F that they were getting worse and needed new orders for a treatment change. LVN K stated she decided to start applying triple antibiotic ointment to the wounds and covering them with duoderm dressings because there wasn ' t an order for [REDACTED].#2, LVN K stated she thought it was her ankle and toes. LVN K added she couldn't remember if she contacted Resident #2's physician or put any information about Resident #2's pressure sores on the 24 hour report or informed the DON. When asked if the facility had protocols for nurses to follow for wound care (i.e. triple antibiotic ointment) she stated no, she was just trying to do something for the resident. Review of a nursing progress note for Resident #2 dated 05/19/15 documented by LVN I (a 10 pm-6 am shift charge nurse) reflected: noted 8.7 cm wound to the left ankle. Previous dressing was soiled with bloody discharge. Site cleansed, TAO (triple antibiotic ointment) applied and a dressing, and made request for wound care physician to see. In a telephone interview on 05/28/15 at 11:00 pm LVN I (night shift charge nurse) stated she thought the last time she cared for Resident #2 was a couple of weeks ago. LVN I recalled she had made a progress note that the treatment needed changing for Resident #2's left ankle and could have possibly made a note on the 24 hour report, but could not remember. LVN I stated she could not remember how or if she communicated that Resident #2 needed to see the wound care physician. LVN I added she applied triple antibiotic ointment and a duoderm dressing to Resident #2's left ankle without an order and stated she thought that was what all of the other nurses were doing. Review of the wound care physician ' s observations of Resident #2 on 05/27/15 dictated to and noted by LVN G dated 05/27/15 reflected the following: Left lateral (ankle) [MEDICAL CONDITION] smells infected. Stage IV measures 4.3 cm x 4.8 cm x .5. 30% yellow drainage and 70% necrotic; Left foot medial and distal infection. Stage IV with pus and 100% necrotic; 2.7 cm x 3.5 cm x .7 cm; right foot Stage IV 1.0 cm x 1.3 cm x ,4 cm. 30% and 70 % granulation ( the process of tissue replacing blood vessels); Right leg lateral Stage III. 1 cm x 1 cm x .5 cm. Recommend I.V. (intravenous) antibiotics. During a telephone interview on 05/28/15 at 8:25 pm LVN E (charge nurse) stated the last time she cared for Resident #2 was on 05/25/15 on the 2:00 pm-10:00 pm shift. LVN E stated she changed Resident #2's dressings and she observed brown drainage and some necrotic tissue on her left foot. LVN E went on to say she applied triple antibiotic ointment after cleaning the wound with wound cleanser and then applied a duoderm dressing. LVN E added she thought triple antibiotic cream and a duoderm was what the physician had ordered. LVN E confirmed that despite finding brown drainage and necrotic tissue she did not notify Resident #2's physician or the DON, and did not document in the progress notes or 24 hour report. LVN E could not recall the last time she did dressing changes for Resident #2 prior to 05/25/15. In a telephone interview on 06/02/15 at 1:14 pm, the facility's contracted Wound Care Physician stated the first time he saw Resident #2 for evaluation of her pressure sores was on 05/27/15 and he found them to be infected and really bad. He stated he recalled there were multiple Stage IV areas and a Stage III and his recommendation was for intravenous antibiotics: and he would not have prescribed triple antibiotic as a treatment for [REDACTED]. In an interview on 05/29/15 at 11:00 am CNA Y stated she typically works the 200 hall (where Resident #2 resided) and the last time she took care of Resident #2 was during the weekend of 05/23/15-05/24/15 and gave Resident #2 a shower on Saturday 05/23/15. CNA Y also stated that Resident #2 had two dressings on her feet and they got a little wet while she was showering her, so she informed LVN F, the 2 pm-10 pm charge nurse, they needed to be changed. CNA Y stated she did not know if the dressings were changed. In an interview on 05/28/15 at 2:39 pm, LVN F (charge nurse) stated she took care of Resident #2 on the 2:00 pm to 10:00 pm shift on Saturday and Sunday 05/23/15-05/24/15 and she did not do any dressing changes on Resident #2. LVN F stated she could not remember being informed by CNA Y that Resident #2's dressings were wet and needed to be changed. LVN F stated since the treatment nurse left in mid- May, 2015 the 10:00 pm - 6:00 am nurses had been doing the dressing changes and treatments because they had more time. When asked if any of the nurses from that shift had reported to her Resident #2's pressure sores were worsening she stated that she could recall a time when LVN K mentioned to her new orders were needed for a treatment change, but she did not know if LVN K contacted the physician for new orders. LVN F added that she had not contacted the physician after being informed by LVN K that a treatment change was needed or put the information on the facility 24 hour report. Review of the facility's 24 hour reports for the 200 Hall for the month of May, 2015 reflected no entries for Resident #2 regarding skin concerns or referrals for the wound care physician. In a telephone interview on 05/28/15 at 4:39 pm, the physician responsible for Resident #2's care in a local hospital stated when she and the emergency room team received Resident #2 on 05/27/15 they were heartbroken by her condition. The physician stated Resident #2's pressure sores appeared infected and in general were severe. The physician added Resident #2 was able to whisper to the emergency room staff she was hungry and hurting, but that was all. The physician went on to say Resident #2 was currently receiving intravenous antibiotics and a MRI completed on 05/28/15 indicated osteo[DIAGNOSES REDACTED], which would require six weeks of antibiotic therapy via a PICC line ( a Peripherally Inserted Central Catheter for long term therapies to avoid repeated intravenous punctures). The physician added in her professional opinion Resident #2's pressure sores and the [DIAGNOSES REDACTED]. In an interview on 05/28/15 at 4:39 pm, the Medical Director stated she received a phone call from the facility in the late afternoon on 05/27/15 regarding Resident #2. It was reported by facility staff Resident #2 had some pressure sores that smelled bad and the wound care physician had recommended intravenous antibiotics to treat them. The Medical Director stated she was going to start Resident #2 on oral antibiotics ([MEDICATION NAME]) and ordered a wound culture until Resident #2's primary care physician could be reached for orders. After reviewing the photos (taken by the surveyor) of Resident #2's pressure sores and the condition of her left leg, she stated osteo[DIAGNOSES REDACTED] was a probably [DIAGNOSES REDACTED]. But based on the information she received verbally from the facility the severity of Resident #2's condition was not reported clearly. In an interview on 05/31/15 at 11:00 am, RN A (the corporate Clinical Services Director) stated since the treatment nurse left employment on 05/15/15 no licensed staff was responsible for measuring and staging pressure sores. RN A added the DON was new to the position (for about 6 weeks) and would assume the responsibilities for staging and measuring pressure sores and ensuring skin assessment and treatments are completed, until a fulltime RN could be hired for the treatment nurse position. RN A stated the facility had not been following corporate guidelines for reviewing new physician orders and nursing/physician progress notes [REDACTED]. B. Review of a face sheet for Resident #1 reflected he was a [AGE] year old male originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a MDS for Resident #1 dated 04/28/15 reflected the following: - a BIMS score of 14, indicating minimal cognitive impairment -Assistance of two persons for transfers and bed mobility -Incontinent of bowel and an indwelling urinary catheter in place for retention -Upper and Lower extremity impairment -One Stage II pressure sore -Preventative measures- pressure relieving mattress, ointments and non-surgical dressings Review of physician orders for Resident #1 reflected the following: -Focused Skin Assessment bilateral ear folds each shift dated 12/13/14 -Refer for podiatry services 03/03/15 Review of a care plan for Resident #1 dated 01/16/15 reflected: resident at risk for pressure ulcer related to open area to resident's right ear. Resident wears a nasal cannula- pressure from tubing. Goal: Resident ' s skin will remain intact. Approach: Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominence and ears where oxygen tubing rests. Keep clean and dry and minimize moisture. Review of a Pressure Sore Risk assessment for Resident #1 dated 04/22/15 reflected a score of 16 indicating at risk for pressure sores and skin breakdown. (Note: there were no physician orders for the open area in the right ear fold identified on the care plan dated 01/16/15). During an interview on 05/27/15 at 2:00 pm, LVN (charge nurse) stated that after reviewing the weekly skin assessments for Resident #1, the most recent skin assessment date was 05/12/15. LVN F stated the assignment for the weekly skin assessments for Resident #1 is scheduled for Tuesdays on the 6:00 am - 2:00 pm shift. LVN F stated the only explanation she had for the missed skin assessments for Resident #1 was due to work overload and time constraints and it was the hope the next shift would do them. LVN F also stated Resident #1 had no current skin issues, but had a healed spider bite on his left arm. During an observation on 05/27/15 at 2:10 pm of Resident #1's skin with the DON the following was identified: -Two linear open areas on the right buttock in close proximity presenting as Stage II (a partial thickness skin loss) each were approximately 3 centimeter in length and 1 cm in width. -Bilateral redness in the ear folds and Resident #1 expressed pain on the right ear fold -Excoriation of the right groin -Deep tissue injury on the inner aspect of the left foot 2nd toe due to pressure from a long toenail on the adjacent toe that curled inward (note: the DON assessed this as a deep tissue injury) -All toenails were long, thick and yellow During an interview with Resident #1 at the time of observed skin assessment on 05/27/15 he stated the area behind his right ear was painful (where the oxygen tubing rests) and he had never been seen by a podiatrist but he would like to be seen. In an interview on 05/27/15 at 2:30 pm, the DON stated she was not aware Resident #1 had not had a weekly skin assessment since 05/12/15. The DON added she was in the process of ensuring weekly skin assessment were done and would change the assignment days to correspond with residents shower days. Review of the facility ' s Wound Care Policies and Procedures - dated 12/2011 reflected the following: -Subject- Wound Documentation -Policy- Documentation of wounds will be performed consistently using approved forms. Procedures: 1. Documentation about the wound provided valuable information about wound progress or lack of progress. 2. On admission and/or discovery, the clinician initiates the wound documentation process. Subject- Evaluations of wounds will be performed on admission, weekly, and on discovery. Objective evaluation components include: Location, Measurements, appearance, Drainage, Odor, Presence of tunneling, Healing, Stage and date of onset if a pressure sore and pain. Resources: National Pressure Ulcer Advisor Panel (PUPA) The facility Administrator, Regional Clinical Services Director, and the DON were notified on 03/27/15 at 3:43 pm that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 05/27/15 at 5:40 pm. The final Plan of Removal was accepted by the survey team on 05/28/15 at 5:45 pm. The Plan of Removal reflected the following: Issues Identified: Failure to identify, communicate and perform an assessment for new and existing pressures ulcers including failure to complete weekly skin assessments, complete ordered treatments, and follow physician orders. 1. Resident #2 ' s physician and responsible party were notified and resident sent to hospital for further evaluation and treatment. Resident #1's physician and responsible party were notified and orders treatment orders were obtained from the physician. Resident # 1's care plan was updated to reflect his current condition. The resident ' s wounds were measured by the Director of Nursing and entered on to the facility wound log for evaluating and tracking. 2. Residents who are found to have a pressure ulcer will have physician and responsible party notification completed by the licensed nurse. The Director of Nursing/RN designee will complete a Skin Assessment, measure and stage the wound(s) and add the resident to the weekly wound log for tracking. A care plan will be formulated by the RN at this time. 3. All facility residents will have a full Skin Evaluation completed by licensed nursing staff by 05/29/15. The Director of Nursing/RN Designee will review the Skin Evaluations and formulate a plan of care based on the findings. Residents identified as high risk will have a Skin Evaluation completed by midnight 05/28/15. 4. Licensed nurses will be re-educated by the Director of Nursing/Clinical Services Director beginning on 05/27/15 and completed by 05/29/15 for all regular staff nurses. {PRN (as needed) will not be receive this education will not be allowed to perform wound care until the education is completed.} Staff Nurses: (Names of 17 licensed nursing staff to be educated were listed here). Education to include: a. Facility policy and procedures for completing weekly skin assessments b. Identification of pressure sores c. Timely notification to the physician, responsible party and Director of Nursing d. Communication of new pressure ulcers and treatments to the Director of Nursing, staff nurses and the facility wound nurse e. Following physician orders f. Nursing assessments for pressure ulcers g. Education of RNs on staging of wounds 5. Residents identified as having a Braden score of 18 or less will have a Skin Risk Analysis/Assessment completed by a RN and an at risk care plan will be formulated. Residents at risk will also have a daily skin check completed by the CNA ' s on the Point of Care (electronic data entry system).CNA ' s will receive re-education by the Director of Nursing/Designee on skin checks to begin 05/28/15 and completed by 05/30/15. 6.All facility residents will be assigned a day/shift for (weekly) skin assessment completion. This will be audited and completed by 05/29/15. New admissions will be assigned a day/shift for a Skin Assessment to be completed by the RN or LVN. Any skin abnormalities identified will be added to the 24 hour report and a progress note written. The Director of Nursing/RN Designee will review the 24 hour report in the morning clinical meeting for further assessment needs. 7. The Director of Nursing/RN Designee will complete a skin assessment on all new admissions and re-admissions and formulate a care plan. The weekend RN will be responsible for new admissions on the weekends and the Director of Nursing/RN Designee will stay after hours for new admissions and complete the assessment. 8. The Director of Nursing/Designee will review all skin assessments weekly for 60 days. Issues identified will be corrected immediately. Trends will be reviewed in the monthly Quality Assurance Performance Improvement meeting. 9. Full facility skin sweeps with assessments will be completely quarterly for 12 months and results reported in the monthly Quality Assurance and Performance Improvement meeting. The survey team monitored the current plan of removal as follows: Licensed staff were interviewed/questioned and their answers demonstrated them to be knowledgeable of the content of the training/in-services for the Plan of Removal regarding: documentation of skin assessments in the nursing progress notes per policy, documentation of changes in wounds or identification of new wounds in the progress notes and the 24 hour report to include notification of the physician and any new orders received; their responsibility of following up on CNA findings written in the CNA Communication Book located at each hall; reporting off to the CNAs at shift change any residents with changes in skin conditions and who require dressings/treatments; transcribing orders for referrals to the Wound Care Physician and ensuring they are completed and the resident is scheduled to be seen; treatment of [REDACTED]. CNAs were interviewed/questioned and their answers demonstrated them to be knowledgeable of the content of the training/in-services for the Plan of Removal regarding: Documentation of any resident skin concerns in the CNA Communication Book located on each hall as well as verbal notification to the charge nurse; if the charge nurse informed of a resident concern does not follow up then the CNA will inform the DON or administrator; documentation each shift in the electronic Point of Care system of any resident skin concerns; procedure when a resident's dressing is missing or in need of being changed; expectation that licensed staff will report to the any residents with skin treatments or changes. On 06/02/15 at 3:52 pm, the Administrator, Regional Clinical Services Director and the DON were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON provided a list of 69 residents at risk for pressure sores.

Based on interview and record review, the facility failed to follow physician orders [REDACTED].#'s 1 and 2) reviewed for medication administration when: A. Facility nursing staff failed to administer 5 doses of [MEDICATION NAME] (anticoagulant- to thin blood and help prevent blood clots) to Resident #1 per physician order [REDACTED]. B. Facility nursing staff failed to administer 1 dose of [MEDICATION NAME] to Resident #2 per physician order [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 1/01/15. While the IJ was removed on 1/02/15, the facility remained out of compliance at a severity level of potential for more than minimal harm with a scope identified as a pattern. This deficient practice placed 3 residents who receive [MEDICATION NAME] at risk for less than therapeutic benefits, development of blood clots or death. Findings include: A. Review of a facility Face Sheet dated 1/02/15 revealed Resident #1 was a [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1's physician orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) syringe; 30 mg/0.3 ml; 0.3 ml subcutaneous (beneath the skin) every 12 hours 8:00 AM, 8:00 PM. Start date: 12/16/14 Review of Resident #1's eMAR (Electronic Medication Administration Record) revealed the following: Order date: 12/16/14 for [MEDICATION NAME] 30 mg/0.3 ml; 0.3 ml subcutaneous every 12 hours 8:00 AM, 8:00 PM. The eMAR revealed electronic signatures (indicating administration of the [MEDICATION NAME]) as follows: 12/23/14 8:00 AM Not Administered: Drug/Item unavailable. Registered Nurse (RN) A 12/28/14 8:00 PM Not Administered: Drug/Item unavailable. RN B 12/30/14 8:00 AM Not Administered: Other. Computers down, unable to see medication orders. Licensed Vocational Nurse (LVN) C. 12/30/14 8:00 PM Not Administered: Drug/Item unavailable. LVN C 12/31/14 8:00 PM Not Administered: Drug/Item unavailable. LVN C The eMAR electronic signatures were for RN A, RN B, LVN C. During an interview with the Director of Nurses (DON) on 1/01/14 at 10:35 AM, she stated that none of the nurses called to tell her Resident #1's [MEDICATION NAME] medication was unavailable. Observation of a [MEDICATION NAME] box for Resident #1 provided by the DON on 1/01/15 at 10:35 AM revealed a pharmacy fill date of 12/27/14. It held 6 unopened cartridges of [MEDICATION NAME], 4 had been removed. When the surveyor asked where she found the box, the DON stated she asked the morning nurse to look in the treatment cart and it was in it. The DON stated that Resident #1's [MEDICATION NAME] had been available when the doses were missed, and she did not understand why it had not been given. During an interview on 1/01/15 at 1:30 PM, the DON stated, RN A or RN B never told me about the [MEDICATION NAME] being unavailable, and there is no documentation notes written by any of the nurses regarding the medication was not being given to Resident #1. If they had called me or the physician you would think they would have documented it. They should have never run out of blood thinner. During a telephone interview with RN A on 1/02/15 at 9:50 AM, she stated that Resident #1's [MEDICATION NAME] had not been available to give at 8:00 AM on 12/23/14, and she had called the DON. She stated that she asked the pharmacy to send it stat (immediately) and she verbally told the Nurse Practitioner (NP). When asked by the surveyor why had she not documented she had called them, she stated, I should have been more careful. I know I didn't chart, and if not charted, it's not done. During an interview on 1/01/15 at 12:45 PM, RN B (who was also the Assistant Director of Nurses, ADON) stated she had worked the 2:00 PM to 10:00 PM shift on 12/28/14 and she could not find Resident #1's 8:00 PM [MEDICATION NAME] dose. She stated that she had not given it, but notified the pharmacy for a refill. When asked by the surveyor if she had notified the physician or DON, she stated, No. During an interview on 1/02/15 at 4:00 PM, Resident #1 was observed in bed watching TV with a family member at bedside. Resident #1's left arm was observed in a cast, result of the motor vehicle accident. During an interview on 1/02/15 at 5:10 PM, the primary care physician (PCP) for Resident #1 stated that she had not been called by the nurses at the time he was not receiving his doses of [MEDICATION NAME]. She stated (while looking at her email) that an INR (International Normalized Ratio) was just drawn and it was 1.1. (Therapeutic INR range 2.0-3.0). She stated that the [MEDICATION NAME] is used as a bridge until the INR is built up by the [MEDICATION NAME]. Review of information on the website ( http://blood.emedtv.com/[MEDICATION NAME]/difference-between-[MEDICATION NAME]-and-[MEDICATION NAME]-p2.html) revealed the following information about bridging [MEDICATION NAME] and [MEDICATION NAME]: If a resident is at a high risk for clots, a healthcare provider may recommend using [MEDICATION NAME] as a bridge therapy while the [MEDICATION NAME] dose is being adjusted. During an interview on 1/06/15 at 3:35 PM, the Nurse Practitioner (NP) stated that when the surveyor told her, it was the first time she had heard of Resident #1 not receiving his [MEDICATION NAME]. She stated she had been in the facility on 12/15/14 and 12/22/14, before this happened. She stated that the nurses should have called her or the physician (about the [MEDICATION NAME]), especially with something that important that could send a resident back to the hospital. She stated, We have a 24 hour on call system and nothing was on it regarding residents not getting their [MEDICATION NAME]. Review of Resident #1's Interim Plan of Care dated 12/31/14 revealed the following: Other (Specify) Goal: Patient on [MEDICATION NAME] Monitor s/sx (signs and symptoms) of bleeding B. Review of a facility Face Sheet dated 1/02/15 revealed Resident #2 was a [AGE] year old male admitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #2's eMAR (Electronic Medication Administration Record) revealed the following: Start date: 12/31/14 for [MEDICATION NAME] ([MEDICATION NAME]) syringe; 100 mg/ml; amt: inject 1 ml; subcutaneous, Twice a Day, 8:00 AM and 8:00 PM The eMAR revealed electronic signatures (indicating administration of the [MEDICATION NAME]) were as follows: 12/31/14 8:00 AM Initialed: Administered 12/31/14 8:00 PM Not Administered: Drug/Item unavailable. LVN C Review of Resident #2's physician orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) syringe; 100 mg/ml; amt: inject 1 ml; subcutaneous Special Instructions: inject 1 ml bid (two times a day) until INR is therapeutic at 2.0--3.0 twice a day 8:00 AM, 8:00 PM. Start date: 12/31/14 Observation on 1/01/15 at 10:35 AM revealed a clear bag labeled with Resident #2's name. The bag held 3 unused [MEDICATION NAME] cartridges, and revealed a pharmacy fill date of 12/31/14. When the surveyor asked where she found the bag, the DON stated she asked the morning nurse to look in the treatment cart and it was in it. The DON stated that the [MEDICATION NAME] had been available and did not understand why it had not been given the night before. (The eMAR revealed Resident #2's [MEDICATION NAME] had been given at 8:00 AM on 12/31/14.) During an interview on 1/01/15 at 2:15 PM, LVN C stated that the 8:00 PM [MEDICATION NAME] had not been available for Resident #2. She stated she had called the pharmacy, but it was closed and she hung up, not leaving a message. She stated she had not called the physician or DON. When the surveyor asked the nurse what could happen if the resident did not receive his [MEDICATION NAME], she stated, He could get a blood clot, a [MEDICAL CONDITION] ([MEDICAL CONDITION]. During an interview on 1/01/15 at 3:35 PM, the DON stated that there had not been any Medication Error worksheets filled out at the time of the [MEDICATION NAME] missed doses for Resident #'s 1 or 2. During an interview on 1/02/15 at 3:00 PM, Resident #2 was sitting up on the side of his bed visiting with family. He stated that he was getting his medication and assistance from staff as needed. During an interview on 1/02/15 at 5:10 PM, the primary care physician (PCP) for Resident #2 stated that she had not been called by the nurses at the time he was not receiving his doses of [MEDICATION NAME]. She stated (while looking at her email) that an INR was just drawn and it was 1.3. She stated that the [MEDICATION NAME] was being used as a [MEDICATION NAME] (precaution measure) for Resident #2. Review of Resident #2's (undated) Interim Plan of Care revealed the following: Other (Specify) Goal: Patient on [MEDICATION NAME] Monitor s/sx of bleeding Review of a facility policy dated email Revision 7/24/14 titled, Medication Management Program revealed the following elements: S. If the authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member is unable to administer the medication, he/she circles his/her initials on the MAR, and documents the reason not given on the designated area of the MAR. (physician is notified as necessary). Review of a facility policy with a revised date of 9/2011 titled, Physician Communication /Change in Condition reflected the following elements: Policy: 1. To improve communication between physicians and nursing staff in order to promote optimal patient/resident care. Physician Communication Grid * Notification of all medication errors. 6. All attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record. Review of a facility policy with a revised date of 9/2011 titled, Step III: Administering the Medication Pass 3. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member follows the MAR prepared for the patient/resident by identifying the: D. The Right Time F. The Right Charting 5. Medications are administered one (1) hour before or one (1) hour after the designated medication pass time. Review of information on the [MEDICATION NAME] website ([MEDICATION NAME].com) site revealed the following information about [MEDICATION NAME]: [MEDICATION NAME] is indicated for the [MEDICATION NAME] of [MEDICAL CONDITION], which may lead to [MEDICAL CONDITION] embolism (Pulmonary Embolism (PE) is a blockage of the main artery of the lung or one of its branches by a substance that has traveled from elsewhere in the body through the bloodstream). Usually this is due to embolism of a thrombus (blood clot) from the deep veins in the leg and can result in death. · In patients undergoing abdominal surgery who are at risk for [MEDICAL CONDITION] complications · In patients undergoing hip-replacement surgery, during and following hospitalization · In patients undergoing knee-replacement surgery · In medical patients who are at risk for [MEDICAL CONDITION] complications due to severely restricted mobility during acute illness · Do not stop taking [MEDICATION NAME] without first talking to the doctor who prescribed it for you. The facility Administrator and DON were notified on 1/01/15 at 2:10 PM that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 1/01/15 at 2:50 PM. The final Plan of Removal was accepted by the surveyor/investigator on 1/01/15 at 4:03 PM. The plan of removal included the following: 1. Director of Nursing notified the physician on the two residents identified related to missed medication. 2. Orders were received and noted to obtain a stat PT INR. The laboratory has been notified by the Director of Nursing and will be in the facility within the hour to draw ordered lab. 3. Director of Nursing has assessed both residents and found no adverse effects at this time. 4. The nurse that failed to administer the medication or notify the Director of Nursing will be suspended pending investigation. 5. The Director of Nursing completed a 100% audit of residents on [MEDICATION NAME] on January 1, 2015 to determine if any other medications were not given. No other errors were noted. 6. Nursing staff will be re-educated on availability and administration of medication and notification to the Director of Nursing or designee if medication is unavailable or unable to be located. No nurses will work until they have the education. 7. This education will be part of the nursing orientation process for new nursing staff. 8. The Director of Nursing or designee will complete audits 5 times per week for one month to monitor medication availability and administration. 9. The Pharmacist Consultant will complete an audit of all residents and medications. 10. Administrator will review audits for concerns. The medication availability will be added to the morning meeting agenda for review. 11. The Director of Nursing will report findings from the medication audits to the Quality Assurance Performance Improvement committee will review monthly x 3 months and then quarterly until the Quality Assurance Performance Improvement Committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. An in-service for the Nurses and Medication Aides was conducted on 1/01/15 and 1/02/15 concerning medications not available for administration, and notifying the DON or designee immediately, the pharmacy, complete an assessment on the resident, notify the physician, and the responsible party. Copies of the in-service were given to the surveyor by the DON with the signatures of who had attended. She stated she would be in-servicing the night staff and the morning staff as soon as they came to work. The surveyor monitored the current plan of removal as follows: During interviews on 1/01/15 at 3:55 PM LVN's C and H stated they had been in-serviced on who to contact if a medication was not available in the facility. During an interview on 1/02/15 at 10:20 AM, MA D stated she had been in-serviced on who to contact if a medication was not available in the facility. During interviews on 1/02/15 at 1:50 PM and 1:55 PM, LVN F and RN G stated they had been in-serviced on who to contact if a medication was not available in the facility. On 1/02/15 at 7:20 PM, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity level of potential for more than minimal harm with a scope identified as a pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The DON identified 3 residents receiving [MEDICATION NAME] medication.

Based on observation, interview and record review, the facility failed to ensure that residents are free of any significant medication errors for 2 of 3 residents (Resident #'s 4 and 5 ) reviewed for administration of [MEDICATION NAME]. A. Facility nursing staff failed to administer 5 doses of [MEDICATION NAME] (anticoagulant- to thin blood and help prevent blood clots) to Resident #1 per physician order [REDACTED]. B. Facility nursing staff failed to administer 1 dose of [MEDICATION NAME] to Resident #2 per physician order [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 1/01/15. While the IJ was removed on 1/02/15, the facility remained out of compliance at a severity level of potential for more than minimal harm with a scope identified as a pattern. This deficient practice placed 3 residents who receive [MEDICATION NAME] at risk for less than therapeutic benefits, development of blood clots or death. Findings include: A. Review of a facility Face Sheet dated 1/02/15 revealed Resident #1 was a [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1's physician orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) syringe; 30 mg/0.3 ml; 0.3 ml subcutaneous (beneath the skin) every 12 hours 8:00 AM, 8:00 PM. Start date: 12/16/14 Review of Resident #1's eMAR (Electronic Medication Administration Record) revealed the following: Order date: 12/16/14 for [MEDICATION NAME] 30 mg/0.3 ml; 0.3 ml subcutaneous every 12 hours 8:00 AM, 8:00 PM. The eMAR revealed electronic signatures (indicating administration of the [MEDICATION NAME]) as follows: 12/23/14 8:00 AM Not Administered: Drug/Item unavailable. Registered Nurse (RN) A 12/28/14 8:00 PM Not Administered: Drug/Item unavailable. RN B 12/30/14 8:00 AM Not Administered: Other. Computers down, unable to see medication orders. Licensed Vocational Nurse (LVN) C. 12/30/14 8:00 PM Not Administered: Drug/Item unavailable. LVN C 12/31/14 8:00 PM Not Administered: Drug/Item unavailable. LVN C The eMAR electronic signatures were for RN A, RN B, LVN C. During an interview with the Director of Nurses (DON) on 1/01/14 at 10:35 AM, she stated that none of the nurses called to tell her Resident #1's [MEDICATION NAME] medication was unavailable. Observation of a [MEDICATION NAME] box for Resident #1 provided by the DON on 1/01/15 at 10:35 AM revealed a pharmacy fill date of 12/27/14. It held 6 unopened cartridges of [MEDICATION NAME], 4 had been removed. When the surveyor asked where she found the box, the DON stated she asked the morning nurse to look in the treatment cart and it was in it. The DON stated that Resident #1's [MEDICATION NAME] had been available when the doses were missed, and she did not understand why it had not been given. During an interview on 1/01/15 at 1:30 PM, the DON stated, RN A or RN B never told me about the [MEDICATION NAME] being unavailable, and there is no documentation notes written by any of the nurses regarding the medication was not being given to Resident #1. If they had called me or the physician you would think they would have documented it. They should have never run out of blood thinner. During a telephone interview with RN A on 1/02/15 at 9:50 AM, she stated that Resident #1's [MEDICATION NAME] had not been available to give at 8:00 AM on 12/23/14, and she had called the DON. She stated that she asked the pharmacy to send it stat (immediately) and she verbally told the Nurse Practitioner (NP). When asked by the surveyor why had she not documented she had called them, she stated, I should have been more careful. I know I didn't chart, and if not charted, it's not done. During an interview on 1/01/15 at 12:45 PM, RN B (who was also the Assistant Director of Nurses, ADON) stated she had worked the 2:00 PM to 10:00 PM shift on 12/28/14 and she could not find Resident #1's 8:00 PM [MEDICATION NAME] dose. She stated that she had not given it, but notified the pharmacy for a refill. When asked by the surveyor if she had notified the physician or DON, she stated, No. During an interview on 1/02/15 at 4:00 PM, Resident #1 was observed in bed watching TV with a family member at bedside. Resident #1's left arm was observed in a cast, result of the motor vehicle accident. During an interview on 1/02/15 at 5:10 PM, the primary care physician (PCP) for Resident #1 stated that she had not been called by the nurses at the time he was not receiving his doses of [MEDICATION NAME]. She stated (while looking at her email) that an INR (International Normalized Ratio) was just drawn and it was 1.1. (Therapeutic INR range 2.0-3.0). She stated that the [MEDICATION NAME] is used as a bridge until the INR is built up by the [MEDICATION NAME]. Review of information on the website ( http://blood.emedtv.com/[MEDICATION NAME]/difference-between-[MEDICATION NAME]-and-[MEDICATION NAME]-p2.html) revealed the following information about bridging [MEDICATION NAME] and [MEDICATION NAME]: If a resident is at a high risk for clots, a healthcare provider may recommend using [MEDICATION NAME] as a bridge therapy while the [MEDICATION NAME] dose is being adjusted. During an interview on 1/06/15 at 3:35 PM, the Nurse Practitioner (NP) stated that when the surveyor told her, it was the first time she had heard of Resident #1 not receiving his [MEDICATION NAME]. She stated she had been in the facility on 12/15/14 and 12/22/14, before this happened. She stated that the nurses should have called her or the physician (about the [MEDICATION NAME]), especially with something that important that could send a resident back to the hospital. She stated, We have a 24 hour on call system and nothing was on it regarding residents not getting their [MEDICATION NAME]. Review of Resident #1's Interim Plan of Care dated 12/31/14 revealed the following: Other (Specify) Goal: Patient on [MEDICATION NAME] Monitor s/sx (signs and symptoms) of bleeding B. Review of a facility Face Sheet dated 1/02/15 revealed Resident #2 was a [AGE] year old male admitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #2's eMAR (Electronic Medication Administration Record) revealed the following: Start date: 12/31/14 for [MEDICATION NAME] ([MEDICATION NAME]) syringe; 100 mg/ml; amt: inject 1 ml; subcutaneous, Twice a Day, 8:00 AM and 8:00 PM The eMAR revealed electronic signatures (indicating administration of the [MEDICATION NAME]) were as follows: 12/31/14 8:00 AM Initialed: Administered 12/31/14 8:00 PM Not Administered: Drug/Item unavailable. LVN C Review of Resident #2's physician orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) syringe; 100 mg/ml; amt: inject 1 ml; subcutaneous Special Instructions: inject 1 ml bid (two times a day) until INR is therapeutic at 2.0--3.0 twice a day 8:00 AM, 8:00 PM. Start date: 12/31/14 Observation on 1/01/15 at 10:35 AM revealed a clear bag labeled with Resident #2's name. The bag held 3 unused [MEDICATION NAME] cartridges, and revealed a pharmacy fill date of 12/31/14. When the surveyor asked where she found the bag, the DON stated she asked the morning nurse to look in the treatment cart and it was in it. The DON stated that the [MEDICATION NAME] had been available and did not understand why it had not been given the night before. (The eMAR revealed Resident #2's [MEDICATION NAME] had been given at 8:00 AM on 12/31/14.) During an interview on 1/01/15 at 2:15 PM, LVN C stated that the 8:00 PM [MEDICATION NAME] had not been available for Resident #2. She stated she had called the pharmacy, but it was closed and she hung up, not leaving a message. She stated she had not called the physician or DON. When the surveyor asked the nurse what could happen if the resident did not receive his [MEDICATION NAME], she stated, He could get a blood clot, a [MEDICAL CONDITION] ([MEDICAL CONDITION]. During an interview on 1/01/15 at 3:35 PM, the DON stated that there had not been any Medication Error worksheets filled out at the time of the [MEDICATION NAME] missed doses for Resident #'s 1 or 2. During an interview on 1/02/15 at 3:00 PM, Resident #2 was sitting up on the side of his bed visiting with family. He stated that he was getting his medication and assistance from staff as needed. During an interview on 1/02/15 at 5:10 PM, the primary care physician (PCP) for Resident #2 stated that she had not been called by the nurses at the time he was not receiving his doses of [MEDICATION NAME]. She stated (while looking at her email) that an INR was just drawn and it was 1.3. She stated that the [MEDICATION NAME] was being used as a [MEDICATION NAME] (precaution measure) for Resident #2. Review of Resident #2's (undated) Interim Plan of Care revealed the following: Other (Specify) Goal: Patient on [MEDICATION NAME] Monitor s/sx of bleeding Review of a facility policy dated email Revision 7/24/14 titled, Medication Management Program revealed the following elements: S. If the authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member is unable to administer the medication, he/she circles his/her initials on the MAR, and documents the reason not given on the designated area of the MAR. (physician is notified as necessary). Review of a facility policy with a revised date of 9/2011 titled, Physician Communication /Change in Condition reflected the following elements: Policy: 1. To improve communication between physicians and nursing staff in order to promote optimal patient/resident care. Physician Communication Grid * Notification of all medication errors. 6. All attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record. Review of a facility policy with a revised date of 9/2011 titled, Step III: Administering the Medication Pass 3. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member follows the MAR prepared for the patient/resident by identifying the: D. The Right Time F. The Right Charting 5. Medications are administered one (1) hour before or one (1) hour after the designated medication pass time. Review of information on the [MEDICATION NAME] website ([MEDICATION NAME].com) site revealed the following information about [MEDICATION NAME]: [MEDICATION NAME] is indicated for the [MEDICATION NAME] of [MEDICAL CONDITION], which may lead to [MEDICAL CONDITION] embolism (Pulmonary Embolism (PE) is a blockage of the main artery of the lung or one of its branches by a substance that has traveled from elsewhere in the body through the bloodstream). Usually this is due to embolism of a thrombus (blood clot) from the deep veins in the leg and can result in death. · In patients undergoing abdominal surgery who are at risk for [MEDICAL CONDITION] complications · In patients undergoing hip-replacement surgery, during and following hospitalization · In patients undergoing knee-replacement surgery · In medical patients who are at risk for [MEDICAL CONDITION] complications due to severely restricted mobility during acute illness · Do not stop taking [MEDICATION NAME] without first talking to the doctor who prescribed it for you. The facility Administrator and DON were notified on 1/01/15 at 2:10 PM that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 1/01/15 at 2:50 PM. The final Plan of Removal was accepted by the surveyor/investigator on 1/01/15 at 4:03 PM. The plan of removal included the following: 1. Director of Nursing notified the physician on the two residents identified related to missed medication. 2. Orders were received and noted to obtain a stat PT INR. The laboratory has been notified by the Director of Nursing and will be in the facility within the hour to draw ordered lab. 3. Director of Nursing has assessed both residents and found no adverse effects at this time. 4. The nurse that failed to administer the medication or notify the Director of Nursing will be suspended pending investigation. 5. The Director of Nursing completed a 100% audit of residents on [MEDICATION NAME] on January 1, 2015 to determine if any other medications were not given. No other errors were noted. 6. Nursing staff will be re-educated on availability and administration of medication and notification to the Director of Nursing or designee if medication is unavailable or unable to be located. No nurses will work until they have the education. 7. This education will be part of the nursing orientation process for new nursing staff. 8. The Director of Nursing or designee will complete audits 5 times per week for one month to monitor medication availability and administration. 9. The Pharmacist Consultant will complete an audit of all residents and medications. 10. Administrator will review audits for concerns. The medication availability will be added to the morning meeting agenda for review. 11. The Director of Nursing will report findings from the medication audits to the Quality Assurance Performance Improvement committee will review monthly x 3 months and then quarterly until the Quality Assurance Performance Improvement Committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. An in-service for the Nurses and Medication Aides was conducted on 1/01/15 and 1/02/15 concerning medications not available for administration, and notifying the DON or designee immediately, the pharmacy, complete an assessment on the resident, notify the physician, and the responsible party. Copies of the in-service were given to the surveyor by the DON with the signatures of who had attended. She stated she would be in-servicing the night staff and the morning staff as soon as they came to work. The surveyor monitored the current plan of removal as follows: During interviews on 1/01/15 at 3:55 PM LVN's C and H stated they had been in-serviced on who to contact if a medication was not available in the facility. During an interview on 1/02/15 at 10:20 AM, MA D stated she had been in-serviced on who to contact if a medication was not available in the facility. During interviews on 1/02/15 at 1:50 PM and 1:55 PM, LVN F and RN G stated they had been in-serviced on who to contact if a medication was not available in the facility. On 1/02/15 at 7:20 PM, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity level of potential for more than minimal harm with a scope identified as a pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The DON identified 3 residents receiving [MEDICATION NAME] medication.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 3 of 4 residents reviewed for pharmacy services. (Resident #'s 1, 2 and 4) A. Facility nursing staff failed to administer 5 doses of Lovenox (anticoagulant-to thin blood and help prevent blood clots) Resident #1 per physician order [REDACTED]. B. Facility nursing staff failed to administer 1 dose of Lovenox Resident #2 each day per physician order [REDACTED]. C. Medication Aide (MA) D administered 3 medications, scheduled for 7:00 AM administration, to Resident #4 at 10:40 AM, three hours and 40 minutes late. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 1/01/15. While the IJ was removed on 1/02/15, the facility remained out of compliance at a severity level of potential for more than minimal harm with a scope identified as a pattern. This deficient practice placed 3 residents who receive Lovenox, and 1 resident who received untimely medications at risk for development of blood clots or death, and/or less than therapeutic benefits from medications. Findings include: A. Review of a facility Face Sheet dated 1/02/15 revealed Resident #1 was a [AGE] year old male admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1's physician orders [REDACTED]. Enoxaparin (Lovenox) syringe; 30 mg/0.3 ml; 0.3 ml subcutaneous (beneath the skin) every 12 hours 8:00 AM, 8:00 PM. Start date: 12/16/14 Review of Resident #1's eMAR (Electronic Medication Administration Record) revealed the following: Order date: 12/16/14 for Lovenox 30 mg/0.3 ml; 0.3 ml subcutaneous every 12 hours 8:00 AM, 8:00 PM. The eMAR revealed electronic signatures (indicating administration of the Lovenox) as follows: 12/23/14 8:00 AM Not Administered: Drug/Item unavailable. Registered Nurse (RN) A 12/28/14 8:00 PM Not Administered: Drug/Item unavailable. RN B 12/30/14 8:00 AM Not Administered: Other. Computers down, unable to see medication orders. Licensed Vocational Nurse (LVN) C. 12/30/14 8:00 PM Not Administered: Drug/Item unavailable. LVN C 12/31/14 8:00 PM Not Administered: Drug/Item unavailable. LVN C The eMAR electronic signatures were for RN A, RN B, LVN C. During an interview with the Director of Nurses (DON) on 1/01/14 at 10:35 AM, she stated that none of the nurses called to tell her Resident #1's Lovenox medication was unavailable. Observation of a Lovenox box for Resident #1 provided by the DON on 1/01/15 at 10:35 AM revealed a pharmacy fill date of 12/27/14. It held 6 unopened cartridges of Lovenox, 4 had been removed. When the surveyor asked where she found the box, the DON stated she asked the morning nurse to look in the treatment cart and it was in it. The DON stated that Resident #1's Lovenox had been available when the doses were missed, and she did not understand why it had not been given. During an interview on 1/01/15 at 1:30 PM, the DON stated, RN A or RN B never told me about the Lovenox being unavailable, and there is no documentation notes written by any of the nurses regarding the medication was not being given to Resident #1. If they had called me or the physician you would think they would have documented it. They should have never run out of blood thinner. During a telephone interview with RN A on 1/02/15 at 9:50 AM, she stated that Resident #1's Lovenox had not been available to give at 8:00 AM on 12/23/14, and she had called the DON. She stated that she asked the pharmacy to send it stat (immediately) and she verbally told the Nurse Practitioner (NP). When asked by the surveyor why had she not documented she had called them, she stated, I should have been more careful. I know I didn't chart, and if not charted, it's not done. During an interview on 1/01/15 at 12:45 PM, RN B (who was also the Assistant Director of Nurses, ADON) stated she had worked the 2:00 PM to 10:00 PM shift on 12/28/14 and she could not find Resident #1's 8:00 PM Lovenox dose. She stated that she had not given it, but notified the pharmacy for a refill. When asked by the surveyor if she had notified the physician or DON, she stated, No. During an interview on 1/02/15 at 4:00 PM, Resident #1 was observed in bed watching TV with a family member at bedside. Resident #1's left arm was observed in a cast, result of the motor vehicle accident. During an interview on 1/02/15 at 5:10 PM, the primary care physician (PCP) for Resident #1 stated that she had not been called by the nurses at the time he was not receiving his doses of Lovenox. She stated (while looking at her email) that an INR (International Normalized Ratio) was just drawn and it was 1.1. (Therapeutic INR range 2.0-3.0). She stated that the Lovenox is used as a bridge until the INR is built up by the Coumadin. Review of information on the website ( http://blood.emedtv.com/lovenox/difference-between-coumadin-and-lovenox-p2.html) revealed the following information about bridging Lovenox and Coumadin: If a resident is at a high risk for clots, a healthcare provider may recommend using Lovenox as a bridge therapy while the Coumadin dose is being adjusted. During an interview on 1/06/15 at 3:35 PM, the Nurse Practitioner (NP) stated that when the surveyor told her, it was the first time she had heard of Resident #1 not receiving his Lovenox. She stated she had been in the facility on 12/15/14 and 12/22/14, before this happened. She stated that the nurses should have called her or the physician (about the Lovenox), especially with something that important that could send a resident back to the hospital. She stated, We have a 24 hour on call system and nothing was on it regarding residents not getting their Lovenox. Review of Resident #1's Interim Plan of Care dated 12/31/14 revealed the following: Other (Specify) Goal: Patient on Lovenox Monitor s/sx (signs and symptoms) of bleeding B. Review of a facility Face Sheet dated 1/02/15 revealed Resident #2 was a [AGE] year old male admitted on [DATE] with the following Diagnosis: [REDACTED]. Review of Resident #2's eMAR (Electronic Medication Administration Record) revealed the following: Start date: 12/31/14 for Lovenox (Enoxaparin) syringe; 100 mg/ml; amt: inject 1 ml; subcutaneous, Twice a Day, 8:00 AM and 8:00 PM The eMAR revealed electronic signatures (indicating administration of the Lovenox) were as follows: 12/31/14 8:00 AM Initialed: Administered 12/31/14 8:00 PM Not Administered: Drug/Item unavailable. LVN C Review of Resident #2's physician orders [REDACTED]. Lovenox (Enoxaparin) syringe; 100 mg/ml; amt: inject 1 ml; subcutaneous Special Instructions: inject 1 ml bid (two times a day) until INR is therapeutic at 2.0--3.0 twice a day 8:00 AM, 8:00 PM. Start date: 12/31/14 Observation on 1/01/15 at 10:35 AM revealed a clear bag labeled with Resident #2's name. The bag held 3 unused Lovenox cartridges, and revealed a pharmacy fill date of 12/31/14. When the surveyor asked where she found the bag, the DON stated she asked the morning nurse to look in the treatment cart and it was in it. The DON stated that the Lovenox had been available and did not understand why it had not been given the night before. (The eMAR revealed Resident #2's Lovenox had been given at 8:00 AM on 12/31/14.) During an interview on 1/01/15 at 2:15 PM, LVN C stated that the 8:00 PM Lovenox had not been available for Resident #2. She stated she had called the pharmacy, but it was closed and she hung up, not leaving a message. She stated she had not called the physician or DON. When the surveyor asked the nurse what could happen if the resident did not receive his Lovenox, she stated, He could get a blood clot, a DVT (deep vein thrombosis). During an interview on 1/01/15 at 3:35 PM, the DON stated that there had not been any Medication Error worksheets filled out at the time of the Lovenox missed doses for Resident #'s 1 or 2. During an interview on 1/02/15 at 3:00 PM, Resident #2 was sitting up on the side of his bed visiting with family. He stated that he was getting his medication and assistance from staff as needed. During an interview on 1/02/15 at 5:10 PM, the primary care physician (PCP) for Resident #2 stated that she had not been called by the nurses at the time he was not receiving his doses of Lovenox. She stated (while looking at her email) that an INR was just drawn and it was 1.3. She stated that the Lovenox was being used as a prophylaxis (precaution measure) for Resident #2. Review of Resident #2's (undated) Interim Plan of Care revealed the following: Other (Specify) Goal: Patient on Lovenox Monitor s/sx of bleeding Review of a facility policy dated email Revision 7/24/14 titled, Medication Management Program revealed the following elements: S. If the authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member is unable to administer the medication, he/she circles his/her initials on the MAR, and documents the reason not given on the designated area of the MAR. (physician is notified as necessary). Review of a facility policy with a revised date of 9/2011 titled, Physician Communication /Change in Condition reflected the following elements: Policy: 1. To improve communication between physicians and nursing staff in order to promote optimal patient/resident care. Physician Communication Grid * Notification of all medication errors. 6. All attempts to notify physicians and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record. Review of a facility policy with a revised date of 9/2011 titled, Step III: Administering the Medication Pass 3. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member follows the MAR prepared for the patient/resident by identifying the: D. The Right Time F. The Right Charting 5. Medications are administered one (1) hour before or one (1) hour after the designated medication pass time. Review of information on the Lovenox website (Lovenox.com) site revealed the following information about Lovenox: Lovenox is indicated for the prophylaxis of deep vein thrombosis, which may lead to pulmonary embolism (Pulmonary Embolism (PE) is a blockage of the main artery of the lung or one of its branches by a substance that has traveled from elsewhere in the body through the bloodstream). Usually this is due to embolism of a thrombus (blood clot) from the deep veins in the leg and can result in death. · In patients undergoing abdominal surgery who are at risk for thromboembolic complications · In patients undergoing hip-replacement surgery, during and following hospitalization · In patients undergoing knee-replacement surgery · In medical patients who are at risk for thromboembolic complications due to severely restricted mobility during acute illness · Do not stop taking Lovenox without first talking to the doctor who prescribed it for you. C. Observation during a medication pass on 1/01/15 at 10:40 AM revealed MA D administered the following medications scheduled to be given at 7:00 AM to Resident #4. 1. Aspirin (blood thinner) 81 mg (milligrams). 2. Lasix (fluid pill) 40 mg 3. Lisinopril (high blood pressure) 5 mg Review of Resident #4's Recapitulation (Recap) Physician order [REDACTED]. During an interview on 1/01/15 at 1:05 PM, the DON stated that she had in-serviced MA D on giving medications in a timely manner. When asked by the surveyor, would you expect your staff to give medications in a timely manner, she stated , Yes, I would. Review of a current facility policy dated Complete Revision: 9/2011 titled, Medication Management Program revealed the following element: 5. Medications are administered one (1) hour before or one (1) hour after the designated medication pass time. The facility Administrator and DON were notified on 1/01/15 at 2:10 PM that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 1/01/15 at 2:50 PM. The final Plan of Removal was accepted by the surveyor/investigator on 1/01/15 at 4:03 PM. The plan of removal included the following: 1. Director of Nursing notified the physician on the two residents identified related to missed medication. 2. Orders were received and noted to obtain a stat PT INR. The laboratory has been notified by the Director of Nursing and will be in the facility within the hour to draw ordered lab. 3. Director of Nursing has assessed both residents and found no adverse effects at this time. 4. The nurse that failed to administer the medication or notify the Director of Nursing will be suspended pending investigation. 5. The Director of Nursing completed a 100% audit of residents on Lovenox on January 1, 2015 to determine if any other medications were not given. No other errors were noted. 6. Nursing staff will be re-educated on availability and administration of medication and notification to the Director of Nursing or designee if medication is unavailable or unable to be located. No nurses will work until they have the education. 7. This education will be part of the nursing orientation process for new nursing staff. 8. The Director of Nursing or designee will complete audits 5 times per week for one month to monitor medication availability and administration. 9. The Pharmacist Consultant will complete an audit of all residents and medications. 10. Administrator will review audits for concerns. The medication availability will be added to the morning meeting agenda for review. 11. The Director of Nursing will report findings from the medication audits to the Quality Assurance Performance Improvement committee will review monthly x 3 months and then quarterly until the Quality Assurance Performance Improvement Committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. An in-service for the Nurses and Medication Aides was conducted on 1/01/15 and 1/02/15 concerning medications not available for administration, and notifying the DON or designee immediately, the pharmacy, complete an assessment on the resident, notify the physician, and the responsible party. Copies of the in-service were given to the surveyor by the DON with the signatures of who had attended. She stated she would be in-servicing the night staff and the morning staff as soon as they came to work. The surveyor monitored the current plan of removal as follows: During interviews on 1/01/15 at 3:55 PM LVN's C and H stated they had been in-serviced on who to contact if a medication was not available in the facility. During an interview on 1/02/15 at 10:20 AM, MA D stated she had been in-serviced on who to contact if a medication was not available in the facility. During interviews on 1/02/15 at 1:50 PM and 1:55 PM, LVN F and RN G stated they had been in-serviced on who to contact if a medication was not available in the facility. On 1/02/15 at 7:20 PM, the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a severity level of potential for more than minimal harm with a scope identified as a pattern due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The DON identified 3 residents receiving Lovenox, and 1 resident was observed to receive untimely medications during medication pass.

Based on observation, interview and record review the facility failed to ensure that one (1) of six (6) residents reviewed for elopement (Resident #1) received adequate supervision and assistive devices to prevent elopement. Resident #1 who had a history of [REDACTED]. The wheelchair rolled down a sloped walkway toward a busy residential street. Resident#1 and wheelchair fell over at the end of the parking lot. Resident #1 sustained a facial laceration requiring staples and bruising to her eye. Emergency 911 was called to transport her to a local hospital emergency room for treatment. This deficient practice could contribute to increased injuries, hospitalization , and possible death for six (6) residents identified elopement/exit seeking tendencies. Findings include: Review of Resident #1's face sheet reflected a [AGE] year old female with an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Status ((MDS) dated [DATE] reflected sometimes understood; rarely/never understands; short term memory loss; daily decision making moderately impaired. Delirium: Inattention, disorganized thinking, and psychomotor retardation behaviors continuously present, does not fluctuate. Wandering, behavior of this type occurred daily. No falls. Review of Resident #1's MDS dated [DATE] reflected long term and short term memory loss; daily decision making moderately impaired. Delirium: inattention and disorganized thinking behaviors present and fluctuates. Other behavioral symptoms not directed towards others occurred daily. Wandering behavior occurred daily. No falls. Review of Resident #1's current care plan dated 8/22/13 reflected the following: 1.) Resident #1 is at risk for adverse consequences related to receiving antipsychotic medication for treatment of [REDACTED]. Intervention: Assess if resident's behavior symptoms present a danger to self and/or others. Wanders; Monitor resident's behavior and response to medication... 2.) Risk for falling related to will attempt to stand alone and med use. Intervention: Observe frequently and place in supervised area when out of bed; Occupy resident with meaningful distractions; Provide resident with wheelchair, no foot pedals, and uses feet to propel... 3.) Resident #1 is a threat to self-related to wandering. Intervention: Avoid over-stimulation; Maintain a calm environment and approach to the resident and redirect when in an unsafe area; Remove resident from other residents' rooms and unsafe situations; Wanderguard, check placement and functioning as ordered (8/1/13). 4.) Resident #1 experiences wandering (wandering with no rational purpose, seemingly oblivious to where she's going) Intervention: Maintain a calm environment and approach; Remove resident from other residents' rooms and unsafe situations; When resident begins to wander, provide comfort measures for basic needs. FYI resident loves to drink water, offer frequently, wears Wanderguard (8/1/13). Review of a telephone order for Resident #1 dated 10/28/13 reflected: Norco 5/325 one tablet orally every 6 hours as needed for pain; Place Wanderguard to Resident #1's wrist for elopement risk. Review of consolidated Physician order [REDACTED].#1 reflected the following: 10/29/13 Cleanse area to left side face pat with normal saline allow steri strips to fall off naturally-monitor abrasions to bilateral knees cleanse with normal saline apply antibiotic and leave open to air once a day; 06:00 AM 10/28/13 Wanderguard bracelet to resident at all times for elopement risk (DX: Alzheimer's disease)... Review of Resident #1's Medication Administration Record for October 2013 had no printed orders for Wanderguard bracelet prior to written order on 10/29/13 for 'Wanderguard bracelet to resident at all times for elopement risk. Wanderguard electronic check daily. Wanderguard visual check every shift. Change Wanderguard every 90 days and as needed.' An observation on 11/13/13 at 8:15 AM revealed Resident #1 in bed on her right side with eyes closed and even respirations. There was a slightly darkened area under her left eye. An interview on 11/13/13 at 8:15 AM with the Director of Nurses (DON) revealed Resident #1 had never tried to get out before. She would propel her wheelchair up and down the hallways and occasionally into another resident's room and needed redirection. An observation on 11/13/13 at 9:00 AM revealed the side door alarming. It was very loud. Staff was taking a resident out for an appointment and failed to silence the alarm prior to exiting the door. At the same time Resident #1 propelled herself around in her wheelchair using her feet for mobility. She was going into another resident's room when staff redirected her back to the hall. She had a Wanderguard on her left wrist. An observation on 11/13/13 at 10:45 AM revealed Certified Nurse Aide (CNA) A provided incontinent care to Resident #1.On the right side there were small bruises. The left lower leg below the knee revealed numerous bruises in various signs of healing from yellow-green to deep purple. No open areas were observed. There was a dressing on the right wrist and Wanderguard on the left wrist. She was appropriately dressed including shoes when transferred with the assistance of two staff and a gait belt from bed to wheelchair. Review of Nurses' Notes dated 10/28/13 at 8:00 PM reflected Resident #1's return from the ER with steri strips to left side of face. She had orders to remove stitches and staples in 5-6 days. Staples and stitches were not visible to writer. DON notified of return, treatment orders written. Wanderguard order reviewed as well as order for Norco. Resident #1's pleasant, denies pain at this time. Will continue to monitor. Review of Nurses' Notes dated 10/29/13 at 2:15 AM reflected Resident #1's vital signs stable. Follow/up day1 fall with ER visit. Laceration/bruises to left side of face. Left side of face swollen. Steri strips to laceration on face intact. No stitches or sutures noted. Review of a Social Service Progress Note dated 10/29/13 reflected: The SW was sitting at her desk in the office when Resident #8 rolled to the door and stated a resident was outside and needed help. SW went to look out her door and saw a resident laying on their side at the end of the parking lot. SW ran to inform the DON and CNA C standing at Station One. The DON, CNA C, RN D, and the SW went to check on the resident. It was Resident #1. Medication Aide (MA) E and two additional CNAs also responded. It happened around 2:50 PM on 10/28/13. During an interview on 11/13/13 at 4:45 PM Resident #8 stated he recalled on 10/28/13 when Resident #1 went outside. He stated he was sitting there in the middle lobby in his wheel chair. He stated, "Back then they didn't have all the doors locked like they do now. She (Resident #1) opened the door and rolled right out and down (due to the incline starting there). She went almost to the road and tipped out of the wheel chair." Resident #8 stated, "There was a lot of blood. So I thought she gashed open her face, but it looked worse than it was. Now they lock us all in. You know how one bad apple spoils the barrel? That's what happened." An interview on 11/13/13 at 3:30 PM revealed LVN B did not know who checked the Wandergards to ensure they're working properly. She stated she just makes sure the residents have Wanderguards on. Review of Incident/Accident Reports reflected on 10/28/13 at 3:00 PM a [AGE] year old female (Resident #1) was found on the ground in the parking lot with a laceration, skin tear, hematoma, scrapes both knees, left top lip and left eye. The physician was notified immediately for an order for [REDACTED]. The SW and Resident #8 were in the front lobby pointing and saying 'There is someone in the parking lot laying on the ground.' The resident was noted alert, confused, and laying face down toward the left side in the parking lot with the wheel chair behind her. Large skin tear/laceration noted to left cheek and a small dark hematoma below left eye; skin/tear to right hand; Resident #1 was confused and saying, "This hurts." Moves all extremities, agrees to getting back into the wheel chair with two staff maximum assist and to Station 2 for further evaluation by the charge nurse. Head to toe assistance done. Witnessed by Resident #8. Order written to place Wanderguard for resident safety per primary care physician (PCP). Upon return resident vital signs were within normal limits. Resident appears in a pleasant mood at time of return from ER. Review of the facility's Maintenance Log revealed 10/28/13 maintenance check lobby door mechanical and electrical. Check out fire door is working properly. Called vender was on hold for tech support for two hours. Will call back tomorrow at normal business hour. No follow up note was found. An interview on 11/13/13 at 5:30 PM during exit conference, the DON stated, "We should have locked the doors earlier." The administrator agreed.